THE AMERICAN BOARD OF UROLOGY, INC MAINTENANCE OF CERTIFICATION (MOC) EXAMINATION PROCESS MANDATORY FORMAT FOR PREPARING PRACTICE CASE LOGS

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1 THE AMERICAN BOARD OF UROLOGY, INC MAINTENANCE OF CERTIFICATION (MOC) EXAMINATION PROCESS MANDATORY FORMAT FOR PREPARING PRACTICE CASE LOGS All logs are due April 1, Courier service is recommended for guaranteed delivery. Logs received after April 15 th must include a $750 late fee. No logs will be accepted after April 15, Retain a copy for your records: The Board office disposes of logs after successful completion of MOC. Your Pediatric log must be twelve (12) consecutive months in length between August 1, 2015 and March 1, DO NOT SEND hospital computer printouts or include diagnosis/procedure s in Lists 2, 3, and 4. ** If you have been previously deferred due to submission of an inadequate log you must re-submit your prior log along with your current submission and include all case numbers in your summary. FOUR SEPARATE lists on 8 1/2 x 11" paper are required. All lists except List 1 must be typed using a font size no smaller than 10-point. A Practice Log Verification/Notarization Statement for all four lists is attached: It must be signed and your signature must be notarized. LIST 1: PROCEDURES SUMMARY. One master summary list of procedures performed, including every setting and facility, for which you were the primary urologist. Complete the attached form. Procedures summarized on this form must reflect all procedures from Lists 3 and 4. Note: Procedures performed by auxiliary personnel under your supervision must be included. Total the number of cases on the last page. LIST 2: LOGS of hospital, ambulatory care facility and office procedures for which you were the primary urologist, listed separately for each setting and facility, in chronological order. LIST 3: LOGS of hospital, ambulatory care facility and office procedures for which you were the primary urologist, listed separately for each setting and facility, in chronological order. Please use the following MANDATORY format for Lists 2 and 3: At the top of each page: Name of Institution, Your Name, List Number & Name (i.e., Mercy Hospital, John Smith, M.D., List No. 3 Adult Log) ^Case Patient Patient Date Diagnosis Urologic Op/Post-op Morbidity Number Age Sex (Chron. Order) (no s) Procedure Complication/Death (no s) Printing the log horizontally will provide more space. If you practice adult or pediatric urology exclusively, only the pertinent list is required. ^Case # refers to the numerical record used by a facility to identify a particular patient (i.e. medical record #, patient #, admission #, hospital #, etc.) Names or numbers must insure patient anonymity: Social Security Numbers and full names will not be accepted.

2 Complications Narratives Instructions The Board is interested in how you approach and manage surgical complications. Please address the following: 1. Report all pre- and 30 day post-operative mortalities that you have experienced for the current 10 year MOC cycle, using the MANDATORY template indicated below. If none, provide such statement. 2. Report all complications of Clavien Grade III or higher (see below) from your practice log. 3. Provide a detailed narrative description of these complications and your management using the MANDATORY template indicated below. Please note: the vast majority of candidates do experience and report such complications; however, if it is your intention to claim no Grade III or higher complications during your practice log period, you are required to submit an electronic signature to that effect. 4. In your complications narrative, indicate whether you obtained any consultations during the care episode to assist with management of the complication. Also, inform the Board why the complication may have occurred. 5. Describe to the Board how complications are tracked and/or reported at the hospitals in which you practice. Do you regularly participate in a morbidity and mortality conference? 6. Does your hospital perform root cause analysis of major adverse events? 7. What have you learned? In retrospect, what could you have done differently? At the top of each page: Name, Diplomate # and Institution (ie: John Doe, M.D., #12345, Mercy Hospital) Patient's Case # Age: Gender: Date of Procedure: Diagnosis: Procedure(s) performed: Clavien Grade: Brief Description of Complication: Narrative: Detailed narrative description and analysis, of at least one paragraph, to include the following elements: 1) Definition of problem, 2) Causal relationships, 3) Statement of solution(s)/intervention to prevent future events (see example below) Definition of the problem: sepsis after transrectal prostate biopsy Causal relationships: antibiotic choice, antibiotic timing, patient education, risk factors (e.g. diabetes) Statement of solutions/intervention to prevent future event: improved understanding of bacterial resistance patterns; methods for broader coverage and/or targeted prophylaxis with rectal swabs; process for patient education prior to prostate biopsy; and consideration of risk factors that increase the likelihood of sepsis. CLASSIFICATION/DEFINITION OF SURGICAL COMPLICATIONS Grade I: Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Grade II: Requiring pharmacological treatment with drugs other than such allowed for Grade I complications. Blood transfusions and total parenteral nutrition are also included. Grade III: Requiring surgical, endoscopic or radiological intervention. Grade IIIa: Intervention not under general anesthesia. Grade IIIb: Intervention under general anesthesia. Grade IV: Life threatening complication (including CNS complications) requiring IC/ICU management. Grade IVa: Single organ dysfunction (including dialysis). Grade IVb: Multiorgan dysfunction. Grade V: Death of a patient. Dindo et al. Annals of Surgery. Volume 240, Number 2, August 2004 Send all complications narratives, log verification statement and completed practice breakdown form to the ABU via , fax or mail. Completed form to: moccoordinator@abu.org or fax to (434)

3 SAMPLE FORM AT FOR LISTS 2 AND 3: Following is a sample of what Lists 2 and 3 should look like. Please note that each setting (that is: hospital, ambulatory care/outpatient facility, and office) should be listed on separate sheets of paper. For example: if you performed procedures on adults at two different hospitals, one ambulatory care facility and two offices, you will have five different headings on your List 2. If you also performed pediatric procedures, follow the same format, but label the heading List 3. Example of procedures performed in a hospital: General Hospital, Dr. John Smith, List 2-Adult Log, Hospital Procedures Case # Age Sex Date Diagnosis Procedure M 6/1/2001 BPH TURP M 6/4/2001 TCC bladder CBF F 6/6/2001 Kidney donor Left donor nephrectomy General Hospital Outpatient Clinic, Dr. John Smith, List 2-Adult Log, Ambulatory Care Procedures Case # Age Sex Date Diagnosis Procedure F 6/1/2001 Hematuria Cystoscopy M 6/2/2001 Elevated PSA TRNBx M 6/4/2001 Kidney Stone Lithotripsy F 6/4/2001 Stress Incontinence Sling, cystoscopy Complication or Morbidity or Mortality Complication or Morbidity or Mortality Example of procedures performed in an office: Urology Associates of Anytown, Inc., Dr. John Smith, List 2-Adult Log, Office Procedures Case # Age Sex Date Diagnosis Procedure JW M 6/1/2001 Urinary retention Uroflow SM M 6/1/2001 Incontinence Needle EMG PT F 6/1/2001 Bladder calculus Uroflow RB M 6/1/2001 Malignant bladder lesion Bladder instillation Complication or Morbidity or Mortality

4 Beginning Date: Ending Date: Procedures performed by: LYMPHATIC (as separate procedure) 1 Lymph node biopsy Lymphadenectomy, inguinal Lymphadenectomy, ilioinguinal Lymphadenectomy, pelvic Lymphadenectomy, retroperitoneal Other (LYM) (Detail) Other (LYM) (Detail) ABDOMEN 8 Exploratory laparotomy Drainage, retroperitoneal abscess Excision, retroperitoneal tumor/cyst Herniorrhaphy, over 5 years Herniorrhaphy, incisional Closure of evisceration Other (ABD) (Detail) Other (ABD) (Detail) 16 Other (ABD) (Detail) ADRENAL 17 Adrenalectomy, unilateral Bilateral 19 Other (ADR) (Detail) Other (ADR) (Detail) 1

5 KIDNEY 21 Drainage of perineal abscess Nephrostomy, open Nephrolithotomy, simple Nephrolithotomy, staghorn Pyelolithotomy Biopsy, needle Renal Biopsy, open Nephrectomy, simple, unilateral Simple, bilateral 30 Nephrectomy, radical Nephroureterectomy Heminephroureterectomy Nephrectomy, partial Renal cyst, unroofing Harvest of cadaver kidneys Nephrectomy, donor Homotransplantation Autotransplantation Percutaneous Nephrostomy Pyeloplasty Pyeloplasty plus symphysiotomy ESWL Renal Ultrasound Other (KID) (Detail) URETER 45 Ureterolithotomy Ureterectomy (separate procedure) Ureterolysis Ureteroureterostomy Transureteroureterostomy Ureteroneocystostomy, unilateral

6 51... Bilateral Ureteroneocystostomy, with bladder flap or 52 hitch Ureterosigmoidostomy Sigmoid conduit, separate procedure bilateral Replacement of ureter with bowel Cutaneous pyelostomy or ureterostomy, unilateral Bilateral 58 Other (UTR) (Detail) Other (UTR) (Detail) 60 Other (UTR) (Detail) 61 Other (UTR) (Detail) BLADDER 62 Repair of enterovesical fistula Cystostomy, trocar Cystostomy, open Cystolithotomy Excision urachal cyst or tumor Diverticulectomy Partial cystectomy Partial cystectomy, with ureteroneocystostomy Simple cystectomy complete Simple cystectomy with cutaneous ureterostomy Radical cystectomy with ureterosigmoidostomy Simple cystectomy with ileal conduit Radical cystectomy with ileal conduit Radical cystectomy with continent diversion

7 76 Pelvic exenteration with male urinary diversion Bladder instillation Cystometrics Complex cystometrogram Uroflowmetrics Needle EMG Voiding pressure studies Intra-abdominal voiding pressure Vesical neck plasty Urethropexy (Marshall-Marchetti) Abdomino-vaginal vesical neck suspension, with or without endoscopic control (e.g., Stamey, Raz, modified Pereyra) Repair of rupture Cystostomy, closure Repair of vesicovaginal fistula (abdominal) Repair of exstrophy, initial Enterocystoplasty Vesicostomy Bladder biopsy Bladder Tumor Fulgeration Cystourethroscopy with removal of calculus Cystourethroscopy with lithotripsy Urethroplasty with tubularization of posterior urethra and/or lower bladder, for incontinence Dilation of urethral stricture Anterior colporrhaphy Combined anteroposterior colporrhaphy Sling operation for stress incontinence Repair of vesicovaginal fistula (vaginal) Other (BLA) (Detail)

8 104 Other (BLA) (Detail) 105 Other (BLA) (Detail) 106 Ultrasound of Bladder (PVR) PROSTATE 107 Needle Bx Prostate Prostatectomy, perineal, radical Prostatectomy, perineal, radical plus pelvic lymphadenectomy Prostatectomy, suprapubic Prostatectomy, retropubic, simple Prostatectomy, retropubic, radical Prostatectomy, retropubic, radical plus 113 pelvic lymphadenectomy Open insertion of radioactive materials Percutaneous insertion of radioactive materials Other (PRO) (Detail) Other (PRO) (Detail) 118 Other (PRO) (Detail) URETHRA 119 Closure, urethro-rectal fistula Urethrostomy, external (separate 120 procedure) Urethrostomy, perineal Meatotomy Incise and drain periurethral abscess Biopsy of urethra Urethrectomy, separate procedure Diverticulectomy (female) Diverticulectomy (male) Excision of urethral prolapse Urethroplasty for anterior stricture

9 Staged Urethroplasty for anterior stricture, one 131 stage Transpubic repair membranous stricture Perineal 134 Reconstruction for incontinence Prosthesis for incontinence Meatoplasty Repair, urethral injury Fistula repair Urethral dilation male sound first Urethral dilation female Straightening of chordee with or without 141 mobilization of urethra Chordee correction for first stage 142 hypospadias repair Magpi/Mathieu Major urethroplasty Penoscrotal hypospadias Repair of epispadias Repair of epispadias with incontinence Closure, urethro-vaginal fistula Other (UTA) (Detail) Other (UTA) (Detail) PENIS 151 Revascularization (microsurgery) Meatotomy: Infant Destruction of lesion, penis Laser destruction, lesion penis Surgical excision, lesion penis

10 Destruction of lesion(s), penis (e.g., condyloma papilloma, molluscum, contagiosum, herpetic vesicle), extensive, 156 any method Biopsy, penis Amputation, partial Amputation, complete Amputation plus ilioinguinal 160 (inguinofemoral) lymphadenectomy Circumcision, Newborn using clamp Circumcision Rigidity test Correction of chordee without hypospadias Insertion of penile prosthesis, non-inflatable Insertion of inflatable penile prosthesis Shunt, cavernosum to saphenous vein Shunt, cavernosum to spongiosum, open Shunt, cavernosum to spongiosum, 169 percutaneous Repair of major injury Drainage, scrotal wall abcess Other (PEN) (Detail) Other (PEN) (Detail) 174 Other (PEN) (Detail) TESTIS 175 Biopsy, testis Excision lesion of testis Orchiectomy, simple, unilateral Bilateral 179 Orchiectomy, inguinal (radical) Reduction plus fixation, torsion Orchiopexy, unilateral Bilateral 7

11 183 Insertion testicular prosthesis Repair testis (trauma) Vasovasostomy Vasotomy for vasogram plus biopsy Other (TES) (Detail) Other (TES) (Detail) EPIDIDYMIS AND SPERMATIC CORD 189 Biopsy epididymis Excision lesion epididymis Excision spermatocele Epididymectomy, unilateral Epididymovasostomy, unilateral Ligation internal spermatic vein Other (EPI) (Detail) Other (EPI) (Detail) SCROTUM 197 Hydrocelectomy Incise and drain abscess Resection of scrotum Repair scrotum (trauma) Vasectomy Other (SCR) (Detail) Other (SCR) (Detail) ENDOSCOPY Percutaneous nephroscopy with calculus 204 removal or lithotripsy up to 2 cm Over 2 cm Percutaneous nephroscopy Percutaneous endopyeloplasty

12 Endoscopic injection of implant material into the submucosal tissue of the urethra 208 and/or bladder neck Cystoscopy Cystoscopy plus ureteral catheterization ureter and/or renal pelvis Cystoscopy plus cup biopsy, bladder Cystoscopy and fulguration Cystoscopy, TUR bladder tumor(s) (<2 cm) Medium bladder tumor(s) (2-5 cm) Large bladder tumor(s) Cystoscopy, hydrodilation of bladder Cystourethroscopy with direct vision 218 internal urethrotomy Cystoscopy, calibration and dilation, 219 stricture Cystourethroscopy with removal of foreign body, calculus or ureteral stent from urethra 220 or bladder (separate procedure) simple Complicated Litholapaxy; crushing or fragmentation of calculus by any means in bladder and removal of fragments simple, small < cm Large or complicated >2.5 cm Cystoscopy, extraction ureteral calculus Cystoscopy with placement of ureteral stent Cystourethroscopy, with ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any 226 method)

13 227 Ureteroscopy with biopsy or fulguration Ureteroscopy with resection of tumor Cystourethroscopy, with incision, fulguration, or resection of bladder neck and/or posterior urethra (congenital valves, 229 obstructive hypertrophic mucosal folds) Transurethral incision of prostate TUR bladder neck Transurethral resection of prostate TUR for regrowth of obstructive tissue 233 longer than one year post-operative Laser prostatectomy - coagulation Laser prostatectomy - vaporization Other (ENDO) (Detail) Other (ENDO) (Detail) 238 Other (ENDO) (Detail) 239 Other (ENDO) (Detail) 240 Other (ENDO) (Detail) 241 Other (ENDO) (Detail) 242 Other (ENDO) (Detail) LAPAROSCOPY 243 Laparoscopy, diagnostic Laparoscopic lymphadenectomy/pelvic Laparoscopic lymphadenectomy/retroperitoneal, single or 245 multiple Laparoscopic 246 lymphadenectomy/retroperitoneal, bilateral Laparoscopic repair of inguinal hernia Laparoscopic ligation of spermatic vessels

14 249 Laparoscopic nephrectomy Laparoscopic orchiopexy, first or one stage Second stage Laparoscopy, adrenalectomy Laparoscopy, partial nephrectomy Laparoscopy, nephroureterectomy Laparoscopy, prostatectomy Laparoscopy, destruction of renal lesion 256 (e.g. cryotherapy) Laparoscopy, other (Detail) Laparoscopy, other (Detail) 259 Laparoscopy, other (Detail) OFFICE VISITS 260 New patient Established patient Normal newborn Consultation Outpatient visit-established Outpatient visit-new patient Prolonged services TOTAL OF ALL PROCEDURES 11

15 AMERICAN BOARD OF UROLOGY PRACTICE LOG VERIFICATION STATEMENT Name Medical School: Urology Residency Training Program: Please indicate if you have an area of special focus in your practice (select one): General Andrology Endourology Female Infertility Oncology Pediatric Urolithiasis If you have had fellowship training, please state the subspecialty area, where and when the fellowship was done: Please describe your current practice in 100 words or less: The electronic log submission and documentation represent a true, complete, and accurate log of my consecutive office visits and surgical procedures for the required time period. Candidate: Signature Office Phone: Office Fax: Your signature on the Practice Log Verification Statement attests that you have reviewed the data contained in your log submission and that it is a true, complete, and accurate log of your consecutive office visits and surgical procedures for the required time period. If, following review by the ABU Committee charged with reviewing logs, it becomes necessary to repeat processing on a log submission due to errors, oversights, or omissions, a $500 fee will be assessed for this process.

16 PRACTICE BREAKDOWN Note: Submit this form by mail with your Practice Log Verification/Notarization Statement and Complicatons Narratives. Applicant Name: ABU ID: _ Total number of Clinical, Surgical and Administrative hours worked per week: Please fill in the appropriate number of hours for each activity for each day of a typical week. Note: Clinical hours are for clinical activities in hospital and office. NON-OPERATIVE CLINICAL WEEKDAY OR ACTIVITY RESEARCH ADMINISTRATIVE OTHER TOTALS Monday Tuesday Wednesday Thursday Friday Saturday Sunday TOTALS Please complete reverse side

17 Applicant Name: ABU ID: Do you perform more than 6 major open or laparoscopic procedures per 6-month period? If no, where do patients needing major surgery go? (Check appropriate response) I do not see this type of patient. Patient is referred to partner in practice. Patient is referred to another urologist outside my practice. Yes No Which of the following populations best describes the metropolitan area where you practice? (Check only one) Over 1,000, ,000-1,000, , , , ,000 Less than 100,000 Current Type of Practice: (Select below - check no more than three) FT - Full time PT = Part time FT PT FT PT FT PT FT PT FT PT FT PT FT PT Priv Prac Solo FT Priv Prac Group/Partnership FT Priv Prac Managed Care (HMO) FT Military/Govt FT Academic Faculty FT Medical Admin FT Salaried Hosp/Clinic FT PT PT PT PT PT PT PT Vet Admin Prac Employed by Industry (PRAC) Employed by Industry (Research) State/Local Govt Inactive Retired Other (please specify)