2017 Flashcards

Question

The initial response of the renal vasculature to complete ureteral obstruction is: A. preglomerular vasodilatation. B. postglomerular vasodilatation. C. afferent arteriolar constriction. D. efferent arteriolar constriction. E. renal artery vasoconstriction.

Answer 1

A The initial rena l response to complete ureteral obstruction is to increase glomerular perf usion pressure. Postglomerula r vasodilation without any change in the preglomerular vessels would result in lower glomerular perfusion pressures, not higher. Likewise, afferent a rteriolar constriction and rena l artery vasoconstriction would result in decreased glomerula r perf usion pressure. Of the choices listed, only preglomerular vasodilation and efferent arteriolar constriction lead to increased glomerular perf usion pressures. Preglomerular vasodilation is the f irst response in both unilateral and bilatera l uretera l obstruction. Efferent arteriolar constriction does occur as a second phase in bilateral uretera l obstruction but does not occur in unilateral obstruction.

Answer 2

D Entero-pouch f istulas have been reported after ileal and right colon urinary diversion. The diagnosis should be suspected in patients who present with gastrointestina l symptoms and metabolic acidosis. These fistulas are most common after pelvic irradiation. Conservative therapy can be effective with low residue diet and continuous pouch dra inage. Further diagnostic eva luation with colonoscopy or pouch endoscopy is of little value, and biopsy or fulguration may enla rge the f istula. Bilatera l nephrostomy drainage alone will not achieve maxima l drainage of the pouch. Open surgica l exploration may be required if this regimen fails. Hyperalimentation alone, without catheter drainage, is insuff icient to resolve the fistula.

Answer 3

E The presence of invasive urothelial carcinoma of the prostate ca rries a high risk of urethral recurrence and is a contraindication to orthotopic bladder replacement. All patients undergoing cystectomy should be counseled about the possibility that intra-operative f indings might change the planned form of urina ry diversion, a nd all of the a lternatives should be discussed prior to surgery. Of the choices listed, the continent cutaneous urinary diversion is the best option for a patient who is strongly averse to an external appliance and has agreed to the concept of CIC.

Answer 4

B The conus medulla ris of the spina l cord terminates between the second and third lumbar vertebra in the newborn. In the adult, the spinal cord usually terminates between the first and second lumbar vertebra. Understanding this relationship is critical to be able to diagnose a tethered cord. Cord tethering is often assumed to be present when the conus is below the L2 interspace, with termination below L3 resulting in a n absolute diagnosis. It is important to note that imaging features support, rather than make, the diagnosis. The clinical diagnosis of a tethered cord is based on the radiologic f indings of tethering a long with the clinical findings of " neurological and musculoskeleta l signs a nd symptoms. " Clinical f indings that help support the diagnosis of a tethered cord a re foot deformities, leg weakness or pain, gait abnormalities, lower back pain, scoliosis, and fecal or urinary incontinence. From a urologic standpoint, urinary incontinence or symptomatic voiding difficulties will be present in up to 50% of patients with a tethered cord, and urodynamic abnorma lities will be found in approximately 70% of patients.

Answer 5

D The patient has bulky retroperitoneal masses from NSGCT. Although the prima ry tumor was teratoma, there was a component of immature teratoma which would classify the patient as a NSGCT. Despite teratoma only, this patient should be treated like metastatic NSGCT, and the correct treatment is three cycles of BEP. The patient has " good risk " NSGCT, def ined as primary testicula r or retroperitonea l disease, no pulmonary metastases, and negative or low tumor markers. For " good risk " patients, three cycles of BEP are equiva lent to four cycles of EP. If the masses rema in after chemothera py, which is likely in patients with teratoma, he will require an extensive post-chemotherapy RPLND. A PET CT is not necessary as the patient needs chemotherapy regardless of the result. A biopsy is not necessary for the same reason.

Answer 6

A It is unusual for extravasation of urine to reach the thigh. This suggests that the normal layers that more commonly contain urinary extravasation have been disrupted. The first layer that has to be disrupted for urine to reach the thigh must be Buck 's fascia. The dartos fascia, Colles' fascia, and insertion of the fascia lata represent a continuation of the same fascial layer.

Answer 7

D The daily risk of acquisition of bacteriuria when an indwelling catheter in-situ is three to seven percent. The rate of bacterial acquisition is higher for women and older persons. Heath care surveys in the USA report that UTls are the fourth most common infection, accounting for 13% of health care infections; two-thirds of UTls are directly related to the presence of an indwelling urinary catheter. Catheter-associated UTls result in increased morbidity and mortality among hospitalized patients. Factors proven to reduce catheter-associated UTls include: a closed drainage system, early catheter removal, and an aseptic insertion technique . Prophylactic antibiotics (systemic or topical) have not been shown to reduce the risk of CAUTI, and indeed some studies have revealed their use increased the presence bacterial resistance and candiduria. Routine meatal cleansing, intravesical antibiotic irrigation, or hydrogen peroxide instillations into the drainage bag have not been demonstrated to reduce the frequency of catheter associated infections.

Answer 8

E The pudenda! nerve arises from the dorsal nerve roots at S2, S3 and S4. The pudenda! nerve provides innervation of the striated external sphincter; transection would cause sphincter weakness. It also gives arise to the dorsal penile nerve which provides somatic sensation to the penis. Interruption of the pudenda! nerve will cause decreased penile sensation, but not affect psychogenic erections. This may be clinically applicable to those patients who undergo dorsal rhizotomy. The sympathetic chain a rising from T10 to L2 is responsible for ejaculation, and will not be impacted by transection of the sacra l dorsal nerve roots.

Answer 9

A Potassium citrate comes in a variety of formulations. Potassium citrate tablets are produced with a wax matrix to optimize their sustained release. It is not infrequent for these wax matrix tablet casts to be visualized in stools. This is most frequently seen in individua ls with ileostomies. Patients should be reassured that the medicine is being delivered. To insure that the citrate is being absorbed, it would be appropriate to check the urine pH. If the urine is acidic, it may be necessa ry to increase the potassium citrate dose.

Answer 10

D Hyperur icemia can be seen during the initia l treatment of acute leukemias and lymphomas, in response to either chemotherapy or radiotherapy. The rapid destruction and cellula r lysis of neoplastic cells results in a rapid rise in uric acid levels. Elevated urinary uric acid crysta ls will, in the presence of acid urine, precipitate within the dista l convoluted tubules, leading to intrarena l obstruction and renal failure. Prophylaxis (and treatment) is accomplished by a combination of alkalinization, allopurinol, and hydration.

Answer 11

C The VCUG demonstrates the presence of posterior urethral valves and vesicoureteral reflux. The majority of neonates with the coexisting findings of posterior urethral valves and oligohydramnios prior to 20 weeks gestation will be found to have pulmonary hypoplasia and neonata l respiratory distress. The presence of pulmona ry hypoplasia in these infants still accounts for the majority of neonatal deaths in boys with posterior urethral va lves. Urosepsis can occur, but usually not in the neonatal period with ea rly diagnosis and initiation of appropriate prophylactic antibiotics. Acute rena l failure can present in the f irst week of life but can be managed with neonata l peritonea l dialysis to avoid immediate renal induced mortality. Urinary ascites is common with high-grade urethral obstruction, but is usually protective for the kidneys, and is almost always successf ully managed with bladder drainage and broad spectrum antibiotics. Posterior urethra l va lves are not associated with lethal congenita l ca rdiac disease.

Answer 12

D The wild type VHL tumor suppressor gene product suppresses the expression of VEGF, a potent stimulator of angiogenesis, through down-regulation of hypoxia-inducible factor 1 (HIF1). Mutation or loss of the VHL tumor suppressor gene leads to dysregulated expression of VEGF, which contributes to the neovascularity associated with RCC. This pathway is of critical importance to practicing urologists as most recently developed tyrosine kinase inhibitors target the pathway directly or indirectly. All of the other listed genes are not directly regulated by HIF1, and, therefore, are not directly affected by VHL loss

Answer 13

D Permanent lower urinary tract dysfunction occurs in 15-20% of patients following radical pelvic surgery. The typical pattern is one of detrusor areflexia or hypocontractility in the presence of fixed residual striated sphincter tone. This fixed tone represents a functional obstruction that frequently results in decreased detrusor compliance. Although poor proximal sphincter function can also occur (intrinsic sphincter deficiency), this is often masked by prostate bulk in male patients.

Answer 14

D In a woman presenting with the acute onset of chronic incontinence following a surgical procedure, she should be evaluated for possible simultaneous upper UTI and ureteral or combined ureteral-vaginal fistulas to rule-out the presence of a perivesical abscess or f luid collection. In the absence of pelvic infection, immediate repair is justified. In the presence of a large diameter vesicovaginal fistu la in an irradiated field, an abdominal approach will concurrently allow an omental pedicle flap to be interposed between the irradiated bladder and vaginal wall tissues. In the presence of an irradiated field, obliteration of dead space, goodbladder drainage, control of infection, and interposition of healthy tissue are critica l elements to successful f istula closure. Proximal urinary diversion with bilatera l percutaneous nephrostomy tubes with delayed repair should be considered in patients where the initial evaluation suggests the presence of a concurrent pelvic abscess. An endoscopic approach with fulguration of the f istula tract and urethral catheter or suprapubic tube drainage may be considered in vesicovaginal f istulas where the diameter of the f istula is \< 5 mm in size and radiographic evaluations (fistulogram) suggests the presence of a long-necked and tortuous f istula.

Answer 15

C Incidentally discovered small asymptomatic renal tumors do not mandate a waiting period prior to transplantation. Repeating the CT scan with contrast risks further nephrotoxic injury with preexisting borderline rena l function, and will not change the management of the renal mass. Although partia l nephrectomy may carry the advantage of preserving additiona l renal mass, this is not applicable to this patient. The appropriate management in this setting is simultaneous nephrectomy and transplantation.

Answer 16

D A variety of host defense and bacteria l virulence factors contribute to the pathogenesis of UTls. Host defenses include high urine osmolality, low pH, high urea, eff icient micturition, and a number of urine inhibitors of bacter ial adherence (e.g., Tamm-Horsfall protein, lactoferrin, oligosaccharides, and mucopolysaccharides). Immune responses to UTls affect hormonal immunity (secretory lgA), as well as, cytokine production (IL6, IL8). Cranberry juice contains substances that inhibit the adherence of uropathogenic bacteria to uroepithelial cells. Cranberry ingestion does not have a substantive effect on urine pH, urine osmolality, secretory lgA, or interleukin levels.

Answer 17

D This neonate, with a normal-sized phallus for a male (\> 2.5 cm), could be a female with elevated testosterone due to congenital adrenal hyperplasia. Therefore, an elevated testosterone does not equate with the presence of a testicle. Levels in newborns of LH, FSH, and testosterone can be normal or elevated with many intersex disorders and does not confirm the presence of a testicle. Elevated 17-hydroxyprogesterone and increased urinary ketosteroids would be findings of adrenal insufficiency, but would not confirm the presence of a testicle. An hCG stimulation test with an increase in testosterone may be of value, but the increase should be \> 20 fold. In addition, the infant may already have an excessively elevated testosterone level which could mask the findings of an hCG stimulation test. A 46 XY karyotype does not confirm the presence of testes. Mullerian-inhibiting substance is secreted by testicular Sertoli cells and is the one test which would diagnostically confirm the presence of at least one testicle.

Answer 18

E This is an unusual site for a benign ureteroileal stricture, and there is a high likelihood that this is the result of tumor recurrence in the ureter. Therefore, observation is not a good option. Endoscopic management, whether it be ureteroscopically or percutaneously, is unlikely to work, and does not establish the etiology of the obstruction. Since the kidney has little remaining parenchyma, reimplantation makes little sense, and, therefore, the best treatment is nephroureterectomy.

Answer 19

D Primary spermatocytes undergo one round of meiosis creating secondary spermatocytes which are 2N in DNA content and haploid. These subsequently undergo a second round of meiosis to form round spermatids which are 1N in DNA and haploid, which are the final products. The spermatids then eventually metamorphose into mature spermatozoa (spermiogenesis).

Answer 20

A Complications of inguina l lymph node dissection can include debilitating lower extremity edema, wound infection, skin flap necrosis, DVT, hemorrhagic events, and sepsis. The greatest risk factor for these complications is palliative indication, primarily in patients with advanced disease with impending erosion into the vessels or through the skin. In the ser ies from MD Anderson Cancer Center, complication rates (minor a nd major combined) were 35 % for a prophylactic dissection, 36% for a therapeutic dissection, and 67% for palliative indications. In addition, most major complications occurred in the latter or " palliative " group. The reasons for the increased complication rate is presumably due to reduced lymphatic and venous drainage a nd compromised blood supply. Together, these factors affect the viability of skin f laps and lymphatic f low, a nd the majority of the complications are due to infectious causes. While diabetes, heart disease, and obesity are all important surgical considerations, they have not been directly associated with complications related to inguina l node dissection. Similarly, prior chemotherapy has not been associated directly with increased complications after inguinal node dissection.

Answer 21

E All patients with a n output \> 200 ml/hr have post-obstructive diuresis and should be closely monitored. High risk patients with chronic obstruction, edema, congestive heart failure, HTN, weight gain, and azotemia a re most likely to exhibit a post-obstructive diuresis after the release of obstruction. In the high risk patient, a spot check urine for osmolality, sodium, a nd potassium will a llow for the determination of the type of post-obstructive diuresis and will provide guidance for f urther management. High risk patients should have vital signs, including postura l blood pressure a nd output measured hour ly. D5 1/2 NS is a n appropriate replacement fluid in the patient with an elevated BUN and creatinine, but genera lly, replacement is given at half of the previous hour 's urine output.

Answer 22

B Abdominal CT studies with contrast offer a fast and all-inclusive evaluation of the abdomen in cases of trauma. With the advent of rapid image acquisition, the a bdomina l, renal vasculature, and the renal cortex will enha nce. However, delayed images of the a bdomen will usually be needed to see contrast in the dista l ureter. If the initial CT cuts reveal a severe renal fracture, perinephric hematoma, or perinephric fluid collection, and especially if medial extravasation of contrast is found, delayed films a re usually necessary to assess for the presence of contrast in the distal ureter. The presence of a UPJ disruption should be considered when there is absence of contrast in the ipsilatera l dista l ureter on a delayed CT study. CT cuts to assess for this f inding are ideally taken 10-20 minutes post-contrast infusion. If delayed CT cuts reveal no contrast in the dista l ureter, the next step is emergent surgery with a retrograde pyelogram to confirm the presence of the UPJ injury and subsequently surgical repair. If the UPJ and ureter are intact, the patient may be managed in a non-operative fashion. Arteriography is not indicated as vital signs are stable.

Answer 23

C Several randomized trials have revealed that ureteral stents are not required after uncomplicated ureteroscopic extraction of distal ureteral stones, even after balloon dilation of the ureter or intracorporeal lithotripsy. Ureteral strictures are uncommon after ureteroscopy for distal stones, whether or not a stent is inserted. Stents do not impact stone free rate, but do increase post-procedure pain, urinary symptoms, and narcotic use.

Answer 24

A The most likely diagnosis is acute interstitial nephritis. The best treatment is to discontinue the offending drug, treat any related HTN that may be present and limit protein intake. The vast majority of patients will have symptoms which spontaneously resolve. If symptoms persist, renal biopsy may be necessary to confirm the diagnosis. Both ampicillin and cephalosporins may cause interstitial nephritis and could actually be harmful if used in this setting. Indeed, adequate treatment for a UTI can be achieved in a single dose of medication and additional antibiotics are not indicated in this patient with a sterile gram stain at this time. The use of prednisone should be reserved following confirmation of the diagnosis with a renal biopsy. There is no role for the use of antihistamines in the treatment of interstitial nephritis.

Answer 25

D Detrusor LPP is the most reliable urodynamic parameter to predict the risk of upper tract deterioration after sphincterotomy. A detrusor LPP of higher than 40 cm H20 indicates that the sphincterotomy has failed, and may serve as a guide to determine whether a repeat sphincterotomy is necessary. Abnormal compliance, which may be detected on CMG, may also be a worrisome finding, but there is much less established predictive value. To date, there is no correlation of urethral function tests (urethral pressure profile, Va IsaIva LPP, EMG) to upper tract deterioration.

Answer 26

C The International Continence Society has established a standa rdized system to quantify pelvic organ prolapse. This classif ication is known as the POPQ system, an acronym for pelvic organ prolapse quantif ication. The system uses the hymena l ring as its centra l identif ication point. The hymen was chosen over the vaginal introitus because it can be more precisely located within the vaginal va ult; a ll measurements are based from this location. This classification avoids use of the terms, cystocele or rectocele, recognizing that the actua l organ prolapsing may be una ble to be determined by a physica l examination. The examination to determine POPQ stage is performed in a dorsa l lithotomy position with the patient straining. The POPQ staging system has excellent inter-observer and intra-observer reliability and has become the standard for reporting outcomes following prolapse repair. The staging system is, however, not perfect and can be significantly affected by patient positioning, with the degree of the prolapse being more severe if the patient is examined with the head of the table raised to 45 degrees or higher. In addition, it fails to assess for unilateral or asymmetric defects. The POPQ staging system is def ined as: Stage 0 - no prolapse, Stage 1 - the most distal portion of the prolapse is more than 1 cm above the hymen, Stage 2 - the most distal portion of the prolapse is +/-1 cm a bove or below the hymen, Stage 3 - the most distal portion of the prolapse protrudes \> 1 cm below the hymen and the total vagina has not prolapsed, and Stage 4 - the entire vagina everts (i.e., complete prolapse).

Answer 27

C Active surveillance is a reasonable option for patients with low-risk prostate cancer. This patient's risk prof ile makes him a reasonable candidate for this approach. However, a six-core biopsy is likely inadequate tissue sampling to truly identify indolent disease. Therefore, initiation of active surveillance protocol with quarter ly PSA and repeat biopsy in one yea r is premature and immediate systematic prostate rebiopsy is the next step. Additiona l imaging, with either bone scan or pelvic CT scan, is unnecessary in low-risk patients and would be inappropriate in this setting. There is no data supporting the use of f inasteride in the management of prostate cancer.

Answer 28

B Large amounts of Randa ll's plaque are unique to idiopathic calcium oxalate stone formers and are invariably composed of ca lcium apatite crysta ls. Using papillary biopsies obtained during the time of PCNL, Randall's plaque were found to initia lly for m on the basement membrane of the thin limbs of the loops of Henle and grow by the continued deposition of ca lcium apatite and organic matr ix. With growth, the plaque will sprea d through the interstitium and eventua lly penetrate the urothelium, exposing the plaque to urine where it will serve as an anchor for urinary solutes. Although Randall's plaque can be found in other stone formers, Randa ll's plaque has been found to be a prerequisite for kidney stone formation in idiopathic calcium oxalate stone formers.

Answer 29

B The use of f luoroscopic imaging in urological surgery requires a basic knowledge of radiation protection principles so that the dose to the patient, physician, and ancillary staff can be minimized. It is important to remember that with an increase in patient size, the dose rate will be greater and accumulate faster. In terms of manipulating the operational factors in fluoroscopy, there is generally a trade-off in terms of image qua lity and radiation dose. Increasing the tube current results in greater image quality and increased dose to the patient and staff. Increasing the tube kilovoltage diminishes image qua lity (less contrast), but is usua lly associated with less radiation dose if the tube current is appropr iately reduced. Decreasing the image intensif ier to skin distance usua lly increases image qua lity depending on focal spot size and decreases the dose to the patient without signif icantly changing the dose to staff. Removing the gr id decreases image qua lity as well as the radiation dose to patient and staff . Increasing the source to skin distance usua lly improves image qua lity and decreases the dose to the patient without signif icantly changing the dose to staff.

Answer 30

D Parathyroid levels are suppressed in patients with absorptive hypercalciuria as a result of transient elevation of serum ca lcium due to increased intestinal ca lcium absorption. The other conditions are associated with secondary elevation of PTH due to PTH-resistance (i.e., obesity, African American), rena l ca lcium loss, and/or elevated serum phosphorus.

Answer 31

C A meta-analysis of seven randomized tr ials comprising near ly 1,500 patients with Ta-T1 bladder cancer, with a median follow-up of 3.4 yea rs, demonstrated that one immediate post-TURBT instillation of intravesical mitomycin C resulted in a 40% reduction in tumor recurrence. Patients undergoing resection of single or multiple tumors benefited, and benef it was not affected by tumor size. The timing of instillation, however, appears to be critica l. In a ll studies documenting eff icacy, the instillation was given within the f irst 24 hours post-TURBT. One study has demonstrated that if the instillation is given 24 hours after tumor resection, the risk of tumor recurrence increased two-fold. Peri-operative instillation is contraindicated in the setting of overt or suspected extra or intraper itoneal perforation or concurrent dilation of a urethral stricture or urethral injury, as severe complications, (e.g., chronic pain, bladder necrosis, necrosis of adjacent soft tissue, and necrosis of either the corpora l spongiosus or cavernosum), have a ll been reported in these settings. lntravesical mitomycin C is most effective in a lkaline urine.

Answer 32

D Prostate MRI scan, especially with combined endorectal and phase-array coils, is used in prostate cancer staging with up to 82% accuracy. The T1 and T2 weighted images are helpf ul in differentiating between post-biopsy hemorrhage, which presents as a high T1 and a low T2 lesion, and prostate cancer, which presents as a low T1 and low T2 lesion

Answer 33

C The scan reveals bilatera l small renal masses. The largest of which is in the left kidney and on this T1-weighted image, the high intensity of the lesion indicates fat within the tumor. This is consistent with an angiomyolipoma. This finding in conjunction with pulmonary lymphangioleiomyomatosis (LAM) is indicative of tuberous sclerosis complex (TSC). Familia l leiomyomatosis would be associated with skin f ibromas and rena l carcinoma. VHL does not cause pulmonary LAM. Birt-Hogg-Dube is associated with chromophobe tumors and oncocytomas. It is a lso associated with lung cysts which can result in spontaneous pneumothorax, but not LAM. Heredita ry papillary RCC has no common pulmonary manifestations and does not ca use angiomyolipomas.

Answer 34

B Chronic antibiotic use may reduce normal levels of Oxa lobacter formigenes in the intestine. This anaerobe metabolizes as much as 50% of ingested oxalate. High ca lcium diets a re associated with decreased oxalate absorption. Few cystic f ibrosis patients have ileal absorption disorders. Vitamin C and glycine, while associated with oxalate metabolism, a re unlikely to increase urinary levels signif icantly. An emerging treatment for reduced intestinal Oxa lobacter formigenes is probiotics.

Answer 35

A Temsirolimus is a specific inhibitor of the mammalian target of rapamycin (mTOR) kinase which is a component of intracellula r signa ling pathway involved in growth and proliferation of cells. Level 1 evidence in a recent study compa ring temsirolimus to interferon alpha focused on patients with a poor prognosis, (e.g., poor risk metastatic RCC patients). Poor risk metastatic RCC patients in this trial had to have at least three of the following poor risk features: LDH \> 1.5 times upper level or norma l, Hgb below norma l, ca lcium \> 10 mg/dL, time from diagnosis of cancer \> 12 months, metastases sprea d to multiple organs, and/or Karnofsky score = 60 or 70. This patient has multiple f eatures that put him in a poorer risk group, including multiple sites of metastasis, anemia, and hypercalcemia. In patients with poor risk features, l.V. weekly infusion of temsirolimus, when compared to interferon, prolongs overa ll surviva l, and is the f irst agent that has demonstrated an overall survival advantage in this category of patients. Sunitinib, bevacizuma b, and sorafenib have not been shown to improve overall survival or prolong survival in patients with multiple poor risk features.

Answer 36

A Individuals with a neurogenic bladder that are being managed with CIC will have bacteriuria 40- 80% of the time . Only symptomatic infections (i.e., pain, fever, new onset of urinary incontinence, or foul smelling, cloudy, urine lasting longer than three days) should be treated with antibiotics. The presence of intermittent cloudy urine and/or mild pyuria is not enough to warrant antibiotic treatment. Overtreatment of asymptomatic bacteriuria in this patient population will lead to resistant organisms that are diff icult to manage. The eff icacy of prophylactic antibiotics in the setting of recurrent symptomatic infections in patients on CIC is not entirely clear. Gentamicin bladder irrigations have been shown to be effective in some patients with recurrent symptomatic infections. Changing CIC to sterile technique will likely be ineffective as well as unfeasible. Circumcision can reduce the risk of infection and should be considered if recurrent symptomatic UTls occur. Vesicostomy is not indicated for non-febrile UTls in this patient.

Answer 37

C Endogenous creatinine and creatinine clearance is the most widely used surrogate for GFR. In the presence of norma l rena l function, 90% of creatinine is filtered and 10% is secreted by the proxima l tubules. As GFR declines, tubular secretion may contribute up to 35 % of all creatinine remova l at levels of 40-80 ml/min. The commonly utilized antibiotic trimethoprim blocks the tubular secretion of creatinine. Since creatinine is produced at a steady state, the serum creatinine will rise, but the GFR does not change. Captopril and spironolactone might a lter renal perfusion causing a change in the GFR that leads to an a ltered creatinine level. Cisplatin has a direct nephrotoxic effect but would not raise creatinine without a lter ing GFR. Cepha lexin could increase the serum creatinine through an acute drug-induced injury to the kidney, such as interstitial nephritis.

Answer 38

A Several useful prognostic parameters exist for tumor progression in patients with Ta/Tis/T1 bladder cancer. The most important of these are tumor stage, grade, and presence of CIS. Tumor size and multiplicity are other factors that may predict progression. Ear ly recurrence is not associated with progression of the disease, except in patients with BCG treatment failure. The relationship between p53 status and tumor progression remains unclear. Age and tumor location do not impact progression risk.

Answer 39

B This child has massive grade 5 reflux into the right kidney. No information is available from the VCUG about the left kidney or the f unction of the right kidney. The abnormal calyces on the VCUG suggest that the function may be compromised. Urodynamics a re often not interpreta ble in the face of high grade reflux (VUR). A DMSA renal scan is needed to determine function of the right'kidney, which will help determine whether reconstruction versus nephrectomy is suitable. Ureteral reimplantation is not indicated before assessment of rena l function. An MR urogram will also give this information; however, the MR urogram will most likely require either a general anesthetic or closely monitored sedation. Creatinine clea rance may be abnormal, but it will not be possible to tell which kidney has the def icit.

Answer 40

D Percutaneous radiofrequency a blation of small renal masses has been offered in recent years as a less invasive method of treatment. Treatment efficacy is genera lly determined by follow-up CT or MRI scan eva luating for enhancement within the lesion. If enhancement is noted, this is considered suggestive of residual or recurrent tumor. In most series, between 5-20% of patients treated by radiofrequency ablation require re-treatment within the first year due to persistent enhancement. While long-term data is not availa ble, those patients undergoing a second ablative procedure appear to have a similar outcome to those treated eff ectively in the first ablation. While partial nephrectomy could be considered in this patient, the frequency of persistent enhancement after the f irst a blation suggests that a second ablation is warranted prior to proceeding with more aggressive therapy. Additiona lly, this is an older patient with multiple co-morbid conditions, suggesting a less invasive approach is warranted prior to surgical intervention. Biopsy is not indicated in this patient given the fact that the previous ablation may obscure histologic interpretation and that the biopsy outcome would not likely influence the desire to complete treatment. PET scan has poor specif icity and would not be informative in this case of localized renal mass. As the enhancement likely represents residual tumor, it is not likely to abate with continued observation

Answer 41

C This patient has developed an uncomplicated large diameter \> 5 mm vesicovaginal fistula following abdominal hysterectomy. Because of its size, it is very unlikely to close with prolonged Foley catheterization. Endoscopic treatment with fulguration is an option for management in sma ll diameter fistula \< 5 mm and is most successful if the fistula tract is long neck and tortuous. In this patient, immediate surgical repair is indicated. The outcomes a re not adversely affected by intervening at six weeks. Given the location of the fistula and the transabdomina l approach used in the prior hysterectomy, a transvagina l approach with interposition of labial or peritoneal flaps between the vesical and vaginal tissues at the time of repair would be optimal.

Answer 42

B Small cell ca rcinoma of the bladder is a relatively rare tumor that may arise in combination with urothelial carcinoma. It is usua lly biologically aggressive with early vascular and muscular invasion. These malignancies usua lly respond to but are not cured by chemotherapy regimens. Neither partial or initial radica l cystectomy nor intravesical chemotherapy is appropr iate in this setting. Radiation or extirpative surgery alone may result in cure rates of 5-20%. However, neoadjuvant chemotherapy followed by surgery or radiation therapy results in cure rates of 40- 65%. Therefore, the best treatment is chemotherapy followed by local treatment such as surgery or radiation if the patient does not progress.

Answer 43

B Elevated urinary cortisol levels conf irm the diagnosis of Cushing ' s syndrome, but do not provide information about the etiology of the condition. The next step to determine the etiology is to measure a plasma corticotrophin or ACTH level. This will determine if the Cushing's is ACTH dependent or ACTH-independent. If ACTH levels are not elevated, then the likely source is adrenal, and an abdominal CT scan with attention to the adrenals is appropriate. However, it is preferable and more efficient to determine if ACTH levels are elevated as the etiology of the Cushing's is unlikely to be of adrenal origin if ACTH is elevated. The high-dose dexamethasone suppression test, and the meta pyrone tests are used in patients with ACTH-dependent Cushing's syndrome to determine if the source of excess ACTH secretion is pituitary or ectopic in nature, and are only appropriate if serum corticotrophin levels are elevated. The high-dose dexamethasone suppression test and the metapyrone test have now largely been supplanted by direct measurements of ACTH in the venous plexus downstream from the pituitary gland (inferior petrosal sinus sampling).

Answer 44

D The success of chemotherapy for high-stage seminoma has led investigators to examine its use in low-stage disease. Its use has been supported by severa l non-randomized trials. In addition, the Medical Research Council recently completed a randomized clinica l tria l compar ing ca rboplatin with standard retroperitoneal irradiation in the setting of stage 1 seminoma. The two treatments had similar efficacy. Therefore, for stage 1 seminoma, the correct chemotherapy agent is carboplatin.

Answer 45

A The patient has bilateral UPJ obstructions incidentally noted on an abdominal CT scan with the radiographic evaluation revealing little to no renal tissue on the left side. In this asymptomatic patient with advance age and multiple medical co-morbidities, observation is most appropriate. Indications for intervention include the development of symptoms, calculi, or infection. Since there is no renal tissue on the left, UPJ repair, whether laparoscopic or open, will not improve renal function and is inappropriate. If the patient became symptomatic, a nephrectomy could be considered.

Answer 46

B Following bladder neck procedures in children with neurogenic sphincter incompetence, the unmasking or development of detrusor hostility can be seen in a subset of children. This is manifested by a decrease in bladder compliance and/or increase in detrusor overactivity. In severe cases, hydronephrosis and secondary reflux can develop. Thus, the bladder and upper tracts must be monitored very carefully following bladder outlet procedures when augmentation is not performed concomitantly. When bladder hostility is recognized, antimuscarinics should be instituted as first line management. However,this will not be effective therapy in approximately one-third of patients. In this patient population, serial urodynamic studies and onabotulinumtoxinA injections can be used for management, or alternatively definitive treatment with a bladder augmentation can be pursued. In the presence of new onset of hydronephrosis and VUR, antibiotic prophylaxis will not be adequate therapy. The outlet resistance is likely adequate for continence, and the new incontinence is more likely due to worsening bladder dynamics. Bladder augmentation without a trial of antimuscarinics would not be the next step. Ureteral reimplantation is not indicated, as the low grade VUR may resolve with bladder management.

Answer 47

D The management of high-grade PIN has changed. With the standard biopsy now including 10 to 12 cores, it is no longer considered mandatory for patients to undergo immediate rebiopsy of their prostate. However, in the setting of accompanying atypical small acinar proliferation (ASAP), immediate rebiopsy and/or additional examination of the original biopsy with deeper sections is usually recommended. In this case, however, the patient has atypical adenomatous hyperplasia (adenosis), which is felt to be a benign process and, therefore, does not require immediate rebiopsy. The patient, therefore, should be treated as if he has isolated high-grade PIN and should have serial PSA monitoring. If the PSA is increased in six months, repeat biopsy can be considered.

Answer 48

B Bariatric surgery patients typically develop enteric hyperoxaluria, which should be managed with calcium supplementation. Calcium will bind intestinal oxalate, thereby reducing absorption of free oxalate, and ultimately decreasing urinary oxalate. Increasing fluids will have little effect as these patients are chronically dehydrated, and the other treatments do not address the problem.

Answer 49

C The urodynamic data documents involuntary detrusor contractions and bladder outlet obstruction, most likely due to BPH. The most reasonable pharmacologic approach is to use an alpha-sympathetic blocking agent. Detrusor-external sphincter dyssynergia is not seen in Parkinson's obstruction. Thus, baclofen, which is intended to induce skeletal muscle relaxation, is not indicated. Antimuscarinics may reduce involuntary detrusor contractions, but may exacerbate emptying failure, so should not be used until his emptying improves. TURP in Parkinson's patients carries with it a risk of urinary incontinence and should be utilized only in patients with definite bladder outlet obstruction due to BPH who have failed more conservative therapy. A trial of alpha-blocker is warranted prior to initiation of CIC or a TURP.

Answer 50

B This patient is found to have stress urinary incontinence on exam. She has no prolapse on POP-Q testing. She has no other medical problems, and there is no reason to suspect an abnormal flow or elevated residual (which might be suspected with prolapse or prior pelvic surgery); therefore, further testing with urodynamics, particularly prior to starting non-invasive therapy, is unnecessary. Since she can contract her pelvic muscles on exam, biofeedback may not be required a nd she should be started on a program of pelvic f loor exercises. Mid-urethral sling may be offered to patients failing conservative management.

Answer 51

A The only recommended test prior to surgery, beyond those a lready mentioned, is a UA. A positive UA may trigger other testing. PSA was normal within the last yea r and need not be repeated. Cystoscopy, urof lowmetry, and postvoid residual testing are all optional. Cystoscopy may be appropriate if the size of the prostate is in doubt, particula rly if it may be too large for endoscopic management. Uroflowmetry, a lthough not specific, may be a reasonable indicator of bladder outlet obstruction. Pressure flow testing is the best assessment for outlet obstruction, but is costly, invasive, and not recommended routinely unless the diagnosis is in doubt (for example, younger men with small prostates and severe LUTS, or if there is concern for neurogenic detrusor dysfunction)

Answer 52

E Nerve-sparing RPLND ca n be performed for stage 1 disease. Normally, the post-ganglionic sympathetic f ibers are identif ied below the renal vessels a nd are dissected out of the lymphatic tissue during a nerve-sparing RPLND. Rega rdless of the side of the dissection, great care is taken during dissection over the aortic bifurcation, as this is the site where the hypogastric plexus crosses anterior to the great vessels . This is the area where the sympathetic nerves are most vulnerable to injury, and this is why the aortic bifurcation is not included in the modif ied RPLND template.

Answer 53

A If the patient is asymptomatic, no immediate treatment is necessary. There is evidence that a 24- hour urine collection will be normal as the stone is most likely secondary to urinary stasis. SWL, ureteroscopic, and percuta neous approaches are not necessary unless the patient becomes symptomatic. Indications for intervention would include pain and recurrent UTls. In this case, if he was symptomatic, both ureteroscopic and laparoscopic approaches would be reasonable for a caliceal diverticulum in an anterior location.

Answer 54

A Most traumatic arterio-venous (AV) fistulas of the kidney, such as those caused by percutaneous biopsy, are asymptomatic, small, and will close spontaneously without intervention. Symptomatic fistulas can cause poorly controlled HTN, persistent hematuria, or high-output heart failure . Symptomatic AV fistulas can be managed by embolization, operative ligation of the feeding vessels, or partial/complete nephrectomy depending upon their size and location. This patient's HTN is well-controlled with medication, and there is, therefore, no indication for intervention.

Answer 55

C The presence of seminal vesicle invasion is the highest risk feature of this case scenario. Although bladder neck invasion is assigned to pathologic T4 status, it has not been associated with any independent increased risk of recurrence following radical prostatectomy. The pre-operative PSA and final Gleason score in this case are categorized as intermediate risk in the D'Amico classification system. In cases of down grading from Gleason 8 to Gleason 7 on final pathologic analysis, the final pathologic grade is most closely associated with risk of relapse

Answer 56

B The postvoid films show missing sacral segments and abnormal lumbar vertebra. The cystogram shows a trabeculated bladder with no reflux. The voiding films show a dilated prostatic urethra, as well as, dilation of the buIbar urethra. However, there are no urethral valves, so valve ablation is not needed. Given the bony abnormalities, urodynamics, and an MRI scan of the lumbar sacral spine to rule-out a coexisting tethered spinal cord are the next diagnostic steps. Starting medications are indicated only after a baseline urodynamic study is performed. The appearance of the urethra is secondary to detrusor sphincter dyssynergia. The patient does not have a buIbar urethra l stricture; therefore, a retrograde urethrogram is not indicated.

Answer 57

A Small cell carcinoma of the prostate is rare but associated w ith a high likelihood of metastatic disease at diagnosis and poor prognosis after treatment. Radica l prostatectomy is not associated with good outcomes. Sma ll cell carcinoma of the prostate does not secrete PSA signif icantly, and is apparently androgen resistant. Systemic chemotherapy is thought to be the most effective strategy followed by, or concurrent with radiation therapy. Chemotherapy agents used are similar to those used in patients with other small cell carcinoma (e.g., lung) with combinations of cisplat in and etoposide or paclitaxel or docetaxel and topotecan.

Answer 58

D Patients undergoing adrenalectomy for Cushing 's syndrome have an excess of corticosteroids from an adrenal adenoma or carcinoma. These patients need stress-dose steroids and careful glycemic control as they often have obesity and dia betes. Alpha-blockers and hydration are indicated peri-operatively for patients with pheochromocytoma. Beta-blockers may a lso be necessa ry pre-operatively for patients with pheochromocytoma if they are tachycardic after a lpha-blockade. Potassium-sparing diuretics are important for the peri-operative management of patients with hyperaldosteronism (Conn's disease) as they often have significant hypokalemia

Answer 59

C Main indications for partial adrenalectomy are solitary adrena l gland, bilateral disease, and patients with familia l syndromes. Pheochromocytoma has been treated with partial adrenalectomy, especially in patients with VHL, familial pheochromocytoma, or multiple endocrine neoplasia type 2a. Observation and biopsy are not appropr iate for patients with pheochromocytoma. Open adrena lectomy and partial nephrectomy may be appropriate for patients with larger renal masses (\> 3 cm). This patient will likely require multiple surgeries on both kidneys and adrenals, so the maximum functioning rena l and adrena l tissue should be preserved.

Answer 60

A This is a typical presentation of pediatric, benign, daytime urinary frequency syndrome. The etiology of this disorder is unclear but often follows a systemic illness. Treatment is with parental reassurance, maintenance of a voiding diary and behaviora l modification therapy to reward for progressive lengthening of the voiding interval. Resolution of symptoms will invariably occur within a f ew months. Antimuscar inic agents are rarely helpful. Imaging and urodynamic studies do not yield any significant f ndings. In the presence of a normal UA, cystoscopic evaluation is not indicated.

Answer 61

C The corporal septum is the weakest portion of the corpora l body. This is of particular importance during insertion of a penile prosthesis, as the corporal septum may be perforated and an unrecognized cylinder cross over may occur after septa l perforation. This complication may be avoided by placing the penis on traction, aiming the tip of the dilator latera lly, and placing a spacer in the contra lateral corpora while its mate is dilated . Thus, the other locations described (dorsally, ventra lly, distally, and proximally) would be incorrect.

Answer 62

B The paired calcif ied tubular structures in the center of the pelvis are the vas deferens. Calcif ication of the vas deferens is virtua lly pathognomonic for diabetes mellitus. Although tuberculosis can, on rare occasions, have similar f indings. This patient has a lso had a left iliac fossa renal transplant which contains a radio-opaque urinary stone.

Answer 63

B The most common ca use of hypomagnesur ia is inflammatory bowel disease, and an appropriate referral to a gastroenterologist to rule-out this disorder should be performed. The benefit of oral magnesium supplementation in the management of hypomagnesuric calcium nephrolithiasis has not been well-established. Though tofu and brown rice are rich in magnesium, the impact of dietary intervention on hypomagnesuria has not been tested. Though increased fluid intake is an empir ic measure to decrease the risk of stone formation, it will not address this specif ic metabolic a bnorma lity. Allopur inol does not impact urinary magnesium levels.

Answer 64

C This is a common clinical scenario. Newborns are relatively oliguric for the first 48 hours of life primarily due to neonatal decreased renal blood flow and low GFR of the immature neonatal kidney. The normal neonatal renal physiology is associated with diminished urine production and may lead to either an underestimation of the severity of hydronephrosis and/or to the presence of a normal renal ultrasound shortly following birth. For this reason, it is always recommended that the child with mild to moderate antenatal hydronephrosis have a follow-up neonatal ultrasound two to six weeks following birth. There has been some debate about whether such patients a lso deserve a VCUG to rule-out vesicouretera l reflux. The 2010 AUA Guideline on reflux management, however, does not recommend a VCUG in patients with mild to moderate antenata l hydronephrosis unless the postnatal ultrasound revea ls a dilated ureter or the presence of coexisting rena l anomalies that would suggest the possibility of reflux. Serum creatinine is unlikely to be helpf ul in cases of mild hydronephrosis and renal scan is not indicated unless moderate or severe hydronephrosis is actually documented to be present via ultrasound.

Answer 65

E The management of reflux has become extremely controversial. Although there is improvement in the evidence-based literature eva luating reflux, there is still a lack of data to definitively esta blish the role of antibiotics and surgery in the management of low to moderate grade reflux. However, the relationship between bladder and bowel dysf unction (BBD) and reflux is now widely recognized and accepted. When present, it is the overriding factor that most affects the incidence of recurrent infections, spontaneous resolution of reflux, and successf ul surgical correction of reflux. When BBD is recognized to be present, it needs to be treated aggressively given its effect on both the medica l and surgical management of reflux. While all of the other listed factors may impact resolution rates of reflux (age), infection (circumcision status), and susceptibility to develop renal scarring (intrarenal ref l ux), none of them have the impact of BBD collectively.

Answer 66

A The AUA Best Practice Statement on urologic surgery antimicrobial prophylaxis states that antimicrobia l prophylaxis is not indicated prior to urodynamic testing, unless specific risk factors exist. These risk factors include: advanced age, anatomic abnormalities of the urinary tract, poor nutritional status, and immunodeficiency. Furthermore, the American Heart Association does not recommend the use of antimicrobial prophylaxis prior to any urologic procedure, solely for the prevention of infectious endocarditis. Therefore, this patient does not require antimicrobial prophylaxis prior to undergoing urodynamic testing.

Answer 67

B The most potent stimulator of a ldosterone secretion is angiotensin II. The juxtaglomerula r apparatus is sensitive to renal perfusion. Decreased perfusion stimulates renin secretion which is converted in the lungs to angiotensin II and stimulates the secretion of a ldosterone. Aldosterone secretion is a lso under the influence of both ACTH and potassium, but they a re secondary influences. Sodium has no direct influence other than through volume expansion and contraction.

Answer 68

E This patient presents with a complex case of recurrent stress urinary incontinence (SUI) in spite of previous treatment, a f ixed urethra, and a low Valsalva LPP. The only reasonable option presented would be an autologous sling. Pelvic f loor exercises would be unlikely to successfully address her symptoms. lmipramine can be considered for off-label utilization for mixed incontinence, but is also unlikely to cure this degree of SUI. Sacral neuromodulation is primarily indicated for urinary urgency, and/or urge incontinence, and is not indicated for the treatment of stress incontinence. Of the two sling options presented, the autologous pubovagina l sling is the better option for recurrent intrinsic sphincter def iciency, particula rly in the face of a f ixed urethra.

Answer 69

B Radiographic assessment for possible GU trauma is required for all symptomatic pediatric patients that have sustained blunt trauma with microscopic hematuria. A normal Focused Assessment with Sonography for Trauma (FAST) exam and serial physical exams for 24 hours will nearly rule-out all significant renal injuries and spare the patient radiation. CT scan with delayed views is recommended if the FAST exam is abnormal or gross hematuria is present. MRI scan is not indicated in the evaluation of trauma.

Answer 70

B Patients with distal or type 1 RTA have a basic defect in eliminating H+ from the distal tubule. Associated urinary changes include both an increase in calcium and a distinct decrease in citrate levels. This combination results in most type 1 patients forming renal calculi. In distinction, type 2 RTA is caused by diminished bicarbonate reabsorption in the proximal tubule. While this defect also results in high urinary calcium levels for reasons that are not fully understood, it does not lower urinary citrate, and thus, these patients do not commonly form renal calculi. Sodium and phosphate handling are altered in both forms of RTA but do not seem to have much impact on stone formation. In patients with type 1 RTA, the administration of potassium citrate is the mainstay of attempting to minimize nephrocalcinosis and the formation of renal calculi.

Answer 71

E Bladder rupture should be suspected in patients with pelvic fractures. Bladder injury may be intraperitoneal or extraperitoneal. Small extraperitoneal lacerations may be managed non operatively with urethral catheter drainage and antibiotics. Contraindications to conservative management include gross hematuria with repetitive clot retention, concomitant rectal or vaginal injury, bladder neck injury, the presence of a foreign body in the bladder (such as a piece of bone or a bullet), or injury due to a gunshot. This patient has clot retention, and, therefore, should be managed by surgical repair. The injury should be approached by an intraperitoneal approach in those with pelvic hematomas. Entering the hematoma through an extraperitoneal approach risks release of a contained pelvic hematoma and significant hemorrhage. Continuous bladder irrigation is contraindicated in the presence of a bladder rupture since the fluid will extravasate, increasing the risk of pelvic abscess and pelvic osteomyelitis. The placement of a percutaneous suprapubic tube will not correct the injury and may be difficult and risky in the presence of a pelvic hematoma. Cystoscopy with clot evacuation will not correct the injury.

Answer 72

A Fish oil is an effective, first-line therapy for mild-moderate hypercalciuria. Fish oils are rich in n-3 fatty acids, more specifically eicosapentaenoic acid (EPA), which undergoes the same pathway of eicosanoid metabolism as the n-6 fatty acids found more commonly in Western diets. EPA is an essential dietary fatty acid as humans are unable to synthesize it from its precursor fatty acid, linoleic acid. EPA is found mainly in such cold-water seafood as salmon, mackerel, tuna, herring, sardines, bluefish, trout, whitefish, and striped bass. Fish oils are sold in pill and liquid form as a source of n-3 fatty acids. EPA is thought to have a protective role in preventing nephrolithiasis by decreasing urinary calcium and oxalate excretion through alteration of prostaglandin metabolism. EPA competes with arachidonic acid for cyclooxygenase, resulting in the formation of less PGE2. When PGE2 is inhibited, urinary calcium excretion is reduced. Decreased PGE2 also leads to an activation of the nephron Na/K/2Ca transporter, which results in increased renal calcium reabsorption. Greenland Eskimos, a population which has an extraordinarily low incidence of renal stone disease, consume approximately 5 to 10 gm of n-3 fatty acids daily. Most human clinical trials using fish oils have given 1200-1800 mg daily to their subjects. None of the other vitamins or supplements listed have any impact on calcium metabolism.

Answer 73

A A prostatic utricle is present in 10-15% of boys with a proximal hypospadias, and is the most common cause of difficulty in catheterizing the bladder with proximal hypospadias. The embryologic origin of the utricle is the paramesonephric duct or Mullerian duct. Remnants of the mesonephric duct give rise to Gartner's cyst, whereas, the mesonephric duct gives rise to the vas deferens and seminal vesicle. The urorectal septum divides the common cloaca into the hindgut and urogenital sinus. The urethral plate gives rise to the urethra and prostate from the urogenital sinus. A narrow urethral plate does not cause difficulty with catheterization.

Answer 74

A Adrenal incidentalomas are unsuspected adrenal masses \> 1 cm in diameter identified on imaging performed for seemingly unrelated causes. Ultrasound is a suboptimal imaging modality for detecting and fully characterizing adrenal lesions. Nevertheless, many incidentalomas will be discovered on ultrasound imaging performed for unrelated reasons. An unenhanced CT scan is the first, and perhaps single best, and most easily interpreted test for intracellular lipid, and can diagnose an adrenal adenoma in more than 70% of cases. Low attenuation (\< 10 HU) on unenhanced CT scan corresponds to high intracytoplasmic lipid content, and is diagnostic for an adrenal adenoma. Ninety-eight percent (98%) of lesions with an attenuation of 10 HU or less on non-contrast CT scan are adrena l adenomas, while less than 30% of adrena l adenomas are lipid-poor (also known as, atypica l adenomas) and have an attenuation of \> 10 HU. If a lesion demonstrates an attenuation of \> 10 HU, then additional radiological eva luation can be performed, including CT washout study to help discriminate lipid-poor adenomas from other adrenal lesions. Gadolinium-enhanced MR washout studies do not exhibit the diagnostic strength of iodine-based CT washout studies, and are not commonly employed. When MRI scan is used, opposed phase chemical-shift MR imaging to evaluate for intracellular lipid content can help distinguish an adenoma from other adrena l lesions. Functional studies such as PET imaging and an MIBG scan (used to evaluate for pheochromocytomas) are not indicated in the initial eva luation of an adrenal incidentaloma.

Answer 75

D Hematuria is one of the most common GU abnormalities in children. An association with hypercalciuria and hematuria in children is well-documented. Calcium excretion exceeding 4 mg/kg is considered abnormal. In children, the collection of 24-hour urine can be difficult. A spot urine ca lcium:creatinine ratio can be used for screening, but hypercalciuria must be conf irmed with a 24-hour urine ca lcium. A fasting level \> 0.21 or a post-prandia l level \> 0.28 are abnormal. It is unclear how the hematuria is produced by the hypercalciuria. However, these children are at risk for subsequent urolithiasis which has been reported in over ten percent of individuals. The imaging eva luation should include a renal ultrasound to exclude both calculi and structura l abnormalities. Further imaging studies are not warranted. C3 and ASO titers are unwarranted, as this child has no red cell casts or proteinuria. The yield of cystoscopy in this pediatric population is very low. Evaluation for rena l inflammatory disease or parenchymal abnormality by biopsy or contrast imaging is very low in the absence of signif icant proteinuria.

Answer 76

D This case exemplifies the classic one-kidney, one-clip anima l model of renovascular HTN and is similar to the findings of the two-kidney, two clip animal model of renovascular HTN. In these models, during the acute phase of obstruction, there is an increase in renin release and activation of the renin-angiotensin-aldosterone system (RAAS) by the ischemic kidney(s) resulting in HTN. With the absence of a contra latera l kidney, or if both kidneys are involved, contra latera l natriuresis by the unaffected kidney will not occur. Consequentially, the stenotic kidney begins to conserve sodium and fluid, resulting in volume expansion and an elevated renin (transitional phase). In the chronic phase, the elevated blood pressure, excess sodium retention, and volume expansion all act as negative feedback mechanisms for suppression of renin release resulting in volume-expanded HTN with norma l renin angiotensin-11 levels. These patients do not respond well to ACE inhibitors or angiotensin-11 antagonists unless concurrent sodium restriction is prescribed. In contrast, the two-kidney, one clip model is cha racterized by unilateral release of renin from the ischemic kidney accompanied by contra lateral suppression of renin from the norma l kidney and natr iuresis. Consequently, there is sodium retention from the ischemic kidney and excretion from the contra lateral kidney. This results in euvolemia and HTN dependent upon angiotensin-11 vasoconstr iction. Medica l management of these patients is directed at the renin-angiotensin system (i.e., ACE inhibitors and angiotensin-11 antagonists) with or without sodium restriction based on the type of renal HTN model.

Answer 77

A Pre-puberta l (in distinction to post-pubertal) mature teratoma of the testis have a benign clinical course. AFP levels are initially elevated in newborns and decline during the f irst year of life, therefore, in this patient, the AFP elevation does not indicate yolk sac elements. Treatment is partial orchiectomy after conf irmation of the frozen section. Orchiectomy and further treatment, such as, chemotherapy, radiation, or RPLND a re reserved for malignant tumors such as yolk sac. Serial ultrasounds are not necessary in pre-puberta l patients with teratoma.

Answer 78

C In a febrile but clinically stable patient, endoscopic incision has the advantage of both draining the system and the possibility that it could be a definitive treatment. The best management is cystoscopic incision of the ureterocele in order to promptly and fully drain the infected urine from the ureterocele. Endoscopic incision of the ureterocele with subsequent decompression of the upper tract would obviate the need for stent placement. Percutaneous nephrostomy placement can be of benefit in a clinically labile patient where general anesthesia for endoscopic incision of the ureterocele would be hazardous. Definitive management may require an open approach including ureterocele excision and ureteral reimplantation. However, that would not be recommended at present in this acute setting.

Answer 79

C She has small bowel herniation which is compressing her ileal loop, resulting in outlet obstruction at the fascial level. Stomal stenosis can present similarly, but without CT scan findings of a hernia. Lymphoid depletion does result in late-onset loop strictures but these are generally mid-loop. Stomal prolapse does not result in obstruction. Intestinal volvulus could result in obstruction of the loop, but again, the principal f inding on the CT scan is the hernia.

Answer 80

A During microsurgical reconstruction of the amputated penis, the urethra is reapproximated, the two dorsal arter ies, the deep dorsa l vein, and as many nerve fascicles as possible, are anastomosed. The cavernosal arteries are typically not reconstructed as they are diff icult to access and the dorsal arter ies provide adequate circulation.

Answer 81

A This patient has a T2 squamous cell ca rcinoma of the distal urethra with negative margins. Assuming that his cystoscopy is normal and there are no other signs of disease, the proper management is observation. Total penectomy is not advocated in the setting of negative margins. Currently, there is no data that prophylactic inguina l node dissection provides any benef it. Adjuvant chemotherapy is not indicated for T2 disease. Radical penectomy with cystoprostatectomy is also not indicated with the finding of negative margins and no evidence of disease in the bladder.

Answer 82

D BP control has been identif ied as one of several measures to help prevent progression of chronic kidney disease (CKD). Others include: lifestyle modification, glycemic control, reduction of proteinuria, protein restriction, lipid control, correction of anemia, correction of acidosis, and maintenance of fluid balance. Angiotensin II is thought to be central to the progression of CKD via both hemodynamic and non-hemodynamic mechanisms . ACE inhibitors can reduce glomerular pressure as well as proteinuria, which has a sentinel role in renal scarr ing. In addition, ACE inhibitors appear to improve interstitial capillary p02 levels, thus decreasing renal sclerosis risk. All other therapies, including ca lcium channel blockers (e.g., amlodipine), beta-blockers (e.g., atenolol), a lpha-agonists (e.g., clonidine), and diuretics (e.g., hydrochlorothiazide) do not provide as much reno-protection as ACE inhibitors or angiotensin receptor blockers (e.g., losartan).

Answer 83

C According to the American Society of Gastroenterology, diarrhea, with a positive test for clostridium difficile with signif icant volume loss and electrolyte abnormalities, is def ined as severe and/or complicated infection. l.V. f luid resuscitation, electrolyte replacement, and pharmacological DVT prophylaxis is recommended. In the absence of ileus or signif icant abdominal distention, ora l or entera l feeding should be given. CT scan of the abdomen and pelvis is recommended. Vancomycin, orally or via the enteral tube at 125 mg PO four times daily plus metronidazole 500 mg l.V. three times daily, is strongly recommended in the guidelines. Oral metronidazole is recommended for mild to moderate infection and considered under treatment for severe cases. Single agent treatment with vancomycin alone is also considered under treatment. Rectal vancomycin and/or metronidazole is reserved for severe infection with ileus, abdominal distention, or toxic colon.

Answer 84

B The determination of stress urinary incontinence (SUI) secondary to sphincter def iciency should be performed at bladder volumes of 200 ml or greater, and require that the patient reaches Va Isa Iva intra-abdomina l pressures of greater than or equa l to 60 cm H20. Failure to reach these intra-abdomina l pressures or bladder volumes during the performance of a videourodynamic study are two of the main reasons for a false negative test for sphincteric incontinence. In the presence of a urodynamic study reaching adequate bladder volumes and adequate Va lsa lva pressures, the next most common cause for a videourodynamic to fail to dia gnose sphincteric incontinence is the presence of an indwelling catheter during the time of urodynamic study. An indwelling catheter may prevent demonstration of SUI at the time of testing by causing a physica l obstruction of a coexisting bladder neck contraction, or alternatively, by causing spasm of the urethral sphincter related to catheterization. In these situations, the urethral catheter should be removed while at maximum bladder capacity and a Va lsa lva maneuver performed. Leakage can be conf irmed by the concurrent use of video portion of the study. If no leakage is found, the patient should be requested to void and conf irmation of complete bladder emptying noted, to rule-out the possibility of coexisting impaired detrusor contractility and overflow incontinence. Alternatively, a simple postvoid ultrasound residual could have been performed as part of the initial eva luation in a patient with post-prostatectomy ur inary incontinence to rule-out this possibility. The use of straining, tapping, and Crede maneuvers a re classically used in a patient with an underactive bladder in an attempt to elicit a detrusor contraction when the patient is unable to void on request. Va Isa Iva intraabdominal pressures of 100 cm or higher are required to evaluate for hypermobility of the bladder neck in women complaining of stress urinary incontinence.

Answer 85

D Patients with an oncocytoma, or small renal tumors with indeterminate histology, should be followed with the same imaging protocols used for untreated, low risk (cT1, NO, Nx) renal cancer patients. This recommendation for benign tumor follow-up is based on two concerns: 1) benign tumors can exhibit substantia l growth patterns over time that may threaten destruction of the renal unit by compression/invasion of surrounding parenchyma and vascular structures; 2) although the accuracy of percutaneous biopsy has improved substantia lly in the past several years, the pathologic differentiation between oncocytoma and oncocytic neoplasms (e.g., chromophobe renal cell carcinoma) and renal cell carcinoma can at times be difficult, with the true pathology of the mass only coming to attention by rapid tumor growth. The purpose of routine imaging of these benign neoplasms is, therefore, to capture undue tumor growth and allowing for expedient surgical/ablative intervention and avoidance of radical nephrectomy. AUA Guidelines for the follow-up of renal cancers and untreated low-r isk tumors, including oncocytoma, include: 1) history and physical examination; 2) basic laboratory testing to include blood urea nitrogen (BUN)/creatinine, urine analysis (UA), and estimated glomerular f iltration rate (eGFR); 3) continued renal imaging (US, CT or MRI scan) at least annua lly, and annual chest X-ray (CXR) to assess for pulmona ry metastases. Repeat biopsy is not indicated or wa rranted for the routine follow-up of such patients, as therapeutic intervention is based on subsequent neoplasm growth rate.

Answer 86

C Spontaneous bladder perforation following enter ic bladder a ugmentation occurs in 8 to 10% of cases, most commonly presenting with signs of peritonitis and acute abdomen. It can be life threatening, especially in the neuropathic population, as often their neurologic def icit causes atypica l presenting symptoms and sepsis can occur rapidly. Late perforations most often occur in the bowel segment, approximately 1 cm from the anastomotic line. A standard cystogram has a high false negative rate, and a CT cystogram is recommended in patients with abdomina l symptoms suggestive of bladder rupture. While most perforations are managed with laparotomy and primary closure, conservative treatment with catheter drainage has been reported successf ul in very selected cases, usua lly with contained, late perforations in patients without VP shunts. Endoscopy is not diagnostic for perforation, and can lead to worsening dissemination of infected urine in the a bdomen. Shunt externalization is often required due to per itonitis and contamination of the a bdomina l shunt catheter, but shunt series is not necessary.

Answer 87

C These symptoms are likely related to the sling being too tight leading to her de novo symptoms. The best option at this time would be to initiate CIC to allow for adequate emptying and minimization of symptoms. Alpha-blockers would not impact this anatomic obstruction. Urethral dilation is likely to be ineffective. Fascia I slings tend to loosen up over time, and with the use of CIC, her residuals can be continua lly monitored for possible improvement. Sling loosening would not likely be effective. Sling incision should be considered if these symptoms do not improve with time. The optimal time for sling incision post-sling placement is not known, though many authors advocate waiting three to four months after the sling has been placed. This is certainly different than how obstruction is managed after mid-urethral sling, with many considering sling incision within the f irst month after sling placement.

Answer 88

A This patient has had an adrenal hemorrhage and displays the classic triad of mass, anemia, and jaundice (secondary to blood absorption from the retroperitoneum). Males can present with scrotal hemorrhage. Ultrasound is the best way to conf irm the diagnosis, and after excluding neuroblastoma, is an ideal follow-up tool. CT scanning often requires heavy sedation or anesthesia in the very young child. Biopsy and surgery are not required. Spontaneous complete resolution will usua lly occur within months.

Answer 89

A Roughly 74% of men who take chronic opioids will have low testosterone. Opioids have been shown to have an inhibitory eff ect on gonadotropin-releasing hormone secretion in the hypothalamus, thus, to decrease gonadotropin production and testosterone production. Weaning opioids may result in an increase in serum testosterone levels. Beca use this couple wants to have children in the future, exogenous testosterone with gels and injections should not be used as this can impair semen parameters. The likely cause of this patient's erectile dysfunction (ED) is his low testosterone, thus, sex therapy will probably not solve his ED problem. Urethral alprostadil suppositories should not be used during unprotected intercourse with a pregnant partner, as this may induce uterine contractions, and should not be used in couples trying to achieve pregnancy.

Answer 90

E Delayed bleeding following percutaneous nephrolithotomy indicates the presence of an arteriovenous fistula or arterial pseudo aneurysm. New onset bright red blood favors an arterial pseudo aneurysm. The next best step is selective angioembolization. The pseudo aneurysm is at risk to bleed, so bed rest is not appropriate in this scenario. A nephrostomy tamponade catheter and/or fulguration is most effective for immediate bleeding following the nephrolithotomy procedure. Renal exploration is reserved for recalcitrant bleeding if angioembolization fails or life threatening bleeding ensues.

Answer 91

D This woman has an uncomplicated UTI. UCx is not necessary when symptoms are present, she has no risk factors for a complicated UTI, and UA reveals pyuria and/or bacteriuria. Bactrim is the best empirical agent for uncomplicated UTI in women. Quinolones should be reserved for cases of recurrent UTI or a history of bactrim resistance.Three day therapy is the preferred treatment regimen for uncomplicated cystitis in women. Single dose therapy has a high rate of recurrence.

Answer 92

A According to the AUA Guidelines on overactive bladder (OAB), a therapeutic trial of therapy is a minimum of four to eight weeks for pharmacologic therapy and eight to twelve weeks for behavioral therapy. This patient has only been treated for two weeks, and further improvement may be seen with her present management plan. A change in oral thera py (solifenacin or mirabegron) should be considered only after she has failed an adequate trial length of her present therapy. Failure is def ined as lack of improvement after four to eight weeks of pharmacologic thera py and/or the development of intolerable pharmacologic side effects. OnabotulinumtoxinA is indicated for patients that have failed oral pharmacologic thera py. In the routine eva luation of the OAB patient, cystoscopy is not indicated unless the screening UA is abnormal.

Answer 93

C Recent studies on post-prostate biopsy sepsis have noted significant resistance to f luoroquinolones (90%), piperacillin (72 %), trimethoprim/sulfamethoxazole (44%), and even gentamicin (22%). However, minima l to no bacteria l resistance is noted to the carbapenems (imipenem and meropenem) and a mikacin. In addition, the oral second (Cef uroxime, Cefaclor) and third-generation cepha losporins (Cef ixime, Cefdinir) maintain a good bacterial sensitivity pattern.

Answer 94

A The low plateau-shaped curve and elevated PVR a re indicative of bladder outlet obstruction, and the increased pelvic f loor activity suggests uncoordinated detrusor-pelvic floor function during voiding. The absence of other neurologic signs or symptoms, high volume incontinence, or high PVR would make neurogenic bladder less likely. VCUG is not necessa ry in the a bsence of f ebrile UTls to rule-out reflux, although imaging of the outlet can show sphincteric dysfunction during voiding. Antimuscarinics a re contraindicated in the setting of elevated PVR without CIC. The PVR volume is not of a suff icient volume to warrant CIC, and CIC is unnecessa rily invasive. Biofeedback has been shown to normalize mictur ition pattern to improve emptying, incontinence, and frequency of UTI. OnabotulinumtoxinA injection in the external sphincter can be used in refractory cases but is not a pproved for use in the sphincter or in children. Alpha block ing agents have been shown to be effective but do not off er the potential of a long-term cure.

Answer 95

C Hand-assisted laparoscopic radical nephrectomy is comparable to conventional laparoscopic techniques by all measures of peri-operative and oncologic outcomes except for higher wound complications, such as hernias and infections at the hand-port site. The published incidence of these complications with hand-assisted nephrectomy is approximately 4-9%.

Answer 96

D The patient presents with muscle-invasive bladder cancer (cT2) with a notable history of renal insufficiency and advanced age. Nevertheless, he remains a candidate for radical cystectomy and this should be the primary recommendation. Comorbidities, not age, should be used when deciding on radical cystectomy, and surgery can and should be considered for this patient as multiple series have demonstrated benefits of radical cystectomy in elderly patients with invasive disease. Multifocal CIS is a contraindication for chemoradiation therapy alone. Neoadjuvant chemotherapy is intended for patients with operable clinical stage T2 to T4a muscle-invasive disease. Although the data available supports the use of either M-VAC (Methotrexate, Vinblastine, Adriamycin, and Cisplatin) or CMV (Cisplatin, Methotrexate, and Vinblastine) as neoadjuvant chemotherapy, it has been estimated that more than 50% of patients are ineligible for cisplatin based chemotherapy because of impaired renal function or medical comorbidities. This patient has impaired renal function that will preclude the use of cisplatin-based neoadjuvant chemotherapy. In patients with compromised renal function, carboplatin + gemcitabine has been utilized. However, the efficacy of carboplatin-based regimens in the neoadjuvant setting is unproven and may contribute to a delay in definitive surgery without a known oncologic benefit. Adjuvant chemotherapy has been advocated for high-risk patients (pT3-4, N+ patients) in an effort to delay recurrence and prolong survival. Unfortunately, the question of the true benefit of adjuvant chemotherapy in high-risk patients with pT3, pT4, and N+ disease is currently unknown. Although this patient may be a candidate for adjuvant chemotherapy, the decision to pursue such an approach will depend on his pathologic staging, and is, therefore, not a foregone conclusion.

Answer 97

A Clinicians should offer a llopurinol to patients with recurrent calcium oxa late stones who have hyperuricosuria and norma l urina ry calcium. A prospective randomized, controlled tria l demonstrated that allopurinol reduced the risk of recurrent ca lcium oxa late stones in the setting of hyperur icosur ia (urina ry uric acid excretion \> 800 mg/day) and normoca lciuria. Whether the drug is effective in patients with hypercalciuria has not been established. Hyperuricemia is not a required cr iterion for allopurinol therapy. In addition to medication, limiting non-da iry anima l protein may maximize the eff icacy of allopurinol. Chlorthalidone and hydrochlorothiazide would be indicated in the setting of hyperca lciuria. Potassium citrate is indicated for hypocitraturia, which is not present either. Triamterene, a lthough it is a potassium-spa ring diuretic, should be avoided as stones of this compound have been reported.

Answer 98

E Everolimus (RAD001) is a n orally administered inhibitor of mTOR. In the RECORD 1 trial which compa red everolimus to placebo in a phase 3 prospective randomized tria l of patients who received previous targeted therapy, progression-free surviva l was improved in the everolimus treated patients (4.0 vs. 1.9 months). As such, treatment with everolimus is a category 1 recommendation after tyrosine kinase inhibitor therapy according to the NCCN Kidney Cancer panel. Axitinib is also a category 1 recommendation for this group of patients. A variety of other studies have evaluated the use of temsirolimus, bevacizuma b, a nd sorafenib in the setting of failure after initial therapy and each of these agents have shown some effect. However, given the limited outcomes, these agents are given a category 2A recommendation in the recurrence. The NCCN guideline panel considers pazopa nib a category 3 recommendation because no data exists for this drug in this setting.

Answer 99

A There are several appropriate analyses in the setting of a tria l with a binary va riable. Fisher's exact test should be used when the expected number of subjects in any subgroup is below f ive. Chi-squa re test is also appropriate when the dependent variable is measured as a binary variable, and any of the expected sample size of subjects per subgroup is five or greater. ANOVA is used to compa re more than two groups. Logistic regression would be the appropriate test if there was an additional independent va riable. The Pearson correlation coefficient is the appropr iate test when assessing the relationship between two variables.

Answer 100

C Abiraterone acetate is a specif ic, potent, and irreversible inhibitor of CYP17. CYP17 both facilitates the conversion of cholesterol to androstenedione and dehydroepiandrosterone (DHEA), made in the adrenal glands, and also inhibits the conversion of seconda ry androgens into testosterone and dihydrotestosterone. CYP17 activity can be inhibited by both ketoconazole and abiraterone acetate; however, ketoconazole competitively inhibits CYP 17. Its pharmacological eff ectiveness is, therefore, a reflection of the concentration of ketoconazole within the cell and a re temporizing in nature. By contrast, once abiraterone acetate binds to a molecule of CYP17, the CYP17 molecule is permanently disabled. Because abiraterone effectively shuts down the effects of CYP17, it inhibits the synthesis of androgens by both the testes and the adrena l. The completeness of this blockade will lead to loss of inhibitory feedback on the pituitary gland, resulting in excess adrenal stimulation and a build-up in steroid precursors that will be diverted into alternative pathways that will eventually result in an increased production of aldosterone. The increase in mineralocorticoids leads to fluid retention and hypokalemia. To prevent this complication, low dose prednisone is administered to enhance a negative feedback on the pituitary system. Although steroids can help reduce inflammation, bone pain, nausea, and anorexia in any cancer patient, steroids a re not used for this indication dur ing treatment with abiraterone. Enzalutamide, not abiraterone, is involved in the process of nuclear translocation of the androgen receptor as part of prostate cancer anti-tumor activity. Abiraterone is not involved in cellular microtubule assembly; this is the anti-tumor mechanism of docetaxel.

Answer 101

B HPV is the most common STI in the US and worldwide. The highest prevalence of genital HPV is found in sexually active adolescents and young adults. HPV is associated with cervical and other cancers, including: penile, anal, vulvar, vaginal, and oropharyngeal. The FDA-approved HPV vaccines have been shown to be very safe. This quadrivalent vaccine (Gardasil) contains no viral DNA and is bioengineered to contain virus-like particles produced from the major capsid protein of HPV types 16, 18, 6 and 11. There is no data to suggest that there are vaccine-specific adverse effects with the exception of rare anaphylaxis to the vaccine components. The HPV vaccines appear to be very effective, but a re beneficial only if an individua l has not previously been exposed to HPV. Therefore, it is recommended that the vaccine is administered before the onset of sexua l activity. The duration of vaccine-induced antibodies is known to be at least f ive years in males and nine years in females. Clinical studies demonstrate a high degree of effectiveness in preventing genital lesions and intraepithelial neoplasia associated with HPV genotypes 6, 11, 16, and 18. The American Academy of Pediatrics recommends routine vaccination of both boys and girls who are 11-12 years of age.

Answer 102

A This patient has adrenal insuff iciency secondary to bilateral adrenal hemorrhage. This can occur in anticoagulated patients, typically during the first three weeks of therapy. The initial therapy should be administration of l.V. fluids and glucocorticoid therapy. Fresh frozen plasma is not acutely indicated with an adequate hemoglobin level. Kayexa late will help lower a high potassium but not improve the hypotension from adrena l steroid deficiency. Chronic but not acute adrena l insuff iciency is treated with fluorohydrocortisone. Vitamin K will help restore clotting factors depleted by warfarin therapy, but is not the initial therapy for this patient.

Answer 103

C This patient has poor prognosis NSGCT because he has non-pulmonary visceral metastases. In that setting, the standa rd f irst line regimen is BEP times four cycles. EP times four cycles or BEP times three cycles are both appropriate first-line options for good prognosis disease, but not poor prognosis as is demonstrated here. The last two regimens, VIP (Vinblastine, lfosfamide, and Cisplatin) and high dose chemotherapy with bone marrow rescue, can be used for sa lvage therapy in patients who relapse or are refractory to f irst-line therapy but a re not standard f irst line regimens.

Answer 104

A This patient has calciphylaxis, an obliterative small vessel vasculopathy that causes skin necrosis and ulceration. Calciphylaxis predominantly affects patients with chronic kidney disease; obesity and diabetes mellitus appea r to be additiona l risk factors. Skin debridement should be carried out very judiciously, as the debrided areas tend to demonstrate poor wound healing and have little impact on the pain. Corticosteroids have not demonstrated eff icacy in the management of calciphylaxis. Infections have not been implicated in the pathophysiology of calciphylaxis; therefore, antibiotics and antifungals are not indicated. Biopsy is contraindicated in this individua l as these lesions a re easily identif ied visualy

Answer 105

A ADR of cytotoxic chemotherapy for metastatic testicular cancer a re well-established, as BEP chemotherapy has been a mainstay regimen for decades. The major toxicity of cisplatin is neuropathy, while the most major side effect of etoposide is bone marrow suppression. Bleomycin has pulmona ry toxicity risks that have also been well-documented with an incidence of approximately 10%. Pulmonary toxicity is dose-dependent, and, thus increasing in severity with more cycles of BEP.

Answer 106

B Cystinuria is an inherited AR disorder cha racterized by excessive urinary excretion of cystine. Average age at first stone diagnosis is 12.2 years. The most important factors in preventing cystine stone formation in the urinary tract are lower ing urinary cystine concentration and maintaining an alkaline urinary pH. Adequate hydration with fluid intake of 3-4 L per day, with waking at night to imbibe, is recommended. Potassium citrate alkalinizes the urine and increases the solubility of cystine in the urine. Renacidin irrigation of the renal collecting system is indicated for apatite (calcium carbonate) or struvite stones. Acetohydroxamic acid enhances eff icacy of antibiotic therapy directed toward UTI caused by urea-splitting organisms. Penicillamine and alpha-mercaptopropionlglycine (alpha-MPG a re chelating agents that combine with cystine to increase solubility and are used when hydration and alkalinization therapies fail. Penicillamine has a higher rate of adverse reactions compa red to alpha-MPG.

Answer 107

C DDx: cystitis, infected VP shunt with secondary peritonitis, peritonitis from an alternative source (e.g., appendicitis), or perforation of the augmented bladder. The chief diagnosis to rule-out in this situation is a rupture of the bladder augment and a CT cystogram should be obtained. If a CT scan documents intra-per itoneal fluid collection a round the VP shunt and the absence of a bladder perforation, strong consideration should be made for a VP shunt infection and appropriate neurosurgical evaluation is indicated. An abdomina l and pelvic ultrasound may demonstrate intra-peritonea l fluid but could not differentiate an infected VP shunt with an associated fluid collection versus rupture of the augment. Cystoscopy places the individual at a higher risk of sepsis if a bladder rupture has occurred and is not as diagnostica lly accurate as a CT cystogram. Starting l.V. antibiotics may be appropr iate, but would not a llow the physician to accurately diagnose the under lying etiology. Exploratory lapa rotomy is not diagnostically indicated at this time.

Answer 108

D First line therapy in patients with uric acid stones is dietary restriction of anima l proteins and a lkalinization of urine to pH \> 6 with potassium citrate. If this fails, then increasing allopurinol to 100-300 mg/day will reduce the urinary uric acid. Alpha-mercaptopropionylglycine is used for treatment of cystine stones. Reducing sodium intake will reduce stone risk in patients with hypercalciuria. Increase in intake of fruits and vegetables does not have suff icient clinical evidence to reduce stone occurrence in patients with low urinary citrate.

Answer 109

A In the study of animal models of erection and detumescence, there are six to seven phases that occur. In the flaccidity or detumescence phase, there a re three phases. The initial event that occurs is cavernosa l smooth muscle contraction (not relaxation which initiates an erection) that ca uses an initia l rise in the intracorporal pressure. Thus, endothelia l relaxation does not initially occur. This is followed by a slow pressure decrease as the reopening of the venous channels occurs with resumption of the baseline a rterial flow. The final phase is a rapid drop in intracorporal pressure leading to complete f laccidity.L

Answer 110

C Tamsulosin, although not approved for use in children, has shown eff icacy as medical expulsive therapy in children, but it is unlikely to be successful with a stone of this size, particula r ly since it has not entered the ureter. SWL is used in children with stones up to 15 mm, but has poor stone free rates in children with a history of urologic condition or reconstruction. Ureteroscopy and PCNL are preferred moda lities in this situation, but ureteroscopic management is less invasive with excellent stone free rates for stones \< 15 mm. Revision pyeloplasty is not appropr iate since there was minimal hydronephrosis on recent ultrasound suggesting no evidence of UPJ obstruction.

Answer 111

C The majority of testosterone that circulates is primar ily bound to serum hormone binding globulin (SHBG), with albumin and cortisol binding globulin (CBG) playing lesser roles. Only 1-3% of total testosterone circulates unbound (free). SHBG production in the liver a nd Sertoli cells are altered by obesity, liver disease, and nephrotic syndrome. Obese males have reduced SHBG, and thus lower total testosterone, while the free testosterone levels are genera lly unchanged. The excess aromatase activity in visceral fat in obese men translates into greater testosterone breakdown to estradiol, which further lowers the total testosterone level and elevates the estradiol level.

Answer 112

B This is a scenario of a signif icant arterial injury due to blind placement of a large bore trocar. The most likely injury, in this case, is either to the aorta or common iliac arteries from blind passage of a trocar. As the patient is rapidly becoming unstable, a vascula r surgeon should be consulted, but immediate action is required. Simply increased insuff lation pressure would not address this major vascular injury. With the trocar presumably still within the injured vessel, the trocar should be closed and kept in place, if possible, to allow for the exploratory laparotomy to be directed to the precise location of the injury. The trocar should not be completely removed as it may be providing some element of tamponade of the injured vessel. Withdrawal of the trocar from the vessel lumen, in addition to the loss of pneumoperitoneum, could result in rapid exsanguination; however, if the troca r has a lready been withdrawn out of the injured vessel a nd a laparoscope placed, attempts can be made to assess the degree a nd site of injury laparoscopically. Ra pid conversion to exploratory laparotomy should be performed, especially in the scenario of cardiovascular collapse. In such a case, the trocar and laparoscope can be angulated along the anterior abdomina l wall, a llowing for rapid cut down onto the trocar. As this particular patient is in rapid clinical decline, adding an additional trocar or converting to a hand-assisted technique to attempt to repair the injury lapa roscopically would be too time consuming and potentially dangerous. However, in a more sta ble situation, both may be reasonable approaches depending on the laparoscopic experience and skill level of the surgeon.

Answer 113

E The patient is bothered by his disease, and his condition is unlikely to improve; therefore, reassurance would not be an a ppropriate option. Additional collagenase would be considered off-label use as only eight injections a re currently indicated for treatment. In addition, collagenase injections are only indicated for greater tha n 30 degrees of curvature. There is no data to suggest that switching to verapamil injections would offer a better response and verapa mil injections are considered off-label use. A penile plication should be avoided in men with moderate ED. The best option is insertion of penile prosthesis.

Answer 114

A Groin/thigh pain after transobturator sling in women with thin, athletic builds is not uncommon. Indeed, some experts believe women fitting this description should preferentially undergo a retropubic mid-urethra l sling, rather than a transobturator sling. If a patient should develop groin/thigh pain following a transobturator sling, conservative therapy with NSAIDs for a nalgesia and the passage of time should resolve the major ity of symptoms. If, however, the pain persists after six to eight weeks, consideration for referral to a pain clinic for trigger point injections and a physical therapy consultation may be of benef it. Sling urethrolysis a nd remova l should be reserved for recalcitra nt problems failing the aforementioned interventions.

Answer 115

B This patient is at risk for a local recurrence and this may present as a f istula, especially with a history of XRT. Biopsy is indicated rather than fulguration. He eventually may need resection and a ppropriate therapy, but radical surgery is not indicated until a diagnosis is conf irmed.

Answer 116

E An injury to the vertebral column at L-4 injures the cauda equina, and depending on the extent of neural damage, will produce a loss of motor a nd sensory f ibers to the bladder, pelvic floor, and externa l sphincter. Detrusor sphincter dyssynergia is produced by suprasacral spinal cord lesions that interrupt the ascending a nd descending pathways between the sacral spinal cord and the center for reflex detrusor a nd urethral function in the brain stem. Reflex detrusor function requires sacral root and sacral cord integrity. While an areflexic bladder faces fixed internal sphincter activity, that activity is normal and not truly dyssynergic. Since within the sacral and lumbar canal the nerve roots are intermingled, a lesion that produces detrusor areflexia would be expected to have a similar effect on the external sphincter, hence, the denervation potentials.

Answer 117

A According to the 2015 AUA Guideline on Peyronie's, NSAIDS are an appropriate treatment option for men presenting with penile pain in the active phase. Vitamin E is not recommended as a treatment option for men with Peyronie's disease. Pentoxifylline and penile stretching device are considered off-label use for the treatment of Peyronie's disease. Finally, intralesional collagenase injections should only be offered during the stable phase of the disease. No oral agents, such as Potaba, other than NSAIDS are indicated for the treatment of Peyronie's disease.

Answer 118

While performing a right, robotic, partial nephrectomy and during an exchange of a robotic instrument by the bedside assistant, the new instrument is inadvertently advanced into the liver. The most likely cause of this injury is due to: A. dislodgement of instrument faceplate. B. forceful insertion of the instrument. C. lack of visualization of instrument tip during advancement. D. accidental activation of instrument arm clutch button. E. defective instrument.

Answer 119

A Renal artery stenosis is estimated to be the etiology of elevations in blood pressure in \< 1% of the total hypertensive patient population and in 10-20% of patients with refractory HTN. The radiographic presence of renal arterial stenosis alone, is not, however, adequate justif ication to warra nt a correction in a hypertensive patient. The stenotic lesion must be f unctiona lly significant, in essence, reduce blood flow in a n amount suff icient to activate renin release. Classically arteriographic findings associated with an increase in renin secretion are rena l arterial narrowing exceeding greater tha n 75 percent or greater than 50 percent renovascular stenosis with post-stenotic dilation. However, the exact degree of renal artery stenosis that would justify revascularization is not known. In patients found to have a 50% or greater arteria l stenosis, duplex Doppler ultrasonographic scanning is recommended. This test is noninvasive, relatively inexpensive, ca n be used in patients with any level of renal function, and is both sensitive (98%) and specific (98%) for the presence of renovascular induced HTN. Currently, this patient is asymptomatic with excellent blood pressure control a nd with a norma l Doppler ultrasound study. Serial monitor ing of blood pressure a nd rena l function are suff icient for follow-up. In patients with a 75 % narrowing, 10% may progress to complete occlusion within two years and up to 60% will progress to stage 3 or higher renal failure within six years. Consideration for interva l radiologic follow-up is usually added to the follow-up protocols in this asymptomatic patient population. Split differential rena l vein renin measurements a re now performed very infrequently because of their limited clinical utility and need for invasive catheterization. A rena l vein renin ratio of greater than or equal to 1.5 (affected to non-affected side) is considered signif icant for the presence of renin-dependent HTN; its clinica l utility in being a ble to determine who will respond to renal revascularization is controversia l. However, it has been found to be usef ul for prognostic purposes in pediatric patients where there is an ipsilatera l diminished renal f unction (less than 25 %) and nephrectomy is a consideration for resolution of HTN. Percuta neous transluminal balloon angioplasty +/ stenting is not indicated in this patient who does not have renovascular HTN. Randomized, controlled trials comparing renal stent placement with balloon treatment alone have documented procedural superiority for primary stent placement. The need to re intervention in the percutaneous translumina l rena l angioplasty group is a pproximately three fold higher (48%) compared with that of the stent group (14%). The reduced restenosis with stenting compared with angioplasty a lone was not, however, associated with a significant difference in benef its in HTN control or renal f unction.

Answer 120

B The primary and direct mechanism by which angiotensin II (ATll) maintains GFR during hypoperfusion is by efferent arter iolar vasoconstriction. The effect of vasoconstriction is greater for the efferent than afferent a rteriole. ATll ca uses a decrease in rena l medullary blood f low rather than an increase. ATll may result in rena l artery constriction during hypovolemia . ATll increases aldosterone production that affects the cortical collecting tubule, activating sodium channels resulting in net sodium and water a bsorption.

Answer 121

A Urethrocutaneous f istula is a complication of hypospadias repair. Although all of the choices listed may reduce f istula recurrence, the most important step for a successful outcome of fistula repair is eva luation for and assurance of absence of urethral str icture dista l to the f istula site. Repair, therefore, needs to include assessment for dista l obstruction as well as excision of the fistula tract with closure of the urethra l opening and vascularized f lap coverage over the defect. Successful fistula repair requires hea lthy skin and subcutaneous tissue immediately sur rounding the f istula site. In general, urethra l stenting does not impact outcome following a straight forward urethrocutaneous fistula repair, and post-operative care requirement should be minimal.

Answer 122

E The patient has a vocationa l indication for stone remova l. The procedure most likely to render him stone-free in a single procedure is ureteroscopy. As the stones are in the kidney, medical expulsive therapy is not indicated. The patient has not yet undergone metabolic work-up, so potassium citrate at this point is premature. SWL will not permit a bilateral treatment in the same session, and does not provide for immediate stone clearance so that the patient may resume his vocation

Answer 123

C The use of a conventional Hasson trocar following balloon dilation in retroperitonea l laparoscopic procedures is often fraught with unique cha llenges, including leakage of gas around the trocar despite securing fascia I sutures to the cone portion of the Hasson trocar. This occurs as the initial fascial incision is often larger than the size of the 12 mm trocar a llowing for diffusion of C02 gas around the trocar and into the subcutaneous space. Subsequent systemic absorption of the subcutaneous gas results in hypercarbia. With the advent of balloon access trocars, this problem is less common than with standard 12 mm trocars that may not form as tight a sea l against the fascia. The retention doughnut-shaped balloon placed on the inside of the fascia and peritoneum is secured against a foam cuff on the outside of the fascia creating a tight seal, thus minimizing gas leakage around the trocar. This patient is healthy and has no history of underlying pulmonary disease. A rupture of an occult pulmonary bleb would result in a pneumothorax but not subcutaneous emphysema. Entry into the peritonea l cavity would not necessarily increase the risk of hypercarbia. Lastly, there is no mention of bleeding or entry into a large vascular structure that would lead one to suspect venous absorption of gas.

Answer 124

E Asymptomatic renal stones in native kidneys do not require any pre-operative intervention. Thus, this patient should proceed with renal transplantation and the stone does not need to be addressed with procedures such as SWL, ureteroscopy, PCNL, and nephrectomy

Answer 125

D Fowler's syndrome, first described in 1985, refers to the development of urinary retention in young women in the absence of overt neurologic disease. The typical clinical history is that of a woman younger than 30 years who has found herself unable to void for a day or more. It is noteworthy that 50% of affected patients will be found to have polycystic ovaries in association with the urinary pathology. Patients classically will not complain of urinary urgency, but invariably complain of increasing lower a bdominal pain and discomfort. Clinical suspicion for Fowler ' s syndrome should be given if a young woman is found in urinary retention, bladder capacity of over 1 L, with no sensation of urinary urgency. On needle electrode, electromyographic (E MG) examination of the external urethral sphincter, abnormal EMG activity with complex repetitive discharges, and decelerating bursts will be noted. This abnormal EMG electrical activity impairs externa l urinary sphincter relaxation. Simultaneous CMG studies reveal excellent bladder compliance associated with detrusor acontractility. Due to the absence of detrusor contractility, true detrusor externa l sphincter dyssnergy is not seen. While the same EMG abnormality on occasion may be found in women with obstructed voiding, it will not be associated with detrusor acontractility; rather, the patient will be found to have high voiding pressures and low urinary flow rates.

Answer 126

E The CHAARTED trial has shown clear survival benefits to ADT and docetaxel chemotherapy in the setting of high volume, hormone-sensitive, metastatic prostate cancer. In the pivotal trial, Sweeney, showed an HR of 0.61 (0.47-0.80), p=0.0003, with median overall survival advantage from 44.0 months to 57.6 months for the entire cohort. Specifically for the high volume disease, the HR was 0.60 (0.45-0.80), p=0.0006 with median overall surviva l advantage from 32.2 months to 49.2 months. The STAMPEDE trial has shown similar results, thus, confirming the eff icacy of cytotoxic chemotherapy with ADT in the hormone-sensitive metastatic setting. While ketoconazole could certainly aid in attaining castrate levels of testosterone, this patient does not display impending pathologic fracture or cord compression, and there is no clear indication for the addition of ketoconazole. Sipuleucel-T, enzalutamide, and abiraterone are approved only for metastatic castration-resistant prostate cancer