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Background: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. Objective: To report a large multi-institutional worldwide series of LESS in urology. Design, Setting, And Participants: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. Intervention: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. Measurements: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. Results and Limitations: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160 ± 93 min. and estimated blood loss was 148 ± 234 mL. Skin incision length at closure was 3.5 ± 1.5cm. Mean hospital stay was 3.6 ± 2.7 d with a visual analog pain score at discharge of 1.5 ± 1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/ robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. Conclusions: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

LESS Natural orifice transluminal endoscopic surgery NOTES Robotics UrologyPlease visit www.eu-acme.org/ europeanurology to read and answer questions on-line. The EU-ACME credits will then be attributed automatically. AbstractContext: Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery. Objective: To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology. Evidence acquisition: A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology. Evidence synthesis: In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or casecontrol studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES. Conclusions: NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

We demonstrate, in simulated and live-operating environments, that eye metrics can reliably distinguish nonexpert from expert surgeons. As current medical educators rely on subjective measures of surgical skill, eye metrics may serve as the basis for objective assessment in surgical education and credentialing in the future. Further development of this potential educational tool is warranted to assess its ability to both reliably classify larger groups of surgeons and follow progression of surgical skill during postgraduate training.

At specific choice points in the periphery, subsets of motor axons defasciculate from other axons in the motor nerves and steer into their muscle target regions. Using a large-scale genetic screen in Drosophila, we identified the sidestep (side) gene as essential for motor axons to leave the motor nerves and enter their muscle targets. side encodes a target-derived transmembrane protein (Side) that is a novel member of the immunoglobulin superfamily (IgSF). Side is expressed on embryonic muscles during the period when motor axons leave their nerves and extend onto these muscles. In side mutant embryos, motor axons fail to extend onto muscles and instead continue to extend along their motor nerves. Ectopic expression of Side results in extensive and prolonged motor axon contact with inappropriate tissues expressing Side.