










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Genitourinary Reconstructive Surgery  
Curriculum and Postgraduate Training  
Program Development in the Caribbean
Jessica DeLong,  Ramón Virasoro

Department of Urology, Eastern Virginia Medical School, Norfolk, United States, Devine-Jordan Center for Reconstructive Surgery and Pelvic Health, Department of 
Urology, Virginia Beach, United States

Abstract

Objectives To describe the development of a genitourinary reconstructive fellowship curriculum and the 
establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the 
Caribbean.

Methods In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican 
Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation 
of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We 
sought accreditation via a well-established local university, and fellowship candidates were selected. A database was 
maintained to track outcomes. Subjective and objective reviews were performed of the fellows.

Results The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum 
was created and implemented. The fellowship has been successfully integrated into the health system, and the fellows 
performed 199 and 235 cases, respectively, during the program, completing all rotations successfully. They have 
been appointed to the national health system. Both graduates are now docents in the program and in the public 
system. Additional staff including radiologists, radiology technicians, nurses, urology residents (both Dominican and 
American), urology attendings, operating room staff, and anesthesia residents were trained as a result of the program.

Conclusions To our knowledge, this is the first fellowship of its kind in the Caribbean. A novel curriculum was 
created and implemented, and the first 2 fellows have successfully completed all rotations. This training model may 
be transferable to additional sites.

Introduction

Global health and global surgery have gained significant interest and momentum over the last decade[1,2]. Many 
surgical programs across the United States have implemented a global surgery rotation that highlights the growing 
interest of American surgical residents in this arena[2–7]. The global health community is committed to furthering 
surgical care and improving outcomes to reduce health inequities[8]; the Lancet Commission on Global Surgery and 
other reports have helped to spur this movement[9–11].

Key Words Competing Interests Article Information

Global surgery, reconstructive surgery, 
curriculum development, surgical training, 
surgical education

None declared. Received on November 13, 2020 
Accepted on January 15, 2021

Soc Int Urol J. 2021;2(2):106–112

DOI: https://10.48083/RORD8326

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mailto:jessicadelong%40gmail.com?subject=SIUJ
https://10.48083/RORD8326
http://www.siuj.org


Over 5 billion people lack access to adequate surgical 
and anesthesia care across the globe, the majority in 
low- and middle-income countries (LMICs)[12–14]. This 
inequity is far-reaching and it has been shown that a 
significant percentage of the global disease burden is due 
to surgical conditions: the World Health Organization 
(WHO) reports 11%, and some contemporary estimates 
are as high as 30%[11–13,15,16]. This uptrend of surgical 
burden will likely continue as the world continues to 
industrialize. Rose and colleagues estimated nearly 
34 million urologic procedures were needed in 2010, 
based on the WHO global health estimate of disease by 
category[10]. Cogent, compelling arguments have been 
made by many authors showing how surgical care is an 
integral part of global health, forming a necessary cog in 
the network that establishes a strong health system[17]. 
The need for access to reliable anesthesia and surgery is 
ubiquitous across countries in all stages of development, 
as well as across a spectrum of disease states[14].

There are multiple barriers to sustainable surgical 
programming abroad. Finances, time constraints, and 
local leadership are all often cited[1,4,6]. In order to 
overcome these obstacles, regional and international 
investment is important. A local champion should be 
identified, and any proposed program needs to be able 
to adapt to the regional environment. The majority of 
published literature revolves around surgical rotations 
and fellowships that are based in United States programs, 
prov iding shor t-term rotations in a sustainable 
environment abroad[1,12,18]. Multi-institutional and 
multinational co-operations lead to valuable learning 
experiences and benefits for all participants[4,5] 
Although some of these advantages may be intangibles 
such as broadening cultural experience, satisfying 
altruistic desires or learning about different health care 
systems, many are concrete. These may include adapting 
surgical technique, participating in publishing research, 
and building surgical capacity.

We present our innovative model for surgical 
education in a resource-poor setting to address a specific 
need identified by the local community.

Materials and Methods
In 2013, the authors began weeklong mission trips to 
the Dominican Republic (DR) in conjunction with 
Physicians for Peace, a United States-based non-profit 
organization. Each year a minimum of 2 trips were 
taken to treat adult men with urethral stricture disease, 
the prevalence and severity of which are high in the DR. 
Over this time the Dominican urologists recognized a 
compelling need for fellowship-trained reconstructive 
surgeons, and the idea for a formal program was born.

A basic needs assessment was performed during 
these mission trips and appropriate centralized hospital 

facilities were identified. A pre-established checklist 
or survey was not used, but consensus was developed 
among key stakeholders within the hospitals and 
residency programs. Essential infrastructure required to 
support fellowship-level surgical training was identified, 
including ability to sterilize surgical equipment, 
availability of basic instruments, and radiology services, 
as well as anesthesia equipment.

The authors set up a partnership among the following 
entities: a non-profit organization in the United States 
(Physicians for Peace), a local prestigious university 
(Universidad Autónoma de Santo Domingo), and a 
medical school in the United States (Eastern Virginia 
Medical School) by the authors. A memorandum 
of understanding was signed by all parties, and the 
strengths of each of these organizations, along with 
other local and international partners, were brought 
together to form the fellowship.

The first fellow was selected via a longitudinal 
evaluation spanning 2 years of biannual mission trips, 
and multiple candidates were considered throughout 
the country. Subsequent fellows were selected via a 
nationwide selection process with interviews with the 
authors. The program is designed for recently graduated 
urology attendings in the DR who show both an interest 
in and an aptitude for reconstructive urology. He or 
she must be fluent in English and in Spanish, able and 
willing to travel, and motivated to help engender positive 
change in surgical education.

The curriculum was designed by the authors 
around established norms for reconstructive urology 
(Supplemental Material, Curricular Plan, available 
online), although no formal curriculum yet exists 
w it hin our internationa l societ y, Genitourinar y 
Reconstructive Surgeons. The fellowship has been an 
on-the-ground pilot test for the curriculum and has 
gone through several iterations since its inception. As 
there was no existing curriculum within Genitourinary 
Reconstructive Surgeons, the authors wrote the 
curriculum based on their expertise in the field as 
well as with curriculum development. The Ministerio 
de Educación Superior (MESCyT), the highest office 
of education in the DR, established standards that 
were followed within the plan for the fellowship. Via a 
cooperation between MESCyT and UASD, the current 
version of the curriculum and overall fellowship plan 
was incorporated.

 The fellow works within the national health system 
Sistema Nacional de Salud, as well as within the private 
system. Funding for the first fellow was provided 
through local and international organizations, as well 
as through the fellow’s billing for services within the 
private sector. For subsequent fellows, the authors 
secured a salary through the Ministry of Health.

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A REDCap database was created and maintained to 
track surgical and perioperative data. The fellows were 
evaluated during their training and input their cases 
into a log.

Results
The needs assessment revealed that there were no 
fellowship-trained reconstructive urologic surgeons, 
but a high burden of care due to pathology that could 
be treated by such a provider. At the major partner 
hospital, Hospital Moscoso Puello in Santo Domingo, 
facilities were adequate to perform the required 
surgeries, although some basic urologic equipment was 
lacking. Via partnerships and publicity generated from 
the inception of the fellowship, several key equipment 
items were donated, including a flexible cystoscope and 
stirrups for patient positioning. Over the fellowship 
period, key advances in anesthesia care have also been 
made.

The curriculum was developed to meet the specific 
criteria requested by local partners at the Dominican 
Urological Society and UASD and was designed around 
4 major areas. It is to our knowledge the first formally 
developed curriculum for a fellowship in reconstructive 
urologic surgery (Table 1). It is meant to be a learning 
resource, adaptable to the needs of each fellow as well as 
the needs of the area.

The fellowship is accredited by the UASD, and the 
fellow graduates with a Diplomate in Reconstructive 
Urology after 18 months of training. The first fellow 
graduated in July 2018, and the second in February 2020, 
and the third was onboarded in March 2020.

The fel lows were eva luated subject ively a nd 
objectively during each segment of training in the 
following categories: patient care, surgical skill, and 
research/academic achievement. Both graduated fellows 
received “highly satisfactory” or “satisfactory” ratings 
when evaluated by faculty.

The first graduate performed 199 reconstructive 
urologic operations, the second 235. These included 
male urethral reconstruction, procedures related 
to incontinence and sexua l hea lt h, and genita l 
reconstruction, as well as female and general urology 
cases (Table 2). Both fellows rotated externally through 
Eastern Virginia Medical School as well as centers 
of excellence in Chile and Argentina for a total of  
6 months. The fellow was able to participate in surgical 
care, conferences and patient care. Regular trips were 
taken by the authors and other collaborators to the  
DR to aid in training and consistent telemedicine 
classes were undertaken to facilitate didactic learning. 
At a minimum, biweekly conferences were held every  
2 weeks.

Su rg ica l a nd per ioperat ive data, as wel l as 
complication rates and follow-up are being collected via 
an institutional REDCap database. The first graduated 
fellow logged 18 urethroplasties in his first postgraduate 
year, and 56 the following year. Additional data 
regarding etiology, case type, and follow-up were also 
recorded (Table 3).

Discussion
To our k nowledge, t his is t he f irst published 
genitourinar y reconstructive surger y fel lowship 
curriculum and is the first formal genitourinary 
reconstructive training program in the Caribbean. The 
success of this program is predicated upon the interest 
and enthusiasm of our local partners in the DR. These 
local champions help to support the program on a daily 
basis. As cited in their work, Riviello and colleagues 
point to key components of a successful program: 
relationships, mutual learning, local advocates, local 
needs superseding those of the visiting institution, 
research, and a mu ltidisciplinar y approach[19]. 
The authors also recognize these pillars and others, 
cultivating the relationships with the urological societies 
and residencies, appreciating the value of education and 
training, and maintaining openness to collaboration.

This degree program provides the fellow with 
previously nonexistent resources: access to a network 
of international surgeons, opportunities to publish 
and present both nationally and internationally, and a 
support network to continue program building. It allows 
for appropriate training and education while providing 
longitudinal follow-up for patients, facets that have been 
identified as important to provision of surgical care[20]. 
The lack of specialty care is ref lective of the overall 
surgical health of the country; it is a privilege to be able 
to develop a fellowship program when the need for basic 
surgical care is still unmet in many areas.

T here a re mu lt iple ex a mple s of long-ter m 
relationships between academic medical centers and 
programs in LMICs[19,20] wherein partnerships have 
been forged to try to address this need. Universities 
such as Vanderbilt and Harvard have successfully 
created sustainable training for not only surgeons but 
also anesthesia providers and nursing staff. Sustainable 
development, capacity building, and programming are 
needed, particularly in resource-poor settings, in order 
to provide long-term solutions[20,21].

The initial needs assessment is very important as 
this will determine suitability of the site for a specialty 
training program and define care gaps; several tools have 
been developed to assess surgical need[22,23]. Surgeons 
OverSeas developed ways to document baseline surgical 
capacity in LMICs. Among them is a survey intended 

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TABLE 1. 
Fellowship Modules

a) Diagnostic evaluation 

Module 1

• History and physical specific to the specialty

Module 3

• Urologic endoscopy, urodynamic studies: techniques and  
interpretation of studies

Module 2
• Radiography, computed tomography, MRI, ultrasound, Doppler: 

techniques and interpretation of studies

b) Decision making

Module 4

• Relevant anatomy review, review of operative equipment for 
genitourinary reconstructive surgery

Module 6

• Morbidity and mortality, case presentations

Module 5

• Interactive case reviews with discussion UASD sponsored course in 
bioethics (required for master’s degree)

c) Surgical techniques

Module 7

• Anterior urethral reconstruction: trauma, iatrogenic and 
inflammatory

Module 11

• Male sexual dysfunction
• Penile revascularization
• Penile prosthesis implantation

Module 8

•  Posterior urethral reconstruction
• Congenital (posterior urethral valves)
• Acquired (trauma, iatrogenic)

Module 12

• Pelvic floor disorders
• Pelvic organ prolapse
• Urinary fistula
• Urethral erosion in patients with neurogenic bladder

Module 9

• Penile and external genitalia reconstruction
• Correction of congenital and acquired curvature
• Correction of buried penis, genital lymphedema and hidradenitis 

suppurativa
• Correction of sequelae due to Fournier gangrene and burns

Module 13

• Utilization of intestinal segments
• Augmentation cystoplasty
• Continent urinary diversion
• Incontinent urinary diversion
• Ureteral reconstruction

Module 10

• Urinary incontinence in the male and the female
• Injection of suburethral bulking agents
• Autologous and synthetic slings
• Artificial urinary sphincter
• Bladder neck closure, perineal approach and abdominal approach

Module 14

• Hypospadias
• Tubularization of the urethral plate
• Reconstruction with flaps
• Reconstruction with grafts
• Management of chordee

to detect care gaps. Divided into sections for Personnel, 
Infrastructure, Procedures, Equipment, and Supplies, 
it has been used to provide an index showing surgical 
capacity. The program in the DR grew from many years 
of ongoing surgical missions and a formal assessment 
using one of these established tools was not performed; 
this is a shortcoming of our work.

The central public Hospital Moscoso Puello is 
able to serve as a support hub and referral center for 
surrounding catchment area in the DR, a concept 
suggested by the WHO global surgery consortium 
2030[14]. Building specia lt y capacit y here helps 
surrounding facilities as well. We continue to meet 
challenges in some areas where certain equipment 
remains unavailable.

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Our collaborative model minimizes cultural and 
linguistic misunderstandings that can create gaps in 
care. It allows for an interchange of information that 
all involved parties find valuable and helps to build 
a successful system of surgical care. This systems-
based approach requires large-scale efforts from 
administrators, local champions, and government/
ministry of health representatives, as well as financial 
engagement. As stated by Paul Farmer and Jim Kim, “To 
do surgery properly requires a significant investment in 
infrastructure and training as well as a steady supply 
of consumables”[24]. Surgery is not simple, nor easy, 
and it does not bear immediate fruits as a vaccination 
campaign might.

Many different approaches exist for monitoring and 
evaluation of these programs. First there is evaluation 
within the program–competencies for the fellow, 
presentations given, papers published. We employed a 
basic, reproducible evaluation form that was completed 
by faculty involved in training the fellows. Equally 
important is the impact regionally: patients treated, staff 
trained, complication rates, and infrastructure change. 
Various authors have set up schema to measure both 
need and impact, some with the idea of the creation of 
national registries to help track surgical encounters in 
LMICs[10].

Continued program evaluation and outputs analysis 
both internally with the fellowship as well as externally 
need to be completed. This program is in its infancy, 
so long-term data are not available. There is a need to 
continue to develop programming, as well as to fine-
tune outputs. A REDCap database is maintained to track 
patient outcomes. Although there have been challenges 
in culling these data, we can report that the first 

graduated fellow completed a total of 74 urethroplasties 
in his first 2 years post training. Data were not available 
for 17 patients (22.3%), but it is of note that a large 
number of patients developed stricture following 
placement of urethral catheter for other indications (28, 
37.8%). Interestingly 14 of these patients (18.9%) had 
failed prior interventions, consistent with the known 
prior poor success rates. Follow-up was poorly recorded, 
and is a shortcoming in our work thus far.

This program is part of a cooperative movement 
to promote surgical care as an integral part of global 
health. There are disparities in surgical care, largely 
based on finances available in the region: Weiser and 
colleagues reported in 2008 that 30% of the world’s 
population receives 73.6% of the surgical care, with the 
poorest third undergoing only 3% to 5% of all surgical 
procedures[16]. Conditions that require surgica l 

TABLE 3.
Initial outcomes data: Fellow 1

n %

Urethroplasties Performed (74)

 Postgraduate year 1 (2018) 18 –

 Postgraduate year 2 (2019) 56 –

Stricture Etiology

Foley trauma 28 37.8

Iatrogenic 10 13.5

Trauma 7 9.5

Lichen sclerosus 2 2.7

Infection 1 1.4

Idiopathic/data not available 17 22.3

Failed prior surgical intervention 14* 18.9*

Surgery Performed

Excision, primary anastomosis 18 24.3

Oral mucosa graft 28 37.8

Perineal urethrostomy 5 6.8

DVIU/dilation 3 4.1

Data not available 20 27

Results

Doing well at 2 years (Qmax >20) 12 16.2

Postoperative infection, resolved 2 2.7

Wound dehiscence, resolved 1 1.4

Stricture recurrence 2 2.7

No data available 57 77

* 5 of these also had known initial etiology and are listed separately, 
does not add to 100

TABLE 2. 
Fellowship cases

Fellow 1 Fellow 2

Case type n n

Urethral reconstruction 96 126

Male incontinence 5 5

Male sexual health 8 13

Genital reconstruction 4 2

Urinary diversion or  
ureteral reconstruction

2 10

Female reconstruction 23 16

General 61 63

Total cases 199 235

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intervention or remediation account for up to 15% of 
total disability adjusted life years[24]. While these data 
highlight the poor access to any procedure, specialty 
care is also severely lacking.

This study has many limitations. Data collection is 
incomplete and lacks certain outcome metrics. Much 
of the impact is challenging to measure in the short 
term, such as public health initiatives, and is an active 
area of interest for the authors. As Saluja and colleagues 
underline, research in academic global surgery needs to 
have rigorous standards[25]. We are working to improve 
our understanding of the local and regional impact of 
this program. Future work will focus on the surgical 
outcomes, complications, and regional impact of the 
program. This intent of this study was to describe the 
fellowship itself.

We met with many challenges in the execution of 
this fellowship. The curriculum and overall fellowship 
plan have undergone many iterations. During the 
first fellow’s training, it was challenging to implement 
and maintain a schedule for didactic lectures. The 
process was more streamlined with the second and 
third fellows, and all requirements have now been 
satisfied. Bureaucracy within the institutions of higher 
learning led to frequent delays. There have also been 
many successes: the curriculum was approved, and the 
fellows were appointed to the national health system 
(securing a position within the public sector). After the 
graduation of the first fellow, UASD took over patronage 
of the fellowship. This is perhaps the greatest sign of 
sustainability: that the local institution has now assumed 
the main role as sponsor.

The goal of this fellowship is to improve urologic 
specialty care in the Dominican Republic. As the 
fellowship continues to mature, we hope to standardize 
urologic training in country, show sustainability, and 
strive for accreditation via the Accreditation Council 

of Graduate Medical Education. Future plans include 
expanding the program to other regional applicants as 
we form a center of excellence.

Conclusions
A comprehensive genitourinary reconstructive surgery 
curriculum was developed and accredited by the 
prestigious New World University. Concomitantly, 
the first formal training program in genitourinary 
reconstructive surgery and pelvic floor in the Caribbean 
was established. Success can be achieved only when 
there is partnership with local colleagues, and there is 
much work yet to be done.

Acknowledgments
The authors would like to thank Physicians for Peace for 
their support, and Dr Charles Horton, Jr, for providing 
this opportunity. The guidance and mentorship of Dr 
Anulfo Lopez was invaluable. They would like to thank 
Dr Merycarla Pichardo for her support and sponsorship 
of the program in the Dominican Republic. They would 
like to particularly thank the docents of the program in 
Chile and Argentina, Dr Reynaldo Gomez, Dr Leandro 
Capiel, and Dr Carlos Giudice for their dedication 
and teaching within the program. They owe a debt of 
gratitude to Ms Carmen Baxley, surgical technician, 
for her unparalleled commitment to help those in need. 
This program would not have been possible without 
the support and care provided by Dr Ezequiel Ferrara, 
anesthesiologist.

Author contributions
Dr Virasoro and Dr DeLong contributed equally to 
this work in program creation, management, and 
manuscript preparation.

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