Prepared by S Tekgul ( Using EBU Forms As Reference) Ankara22:45 08.10.2018

Prepared by S Tekgul ( using EBU forms as reference) Ankara22:45 08.10.2018

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.

1Community hospital, private clinic, university hospital, goverment institution, military hospital, other.

PART II

DEFINE HOSPITAL TYPE:

HOSPITAL STATISTICS

TotalHospital ( No )
Number of beds
Total
Paediatric
Day Care
Number of admissions/year
Medical Specialities Concerning
Child Care1 / Y/N / Medical Specialities Concerning
Child Care 1 / Y/N
Urology / Oncology
Radiology
Radiotherapy
Nuclear Medicine
Renal Transplantation / Neurology
Neurosurgery
Psychiatry ( including child care)
Nephrology
Dialysis / Paediatric Intensive care unit
Neonatal intensive care unit
Emergency Department
General Surgery
General Paediatric Surgery
Vascular Surgery
Thorasic Surgery
Orthopaedics / Clinical Biology
Microbiology
Pathology
Anaesthesiology / Dermatology
ENT
Ophtalmology
Internal Medicine
Cardiology
Haematology
Rheumatology / Physical Therapy
Gynaecology/Obstetrics
Perinatology Unıt / Other

1 Please indicate if available(Y), non- existant (N)

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 Total
Paediatric Urology
Day Care
Number of outpatients /year Total
Paediatric Urology
DIAGNOSTIC FACILITIES / Y/N / DIAGNOSTIC FACILITIES / Y/N
Ultrasound / CT
Endoscopy Unit / MRI
Urodynamic Unit / Angiography
Interventional Radiology / Nuclear Medicine

1 Established independently , under Urology or under Paediatric surgery departments.

Paediatric Urological Procedures

Open Surgery Total Number:
No/yr No/yr
KIDNEY
Nephrectomy
.Tumour
-Wilms
-Neuroblastoma
.Non Tumour
Nephrouretectomy
Partial Nephrectomy
Pyelolithotomy/Neprolitotomy
Open Nephrostomy
Open Biopsy
Nephropexy
Pyeloplasty
Ureterocalycostomy
Other(Anomalies/Injury) / RETROPER./NODES/VASC
Retroperiteneum
.adrenal surgery
.Retoperitoneal Tumour
Nodes
.Periaortic
.Retroperitoneal
.Pelvic
.Inguinal
Vascular
. Cavotomyfor tumour thrombus
.Microvascular orchidopexy
.Other
URETER
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 / EXTERNAL GENITALIA
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
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 / No/yr / OTHER
Laparotomy(explotary)
Appendectomy
Herniorapy
Vaginoplasty
Cliteroplasty
Other / No/yr
URETHRA
Uretroplasty(all except Hypospadias)
Hypospadias
.Distal
.Penil
.Penoscrotal
.Chordee
.Re-do
.Fistula repair
Epispadias
Other / TRANSPLANTATION
Renal Transplantation
.Transplantation
.Donor Nephrectomy
.Transplant Nephrectomy
.Revision
Dialysis surgery
.CAPD
Replacement
Revision
.Vascular Access For dialysis
Other
Endoscopic Surgery Total Number:
No/yr No/yr
PERCUTANEOUS UPPER
TRACT
KIDNEY /URETER
Stone
Stricture
Other / URETHRA
Internal uretrotomy
TUR posterior urethral valves
Other
RETROGRADE UPPER TRACT
KIDNEY/URETER
Stone
Stricture
Internal Stends
Other / LAPAROSCOPY
Testis
Varicocele
Kidney
Bladder
other
BLADDER
TUR tumour/biopsy
Stone /foreign Body
Injection therapy for reflux
Bladder neck injection
Other / DIAGNOSTIC ENDOSCOPY
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)
OTHER
Peritoneal catheter placement
Central line placement

PAEDIATRIC UROLOGY OUTPATIENT UNIT

No Pts Total (per year) / % New Pts (average)
Total
Units
General
Urodynamics / urotherapy
Oncology
Congenital defects
Others(specify)

PART III

FELLOW TRAINING PROGRAMME
PAEDIATRIC UROLOGY TEACHING STAFF

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 / No
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.

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 / Total Years Training (Paed. Surg/ Urology +Surgery)
1.
2.
3.
4.
Total number of training positions at the clinic / No

Duration of training in the Paediatric Urology Department ………..Months.

Scheduled Rotation between Subspecialites within the institution.

Subspeciality / Months
Urodynamics/ Urotherapy
Paediatric Nephrology
Paediatric Radiology
Endourology / ESWL
Others

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.

FELLOW TRAINING FACILITIES

MEDICAL RECORDS Y/N
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
How many nights is each resident on call? ………./week

Please list below and comment upon the strong points in your training programme.