Association of Women Surgeons

Although classified as a surgical subspecialty, urology focuses on both the surgical and medical management of diseases of the male and female urinary tract as well as the male reproductive organs. As a result, urology presents a wide spectrum of practice opportunities, ranging from office practice to minimally invasive endoscopies to major open surgical procedures. This variety is a particularly attractive feature of urology.

Urinary stone disease has been the mainstay of urologic practice since ancient times. The highly morbid surgical procedures of early urologists were primarily designed remove bladder stones, usually via a perineal approach. Positioning patients for such procedures resulted in the term “lithotomy position” which is still commonly used today for both urological and non-urological procedures. Rigid and flexible ureteroscopy, percutaneous endoscopic methods of renal stone fragmentation/ removal, and extracorporeal shockwave lithotripsy have largely rendered open surgical procedures for urinary stone disease obsolete. In addition, advances in the understanding and diagnostic techniques for metabolic disorders that cause stone disease has resulted in improvements in the medical management of nephrolithiasis, reducing the risk of recurrent stone formation.

Another disorder which has historically distinguished urology from other surgical fields is obstructive uropathy. Removing obstruction in the urinary collecting system in order to preserve and improve renal function and/or relieve discomfort is typically perceived to involve the reduction of bladder outlet obstruction caused by benign prostatic hyperplasia in older men. However, the treatment of obstructive uropathy encompasses a wide range of disease processes and patient populations, including the correction of congenital posterior urethral valves or ureteropelvic junction obstruction in children. In fact, the urinary tract is affected by congenital anomalies more than any other organ system. These congenital abnormalities run the gamut from the relatively common problem of the undescended testis to the complex area of ambiguous genitalia. Most urologists routinely repair the typical congenital urologic anomalies in children, but the more complex problems are often referred to urologists with specialized training in pediatric urology.

The detection and treatment of urologic cancers is a large portion of most urologic practices. The largest proportion of urologic oncology practice is usually spent in the diagnosis and treatment of prostate cancer. In addition, urologists commonly perform open surgical procedures for renal, bladder, and prostatic malignancies. The same endoscopic skills utilized by urologists to treat urinary stone disease are frequently employed for diagnosis and management of most cases of transitional cell carcinoma. These endoscopic approaches have expanded to include laparoscopy for the performance of nephrectomy for appropriate renal cell carcinomas. Laparoscopic performance of other urologic cancer surgery is performed in referral centers. For advanced tumors, the development of multimodal therapy, in which chemotherapy, radiation therapy, and surgical treatment are used in conjunction, have yielded dramatic successes in the treatment of testis tumors and Wilms' tumor. Similar multimodal regimens are being developed for other advanced genitourinary malignancies.

Male sexual dysfunction and infertility are commonly treated by urologists; however, the introduction of oral medications for impotence has opened this field to internists and general practitioners. Other non-surgical therapies are also available for erectile dysfunction. For individuals failing less invasive management, urologists can restore function by the placement of a prosthetic device. The area of prosthetics in urology not only encompasses the various forms of penile prostheses, but also artificial urinary sphincters. The management of male infertility has generally focused on the surgical ligation of varicoceles and relief of acquired and congenital obstructions within the genital system. Advanced in vitro fertilization techniques, particularly the ability to perform intracytoplasmic injection of a single sperm into an ovum, has stimulated the development of microscopic testicular dissection to retrieve sperm and improve the chances of fathering a child for significantly subfertile men. 

Few areas within the scope of urology are shared with other surgical specialties. Urologists may serve as primary or assistant surgeons for renal transplantation procedures and may perform other areas types of vascular surgery such as microvascular surgical procedures performed for certain cases of impotence and renal artery reconstruction in patients with renovascular hypertension. Urologists also often play a substantial role in the evaluation and surgical treatment of adrenal disorders. Trauma to the genitourinary system often involves the urologist as one member of the trauma team during the initial evaluation of the multiply-injured patient. Urinary tract infections affect every age group in both sexes thus there is inevitably a large cross-disciplinary approach to this problem with Urologists interacting with internists, pediatricians, and gynecologists in the management of patients with bacteriuria. In addition to stone disease, congenital malformations, and malignancies, which occur in both genders, there are urologic problems seen almost entirely in women such as stress urinary incontinence and interstitial cystitis. In addition to urologists, these female urologic disorders, may be treated by some gynecologists. Many fellowship training programs in urogynecology accept both urologists and gynecologists.

The field of urology has long been a desirable specialty, attracting some of the most competitive medical students. The urology match typically takes place in January, in contrast to the National Residency Matching Program (NRMP) match, which usually occurs in March. Due to this timing, the urology match is commonly referred to as an "early" match. The early match allows students who do not match with a urology training program to enter the NRMP match for alternatives without having to wait a full year until the next match takes place. Applicant interviews with urology training programs typically occur October through December. In 2000, there were 113 civilian urology residency programs accepting a total of 230 first year residents. Individuals participating in the urology match are encouraged to rank several programs to increase their chances of obtaining a training position. For more about the urology matching program, contact the American Urological Association Office of Education, 2425 West Loop South, Suite 333, Houston, TX 77027-4207. In 2003 urology residency programs began participating in the matching program administered through the American Association of Medical College’s centralized Electronic Residency Application Service (ERAS) matching system. Previously, resident applicants were required to submit separate applications to each prospective program in formats that varied from institution to institution. Access to the ERAS system is available here. For individuals who have already completed a portion of residency training in urology or other fields and are seeking vacancies in urology residency programs, see a current list here.

First and second year medical students considering urology as a specialty should identify members of the urology faculty at their medical school who are willing to review their curriculum vitae and offer specific advise regarding enhancing their application. Generally, if the student’s schedule allows, participation in a research project will improve the chances of matching with a program high on their list. The more in-depth the research, the more the application is enhanced. Research does not necessarily have to be in the field of urology to boost one’s application. If the student is unsure of having adequate time to complete a project, however, she should not obligate herself. Failing to follow-through on the research commitment will reflect more poorly on the applicant than the lack of any research experience.

Classroom performance is important as many top programs use class rank or other honors as criteria for an invitation for an interview. Similarly, a student’s performance on Parts 1 and 2 of the National Board of Medical Examiners licensing examination is also considered during the review of applications by urology residency programs.

Medical students interested in urology should participate in a urology rotation at their home institution late in their junior year or early in their senior year. Students should strive to perform their best during this rotation. Once becoming familiar with the faculty, prospective urology residents should solicit letters of recommendation from the urology leadership at their medical school. Participating in a urology rotation at an institution other than the student’s home institution may be beneficial if it is a program at which the student is particularly interested completing residency training. A visiting student rotation can also give students the chance to impress the urology faculty at another institution if their clinical skills outweigh their academic record or who attend a medical school of lesser reputation.

Other elective clinical rotations to consider during medical school include general surgery, renal transplantation, pediatric surgery, nephrology, neurology, gynecology, radiology, pathology, and anesthesia.

Residency

Urologic residency training consists of a minimum of 5 years of clinical postgraduate education of which 12 months must be spent in general surgery and 36 months must be spent in clinical urology. The remaining 12 months must be spent in general surgery, urology, or other clinical disciplines relevant to urology. The final 12 months must be spent as a chief resident in urology with appropriate clinical responsibility.

The Society of Women in Urology (SWIU) has published a handbook for female urology residents with tips on surviving, and excelling, during residency. This handbook is provided at no cost to female urology residents (usually sent automatically if residents have matched in their residency position through the AUA matching service) or can be purchased for approximately $10 through the SWIU website.

Board Certification

Board certification in urology is a multiple step procedure. The American Board of Urology (ABU) arranges and conducts this process. Initially the written, or “qualifying,” examination is taken; this test is given in June of each year. The two-day qualifying exam consists of standard multiple-choice format of questions about anatomy, pathophysiology, and therapy of urologic diseases as well as interpretation of pathological and radiological images. It is usually taken during the final, chief resident, year of residency training, and must be taken (or re-taken if failed initially) within five years after completing an approved urology residency. After successful passage of the qualifying examination and completion of 18-months of post-residency urologic practice, the oral, or “certifying,” examination is taken. A log of cases performed, any complications, and letters of recommendation from peers during the 18-months of post-residency practice must be submitted and approved by the ABU prior to taking the oral examination. This exam is given in February of each year and must be taken within five years of successful completion of the written examination. Over the past decade, approximately 80% of the candidates taking the written qualifying examination have passed, with the highest passing rate being among United States Medical School graduates. The certifying examination also has a failure rate of about 20%. Certification is for a 10-year period with recertification required after that time. For more information, see the ABU website.

Fellowship Training

Most urologists in private practice are generalists and see a gamut of diseases ranging from benign prostatic enlargement (BPH), stones, incontinence, and cancer. There are recognized areas of subspecialization within urology, which are common among urologists at academic centers and in large group practices. Individuals interested in subspecialization usually acquire additional fellowship training after residency. There are multiple research fellowships available, most of which are sponsored through the American Foundation for Urological Disease. Other fellowships, ranging from 1 to 3 years in length, combine research and clinical training in subspecialty areas such as Pediatric Urology, Male Infertility/Andrology, Female/Reconstructive Urology, Urologic Oncology, and EndoUrology. Many fellowship positions can be found on the CareerMD website, while other positions are listed only by individual institutions or specialty societies.

Pediatric urologists specialize in the treatment of genitourinary disorders in infants, children, adolescents, and young adults. Most of the diseases seen by this subspecialty are congenital but urinary tract infections, pediatric renal and testicular malignancies, and dysfunctional voiding also contribute to the patient population. The specialty of pediatric urology is closely aligned with the American Academy of Pediatrics and most fellowship-trained pediatric urologists become fellows of this organization. Most fellowships are 1 year in duration. A list of Pediatric Urology fellowship programs can be found through the Society of Pediatric Urology website, which is administered at the University of Alabama Birmingham.

There are 1-2 year fellowship positions in Male infertility which focus on the microsurgical techniques of relieving obstructions in the male reproductive tract as well as sperm retrieval and manipulation of the male hormonal status to improve sperm quality.  Some fellowships, often referred to as Andrology fellowships, teach trainees about a broader range of male reproductive difficulties and include training in the evaluation and treatment of male erectile dysfunction in addition to infertility management. Information on some of the available Infertility/Andrology fellowships can be found at http://www.maleinfertility.org/training.html, http://www.urol.bcm.tmc.edu/fellowships.html, 
http://www.clevelandclinic.org/reproductiveresearchcenter/training.html, 
and http://urology.northwestern.edu/education/fellowship.html.

Female/Pelvic Reconstructive Surgery or Urogynecology Fellowships are available as purely urology subspecialty training, or as training for both urologists and gynecologists. The fellowships accepting both specialties require 3 years of training for gynecologists and 2 years for urologists. Despite the longer time commitment, gynecologists predominantly choose these fellowships and most are accredited by The American Board of Obstetrics and Gynecology. Most of these multidisciplinary fellowships participate in the NRMP match; a list of these fellowships can be found on the American Urogynecology Society website. Urology residents frequently apply to female urology fellowship programs that are not conducted in conjunction with a gynecology service. In addition to the surgical treatment of pelvic prolapse, the training provided in these 1- to 2-year programs also encompasses diagnosis and treatment of neurogenic bladder dysfunction, interstitial cystitis, and other diseases affecting bladder emptying.

Urologic Oncology fellowships train individuals on the care of patients with urologic malignancies. These 2-year training programs involve learning the techniques necessary to perform some of the most complex open surgical cases in the field as well as supportive medical care for at least one year. At least one year of research is generally required during urologic oncology fellowships. More information about urologic oncology fellowships can be found on the Society of Urologic Oncology website.

EndoUrology has historically been a specialty focusing on procedures performed during cystoscopy, ureteroscopy, and percutaneous nephroscopy. In recent years, the focus of this specialty has switched to laparoscopic procedures resulting in a surge of interest in this type of training. Some programs offer 3- to 6-month mini-fellowships that are designed primarily to update the skills of practicing urologists rather than focused post-residency subspecialization, which requires 1 year of training. A list of the 1-year fellowship programs in Endourology can be found here. A matching program, similar to residency match, debuted in 2002 for positions available in the 2003-2004 academic year. The deadline for applications is in April of the chief resident year.

Funding Opportunities

The major funding sources for urological research are American Foundation for Urological Disease and two branches of the NIH, the National Institute of Diabetes & Digestive & Kidney Diseases and the National Cancer Institute. Applications for research funds are also successful through the Department of Defense and the Veterans Administration.

Private organizations accepting applications for research funding for the study of urologic diseases include the National Kidney Foundation, the American Cancer Society, and CAPCure.

While some urologists join subspecialty societies, such as those mentioned above, most urologists become members of the American Urological Association (AUA), the primary urological society in the United States. The AUA publishes the Journal of Urology, as well as educational programs, treatment guidelines, practice policies, and other useful information. Many academic urologists belong to the Society of University Urologists, which serves as the Chairmen/Program Directors committee for the specialty and decides policies on residency and fellowship issues.

There are just over 200 board certified women in the field of urology as well as approximately 100 female urology residents, fellows, post-residency, and pre-board-certified women. These women comprise less than 2% of the urologists in the United States. The Society of Women in Urology allows the small number of women urologists to meet and discuss issues and experiences and provide mentoring to those still in training. The society also has representatives in key committees within the American Urological Association. To find out more, log onto the SWIU website.

Conclusions