APPLICATION FORM

Prepared by S Tekgul ( using EBU forms as reference) Ankara 01:24 08.04.2023

APPLICATION FORM

PART IPARTICIPATING INSTITUTION(S)

Date Name of Programme Primary Institution

Affiliated Institution(s)

Programme director

Local Head

SignatureType of department

Urology/ Peeadiatric Surgery /Paediatric Urology

Name of InstitutionStreet ,no

Postal code & TownCountry

TelephoneFax

E mailType 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.


PART II

DEFINE HOSPITAL TYPE:

HOSPITAL STATISTICSTotal Hospital ( 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 OncologyRadiologyRadiotherapyNuclear Medicine

Renal Transplantation NeurologyNeurosurgeryPsychiatry ( including child care)

NephrologyDialysis

Paediatric Intensive care unitNeonatal intensive care unitEmergency Department

General SurgeryGeneral Paediatric SurgeryVascular SurgeryThorasic SurgeryOrthopaedics

Clinical Biology

Microbiology

PathologyAnaesthesiology Dermatology

ENTOphtalmology

Internal MedicineCardiologyHaematologyRheumatology

Physical Therapy

Gynaecology/ObstetricsPerinatology 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 StaffNumber Of Paediatric Urologists within the StaffTotal Number of ResidentsTotal Number of FellowsNumber of Fellows in Paediatric Urology

Urology / Paediatric Surgery Dpt ( No)

Number of Beds Total Paediatric Urology Day CareNumber of outpatients /year Total Paediatric Urology

DIAGNOSTIC FACILITIES Y/N DIAGNOSTIC FACILITIES

Y/N

Ultrasound CTEndoscopy Unit MRIUrodynamic Unit AngiographyInterventional 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 TumourNephrouretectomyPartial NephrectomyPyelolithotomy/NeprolitotomyOpen NephrostomyOpen BiopsyNephropexyPyeloplastyUreterocalycostomyOther(Anomalies/Injury)

RETROPER./NODES/VASC

Retroperiteneum .adrenal surgery .Retoperitoneal TumourNodes .Periaortic .Retroperitoneal .Pelvic .InguinalVascular . Cavotomyfor tumour thrombus .Microvascular orchidopexy .Other

URETER

Ureterotomy-ureterolithotomyUretero-uretostomyUreteroplastyUreterectomyUretero-neocystostomy(No Ureters) -Extravesical -Intravesical -Psoas HitchRemodelling of megaureterSurgery for ureteral duplicationExternal urinary diversionInternal urinary diversionRevision urinary diversionOther

EXTERNAL GENITALIA

Penis .Circusion .buried Penis .Penoscrotal web . Penoscrotal Transposition .Priapism .Penil CurvatureTestis .Radical orchidopexy .Inguinal hernia .Inguinal Orchidopexy .Two stage OrchidopexyEpididim,spermatic cord,scrotum .Hyrocele .varicocele .scrotum excisionOther

BLADDER

Augmentation

No/yr OTHER

Laparotomy(explotary)

No/yr


.Intestinal .Gastric .Ureteral . AutoaugmentationMitrofanoff ProcedureBladder SubstitutionDiverticulectomyExcion urachal cyst/ tumorCystotomy/CystostomyExtrophy RepairCloacal RepairFistulaTrauma repairIncontinence surgery .Bladder Neck Plasty .Sling .Artificial urinary sfincter .ClosureOther

AppendectomyHerniorapyVaginoplastyCliteroplastyOther

URETHRA

Uretroplasty(all except Hypospadias)Hypospadias.Distal.Penil.Penoscrotal.Chordee.Re-do.Fistula repairEpispadiasOther

TRANSPLANTATION

Renal Transplantation .Transplantation .Donor Nephrectomy .Transplant Nephrectomy .RevisionDialysis surgery .CAPD Replacement Revision .Vascular Access For dialysisOther

Endoscopic Surgery Total Number:


No/yr No/yrPERCUTANEOUS UPPER TRACTKIDNEY /URETER

StoneStrictureOther

URETHRAInternal uretrotomyTUR posterior urethral valvesOther

RETROGRADE UPPER TRACTKIDNEY/URETER

StoneStrictureInternal StendsOther

LAPAROSCOPY

TestisVaricoceleKidneyBladderother

BLADDER

TUR tumour/biopsyStone /foreign BodyInjection therapy for refluxBladder neck injectionOther

DIAGNOSTIC ENDOSCOPY

Urethro/cystoscopyUreteral catheterisationUrethral dilationother

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 .BiofeedbackINVESTIGATIONAL 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 / urotherapyOncology

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

certification1.23.4.5.6.7.8.9.

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 / NoDoes 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 ?CONFERENCESAre 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 FACILITIESDo fellows have a room where they can work or study?

Are fellows allowed study leave? RESEARCH FACILITIESIs 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)WORKLOADWhat 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.

APPLICATION FORM

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