2011 Flashcards
A 66-year-old diabetic man with peripheral neuropathy and a 25 gm palpably normal prostate has urinary frequency, urgency, and urge incontinence. He voided 300 ml with a PVR of 380 ml. Urodynamic studies reveal a maximum uroflow of 8 ml/sec, a voiding pressure of 88 cm H2O, and a bladder capacity of 850 ml with decreased bladder sensation. Cystourethroscopy reveals mild trilobar prostatic enlargement. The most effective treatment is:
- CIC
- CIC and oxybutynin
- neuromodulation
- tamsulosin
- TURP.
5
Typically described urodynamic findings in diabetics include: impaired bladder sensation, increased cystometric capacity, decreased bladder contractility, impaired uroflow, and later, increased residual urine. The main differential diagnosis in men is the presence or absence of bladder outlet obstruction. In this patient, urodynamic data document bladder outlet obstruction as well as probable diabetic cystopathy. Cystourethroscopy excluded urethral stricture; thus, prostatic obstruction is the likely etiology. CIC with or without medications, is an acceptable treatment but in the face of prostatic obstruction, TURP will alleviate the symptoms provided the patient does timed voiding to prevent overdistention. Neuromodulation is not indicated in a patient with bladder outlet obstruction. Given the degree of bladder outlet obstruction and the amount of residual urine, tamsulosin is unlikely to be as effective as TURP.
Placement of a ureteral stent in an unobstructed system will result in:
- increase in ureteral contractility
- decrease in ureteral contractility
- atrophy of the ureteral mucosa
- atrophy of the ureteral smooth muscle
- decrease in intrapelvic pressure.
2
A number of changes occur after placement of a ureteral stent including: hyperplasia and inflammation of the urothelium, smooth muscle hypertrophy, increased intrapelvic pressure, a decrease in ureteral contractility and vesicorenal reflux. Decreased ureteral contractility does contribute to vesicorenal reflex, which may have implications in infected systems in the setting of bladder outlet obstruction.
A 25-year-old man has a thickened, indurated fat mass excised from his spermatic cord at the time of inguinal hernia repair. Final pathology reveals low grade liposarcoma with negative margins. The next step is:
- observation
- inguinal orchiectomy
- inguinal orchiectomy and RPLND
- inguinal orchiectomy and hemiscrotectomy
- inguinal/abdominal radiation.
2
Liposarcoma of the paratesticular structures is most often associated with the spermatic cord. it is a rare tumor that is usually well-differentiated. As with all sarcomas of the paratesticular region, inguinal orchiectomy with high ligation of the spermatic cord with inguinal orchiectomy is generally advised to minimize the chance of local recurrence. Because of the low likelihood of hematogenous or lymphatic spread in a low grade sarcoma, additional radiation or chemotherapy would not likely be necessary. This tumor has a low likelihood of complete response to primary radiotherapy and therefore it is not a reasonable option. Hemiscrotectomy is unnecessary with no violation of the scrotum.
Angiotensin II causes blood pressure elevation by its effect on:
- peripheral vascular tone and cardiac rate
- peripheral vascular tone and blood volume
- blood volume and cardiac output
- blood volume and renin substrate
- the juxtaglomerular apparatus.
2
Renin is a proteolytic enzyme secreted in the juxtaglomerular apparatus of the kidney and is physiologically inert. Angiotensinogen is a plasma globulin substrate of hepatic origin, upon which renin acts to produce angiotensin I. Angiotensin I is a decapeptide which is also physiologically inert. Angiotensin I is acted upon by converting enzyme to produce the octapeptide angiotensin II. Angiotensin II is the first effector hormone of the renin system, and is the only substance directly responsible for elevation in blood pressure in patients with renovascular HTN. It acts upon the smooth muscle of the peripheral vasculature to cause vasoconstriction, and also stimulates the zona glomerulosa to produce aldosterone which causes sodium retention in the distal tubule and thus produces volume expansion.
Serum osmolality is determined by utilizing a formula which involves the sum of which three osmotically active substances in the blood:
- sodium, potassium, glucose
- sodium, chloride, urea nitrogen
- sodium, glucose, urea nitrogen
- albumin, glucose, creatinine
- albumin, globulin, urea nitrogen.
3
Osmolality is estimated by computing the sum of serum sodium (mEq/l) x 2, glucose (mg/dl)/18 and urea (mg/dl)/3. These three solutes are the major contributers to osmolality with creatinine, magnesium, phosphate and potassium contributing less. The chloride contribution is taken into account by doubling the sodium concentration.
A two-year-old boy has foul smelling urine and dysuria. A urine culture grew pan-sensitive coagulase negative Staphylococcus. His symptoms resolved with antibiotics and a renal ultrasound is normal. A VCUG is shown. The next step is:
- prophylactic antibiotics
- behavioral modification
- transurethral incision of valves
- endoscopic puncture
- diverticulectomy and ipsilateral ureteral reimplantation.
5
The imaging reveals a large congenital right sided bladder diverticulum. There is no evidence of bladder outlet obstruction or valves. This is a source of stasis (incomplete bladder emptying) that will not spontaneously resolve. Smaller periureteral diverticula are associated with dysfunctional elimination and are not treated surgically but in this case diverticulectomy is indicated. Based upon the size of the diverticulum, this child will almost certainly have recurrent infections. As such, prophylactic antibiotics or observation are not appropriate options in a pediatric patient. The diverticulum arises cephalad and lateral to the ureteral orifice. The ureter and diverticulum are intimately associated. The ipsilateral ureter should be reimplanted if it is near or included in the diverticulum whereas a diverticulum on the lateral bladder wall or dome (urachal diverticulum) can be resected without ureteral reimplantation. Both can be performed extravesically with entry into the bladder only when the diverticulum is entered.
A 22-year-old man involved in an MVC is evaluated for multi-system trauma. CT scan shows complete enhancement of both kidneys, a 2 cm laceration in the lower pole of the left kidney, and a left perinephric hematoma. A 3 cm splenic laceration that does not extend to the hilum is also seen. He is managed with observation. Ten days later, he develops acute abdominal pain. On physical examination, he is diaphoretic and has a rigid abdomen. His temperature is 38.5%b0C, pulse 120/min, and blood pressure is 90/70 mm Hg. This clinical condition is most likely due to:
- delayed sepsis
- persistent urinary extravasation
- delayed renal hemorrhage
- delayed splenic hemorrhage
- missed bowel injury.
4
Associated organ injury is common in patients with renal trauma. Nonrenal trauma accounts for the majority of the morbidity and mortality that occurs in such patients. As in the case described, CT allows staging of renal injury and detection of associated organ injury. Nonoperative management of both splenic and renal injury is possible in selected patients with renal injuries associated with limited extravasation and bleeding. Development of delayed bleeding, infection, or HTN (related to the renal injury) is unlikely. Those cases where there are nonviable renal segments are more likely to require delayed laparotomy. Although splenic lacerations may be managed nonoperatively, up to 40% of those with Type II injuries (splenic laceration not extending to hilum) may require operative intervention. Although either injury described in the case presented may require delayed laparotomy, the splenic injury is more likely. The finding of the rigid abdomen suggests an intraperitoneal process. A missed bowel injury would present within the first several days after injury.
A 24-year-old man with azoospermia and an ejaculate volume of 0.5 ml has a palpably normal left vas deferens, a nonpalpable right vas deferens, and a normal DRE. Both testes measure 30 ml. The most useful diagnostic study for infertility is:
- TRUS
- serum testosterone
- post-ejaculatory urinalysis
- testicular biopsy
- seminal fructose.
1
The differential diagnosis for low ejaculate volume azoospermia is vasal agenesis, ejaculatory duct obstruction, and ejaculatory dysfunction. The presence of unilateral vasal agenesis on physical examination strongly suggests the presence of a congenital anomaly with contralateral segmental vasal atresia. TRUS will help differentiate between a potentially treatable ejaculatory duct obstruction and, more likely, absence or hypoplasia of the contralateral seminal vesicle and ampullary vas deferens. Patients with vasal agenesis do not require either a serum FSH or testicular biopsy unless they have testicular atrophy or another historical risk factor. Seminal fructose does not help differentiate between these two disorders; it is absent in both.
A 47-year-old man has palpable right inguinal adenopathy following partial penectomy for a 4 cm T2 squamous cell cancer. Needle biopsy of a right inguinal lymph node reveals metastatic cancer. The pelvic lymph nodes are radiologically normal. The next step is:
- antibiotic therapy and reexamination
- pelvic node dissection
- right superficial inguinal node dissection
- right superficial and deep, left superficial inguinal node dissection
- bilateral superficial and deep inguinal node dissection.
4
Men with invasive penile cancer are at high risk of inguinal metastasis. Those men who present with palpable inguinal lymph nodes often have an inflammatory or infectious etiology due to poor hygiene. In these patients, two approaches can be employed. Patients can be treated with a two to four week course of antibiotic therapy to assess for resolution of lymphadenopathy. Alternatively, fine needle aspirate of suspicious nodes can be performed at presentation. If positive, this removes the need for delayed therapy due to antibiotics. Men with palpable nodes proven positive for metastatic disease should undergo superficial and deep inguinal node dissection as those with limited nodal disease are found to have up to an 80% five year disease-free survival with complete resection of nodal disease. Owing to the high rates of cure achieved with aggressive resection in limited nodal disease, many have advocated early dissection in men with invasive penile cancer and no palpable lymphadenopathy. In these men, dissection can be limited to nodes superficial to the fascia lata unless positive on evaluation. In men with palpable disease on one side, contralateral superficial dissection is mandatory owing to the high rate of lymphatic cross-over. In these cases, contralateral metastasis is noted in 50% of patients.
The best predictor of immediate graft function following living donor renal transplantation is:
- warm ischemia time
- cold ischemia time
- renal revascularization time
- total ischemia time
- donor kidney urine output just prior to nephrectomy.
5
While both cold (storage) and warm (anastomotic) ischemic times have important roles in determining immediate function for deceased donor renal transplant recipients, these times are negligible in living donor transplantation and rarely affect immediate graft function. The single best determinant of immediate function in live donor transplantation is the functional status of the kidney at the moment it is removed from the donor.
A 10 Fr nephrostomy tube was placed uneventfully to drain a pyonephrotic kidney. Follow-up nephrostogram reveals a 6 cm staghorn calculus. The percutaneous nephrostomy tube enters directly into the renal pelvis. At time of percutaneous nephrolithotomy, optimal access is obtained via:
- dilating the established nephrostomy tract
- a new percutaneous tract - middle anterior calyx
- a new percutaneous tract - middle posterior calyx
- a new percutaneous tract - inferior anterior calyx
- a new percutaneous tract - inferior posterior calyx.
5
Percutaneous renal access into the collecting system should be as peripheral as possible to help avoid serious hemorrhage. Direct puncture into an infundibulum or into the renal pelvis substantially increases the risk of hemorrhage. The temptation to utilize a previously placed nephrostomy tube in a suboptimal location should be abandoned. A new percutaneous access should be established. Staghorn calculi are best approached through polar access. Inferior or superior pole entry optimizes access to most of the collecting system. An interpolar puncture hinders entry into the superior or inferior calyceal groups. A posterior calyceal puncture decreases the need to torque instruments into the collecting system and helps reduce hemorrhage and eases stone extraction.
The most useful parameter to assess the malignant risk of an incidental adrenal mass is tumor:
- grade
- histology
- isointensity on MRI scan
- metabolic activity
- size.
5
Incidentally discovered adrenal masses have been reported in up to 4.4% of abdominal CT scans, most commonly in female patients between the ages of 50 and 70 years. A small minority of adrenal masses will be malignant, most often due to adrenocortical carcinoma or metastases to the adrenal gland. The primary indication for surgery is suspicion of malignancy based on size criteria, radiographic findings, or interval growth documented on follow-up imaging. The most useful parameter for assessing risk of malignancy is size; 5-6 cm is generally considered worrisome enough for surgical excision. Tumor histology and grade do not readily predict metastatic behavior. A high signal intensity ratio on T2 weighted MRI images suggests that the lesion is not a benign adenoma. Metabolic activity is common in both benign and malignant adrenal masses.
A 65-year-old post-menopausal woman with decreased bone density develops her third calcium oxalate renal calculus in five years. Metabolic evaluation reveals a mildly elevated urinary calcium after calcium loading, consistent with Type I absorptive hypercalciuria. The most appropriate treatment is:
- sodium cellulose phosphate
- orthophosphate
- hydrochlorothiazide
- potassium citrate
- magnesium oxide.
3
Sodium cellulose phosphate can restore normal calcium excretion in those with absorptive hypercalciuria. However, it can lead to a negative calcium balance. Thiazides are appropriate treatment for those with mild to moderate absorptive hypercalciuria and those at an increased risk of bone disease such as post-menopausal women and growing children. Thiazide therapy induces an increase in bone density. Thiazides may lose their hypocalciuric effect after two to four years, and patients may be switched to sodium cellulose phosphate for a short period of time. Orthophosphates are indicated for the management of absorptive hypercalciuria, Type III, where a renal leak of phosphate is thought to stimulate 1,25-(OH)2D synthesis. Orthophosphates inhibit this synthesis. Potassium citrate will alkalinize the urine but will not affect the serum or urinary calcium. Magnesium oxide may bind oxalate in the gut but will no effect on urinary calcium.
In patients with androgen-independent metastatic prostate cancer, the median improvement in overall survival of docetaxel % prednisone every three weeks compared to mitoxantrone % prednisone is:
- 2.5 months
- 3.5 months
- 6 months
- 12 months
- 18 months.
1
Docetaxel is currently the only FDA-approved agent that has been shown to prolong survival in men with androgen-independent metastatic prostate cancer. In the pivotal trial of docetaxel, patients who received an every three week administration of the drug had a median survival of 18.9 months, as opposed to a 17.3 month median survival for patients who received docetaxel on a weekly basis and 16.4 months (difference of 2.5 months) for those who received mitoxantrone. The p-value comparing docetaxel every three weeks to mitoxantrone (which does not prolong survival but improves quality of life) was p=0.009. These findings led the FDA to approve docetaxel for use in these patients.
A 24-year-old man elects to undergo a modified right template RPLND following right radical orchiectomy for stage I NSGCT. The left limit of the dissection should be:
- the medial edge of vena cava
- the medial edge of the aorta
- the mid-aorta
- the lateral edge of the aorta
- the medial edge of the left ureter.
5
Lymphatic spread of testicular cancer to the contralateral retroperitoneum is rare with left-sided tumors, but more common with right sided tumors. To this end, the contralateral margin differs for left- and right-sided modified RPLND templates. For left sided dissections, the right margin is the lateral edge of the IVC, primarily to ensure collection of the interaortacaval lymph nodes. On the right side, the dissection should be carried out further, optimally to the left ureter, as occasionally there will be involvement of the para-aortic lymph nodes in these patients. Although some authors have suggested that bilateral modified RPLND should be performed in all patients with right-sided tumors, the additional dissection down the left common iliac artery has not been shown to be of any additional benefit.
One month after L5 laminectomy, a 30-year-old woman develops lower extremity weakness, a residual urine of 300 ml, and an intermittent urinary stream. Videourodynamics demonstrates detrusor-sphincter dyssynergia. The most likely explanation is:
- pseudodyssynergia
- recurrent lumbar disk herniation
- cauda equina syndrome
- undiagnosed multiple sclerosis
- permanent nerve injury from disk.
4
The urodynamic finding of detrusor external sphincter dyssynergia (DESD) indicates that a suprasacral spinal lesion is present. This cannot be explained by a recurrent hernia or permanent injury to L5. The most likely supraspinal lesion in a woman this age is multiple sclerosis.
Bacterial biofilms forming on implants and foreign bodies in the urinary tract are comprised of a(an):
- surface film of compact microorganisms
- conditioning film comprised of carbohydrate molecules
- linking film from which plank-tonic organisms can arise and spread
- accumulation of microorganisms and their extracellular products forming a structured community
- layer of mucopolysaccharide excreted by bacterial cells to protect them from WBC infiltration.
4
Bacterial biofilms arise from bacterial adherence and growth of bacteria on solid surfaces and foreign bodies in the urinary tract. Bacteria form biofilms in a variety of environments, particularly on implants and stents in the urinary tract. A biofilm is defined as the accumulation of microorganisms and their extracellular products to form a structured community on a surface. Factors that influence bacterial adhesion to devices include the biomaterial surface characteristics, bacterial surface features, and the presenting clinical condition.
A 25-year-old man has inadequate erections since sustaining a pelvic fracture in a MVC two years ago. After a successful urethral stricture repair, he denies any difficulty with orgasm and ejaculation. Intracavernosal injection of 15 ug of prostaglandin E1 produces a soft erection. The next step is:
- infusion cavernosography
- pelvic/pudendal arteriography
- infusion cavernosometry
- intracavernosal injection of 30 ug of prostaglandin E1
- color Doppler study of penile arteries.
5
This patient most likely has either an arterial or a neurologic injury to explain his erectile difficulty. A neurologic lesion is less likely because of his failure to respond with an erection to a reasonable dose of prostaglandin E1 Patients with neurogenic injuries frequently respond to very low doses of intracavernosal agents. The major clinical question which needs to be answered is whether or not this patient has an arterial injury. Infusion cavernosography and infusion cavernosometry are studies which demonstrate the extent and site of corporovenous leakage. Fifteen ug of prostaglandin E1 is a reasonable dose of drug to administer and increasing the dose to 30 ug would likely not produce more information. The study of choice to determine the presence of arterial disease in this clinical situation is a color Doppler study of the penile arteries before and after the intracavernosal injection of vasoactive drugs. Only after arterial disease has been diagnosed and only when operative revascularization is under consideration should pelvic/pudendal arteriography be performed.
Three weeks after a retropubic bladder neck suspension, a 40-year-old woman develops pelvic and suprapubic pain associated with temperatures to 38.5%b0C. She experiences difficulty adducting her thighs and has pain on palpation of her symphysis pubis. The most likely diagnosis is:
- osteitis pubis
- osteomyelitis of pubis
- obturator nerve injury
- urinary extravasation
- pelvic abscess.
1
This patient exhibits classic signs and symptoms of osteitis pubis. Pelvic and suprapubic pain, fever, and difficulty with thigh adduction are classic findings. Osteitis pubis has been reported to occur in up to 2.5% of women who have undergone the retropubic bladder neck suspension. Pubic osteomyelitis is possible but is far less common than osteitis pubis. Obturator nerve injury (usually secondary to retractors) can occur following cystourethropexy but does not present with symptoms three weeks postoperatively. Urinary extravasation would be very rare three weeks postoperatively. The signs and symptoms are much more in keeping with osteitis pubis than they are with pelvic abscess.
A 19-year-old woman is treated with ampicillin for a UTI and develops a pruritic groin rash. Physical examination reveals poorly marginated, red patches on her inner thighs, inguinal folds, and labia. Satellite papules and pustules are scattered at the periphery of the inflammatory process. The most likely diagnosis is:
- fixed drug reaction
- contact dermatitis
- candidiasis
- molluscum contagiosum
- lichen planus.
3
Infection of the crural folds with Candida albicans and other Candida species is a very common condition. In women, Candida species are normal inhabitants of the gastrointestinal tract and are commonly present asymptomatically in the vagina. With a constant source of these organisms so nearby, it is not surprising that they frequently spread to the cutaneous aspects of the groin. The hallmark of cutaneous candidiasis is that of bright red inflammation. The initial changes occur at the apex of the crural fold; subsequently, the inflammatory plaque expands in a radial fashion to all surrounding skin. Generally small pustules overlying the red plaques can be identified, and sometimes, satellite lesions are found as solitary papulopustules separate from, but adjacent to the larger primary plaque. The degree to which pruritus is present varies greatly, but itching can be quite severe at times. A clinical diagnosis can be confirmed by culture. Alternatively, a KOH examination is useful if intact pustules are present. Fixed drug eruptions are typically circular hyperpigmented lesions. Contact dermatitis would not be expected to be bilateral. Molluscum contagiosum occurs primarily in children and has a different appearance, although a sexually transmitted form exists. Lichen planus has violacious flat topped papules and small white lesions on the genitalia.
The prostate biopsy technique that samples the anterior prostate gland most effectively is the:
- 10-core biopsy
- 12-core biopsy
- saturation biopsy
- transurethral biopsy
- transperineal biopsy.
5
Traditional 10-core, 12-core, and even saturation biopsies utilize a transrectal approach, which limits access to the anterior prostate. Under regional or general anesthesia, the transperineal approach uses a template system to sample the prostate. This grid system is similar to the one used for brachytherapy. The advantage to the transperineal approach is its optimal access to the anterior and apical gland, particularly in high-risk patients with prior negative biopsies. The 10-core, 12-core, and saturation biopsy are most apt at sampling the peripheral zone.
Patients with polycystic kidney disease, pain, azotemia, and hypertension who undergo laparoscopic marsupialization of their cysts will most likely experience:
- deterioration of renal function
- deterioration of blood pressure control
- improvement in renal function
- improvement in blood pressure control
- relief of pain.
5
Patients with autosomal dominant polycystic kidney disease (ADPKD) may have intractable cyst pain. Standard practice has been to attempt percutaneous drainage of affected cysts, and if unsuccessful, to proceed with open surgical drainage. More recently laparoscopic renal cyst marsupialization has been performed for painful ADPCKD. The results document prolonged pain relief without significant long-term effects on renal function or blood pressure. There may be some improvement in blood pressure, but it is transient.
A 63-year-old woman has lethargy and joint pain four years following sigmoid neobladder creation. Serum studies reveal bicarbonate 20 mEq/l, calcium 9.1 mg/dl, alkaline phosphatase 249 U/l, hematocrit of 34%. The next step is:
- oral calcium and Vitamin D
- oral magnesium and Vitamin D
- oral calcium and potassium citrate
- intramuscular Vitamin B12
- oral bisphosphonate.
3
Osteomalacia occurs when mineralized bone is reduced and the osteoid component becomes excessive. Osteomalacia has been reported in patients with all forms of urinary diversion but is most common in colonic continent diversion and especially in postmenopausal women. The metabolic acidosis is buffered by the bone with release of bone calcium. Correction of acidosis and calcium supplementation will result in symptomatic relief and restoration of bone density. Major alterations in serum bicarbonate are not usually present and calcium is usually low normal. Patients who develop osteomalacia generally complain of lethargy; joint pain, especially in the weight-bearing joints; and proximal myopathy. The alkaline phosphatase level is elevated. Although bisphosphonates will decrease bone resorption they do not address the root cause of the problem. Vitamin B12 deficiency is not seen in colonic urinary diversion.
A 50-year-old man with end-stage polycystic kidney disease is on chronic hemodialysis. His pre-dialysis potassium is consistently in excess of 5.6 mEq/l. He is dialyzed three times per week for 4-1/2 hours per treatment. The most likely cause of his hyperkalemia is:
- dietary indiscretion
- chronic alkalosis
- gastrointestinal bleeding
- inadequate dialysis
- adrenal insufficiency.
1
Hyperkalemia is usually not a problem for patients with chronic renal failure. Even end-stage kidneys are capable of some potassium excretion, and significant amounts of potassium may be lost via the intestinal tract. Potassium is restricted in a chronic renal failure diet and the associated protein restriction also curtails potassium intake. While all of the answers are possibilities, excessive intake of potassium is the most common cause of hyperkalemia.
A newborn boy with a history of left prenatal hydroureteronephrosis develops gram negative urosepsis despite prophylactic amoxicillin. VCUG is normal. Renal ultrasound and MAG-3 renal scan are shown. The differential renal function is 74/26 (right/left). The next step is:
- observation
- change prophylaxis to trimethoprim-sulfamethoxazole
- cutaneous pyelostomy
- distal cutaneous ureterostomy
- tapered ureteral reimplantation.
4
Gram negative sepsis in a child less than three months of age has a mortality approaching 15-20%. In an infant less than three months of age with a gram negative UTI, there is a 30% chance of a recurrent UTI over the next six months. In this infant with an obstructing primary megaureter and ipsilateral decreased renal function, surgical intervention is indicated. A tapered ureteral reimplantation would be technically very difficult at this age and should be deferred until older than one year of age. The preferred treatment is a low end cutaneous ureterostomy. Altering prophylaxis to sulfamethoxazole trimethoprim should not be done in an infant due to the risk of kernicterus and hematopoietic dysfunction.
A 36-year-old man with a T10 spinal cord injury has chronic, asymptomatic bacteriuria unresponsive to antimicrobial therapy. He is managed by CIC obtaining volumes up to 400 ml. Cystometry demonstrates detrusor areflexia with high bladder compliance. A renal ultrasound is normal except for a 4 mm calculus in the left renal parenchyma. The best method of management is:
- reassurance
- localizing urine cultures
- urinary acidification
- SWL
- sphincterotomy and condom catheter drainage.
1
Bacteriuria occurs in the majority of spinal cord injured patients managed by CIC. This patient’s bacteriuria is not likely to originate from the small renal stone, nor would stone removal alleviate the bacteriuria. Localizing urine cultures are not necessary. The patient needs reassurance that chronic bacteriuria is not concerning, provided his urine storage pressures are low and he is symptom free. Urine acidification has not been proven to decrease the risk of bacteriuria in spinal cord injured patients. Sphincterotomy and condom catheter drainage in this patient with reasonable hand function is not an appropriate alternative, and will not reduce the incidence of bacteriuria.
A patient has stress urinary incontinence one year after radical retropubic prostatectomy. However, stress incontinence observed on physical examination is not documented during a Valsalva maneuver under fluoroscopy. The test was performed using a 12 Fr urethral catheter at a volume of 200 ml. The most likely explanation for the absence of demonstrable incontinence during the urodynamic test is:
- insufficient volume instilled
- urethral catheter is too large
- involuntary bladder contraction
- poor Valsalva effort
- impaired contractility.
2
With a stricture of the urethra or a bladder neck contracture using a catheter as small as 9 Fr may not allow urine to exit around it. Using a rectal pressure as an estimate of intra-abdominal pressure or use of a suprapubic catheter represent alternative methods. More simply, a smaller diameter catheter such as 7 Fr or less can be used
The most appropriate perioperative management of a patient undergoing adrenalectomy for Cushing’s syndrome is:
- hydration, alpha-blockers, and stress-dose steroids
- beta-blockers, stress-dose steroids and careful glycemic control
- potassium sparing diuretics and stress-dose steroids
- stress-dose steroids and careful glycemic control
- potassium sparing diuretics, stress-dose steroids, and careful glycemic control.
4
Patients undergoing adrenalectomy for Cushing’s syndrome have an excess of corticosteroids from an adrenal adenoma or carcinoma. These patients need stress-dose steroids and careful glycemic control as they often have obesity and diabetes. Alpha-blockers and hydration are indicated perioperatively for patients with pheochromocytoma. Beta-blockers may also be necessary preoperatively for patients with pheochromocytoma if they are tachycardic after alpha-blockade. Potassium sparing diuretics are important for the perioperative management of patients with hyperaldosteronism (Conn’s disease) as they often have significant hypokalemia.
In chronic ureteral obstruction, the glomerular filtrate exits the renal pelvis primarily by:
- pyelosinus backflow
- pyelolymphatic backflow
- extravasation from the renal pelvis
- reabsorption from renal pelvis
- pyelovenous backflow.
5
Following acute ureteral obstruction, the renal pelvic pressure is initially elevated but gradually returns to normal. Glomerular filtrate exits the renal pelvis by extravasation into the perirenal spaces, pyelolymphatic backflow and pyelovenous backflow. It is believed that 80-90 percent of the filtrate in chronic hydronephrosis is reabsorbed in the tubules and exits via the renal veins.
A 47-year-old uncircumcised married man is diagnosed with high grade Ta squamous cell carcinoma of the foreskin. His wife should undergo:
- observation
- HPV vaccination
- Pap smear
- imiquimod therapy
- cervix biopsy.
3
HPV infection is associated with the development of penile cancer. Wives or ex-wives of men with penile cancer have a threefold higher risk of cervical carcinoma. The male partners of women with cervical intraepithelial neoplasia have a significantly higher incidence of penile intraepithelial neoplasia. Therefore, screening with Pap smear and pelvic exam is prudent in this setting. HPV vaccination is inappropriate because it is only effective prior to exposure. More aggressive therapy such as biopsy or topical therapy is inappropriate unless a diagnosis of cervix cancer is suspected on physical exam and Pap smear.
A 36-year-old woman with cerebral palsy on CIC develops urgency, incontinence with severe perineal skin ulceration. Urodynamics show a 200 ml capacity bladder with overactive contractions and no stress urinary incontinence. She has failed antimuscarinics. Due to her body habitus, CIC is difficult per urethra. The best management is:
- detrusor myomectomy
- ileal conduit
- Indiana pouch
- bladder augmentation with catheterizable abdominal channel
- bladder augmentation with fascial sling.
4
Bladder augmentation represents the best solution to this complex problem; however, this will commit the patient to CIC. In selected circumstances such as this, a continent catheterizable abdominal channel in conjunction with a bladder augmentation is appropriate. The urethral sphincter is intact in this patient as evidenced by a very high abdominal leak pressure. In a patient desiring a continent solution, an ileal conduit would not be indicated. Use of an Indiana pouch would require ureteral-enteric reanastomosis and a small but definitive risk for upper tract obstruction at the anastamosis. Detrusor myomectomy has not been shown to improve capacity long-term.
A 47-year-old man with relapsing remitting multiple sclerosis has severe urinary frequency and incontinence. He has been treated with tamsulosin for six months with no improvement in his symptoms. Examination reveals a 40 gm smooth prostate. CMG, pressure-flow study is shown. The next step is:
- renal ultrasound
- videourodynamics
- MRI scan of the spine
- TRUS
- cystoscopy.
1
This urodynamic study documents neurogenic detrusor overactivity and detrusor external sphincter dyssynergia in a patient with MS. Videourodynamics would be redundant and unnecessary. Male MS patients with detrusor sphincter dyssynergia appear to be at greatest risk for urological complications including upper tract deterioration. The upper tracts must be assessed early in a male patient with dyssynergia. Cystoscopy is unlikely to influence treatment planning, and would not be the most appropriate first step. MRI scan of the spine would be indicated in the scenario of unknown pre-existing neurogenic disease, but is unnecessary with a diagnosis of MS. A TRUS would be unnecessary as a TURP would not be recommended treatment in the scenario of neurogenic voiding dysfunction.
A four-year-old boy with a PUV has a vesicostomy. Serum creatinine is 0.6 mg/dl. Ultrasound shows minimal hydronephrosis. Videourodynamics show a bladder capacity of 30 cc with a pressure of 14 cm H2O when leakage occurs from the vesicostomy with no reflux. Undiversion is considered. The best management is resection of the posterior urethral valves and:
- ileal augmentation cystoplasty
- ileal augmentation with appendicovesicostomy
- bladder cycling via the vesicostomy
- primary closure of the vesicostomy
- autoaugmentation cystoplasty.
4
There was at one time concern that a cutaneous vesicostomy caused permanent loss of bladder volume and compliance. However, recent studies show that it does not significantly affect either. Preoperative videourodynamics showing a small bladder capacity do not predict eventual functional bladder capacity. Approximately 75% of children will have normal bladder function after vesicostomy closure. The need for bladder augmentation is more related to the effects of the primary pathological condition on the detrusor. Augmentation cystoplasty is rarely needed after undiversion in patients with a PUV. The eventual need for augmentation should be assessed with sequential follow-up after the vesicostomy has been closed.
A 28-year-old man with Kallmann’s syndrome is treated with hCG and FSH injections over two years. His serum testosterone and FSH levels are normal. His semen volume is 1.0 ml, sperm count is six million sperm/ml, and sperm motility is 90%25. Well-timed sexual intercourse has not resulted in pregnancy for his wife, whose evaluation is normal. The next step is:
- intrauterine insemination
- color Doppler scrotal ultrasound
- ICSI
- transrectal ultrasound
- testis biopsy.
1
Intrauterine insemination (IUI) is a highly effective treatment for men with normal semen parameters, especially normal sperm motility. IUI involves placing processed sperm via a catheter inserted through the cervix into the uterine cavity. This bypasses cervical mucous and higher numbers of motile sperm will be able to reach the fallopian tubes. Semen volume and sperm production is limited in men with Kallman’s syndrome, because prostate, seminal vesicle and testicular size are affected. However, sperm quality tends to be completely normal. In vitro fertilization is not required at this point, and ICSI is unnecessary. Testis biopsy will not be helpful since the patient is not azoospermic. TRUS is useful to evaluate ejaculatory duct obstruction which is usually associated with azoospermia. It is not associated with Kallmann’s syndrome.
The upper ureter is more susceptible to serious injury during endourological procedures because it:
- is less distensible
- has thin suburothelium
- has thin muscularis
- has thin urothelium
- has variable blood supply.
3
The ureteral wall consists of three different layers. However, the composition of these layers is not constant for the entire length of the ureter. The urothelium is four or five cell layers thick. Beneath the urothelium is a lamina propria with loose or dense connective tissue, but not a distinct structure. The muscularis varies in its composition over the course of the ureter. In the proximal ureter, it consists of a thin, poorly defined inner circular and an outer longitudinal layer. Both the mid and distal ureter have a muscularis which is distinctly composed of an inner longitudinal, middle circular, and outer longitudinal fibers. The deficiency in the muscularis of the upper ureter and the geometric arrangement of large areas of collagenous connective tissue interspacing the muscle bundles is thought to make the upper ureter more susceptible to serious ureteral injury.
A 74-year-old man has a 2 cm lower pole renal mass that enhances on CT scan. His medical history includes hypertension, congestive heart failure, and renal insufficiency with a creatinine of 1.8 mg/dl. The next step is:
- renal mass biopsy
- cryoablation
- radiofrequency ablation
- partial nephrectomy
- radical nephrectomy.
1
Renal mass biopsy should now be considered in select patients with small renal masses to help stratify oncologic risk and offer the optimal treatment intervention. Most studies suggest that biopsy has an accuracy of over 90% in distinguishing benign vs. malignant histology and an associated 70-80% accuracy in assessing tumor histology and grade. Needle tract seeding is exceedingly rare. This patient has comorbidities that might encourage surveillance of his small renal mass, but a minimally invasive treatment would also be appropriate for an aggressive histology given the favorable tumor size and location. Knowing the histology could assist in counseling this patient, particularly since about 20% of small renal masses are benign. Radical nephrectomy would be inappropriate in treating a small exophytic lesion in a patient with renal insufficiency. Given the patient comorbidity and the potential morbidity of partial nephrectomy, a less invasive approach is favored in this setting. This patient is also a reasonable candidate for observation.
An 82-year-old woman living in a nursing home has urinary urgency and urge incontinence. Neurologic examination is normal. Urinalysis is normal. Residual urine is 140 ml after voiding 160 ml. The most likely etiology of her symptoms is:
- detrusor overactivity
- detrusor sphincter dyssynergia
- decreased detrusor compliance
- detrusor overactivity with impaired contractility
- intrinsic sphincter deficiency.
4
Detrusor overactivity with impaired contractility is the most common cause of urinary incontinence in the frail elderly and presents as urge incontinence or unspecified incontinence with large postvoid residual urine. Detrusor-sphincter dyssynergia is only seen in patients with neurologic disorders. Patients with intrinsic sphincter deficiency complain of stress incontinence. She has no risk factors for decreased bladder compliance.
A 28-year-old woman in her third trimester of pregnancy has a cervical culture positive for Neisseria gonorrhoeae. She developed a skin rash and urticaria after taking penicillin previously. A skin test for penicillin allergy is negative. The most appropriate treatment is:
- procaine penicillin G
- tetracycline
- erythromycin
- ceftriaxone
- spectinomycin.
4
Ceftriaxone is the drug of choice for Neisseria urethritis and cervicitis. It is safe to administer during pregnancy. Tetracycline and spectinomycin should be avoided. Although erythromycin may be given, it is not the preferred antibiotic in this situation. The decision to administer penicillin to a patient with a history of allergy is dependent on the severity of the reaction and the availability of alternative drugs. Only one-fourth of those with a history of allergic reactions to penicillin have an adverse effect when re-challenged with the drug. Desensitization techniques may be of value to those with a history of major allergic reaction and where there is a strong need to give the drug. Ceftriaxone can be administered to women in their 3rd trimester.
The maximum yearly whole-body exposure to radiation recommended by the National Council on Radiation Protection is:
- 1 rem
- 5 rem
- 10 rem
- 50 rem
- 100 rem.
2 Urologists may have significant occupational radiation exposure. It is important to wear radiation protection for the body, thyroid and eyes. Place the fluoroscopy beam under the table if possible and use the principle ALARA or as low as reasonably achievable. The maximum yearly dose recommended by the National Council on Radiation Protection is 5000 mrem or 5 rem.
Administration of I.V. mannitol prior to renal artery occlusion for partial nephrectomy helps prevent tissue damage by:
- increasing cellular pH
- preventing cellular edema
- inhibition of Na/K ATPase
- preventing lactic acidosis
- limiting intracellular calcium influx.
2
Renal ischemia will deplete ATP energy stores, decreasing activity of active transport via Na2KB and Ca/Mg ATPases. As a result, intracellular influx of Na, Ca, Cl- and water occur. The influx of water causes cellular swelling and tissue damage. The use of solutions containing impermeable solutes, such as mannitol, help reduce cellular edema. Additionally, mannitol infusion results in improved renal hemodynamics and an osmotic diuresis.
A 40-year-old man underwent a vasectomy ten years earlier. He undergoes vasoepididymostomy, and sperm are noted in the epididymis. Six months after this procedure, semen analysis reveals azoospermia. The next step is:
- repeat vasoepididymostomy
- epididymal sperm aspiration and ICSI
- testis biopsy
- repeat semen analysis in three months
- donor insemination.
4
Delayed return of sperm in the ejaculate may occur after vasoepididymostomy. Men without sperm in the epididymal fluid at the time of the anastomosis will never recover sperm in the ejaculate. Forty-one percent of patients will have delayed appearance of sperm in the ejaculate which can take up to one year or longer. The ultimate mean sperm count will be similar in those with immediate and delayed return of sperm. Delayed anastomotic obstruction is also the same in both groups.
During a left laparoscopic pyeloplasty the inferior mesenteric artery is accidentally ligated. Blood supply to the left colon will be primarily maintained by:
- left colic artery
- left colic artery and inferior hemorrhoidal arteries
- middle colic artery and superior hemorrhoidal arteries
- marginal artery and superior hemorrhoidal arteries
- middle colic and middle hemorrhoidal arteries.
5
The inferior mesenteric artery supplies the main blood supply to the left colon via the left colic artery and superior hemorrhoidal arteries. When this is injured or ligated, blood supply is maintained proximally via the middle colic artery which is a branch of the superior mesenteric artery and distally via the middle and inferior hemorrhoidal arteries. The middle colic and hemorrhoidal arteries connect with each other via the marginal artery of Drummond. This artery runs parallel to the wall of the colon. It is important to maintain this artery during any dissection of the left colon in cases where injury to the inferior mesenteric artery may occur.
Compared to primary penile prosthesis insertion, prosthesis revision is associated with an increased risk of:
- infection
- mechanical failure
- erosion
- persistent penile pain
- hemorrhage.
1
Overall infection rates following initial penile prosthesis insertion range from 1 to 3%. This rate is considerably higher for revision surgery (7-18%). Antibiotic impregnation of prostheses components has reduced the risk of infection. Risk of mechanical failure, erosion, penile pain, and hemorrhage are not higher after repeat prosthesis insertion. Loss of penile size has been associated with delayed reimplantation, and so early replacement has been advocated for patients considering replacement.
A 62-year-old man undergoes a TURBT at the dome. Final pathology reveals muscle-invasive small cell carcinoma. Metastatic work-up is negative. The next step is:
- restaging TURBT
- neoadjuvant cisplatin-based chemotherapy
- XRT
- partial cystectomy
- radical cystoprostatectomy.
2
Small cell carcinoma of the bladder is a relatively rare tumor of the bladder that may arise in combination with urothelial carcinoma. It is usually biologically aggressive with early vascular and muscular invasion. These malignancies usually respond to, but are not cured by, cisplatin-based chemotherapy regimens. Neither partial cystectomy nor intravesical chemotherapy is appropriate in this setting. Radiation or extirpative surgery alone may result in cure rates of 5 to 20%. However, neoadjuvant chemotherapy followed by surgery or radiation therapy results in cure rates of 40 to 65%. Therefore, the best treatment is cisplatin-based chemotherapy followed by an aggressive local treatment such as surgery or radiation if the patient does not progress.
Beta-lactamase inhibitors are useful for treating UTIs because they:
- enhance entry of a second antimicrobial agent into bacteria
- protect a penicillinase-susceptible agent from hydrolysis
- are bactericidal
- are active against methicillin-resistant staphylococcus
- antagonize the bactericidal effect of penicillin-like drugs.
2
Bacteria that make beta-lactamase (penicillinase) are resistant to penicillin because the beta-lactamase hydrolyzes the penicillin. The beta-lactamase inhibitors bind to beta-lactamase to make it unavailable for causing enzymatic hydrolysis of penicillinase-susceptible penicillin. In this way, clavulanic acid and sulbactam, inhibitors of microbial beta-lactamases, will allow hydrolysable penicillins to continue to be active against resistant organisms. These inhibitors do not enhance drug entry into bacteria, nor are they active against the bacteria on their own. They are used in combination with a penicillin-like antimicrobial agent such as: ticarcillin-clavulanic acid (Timentin), ampicillin-sulbactam (Unasyn), amoxicillin-clavulanic acid (Augmentin). Methicillin itself is a penicillinase-resistant penicillin, and as such the addition of a beta-lactamase inhibitor is not useful in treating bacteria already resistant to methicillin.
A 50-year-old man has a two year history of erectile dysfunction, urinary frequency, nocturia, and recurrent UTIs. Physical examination reveals an absent bulbocavernosus reflex and an enlarged prostate. Neurologic evaluation reveals decreased vibratory sensation in his hands and feet. A CMG shows 200 ml residual urine and first sensation at 400 ml. These findings are most consistent with:
- multiple sclerosis
- Shy-Drager syndrome
- Parkinson’s disease
- herpes zoster
- diabetes mellitus.
5
The decrease in vibratory sensation of the hands and feet, a delayed first sensation at 400 ml on a CMG, and increased residual urine all favor the diagnosis of diabetic cystopathy. Urinary frequency and nocturia may also be due to an osmotic diuresis. The absent bulbocavernosus reflex is unusual but can occur in normal men. Good sphincter tone and voluntary sphincter contraction would suggest there is no abnormality in the sacral reflex. The findings presented are more consistent with undiagnosed diabetes mellitus. These urodynamic findings are not typical for Parkinson’s disease which is usually detrusor overactivity and impaired contractility. In contrast, Shy-Drager syndrome would have detrusor overactivity, open bladder neck, and denervation of the external sphincter. Herpes zoster tends to have cutaneous lesions and exhibit a dermatomal pattern, not a symmetrical neuropathy as described in this scenario.
A 30-year-old woman sustains a complete transection of the left ureter at the level of L5 during removal of a large ovarian cyst. Preoperative CT scan was within normal limits. The most appropriate treatment is:
- transureteroureterostomy
- ureteroureterostomy
- nephrostomy and delayed ureteral repair
- psoas hitch and ureteroneocystostomy
- Boari flap and ureteroneocystostomy.
2
Hysterectomy is responsible for the majority (54%) of surgical ureteral injuries. Next most common was colorectal surgery (14%), followed by pelvic surgery such as ovarian tumor removal and transabdominal urethropexy (8%), followed lastly by abdominal vascular surgery (6%). Ureteroureterostomy, or so-called end-to-end repair, is used in injuries to the upper two thirds of the ureter. It is required commonly, up to 32% of the time in large series. Simple transection of the ureter at the L5 level can be easily managed by spatulating each end of the ureter and performing an elliptical anastomosis over a stent. Transureteroureterostomy could potentially compromise the contralateral ureter. In the absence of life threatening bleeding or other traumatic injuries, injuries recognized intraoperatively should be repaired immediately; delayed repair is thus inappropriate. Psoas hitch should be reserved for defects of the distal ureter; Boari flaps are only necessary when larger defects of the distal and mid ureter preclude simpler reconstructive approaches.
A 65-year-old man undergoes a radical cystectomy with ileal neobladder reconstruction. On post-op day three, he has a mild abdominal distention and increased bilious output from his nasogastric tube. His urine output is slightly diminished but adequate. He is hemodynamically stable. His maintenance fluid is 0.45 NS at 85 cc/hr. His nasogastric tube output should be replaced with:
- 0.45 NS
- 0.45 NS with 20 mEq/l KCl
- 0.45 NS with 30 mEq/l KCl
- 0.9 NS with 20 mEq/l KCl
- Lactated Ringer’s.
5
This patient has a post-op ileus in which there will be increased fluid losses of isotonic fluid into the bowel lumen. The presence of bilious output is indicative of the ileus and the associated loss of fluids and secretions (including pancreatic) into the bowel lumen. When a post-op ileus occurs, these insensible losses need to be replaced early on in the process to prevent dehydration and secondary vascular compromise. This is best accomplished with a fluid that is isotonic like Lactated Ringer’s that also provides replacement with approriate levels of potassium, chloride, and bicarbonate. Saline with KCl supplementation would be more appropriate for replacement of gastric secretions.
A 63-year-old man has a temperature of 39%b0C and fecaluria eight days after radical prostatectomy. A pelvic CT scan demonstrates a 5 by 4 cm heterogeneous peri-rectal fluid collection. He had received an oral bowel prep and antibiotics pre-operatively. The best management is parenteral antibiotics, percutaneous drainage of the fluid collection, and:
- low-residual diet
- parenteral hyperalimentation
- suprapubic tube
- colostomy
- enteral hyperalimentation.
4
Rectal injury occurs in approximately 1.5% of patients undergoing radical prostatectomy. If the injury is recognized intraoperatively and the patient has received an appropriate combination bowel prep, the injury can be repaired primarily. If the rectal injury is recognized post-operatively as a vesicorectal fistula, conservative management is not indicated. In this case, the patient also has associated infection and therefore a colostomy with delayed primary repair is indicated. In the face of a large fluid collection and active infection, less aggressive approaches are not indicated.
A 30-year-old woman complains of a vaginal discharge and odor. She has no itching, burning, or soreness. On physical examination, she has a malodorous, gray-yellow discharge. Microscopic examination of the discharge shows clue cells. A whiff test is positive. The etiology her vaginitis is:
- Candida albicans
- Gardnerella vaginalis
- Trichomonas vaginalis
- Chlamydia trachomatis
- mucorrhea.
2
The presence of clue cells (vaginal epithelial cells whose borders are obscured by bacteria) and a positive whiff test (fish odor after adding potassium hydroxide to the discharge) are diagnostic of a Gardnerella vaginalis infection. The organism is not a tissue pathogen, so local symptoms are absent. Treatment with oral metronidazole is the standard. New molecular techniques have identified a biofilm containing mostly Gardnerella and Atopobium vaginae, which can persist after treatment; thus suppressive treatment with metronidazole gel can prevent recurrence. Candida vaginitis and Trichomonas vaginalis are diagnosed by finding the organisms that cause these infections on microscopic examination. Chlamydia causes a cervicitis, and mucorrhea (a clear or cloudy discharge) is normal.
The most likely neurologic deficit following nerve injury at the time of laparoscopic varicocelectomy is:
- numbness on the base of the penis and anterior scrotum
- numbness on the anterior thigh
- numbness on the lateral thigh
- inability to extend the knee
- inability to adduct the thigh.
2
Laparoscopic varicocelectomy is a minimally invasive option for management of varicoceles. The genitofemoral nerve lies directly atop the psoas muscle. Approximately 4-5 % of patients undergoing laparoscopic varicocelectomy will complain of either temporary or permanent alterations in the sensory innervation of the anterior thigh consistent with injury to the genitofemoral nerve. The genitofemoral nerve arises from L1-L2, emerges from the psoas, passes posterior to the ureter and divides into the genital and femoral branches above the inguinal ligament. The femoral branch then passes behind the inguinal ligament and enters the femoral sheath. The genital branch enters the inguinal canal close to the internal inguinal ring to supply the cremaster muscle and the scrotal skin. The ilioinguinal nerve (numbness on the base of the penis and anterior scrotum) and lateral femoral cutaneous nerve (numbness on the lateral thigh) run at least 3 cm lateral to the internal ring and, therefore, should be at little risk during routine laparoscopic varicocelectomy. The obturator nerve (inability to adduct the thigh) is medial and caudal to the iliac vessels and should not be injured during varicocelectomy. The femoral nerve (inability to extend the knee) is deep in the psoas muscle. It can be injured during open surgery with retraction but injury is unlikely during laparoscopy.
A 54-year-old woman underwent radiation therapy for cervical cancer two years ago now has microscopic hematuria. TUR of a lesion 2 cm above the left ureteral orifice reveals an inverted papilloma. Three days post-operatively, she develops a vesicovaginal fistula. The best treatment is:
- immediate transvaginal repair
- transvaginal repair in six months
- immediate transabdominal repair
- transabdominal repair in six months
- urinary diversion.
3
In a woman with no evidence of abscess formation or a fluid collection, there is little need to wait an extended period of time before fistula repair. The abdominal approach provides better access to a radiation induced fistula and allows an omental pedicle flap to be interposed between the bladder and vaginal wall. Obliteration of dead space, good bladder drainage, control of infection and interposition of healthy tissue are critical elements to fistula closure.
Primary hyperaldosteronism caused by bilateral adrenal hyperplasia is best managed by:
- salt restriction
- spironolactone administration
- captopril administration
- unilateral adrenalectomy of the larger adrenal
- bilateral adrenalectomy.
2
Patients with bilateral adrenal hyperplasia are best treated medically. Bilateral adrenalectomy will sacrifice glucocorticoid and mineralocorticoid function. Moreover, either partial or unilateral adrenalectomy will not correct the HTN accompanying this disorder. While patients become hypokalemic with hyperaldosteronism, neither potassium supplementation nor salt restriction will correct the etiology of the HTN. Captopril may be indicated in a subset of primary hyperaldosteronism patients in whom aldosterone production is not completely autonomous from angiotensin II stimulation.
A six-year-old boy has a history of a PUV treated with endoscopic resection. He now has worsening bilateral hydronephrosis and his serum creatinine has increased from 0.6 to 1.0 mg/dl over the past nine months. He is dry and has no voiding complaints. Videourodynamics reveal no reflux, near complete emptying without outflow obstruction and filling pressures of 20 cm H2O at 220 ml and 32 cm H2O at 280 ml. The initial plan should be:
- voiding diary
- start oxybutynin
- start alpha-blocker
- nocturnal indwelling catheter
- initiate CIC every four hours.
1
Children with correction of severe obstructive uropathy will sometimes demonstrate a persistent decrease in renal concentrating ability. This tends to worsen with growth and may lead to very high obligate urine output. This output can, at times, be so high that children cannot void frequently enough to maintain safe intravesical pressures; hydronephrosis and rising creatinine will ensue. This boy appears to void without obstruction. He does have reduced bladder compliance (as many valve patients do), but his pressures only reach 32 cm H2O by 280 ml - which should be an average six-year-old bladder capacity. However, if his urine output is very high, then he will reach this capacity very quickly after voiding. While he may eventually need timed voiding, antimuscarinic medication, CIC, or use of a nocturnal indwelling catheter, none of them can be used in a logical way without first knowing more about the patient’s daily urine output volume. An alpha-blocker is not indicated in this patient.
A 42-year-old woman has a slow rise in serum creatinine from 1.2 to 2.0 mg/dl one year after uneventful live donor transplantation. Ultrasound shows significant hydronephrosis and no perinephric fluid collection. The next step is:
- CT scan
- MAG-3 renal scan
- VCUG
- retrograde ureterogram
- renal allograft biopsy.
3
The absence of a perinephric fluid collection and late presentation of hydronephrosis accompanied by slowly declining renal function suggests the possibility of significant reflux into the transplant ureter. The most appropriate initial diagnostic study is a voiding cystourethrogram. Although a CT scan of the abdomen and pelvis can demonstrate the anatomy to a better degree than the ultrasound, the findings here with additional definition does not help with diagnosing the rise in creatinine. If a VCUG shows no reflux, a diuretic MAG-3 renal scan would be done to quantify any degree of obstruction at the ureterovesical junction where the anastomosis was performed. A retrograde ureterogram would be helpful but that is a diagnostic procedure that requires anesthesia and also the location of the ureteroneocystostomy is difficult to cannulate especially in the suspicion of ureteric complications such as stenosis. Renal allograft biopsy is not indicated as the first step in an ultrasound finding of significant hydronephrosis. The likelihood of long-term ureteric stenosis is 5-8%, whereas the likelihood of reflux exceeds 50% in the post-transplant population
The urine sample that should be collected for pH testing to establish the diagnosis of RTA is:
- fasting
- postprandial
- diurnal
- nocturnal
- hydrated.
1
Distal RTA (Type I) is commonly associated with urinary calculi, primarily calcium phosphate stones. The hallmark of RTA is an inability to acidify the urine. Initial screening for RTA can be done by measuring the pH of the second voided morning urine specimen after the patient has fasted overnight. The second voided specimen is better than the first because the first voided specimen may have an elevated pH as a result of pre-fasting food intake.
A six-year-old girl has a palpable abdominal mass. CT scan demonstrates a 5 cm mass in the lower pole of the left kidney and a 2 cm lesion in the upper pole of the right kidney. Biopsy of the left renal mass shows Wilms’ tumor. The next step is:
- chemotherapy
- chemotherapy and XRT
- bilateral partial nephrectomies
- left radical nephrectomy and right partial nephrectomy
- left radical nephrectomy and chemotherapy.
1
There is current controversy as to whether patients with Wilms’ tumor should undergo primary surgical exploration or initial pre-operative chemotherapy. However, there is general consensus that there are several instances when surgical therapy should not be undertaken, other than biopsy. This includes vena caval extension of the tumor above the hepatic veins, inoperable tumor, and bilateral disease. Bilateral disease is seen in about 5% of cases. In these cases, therapy is directed towards preservation of renal tissue since there is high incidence of renal failure, especially when a primary nephrectomy is undertaken. Thus, primary chemotherapy is indicated in patients with bilateral disease with a subsequent surgical exploration following completion of the first course of chemotherapy.
A 28-year-old paraplegic man had a sphincterotomy seven years ago and wears a condom catheter. During an evaluation for renal insufficiency, renal ultrasonography reveals bilateral hydroureteronephrosis. The parameter or study most predictive of this complication is:
- EMG
- CMG
- Valsalva LPP
- detrusor LPP
- urethral pressure profilometry.
4
Detrusor LPP is the most reliable urodynamic parameter to predict the risk of upper tract deterioration after sphincterotomy. A detrusor LPP of higher than 40 cm H2O indicates that the sphincterotomy has failed, and may serve as a guide to determine whether a repeat sphincterotomy is necessary. Abnormal compliance, which may be detected on CMG, may also be a worrisome finding, but there is much less established predictive value. To date, there is no correlation of urethral function tests (urethral pressure profile, Valsalva LPP, EMG) to upper tract deterioration.
An oligospermic man who takes 25 mg of clomiphene citrate a day will usually have a:
- low serum LH
- low serum FSH
- low serum estradiol
- high serum testosterone
- high prolactin.
4
Clomiphene citrate is an antiestrogen that blocks the negative feedback of estrogen on the hypothalmus and pituitary. It will raise the serum FSH, LH, and testosterone. Estradiol may also rise because of peripheral conversion of testosterone through the action of aromatase. When used for idiopathic oligospermia, the majority of (but not all) controlled studies show no effect on pregnancy rates. Clomiphene citrate does not affect prolactin levels.
An eight-year-old girl has urinary urgency, urge incontinence, and constant leakage of urine between voids. She is started on timed voiding and has improvement with the urge incontinence but still has constant urinary leakage. An ultrasound does not show any evidence of hydronephrosis or bladder wall thickening. The next study that will most definitively diagnose her problem is:
- MRI scan of the abdomen
- MRI scan of the spine
- VCUG
- videourodynamics
- MAG-3 renal scan.
1
The clinical history strongly suggests that this girl has an ectopic ureter even though the ultrasound does not show evidence of this. The absence of an abnormality on ultrasound does not rule out an ectopic ureter. Occasionally, the renal parenchyma from the upper pole of the kidney that is associated with the ectopic ureter is difficult to locate and may be identified only by alternative imaging studies. In cases in which an ectopic ureter is strongly suspected because of incontinence yet no definite evidence of the upper pole renal segment is found, magnetic resonance imaging (MRI or CT scanning) will likely demonstrate the small, poorly functioning upper pole segment and ureter. None of the other options will adequately visualize the ectopic ureter.