Urological surgeryBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7167.2 (Published 31 October 1998) Cite this as: BMJ 1998;317:S2-7167
The public profile of surgery's oldest subspecialty has increased recently, thanks to a certain drug with priapic powers. Neville Harrison gets to the reality behind the hype
Over 2,000 years ago Hippocrates recognised the value of specialist surgical skills: “I shall not cut for stone but leave it to those who are specialist in the art.” Just over 50 years ago, 66 surgeons formed the British Association of Urological Surgeons, and today the specialty's separation from general surgery is complete, consultant expansion continues, and many of the 470 consultant urologists in the United Kingdom are developing subspecialty interests within urology (uro-oncology, reconstruction, endourology, andrology, female urology, neurourology, and paediatric urology).
Few enter medical school knowing they want to be surgeons, yet alone urologists, and most are drawn to the specialty only after experiencing it as a house surgeon or senior house officer. They are attracted to its breadth of pathology; its combination of surgical skills, both endoscopic and open, and technology; its diagnostic precision; and the positive impact it can make on patients' lives - it has been called “a compassionate specialty.”
Training in urology
The minimum entry requirements for the specialty are completion of two years of basic surgical training in recognised posts and the MRCS or AFRCS. Competition for specialist registrar posts is intense, and most trainees find they need to spend at least a further year at senior house officer level or acquire some research experience before they become sufficiently competitive to get a specialist registrar post.
Training programme in urology
Each of the 15 deaneries in England and Wales, Scotland, Northern Ireland, and the Republic of Ireland have training programmes in urology which conform to the curriculum and standards set by the surgical royal colleges through the Specialist Advisory Committee in Urology. Smaller programmes may have only seven or eight trainees, while larger ones have over 30, divided into a number of rotations.
The specialist registrar training programme lasts five years, of which four must be in clinical urology and one is a flexible option to gain additional experience in a subspecialty, in research, or overseas. The options are wide, but the one selected must be approved by the deanery specialty training committee and the specialist advisory committee.
The curriculum covers the whole spectrum of urological diseases and urological surgery. A thorough understanding of the basic sciences related to urology is expected, and the specialty has well developed compulsory core training programmes in every regional scheme, usually organised as an educational half day for three 10 week terms each year. In the Thames regions a day release MSc course is proving a popular way of acquiring an understanding of research methodology, the discipline of writing a dissertation, and the opportunity to present and publish results - a level of research experience expected of all trainees. Some with academic aspirations may choose to spend additional time in research, either before entering the grade or during specialist registrar training by taking time out of the programme, to acquire a higher degree. Traditionally, this was an MSc or MD, but serious researchers are now tending to prefer a PhD.
Training supervision Trainees can expect to spend two of their four clinical years in two different district general hospitals and two years in an undergraduate teaching hospital or a larger district general hospital. Day to day training is supervised by the local consultant. Other key people are the programme director, who is responsible for a group of trainees, and the dean's specialty training committee, which oversees the whole regional programme. In addition to regular appraisal by their local trainer or programme director, trainees' progress is formally assessed twice in the first year and annually thereafter; it is essential to reach a satisfactory level of competence to move on to the next year.
Urology has a compulsory intercollegiate specialty examination, FRCSUrol, which can be taken after successfully completing the third clinical year. The exam consists of multiple choice questions, a clinically oriented “spot test,” and three in depth vivas. Trainees now have plenty of opportunity to be well prepared for the examination with the help of the structured core training programme and compulsory annual multiple choice questions and mock examination. After success in the exam there are opportunities to gain additional experience in a subspecialty (although none has separate certification).
Urology in practice
Most district general hospitals have a department of urology with a minimum of two consultants. An ageing population, new treatments, and patients' increasing expectations have led to a rising demand for urologists, and the specialty has seen a rapid expansion of about 8% a year for the past five years. The British Association of Urological Surgeons recommends a ratio of one urologist to 80,000 to-100,000 of the population. The ratio has currently reached 1:127,000, and if the rate of expansion continues the target should be achieved within five years or so.
The number of trainees has also increased and there are now over 200 national training numbers. Once our consultant targets have been met we will need fewer trainees to maintain consultant numbers, and to prevent “overshooting” a reduction is likely to start in the next few years.
Getting into the specialty
What sort of qualities does success in urology require? Certainly an enjoyment of practical skills and the ability to perform endoscopic manipulations from a TV screen are essential. If you are not sure about this, have a go on a laparoscopic trainer or attend a training course for transurethral resection or endoscopic skills. You need to enjoy diagnostic challenges, but with the reassurance of accurate diagnostic techniques, some of which (such as flexible cystoscopy and urodynamics) may be carried out by the urologist personally. There is much patient contact, and you need to enjoy good patient communications and the satisfaction of dealing with a wide range of emotional reactions. Teamwork is vital as urologists work closely with many other specialties, particularly radiology, nephrology, pathology, and anaesthetics; with specialist nurses such as continence advisers and Macmillan nurses, both in hospital and in the community; and with general practitioners on “shared care” projects.
If you are drawn to the specialty choose a basic surgical training rotation that includes urology (there are 165 of these), try to get at least six months' good general surgical experience, and make the most of the opportunities offered by being on call in acute surgery. An additional senior house officer post in urology (there are 121 “stand alone” posts) will strengthen your claim of commitment to the specialty.
Your local consultant urologists will be pleased to give you advice, and you would be wise to seek out the programme director or regional specialty advisor. The chairman of the urology specialty training committee or postgraduate dean can provide more general guidance. For really useful information about a particular training programme, seek out one of the specialist registrars.
The prospects for urology look good, and the specialty has shown itself able to adapt to major technological and pharmacological changes - such as lithotripsy for kidney stones, flexible cystoscopy, new technologies for treating prostates, and new drug treatments for lower urinary tract symptoms and erectile dysfunction - and should be able to respond to new challenges in the future. Subspecialisation, pressures to improve quality, and mergers of hospital trusts are the drivers towards larger urology departments, and three to six urologists serving a population of up to half a million are likely to become the norm.
Structured training programmes means that most trainees will be appointed to a consultant post at a younger age than in other specialties, and, as a result, there will be greater opportunities for continuing professional development. It may become both acceptable and usual to move on from one's initial consultant appointment. Most consultant urologists have a maximum part time contract, indicating that private practice is both professionally satisfying and financially rewarding.
Urology is an acute specialty and deals with emergency admissions every day retention of urine, renal colic, and various acute infections make up the bulk. Only a few situations require immediate surgical intervention, and most urgent operations can be undertaken during normal working hours, an aspect which most urologists find appealing, though they may have been rather coy about this in the past.
The specialty has only a small number of women consultants, but more are being attracted to the specialty and women now form 10% of the trainees, a trend we hope will continue. Urology has not been a glamourous specialty and has been largely content to remain out of the public gaze. All this has changed with media interest in prostate cancer and erectile dysfunction; thanks to Viagra, there can be few people now who have not heard of the specialty.
Key points: training in urological surgery
Five year training programme
Well organised and supervised rotations
Core teaching in all programmes
Annual objective assessment by multiple choice questions, etc
Annual summative assessment of progress
Intercollegiate exam (FRCSUrol) at year 4