2018 Flashcards
Oliguria associated with acute tubular necrosis is characterized by which urinary findings:
A. ↑ sodium, ↓ urea, ↓ osmolality.
B. ↓ sodium, ↓ urea, ↓ osmolality.
C. ↓ sodium, ↑ urea, ↓ osmolality.
D. ↑ sodium, ↑ urea, ↑ osmolality. E. ↓ sodium, ↓ urea, ↑ osmolality.
A: Most major causes of acute renal failure can be differentiated by urinalysis and urinary chemistries. With tubular cell injury, the kidney is no longer able to reabsorb filtered salt and water (under normal conditions, approximately 99% of filtered NaCl and water are reabsorbed and 50-80% of all filtered urea is excreted). In acute tubular necrosis, renal tubular function is injured resulting in loss of filtered water which causes a decrease in urinary osmolality. In addition, failure to resorb filtered sodium and failure to excrete urea (other functions of the renal tubular cell) will result in an increased urinary sodium and decreased urinary urea.
The most important factor responsible for the frequent recurrence of UTIs in an otherwise healthy, young woman is:
A. adhesive fimbriae of uropathogens.
B. specific receptors on urothelial cells.
C. presence of pathogenic coliforms in stool.
D. feminine hygiene practices. E. method of contraception.
B:
Properties of uropathogens, sexual activity, feminine hygiene practices, and the use of an IUD and/or spermicide may increase the frequency of UTIs in predisposed women; however, they are not the most important etiologic factors. Many women who have uropathogenic bacteria present in their bowel, use various contraceptive and hygiene methods, and are sexually active without developing infections. E. coli must colonize the peri-urethral area before an uncomplicated infection can occur. Coliform organisms are recovered only rarely from the region of the vaginal vestibule, and external urethra in otherwise healthy women who do not have recurrent UTIs. It is postulated by most researchers that host factors, rather than specific pathogenicity of the micro-organisms, are the prime determinants of colonization. E. coli tend to adhere more to vaginal and buccal epithelial cells obtained from women with recurrent infection than to controls. This explains why certain women are prone to frequent recurrent infections. It would also explain why women with asymptomatic bacteruria are more prone to recurrent infection with marriage and pregnancy, and would account for UTIs associated with intercourse, various contraceptive methods, etc., in highly susceptible women.
The antimicrobial agent that can be used at the usual dosage in an azotemic patient is:
A. nitrofurantoin.
B. sulfamethoxazole.
C. doxycycline.
D. trimethoprim.
E. fluconazole.
C:
All the antibiotics listed including most tetracyclines, except doxycycline, are excreted primarily in the urine and their blood levels increase in the presence of renal insufficiency. Doxycycline is excreted mainly in the feces and does not require consideration for a dosage reduction in an azotemic patient.
A 23-year-old woman suffers a complex pelvic fracture in an MVC. A cystogram reveals limited extraperitoneal extravasation of contrast at the bladder neck. The bladder is compressed by a pelvic hematoma and an anterior vaginal laceration is also present. No other injuries are noted, and she is hemodynamically stable. Treatment should be:
A. urethral catheter drainage.
B. suprapubic cystostomy.
C. urethral catheter placement and repair of vaginal lacerations.
D. bladder repair and vaginal packing.
E. repair of vaginal and bladder lacerations.
E:
Urethral and bladder neck injuries in women are rare but potentially devastating in their effects on long-term continence and bladder function. The urethra is short, mobile, and protected by the pubis in women. Female urethral and bladder neck injuries occur in 4.6% to 6% of women suffering pelvic fractures. The typical presentation includes gross hematuria or blood at the introitus. Despite blood in the vaginal vault, over 40% of female bladder neck and urethral injuries are missed in the emergency department and only half will be detected on CT cystogram. As a result, one must have a high index of suspicion and low threshold for performing a vaginal examination in females with pelvic fractures. Female bladder neck injuries should undergo immediate repair with primary closure of any vaginal lacerations to prevent fistula formation. Longitudinal tears of the female bladder neck have been associated with higher rates of incontinence. Such injuries should be repaired immediately to preserve the functional integrity of the bladder neck. In one recent series, despite operative repair, 16% of women developed vesicovaginal fistulas, 43% had moderate or severe lower urinary tract systems, and 38% had sexual dysfunction.
A two-year-old boy with normal penile development is explored for non-palpable testes through bilateral groin incisions. On each side, the vas deferens and spermatic vessels end blindly at the internal ring. The next step is:
A. observation.
B. CT scan of abdomen.
C. serum inhibin B and abdominal ultrasound.
D. FSH, LH, testosterone level, and stimulate with hCG.
E. diagnostic laparoscopy.
A:
In a young patient with absent testes and normal penile development, testosterone stimulation was present at 16 weeks gestation. Loss of testicular function before this time leads to inadequate virilization. The finding of a blind-ending vas deferens and vessels is adequate to define the pathology and further exploration in this case is unnecessary. Chromosomal study of such cases is usually unnecessary as they carry none of the stigmata of intersexuality and will have a normal (46 XY) karyotype. At age of puberty, such anorchid patients will have elevated gonadotropin and require testosterone therapy.
A 55-year-old woman, who had a sacral neuromodulation implant placed four years ago, has declining efficacy despite several reprogramming sessions. A plain film X-ray is shown. The next step is:
A. revise lead, place electrodes deeper.
B. revise lead, place lead more laterally in S3.
C. revise lead, place lead in S4.
D. revise lead, place lead with curved stylet.
E. remove IPG and lead, initiate 200 units onabotulinumtoxinA injections.
D:
This plain film AP view shows the lead lateral in the S3 foramen. The lateral view shows it too deeply placed, and this puts her at risk for deep stimulation of S2 roots causing leg and other lower extremity untoward stimulation. The use of the curved stylet would allow placement of the lead into S3 in a more medial to lateral configuration, thereby, allowing maximal contact of electrodes to the nerve. This is due to the nerve following a medial to lateral course. Revising leads to place deeper may create stimulation of leg and other untoward effects as mentioned above. S4 stimulation has not been shown to create better efficacy than S3. Lateral lead placement would not allow best contact with the nerve. It would be premature to remove the system and start onabotulinumtoxinA injections. If ultimately utilized, the dose onabotulinumtoxinA used for OAB is 100 units.
A five-day-old boy has vomiting and dehydration. His serum CO2 is 12 mEq/L, K+ 5.5 mEq/L, and creatinine 2.2 mg/dL. A VCUG demonstrates PUV and bilateral grade 4 VUR. The next step is:
A. percutaneous cystostomy.
B. percutaneous nephrostomies.
C. valve ablation.
D. urethral catheter drainage.
E. cutaneous vesicostomy.
D:
The management of the infant with a PUV depends on the severity of the obstruction and the degree of any renal dysplasia present. The main problems arise in management of the infant with severe obstruction and compromised renal function with dehydration, acidosis, and sepsis. Initially, a small infant feeding tube, placed transurethrally, can provide bladder drainage. Once stabilized, valve ablation can be undertaken. Vesicostomy is reserved for infants who cannot undergo primary valve ablation because of the inadequate size of their urethra or for very small, unstable infants. If initial bladder level drainage does not result in satisfactory clinical improvement, temporary supravesical diversion may be considered; however, the vast majority of these patients will be found to have renal dysplasia, not ureterovesical obstruction, as the etiology of the persistently elevated creatinine.
A 40-year-old man suffers a gunshot to the abdomen with left ureteral transection at the L3 vertebral level, and a ureteroureterostomy is performed. Post-operatively, he is not able to flex his thigh. These deficits are due to injury to the:
A. femoral nerve.
B. ilioinguinal nerve.
C. genitofemoral nerve.
D. lateral femoral cutaneous nerve.
E. obturator nerve.
A:
The femoral nerve arises from the second, third, and fourth lumbar spinal segments. It appears at the lateral edge of the psoas muscle and descends into the thigh. It supplies a number of muscles including the quadriceps femoris complex, articularis genu, sartorius, pectineus, and iliopsoas. Ilioinguinal, genitofemoral, and lateral femoral cutaneous nerves are sensory nerves. The obturator nerve would be responsible for adduction of his leg.
A two-month-old, uncircumcised boy with a sacral dimple undergoes evaluation of a febrile UTI. Ultrasound shows bilateral hydroureteronephrosis and a conus medullaris at the mid-aspect of L4. VCUG shows bilateral grade 4 reflux and a normal urethra. The next step is:
A. CMG.
B. cystoscopy.
C. MAG-3 renal scan.
D. circumcision.
E. vesicostomy.
A: “CMG.” is correct.
This infant has a compromised urinary tract and a neurogenic cause must be considered. The conus normally ends above L3 and spinal ultrasound is a convenient and accurate method of screening in the neonatal period. Given his low conus, a CMG would be important to see if filling curve and storage pressure are abnormal with abnormal urodynamic findings substantiating the presence of a clinically significant tethered cord. Circumcision is not mandatory. Vesicostomy at this point is premature and cystoscopy is not necessary. The hydronephrosis, in this case, is related to the bladder dysfunction and a MAG-3 scan is unnecessary.
A 42-year-old man with azoospermia and primary infertility has a FSH of 15 mIU/L, small volume testes, and an otherwise normal physical examination. The factor that most reliability predicts his ability to have a biologic child is:
A. vasography.
B. serum FSH.
C. wife’s fertility.
D. testicular volume.
E. testicular biopsy.
C: “wife’s fertility.” is correct.
The presence of small volume testes with an elevated FSH suggests the presence of non-obstructive azoospermia. Most men with non-obstructive azoospermia will have sperm retrievable from the testes that can be used in conjunction with in vitro fertilization for the wife. The most important characteristic to determine eligibility for treatment will be the wife’s age and fertility. Screening for obstruction with vasography is not of value. Testicular biopsy may be useful as an indicator for success with intracytoplasmic sperm injection (ICSI) and sperm harvest. With an elevated FSH, diagnostic biopsy is not indicated.
A 34-year-old woman is hypertensive. Laboratory studies reveal a serum sodium of 149 mEq/L, potassium 2.9 mEq/L, and CO2 28 mEq/L. Plasma renin activity is suppressed. A CT scan reveals an enlarged left adrenal gland but no distinct mass. The next step is:
A. spironolactone.
B. nifedipine.
C. MRI scan of adrenal.
D. serum aldosterone:renin ratio.
E. adrenal vein aldosterone sampling.
E: “adrenal vein aldosterone sampling.” is correct.
This woman has hypertension due to primary hyperaldosteronism. The CT scan suggests hyperplasia of the left adrenal gland. In order to differentiate hyperplasia from an adenoma, adrenal vein sampling for aldosterone will show elevated levels on the left and suppressed levels on the right if an adenoma is present. MRI scan will not differentiate between an adenoma and hyperplasia. A serum aldosterone:renin ratio will not lateralize the lesion. If adrenal vein sampling does not lateralize, then medical therapy with spironolactone is indicated, rather than nifedipine, which is not potassium sparing. If an adenoma is present, surgical removal is the best treatment.
A 67-year-old man has bothersome LUTS six months after hip surgery despite tamsulosin treatment. His urinalysis shows 0-2 RBC/hpf, and his PVR is 90 mL. DRE demonstrates 35 gm prostate. He undergoes urodynamics as shown. The next step is:
A. creatinine.
B. antimuscarinics.
C. cystoscopy.
D. prostatic onabotulinumtoxinA.
E. TURP.
E: “TURP.” is correct.
This patient has urodynamically demonstrable bladder outlet obstruction. While antimuscarinics may help his irritative symptoms (e.g., frequency, urgency, urge incontinence), it will not address his primary obstructive problem, and indeed, may worsen his symptoms. Obtaining a serum creatinine is not useful or recommended in the BPH guidelines for work-up of LUTS. Cystoscopy may help assess prostatic size, but would be unlikely to change management as his DRE shows a 35 gm prostate on exam. OnabotulinumtoxinA injections are not approved for, nor do they have documented efficacy for the treatment of LUTS related to bladder outlet obstruction. In this patient, TURP is the next step for the treatment of bladder outlet obstruction.
A 49-year-old man had a lesion of the glans penis and undergoes excisional biopsy. Pathology reveals squamous cell CIS with a positive margin. Physical examination reveals a well-healed scar and no inguinal adenopathy. The next step is:
A. podophyllin.
B. brachytherapy.
C. excision of previous scar.
D. partial penectomy.
E. total penectomy.
C: “excision of previous scar.” is correct.
Given the positive margin, this patient requires further therapy around the scar. This can include the excision of the scar, laser therapy, or topical therapy with either 5-FU or imiquimod. Podophyllin is used to treat genital warts and has no role in the treatment of carcinoma. Partial or complete penile amputation and radiation therapy are too aggressive for this patient with CIS.
A ten-day-old infant boy is hospitalized for failure to thrive. After his umbilical stump fell off, fluid has intermittently drained from the umbilicus. The umbilical fluid has a creatinine of 10 mg/dL and grows > 105 CFU/mL of E. coli. The next step should be antibiotics and:
A. observation.
B. urethral catheter drainage.
C. VCUG.
D. cauterization of tract.
E. closure of fistula.
C: “VCUG.” is correct.
The differential diagnosis of a wet umbilicus in the infant, includes patent urachus, omphalitis, simple granulation of the healing stump, patent vitelline or omphalomesenteric duct, infected umbilical vessel, and external urachal sinus. The finding of a urinary creatinine level in the fluid draining from the umbilical stump suggests a patent urachus. While probing the urachal tract may aid in diagnosis, a VCUG should confirm the diagnosis and fully evaluate the lesion and any associated bladder outlet obstruction. Cauterization of the tract and closure of the fistula are not indicated until VCUG is performed to rule-out bladder outlet obstruction. Urethral catheter drainage will not definitively treat the patent urachus if obstruction is present.
A 76-year-old man with diabetes has hematuria. CT urogram shows a 5 mm filling defect in the distal right ureter. Ureteroscopic biopsy reveals a low grade urothelial carcinoma. The next step is:
A. nephroureterectomy.
B. ureteral stent and intravesical BCG.
C. segmental resection and ureteroureterostomy.
D. ureteroscopic tumor ablation.
E. distal ureterectomy and reimplantation.
D: “ureteroscopic tumor ablation.” was the correct answer.
In an older patient with medical problems, ureteroscopic biopsy, electro-resection, and laser destruction have been utilized to successfully manage small, low grade, non-invasive ureteral tumors. This approach may avoid nephroureterectomy or partial ureteral resection. Although historically, distal ureterectomy and reimplantation has been considered, endoscopic management of solitary low-grade tumors has become the preferred treatment. Upper tract BCG may be effective for high-grade disease, but delivery of the agent is least consistent when relying on reflux around a ureteral stent.
A 72-year-old woman undergoes an abdominal hysterectomy. In the recovery room, she is anuric for four hours despite several boluses of I.V. fluids. Her indwelling catheter is patent, blood pressure is 100/50 mmHg, and pulse is 100 BPM. Her estimated blood loss during the procedure was 1000 mL. The best explanation for her condition is:
A. acute tubular necrosis.
B. bilateral ureteral obstruction.
C. prerenal azotemia.
D. hypovolemic shock.
E. bladder perforation.
B: “bilateral ureteral obstruction.” is correct.
Hysterectomy accounts for over 50% of iatrogenic ureteral injuries and a high index of suspicion must be kept in this scenario. Anuria always implies complete ureteral obstruction until proven otherwise. The two most likely areas where the ureter can be occluded during hysterectomy are at the level of the broad ligaments and at the vaginal cuff and bladder trigone. Consequently, the most likely finding in this patient would be a ureteral obstruction at the level of the vaginal cuff. While hypovolemic shock and low urine output are commonly seen after all types of abdominal operations, the presence of anuria in this case suggests an obstructive etiology. Acute tubular necrosis does not normally occur in a precipitous fashion as in this case. Bladder perforation is unlikely if the catheter has been irrigated with good return.
The boundaries of a standard inguinal lymph node dissection for the treatment of penile cancer should include:
A. inguinal ligament, sartorius, adductor longus.
B. inguinal ligament, sartorius, fascia lata.
C. inguinal ligament, gracilis, adductor longus.
D. Cooper’s ligament, sartorius, adductor longus.
E. Cooper’s ligament, gracilis, adductor brevis.
A: “inguinal ligament, sartorius, adductor longus.” is correct.
The limits of dissection for a standard inguinal lymph node dissection are the triangular area bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus medially. Modified templates are frequently used for inguinal lymph node dissections.
A 17-year-old boy with spina bifida has a two-week history of fever and vague abdominal pain. He has a prior bladder augmentation, appendicovesicostomy, bladder neck sling, and bilateral cross-trigonal ureteral reimplantation. Renal ultrasound is shown. The next step is antibiotics and:
A. observation.
B. tamsulosin.
C. cystoscopy and ureteral stent.
D. percutaneous nephrostomy tube.
E. CT cystogram.
D: “percutaneous nephrostomy tube.” is correct.
This boy has a large proximal ureteral stone with acoustic shadowing and debris in the collecting system on ultrasound. With the size of the stone and duration of symptoms, the stone is unlikely to pass spontaneously and will require surgical intervention. The previous reconstructive procedure (bladder neck sling, cross trigonal reimplant, and Mitrofanoff) makes bladder/ureteral access difficult, and the small ureteral stent may become occluded from mucus in bladder from the bladder augmentation. The best way to remove the stone will likely be through the percutaneous approach, and in the face of fever, an initial drainage procedure with a nephrostomy tube will allow a period of antibiotic therapy and access for percutaneous removal. The patient is unlikely to have a secondary bladder perforation, making CT cystogram not helpful.
5-alpha-reductase deficiency is associated with:
A. poorly differentiated Wolffian structures.
B. presence of developed Müllerian structures.
C. gynecomastia.
D. elevated concentration of testosterone at puberty.
E. elevated dihydrotestosterone:testosterone ratio.
D: “elevated concentration of testosterone at puberty.” is correct.
The defective conversion of testosterone to dihydrotestosterone, due to 5-alpha-reductase deficiency, produces a unique form of male disorder of sexual differentiation. At birth, the Müllerian structures are absent (as Müllerian-inhibited substance is made appropriately by the testes) and testosterone-dependent Wolffian structures are well-differentiated. The genitalia are ambiguous to a variable degree. Gynecomastia can be seen in adults on 5-alpha-reductase inhibitors, but is not seen in congenital 5-alpha-reductase deficiency. The 5-alpha-reductase enzyme defect is generally incomplete, and at puberty, the plasma concentration of dihydrotestosterone, while low, is detectable. Plasma testosterone and LH are elevated while the dihydrotestosterone:testosterone ratio is abnormally low. This is due to dihydrotestosterone being a major inhibitor of LH production via the gonadal-pituitary negative feedback loop. 5-alpha-reductase deficiency is inherited as an autosomal recessive trait, and the enzymatic defect exhibits genetic heterogeneity.
A 32-year-old woman with a solitary kidney underwent urinary diversion with an ileal conduit as a child. She has stable, moderate hydronephrosis, but her serum creatinine has risen to 2.8 mg/dL. A loopogram shows no reflux and no residual urine. A diuretic renogram reveals delay in uptake of the radiopharmaceutical and poor response to diuretic with a T1/2 of 22 minutes. The next step is:
A. hydrate and repeat the renogram.
B. contrast CT scan.
C. percutaneous nephrostomy tube.
D. renal biopsy.
E. revision of the ileal conduit.
C: “percutaneous nephrostomy tube.” is correct.
This woman most likely has chronic renal insufficiency, and the renogram reflects this condition. Diseased kidneys may respond poorly to diuretic in the absence of obstruction. The only way to establish, conclusively, if an obstruction exists, would be to place a nephrostomy tube. A pressure-flow study can then be performed and the serum creatinine observed. A renal biopsy, if performed, is likely to show focal segmental sclerosis and/or chronic pyelonephritis, but this is not helpful in management. Non-contrast CT scan would be helpful to rule-out an obstructing stone; however, a contrast CT scan is contraindicated due to poor renal function. It is unlikely that hydration would reverse any renal dysfunction, unless the patient were very dehydrated and pre-renal, which does not fit this scenario. Revision of the ileal conduit is not indicated until an obstruction has clearly been demonstrated.
A 60-year-old man has a high grade, T1 urothelial carcinoma of the bladder. He receives the fifth of six weekly instillations of intravesical BCG. Twelve hours later, he has a temperature of 39.5°C, difficulty breathing, and hypotension. The most likely cause of this complication is:
A. reflux of BCG into the upper tracts.
B. acute UTI.
C. traumatic catheterization.
D. more virulent strain of BCG.
E. impaired immunological state.
C: “traumatic catheterization.” is correct.
The majority of patients tolerate BCG instillation well. In 2,602 patients treated with different strains of BCG, high fever (> 39°C) was noted in 2.9% of patients. Life-threatening BCG sepsis was noted in 0.4%. Fever > 39.5°C that does not resolve within 12 hours despite antipyretic therapy is potentially dangerous. Since most cases of BCG sepsis are associated with I.V. absorption of BCG, it is recommended that BCG not be given until at least one week after tumor resection. In the patients who died from BCG sepsis, almost all cases had traumatic catheterization before instillation therapy, or they were treated too early after TURBT or biopsy. Treatment should include isoniazid 300 mg, rifampin 600 mg, and ethambutol 1200 mg daily. After antituberculosis drugs are started, corticosteroids may be given if the patient is toxic. Given the timing of the signs and symptoms in relation to the BCG instillation, acute UTI is much less likely to be a cause of this patient’s symptoms.
A 45-year-old man with a history of hypertension and significant tobacco use has erectile dysfunction one year following a crush injury to the pelvis. An arteriogram at the time of his injury revealed unilateral focal occlusion of the internal pudendal artery. Treatment should be:
A. intracavernous vasoactive injections.
B. dorsal venous ligation.
C. percutaneous angioplasty.
D. arterial revascularization.
E. penile prosthesis.
A: “intracavernous vasoactive injections.” is correct.
Percutaneous or surgical revascularization of the internal pudendal arteries is not indicated owing to the patient’s age and associated risk factors for atherosclerotic vascular disease, (e.g., hypertension and smoking). There is no indication for venous ligation. Owing to the vascular disease, penile injections may not be successful, but should be implemented prior to insertion of a penile prosthesis.
A 39-year-old man with a large, left varicocele requests vasectomy reversal four years after vasectomy. At scrotal exploration, he has rare non-motile sperm in the right vas deferens and an absence of sperm in clear fluid from the left vas deferens. The next step is:
A. bilateral vasovasostomy.
B. left varicocelectomy and bilateral vasovasostomy.
C. right vasovasostomy and left vasoepididymostomy.
D. left testis biopsy and intra-operative wet prep evaluation.
E. testicular sperm extraction.
A: “bilateral vasovasostomy.” is correct.
With sperm in the vas and a patent abdominal vas deferens, right vasovasostomy is indicated. For men with clear fluid in the vas deferens, the prognosis for return of sperm to the ejaculate is excellent after vasovasostomy alone; therefore, left vasovasostomy is also indicated. Epididymal exploration and intra-operative testis biopsy will not provide material information to affect treatment decisions. Varicocelectomy and vasovasostomy should not be performed simultaneously as venous outflow from the testis after varicocele repair is dependent primarily on the vasal vessels that are divided during vasectomy or vasovasostomy, and testicular atrophy may result.
A 21-year-old man develops a large dorsal hematoma after a seemingly superficial stiletto knife wound to his penis at the dorsal penoscrotal junction. He is able to void normally after the injury and has no urethral bleeding or gross hematuria. The next step is:
A. pelvic MRI scan.
B. retrograde urethrography.
C. urethroscopy.
D. antibiotics and wound closure.
E. exploration.
E: “exploration.” is correct.
Patients with tangential or superficial wounds clearly away from the urethra and that can void without urethral bleeding or hematuria, do not require a retrograde urethrogram. However, these patients should be explored except those with clearly superficial injuries. Patients with stab wounds usually can be expected to have preservation of potency. While most surgeons recommend retrograde urethrography in all patients with penetrating penile trauma, experience in the literature suggests that few truly occult urethral injuries occur in these patients. In patients with low velocity injuries, only those with blood at the meatus, hematuria, difficulty voiding, or injury near the urethra may require retrograde urethrography. Most patients will require retrograde urethrography to rule-out urethral injury and many will need surgical exploration to rule-out and repair any corporal injury or other cause of bleeding. However, select patients, such as the one in this patient scenario, do not require retrograde urethrography. Some patients with minimal wounds can be treated non-operatively. Pelvic MRI scan is not indicated for penetrating genital injuries but may be helpful in blunt genital trauma.
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.
A: “preglomerular vasodilatation.” is correct.
The initial renal response to complete ureteral obstruction is to increase glomerular perfusion pressure. Postglomerular vasodilation without any change in the preglomerular vessels would result in lower glomerular perfusion pressures, not higher. Likewise, afferent arteriolar constriction and renal artery vasoconstriction would result in decreased glomerular perfusion pressure. Of the choices listed, only preglomerular vasodilation and efferent arteriolar constriction lead to increased glomerular perfusion pressures. Preglomerular vasodilation is the first response in both unilateral and bilateral ureteral obstruction. Efferent arteriolar constriction does occur as a second phase in bilateral ureteral obstruction but does not occur in unilateral obstruction.
A 54-year-old woman undergoes a continent cutaneous urinary diversion two years after pelvic radiation for cervical cancer. Four months later, she has right lower quadrant pain and fecaluria. A pouchogram reveals contrast extending into the colon adjacent to the pouch. The next step is:
A. hyperalimentation.
B. bilateral nephrostomy drainage.
C. pouch endoscopy and fulguration of fistula.
D. catheter drainage and low residue diet.
E. colonoscopy.
D: “catheter drainage and low residue diet.” is correct.
Entero-pouch fistulas have been reported after ileal and right colon urinary diversion. The diagnosis should be suspected in patients who present with gastrointestinal symptoms and metabolic acidosis. These fistulas are most common after pelvic irradiation. Conservative therapy can be effective with low residue diet and continuous pouch drainage. Further diagnostic evaluation with colonoscopy or pouch endoscopy is of little value, and biopsy or fulguration may enlarge the fistula. Bilateral nephrostomy drainage alone will not achieve maximal drainage of the pouch. Open surgical exploration may be required if this regimen fails. Hyperalimentation alone, without catheter drainage, is insufficient to resolve the fistula.
A 55-year-old man with bladder cancer undergoes a radical cystectomy. He is averse to an incontinent diversion. Intra-operative frozen-section reveals negative lymph nodes but invasive urothelial carcinoma at the prostatic apical margin. The next step is:
A. ileal neobladder.
B. ileal neobladder and adjuvant pelvic radiotherapy.
C. ileal neobladder and adjuvant chemotherapy.
D. ileal conduit.
E. continent cutaneous urinary diversion.
E: “continent cutaneous urinary diversion.” is correct.
The presence of invasive urothelial carcinoma of the prostate carries 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 findings might change the planned form of urinary diversion, and all of the alternatives 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.
The vertebral level at which the conus medullaris in the neonate terminates is:
A. L1.
B. L3.
C. L5.
D. S1.
E. S3.
B: “L3.” is correct.
The conus medullaris of the spinal 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 an 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 findings of tethering along with the clinical findings of “neurological and musculoskeletal signs and symptoms.” Clinical findings that help support the diagnosis of a tethered cord are 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 abnormalities will be found in approximately 70% of patients.
A 25-year-old man with negative tumor markers underwent a left radical orchiectomy with pathology showing mature and immature teratoma. Chest CT scan is negative. CT scan images of the abdomen and pelvis are shown. The next step is:
A. PET CT scan.
B. percutaneous biopsy of the retroperitoneal mass.
C. three cycles of EP.
D. three cycles of BEP.
E. RPLND.
D: “three cycles of BEP.” is correct.
The patient has bulky retroperitoneal masses from NSGCT. Although the primary 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, defined as primary testicular or retroperitoneal disease, no pulmonary metastases, and negative or low tumor markers. For “good risk” patients, three cycles of BEP are equivalent to four cycles of EP. If the masses remain after chemotherapy, 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.
A 25-year-old man sustains perineal trauma and a pelvic fracture. A retrograde urethrogram shows contrast in the upper thigh. The initial tissue plane the contrast passed through to reach the thigh is:
A. Buck’s fascia.
B. Colles’ fascia.
C. fascia lata.
D. external spermatic fascia.
E. dartos fascia.
A: “Buck’s fascia.” is correct.
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.
The prevalence of catheter-associated UTIs can be reduced by:
A. prophylactic oral antibiotics.
B. routine meatal cleansing.
C. antibiotic irrigation of the bladder.
D. maintenance of a closed drainage system.
E. hydrogen peroxide instillation into the drainage bag.
D: “maintenance of a closed drainage system.” is correct.
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 UTIs are the fourth most common infection, accounting for 13% of health care infections; two-thirds of UTIs are directly related to the presence of an indwelling urinary catheter. Catheter-associated UTIs result in increased morbidity and mortality among hospitalized patients. Factors proven to reduce catheter-associated UTIs 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.
Transection of the dorsal nerve roots at S2-S4 results in:
A. urinary incontinence.
B. detrusor sphincter dyssynergia.
C. loss of psychogenic erections.
D. anejaculation.
E. decreased penile sensation.
E: “decreased penile sensation.” is correct.
The pudendal nerve arises from the dorsal nerve roots at S2, S3 and S4. The pudendal 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 pudendal 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 arising from T10 to L2 is responsible for ejaculation, and will not be impacted by transection of the sacral dorsal nerve roots.
A 24-year-old man has recurrent cystine nephrolithiasis. Urine volume is more than 3.0 L/day. He is taking alpha-mercaptoproprionylglycine (Thiola®) and potassium citrate tablets three times per day with no side effects. He notes that his stools are filled with tablet-like material. The best recommendation is:
A. reassurance.
B. take the tablets before meals.
C. evaluate for malabsorption.
D. change Thiola® to D-penicillamine.
E. change potassium citrate formulation.
A: “reassurance.” is correct.
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 individuals 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 necessary to increase the potassium citrate dose.
A 35-year-old man with Hodgkin’s disease has not voided for 18 hours. He is being treated with abdominal XRT and chemotherapy. The most likely cause of anuria is:
A. bilateral ureteral obstruction from retroperitoneal lymphoma.
B. radiation enteritis with dehydration.
C. acute tubular necrosis.
D. renal tubular obstruction with uric acid crystals.
E. acute radiation nephritis.
D: “renal tubular obstruction with uric acid crystals.” is correct.
Hyperuricemia can be seen during the initial treatment of acute leukemias and lymphomas, in response to either chemotherapy or radiotherapy. The rapid destruction and cellular lysis of neoplastic cells results in a rapid rise in uric acid levels. Elevated urinary uric acid crystals will, in the presence of acid urine, precipitate within the distal convoluted tubules, leading to intrarenal obstruction and renal failure. Prophylaxis (and treatment) is accomplished by a combination of alkalinization, allopurinol, and hydration.
A one-day-old boy has a history of severe prenatal bilateral hydroureteronephrosis and oligohydramnios diagnosed at 19 weeks of gestation. Postnatal ultrasound confirms bilateral hydroureteronephrosis and his VCUG is shown. The most common cause of neonatal mortality is:
A. urosepsis.
B. acute renal failure.
C. pulmonary hypoplasia.
D. urinary ascites.
E. congenital cardiac disease.
C: “pulmonary hypoplasia.” is correct.
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 neonatal respiratory distress. The presence of pulmonary hypoplasia in these infants still accounts for the majority of neonatal deaths in boys with posterior urethral valves. Urosepsis can occur, but usually not in the neonatal period with early diagnosis and initiation of appropriate prophylactic antibiotics. Acute renal failure can present in the first week of life but can be managed with neonatal peritoneal 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 successfully managed with bladder drainage and broad spectrum antibiotics. Posterior urethral valves are not associated with lethal congenital cardiac disease.
The VHL tumor suppressor gene regulates the expression of:
A. basic fibroblastic growth factor.
B. epidermal growth factor receptor.
C. c-Met proto-oncogene.
D. VEGF.
E. transforming growth factor beta.
D: “VEGF.” is correct.
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.
A 65-year-old man with rectal carcinoma treated by abdominal perineal resection develops urinary incontinence two years later. His urinalysis is normal and PVR is 300 mL. Renal ultrasound demonstrates moderate bilateral hydronephrosis. The most likely urodynamic findings are:
A. detrusor overactivity with bladder outlet obstruction.
B. detrusor overactivity with detrusor external sphincter dyssynergia.
C. detrusor areflexia with normal compliance.
D. detrusor areflexia with reduced compliance.
E. impaired bladder contractility with intrinsic sphincter deficiency.
D: “detrusor areflexia with reduced compliance.” is correct.
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.
A 54-year-old woman, with a history of cervical cancer treated with radiation therapy five years ago, undergoes a TUR of a 2 cm mass above the left ureteral orifice. Final pathology reveals an inverted papilloma. On the third post-operative day, she develops continuous urinary incontinence. CT urogram reveals no evidence of upper tract pathology, perivesical abscess, or urinoma. Subsequent cystoscopic evaluation reveals a 2 cm vesicovaginal fistula at the site of the resection. The next step is:
A. cauterization of the fistula site and placement of a urethral catheter.
B. immediate transvaginal repair.
C. transvaginal repair in three months.
D. immediate transabdominal repair.
E. transabdominal repair in three months.
D: “immediate transabdominal repair.” is correct.
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 fluid collection. In the absence of pelvic infection, immediate repair is justified. In the presence of a large diameter vesicovaginal fistula 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, good bladder drainage, control of infection, and interposition of healthy tissue are critical elements to successful fistula closure. Proximal urinary diversion with bilateral 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 fistula tract and urethral catheter or suprapubic tube drainage may be considered in vesicovaginal fistulas where the diameter of the fistula is < 5 mm in size and radiographic evaluations (fistulogram) suggests the presence of a long-necked and tortuous fistula.
A 50-year-old man is scheduled for a living-related renal transplant. He has a serum creatinine of 5.5 mg/dL and is not yet on dialysis. His non-contrast CT scan shows a 2 cm solid left renal mass. The next step is:
A. repeat CT scan with I.V. contrast.
B. radical nephrectomy and exclude patient from transplantation.
C. simultaneous radical nephrectomy and renal transplantation.
D. radical nephrectomy, transplant in two years if no recurrence.
E. partial nephrectomy, transplant in two years if no recurrence.
C: “simultaneous radical nephrectomy and renal transplantation.” is correct.
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 renal function, and will not change the management of the renal mass. Although partial nephrectomy may carry the advantage of preserving additional renal mass, this is not applicable to this patient. The appropriate management in this setting is simultaneous nephrectomy and transplantation.
Cranberry juice may help prevent UTI by reducing:
A. urine pH.
B. urine osmolality.
C. secretory IgA.
D. bacterial adhesion.
E. interleukin 6 (IL-6).
D: “bacterial adhesion.” is correct.
A variety of host defense and bacterial virulence factors contribute to the pathogenesis of UTIs. Host defenses include high urine osmolality, low pH, high urea, efficient micturition, and a number of urine inhibitors of bacterial adherence (e.g., Tamm-Horsfall protein, lactoferrin, oligosaccharides, and mucopolysaccharides). Immune responses to UTIs affect hormonal immunity (secretory IgA), 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 IgA, or interleukin levels.
A neonate with a 3 cm phallus and non-palpable gonads can be confirmed to have at least one testicle by:
A. 46 XY karyotype.
B. elevated 17-hydroxyprogesterone.
C. normal LH, FSH levels.
D. normal Müllerian inhibiting substance concentration.
E. increased urinary ketosteroids.
D: “normal Müllerian inhibiting substance concentration.” is correct.
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. Müllerian-inhibiting substance is secreted by testicular Sertoli cells and is the one test which would diagnostically confirm the presence of at least one testicle.
A 78-year-old man had a radical cystectomy and ileal conduit for recurrent bladder cancer. Pathology showed stage pT3bN0M0 cancer. CT scan at one year was normal, but at two years, there was marked right hydroureteronephrosis with very thin residual renal parenchyma. Loopogram shows a tight narrowing of the right distal ureter 2 cm above the ureteroileal junction. He is asymptomatic and serum creatinine is 1.6 mg/dL. The next step is:
A. observation.
B. retrograde balloon dilation of the ureter.
C. percutaneous laser incision of the stricture.
D. open reimplantation of the ureter into the ileum.
E. right nephroureterectomy.
E: “right nephroureterectomy.” is correct.
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.
In the process of spermatogenesis, the final product of meiosis is the:
A. spermatogonia.
B. primary spermatocyte.
C. secondary spermatocyte.
D. spermatid.
E. spermatozoa.
D: “spermatid.” is correct.
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).
Complications associated with inguinal lymph node dissection for penile cancer are documented to occur most frequently in which of the following settings:
A. palliative indication.
B. prior chemotherapy.
C. insulin-dependent diabetes.
D. congestive heart failure.
E. obesity.
A: “palliative indication.” is correct.
Complications of inguinal 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 series from MD Anderson Cancer Center, complication rates (minor and 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 and compromised blood supply. Together, these factors affect the viability of skin flaps and lymphatic flow, and 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 inguinal node dissection. Similarly, prior chemotherapy has not been associated directly with increased complications after inguinal node dissection.
An 80-year-old man has urinary retention. He has bilateral pitting edema, an elevated jugular venous pulse, and a blood pressure of 200/120 mmHg. His creatinine is 4.0 mg/dL. The serum K+ and Na+ are normal. An ultrasound shows a very distended bladder and bilateral pelvicaliectasis. Three liters of urine is obtained from his bladder when he is catheterized. Urine output over the next two hours is 700 mL. The next step is:
A. serial creatinine measurement.
B. replace output mL per mL with D5 1/2 NS.
C. monitor fluid intake and output every four hours.
D. monitor postural blood pressure for two hours.
E. spot check urine for osmolality, sodium, and potassium.
E: “spot check urine for osmolality, sodium, and potassium.” is correct.
All patients with an output > 200 mL/hr have post-obstructive diuresis and should be closely monitored. High risk patients with chronic obstruction, edema, congestive heart failure, hypertension, weight gain, and azotemia are 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, and potassium will allow for the determination of the type of post-obstructive diuresis and will provide guidance for further management. High risk patients should have vital signs, including postural blood pressure and output measured hourly. D5 1/2 NS is an appropriate replacement fluid in the patient with an elevated BUN and creatinine, but generally, replacement is given at half of the previous hour’s urine output.
A 15-year-old boy is involved in a high-speed MVC. His vital signs are stable. Urinalysis reveals 25-50 RBC/hpf. An abdominal CT scan with I.V. contrast is shown. The next step is:
A. observation.
B. delayed CT imaging.
C. arteriography.
D. retrograde pyelogram.
E. immediate renal exploration.
B: “delayed CT imaging.” is correct.
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 abdominal, renal vasculature, and the renal cortex will enhance. However, delayed images of the abdomen will usually be needed to see contrast in the distal 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 are 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 ipsilateral distal ureter on a delayed CT study. CT cuts to assess for this finding are ideally taken 10-20 minutes post-contrast infusion. If delayed CT cuts reveal no contrast in the distal 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.
Stent placement after uncomplicated ureteroscopic stone extraction for a 5 mm distal ureteral calculus:
A. is indicated if intracorporeal lithotripsy is performed.
B. improves stone-free rate.
C. increases post-procedure pain.
D. is indicated if balloon dilation was performed.
E. reduces the likelihood of ureteral strictures.
C: “increases post-procedure pain.” is correct
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.
A 27-year-old woman is prescribed a ten day course of an oral quinolone for a pan-sensitive E. coli UTI. Four days later, she develops a low-grade fever to 38° C and a skin rash. Urinalysis shows 1+ protein with WBC casts, occasional eosinophils, and 5-10 RBC/hpf. Urine gram stain is negative for bacteria. Serum creatinine is 1.8 mg/dL. The next step is discontinuation of quinolone antibiotics and:
A. observation.
B. change to ampicillin.
C. change to cephalosporin.
D. oral antihistamines.
E. prednisone.
A: “observation.” is correct.
The most likely diagnosis is acute interstitial nephritis. The best treatment is to discontinue the offending drug, treat any related hypertension 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.
A 28-year-old, paraplegic man had a sphincterotomy seven years ago and wears a condom catheter. During an evaluation for renal insufficiency, renal ultrasound reveals bilateral hydroureteronephrosis. The parameter or study most predictive of this complication is:
A. EMG.
B. CMG.
C. Valsalva LPP.
D. detrusor LPP.
E. urethral pressure profilometry.
D: “detrusor LPP.” is correct.
Detrusor LPP is the most reliable urodynamic parameter to predict the risk of upper tract deterioration after sphincterotomy. A detrusor LPP of higher than 40 cm H2O indicates that the sphincterotomy has failed, and may serve as a guide to determine whether a repeat sphincterotomy is necessary. Abnormal compliance, which may be detected on CMG, may also be a worrisome finding, but there is much less established predictive value. To date, there is no correlation of urethral function tests (urethral pressure profile, Valsalva LPP, EMG) to upper tract deterioration.
Stage 3 prolapse in the Pelvic Organ Prolapse Quantification (POPQ) system occurs when the most distal portion of the prolapse is:
A. 1 cm or less proximal or distal to the hymenal plane.
B. 1 cm or less proximal or distal to the introitus.
C. > 1 cm distal to the hymen; entire vagina has not prolapsed.
D. > 1 cm distal to the introitus; entire vagina has not prolapsed.
E. associated with complete vaginal eversion.
C: “> 1 cm distal to the hymen; entire vagina has not prolapsed.” is correct.
The International Continence Society has established a standardized system to quantify pelvic organ prolapse. This classification is known as the POPQ system, an acronym for pelvic organ prolapse quantification. The system uses the hymenal ring as its central identification point. The hymen was chosen over the vaginal introitus because it can be more precisely located within the vaginal vault; all measurements are based from this location. This classification avoids use of the terms, cystocele or rectocele, recognizing that the actual organ prolapsing may be unable to be determined by a physical examination. The examination to determine POPQ stage is performed in a dorsal 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 defined 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 above 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).
A 64-year-old man undergoes a six core biopsy for a PSA of 5.6 ng/mL. Pathology is a Gleason 6 (3+3) prostate cancer in a single core involving less than 10% of the tissue. The other cores are normal. He prefers active surveillance. The next step is:
A. CT scan.
B. initiate finasteride.
C. repeat prostate biopsy with 12 or more cores.
D. check PSA quarterly and repeat biopsy in one year.
E. counsel patient that he is not appropriate for active surveillance.
C: “repeat prostate biopsy with 12 or more cores.” is correct.
Active surveillance is a reasonable option for patients with low-risk prostate cancer. This patient’s risk profile 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 quarterly PSA and repeat biopsy in one year is premature and immediate systematic prostate rebiopsy is the next step. Additional 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 finasteride in the management of prostate cancer.
Randall’s plaques are composed of:
A. calcium oxalate.
B. calcium apatite.
C. brushite.
D. hydroxyproline.
E. cholesterol.
B: “calcium apatite.” is correct.
Large amounts of Randall’s plaque are unique to idiopathic calcium oxalate stone formers and are invariably composed of calcium apatite crystals. Using papillary biopsies obtained during the time of PCNL, Randall’s plaque were found to initially form on the basement membrane of the thin limbs of the loops of Henle and grow by the continued deposition of calcium apatite and organic matrix. With growth, the plaque will spread through the interstitium and eventually 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, Randall’s plaque has been found to be a prerequisite for kidney stone formation in idiopathic calcium oxalate stone formers.
The C-arm fluoroscopic operational factor resulting in an increased radiation dose to both the patient and operating room personnel is:
A. increasing tube kilovoltage (kVp).
B. increasing tube current (mA).
C. decreasing image intensifier to skin distance.
D. removing the image intensifier grid.
. increasing the X-ray tube (source) to skin distance.
B: “increasing tube current (mA).” is correct.
The use of fluoroscopic 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 quality 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 quality (less contrast), but is usually associated with less radiation dose if the tube current is appropriately reduced. Decreasing the image intensifier to skin distance usually increases image quality depending on focal spot size and decreases the dose to the patient without significantly changing the dose to staff. Removing the grid decreases image quality as well as the radiation dose to patient and staff. Increasing the source to skin distance usually improves image quality and decreases the dose to the patient without significantly changing the dose to staff.
Parathyroid hormone level is suppressed in a patient with:
A. obesity.
B. a recent renal transplant.
C. renal calcium leak.
D. absorptive hypercalciuria.
E. renal insufficiency.
D: “absorptive hypercalciuria.” is correct
Parathyroid levels are suppressed in patients with absorptive hypercalciuria as a result of transient elevation of serum calcium due to increased intestinal calcium absorption. The other conditions are associated with secondary elevation of PTH due to PTH-resistance (i.e., obesity, African American), renal calcium loss, and/or elevated serum phosphorus.
Following TURBT for papillary urothelial carcinoma of the bladder, peri-operative instillation of mitomycin C:
A. is unnecessary for small, solitary, low grade tumors.
B. is most effective in acidic urine.
C. should be given within 24 hours of the resection.
D. should be followed by an induction course of intravesical therapy.
E. should be delayed for 24 hours if an extraperitoneal perforation occurs.
C: “should be given within 24 hours of the resection.” is correct
A meta-analysis of seven randomized trials comprising nearly 1,500 patients with Ta-T1 bladder cancer, with a median follow-up of 3.4 years, 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 benefit was not affected by tumor size. The timing of instillation, however, appears to be critical. In all studies documenting efficacy, the instillation was given within the first 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 intraperitoneal 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 corporal spongiosus or cavernosum), have all been reported in these settings. Intravesical mitomycin C is most effective in alkaline urine.
The signal intensity of prostate cancer on T1 and T2 weighted MRI scan images is:
A. high T1 and high T2.
B. low T1 and high T2.
C. high T1 and low T2.
D. low T1 and low T2.
E. intermediate T1 and high T2.
D: “low T1 and low T2.” is correct
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 helpful 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.
A 21-year-old woman undergoes resection of a cystic lung mass. The pathology reveals lymphangioleiomyomatosis (LAM). Abdominal T1 MRI scan is shown. The most likely diagnosis is:
A. VHL.
B. Birt-Hogg-Dubé.
C. tuberous sclerosis.
D. hereditary papillary RCC.
E. familial leiomyomatosis RCC.
C: “tuberous sclerosis.” is correct.
The scan reveals bilateral 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). Familial leiomyomatosis would be associated with skin fibromas and renal carcinoma. VHL does not cause pulmonary LAM. Birt-Hogg-Dubé is associated with chromophobe tumors and oncocytomas. It is also associated with lung cysts which can result in spontaneous pneumothorax, but not LAM. Hereditary papillary RCC has no common pulmonary manifestations and does not cause angiomyolipomas.
A 23-year-old woman with cystic fibrosis takes nutritional supplements, Vitamin C, and antibiotic prophylaxis to prevent respiratory infections. She has hyperoxaluria and recurrent calcium oxalate stones. The most likely cause of her stones is:
A. Vitamin C therapy.
B. reduction of intestinal Oxalobacter formigenes.
C. high calcium diet.
D. cystic fibrosis-associated ileal absorption disorder.
E. dietary glycine excess.
B: “reduction of intestinal Oxalobacter formigenes.” is correct.
Chronic antibiotic use may reduce normal levels of Oxalobacter formigenes in the intestine. This anaerobe metabolizes as much as 50% of ingested oxalate. High calcium diets are associated with decreased oxalate absorption. Few cystic fibrosis patients have ileal absorption disorders. Vitamin C and glycine, while associated with oxalate metabolism, are unlikely to increase urinary levels significantly. An emerging treatment for reduced intestinal Oxalobacter formigenes is probiotics.
A 45-year-old man with metastatic RCC involving the lung, liver, lymph nodes, and bone undergoes a right radical nephrectomy. His pre-operative labs include a hemoglobin of 9 gm/dL and a calcium of 11.5 mg/dL. The treatment most likely to prolong overall survival is:
A. temsirolimus.
B. interferon alpha.
C. bevacizumab.
D. sorafenib.
E. sunitinib.
A: “temsirolimus.” is correct.
Temsirolimus is a specific inhibitor of the mammalian target of rapamycin (mTOR) kinase which is a component of intracellular signaling pathway involved in growth and proliferation of cells. Level 1 evidence in a recent study comparing 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 normal, Hgb below normal, calcium > 10 mg/dL, time from diagnosis of cancer > 12 months, metastases spread to multiple organs, and/or Karnofsky score = 60 or 70. This patient has multiple features that put him in a poorer risk group, including multiple sites of metastasis, anemia, and hypercalcemia. In patients with poor risk features, I.V. weekly infusion of temsirolimus, when compared to interferon, prolongs overall survival, and is the first agent that has demonstrated an overall survival advantage in this category of patients. Sunitinib, bevacizumab, and sorafenib have not been shown to improve overall survival or prolong survival in patients with multiple poor risk features.
A one-year-old, uncircumcised boy with spina bifida is managed with CIC and oxybutynin. Ultrasound and VCUG are normal. He has recurrent asymptomatic episodes of cloudy urine. A recent urinalysis shows 10-20 WBC/hpf and a urine culture grows 105 E. coli. The next step is:
A. observation.
B. treat with culture specific antibiotics and start prophylaxis.
C. gentamicin bladder irrigations.
D. circumcision.
E. vesicostomy.
A: “observation.” is correct.
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 difficult to manage. The efficacy 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 UTIs occur. Vesicostomy is not indicated for non-febrile UTIs in this patient.
An asymptomatic, 75-year-old man with multiple medical co-morbidities has the incidental finding on CT scan as shown. Serum creatinine is 1.0 mg/dL. The appropriate management of the left kidney is:
A. observation.
B. ureteral stent placement with interval changes.
C. percutaneous nephrostomy with interval changes.
D. laparoscopic pyeloplasty.
E. nephrectomy.
A: “observation.” is correct
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.
A ten-year-old boy has nocturnal enuresis, daytime dampness, and two febrile UTIs. Treatment with antibiotics fails to resolve his incontinence. An ultrasound reveals no hydronephrosis. KUB reveals no bladder stones, voiding and postvoid films from a VCUG are shown. The next step is timed voiding and:
A. retrograde urethrogram.
B. urodynamics.
C. alpha-blockers.
D. antimuscarinic therapy.
E. endoscopic valve ablation.
B: “urodynamics.” is correct
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 bulbar 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 bulbar urethral stricture; therefore, a retrograde urethrogram is not indicated.
In the patient whose external genitalia are shown, the arrows denote the urethral meatus. The embryologic origin of the structure that may cause difficulty with catheterization is:
A. Müllerian duct.
B. mesonephric duct.
C. urorectal septum.
D. urogenital sinus.
E. urethral plate.
A: “Müllerian duct.” is correct
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 Müllerian 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.
An 80-year-old woman has vague abdominal pain and no urine output for 12 hours. She underwent cystectomy and ileal conduit urinary diversion for urothelial carcinoma three years ago. Serum creatinine is normal and CT loopogram images are shown. The diagnosis is:
A. stomal stenosis.
B. intestinal stricture due to lymphoid depletion.
C. parastomal hernia.
D. stomal prolapse.
E. intestinal volvulus.
C: “parastomal hernia.” is correct.
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 finding on the CT scan is the hernia.
