CLEVELAND AMBULATORY SURGERY CENTER DELINEATION OF CLINICAL PRIVILEGES Urology Applicant’s Signature Date
The granting, reviewing and changing of clinical privileges will be in accordance with the Medical Staff Bylaws. Assignment of such clinical privileges must be based upon education, clinical training, demonstrated skills and capacity to manage procedurally related complications.
Indicate procedures for which you do and do not wish to be credentialed. Return this form with your Application.
Recommendation by Procedures Credentialing Request QM Committee
Yes No Yes No
Hernia hydrocele repair
Repair inguinal hernia w/orchiectomy
Repair inguinal hernia w/excision of hydrocele
Repair inguinal hernia, recurrent
Repair inguinal hernia, sliding
Repair ventral hernia
Repair ventral hernia, recurrent
Repair unbilical hernia, age 5 or over
Drain perineal abscess
Cath or stent ureter
Injection for pyelography thru cath
Injection procedure for pyelography
Change nephrostomy tube
Renal endoscopy thru established nephrostomy
Renal endoscopy w/fulguration and/or excision
Injection ureterography thru cath
Injection vis ileal conduit
Ureteral endoscopy w/ureteral cath
Ureteral endoscopy w/biopsy
Fulguration prostate
Urethrotomy pendulous urethra
Urethrotomy perineal urethra
Meatotomy
Meatotomy infant
Drainage deep periurethral abscess
Excision or fulguration carcinoma urethra
Excision urethral diverticulum female
Excision urethral diverticulum male
Marsup urethral caruncle
Excision urethral caruncle
Excision urethral prolapse
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Recommendation by Procedures Credentialing Request QM Committee
Yes No Yes No
First stage urethroplasty
Second stage urethroplasty
Urethroplasty 1 stage
Urethroplasty 2 stage
Urethroplasty scrotal perineal
Urethroplasty female
Incontinence procedure male
Urethromeatoplasty w/mucosal adhesions
Urethromeatoplasty w/partial excision
Urethrorrhaphy female
Urethrorrhaphy perineal
Urethrorrhaphy prostate
Close urethrostomy fistula
Urethral dilatation male sound
Urethral dilatation sound-anesthesia
Urethral dilatation male filiforms & followers
Urethral dilatation female
Dilatation female urethral w/anesthesia
Dorsal slit
Biopsy penis deep
Excision of penile plaque
Removal foreign body from deep penis
Amputation penis partial
Ureteral endoscopy w/fulguration, incision
Ureteral endoscopy w/removal foreign body
Ureteral endoscopy thru ureterotomy
Aspiration bladder trochar intracath
Punch cystostomy
Injection procedure for cystography
Injection procedure for retrograde urethrocysto
Change of cystostomy tube
Cystorrhaphy complex
Cystoscopy
Cysto w/ureteral catheter
Brush biopsy renal pelvis
Cystourethroscopy w/ejaculation duct
Cysto and biopsy
Cysto with fulguration
Cystourethroscopy w/fulguration minor
Page 2 of 5 MS2O DELINEATION OF CLINICAL PRIVILEGES - Urology - (continued)
Recommendation by Procedures Credentialing Request QM Committee
Yes No Yes No
Cysto & dilation bladder
Cysto & inter urethrotomy female
Cysto & inter urethrotomy male
Direct vision cold urethrotomy
Cystourethroscopy w/steroid injection
Cystourethroscopy urethral syndrome
Cysto w/resection ureterocele
Cysto incompetent bladder diverticulum
Cysto removal of foreign body/DJ stent
Cystourethroscopy w/removal foreign body or calculus
Lithopaxy small
Lithopaxy large
Cysto stone basket extraction
Cysto stone basket manipulation
Cysto insert DJ stent
Ureteroscopy complete and dilatation
Ureteroscopy w/stone extraction
Ureteroscopy w/ultra lithotripsy
Ureteroscopy w/biopsy/fulguration
Cysto imcompetent bladder neck
Amputation penis complete
Circumcision, clamp except newborn
Circumcision, newborn
Circumcision surgery except newborn
Injection Peyronie's expose plaque
Irrigation corpora cavernosa/priaprism
Injection procedure for corpora cavernosopraphy
Plastic operation of penis, injury
Biopsy of testis, incision unilateral
Biopsy of testis, incision bilateral
Excision local lesion testis
Orchiectomy, unilateral
Orchiectomy radical inguinal approach
Orchidopexy unilateral
Orchidopexy bilateral
Repair testicular injury
Transposition of testis to thigh
Incision & drainage of epididymis
Excision local lesion epididymis
Page 3 of 5 MS2O DELINEATION OF CLINICAL PRIVILEGES - Urology - (continued)
Recommendation by Procedures Credentialing Request QM Committee
Yes No Yes No
Epididymectomy unilateral
Epididymectomy bilateral
Epididymovasostomy, unilateral
Epididymovasostomy, micro bilateral
Excision hydrocele unilateral
Excision hydrocele bilateral
Repair hydrocele bottletype
Removal of foreign body in scrotum
Resection of scrotum
Scrotoplasty, simple
Scrotoplasty, complicated
Vasovasostomy, unilateral
Excision hydrocele sperm cord unilateral
Excision lesion sperm cord
Excision varicocele or ligation of sperm cord
Ligation internal sperm vein
Excision varicocele of sperm cord w/hernia
Excision Mullerian duct cyst
Needle biopsy of prostate
Biopsy prostate incisional
Prostatotomy simple
Incision & drainage of perineal abscess
Marsupialization of Bartholins
Destruction of lesions, vulva extensive
Excision of Bartholins gland
Colpocentesis
Biopsy vaginal mucosa, extensive
Excision of vaginal septum
Injection procedure for retrograde urethroscopy
Interpretation of x-rays taken within the facility
Establish nephrostomy tubes
Extracorporeal Shockwave Lithotripsy
Excision Spermacele
For Administrative Purposes Only
Clinical privileges recommendations approved by Governing Body: .______Facility President Date
Page 4 of 5 MS2O