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 Page 1 of 5 MS2O DELINEATION OF CLINICAL PRIVILEGES - Urology - (continued) 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 .