POCKET GUIDE

POCKET GUIDEfor theINTERN & MEDICAL STUDENT

Table of contentsWelcome3Description of urology clinical service4Sub-intern goals and responsibilities4-7Intern goals and responsibilities8-9Overview of residency10Research at MGH Department of Urology11-12Basic concepts in urologyUrologic emergenciesGenitourinary trauma13-17Priapism17-20Fournier’s gangrene21-22General UrologyUrinary retention23-27Acute Renal Colic27-29Erectile dysfunction29-31Benign prostatic hyperplasia (BPH)31-33Evaluation of scrotal masses33-34Urinary tract infection35-38Urologic OncologyRenal Cell Carcinoma & Renal Cysts39-42Upper Tract Urothelial Carcinoma42-44Bladder Cancer45-47Prostate Cancer48-52ProceduresFoley catheter placement/Bladder irrigation53-57Bedside cystoscopy57-59Priapism – Corporal Irrigation59-60Updated 6/20152

WelcomeDear sub-intern/intern,We are proud to welcome you to the MGH department of urology. This is a very excitingtime in your career and finding a residency that fits you is of utmost importance. The goal ofour residency is to train you to be the best urologic surgeon you can be, and expose you to allaspects of urology. In addition, we hope to provide opportunities to help develop your interestsand take full advantage of the opportunities for collaboration that come along with training inthe city of Boston.In this guide you will find an introduction to our department and to provide you withbasic information that you might find useful during your initial arrival at MGH. More specific toour interns, we provide you a list of the faculty’s research interests and guidelines for choosinga mentor and project as you progress through your intern year.Michael L. Blute, MDChairmanAria F. Olumi, MDResidency Program DirectorUpdated 6/20153

Description of urology clinical serviceThe current clinical service is divided into three separate teams (Leadbetter, O’neil, andKerr). Average daily patient census is 6-8 patients per service. Each service has a junior resident,chief resident, and occasionally an intermediate resident. We have a wonderful PA, Diane Levis,who usually covers the O’neil and Kerr services while junior residents are in the operatingroom. The intern usually spends time on Leadbetter during which he/she will carry theemergency department consult pager and cover the patients on that service. Sub-interns willrotate through two of the teams (2 weeks on each team) at the discretion of the chiefresidents.Sub-intern rotation detailsAccommodationsPlease make plans for accommodations early since it can be challenging to find a place close toMGH. If you have any questions or have difficulty obtaining a place to stay please contact KimWilliams (kwilliams40@partners.org) and she well put you in touch with a resident who may beable to assist you. Consider proximity to the public transportation when choosing a place tostay.Useful tatingroom.com/ - sublet website for medical students, by medical students.Please be advised that these listings are provided simply as a convenience to students and thatwe do not officially endorse these establishments. Arrangements are made independentlybetween the establishment and the student.Public transportationBoston is a city with excellent public transportation. Please check the MBTA website(http://www.mbta.com/) for up to date information. Please note the earliest times that the Topens to properly plan your arrival for rounds during your rotation.Identification cardsThe ID office is located on the second floor of the Wang building. When you exit theelevators make a right and follow the signs to the MGH security office. There you will be able toget your picture ID.Updated 6/20154

Important locationsUrology resident call room – located in the Gray/Bigelow building on the 11th floor. This iswhere you will go to print your team lists and where operating room schedules will be postedon the board.Urology offices/library – Gray/Bigelow 1102. To access the urology library turn right afterentering the urology offices and head down the hall towards the room at the end.Emergency department – located on the first floor close to the Fruit street entrance to thehospital. As a sub-intern you are encouraged to follow the intern/residents to see consults inthe emergency department to get an idea of the breadth of consults that we have theopportunity to see at MGH as a result of being a large tertiary and level 1-trauma center.Cafeteria – located in the basement. There is also a coffee shop outside of the Gray/Bigelowelevators on the first floor and a small cafeteria on the basement floor of the Wang building.Computers – if there are no available computers in the urology call room you can use thecomputer in the urology library or you can use the resident lounge on the first floor of theWang building.Computer access/Online resourcesAfter obtaining computer access, please double check that you have access to CAS,Mosaic, and Apprentice. You will use these programs to access patient clinical information,operating room schedules, and to help print patient lists for rounds, respectively. If you do nothave access to these programs, please email Cindy Murphy (CMURPHY3@mgh.harvard.edu).Meeting with Chief residentEach sub-intern should meet with one of the three chief residents during the first fewdays of the rotation to discuss goals and responsibilities for the month.Team-workSub-interns are expected to work together as a team with their co-residents andmedical students. We expect that you will try to incorporate yourself into the team and reallytry to experience what it may be like to be an MGH resident. Your focus should be on trying tofollow your patients throughout the rotation (e.g. volunteer to write the post-op check on thepatient who you were in the OR with). At times there may be up to four other medical studentson service. Make sure that you are working together to assign each other cases in a way thatwill allow you to obtain a grasp of the different procedures performed at MGH, but also giveyou an opportunity to get to know the faculty.Pre-rounding/roundingTouch base with the junior resident on your team to find out exact details about how topre-round and other tasks that may be helpful in the morning. Rounds usually start at 6 AM, butUpdated 6/20155

may be earlier if there are conferences scheduled that morning or the team has a particularlylarge census (important to take into account when choosing your accommodations). Try to preround (obtain vitals) on the patients in your team if time allows. There will be times that the listwill be very large. In general, try to at least pre-round on the patients whom you have seen inthe OR and examine them before rounds. It will be up to your team chief, but you should try tocome up with an assessment and plan for your patient to be presented during rounds. Helpfollow-up on tasks during the day that may be helpful to other team members.Operating roomThe first day of the rotation make sure to take the scrub class so that you are able toscrub into cases. Once you are done with your scrub class please report to the urology officewhere Cindy Murphy will give you the information about who to report to next.The operating room schedule will be posted in the call room several days in advance.Please make sure to discuss which cases you will be scrubbing in on with your fellow medicalstudents a couple of days prior to the operation to allow time for preparation. In general, try tospend the day with one attending rather than trying to bounce around different rooms. This willgive you an opportunity to get to know the faculty in the department.You should have access to the patient’s medical record including clinic visits, imaging,and pathology. Make sure you come prepared to discuss the patient’s presentation, physicalexam findings, and indication for the procedure. In addition, be ready to discuss relevantanatomy for the procedure. You have access to Campbell’s urology through the MGH Treadwelllibrary (http://www2.massgeneral.org/library/ - ebooks - search for Campbell’s urology - login with partners username and password). Alternatively, in CAS you have a tab that is called“handbook” which contains links to pubmed, ebooks, and UptoDate for your review.ClinicDuring your rotation try to spend at least one afternoon per week in clinic to get a sensefor what office urology is like (schedule included in the appendix). This will be another way foryou to get to know the faculty in the department.PresentationMedical students who are applying to urology residency programs are required to give a10-minute presentation (8 minutes plus 2 minutes for questions) on a topic of their choice.Residents should try to identify a topic early on in the rotation and ask the chief residents forguidance on the specific topic. This should be a focused presentation with a thorough literaturereview. Students should be able to show mastery in the specific area and try to avoidpresenting summaries of chapters in Campbell’s. Furthermore, try to stay away from choosingtopics that are currently controversial in the field and/or do not have a clear consensus.Updated 6/20156

Letters of recommendationStudents should try to schedule a meeting with Dr. Blute (please email Cindy Murphy atcmurphy3@mgh.harvard.edu) towards the end of their rotation to discuss the departmentalletter of recommendation. Letters will be a compilation of comments received from residents,faculty, and assessment of your presentation. Please bring a copy of an up to date CV to yourmeeting with Dr. Blute.Updated 6/20157

Intern goals and responsibilitiesScheduleYou will have a total of 3 months of urology during your intern year. Your schedule willusually be Monday through Saturday. During your general surgery rotation you will rotatethrough surgical oncology, pediatric surgery, SICU, trauma surgery, and general surgery.ObjectivesThe objectives of the urology intern rotation:1.2.3.4.Become familiar with the management of post-operative urologic patientsUnderstand the management of common emergent urological consultsBecome facile in the placement of difficulty Foley catheters and bladder irrigationLearn the basics of endoscopy in the operating roomTeam-workThe intern will usually start on the Leadbetter service as the responding clinician andhold the emergency department consult pager (see details below). The urology intern jobcomes with great responsibility as you will be the first one assessing patients in the emergencydepartment and in charge of triaging these patients. If our PA is off, the intern will often assistin covering the list of the post-call resident.KnowledgeDr. Olumi will be providing you (the Urology categorical interns) with a copy of Smith’sUrology that you should read in completion during your intern year. In preparation for the inservice we will have a mock 25-question exam after intern year and 50-question exam afteryour first year of urology.ConsultsThe intern usually holds the consult pager that is usually used to call intra-operative,emergency department, and occasionally floor consults. Intra-operative – you will at times be called directly from the operating room for anintra-operative consult. This will range from a difficulty Foley placement toassistance with a potential bladder and/or ureteral injury. If it is the latter, try to getas much information about their primary concern, patient name/MRN, andimmediately contact the proper attending with the details of the consult. For theformer, ask about what catheters have been tried. Prior to going to the operatingroom make sure to take a thorough look through the patient’s history, labs, andprior imaging to look for a history of BPH, urethral stricture disease, and/or priorurologic surgery.Updated 6/20158