2008 Flashcards
A 16-year-old girl with known inflammatory bowel disease develops disabling frequency, urgency, and nocturia. She has recurrent E. coli UTIs. Ultrasound shows mildly dilated upper tracts bilaterally. A CT scan shows a thickened bladder wall. Cystoscopy reveals an inflamed trigone without discrete evidence of a fistula. The most important form of therapy for her is:
- intravenous antibiotics
- temporary diverting colostomy
- a temporary suprapubic cystostomy
- medical management of the bowel disease
- exploratory laparotomy with appropriate bowel resection.
4
The most common urologic complication of inflammatory bowel disease is cystitis. This can happen with or without an enteric-urinary fistula. Management should be directed at the inflammatory bowel disease and should be non-surgical if at all possible. Surgical procedures such as diverting colostomy, suprapubic tube or bowel resection are inappropriate as initial management. Intravenous antibiotics will not be any more effective than oral antibiotics.
Following a nephrectomy for calculous disease, a patient with a normal contralateral kidney has a urine output of 800 ml/day despite receiving 2000 ml I.V. fluids daily. Blood loss at nephrectomy was replaced. The serum sodium is 125 mEq/l, the serum potassium is 3.5 mEq/l, and the serum osmolality is 270 mOsm/l. The urinary sodium is 20 mEq/l and the urine osmolality is 480 mOsm/l. The most likely cause of these findings is:
- inappropriate ADH secretion
- acute tubular necrosis
- adrenal insufficiency
- dehydration
- exogenous water intoxication.
1
The syndrome of inappropriate ADH secretion (SIADH) may be associated with malignancy, pulmonary and CNS disorders, and certain drugs. Hyponatremia, decreased serum osmolarity (< 285 mOsm/l) with inappropriately increased urine osmolarity (> 300 mOsm/l), normal adrenal and thyroid function and urine sodium in excess of 20 mEq/l characterize the process. A diagnosis of SIADH can only be made if a patient is euvolemic (as in the present case), as increased ADH secretion is physiologic in hypovolemic states. Adrenal insufficiency would result in increased serum potassium. Dehydration would result in mild hypernatremia and a higher urine osmolarity. There is no reason, in the present case, to consider water intoxication given the administration of only 2000 ml of I.V. fluid daily.
Among patients with metastatic renal cell carcinoma, sorafenib:
- is ineffective if prior IL-2 was given
- is palliative in those with brain metastases
- improves resectability if given neoadjuvantly
- improves progression-free survival
- improves overall survival.
4
Sorafenib is an FDA approved oral medication for use in patients with metastatic renal cell carcinoma. The effects of sorafenib (BAY 43-9006), an oral multikinase inhibitor targeting the tumor and vasculature, on tumor growth in patients with metastatic renal cell carcinoma was evaluated in a randomized Phase II trial. Patients with brain metastases were excluded from the study, however patients with prior immunotherapy were included. Patients initially received oral sorafenib 400 mg twice daily during the initial run-in period. After 12 weeks, patients with changes in bi-dimensional tumor measurements that were less than 25% from baseline were randomly assigned to sorafenib or placebo for an additional 12 weeks; patients with >/= 25% tumor shrinkage continued open-label sorafenib; patients with >/= 25% tumor growth discontinued treatment. The primary end point was the percentage of randomly assigned patients remaining progression free at 24 weeks after the initiation of sorafenib. Of 202 patients treated during the run-in period, 73 patients had tumor shrinkage of >/= 25%. Sixty-five patients with stable disease at 12 weeks were randomly assigned to sorafenib (n = 32) or placebo (n = 33). At 24 weeks, 50% of the sorafenib-treated patients were progression free versus 18% of the placebo-treated patients (P = .0077). Median progression-free survival (PFS) from randomization was significantly longer with sorafenib (24 weeks) than placebo (6 weeks; P = .0087). Median overall PFS was 29 weeks for the entire renal cell carcinoma population (n = 202). Thus, sorafenib has significant disease-stabilizing activity in metastatic renal cell carcinoma. There has been no data to suggest a survival advantage with sorafenib and it has not been used in the neoadjuvant setting. A recently published phase II randomized trial has shown similar results.
A 72-year-old woman undergoes an abdominal hysterectomy for uterine fibroids. In the recovery room, she is anuric for four hours despite several boluses of intravenous fluids. Her indwelling catheter is patent. Her blood pressure is 100/50 mmHg, pulse is 100. Estimated blood loss during the procedure was 1000 ml. The best explanation for her condition is:
- acute tubular necrosis
- bilateral ureteral obstruction
- prerenal azotemia
- hypovolemic shock
- vesicovaginal fistula.
2
Anuria always implies complete ureteral obstruction until proven otherwise. The two most likely areas where the ureter can be occluded during hysterectomy are at the level of the broad ligaments and at the vaginal cuff and bladder trigone. Consequently, the most likely finding in this patient would be a ureteral obstruction at the level of the vaginal cuff. While hypovolemic shock and low urine outputs are commonly seen after all types of abdominal operations, the anuria in this case suggests an obstructive etiology. Acute tubular necrosis does not normally occur in a precipitous fashion as in this case. A vesicovaginal fistula should be obvious clinically.
A 43-year-old potent man is diagnosed with a 4 cm micropapillary TCC that extensively invades the lamina propria. Muscularis propria is present and uninvolved. Lymphovascular invasion is identified. The next step is:
- restaging TURBT and intravesical BCG if muscle invasion is absent
- partial cystectomy followed by radiation therapy
- neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy
- nerve sparing radical cystoprostatectomy
- cisplatin-based chemotherapy and radiation therapy.
4
T1 tumors with aggressive features (tumor size > 3 cm, micropapillary histology, and lymphovascular invasion) have an increased risk of progression and should undergo definitive cystectomy that is highly effective for early stage tumors. While intravesical BCG is an option for the treatment of T1 bladder cancer, the high risk features of this tumor leave the patient at a very high risk of relapse and progression. This is inappropriate given his young age and excellent health. Partial cystectomy is not the best choice for tumor control given the high risk of multifocal recurrences within the remaining bladder. Prophylactic radiotherapy and systemic chemotherapy have not been shown to reduce the risk of recurrence in individuals with T1 disease.
A 36-year-old obese paraplegic man undergoes evaluation for an ileal conduit diversion. The preferred site for urostomy placement is:
- right upper quadrant lateral to rectus
- right upper quadrant through rectus
- right lower quadrant through rectus
- right lower quadrant lateral to rectus
- in midline at umbilicus.
2
Careful selection of the optimal site for a stoma is a critically important part of the preoperative evaluation of the patient. The stomal site should avoid the umbilicus, bony prominences, scars, and folds. It should be placed in a region where the flat abdominal skin measures 5-7 cm in both directions. The stoma for an ileal conduit is usually located in the right lower quadrant. Paraplegics, often with abdominal prolapse and wheel-chair existence pose a special problem for stomal site selection. A right lower quadrant site often results in a stoma that is difficult for the patient to see and the stoma and appliance are squeezed between the abdomen and thigh. For this reason, in the paraplegic patient the stoma should always if possible be placed in the upper abdomen. In addition, in all patients the stoma should be brought through the rectus muscle to minimize the risk of peristomal herniation.
The coagulation of human semen is dependent on:
- seminal vesicle-specific antigen
- PSA
- calcium
- fibrinogen
- factor XII.
1
The major clotting protein in semen has been termed semenogelin, which has been shown to be the seminal vesicle-specific antigen. These clotted proteins serve as the substrate for PSA which liquefies the semen. Calcium-binding substances, such as sodium citrate, and heparin do not inhibit the coagulation. Blood clotting proteins such as prothrombin, fibrinogen, and factor XII are not present in semen.
Headache, facial flushing and hypertension during cystoscopy is most commonly seen in patients with:
- cervical cord lesion
- spinal cord injury between T6 and S2
- cauda equina injury
- multiple sclerosis
- reflex sympathetic dystrophy.
1
Autonomic dysreflexia is associated with spinal cord injuries at T6 and higher. Symptoms commonly include palpitations, headache, facial flushing and HTN. It is caused by stimuli below the level of the spinal cord injury precipitating an exaggerated sympathetic response. Treatment should include immediate removal of the stimulus if possible. Calcium channel blockers, alpha adrenergic antagonists and chlorpromazine can be used to treat this condition. The other injuries do not typically cause autonomic dysreflexia.
A distal urethral perforation occurs during insertion of a malleable penile prosthesis. The contralateral cylinder has not been placed. The next step is:
- place urethral catheter and complete the implantation
- repair urethra and implant the contralateral prosthesis
- repair urethra and place a suprapubic tube only
- repair urethra, proceed with implantation, and place a suprapubic tube
- place urethral catheter and terminate the procedure.
5
If urethral perforation occurs during dilation, it is best to abandon the procedure, divert the urine with a urethral catheter, and return at a later date. If the contralateral prosthesis has already been placed and there is no septal perforation, then it may be left in place. The urine should be diverted. Urethral repair would be difficult and is unnecessary.
A 45-year-old woman has chronic indwelling ureteral stents for bilateral ureteral strictures from radiation therapy for cervical carcinoma. During stent exchange, brisk, bloody efflux occurs upon right ureteral stent removal. After replacing the stent, the next step is:
- observation
- abdominal and pelvic arteriogram
- abdominal and pelvic CT scan
- immediate open exploration
- nephrectomy.
2
Ureteroarterial fistulas are rare with a reported mortality of nearly 40%. Thus, observation is not appropriate. Risk factors associated with the development of ureteroarterial fistulas include pelvic surgery, pelvic malignancy, pelvic irradiation, pelvic vascular disease and chronic ureteral intubation. Diagnosis is difficult in the absence of active bleeding. Despite the hemorrhage that accompanies these lesions, standard arteriography is frequently falsely negative. Still, arteriography may establish the diagnosis and then the fistula can be occluded with common iliac artery embolization followed by arterial bypass grafting. Provocative arteriography has been reported to demonstrate the fistula in almost all of cases. When clinical suspicion remains strong despite a negative arteriogram, exploratory laparotomy may be necessary to confirm the diagnosis and treat the condition. Immediate exploration is ill advised without a clear etiology of the bleeding, which will be poorly assessed with CT imaging. Nephrectomy is not indicated as the kidney is not the source of bleeding.
A 71-year-old woman develops a mass in the allograft two years after renal transplant. Needle biopsy of the mass reveals a large B cell lymphoma. Representative images from the MRI scan are shown in exhibits 1 and 2. The next step is:
1 reduce immunosuppression
- administer chemotherapy
- allograft irradiation
- subcapsular allograft nephrectomy
- radical allograft nephrectomy.
1
Post transplant lymphomas are most commonly non-Hodgkin and associated with Epstein-Barr virus infection. The reported incidence ranges from 0.8 to 15, and varies with the type of immunosuppression utilized. These tumors may respond to drastic reduction or withdrawal of immunosuppression. Standard chemotherapy and irradiation are not generally effective and may exaggerate the degree of immune compromise. Treatment with anti-viral medications such as gancyclovir may be beneficial. Nephrectomy may be necessary, but is not the initial treatment.
The spread of urinary extravasation secondary to urethral injury below the urogenital diaphragm, when associated with a tear in Buck’s fascia, is limited by the following fascial layers:
- Denonvilliers’ and Colles’
- Colles’ and Scarpa’s
- Scarpa’s and Denonvilliers’
- dartos and Colles’
- dartos and Denonvilliers’.
2
When infradiaphragmatic urinary extravasation extends through Buck’s fascia, it is limited only by Colles’ fascia which attaches posteriorly at the triangular ligament and laterally at the fascia lata of the thigh. Colles’ fascia is continuous anteriorly with Scarpa’s fascia which extends superiorly to the coracoclavicular fascia. Therefore, both Colles’ and Scarpa’s fascia limit such an extravasation. Such an extravasation, particularly when associated with infection (periurethral phlegmon), can result in edema and necrosis of the skin of the penis, scrotum, and anterior body wall.
A 32-year-old infertile man with hyperthyroidism has two semen analyses with volumes of 2.2 and 2.5 ml, densities of 5.3 and 7.8 million/ml, and motilities of 48%25 and 56%25, respectively. Serum testosterone is 280 ng/dl (normal 300-1000 ng/dl). Estradiol, LH, FSH, and prolactin are normal. The next step is:
- repeat semen analysis with post-ejaculatory urinalysis
- serum albumin and sex hormone binding globulin
- TRUS
- clomiphene citrate 25 mg daily
- hCG 5000 units twice weekly.
2
Conditions that increase sex hormone binding globulin levels include anorexia, hyperthyroidism, and cirrhosis. Men with these diseases may have normal bioavailable testosterone with decreased total testosterone. Common clinically available assays for free testosterone are inaccurate, and in the absence of an equilibrium dialysis assay for free testosterone, bioavailable testosterone is best calculated from serum albumin. The semen analyses reveal normal volumes, near normal motilities and low sperm densities. With normal volumes, retrograde ejaculation and ejaculatory ductal obstruction are unlikely, and post-ejaculatory UA and TRUS are not indicated. While both clomiphene citrate and hCG will increase serum testosterone levels, clomiphene citrate is the best initial therapy due to the cost of hCG administration. Prior to therapy, accurate assessment of bioavailable testosterone is necessary in a patient with comorbidities that may alter sex horomone binding globulin.
A 68-year-old man with bothersome voiding dysfunction completes a voiding diary revealing 12 voids in 24 hours with volumes ranging from 30 ml to 150 ml, nocturia x 3, and one episode of incontinence. PVR is 50 ml. PSA is 1.8 ng/ml. Non-invasive uroflowmetry reveals a flattened pattern with a peak flow of 6 ml/sec. His condition is best described as:
- BPH
- bladder outlet obstruction
- detrusor overactivity
- detrusor underactivity
- LUTS.
5
BPH is a histological diagnosis. This patient has not had a biopsy. Bladder outlet obstruction is a urodynamic diagnosis made on the basis of the relationship between pressure and flow. The poor flow rate in this case may be due to either detrusor underactivity or bladder outlet obstruction and is not diagnostic of either entity. Detrusor overactivity and detrusor underactivity are a urodynamic diagnosis that cannot be made in the absence of a pressure-flow urodynamic study. LUTS is a generic term describing LUTS and does not imply an underlying pathology or pathophysiology.
A 32-week-gestation neonate is found to have candiduria on two successive urine cultures. He is voiding spontaneously, and his renal/bladder ultrasound is normal. The most appropriate therapy is:
- repeat urine culture in one week
- circumcision
- intravesical amphotericin
- parenteral fluconazole
- parenteral amphotericin.
4
The incidence of nosocomial fungal urinary tract infections is increasing. Candida is the most common offending organism. Aggressive treatment is required due to a high incidence of subsequent candidemia that has been reported to occur in 25-85% of neonates with candiduria. Isolating treatment to the bladder with topical irrigation will not effectively treat the upper tract. Parenteral treatment is required. Fluconazole is the treatment of choice in a premature infant when compared to amphotericin because of significantly diminished side effects.
A 48-year-old woman complains of stress incontinence. She denies any symptoms of urge incontinence. On exam she has urethral hypermobility. Videourodynamics confirms the diagnosis of stress incontinence with mobility. Detrusor overactivity is demonstrated at 400 ml with a detrusor contraction of 25 cm H2O. The best next step is:
- oxybutynin
- pseudoephedrine and oxybutynin
- transurethral collagen injection
- transvaginal needle suspension
- sling procedure.
5
The patient’s complaint is stress incontinence. Detrusor overactivity may be asymptomatic and occurs in up to 69% of normal volunteers with ambulatory monitoring. In patients with mixed symptoms when stress symptoms predominate and stress incontinence is objectively demonstrated, surgical repair will alleviate all the symptoms 50-70% of the time. Antimuscarinic therapy may treat her detrusor overactivity but this is not her complaint. Imipramine and pseudoephedrine will improve her stress incontinence but they are not definitive therapy. Transurethral collagen injections are not approved for women with urethral hypermobility. A sling procedure will treat her stress incontinence from her hypermobility and has a 70% chance of alleviating her detrusor overactivity. Transvaginal needle suspensions are inferior to sling procedure for the treatment of stress urinary incontinence.
A 68-year-old man with end-stage renal failure due to chronic glomerulonephritis has been on peritoneal dialysis for three years. He is anuric and asymptomatic. An ultrasound reveals several non-echogenic cysts involving the left kidney. The next step is:
- left nephrectomy
- CT scan
- renal arteriography
- repeat ultrasound in two years
- conversion to hemodialysis.
4
Acquired renal cystic disease (ARCD) occurs in up to 45% of patients with chronic renal failure. Retrospective studies have indicated that renal cell carcinoma may develop in a small percentage (< 10%) of patients with ARCD. For this reason, periodic ultrasound is recommended for patients on chronic dialysis. It is appropriate to consider CT scan, arteriography, or surgical intervention only when the ultrasound suggests a complex cyst or tumor. Both hemodialysis and peritoneal dialysis have been associated with an equivalent incidence of ARCD, and there is no evidence that conversion from one form of dialysis to another influences this disease. Simple cysts in the nondialysis population do not require surveillance.
A 74-year-old man with metastatic prostate cancer is treated with leuprolide and bicalutamide. After an initial response, his PSA rises to 34.5 ng/ml and the anti-androgen is stopped. Over the next six weeks, the PSA rises to 64 ng/ml, and he develops a left leg DVT as well as mild lower back pain. The next step is anticoagulation and:
- flutamide
- ketoconazole and hydrocortisone
- docetaxel and estramustine
- spinal radiation
- strontium 89.
2
Patients with a rise in PSA while under the influence of combined androgen blockade may respond to further hormonal manipulations. The removal of anti-androgens, especially flutamide, may result in decreased PSA in up to 1/3 of patients. The addition of nilutamide, but not flutamide, has been reported to have some secondary activity. Since the patient has just been diagnosed with a DVT, one would want to avoid estramustine in the immediate time period and thus the patient should be treated with ketoconazole and hydrocortisone, a combination that is active in about 50% of patients.
A 24-year-old man with a gunshot wound shattering the L-4 vertebral body achieves stable neurogenic bladder dysfunction nine months later. Pressure flow urodynamic studies will likely show:
- detrusor overactivity, sphincter dyssynergia
- detrusor overactivity, normal sphincter EMG
- detrusor areflexia, sphincter dyssynergia
- detrusor areflexia, normal sphincter EMG
- detrusor areflexia, denervation potentials on EMG.
5
An injury to the vertebral column at L-4 injures the cauda equina and, depending on the extent of neural damage, will produce a loss of motor and sensory fibers to the bladder, pelvic floor, and external sphincter. Detrusor sphincter dyssynergia is produced by suprasacral spinal cord lesions that interrupt the ascending and descending pathways between the sacral spinal cord and the center for reflex detrusor and urethral function in the brain stem. Reflex detrusor function requires sacral root and sacral cord integrity. While an areflexic bladder faces fixed internal sphincter activity, that activity is normal and not truly dyssynergic. Since within the sacral and lumbar canal the nerve roots are intermingled, a lesion that produces detrusor areflexia would be expected to have a similar effect on the external sphincter; hence, the denervation potentials.
A 34-year-old woman with recurrent, uncomplicated bacterial cystitis has a past history of multiple episodes of fungal vaginitis. The optimal agent for low-dose, long-term antimicrobial prophylaxis is:
- norfloxacin
- trimethoprim
- trimethoprim-sulfamethoxazole
- ciprofloxacin
- nitrofurantoin.
5
Premenopausal women with recurrent cystitis (> 3 infections/year) can be managed with continuous antimicrobial prophylaxis, post-coital prophylaxis or patient-administered self-treatment. Many antibiotics are used for continuous prophylaxis. Trimethoprim, trimethoprim-sulfamethoxazole and fluoroquinolones work by reducing vaginal colonization with uropathogens while other antibiotics, e.g., nitrofurantoin, cephalexin, sulfa, work by intermittently sterilizing the urine. Drugs in the former category increase the risk of fungal vaginitis because of their effect on the commensal bacterial (uropathogens, lactobacilli) in the vagina.
During exploration of a retroperitoneal hematoma from blunt renal trauma, the best anatomic landmark for the left renal artery is the:
- inferior mesenteric artery
- left renal vein
- right renal artery
- left gonadal vein
- left ureter.
2
The left renal artery originates from the aorta just lateral and superior to the left renal vein. Identifying the left renal vein as it crosses the aorta provides the best anatomic landmark for the left renal artery. The right renal artery is retrocaval and not a good landmark. The inferior mesenteric artery is caudad to the renal artery. The inferior mesenteric vein is a good landmark for the location of the aorta during emergent exploration. An incision is made medial to the inferior mesenteric vein. This is extended cephalad to the ligament of Treitz. The aortic dissection is carried cephalad to the left renal vein allowing identification of the renal arteries.
A 52-year-old man develops abrupt and severe hypertension. He is poorly controlled with an ACE inhibitor, calcium channel blocker, diuretic, and minoxidil. None of these medications can be safely withheld. Serum creatinine is 1.3 mg/dl. The best way to evaluate for renovascular hypertension is:
- captopril plasma renin activity test
- unstimulated plasma renin activity test
- captopril renography
- duplex ultrasound
- diuretic renography.
4
This 52-year-old man is at risk for renovascular HTN. Of the captopril modulated testing (PRA and captopril renogram) the renogram is a better test than peripheral PRA. Critical to the performance of these tests is appropriate patient preparation. Ideally, patients should be off all medications for two weeks. This is usually not possible clinically. It is apparent that ACE inhibitors will reduce the sensitivity of testing. Other antihypertensives can be used up to the morning of testing. In this setting, duplex ultrasound will give anatomic information on the renal arteries sufficient to determine the need for angiography.
During transabdominal placement of an artificial urinary sphincter reservoir for post-radical prostatectomy urinary incontinence, the peritoneal cavity is entered. There is no bowel injury. The next step is:
- close the wound and terminate the procedure
- close the wound and relocate the reservoir to another abdominal location
- place the reservoir intraperitoneally and complete the procedure
- close the peritoneum and place the reservoir above the rectus abdominis musculature
- convert to a trans-scrotal placement of the reservoir.
3
Inadvertent entry into the abdominal cavity may occur during placement of an artificial urinary sphincter. In the absence of bowel injury, this is of no consequence and the procedure can be completed as planned. Placement of the reservoir above the rectus abdominis may result in postoperative herniation of this component.
A 21-year-old man who underwent inguinal orchiectomy for a pure seminoma of the right testis has an 11 cm retroperitoneal mass. Serum beta-hCG and AFP are normal. Following three cycles of bleomycin, etoposide, cisplatin chemotherapy (BEP), repeat CT scan demonstrates a residual 2 cm mass in the inter-aortocaval region. A chest CT scan is negative, and tumor markers remain normal. The next step is:
- local excision of the mass
- RPLND
- observation
- salvage chemotherapy
- retroperitoneal radiation.
3
Small (< 3 cm) residual masses after chemotherapy for advanced seminoma rarely (< 10%) contain residual viable tumor. Moreover, surgical resection is technically difficult due to severe fibrosis, and often incomplete. The recommended management for this situation is observation with serial physical exam, serum markers, and CT scans. Recently, it has been suggested the PET scanning can aid in determining if surgical resection of a post-chemotherapy retroperitoneal mass is indicated in seminoma patients. This management should be distinguished from individuals with mixed germ cell tumors or non-seminomatous germ cell tumors in whom RPLND is indicated for the vast majority of residual masses within the retroperitoneum.
The medication associated with an increased incidence of renal insufficiency in patients with either bilateral renal artery stenosis or renal artery stenosis in a solitary kidney is:
- hydrochlorothiazide
- doxazosin
- propranolol
- lisinopril
- furosemide.
4
Lisinopril causes a pharmacologic blockade of the renin-angiotensin system. Glomerular-capillary hydraulic pressure is determined by the balance between afferent and efferent vascular tone. Efferent arteriolar constriction serves to maintain an effective filtration pressure and glomerular filtration rate when renal arterial perfusion pressure is reduced. In bilateral renal artery stenosis or in renal artery stenosis of a solitary kidney, settings in which total renal blood flow is fixed, failure to autoregulate filtration rate would lead to elevations of the BUN and creatinine. Since evidence suggests that the renin-angiotensin system is responsible for this autoregulation, blockade by captopril would lead to transient renal insufficiency. None of the other drugs listed would produce this effect.
The most significant complication of cyclosporine administration is:
- cardiac toxicity
- bone marrow depression
- renal toxicity
- urticarial skin rash
- sodium retention.
3
Nephrotoxicity is the most common side effect of treatment with cyclosporine and has been observed in as many as 50% of patients. This is preventable by monitoring blood levels of cyclosporine with appropriate dose reduction as needed. Cyclosporine nephrotoxicity is usually reversible and occasionally necessitates complete discontinuation of the drug.
A 62-year-old woman with metastatic renal cancer develops lethargy and confusion. Laboratory studies reveal: serum calcium 15.6 mg/dl, phosphorus 4.4 mg/dl, and creatinine 2.0 mg/dl. The best initial therapy is:
- mithramycin
- furosemide
- steroids
- intravenous saline
- calcitonin
4
This patient manifests the paraneoplastic syndrome of hypercalcemia. The hypercalcemia needs to be controlled promptly, and therapy should begin with hydration with isotonic sodium chloride. Hydration should result in an increase in calcium excretion and lowering of serum calcium levels to acceptable ranges. All other therapies are appropriate and effective if saline hydration is inadequate to return serum calcium to safe levels.
The best test to diagnose acute bacterial cystitis is:
- nitrite test
- microscopy
- leukocyte esterase test
- streak plate culture
- pour plate culture.
2
Microscopic examination of the urine is the most rapid and inexpensive means to diagnose UTIs and determine the response to therapy. It provides useful information concerning the likely invaders and whether cultures and susceptibility tests might be needed. The urine may be examined with or without staining and with or without centrifugation, depending on the expertise of the examiner. Unstained specimens are useful for rapid diagnosis. Gram stains provide more reliable information about the potential pathogen.
A 50-year-old woman has urinary frequency, occasional urge incontinence, and dyspareunia. She has a history of recurrent UTIs. On physical examination, the bladder is not distended, but the urethra is tender to palpation. Which of the following would most reliably establish a definitive diagnosis:
- cystogram
- urethral calibration with PVR assessment
- pelvic MRI scan
- cystoscopy
- urodynamics.
3
In this clinical setting, the most likely diagnosis is chronic urinary infection secondary to a urethral diverticulum. Although many of these lesions can be demonstrated on a VCUG, pelvic MRI is being used with increasing frequency to confirm the diagnosis. Endoscopic examination under general anesthesia with good relaxation and simultaneous digital compression of the anterior vaginal wall may be necessary to satisfactorily demonstrate these lesions. In some cases, a retrograde urethrogram, utilizing the double balloon compression technique, is necessary to demonstrate the diverticulum. Cystogram does not image the urethra. Quantitative urine cultures, although positive in these cases, do not establish the diagnosis. Urodynamics are not indicated in patients with suspected local urethral disease unless there is clinical evidence of co-existent neurogenic disease.
The optimal dose of 30% iodinated contrast material for an intraoperative IVP in a non-obese adult patient suspected of having renal trauma is:
- 0.5 ml/kg
- 1 ml/kg
- 2 ml/kg
- 2.5 ml/kg
- 3.0 ml/kg
3
Intraoperative IVP is performed in unstable trauma patients who can’t undergo a radiographic evaluation in the emergency room. A film is taken ten minutes after contrast is administered intravenously. A 2 ml/kg dose of contrast material is recommended for this study.
A 55-year-old woman has unilateral hydronephrosis on a follow-up CT urogram two years after radical cystectomy and refluxing colon conduit diversion for a Stage T2, Grade III TCC of the bladder. She received pelvic irradiation 12 years ago for cervical carcinoma. The next step is:
- loopogram
- urinary cytology
- loop endoscopy
- antegrade nephrostogram
- balloon dilation.
2
Early hydronephrosis in this patient suggests recurrent tumor. CT scan and urinary cytology is the best approach to assessing the recurrent cancer in this patient. Urinary cytology from the conduit will be positive with a high grade tumor in greater than 80% of cases and is therefore the next test, as the patient has already had a CT urogram. If urinary cytology is positive, appropriate cancer therapies should be initiated. Assuming the cytology is negative, loopogram, loop endoscopy, and percutaneous nephrostomy can be performed later to aid in surgical planning.
A 60-year-old man with squamous cell carcinoma of the penis invading the right corpus cavernosum undergoes partial penectomy. After six weeks of cephalexin, a 3.5 cm right inguinal lymph node has decreased in size to 2.0 cm. Pelvic CT scan is normal. The next step is:
- reevaluation in three months
- needle aspiration of the suspicious node
- sentinel node biopsy
- bilateral inguinal node dissection
- right inguinal node dissection.
4
The patient has a Stage II penile cancer with invasion of the corpora that is associated with a much higher incidence of positive lymph nodes. Although the lymph node has decreased in size, it is still palpable after six weeks and deserves excision. Since this patient is at high risk for nodal disease, neither a negative needle aspiration nor a negative sentinel node biopsy should dissuade one from lymphadenectomy. Among patients found to have unilateral positive groin nodes, a bilateral lymphadenectomy is indicated due to the high rate of bilateral disease. By comparison, patients who present with unilateral adenopathy beyond one year are treated with ipsilateral lymphadenectomy.
Twenty-four hours after a newborn circumcision, a 1.5 cm skin separation is noted. The best management is:
- immediate reapproximation
- delayed reapproximation
- split thickness skin graft
- full thickness skin graft
- healing by secondary intention.
5
Minor degrees of separation of circumcision edges are common. Complete separation as described is uncommon. This incision should be considered contaminated in the baby’s diaper. Therefore, immediate closure is not recommended. Skin grafts are not indicated because of the contaminated bed and would have a high risk of infection. Since the length of the skin was adequate at the time of circumcision, observation is the best choice. Usually this complication rapidly heals well and nothing further will be necessary. If an undesirable scar develops, it can be revised or grafted electively at a later time.
The presence of nephrogenic rests may predispose to:
- adenocarcinoma
- sarcoma
- adenoma
- hamartoma
- Wilms’ tumor.
5
Lesions apparently representing Wilms’ tumor precursors have been recognized for many years. They have been found in 1% of kidneys in infants on postmortem and in 30-40% of kidneys removed for Wilms’ tumor. The terminology for these lesions has evolved over the years. These lesions were previously termed persistent nodular renal blastema, Wilms’ tumorlet or nephroblastomatosis if there were diffuse lesions. The current preferred term is nephrogenic rest which is defined as foci of abnormally persistent nephrogenic cells that can potentially form a Wilms’ tumor. It is has estimated that approximately 1 in 80 nephrogenic rests will develop into a Wilms’ tumor.
An 18-year-old man injured in a MVC has blood at the external urethral meatus. An indication for urethral catheter drainage of the bladder, without further surgical exploration, is:
- retrograde urethrogram demonstrating disruption of the penile urethra
- retrograde urethrogram demonstrating partial tear of the posterior urethra
- extraperitoneal bladder perforation in association with pelvic fracture requiring surgical repair
- extraperitoneal bladder perforation with bone fragment penetrating the bladder wall
- intraperitoneal bladder perforation with only microscopic hematuria.
2
Direct injury to the penile urethra is usually best managed with primary surgical repair. In contrast, partial injuries to the posterior urethra will usually heal well over a urethral catheter if one can be placed atraumatically. While extraperitoneal bladder injuries can usually be managed by urethral catheter drainage of the bladder, indications for primary surgical closure of the bladder and placement of a suprapubic cystostomy include co-existing open pelvic fracture, patients undergoing laparotomy or open surgical repair of pelvic fracture, rectal perforation, and bone fragment projecting into the bladder. Intraperitoneal ruptures require primary surgical exploration and repair.
A 63-year-old man, two years after a successful renal transplant, has an edematous scrotum with a 2 cm nontender erythematous patch. In-situ hybridization on the biopsy tissue is positive for human herpes virus 8. This lesion is most likely:
- Kaposi’s sarcoma
- condyloma acuminata
- Bowen’s disease
- posttransplant lymphoproliferative disorder
- erythema multiforme.
1
Kaposi’s sarcoma is a rare neoplasm of endovascular cells that is seen in men of Mediterranean descent, HIV infected patients, and those on immunosuppression. The lesions are associated with the human herpes virus 8. The lesions are violaceous to light brown. They can cause venous and lymphatic obstruction resulting in local edema.
A 72-year-old man on LH-RH agonist therapy reports difficulty voiding 30 months following brachytherapy for localized prostate cancer, and undergoes TURP. Before brachytherapy, his prostate volume was 30 gm, his PSA was 5.2 ng/ml and International Prostate Symptom Score (IPSS) was 7. The factor most likely to correlate with incontinence following TURP is:
- pre-operative PSA
- prostate volume
- treatment with LH-RH agonist therapy
- time since brachytherapy
- preoperative IPSS.
4
Rates of incontinence can be high in patients undergoing TURP following brachytherapy (at least 18%). The presence of obstructive symptoms at the time of TURP, and a period of at least two years since brachytherapy are associated with a greater likelihood of incontinence. Treatment with Lupron, prostate size, pretreatment IPSS, dosage of brachytherapy, and pre-treatment PSA do not seem to affect the likelihood of incontinence.
A 77-year-old man with hypertension, coronary artery disease, and a creatinine of 1.9 mg/dl has gross hematuria. Cystoscopy reveals a normal bladder and bilateral retrogrades show a small right distal ureteral filling defect. On ureteroscopy there is a 5 mm solitary papillary tumor and biopsy demonstrates a low grade TCC. The next step is:
- intravesical BCG with ureteral stent in place
- ureteroscopic laser ablation of tumor
- segmental resection and ureteroureterostomy
- distal ureterectomy with reimplant
- laparoscopic nephroureterectomy.
2
Multiple series have documented the safety and efficacy of endoscopic management of upper tract TCC. This elderly patient has significant comorbidities and a low grade distal ureteral TCC. Low grade tumors at ureteroscopic biopsy have a strong correlation with noninvasive stage at the time of nephroureterectomy. Similarly, high grade disease identified on ureteroscopic biopsy is very likely to represent invasive disease at the time of final pathologic staging. While optimal therapy for a low grade ureteral tumor in a younger, healthier patient would be distal ureterectomy and reimplantation, this patient would be well-served with endoscopic management. Although upper tract tumors can be ablated with electrocautery delivered through a small Bugbee electrode, the variable depth of penetration and risk of stricture formation have made the use of laser energy for ablation more popular. Follow-up of the patient should include endoscopic evaluation (ureteroscopy) on a periodic basis.
A 66-year-old man is scheduled for elective repair of a 7 cm abdominal aortic aneurysm. CT scan shows peri-aneurysmal fibrosis, a normal right kidney, and marked left hydronephrosis with cortical loss. Renogram demonstrates 25% function on the left, and a retrograde pyelogram reveals entrapment of a 6 cm segment of the mid-left ureter. The serum creatinine is 1.6 mg/dl. The next step is aneurysm repair and:
- left ureterolysis
- delayed ureterolysis
- steroid therapy
- left nephrectomy
- balloon dilation.
4
The management of ureteral obstruction in association with inflammatory abdominal aortic aneurysms is controversial. Peri-aneurysmal fibrosis has been reported to subside in some cases after aneurysm repair and there have been some who have recommended steroid treatment for this condition. Since the right kidney is functioning normally and there is a long ureteral stricture, left nephrectomy should be strongly considered. Ureterolysis concomitantly with aneurysm repair would likely to require an ileal ureter or autotransplantation which would be ill-advised in this setting.
A 17-year-old girl with neurogenic bladder secondary to meningomyelocele had an artificial urinary sphincter placed two years ago. At that time, her detrusor LPP was 15 cm H2O at bladder capacity of 350 ml. Two years later, she is continent, but renal ultrasonography shows new moderate bilateral hydronephrosis. The most likely etiology is:
- sphincter erosion
- ureterovesical junction obstruction due to the sphincter
- decreased bladder compliance
- excessive sphincter cuff pressure
- changing neurologic lesion.
3
New hydronephrosis after artificial urinary sphincter (AUS) placement is a well described complication. It is usually due to decreased bladder compliance that was unrecognized at the time of AUS placement or has developed subsequent to and as a result of the outlet resistance from the AUS. It is essential to monitor bladder compliance following AUS placement. A changing neurologic lesion (such as tethered cord) is unlikely to occur in a patient who has completed linear growth.
An 11-year-old boy has hypertension associated with paroxysmal headaches, nausea, and vomiting. A renal Doppler ultrasound is normal. Plasma and urine catecholamine levels are highly elevated during a hypertensive episode. The next step is:
- glucagon stimulation test
- clonidine suppression test
- abdominal CT scan
- abdominal MRI scan
- MIBG scan.
4
The patient has a classic history for a pheochromocytoma. This includes his age, sex, and symptoms. The normal renal Doppler ultrasound rules out most secondary renal causes of HTN. The elevated plasma and urine catecholamine levels document biochemical evidence for a pheochromocytoma. Children have an increased incidence of bilaterality, multifocality, and a greater tendency for familial occurrence. MR imaging is the most sensitive study for localizing adrenal and extra-adrenal tumors. The glucagon stimulation and clonidine suppression tests are used in instances of non-diagnostic plasma and urine catecholamine levels.
A 13-year-old boy is undergoing a laparoscopic colectomy for ulcerative colitis during which the lower half of the left ureter is resected with the colon. The procedure has been converted to an open technique for completion. The next step is:
- ileal ureter
- cutaneous ureterostomy
- transureteroureterostomy
- auto transplantation and ureteroneocystostomy
- nephrectomy.
3
With loss of the distal half of the ureter and the inflammatory process of the ulcerative colitis, a primary anastomosis with a psoas hitch would not be possible. Because of his bowel disease, creating an ileal ureter would not be ideal. A left auto transplantation is possible but not worth the post operative risks. A cutaneous ureterostomy would only be temporizing and require another open procedure. It would be best to perform a transureteroureterostomy. If the left ureter does not reach to the right, the right ureter can be mobilized, passed to the left and reimplanted into the bladder. A nephrectomy should be avoided as the initial management.
A 36-year-old man on chronic hemodialysis has gynecomastia, diminished libido, erectile dysfunction, and bone pain. The primary etiology is:
- reduced sex hormone binding globulin
- high prolactin
- low cortisol
- hyperparathyroidism
- elevated estradiol.
2
Hyperprolactinemia is a common result of hemodialysis. Physical signs of this condition include diminished libido, erectile dysfunction, infertility and gynecomastia. Treatment with cabergoline or bromocriptine reverses the osteoporosis and low testosterone improving libido and erectile dysfunction.
The obliterated umbilical artery originates from which of the following arteries:
- superior gluteal
- obturator
- middle sacral
- internal iliac
- external iliac.
4
The umbilical artery is the first visceral branch of the internal iliac artery and is very commonly a large trunk that in its proximal unobliterated section gives rise to the superior vesical artery as its first branch. The obliterated umbilical artery is an important landmark in the pelvis as it sweeps lateral to the ureter at the pelvic brim. It can be used to mark the peritoneum in pelvic dissections and may be confused with the vas deferens in the male.
A 74-year-old man with a Studer ileal neobladder develops TCC of the proximal urethra three years post-cystectomy. A metastatic evaluation is negative. The next step is:
- BCG instillation in the urethra and neobladder
- urethrectomy and transverse colon loop construction
- urethral laser fulguration
- urethrectomy and continent cutaneous diversion
- urethrectomy and use afferent limb for cutaneous diversion.
5
Urethral recurrence after neobladder is an uncommon but troublesome complication best treated with urethrectomy and some form of urinary diversion. The Studer neobladder affords a reasonable solution to this problem since the non-intussuscepted afferent limb may be detached from the neobladder and converted to a standard ileal loop. A transverse colon conduit would require ureteral reimplantation and continent cutaneous diversion while an operation would have a greater complication rate in an older, previously operated upon patient. Local therapy is inadequate.
A 56-year-old man undergoes a TUR of a sessile bladder tumor. The pathology reveals a T1 TCC. Before deciding upon additional treatment, a repeat resection must be done if the initial pathology has:
- lymphovascular invasion
- carcinoma in-situ
- high grade disease
- no muscularis propria
- no muscularis mucosa.
4
The rate of clinical understaging in high-risk nonmuscle invasive bladder cancer is as high as 40% among those tumors with involvement of the lamina propria (clinical stage T1). Therefore, to reduce this staging error, the presence of uninvolved muscularis propria should be identified. While the presence of lymphovascular invasion, carcinoma in-situ and high grade tumors are all factors that place the patient at high risk for progression in stage, of the options listed only the absence of muscularis propria would necessitate an automatic restaging by repeat TUR. While muscularis mucosa has been suggested by some to be associated with risk of understaging and progression among T1 tumors, it is not identified in up to one half of TUR specimens and therefore the failure to identify this layer does not justify an automatic repeat resection.
A 56-year-old woman undergoes PCNL for a staghorn calculus. Eight days later she presents to the emergency room with sudden onset gross hematuria and hypotension. Following fluid resuscitation, the next step is:
- CT scan
- renal angiography
- cystoscopy with retrograde pyelography
- ureteroscopy
- exploration of nephrostomy tract.
2
This is a typical clinical presentation of delayed hemorrhage from vascular pseudoaneurysm owing to arterial injury during PCNL. A similar injury can occur during partial nephrectomy. The reported incidence of serious arterial injuries in association with percutaneous renal surgery, including arteriovenous fistulas, pseudoaneurysms, and lacerations, ranges from 0.9% to 3%. The diagnosis is presumptive, and therefore therapeutic rather than diagnostic interventions are indicated. Most patients require superselective embolization of bleeding arteries under angiographic control, which is very effective at controlling hemorrhage and preserving renal function. The small number of patients whose bleeding is refractory to embolization may require surgical exploration.
The manifestation of the von Hippel-Lindau syndrome that tends to be clustered only within a subset of affected families is:
1 renal cell carcinoma
- pheochromocytoma
- retinal angioma
- cerebellar hemangioblastoma
- epididymal papillary cystadenoma.
2
Penetrance for all of the manifestations of VHL is incomplete. Pheochromocytoma is found only in certain families with the VHL syndrome, primarily those with a missense mutation of the VHL gene. All of the other manifestations of VHL are found in most families with the syndrome.
A 26-year-old schizophrenic man is evaluated two hours after self-amputation of his phallus at its base with a knife. The amputated organ has been preserved at room temperature. The next step is suprapubic cystotomy, debridement, and:
- stump closure with distal spatulation of urethra
- stump closure with perineal urethrostomy
- leave stump open to heal by secondary intention
- creation of neophallus with abdominal pedicle flap
- reimplantation of phallus.
5
Reimplantation of the amputated phallus is usually successful even after two hours ischemia without ice. In fact, many organs may be damaged through frost injury if improperly stored in ice. The edges should be debrided and the corpora and urethra re-approximated without attempting reanastomosis of the cavernosal arteries. Microsurgical technique should be employed to re-anastomose the dorsal nerves, arteries and veins. Skin loss frequently occurs but it can be managed later with skin grafting.
A 32-week-male fetus has bilateral hydroureteronephrosis and a thick-walled bladder on ultrasound. The most important information needed to determine further prenatal care is:
- renal parenchymal echogenicity
- presence and timing of onset of oligohydramnios
- degree of bladder dilation and thickening
- urine electrolytes and beta-2 microglobulin levels
- presence of a perinephric urinoma.
2
The most likely diagnosis in this fetus is posterior urethral valves based upon male sex, bilateral hydronephrosis, and a thick walled bladder. The clinical outcome of a child with severe posterior urethral valves is most specifically predicted by the presence or absence of oligohydramnios and when the onset of oligohydramnios was noted to occur. Increased renal echogenicity alone is not predictive, although in the setting of oligohydramnios, it is a poor prognostic indicator. Bladder dilation is not a good prognostic indicator. Urinary electrolytes have been shown to be useful as an indicator of renal salvageability only in the setting of oligohydramnios and in early gestation (18 to 24 weeks). A perinephric urinoma does not predict a poor outcome.
A 58-year-old obese man has 400 ml of bile-stained fluid coming from his drain two days following transperitoneal laparoscopic unroofing of a large right renal cyst. He is afebrile and his bowel sounds are normal. The leakage persists over the next five days despite nasogastric suction. KUB and upright abdominal x-rays are normal. The next step is:
- feeding jejunostomy tube
- laparotomy
- parenteral nutrition
- somatostatin
- small bowel suction (Kantor) tube.
3
Immediate reoperation for fistula closure is not indicated as most fistulae heal with parenteral nutrition. Immediate operative intervention is not indicated unless the patient has signs of peritonitis or an acute abdomen. Parenteral nutrition has significantly improved the prognosis of patients with enterocutaneous fistula and has not only increased the rate of spontaneous fistula closure but also improved nutritional status of patients needing repeated operations.
A 22-year-old primigravida woman in her 28th week of pregnancy develops hematuria and intermittent right flank pain. Ultrasound reveals a 12 mm calculus at the level of the right UPJ. She is afebrile, and a urine culture is sterile. The next step is:
- hydration and observation
- PCNL
- percutaneous nephrostomy
- ureteroscopy and laser lithotripsy
- ureteral stent.
5
Among pregnant women with a calculus, one-half to two-thirds will pass their stone spontaneously. The average size of a passed calculus is 6 mm (2-11 mm). Among the remaining patients, over 80% will likely be in their third trimester; in this group, placement of an indwelling stent is the most generally accepted next step. The stent can be placed under ultrasonic or fluoroscopic control. If fluoroscopy is used, the fetus should be shielded; however at this time, chances of any adverse developmental effect of radiation to the fetus are low. It is recommended that the stent be changed every 4-8 weeks, although some urologists have reported stent indwell times for the duration of the last trimester with successful retrieval of the encrusted stent. The use of a percutaneous nephrostomy in the third trimester is less acceptable due to the discomfort to the patient, invariable bacterial colonization of the urine, and the frequent problems of encrustation and blockage of the nephrostomy tube necessitating emergency changing of the tube approximately once a month. In this patient, hydration and observation are not reasonable. Spontaneous passage is unlikely given the size of the stone. A surgical procedure also is not indicated, as the goal of therapy is to relieve the stone-induced obstruction. After the patient delivers her child, the stone can be treated with SWL, a less morbid treatment than a percutaneous or ureteroscopic procedure.
A 40-year-old man has recent onset of erectile dysfunction. He also has a long-standing history of hypertension and dyslipidemia, treated with an ACE inhibitor and a statin, respectively. He has been using tadalafil for the past month for his erectile dysfunction. He complains of profound lower limb muscle pain. The next step is:
- switch to another PDE5 inhibitor
- switch anti-hypertensive to a CCB
- check serum creatine kinase level
- co-administer a NSAID
- Doppler ultrasound of lower extremity.
1
Myalgia (leg, back, buttock pain) occurs in about 10% of men using tadalafil, due to venous congestion of the large muscle of the body and there is no evidence that it is the result of rhabdomyolysis. Its severity is variable, however it is severe enough in some men that the medication needs to be switched to another PDE5 inhibitor. While, statins can cause rhabdomyolysis, in this patient, his long-standing use of the statin without myalgia and the chronological association between the pain and the commencement of the tadalafil suggest that the latter is to blame.
When comparing prostatic secretions to those of the seminal vesicles, one would expect the prostatic secretions to exhibit:
- Citrate Level: higher Fructose Level: lower
- Citrate Level: higher Fructose Level: higher
- Citrate Level: lower Fructose Level: lower
- Citrate Level: lower Fructose Level: similar
- Citrate Level: similar Fructose Level: lower
1
The prostate forms tremendous amounts of citric acid, almost 100 times higher than other soft tissues. The secretory epithelium of the prostate has a special metabolic ability to form citrate from aspartic acid and glucose. Its role in normal prostatic metabolism or reproduction is unknown. Similarly, the seminal vesicles have an increased capacity for fructose production. This production of fructose is the product of glucose metabolism by aldose reduction to sorbitol and a ketone reduction to form fructose.
The agent that is part of second line therapy for multi-drug resistant genitourinary tuberculosis is:
- isoniazid
- ciprofloxacin
- para-aminosalicylate
- pyrazinamide
- rifampin.
2
Multi-drug resistant tuberculosis is a form of tuberculosis that is resistant to two or more primary drugs, including isoniazid, pyrazinamide, and rifampin. Multi-drug resistant tuberculosis infection results in increased morbidity, mortality and increased drug-treatment costs. Prevalence rates for multi-drug resistance rates (exceeding 5%) are high in the former Soviet Union, the Baltic States and Peru. Recommended second-line treatment for multi-drug resistant tuberculosis consists of at least 5 drugs including a fluoroquinolone (Ciprofloxacin) and an aminoglycoside (streptomycin, amikacin).
A 65-year-old man with rectal carcinoma treated by abdominal perineal resection develops urinary incontinence two years later. His urinalysis is normal and PVR is 300 ml. Renal ultrasound demonstrates moderate bilateral hydronephrosis. The most likely urodynamic findings are:
- detrusor overactivity with bladder outlet obstruction
- detrusor overactivity with external sphincter dyssynergia
- detrusor areflexia with normal compliance
- detrusor areflexia with poor compliance
- impaired bladder contractility with intrinsic sphincter deficiency.
4
Permanent lower urinary tract dysfunction occurs in 15-20% of patients following radical pelvic surgery. The typical pattern is one of detrusor areflexia or hypocontractility in the presence of fixed residual striated sphincter tone. This fixed tone represents a functional obstruction that frequently results in decreased detrusor compliance. Although poor proximal sphincter function can also occur (intrinsic sphincter deficiency), this is often masked by prostate bulk in male patients.
Seminal emission depends on an intact:
- parasympathetic and somatic nervous system
- sympathetic nervous system
- parasympathetic nervous system
- sympathetic and parasympathetic nervous system
- sympathetic and somatic nervous systems.
2
Emission is defined as the deposition of seminal fluid into the posterior urethra by the vasa deferentia and the seminal vesicles. Ejaculation is the forceful expulsion of seminal fluid out the urethral meatus by contraction of the bulbospongiosus and ischiocavernosus muscles. Since the vasa and the seminal vesicles are innervated primarily by the sympathetic nervous system, emission is under control of the sympathetic nervous system. Alpha-adrenergic nerve stimulation causes not only contraction of the seminal vesicles and vasa deferentia but also closure of the bladder neck. Ejaculation is the result of somatic nerve stimulation of the periurethral striated musculature. The parasympathetic nervous system is not directly involved with either emission or ejaculation.
A three-year-old boy lost one-half of his scrotal skin after a dog attack two hours ago. His testicles, penis and urethra are spared. Best management includes antibiotics, debridement, and:
- split thickness skin graft
- full thickness skin graft
- placement of testicles in the thigh
- scrotal closure with drainage
- secondary scrotal closure.
4
Skin grafts and placement of the testicles in the thigh are seldom required when half of the scrotal skin remains. Secondary closure for such a recent injury is unnecessary. The best choice for management is a tetanus immunization if he is not up to date, antibiotics, debridement, and primary closure with drainage. If grafting is required, a meshed split thickness graft is preferable because the meshing allows exudate to escape and gives improved cosmesis. Thigh pouches are rarely required as wet to dry dressings of the exposed gonads can be effective in critically ill patients until reconstruction is feasible.
A newborn baby has a palpable abdominal mass. An ultrasound shows a normal right kidney and numerous large and small cysts replacing the left kidney. A VCUG shows Grade I/V right VUR and a DMSA scan demonstrates no function in the left kidney. The most likely consequence of this condition is:
- hypertension
- renal insufficiency
- pancreatic cysts
- involution of the left kidney
- hepatic fibrosis.
4
The scenario is characteristic of a left multicystic kidney that is nearly always unilateral and is likely to involute. HTN can occur, but is rare. Autosomal dominant polycystic kidney disease is associated with aneurysms and recessive disease is associated with hepatic fibrosis.
A 42-year-old man had a right radical nephrectomy two years ago for a Stage T3aNoMx RCC. He now has right hip pain. Bone scan shows intense uptake in the right hip area and plain films of the right femur show a 3.5 cm lytic lesion. The next step is:
1 external beam radiation to the femur
- strontium-89
- internal fixation of the femur
- pain management
- systemic immunotherapy.
3
Approximately 50% of patients with multi-organ metastases from renal cell carcinoma exhibit evidence of skeletal involvement. It has been estimated that between 15% and 30% of such skeletal lesions are solitary. Eighty percent of skeletal metastases occur in the axial skeleton, thoracic/lumbar spine, and pelvis. When long bones are involved, only the proximal portions are characteristic targets for metastatic disease. Surgical treatment of bony metastases is indicated for weight-bearing bones with lytic lesions greater than 3 cm. Internal stabilization or replacement of the destroyed periarticular segment often results in significant pain relief and tremendously improves the patient’s quality of life.