EBU - European Board of Urology - Online RTPU Application Form

EBU UROLOGICAL TRAINING PROGRAMME COMMITTEE

CERTIFICATION RESIDENCY TRAINING PROGRAMME IN UROLOGY

APPLICATION FORM

PART A: PARTICIPATING INSTITUTE(S)

Date application
(dd/mm/yyyy)

Name primary institute

Name Programme Director

This form contains information from the following institute¹

Name of the institute

Address 1

Address 2

Postal Code

City

Country

Phone Number

Fax number

E-mail address

Website

Type of institute

Community hospital
Private clinic
University hospital
Government institute
Military hospital
Other

Name affiliated institute(s)

Distance from primary affiliated institute
km

¹ This form needs to be completed by the Primary Institute and each of the Affiliated Institutes (if any)

ACCREDITATION BY NATIONAL AUTHORITIES

1.1

Date of issue National Urological Certificate

(dd/mm/yyyy)

1.2

Validation period

From:	(dd/mm/yyyy)
Till:	(dd/mm/yyyy)

1.3

Issued by (name authority):

Note: provide copy of the certificate in English (pdf)

PART B: HOSPITAL INFORMATION

NUMBER OF BEDS AND ADMISSIONS
3.1 Total number of beds in hospital
3.2 Number of beds adult patients
3.3 Number of beds paediatric patients
3.4 Number of beds day care
4.1 Number of admissions during last year

DEPARTMENT OF UROLOGY INFORMATION
6.1 Total number of beds
6.2 Number of day care beds
6.3 Number of adult patient beds
7.1 Total number of admissions during previous year (minimum stay of 1 night)
7.2 Total number of day care procedures
8. Sub-specialisation teams (tick boxes as applicable)	Oncology Reconstruction Lithiasis Incontinence Female urology Neuro-urology Paediatrics Infertility Other:

STAFFING
9.1 Number of certified urologists
9.2 Number of other specialists
9.3 Number of residents
9.4 Number of fellows

DIAGNOSTIC FACILITIES (tick boxes as applicable)
10.1 Ultrasound
10.2 Endoscopy - endovideo system
10.3 Urodynamic unit
10.4 Intraventional radiology
10.5 Angiography
10.6 CT
10.7 MRI
10.8 Nuclear Medicine

SURGICAL ACTIVITY DURING LAST YEAR OPEN SURGERY NUMBER OF PROCEDURES
11.1	KIDNEY	11.5	URINARY DIVERSION
11.1.1	Radical nephrectomy	11.5.1	Ileal/colon conduit
11.1.2	Nephroureterectomy	11.5.2	Continent urinary diversion
11.1.3	Open lithotomy (all)	11.5.3	Orthotopic voiding diversion
11.1.4	Pyeloplasty
11.1.5	Nephron-sparing surgery
11.1.6	Kidney transplantation
11.2	BLADDER	11.6	URETHRA
11.2.1	Radical cystectomy	11.6.1	Urethroplasty
11.2.2	Partial cystectomy
11.2.3	Diverticulectomy
11.2.4	Vesico-vaginal fistula
11.3	EXT. GENITALIA	11.7	OTHER PROCEDURES
11.3.1	Circumcision	11.7.1	Adrenalectomy
11.3.2	Orchidopexy	11.7.2	Retroperitoneal
11.3.3	Radical orchiectomy	11.7.3	Lymphadenectomy
11.3.4	Hydrocele, varicocele	11.7.4	Incontinence surgery
		11.7.5	Genital surgery
11.4	PROSTATE
11.4.1	Open adenectomy
11.4.2	Radical prostatectomy
LAPAROSCOPIC SURGERY NUMBER OF PROCEDURES
12.1	Radical nephrectomy	12.6	Heminephrectomy, nephron sparing surgery
12.2	Paediatric	12.7	Adrenalectomy
12.3	Retroperitoneal lymph adenectomy	12.8	Radical prostatectomy
12.4	Renal cysts	12.9	Other laparoscopic procedures (e.g. varicole, non-palpable testis)
12.5	Robotic surgery
ENDOSCOPIC SURGERY NUMBER OF PROCEDURES
13	PERCUTANEOUS PROCEDURES	15	BLADDER
13.1	Upper tract	15.1	TUR - tumour
		15.2	Lithotripsi
14	RETROGRADE UPPER TRACT	16	PROSTATE
14.1	Stone	16.1	TUR - prostate
14.2	Tumor	16.2	Laser vaporisation
		16.3	Other BPH-treatments (TUMT, TUNA etc.)

ESWL
17	Number of procedures (all session/all sites)
NUMBER OF DIAGNOSTIC AND MINOR PROCEDURES
18.1	Transrectal ultrasound
18.2	Interventional uro-radiological procedures
18.3	Urodynamic studies (excluding flow)
18.4	Prostate biopsy
18.5	Cystoscopy
18.6	Other procedure(s)

UROLOGY OUTPATIENT
		Number of visits last year	Avg % new patients (indication)
19.1	General urology (UTI, LUTS, etc.)
19.2	Urinary stone disease
19.3	Oncology
19.4	Paediatric urology
19.5	Transplantation
19.6	Andrology and erectile dysfunction
19.7	Functional urology

SCHEDULED WEEKLY ROTATION DURING 1 MONTH
		Nr. of hours
20.1	Ward
20.2	Outpatient clinic
20.3	Operation theatre
20.4	Administration
20.5	Research
SUPERVISION
21.1	Does every resident have a personal written training programme?	Yes No
21.2	Does every resident keep a (EBU) personal logbook? Note: if yes, please submit the completed logbook (in English) of the final year resident(s) covering their entire training period	Yes No
21.3	Does every resident have a personal tutor/supervisor?	Yes No
21.4	Are all residents supervised during clinical work?	Yes No
UROLOGY TEACHING STAFF
22.1	Total number of positions for full-time urologists
22.2	Total number of positions for part-time urologists
22.3	Number of urologists with FEBU-title
22.4	Number of other specialists in the department of urology

STAFF MEMBERS PARTICIPATING IN RESIDENTS EDUCATION

* Full Time Equivalent

RESIDENTS AT PRESENT
#	Surname	Graduation MD (year)	Total number of years urological training	Current year of urological training