The European Board of Urology

Page 1 of 15 The European Board of Urology Sub-specialty certification application: Prostate cancer, A - General information A1 - APPLICATION IDENTIFICATION 1a. Application code blank 1b. EBU internal code 2. Date of application 3. Contact person 4. Contact email address 5. Contact telephone 6. Data collection period of treatments and results A2 - SUB-SPECIALTY OF THIS APPLICATION Sub-specialty

Page 2 of 15 A3 - CONTACT DETAILS 1. Name of the institute 2. Title and name of the Head of the Department of urology 3. Title and name of the Director of the Sub-specialty programme 4. Address 1 5. Address 2 6. Postal Code 7. City 8. Country 9. Phone Number 10. Fax number 11. E-mail address 12. Website

Page 3 of 15 B Institutional organization B1 - SUB-SPECIALTY 1. As a referral centre, the centre serves locally regionally nationally internationally 2. Number of population served by the centre regarding this specific sub-specialty 3. Total number of patients investigated per year in the subspecialty 4. Total number of patients treated per year in the sub-specialty B2 - UNIVERSITY AFFILIATION OF THE SUB-SPECIALTY CENTRE 1. University affiliation Yes No 2. If yes, name of university (universities) 3. Number of academic positions 4. Number of Ph.D. students

Page 4 of 15 B3 TEAMWORK 1. Supporting specialties in the multidisciplinary teamwork a. Oncology Yes No b. Pathology Yes No c. Radiology, including interventional radiology Yes No d. Nuclear medicine Yes No e. Intensive care unit Yes No f. Psychology Yes No g. Physiotherapy Yes No h. Pain centre Yes No 2. Regular multidisciplinary meetings a. Radiology meetings per month b. Oncology meetings per month c. Pathology meetings per month 3. Please list sub-specialised team members (consultants, and other dedicated staff members) Name Specialty (e.g. urology, radiology, oncology) Professional category (e.g. physician, nurse) Academic level (e.g. Ph.D.) Gender Total number of team members: 0

Page 5 of 15 B4 PATIENT'S PATHWAY Please describe the number of days for the average patient's pathway from referral assessment to follow-up. 1. Days from referral assessment to meeting with the specialist 2. Please fill in the number of days for each of the following two scenarios. Scenario A: patient goes directly to surgery Scenario B: patient goes to further investigation before surgery A: Days from meeting with the specialist to surgery B: Days from meeting with the specialist to further investigation B: Days from further investigation to surgery 3. Systematic follow-up Yes No Percent of treated patients 4. Institution of follow-up Own department % Referral unit % GP % 5. If follow-up is carried out at an external institution, please indicate to what extent (percentage of cases) there is a feedback of treatment results. %

Page 6 of 15 B5 DATABASES Does the sub-specialty centre have the following databases? 1. Disease register Yes No If yes: internal or national? Internal National 2. Results Yes No If yes: internal or national? Internal National 3. Complications Yes No If yes: internal or national? Internal National B6 FOLLOW-UP AT SUB-SPECIALTY CENTRE 1. Clinical follow-up? Yes No If yes, please describe in brief: 2. PSA measurment Yes No 3. Prostate biopsies Yes No 5. Are there morbidity and mortality (M&M) conferences? Yes No Frequency per month:

Page 7 of 15 C Facilities and resources C1 - TECHNICAL EQUIPMENT AND RESEARCH FACILITIES 1. Technical equipment available (you may choose both "In own department" and "In supporting unit") a) Transrectal ultrasound In own department In supporting unit Not available b) Transrectal prostate biopsy equipment In own department In supporting unit Not available c) MRI In own department In supporting unit Not available d) CT In own department In supporting unit Not available e) PET-scan In own department In supporting unit Not available f) Bone scintigraphy In own department In supporting unit Not available g) Laparoscopy, conventional In own department In supporting unit Not available h) Laparoscopy, robot assisted In own department In supporting unit Not available i) Transurethral resection equipment with endoscopic camera In own department In supporting unit Not available j) Radiation therapy unit: brachytherapy In own department In supporting unit Not available k) Radiation therapy unit: conventional external beam radiation therapy l) Radiation therapy unit: high dose radiation therapy In own department In supporting unit Not available In own department In supporting unit Not available 2. Research facilities Library including Internet access to medical journals Yes No Laboratory facilities Yes No Professional support for medical statistics Yes No 3. Bio-banking Does the centre have permission and a functional system for bio-banking? Yes No

Page 8 of 15 D Performance D1 - INVESTIGATIONS AND TREATMENTS PERFORMED AT THE CENTRE 1. Investigative method Number of investigations per year a) Transrectal ultrasonography + prostate biopsies b) MRI prostate c) CT prostate and pelvis d) Lymph node dissection, open e) Lymph node dissection laparoscopic f) Bone scintigraphy 2. Treatment modality Treatments performed at the sub-specialty centre a) Active surveillance / monitoring b) Watchful waiting c) Radical prostatectomy, open d) e) Radical prostatectomy, robot assisted laparoscopic Radical prostatectomy, conventional laparoscopic f) Transperineal brachy therapy g) Radiation therapy, curative external h) Radiation therapy, curative external, combined with hormonal therapy i) Salvage or adjuvant radiotherapy j) Salvage radical prostatectomy k) Palliative TURP l) Hormonal therapy, surgical m) Hormonal therapy, drug n) Radiation therapy, palliative o) Other medical treatment, advanced disease

Page 9 of 15 D2 - RESULTS LAST 2 YEARS Note: The data to be presented in the table below shall refer to the two-year data collection period you have choosen in form field A1: 1. Treatment modality (as primary treatment) Number of cases (please fill in the number of cases for all treatment modalities, also for those with N/A indicated in other columns) Freedom from biochemical progression, pad-free continence, good erectile function (if appropriate), freedom from radiation induced cystitis and proctitis, at 1year after completed treatment Need of 2:nd line treatment with curative intent, at 3 years after completed treatment (*) Need of palliative therapy after failure of treatment with curative intent, at 5 years after completed treatment (**) a) b) c) d) e) f) g) h) Radical prostatectomy, open Radical prostatectomy, robot assisted laparoscopic Radical prostatectomy, conventional laparoscopic Transperineal brachy therapy Radiation therapy, curative external Radiation therapy, curative external, combined with hormonal therapy Salvage or adjuvant radiotherapy Salvage radical prostatectomy i) Palliative TURP N/A (not applicable) N/A N/A j) Hormonal therapy, surgical N/A N/A N/A k) Hormonal therapy, drug N/A N/A N/A l) m) n) Radiation therapy, palliative Other medical treatment, advanced disease Active surveillance / monitoring N/A N/A N/A N/A N/A N/A o) Watchful waiting (*) Number of patients with a need of second line treatment with curative intent, on whom primary treatment was carried out 3 1 years before the starting point of the 2-year data collection period. (**) Number of patients with a need of pallative therapy, on whom primary treatment was carried out 5 3 years before the starting point of the 2-year data collection period. Example: The data collection period of a sub-specialty application is ranging from January 2011 to December 2012. Data on need of palliative therapy at 5 year may be collected for patients treated between January 2006 to December 2007.

Page 10 of 15 D3 - TREATMENT COMPLICATIONS BASED ON THE MODIFIED CLAVIEN'S SYSTEM LAST 2 YEARS Note: The data to be presented in the table below shall refer to the two-year data collection period you have choosen in form field A1: 1. Number of complications, occuring within 60 days of any treatment, or within the same time of hospitalization, based on the modified Clavien's system Treatment modality G1 G2 G3a 3b 4a 4b 5 a) b) c) d) e) f) g) h) Radical prostatectomy, open Radical prostatectomy, robot assisted laparoscopic Radical prostatectomy, conventional laparoscopic Transperineal brachy therapy Radiation therapy, curative external Radiation therapy, curative external, combined with hormonal therapy Salvage or adjuvant radiotherapy Salvage radical prostatectomy i) Palliative TURP j) Hormon therapy, surgical k) Hormon therapy, drug l) m) Radiation therapy, palliative Other medical treatment, advanced disease Show percentages (complications / total number of cases) D4 - COMMENTS 1. Any comments concerning performance.

Page 11 of 15 E Research and clinical studies E1 - ON-GOING RESEARCH AND CLINICAL STUDIES 1. Please list on-going research and clinical studies within the sub-specialty centre. 2. Please list on-going participation in multi-centrered studies in affiliation with the sub-specialty centre. 3. Please list on-going sponsor initiated clinical trials within the sub-specialty centre. E2 - NATIONAL SCIENTIFIC NETWORKS 1. Please list and briefly describe participation in national scientific networks. E3 - INTERNATIONAL SCIENTIFIC NETWORKS 1. Please list and briefly describe participation in international scientific networks. E4 RESEARCH FUNDING AND INDUSTRIAL COLLABORATION 1. Research fundings: please list Contributor, Amount, and Year for each funding. 2. Is there any financial connection to industry? Yes No If yes, please specify names of financing companies: 3. Please describe: what does the collaboration with the industry entail? Please describe the projects, and the financial and organizational frames of the collaboration.

Page 12 of 15 F Sharing of knowledge, teaching and training F1 - SCIENTIFIC PUBLICATIONS FROM THE SUB-SPECIALTY CENTRE 1. Publications in international, peer-reviewed journals last 10 years (non international, peer-reviewed publications will not be taken into consideration). Please list up to 25 most important publications in chronological order, the most recent publication first. 2. b) Books or book chapters last 10 years. Please list up to 25 most important publications in chronological order, the most recent publication first. F2 - ABSTRACTS FROM THE SUB-SPECIALTY CENTRE PRESENTED AT SCIENTIFIC MEETINGS 1. Please list up to 25 most important publications last 10 years in chronological order, the most recent publication first. F3. ACTIVITY IN COURSES AND MEETINGS THE LAST 5 YEARS 1. As members of organizing committees Please list up to 10 activities of most importance: name of courses or meetings, and organizations. 2. As faculty members Please list up to 10 activities of most importance: name of courses or meetings, and organizations. F4 - POST-GRADUATE FELLOWSHIP AND SHORT-TERM VISIT PROGRAMMES PROVIDED BY THE CENTRE 1. Please list the current fellowship programmes (FS > 6 months) and short-term visit programmes (STV 12 weeks) provided by the centre: Name of programme, Type of programme (FS / STV), Duration, Target group 2. Number of fellowship positions offered at the same time 3. Number of short-term visit positions offered at the same time 4. Number of consultants supervising fellows / short-term visitors 5. Do you train residents at the same time as fellows / short-term visitors? Yes No If yes, how many resident positions are there?

Page 13 of 15 6. a) How many fellows have been trained in the last two years? b) How many short-term visitors have been trained in the last two years? 7. Is surgical training or other practical training included in the fellowship / short-term visit? Yes No 8. What are the legal and hospital administrative requirements for a fellow / short-term visitor to perform hands-on training, and what are the required certificates (for domestic visitors, visitors from other European countries, and visitors from non-european countries)? 9. Please describe how the centre assures that the legal requirements are fulfilled, and assists the fellow / shortterm visitors in obtaining the required certificates? 10. Do the fellows / short-term visitors take part in activities other than related to the sub-specialty? Yes No If yes, please describe, and estimate to what extent (workload percentage) participation in other activities is required. 11. Do the fellows / short-term visitors get paid by the centre during their stay? Yes No 12. How are the fellowship / short-term visit programmes financed? Hospital budget Government foundation Private research fundations Industry Other: 13. Is any kind of test or certification of language skills required of the fellow / short-term visitor? Yes No If yes, please describe. 14. Are there possibilities to be accommodated nearby the institute? Yes No 15. Please provide us with contact details of the fellows / short-term visitors who have completed the fellowship /shortterm visit programmes over the last three years: Name, Year of completion, Name of institute, Hospital address, E-mail address

Page 14 of 15 G General information about the hospital G1 - TYPE OF HOSPITAL 1. Type of hospital Community hospital Private clinic University hospital Government institute Military hospital Other: G2 - MEDICAL SPECIALTIES 1. Urology Paediatric urology 2. Renal transplantation 3. Nephrology Dialysis unit 4. General surgery Paediatric surgery Vascular surgery Thoracic surgery Orthopaedics Plastic surgery Traumatology 5. Anaesthesiology Intensive care unit Emergency unit 6. Internal medicine Cardiology Haematology Gastroenterology Rheumatology Paediatrics 8. Oncology Radiotherapy Radiology Nuclear medicine 9. Neurology Neurosurgery Psychiatry 10. Emergency department 11. Clinical biology Microbiology Pathology 12. Dermatology Ophthalmology 13. Physical therapy Rehabilitation 14. Other (e.g. immunology) 7. Gynaecology/obstetrics

Page 15 of 15 H The department of urology H1 - NUMBER OF BEDS, Department of urology 1. Number of beds 2. Number of admissions per year 3. Number of outpatients per year H2 - STAFFING, Department of urology 1. Number of certified urologists 2. Number of other specialists 3. Number of residents 4. Number of fellows