NOTES: Education and training.

The concept of minimally invasive surgery has gained widespread acceptance because of significant reduction in the patient postoperative morbidity that is associated with these surgical procedures. Natural orifice translumenal endoscopic surgery (NOTES) could theoretically maximize the advantages of minimally invasive surgery by performing intra-abdominal surgery in an "incisionless" manner. NOTES requires a new surgical skill set that would need to be taught to urologists to ensure its safe implementation. Several fundamental issues must be determined regarding safety and efficacy before any widespread implementation of this new technology to urologic surgery can be entertained. The development of specialized instruments designed for NOTES will certainly be crucial. Human ingenuity will undoubtedly succeed in this endeavor. Therefore, development of guidelines for training will be necessary for the safe adoption of this technique by urologists in their clinical practice. As previously demonstrated in laparoscopic surgery, a dedicated curriculum with clearly delineated objectives and teaching strategies will govern the success of postgraduate courses and residency training in urologic NOTES. These types of comprehensive educational programs will provide the basic foundation for the acquisition of the necessary knowledge and the development of the appropriate surgical skills. Animal and cadaveric laboratories will provide realistic interaction with tissue. Mentoring and surgical simulators will facilitate progressive acquisition and maintenance of NOTES skills in the future.