BPH Global Registry Institution Application

BPH Global Registry Institution Application

For any questions regarding this questionnaire or for help with an error, please contact Elena Lukic at elena.lukic@siu-urology.org

Principal Investigator Information

PI First Name*

PI Last Name*

PI Email Address*

My institutional email address differs from my primary one.

Institutional Email Address*

PI Telephone Number*

Including country code.

Institution Information

Institution Name*

Street address*

City*

Province/State

If applicable.

Country*

Business telephone #*

Please include country code.

Business fax #

If available. Please include country code.

BPH Procedures*

Please indicate which of the following surgical treatments are commonly performed at your institution.

TURP

TUIP

PVP

Transurethral Enucleation

Aquablation

Urolift

Rezum

Simple Prostatectomy

Other

BPH Procedures (Other)*

If other, please list any procedures not listed.

Average yearly number of TURP procedures*

On average, how many TURP procedures does your institute perform yearly (rounded to the nearest 10)

Average yearly number of TUIP procedures*

On average, how many TUIP procedures does your institute perform yearly (rounded to the nearest 10)

Average yearly number of PVP procedures*

On average, how many TURP procedures does your institute perform yearly (rounded to the nearest 10)

Average yearly number of Transurethral Enucleations*

On average, how many Transurethral Enucleations does your institute perform yearly (rounded to the nearest 10)

Average yearly number of Aquablation procedures*

On average, how many Aquablations does your institute perform yearly (rounded to the nearest 10)

Average yearly number of Urolift procedures*

On average, how many Urolifts does your institute perform yearly (rounded to the nearest 10)

Average yearly number of Rezum procedures*

On average, how many Rezum procedures does your institute perform yearly (rounded to the nearest 10)

Average yearly number of Simple Prostatectomies*

On average, how many Simple Prostatectomies does your institute perform yearly (rounded to the nearest 10)

Average yearly number of other procedures*

On average, how many other BPH procedures does your institute perform yearly (rounded to the nearest 10, not including pharmaceutical interventions).

Does your institution support electronic and/or mobile access to patient records?*

Multiple responses allowed.

Electronic (by desktop computer)

Mobile phone-supported patient record system

No

Don't know

Other

If 'Other', please specify*

Does your institution support automatic data extraction?*

Yes

No

I don't know

How did you hear about our registry?*

Select or enter value

Name of referrer*

Please select the referrer's name fromthe dropdown. If the referrer is not on this list, please select "Other."

Select

Additional Comments

Please use this text box for any comments you would like to add.

Completed by/Role*

E.g., Dr. Zlata Letícia, Principal Investigator

Send me a copy of my responses

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