KALEIDA HEALTH Name ____________________________________________ Date __________________________ DELINEATION OF PRIVILEGES – UROLOGY ADULT UROLOGY (patients >18yrs.) LEVEL I (CORE) PRIVILEGES Applicant must have completed an ACGME-Accredited Residency in Urology or its Equivalent Level 1 (core) privileges are those able to be performed after successful completion of an ACGME accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually. History and Physical for Diagnosis and Treatment EPIDIDYMIS AND SPERMATIC CORD Admission and Discharge Privileges Epididymectomy, Unilateral ABDOMEN Epididymovasostomy, Unilateral, Bilateral Closure of Evisceration Excision Spermatocele Drainage, Retroperitoneal Abscess Ligation Internal Spermatic Vein Excision, Retroperitoneal Tumor/Cyst Vasectomy Exploratory Laparotomy Vasovasostomy Herniorrhaphy, Incisional KIDNEY Sacrocolpopexy - Open Continent Urinary Diversion (separate procedure) ADRENAL Drainage Renal of Perirenal Abscess Adrenalectomy, Unilateral or Bilateral ESWL BLADDER Harvest of Cadaver Kidneys Anterior Pelvic Exenteration with Urinary Diversion Heminephrourecterectomy Cystolithotomy Ileal Conduit (separate procedure) Cystostomy, Open Closed; or Trochar Nephrectomy, Donor Diverticulectomy Nephrectomy, Partial Enterocystoplasty Nephrectomy, Radical Excision Urachal Cyst or Tumor Nephrectomy, Simple, Unilateral; Bilateral Partial Cystectomy Nephrolithotomy, Simple, Staghorn or Percutaneous Partial Cystectomy with Ureteroneocystostomy Nephrostomy, Open or Percutaneous Radical Cystectomy with Ileal Conduit, Continent Urinary Nephroureterectomy Diversion, or Neobladder Percutaneous Endopyeloplasty Repair of Enterovesical Fistula Pyeloplasty;with Symphysisotomy Repair of Rupture Renal Biopsy, Open Repair, Vesicovaginal Fistula (Abdominal, Vaginal) Renal Cyst, Unroofing Simple Cystectomy Replacement of Ureter with Bowel Simple Cystectomy with Cutaneous Ureterostomy Sigmoid Conduit (separate procedure) Simple Cystectomy with Ileal Conduit LYMPHATIC Vesical Neck Plasty Lymph Node Biopsy Vesicostomy Lymphadenectomy, Pelvic, Inguinal or Ilioinguinal ENDOSCOPY Lymphadenectomy, Retroperitoneal Cystoscopy PENIS Cystoscopy + Cup Biopsy, Bladder Amputation, Partial or Complete Cystoscopy + Ureteral Catherization Circumcision Cystoscopy and Fulguration Insertion Penile Prosthesis Cystoscopy with Placement of Ureteral Stent Repair Major Injury Revascularization Cystoscopy, Calibration and Dilation Stricture; Shunt, Cavernosum to Spongiosum,Open or Percutaneous Internal Urethrotomy; Litholapaxy; Removal Foreign Body; Extration Ureteral Calculus;Hydrodistention of Bladder TUR Prostate; Valves; Bladder Neck; Bladder Tumor Urology DOP 5/2017 Urology Name:________________________________________________________ Page 2 ADULT LEVEL I (CORE) PRIVILEGES ADULT LEVEL I (CORE) PRIVILEGES PROSTATE URETER (CON’T) I & D Prostatic Abscess Ureteronecystostomy, with Bladder Flap Needle Biopsy - Ultrasound Guidance Ureteroscopy Needle or Open Biopsy Ureteroscopy with Calculus Removal, Biopsy or Fulguration Percutaneous Insertion of Radioactive Materials Ureteroureterostomy Prostatectomy, Perineal, Simple or Radical URETHRA Prostatectomy, Retropubic, Simple or Radical Anterior Hypospadias Repair (Magpi/Mathieu) Prostatectomy, Suprapubic Biopsy of Urethra Transrectal Ultrasound of Prostate Closure, Urethro-Vaginal or Rectal Fistula Transurethral Laser ablation of prostate Correction of Chorde without Hypospadias Repair Transurethral resection of prostate (TURP) Diverticulectomy SCROTUM Excision of Urethral Prolapse Excision, Partial or Complete Fistula Repair Hydrocelectomy Incise and Drain Periurethral Abscess Incise and Drain Abscess Major Urethroplasty Repair Scrotum (Trauma) Male Sling Procedure for Incontinence TESTIS Meatoplasty Biopsy, Testis Meatotomy Excision Lesion of Testis Prosthesis For Incontinence Insertion Testicular Prosthesis Reconstruction for Incontinence (Young-Dees-Leadbetter) Orchiectomy, Inguinal (Radical) Repair of Epispadias Orchiectomy, Simple, Unilateral or Bilateral Repair of Epispadias with Continence Procedure Orchiopexy, Unilateral or Bilateral Repair of Urethral Injury Reduction ofTorsion + Fixation (Bilateral) Retropubic Urethropexy (Marshall-Marchetti; Burch) Repair Testis (Trauma) Sling procedure, transvaginal, tran-obturator, retropubic, or Vastomy for Vasogram pubovaginal approach URETER Total Complex Repair Cutaneous Pyelo or Ureterostomy, Unilateral or Bilateral Transpubic Repair Membranous Stricture, Perineal Transureteroureterostomy Urethrectomy, (separate procedure) Ureterolithotomy Urethroplasty for Anterior Stricture, One Stage or Staged Ureterolysis Urethrostomy, Internal, External or Perineal Ureteronecystostomy, Unilateral or Bilateral Vaginal Urethropexy (Stamey; Raz; Gittes; Tanagho) Urology DOP 5/2017 Urology Name:________________________________________________________ Page 3 PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. ADULT LEVEL II PRIVILEGES With Following If proctorship is a pre-requisite, contact the Medical Staff Office PHYSICIAN Not Requirements** for instructions & to obtain the required forms. You must be REQUEST Granted Granted* (Provide Details) “approved with proctoring” PRIOR to performing the procedure within Kaleida. LASER SURGERY Requires completion of laser surgery training in ACGME residency program (provide verification letter from you program director) or 1.) Completion of an approved laser surgery training program within 18 months including “hands on training for each laser privilege requested (attach documentation), 2.) Supervision of applicant performing new laser surgery procedures may be required. Vesical Neck Contracture with YAG or KTP Urethral Stricture with YAG or KTP Ablation of condyloma of external genitalia with CO2, YAG or KTP. Penile Lesion with YAG Prostatectomy with YAG, KTP or INDIGO Urethral Stone with YAG or KTP (unless fragmentation of stone prevents obtaining specimen) Ablation Urethral Lesion with YAG or KTP Ablation Ureteral Lesion with YAG or KTP Ablation of Renal Pelvic Lesion with YAG or KTP Ablation of Bladder Lesion with YAG or KTP Ablation Bladder Tumor with YAG or KTP LAPAROSCOPIC PROCEDURES – PURE (NO Hand Assist) Requires completion of a Pure Laparoscopic Surgery course which includes “Hands On” experience in Pure Laparoscopy (attach documentation) and proctored performance of at least two (2) Pure Laparoscopic surgical cases with a Laparoscopically (Pure) credentialed Kaleida Health surgeon or Urologist in attendance (attach proctor form); OR Laparoscopic(Pure) surgery training in ACGME Accredited residency program (provide verification letter from Residency Program Director); OR unrestricted privileges to perform Laparoscopic (Pure) Surgery in a WNY Consortium Hospital (provide letter from facility). Adrenalectomy; Nephrectomy (simple or radical); Nephroadrenalectomy; Nephroureterectomy (simple or radical); Partial Nephrectomy; Renal Cyst Decortication or Excision; Partial Pyeloplasty Pelvic Lymphadenectomy; Retroperitoneal Abdominal Lymphadenectomy; Variocelectomy; Abdominal Bladder Suspension Abdominal Sacrocolpopexy HAND-ASSISTED LAPAROSCOPIC PROCEDURES Requires completion of Hand-Assisted Laparoscopic course which includes “Hands On” experience (attach documentation) and proctored performance of at least two (2) of the listed Hand-Assisted Laparoscopic Procedures performed with the assistance of a credentialed Kaleida Health laparoscopic (Pure or Hand-Assisted) surgeon in attendance (attach proctor form); OR Hand-Assisted Laparoscopic training in an ACGME Accredited residency program (provide verification letter from Residency Program Director) OR Unrestricted privileges to perform Hand-Assisted Laparoscopic Surgery in a WNY Consortium Hospital (provide letter from facility). Adrenalectomy; Nephrectomy (simple or radical); Nephroadrenalectomy; Nephroureterectomy (simple or radical); Partial Nephrectomy; Renal Cyst Decortication or Excision; Pyeloplasty Pelvic Lymphadenectomy; Retroperitoneal Abdominal Lymphadenectomy; Variocelectomy; Bladder Suspension Abdominal Sacrocolpopexy Urology DOP 5/2017 Urology Name:________________________________________________________ Page 4 With Following ADULT LEVEL II PRIVILEGES PHYSICIAN Not Requirements** (CON’T) REQUEST Granted Granted* (Provide Details) INTERSTIM THERAPY Requires documentation of having received training during ACGME accredited urology residency OR (1) attending a Theory & Technique course on InterStim Therapy, observing 2 cases performed by an InterStim-credentialed physician; OR (2) completing the InterStim on-line educational program and successfully completing training with the InterStim simulator; OR (3) completing the InterStim on-line education program and observing chronic lead placement at an InterStim experience physician site. If either pathway (1) or pathway (2) or pathway (3) is selected, then the physician requesting privileges in InterStim Therapy must be proctored on his first case by an InterStim credentialed physician and the requesting physician’s performance deemed satisfactory by the proctoring physician. InterStim Therapy PROSTATE BRACHYTHERAPY Requires completion of Prostate Brachytherapy course including “hands on” experience