Application for Re-Certification of a Paediatric Urology Trainingprogramme

Page 1 / 14

Application for Re-Certification of a Paediatric Urology TrainingProgramme

This form needs to be filled, printed, signed and sent as an online applicationas a signed PDF file to the administrative coordinator and secretary

Deadline for re-certification as a training programme is December 31st, 2017

Application

Part I
Participating Institution(s)

Date of application
Primary Institution
Affiliated Institution(s)
Programme director
Chair of the applying department
Type of department / Select an item... Select an item in the list...UrologyPaediatric Surgery Paediatric Urology
Street, n°
Postal code & Town
Country
Telephone
Email
Type of Hospital / Select an item... /

Part II

Hospital / Department

Statistics

Name of the Hospital
Total Number of beds /
Total Number of paediatric beds
Total
Number of paediatricadmissions/year
Urology / Paediatric Surgery Department (Number of Beds)
Main Department (Paediatric Surgery / Urology
Paediatric Urology
Day Care Paediatric Urology

Define how the Department of Paediatric Urology is established:

Main Department / Department or Section / Division of Pediatric Urology

Total Number of Qualified Staff (total)
Number Of Paediatric Urologists within the Staff
Total Number of Residents (total)
Total Number of Fellows (total)
Number of Fellows in Paediatric Urology
Medical Specialtiesavailable / Yes/No
Paediatric Urology
Paediatric Renal Transplantation
Paediatric Nephrology
Paediatric Dialysis
General Paediatric Surgery
Paediatric Vascular Surgery
Paediatric Thoracic Surgery
Paediatric Anaesthesiology
Paediatric Orthopaedics
General paediatrics
Paediatric Cardiology
Paediatric Haematology
Paediatric Rheumatology
Paediatric Endocrinology
Paediatric infection diseases
Paediatric Gynaecology/Obstetrics
Perinatology Unıt
Paediatric Oncology
Paediatric Radiology
Paediatric Radiotherapy
Paediatric Neurology
Paediatric Psychiatry
Paediatric Psychology
Paediatric Intensive care unit
Neonatal intensive care unit
Paediatric Emergency Department
Clinical Biology
Microbiology
Pathology
Paediatric Dermatology
Paediatric Osteopathy
Paediatric Oto-Rhino-Laryngology
Paediatric Ophtalmology
Paediatric Physical Therapy
Paediatric Urotherapy
Other

Diagnostic Facilities for children

Facilities / Yes/No
Ultrasound (central)
Ultrasound (in the clinic)
Endoscopy Unit
Urodynamic Unit
Interventional Radiology
CT
MRI
Angiography
Nuclear Medicine

Paediatric Urology outpatient unit

Patientstotal (per year) / New Patients
Total
Units
General
Urodynamics /
Videourodynamics/ Urotherapy
Oncology
Congenital defects
Others(specify)

Paediatric Urological Procedures within the last 24 months

(from______to ______)

Open Surgery
Total Number / Lap. Surgery
Total Number / Robot. Surgery
Total Number
Kidney
Nephrectomy
Tumour
-Wilms
-Neuroblastoma
Non Tumour
Nephrouretectomy
Partial Nephrectomy
-Tumour
-Non-tumour
Pyelolithotomy/Neprolithotomy
Pyeloplasty
Ureterocalicostomy
Other (Anomalies/Injury)
Ureter
Ureterotomy-ureterolithotomy
Uretero-ureterostomy
Ureterectomy
Uretero-neocystostomy (No Ureters)
-Extravesical
-Intravesical
-Psoas Hitch
Remodelling of megaureter
Surgery for ureteral duplication
Ureterocutaneostomy
Other
Bladder
Augmentation
Intestinal (ileal,colonicor gastric segments)
Ureter
Autoaugmentation
Continent catheterizable stoma
Orthotopic Bladder Replacement
Diverticulectomy
Excision urachal cyst/ tumor
Vesicostomy
Epispadias-Extrophy-Complex
Cloacal Extrophy
Urogenital sinus
Cloaca
Bladder Fistula
Bladder Trauma
Incontinence surgery
Bladder Neck Plasty
Sling
Artificial urinary spincter
Bladder neck Closure
Urinary diversions using bowel segments
Continent anal diversions
Continent cutaneous diversions
Conduit Diversion (Ileal / colonic)
Urethra
Urethroplasty (all except Hypospadias)
Primary Hypospadias
Distal
Penile
Proximal
Two-stage Surgery
Chordee
Minor Revision hypospadias
Major Revision hypospadias
Primary Epispadias
Secondary epispadias surgery
Other
Retroper/Nodes/Vasc
Retroperitoneum
Adrenal surgery
Retroperitoneal Tumour
Nodes
Retroperitoneal
Pelvic
Inguinal
Vascular
Cavotomyfor tumour thrombus
Other
External Genitalia
Penis
Circumsion
Buried Penis
Penoscrotal web
Penoscrotal Transposition
Priapism
Penil Curvature
Testis
Radical orchiectomy
Orchidopexy
Two stage Orchidopexy
Epididymis, spermatic cord, scrotum
Hydrocele
Varicocele
Scrotum excision
Other
Other
Vaginoplasty
Clitoroplasty
Female urethral surgery
Other
Transplantation
Renal transplantation
Donor Nephrectomy
Transplant Nephrectomy
Revision
Dialysis surgery
CAPD
Replacement
Revision
Other
Tumours
Wilms tumours
Neuroblastomas (retroperitoneal)
Rhabdomyosarcomas (bladder prostate, vagina, paratesticular)
Testicular Tumours (malignant)
Testicular Tumours (benign)
Endoscopic Surgery /
Total Number
Percutaneous upper tract
PCNL
Endopyelotomy
Nephrostomy
Renal biopsy
Retrograde upper tract
Retrograde intrarenal Surgery (RIRS)
Endopyelotomy
URS
Stents
Ballon dilatation
Bladder
TUR tumor/biopsy
Stone /foreign body
Injection therapy for reflux
Botolinum toxin injection
Bladder neck injection
Bladder neck incision
Other
Urethra
Incision of posterior urethral valves
Internal urethrotomyurethral stricture
Other
Diagnostic endoscopy
Urethro- /cystoscopy
URS without intervention
Other
Total number
ESWL(all sessions/all sites)
Kidney
Ureter
Bladder
Total number
Diagnostic & Minor Procedures
Percutaneous cystostomy
Urethral Dilatation
Urodynamic studies (excluding flow)
Ultrasound of genitourinary tract

Part III

Fellow Training Programme
Paediatric Urology Teaching Staff

Number
Total No of positions for full time paediatricUrologists
Total No of positions for part time paediatricUrologists (specify contract in %)
No other specialists in the department of paediatricUrology
List below those staff members who currently participate in the education of the paediatric urology fellow
Name / Title / Position / Specialty / Year of board certification (Urology/ Paediatric Surgery / Year of FEAPU certification
1.
2.
3.
4.
5.
6.
7.
8.
9.

Attach a curriculum vitae of each staff member.

Fellows at present

Name / MDgraduate (year) / Training Years before Paediatric Urology / Years of Paediatric Urology Training / Total Years Training (Paediatric Surgery / Urology)
1.
2.
3.
4.

Fellows in the past

Name / Current Address / Training period
(from.. to ..) / FEAPU exam
(Yes/no / FEAPU certification
(year)
1.
2.
3.
4.
5.
6.

Fellow training Facilities

Teaching Facilities Yes/No
Free Access to Online journals /library
Conferences
Are there regular conferences on
(Please indicate frequency/ month)
Pathology
Radiology
Morbidity/ mortality
Basic science
Journal club
Other
Are there regular teaching ward rounds? / ……/month
……/month
……/month
……/month
……/month
……/month
Study Facilities
Do fellows have a room where they can work or study?
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 current fellows at (inter)national meetings during the last year
Workload
What are the scheduled working hours from..…..am, until…….pm
How many hours average does the current fellow spent in the institution per week
(including on call periods)? ………../week
How many nights is the current fellow on call? ………./week

Add the Log-Book for the fellows of your department

Add the 2-year training programme for the fellowship

Please list below 3 strong points and 3 weak points for improvement in your training program.

Strong points:

1.

2.

3.

Weak points:

1.

3.

4.