American College of Osteopathic Surgeons Urological Surgery: Principal ...
109American College of Osteopathic Surgeons Urological Surgery: Principal Surgical Areas The principal surgical areas are the heart of the surgical residency training; therefore, competence in each
area is required. All American Osteopathic Association (AOA) competencies have been integrated into
each principal surgical area. Each of these areas is evaluated monthly by attending physicians and staff.110American College of Osteopathic Surgery Urological Surgery Residency Principal Surgical Areas: Adrenal Developed by:
Albert DePolo Jr., D.O., FACOS, FICS,
MHPE
Reviewed by:
John Kowalczyk, D.O., FACOS Resident Outcomes: Osteopathic Principles and Practices Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills ProfessionalismSystems-Based PracticeRationale
The adrenal glands, paired in the human, are located in the retroperitoneum at the superior pole of each
kidney. Their location and close proximity to other vital structures make them relatively inaccessible.
The urological surgeon evaluates disease of the adrenal gland. Disease states range from Cushing’s
Disease to adenocarcinoma. Frequently the urological surgeon evaluates incidental tumors of the adrenal
gland. With the development of precise urine and plasma tests, accurate diagnosis of metabolic disease of
the adrenal is very possible. Newer imagining techniques have allowed for more accurate identification
and location of neoplasia or functional disease such as pheochromocytoma. Surgical treatment of the
adrenal glands includes both open and laparoscopic approaches. The resident must have enough
experience in the diagnosis and treatment of disease of the adrenal glands to become competent in this
area of surgery.Prerequisites
Prior to entering a urological surgical residency, the resident should:
• Understand the anatomy, physiology, pathophysiology, and pharmacology of the adrenal gland• Perform an appropriate history and physical exam with attention to signs of adrenal disease• Understand the indications and techniques of imaging tests such at computerized tomography (CT)scan and magnetic resonance imaging (MRI)• Understand basic radiographic anatomy and be able to review imaging looking for adrenal diseaseLearning Outcomes
Upon completion of the urological surgical residency, the resident will:
• Understand the anatomy, physiology and pharmacology of the adrenal gland and its implications inthe diagnosis and treatment of various adrenal diseases• Perform and interpret laboratory and imaging tests leading to the diagnosis of adrenal diseases• Coordinate a multidisciplinary approach to adrenal disease and its management• Perform appropriate surgical approaches to the adrenal gland including laparoscopic surgicaltechniques• Manage patients postoperative who have undergone adrenal surgery.• Recognize signs and symptoms and manage complications following adrenal surgery• Perform or refer postoperative Osteopathic Manipulative Therapy (OMT) to minimize complicationsand restore normal function• Communicate effectively with patients, family members and colleagues111Phase I: Performance
IndicatorsPhase II: Performance
IndicatorsPhase III: Performance
IndicatorsCognitive
Understand the physiology and
pathophysiology of adrenal
disease
Perform a complete history and
physical exam with emphasis
upon adrenal pathology
Evaluate and diagnose suspected
adrenal disease with the
appropriate laboratory and
imaging studies
• Cushing's Syndrome
• Addison's Disease andsecondary hypoadrenalism• congenital adrenalhyperplasia• primary hyperaldosteronism• phaeochromocytoma• Nelson’s syndrome• Conn’s syndrome
Illustrate the benefits of pre- and
postoperative OMT in
normalizing tissues, removing
restriction and normalizing
function
Select from different surgical
approaches to the adrenal gland
based on disease and condition of
the patient
Prepare a patient preoperatively
who is undergoing adrenal gland
surgery
Manage phaeochromocytoma,
pharmocologically and
anaestheticly
Technical
Perform incisions and closures
used in adrenal surgeryCognitive
Compare Multiple Endocrine
Neoplasia (MEN) type 2 with
other adrenal tumors, both
cortical and medullary
Evaluate and treat
adenocarcinoma and
incidentaloma
Perform tumor nodes metastasis
(TNM) staging
Interpret the laboratory and
imaging studies for patients with
adrenal disease
Collaborate with other specialists
(e.g., endocrinologists,
pathologists, urologists,
oncologists radiologists)
involved in the diagnosis of
adrenal disease
Manage postoperative care,
including replacement therapy,
for patients having undergone
adrenal surgery
Recognize and manage
complications of adrenal surgery
Understand the role of OMT for
patients with impaired
pulmonary function undergoing
adrenal surgery
Communicate using appropriate
language and depth with patients
and families concerning adrenal
disease
Technical
First assist during adrenal
surgical proceduresCognitive
Use a multidisciplinary team
approach to patients with adrenal
disease
Manage medical diseases
associated with disease of the
adrenal gland
Technical
Perform adrenalectomy
Perform adrenal surgery using a
laparoscopic approach 112Learning Experiences (list titles specific teaching conferences, procedure workshops, skills labs, etc.)
Self Assessment Study Program
Participate in and lead teaching rounds
Participate in and lead appropriate academic and didactic sessions
Attend urological conferences and integrate current techniques and literature of the adrenal gland into
daily rounds, surgeries and teaching
Resources
Albala DM, Grasso M. Color Atlas of Endourology. Baltimore, MD: Lippincott Williams and Wilkins,
1999.
American Urologicalal Association Update Series:
http://www.auanet.org/catalog/cme/print/updateseries.cfm
Campbell MF, Walsh PC, Retik AB. (Eds). Campbell’s Urology, 8th edition. Philadelphia, PA: W.B.Saunders Company, 2002, Vol 1 – 4.
Gillenwater JY, Howards SS, Grayhack JT Mitchell M. (Eds) Adult and Pediatric Urology, 4th edition.Baltimore, MD: Lippincott Williams and Wilkins, 2002.
Graham SD, Glenn JF. Glenn’s Urological Surgery, 6th edition. Baltimore, MD: Lippincott Williams andWilkins, 2004.
Hinman F, Stempen PH (Illustrator). Atlas of Urological Surgery, 2nd edition. Philadelphia, PA: W.B.Saunders Company, 1998.
van Heerden JA, Grant CS. Diseases of the adrenal glands: surgical aspects. In: Adkins RB, Jr., Scott
HW, Jr. (eds), Surgical Care for the Elderly (2nd ed). Philadelphia: Lippincott-Raven Publishers,1998;411-426.
Volgelzang NJ, Scardino PT, Shipley WU, Debruyne FMJ, Linehan WM (Eds). Comprehensive Textbook
of Genitourinary Oncology, 3rd edition. Baltimore, MD: Lippincott Williams and Wilkins, 2005.
Journal of Urology
Resident Assessment
Self-Assessment Study Program (SASP) testing Direct observation during surgery
In-service examinations
Quarterly (or post-rotation) evaluation by attending surgeons and chiefs of service
Written and Oral Board Examinations 113American College of Osteopathic Surgery Urological Surgery Residency Principal Surgical Areas: Bladder
Developed by:
Kathy Ravanbakhsh, D.O., FACOS Resident Outcomes: Osteopathic Principles and Practices Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills ProfessionalismSystems-Based PracticeRationale
Bladder cancer is the second most common malignancy of the genital urinary tract. It is more than 2.5
times more common in men, and is the fourth most common cancer after prostate, lung, and colorectal
cancers, accounting for 6.2% of all cancer cases. In addition to the evaluation and treatment of bladder
cancer, a urological surgeon must be competent in acute and chronic disease state of the bladder. Urinary
tract infections account for more than 7 million visits to physicians’ offices and can complicate over 1
million hospital visits. In addition, urinary incontinence is a major health issue that affects more than 10
million patients, with approximately 50% of nursing home patients that are symptomatic. In excess of
$15-20 billion dollars is spent on this problem annually. Trauma to the bladder is associated with pelvic
fractures, occurring 6-10% of the time. Conversely, most bladder injuries (83-100%) have an associated
pelvic fracture. Diseases of the bladder provide a wide variety of surgical challenges that are unique to the
field of urological surgery. A resident’s experience with a wide variety and scope of these acute and
chronic problems is essential in training a competent urological surgeon.Prerequisites
Prior to entering a urological surgery residency, the resident should:• Understand the anatomy, physiology and pharmacology of the bladder
• Understand the pathogenesis of bladder cancer, urinary tract infections, voiding dysfunction, andtrauma to the bladder• Understand the risk factors for bladder cancer and the work up for hematuria• Understand the physiology of normal and pathologic voidingLearning Outcomes
Upon completion of the urological surgery residency, the resident will:• Understand the anatomy, physiology and pharmacology of the bladder and their implications indiagnosis and treatment of various disease processes• Perform surgical treatments for diseases, disorders and trauma of the bladder
• Plan postoperative intravesical therapy for bladder cancer• Coordinate multidisciplinary treatments both operative and nonoperative for advanced bladder cancer• Perform or refer Osteopathic Manipulative Treatment (OMT) in the pre- and postoperative period tofacilitate normal function and minimize postoperative complications• Manage urinary tract infections based the principles of antimicrobial therapy
• Recognize the presentation of bladder trauma and plan nonoperative management
• Communicate effectively with patients and families 114Phase I: Performance
IndicatorsPhase II: Performance
IndicatorsPhase III: Performance
IndicatorsCognitive
Understand the neurophysiology
of normal and dysfunctional
voiding
Select and interpret imaging
studies of the bladder including
MRI, CT, ultrasound and nuclear
medicine
Perform preoperative evaluation
as it pertains to operative risks
Understand the unique aspects of
the postoperative management of
the urological patient
Evaluate microscopic and gross
hematuria
Select a nonoperative treatment
based on its specific
complications and their
prevention or treatment
Understand the benefits of pre-
and postoperative OMT in
normalizing tissues and
increasing mobility and function
Understand the requirement for
appropriate discharge from the
hospital and appropriate follow-
up evaluations
Understand the risk factors and
the natural history of bladder
cancer
Understand the pathogenesis of
urinary tract infection (UTI)
Diagnose and manage UTI
medically
Evaluate and treat urinary
incontinenceCognitive
Stage and grade bladder cancer
based on physical, clinical, and
pathologic findings
Plan the treatment of bladder
cancer based on its stage
Assess the indications for
intravesical chemotherapy and
immunotherapy for bladder
cancer and plan for
complications
Understand the pharmacology of
chemotherapy and
immunotherapy
Interpret noninvasive and
invasive imaging modalities in
diagnosis of bladder pathology
Understand the anatomic and
physiologic changes in
complicated UTI
Interpret urodynamics and
formulate medical or surgical
treatments
Understand the pathophysiology
and categorization of voiding
dysfunction
Identify the indications for
medical and surgical treatments
for voiding dysfunctions
Select among the treatment
options for bladder injury and
know the indications for
conservative management or
surgical treatmentCognitive
Evaluate and treat complications
of surgical
treatment of bladder cancer
Evaluate and treat complications
of chemotherapy and
immunotherapy
Formulate a multidisciplinary
treatment plan for complicated or
advanced bladder cancer
Plan the treatment of complicated
UTI
Understand the pathophysiology
of complicated urinary
incontinence and its medical and
surgical treatments
Develop the strategies to treat
complicated bladder injuries 115Evaluate bladder trauma and
formulate a treatment plan
Communicate with patients and
families using compassion
Explain diagnoses and treatment
options to patients and families in
language they can understand
Technical
Place an indwelling urethral
Foley catheter in patients with
uncomplicated and complicated
bladder diseases and disorders
Perform bedside urethral dilation
Perform bedside percutaneous
suprapubic tube placement
Perform multichannel
urodynamics
Perform basic endoscopic
procedures including
cytourethroscopy and bladder
biopsyTechnical
Perform bladder biopsy and
fulguration
Participate in the transurethral
resection of a bladder tumor
Perform bladder
diverticulectomy and
cystolithotomy
Perform cystotomy, with or
without the removal of a calculus
or foreign body
Perform surgical treatments for
urinary incontinence
Repair bladder perforationTechnical
Perform transurethral resection of
a bladder tumor with minimal
assistance
Perform radical and partial
cystectomy
Perform bladder augmentation
Perform surgical procedures for
stress incontinence including
bladder vesicourethropexy, neck
suspension, periurethral bulking
therapy, pubovaginal sling and
artificial urinary sphincter
Perform surgical procedures for
urge incontinence including
detrusor myomectomy,
Ingelman-Sundberg, sacral nerve
modulation and bladder
augmentation
Repair cystocele or
cystourethrocele
Perform bladder reconstruction
or substitution (neobladder) 116Learning Experiences (list titles specific teaching conferences, procedure workshops, skills labs, etc.)
Self Assessment Study Program
Participate in and lead teaching rounds
Participate in and lead appropriate academic and didactic sessions
Attend urological conferences and integrate current techniques and literature of the prostate into daily
rounds, surgeries and teaching
Resources:
Albala DM, Grasso M. Color Atlas of Endourology. Baltimore, MD: Lippincott Williams and Wilkins,
1999.
American Urologicalal Association Update Series:
http://www.auanet.org/catalog/cme/print/updateseries.cfm
Campbell MF, Walsh PC, Retik AB. (Eds). Campbell’s Urology, 8th edition. Philadelphia, PA: W.B.Saunders Company, 2002, Vol 1 – 4.
Gillenwater JY, Howards SS, Grayhack JT Mitchell M. (Eds) Adult and Pediatric Urology, 4th edition.Baltimore, MD: Lippincott Williams and Wilkins, 2002.
Graham SD, Glenn JF. Glenn’s Urological Surgery, 6th edition. Baltimore, MD: Lippincott Williams andWilkins, 2004.
Hinman F, Stempen PH (Illustrator). Atlas of Urological Surgery, 2nd edition. Philadelphia, PA: W.B.Saunders Company, 1998.
Volgelzang NJ, Scardino PT, Shipley WU, Debruyne FMJ, Linehan WM (Eds). Comprehensive Textbook
of Genitourinary Oncology, 3rd edition. Baltimore, MD: Lippincott Williams and Wilkins, 2005.
Journal of Urology
Resident Assessment:
Self-Assessment Study Program (SASP) testing Direct observation during surgery
In-service examinations
Quarterly (or post-rotation) evaluation by attending surgeons and chiefs of service
Written and Oral Board Examinations 117American College of Osteopathic Surgery Urological Surgery Residency Principal Surgical Areas: Kidney and Ureters Developed by:
Carolyn Langford, D.O. and Aaron
Geswaldo, D.O. Resident Outcomes: Osteopathic Principles and Practices Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills ProfessionalismSystems-Based Practice Rationale
Diseases of the kidney constitute a large part of the urological surgeon’s clinical practice with radical
nephrectomy being one of the most commonly performed open surgical procedures on the kidney. The
urological surgeon is called upon to evaluate a wide range of kidney problems ranging from the benign
cystic mass to renal cell carcinoma, requiring a thorough understanding of history and progression of
kidney diseases. The urological surgeon also evaluates a wide range of ureteric problems ranging from
asymptomatic calculi to invasive transitional cell carcinoma. Endoscopy is the most commonly used
approach for both diagnosis and treatment of the ureter. The urological surgeon gives attention to
potential etiologies of processes that affect the kidney and ureters including congenital abnormalities,
neoplastic processes, iatrogenic injury and outflow obstruction.
The urological surgeon takes into account the overall health and wellbeing of an individual in order to
appropriately manage the patient with kidney or ureteric problems. Each individual problem requires
different diagnostic and therapeutic interventions; therefore it is essential to have a close working
relationship with other specialists in the fields of urology, radiology, internal medicine and oncology. At
times, a multidisciplinary team approach is necessary to minimize morbidity and maximize successful
treatment of disease. Prerequisites
Prior to entering a urological surgical residency, the resident should:
• Understand the anatomy of the kidneys and ureters as well as their primary function andinterrelationships• Identify the basic laboratory tests used to evaluate kidney or ureteric function• Understand the variety of modalities used to diagnose kidney or ureteric problems such asradiographs, computed tomography, nuclear medicine and retrograde ureteropyelography and when
they should be utilized 118Learning Outcomes
Upon completion of a urological surgical residency, the resident will:
• Understand the etiology, pathophysiology, presenting signs and symptoms, differential diagnosis andtreatment options of kidney and ureteric diseases• Diagnose kidney and ureteric diseases by history and physical examination, as well as appropriate useof laboratory and imaging studies• Perform surgical procedures appropriate for congenital, benign and malignant disease of the kidney orureter• Understand the consequences of disease of the organs to the patient as a whole
• Coordinate multidisciplinary operative and nonoperative care for diseases of the kidney or ureter
• Counsel patients and their families on all aspects of the diagnosis and treatment of surgical diseases ofthe kidney or ureter• Perform or refer osteopathic manipulative treatment (OMT) in the pre- and postoperative period tofacilitate early return to normal function and prevention of postoperative complications 119Phase I: Performance
IndicatorsPhase II: Performance
IndicatorsPhase III: Performance
IndicatorsCognitive
Understand the normal
physiology, anatomic
relationships and variant anatomy
of the kidney and ureter
Analyze the fundamental
pathologic processes and overall
clinical significance of conditions
of the ureter such as
ureterolithiasis, ureteral
obstruction, and transitional cell
carcinoma
Analyze fundamental pathologic
processes and overall clinical
significance of conditions of the
kidney such as flank pain, renal
colic and pyeolonephritis
Understand the pathophysiology
and prevention of stone
formation including chemolysis
Manage kidney and ureteric
diseases in adults
Understand the benefits of pre-
and postoperative OMT in
normalizing tissues, removing
restriction and normalizing
function
Understand the etiology and plan
the management of acute and
chronic renal failure
Request, read and interpret
radiographs, computed
tomography, nuclear medicine
and retrograde uretero-
pyelography for diagnosis of
kidney and ureteric diseaseCognitive
Evaluate the common and
unusual pathologic problems of
the kidney or ureter and their
interrelationship with other organ
systems
Understand the pathogenesis of
kidney disease and related
complications including:
pyelonephritis, nephrolithiasis,
upper tract obstruction,
carcinoma, and congenital
abnormalities
Understand the pathogenesis,
congenital anomalies, related
complications and surgical
treatment of duplicate collecting
systems, ectopic ureters,
ureteropelvic junction
obstruction, ureterolithiasis and
ureteric tumors
Understand the pathophysiology
of stone formation as it relates to
pregnancy and pediatric patients
Educate patients and their
families of the possible risks and
complications associated with
kidney and ureteral surgery and
inform them of alternative
treatments
Identify and manage early and
late post-nephrectomy problems
Identify ureteric surgical
complications
Manage kidney and ureteric
diseases in pregnant and pediatric
patientsCognitive
Choose and utilize
instrumentation and treatment
modalities for major surgery of
the kidney
Choose and utilize
instrumentation and treatment
modalities for open or
endourological surgery of the
ureter
Diagnose, grade and manage
vesicoureteral reflux (VUR)
Plan the management of diseases
of the kidney including
malignancy, renal cysts, injury,
congenital anomalies,
pyelonephritis and inflammatory
disorders
Plan the management of diseases
of the ureter including
malignancies, ureteric injuries,
congenital anomalies, ureteric
obstruction, and stricture disease
Evaluate factors associated with
poor outcomes in advanced
kidney or ureteric diseases
Communicate effectively with
patients and their families
regarding congenital, benign and
malignant diseases of the kidney
or ureter
Collaborate with professionals in
urology pathology, radiology,
internal medicine, nephrology,
and oncology when necessary in
the treatment of kidney or
ureteric diseases 120Technical
Perform any preoperative
resuscitation and preparation that
a patient may require prior to
kidney or ureteral surgery
Assist open and laparoscopic
kidney surgery and identify
techniques to avoid adverse
events
Assist in ureteroscopy
Perform cystoscopy and
retrograde pyelography and
identify proper endoscopic
techniquesSelect hemostatic techniques in
urological surgery based on an
understanding of their
mechanism of action
Technical
Plan and perform port placement
for laparoscopic surgery
Perform endourological
procedures including holmium
laser, biopsy and open ureteric
reimplantation
Plan and perform stone surgery
including laser lithotripsy and
extracorporeal shock wave
lithotripsy (ESWL) and
percutaneous
nephropyelolithotomy (PCNL)
Insert and remove ureteral stents
Perform surgery for kidney or
ureteric obstruction
Perform ureteral catheterizationCollaboratively manage non-
resectable malignancies
including decompressions,
diversions and non-curative
ablations
Technical
Perform radical nephrectomy
both open and laparoscopically
Perform partial nephrectomy
surgery for nephron sparing
Perform nephroureterectomy
Perform surgery for renal cystic
disease
Perform dismembered
pyeloplasty
Perform complicated ureteric
reimplantation and reconstruction
including the transtrigonal
(Cohen), intravesical
(Leadbetter-Politano), and
extravesical detrusorrhaphy
techniques
Perform open pyelolithotomy or
urterolithotomy and
endourological procedures with
and without BEC and
electrohydraulic lithotripsy
(EHL)
Perform ureteroileostomy and
ureteroneocystostomy
Perform reno-ureteral
anastomoses
Repair uretero-pelvic junction
(UPJ) obstruction selecting
• open pyeloplasty• antigrade percutaneousendopyelotomy• retrograde ureteroscopicendopyelotomy or• balloon with a cutting 121electrodePerform diagnostic and
therapeurtic ureteroscopy
Perform kidney and ureteric
surgeries required as a result of
trauma or iatrogenic injuries
Perform surgical intervention for
renal failure 122Learning Experiences (list titles specific teaching conferences, procedure workshops, skills labs, etc.)
Self Assessment Study Program
Participate in and lead teaching rounds
Participate in and lead appropriate academic and didactic sessions
Attend urological conferences and integrate current techniques and literature of the kidney and ureter into
daily rounds, surgeries and teaching
Resources
Albala DM, Grasso M. Color Atlas of Endourology. Baltimore, MD: Lippincott Williams and Wilkins,
1999.
American Urologicalal Association Update Series:
http://www.auanet.org/catalog/cme/print/updateseries.cfm
Campbell MF, Walsh PC, Retik AB. (Eds). Campbell’s Urology, 8th edition. Philadelphia, PA: W.B.Saunders Company, 2002, Vol 1 – 4.
Gillenwater JY, Howards SS, Grayhack JT Mitchell M. (Eds) Adult and Pediatric Urology, 4th edition.Baltimore, MD: Lippincott Williams and Wilkins, 2002.
Graham SD, Glenn JF. Glenn’s Urological Surgery, 6th edition. Baltimore, MD: Lippincott Williams andWilkins, 2004.
Hinman F, Stempen PH (Illustrator). Atlas of Urological Surgery, 2nd edition. Philadelphia, PA: W.B.Saunders Company, 1998.
Volgelzang NJ, Scardino PT, Shipley WU, Debruyne FMJ, Linehan WM (Eds). Comprehensive Textbook
of Genitourinary Oncology, 3rd edition. Baltimore, MD: Lippincott Williams and Wilkins, 2005.
Journal of Urology
Resident Assessment
Self-Assessment Study Program (SASP) testing Direct observation during surgery
In-service examinations
Quarterly (or post-rotation) evaluation by attending surgeons and chiefs of service
Written and Oral Board Examinations 123American College of Osteopathic Surgery Urological Surgery Residency Principal Surgical Areas: Male & Female Genitalia Developed by:
Cynthia Cartwright, MT, RN, MSEd
Reviewed by:
Albert DePolo Jr., D.O., FACOS, FICS,
MHPE Resident Outcomes: Osteopathic Principles and Practices Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills ProfessionalismSystems-Based Practice Rationale
The urologist is frequently called upon to diagnose and treat disorders of the male and female genitalia,
both the external genitalia and the urethra. Disorders may be of an inflammatory, infectious or genetic
nature. Treatment may include operative or non-operative approaches. Patients with skin diseases of the
external genitalia, fearing infection, often over treat lesions leading to prolonged and complicated
conditions. In the case of drug eruptions, the groin may be involved before widespread lesions appear.
Some of the most challenging disorders of the genitalia are those involving sexual differentiation. These
disorders may present during the newborn period as having ambiguous genitalia, during puberty with
inappropriate or delayed development or later in life as having infertility. In the case of ambiguous
genitalia, the urologist is presented with the challenge of making an accurate diagnosis and the even
greater challenge of communicating with new parents faced with a stressful family event. A thorough
examination including history, physical, chromosomal, laboratory and radiographic usually produces a
definitive answer to the gender of a newborn with ambiguous genitalia. However, when the answer
remains unclear, the urologist has the opportunity to assign a non-binding gender to the newborn until such
time the individual can reassign their sex. At the appropriate time, the urologist can help guide the patient
to successful gender assignment using an understanding of the continuum of sexual identity from male to
female. Prerequisites
Prior to entering a urological surgery residency, the resident should:• Understand the embryologic development and anatomy of the genitourinary system• Understand the etiology, pathophysiology and the presenting signs and symptoms of diseases anddisorders of the male and female genitalia• Perform a complete history and physical exam, including the male and female genitalia
• Recognize and diagnose common causes of urethral discharge 124Learning Outcomes
Upon completion of a urological surgery residency, the resident will:• Perform a focused history and physical examination of the male and female genitalia
• Diagnose diseases and disorders of the male and female genitalia by history and physical examination,and appropriate use of imaging studies• Consult, evaluate and recommend surgical intervention for diseases and disorders of the male andfemale genitalia• Coordinate multidisciplinary operative and non-operative care for diseases and disorders of the maleand female genitalia• Perform surgery appropriate to the type of disease or disorder and condition of the patient
• Counsel patients and their families on all aspects of the diagnosis and treatment of diseases anddisorders of the male and female genitalia• Value the need for sensitivity regarding communication with patients and families and the operative andnonoperative treatment of the genitalia• Perform or refer Osteopathic Manipulative Treatment (OMT) in the pre- and postoperative period tofacilitate early return to normal function and prevention of postoperative complications 125Phase I: Performance
IndicatorsPhase II: Performance
IndicatorsPhase III: Performance
IndicatorsCognitive
Recognize and treat bacterial,
fungal, parasitic and viral
diseases of the genitaliaIdentify and treat cutaneous
manifestations of sexually
transmitted diseases
Diagnose and treat acute, chronic
and senile urethritis
Diagnose and treat distal urethral
stenosis and labial fusion
Diagnose and understand the
treatment for hypospadias,
chordee and epispadias
Identify benign, pre-malignant
and malignant lesions of the
genitaliaPerform appropriate preoperative
evaluations
Perform diagnostic and
therapeutic procedures for benign
and malignant lesions of the
genitaliaPerform OMT in the pre and
postoperative period to facilitate
early return to normal function
and prevent postoperative
complications, such as
lymphedema and deep vein
thrombosis (DVT)
Technical
Perform incisional or excisional
biopsy of lesions
Debride simple abscesses
Perform circumcisions if
indicated for foreskin lesionsCognitive
Identify and treat inflammatory
diseases of the genitalia,
including:• contact dermatitis • circumscribed neurodermatitis • drug eruptions • psoriasis • seborrheic dermatitis • lichen planus • lichen scherosus
Understand disorders of sexual
differentiation based on
chromosomal, gonadal and/or
phenotypic abnormalities
Determine the gender of a
newborn with ambiguous
genitalia based on:• history • physical examination • chromosomal evaluation • biochemical evaluation • radiographic evaluation • diagnostic laparotomy or laparoscopy
Acknowledge the unique
psychosocial aspects of gender
assignment including the
relationship of sexual identity
and self-esteem to wellbeing
Treat priapism, both
pharmacologically and
operativelySelect partial versus total
penectomy based on indications
Technical
Perform partial penectomy
Surgically correct hypospadias,
chordee and epispadias
Perform dilatation of the urethra
for urethral stenosisCognitive
Recognize and treat the
complications of penectomy
Diagnose and treat disorders of
the female urethra:• urethral caruncle • prolapse of the urethra • urethral diverticulum • urethral stricture
Technical
Perform total penectomy,
perineal urethrostomy
Perform a shunting technique to
surgically treat priapism 126Learning Experiences (list titles specific teaching conferences, procedure workshops, skills labs, etc.)
Self Assessment Study Program
Participate in and lead teaching rounds
Participate in and lead appropriate academic and didactic sessions
Attend urological conferences and integrate current techniques and literature of male and female genitalia
into daily rounds, surgeries and teaching
Resources
Albala DM, Grasso M. Color Atlas of Endourology. Baltimore, MD: Lippincott Williams and Wilkins,
1999.
American Urologicalal Association Update Series:
http://www.auanet.org/catalog/cme/print/updateseries.cfm
Campbell MF, Walsh PC, Retik AB. (Eds). Campbell’s Urology, 8th edition. Philadelphia, PA: W.B.Saunders Company, 2002, Vol 1 – 4.
Gillenwater JY, Howards SS, Grayhack JT Mitchell M. (Eds) Adult and Pediatric Urology, 4th edition.Baltimore, MD: Lippincott Williams and Wilkins, 2002.
Graham SD, Glenn JF. Glenn’s Urological Surgery, 6th edition. Baltimore, MD: Lippincott Williams andWilkins, 2004.
Hinman F, Stempen PH (Illustrator). Atlas of Urological Surgery, 2nd edition. Philadelphia, PA: W.B.Saunders Company, 1998.
Volgelzang NJ, Scardino PT, Shipley WU, Debruyne FMJ, Linehan WM (Eds). Comprehensive Textbook
of Genitourinary Oncology, 3rd edition. Baltimore, MD: Lippincott Williams and Wilkins, 2005.
Journal of Urology
Resident Assessment
Self-Assessment Study Program (SASP) testing Direct observation during surgery
In-service examinations
Quarterly (or post-rotation) evaluation by attending surgeons and chiefs of service
Written and Oral Board Examinations 127American College of Osteopathic Surgery Urological Surgery Residency Principal Surgical Areas: Prostate
Developed by:
Anthony M. Grimaldi D.O., FACOS
John A. Grimaldi D.O. Resident Outcomes: Osteopathic Principles and Practices Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills ProfessionalismSystems-Based PracticeRationale
The prostate is shaped like an inverted pyramid and lies between the urinary bladder and pelvic floor in
males. It is a fibromuscular glandular organ that surrounds the prostatic urethra. The urologist will likely
see 25% or of his or her practice revolve around diseases of the prostate. Benign prostatic hypertrophy
(BPH) is ubiquitous in America. BPH accounted for 6.4 million visits to the physician in the year 2000.
The estimated cost was over 4 billion dollars. Between 20% and 36% of men aged 55 to 75 years will
suffer from the effects of BPH.
Prostate cancer is the second leading cause of cancer in men in the United States. It has surpassed lung
cancer as the most common non-skin cancer in men. One hundred-thousand cases are diagnosed each year
and 30,000 men will die in the same period from prostate cancer. Although prostate cancer is uncommon
before the age of 50, its incidence increases with age. Indeed, 80% of men diagnosed with prostate cancer
are 65 or older with 72 being the average age at diagnosis. The incidence of prostate cancer worldwide in
black men is 1 in 9. The lowest incidence is in Asian men. An estimated nine percent of prostate cancer
overall and 40% of early onset prostate cancer have an autosomal dominant pattern of inheritance.
Estimates are that 50-70% of men over 80 years of age have histologic evidence of carcinoma in their
prostate, but the majority will never develop symptoms since many tumors are very slow growing and
other comorbidities may intervene. Moreover, it is estimated that 1 in 10 histologic tumors will never
progress.Prerequisites
Prior to entering a urological surgical residency, the resident should:• Understand the anatomy, physiology, and pharmacology of the prostate and surrounding organs
• Understand the pathophysiology of benign prostatic hypertrophy (BPH) and other benign prostateconditions• Understand the rationale, methods and controversies surrounding the screening for prostate cancer• Understand free and total prostate specific antigen (PSA) levels and what implications they have onscreening for prostate cancer• Understand the pathophysiology of prostate cancer
• Understand treatment modalities for prostate cancer and the common postoperative complications 128Learning Outcomes
Upon completion of a urological surgical residency, the resident will:
• Understand the categories of prostatitis and how they are diagnosed and treated
• Evaluate and treat patients for BPH, Lower Urinary Tract Symptoms (LUTS), and urinary retention• Develop treatment plans with an understanding of the possible risks and complications of surgery forLUTS and urinary retention• Diagnose, stage and grade prostate cancer
• Treat prostate cancer it in its various stages both surgically and non-surgically and evaluate when andto whom treatment should be administered• Recognize and manage the common complications of prostate cancer and its treatments
• Diagnose and treat prostatitis in its various forms
• Perform or refer patients for pre and postoperative osteopathic manipulative therapy (OMT) tooptimize their outcome and recovery• Interpret and analyze scientific papers pertaining to the prostate in particular and urology in general
• Participate on a multidisciplinary team to treat patients with prostatic problems compounded bycomorbid conditions• Communicate effectively with patients, their families and colleagues to provide the best possible care 129Phase I: Performance
IndicatorsPhase II: Performance
IndicatorsPhase III: Performance
IndicatorsCognitive
Evaluate and treat prostatitis,
following the patient in an
outpatient settingUnderstand the pathophysiology
of BPH, LUTS, and urinary
retention
Evaluate and treat BPH, LUTS,
and urinary retention using
medications tailored to the
patient
Assess the indications for
surgical intervention of the
patient with BPH, LUTS, and
urinary retention
Select inpatient or outpatient care
for patients with BPH, LUTS,
and urinary retention with an
understanding of how each
setting affects the patient’s
overall healthStage and grade prostate cancer
based on physical, clinical, and
pathologic findingsPerform or refer pre- and
postoperative OMT to facilitate
early return to normal function
and prevention of postoperative
complicationsIdentify the indications for
watchful waiting, non-
surgical/hormonal, and surgical
treatment for prostate cancer
Function as an integral part of the
management team of patients
with prostatic pathology
Discuss the prostatic disease
process, treatment options and
outcomes of the various
treatments with the patient andCognitive
Understand the pathophysiology
of prostate cancer
Analyze the indications for
surgical and non-surgical
treatment of prostate cancer
Administer hormonal therapy for
prostate cancer and follow these
patients on a long-term basis
Predict the effect of chronic and
acute prostatitis on PSA levels
Understand the epidemiology,
embryology, evaluation, and
medical/surgical interventions for
BPH, LUTS, and urinary
retention
Interpret MRI, CT scans,
transrectal ultrasound, retrograde
and voiding urography and
urodynamic studies as they relate
to the prostate
Technical
Perform minimally invasive
procedures for BPH and LUTS
including transurethral needle
ablation of the prostate (TUNA),
transurethral laser incision of the
prostate (TULIP), and
photovaporization of the prostate
Perform portions of transurethral
resection of the prostate
including fulguration and control
of intraoperative bleeding with
the assistance of the attending
physician
Perform bilateral pelvic lymph
node dissection with assistance
from the attending physicianCognitive
Follow all patients
postoperatively, including
complicated cases of prostatic
surgery, and show consistent and
proper decision making with
little input from attending
physicians
Technical
Perform all surgery of the
prostate with little assistance
from the attending physician
including minimally invasive
procedures, transurethral
resection of the prostate,
suprapubic prostatectomy, and
radical retropubic prostatectomy
Recognize and respond to
intraoperative complications
from prostatic surgery
Demonstrate sound
intraoperative decision making
including the orchestration of the
operating room personnel 130his families
Recognize and treat
intraoperative complications of
prostatic surgery
Manage the care of patients
postoperatively and recognize
complications early in their
courseTechnical
Perform basic endoscopic skills
including urethroscopy and
cystoscopy
Perform urodynamic studies
Perform catheterization, with and
without the use of various
urethral dilators, in the male
patient both uncomplicated and
complicated
Assess the indications for and
place percutaneous suprapubic
urinary diversion at the bedside
Perform transrectal ultrasound
and biopsy of the prostate
Perform proper bladder irrigation
techniques for prostatic bleeding
and the institution of continuous
bladder irrigation (CBI)Participate in radical
prostatectomy
Control intraoperative bleeding
Perform simple cystotomy as it
pertains to suprapubic
prostatectomy
Perform suprapubic
prostatectomy or retropubic
prostatectomy for BPH with the
assistance of the attending
physicianPerform surgery to correct the
complications of prostatic
surgery including re-operation
for bleeding, prostatic abscess,
and bladder neck/anastomotic
stricture 131Learning Experiences (list titles specific teaching conferences, procedure workshops, skills labs, etc.)
Self-Assessment Study Program (SASP) testing
Participate in and lead teaching rounds
Participate in and lead appropriate academic and didactic sessions
Attend urological conferences and integrate current techniques and literature of the prostate into daily
rounds, surgeries and teaching
Resources
Albala DM, Grasso M. Color Atlas of Endourology. Baltimore, MD: Lippincott Williams and Wilkins,
1999.
American Urologicalal Association Update Series:
http://www.auanet.org/catalog/cme/print/updateseries.cfm
Campbell MF, Walsh PC, Retik AB. (Eds). Campbell’s Urology, 8th edition. Philadelphia, PA: W.B.Saunders Company, 2002, Vol 1 – 4.
Gillenwater JY, Howards SS, Grayhack JT Mitchell M. (Eds) Adult and Pediatric Urology, 4th edition.Baltimore, MD: Lippincott Williams and Wilkins, 2002.
Graham SD, Glenn JF. Glenn’s Urological Surgery, 6th edition. Baltimore, MD: Lippincott Williams andWilkins, 2004.
Hinman F, Stempen PH (Illustrator). Atlas of Urological Surgery, 2nd edition. Philadelphia, PA: W.B.Saunders Company, 1998.
Volgelzang NJ, Scardino PT, Shipley WU, Debruyne FMJ, Linehan WM (Eds). Comprehensive Textbook
of Genitourinary Oncology, 3rd edition. Baltimore, MD: Lippincott Williams and Wilkins, 2005.
Journal of Urology
Resident Assessment
SASP testing Direct observation during surgery
In-service examinations
Quarterly (or post-rotation) evaluation by attending surgeons and chiefs of service
Written and Oral Board Examinations
refer page:-------http://www.officesoon.com/doc/187801-american-college-of-osteopathic-surgeons-urological-surgery-principal
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