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APPLICATION FORM
PART I
PARTICIPATING INSTITUTION(S)
Date
Name of Programme
Primary Institution
Affiliated Institution(s)
Programme director
Local Head
Signature
Type of department
Urology/ Peeadiatric Surgery /Paediatric
Urology
Name of Institution
Street ,no
Postal code & Town
Country
Telephone
Fax
E mail
Type of Institution1
Distance from Primary Institution
If there is more than one institution involved in the training programme this form needs
to be completed by each of the affiliated Institutions as well as the Primary institution.
1
Community hospital, private clinic, university hospital, goverment institution,
military hospital, other.
Prepared by S Tekgul ( using EBU forms as reference) Ankara 19:32 15.02.2016
PART II
DEFINE HOSPITAL TYPE:
HOSPITAL STATISTICS
Total Hospital ( No )
Number of beds
Total
Paediatric
Day Care
Number of admissions/year
Medical Specialities Concerning
Child Care1
Urology
Renal Transplantation
Nephrology
Dialysis
General Surgery
General Paediatric Surgery
Vascular Surgery
Thorasic Surgery
Orthopaedics
Anaesthesiology
Internal Medicine
Cardiology
Haematology
Rheumatology
Gynaecology/Obstetrics
Perinatology Unıt
1 Please
Y/N
Medical Specialities Concerning
Child Care 1
Oncology
Radiology
Radiotherapy
Nuclear Medicine
Neurology
Neurosurgery
Psychiatry ( including child care)
Paediatric Intensive care unit
Neonatal intensive care unit
Emergency Department
Clinical Biology
Microbiology
Pathology
Dermatology
ENT
Ophtalmology
Physical Therapy
Other
indicate if available(Y), non- existant (N)
Y/N
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DEFINE HOW THE DEPARTMENT OF PAEDIATRIC UROLOGY IS
ESTABLISHED 1 :
DEFINE HOW THE DEPARTMENT IS ESTABLISHED?
Main Department name (Paediatric Surgery/ Urology)
Total Number of Qualified Staff
Number Of Paediatric Urologists within the Staff
Total Number of Residents
Total Number of Fellows
Number of Fellows in Paediatric Urology
Urology / Paediatric Surgery
Dpt ( No)
Number of Beds
Number of outpatients /year
Total
Paediatric Urology
Day Care
Total
Paediatric Urology
DIAGNOSTIC FACILITIES
Ultrasound
Endoscopy Unit
Urodynamic Unit
Interventional Radiology
Y/N
DIAGNOSTIC
FACILITIES
CT
MRI
Angiography
Nuclear Medicine
Y/N
1 Established independently , under Urology or under Paediatric surgery departments.
Prepared by S Tekgul ( using EBU forms as reference) Ankara 19:32 15.02.2016
Paediatric Urological Procedures
Open Surgery
Total Number:
No/yr
No/yr
KIDNEY
RETROPER./NODES/VASC
Nephrectomy
.Tumour
-Wilms
-Neuroblastoma
.Non Tumour
Nephrouretectomy
Partial Nephrectomy
Pyelolithotomy/Neprolitotomy
Open Nephrostomy
Open Biopsy
Nephropexy
Pyeloplasty
Ureterocalycostomy
Other(Anomalies/Injury)
Retroperiteneum
.adrenal surgery
.Retoperitoneal Tumour
Nodes
.Periaortic
.Retroperitoneal
.Pelvic
.Inguinal
Vascular
. Cavotomyfor tumour thrombus
.Microvascular orchidopexy
.Other
URETER
EXTERNAL GENITALIA
Ureterotomy-ureterolithotomy
Uretero-uretostomy
Ureteroplasty
Ureterectomy
Uretero-neocystostomy(No Ureters)
-Extravesical
-Intravesical
-Psoas Hitch
Remodelling of megaureter
Surgery for ureteral duplication
External urinary diversion
Internal urinary diversion
Revision urinary diversion
Other
Penis
.Circusion
.buried Penis
.Penoscrotal web
. Penoscrotal Transposition
.Priapism
.Penil Curvature
Testis
.Radical orchidopexy
.Inguinal hernia
.Inguinal Orchidopexy
.Two stage Orchidopexy
Epididim,spermatic cord,scrotum
.Hyrocele
.varicocele
.scrotum excision
Other
BLADDER
No/yr OTHER
No/yr
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Augmentation
.Intestinal
.Gastric
.Ureteral
. Autoaugmentation
Mitrofanoff Procedure
Bladder Substitution
Diverticulectomy
Excion urachal cyst/ tumor
Cystotomy/Cystostomy
Extrophy Repair
Cloacal Repair
Fistula
Trauma repair
Incontinence surgery
.Bladder Neck Plasty
.Sling
.Artificial urinary sfincter
.Closure
Other
Laparotomy(explotary)
Appendectomy
Herniorapy
Vaginoplasty
Cliteroplasty
Other
URETHRA
TRANSPLANTATION
Uretroplasty(all except
Hypospadias)
Hypospadias
.Distal
.Penil
.Penoscrotal
.Chordee
.Re-do
.Fistula repair
Epispadias
Other
Renal Transplantation
.Transplantation
.Donor Nephrectomy
.Transplant Nephrectomy
.Revision
Dialysis surgery
.CAPD
Replacement
Revision
.Vascular Access For dialysis
Other
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Endoscopic Surgery
Total Number:
No/yr
PERCUTANEOUS UPPER
TRACT
KIDNEY /URETER
Stone
Stricture
Other
RETROGRADE UPPER TRACT
KIDNEY/URETER
No/yr
URETHRA
Internal uretrotomy
TUR posterior urethral valves
Other
LAPAROSCOPY
Stone
Stricture
Internal Stends
Other
Testis
Varicocele
Kidney
Bladder
other
BLADDER
DIAGNOSTIC ENDOSCOPY
TUR tumour/biopsy
Stone /foreign Body
Injection therapy for reflux
Bladder neck injection
Other
Urethro/cystoscopy
Ureteral catheterisation
Urethral dilation
other
No/yr
ESWL(all sessions/all sites)
.Kidney
.Ureter
.Bladder
DIAGNOSTIC& MINOR PROCEDURES
1.Interventional uroradiology
.Percutaneous nephrostomy
.Drainage
.Percutaneous cystostomy
2.Urodynamics studies (excluding flow)
.Urodynamics studies
.Radio urodynamic studies
.Biofeedback
INVESTIGATIONAL PROCEDURES
(define)
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OTHER
Peritoneal catheter placement
Central line placement
PAEDIATRIC UROLOGY OUTPATIENT UNIT
No Pts Total (per year)
Total
Units
General
Urodynamics /
urotherapy
Oncology
Congenital defects
Others(specify)
% New Pts (average)
Prepared by S Tekgul ( using EBU forms as reference) Ankara 19:32 15.02.2016
PART III
FELLOW TRAINING PROGRAMME
PAEDIATRIC UROLOGY TEACHING STAFF
No
Total No of positions for full time Paed. Urologists
Total No of positions for part time Paed. Urologists
No other specialists in the department of
Paed.Urology
List below those staff members who currently participiate in the education of the paeditric
urology fellow
Name
Title
Position
Speciality
Year of
certification
1.
2
3.
4.
5.
6.
7.
8.
9.
Attach a curriculum vitea of each staff member.
Prepared by S Tekgul ( using EBU forms as reference) Ankara 19:32 15.02.2016
FELLOWS AT PRESENT
Please note that a questionnaire will be sent to the residents
Name
Md
graduate
(year)
Training
Years
before
Paed.
Urology
Years of
Paed.
Urology
Training
1.
2.
3.
4.
Total number of training positions at the clinic
Total Years
Training (Paed.
Surg/ Urology
+Surgery)
No
Duration of training in the Paediatric Urology Department
Scheduled Rotation between Subspecialites within the institution.
Subspeciality
Urodynamics/ Urotherapy
Paediatric Nephrology
Paediatric Radiology
Endourology / ESWL
Others
Months
………..Months.
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Scheduled weekly rotation
Scheduled weekly work in
Hours
Ward
Outpatient Clinic
Operation theatre
Administration
Research
Supervision
Yes / No
Does every fellow have a personal written
training programme?
Does every fellow have a personal tutor/
supervisor?
Does every fellow have a personal
logbook?
Are all fellows supervised ?
Please attach the training programme and a copy of log-book for each fellow.
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FELLOW TRAINING FACILITIES
MEDICAL RECORDS
Do all patients have medical report kept up date?
Are patients’ records available for research?
How many secretaries are working for the department ?
TEACHING FACILITIES
Number of conference rooms
Do you have national reference facilities (e.g. Medline) ?
Is there a departmental library with at least…… international paediatric
urology journals ?
CONFERENCES
Are there regular conferences on
(Please indicate frequency/ month)
Pathology
……/month
Radiology
……/month
Morbidity/ mortality
……/month
Basic science
……/month
Journal club
……/month
Other
……/month
Are there regular teaching ward rounds?
STUDY FACILITIES
Do fellows have a room where they can work or study?
Are fellows allowed study leave?
RESEARCH FACILITIES
Is clinical research offered to the fellows?
Is basic research offered to the fellows?
Is statistical advice available for the fellows?
Number of papers or posters presented by fellows at (inter)national meetings
during the last year
(attach list with names,titles and meetings and provide reprint or copy)
WORKLOAD
What are the scheduled working hours
from…..am, until…….pm
How many hours average does each fellow spent in the institution per week
(including on call periods) ?
………../week
Y/N
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How many nights is each resident on call?
………./week
Please list below and comment upon the strong points in your training programme.