a. The research experience.
The first year of the SUO-accredited Fellowship is spent doing translational research on peer-reviewed and funded research projects conducted in the laboratories and under the supervision of a preceptor or participation in QOL or outcome projects made possible by the prospectively populated departmental databases that include all patients who have prostatectomies, undergone radical cystectomy or pariral or radical nephrectomy. The Fellow joins ongoing research that enables generation of the required minimum of two publications.
b. Clinical assignments, context, objectives, and duties and responsibilities for services
The Urology Department provides two Fellows with clinical training each year. The clinical objective of the Fellowship is to provide an education in diagnosis and treatment of GU malignancies with particular emphasis on cancers of the prostate, bladder, kidney and testis.
The clinical service is divided into two teams. Team 1 is staffed by Drs. Mohler, Guru, and Underwood, and emphasizes prostate and bladder cancer. Team 2 is staffed by Drs. Schwaab and Kauffman and emphasizes kidney, prostate, and testis cancer.
Each Fellow spends two months at a time on each Team. During the course of the training, Fellows are given increasing responsibilities in the clinic, ward and operating room. The SUO Fellowship includes training in the following areas:
- Diagnosis and management of urologic malignancies
- Interpretation of imaging studies
- Preoperative and postoperative care of urologic cancer patients
- Implementation of multidisciplinary care
- Organizing and running multidisciplinary conferences
- Open, laparoscopic and robotic operations
- Initiating and conducting clinical trials
The program recognizes that Fellows are fully trained and board eligible urologists who are at RPCI to receive additional training. Therefore, activities in the operating room and teaching conferences take precedence over clinics and ward rounds. Only ongoing surgery takes precedence over conferences. Attending Staff are required to avoid conflicts of operating room versus clinic, and Fellows are expected to spend no more than two days per week in the outpatient clinic.
Dr. Mohler shares an overview of Roswell Park's Urology Fellowship curriculum.
c. Implementation of progressive and graded patient care responsibility
All patient care occurs under the supervision of the Attending Staff. In the clinic, Fellows interview and examine patients. They present their findings and suggest a treatment plan to the Attending Staff. On the ward, the Fellows run inpatient rounds twice daily. The inpatients are examined during the day with the Attending Staff. In the operating room, all major surgeries are performed under the direct supervision of Attending Staff. Fellows are provided with progressively increasing operative experience commensurate with their skills and experience. For example, with robotic surgery training, the Fellow initially serves as the bedside assistant. They progress to participating at the console and perform various steps of the surgery. Towards the end of the training, the Fellow is able to perform all steps and then the entire operation.
d. Familiarity with all state‑of‑the‑art imaging modalities
The Urology Clinic has two procedure rooms that are equipped for cystoscopy, transrectal ultrasound and urethral instrumentation. The clinic has three flexible digital cystoscopes and two rigid cystoscopes. Endoscopic procedures are viewed on a 13-inch CRT monitor. Two ultrasound machines are available for transrectal guided prostate biopsies.
The Department of Radiology is located immediately above the Urology Clinic. Twenty-four Fellowship-trained radiology subspecialists deal with each of the recognized imaging areas: Nuclear Medicine, Body Imaging (MRI, CT, PET, and Ultrasound from thoracic inlet to pelvic floor), and Angio/Interventional Radiology. Equipment is state-of-the-art and includes: Three CT scanners (including 64-slice), a fully up-graded 1.5 Tesla GE magnet, a new 3.0 Tesla GE magnet equipped for fMRI and advanced prostate imaging, stationary and multiprobe portable ultrasound units, a GE Discovery PET/CT system, two new Phillips SPECT/CT units, two new IR rooms, a new fluoroscopic/radiographic room, McKesson PACS, Power Scribe Word Recognition Dictation software, and an eight-bed recovery ward for patients post-procedure. The subspecialists perform approximately 40 procedures daily that include image-guided organ biopsies from the skull base to the toes, vertebraplasties, kyphoplasties and insertion of venous access devices. The department has 12 radiology nurses, four radiology PAs and manages its own conscious sedation.
Radiology procedures performed at Roswell Park that apply to urological cancers include:
- Intraoperative ultrasound of the kidney — critical for evaluating the kidney prior to resection or therapy, including ultrasound-guided radiofrequency ablation and cryoablation
- Radiofrequency or chemoablation of hepatic lesions via hepatic arterial catheterization
- Imaging-guided biopsies of lesions of any organ including bone
- Use of on-site real-time cytology, to assure adequate sampling and sample processing
- Total body tumor localization with FDG-PET and FLT-PET
- Advanced prostate MRI
- Extensive CT Angiography of tumors and surrounding tissue pre-surgery
e. Knowledge and the ability to apply the critical principles of medical oncology, radiation oncology, and uropathology
In the outpatient clinics, Fellows receive training by interacting with both Attending Staff urologists and medical oncologists. Outpatient clinics at RPCI are organized by disease site. The kidney cancer clinic is staffed by Dr. Schwaab (urologist),Dr. Underwood (urologist), and Dr. Kauffman (urologist). The prostate cancer clinic is staffed by Dr. Mohler (urologist), Dr. Guru (urologist), Dr. Kauffman (urologist), Dr. Pili (medical oncologist) and Dr. Trump (medical oncologist). The bladder cancer clinic is staffed by Dr. Guru (urologist), Dr. Levine (medical oncologist), Dr. Pili, Dr. George (medical oncologist).
Radiation Medicine is in contiguous clinic space and Dr. Michael Kuettel is chair and specializes in urologic oncology.
All new prostate cancer patients are presented at a multidisciplinary conference held biweekly and organized by Radiation Medicine.
All advanced cases are reviewed at a GU Multidisciplinary Conference held biweekly that is organized by the Department of Urology and attended by Fellows and Attending Staff from Urology, Medical Oncology, Radiation Medicine, Radiology and Pathology, clinical research, nurses and other support staff. Surgical pathology is reviewed with one of three Uropathologists at this conference and all radiographic studies are reviewed by our GU radiologists.
f. Ability to perform complex tumor resections with a clear understanding of the benefits and the technical limitations of surgical procedures
Fellows participate in outpatient evaluation and patient counseling. They learn the principals and skills of urologic oncologic procedures including but not limited to:
- Robot-assisted radical nerve-sparing and extrafascial prostatectomy, radical cystectomy and urinary reconstruction, partial nephrectomy
- Open radical surgery including complicated and partial nephrectomy and sympathetic nerve-sparing retroperitoneal lymph node dissection
- Laparoscopic adrenalectomy, nephrectomy, nephroureterectomy, and retroperitoneal lymph node dissection
g. Extensive knowledge of and technical experience in urinary tract diversion and reconstruction
Fellows receive training in construction of ileal conduits, Indiana pouches, orthotopic neobladders and distal ureterectomies and reimplants. These procedures are almost always performed intracorporeally and robotically at RPCI.
h. Knowledge of the biologic potential of urologic malignancies
Fellows gain knowledge of the biologic potential of urologic malignancies through didactic sessions and clinical experience. The Urology Department is divided into two services. By spending two months at a time on each service, Fellows are able to follow a patient’s course from diagnosis to treatment to postoperative management. They learn to use adjuvant therapies when appropriate and consider patients for clinical trials of novel adjuvant therapies.
i. Comprehension of and facility with scientific methodology, study design, biostatistics, clinical trials, and data analysis
Fellows are required to submit two manuscripts suitable for publication in the peer-reviewed literature during each of the research and clinical years and develop one clinical protocol during the clinical year of Fellowship. Fellows learn manuscript writing techniques and editing, and review the literature in conjunction with the Attending Staff. Fellows attend a course organized by the Department of Surgical Oncology entitled “Methods of Clinical Research”, which is a weekly course that meets Mondays 5 - 6 p.m. from August to May. The target audience includes Fellows and junior faculty. Topics covered include cancer control, clinical trial design, epidemiology, statistics, cell and molecular biology, clinical pharmacology, genetics, cancer prevention, responsible conduct of research, and ethical issues relating to clinical trials.
j. Ability to manage academic or tertiary referral practice, participate in continuing medical education
Fellows play an active role in communicating with referring physicians. They assist with generating letters to referring physicians. They are responsible for presenting at two Grand Rounds, which are attended by local urologists and for which continuing medical education credits are provided.
k. Skills for self-education and collaboration in translational research
Fellows organize and run monthly journal clubs where they present specific articles from the Journal of Urology, Urology, Seminars in Urology, European Urology, Journal of Clinical Urology and other journals. They participate in monthly Disease Site Research Group (DSRG) meetings, which are attended by clinicians, basic scientists, and clinical research nurses. Presentations and discussions focus on translational research collaborations between clinicians and laboratory scientists.
l. Duty and call hours
The two Fellows provide call coverage for Department of Urology at RPCI as primary responders. During call hours, Fellows address inpatient issues and field calls from outpatients, outside physicians and other hospitals. The Attending Staff provide backup coverage. Fellows have the opportunity to develop their own call schedule, which requires the approval of the Program Director. The Program Director has the responsibility of making sure reasonable duty hours have been assigned.
A typical call schedule rotates call among both SUO Fellows, the International Fellow (if present), and a fourth year (UB) Urology Resident, a laboratory Fellow replaces the clinical Fellow during vacations, meetings, or other absences. Call averages every 3-4 days and every third or fourth weekend, which results in reasonable work loads. RPCI is a 130-bed hospital with no emergency room. An urgent care clinic is staffed by a nurse practitioner to serve established patients of RPCI. Finally, patients in the intensive care unit are managed at all times in association with the critical care Attending Staff.
No call rooms are available since Fellows provide call coverage from home. Urology Fellows are not required to provide cross coverage for other services.
m. The program adheres to institutional policy, which requires that Attending Staff document participation in obtaining histories and physical exams. All charts require Attending Staff signatures on consents and preoperative history and physicals before the patient is allowed to enter the operating room. The Attending Surgeon is required to be present for all critical portions of major surgical cases. Fellows and Attending Staff have access to the Program Director as well as the RPCI Chief of Staff/Medical Director to voice concerns about lack of supervision.