2012

Question 1

48 yo M undergoes radical cystectomy with Studier-Type orthotropic urinary diversion. Three months postoperatively, he complains of frequency and day and nighttime incontinence. Video UDS reveals capacity of 300 ml, detrusor presser 10 cm H20, valsalva LPP 140 cm H20, and PVR 75 ml. 
Next step is:
a. obs
b. alpha-blocker therapy
c. CIC every 2-3 hr
d. placement of AUS
e. augmentation of orthotropic diversion

Answer 1

a. observation. Length of time pos op after orthotropic diversion influences continence results. Resevoir capacity can and does increase over time the first 6-12 months and even longer in patients with anti-reflux afferent limbs (Studer type). CIC will decrease incontinence, but frequency CIC will prevent reservoir from increasing capacity over time. Alpha-blocker may relax proximal urethra and exacerbate incontinence.

Question 2

Central diabetes insipidus, the nephron segment that contains the most dilute fluid is:
a PCT
b. descending limb of loop of Henle
c. ascending limb of loop of Henle
d. DCT
e. collecting duct

Answer 2

e. collecting duct. Central diabetes insidious involves defect in production or release of ADH from hypothalamo-neurohypophyseal system. ADH affect permeability of DCT and collecting duct to water from the filtrate. Most dilute urine will be in collecting duct.

Question 3

During a PCNL, a collecting system perforation is noted. The first sing of significant extravasation of irritant into the peritoneal cavity is:

a. hypotension
b. hypercarbia
c. abdominal distension
d. narrowed pulse pressure
e. increasing ventilatory pressures

Answer 3

d. narrowed pulse pressures
Narrowed pulse pressures (rise in diastolic pressure) precede difficulty with ventilation, hypercarbia, and a rise in central venous pressure. Extravasated irritant increases abdominal pressure leading to decreased venous return and thus narrowing pulse pressure. Distention is not appreciated in the prone position until lateraled in the course. Hypotension would signal possibility of significant hemorrhage. Increasing ventilatory pressures is a later sign when there is significant fluid in the peritoneal cavity and when the patient is returned to the supine position.

Question 4

A 77 yo M has a retracted stoma and clear fluid leaking from his midline incision 3 weeks after radical cystectomy and ileal conduit. Three images from CT loopogram are shown (fluid outside conduit, extravasation through skin). Next step is percutaneous pelvic drain and:

a. stomal catheter
b. loop endoscopy
c. fascial repair
d. stomal revision
e. exploration, repair of leak

Answer 4

a. stomal catheter
A delayed urinary leak following urinary reconstruction should lead clinician to suspect tissue ischemia/necrosis. In these cases, leak is unlikely to resolve with observation alone. Fascial repair is unnecessary unless signs of dehiscence are present. Maximal drainage of the reconstructed segment is essential in oder to minimize the output of the leak. In this case, CT shows leakage from proximal end of conduit. Need catheter drainage to decompress leak and perc drain given pooling of contrast in pelvis. May ultimately require stomal revision, but conservative measurements first.

Question 5

A 27 yo M states that since radical orchiectomy for stage A seminoma 6 months prior, the frequency and quality of erections are poor. He received XRT to his per aortic nodes. The last treatment was 2 months after orchiectomy. His CXR, serum markers, glucose, and T are normal. Next step is:

a. intracavernosal injection therapy
b. sexual dysfunction counseling
c. intraurethral alprostadil
d. nocturnal penile tumescence studies
e. testosterone patch

Answer 5

b. sexual dysfunction counseling. Early months after surgery, depression and loss of vigor are common along with impaired sense of body image and mood disturbances. Patients cured of testis cancer rarely have persistent emotional disturbances. Sexual drive does not appear to be permanently disrupted by curative therapy. Concomitant use of PDE5 inhibitors may be useful to reestablish confidence.

Question 6

Sepsis after PCNL best correlates with
a. preop UCx
b. stone culture
c. length of procedure
d. blood loss
e collecting system violation

Answer 6

b. stone culture. Occurrence of SIRS correlated more with stone culture or renal pelvis culture, not voided urine culture

Question 7

45 yo hypertensive M with fhx of renal failure is noted to have b/l enlarged polycystic kidneys, and hepatic and pancreatic cysts during an abdominal us for abdominal/flank pain and fever. He also complains of marked dysuria. He is admitted with presumed diagnosis of pyelonephritis. Ucx is sent. Initial abs should be:

a. gent
b. amp
c. cephalexin
d. cipro
e. nitrofurantoin

Answer 7

d. ciprofloxacin. Patient has ADPCK (associated hepatic and pancreatic cysts). Need lipid soluble antibiotic to treat in these cases: trimethoprim, tetracycline, doxyclicline, ciprofloxacin, levofloxacin, chloramphenicol. Amp, aminoglycosides, cephalosporins, and nitrofurantoin are NOT lipid soluble and thus are poor choices.

Question 8

Transcatheter arterial embolization is an acceptable alternative to pretransplant native nephrectomy for patients with:

a. goodpasture syndrome
b. severe proteinuria
d. symptomatic polycystic kidney disease
e. history of peel\

Answer 8

b. Current indications for pretxplant nephrectomy may include HTN not controlled by dialysis and medication, persistent renal infection, renal calculi, or renal obstruction. Addition indications: severe proteinuria or polycystic kidneys symptomatic from infection, severe bleeding, or massive enlargement. Only severe proteinuria can safely and reliably be managed by pretransplant embolization.

Question 9

56 yo M undergoes partial penectomy for pT2 squamous cell carcinoma. Exam reveals no inguinal adenpathy. Primary tumor characteristic most predictive of pathological LN involvement is:

a. HPV status
b. tumor thickness >5 mm
c. LVI
d. corpora spongiosum involvement
e. corpora cavernous involvement

Answer 9

c. LVI.

Question 10

Impaired ammonia production in the kidney will most likely result in:

a. calcium oxalate renal lithiasis
b. decreased urine titratable acidity
c. impaired urea excretion
d. systematic alkalosis
e. metastatic calcification

Answer 10

b. decreased urine titratable acidity
Ammonia production allows kidney to rid itself without lowering the pH (titratable acidity).
NH4+ is produced from glutamine, primarily in PCT cells. Ammonium excretion can increase significantly during systemic acidosis, which is key mechanism for excreting excess H+.
Lack of ammonia production will result in systemic acidosis, followed by demineralization of bones, and uric acid stones.