Duke Reconstructive Urology and Genitourinary Cancer Survivorship Fellowship Curriculum

Teaching Methods:

1. Clinical performance with direct observation
2. Operating room with observed performance
3. Rotation specific readings
4. Direct faculty mentorship
5. Daily supervised care of surgical patients
6. Presentations in clinic
7. Rotation specific conferences
8. Supervised on-call experiences
9. Surgical checklist

Goal 1:  The fellow will perform advanced, detailed cancer survivorship focused urologic physical examination.

Objectives:

1. Discuss and demonstrate ability to perform a detailed examination of the following genitourinary organ systems as it relates to the cancer survivor:
   1. Abdominal examination with attention to radiation changes, and prior surgical interventions 
   2. Inspection and palpation of the penis with respect to survivorship issues including stress incontinence, radiation changes, skin and tissue availability for reconstruction
2. Discuss and demonstrate an appropriate vaginal and recto-vaginal examination in the female. Be able to evaluate and grade pelvic organ prolapse (POP-Q)
3. Be able to perform and interpret a focused neuro-urologic examination as it relates to survivorship specific abnormalities such as neuropraxia associated with radiation and prior chemotherapies. 
4. When performing physical examination, be sensitive to radiation changes of tissues and pliability for possible use in future reconstructive procedures. 

Goal 2:  The fellow will be able to accurately perform and interpret commonly performed urologic laboratory studies as they relate to cancer survivorship

Objectives:

1. Routine urinalysis and analysis of hematuria with respect to radiation changes of the bladder and genitourinary system
2. Residual urine measurements and other noninvasive urodynamics tools to evaluate for voiding dysfunction after radiation and pelvic surgery as well as chemotherapy
3. Serum electrolyte studies and acid-base analysis as well as nutrition labs related to future interventions in the survivor with diversion (albumin, B12, metabolic acidosis)

Goal 3:  The fellow will perform and accurately interpret radiographic studies performed in the outpatient clinic as they pertain to cancer survivorship

Objectives:

1. Be able to competently perform and interpret the following radiographic studies:
   1. Plain films and tomography of the kidney, ureters and bladder (KUB)
   2. Intravenous pyelogram (IVP)
   3. Retrograde pyelogram
   4. Retrograde urethrogram
   5. Voiding cystourethrogram (VCUG)
   6. Abdominal/pelvic CT scan, MRI scan, renal ultrasound and radionuclide studies of the genitourinary tract
   7. Antegrade nephrostograms
   8. Nuclear imaging studies of the kidney

Goal 4: The fellow will perform diagnostic and therapeutic procedures encountered in the urology outpatient clinic as they pertain to cancer survivorship

Objectives:

1. Flexible and rigid cystoscopy to evaluate the urethra, bladder and outlet for the capability of reconstruction
2. Suprapubic tube placement
3. Urethral dilation for survivors with urinary obstruction from radiation and scar tissue after radical prostatectomy

Goal 5:  The fellow will competently care for and evaluate the preoperative and postoperative care of the cancer survivorship patient

Objectives:

1. Perform and write clear, legible and an appropriately detailed cancer survivorship history and physical examination on all preoperative patients.
2. Prepare and write clear and detailed admission orders for the cancer survivorship patient
3. Assess and discuss the operative and anesthetic risks of cancer survivorship and reconstructive surgical procedures as they relate to the survivor with emphasis on possible outcomes after complex reconstruction in the multiply operated upon abdomen, radiated abdomen and patients with fistula.
4. Obtain informed consent for all cancer survivorship and reconstructive surgical procedures.
5. Understand the indications for obtaining consultation with other health care specialists prior to the surgical procedure in select patients including plastic surgery, colorectal surgery and the need for the multidisciplinary team approach in the care of the cancer survivor. 
6. Discuss the physiologic response of the normal patient to surgical procedures and factors that modify these responses in the cancer survivor such as nutrition, prior radiation, prior chemotherapy and multiple operations.
7. Discuss and evaluate wound healing as it relates to surgical incisions in the cancer survivor
8. Treat and evaluate pain in a safe and effective manner in the post-surgical patient.
9. Discuss and evaluate the role of pharmacological agents, singly or in combination, and apply this knowledge to the care of the reconstructive cancer survivor patient.
10. Understand the influence of other diseases and co-morbidities upon cancer survivorship surgical care.
11.  Recognize that nutrition is commonly an issue and how to correct this issue in the cancer survivor patient.
12. Recognize and deal effectively with the psychological and emotional problems associated with anxiety and depression imposed by cancer survivorship and reconstructive urologic surgery

Goal 6: The fellow will demonstrate proficiency in independent evaluation of the cancer survivor surgical patient.

Objectives:

1. Establishing criteria for admission, and managing a patient in the hospital environment with cancer survivorship reconstructive urological services.
2. Assure implementation and follow-up of all management plans including the completion of a cancer care summary.

Goal 7: The fellow will advance technical skills with mastery and be capable of independently completing indexed procedures.

Objectives:

1. Advance on to more technically difficult procedures.
   1. Major index reconstructive procedures
   2. Ureteral reimplantations including replacement with bowel (ileal ureter) as well as autotransplant
   3. Urethral reconstruction
2. Continue to develop skills as a teaching assistant and lead surgeon in the operating room by proctoring residents on cancer survivorship and reconstructive procedures.
3. Demonstrate correct surgical techniques of incising, dissecting, suturing, knot tying and video-endoscopic technique for the complex cancer survivor in the operating room through operative experience tutored by experienced attendings.

Goal 8:  The fellow will become proficient in clinical based procedures.

Objectives:

1. Cystoscopy in the evaluation of the dysfunctional bladder, hemorrhagic cystitis, radiation cystitis
2. Clinical based radiographic procedures such as retrograde urethrogram, retrograde pyelogram, cystograms and voiding cystourethroscopy as indicated in the patient with survivorship issues.
3. Urodynamics

Teaching Methods:

1. Rotation specific readings
2. Direct faculty mentorship
3. Presentations in clinic
4. Rotation specific conferences
5. Simulation

Goal 1:  The fellow will understand the principles of and gain skills pertaining to complex genital reconstructive surgery as required for cancer survivorship, employing plastic surgical techniques, and understand the particular advantages and limitations to their use. 

Objectives:

1. Participate in the multidisciplinary diagnosis and management of diseases of the genitalia/perineum which can result in the need for complex reconstruction following initial stabilization (e.g., fistula disease, ionizing radiation, thermal injury/burns, skin disorders, lymphedema).
2. Demonstrate an understanding of plastic surgical reconstructive techniques and principles as they apply to cancer survivorship.  Such techniques includes:  surgical debridement, dressing care, urinary diversion, skin grafting, graft bed preparation, skin flap rearrangement, use of vascularized flaps (e.g., muscle, omental, peritoneal, Martius).
3. Demonstrate an understanding of the microsurgical principles as they relate to penile reconstruction.
4. Demonstrate an understanding of the current indications and imaging modalities relevant to diagnosis, surveillance and preoperative planning as they apply to urologic cancer survivorship reconstructive surgery:  urethral stricture, ureteral stricture, UPJ obstruction. 
5. Acquire an understanding of the physical, psychological and social implications that may be associated with complex genital/perineal cancer survivorship reconstruction.

Goal 2:  The fellow will acquire an advanced understanding of complex urethral reconstructive surgery with an understanding of the benefits and the technical limitations of surgical procedures.

Objectives:

1. Participate in the clinical evaluation, diagnosis, radiological evaluation and decision-making process of patients with urethral stricture disease, urethrocutaneous fistulae and failed prior reconstruction.
2. Demonstrate knowledge of indications for minimally invasive procedures for urethral stricture disease, such as urethral dilatation, urethrotomy, suprapubic (open, percutaneous) catheter insertion, and be able to perform these procedures.
3. Participate in open urethral reconstructive cases as they pertain to the lesion and become familiar with the techniques of:
   1. Anastomotic urethroplasty
   2. Graft or flap onlay techniques
   3. Combined anastomotic/graft techniques
   4. Staged urethral reconstruction
   5. Perineal urethrostomy
   6. Posterior stricture repair
4. List the adjunctive surgical maneuvers that may be required to facilitate successful urethral reconstruction for anterior and posterior strictures:
   1. Corporal splitting
   2. Corporal rerouting
   3. Urethral mobilization
   4. Inferior pubectomy
5. Participate in all aspects of postoperative care for these patients, including dressing care, catheter care, clinical assessment and evaluation for complications and participate in their management (e.g., stricture recurrence, fistula, incontinence, acquired penile curvature, erectile dysfunction).

Goal 3:  The fellow will gain advanced expertise in urodynamic studies in patients with voiding dysfunction as related to cancer survivorship.

Objectives:

1. Discuss the value and indications for urodynamic evaluation of the lower urinary tract for the survivor and how this study can change with prior therapies such as radical pelvic surgery, radiation, and chemotherapy.
2. Have an in depth knowledge of the relationship of specific parts of the urodynamic study to the filling/storage and emptying phases of micturition and have each is affected by prior cancer therapies such as radical pelvic surgery, radiation, and chemotherapy.
3. Demonstrate the ability to independently set up and perform filling and voiding cystometry and be able to identify and interpret all of the following:
   1. Urinary flow rate
   2. Residual urine volume   
   3. Flow patterns
   4. Bladder compliance
   5. Involuntary bladder contractions
   6. Abnormal bladder sensation
   7. Leak point pressures
   8. Pressure/flow studies
4. Demonstrate the ability to independently set up and perform video urodynamics. 
5. Demonstrate the ability to independently set up and perform electromyography utilizing both needle and patch electrodes.

Goal 4:  The fellow will gain advanced expertise in the evaluation, diagnosis and treatment of patients with pelvic pain syndromes including radiation cystitis in the face of cancer survivorship specifically radiation-induced pelvic pain.

Objectives:

      1. Demonstrate an understanding of the epidemiologic aspects of radiation cystitis.
      2. Be familiar with the common theories regarding the pathogenesis of radiation cystitis. 
      3. List the typical symptoms of radiation cystitis in men and women. 
      4. Discuss the differential diagnosis of the symptoms of radiation cystitis. 
      5. Be familiar with the cystoscopic findings in patients with radiation cystitis and the indications and limitations of bladder biopsy. 
      6. Explain the therapeutic rationale for the various treatments used in radiation cystitis and be familiar with their benefits, efficacy and side effects.
      7. List the systemic and intravesical pharmacotherapies used to treat radiation cystitis. 
      8. Know the role of hyperbaric therapy in patients with radiation cystitis. 
      9. Know the role of pelvic floor neuromodulation in the treatment of patients with pain from cystitis and other pelvic pain syndromes. 
      10. Know the role of surgical therapy for patients with refractory radiation cystitis.
      11. Demonstrate proper selection of radiation cystitis patient for surgical therapies.

Goal 5:  The fellow will become competent in the diagnosis and treatment of patients with vesicovaginal and ureterovaginal fistulae.

Objectives:

1. List the signs and symptoms commonly associated with vesicovaginal (VVF) and ureterovaginal (UVF) fistulae. 
2. Describe the pathogenesis of VVF including iatrogenic, post-irradiation and obstetric trauma induced fistulae. 
3. Describe the important components of the history and physical examination in patients with VVF and UVF. 
4. Distinguish between VVF and UVF using historical and diagnostic techniques.
5. Discuss the surgical principles involved in repair of these fistulas including the biology of wound repair and the preparation of tissues for surgery. 
6. Describe the conservative management of VVF and UVF.
7. Discuss in detail the surgical repair options for patients with VVF or UVF. 

Teaching Methods:

1. Clinical performance with direct observation
2. Direct faculty mentorship
3. Daily supervised care of surgical patients
4. Presentations in clinic
5. Supervised on-call experiences

Goal 1:  The fellow will develop an advanced working knowledge of the regular conferences needed to provide excellent urological care.

Objectives:

1. Participate and run weekly department conferences and apply knowledge learned to your patients.
2. Participate and run weekly hospital-based conferences and apply knowledge learned to your patients. 
3. Prepare, document, and present regular M&M Rounds.  
4. Become familiar with complication and consent issues regarding surgery and investigate ways to prevent adverse outcomes. 

5. Organize and run the monthly multidisciplinary reconstructive conference with colorectal surgery, orthopedic surgery, plastic surgery and infectious disease as part of the genitourinary cancer survivorship preoperative pathway.

Goal 2:  The fellow will gain become proficient at contributing to education of those around them.

Objectives:

1. Demonstrate proficiency in the teaching of medical students and residents. 
2. Demonstrate proficiency at training paraprofessional care givers, technicians and nursing staff in clinic and OR. 

Teaching Methods:

1. Clinical performance with direct observation
2. Operating room with observed performance
3. Direct faculty mentorship
4. Daily supervised care of surgical patients
5. Presentations in clinic
6. Rotation specific conferences
7. Supervised on-call experiences

 Goal 1:  The fellow will develop advanced presentation skills both for conferences as well as large group presentations such as grand rounds. 

Objectives:

1. Present advanced survivorship cases to faculty at conferences, on rounds, on call and in clinic. 
2. Learn to speak and present effectively in front of their peers and faculty. Be able to handle advanced questions and prepare well thought out responses at the faculty level. 
3. Pick or be assigned a faculty who will mentor them and serve as their advisor for the research endeavors. 

Goal 2:  The fellow will demonstrate proficiency in the management and leadership of a ward service, utilizing the cooperative skills of medical students, residents, nurses, consult staff, and ancillary personnel to manage and lead the reconstructive survivorship service.

Objectives:

1. Demonstrate skill and sensitivity for appropriately counseling and educating patients and their with respect to survivorship issues and plans of care.
2. Demonstrate effective documentation of practice activities with proper operative/procedure note dictations, clinic visit dictations, discharge summary dictations, daily progress notes and event notes. 
3. Demonstrate how to properly consult a specialty service (radiology, GI, PT, etc..) by correctly formulating the specific question to be answered.  Follow through with consultant’s suggestions after appropriate discussion with the attending staff. 
4. Demonstrate an advanced, thoughtful, understanding and helpful attitude to consulting services.
5. Demonstrate ability to independently manage the survivorship service, to include administrative, clinical and academic responsibilities while acting as the faculty. 
6. Demonstrate leadership by assuring the attendance of team members at all rounds and conferences.

Teaching Methods:

1. Clinical performance with direct observation
2. Operating room with observed performance
3. Direct faculty mentorship
4. Daily supervised care of surgical patients
5. Presentations in clinic
6. Rotation specific conferences
7. Supervised on-call experiences

Goal 1:  The fellow will demonstrate respectful, altruistic and ethically sound behavior with patients and all members of the health care team.

Objectives:

1. Wear proper attire at all times.  Maintain professional bearing at all times. 
2. Adhere to all hospital-specific policies.  

Goal 2:  The fellow will maintain professional bearing at all times.

Objectives:

1. Attend all conferences.
2. Demonstrate leadership by assuring the attendance of team members at all rounds and conferences. 
3. Maintain a current unrestricted medical license. 
4. Maintain daily/weekly updates of your Surgical Operative Log. 
5. Treat each patient, regardless of social or other circumstances with the same degree of respect they would afford to their own family members. 
6. Demonstrate administrative skill in preparation of the weekly M&M reports and presentation at conferences.
7. Educate and incorporate medical students, sub-interns into the service.
8. Continue work on research project, with goal of one publication in a peer-reviewed journal or presentation at a national meeting prior to graduation

Teaching Methods:

1. Clinical performance with direct observation
2. Operating room with observed performance
3. Direct faculty mentorship
4. Daily supervised care of surgical patients
5. Presentations in clinic
6. Rotation specific conferences
7. Supervised on-call experiences

Goal 1:  The fellow will demonstrate effective interaction with referring physicians throughout the medical system.

Objectives:

1. Demonstrate effective and safe patient care which minimizes delays in discharge
2. Demonstrate effective time management.
3. Demonstrate an understanding of the larger system of hospital care by:
   1. Participating in weekly multidisciplinary rounds.
   2. Participating in daily patient care rounds.
4. Demonstrate an understanding of how patients are properly referred, scheduled, and approached for surgery. 

Goal 2: Gain an understanding of the SBP aspects of providing care in a large hospital with a diverse patient population.

Objectives: 

• Become familiar with the provided computer training and skills for appropriate patient care.  
• Demonstrate skills on the computer system.
• Utilize computer and library research facilities for safe patient care. 
• Begin to learn about proper documentation and coding principles.