Renal Transplant Urology Fellowship

The University of Alberta surgical fellowship in transplantation requires two full academic clinical years of training.  Further 1-2 years of basic science training in experimental surgery, tissue engineering, cryobiology and immunology are available to the suitable candidate.  The fellows have to be graduated from a formal surgical program in North America or elsewhere and have a strong commitment to transplantation.

The fellowship is open to those able to obtain medical licensure in the province of Alberta or graduates outside of Canada who have external funding.

Requirements

• Applicant should obtain medical licensure or postgraduate registration with the College of Physicians and Surgeons of Alberta (depending on funding source).
• Applicant should have completed the LMCC (parts 1 and 2) unless they have external funding.
• Registration with the Post-graduate Medical Education (PGME) office at the University of Alberta ($945).
• Applicant should have a valid work permit if not a Canadian citizen or permanent resident.
• Membership with the Canadian Medical Protective Association (CMPA) as a clinical fellow.
• Applicant must send a cover letter, current CV, and three reference letters supporting their application.
• One of these letters must be from the residency program director.

The successful candidate will either:

1. Provide external funding
2. Generate salary support through clinical billings.

This requires full licensure in the province of Alberta and will be administered through the Department of Surgery.

The Division of Transplantation is part of the Department of Surgery.

All patients who undergo organ transplantation are admitted to a dedicated inpatient multi-organ transplant (MOTS) unit of 16 beds coordinated by a trained charge nurse. Transplant specific nurses attend the needs of patients who are admitted to the unit. Immediate postoperative care is delivered in recovery room and intensive care unit as necessary according to the extent of the surgical procedure. Patients who require intensive care support are under the primary care of dedicated intensivist attending that supervise residents and fellows. Transplant surgeons, hepatologists, nephrologists, infectious disease specialists, pharmacists and fellows dedicated to transplantation are consulted for the specific patients’ care during their stay both on the MOTS unit and in the intensive care unit.

The highest standard of care for patients who undergo organ transplantation at the University of Alberta Hospital is additionally supported by the presence of approved Canadian graduate medical education training program in Cardiovascular Surgery, General Surgery, Urology, Nephrology, Hepatology, Endocrinology, Cardiology, Infectious Disease, Immunology, Radiology, Pulmonary, Gastroenterology and by a dedicated pharmacist. The presence of all these services provides a multidisciplinary care that spans 24 hours a day, seven days a week whenever the clinical necessity requires specific expertise.

In addition, modern laboratory and radiology facilities are available for advanced diagnostic and therapeutic knowledge in:

• multi-organ procurement and storage
• cadaveric and living donor kidney transplantation
  living donor nephrectomy techniques (open in laparoscopic)
• kidney-pancreas transplantation

At the University of Alberta, the transplant surgical program aims to specifically train fellows to develop proficiency in:

• pre-operative management
• post-operative management
• surgical techniques

During their fellowship, the fellows will develop the necessary skill for:

1. Surgical and medical management of patients with end-stage organ diseases amenable to transplantation
2. Optimal preoperative preparation of organ recipients, including immunosuppressive protocols, as well as the diagnosis and complex postoperative management of these patients, who are at risk of developing allograft rejection, opportunistic infections and surgical complications
3. Completing history and physical examinations, presenting inpatient cases, interpreting laboratory and radiology findings, performing transplant operations, multi-organ donor procurement surgery, and actively participating in non-invasive and surgical procedures for pre and post-operative complications
4. Understanding aspects of the basic science of transplantation such that they will be able to describe in general terms the HLA, the recognition of antigens, describe the events of T cell activation, and the components of the allograft response
5. Understanding mechanism of action, efficacy, indications, monitoring and toxicity of the following available immunosuppressive agents: glucocorticoids, azathioprine, cyclosporine, tacrolimus, mycophenolate acid and its analogues, sirolimus and everlimus, polyclonal antilymphocyte preparations, OKT3, belatacept and anti-IL2R monoclonal antibodies
6. Understanding the principles and methods of tissue typing, panel reactive antibody testing, and cross-matching and their impact on recipient selection
7. Recognizing the relative and absolute contraindications to specific organ transplantation
8. Working-up patients with end-stage organ disease considered for transplantation and demonstrate knowledge of patient and graft survival, and impact and management of co-morbid conditions pre-transplant
9. Understand donor selection and contraindications and brain death criteria, the management of organ donors, and organ preservation
10. Evaluating risks, psychosocial and ethical issues of living organ donation (Specifically for kidney and liver transplantation)
11. Developing a systematic approach to the evaluation and management of transplant recipients with deteriorating allograft function late post-transplant
12. Mastering technique of transplant organ biopsies, including the management of common complications of the procedure
13. Recognizing and describing the mechanism, pathology, and treatment of hyper acute, acute and chronic rejection
14. Discussing the ethical issues in transplantation, including the equitable access to organ transplantation, the allocation of cadaveric and living organ donation
15. Being familiar with the common complications of transplantation, including:
    • Bacterial Infections
    • CMV infection
    • EBV infection
    • Polyomavirus infection
    • Post-transplant malignancy, including post-transplant lymphoproliferative disorder
    • Post-transplant hematological disorders
    • Hypertension
    • Diabetes mellitus
    • Post-transplant bone disease
    • Dyslipidemia and cardiovascular disease

The teaching program emphasizes responsibility, self-directed learning, and exposure to a broad spectrum of clinical material. The transplant fellows round twice daily on the patients and supervise residents and medical students assigned to the transplant service. Constant interaction with other fellows and the faculty allows opportunity for feedback and clinical instruction. In addition, transplant fellows are encouraged to initiate self-learning by weekly presentations on topics pertinent to transplantation and by monthly journal club. This occurs within the context of a structured didactic teaching schedule that reflects a two-year cycle of core material.

Operative experience is based on the one to one interaction between the transplant fellow and the attending surgeon during the surgical procedure. Once competent in the procedure the transplant fellow is encouraged to take on the role of primary surgeon unless technical complexity of the specific case requires the attending surgeon to be the primary operator.

Transplant surgery fellowship at the University of Alberta Hospital involves a closely supervised two-year period of education with the trainees having progressive responsibilities and independence. Constant communications between the trainee, the attendings and nursing staff is expected. During the second year of training, the transplant surgery fellow is expected to perform in a more independent fashion, making important decisions regarding preoperative, intraoperative, and postoperative patient management. The transplant fellow is also given additional teaching, research and administrative responsibilities. Progression of responsibility toward independent performance by the transplant fellow especially during the last six months of clinical training is strongly promoted by the surgery faculty. The transplant attendings continually monitor and provide appropriate feedback to the fellows throughout their clinical training both in and out of the operating room with a six monthly report filled out in a Can-Meds fashion.

The transplant surgery fellow is responsible for the direct patient management of those patients they operate on. They are expected to collaborate with the nephrology fellow and attend, demonstrating excellent multidisciplinary communication skills. The fellow is expected to round twice daily and to attend the weekly multidisciplinary rounds. The fellow may be assigned to coordinate patient care activities for the transplant surgery service, namely in-patient care, operating room case assignments, emergency room consultation, daily rounds, consultations, coverage of outpatient clinics, and attendance at conferences and teaching rounds. The surgical caseload allows for the trainee to gain a well-rounded experience.

Transplant patients are seen in a designated pre transplant surgical assessment clinic as well as the individual renal transplant surgeon’s clinics. The donors are seen in the individual renal transplant surgeon’s clinics. The transplant fellow will be responsible for in-house renal transplant consultation and will review the consult with the appropriate attending surgeon.

During these sessions, the transplant fellows are exposed to new potential recipients. This experience allows the fellows the opportunity to establish long-term patient interaction, gaining a perspective on expectations of outcomes, risk management stratification, assessment and correction of vascular and urinary tract issues pre-operatively and management of complex patients on an outpatient basis. The fellows are responsible for documentation on patients seen during these clinic visits. The fellows are responsible for determining the fitness for surgery, further diagnostic work-up, and outlining a treatment plan for all patients. While the attending surgeon always reviews the course of treatment and plans with the trainee, the transplant fellow will be responsible for orchestrating the needed interventions or investigations prior to listing for transplantation. This will be done with the help of the patient coordinators and transplant urologist’s support staff.

During the two years of training, the surgical fellows will spend one week in the HLA laboratory to study the technical aspects of PRA assessment, flow cross match, DNA typing and tissue compatibility immune response.

 

The fellow after specific training with the liver transplant fellow or attending surgeon will be expected to participate in the retrieval of organs (locally and distantly) on a call schedule.

Because of the mission as an academic institution, during the two-year training period, transplant surgical fellows at the University of Alberta Hospital will be required to complete a clinical research project with submission of an abstract and final paper to one of the peer-reviewed North American or European surgical journals. Annually the fellows will be expected to review and present clinical outcomes for that year.