Maxim Physician Resources
Urology
Skills Checklist
Enter the appropriate provider code in the blank next to the procedure. Failure to fill this
out correctly can delay the screening process.
Provider Codes
1 Fully competent to perform
2 Competent with supervision
3 Not requested due to lack of expertise
Please check all that apply to your scope of practice.
I. GENERAL PROCEDURES
General clinical procedures customary to the practice of urology:
___ Outpatient
___ Inpatient
II. SPECIFIC PROCEDURES
KIDNEY
Incision
___ Drainage of kidney abscess
___ Drainage of perirenal abscess
___ Removal of calculus or foreign body in perirenal tissues
___ Nephrostomy with drainage
___ Nephrolithotomy
___ Division or transection of aberrant renal vessel
___ Pyelolithotomy
___ Pyeloplasty
Excision
___ Renal Biopsy
___ Nephrectomy
___ Heminephrectomy
___ Renal capsulectomy (capsulation of kidney)
___ Excision cyst of kidney
___ Renal Artery Repair By -pass graft- vein, artery or synthetic
___ Diagnostic Procedure Perirenal insufflation
Subsection Repair
___ Renal arteriography
___ Pyeloplasty (plastic operation of renal pelvis)
___ Nephropexy
___ Suture of kidney wound
___ Suspension of kidney
___ Other _____________________________________________________________
URETER
Incision
___ Ureterotomy
___ Meatotomy of the ureter
___ Ureterolithotomy
Excision
___ Ureterectomy
___ Ureterocele Fulguration
___ Ureterocele suprapubic excision
___ Ureteroplasty (plastic repair on ureter)
___ Ureteropyelostomy (anastomosis of the reter of renal pelvis)
___ Ureter-enterostomy
___ Uretercystostomy (anastomosis of the ureter to bladder, unilateral)
___ Ureter-enterostomy (anastomosis of ureter to intestine including creation of ileal
conduit)
___ Ureterostomy (transplantation of ureter to skin)
___ Suture
___ Closure of ureterovaginal fistula with ureterovesical anastomosis
___ Other _______________________________________________________________
BLADDER
Incision
___ Puncture aspiration of bladder by trocar
___ Aspiration with insertion of suprapubic catheter
___ Cystotomy with exploration
___ Cystotomy with insertion radioactive substance
___ Cystolithotomy
___ Drainage of perivesical space
Excision
___ Cystectomy
___ Suprapubic resection of bladder neck
___ Transurethral
___ Eleco resection of bladder neck
___ Excision of bladder diverticulum
___ Excision of bladder tumor with segmental resection of bladder
___ Transuretheral resection of bladder tumors
Endoscopy
___ Cystoscopy
___ Cystoscopy with ureteral catheterization
___ Cystoscopy with stone removal
___ Cystoscopy with manipulation of ureteral calculus
___ Cystoscopy with fulguration of bladder tumor
___ Cystoscopy with insertion of radioactive substance or with biopsy
Reconstruction
___ Litholapaxy
Suture
___ Cystorrhaphy, suture of bladder wall
___ Closure of vesical-vaginal fistula
___ Closure of extrophy of bladder
___ Other _____________________________________________________________
URETHERA
Incision
___ Urethrotomy, internal
___ Urethrotomy, external
___ Meatotomy, cutting of meatus
Excision
___ Excis ion of urethral caruncle or fulgruation
___ Excision of bulbourethral, planned
___ Excision of Carcinoma of urethra
___ Excision of diverticulum urethra
___ Excision of urethral polyps
Endoscopy
___ Urethroscopy
___ Urethroscopy with removal calculus or foreign body
Repair
___ Urethroplasty (plastic operation on urethra)
Suture
___ Closure of urethral wound
Manipulation
___ Dialation of urethral structure by passage of sound
___ Other _______________________________________________________________
PENIS
Excision
___ Biopsy of penis
___ Amputation of penis
___ Amputation of penis radical with bilateral, no dissecton
___ Circumcision
Repair
___ Plastic repair of penis for hypospadias
___ Injection of Peyronies Plague
___ Insert penile prosthesis
___ Other _______________________________________________________________
TESTES
Excision
___ Biopsy of testes
___ Orchidectomy
___ Orchidectomy, radical or bilateral with retrooperitoneal lymph node dissection
Repair
___ Reduction of Torsion the testes by surgical means
___ Orchidopexy
___ Other __________________________________
EPIDIDYMIS
Incision
___ Drainage of abscess of epididymis
Excision
___ Biopsy of epididymis
___ Excision of supermatocele
___ Epididymectomy
Repair
___ Epididymovasostomy, anastomosis of epididymis to vas
___ Other _______________________________________________________________
TUNICA VAGINALIS
Incision
___ Puncture aspiration of hydrocele
___ Excision of hydrocele
___ Excision of hydrocele with hernia repair
___ Other _______________________________________________________________
SCROTUM
Incision
___ Drainage of scrotal abscess
___ Local excision of lesion of scrotum
___ Other _______________________________________________________________
VAS DEFERENS
___ Vasotomy division or transection of vas
___ Vasectomy
___ Vaso-vasostomy
___ Ligation of vas
___ Other _______________________________________________________________
SPERMATIC CORD
___ Excision of hydrocele of spermatic cord
___ Excision of varicocele
___ Other _______________________________________________________________
SEMINAL VESICLES
___ Vesiculotomy
___ Vesiculectomy
___ Other _______________________________________________________________
PROSTATE
___ Prostatotomy, external drainage of prostatic abscess
___ Biopsy of prostate
___ Prostatectomy, perineal
___ Prostatectomy, perineal
___ Prostatectomy, suprapubic
___ Prostatectomy, retropubic
___ Transurethral resection of prostate
___ Bilateral iliac lymph adenectomy to stage prostatic carcinoma
Printed Name: ________________________________________________________________
Signature: _________________________________________________ Date: ____________