Definition

Urology is the branch of medicine and surgery concerned with the study, diagnosis and treatment in adults and children of abnormalities and diseases of the genitourinary tract of the male and the urinary tract of the female.

Objectives of Training

The objectives of the residency program are as mandated by the Royal College of Physicians and Surgeons of Canada.

Specialty Training Requirements

A minimum of five years of approved training. This period must include:

1. Two years of core training in surgery
2. Three years of approved residency training in urology, one of which must be in a senior residency position. Senior residency is defined as a year in which the resident is regularly entrusted with the responsibility for pre-operative, operative and post-operative care, including the most difficult problems in urology. The senior resident shall be in charge of a urological unit – no other resident shall intervene between the senior resident and the attending staff urologist.
3. Three clinical years in urology are required to allow residents to become proficient in both open and endoscopic procedures.
4. Experience at a community based teaching unit should be undertaken during the residency.

The five-year program outlined above will permit most residents to become proficient consultants in urology. It must be regarded as the minimum training requirement and additional years of training may be required by the program director to ensure that clinical competence has been achieved. Residents interested in research and other academic aspects of the specialty will require additional training to accommodate those career goals.

Overview

The Principles of Surgery (POS) examination is offered annually at all centres where Royal College examinations are written.

This examination, developed by an inter-specialty test committee, allows the other components of the examination process to be made more specific to the specialty concerned. As it may be written after two years of surgical training, and since feedback will be provided, candidates will be helped in assessing their in-training progress.

Candidates must pass the POS examination, the final examinations and satisfactorily complete the required residency training to obtain Certification by the Royal College.

At the present time, the POS examination is voluntary for candidates in the other surgical specialties. Candidates who pass the POS examination will receive credit and will not be required to repeat that examination if it has become mandatory in their specialty by the time they come to their final examinations.

Residents who wish to be ruled eligible for the final examinations in the surgical specialties identified above must have successfully completed the POS examination.

Format

The six-hour examination contains approximately 300 multiple choice questions covering the categories listed in the outline of contents for the POS examination.

The POS examination is part of the examinations process leading to certification in:

• Cardiac surgery
• General surgery
• Neurosurgery
• Orthopedic surgery
• Otolaryngology
• Plastic surgery
• Urology

Overview

Comprehensive objective examinations make it possible to obtain a more complete evaluation of the candidate’s strengths and weaknesses.

The important feature of comprehensive objective examinations is that candidates do not need to pass the written component in order to take the oral component. Success or failure is based on consideration of all components of the examination. The comprehensive objective examinations are considered a “whole” and cannot be fragmented.

Candidates who are unsuccessful at this examination must, if within their period of eligibility, repeat all components of the examination.

Components

Principles of Surgery Examination

This examination may be taken after a minimum of two years of training that meet the specialty training requirements in one of the surgical disciplines recognized by the College. All candidates must pass this examination to be eligible for the comprehensive objective examination.

Written Component

The written component consists of three, two-hour papers on the principles, practice and basic sciences as applied to urology.

• Paper 1
  • Short-answer questions
• Paper 2
  • Part I: Multiple choice questions
  • Part II: Multiple choice questions

Objective Structured Clinical Examination (OSCE) Component

The OSCE component consists of multiple standardized examination stations, of approximately five hours in duration.

Overview

The residents are evaluated in a manner consistent with the standards of the Royal College of Physicians and Surgeons. Evaluations are completed at the end of each of the rotations by their supervisor using the In-Training Evaluation Report (ITER) developed for the program in the CanMEDS format.

Residents also undergo an oral examination of 45 minutes on a six-month basis. This is followed later in the day with a meeting with the program director to review their progress.

During the first two years (surgical foundations) the residents take the Canadian Association of General Surgeons exam with the general surgery residents. Beginning in PGY-3, they will take the American Urological Association in-service examination.

If there are any particular difficulties during the rotation the residents and faculty are encouraged to meet and review the concerns and share them with the program director.

Overview

Urology grand rounds occur every Wednesday at 7:30 a.m in room G348 at the McMaster Institute of Urology Theatre in St. Joseph’s Hospital. They alternate between subject-based rounds and case-based rounds and are attended by faculty, residents and urologists from the surrounding community and pharmaceutical industry representatives.

Dr. Sowery is in charge of organizing the rounds. Visiting professors and speakers are integrated into the rounds. Typically, there are three to four visiting professors and speakers over the course of each academic year. The visiting professors speak on a Tuesday evening, give rounds on the next Wednesday morning and then review case presentations from residents on Wednesdays after rounds.

Journal club occurs once a month and is arranged by Dr. Tim Davies. The journal club is held in the evening and over dinner. The residents have expanded the journals covered to include not only the Journal of Urology, but important articles in the New England Journal of Medicine (NEJM) and Journal of the American Medical Association (JAMA). Once or twice a year, a speaker with training in the critical analysis of journal articles is invited to provide critical appraisal and teach the group proper analysis of an article.

A combined pathology/radiology/urology is held once a month at St. Joseph’s Hospital.

Chief resident rounds are held every Friday morning at St. Joseph’s Hospital. During these rounds, a junior resident presents a case that is new to the chief and questions the chief on how they would handle the case. At least one faculty member is always present at these rounds. The goal is to prepare chiefs for their final oral exams and to improve their examinship.

Overview

PGY-1 and PGY-2 residents participate in the multi-disciplinary comprehensive surgical core program to prepare for the surgical foundations. This occurs every Wednesday morning and is coordinated by Dr. Amin.

PGY-3, PGY-4 and PGY-5 residents attend a lecture series every Wednesday morning following the curriculum in Chapter 7 of this manual. It is based on the contents of the major textbook in urology, Campbell’s Urology, and the lectures are referenced to the related chapters in the book. All the residents are provided with this text when they enter the program.

The residents are also provided with educational modules for each of the major disciplinary areas in urology including goals and objectives, classic articles and texts.

7.1 Surgical Anatomy

Schedule of Lectures

• Kidney, retroperitoneum, adrenal glands- clinical- flank incisions, retroperitoneal node dissection, adrenal surgery, emergency laparotomy for trauma (two lectures)
• Pelvic anatomy, bladder, prostate, female anatomy-clinical- inguinal canal incisions, pfannenstiel incisions, gibson incisions, radical prostatectomy, radical cystectomy, radical groin dissection (three lectures)
• Perineal anatomy- clinical- penile implant, urethroplasty, insertion of artificial sphincter (one lecture)
• Covered in Chapter 1 and Chapter 2.
• Dr. Ball, lecturer from the Department of Anatomy

7.2 Laboratory Evaluation of the Urologic Patient

To be incorporated into nephrology lectures

• Urinalysis and microscopy
• 24-hour urine collections

7.3 Imaging of the Urinary Tract

Schedule of Lectures

Note: This section is also covered in a combined radiology, urology, nephrology rounds.

The lecture series a total of eight sessions covering these topics:

• Principles of imaging-contrast toxicity, allergy
• Excretory urography
• Retrograde pyelograms
• Cystourethrography
• Ultrasonography and transrectal ultrasound guided biopsy of the prostate
• Computed tomography and MRI
• Nuclear Medicine
• Angiography and percutaneous nephrostomy placement
• Covered in Chapters 5 and 87 of Campbell’s Urology and Davidson’s Radiology of the Urinary Tract

7.4 Renal Physiology

Chapter 6 of Campbells, lecture by nephrology faculty

7.5 Renovascular Hypertension

• Evaluation of the patient with renovascular hypertension
• Medical and radiologic treatments
• Surgical treatment

Chapter 7, lecture by nephrology faculty but surgery covered in kidney surgery lectures.

7.6 Acute & Chronic Renal Failure

• Acute Renal Failure-Chapter 8, lecture by nephrology faculty
• Chronic Renal Failure-Chapter 8, lecture by nephrology faculty

7.7 Principles of Immunology

Chapter 9, lecture by Drs. Arlen and Trelevan

• Immunology physiology
• Immunosuppression in transplantation
• Risks of immunosuppression

7.8 Renal Transplantation

Chapter 10, lecture by Dr. Kapoor

• Assessing pre-transplantation patients
• Donor selection
• Transplant surgery
• Rejection and complications

7.9 Physiology and Pharmacology of the Renal Pelvis and Ureter and Pathophysiology of Urinary Tract Obstruction

Chapter 11 and 12, lecture by Dr. Whelan

7.10 Management of Upper Urinary Tract Obstruction

Chapter 12, lecture by Dr. Whelan

• Ureteropelvic junction obstruction
• Retrocaval ureter
• Ureteral stricture
• Retroperitoneal fibrosis

7.11 Infections & Inflammation of the Genitourinary Tract

Schedule of Lectures

• Urinary tract infections
• Prostatitis
• Interstitial cystitis
• Sexually transmitted diseases
• AIDS
• Cutaneous diseases of the external genitalia
• Tuberculosis and parasitic diseases
• Fungal infections

Lecturers

• Chapter 14, 16, UTI’s and Interstitial Cystitis, Dr. Piercey
• Chapter 15, Prostatitis, Dr. Winter
• Chapter 19 and 20, Dermatologist Dr. Murphy

7.12 Voiding Function & Dysfunction

Schedule of Lectures

Six lectures:

• Bladder and voiding physiology
• Neurology and pharmacology of the bladder, prostate and urethra
• Abnormalities of bladder function, storage versus emptying
• Evaluation of the patient with a neuro-urologic problem
• Classification and treatment of neurogenic bladders
• Incontinence, mechanisms, classification and assessment of patients
• Post-prostatectomy incontinence
• Treatment of female incontinence, non-surgical, injection therapy, procedures.
• Sphincter implantation
• Surgery for vesicovaginal, urethrovaginal fistula, urethral diverticulum

Lecturers

• Chapters 23,4,5,6, Physiology and Pharmacology of Voiding, 1 and 2, Dr. Winter
• Urodynamic Evaluation, Dr. Zikman
• Chapters 27,8,9, 30, Incontinence 1, 2 and 3, Dr Piercey

7.13 Benign Prostatic Hyperplasia (BPH)

Schedule of Lectures

Two lectures:

• Prostatic physiology and the development of BPH
• Evaluation of the patient with BPH
• Pharmacologic treatments
• Minimally invasive treatments
• Endoscopic surgery of the prostate
• Open surgery of the prostate for benign disease.

Lecturers

• BPH 1, Chapters 37, 8, 9, Dr. Matsumoto
• BPH 2, Chapters 40, 41, Dr. Matsumoto

7.14 Reproductive Physiology

Three lectures

*Chapters 42, 43, 44, lecturer – Dr. Fischer

• Physiology of male reproduction and assessment of male infertility*
• Treatment of Infertility including surgery of the scrotum for infertility related conditions
• Andrology and andropause

7.15 Erectile Dysfunction

Schedule of Lectures

Two lectures

• Physiology of penile erection (ED)
• Priapism
• Medical treatment of ED
• Surgical treatment of ED
• Peyronnie’s disease

Lecturers

• Chapters 45 and 46. Dr. Greenspan

7.16 Pediatric Urology

7.17 Oncology

Schedule of Lectures

• Molecular genetics and cancer biology (two lectures)
  • Latest theories on the development of malignancies with a focus on the urologic tumours
  • Dr. Kawakami and Dr. Major
• Renal tumour (two lectures)
  • Renal cell carcinoma
  • Other renal tumours
  • Radical nephrectomy
  • Partial nephrectomy
  • Laparoscopic radical nephrectomy
  • Dr. Kapoor, Chapter 75, 102
• Urothelial tumours of the urinary tract (two lectures)
  • Upper tract tumours, to include open and laparoscopic nephroureterectomy and segmental resection of the ureter, as well as endoscopic and chemotherapeutic prescription
  • Dr. Kapoor, chapters 76 and 80
• Bladder cancer (three lectures)
  • Superficial bladder cancer
  • Intravesical chemotherapy
  • Role of radiation and radical surgery
  • Radical cystectomy
  • Ileal conduit and continent diversions
  • Systemic chemotherapy
  • Dr. Davis, chapters 76, 77, 78, 79 and 80
• Testicular neoplasms
  • Classification of tumours
  • Surgical management of testicular cancer
  • Chemotherapy and radiation of testicular tumours
  • Dr. Davis, chapter 81 and 2, Radiation by Dr. Hemu Lukka and Chemotherapy by Dr. Sebastian Hotte
• Penile tumours
  • Types of tumours
  • Treatment of squamous cell carcinoma
  • Inguinal lymph node dissection
  • Dr. Orovan, chapter 83, 4
• Prostate cancer
  • Epidemiology, etiology and prevention
  • Pathology, including gleason score
  • Ultrasonographic biopsy
  • Diagnosis and staging
  • Radical prostatectomy, lap, perineal, nerve sparing—radiation therapy
  • Cryotherapy
  • Hormonal therapy
  • Chemotherapy

Suggest the following lectures:

• Etiology, Pathology and Diagnosis including role of prostate-specific antigen (PSA) and biopsy – Dr. Kawakami, Chapters 85, 6 and 8
• Surgery of Prostate Cancer, Dr. Kawakami, Chapters 89, 90 and 91
• Role of Radiotherapy- to include brachiotherapy, Dr. Lukka, Chapter 92
• Role of Hormonal therapy, Dr. Kawakami, Chapter 94
• Chemotherapy for Hormone Resistant Prostate Cancer, Dr. Sebastian Hotte, Chapter 95

Overview

Lower urinary tract dysfunction includes abnormalities of the filling phase and those of the emptying phase:

• Filling phase dysfunction includes a rise of detrusor pressure (detrusor instability) or incompetence of the urethral sphincter mechanism (stress incontinence).
• Emptying phase dysfunction includes a failure of the detrusor to maintain sufficient pressures to empty the bladder (detrusor hypotonicity) and obstruction of the urethra (outflow obstruction).

8.1 General Objectives

Overview

On completion of the educational program, the graduate urologist will be competent to diagnose and treat disorders of the lower urinary tract. The graduate urologist will also be familiar with the role of gynecologists, visiting and hospital based nurses, physiotherapists and community resources involved in the care of patients with lower urinary tract disorders.

• The management of lower urinary tract disorders requires an understanding of the embryology, anatomy and physiology of the lower urinary tract, as well as the relevant neuroanatomy and neurophysiology of the central and peripheral nervous systems.
• Diagnosis of lower urinary tract dysfunction requires skills in relevant history and examination of the patient, interpretation of laboratory tests and imaging studies, cystoscopic examination and urodynamic evaluation.
• Treatment skills include a knowledge of behavioral and lifestyle modification strategies and lower urinary tract pharmacology, as well as performance of endoscopic and open procedures for correction of stress incontinence and outflow obstruction.

The graduate urologist must understand and be able to convey to the patient the relative merits of diagnostic and treatment alternatives, based on their indications, contraindications and complications.

The graduate urologist must also be able to interpret the relevant urological literature and be able to incorporate new developments into his or her practice.

8.2 Specific Objectives

Faculty

• Dr. Kevin Piercy
• Dr. A. Leo Winter
• Dr. Jerold Zikman

Cognitive Skills

The following is a listing of disease entities that are commonly included in the management of lower urinary tract dysfunction. The list is not exhaustive. The graduate urologist should be able to demonstrate a working knowledge for the following disease entities sufficient for the competent practice of the specialty.

Lower Urinary Tract Anatomy & Physiology

• Pelvic floor — muscles, ligaments, blood vessels
• Organs — bladder, urethra, prostate, vagina
• Neuroanatomy — central nervous system (CNS), peripheral nerves, somatic vs. autonomic
• Differences between male and female

Lower Urinary Tract Dysfunction

• Storage phase disorders
  • Detrusor instability(overactive bladder)
  • Hyperreflexia (neurogenic bladder)
  • Non-compliance
  • Fistula
  • Prolapse
  • Urethral incompetence
• Emptying phase dysfunction
  • Detrusor hypotonicity
  • Flaccid neurogenic bladder
  • Urethral Obstruction – benign prostatic hyperplasia (BPH), stricture disease, etc.
  • Detrusor-sphincter dyssynergia

Neurological Disease Affecting the Urinary Tract Spinal cord injury

• Brain injury
• Stroke
• Multiple sclerosis (MS)
• Parkinson’s
• Diabetes

Idiopathic Disorders

• Lower urinary tract symptoms (LUTS)
• Pelvic pain
• Abacterial prostatitis

Pharmacology of the Lower Urinary Tract

• Anticholinergics and antispasmodics
• Alpha blockers
• 5-DHT inhibitors
• Alpha adrenergic agonists
• Cholinergic agonists
• Other

Behaviour & Lifestyle Modification

• Fluid and diet management
• Intermittent catheterization
• Indwelling catheter care
• Padding and diapers

Technical Skills

The graduate urologist must be able to describe and basic biochemistry, physics and technological application of the following diagnostic and therapeutic modalities.

History & Examination

• Urological findings
• Relevant non-urological findings

Diagnostic Tests & Procedures

• Urinalysis
• Prostatic fluid examination
• Imaging
• Cystourethrography
• Transrectal ultrasonography
• Urodynamic studies
• C cystometrogram
• Uroflowmetry
• Urethral pressure profile
• Pressure/flow study
• Pelvic floor electromyography
• Video-urodynamic studies

Therapeutic Procedures List A

• Endoscopic procedures
  • Cystoscopy and urethroscopy
  • Urethral dilation and visual urethrotomy
  • Transurethral biopsy of bladder and hydrodistension
  • Transurethral resection/incision of prostate
  • Transurethral incision of bladder neck
  • Transurethral incision of sphincter
  • Insertion of supra-pubic catheter
• Open surgical procedures
  • Vesical neck suspension by needle or tension-free vaginal tape (TVT)
  • Open vesical neck suspension (Burch or Marshall Marchetti)
  • Insertion of artificial sphincter
  • Repair of urethral and bladder fistulae
  • Repair of bladder and urethral trauma
  • Vesical diverticulectomy
  • Simple retropubic prostatectomy
  • Anterior bladder repair

Therapeutic Procedures List B

• Open surgical procedures
  • One and two stage open urethroplasty
  • Vaginal vault suspension
  • Augmentation cystoplasty

Overview

Renal stone disease is a common illness, affecting one in ten individuals at some time in their life. Although the pain can be excruciating, 85% of the stones will actually pass spontaneously. The management of the rest of the patients can be completed using relatively new endoscopic and minimally invasive techniques, resulting in open surgery being reserved for exceptional cases.

This module will review the current status of medical and surgical treatment of urolithiasis and its prevention.

9.1 Medical Expert

Cognitive Skills

Required Reading

• Campbell’s Urology, Volume 1, Nephrolithiasis
• Need nephrology text or some other text on medical workup and management
• American Urologic Association (AUA) Guidelines Committee report on Management of Urolithiasis

Optional Reading

• AUA Updates on Stone Surgery
• Journal of Endourology

Residents will participate in a lecture series which will cover the following topics:

• Physiology of stone formation — biochemistry of stone formation, role of the inhibitors, formation and chemistry of all types of stones
• Medical work-up of the recurrent stone former and the prophylaxis of further stone disease — to include a critical assessment of the role for medical management in 2003, work-up of the patient with recurrent stones, dietary management and review of medications available to aid in prevention of stones
• Management of renal stones — to include a discussion of asymptomatic renal stones, Extracorporeal shock wave lithotripsy (ESWL), Percutaneous nephrolithotripsy and open surgery
• Management of upper ureteral stones — to include a discussion of flexible ureteroscopy, role of ESWL and its success rate, antegrade ureteroscopy and ureterolithotomy. The different modalities used to fracture stones in the ureter will be reviewed at this lecture.
• Management of the lower ureteral stone — to include a discussion of indications for surgery, rigid ureteroscopy, and a review of the potential complications of ureteroscopy and their management
• Radiology of stone disease — to include a discussion of the role of intravenous pyelogram, CT scan, ultrasound and retrograde pyelogram in the management of stone disease. The radiologic anatomy of the kidney and the procedure of percutaneous nephrostomy tube insertion will be reviewed. Contrast toxicity in the renal failure patient will be reviewed.
• Endourologic procedures for non-stone related conditions — this lecture will discuss endopyelotomy, management of calyceal diverticulum, endoureterotomy and other options in the management of ureteral strictures.

Lectures will be provided to review the physics of lasers and discuss laser physics as part of a laser safety course which will result in certification.

Technical Skills

Core Program Rotations

Residents should focus on the following areas:

• Develop a working knowledge of the cystoscopes, ureteroscopes and nephroscopes used in completing these procedures
• Understand the differences in guidewires, stents and baskets and in particular, the different characteristics of the materials used in these disposable items
• Develop a working knowledge of the anatomy of the urinary tract and understand the passage of catheters and guidewires from the ureteric orifice to the kidney
• Residents should appreciate the role of fluoroscopy and how to safely utilize imaging with the minimum in radiation exposure
• Insertion of ureteric stents and catheters following endoscopic procedures and for the diversion of urine where an obstruction is present

Urology — PGY-3, -4, -5

Residents will learn:

• To access the lower ureter with rigid and flexible ureteroscopes and determine when dilatation of the intramural portion of the ureter is indicated
• How to pass the endoscope to the level of the stone and then determine whether it can be removed primarily or if some form of fragmentation is indicated
• To safely fragment the stone and remove the fragments if indicated. Later in their training, they will learn to access intrarenal stones and to fragment these in-situ or by moving them to the renal pelvis.
• Dilatation of a percutaneous nephrostomy tube tract for the purpose of completing percutaneous nephrolithotripsy. They will learn to access the various regions of the calyceal system and then fragment the stone and remove it. Principles of drainage and indications for stenting will also be reviewed.

Senior residents will:

• Learn the indications for open stone surgery and develop an approach to the collecting system and ureter if this form of stone extraction is indicated.
• Visit an ESWL facility and observe the procedure. They will review the need for ancillary procedures with this modality and the management of steinstrasse.

Faculty for Cognitive & Surgical Skills

• Dr. J. Paul Whelan and Dr. Edward Matsumoto: Endourology and Physiology of Stone Development
• Dr. David Churchill: Medical Management of Stones
• Dr. Julian Dobranowski: Radiology of the Urinary Tract

9.2 Communicator

General Objectives

• Develop a therapeutic relationship with patients and their families and obtain information in an effective and caring manner

Specific Objectives

• As many of these patients will be in significant pain, the resident should be able to assess the analgesic needs of the patient and whether this needs to be addressed before a detailed interview is to occur
• The resident should be able to assess the location and severity of the pain and any associated symptoms such as fever or hematuria
• They should also learn to assess the frequency of stone passage and any family history of stones
• Residents should be able to record the data from the history, laboratory work and radiologic investigations in an effective manner and communicate it to others in order to develop a management plan
• The resident will learn to communicate the management plan to the patient and their family in a manner that facilitates patients’ willing participation

9.3 Collaborator

General Objectives

• Consult and work with physicians and other health care team members to resolve the acute and long term problems with urolithiasis

Specific Objectives

• Interact with dieticians, nephrologists and endocrinologists to deal with issues related to the prevention of stone disease
• Arrange for patients to be properly prepared for transfer to an ESWL unit for treatment and to complete instructions from the treating urologist
• Assess and review new technologies in stone disease and make appropriate recommendations to hospitals regarding acquisitions

9.4 Manager

General Objectives

• Utilize information technology and meetings to facilitate lifelong learning in the area of urolithiasis
• The resident will learn to organize a practice and work effectively within a healthcare organization

Specific Objectives

• The resident will learn to develop a system of prioritizing patients for surgery
• They will learn to assess new technologies for diagnosis, treatment and prevention of stones

9.5 Health Advocate

General Objectives

• Identify the factors predisposing to this condition in their patients
• Contribute to the prevention of urolithiasis and advocate for better treatment options

Specific Objectives

• Understand the risk factors for urolithiasis and how they may impact on individuals within a community
• Understand the role of the Canadian Urologic Association and other organizations in providing guidelines for treatment of stones and patient education information

9.6 Scholar

General Objectives

• Develop and implement a continuing personal learning strategy in the field of urolithiasis
• The resident will critically appraise the information and facilitate the education of others (housestaff, patients, staff and other health professionals)

Specific Objectives

• The resident will evaluate their own capabilities and limitations in the field of stone surgery and determine a course to improve and refine their skills and knowledge base
• They will demonstrate an ability to research a topic using available data bases and critically evaluate the studies they find
• They will maintain an inquisitive attitude and may pursue the development of research protocols. If they pursue this they will be aware of the ethics of human and animal experimentation.

9.7 Professional

General Objectives

• The resident will learn to deliver the highest quality care with integrity, honesty and compassion
• They will practice ethically and demonstrate appropriate behaviour for a urologic consultant

Specific Objectives

• The resident will demonstrate personal responsibility by maintaining confidentiality, being available and being sensitive to the patient’s level of physical and emotional comfort
• They will be aware of best practice and where appropriate refer to a centre of excellence
• They will understand the process of informed consent, delegated consent and informed decision making as it applies to stone surgery

Overview

Male factor infertility is a common illness affecting 10% of the population and is involved in at least 50% of cases of couple infertility.

Management of this clinical problem involves microsurgical techniques as well as a clear understanding of the use of assisted reproductive technologies. This module will be the current status of medical and surgical treatments of male factor infertility.

10.1 Medical Expert

Cognitive Skills

Required Reading

• Campbell’s Urology Volume II, male factor infertility. Infertility in the Male, 3rd addition, Author Larry Lipshultz, Stewart Howards Mosby, Canada, 1997
• American Urologic Association; Guidelines Committee report on the Optimal Evaluation of the Infertile Male;
• Management of Obstructive Vasospermia and Management of Varicoceles

OPTIONAL READING

• Updates on Male Factor Infertility, Fertility and Sterility Journal, Human Reproduction Journal, The Journal of Urology

Our residents will participate in elective surgeries and will cover the following topics:

• The physiology of male reproduction
• Clinical evaluation of male factor infertility
• Clinical evaluation of female infertility
• Microsurgical management of male factor infertility to include discussion of varicocele surgery and obstructive azoospermia
• Medical management of male factor infertility to include discussion of management of endocrinologic causes of male factor infertility
• Management of infertility with assisted reproduction to include discussion on techniques available, indications and contraindications to use of assisted reproduction in male factor infertility

Technical Skills

Core Program Rotations

The residents should focus on the following areas:

• Develop a working knowledge of the operating microscope and microsurgical instruments used in completing microsurgical procedures
• Understand the differences in sutures, characteristics of these sutures used in microsurgery of male infertility
• Develop a working knowledge of the anatomy of the male genitourinary tract

Urology PGY-3, PGY-4, PGY-5

Residents will learn to:

• Access the testicle via approaches both transscrotal and subinguinal
• Perform testicular biopsy both open and percutaneous, as well as how to access the vas deferens and epididymis
• Perform lymphatic arterial sparing, subinguinal microsurgical varicocelectomy
• Senior residents will learn the indications for testicular biopsy, percutaneous epididymal sperm retrieval, microscopic epididymal sperm retrieval, microsurgical subinguinal varicocelectomy, electroejaculation of vibration of ejaculation

Faculty for Cognitive Surgical Skills

• Dr. Marc Anthony Fischer, Diagnosis, Surgical Management and Medical Management of Factor Infertility
• Dr. John Booth, Endocrinological Management of Male Factor Infertility
• Dr. Ed. Hughes, Reproductive Technologies

10.2 Communicator

General Objectives

• The resident would help the therapeutic relationship with patients and their partners and entertain information in an effective and caring manner

Specific Objectives

• Many of these patients will have significant social and psychological pressures – the residents should be able to assess and properly address these issues with the patients.
• The resident should be able to record data from history and physical examination, laboratory work in an effective manor and communicate to others in order to develop an effective management plan.
• The resident will learn to communicate the management plan to the patient and their family in manner that facilitates the patient’s appropriate management.

10.3 Collaborator

General Objectives

• The resident will consult and work with physicians and other health team members to treat the infertile couple.

Specific Objectives

• The resident will interact with gynecologists, nurses and geneticists and endocrinologists to deal with the issues related to male factor infertility.

10.4 Manager

General Objectives

• The resident will utilize information technology and meetings to facilitate lifelong learning in the area of male factor infertility and will learn to organize their practice and work effectively within the healthcare organization.

Specific Objectives

• The resident will develop a system of prioritizing patients for surgery and will be able to assess the appropriateness of assisted reproductive technologies for treatment of male factor infertility.

10.5 Health Advocate

General Objectives

• The resident will identify factors predisposing to male factor infertility in their patients and will contribute to the prevention of male factor infertility and advocate for better treatment options.

Specific Objectives

• The resident will understand the risk factors for male factor infertility and how they may be impacted in individuals in their community, as well as understand the cost implications of reproductive technology for patients.

10.6 Scholar

General Objectives

• The resident will develop a continued personal learning strategy in the field of male factor infertility and the resident will quickly appraise the information to facilitate the education of others including house staff, patient staff and the health care professionals.

Specific Objectives

• The resident will evaluate their own capabilities and limitations in the fields of microsurgical and the general evaluation of male factor infertility and will develop a course to improve and refine their skills.
• They will demonstrate a research a topic using available database and to critically evaluate the studies that they find. They will maintain an inquisitive attitude and may pursue to the development of research protocols. They will also need to be aware of the ethics of assisted reproductive technologies.

10.7 Professional

General Objectives

• The resident will learn to develop the highest quality of care with integrity, honesty and compassion.
• They will practice ethically and demonstrate appropriate behavior for a urologic consultant.

Specific Objectives

• The resident will demonstrate personal responsibility by maintaining confidentiality, being available and being sensitive to the patients at a level of emotional and social discomfort.
• The resident will be aware of the best practice and where appropriate refer patients to Centres of Excellence.
• The resident will understand the process of informed consent and informed decision making as it applies to male factor infertility.

Description

The program utilizes the stated goals and objectives of the Royal College of Physicians and Surgeons (RCPSC) as the basis for its training. It also utilizes the documents developed by the RCPSC and by McMaster with respect to training in core areas in surgery. The objectives stated in sections 12 and 13 are meant to complement these and be more specific to the rotations.

In December of 2001, a meeting was held with the division of urology, the chief executive officers of both hospital corporations, the hospital chiefs of surgery and the chairman of Department of Surgery. At this meeting, it was agreed that the lead hospital for the urology residency program would be St. Joseph’s Healthcare (SJH) and that Hamilton Health Sciences (HHS) would also play a pivotal role in the development of the training program.

Further to this, St. Joseph’s has gone forward with recruitment to bring its complement of urologists to six individuals with all of the faculty geographic full-time. Hamilton Health Sciences has recruited an additional urologist with expertise in uro-oncology, who is geographic full-time and this brings their complement to five, with two being geographic full-time.

Program Design

Topics

12.1 St. Joseph’s Hamilton Healthcare

12.2 Hamilton Health Sciences

12.3 Mississauga Credit Valley Hospital & Etobicoke General Hospital

These sites will be used for the completion of the community practice elective in the PGY-4 and provide exposure to highly motivated, well-trained urologists within a community setting.

Dr. Rajiv Gupta at the Etobicoke General and Dr. Munir Jamal at Mississauga Credit Valley Hospital are both experienced teachers, having taken residents from the University of Toronto urology residency program for many years.

PGY-1

• PGY-1 Urology Rotation
• PGY-1 General Surgery Rotation
• PGY-1 Nephrology Rotation
• PGY-1 Emergency Medicine Rotation
• PGY-1 Pediatric General Surgery Rotation

PGY-2

• PGY-2 Urology Rotation
• PGY-2 Plastic Surgery Elective Rotation
• PGY-2 Radiology Rotation
• PGY-2 Surgery Rotation
• PGY-2 Intensive Care Unit (ICU) Rotation

PGY-3

• PGY-3 Infertility, Neurourology
• PGY-3 Pediatric Urology Rotation
• PGY-3 Urology Rotation
• PGY-3 Urological Pathology Rotation

PGY-4

• PGY-4 Pediatric Urology Rotation
• PGY-4 Medical Radiation Uro-Oncology Rotation
• PGY-4 Community Urology Elective Rotation
• PGY-4 Urology Hamilton Health Sciences (HHS)
• PGY-4 Urology St. Joseph’s Healthcare (SJH)

PGY-5

• PGY-5 Urology SJH Rotation (chief)
• PGY-5 Urology HHS Rotation (chief)

Topics

Residents will refrain from accepting gifts or funds for travel from industry representatives without written approval from the program director.

Residents will not attend social activities with industry representatives unless the event has been approved by the program and all members of the resident staff have been invited to the event.

If residents are offered funds from an industry representative for travel to a meeting or for books, they should direct the representative to the program director so that the funds can be placed in an account to be used for this purpose and to be distributed by the program director.

Residents will not make presentations for any industry at meetings and, in particular, will not receive honorariums for making presentations.

If you have concerns that what you are doing is not endorsed by the program or is unethical, then review it with the program director before starting down a path that could endanger your position in the program or your license to practice medicine.