2015 Flashcards
Seminal emission depends on an intact:
- parasympathetic and somatic nervous system
- sympathetic nervous system
- parasympathetic nervous system
- sympathetic and parasympathetic nervous system
- sympathetic and somatic nervous systems.
2
Emission is defined as the deposition of seminal fluid into the posterior urethra by the vasa deferentia and the seminal vesicles. Ejaculation is the forceful expulsion of seminal fluid out the urethral meatus by contraction of the bulbospongiosus and ischiocavernosus muscles. Since the vasa and the seminal vesicles are innervated primarily by the sympathetic nervous system, emission is under control of the sympathetic nervous system. Alpha-adrenergic nerve stimulation causes not only contraction of the seminal vesicles and vasa deferentia but also closure of the bladder neck. Ejaculation is the result of somatic nerve stimulation of the periurethral striated musculature. The parasympathetic nervous system is not directly involved with either emission or ejaculation.
After starting antimicrobials in healthy individuals with uncomplicated acute pyelonephritis, the urine is typically sterile within:
- a few hours
- twenty-four hours
- forty-eight hours
- three days
- seven days.
1
The urine usually becomes sterile within a few hours of starting antibiotics even though fever, chills, and flank pain may continue for several days. A delay in clearance of bacteria may occur with obstruction, stone disease, anatomic abnormalities or impaired renal function. Symptoms of pyelonephritis continuing for 72 hours after initiation of culture appropriate antibiotics should result in the physician considering the need for imaging studies and repeat cultures to rule-out anatomic abnormalities or the emergence of antibiotic resistant bacteria.
A 55-year-old woman with breast cancer has a 3.5 cm right adrenal nodule. The nodule has an attenuation of 25 Hounsfield units on non-contrast CT scan, 80% washout on contrast enhanced CT scan, and signal loss of 40% on chemical shift MRI scan. The lesion is a:
- lipid rich adenoma
- lipid poor adenoma
- myelolipoma
- breast cancer metastasis
- primary adrenal cancer.
2
In patients with a history of cancer found to have a > 2 cm adrenal mass on a CT scan, approximately 50% of the lesions will be due to a metastasis from the primary tumor. Through the use of CT and MRI manipulations, the indeterminate adrenal mass (classified as a mass 2-5 cm in size) can usually be accurately characterized without biopsy. Benign adrenal tumors, such as a myelolipoma or lipid rich adenoma will usually have non-contrast CT Hounsfield units of < 10. In an adrenal lesion with a CT Hounsfield value of > 10, differentiation of lipid poor adenomas from malignant lesions will require a CT study with contrast and washout, as well as chemical shift MRI scans for differentiation of a benign from a malignant mass. The common features of lipid poor benign adenoma are > 60% washout on CT scan with I.V. contrast while a malignant lesion will usually have a < 60% washout on CT scan. MRI findings consistent with a lipid poor benign adenoma is an adrenal to spleen ratio (ASR) of < 70% and signal loss of > 20% on out of phase imaging. Malignant lesions will display an ASR of > 70% and signal loss of < 20% on out of phase imaging.
A 54-year-old man with hypertension and a creatinine of 1.7 mg/dl is started on an ACE inhibitor. After two weeks, the creatinine is unchanged, but hypertension persists and a diuretic is added. One week later, the creatinine is 2.5 mg/dl (eGFR of 27 ml/min/1.73 m2). The next test is:
- split renal vein renin measurements
- contrast-enhanced MR angiography
- nonenhanced MR angiography
- contrast-enhanced CT angiography
- captopril renography.
3
Up to 10% of patients with HTN may have an element of renal vascular disease as the etiology of their rise in blood pressure. In patients with bilateral renal artery disease, HTN is largely a volume-dependent phenomenon with excess fluid volume protecting renal function. When diuretics are given to these patients, volume depletion occurs, with renal perfusion subsequently becoming angiotensin-dependent. The combination of diuretics and ACE inhibitors in a patient with bilateral renal artery stenosis will therefore result in the onset of renal insufficiency. Based on this knowledge, the use of the combination of ACE inhibitors with diuretics may be used as a provocative test to identify patients with bilateral ischemic (renal vascular) nephropathy. In essence, a finding of an elevation in serum creatinine within two to four weeks of starting the combination of a diuretic and an ACE inhibitor is highly suggestive of the presence of bilateral renal artery stenosis. Screening for renal artery stenosis in this clinical scenario is mandatory.Captopril enhanced testing is less accurate in the setting of renal insufficiency and is not the test of choice in patients associated with an elevation in serum creatinine. Renin-based testing is mainly utilized to determine the possible presence of renovascular-induced HTN, and is not indicated once bilateral ischemic nephropathy has been suspected to be present by a provocative test using a diuretic and an ACE inhibitor.The key evaluation in this patient is the anatomical assessment of the renal arteries to determine the possibility for vascular intervention. Imaging studies used to diagnose renal artery stenosis include ultrasound, contrast-enhanced CT angiography, and contrast-enhanced or nonenhanced magnetic resonance (MR) angiography. Although ultrasound is an effective screening tool, visualization of the entire renal artery to assess for interventional repair can be problematic. Contrast-enhanced CT and MR angiography can provide exquisite details of the renal arterial anatomy, and are highly accurate for determining both the diagnosis and extent of renal artery stenosis. However, the use of iodinated contrast for CT or the gadolinium-based contrast for MR angiography may be problematic for patients with renal dysfunction, eGFR < 30 ml/min/BSA. In these patients, the iodinated CT contrast may potentially cause further kidney injury, and the use of gadolinium-based contrast can lead to a condition called nephrogenic systemic fibrosis (fibrosis of the skin, joints, and internal organs) that will lead to significant morbidity or death. The preferred test of choice in a patient with an eGFR of < 30 ml/min/BSA under consideration for surgical intervention is the use of nonenhanced MR angiography.
A 25-year-old man has left scrotal pain after sustaining an injury playing soccer. The left testis is tender and enlarged on exam. Scrotal ultrasound reveals a 5cm hematocele, normal intraparenchymal blood flow, and a focal area of increased left testis echogenicity. The tunica albuginea cannot be fully visualized. The next step is:
- observation
- MRI scan of the scrotum
- repeat scrotal ultrasound in 48 hours
- obtain tumor markers
- scrotal exploration.
5
The patient has a 5 cm hematocele following blunt scrotal trauma with an indeterminate ultrasound examination. Significant hematoceles (5 cm or greater) should be explored, regardless of imaging studies, as up to 80% will be associated with a testicular rupture. The increased area of echogenicity does not infer tumor, and thus, tumor markers are not indicated. MRI will not add useful information.
A 55-year-old active woman desires surgical repair of a vaginal bulge. She has urinary frequency but no urinary or fecal incontinence. The physical examination with a cystoscope in the urethra is shown followed by a cystogram at maximal Valsalva taken during a videourodynamic study. The next step is:
- anterior (cystocele) repair with sling
- transvaginal vault suspension and anterior (cystocele) repair
- uterosacral vault suspension and rectocele repair
- robotic sacrocolpopexy
- robotic sacrocolpopexy and midurethral sling.
5
This patient has vaginal vault prolapse. The image from the videourodynamics study does not demonstrate a cystocele. The majority of physicians would recommend that this patient should undergo repair of the vault prolapse with a concurrent anti-incontinence procedure. The concurrent anti-incontinence procedure is performed due to the increased risk of de novo stress incontinence following vault suspension. In the context of a robotic sacrocolpopexy, a midurethral sling would be the most appropriate approach. Urodynamics, with or without prolapse reduction, are not predictive of which patients will develop de novo SUI following vault suspension. While acceptable to proceed with robotic sacrocolpopexy and no sling, the patient should be informed of the risk of postoperative stress incontinence. Some patients may prefer this approach due to the inherent risks of sling procedure, however rare they may be.
During the third trimester of pregnancy, the most common changes in renal function tests are:
- elevated BUN; decreased creatinine
- elevated BUN; elevated creatinine
- decreased BUN; decreased creatinine
- decreased BUN; elevated creatinine
- unchanged BUN and creatinine.
3
In pregnancy, it has been proposed that the increase in cardiac output leads to increase in glomerular filtration rate (GFR) and renal plasma flow. GFR increases between 30-50% as full term approaches. This increase in GFR leads to a decrease in the serum BUN and creatinine. Therefore, the normal values for BUN and creatinine are lower in pregnant women than they are in non-pregnant women.
A 28-year-old man has 1 proteinuria and moderate blood on two dipstick analyses. Two microscopic urinalyses each reveals 0-2 RBC/hpf. According to the AUA Guidelines, the next step is:
- reassurance and no further evaluation
- serum albumin level
- urine cytology
- 24-hour urine collection for protein
- cystoscopy and upper tract imaging.
4
Proteinuria of 1 or greater on repetitive dipstick urinalyses should prompt a 24-hour collection to quantitate the degree of proteinuria. In the absence of significant bleeding, > 1 g/24 hour should then prompt a more extensive evaluation for renal parenchymal disease and possible nephrology referral. This patient in fact does not meet criteria of microhematuria because the number of RBCs/hpf is < 3 thus further hematuria evaluation is not warranted. Mild proteinuria would be unlikely to affect serum albumin levels.
A 68-year-old man with ESRD has been on peritoneal dialysis for four years. He is anuric and asymptomatic. Ultrasound reveals several non-echogenic cysts involving the left kidney. The next step is:
- left nephrectomy
- CT scan
- renal arteriography
- repeat ultrasound in six months
- conversion to hemodialysis.
4
The overall prevalence of RCC in patients with ESRD is 1%. This risk is increased three-four fold in individuals with acquired renal cystic disease of dialysis (ARCD). The onset of ARCD is directly related to the severity of azotemia and the length of time the individual has been on dialysis. RCC in patients with ESRD generally occurs within ten years of the initiation of dialysis. They are multicentric, bilateral, less aggressive than sporadic RCC, and have a male predominance. Both hemodialysis and peritoneal dialysis have been associated with an equivalent incidence of ARCD, and there is no evidence that conversion from one form of dialysis to another influences this disease. For this reason, periodic ultrasound is recommended every six months for patients on chronic dialysis for > 3 years. In this patient population it is appropriate to consider CT, MRI scan, or proceed directly to surgical intervention when the ultrasound suggests a complex cyst or a solid mass > 3 cm.
A 55-year-old man is scheduled to undergo TRUS-guided prostate biopsies. He has a severe allergy to ciprofloxacin. The best antibiotic regimen is:
- trimethoprim and sulfamethoxazole orally twice daily for three days
- cefuroxime 500 mg orally twice daily for three days
- levofloxacin 500 mg orally once daily for three days
- gentamicin 5 mg/kg IV 30 minutes prior to the biopsy
- ceftriaxone 1 gm I.V. 30 minutes prior to the biopsy.
5
TRUS and biopsy is one of the most common urologic procedures. Antibiotic prophylaxis is well-established as reducing infection after the procedure. The AUA Best Practice Statement on Antimicrobial Prophylaxis states that the only oral agent approved for TRUS and biopsy prophylaxis is an oral fluoroquinolone. Alternatives are an I.V. 1st, 2nd or 3d generation cephalosporin or aminoglycoside plus metronidazole or clindamycin. Septra and oral cefuroxime are incorrect because of the oral route of administration. Levofloxacin is incorrect since the patient had a severe ciprofloxacin allergy, so other fluoroquinolones should be avoided unless tolerance testing is performed. Gentamicin without metronidazole or clindamycin is also incorrect.
A 78-year-old woman with history of anaphylactic reaction to penicillin, renal insufficiency (Cr 2.3) has right-sided flank pain and high fever. Recent culture revealed E. coli with sensitivity to nitrofurantoin, gentamicin, ceftriaxone, and intermediate sensitivity to ciprofloxacin. The next step is to admit her to the hospital and start:
- ciprofloxacin
- gentamicin
- imipenem
- ceftriaxone with diphenhydramine and hydrocortisone
- ciprofloxacin and nitrofurantoin.
2
Aminoglycosides remain a mainstay of treatment for life-threatening gram negative infections. The risk of nephrotoxicity is increased in the elderly, diabetics, and in patients with pre-existing renal insufficiency. However, the acuity of this patient’s pyelonephritis makes those considerations secondary. Cephalosporins and beta-lactam antibiotics (imipenem) are generally contraindicated with a history of anaphylactic reaction to penicillin, even though the absolute risk of severe reaction appears to be quite low. There is no evidence that pre-treatment with diphenhydramine and hydrocortisone would further reduce this risk. Ciprofloxacin is not an ideal choice because the organism exhibits only intermediate sensitivity and antibiotic concentrations in the urine are lower in a kidney with markedly diminished function. Nitrofurantoin is only active in the urine and is not appropriate for the treatment of tissue infections.
A 17-year-old boy has a left radical orchiectomy for a pathologic T2 5 cm tumor, which is 70% embryonal cancer and 30% teratoma. He has a 2 cm para-aortic adenopathy and no other visible metastases. His initial markers show an AFP of 7,000 IU/ml and a normal beta-hCG. Two weeks later, his beta-hCG is normal and his AFP is 5,000 IU/ml. The next step is:
- repeat tumor markers in two weeks
- three cycles BEP
- four cycles etoposide and cisplatin
- four cycles of BEP
- RPLND.
4 T
his patient has T2N2M0S2 NSGCT, also categorized as clinical stage 2B. The standard treatment should be primary chemotherapy. The selection of chemotherapy regimen depends on the International Germ Cell Cancer Collaborative Group Risk Classification for Advanced Germ Cell Tumor (IGCCG) that includes location of primary tumor, metastases and tumor marker levels. This patient is considered intermediate risk based on the post orchiectomy AFP over 1,000 IU/ml, and all intermediate and high risk patients should receive four cycles of BEP.
A 46-year-old woman sustained a ureteral injury during an abdominal hysterectomy for fibroids six weeks ago. A left percutaneous nephrostomy tube was placed. A retrograde ureterogram and an antegrade pyeloureterogram are shown. The next step is:
- balloon dilation
- endoureterotomy
- ureteroureterostomy
- ureteral reimplant with psoas hitch
- ureteral reimplant with Boari flap.
4
The retrograde and antegrade studies show a complete obstruction of the left distal ureter at the level of the uterine vessels. Most likely, the ureter was divided during clamping of the left uterine vascular pedicle or a thermal injury was sustained. The high grade obstruction (no contrast goes through the obstruction with both retro and antegrade injections) demonstrated makes the success of an endoscopic approach unlikely. Ureteroureterostomy is not a good option in the distal ureter, and should be reserved for short mid- to upper ureteral defects. The best repair for this patient is a ureteral reimplant with a psoas hitch. A Boari flap is not necessary in this patient and is reserved for lengthy distal ureteral defects up to 15 cm long.
A 58-year-old man develops abdominal pain and fever to 101°F three days after left radical nephrectomy. He is treated with I.V. antibiotics. The next day, the previously dry incision leaks 100 ml of cloudy fluid (pH 9.5, amylase 8,000 U/l). CT scan shows a 5 cm fluid collection in the left renal fossa. The next step is a naso-gastric tube and:
- low triglyceride diet
- percutaneous drainage and TPN
- open surgical drainage
- open ligation of fistula site and drainage
- distal pancreatectomy and drainage.
2
A particularly distressing postoperative complication following radical nephrectomy is the development of a pancreatic fistula because of an unrecognized intraoperative injury to the pancreas. This is usually manifested in the immediate postoperative period with signs and symptoms of acute pancreatitis and drainage of alkaline fluid from the incision. A CT scan of the abdomen demonstrates a fluid collection in the retroperitoneum. Fluid draining from the incision should be analyzed for pH and the presence of amylase. Treatment involves percutaneous drainage of the pseudocyst or abscess. The majority of fistulae close spontaneously with the establishment of adequate drainage. Because the healing of a pancreatic fistula is usually a slow process associated with significant nutritional loss, the patient is also supported with hyperalimentation. Surgical treatment with resection of the distal pancreas is necessary if nonoperative management fails. Open surgical drainage or ligation of the fistula would not be indicated and/or considered the treatment of choice. A low triglyceride diet would be indicated for a lymphatic leak.
Cystine calculi can be diagnosed with the following test:
- sodium nitroprusside
- phenolphthalein
- thiazide challenge
- serum pH
- serum chloride.
1
The sodium nitroprusside spot test will turn urine purple in the presence of cystine. This test is used for screening purposes to identify patients with cystine stone disease who are undergoing a 24 hour urine collection for evaluation. Phenolphthalein is a urinary marker for laxative abuse and may be helpful in the diagnosis of ammonium acid urate stones. A thiazide challenge may be helpful in the diagnosis of hyperparathyroidism. Serum pH and serum chloride may be helpful in the diagnosis of RTA type I.
A 54-year-old man has a muscle invasive urothelial carcinoma on TURBT. The preoperative CT scan shows loss of the fat plane on the right side of the bladder. The next step is:
- PET scan
- MRI scan
- neoadjuvant chemotherapy
- XRT
- cystectomy.
3
This patient most likely has T3 or T4 disease based on this CT scan. For T2 to T4 disease, large prospective randomized trials and meta-analyses have demonstrated that outcomes are better in patients who receive neoadjuvant chemotherapy prior to surgery rather than surgery alone. There is no evidence that MRI is significantly better at determining whether there is organ confined disease than a CT scan. In addition, with a CT scan that is fairly unequivocal there is no benefit from additional local imaging.
The renal toxicity of intravenous contrast material is due to:
- glomerular injury
- afferent arteriolar constriction
- efferent arteriolar constriction
- intrarenal vasoconstriction and tubular necrosis
- efferent arteriolar dilation and tubular necrosis.
4
Contrast media accounts for 10% of all causes of hospital-acquired acute renal injury. Three key risk factors that may provoke this injury are: pre-existing renal dysfunction (serum creatinine > 1.6 mg/dl or eGFR < 60 ml/min/BSA), pre-existing diabetes, and reduced intravascular blood volume. Contrast agents evoke renal injury by two mechanisms: first, by acting as an intrarenal vasoconstricting agent resulting in decreased intrarenal blood flow and hypoxemia; second, by a direct toxic effect of the contrast agent on tubular epithelial cells. The combination of renal medullary ischemia and direct cellular toxicity leads to increased renal epithelial cell apoptosis and acute tubular necrosis. The osmolality of the contrast agent once believed to be of paramount importance in the induction of contrast-induced nephropathy has been shown to play a minimal role in contrast-induced nephropathy. Indeed, recent studies have found that viscosity of the contrast agent is more important than osmolality. These findings resulted in the recommendation that periprocedural hydration along with limiting the amount of contrast agent are the key to prevent contrast-induced renal failure. A recent meta-analysis to evaluate the various interventions employed for prevention of this complication, assessing sodium bicarbonate solutions, adenosine antagonists (theophylline), N-acetylcysteine and ascorbic acid noted mixed results with no definitive proof that these agents could prevent the complication. Randomized control studies have, however, shown that in patients with a creatinine of > 3.5 mg/dl prophylactic hemodialysis prior to and following the study can reduce the risk of this complication.
A 38-year old man is referred for prostate cancer screening. According to the AUA Guidelines, the next step is:
- advise against screening
- initiate yearly screening
- initiate yearly screening if positive family history or African American
- initiate biennial screening
- screen now and repeat in five years.
1
According to the EARLY DETECTION OF PROSTATE CANCER: AUA GUIDELINES, guideline statement number 1 states that the panel recommends against screening in all men under age 40. In this age group, there is a low prevalence of clinically detectable prostate cancer. There is no evidence to demonstrate a benefit of screening, and there are likely the same harms of screening as in other age groups. This recommendation holds even for African-Americans or those with a family history of prostate cancer. The panel does state that to reduce the harms of screening, a routine screening interval of two years (biennial screening) or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening (Guideline statement 4). As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over-diagnosis and false positives. However, in this patient population, no screening is recommended. Some authors have put forth the strategy of initial screening and then follow-up in five years. Although such strategies may help reduce over-diagnoses and better select men who are likely to be true positives, this approach has not been well-validated and accepted by the AUA Guidelines.
A 67-year-old man has a rectourethral fistula one year after cryotherapy for localized prostate cancer. An initial fulguration failed and six months ago, he underwent proximal colostomy and suprapubic tube placement. He continues to have urine leakage per rectum and recurrent UTIs. Biopsy of the prostate shows no cancer and serum PSA is 0.3 ng/ml. The best therapy is:
- pelvic exoneration
- transabdominal repair
- urinary diversion
- salvage prostatectomy
- York Mason transrectal, transsphincteric repair.
5
A rectourethral fistula is relatively low in the pelvis and is best managed by the posterior-transanal repair (York-Mason) approach, in which the posterior anal sphincter is split to provide good exposure of the anterior rectal wall. The fistula site can then be excised with a multilayer closure. A transabdominal repair is difficult in this setting due the location deep within the pelvis, and this type of fistula is better repaired through the posterior-transanal approach. A urinary diversion may need to be considered, but only if attempts for primary repair have failed. This patient’s PSA is <0.5 and he is likely to stay cancer free, so salvage prostatectomy or pelvic exoneration should not be considered.
A 76-year-old man with insulin dependent diabetes returns six years after artificial urinary sphincter (AUS) placement with difficulty emptying his bladder despite appropriate action of his control pump. Examination reveals perineal induration without fluctuance or tenderness. Urinalysis is normal and PVR is 250 cc. Urodynamics reveals low pressure voiding with incomplete emptying. Urethroscopy shows no evidence of erosion. The next step is:
- ciprofloxacin
- deactivate cuff
- initiate CIC
- pelvic CT scan
- remove AUS.
5
For late-onset urinary retention found in patients with an AUS in situ, endoscopic and urodynamic evaluation is required to identify urethral erosion, proximal obstruction, or the development of detrusor failure.In this case, obstructive voiding symptoms, an abnormal physical examination with a normal endoscopic and complete urodynamic evaluation are highly consistent with periprosthetic infection without urethral erosion, secondary pericuff edema resulting in the obstructive symptoms. Late infections of AUS are usually due to gram positive cocci (S. aureus or S. epidermidis). Treatment with ciprofloxacin will not clear the infection due to bacterial adherence to the biofilm of the AUS. In addition, in this patient with diabetes, the local infection could quickly escalate resulting in widespread cellulitis and Fournier’s gangrene. Removal of the AUS with appropriate cultures and, if indicated, salvage AUS replacement should be considered.Cuff deactivation will not prevent retention unless the patient is incapable of using the device. CIC will not treat the underlying problem, which remains undiagnosed. A pelvic CT scan may define inflammation around the device; however, a negative CT scan does not indicate absence of infection and, therefore, cannot be relied upon. Cuff size is not likely to influence voiding status except in the immediate postoperative period when, if retention occurs, cuff upsizing may be necessary. In this patient with a long history of an AUS, sub cuff atrophy is more likely.
In a testicular cancer patient, positron emission tomography (PET):
- has decreased sensitivity due to high cell turnover of germ cell tumors
- is most useful at the time of initial diagnosis
- is most useful in patients with lung nodules
- has good sensitivity for post-chemotherapy seminomas
- can distinguish teratoma versus fibrosis.
4
Malignant GCT accumulates fluorodeoxyglucose (FDG), and several studies have investigated FDG-labeled positron emission tomography (FDG-PET) in the staging of GCT at diagnosis and assessing response after chemotherapy. The high sensitivity is likely due to the high turnover and increased metabolic rate of GCTs. Due to limited sensitivity at the time of initial diagnosis, there is currently no role for FDG-PET in the routine evaluation of NSGCT and seminoma at the time of diagnosis. However, there may be a role for detection of recurrent disease and the assessment of residual masses after chemotherapy. For example, PET does appear to be a useful tool in seminoma patients when evaluating post-chemotherapy residual masses. In a series of seminoma patients who were evaluated post-chemotherapy for residual retroperitoneal masses, PET was accurate in 14/14 patients with tumors > 3 cm and in 22/23 patients with lesions < 3 cm. Overall, the sensitivity and specificity was 89% and 100%, respectively. The utility of FDG-PET in the prediction of retroperitoneal histology in NSGCT (particularly in the post-chemotherapy setting) is limited by the fact that teratoma is not FDG avid (likely due to the relatively low metabolic rate of teratomas). This likely accounts for the high false negative rates observed. Similarly, the utility of PET scanning in the immediate post-chemotherapy period appears to be limited. This is likely due to decreased metabolism and increased macrophage activity at that time, which compromises the accuracy of PET scanning. It is recommended that PET/CT be delayed for four to 12 weeks following completion of chemotherapy. There is no difference between abdominal and thoracic imaging using a PET scan in this setting.
A 62-year-old man develops penile pain three months after implantation of an inflatable penile prosthesis. He denies fever or chills. The prosthesis is functional and in excellent position. Tenderness is localized to the left corpus. WBC count and urinalysis are normal. The most likely cause of the penile pain is:
- oversized cylinder
- prosthetic erosion
- corporal fibrosis
- staphylococcal infection
- psychogenic.
4
Prosthetic infections occur in 1-3% of patients following inflatable penile implants with antibiotic coating, and usually occur within the first three months of implantation. The most common organism is staphylococcus, and infection occurs at the time of implantation. Pain without WBC count elevation or increase in erythrocyte sedimentation rate is common. The increasing nature of the pain is not consistent with post-operative pain or pain from a traumatic event. Prosthetic erosion would be apparent on physical exam. Corporal fibrosis is an uncommon late complication of penile prosthesis. An oversized cylinder is associated with buckling and pain with prosthetic inflation.
A 55-year-old man with a history of chronic bacterial prostatitis experiences urosepsis during induction chemotherapy for small cell lung cancer. Urine culture is positive for E. coli resistant to trimethoprim/sulfamethoxazole and ciprofloxacin; sensitive to nitrofurantoin, tobramycin, amikacin, and meropenem. Thorough urologic evaluation is normal except for documented persistence of the bacteria in the expressed prostatic secretions following a ten day course of I.V. meropenem. The next step is:
- observation
- nightly prophylaxis with oral nitrofurantoin
- daily intravesical tobramycin instillation
- IV tobramycin for six to eight weeks
- TURP.
2
Observation places the patient at risk of recurrent urosepsis. This can be prevented by continued nitrofurantoin prophylaxis which will prevent recurrent cystitis and symptomatic infection. I.V. tobramycin achieves poor penetration of the prostate and is unlikely to eradicate infection. Tobramycin instillations would be effective but are more invasive than oral prophylaxis. TURP would be inappropriate in this patient.
A 61-year-old woman underwent percutaneous cryoablation of a 2.4 cm renal mass one year ago. On follow-up imaging, the mass now measures 3 cm with some nodularity within the treatment zone. According to the AUA Guidelines, the next step is:
- repeat imaging in six months
- repeat imaging in one year
- PET scan
- percutaneous biopsy
- repeat cryoablation.
4
There is little long-term data on the cancer control of ablative procedures. Additionally, there is a well-recognized slow natural history of RCC in terms of growth rate. Thus, if imaging findings reveal increasing size, new nodularity, satellite lesions or failure of the treated lesion to regress over time even in the absence of enhancement, then the next step should be lesion biopsy. These findings would be concerning enough to warrant an intervention rather than routine imaging in 6-12 months. There is no data to support the routine use of PET scanning in the evaluation or follow-up of patients with small renal neoplasms, although ongoing studies with newer imaging agents are underway. Repeat ablation with no biopsy is also not indicated.
Two months following closure of a traumatic bladder rupture associated with a pelvic fracture, a 20-year-old man has persistent urinary leakage through the suprapubic cystostomy site despite voiding. The diagnostic test most likely to diagnose the etiology of the problem is:
- CT urogram
- pelvic MRI scan
- fistulogram
- cystourethroscopy
- urodynamics.
4
When faced with a patient with a persistent urinary fistula, the acronym FETID will aid the physician in determining its etiology and hence management plans: F- Foreign Body, E- Epithelization of the fistula tract, T- Tumor or chronic trauma causing persistence, I-Infection or chronic inflammation arising from inflammatory bowel disease, radiation therapy, etc. D-Distal obstruction. In this young patient with a history of persistent fistula, following closure of a bladder rupture after a pelvic fracture, persistent drainage from a suprapubic tube site is most likely from either a foreign body within the bladder, i.e., bony spicule or bladder calculi formed as a nidus from the prior indwelling suprapubic tube or bladder outlet obstruction arising from either a bladder neck contracture or urethral stricture. The single best diagnostic study is cystourethroscopy. Pressure flow urodynamic studies could demonstrate findings consistent with high pressure voiding and outlet obstruction. But the source of the obstruction, which is likely a urethral stricture or a bladder neck contracture, would not be able to be determined by this test and this test does not rule-out the possibility of a foreign body within the bladder. A CT scan may allow one to visualize either a foreign body or bladder calculi to be present, but would not be able to assess the urinary outlet. Similarly, a fistulogram or pelvic MRI scan are unlikely to yield adequate diagnostic information in this situation to result in definitive operative plans.
Two days after PCNL, a patient is febrile with abdominal pain, rebound, and guarding. A nephrostogram via the nephrostomy tube opacifies the colon and the renal pelvis. The next step is antibiotics and:
- withdraw the nephrostomy tube into the colon
- remove nephrostomy tube and place ureteral stent
- withdraw the nephrostomy tube into the colon and place a ureteral stent
- withdraw the nephrostomy tube into the colon and place another nephrostomy tube into the kidney
- abdominal exploration, diverting colostomy, nephrostomy tube.
5
The patient has peritoneal signs, which dictate exploration and intestinal diversion. If the patient did not have peritoneal signs, then repositioning the tube in the colonic lumen and placing a ureteral stent would be an optimal approach to prevent a nephrocolonic fistula.
The use of µ-opioid receptor antagonists after radical cystectomy and urinary diversion is associated with:
- increased cardiac events
- reduced opioid consumption
- reduced length of stay
- increased hospitalization costs
- reduced early readmission for post-operative ileus.
3
Alvimopan, a peripherally acting µ-opioid receptor antagonist, is indicated to accelerate upper and lower GI recovery following surgeries that include a bowel resection. In October 2013, the U.S. Food and Drug Administration (FDA) authorized an expanded indication on the basis of a Phase 4 randomized multicenter clinical trial. In this trial, patients receiving alvimopan experienced more rapid bowel recovery and had a shorter hospital stay compared with those who received placebo. There were no differences with regard to early (< 7 day) post-op ileus (POI) or 30-day all cause readmission rates between the two groups. Alvimopan has been associated with the potential for increased cardiac toxicity in patients with chronic narcotic use, and is therefore contraindicated in this patient population. In the aforementioned trial, such patients were excluded, and there were no differences in cardiac adverse events between the alvimopan and placebo groups. In a preplanned economic analysis of this study, alvimopan use decreased hospitalization costs by reducing health care services associated with POI and decreasing hospital length of stay; total costs were $2,640 lower per patient for alvimopan compared with placebo. The study did not address opiate consumption, but it is unlikely that a µ-opioid receptor antagonist should affect opioid intake. Instead, it would be expected to affect the peripheral effects of opioids on bowel motility.
A 45-year-old woman has recurrent episodes of graft pyelonephritis following a kidney transplantation two years previously. She denies voiding symptoms when she is infection-free. Her renal function is normal and cystogram reveals reflux into the transplanted kidney. Urodynamics are shown. The next step is:
- oxybutynin
- mirabegron
- suppressive antibiotics
- non-refluxing ureteral reimplant
- decrease immunosuppression dose.
3
There is no consensus as to whether transplanted ureters should be reimplanted into a recipient’s native bladder with an antirefluxing technique. However, there is certainly a concern that reflux of infected urine and/or reflux associated with elevated detrusor pressures can be damaging to the transplanted kidney. This patient does not have any LUTS and there is no evidence of elevated storage pressures on her urodynamic study (i.e., no detrusor overactivity and normal compliance); thus, there is no reason to initiate therapy for OAB with either oxybutynin or mirabegron. She does abdominally recruit with some degree of Valsalva voiding at the end of her micturition, but that is unlikely related to bladder infections or pyelonephritis because she empties effectively. Decreasing her immunosuppression would not address the issue of her infections, would not minimize risk of future episodes of pyelonephritis, and would only place the kidney at possible risk for rejection. Low dose suppressive antibiotic therapy would be the appropriate next step to minimize future episodes of pyelonephritis. If this is not effective then revision of her ureteral reimplant with a non-refluxing neocystostomy should be considered.
The best treatment for a symptomatic 1.5 cm proximal ureteral stone is:
- medical expulsive therapy
- in situ SWL
- stent placement and SWL
- ureteroscopy and laser lithotripsy
- percutaneous stone removal.
4
The option with the best stone-free rate for larger ureteral stones is ureteroscopy. While SWL is acceptable, the best option is ureteroscopy for stones > 1 cm according to the data extracted in the AUA/EAU Ureteral Stone Guidelines. A stone this large would likely not pass. Percutaneous stone removal would be definitive, but should only be considered when the patient already has a pre-existing nephrostomy tube or has failed a retrograde ureteroscopic approach or SWL.
Compared to typical prostate adenocarcinoma, prostatic ductal adenocarcinoma often exhibits:
- less aggressiveness and lower PSA
- abnormal DRE and higher PSA
- increased sensitivity to radiation
- more aggressiveness and more frequent obstructive symptoms
- should be treated with neoadjuvant systemic chemotherapy.
4
Prostatic duct adenocarcinomas arise in the periurethral prostatic ducts, and usually grow as an exophytic lesion in the urethra. They can give rise to either hematuria or obstructive symptoms, and often both are present. These tumors are often underestimated clinically because serum PSA levels and DRE are often normal. Consequently, many ductal adenocarcinomas are at an advanced stage at presentation and have an aggressive course. They are graded as 44=8 because of their cribriform morphologic features. These tumors should be treated aggressively and approached surgically. There is no indication that ductal adenocarcinomas are more sensitive to radiation, and similarly, chemotherapy is not indicated in this situation.
A 68-year-old woman with a history of a lengthy ureteral stricture developing following pelvic surgery and radiation therapy is managed with a chronic indwelling ureteral stent. At the time of stent exchange, she develops profuse bright red blood per ureteral orifice that stops within five minutes of stent placement, the next step is:
- observation and stent exchange in three months
- placement of nephrostomy tube and removal of the ureteral stent
- radiologic placement of an endovascular stent
- oversewing of arterial fistula, ureteroureterostomy, omental wrap around the ureter, and extraperitoneal lateralization of the ureter
- vascular bypass procedure and nephrostomy tube placement.
3
Arterioureteral fistula (AUF) is a rare but acute condition that predominantly affects women (> 70%) with a wide time range between the initial placement of the ureteral stent to fistulization, ranging from 2 to 25 years. Factors that should raise suspicion of an AUF include history of hematuria in a patient with indwelling ureteral stents especially in patients with a past medical history of prior abdominal or pelvic irradiation, pelvic surgery or aortoiliac or aortofemoral grafts. Although 55% of patients will present with a history of persistent gross hematuria plus or minus shock, 45% of patients present with herald bleeding (gross hematuria occurring from the ureteral orifice during a ureteral stent exchange.) When herald bleeding occurs as in the patient in this question, treatment should be pursued to prevent a possible exsanguinating emergent fistula complication. The diagnostic goal in these patients is to identify the specific location of the fistula. In patients with bilateral indwelling stents, the side in which the gross hematuria is found is helpful for locating the side involved but is nonspecific in nature. Computed tomographic angiography will document the location in < 40% of patients. However, it may be useful because it can identify a concurrent periarterial abscess, aneurysmal enteric communication, aneurysmal dilation, significant arterial calcification, and concomitant thrombus. Diagnostic provocative angiography with selective iliac views remains the gold standard and is 90% diagnostic. Provocative angiography will require exchange of the double-J ureteral stent for a straight ureteral catheter. This will allow the interventionalist the ability to manipulate the ureteral stent at time of angiography to induce bleeding and identify the site and location of the fistula. While exchanging the stent, it is imperative not to lose access to the ureter; this procedure is best done in an endovascular suite with an operative team immediately available. It should be noted that a minority of patients, 10% will be empirically treated for an AUF without identification of the exact AUF location. These individuals will have a history of herald hematuria with predisposing factors for AUF and no other identifiable source of urinary bleeding. Prior studies have documented that once the AUF has developed, simple removal of the stent is inadequate for fistula closure. Previously, open repair of the fistula (often with vascular bypass procedure of the affected vessel and percutaneous nephrostomy tube placement) was the standard therapy. However, recent advances in endovascular stents have made this the least morbid procedure and the best initial therapeutic option. It is noteworthy that after placement of an endovascular graft, greater than 60% of the patients are still treated by chronic ureteral stent drainage along with chronic antibiotic prophylaxis, while the remaining 40% are managed by either permeant ipsilateral nephrostomy tube drainage or nephrectomy.
A 32-year-old anorexic woman with a history of seizures has recurrent urolithiasis. On a 24 hour urine, pH is 7.0 and urinary citrate is 45 (normal > 450 mg/day) The medication responsible for her stone disease is:
- indinavir
- guaifenesin
- carbamazepine
- topiramate
- ephedrine.
4
Drug-induced renal calculi represent 1-2% of all renal calculi. They include two categories: those resulting from the urinary crystallization of a highly excreted, poorly soluble drug or drug metabolite, and those due to the metabolic effects of a drug. Four drugs that can induce calculi through precipitation of the medication or its metabolite include: 1) Indinavir, a protease inhibitor used to treat HIV infections, 2) Magnesium Trisilicate, an antacid used to treat gastroesophageal reflux, 3) Triamterene, a potassium sparing diuretic used to treat edema and HTN, 4) Ephedrine used in a variety of nutritional or energy supplements for its stimulant properties, can when used alone or in combination with guaifenesin, the combination used as an expectorant, induce calculi containing either ephedrine, or both ephedrine and guaifenesin. Five commonly used medications may induce physiologic changes that can lead to metabolic abnormalities that facilitate the formation of calculi these include: 1) Loop diuretics (Furosemide, Lasix), it is noteworthy that up to two thirds of low-birth-weight infants who have received furosemide therapy will develop precipitation of calcium crystals, 2) Carbonic anhydrase inhibitors, drugs such as acetazolamide (Diamox), used to treat glaucoma, altitude sickness, and epilepsy, and 3) topiramate (Topamax), an anticonvulsant medication used to treat refractory seizures, can produce severe hypocitraturia and high urinary pH, and will induce calcium phosphate calculi in up to 2% of patients on long-term therapy, 4) Zonisamide (Zonegran), a sulfonamide anticonvulsant will result in the formation of calcium phosphate calculi in 4% of the patients on this mediation, 5) potential laxative abuse should be considered when ammonium acid urate calculi are found in the absence of UTI or bowl disease. Carbamazepine (Tegretol) used to treat seizure disorders, nerve pain and bipolar disorder is not known to be associated with urolithiasis.
A 66-year-old man undergoes a radical cystectomy and ileal conduit for pT2N0 urothelial carcinoma of the bladder. Final pathology demonstrates CIS at the right ureteral margin. The next step is:
- surveillance
- brush biopsy of ureteral anastomosis
- BCG via nephrostomy tube
- distal ureterectomy and reimplantation
- nephroureterectomy.
1
Every reasonable effort should be made to obtain a negative proximal margin before re-implantation when a frank tumor is encountered at the margin. However, the findings of CIS at the ureteral margin (either at the time of frozen section or on final pathology) is more uncertain. The group at Memorial Sloan Kettering has questioned the value of achieving a negative margin because this did not alter the risk of development of subsequent upper tract tumor and CIS of the ureter is not independently associated with a worse outcome following cystectomy. Cancer recurrence at the anastomosis is rare even with a positive margin showing CIS, but a positive margin is a risk factor for developing a second primary tumor of the ureter or renal pelvis. Schumacher and colleagues demonstrated that upper tract recurrences occur in 3% to 5% of patients, and they are usually at sites distant from the anastomosis. However, they found no correlation between frozen and permanent section findings in their cohort.Accordingly, the data would suggest that patients with CIS at the ureteral margin may have a mildly increased risk of an upper tract recurrence (often remote from the margin, either on the ipsilateral or contralateral side). As a result, such patients (like all patients with invasive bladder cancer) require close follow-up with upper tract surveillance. Although the most commonly performed method of upper tract surveillance is with imaging (e.g., CT urogram), the most sensitive means involves surveillance ureteroscopy, and this can be used in patients with a very high degree of suspicion for upper tract recurrence. The median time to occurrence in one recent series was 53 months. Pre-emptive antegrade brush biopsy is not indicated at this time in the absence of obstruction or other abnormalities in imaging. BCG is also not indicated, as the finding of CIS at the margin only suggests a slightly increased incidence of recurrence, and often this recurrence is at a location remote from the margin site. Similarly, pre-emptive re-implantation or ipsilateral nephroureterectomy are not indicated or warranted as most patients will not have a local recurrence or ipsilateral upper tract recurrence.
A 57-year-old man develops fever, nausea, and increasing abdominal pain seven days following a laparoscopic nephrectomy. Despite bowel rest and antibiotics, he develops worsening symptoms. A KUB reveals free air in the abdominal cavity with dilated loops of small bowel. The next step is:
- abdominal ultrasound
- barium enema
- CT scan of the abdomen with IV contrast
- CT scan of the abdomen with oral contrast
- immediate surgical exploration.
4
During laparoscopic surgery, electrosurgically induced thermal injury may occur via one of four mechanisms: inappropriate direct activation, coupling to another instrument, capacitive coupling, and insulation failure. Intraoperatively, thermal injuries of the bowel may present as whitish spots on the serosal lining. In severe cases, the muscularis mucosae or the intestinal lumen may be seen. However, in many patients, thermal injury of the bowel is not realized at the time of the procedure. Postoperatively, the patient with unrecognized bowel trauma may not develop fever, nausea, or signs of peritonitis for three to seven days; the full extent of the bowel necrosis may take up to 18 days to fully develop. Therefore, the problem often does not become manifest until the patient has been discharged. Accordingly, bowel injury must be ruled-out for any patient who develops a fever beyond postoperative day one or who complains of increasing abdominal discomfort. Abdominal radiographs are notoriously inaccurate because the carbon dioxide from the laparoscopy may remain as free air for more than two weeks after the procedure; however, an ileus pattern is usually present. An abdominal ultrasound will similarly be nonspecific and may detect loops of bowel or free fluid. The more sensitive test is an abdominal CT scan with oral contrast and delayed films. Minor postoperative thermal injuries of the bowel may be managed conservatively, aided by administration of antibiotics and an elemental diet. However, if the patient does not respond rapidly or develops worsening peritonitis, open surgical exploration is mandatory. Thermal injury caused by monopolar cautery often results in tissue damage that extends beyond the visible area of necrosis. With this in mind, the surgeon should perform a bowel resection with a safety margin of 6 cm on either side before completing an end-to-end anastomosis. Thermal injury caused by bipolar electrosurgery is more confined to the visible area of damage; thus, if the injury is small, it can be managed by simple excision of the defect and closure of the bowel wall. Injuries that involve more than half of the circumference of the bowel should be treated by excision of the affected bowel segment and end-to-end anastomosis.
The most important benefit of using 60 versus 120 shocks per minute for SWL of a 9 mm proximal ureteral stone is:
- reduced number of shocks
- reduced renal damage
- reduced anesthetic requirement
- reduced steinstrasse rate
- reduced retreatment rate.
5
Decreasing the rate of shock wave administration from 120 to 60 shocks per minute results in improved stone-free rates. A slower treatment rate of proximal ureteral stones reduces the need for additional SWL or more invasive treatments to render patients stone-free without any increase in morbidity and with an acceptable increase in treatment time. The hypothesized mechanism of this effect is due to the formation of cavitation bubble cloud around the stone, which may shield the stone from subsequent shock waves. This effect is most pronounced at higher shock wave frequency.
A 52-year-old woman has an incidentally-detected right renal lesion on triphasic CT scan. The lesion is classified as complex due to a few hairline septae with fine calcifications noted within the wall, Hounsfield units of 8 is noted. The next step is:
- no follow-up necessary
- ultrasound in six months
- CT scan in six months
- CT scan in one year
- biopsy or fine needle aspiration of lesion.
1
Bosniak classifications of renal cysts are:1) Simple hairline thin cyst wall, Hounsfield units < 102) Simple hairline thin cyst wall, few hairline thin septa within cyst, short, thin areas of calcification maybe present, septa and wall do not enhance, Hounsfield units < 10. The patient described in the question has a Bosniak 2 cyst. No follow-up evaluation is indicated for a class 1 or 2 Bosniak cyst.2F) Thickened cyst wall, multiple septa that may be thickened or contain calcium, Hounsfield units of 10-15 no significant enhancement with contrast. Follow-up is indicated due to an increased risk of malignancy (5-10%). These cysts should therefore undergo periodic surveillance with no set time limit; evaluations every 6-12 months have been purposed. Biopsy is not indicated due to poor reliability in sampling areas of concern.3) Cystic mass with thickened wall, thick irregular septum, cyst wall or septa enhance with contrast, Hounsfield units >15.4) Cystic mass with thickened wall, thick irregular septum, cyst wall, septa, and areas within cyst, not associated with the wall or septa enhance, Hounsfield units >15.Both Bosniak 3 and 4 cysts should at a minimum be considered for a biopsy or alternatively surgical excision.
A 68-year-old man with bothersome voiding dysfunction completes a voiding diary revealing 12 voids in 24 hours with volumes ranging from 30 ml to 150 ml, nocturia x 3, and one episode of incontinence. PVR is 50 ml. Uroflowmetry reveals a flattened pattern with a peak flow of 6 ml/sec. His condition is best described as:
- BPH
- benign prostatic obstruction
- detrusor overactivity
- detrusor underactivity
- LUTS.
5
BPH is a histological diagnosis. This patient has not had a biopsy. Benign prostatic obstruction is a urodynamic diagnosis made on the basis of the relationship between pressure and flow. The poor flow rate in this case may be due to either detrusor underactivity or bladder outlet obstruction and is not diagnostic of either entity. Detrusor overactivity and detrusor underactivity are urodynamic diagnoses that cannot be made in the absence of a urodynamic study. LUTS is a generic term describing LUTS and does not imply an underlying pathology or pathophysiology.
According to the AUA Guidelines, a patient with progressive metastatic castrate resistant prostate cancer having pain controlled with acetaminophen should be offered treatment with:
- observation
- sipuleucel-T
- cabazitaxel
- radium-223
- mitoxantrone.
2
The patient presented here is Index Patient 2 of the AUA Guidelines and should be considered for sipuleucel-T immunotherapy. This patient is only minimally symptomatic (not requiring narcotics) and thus is a candidate for sipuleucel-T, which has demonstrated a survival advantage in this patient population. Abiraterone acetate is also an option but is not listed here. The other treatment options are not appropriate for Index Patient 2. Cabazitaxel is indicated for patients who have failed prior docetaxel chemotherapy. Radium-223 in general is reserved for patients with symptomatic bone metastases. Mitoxantrone has not been shown to provide a survival advantage and in general has been used for palliative purposes in symptomatic patients.
A 35-year-old woman with urinary urgency and frequency has a pelvic mass and gross hematuria. Cystoscopy and biopsy of the mass reveals endometriosis. A CT cystogram after four months of a GnRH agonist is shown. The next step is:
- CT urogram
- repeat biopsy of mass
- transurethral resection of mass
- partial cystectomy
- radical cystectomy with urinary diversion.
1
This patient has a persistent mass following hormonal therapy for endometriosis invading the bladder. She had an adequate trial of GnRH agonist therapy. The next step is upper tract imaging; this test should be obtained in all patients with pelvic endometriosis prior to and following hormonal therapy, and again prior to surgical intervention due to the potential for silent upper urinary tract obstruction which can occur in 10-20% of these women. Repeat biopsy of the bladder mass, endoscopically or percutaneously, is unlikely to be helpful as it will show either fibrosis or persistent endometriosis. Partial or radical cystectomy is overly aggressive and certainly not indicated until the upper tracts have been evaluated. An anatomic study with CT urogram will provide more information than nuclear renography and will complete the hematuria workup.
The diminished long term effectiveness of thiazides in the treatment of hypercalciuria is mediated by:
- increased dietary sodium
- increased serum calcitonin
- increased parathyroid hormone
- decreased urinary magnesium
- increased gastrointestinal absorption of calcium.
2
Thiazide diuretics will lose their effectiveness in the treatment of hypercalciuria in up to 25% of patients on long-term management. The loss of effectiveness is due to increased serum calcium levels which stimulate the C cells in the thyroid to produce more calcitonin. Increased calcitonin leads to increased urinary calcium excretion. Increased dietary calcium, decreased patient compliance, increased GI absorption or increased PTH could all lead to hypercalciuria, but are not the proposed mechanisms for tachyphylaxis with thiazides.
A 25-year-old woman has recurrent pan-sensitive E. coli UTIs with urgency and frequency but no fever. The next step is:
1 .post-coital voiding
- nightly trimethoprim-sulfamethoxazole
- nightly fluoroquinolone
- abdominal ultrasound
- cystoscopy.
2
In women with recurrent symptomatic UTI, continuous low-dose antibiotic prophylaxis or if the recurrent UTI can be related to intercourse post-coital antibiotics are indicated. Appropriate antibiotics include: trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. Fluoroquinolones should be reserved for instances of bacterial resistance or allergy. Therapy is usually continued for six months followed by a trial period off prophylaxis. Other strategies such as post-coital voiding, changing to cotton underwear, wiping away from the urethra and avoidance of hot tubs have not been shown to decrease the rate of infections. Cystoscopy is not indicated for recurrent simple cystitis in women.
A novel medication is being studied to determine efficacy in reducing urinary frequency in patients with overactive bladder. The best statistical method to compare the mean number of voiding episodes per day in three groups of subjects receiving either one of two doses of the medication or placebo is:
- ANOVA (analysis of variance)
- chi-square test
- Pearson r test
- t-test
- Spearman rank order.
1
ANOVA (analysis of variance) is used when comparison is being made between the mean of more than two groups. A t-test is used to make comparison between the mean of two groups. Chi-square test is used to compare differences in proportions. Pearson r test is used to evaluate the strength and direction of an association. Spearman rank order correlation is used to compare ordinal data.
A 65-year-old woman undergoes a retropubic midurethral synthetic sling and is unable to void after surgery. At one month, she is still catheterizing herself and is unable to void on her own. The next step is:
- continue CIC and reassess at three months
- urethral dilation
- sling incision
- transvaginal urethrolysis
- suprameatal urethrolysis.
3
It is very unlikely that this patient, who is in complete urinary retention one month after a retropubic mid-urethral sling, will resume normal voiding. If the patient had undergone an autologous sling, it would be appropriate to wait three months before intervening as spontaneous sling loosening may occur with resorption of the sling. In this patient with a synthetic sling, if she desires to void spontaneously, she will need to have the sling loosened or cut. Sling loosening may be attempted within the first week to ten days after surgery, but this must be done surgically by exposing the sling and attempting to loosen it and not by urethral dilation. If loosening is not selected or is ineffective, the sling will need to be cut. Incision of the synthetic sling will restore voiding in approximately 90% of patients; however, recurrent stress incontinence may occur in 15-20% of patients. Transvaginal urethrolysis is indicated when an incision does not work or if the urethra is felt to be fixed to the underside of the pubic symphysis. Suprameatal urethrolysis is unnecessary following mid-urethral sling procedures, as there is very little scarring immediately anterior to the urethra, and the obstruction is presumablye due to excessive obstruction from the suburethral sling. Classically, suprameatal urethrolysis is indicated for obstruction following a Marshall-Marchetti-Krantz procedure, or for persistent obstruction following sling incision and/or transvaginal (submeatal) urethrolysis.
In utero myelomeningocele closure has a favorable impact on:
- incidence of spinal cord tethering
- bladder continence
- bowel function
- the need for ventriculo-peritoneal shunting
- complications at delivery.
4
The need for ventriculo-peritoneal shunting was found in approximately 70% of the infants in the prenatal-surgery group and 98% of those in the postnatal-surgery group. Prenatal surgery also resulted in improvement in the composite score for mental development and motor function at 30 months (p=0.007) and an improvement in several secondary outcomes, including ambulation by 30 months. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at delivery. There has been no documentation of a positive effect on the incidence of spinal cord tethering, urinary continence or bowel function with in utero myelomeningocele repair. In non-randomized, controlled studies, prenatal surgery has not been shown to result in improved bladder dynamics nor function compared to historical controls.
A risk factor for systemic allergic-type reactions to radiocontrast media is:
- povidone-iodine (Betadine) allergy
- African-American ethnicity
- asthma
- obesity
- diabetes.
3
Urologists frequently obtain imaging studies utilizing I.V. contrast agents that are often performed in the office under their direct supervision. Since use of these agents is associated with adverse events including potentially life-threatening anaphylactic-like reactions, an appreciation of the risk factors predisposing to these adverse events is essential. Adverse reactions to radiocontrast media are classified as either systemic allergic-type reactions or chemotoxic-type reactions. Chemotoxic events arise as a result of the physiochemical properties of radiocontrast agents, and include contrast-induced renal failure and seizures. Individuals with poor renal function, diabetes and intravascular volume depletion are predisposed to these events. Obesity, due to its association with metabolic syndrome and diabetes, is a known risk that increases the patient’s susceptibility to a chemotoxic event.System allergic-type reactions occur due to the release of active cellular mediators that can result in urticaria, bronchospasm, laryngeal edema, hypotension, and anaphylaxis-like reactions. Patients who have a history of multiple systemic allergies (drug or nutritional allergies) or a history of asthma account for an inordinately large percentage of patient with allergic reactions. In point of fact a history of asthma results in a 3-5x increased risk of a systemic allergic type of reaction to radiocontrast media. Allergy to Betadine is a type of contact dermatitis and not associated with increased risk. There does not appear to be any racial differences in risk to either type of event.
A 64-year-old, T4 paraplegic man on CIC is admitted for treatment of pneumonia. He suddenly develops a severe headache and has a heart rate of 42 bpm, and blood pressure of 210/130 mmHg. The next step is:
- sublingual nifedipine
- sublingual terazosin
- oral nitroglycerine
- nitroglycerine paste
- place a urethral catheter.
5
Autonomic dysreflexia (AD), a syndrome of unopposed sympathetic discharge classically occurs in patients with a complete spinal cord injury (SCI) at or above T-6 (above the T10-L2 sympathetic outflow. This dysreflexic response will typically occur secondary to, visceral distension (bladder or bowel), or pain stimulation below the level of the lesion. Symptoms classically are sweating and diaphoresis above the level of the lesion, a blood pressure rise of > 20 mm Hg over baseline levels, headache and bradycardia. In the treatment of AD, it should always be assumed that the bladder is distended and/or the urethral catheter malpositioned. Drainage of the bladder, placement of a urethral catheter, or verification that an indwelling catheter is functional and in the correct position, should always be the first step in management. All clothing should subsequently be loosened and the patient’s upper torso should be elevated. If these maneuvers do not result in a decrease in blood pressure, topical or oral nitroglycerin is the recommended first line medical therapy. Topical nitroglycerin is preferred due to the ability to wipe off the medication from the skin if rebound hypotension should occur. Prior to nitroglycerin use, it must be verified that the patient has not taken a PDE-5 inhibitor within the prior 24 hours, the combination of NTG and a PDE-5 inhibitor increases the risk of severe rebound hypotension. If the patient has used a PDE-5 inhibitor, captopril 25 mg given sublinguinally or chewed is the drug of choice. Sublingual nifedipine once routinely recommended for this complication is no longer the drug of choice due to variable absorption, and episodic rebound hypotension that has resulted in strokes or myocardial infarction. If the blood pressure does not improve rapidly or rebound, HTN develops the patient should be examined for other causes of AD including fecal impaction, renal or bladder calculi, decubitus ulcers and asymptomatic broken bones.
During testosterone replacement therapy for androgen deficiency, significant mood swings, and variations in libido are most likely to develop when using:
- testosterone enanthate
- testosterone gel
- transdermal testosterone patch
- methyltestosterone
- subcutaneous testosterone pellets (TestopelTM).
1
Parenteral testosterone injection therapy (testosterone enanthate or cypionate) will cause significant peaks and valleys in serum testosterone levels which can cause mood swings and variations in libido and potency (roller-coaster effect). Oral, subcutaneous, and transdermal preparations do not have this roller-coaster effect. The alkylated oral androgens, e.g., fluoxymesterone, methyltestosterone, have serious liver toxicity and adverse effects on serum lipids (increased LDL, decreased HDL) and should not be used
An eight-year-old boy with a large expanding cystic right testicular mass has normal tumor markers and organ confined mature testicular teratoma on radical orchiectomy. The next step is:
- serial examination
- abdomen and pelvis CT scan
- serial tumor markers
- RPLND
- platinum-based chemotherapy.
1
A presumptive diagnosis of testicular teratoma can often be made based on testicular ultrasound findings. When a prepubertal testicular teratoma is expected it should be approached via an inguinal incision with vascular control of the spermatic cord. Juvenile testicular teratomas may be treated by either partial orchiectomy or orchiectomy depending upon the size of the mass. This prepubertal boy had a unilateral mature testicular teratoma that has been completely resected with radical orchiectomy. In a prepubertal boy, this is a benign lesion and can be followed with serial annual examinations if an orchiectomy was performed, or serial annual testicular ultrasound evaluations if a partial orchiectomy or enucleation was performed. Follow-up should be through puberty to verify adequate hormonal function of the contralateral testis. In a patient with a prepubertal testicular teratoma there is no need for further CT scans, tumor markers, surgery, or chemotherapy. However, mature teratoma in the pubertal child or postpubertal adolescent has a clinical behavior similar to adults and should be managed with a standard post-orchiectomy protocol for NSGCT.
A man with erectile dysfunction is given a test dose of intraurethral alprostadil 1000 mcg, and achieves complete rigidity. He complains of penile, scrotal, and leg pain during the erection. The next step is:
- reassurance
- oral terbutaline
- intraurethral lidocaine
- methylene blue intracavernosal injection
- phenylephrine intracavernosal injection.
1
The overall success rate for obtaining an erection with intraurethral alprostadil is approximately 55%. If it is successful in producing an erection, the most common side effect is penile pain that can include the scrotum and extremities. No treatment is needed for this pain, but it can be dose limiting in some patients. Terbutaline, methylene blue and Neo-Synephrine are useful for the treatment of priapism, which this patient does not have. No data is available for the use of ibuprofen with PGE-1 induced pain and it is unlikely to work based on ibuprofen’s mechanism of action.
Compared to a normal kidney, the percutaneous access for nephrolithotomy in the kidney shown will be more:
- superior and medial
- inferior and medial
- superior and lateral
- inferior and lateral
- posterior and medial.
2
The horseshoe kidney is positioned more inferior, anterior and medial than a normal kidney. The upper pole is typically subcostal and superficial, making it the best option for percutaneous access. The medial position of the kidney often requires a percutaneous tract that passes through the paraspinous musculature.
The right adrenal vein enters:
- right renal vein
- right inferior phrenic vein
- right gonadal vein
- IVC
- ascending lumbar vein.
4
The right adrenal vein enters the IVC directly on its posterolateral aspect. It does not enter other veins between the adrenal gland and the IVC as occurs on the left side. The left adrenal vein joins with the left phrenic vein and enters the cranial aspect of the left renal vein. The lumbar vein and left gonadal vein enter the left renal vein but do not receive the adrenal vein.
Three years after placement of a sacral neuromodulator for refractory urinary urgency and urgency incontinence, a 45-year-old woman develops new symptoms of blurred vision, numbness in her lower extremities, and significant exacerbation of her urinary symptoms. The next step is:
- anterior, posterior and lateral radiograph of the sacrum
- reprogramming of the device
- MRI scan of the brain and spine
- surgical revision of the impulse generator
- removal of the device.
5
This patient has progressive urologic symptomatology that is refractory to a therapeutic modality that was once effective. When the physician encounters a patient with progression of the severity of symptoms, particularly in conjunction with new neurologic symptoms, a neurologic diagnosis such as multiple sclerosis should be considered. Performance of MRI (below the neck) is important in establishing the diagnosis of a neuropathic disease, and is contraindicated in patients with a sacroneuromodulation device in place. Therefore, it must be removed to allow this patient to proceed with the diagnostic MRI scan. Although evaluation of the position of the lead, consideration of reprogramming of the device, surgical revision of the device (pending the effects of reprogramming), or change in treatment modality might all be reasonable, in a patient without progressive neurologic deterioration they are not reasonable alternatives in this clinical scenario.
A 38-year-old woman with recurrent nephrolithiasis has a serum calcium of 10.8 mg/dl and serum parathyroid hormone level of 85 pg/ml. After administration of thiazide, serum calcium is 11.8 mg/dl. She is currently stone free. The treatment that will best reduce her risk of nephrolithiasis is:
- sodium restriction
- potassium citrate
- low calcium diet
- orthophosphates
- parathyroidectomy.
5
Hyperparathyroidism should be suspected in patients with renal calculi and serum calcium levels over 10.1 mg/dl. In patients with suspected hyperparathyroidism, a thiazide challenge may unmask subtle primary hyperparathyroidism by increasing proximal tubular resorption of calcium resulting in a significant rise in serum calcium. The treatment of patients with primary hyperparathyroidism and renal calculi is parathyroidectomy, with over 90% improvement in calculus recurrence. In patients who present with symptomatic or obstructive renal calculi and who are not in hypercalcemic crisis, the calculi should be treated prior to the parathyroid gland.
A novel medication is being studied for the treatment of urinary frequency. The best statistical method to compare the mean number of voiding episodes per day in subjects receiving the medication versus those receiving placebo is:
- chi-square test
- ANOVA (analysis of variance)
- Pearson r test
- t-test
- Spearman rank order test.
4
The t-test is the most commonly used method for comparison of means between two groups. Chi-square analysis is the most important nonparametric test and is used to compare proportions. ANOVA is the appropriate test when more than two groups are being compared. Pearson’s r test is used to evaluate strength and direction of the relationship between two interval variables. Spearman’s rank order test is used to test for an association between ordinal positions in rankings.
Three years following placement of a retropubic midurethral sling, a 58-year-old woman has recurrent stress urinary incontinence. Valsalva LPP is 32 cm H2O with a stable bladder and a capacity of 400 ml. The urethra is well-supported. The best option is:
- pelvic floor muscle training
- imipramine
- Burch urethropexy
- transobturator sling
- autologous fascial sling.
5
Indications for autologous sling include a severely dysfunctional urethra, as indicated by low LPP (0-60 cm H2O), loss of urethral tissue (e.g., following synthetic mesh erosion into the urethra, urethral diverticulectomy, or urethrovaginal fistula repair), and multiple previous anti-incontinence procedures. While the other options listed are reasonable options to discuss with patients, this patient’s low LPP and her history of previous surgery make autologous sling the best option of those listed.
A 60-year-old paraplegic woman with multiple medical problems has an ileal conduit because she was unable to perform intermittent catheterization. She develops pyocystis unresponsive to three weeks of oral ciprofloxacin. Pyocystis recurs one week following three days of intravesical bladder irrigation with neomycin. The next step is:
- formalin bladder irrigation
- suprapubic cystotomy
- broad spectrum IV antibiotics
- vesicovaginostomy
- convert to ileovesicostomy.
4
Pyocystitis may be a complication following supravesical diversion in individuals with a neurogenic bladder when a cystectomy is not performed. The failure of irrigation therapy to permanently suppress recurrent pyocystitis is an indication for surgical intervention. Vesicovaginostomy allows the bladder to drain and usually results in symptomatic improvement in patients who have pyocystitis unresponsive to standard treatment. In this woman, vesicovaginostomy would be a significantly less morbid option than simple cystectomy.
A six-year-old boy undergoes right pyeloplasty and pyelolithotomy for UPJ obstruction and 1 cm renal pelvic stone. The stone is composed of calcium oxalate. Three months post-op, ultrasound shows improved hydronephrosis and diuretic renography shows no obstruction. The next step is:
- observation
- metabolic stone evaluation
- low oxalate diet
- hydrochlorothiazide
- potassium citrate.
2
The incidence of renal calculi in patients with UPJ obstruction is nearly 20%. Husmann and colleagues reported a 70-fold increased risk of stone formation in the pediatric population with UPJ obstruction. Although the obstruction plays a role in stone formation, several studies have demonstrated that patients with UPJ obstruction and concurrent renal calculi carry the same metabolic risks as other stone formers. Correction of UPJ obstruction did not prevent recurrent stones in most patients, and thus metabolic evaluation, rather than annual UA alone, is the correct next step. Based on the findings of the metabolic evaluation, treatments such as dietary changes, potassium citrate, or hydrochlorothiazide may be appropriate, but not until the work-up is completed. Despite the fact that this was discovered during the evaluation of a UTI, antibiotic prophylaxis is not indicated.
A unique challenge of robotic vesicovaginal fistula repair as compared to robotic sacrocolpopexy is:
- adequate exposure
- ease of suturing
- maintaining pneumoperitoneum
- avoiding ureteral injury
- port site complications.
3
Repair of vesicovaginal fistula, whether via an open or minimally invasive technique, requires adherence to basic principles of fistula repair. These include: adequate excision of the fistula, use of healthy tissues for repair, performance of a tension free anastomosis with multi-layered closure, interposition with omentum, and adequate bladder drainage. However, the challenge of a minimally invasive approach is losing pneumoperitoneum after the fistula is excised. Techniques such as packing gauze in the vagina and clamping the urethral catheter are helpful but they do not seal the opening adequately to maintain pneumoperitoneum and thus can make suturing more difficult. If pneumoperitoneum is maintained, exposure and ease of suturing should be no different. Risk of ureteral injury and port site complications should not differ between the procedures.
Eighteen hours after a radical nephrectomy, a 35-year-old man has a high grade fever, pain, and impressive erythema at the operative site associated with a thin, watery discharge from the incision. The infection is most likely caused by:
- Clostridium perfringens
- beta-hemolytic streptococci
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Candida albicans.
2
Streptococcal and Clostridial wound infections are characteristically invasive, painful, and occur within 24 hours after surgery. A thin, watery purulent discharge without frank abscess formation or foul smell is characteristic for Streptococcal infections. Clostridial infections are usually associated with intraoperative fecal contamination; the discharge is gray or reddish brown and foul smelling, and associated with wound crepitus and necrosis. Treatment should include systemic high dose penicillin. Opening of the surgical wound with debridement and drainage is necessary only if there are signs of crepitus or wound fluctuance or wound margin necrosis. Staphylococcal infections usually occur > 24 hours postoperatively, and are characterized by a localized indurated area of cellulitis with associated abscess formation with a thick yellow or cream-colored pus. Postoperative wound infections caused by enteric bacilli have a longer incubation period than those caused by staphylococcus.
A four-year-old boy who recently emigrated from Ethiopia has gross hematuria. There is no history of UTI. KUB demonstrates a 2 cm bladder stone. The most likely stone composition is:
- ammonium acid urate
- calcium oxalate
- calcium phosphate
- cystine
- struvite.
1
Primary idiopathic (endemic) calculi form in children, most commonly from North Africa, the Middle East and Far East. With a large immigrant population in the United States, it is important to be aware of this health problem. These children rely on a cereal-based diet that is lacking in animal proteins. This leads to a dietary phosphate deficiency, low urinary phosphate and high peaks of ammonia. Due to this, the most common stone is ammonium acid urate. Though chronic dehydration can lead to calcium oxalate and uric acid stones, high urinary sodium, calcium and oxalate are not characteristic findings with endemic bladder stones.