KALEIDA HEALTH

Name ______Date ______

DELINEATION OF PRIVILEGES –

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 AND SPERMATIC CORD Admission and Discharge Privileges Epididymectomy, Unilateral Epididymovasostomy, Unilateral, Bilateral Closure of Evisceration Excision Spermatocele Drainage, Retroperitoneal Abscess Ligation Internal Spermatic Vein Excision, Retroperitoneal Tumor/ Herniorrhaphy, Incisional Sacrocolpopexy - Open Continent (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 , Donor Diverticulectomy Nephrectomy, Partial Enterocystoplasty Nephrectomy, Radical Excision Urachal Cyst or Tumor Nephrectomy, Simple, Unilateral; Bilateral Partial Nephrolithotomy, Simple, Staghorn or Percutaneous Partial Cystectomy with Ureteroneocystostomy , 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 , Open Repair, Vesicovaginal Fistula (Abdominal, Vaginal) , Unroofing Simple Cystectomy Replacement of with Bowel Simple Cystectomy with Cutaneous Sigmoid Conduit (separate procedure) Simple Cystectomy with Ileal Conduit LYMPHATIC Vesical Neck Plasty Lymph Node Biopsy Vesicostomy Lymphadenectomy, Pelvic, Inguinal or Ilioinguinal Lymphadenectomy, Retroperitoneal PENIS Cystoscopy + Cup Biopsy, Bladder Amputation, Partial or Complete Cystoscopy + Ureteral Catherization 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 ; Litholapaxy; Removal Foreign Body; Extration Ureteral Calculus;Hydrodistention of Bladder TUR ; Valves; Bladder Neck; Bladder Tumor

Urology DOP 5/2017

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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 Needle or Open Biopsy Ureteroscopy with Calculus Removal, Biopsy or Fulguration Percutaneous Insertion of Radioactive Materials , Perineal, Simple or Radical 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 Excision of Urethral Prolapse Excision, Partial or Complete Fistula Repair Hydrocelectomy Incise and Drain Periurethral Abscess Incise and Drain Abscess Major 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) , Inguinal (Radical) Repair of Epispadias Orchiectomy, Simple, Unilateral or Bilateral Repair of Epispadias with Continence Procedure , Unilateral or Bilateral Repair of Urethral Injury Reduction ofTorsion + Fixation (Bilateral) Retropubic (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 , (separate procedure) Ureterolithotomy Urethroplasty for Anterior Stricture, One Stage or Staged Urethrostomy, Internal, External or Perineal Ureteronecystostomy, Unilateral or Bilateral Vaginal Urethropexy (Stamey; Raz; Gittes; Tanagho)

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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 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 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 (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

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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 Requires completion of course including “hands on” experience (attach documentation), and proctored performance at 3 Prostate Brachytherapy cases with credentialed and accredited surgeon in attendance (attach proctor form) OR Prostate Brachytherapy training in ACGME Accredited Residency Program in Urology. Prostate Brachytherapy privileges TRANSURETHRAL NEEDLE ABLATION OF PROSTATE (TUNA) Initial request requires completion of course in TUNA including “Hands On” experience (attach documentation) OR received training in Prostate TUNA during an ACGME Accredited Residency Program in Urology (provide verification letter from program director) TUNA privileges TRANSURETHRAL MICROWAVE THERMOTHERAPY OF PROSTATE (TUMT) Initial request requires completion of course in TUMT including “Hands On” experience (attach documentation) OR received training in TUMT during an ACGME Accredited Residency Program in Urology (provide verification letter from program director) TUMT privileges RECIPIENT RENAL TRANSPLANTATION Requires documentation of completion of an accredited fellowship in Renal/solid Organ Transplantations with documentation by Fellowship Director as to proficiency in Renal Transplantation. Recipient Renal Transplantation – allograft or autograft RETROPERITONEAL COLPOPEXY WITH VAGINAL MESH FOR CYSTOCELE (ANTERIOR) REPAIR – Must submit evidence of having completed a didactic course on the use of vaginal mesh insertion in Cystocele repair and mentoring by a surgeon credentialed in this procedure for five cases OR received training in this procedure during an ACGME Accredited Residency Program in Urology (provide verification letter from program director). Retroperitoneal Colpopexy with Vaginal Mesh for Cystocele (anterior) repair

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MODERATE/CONSCIOUS SEDATION PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course – cost $199.00 (www.asahq.org/education/online-learning/safe-sedation- training-moderate) or Medsimulation course – cost $75.00 (www.medsimulation.com) receiving a score of 85% or above. * Note: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via e-mail ([email protected]) or fax (859-5592 or 859-5593). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call 716-859-5515 for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: https://promedcert.com/ $179.00, www.buffalocpr.com/aclsatubcampus.html $135.00 or www.wnyhe.com/courses/acls/ $175.00.) 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

ADULT LEVEL III PRIVILEGES With If proctorship is a pre-requisite, contact the Medical Staff Office PHYSICIAN Not Following for instructions & to obtain the required forms. You must be REQUEST Granted Granted* Requirement “approved with proctoring” PRIOR to performing the procedure s** within Kaleida. (Provide Details) CRYOTHERAPY OF THE PROSTATE Requires successful completion of a recognized course in Cryotherapy of the Prostate (attach documentation) and proctored performance of at least 2 Cryotherapy procedures under the supervision and mentorship of a Cryotherapy certified urologist (attach proctor form) or received training in Cryotherapy of the Prostate during an ACGME Accredited Residency Program in Urology (Provide Verification from Program Director Cryotherapy of the Prostate

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ROBOTIC ASSISTED SURGERY – UROLOGY LEVEL I 1. Applicant must have unrestricted privileges for open and/or laparoscopic surgery procedures for which robot assisted /procedures will be performed. 2. When 2 robotic cases are completed at a particular level (as per the DOP level I, II, III) the applicant is then qualified to perform any cases in that level. 3. Current medical staff members: Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 4. Initial applicants to medical staff: A. If completing residency or fellowship - Documentation from the program director of the accredited training program in which robotics is a part of the experience obtained and verification of the individual’s competency in the use of the robot for the procedures requested. This would include a case log and documentation as to the number of cases the applicant has been involved in. AND 2 cases proctored by a robotics experienced surgeon in the same specialty as the applicant (if the applicant is trained in a Kaleida Health residency program it is up to the discretion of the program director if trainee is required to have any proctored cases). B. If > 1 year since completion of residency or fellowship and held robotics privileges at another institution - Documentation from the Chair of that surgical specialty department of the previous institution stating a history of safe use of the requested robotics surgeries. AND 10 cases minimum, at least 2 of which were during the previous year, as the primary surgeon; documentation from hospital or physician case log. C. If no robotics privileges held at another institution - Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. 5. Re-privileging - To demonstrate current competence and maintain privileges, 12 cases must be performed at Kaleida Health during the 2-year reappointment cycle. 6. There will be periodic evaluations to monitor outcomes of all surgeons including patient safety, intra-op complications and O.R. time efficiency. 7. In the future if a Robot is placed at Children’s Hospital these adult criteria may need to be revisited. 8. It is the responsibility of the surgeon applying for robotic privileges to arrange for the proctor. All efforts should be made by the applicant to secure a Kaleida Health surgeon to proctor. If this is not feasible then an outside proctor can be used. If the proctor does not have privileges at Kaleida Health and is going to assist in any way other than observation and discussion, the proctor must obtain temporary Kaleida Health privileges. 9. Proctor - To qualify to Proctor Level I Robotic Assisted Surgery robotic surgery, in the Kaleida system an applicant must also have completed a minimum of (25) Level I Robotic Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. a. Robotic Prostatectomy Surgery  A pre- or pro- peritoneal inguinal hernia repair may be performed through the same incision. b. Robotic Bladder Repair independent or in conjunction with Robotic Prostatectomy Surgery c. Independent Robotic Bladder/Cystotomy Repair d. Robotic removal of a urachal cyst May Act as a Proctor for Level I Robotic Assisted Surgery in the Department of Urology.

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ROBOTIC ASSISTED SURGERY – UROLOGY LEVEL II 1. Applicant must have Robotic Level I privileges at Kaleida Health. 2. Applicant must have 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 3. Proctor - To qualify to Proctor Level II Robotic Assisted Surgery in the Kaleida system, an applicant must also have completed a minimum of (25) Level II Robotic Assisted Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. a. Robotic Ureteral Reimplantation b. Robotic Pyeloplasty c. Robotic Repair of a Vesicovaginal Fistula d. Robotic Retroperitoneal Lymph Node Dissection e. Robotic Renal Decortication f. Robotic Adrenalectomy g. Robotic Adrenalectomy h. Robotic Radical/Total Nephrectomy i. Robotic Partial Nephrectomy j. Robotic Sacrocolpopexy k. Robotic Vasovasostomy May Act as a Proctor for Level II Robotic Assisted Surgery in the Department of Urology.

LEVEL III ROBOTIC ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL OR EXTRACORPORAL ILEAL CONDUIT URINARY DIVERSION OR EXTRACORPORAL URINARY DIVERSION (MALE OR FEMALE). IN FEMALES A MAY BE PERFORMED AS PART OF THE CYSTECTOMY. Or ROBOTIC ASSISTED ANTERIOR PELVIC EXENTERATION WITH INTRACORPORAL OR EXTRACORPORAL ILEAL CONDUIT URINARY DIVERSION OR EXTRACORPORAL CONTINENT URINARY DIVERSION (FEMALE). 1. Applicant must have Robotic Level II privileges at Kaleida Health. 2. Applicant must be proctored for 2 cases of Robotic Assisted (male) and/or Robotic Assisted Anterior Pelvic Exenteration (female) by a Urologic Surgeon credentialed to perform a Robotic Assisted Cystectomy at Kaleida Health. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 3. Proctor - To qualify to Proctor Level III Robotic Assisted Surgery in the Kaleida system, an applicant must also have completed a minimum of (25) Level III Robotic Assisted Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. a. Robotic Assisted Radical Cystectomy (male) with intracorporal or extracorporal ileal conduit urinary diversion and/or continent urinary diversion. Note: A pre- or pro- peritoneal inguinal hernia repair may be performed through the same incision. b. Robotic Assisted Anterior Pelvic Exenteration (female) with intracorporal or extracorporal ileal conduit urinary diversion and/or continent urinary diversion. May Act as a Proctor for Level III Robotic Assisted Surgery in the Department of Urology

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PEDIATRIC LEVEL I UROLOGY PRIVILEGES Applies to children 18 months to 18 years of age (except for circumcision). Applicant must have completed an ACGME-Accredited Residency in Urology or its Equivalent History and Physical for Diagnosis and Treatment Excision of tumor or cyst Admission and Discharge Privileges Repair (injury) ADRENAL PROSTATE Excision of cyst Biopsy: needle or open Exploration only: unilateral or bilateral Incision & drainage of abscess: endoscopic or perineal BLADDER Prostatolithotomy: perineal, suprapubic Cystolthotomy Repair of recto-urethral fistula Cystostomy: punch or open SCROTAL CONTENTS Diverticulectomy Epididymovasostomy Litholapaxy Excision of lesion of cord: hydrocele or tumor Operation for incontinence, stress (female)-abdominal or vaginal Excision of skin lesion approach Excision, hydatid, torsion Operation for incontinence, stress (male) prosthesis or other Excision, lesion of testis Operation for total incontinence (female) vesical neck plasty with Hydrocelectomy (tunica vaginalis) ureteroneocystostomy Incision & drainage of abscess Repair of rupture Ligation of spermatic veins (varicocele) DIAGNOSTIC PROCEDURES Orchiectomy, unilateral, bilateral incl. cord Cystogram Orchiopexy (scrotal) Cystoscopy and/or panendoscopy, diagnostic Reduction, torsion +fixation(unilateral/bilateral) Cystourethrogram, voiding or with Cine Repair of testis (injury) Ileal conduitogram Spermatocelectomy Nephrostogram Testis biopsy Nephrotomogram Vas ligation , intravenous Vaso-vasostomy Pyelogram, percutaneous URETER Seminal vesiculogram Biopsy, endoscopic or open Urethral catheterization: with pyelogram or with differential Manipulation of stone with or without removal) function Ureteral repair; lysis, excision of ovarian vein, retrocaval ureter; Urethrogram, retrograde ureteroneocystostomy: simple or with plastic narrowing; excision KIDNEY and anastomosis. Ureteroplasty; ureteroureterostomy, ipsilateral, Biopsy: needle or open contralateral; ureter-calyceal anastomosis; closure of fistula: Ureter- Drainage of abscess: perirenal or renal vaginal or ureter-intestinal ESWL Ureterolithotomy Excision or decortication of cyst Ureteroscopy Exploration Ureteroscopy with Calculus Removal, Biopsy or Fulguration Nephrolithotomy: simple or staghorn calculus URETHRA Nephrostomy Biopsy Nephroureterectomy Diverticulectomy: male, female, urethrotomy, external, internal Pyelolithotomy Drainage of periurethral abscess Pyelostomy Drainage of urinary extravasation Pyeloureteroplasty Excision of caruncle; Repair (injury) primary Symphysiotomy (horseshoe kidney): alone or with pyeloplasty Excision, , partial, for stricture or carcinoma MISCELLANEOUS Meatomy: male or female Closure of evisceration Repair injured urethra membranes: perineal, primary; suprapubic, Exploratory laparotomy primary; secondary, plastic repair Incisional hernia Repair, urethral stricture, 1st or 2nd stage PENIS Repair, urethrovaginal fistula Amputation:partial, complete with perineal urethrostomy Urethral diverticulectomy (female) Biopsy Urethrectomy, total Circumcision Construction, penis Dorsal slit Urology DOP 5/2017 Urology Name: ______Page 8

PEDIATRIC LEVEL II PRIVILEGES (a) For those in practice five years or more, a letter and five case experiences documented within the last five years is required With Following (b) For those in practice five years or less, a letter from trainee’s PHYSICIAN Not Requirements** department chair and case list from residency is required REQUEST Granted Granted* (Provide Details) (c) For those in practice five years or more without case experience, list five cases under supervision with a Urologist already credentialed at Kaleida Health for these procedures Hypospadias repair: distal-glandular - subglandular ages 12 to 18 months Orchiopexy, inguinal, ages 12 to 18 months Inguinal hernia, ages 12 to 18 months Inguinal hydrocoelectomy, ages 12 to 18 months Scrotal hydrcoelectomy, ages 12 to18 months Renal Transplantation, newborn to 18 yrs.

PEDIATRIC LEVEL III PRIVILEGES With Following Requires 1 year post-residency fellowship training in Pediatric PHYSICIAN Not Requirements** Urology and membership or eligibility for Urologic Section REQUEST Granted Granted* (Provide Details) Pediatrics and Society for Pediatric Urology (newborn to 18 yrs.) ADRENAL Adrenalectomy, bilateral Adrenalectomy or Partial Adrenalectomy: Cortical Tumor or pheochromocytoma BLADDER Cystotomy for tumor: excision, electrocoagulation or insertion of radioactive substance Bladder tumor: biopsy or endoscopy resection Cystectomy: partial, simple with ureteroneocystostomy. Complete simple with cutaneous ureterostomy, ileal conduit, urterosigmoidostomy, bladder substitution or rectal bladder. Radical, with cutaneous ureterostomy, ileal conduit, or rectal bladder Cystoplasty: ileum, sigmoid or cecum Vesicostomy Repair of exstrophy Repair of fistula: vesicocutaneous, vesicovaginal, vesicosigmoid, vesicorectal, vesicovaginorectal KIDNEY Repair (Trauma) Renal vascular operation , peritoneal, extracorporeal, establishment of arteriovenous shunt PROSTATE Prostatectomy: transurethral, Cryosurgical, suprapubic, retropubic simple or radical, perineal, simple or radical

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With Following PEDIATRIC LEVEL III PRIVILEGES PHYSICIAN Not Requirements** (CON’T) REQUEST Granted Granted* (Provide Details) URETHRA Hypospadias repair: proximal and midshaft Epidspadias repair: urethral construction, repair of epispadias with incontinence URETER Repair of ureterocele, meatotomy, endoscopic, open repair with ureteroneocystostomy Ureterotomy for tumor Ureterectomy: partial or complete Ureterostomy: in situ or cutaneous Ureter-enterostomy (alone): Sigmoid, ileal conduit, colon: conduit Rectal bladder with sigmoid pull-through Ureteral substitution: bladder flap or ileum MISCELLANEOUS Pelvic Exenteration (Male or Female) Biopsy of retroperitoneal tumor Excision of retroperitoneal tumor Retroperitoneal node dissection Lymphadenectomy, Pelvic, Inguinal/Ilioinguinal Lymphadenectomy, Retroperitoneal Laparoscopy without orchiopexy Laparoscopy with orichiopexy Abdominoplasty for Prune Belly Syndrome Orchiopexy, abdominal, single or two staged Gonadectomy – Unilateral or Bilateral Oophorectomy – Unilateral or Bilateral

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KEY *NOT GRANTED DUE TO: **WITH FOLLOWING REQUIREMENTS Provide Details Below Provide Details Below

1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define)

DETAILS:______

______

National Practitioner Databank Disclaimer Statement: Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.)

/ Signature of Applicant Date

_____ I recommend approval of the procedures requested by the applicant: ____ a) as requested ____ b) as amended

_____ I have consulted with the Chief of Pediatric Surgery who recommends approval of the requested Level II/III privileges for Pediatric care in Urology.

______/______Signature of Chief of Service Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

Urology DOP 5/2017