MISSION STATEMENT

The mission of Endourology Society fellowship training and certification of advanced clinical training programs is to facilitate the development of academic and clinical excellence in endourology and minimally invasive surgery including robotic urologic oncology.

I. SCOPE OF TRAINING

Fellowship training is focused on development of advanced knowledge, experience and technical skills in endourologic and laparoscopic and/or robotic assisted surgery. Fellows should also receive training in translational or basic science, as an underlying goal is the training of future academicians and potential national and international leaders in the specialty.

Three tracks for fellowship training exist:  endo/stone, laparoscopic/robotics, and combined endo/stone, laparoscopic/robotics.  Additional certification and recognition for completing a Robotic Surgery and Minimally Invasive Urologic Oncology Fellowship is attainable within the scope of training (effective July 1, 2023).

II. QUALIFICATION OF THE APPLICANT

The applicant must have completed a nationally approved and accredited residency program in urology.

III DURATION OF FELLOWSHIP TRAINING

Both two year and one year fellowship programs are offered and endorsed by the Endourological Society. Each type of training program will offer their fellows a unique and distinct certificate upon completion of their training requirements with the appropriate designation to distinguish one from another.  For two year fellowships, the duration of training is 24 months of which 12 months (or 50% of duration of fellowship) is devoted to research.  The 12 month research time can be nonconsecutive.  A program may participate in both two year and one year fellowships provided that the appropriate resources are available and approved by the Fellowship Committee. 

NOTE:  Once the type of fellowship or advanced clinical training is determined and filled and the fellowship year has begun, programs are not allowed to change designations at any time during the fellowship.

IV. INSTITUTIONAL REQUIREMENTS

• The training program must have an affiliation with an ACGME or Royal College of Physicians and Surgeons accredited urology residency program or a nationally accredited alternative body such as a medical school. The sponsoring institution must have sufficient clinical volume and technology to meet the needs of the trainee.
• The sponsoring institution must have a solid research environment. Fellows are expected to participate in translational and/or basic science research for at least 50% of the time during a fellowship. They must work in either a laboratory which has external funding (NIH, NCI, DOD, etc) or in which the mentor is doing novel research and has had a history of publications in high impact scientific journals. Another option is for the fellow to complete an advanced degree (Masters) during these two years such as a MPH, MPHE, Masters in clinical research, Masters in a biological discipline (pathology, biochemistry, molecular genetics, physiology, pharmacology etc.). 
• Administrative Fee:  A yearly $500 (US) administrative fee is required from each fellowship program payable to the Endourological Society. Fellowship programs are also responsible for the annual Endourological Society membership fee for their fellow/s at $100 per year per fellow. 

V. DIRECTOR RESPONSIBILITIES / REQUIREMENTS

• To qualify as a program director, one must be an official member and in good standing with the Endourological Society. 
• Must demonstrate commitment to the clinical and academic education of the trainee, be 3 years out of fellowship/residency training and in practice at the sponsoring institution for at least 2 years. 
• A separate director for each clinical domain is recommended (e.g. one for endourology and a separate one for laparoscopy and robotics)
• The focus of the directors' practice and academic endeavours should be the respective domain area. The majority of the directors' cases must be endourologic, laparoscopic or robotic. Imaged-guided procedures, including percutaneous ablation, are encouraged. They must submit details of surgical volume at the time of applying for a fellowship program and fellowship program review.
• Program directors must also be actively involved in clinical, translational and/or basic science research. The collective faculty of the fellowship program must have a minimum of 6 publications pertaining to the field every 2 years.
• Program directors must have attended the World Congress meeting at least 2 out of every 3 years.
• All directors must be approved by the fellowship committee based upon reviw of their CV, academic track record, engagement within the society and contribution to the field of endourology. 
• Barriers to Practice:  It is the responsibility of the fellowship program director (along with institutional credentialing committee) and the fellow candidate to ensure that all barriers to practice (i.e. visas, licensure, language, religion, handicap, others) within the program's institution, facilities and clinical practice sites are resolved in a timely manner prior to the agreed start date of the fellowship. The fellow must bear the cost of any associated application fees unless there has been an alternate arrangement made with the program or institution. In the event that the fellow candidate is found to be negligent in completing these necessary tasks in time to begin fellowship upon the agreed start date, it is the right of the program with support from their institution to discharge the fellow candidate from his/her fellowship and void the contract of employment. The Endourological Society is responsible only for conducting the fellowship match process and ensuring the quality of the fellowship program sites, but is not liable or responsible for resolving any barriers to practice. Furthermore the Endourological Society does not bear any responsibility for finding an alternative fellowship position in the event that a fellow is discharged from his position due to noncompliance with completing paperwork to mitigate any and all barriers to practice or for other legitimate reasons whereby the employment contract is terminated.  
• Fellow Compensation: All program directors are responsible to ensure that there is department or institutional funding for salary and fringe benefits for the fellow unless the fellow is self-funded.
• Formal Fellow Evaluations: The director must formally evaluate the fellow at least every 6 months and forward these evaluations to the fellowship review committee via society headquarters, the technical and clinical skills, research and academic acumen and productivity must be key components of this evaluation/report. The director(s) is responsible for approving and validating the fellow’s case log that is submitted both at 6 months and at the end of the fellowship. It cannot be changed once these signed documents have been submitted.
• Fellow Endorsement Letter: A summary of the director’s fulfilment of these requirements must be submitted as an endorsement letter in June of every year to the Endourology Society Office for review by the Fellowship Review Committee. Program director endorsement letter must state that they have signed off on fellow case logs to ensure that the fellow did indeed participate in and enter their cases appropriately.
• Fellowship Program Website: Program directors are advised to periodically update their program description on the Endourological Society Website Fellowship Program Page (https://www.endourology.org/fellowships/clinical#sort=name&sortdir=asc) for accuracy.  Programs must declare whether they will take only North American graduates or if they are willing to take foreign graduates as well.
• Transferring A Fellowship: The Program Director of an accredited fellowship may transfer the fellowship program to a different institution subject to application, review and approval by the fellowship committee.
• Transferring Program Directors: In the event that a fellowship program director wishes to transfer leadership to a new program director(s), a letter of support from the original program director should first be sent to the fellowship committee. The committee will then review the credentials of the new program director(s) subject to the same requirements of any new program.

VI. FELLOWSHIP REQUIREMENTS (2 Year Programs)

A.  2 Year Fellowship in Endourology and Stone Disease:

Case Requirements:

• 60 percutaneous renal cases 
• 120 ureteroscopic cases 

 As management of complex stone patients often require integration of care including other health-care providers such as nutritionists and nephrologists, all fellows involved in such training should demonstrate participation in multidisciplinary care of the complex stone patient during their fellowship. This is to ensure comprehensive training in the evaluation, counselling, care and treatment offerings for such stone patients. This can include documentation by the fellowship director(s) of participation in multidisciplinary clinics or conferences (e.g. with radiology, nephrology, nutrition, etc.)

B.  2 year Fellowship in Laparoscopic and Robotic Surgery:

Case Requirements:

• 150 robotic cases, 30 of which should be upper and lower tract procedures 

As laparoscopic/robotics has become intimately part of urologic oncology training, all fellows involved in such training should demonstrate participation in multidisciplinary oncologic care of the urologic patient during their fellowship. This is to ensure comprehensive training in the evaluation, counselling, care and treatment offerings for the urologic oncology patient. This can include documentation by the fellowship director(s) of participation in multidisciplinary clinics or conferences (e.g. with radiation oncology, medical oncology, urologic pathology, urologic radiology, etc.)

C.  2 Year Combined Endourology Fellowship:

Case Requirements:

• 30 percutaneous renal cases
• 60 ureteroscopic cases, 100 laparoscopic/robotic cases of which 20 of these must be upper and lower urinary tract procedures. 

D.  2 Year Robotic Surgery and Minimally Invasive Urologic Oncology Fellowship Certification (optional)

Case Requirements:

•         150 oncologic surgical cases to include at minimum 100 lap/robotic cases of which:
•         30 laparoscopic/robotic upper tract cases
•         30 laparoscopic/robotic lower tract cases
•         12 percutaneous/transcutaneous ablation/focal therapy upper or lower tract 

Case Log Entry:  Fellows should actively update their cases throughout the year through the case log entry system to allow both the fellow and fellowship program director(s) to monitor progress in completing the requisite program requirements.  Clinical training towards a fellow's operative case log can occur at any facility that the mentor(s) are affiliated with (e.g. academic hospital, VA, ambulatory surgical center).  Only cases where the fellow was primary surgeon or first assistant should be logged.  Of note, bilateral procedures count as two separate procedures. 

Mission Trips:  For those programs that are involved in sending fellows on mission trips, operative cases performed during mission trips may count towards a fellow's case requirements, provided that the cases are specific to the fellow's training program and are signed off by both the mission surgeon mentor and the program director.  A formal document must be submitted to the Fellowship Committee and Society Executive Secretary. 

Research Requirement: The fellow must participate in basic science/translational research for a minimum of 12 months or receive an advanced degree as previously described during the 2-year period of training. The 12-month research time can be non-consecutive. Approximately 50% of the 2 years should be devoted to research.

Publication Requirement: Fellows are required to have 1 article submitted to the Journal of Endourology and one article accepted for publication or published in any journal from work they performed during the fellowship with the fellow as the first author, to receive certification. Publications in open access journals or case reports do not qualify.

Endourological Society Essay Contest: The fellows must also submit a paper to the annual essay contest of the Endourological Society during the last year of training before successful certification can be awarded.

• This paper must be based upon work they performed during their fellowship and may be either a translational or basic science investigation or an original clinical study (case reports and literature reviews are not acceptable).
• The subject must be related to the field of endourology or minimally invasive surgery including topics such as stone disease treatment and prevention, laparoscopy and robotic surgery, lasers, ESWL, ureterorenoscopy and percutaneous surgery, tumor ablation, uroradiology or new technologies and innovations pertinent to the field of endourology. Quality improvement projects are encouraged.
• The essays can have additional co-authors, but the first author must be the fellow.
• Note that the essay may also be used to fulfil the fellow’s Journal of Endourology submission requirement, however, manuscript submissions to the fellow essay contest does not automatically guarantee publication in the Journal. Rather, the fellow must still formally submit his/her manuscript through the normal Journal of Endourology process (https://home.liebertpub.com/publications/journal-of-endourology/32/for-authors)
• Review of the fellowship essays will be conducted by a panel of judges appointed by the fellowship committee. The review committee is divided into Basic/Translational Science and Clinical Research categories. The criteria used to assess the suitability of the fellows essay is based upon whether the essay meets the scientific quality for publication in the Journal of Endourology.
• If the majority of the judges believe that the essay is thought to be of insufficient quality to be submitted for publication, the fellowship committee will review the manuscript to determine if it is acceptable for certification. If not, the fellow will be given 4 weeks to submit a revised manuscript to the fellowship committee for review. If the committee determines that the revised manuscript is again deficient, the fellow will not receive a certificate and the program will be issued a warning. If this again occurs the following year, the program will be placed on probation and if happens a third year in a row, the program will lose its accreditation for at least 3 years.
• Monetary awards will be given to the top three essays in each category as follows and will be announced by email. The 1st place winner from each category is expected to make a 5 minute presentation of their essay at the World Congress of Endourology meeting.

Academic Portfolio: Graduating fellows must submit an academic portfolio of works produced during their 2 years of training including manuscripts, chapters, videos, lectures, poster presentations and abstracts (to national and international meetings) to the Society Office.

The program director(s) must submit a letter of endorsement regarding the fellow’s progress and successful completion of their training program.

Fellowship Certificate: A certificate of completed fellowship training will only be granted to those who have completed the all of aforementioned requirements in addition to receiving a positive fellowship endorsement letter from the program director. If fellows have not complete all requirements at the end of their training due to extenuating circumstances, the primary program director may request a variance addressed to the Fellowship Committee Chair, which must be reviewed and approved by the Fellowship Committee members before a certificate is granted. 

VII. 1 YEAR FELLOWSHIP PROGRAMS

• The Society recognizes that individuals may desire further training in endourology/stone surgery or laparoscopic/robotic assisted surgery. Such training should result in the improved delivery of patient care which is a priority of the Society.
• Individuals can participate in one year fellowship programs. This is in distinction from a two-year Endourology Society fellowship training program. 
• Individuals can obtain RSMIUO fellowship designation if all criteria are achieved and upon review by the Fellowship Committee upon completion.
• Training programs must be approved by the Endourology Fellowship Review Committee.
• The requirements of the program director(s) and sponsoring institution are the same as to those listed for the fellowship programs.
• The participants and the programs are subject to the same process as those for fellowship programs.
• Participants must submit a clinical, translational or basic science paper for the annual essay contest as the first author. Quality improvement projects are encouraged. These papers will be judged using the same process for the fellowship essay contest. If the majority of judges feel that the essay is not suitable to be submitted for publication, the previously outlined process for essays thought to be deficient will be enacted.
• Image-guided procedures, including percutaneous ablation, are encouraged. 
• Candidates for these programs in North America must participate in a match conducted by the American Urological Association. 
• Participants must complete the aforementioned requirements to receive a certificate in fellowship training.
• Participants can also receive a certificate of RSMIUO fellowship completion if the aforementioned requirements are completed.
• An individual can only receive 1 certificate at the completion of their one-year training period (no dual certificates).
• The Endourological Society Fellowship Review Committee will be responsible for reviewing these metrics. 
• Deficiencies in case volume and/or completion of the essay will result in a program being put on probation and may eventuate in loss of the program accreditation as per the process outlined for fellowship training.  The appeals process is the same as for fellowship programs. 
• A program may lose accrediation for the same reasons listed for the fellowship programs.  The appeals process penalities and re-instatement policies are also identical. 

The following 3  programs are available: endourology/stone surgry, laparoscopic/robotic surgery or a combined (i.e. endo/lap/robotic) program.  The trainees will need to actively participating in at least the following number of cases to obtain a certificate:

A. 1-Year Endourology and Stone Disease Program

Case Requirements: 

• 60 ureteroscopic cases
• 30 percutaneous renal cases
• Participation in multidisciplinary clinics or conferences

B. 1-Year Laparoscopic and Robotic Surgery Program

Case Requirements:

• 100 laparoscopic/Robotic cases (of which 20 of these must be upper and lower urinary tract procedures.
• Participation in multidisciplinary clinics or conferences.
• If the minimum numbers of upper or lower tract lap/robotic cases are not performed but the training is otherwise acceptable in all respects, the committee will award a certificate that specifies the area of expertise at the training center. (e.g. lower tract, prostate, upper tract).

C. 1-Year Combined Program 

Case Requirements:

• 30 retrograde ureteroscopic cases
• 15 percutaneous renal cases
• 50 laparoscopic/robotic cases

D.  Robotic Surgery and Minimally Invasive Urologic Oncologic Certificate

• 100 oncologic surgical cases to include a minimum of 100 lap/robotic cases of which:

                 30 laparoscopic/robotic upper tract cases

                 30 laparosopic/robotic lower tract cases

                 12 percutaneous/transcutaneous ablation/focal therapy upper or lower tract

VIII.  ROBOTIC SURGERY AND MINIMALLY INVASIVE UROLOGIC ONCOLOGY FELLOWSHIP (RSMIUO)

Administered by the Endourological Society with the support of the Society of Urologic Robotic Surgery and Focal Therapy Society. 

Fellowship Structure:

**All Fellows and Fellowship Directors must be active, paying members of the Endourological Society, Society of Urologic Robotic Surgery and/or Focal Therapy in good standing.  

1. Curriculum 
   1. Core knowledge outline: The fellowship directors are to ensure that each fellow has this resource available and access to references. Knowledge of this material is expected to be learned via self-study.
   2. Attend/view video conference lecture series provided by Endourology Society members.
   3. Fellow self-reported attendance at oncology oriented Endourology Society Webinars and reviews of Atlas of Minimally Invasive Urologic Surgery (Videourology)

2. Training period: Expectation that all fellowships have minimum one year clinical training that meets the surgical and educational requirements. Two-year fellowship wherein the second year is additional clinical or research exposure to be determined by host institution. Approximately 50% of the duration of a 2 year fellowship must be devoted to research or an advanced degree.

3. Surgical Case Requirement:
   1. 150 laparoscopic/robotic oncologic surgical cases to include at minimum:
      1. 30 laparoscopic/robotic upper tract cases
      2. 30 laparoscopic/robotic lower tract cases
      3. 12 percutaneous/transcutaneous ablation/focal therapy upper or lower tract**
   2.  Completed case log requires fellowship committee approval to grant certificate

4. Peer reviewed publication requirement
   1. 1 published article in the subject matter of oncology
   2. 1 submitted to Journal of Endourology.

5. Oncology Knowledge Assessment Test (OKAT)
   1. OKAT exam is required for the fellow in this program.  Registration is as per the AUA administered site.  In additiona, all fellowship faculty are encouraged to take the exam at least every 2-3 years. 

   2. Advanced Instructions for the Oncology Knowledge Assessment Test - American Urological Association (auanet.org)

      OKAT Program Deadlines and Timetable - American Urological Association (auanet.org)

6. Multidisciplinary Exposure
   1. Every program must provide structure to this requirement
   2. Approval by fellowship committee required
   3. Expectation of monthly attendance at multidisciplinary cancer conferences
      1. DOT meetings
      2. Journal club
   4. Opportunity for structured clinical rotations (5% time commitment). Examples include:
      1. Medical oncology
      2. Radiation oncology
      3. Radiology
      4. Advanced imaging
      5. Ablation/focal therapy
      6. Pathology

**  The Endourological Society recognizes that various procedures may qualify as meeting this requirement including but not limited to percutaneous upper tract urothelial carcinoma resections, percutaneous renal tumor ablations, and prostate focal therapy.  Transperineal prostate biopsy is a diagnostic procedure and does not qualify for this criterium.  The Society recognizes that procedures such as renal tumor ablation and focal therapy may be performed by radiology at some institutions.  For this requirement, it expects that the fellow should observe/participate/be involved in the evaluation and treatment plan to whatever extent the institution allows. 

IX. EVALUATION

The endourology fellowship program must have an ongoing independent assessment of the following components of the education program: fellow performance (clinical judgment, management strategy, informed consent, operative ability, aftercare and management of complications, critical evaluation of journal articles and research domains), faculty performance, patient care, and program objectives. Well-defined mechanisms for evaluation of each of these components must be implemented as well as methods for using the feedback gained for improvement of the program.

X. MATCH PROCESS

• Fellowship programs in the United States and Canada must participate in the match process which is conducted by the American Urological Association. A fee of $200 (US) is required for the applicants participating in the match.
• It is each respective program’s responsibility to determine whether a candidate has proper credentials to be a fellow at their respective institution and that any barriers to practive are addressed (i.e. visas, licensure, language, religion, handicap) If they do not have proper credentials or if unsurmountable barriers exist, the program should not list the candidate on their match list.  If a candidate matches with a program, the program is obligated to provide training and resources unless the candidate provided false information regarding their credentials.  If the program refuses to train a matched applicant, they will lose their accreditation.  They may re-apply for  fellowship accreditation 3 years later.  If the candidate does not accurately disclose credentials, the matching program is not obligated to provide fellowship training. In addition, the individual will be banned from participating in the endourology match process.
• All programs must submit match lists for each of the positions that they register for and are obligated to accept the applicant that they match with.
• If a program does not match and finds a fellow outside the match, a fellowship application needs to be completed by the fellow and reviewed by the fellowship committee. There will be a $200 application fee if the applicant has not already registered for the match. Trainees whose programs do not participate the match will not receive a training certificate from the Endourology Society.
•  Trainees whose programs do not participate in the match will not receive a training certificate from the Endourological Society. 

X1. REMEDIAL ACTION(S)

A. PROBATION

• A program may be placed on probation for 2 years if the minimum number of index cases is not performed, if the academic productivity (minimum number of publications and fellowship essay) is inadequate, if case logs are not submitted by the end of the fellowship, if the program director is delinquent in the aforementioned responsibilities/qualifications, if substantive and repeated concerns are raised about the program director’s ability to adequately mentor or train a fellow.
• The program director will receive written notification, and is expected to respond by letter within a month on how each deficiency in the training program will be rectified in a reasonable time scale.
• The probation may be appealed. The initial step in this process is to send a letter to the Fellowship Review Committee outlining the rationale for reversal of probation. Subsequent steps may include a phone interview with the head of the Fellowship Review Committee or interview with the Fellowship Review Committee members during the occasion of the World Congress meeting.
• If the deficiencies in the program are not rectified within one year of the start of probation, the program will lose accreditation. The program must wait a minimum of 2 years before reapplying for accreditation. Programs on probations will be listed on the Endourology Society’s website.

B. LOSS OF ACCREDITATION

• Reasons for loss of accreditation include issues surrounding probation thar ere not addressed or rectified as listed above. Absence of a qualified program director, academic fraud/unethical conduct, and violation of the match process. An example of the latter is if the program offers specific ranking information or makes a job offer to an applicant prior to the match. If accreditation is lost because of lack of a qualified program director, it will be restored immediately once this deficiency is rectified.
• If match rules are violated, the program must wait 3 years before applying for accreditation.
• Individuals who have matched with a program that has lost accreditation but have not started their fellowship may be allowed to seek positions in accredited program which have open positions post-match. In addition, those who are currently enrolled in such a program may transfer to an accredited program which has an open position after the match. If the fellow elects to stay in the program, he/she may be eligible to receive a fellowship certificate if the aforementioned fellowship requirements have been met.
• If the reason for the loss of accrediation is academic fraud/unethical behavior, the program and the director must wait 5 years before reapplying for accreditation. The same process outlined for probation can be used to appeal loss of accreditation.
• Programs that do not have a fellow for 3 consecutive years, must reapply for fellowship program site.