UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF SURGERY

SECTION OF UROLOGY

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: MD or DO

TRAINING:

Successful completion of an approved residency training program in Urology. Applicant must meet the

requirements for board certification outlined in the Medical Staff Bylaws.

EXPERIENCE:

The initial applicant must be able to demonstrate training and/or experience on a level commensurate with

specialty training from an accredited Urology residency program or current competency in providing

medical/surgical management and/or treatment to patients within the scope of core privileges for Urology.

Adequate documentation of this performance requires submission of a case list and a reference letter. All initial

applicants at completion of residency and/or fellowship must provide an official case list and letter of

recommendation assessing performance from the Residency and/or Fellowship Program Director. All initial

applicants beyond 12 months of residency completion must provide a case list from the hospital where the

applicant has been actively practicing for the last year and a letter of recommendation assessing performance

from the hospital’s Chief of Staff or Department Chair.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result

of care according to the hospital’s existing quality mechanisms.

CORE PRIVILEGES to include: REQUESTED GRANTED

|Admission of patients | | |

|Evaluation, diagnosis, and any diagnostic and operative procedures for involving the | | |

|genitourinary system of the male and the urinary system of the female, both within the | | |

|abdomen and retroperitoneum, and all ages both pediatric and adult, inclusive of the | | |

|genitalia, urethra, bladder, ureters, kidneys, and adrenal glands. | | |

|Diagnostic and surgical endoscopic procedures involving the urinary tract. | | |

|Endourological manipulation of the kidneys, ureters and upper urinary systems by | | |

|percutaneous manipulation. | | |

|Specific Core Procedures/Treatments include: | | |

|Cystoscopy | | |

|Extracorporeal shock wave lithotripsy | | |

|Female incontinence, all categories | | |

|Lymphadenectomy, pelvic | | |

|Lymphadenectomy, retroperitoneal | | |

|Renal surgery, partial or total nephrectomy | | |

|Penile surgery | | |

|Percutaneous renal surgery | | |

|Prostatectomy, radical, all categories | | |

|Radical cystectomy | | |

|Scrotal surgery | | |

|Transrectal ultrasound/prostate biopsy | | |

|Transurethral resection, bladder tumor | | |

|Ureteroscopy | | |

|Urethroplasty/utethral surgery | | |

|Urinary diversion, all types | | |

SECTION OF UROLOGY

REQUEST FOR PRIVILEGES

PAGE 2

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Lithotripsy | | |

|Cryosurgery – Ablation of the prostate (First three cases to be proctored) | | |

|Laparoscopic nephrectomy | | |

|Laser privileges | | |

|Moderate Sedation | | |

|The applicant is required to submit a separate letter of | | |

|request for any privilege not included on this form. | | |

________________________________________ ___________________________

Applicant’s Signature Date 8/07

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