UNIVERSITYHOSPITAL

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 inUrology. Applicant mustmeet the

requirements forboard 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 programor current competency inproviding

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 referenceletter. All initial

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

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

applicants beyond 12 months of residency completion must provide a case list fromthe hospitalwhere the

applicant has been actively practicing for the last year and a letter ofrecommendationassessing performance

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

The reappointment applicant must demonstratecontinuing 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 thehospital’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 oftraining in

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

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

and the Governing Board of UniversityHospital.

SPECIAL PRIVILEGES to include: REQUESTEDGRANTED

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.

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Applicant’s SignatureDate8/07