Iraqi BOARD OF UROLOGY

Station gradingiaverag

Calibration sheet:

What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarising findings to the examiner

F. Provide a provislonal diagnosis & Make appropriate differential diagnesis.

G. Ask for the appropriate investigations according to the priority

H. Give plan for suggested management system

L. Answer related questlons.

IRAQ Beard of Urology

Clinical Skills Assessment (CSA)

Type of station: Long Case

Station Title:LUTS / BPH&Bladder diverticulum &

vesical stones

Author's name:

Revised by: Urology accreditation team

Reference: Iraqi BU

Duration: 40 minutes
Patient Data :

History: 65

Luts several weaks before admision

BPH + vesical stones + RT sided bladder diverticulum

open prostatectomy and vesicostomy with incision of diverticulum neck.

Iraqi BOARD OF UROLOGY

Instructions to the assessors:

Patient data(to be completed based on real patient data):

History 65

Luts several weaks before admision

BPH + vesical stones + RT sided bladder diverticulum

open prostatectomy and vesicostomy with incision of diverticulum neck.

General examination:

Local examinaticn:

This station tests the candidate's ability to:diagnose, investigate and manage a case of LUTS

due BPH as well as communicate the management plan with the patient based upon the history

and clinical findings in the case as well as the investigations requested and provided to the patient.

Duration of the station: 60 minutes

Supervsed history taking and examination

Sheet presentation & Discusslon

20 minutes

20 minutes

Conduct of the assessors:

Observation:

The avaminers are expected to observe the candidate while he's taking a detailed history

and performing general and local examination.

Interaction:

The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the axaminer provldes

the results to the candidate.

Discussion:

Assessors will discuss the case with the candidate for 25 minutes.

Bell:

The bell rings at the end of the discussion time.The candidate has to leave the station once

the bell rings.

The Marking Sheet

It is recommended to fill the "History Taking" and "Esamination" sections of the marking

sheet as the task is being performed by the candidate

You must provide comments in case the examinee is awarded a "fail" describing the reason

for failure. These comments will be used for providing the examinee with feedback.

Page 4 of 10
Iraqi BOARD OF UROLOGY

31 What are the recommended tests ?

Recommended tests:

Relevani medical history

-Assessment of LUTS

Sevetty and bother (e, ALIA-SI)

-Plysical oxamination including

DRE

-Urinalysis

- Serum PSA

Frequenty-volume chart

‫ فراس صباح‬.‫جمع وتصویر د‬

‫مرحله خامسه مركز الجراحات‬

4) What is your differentlal diagnosis in this case?

5) Describe radiological findings in this case.?

6) What are the absolute & relative indications of surgery?

1-Although this previously was the presence of voiding symptoms without formal subjective or

objective quantification, wwe now recognize that the Indication is more likely to be moderate-to-

severe voiding symptoms attributed to BPH that are refractory to medical therapy.

2-Recurrent and robust gross hematuria

3-The findings of bladder calculi bladder diverticula

4-Bilateral hydronephrosis with renal functional impairment.

7) What are the indications & C/I for open surgery ?

ebreve lie is estimted tawish than Ifsiestde lader diherticua sih realrepabie
preateamy and divertksiectuny shoald be perfareed eneurently. If the pressteteny ia perfarmed vithent
he

divertkeletes, lacapete yg of the blader diverdium and satequent pesistest infection mas cerur. Large

hadder cal he ar at eable te y tarehrel fregctatke ay sle be reved dering the epen precelan.

Zoen prestteiory sheud aa beesderedwhm a patiee premts nakalmb efrhe hr ether anbo

ceedtiees that arment prpar pseitianing fer TUHP. Al, y h wbe tperfar in opee prestaleetom in mm with

recerre er caraks arethral endisees sacha ertral tricturer pvisypaspedias repuir, te avold the erethesl

traues sciated sith TERE. Finally, he assecialieeofiialhersia with an arged prstae gtspen

precnlare, beeathe hermia may be reaed s thesane kwer ahdeninal incive

Cantrintiatias ta open prestatectemy inclade ull fhreas glend, e preseace of prestale caner.nd pr

prestateckety r petvk ergery thet nay stiterate acrea ta the pretate gind.

8| What is the most appropriate period of stopping anticoagulation prior to proceeding with

endoscopic management of BPH? And does the period differ with the type of

anticoagulation.?

Page 7 of 10

Iraqi BOARD OF UROLOGY

Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination. You will
then present your findings and discuss the case with the examiners

Duration of the station: 40 minutes

Supervised history taking and examination

Sheet presentation & Discussion

20 minutes

20 minutes

Iragi BOARD OF UROLOGY

* Whats your management if significant hemorrage encountered post operatively ?

If significant hemorrhage is noted, the urethral catheter may be placed on traction so that the balloon

esataining 50 mL of saline ean compress the bladder neck and prostatic fossa. Constant and reliable

traction can be maintained by securing the catheter to the abdomen. In addition, continuos bladder

irrigation should be iaitiated to prevent clot formation. For maximal effect the inffow should be

through the rethral catheter and the outflow through the suprapubic tube. For most patients these

measures are nckequate and effective. However, if excessive bleeding persists after these measures, the

urethral catheter can be removed in the operating suite and a cystoscopie inspection of the prostatie

fossa and bladder eck can be performed to identify and fulgurate discrete Meeding sites. If marked

hemorrhage should continue to persist, open re-exploration should be strongly considered.

10) What is the post operative management for un eventual procedure?

On the first postoperative day the patient is started on a clear liquid diet and asked to

ambulate four times per day. Pulmonary exercises are continued. If the hematuria is resolved,

continuous bladder irrigation can be discontinued with hoth urethral catheter and suprapubic
tube placed to gravity drainage. Also, the balloen in the urethral catheter is partially deflated

to 30 ml of saline and residual clots are removed by irrigation.

On the seeond postoperative day, if urine is elear, the urethral catheter may be removed and

the suprapuble iube is elamped to allow a voiding trinl. The patient is cacouraged to ambuiate

and continue pulamonary exercises. When the patient tolerstes a regular diet, oral aaalgesies ean

be given and pareateral narcoties diseontinued. Appropriate discharge instructions are reviewed

Mith the patient at this time in preparation for discharge on the third day afler surgery.

On the third postoperative day the pelvie drain i removed if the drainage is less than 75

mL/24 hr. The skin staples are removed and replaced with Steri-strips in nonobese men. The

pathologic examination of the enucleated prostatie adenoma should be performed to confirm the

absence of adenocarcinoma of the prostate.

On discharge from the hospital the patient is encouraged to gradually increase his activity. If

the patient voids well with a minimal postvoid residual urine volume, the suprapubie tube is

then removed in the elinic on the fith day after surgery. The patient should be able to resume full

activity 4 to 6 weeks postoperatively with outpatient visits at 6 wecks and 3 months.

11) What ure the potential risks of open prostatectomy?

Potential risks of apen prostatectomy include urinary incontinence, erectile dysfunction, retrograde

ejaculation, urinary tract infection, bladcder neck contraeture, urethral stricture, deep vein thrombosis,

pulmonary embolus, and the need for blood transfusicn.

Page 8 of 10

Iraql BOARD OF UROLOGY

Aim/Focus of the station:

This station tests the ability of the candidate to diagnose, investigate and manage a case LUTS due

tobladder outlet obstruction and benign enlargement of prostate.

Station setup

Clothing& props

• Hospital gown

Set pieces:

• 3 chairs and a desk

Blue pen and white paper sheets

Examination bed & white sheet

Examination gloves

Disinfectant

Examination lubricant

• Paravan / partition for examination in privacy

• Stethoscope and sphygmomanometer

Laboratorylnvestigations:(given when requested by the candidate)

Urine analysis, urine culture & sensitivity

Kidney function test

• CBC

• Bleeding Profile

• PSA (Free and Total)

Radiologicallnvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography

Urological Investigations:(given when requested by the candidate)

Iraqi BOARD OF UROLOGY

Questions to be asked to the candidate:

1) What's meant by LUTS and IPSS?

e 121 TheP5 sore with pplemantary ity fe tion

Over the past mnth how d

have you

Not at Las than Lass than haf Abou haf

the tme

More thas

half the time

Aimot

alvan

all

dme in5

the time

Lhada ion of nt emptyng

yur blar omplely ater y

hedurinatine

2 had to uinate agan les than 2

hous ter you feshed unnating

1. oppet and sted agin

everalimes when you uirgted

14 fundtfcul to potpone

wirution
..had a weak urinary eam

2.

3.

6...had to pahar trun to begn

uretien

Ste or

No

Onca

Teie

3 ine

4 tiones

mors

7.Oer he ped monhowm

smes dd you mot typicaly t up

toate rom the tme yo t

to bad at nght al the t you

got the muming

Supplanntory quton- Qualty af det unery mns

(Uyauwere to pend the ret of your l wih jer umary conin theyisnow how would you t t

aDigted

2) What would you loek for on axamination?

Palpable bladder

Enlarged (balotable) kidneys

Specific festures
Prostate-size, consisoncy, presence of nodules

Note Assess anal tone and sensation during digtal rectal examination (DRE)

Renal falure, eg fluid overicad signs of uraenia

General features

Neurological disorders eg tremor gait disturbance

Iraqi BOARD OF UROLOGY

UROLOGYLONG CASEMARKING SHEET

Examiner's Name

Examiner's Name:

Candidate's Name:

Candidate's Number:

Performance

Area
Items

Clear

Marginal Marginal Clear Fail Comment

Pass

Pass

Fail

History Taking

Personal H

c/o & PresentH

Past H& Family H

20

16

14

Examination

General status

Vital Signs

Regional esam

Systems review

Exposure & position

Inspection & palpation

Percussion & Auscult.

General

Examination

Lecal

20
(Abdomino

vehic)

16

14

Special tests

DRE

Ecternal Genitala

Main signs in this ca:

dentilying

Physisal Signs

Communication

Introduction to patent

Attitude

Language

Skls

Interpretation & Summary of findings &

Management

Diff. Du for this case:

21

17

10

Main management

lines for this case:

Answering related

questions
20

16

14

9.

Global Judgment

Serious Concern

Pape 9 of 10