2014 Flashcards
32-year-old woman has a 0.5 cm vaginal mesh exposure one year following sling placement. There is no urinary tract involvement. Although she has occasional spotting, she is continent and neither she nor her sexual partner are bothered by the mesh. The next step is:
- observation
- abstain from sexual intercourse until the mesh is epithelialized over
- local hormone therapy
- vaginal excision of exposed mesh
- remove the entire sling and perform a urethral bulking injection.
1
Conservative measures, including observation, are reasonable in the properly-selected patient who has a small area of exposure of mesh in the vagina. If the patient is not symptomatic, she does not necessarily need to abstain from intercourse, though it would be advisable to counsel her on the possibility that intercourse could exacerbate mesh exposure. Addition of local hormone therapy would be very reasonable in a postmenopausal woman, however, in a premenopausal woman, her vaginal tissue is likely to be adequately estrogenized; supplementation would therefore be of little to no benefit. Vaginal excision of the exposed mesh could be considered if she or her partner are symptomatic, but does not need to be performed in an asymptomatic patient. Removal of the entire sling is not indicated in this asymptomatic patient.
A 42-year-old man is unable to void following a straddle injury. Physical examination reveals blood at the meatus and a large perineal hematoma. Retrograde urethrography reveals a complete bulbar urethral disruption with contrast extravasation. The next step is:
- urethral catheter placement
- suprapubic tube placement
- flexible cystoscopy with urethral realignment
- open cystotomy and antegrade urethral realignment
- perineal exploration and repair.
2
The patient has suffered a major straddle injury resulting in complete bulbar urethral disruption. The next best step is suprapubic tube placement and delayed reconstruction. Perineal exploration is not indicated in the setting of acute blunt trauma and complete disruption of the bulbar urethra. Catheter placement is not indicated with complete disruption. Antegrade or retrograde urethral realignment is not indicated with complete bulbar urethral disruption, yet may be possible with an anterior urethral contusion or incomplete disruption.
A patient has a transscrotal orchiectomy for a 3 cm testicular mass. At the time of exploration, there is violation of the tunica vaginalis. Pathology is pure seminoma. Chest and abdominal CT scan and serum markers are negative. The next step is:
- surveillance
- retroperitoneal XRT
- retroperitoneal XRT including the groin and hemiscrotum
- excision of scrotal scar and retroperitoneal XRT
- three cycles of BEP.
3
Suboptimal approaches to testicular 6s, including scrotal orchiectomy, transscrotal biopsy, or fine-needle aspiration are reported from 4-17% of the time. A recent meta-analysis of 206 cases of scrotal violation reported a local recurrence rate of 2.9% compared with 0.4% of patients treated by inguinal orchiectomy, but no difference in systemic relapse or survival rates. There did not appear to be any advantage to adjuvant therapy. Others have reported an increased local recurrence rate in patients with scrotal contamination and an 11% presence of tumor in hemiscrotectomy specimens of patients with scrotal violation. Therefore, for patients with scrotal violation with low-stage seminoma, the radiation portals should be extended to include the ipsilateral groin and scrotum. This may result in an increased risk of azoospermia. Observation is not appropriate in the setting of scrotal violation. Platinum, etoposide, and bleomycin (BEP) is appropriate for treatment of non-seminomatous germ cell tumors and advanced seminoma, not low-stage seminoma.
The effect of finasteride on serum and intraprostatic testosterone is:
There are two isoenzymes of 5-alpha-reductase (Type I and Type II). Finasteride blocks only the Type II isoenzyme. The prostate contains the Type II enzyme. Therefore, dihydrotestosterone (DHT) levels are decreased in the prostate. There is an upregulation of serum and intraprostatic testosterone. The serum DHT is typically decreased by about 85%, but not to castrate levels as circulating testosterone is converted to DHT by Type I isoenzyme in the skin and liver. The decreased DHT production leads to reduction in negative feedback which leads to increased LH production, hence increase serum testosterone.
A 21-year-old man receives a stem cell transplant with high-dose salvage chemotherapy for a Stage III NSGCT refractory to primary chemotherapy. After his salvage chemotherapy, his markers normalize and his CT scan is shown. The next step is:
- observation
- PET scan
- percutaneous biopsy
- two additional cycles of chemotherapy
- RPLND.
5
This patient has several residual masses after salvage chemotherapy. Given that he has received salvage chemotherapy and that his markers are normal, his best option is RPLND. The chance of viable disease is approximately 50%, teratoma 40%, and necrosis/fibrosis only 10%, thus, observation is a poor choice. A PET scan would not tell about teratoma which would need to be resected. A percutaneous biopsy could have sampling errors and would not obviate the need for additional treatment. Since the markers are normal, there is no indication at this time for additional chemotherapy especially in the salvage setting.
A 56-year-old man undergoes a radical cystoprostatectomy and orthotopic neobladder. Long-term preservation of renal function is most dependent on:
- preferential use of ileum over colon
- use of > 60 cm of detubularized bowel
- performance of an antirefluxing ureteroileal anastomosis
- intraoperative neobladder capacity of >= 500 ml
- postoperative avoidance of any bacteriuria.
1
Reservoirs made of detubularized ileum appear to have the greatest compliance and lowest likelihood of generating intermittent high-pressure contractions. Several clinical studies have demonstrated that the urodynamic characteristics of the ileum appear to be superior to those of the colon and is therefore the preferred segment of bowel used for a neobladder. Larger bowel lengths with increased intra-operative volumes are not necessary as all bowel segments effectively stretch over time if there is adequate outflow resistance. In fact, commonly utilized techniques (e.g. Studer, T-pouch) utilize 40-44 cm of ileum with resultant intra-operative volumes of 200 ml or less. For ileal neobladders, it has been shown that the capacity increases sevenfold after one year. The true benefits of anti-refluxing anastomosis remain uncertain. It does not appear that conduit pressures are transmitted to the renal pelvis. Also, there is no difference in conduits between those with versus without reflux, with regard to renal function measured two to five years postoperatively. Furthermore, the successful construction of an anti-refluxing anastomosis does not prevent bacterial colonization of the renal pelvis. Many of these patients have no untoward effects and seem to do well with chronic bacteriuria. Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas, and should therefore be treated, whereas those with mixed cultures may generally be observed, provided they are not symptomatic.
A 63-year-old man undergoes partial nephrectomy in a solitary kidney. The renal artery is clamped for 40 minutes without the use of surface hypothermia. Postoperatively, the creatinine rises from 1.5 mg/dl to 2.5 mg/dl. The renal structure most likely to have been injured is:
- cortical collecting duct
- distal convoluted tubule
- juxtaglomerular apparatus
- proximal convoluted tubule
- medullary thick ascending loop of Henle.
5
The clinical scenario described is ischemic acute tubular necrosis (ATN). This is characterized by tubular cell injury which may be sublethal or lethal. During normal renal function, the medulla operates at the brink of hypoxia due to countercurrent diffusion of oxygen in the vasa rectae. During prolonged ischemia, medullary hypoxia is intensified and high metabolic requirements of the structures located in the outer medulla are most sensitive to injury. The medullary thick ascending limb of Henle is rich in the energy requiring Na-K ATPase and is most sensitive to ischemic damage. The concept of ATN is important in partial nephrectomies and renal transplantation. The other structures are not located in the medulla. Management of ATN would include optimizing perfusion and oxygenation of the kidney, and minimizing nephrotoxic agents.
A 34-year-old man and his 29-year-old wife have a two year history of infertility. His physical exam is normal. Semen analysis reveals a volume of 2 ml, sperm 23 mil/ml, 2%25 motility, and 12%25 normal morphology. Repeat analysis is similar. The next step is:
- sperm viability assay
- testosterone and FSH levels
- karyotype and Y chromosome microdeletion testing
- scrotal ultrasonography
- testicular sperm extraction.
1
This patient has a less than 5% motility. This raises the prospect of an ultrastructural abnormality in the sperm tails such as primary ciliary dyskinesia. This is characterized by extremely low motility but relatively high sperm viability on a sperm viability assay. Since the sperm concentration is normal, there is no indication for determination of testosterone, FSH, karyotype, or Y chromosome microdeletion testing. Scrotal ultrasonography will not add any useful information. Testicular sperm extraction is indicated for azoospermia. Since this patient has motile sperm in the semen, there is no reason for sperm extraction. Sperm from patients with ciliary dyskinesia may be used for intra-cytoplasmic sperm injection (ICSI), but pregnancy rates are low.
A morbidly obese 72-year-old man undergoes XRT for prostate cancer complicated by a urethral stricture requiring multiple direct visual internal urethrotomies. He subsequently develops BCG refractory CIS of the bladder cancer and chooses to undergo cystectomy. The risk factor that makes him an unacceptable candidate for orthotopic diversion is:
- prior XRT
- morbid obesity
- urethral stricture disease
- age
- presence of CIS.
3
The patient has multiple risk factors which increase his risk for complications after surgery for cystectomy and orthotopic diversion, however, only urethral stricture disease would be a contraindication for the diversion. CIS does not appear by itself to significantly increase the risk of urethral recurrence after orthotopic diversion. Obese patients may actually do better with an orthotopic diversion as it avoids stomal issues that are common in the morbidly obese. Studies have demonstrated the safety and feasibility of performing orthotopic diversions in previously radiated patients. Similarly, age is not a contraindication. Patients with urethral stricture disease should not undergo orthotopic diversion as they may be unable to catheterize should the need arise and may cause overdistension of the neobladder which could lead to rupture.
A 47-year-old woman undergoes an abdominal sacrocolpopexy and a suburethral sling procedure. She is a nonsmoker and does not use estrogen replacement therapy. She is not obese. Recommended DVT prophylaxis is:
- early ambulation only
- pneumatic compression device only
- heparin 5000 units subcutaneous every eight hours starting after surgery
- heparin 5000 units subcutaneous every 12 hours starting after surgery
- heparin 5000 units subcutaneous every 24 hours starting after surgery.
4
The patient is classified as moderate risk for DVT based on her age (> 40) and absence of additional risk factors, therefore prophylaxis is indicated. A pneumatic compression device would be recommended if the risk of intraoperative bleeding were high. Otherwise, heparin 5,000 units every 12 hours is recommended. Heparin 5,000 every eight hours dosing is recommended for those at high risk for DVT.
A 25-year-old man is evaluated as a potential living renal donor to his sister. Arteriography shows a single artery to each kidney. A left donor nephrectomy is undertaken and at surgery, a second unsuspected 1.5 mm diameter artery to the lower pole is found 5 mm inferior to the main renal artery. The best management is:
- ligation of the polar artery
- use of a donor aortic patch encompassing both arteries
- use of a donor aortic patch encompassing the polar artery
- ex vivo anastomosis of the polar to the main renal artery
- ex vivo anastomosis of both arteries to a Dacron patch.
4
The proper management is to divide the two arteries separately during kidney removal and perform ex vivo end-to-side anastomosis of the small artery to the larger one. Unlike in cadaveric kidney donation, use of an aortic patch is contraindicated in living renal donors due to potential risk to the donor. Ligation of the lower pole vessel may lead to lower pole ischemia and potentially a urinary fistula. Transplantation with two arterial anastomoses in the recipient will lengthen the revascularization time and increase the risk of ischemic renal damage. Use of a Dacron patch is rarely indicated unless the recipient has significant atherosclerosis.
A 25-year-old woman experiences recurrent UTIs following sexual activity. Cultures with each episode reveal pan-sensitive E. coli. Each symptomatic episode has been treated for 14 days with nitrofurantoin. Five days after completing her most recent treatment, catheterized urine is sterile, PVR is negligible, and pelvic exam is normal. If she experiences another UTI, the next step is:
- retreat with nitrofurantoin and counsel the patient to drink more fluids, improve hygiene, and void after intercourse
- treat with three days of trimethoprim-sulfamethoxazole
- renal bladder ultrasound
- renal bladder ultrasound and cystoscopy
- renal bladder ultrasound, cystoscopy, and localization cultures.
2
Conservative measures such as hydration, hygiene, and voiding after intercourse have been documented to be ineffective in preventing post-coital UTIs. The most likely cause for her recurrent infections is persistence of uropathogenic bacteria in the vaginal flora, which were ineffectively treated with the urinary concentrated antibiotic, nitrofurantoin. Treatment with three days of trimethoprim-sulfamethoxazole will eliminate vaginal colonization. Upper tract imaging and cystoscopy are indicated if recurrence of the same bacteria occurs rapidly despite treatment with an antibiotic that eradicates vaginal colonization. Localization cultures may be indicated if cystoscopy and upper tract imaging are unrevealing. Post-coital antibiotic prophylaxis is another treatment option.
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 cylinder 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. Should this occur with an inflatable prosthesis, the entire device should be removed and the urethra allowed to heal.
A 27-year-old man with a C5 spinal cord injury has recurrent problems with sediment and clogging of his indwelling urethral catheter despite frequent catheter changes. The next step is:
- urine culture to identify urease producing organism
- daily acetic acid irrigation
- placement of a large lumen suprapubic tube
- non-contrast CT scan
- cystoscopy.
1
Simple measures such as catheter irrigations and placement of a larger diameter suprapubic tube may temporize but not completely address the underlying problem of recurrent catheter encrustation with sediment. Catheter encrustation is attributed to bacterial biofilm, particularly biofilms made by urease producing bacteria such as proteus mirabilis. Urine culture is the appropriate next step. If a urease producing organism is identified, both treatment of the offending organism and evaluation for the presence of bladder or upper tract stones that could be serving as a nidus for bacterial infection is necessary.
A 58-year-old woman undergoes an uncomplicated laparoscopic right adrenalectomy for a 6 cm cortisol hypersecreting right adrenal mass. On postoperative day two, she has a low-grade fever, nausea, vomiting, hypotension, and abdominal pain. The next step is:
- 24-hour urine-free cortisol measurement
- measurement of plasma metanephrine levels
- hydrocortisone therapy
- broad-spectrum antibiotics
- exploratory laparotomy.
3
Acute adrenal insufficiency, or adrenal crisis, is an acute condition often preceded by hypotension unresponsive to fluid resuscitation. Patients are often misdiagnosed with an acute abdomen, whereas abdominal pain, nausea, vomiting, and fever frequently accompany hypovolemia. Adrenal insufficiency following adrenalectomy in the setting of a normally functioning contralateral adrenal gland is unlikely, but possible. This is especially true for patients who are undergoing adrenalectomy for a cortisol-secreting lesion, because functionality of the contralateral gland can be suppressed as in this patient. The diagnosis of primary adrenal insufficiency is primarily made on clinical grounds, with a high index of suspicion given a patient’s history, exam, and laboratory evaluation. Because adrenal crisis can be an acute and potentially life-threatening condition, consideration for treatment (i.e. repletion) should be made at the outset. If desired, the diagnosis is ultimately secured by measurements of morning serum cortisol and ACTH, but unnecessary delay in treatment should not be made simply to secure this diagnosis. Urinary cortisol and metanephrine levels are not indicated or necessary in this case. Furthermore, the initiation of broad-spectrum antibiotics will not address the underlying problem of adrenal insufficiency. The treatment of adrenal insufficiency involves adrenal hormonal repletion. Cortisol is replaced with hydrocortisone or with cortisone acetate.
A 45-year-old neurologically normal man has worsening urinary incontinence for several years. Videourodynamic study is shown with the voiding image. The diagnosis is:
- striated sphincter dyssynergia
- stress urinary incontinence
- bulbar urethral stricture disease
- detrusor overactivity with impaired contractility
- bladder neck obstruction.
5
The urodynamic tracing indicates detrusor overactivity associated with incontinence and bladder outlet obstruction during emptying. The tracing does show increased EMG activity during the detrusor overactivity but this is due to volitional suppression, not true striated dyssynergia. The image demonstrates narrowing at the proximal urethra consistent with bladder neck obstruction with voiding. At the time, the voiding image is taken there is no increased EMG activity excluding striated sphincter dyssynergia. There is no bulbar urethral narrowing to suggest urethral stricture disease. High-pressure voiding excludes impaired detrusor contractility.
Three months following a bilateral nerve sparing radical prostatectomy, a 65-year-old man has erectile dysfunction. He has failed oral therapy and wishes not to pursue intracavernosal injection therapy. He attempts intraurethral alprostadil 1000 mcg. The most likely occurrence is:
- inadequate erection
- penile pain
- headache
- hypotension
- urethral bleeding.
1
Intra-urethral prostaglandin administration is a reasonable alternative to intracavernosal injection therapy. Significant decrease in blood pressure occurs in approximately 2% of men. Penile pain is estimated to occur in 18-33% of men. Only 40% of men will consistently attain an erection adequate for penetration with intra-urethral alprostadil. Urethral bleeding is reported in about 5% of men and headache is rare.
An adverse prognostic feature not included in the Motzer Criteria for patients with metastatic RCC is:
- Karnofsky performance status (KPS) < 80%
- elevated LDH
- thrombocytopenia
- prior nephrectomy
- hypercalcemia.
3
The natural history of RCC is highly unpredictable. For instance, approximately 5% of patients with what are usually small indolent tumors (< 4 cm in size), will have metastatic disease at presentation and subsequently an elevated risk of disease-specific mortality. In contrast, up to 40% of patients with lymph node metastases diagnosed at the time of nephrectomy are alive five years after surgery. The Motzer criteria is a validated risk measurement tool that the physician may employ to aid in the discussion regarding the patient’s prognosis and is a useful guide in the formulation of treatment options. RCC risk groups are determined by the number of existing adverse features. The adverse features included in the Motzer criteria are Karnosky performance status < 80%, elevated LDH, anemia, hypercalcemia, and prior partial or total nephrectomy. Thrombocytopenia is not part of the criteria. If no risk factors are present, the patient is considered at low risk for recurrence. The presence of one to two features indicates intermediate risk and the presence of three to five adverse features poor/high risk for tumor recurrence.
The imaging study providing the best sensitivity and specificity for assessing bony metastatic disease in men with high-risk prostate cancer is:
- plain film tomography
- CT scan with bone windows
- 99mTc-MDP bone scan
- 18F-fluoride PET scan
- single-photon emission computed tomography (SPECT) scintigraphy.
4
In 2009, the Division of Cancer Treatment and Detection of the National Institutes of Health (NIH) conducted a review concerning 18F-PET imaging and its utility for assessing cancer metastases to bone, and concluded that 18F-PET provides the best sensitivity and specificity for the detection of bony metastases in prostate cancer. This review and other studies have demonstrated the superiority of 18F-PET to conventional (99mTc-MDP) bone scan with regard to specificity and sensitivity. Plain film tomography, CT scan with bone windows, and SPECT/CT have been used to evaluate suspicious or suspected areas of bony metastasis, but are not utilized for the initial survey of metastases in the high-risk patient. Each of these studies have more limited performance characteristics than 18F-PET. It remains to be seen whether this imaging modality will become the standard of care.
A 32-year-old man with infertility has unilateral absence of the vas deferens and 28 ml testes. Semen analysis reveals a volume of 0.5 ml, azoospermia, and pH of 6.4. FSH is 4.9 IU/l. Transrectal ultrasound reveals ipsilateral seminal vesicle agenesis and contralateral seminal vesical hypoplasia. Genetic testing is normal. The next step is:
- renal ultrasonography
- scrotal exploration with vasography
- scrotal ultrasound
- sweat test
- testis biopsy.
1
Low volume azoospermic acidic semen suggests lack of seminal vesicle contribution to the semen. The differential diagnosis of this finding is: bilateral ejaculatory duct obstruction and congenital bilateral absence of the vas deferens (CBAVD). Transrectal ultrasound can differentiate between the two entities with CBAVD patients having either seminal vesicle agenesis or seminal vesicle hypoplasia. Bilateral ejaculatory ductal obstruction is associated with midline urethral cysts, bilateral seminal vesicle cysts, or the bilateral seminal vesical cysts with dilation of the ejaculatory ducts. CBAVD variants, as in this patient, one vas may be non-palpable while the other is present in the scrotum but absent in the pelvis. All CBAVD patients (including variants) should have genetic testing for cystic fibrosis. Up to 30% of patients will have no identifiable cystic fibrosis mutation. Some of these patients will have unilateral renal agenesis. It is thought that these patients have CBAVD due to mesonephric ductal-ureteral bud abnormalities. Up to 5% of these patients will be found to have renal agenesis, a finding not associated with CBAVD due to cystic fibrosis. It is therefore recommended that patients with CBAVD with a negative genetic test for cystic fibrosis, have a renal ultrasound performed. Scrotal exploration and vasography are not indicated in CBAVD patients, diagnosis is made by physical exam plus transrectal ultrasound for CBAVD variants. Scrotal ultrasound will not help with the diagnosis. The sweat test is not indicated in this patient with normal genetic testing and no clinical symptoms of cystic fibrosis. Testis biopsy to evaluate infertility is not indicated because the patient has CBAVD, normal FSH, and normal-sized testes. Treatment options for infertility in CBAVD patients is ICSI with sperm retrieval by TESE and implantation by IVF. Note in patients with CBAVD negative for cystic fibrosis, offspring may carry the trait and children with unilateral and bilateral renal agenesis have been reported.
A 50-year-old smoker with gross hematuria has a 1 cm left mid-ureteral filling defect on CT urography. The lesion is biopsied and laser ablated ureteroscopically. Histology reveals an inverted papilloma. The next step is:
- no further treatment or follow-up
- long-term antibiotics
- surveillance of the bladder and upper tracts
- segmental ureterectomy
- left nephroureterectomy.
3
Inverted papillomas are typically of two types (Type 1 and Type 2). Type 2 may exhibit a malignant behavior whereas Type 1 is benign. Unfortunately, they are histologically indistinguishable. Because of this, conservative treatment followed by surveillance for two years is recommended. Therefore no further treatment or follow-up is incorrect. Since it is possibly a benign lesion and presumably completely ablated by the laser, no additional treatment is warranted including antibiotic therapy.
A 40-year-old woman has urine draining from a port site three days following laparoscopic assisted vaginal hysterectomy. Cystogram is shown and bilateral retrograde pyelograms are normal. The next step is:
- prolonged catheter drainage
- bilateral percutaneous nephrostomies
- exploratory laparotomy
- transvaginal repair
- place pelvic drain.
3
This patient has a large intraperitoneal bladder perforation and urinary ascites from an unrecognized bladder injury during hysterectomy. The best choice for management is immediate transperitoneal exploration with repair of the bladder injury. This will allow drainage of the urinary ascites, washing out of the peritoneal cavity, and significantly reduce the risk of peritonitis and vesicovaginal fistula formation. The use of a pedicalized omental flap to place between the bladder repair and the vaginal cuff suture lines should also be attempted to avoid overlapping suture lines and further minimize risk of post-operative fistula. Prolonged catheter drainage is the incorrect management of an intraperitoneal bladder injury and may result in prolonged urinary ascites with resultant persistent ileus and peritonitis. Bilateral nephrostomy tubes often do not result in complete 12 and would likely result in a prolonged clinical course and delay recovery. Transvaginal repair is the wrong approach to repair an intraperitoneal bladder injury.
A 27-year-old gunshot victim has a short upper ureteral injury and a splenic injury. During exploratory laparotomy, his vital signs are unstable with significant hypotension despite management of the splenic injury. No other acute injuries are present. The next step in management of his ureteral injury is:
- retrograde ureterogram and placement of a ureteral stent
- excision of injured segment and ureteroureterostomy
- transureteroureterostomy
- ligation of ureter and percutaneous nephrostomy
- nephrectomy.
4
In an unstable patient, ureteral injuries are best managed by ureteral ligation, percutaneous nephrostomy drainage, and delayed repair. In these instances, other choices are inappropriate because of the time needed for completion of the repair. In stable patients, short upper ureteral injuries may be managed by ureteroureterostomy with excision of the injured segment. A transureteroureterostomy may be appropriate with a long mid-ureteral injury but not an upper ureteral injury. A nephrectomy is not indicated in the absence of renal trauma especially if delayed salvage of the ureter is possible.
A 60-year-old smoker has a highly suspicious voided urinary cytology. CT urogram is normal. Cystoscopy, bladder biopsy, and bilateral retrograde pyelograms are normal. Selective left upper tract cytologies are highly suspicious for malignancy. The next step is:
- repeat cystoscopy, biopsy, retrograde pyelography, and selective cytologies in three months
- repeat left ureteral washings for fluorescent in-situ hybridization (FISH)
- left ureteropyeloscopy
- left ureteral stent and intravesical BCG
- left percutaneous nephrostomy and antegrade BCG therapy.
3
In cases of unilateral upper tract cytologic abnormalities (with normal cystoscopy, pyelography, and bladder biopsies), ureteropyeloscopy is indicated as the next step. Ureteropyeloscopy allows for direct visualization of small lesions and is superior to retrograde pyelography in the detection of small tumors. Biopsy at the time of ureteropyeloscopy should be attempted, if feasible. A persistently abnormal cytology without any visualized lesions may signify CIS. In the past, nephroureterectomy was performed for a unilateral cytologic abnormality of the upper tract to eliminate presumed CIS, but this is no longer considered an appropriate initial approach. Observation is also not appropriate without further evaluation given the repeated abnormal cytologies. Current approaches for presumed upper tract CIS include topical immunotherapy or chemotherapy, delivered retrograde intravesically with ureteral stents in place to assist with reflux or antegrade via a nephrostomy tube under careful pressure control. Novel urinary markers (e.g., FISH) have been reported for upper tract tumor surveillance and may aid in the detection of such tumors. To date, none of these markers have a high enough sensitivity or specificity to make decisions for or against therapeutic intervention. In this case, repeat procedure under anesthesia to obtain a selective urinary sample for FISH is not warranted.
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 two captopril modulated tests: plasma renin activity (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. In patients on medications it is critically important to recognize that the use of ACE inhibitors will significantly reduce the sensitivity of captopril stimulated testing and should be discontinued two weeks prior to the test. However, other antihypertensive medications can be used up to the morning of testing. In this clinical setting, duplex ultrasound will give anatomic information on the renal arteries sufficient to determine the need for angiography. Diuretic renography is not generally used as a test for renal artery stenosis.
A 65-year-old woman with controlled flank pain has an opaque 6 mm distal right ureteral stone. Urine pH is 6.0. She has no pyuria, fevers, or chills. She is scheduled to undergo cataract surgery in four weeks. The next step is:
- corticosteroids
- tamsulosin
- sodium bicarbonate
- ureteral stent
- ureteroscopic extraction.
5
The AUA Ureteral Calculi Guideline states that for newly diagnosed ureteral stone < 10 mm and whose symptoms are controlled, observation with periodic evaluation is an initial option. Furthermore, such patients may be offered an appropriate medical therapy to facilitate stone passage during this observation period. Metanalysis has shown tamsulosin to be superior to nifedipine in medical expulsive therapy. However, tamsulosin has been described to cause intraoperative floppy iris syndrome (IFIS) and complicates cataract surgery. Therefore, in a patient who is about to undergo cataract surgery, it would be best to avoid tamsulosin. Therefore, the options for this particular patient are observation, SWL, ureteroscopic extraction, or ureteral stent. A 6 mm stone is best treated by ureteroscopic extraction, because more often than not (53% of the time), these stones will not spontaneously pass. An opaque stone implies that the stone is not uric acid and therefore alkalization with sodium bicarbonate would be an incorrect choice.
Screening for RCC in patients with ESRD should be reserved for patients:
- with significant comorbidities
- initiating hemodialysis
- with a history of obesity and tobacco abuse
- who have undergone at least three years of dialysis
- with autosomal dominant polycystic kidney disease.
4
The relatively low incidence of RCC in the general population and the potential risk of identifying clinically insignificant lesions argue against widespread screening. However, several well-defined target populations who are at increased risk of RCC may be suitable for screening efforts. The relative risk of RCC in patients with ESRD has been estimated to be 5-20 times higher than that in the general population. The majority of patients with ESRD will develop acquired renal cystic disease (ARCD) and some of these patients will develop RCC. Cystic disease is associated with time of maintenance dialysis; increasing with duration of therapy. In renal failure patients, a reasonable approach to screening for patients with ESRD without other major comorbidities, is to delay screening until the third year on dialysis. Those with significant comorbidities, and thereby limited life expectancies, are not felt to benefit from screening and thereby should not be screened. Patients undergoing maintenance hemodialysis were previously thought to have a higher incidence of ARCD and thereby a higher risk of renal carcinoma than patients on peritoneal dialysis. However, recent studies have demonstrated similar rates of ARCD in both dialysis subgroups, and thereby suggests both forms of maintenance dialysis would increase the risk of developing renal carcinoma. Obesity and tobacco abuse have been shown to be risk factors for RCC, but these conditions themselves do not necessarily warrant screening efforts in patients with renal dysfunction. Screening for RCC in autosomal dominant polycystic kidney disease (ADPKD) was previously recommended. However, recent studies suggest no significantly increased risk of RCC in ADPKD and imaging is extremely difficult in this population related to the altered intrarenal architecture. Taken together, these considerations suggest that screening for RCC in patients with ADPKD should not be pursued.
A 55-year-old man has flank and bladder pain with a ureteral stent after uncomplicated ureteroscopy. The next step is analgesics and:
oxybutynin
- nifedipine
- tamsulosin
- prednisone
- phenazopyridine.
3
A metanalysis of patients treated with alpha-blockers for stent discomfort identified 12 randomized controlled trials with 946 patients. It concluded that alpha-blockers were associated with a significant decrease in urinary symptoms and pain, and significant improvement in general health. In contrast, randomized controlled studies failed to demonstrate benefits with oxybutynin, phenazopyridine, or a ketorolac eluting ureteral stent. Periureteral botulinum toxin injection at the time of stent placement has been demonstrated to decrease stent morbidity, however, this would require a secondary cystoscopic procedure, and has not been studied as a rescue procedure after stent placement. Nifedipine and prednisone have not been studied for use in stent pain.
A 58-year-old woman returns to the office two months following sacral neuromodulation with a low grade fever and incisional drainage associated with pain and erythema over the implantable pulse generator (IPG) site. The next step is explantation of the:
- IPG only
- IPG and lead
- IPG, wound irrigation and cleansing with antibiotic solution, and reimplantation of the IPG
- IPG and lead with simultaneous test stimulation of a new lead
- IPG with simultaneous placement of an IPG on the contralateral side.
2
This patient has an infected IPG. The bacterial infection of the artificial IPG will result in a bacterial biofilm that will also contaminate the lead. Both the IPG and lead should be explanted. Their risk of infection of a new device or new lead placement at the time of explantation is too high and should not be pursued. The proper management is explantation of all prosthetic material, treatment of the infection, and repeat test stimulation in the future when the patient is completely recovered.
A 35-year-old woman with no significant findings on medical history has a non-contrast CT scan performed for right flank pain. A 2 cm left adrenal mass (5 HU) is identified. The next step is:
- observation
- repeat CT scan in three months
- biochemical work-up
- percutaneous biopsy
- gadolinium enhanced MRI scan.
3
The incidental adrenal lesion, or incidentaloma, is an adrenal mass 1 cm or larger in size discovered during radiographic imaging performed for indications other than adrenal disease. They are found in approximately four to six percent of the imaged population. Almost all of incidental adrenal lesions < 4 cm in size will prove to be benign in a patient without a known history of cancer. In patients with a known history of cancer, up to 50% will represent metastatic malignancy. This patient has an incidentally discovered adrenal adenoma that is probably benign based on its size and the HU of 5. Specifically, a non-contrast CT scan revealing a < 4 cm adrenal mass with HU < 10 carries a 98% specificity that the diagnosis is a benign adrenal adenoma. In masses with HU > 10, a contrast CT scan with early phase wash-out could be obtained to rule-out malignancy; it is, however, not necessary in this instance. Similarly, a gadolinium-enhanced MRI scan is not indicated and is not as good as CT scan when looking for adrenal hypervascularity. The current recommendation for the management of an incidentally discovered adrenal mass < 4 cm in size with an HU value of < 10 is a biochemical work-up to include cortisol and catecholamines. In patients with a history of HTN, a hyperaldosteronemia should also be ruled out. Approximately 7% of these incidentalomas are metabolically active, 6% cortisol, and 1% sex or aldosterone secreting. Surgical resection is recommended for all metabolically active adrenal tumors or adrenal tumors > 4 cm. Of note, in a seven year follow-up study of 231 patients with incidental adrenal tumors < 4 cm in size and HU < 10, less than 2% of the metabolically inactive adrenal tumors will either substantially grow or become metabolically active. Therefore, neither observation nor repeat CT scan in three months is appropriate. If the patient had a history of a prior malignancy, higher HU, or larger mass, then biopsy might be indicated.
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.
A 12-year-old boy has painless terminal gross hematuria. Physical examination is normal. Urinalysis shows 3-5 RBC/hpf. Urine culture is negative. The next step is:
- observation
- urine calcium to creatinine ratio
- non-contrast CT scan
- VCUG
- cystoscopy.
1
The clinical picture is consistent with benign urethrorrhagia based on terminal gross hematuria and normal physical examination. UA shows microscopic hematuria only, and the culture is negative. This condition is caused by transient inflammation of the bulbar urethral epithelium. The cause is not known. No further work-up such as calcium to creatinine ratio, non-contrast CT scan, VCUG, or cystoscopy is necessary since this is self-limiting.
A 49-year-old man with a continent cutaneous reservoir has a KUB as shown. He has good continence. Serum creatinine is 1.4 mg/dl. Split renal function by renal scintigraphy is 10% right, 90% left. The next step is:
- open extraction of reservoir stones
- percutaneous extraction of reservoir stones
- percutaneous extraction of reservoir and renal stones
- open extraction of reservoir stones and right nephrectomy
- revision of reservoir and right nephrectomy.
4
The radiograph reveals a staghorn stone in the right kidney and several large stones in the Indiana Pouch. SWL or percutaneous extraction of the pouch stones does not address the renal calculi. The staghorn stone needs to be treated as well, an untreated staghorn stone risks urosepsis. Since the right kidney is contributing little to the patient’s adequate renal function, nephrectomy is recommended over stone removal procedures that leave the kidney in place. Though percutaneous extraction of pouch stones is recommended, open surgical extraction is a good alternative with this large stone burden. In a 12 with good continence, pouch revision is not necessary. The patient should be encouraged to catheterize and irrigate the pouch more frequently.
A 55-year-old woman has new onset moderate left hydronephrosis on non-contrast CT scan. Twenty years earlier, she underwent cystectomy and ileal conduit for a neurogenic bladder. Her serum creatinine is 1.4 mg/dl. The next step is:
- observation
- urine cytology
- loopogram
- percutaneous nephrostomy
- looposcopy with catheterization of the left ureter.
3
Some hydronephrosis is expected after ileal conduit 12. Without a history of malignancy, computed tomography with contrast is not necessary. Loopography is the recommended next step with the new onset of hydronephrosis. It can assess for reflux into the left kidney. If there is free reflux, then obstruction is unlikely. If reflux is absent, then diuretic renal scintigraphy can be used to assess for obstruction. If obstruction is present, percutaneous nephrostomy can drain the kidney and allow the system to be studied. Looposcopy with ureteral catheterization is unlikely to succeed if the system is obstructed, and is unnecessary if it is not obstructed.
A 26-year-old infertile man has an ejaculate volume of 0.9 ml, sperm count of 10 million/ml, and 20% motility. Physical examination and hormonal evaluation are normal. The next step is:
- antisperm antibody testing
- semen culture
- post-ejaculatory urinalysis
- TRUS
- scrotal Doppler ultrasonography.
3
The patient’s evaluation reveals oligoasthenospermia with low ejaculate volume without any obvious cause. Post-ejaculatory UA (PEU) is the best next step in order to identify a correctable cause for this patient’s semen abnormalities. Hamster egg penetration test and antisperm antibody testing are useful for prognostic purposes but will not identify a correctable abnormality. Post-coital test is helpful in patients with isolated volume problems but would not be helpful in patients with oligoasthenospermia. Scrotal ultrasonography for subclinical varicocele is not indicated. TRUS may be considered if the PEU is negative but should not be considered first since it is more invasive than a PEU.
A 70-year-old man is undergoing radical cystectomy and continent orthotopic urinary diversion for muscle-invasive high-grade urothelial carcinoma. During lymphadenectomy, a suspicious, firm 1.5 cm positive external iliac lymph node is confirmed to be positive for metastasis. The next step is:
- abort surgery and treat with chemotherapy and XRT
- abort surgery and treat with chemotherapy followed by cystectomy
- perform lymphadenectomy and treat with chemotherapy and XRT
- complete surgery but perform an ileal conduit urinary diversion
- complete surgery as planned.
5
At the time of radical cystectomy, suspicious lymph nodes can be encountered. Approximately 25% of patients will ultimately have positive lymph nodes at the time of radical cystectomy. If the suspicious node(s) can be safely resected and the volume of suspicious lymph nodes is limited, it is reasonable to continue the cystectomy and continent 12. The patient will benefit from the local control of the lymphadenectomy and cystectomy. There is no evidence that stopping the surgery to treat with neoadjuvant chemotherapy or chemotherapy and radiation therapy is superior to completing the cystectomy. Positive lymph nodes are not a contraindication to continent 12.
Three months after placement of a three-piece inflatable penile prosthesis, a patient has persistent penile shaft pain with inflation. Physical examination of the penis and scrotum is normal. The next step is:
- pelvic and scrotal MRI scan
- cystourethroscopy
- 500 mg cephalexin BID for 30 days
- glansplasty
- revision of reservoir with a lock out valve.
1
This patient complains of pain only when the device is inflated during intercourse which may indicate that the cylinders are too large and are buckling, causing pain. MRI scan with the prosthesis inflated is the best imaging modality to prove the possible size discrepancy and buckling is the next step. If the diagnosis is confirmed, revision of the penile prosthesis with placement of smaller cylinders will usually resolve the problem. Penile infection following prosthetic placement usually has associated physical signs of infection (warmth, tenderness, erythema, etc.) that exist in both the flaccid or erect state. An SST deformity (floppy glans) is usually well-described by a patient and can be confirmed by physical examination. It can be repaired by moving the glans onto the distal portion of the cylinders with a glansplasty. Cystourethroscopy is indicated in the presence of voiding symptoms and/or possible infection of the penile prosthesis to rule out urethral erosion, but is not indicated in patients with pain only on inflation. Revision with a lock-out valve would only be useful in cases of autoinflation.
In patients with uric acid stones, the primary underlying metabolic defect is:
- hyperuricosuria
- hyperuricemia
- low urine pH
- low urine volume
- RTA.
3
Although hyperuricosuria, low urine pH, and low urine volume are all important contributors to uric acid stone formation, a persistently acid urine (pH < 5.5) is the most important determining factor for uric acid stones. Although hyperuricemia is the hallmark of primary gout, not all patients with uric acid stones have either hyperuricemia or gout. Renal tubular acidosis is associated with high rather than low urine pH, hyperchloremia, and hypokalemia.
A seven-year-old boy has had multiple repairs for penoscrotal hypospadias. He has recurrent lower UTIs and post-void dribbling. A renal ultrasound is normal. A pelvic ultrasound is shown. The most likely diagnosis is:
- cecoureterocele
- ectopic ureter
- Cowper’s duct cyst
- prostatic utricle
- bladder diverticulum.
4
In boys with proximal hypospadias, the prostatic utricle is often enlarged. In a female, this would represent the distal one-third of the vagina. The utricle is of urogenital sinus origin. While an ectopic ureter or bladder diverticulum could have a similar appearance on ultrasound, they generally are not midline in location. Ectopic ureter or bladder diverticulum are not seen commonly with hypospadias. A cecoureterocele would have a bladder deformity in addition to a suburethral extension. A Cowper’s duct cyst or syringocele should be confined to the bulbous or prostatic urethra where Cowper’s ducts drain.
A 45-year-old man undergoes a partial penectomy for a 3 cm, grade 3, squamous cell carcinoma of the penis. Pathology reveals invasion of the corpus cavernosum and negative margins. On exam, he has matted firm 6 cm right inguinal lymph nodes and a CT scan of the chest, abdomen, and pelvis reveals right sided inguinal adenopathy but no other metastases. The next step is:
- percutaneous biopsy of the inguinal lymph nodes
- right inguinal lymph node dissection
- bilateral inguinal lymph node dissection
- bilateral inguinal and pelvic lymph node dissection
- neoadjuvant chemotherapy.
5
Neoadjuvant platinum-based chemotherapy is indicated for patients with difficult to resect matted or fixed inguinal lymph nodes from metastatic penile cancer. The neoadjuvant chemotherapy should reduce the size of the nodes and enhance their resectability. Following neoadjuvant chemotherapy, the patient should have a bilateral inguinal and pelvic lymphadenectomy. A percutaneous biopsy is not necessary in this setting.
Pyospermia in an infertile man commonly suggests:
- a sexually transmitted infection
- UTI
- antisperm antibodies
- functional sperm damage
- failure to retract foreskin.
4
Leukocytes are often present in the semen of infertile men. They are seldom due to documentable infection or antisperm antibodies. They do often indicate functional damage from DNA fragmentation to sperm membrane lipid peroxidation from reactive oxygen species released from the leukocytes. Leukocytes can occur with UTIs, but unless urine is in the semen, this is an unlikely source. Sexual transmitted infections can also lead to leukocytes in semen and this does need to be ruled-out, however, even PCR DNA testing for sexual transmitted pathogens are often negative verifying the situation is most commonly idiopathic.
A three-year-old girl undergoes an upper pole heminephrectomy for an ectopic ureter. Three days later, she has worsening pain, fever, and hematuria. The next step is:
- observation
- Doppler ultrasound
- retrograde pyelogram
- CT angiogram
- ureteral stent.
2
The symptoms suggest either a urinoma or vascular injury to the lower pole segment, and is best evaluated with Doppler ultrasound. Pain, fever, and hematuria are common early, but should improve in the first 48-72 hours. Retrograde pyelogram and ureteral stent would be indicated for documented unresolving urinoma. CT angiogram has the disadvantage of radiation exposure without added clinical information that Doppler ultrasound would provide.
During performance of a transobturator midurethral polypropylene sling, the trocar normally passes through the:
- ischiorectal fossa
- obturator canal
- sartorius muscle
- bulbospongiosus muscle
- ischiocavernous muscle.
1
During placement of an obturator sling, regardless of approach, the trocar should pass through the ischiorectal fossa. It passes through the obturator foramen but not the obturator canal. It does not normally pass through any of the other listed structures. An outside-in transobturator passage traverses the gracilis muscle, adductor longus and brevis muscles, obturator externus muscle, obturator membrane, and obturator internus muscle. The gracilis muscle adducts and flexes the hip. The adductor longus and adductor brevis muscles adduct the thigh. The obturator externus and obturator internus muscles aid with thigh adduction and lateral rotation. Structures that affect medial thigh rotation are not traversed with a transobturator approach.
A 45-year-old, otherwise healthy woman, has mild left CVA tenderness, bacteruria, and a temperature of 38.8° C. She is able to take oral fluids. The next step is:
- urine culture and IV antibiotic therapy
- abdominal and pelvic CT scan
- renal ultrasonography
- outpatient therapy with oral nitrofurantoin
- outpatient therapy with an oral fluoroquinolone.
5
In patients with an acute uncomplicated pyleonephritis, hospitalization is not required if they are able to maintain oral hydration. These patients should have a urine culture and sensitivity obtained and empirical antimicrobial therapy should be initiated immediately. Fluoroquinolones and TMP-SMX are excellent choices. Nitrofurantoin is effective in urine, but does not obtain therapeutic levels in most body tissues and is therefore not preferred for UTIs. Upper tract imaging is not required when uncomplicated pyelonephritis is suspected. However, imaging should be considered if the patient does not respond to antibiotic therapy within 72 hours, or in the presence of specific indications suggestive of a complicated UTI such as diabetes mellitus, immunosuppression, and history of nephrolithiasis or symptoms suggestive of urinary tract obstruction.
A 70-year-old man undergoes a difficult radical cystectomy for high-risk bladder cancer. His perioperative course is complicated by hypotension managed with crystalloid, two units of packed RBC, vasopressors, and intensive care monitoring. He later develops severe renal insufficiency requiring dialysis. According to the Clavien-Dindo Classification, his surgical complication grade is:
- II
- IIIa
- IIIb
- IVa
- V.
4
The Clavien-Dindo classification of surgical complications is largely becoming the standard system for reporting adverse events after surgery that deviate from the normal postoperative course. As the patient required dialysis, due to single organ dysfunction, he would be considered grade IVa. The classification is: Grade I: Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Grade II: Requiring pharmacological treatment with drug other than such allowed for grade 1 complications. (Includes blood transfusion and TPN)Grade III: Requiring surgical, endoscopic or radiological intervention.Grade IIIa: Intervention not under general anesthesia.Grade IIIb: Intervention under general anesthesia.Grade IV: Life-threatening complicationIVa: Single organ dysfunction.Grade IVb: Multiorgan dysfunction.
A 57-year-old woman complains of stress urinary incontinence and pelvic pressure. On exam, she is noted to leak with Valsalva. Relevant pelvic organ prolapse quantification (POP-Q) exam points reveal Aa and Ba at -3, Ap at 1, Bp at 2, and C at 0. The correct surgical procedure is:
- a mid-urethral sling only
- with anterior repair
- with posterior repair
- with anterior and apical vault repair
- with posterior and apical vault repair.
5
Mid-urethral sling is warranted due to visualization of leak with Valsalva. Additionally, POP-Q exam reveals both posterior (Bp2 notes most distal portion of posterior vaginal wall is 2 cm beyond the hymen) and apical prolapse (C at 0 notes vaginal cuff is at the hymen). The anterior vaginal wall is well supported (Aa and Ba -3). A posterior repair and procedure for apical prolapse is indicated.
A 32-year-old woman complains of a malodorous fishy vaginal discharge. She has a single male partner and uses an intrauterine device for contraception. The next step is:
- remove intrauterine device
- metronidazole for patient
- metronidazole for patient and partner
- ciprofloxacin for patient
- ciprofloxacin for patient and partner.
2
Bacterial vaginosis results from an alteration of normal vaginal flora with a predominance of Lactobacillus species and high concentrations of anaerobic bacteria. Diagnosis can be confirmed with identification of clue cells, a homogenous vaginal discharge, a vaginal pH > 4.5, and a malodorous fishy vaginal discharge. Risk factors may include multiple sexual partners, a new sexual partner, use of an intrauterine device, and douching. Treating the patient is as effective as treating the patient and partner. Symptoms may recur in 1/3 of patients after treatment. Metronidazole is the treatment of choice.
A ten-year-old boy undergoes ureteroscopic stone extraction for a 1 cm right distal ureteral stone. After placing a guidewire, a 6.5 Fr semirigid ureteroscope will not pass easily at the ureteric orifice. The next step is:
- place ureteral stent and retry three days later
- dilate the ureteric orifice
- SWL
- percutaneous stone extraction
- laparoscopic ureterolithotomy.
2
When the semirigid ureteroscope will not pass easily over a guidewire in a prepubertal child, the next step is to perform a ureteric orifice dilation using either coaxial dilators or balloon dilator. Studies have demonstrated that ureteric dilation at the time of ureteroscopy is safe in children. After dilation, ureteral access sheath may also be used to minimize trauma. If the dilators do not pass easily, then placing a ureteral stent for passive dilation for several weeks is appropriate, but dilation should be tried first to avoid second anesthesia. Flexible ureteroscope is comparable in size (6.9 Fr) to the 6.5 Fr semirigid scope and may not offer any additional advantage in passing it up the ureter. Furthermore, a smaller working channel may make the stone fragmentation and extraction more difficult. SWL, percutaneous stone extraction, and laparoscopic ureterolithotomy are inappropriate for a distal ureteral stone.
A 53-year-old man complains of four months of pain with erections, poor tumescence, and a 30 degree dorsal penile curvature. Physical examination reveals a 1 cm dorsal plaque. The next step is:
- reassurance and observation
- treatment with sildenafil
- intracavernous injection therapy
- tunical plication
- plaque excision and grafting.
2
Many think that the clinical incidence of Peyronie’s disease is increasing. The increase however may be associated and coincide with the increased use of erection-enhancing medications. Phosphodiesterase type 5 (PDE5) inhibitor medications are not contraindicated in the treatment of Peyronie’s disease, while intracavernous injection therapy has been linked to the development of penile fibrosis. There has never been any suggestion that PDE5 inhibitors are in any way directly causally related to the development of Peyronie’s disease, nor is there suggestion that their use would worsen the course of Peyronie’s disease. Data is emerging to suggest that certain endothelial impairment may be reversed with the initiation of PDE5 inhibitor therapy. This patient has erectile dysfunction (ED) and it is reasonable to treat the ED with sildenafil. Reassurance will not improve his ED and surgical correction is not indicated early in the disease course.
A patient is undergoing fluoroscopy for a ureteroscopic procedure. The fluoroscopic set-up which will result in the least amount of scatter radiation to the operating room personnel is illustrated in the diagram labeled:
- A
- B
- C
- D
3
The image intensifier should be positioned above the patient and the x-ray tube below the patient to minimize radiation exposure (Images A, B, C). The x-ray tube should be positioned as far from the patient as feasible. (Image C) Angulation of the C-arm to a lateral or oblique position (Images B, D) increase the dose rate due to the increased body mass thickness that must be penetrated, and also brings the x-ray tube closer to the patient.
A 36-year-old woman with a horseshoe kidney has a symptomatic 1.8 cm left lower calyceal stone. The next step is:
- SWL
- open nephrolithotomy
- ureteroscopic stone extraction
- ureteral stent and SWL
- percutaneous nephrolithotomy.
5
Symptomatic lower calyceal stones clear poorly after fragmentation with SWL, especially in horseshoe kidneys. Ureteroscopic fragmentation and stone extraction in these malrotated kidneys can be difficult. Residual stone fragments are unlikely to pass spontaneously and the likelihood of rendering the patient stone-free is limited. Percutaneous renal access can be performed safely through a superior and posterior calyceal puncture. The entry site of the puncture needle is more medial, just lateral to the paraspinous musculature, in comparison to inferior pole punctures in normally positioned kidneys. An inferior calyceal puncture in a horseshoe kidney could be dangerous due to its medial, more anterior and inferior location. Even in thin patients, one may need to utilize longer instruments including flexible cystoscopes, flexible or rigid ureteroscopes, or extra-long nephroscopes. Percutaneous renal access through a superior pole puncture can be performed in a safe fashion and is the most optimal route to render the patient stone free. The only variable identified that decreases the efficacy of PCNL in a horseshoe kidney is the presence of a Staghorn calculus. Stone-free rates are 84% with a primary PCNL and rise to 93% after a second-look nephroscopy.
During placement of a two-piece inflatable penile prosthesis, the glans penis is noted to have poor support and minimal movement over the top of the prosthetic with a mild SST deformity. The best treatment is:
- observation and cycling
- glansplasty
- placement of an additional 1 cm rear tip extender
- upsize the prosthesis
- convert to a three-piece inflatable prosthesis.
2
Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, in which it appears to flop over the prosthesis. This deformity may result from inadequate distal dilation, too short cylinders, or in the case of minor deformity, variations in anatomy where the corpora cavernosum does not extend completely under the glans. For a severe deformity, definitive correction involves removing both cylinders, perforating the distal corpora with scissors, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders. For mild defects, like in this patient, dorsal plication of the glans back onto the shaft of the penis (glansplasty) is preferable when there are minor but otherwise bothersome degrees of poor glanular support. Changing to a three-piece prosthesis is not needed and adding a larger cylinder (upsizing) could result in pain and buckling.
A 50-year-old woman has azotemia and an obstructed solitary kidney. A percutaneous nephrostomy is placed and urine output is initially 200 ml/hr. She receives I.V. fluids. Her renal function improves over the next four days but the diuresis is now more pronounced. Vital signs and neurocognitive exam are normal. The next step is:
- oral vasopressin
- IV vasopressin
- hydrochlorothiazide
- decrease IV fluids
- increase I.V. fluids.
4
This patient’s persistent, post-obstructive diuresis is most likely iatrogenic. The brisk diuresis that accompanies release of obstruction may represent a physiologic response to the expansion of extracellular fluid volume occurring during the period of obstruction in many patients. This may be perpetuated by overzealous administration of intravenous fluids after relief of the obstruction. It would be safe in this clinically stable, neurologically intact patient to decrease intravenous fluids, allow her free access to fluid, and observe her closely for signs of hypovolemia and electrolyte imbalance. Hydrochlorothiazide is a diuretic and may worsen her diuresis. Vasopressin (ADH) acts to increase water reabsorption at the collecting duct and is not indicated in this scenario.
A 22-year-old man with history of NSGCT completed chemotherapy that included ifosfamide two weeks ago. He has weakness and lethargy. Serum labs reveal Na 137 mEq/l, Cl 135 mEq/l, CO2 12 mEq/l, K 2.7 mEq/l, and creatinine 0.9 mg/dl. Blood gas reveals serum pH 7.3. Urinalysis reveals pH 7.6. The next step is:
- IV Ringer’s lactate
- IV D5W with 20 mEq/l KCL
- IV hydrocortisone
- oral spironolactone
- oral potassium citrate.
5
The clinical presentation is that of weakness and lethargy following the course of chemotherapy accompanied by significant hypokalemia and hyperchloremic metabolic acidosis. Despite the acidosis, his urinary pH is alkaline, indicating inability to acidify urine. The most likely diagnosis is a drug-induced renal tubular acidosis (RTA) type I (distal), in which there is a failure of ammonium secretion in the distal tubule. The type II (proximal) RTA represents a defective reabsorption of bicarbonate in the proximal tubule. Although distal RTA can be genetic, this most likely represents an acquired condition due to ifosfamide chemotherapy. The treatment is oral potassium and bicarbonate supplementation. I.V. fluid hydration is unnecessary with no evidence of dehydration, and normal creatinine with no evidence of contraction alkalosis. The use of steroids or diuretics would be detrimental to this patient.
A 64-year-old man has a radical cystectomy and ileal neobladder. Ten days after surgery, 2.5 liters of bilious fluid drains from his incision over 24 hours. He is otherwise stable. The next step is:
- observation
- discontinue diet and start TPN
- oral loperamide
- oral octreotide
- surgical repair.
2
This patient has developed a high output (> 500 ml per day) enterocutaneous (EC) fistula. Management of high output EC fistula when they develop is extremely challenging and complex due to significant fluid and electrolyte loss and coexisting malnutrition. Emergent surgical repair in this patient would be highly technically demanding due to significant perisurgical reactive fibrosis with healing greatly impaired by concurrent malnutrition. Indeed up to 70% of patients with high output fistulae have concurrent malnutrition with documented hypoalbumemia, the latter of which is a significant prognostic factor. The loss of large amounts of fluid in the immediate postoperative period can lead to severe dehydration with oral intake frequently worsening the high output. The immediate step is to discontinue oral intake and initiate TPN. Agents that can decrease bowel motility (loperamide, diphenoxylate/atropine, etc.) can be helpful if the high output continues after the initial steps are taken. Although octreotide can be used to decrease pancreatic secretions, prospective double blinded placebo controlled trials demonstrated no significant reduction in postoperative EC fistula fluid losses nor did they find an increased rate of spontaneous EC closure. It should therefore only be used if high EC fistula outputs continue after initial measures fail.
A 26-year-old infertile body builder with a five year history of heavy anabolic steroid use is azoospermic 12 months after discontinuing all steroids. His serum testosterone is 150 ng/dl and FSH is normal. The next step is:
- observation
- testosterone replacement
- hCG
- testicular biopsy
- clomiphene citrate.
3
The non-medical use of anabolic steroids by athletes is potentially a significant cause of infertility in male adolescents and adults. It has been estimated that 3-12% of male athletes of high school age in the United States have used steroids. Infertility associated with anabolic steroid use commonly presents as oligospermia or azoospermia along with abnormalities of sperm motility and morphology. As with many of the other steroid side effects, the semen parameter deficits are thought to be reversible and consequently, the discontinuation of all steroids is the first course of therapy. Unfortunately, some steroid abusers develop a chronic anabolic-induced hypogonadism syndrome/state. Successful gonadotropin (hCG) replacement is the best therapy when this occurs. This patient has already been off steroids with no return of sperm after one year, therefore, continued observation is not likely to work at this point and a trial of hCG therapy is indicated. Testosterone supplementation will only continue to suppress the central axis (decrease FSH and LH release) and perpetuate the problem. Clomiphene citrate might work by blocking testosterone and estradiol feedback on the central axis and stimulate LH/FSH release, but will not be as effective as hCG. Testis biopsy is not needed at this time, but might be needed if the patient does not respond to hormonal manipulation and maturation arrest is suspected.
A two-day-old boy has gross hematuria. He was born at 38 weeks gestation via Caesarian section for failure to progress. Ultrasound shows bilaterally enlarged kidneys without cysts or hydronephrosis and a normal bladder. Hemoglobin and platelet count are low. The next step is:
- observation
- IV hydration
- anticoagulation
- VCUG
- CT angiogram.
2
Renal venous thrombosis is suggested in the neonate with enlarged kidneys, hematuria, anemia, and thrombocytopenia, often with a history of prolonged delivery and prematurity. Thrombosis is peripheral and initial therapy should be aimed at support and I.V. fluid administration in order to treat the underlying dehydration. Observation would be inadequate with the thrombotic phenomenon likely to escalate in severity with extension of the thrombus. Anticoagulation is indicated if the process extends beyond the renal vein(s). The clinical scenario presented and the imaging reported of bilaterally enlarged kidneys on ultrasound are sufficient to make the diagnosis and no further imaging is necessary.
A 38-year-old woman developed a 10 mm vesicovaginal fistula following a complicated hysterectomy. She has failed two prior attempts at repair, one transvaginally using a Martius flap and the other transabdominally using an omental flap. Upper tracts are normal. The next step is:
- cystoscopy, fulguration of the fistula tract, and suprapubic tube drainage
- cystoscopy with fibrin glue application to the fistula
- repeat vaginal repair with contralateral Martius fat pad graft
- abdominal repair with rectus muscle interposition
- ileal conduit.
4
This patient has failed two previous attempts at fistula closure following a complicated surgery. One would expect significant scarring in her pelvis and anticipate a difficult dissection for exposure of the fistula. Although cystoscopy and fulguration of the fistula tract is appealing for its surgical ease and is associated with a high rate of success (> 66%) for fistula < 7 mm in size, when used as either a primary or secondary treatment modality, it has no role in the management of large > 7 mm vesicovaginal fistula. Retrograde endoscopic injection of fibrin glue is a minimally invasive approach that may avoid the morbidity of an open surgery. It has been used to close complex fistulas up to 15 mm in size. Although short term outcomes less than one year are encouraging, approximately 75% successful long-term follow-ups reveal the success of this technique breaks down with time. Whether late break downs can be successfully retreated with fibrin glue injection remains to be clarified. Clearly, with each subsequent surgery, the likelihood of successful repair decreases. Optimal success is achieved with a tension-free primary bladder closure with an interpositional graft between the bladder and vaginal vault. Of the choices, the abdominal approach with rectus muscle graft interposition would provide the best technical option and be considered the gold standard in a patient who has undergone repeated failed attempts at vesicovaginal fistula closure. An ileal conduit is not indicated in this otherwise healthy young woman.
A 19-year-old man has painful severe left scrotal swelling after being kicked. The right testicle is palpably normal, but the left testicle and epididymis are nonpalpable secondary to a left hemiscrotal hematoma. The next step is:
- observation
- nuclear medicine scan
- MRI scan
- testicular ultrasound
- surgical exploration.
5
The history and physical examination of this patient is highly suspicious for a testis fracture. Immediate exploration is indicated without the need for scrotal imaging for a definitive diagnosis. Indeed, ultrasonography should not deny or delay surgical exploration if the physical examination findings dictate a possible fracture. The overall accuracy of ultrasonography for detection of traumatic testis fracture has been found to be highly operator dependent with both significant false positive and false negative rates found in the published literature. MRI scan has not been extensively studied, is costly, and could delay definitive treatment. Nuclear medicine scan will delay diagnosis and will not add useful information.
A four-year-old girl with bilateral grade 3 VUR has recurrent breakthrough UTIs despite continuous antibiotic prophylaxis. She undergoes a bilateral ureteroneocystostomy. According to the 2010 AUA Guideline on vesicoureteral reflux, the required step in postoperative management is:
- observation, postoperative imaging only required if additional UTIs occur
- renal ultrasound
- VCUG
- DMSA renal scan
- MAG-3 diuretic enhanced renal scan.
2
According to the most recently published AUA Guideline for the Management of VUR, the required step after an open-robotic surgical intervention for VUR is renal ultrasound. Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented. Based on the rigorous meta-analysis performed on the available literature, the use of postoperative VCUG following an open robotic ureteral reimplantation is considered optional. Renal ultrasonography obtained postoperatively will reveal Society of Fetal Urology (SFU) Grade 2 or higher hydronephrosis in approximately 25% of patients one month after a ureteral reimplantation and in 15% of patients three months after a ureteral reimplantation. The exact percentage of patients with postoperative hydronephrosis is dependent upon the percentage of patients with preoperative hydronephrosis, and the percentage of patents with preoperative grade of 4-5/5 VUR. If SFU Grade 2 or higher, hydronephrosis was noted preoperatively, approximately 60% resolve their hydronephrosis by three months, 30% improve, and the remainder are unchanged to slightly worsened. MAG-3 renal scan and VCUG can be obtained in individuals with persistent or worsening hydronephrosis. Evaluation of these patients will reveal persistent VUR in 4-8%, ureteral obstruction and/or bladder dysfunction (noncompliance) noted to be the cause of the hydronephrosis in approximately 1-2%. It is noteworthy that following injection of a bulking agent for treatment of VUR both a VCUG along with a renal ultrasound is recommended. DMSA scan is optional if additional febrile UTI’s should occur.
