DEFINITION:Urology is that branch of medicine and surgery concerned with the study, diagnosis, and treatment in adults and children of abnormalities and diseases of the genito-urinary tract of the male and the urinary tract of the female. The practice of urology involves, aside from routine diagnostic and therapeutic activities, special knowledge and skills in the diagnosis and treatment of traumatic injuries to the genito-urinary tract, congenital urologic problems, infections of the genito-urinary tract, neoplasms (benign and malignant) of the genito-urinary tract, andrologic problems including male factor infertility and male sexual dysfunction, problems relating to micturition including neurogenic voiding dysfunction and outlet obstruction, renal transplantation, renal obstructive disease including urolithiasis, and endocrine problems as they relate to the adrenal, testis and prostate.

GENERAL OBJECTIVES:On completion of the program, the graduate physician will be competent to function as a consultant in urology.

Because of the shared responsibility in patient care that characterizes the delivery of medical care, a close working relationship and integration of care delivery with primary care physicians referring patients to urologists is essential. There also needs to be a good working relationship with specialists in the fields of anesthesia, diagnostic radiology, pathology, pediatrics, internal medicine including nephrology, endocrinology and medical oncology, rehabilitation medicine, general surgery and radiation oncology.

During the course of the residency, the resident must acquire knowledge of the basic sciences necessary to the understanding and practice of urology. This may be done concurrently with the resident attending special courses in basic science or spending specific periods of full-time training in basic science related activity.

A urology resident must understand the normal function and the pathological processes and diseases that affect the adrenal gland, the kidneys, ureters, bladder, urethra in the male and female, and the prostate and external genitalia of the male. This includes an understanding, appropriate to the practice of urology of normal development and embryology, biochemistry and pharmacology, physiology, anatomy, and gross and microscopic pathology of the genito-urinary tract.

Management of a patient with a urological problem will require that the resident has the ability to:

1. take a history of the patient's problem
2. conduct a complete physical examination
3. understand the value and significance of laboratory, radiological and other diagnostic studies
4. understand the relative merits of various treatment alternatives
5. understand the indications, contraindications, types, variations and complications of surgical and non-surgical treatments
6. understand the significance of peri-operative and post-operative problems that might arise following urological surgical procedures

SPECIFIC OBJECTIVES:At the completion of training, the resident will have acquired the following competencies and will function effectively as:

Medical Expert/Clinical Decision-Maker

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements

The resident will demonstrate an understanding and a thorough knowledge of the following problems as they relate to the practice of urology

COGNITIVE SKILLS

The following is a listing of disease entities that are commonly included in the specialty of urology. This listing should be considered in its totality and not considered as exhaustive of the various disorders that involve the genito-urinary tract. The resident will be able to demonstrate a working knowledge of the following disease entities sufficient for the competent practice of the specialty.

4.      Congenital and Developmental Abnormalities

1. Kidney and Ureter
1. Cystic Diseases of the Kidney
2. Horseshoe Kidney and Other Renal Anomalies
3. Duplication, Retrocaval ureter and Other Anomalies
2. Bladder and Urethra
1. Vesicoureteral reflux
2. Epispadias and Extrophy
3. Hypospadias and chordee
4. Other anomalies
3. External Genital Anomalies
1. Intersex
2. Undescended Testis
3. Scrotal and External Genital Anomalies

5.      Obstructive Disease of the Upper Urinary Tract

1. Obstructive Uropathy, Hydronephrosis and Obstructive Renal Failure
2. Ureteropelvic Junction Obstruction
3. Urinary Fistulae

6.      Obstructive Disease of the Lower Urinary Tract

1. Bladder Outflow Obstruction
2. Benign Prostatic Hypertrophy
3. Lower Urinary Tract Symptoms ("LUTS")
4. Posterior Urethral Valves
5. Functional Obstruction secondary to Neurological Disorders

7.      Urinary Calculus Disease

1. Renal and Ureteral Calculi
2. Bladder Calculi

8.      Urinary and Genital Infections, and Sexually Transmitted Disease

1. Bacterial (complicated and uncomplicated) and non-bacterial cystitis and urethritis
2. Pyelonephritis and other renal infections
3. Prostatitis including Prostatodynia
4. Sexually transmitted diseases
5. Genito-urinary tuberculosis
6. Genito-urinary parasitic diseases
7. Fungal/yeast urinary tract infections
8. Other granulomatous infections (including xanthogranulomatous disease)
9. Other Genital Infections (including Fournier's gangrene)

9.      Trauma

(including the management and evaluation of a patient with multisystem trauma involving the GU Tract and the role of the urologist in multidisciplinary approach to multisystem trauma)

1. Renal Trauma
2. Ureteral Trauma
3. Vesical Trauma
4. Urethral Trauma
5. External Genital Trauma

10.  Renovascular Hypertension

1. Surgically Correctable Hypertension

11.  Renal Transplantation

1. Organ donation
2. Recipient selection
3. Relevant transplantation immunology
4. Immunosuppresion (including principles of management of rejection)
5. Management of Surgical Complications of Renal Transplantation

12.  Andrology

1. Male Sexual Function and Dysfunction
2. Fertility and Male factor Infertility

13.  Urological Oncology

For all tumors (benign and malignant) of the genito-urinary tract, residents will be able to describe the etiology, prevention and nutritional aspects of urologic malignant disease, natural history, histology and pathology, investigation and diagnostic techniques, grading and staging techniques in common use, principles of cancer management, role of surgery, radiotherapy, chemotherapy and immunotherapy for each stage and the principles of management when cure is not the primary goal. Under each heading are listed other features about specific tumors, that the candidate will be able to describe.

1. Cancer of the kidney:

1. Renal adenocarcinoma - etiology (including von Hippel Lindau syndrome)
2. Wilm's Tumor
3. Transitional Cell Carcinoma of Renal Pelvis and Ureter
4. Angiomyolipoma
5. Other Tumors
1. Cancer of the bladder:
0. Transitional Cell Carcinoma
1. Squamous Cell Carcinoma
2. Other Tumors
2. Cancer of the prostate:
0. Adenocarcinoma
1. Other tumors
3. Cancer of the testis:
0. Germ cell (including seminoma and non-seminoma )
1. Non-germ cell tumors
4. Cancer of the penis:
0. Squamous cell carcinoma
5. Cancer of the urethra
6. Cancer of the adrenal:
0. Pheochromocytoma
1. Neuroblastoma
2. Adrenal adenoma and adenocarcinoma
3. "Incidentaloma"
4. Other tumors
7. Metastatic Cancers to Genito-urinary Tract

14.  Voiding Disorders including Relevant Neurourology

1. Urinary incontinence (including stress urinary incontinence, urgency incontinence, total incontinence)
2. Voiding dysfunction due to neurological disease
3. Enuresis
4. Functional Voiding Disorders

15.  Adrenal Diseases

1. Adrenal cysts, hyperplasia
2. Adrenal hyperfunction and hypofunction and associated syndromes

16.  Systemic Diseases and Other Processes Affecting the Urinary Tract

1. Urological manifestations of systemic diseases (including e.g. diabetes mellitus, sepsis, AIDS, immunocompromised or immunoincompetent patients,)
2. The urinary tract in pregnancy (including normal physiologic and anatomic changes and management of urinary tract problems in the pregnant patient)

17.  Miscellaneous

1. External Genital problems (including hydrocele, varicocele, spermatocele, cysts)
2. Torsion of testis, cord and appendages
3. Dermatological lesions of the male external genitalia (including benign, pre-malignant and malignant lesions)
4. Interstitial Cystitis

  TECHNICAL SKILLS

18.  Diagnostic Procedures and Techniques

The Urologist in practice requires the availability and will utilize a number of investigational techniques and procedures. In addition to a through knowledge and understanding of routine investigative modalities, the resident will understand the indications for the following investigative techniques of specific importance to the practice of urology, the physiologic basis for each study and will demonstrate proficiency in interpretation of the results of these studies.

1. Urinalysis

0. routine urinalysis
1. urine culture techniques
2. urinary collections for metabolic studies
3. urine cytologic studies
1. Semen Analysis
0. qualitative and quantitative analysis
2. Prostatic Fluid examination
0. microscopic examination
3. Biochemical Serum Studies
0. Renal function tests
1. Adrenal function tests
2. Tumor markers - e.g. alpha-feto protein, b-HCG, PSA, etc.

19.  Imaging Studies

1. Radiological Studies —

Residents will demonstrate knowledge of the application of each of the following techniques to particular clinical situations, including the indications, interpretation, potential complications and management of complications for each technique, and the use of appropriate contrast agents when indicated:

0. intravenous excretory urography
1. retrograde urethrography, cystography and pyelography
2. antegrade pyelography
3. angiography of the kidneys and pelvic vessels
4. venography (including vena cavography)
5. loop-o-graphy
6. voiding cystourethrography
7. cavernosography
1. Ultrasonography—
   The principles and application of ultrasound techniques for imaging:
0. kidney
1. bladder
2. prostate (including transrectal ultrasonography)
3. scrotal contents
4. Doppler studies of renal, gonadal and penile vessels
2. Radioisotope Studies —

The indications, application to clinical urology, principles, pharmacokinetics and application of radiopharmaceuticals used in:

0. renal imaging (including function studies)
1. voiding cystograms
2. testicular scans
3. bone scans for staging of malignant disease
4. scans for localization of inflammatory lesions
5. scans for adrenal localization
3. CT scanning and MRI scanning of the urinary tract

20.  Urodynamic Studies

1. cystometrogram
2. uroflowmetry
3. voiding pressure studies
4. pelvic floor electromyography
5. videourodynamic studies

21.  Phallodynamics

1. Vascular studies of the penis
2. Cavernosometry including diagnostic injection of vasoactive drugs
3. Sleep studies (NPT)

22.  Diagnostic Histopathology

The resident will be able to describe and recognize the gross and microscopic characteristics of the following:

1. malignant lesions of the kidney - renal cell carcinoma, Wilm's tumor
2. benign lesions of the kidney - oncocytoma, angiomyolipoma
3. urothelial neoplasms of the renal pelvis, ureter, bladder and urethra
4. prostatic neoplasms - prostatic adenocarcinoma including prostatic intraepithelial, benign prostatic hyperplasia
5. testis tumors - including germ cell tumors, (seminoma and non-seminoma), functional tumors of the testis (Leydig tumors), Sertoli tumors
6. inflammatory lesions of the kidney - xanthogranulomatous pyelonephritis, tuberculosis, chronic pyelonephritis
7. inflammatory lesions of the lower urinary tract - interstitial cystitis, cystitis cystica, cystitis glandularis, cystitis follicularis, prostatitis

23.  Therapeutic Technologies

The resident will be able to describe the basic physics and technological application of the following therapeutic modalities. He/she will be able to describe the indications, contraindications, peri-operative and post-operative complications specific for each modality:

1. Electrosurgery
2. Extracoporeal Shock Wave Lithotripsy
3. Lasers in urology - carbon dioxide, Nd/YAG, Holmium-YAG, etc.
4. Transurethral prostatic hyperthermia/thermotherapy and other alternative modalities used in the management of patients with benign prostatic hyperplasia

SURGICAL SKILLS

The list of surgical skills is divided into categories reflecting the frequency with which these procedures are encountered in urological practice and during residency training. All residents should be competent to independently perform the following procedures in List A, be able to manage a patient prior to, during and after all of the following procedures. Residents will be able to describe the management of the common complications that may occur following any of the listed procedures.

24.  Surgical Procedures List A

Endoscopic Procedures

0. Cystoscopy and urethroscopy, ureteric catheterization including ureteric stent insertion and removal, retrograde pyelography
1. Urethral dilatation and visual internal urethrotomy
2. Transurethral biopsy of bladder and urethra
3. Transurethral resection of prostate
4. Transurethral resection of bladder tumors
5. Transurethral resection/ incision of ureterocele
6. Transurethral resection of external sphincter
7. Manipulation and extraction of calculi including litholopaxy, basket extraction
8. Ureteroscopy and lithotripsy of ureteric calculi
9. Percutaneous renal surgery including nephrolithotomy with ultrasound / electrohydraulic lithotripsy

Open Surgical Procedures

10. Circumcision
11. Suprapubic catheterization
12. Urethral meatotomy, meatoplasty
13. Meatal repair for glanular hypospadias
14. Fulguration of venereal warts, biopsy of penile lesions
15. Cavernosal shunting procedures for priapism
16. Testis biopsy
17. Vasectomy
18. Vasovasostomy
19. Scrotal surgery - hydrocele, epididymal cyst, epididymectomy, simple orchidectomy
20. Inguinal surgery - varicocele, herniotomy, orchidopexy
21. Radical orchidectomy
22. Repair of testis torsion
23. Orchidopexy for undescended testis
24. Insertion testis prosthesis
25. Procedures for correction penile curvature and Peyronie's Disease
26. Insertion of penile prosthesis
27. Penectomy
28. Urethrectomy
29. Vesical neck suspension and procedures for stress urinary incontinence
30. Insertion artificial sphincter
31. Uretero-neocystostomy
32. Augmentation cystoplasty
33. Repair of urinary fistulae - involving bladder, urethra, ureter, kidney
34. Urinary diversion procedures - continent, orthotopic and conduits
35. Radical cystectomy and anterior pelvic exenteration
36. Procedures for renal, ureteral and bladder trauma repair
37. Pelvic lymphadenectomy
38. Vesical diverticulectomy
39. Simple retropubic prostatectomy
40. Radical prostatectomy
41. Pyeloplasty for ureteropelvic junction obstruction
42. Nephrectomy
43. Partial nephrectomy
44. Radical nephrectomy for cancer
45. Nephroureterectomy
46. Retroperitoneal node dissection for carcinoma testis

The following procedures in List B are those that the resident will know how to do, including indications, management of a patient perioperatively. The resident may not have actually done one of these procedures independently during the residency training program.

25.  Surgical Procedures List B

0. Open renal biopsy
1. Open nephrolithotomy and ureterolithotomy
2. Ureterolysis, ureteroplasty, uretero-pyelostomy or -calycostomy
3. Cutaneous ureterostomy
4. Uretero-ureterostomy
5. Uretero-sigmoidostomy
6. Inguinal lymphadenectomy for carcinoma penis
7. Seminal vesiculectomy
8. Resection of posterior urethral valves
9. Endoscopic pyeloplasty (endopyelotomy)
10. Drainage of perinephric, perivesical and retroperitoneal abscess
11. Deroofing renal cyst
12. Anatrophic nephrolithotomy
13. Extra-corporeal shock wave lithotripsy
14. Renal transplantation
15. Cadaveric and live donor renal harvesting for transplantation
16. Transplant nephrectomy
17. Adrenalectomy including surgery of pheochromocytoma

The following procedures in List C are those for which the resident will be able to describe the principles of the procedure, indications for referral for the procedure and

particular perioperative problems that might be encountered.

26.  Surgical Procedures List C

0. Correction of proximal hypospadias and epispadias
1. Surgical reconstruction for extrophy
2. Vena cava resection and retrieval of atrial thrombus for carcinoma kidney
3. Open urethroplasty for urethral stricture
4. Epididymo-vasostomy with microscope

Communicator

General Requirements

• Establish therapeutic relationships with patients and families.
• Obtain and synthesize relevant history from patients, families and communities.
• Listen effectively.
• Discuss appropriate information with patients and families and the health care team.

Specific Requirements

 
The resident will relate to patients in an understanding and empathetic manner, respecting the patient's dignity, individuality, and accept them as participants in decisions regarding their medical care. Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to urology.

To achieve these objectives, residents must develop the ability to:

5.      Record accurately and succinctly data collected from patients, laboratory tests and radiological studies and to communicate conclusions based on these data to referring physicians and other involved health care personnel;

6.      Be sensitive to patients fears, anxieties and needs for privacy;

7.      Be able to explain clearly and concisely:

1. diagnosis and management plans that are understandable to patients, that motivates and facilitates patients' willing participation;
2. management plans to other health care personnel in a way that ensures their effective participation;
3. steps necessary for problem management when acting as a consultant for other physicians.

Collaborator

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

 
To achieve these objectives, residents must develop the ability to:

3.      Interact effectively with:

1. personnel in community service agencies,
2. other health care personnel,
3. patients from all varying lifestyles, socioeconomic backgrounds and value systems always respecting the confidentiality of the patient-physician relationship.

4.      Accept responsibility for participation in activities that foster good patient care, including contributions to the administration of patient care facilities.

5.      Participate in professional organizations - local, provincial and national.

Manager

General Requirements

• Utilize personal resources effectively to balance patient care, learning needs and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care and life long learning and other activities.

Specific Requirements

To achieve these objectives, residents must develop the ability to:

5.      Access appropriate urological diagnostic and therapeutic technology in a timely and efficient manner to benefit all of their patients.

6.      Organize a priority list for patients waiting surgery.

7.      Maintain a sytematic program of self directed learning suitable for life long learning.

Health Advocate

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

To achieve these objectives, residents must develop the ability to:

4.      Participate with community based patient support groups.

5.      Understand the role and function of the Urological Association and related urological societies in support of urologists and the urological care internationally.

Scholar

General Requirements

• Develop, implement, and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, housestaff/students and other health professionals.
• Contribute to the development of new knowledge.
• To use information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

To achieve these objectives, residents must develop the ability to:

6.      Demonstrate continuing evaluation of their own capabilities and limitations.

7.      Develop techniques for continuous improvement, information acquisition and information handling and participate in the quality improvement and quality assurance programs of the institutions in which they practice.

8.      Maintain an inquisitive attitude, and understand the time commitment required for ongoing self study for the maintenance of competence.

9.      Demonstrate the use of data bases for literature searches and reviews.

10.  Formulate a research plan to answer clinical problems.

11.  Understand the ethics of animal and human experimentation.

12.  Describe basic statistical methods used in clinical trials.

13.  Residents will be able to critically evaluate reports of clinical trials and research protocols. All residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

Professional

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practice medicine ethically consistent with the obligations of a physician.

Specific Requirements
To achieve these objectives, residents must develop the ability to:

4.      Demonstrate personal responsibility to patients by availability, confidentiality and respect for each patient's physical and emotional comfort.

5.      Demonstrate adherence to the best available practice, including referral to other qualified practitioners when appropriate.

6.      Demonstrate meticulous accuracy in reporting clinical and scientific information.

7.      Demonstrate knowledge of the ethical problems of human organ procurement for the purposes of transplantation.

8.      Demonstrate a working knowledge of provincial and federal laws and regulations related to the practice of medicine in general and urology in particular.

9.      Demonstrate an understanding and appreciation for patients' legal rights in matters related to informed consent, delegated consent and informed decision making.

10.  Understand medical protective procedures and the role of the Medical Protective Association in areas of patient-physician dispute.

11.  Be aware of their own feelings and biases and recognize any personal reactions which may be detrimental to physician-patient relationships because of these feelings or biases and explore and willingly accept possible ways of changing detrimental or prejudicial feelings.

12.  Identify a colleague or faculty member with whom they may discuss personal and professional goals, conflicts and stresses.