2019 Flashcards
A 78-year-old malnourished woman with a history of prior pelvic radiation for cervical cancer has a radical cystectomy and ileal conduit with bilateral ureteral stents for urothelial cancer. Four days postoperatively, her urine output decreases with a marked increase in output from her abdominal drain. The next step is:
A. TPN.
B. placement of a catheter into the ileal stoma.
C. bilateral percutaneous nephrostomy tube placement.
D. revision of the ureteroileal anastomoses.
E. excision of the ileal conduit and replacement with a transverse colon conduit.
B: “placement of a catheter into the ileal stoma.” is correct.
Leakage and fistula formation from a urinary diversion occur in 2 to 9% of patients; however, 20 to 60% of these fistulae close spontaneously. Conservative management can be safely attempted assuming the patient is not septic and that adequate drainage is maintained. Leakage could be from the ureteroileal anastomosis or from the butt end of the conduit. Bilateral ureteral stents are already in place, which should address any concerns about a ureteroileal anastomotic leak. Therefore, the best initial therapeutic maneuver in this patient is placement of a catheter into the ileal loop to facilitate drainage. While TPN is important in malnourished patients and should also be initiated, this would not address the immediate issue of the leak. If the stomal catheter failed to decrease the fistulous output, bilateral percutaneous nephrostomy tubes could be placed to divert the urinary stream. If this failed, surgical intervention would be required to address the problem.
A 24-year-old man has a transpubic urethroplasty in the extended lithotomy position. Postoperatively, he has anteromedial thigh paresthesia and right lower extremity weakness. The nerve most likely injured is the:
A. femoral.
B. obturator.
C. genitofemoral.
D. sciatic.
E. ilioinguinal.
A: “femoral.” is correct.
Femoral neuropathy can occur after lithotomy procedures due to hip hyperabduction, or secondary to retractor injury with abdominal/pelvic procedures. The femoral nerve, the largest branch of the lumbar plexus, is formed within the psoas muscle from the fusion of the anterior divisions of L2-L4. It emerges between the psoas major and iliacus muscles just superior to the inguinal ligament and enters the thigh lateral to the external iliac artery. Sensory branches are the anterior and medial femoral cutaneous and long saphenous nerves. Motor supply is to the psoas, iliacus, quadriceps, pectineus, and sartorius muscles. The obturator nerve is a predominantly motor nerve providing adduction of the obturator internus muscle and also originates between L2-L4 nerve roots. The genitofemoral nerve has a genital branch providing motor supply to cremaster muscle and sensation to the anterior scrotum, and the femoral branch provides sensation to the anterior thigh. The sciatic nerve, derived from nerve roots L4-S3 exits the sciatic foramen and provides sensory and motor innervation to the back of the thigh, leg, and foot. The ilioinguinal nerve is a branch of L1 and provides sensory innervation to the upper scrotum and base of the penis (males) or mons pubis and labia majora (females) and motor innervation to the internal oblique and transversus muscles.
A 52-year-old man with a history of lung cancer has a 5 cm adrenal mass with an attenuation of 45 Hounsfield units noted on follow-up non-contrast CT scan. Metastatic evaluation is otherwise negative. Metabolic evaluation is normal. The next step is:
A. repeat imaging and metabolic evaluation in six months.
B. MRI scan.
C. MIBG scan.
D. percutaneous needle biopsy.
E. adrenalectomy.
D: “percutaneous needle biopsy.” is correct.
Given the size of a 5 cm adrenal mass and a history of lung cancer, observation alone is not acceptable. The CT findings are not consistent with an adenoma (Hounsfield units < 10), and as such, further evaluation is indicated. The primary utility of adrenal mass biopsy is to differentiate the presence of metastatic disease, especially in patients with a separate primary malignancy. In such cases, treatment options might depend on the pathology of the lesion, and, therefore, biopsy would be indicated. Importantly, a metabolic evaluation should be performed prior to biopsy, specifically to establish the absence of catecholamine production, which may be triggered by biopsy.
When MRI is used in the evaluation of an adrenal lesion, opposed phase chemical-shift MR imaging is employed to evaluate for intracellular lipid content and help distinguish an adenoma from other adrenal lesions. Nevertheless, MRI would not be reliably able to differentiate between adrenocortical carcinoma, which must be considered given the size of the lesion, and an adrenal metastasis, given the patient’s history of lung cancer.
Likewise, PET scan would not be able to distinguish between a metastasis and primary adrenocortical carcinoma and so would not be helpful at this point (though it could play a role if metastasis was established). MIBG is an analog of norepinephrine, and as such, MIBG scanning has been used in the evaluation of pheochromocytoma. In a patient with normal metabolic parameters, this scan would be unlikely to impact management, and, therefore, not recommended. To proceed immediately to an adrenalectomy in this setting of a previous primary malignancy, such as lung cancer, is inappropriate until tissue diagnosis is obtained as treatment options may depend upon pathology of the lesion.
A 45-year-old hypertensive man with a family history of renal failure is noted to have bilaterally enlarged cystic kidneys and hepatic and pancreatic cysts during an abdominal ultrasonographic examination for abdominal/flank pain and fever. He also complains of marked dysuria. He is admitted with a presumptive diagnosis of pyelonephritis. Urine culture has been sent. Initial antibiotic therapy should be:
A. gentamicin.
B. ampicillin.
C. cephalexin.
D. ciprofloxacin.
E. nitrofurantoin.
D: “ciprofloxacin.” is correct.
Autosomal dominant polycystic kidney disease is a systemic disease with varied renal pathology, including renal cysts, calculi, infection, hemorrhage, and eventual renal insufficiency. Associated gastrointestinal pathology includes hepatic and pancreatic cysts. These patients also have an increased incidence of cerebral artery aneurysms. The cysts eventually become isolated structures and standard empiric antibiotics for pyelonephritis penetrate cysts poorly. Lipid soluble antibiotics are required and include trimethoprim, tetracycline, doxycycline, ciprofloxacin, levofloxacin, and chloramphenicol. Ampicillin, aminoglycosides, cephalosporins, and nitrofurantoin are not lipid soluble, and thus, are poor choices.
Five months after continent cutaneous diversion, a 58-year-old woman has persistent low-grade fevers, malaise, and mild abdominal discomfort over the diversion. Her creatinine is 1.2 mg/dL, and a CT scan shows mild bilateral hydronephrosis. Urine culture is positive for E. coli. After treating the infection, the next step is:
A. urine acidification.
B. program of mechanical pouch irrigation.
C. prophylactic antibiotic administration.
D. increase size of drainage catheter.
E. pouchogram to evaluate reflux.
B: “program of mechanical pouch irrigation.” is correct.
It is not uncommon to develop pouchitis after construction of a continent urinary reservoir. This is especially true in the early postoperative period when mucous accumulation can be high. A simple program of mechanical irrigation can decrease the incidence of infections, though asymptomatic colonization may not decrease. Using a larger catheter may help urine drainage, but usually does not drain all the mucous. Prophylactic antibiotics or urine acidification are useful in patients who do not respond to simple measures and remain persistently infected. A pouchogram is not the initial step in evaluation of recurrent UTIs in the early postoperative period after continent diversion.
A 57-year-old woman has a CT scan for severe left flank pain. Pre- and post-contrast CT scans are shown. The next step is:
A. repeat CT scan in three months.
B. percutaneous nephrostomy tube.
C. percutaneous drainage.
D. renal biopsy.
E. radical nephrectomy.
A: “repeat CT scan in three months.” was the correct answer.
The image demonstrates a subcapsular hematoma. While subcapsular hematoma can occur in the absence of renal malignancy, the clinician should always be suspicious of an underlying tumor as a cause for the bleeding.
In those cases in which an underlying tumor is not evident, delayed imaging is advised as it can allow evaluation for tumor after the hematoma is reabsorbed. A ureteral stent or percutaneous nephrostomy tube is not indicated given the absence of hydronephrosis on the image. Open or percutaneous drainage is not indicated given the risk of underlying tumor and the high likelihood of worsening the bleeding. There is insufficient evidence of a clear tumor to warrant either renal biopsy nor radical nephrectomy until a discernible mass is evident.
A debilitated 85-year-old woman with an ileal conduit has recurrent sepsis due to pyocystis despite weekly bladder irrigations with antibiotic solution. Cystoscopy demonstrates no evidence of malignancy. The next step is:
A. prophylactic oral antibiotics.
B. intravesical silver nitrate.
C. suprapubic cystostomy.
D. vaginal vesicostomy.
E. cystectomy.
D: “vaginal vesicostomy.” is correct.
Pyocystis occurs in approximately 20% of patients who undergo supravesical diversion. Patients typically have a malodorous discharge and may develop sepsis. If conservative measures, such as routine bladder irrigations fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in women. This is an especially good alternative for an elderly or high risk patient. A stapling device can be used to quickly perform this operation. Absorbable staples should be used if the patient is sexually active. Prophylactic oral antibiotics will not be effective in preventing pyocystis in a defunctionalized bladder. Intravesical silver nitrate will not prevent bladder secretions and is likely to be no more effective than routine bladder irrigations. A suprapubic tube will not facilitate bladder drainage, as well as a vaginal vesicostomy, and would be prone to infectious complications in a defunctionalized bladder. Cystectomy is an effective treatment for pyocystis and would likely be required if the patient was a male or if there was evidence of tumor on the cystoscopy. However, the morbidity of this procedure in this elderly patient is high.
A 75-year-old man has severe bleeding from radiation cystitis requiring transfusion. Cystogram reveals no reflux. Previous therapeutic measures have failed including fulguration, clot evacuation, and irrigations with silver nitrate and 1% alum. The next step is:
A. ileal loop urinary diversion.
B. instillation of 10% formalin.
C. instillation of 5% formaldehyde.
D. instillation of 2% formalin.
E. internal iliac artery embolization.
D: “instillation of 2% formalin.” is correct.
Formaldehyde is a 37% solution of formaldehyde gas dissolved in water and should not be used intravesically. Formalin solution is made up of 1-10% formaldehyde diluted with normal saline and has been given in bladder instillations to control hemorrhage from advanced bladder tumors or radiation cystitis. Formalin solution is exceedingly irritating to the bladder, and thus, requires general or regional anesthesia. Because a 10% formalin solution may cause fibrosis and obstruction of the ureteral orifices, formalin instillation should begin with a 1% solution and be repeated with a 5% and then a 10% solution, if necessary. Many begin with a 1-2% solution if other measures (i.e., silver nitrate and 1% alum) have failed. A cystogram should be performed before instillation to rule-out vesicoureteral reflux. If reflux is present, Fogarty catheters should be passed up both ureters, and the patient should be tilted into the head-up position to protect the upper tracts from the toxic effects of formalin. Selective internal iliac arterial embolization is more invasive and should be reserved for patients that fail formalin instillation. Ileal loop urinary diversion is the final option for patients with intractable hemorrhage and a nonfunctional bladder.
A 38-year-old azoospermic man with secondary infertility has an ejaculate volume of 0.3 mL. Post-ejaculate urine contains no sperm. Serum testosterone and FSH are normal, both vasa are palpable, and testicular volume is normal. TRUS reveals a normal prostate, ejaculatory ducts, and dilated seminal vesicles. The next step is:
A. ejaculatory duct cannulation.
B. testis biopsy.
C. vasography.
D. seminal vesicle aspiration.
E. renal ultrasound.
D: “seminal vesicle aspiration.” is correct
The differential diagnosis of low ejaculate volume azoospermia is ejaculatory duct obstruction, hypogonadism, vasal agenesis, ejaculatory failure, and testicular failure. Hypogonadism was excluded by a normal testosterone level and the patient has palpable vasa. Retrograde ejaculation is not present as sperm were not found in the post-ejaculate urine. This patient has either testicular failure or an obstruction of the ejaculatory ducts. Seminal vesicle aspiration under TRUS guidance will reveal numerous sperm if obstruction is present and is the least invasive method to diagnose this treatable lesion. While vasography would reveal a distal obstruction, it is more invasive than TRUS. Ejaculatory duct cannulation is difficult and, thus may not diagnose the problem. Finally, renal ultrasound is indicated in the work-up of patients with congenital unilateral or bilateral absence of the vas deferens, which this patient does not have based on his examination.
After ligation of the adrenal vein during removal of a right adrenal pheochromocytoma, there is a precipitous fall in blood pressure. The next step is:
A. blood transfusion.
B. epinephrine.
C. norepinephrine.
D. dopamine.
E. saline bolus.
E: “saline bolus.” is correct.
Preoperative alpha-blockade is recommended for patients with pheochromocytoma in an attempt to stabilize the patient’s hemodynamic status and expand their intravascular volume. Beta-blockers can also be used preoperatively to decrease the risk of arrhythmias. When the blood supply of the tumor has been curtailed, a fall in circulatory catecholamine levels may result in hypotension. Volume replacement with saline is the initial treatment of choice, with careful cardiovascular monitoring. In the absence of bleeding, transfusion is not indicated. Vasopressors are rarely required and may be discontinued once vascular volume approaches normal.
The safest chemotherapeutic agent for use in patients who have received extensive prior bone marrow radiation is:
A. cisplatin.
B. methotrexate.
C. vinblastine.
D. bleomycin.
E. Adriamycin®.
D: “bleomycin.” is correct.
The primary toxicity of bleomycin is pulmonary fibrosis and it has only mild myelosuppressive effects at high doses. All of the other agents listed can have significant bone marrow toxicity. Although cisplatin is most commonly associated with renal toxicity, it can have myelosuppressive side effects as well.
The inferior mesenteric artery is ligated during a RPLND for testis cancer. Blood supply to the sigmoid colon is now derived from which artery:
A. right colic.
B. superior hemorrhoidal.
C. middle hemorrhoidal.
D. sigmoid.
E. middle sacral.
C: “middle hemorrhoidal.” is correct.
The main arterial supply of the sigmoid colon is from the sigmoid and superior hemorrhoidal branches of the inferior mesenteric artery (IMA). The major collateral vessels are the middle and inferior hemorrhoidal arteries which arise from the internal iliac artery. They anastomose freely with the superior hemorrhoidal branches. It is distributed to the rectum, anastomosing with the inferior vesical artery, superior rectal artery, and inferior rectal artery. The right colic artery arises from the superior mesenteric artery and does not have collaterals to the distal colon. The superior hemorrhoidal arteries and sigmoid arteries are continuations of the IMA and are filled retrograde when the IMA is ligated. The middle sacral artery arises from the posterior aspect of the aorta and gives some blood supply to the rectum.
A newborn girl has an abdominal mass. An interlabial bulging mass is also noted. Ultrasound shows a cystic mass anterior to the rectum that does not change with bladder catheterization. The most likely diagnosis is:
A. imperforate hymen.
B. rhabdomyosarcoma.
C. sacrococcygeal teratoma.
D. Gartner’s duct cyst.
E. prolapsed ureterocele.
A: “imperforate hymen.” is correct.
This patient has an imperforate hymen causing obstruction of the vagina. The cervical glands produce mucous in response to maternal hormones. The presentation is that of an interlabial mass. Catheterization of the bladder does not decompress the mass. Ultrasound will confirm the cystic nature of the lesion and its location excludes sacrococcygeal teratoma. Rhabdomyosarcoma would be uncommon in this age group and would be solid. Ureterocele can present as an interlabial mass, but the ureterocele is intravesical rather than between the bladder and the rectum. Gartner’s duct cysts usually are found in the wall of the vagina. They can occur with renal anomalies (ectopic ureter or renal hypoplasia), but rarely present with symptoms of abdominal and/or vaginal mass.
Calcium oxalate calculi appear on MRI scan as:
A. high intensity T1-weighted image.
B. low intensity T2-weighted image.
C. low core intensity image.
D. poorly visualized image.
E. bright bone-like signal image.
D: “poorly visualized image.” is correct.
MRI scan is unable to reliably identify urinary calculi since it does not visualize calcium. Therefore, stones are noted as filling defects overlying the high signal intensity of urine on a T2-weighted image. Stones are not visualized on T1-weighted images. Low core intensity and bright bone-like signal images are not standard findings or terminology for stone disease on MRI scans.
A two-month-old boy has a 4 cm right adrenal mass. Biopsy reveals neuroblastoma. There are metastases to the skin, liver, and bone marrow. Skeletal survey is negative. The next step is:
A. observation.
B. flank XRT.
C. multi-agent chemotherapy.
D. right adrenalectomy.
E. total body XRT and bone marrow transplant.
A: “observation.” is correct.
This infant has stage 4-S neuroblastoma. This can include involvement of skin, liver, and bone marrow without bone metastases on skeletal survey. Observation therapy alone in children less than one year of age is usually sufficient and metastases regress spontaneously, and therefore, do not require any of the other options at this time. In older children, or in cases where metastases do not regress, chemotherapy is used. In this patient, there is no role for XRT or adrenalectomy.
The antibiotic which can be used in a patient with a history of an anaphylactic reaction to penicillin is:
A. ceftriaxone.
B. imipenem.
C. ceftazidime.
D. aztreonam.
E. ampicillin.
D: “aztreonam.” is correct.
Carbapenems and cephalosporins are immunogenically similar in their ability to effect hypersensitivity reactions in patients who are allergic to penicillin. However, cephalosporins can usually be safely administered to patients with mild allergic reactions to penicillin. Ampicillin is immunogenically very similar to penicillin. These reactions are not seen in patients given aztreonam, although allergic cross-reactivity can occur due to reactivity to its side chain component, which is unrelated to penicillin hypersensitivity.
A healthy 60-year-old man is diagnosed with Gleason 9 (4+5) prostate cancer. CT abdomen and bone scan are negative. MRI is shown. The next step is:
A. fluciclovine F-18 PET (AxuminTM).
B. leuprolide acetate and docetaxel.
C. leuprolide acetate and XRT.
D. radical prostatectomy.
E. radical cystoprostatectomy.
C: “leuprolide acetate and XRT.” is correct.
The patient has evidence of locally advanced (cT4) and N1 prostate cancer based on evidence of bladder invasion and a right lymph node on the MRI scan. However, he does not appear to have metastatic disease (M0). Axumin PET is FDA approved for evaluation of recurrence after treatment and would not be indicated for staging at the time of diagnosis. Although some studies may suggest that the combination of androgen deprivation therapy (ADT) and chemotherapy is beneficial in N1M0 patients, the evidence currently only supports the benefit of ADT and docetaxel in metastatic, hormone-sensitive prostate cancer. The best treatment would be XRT combined with long-term ADT (2-3 years). Even with the significant potential for disease recurrence, treatment of the primary tumor within the prostate may reduce local complications; however, neither radical prostatectomy nor cystoprostatectomy would be indicated.
In girls who have suffered sexual abuse, the most frequent finding on physical examination is:
A. no abnormality.
B. tear of the labia minora.
C. bruising of the inner thigh.
D. laxity of the anal sphincter.
E. enlargement of the hymenal opening.
A: “no abnormality.” is correct.
Sexual abuse in children will often leave no physical findings. All of the choices are findings consistent with sexual abuse, but a normal examination is the usual finding. Consequently, one cannot rule-out sexual abuse on the basis of the physical examination alone. A complete history, knowledge of associated risk factors, and a thorough physical examination, combined with a high index of suspicion, may lead to the diagnosis.
A 26-year-old man has had four ureteroscopic stone extractions over the past three years. All stones were pure calcium phosphate (brushite). He denies prior UTIs. The most likely etiology for his stone disease is:
A. hyperuricosuria.
B. resorptive hypercalciuria.
C. phosphate renal leak.
D. renal hypercalciuria.
E. excess meat consumption.
B: “resorptive hypercalciuria.” is correct
Calcium phosphate stones can be classified as brushite (pH <6.6) or apatite (pH>6.6). Recurrent calcium phosphate (100%) brushite stones are unusual and should arouse suspicion for primary hyperparathyroidism (resorptive hypercalciuria). Serum parathyroid and calcium levels should be evaluated. Hyperuricosuric calcium nephrolithiasis is most commonly due to excessive purine intake and can be successfully treated with dietary manipulation. Excess meat consumption is associated with hyperuricosuria. Excessive uric acid production from catabolic states or other metabolic factors can be successfully treated with allopurinol or potassium citrate. Phosphate renal leak hypercalciuria is associated with elevated Vitamin D levels and calcium oxalate or mixed calcium oxalate and calcium phosphate calculi. Renal hypercalciuria is associated with calcium oxalate stones and is successfully treated with hydrochlorothiazides over the long-term.
A 55-year-old man has mild right flank pain eight weeks after an aorto-iliac vascular graft. Serum creatinine is 1.4 mg/dL, WBC 12,000/cu mm, and urine culture is sterile. Renal ultrasound shows moderate right hydronephrosis, and CT scan demonstrates the graft is posterior to the right ureter. The next step is:
A. percutaneous nephrostomy.
B. oral steroid therapy.
C. transureteroureterostomy.
D. nephrectomy.
E. ureterolysis.
B: “oral steroid therapy.” is correct.
Hydronephrosis occurs in 5% of ureters at risk following reconstructive vascular surgery. The cause of ureteral obstruction is anterior graft placement (30%) and localized retroperitoneal fibrosis (70%). Grafts should be placed posterior to the ureter, as in this case. Early ureteral obstruction due to secondary retroperitoneal fibrosis occurring within six months of surgery can resolve with a four-week course of oral steroid therapy. Percutaneous nephrostomy is not indicated with only mild flank pain and a normal serum creatinine. Transureteroureterostomy should be reserved for major loss of ureteral length and nephrectomy is not indicated. Ureterolysis would be reserved for failure of more conservative measures.
While performing a videourodynamic study in a three-year-old child, the recommended rate of bladder filling is:
A. 10 mL/min.
B. 20 mL/min.
C. 30 mL/min.
D. 40 mL/min.
E. 50 mL/min.
A: “10 mL/min.” is correct.
The rate of bladder filling (mL/min) is calculated by determining the child’s predicted bladder capacity [average bladder capacity in mL = (age in years + 2) X 30] and dividing the result by 10. In this case, (3+2) X 30 = 150/10 = 15 mL/min or less. It is important not to fill the bladder too rapidly as it may result in falsely low levels of detrusor compliance and may produce artifactual detrusor contractions. Filling at 10% of the calculated bladder capacity (or less) per minute will minimize these problems.
A 40-year-old woman has a bilateral adrenalectomy for Cushing’s disease with complete resolution of her symptoms. Her replacement therapy consists of cortisone and fludrocortisone. Three years later, she complains of visual disturbances and has skin hyperpigmentation. The most likely explanation is:
A. inadequate cortisone replacement.
B. pituitary adenoma.
C. excessive cortisone replacement.
D. ectopic ACTH production.
E. ectopic melanocyte-stimulating hormone secretion.
B: “pituitary adenoma.” is correct.
After bilateral adrenalectomy, reports have noted that between 8-29% of patients develop Nelson’s syndrome, a condition of increased ACTH secretion due to pituitary adenoma growth. While the pathophysiology remains in some debate, a lack of negative feedback from cortisol after bilateral adrenalectomy and subsequent increase in CRH (corticotropin releasing hormone) production has been hypothesized to be responsible. Local symptoms from tumor growth include headaches and visual field changes, while hyperpigmentation accompanies the increased ACTH levels. Diagnosis can be established with an MRI scan of the brain, measurement of elevated ACTH levels, as well as clinical manifestations. Treatments include radiation (either prophylactic or therapeutic), surgery (transsphenoidal), or pharmacotherapy (octreotide, temozolomide, pasireotide). Prophylactic radiation at the time of bilateral adrenalectomy may prevent the development of Nelson’s syndrome, but its routine use remains controversial. The ACTH overproduction is not ectopic, but from the pituitary. Likewise, the clinical symptom complex in this setting is not likely to result from either excessive or inadequate hormone replacement. Indeed, excessive cortisone replacement would result in a Cushingoid appearance (purple striae, buffalo hump, central obesity).
In women with invasive carcinoma of the proximal urethra, the primary lymphatic nodes for metastatic disease are the:
A. superficial inguinal.
B. deep inguinal.
C. external iliac.
D. hypogastric.
E. obturator.
C: “external iliac.” is correct.
Urethral carcinoma is more common in women, and may involve either the distal or proximal urethra. The location of the primary tumor will dictate the primary landing zone for lymphatic spread. The distal urethra and labia drain to the superficial and then deep inguinal nodes, while the proximal urethra drains primarily to the external iliac and then secondarily to the hypogastric and obturator lymph nodes.
A 24-year-old woman had an ileocystoplasty for neurogenic bladder four years ago. During an emergency cesarean section, the vascular pedicle to the cystoplasty segment is divided. The next step is:
A. revascularization of the pedicle.
B. excise ileal patch; immediate ileal augmentation.
C. excise ileal patch; delayed sigmoid augmentation.
D. place suprapubic tube and drain.
E. observation with follow-up urodynamics.
E: “observation with follow-up urodynamics.” is correct.
Experimental studies have shown that the augmented bowel segment receives collateral blood flow from the native bladder. Interruption of the vascular pedicle may cause some decrease in the size of the augmented segment, but the augment segment remains intact. Intraoperative assessment of blood flow to the augmented segment immediately after ligation of the pedicle demonstrates decreased perfusion. However, perfusion returns to normal after eight weeks. Observation of the patient with repeat urodynamic studies is indicated. If this shows a significant decrease in functional capacity, consideration can be given to revision of the ileocystoplasty. Primary revision with sigmoid in this patient would be ill-advised without a bowel prep. There should be no need for a suprapubic tube as extravasation is not likely. Immediate re-augmentation would not be indicated. Subsequent demonstration of a reduction in capacity or compliance would be an indication for re-augmentation.
The most common metabolic disturbance that occurs in a patient with an ileal conduit is:
A. hyperkalemic, hyperchloremic, metabolic acidosis.
B. hyponatremic, hypochloremic, metabolic acidosis.
C. hypochloremic, hypokalemic, metabolic alkalosis.
D. hypokalemic, hyperchloremic, metabolic acidosis.
E. hyponatremic, hypochloremic, metabolic alkalosis.
D: “hypokalemic, hyperchloremic, metabolic acidosis.” is correct.
In the setting of an ileal conduit urinary diversion, ammonium absorption occurs with chloride in exchange for hydrogen and bicarbonate ions, and may be accompanied by renal potassium wasting. This results in a hypokalemic, hyperchloremic metabolic acidosis. Hyponatremic, hypochloremic, hyperkalemic metabolic acidosis occurs with the use of jejunum due to sodium chloride loss with increased reabsorption of potassium and hydrogen ions. Use of stomach may lead to hypochloremic, hypokalemic metabolic alkalosis due to hydrogen and chloride loss with renal oversecretion of potassium to compensate for proton loss.
Renovascular hypertension that is likely to respond to angiographic or surgical intervention is characterized by:
A. marked elevation in plasma renin values.
B. elevation of renal vein over inferior vena caval concentrations of renin by at least 25%.
C. elevation of ipsilateral renal vein renin by at least 50% over peripheral and contralateral renal vein renin.
D. elevation of ipsilateral renal vein renin by 50% over peripheral plasma renin, and by 25% over the contralateral renal vein renin.
E. marked elevation of ipsilateral and contralateral renal vein renin as well as peripheral plasma renin.
C: “elevation of ipsilateral renal vein renin by at least 50% over peripheral and contralateral renal vein renin.” is correct.
The response of renovascular hypertension to surgery or angiographic intervention depends upon the type of lesion and its location. Renin is a mediating substance for renovascular hypertension and a search for its origin is helpful. Significantly elevated renin from one renal vein and not the other leads to localization of a candidate for intervention. Further evaluation by imaging and provocative studies involving ACE inhibitors may also confirm the diagnosis and help decide whether surgical treatment is necessary.
A 27-year-old woman at 30 weeks of gestation has gross hematuria. Ultrasound shows a normal fetus and a maternal bladder lesion. Cystoscopy reveals a 3 cm pedunculated papillary lesion. The remainder of the bladder is normal. The next step is:
A. immediate transurethral resection.
B. early delivery followed by transurethral resection.
C. transurethral resection after term delivery.
D. remove tumor with cup biopsy forceps at initial cystoscopy.
E. immediate tumor ablation with Nd:YAG laser.
C: “transurethral resection after term delivery.” is correct.
Hematuria during pregnancy may be mistaken for antepartum bleeding and is most commonly caused by an infection; however, other causes must be considered. Urothelial carcinoma of the bladder during pregnancy is uncommon but can present as hematuria. Ultrasound may detect bladder tumors incidentally or as part of a hematuria evaluation. Although ultrasound is a good screening technique, it is still not reliable and cystoscopy should be considered in all pregnant patients with documented gross hematuria or persistent microscopic hematuria.
Bladder tumors in this age group almost always are low-grade and non-invasive, which is consistent with the findings on cystoscopy in this case. As such, these low-grade tumors do not require urgent removal. Therefore, immediate biopsy, transurethral resection, laser ablation, or early delivery for subsequent tumor resection are not indicated. In fact, immediate resection under anesthesia or cold cup removal in the office has the potential to induce uterine contractions and precipitate premature labor. The tumor resection should be delayed and performed in the standard fashion after a term delivery.
A 31-year-old woman has acute cystitis. The most appropriate treatment is three days of:
A. fosfomycin.
B. nitrofurantoin.
C. ampicillin.
D. ciprofloxacin.
E. trimethoprim/sulfamethoxazole.
E: “trimethoprim/sulfamethoxazole.” is correct.
Practice guidelines from the Infectious Disease Society of America suggest that three days of antibiotics is optimal therapy for acute uncomplicated cystitis in women, except for nitrofurantoin which requires five days of therapy to be equal to other antibiotics. TMP-SMX is the recommended agent since approximately 80% of E. coli are sensitive to this regimen. Fosfomycin (Monurol) may also be used but is single dose therapy. Beta-lactams are less effective in community-acquired organisms with resistance as high as 50% in some communities. Oral fluoroquinolones are not recommended for the treatment of uncomplicated cystitis in women due to the risk of adverse events with these agents.
A 67-year-old man with a clinical stage T2bN0M0 Gleason 7 (3+4) prostate cancer with a PSA of 7.8 ng/mL is treated with 78 Gy external beam XRT. His PSA nadirs to 0.8 ng/mL six months after therapy. Six months later, he is asymptomatic, has a normal DRE, and a PSA of 6.5 ng/mL. The most likely explanation for the elevated PSA level is:
A. prostatic infarct.
B. persistent prostate cancer.
C. PSA bounce effect.
D. radiation-induced prostatitis.
E. insufficient period of observation after therapy.
B: “persistent prostate cancer.” is correct.
A marked increase in serum PSA after a nadir within six months of external beam XRT is a sign of persistent local or occult metastatic prostate cancer and has a poor prognosis. Radiation-induced cellular injury or prostatitis may cause a minor rise in PSA which usually returns to normal within a few weeks. A “bounce” can be defined as a rise greater than 0.1 to 0.5 ng/mL followed by a durable decline and is especially common after brachytherapy, where it is reported to occur in 24% to 35% of men. These can start any time from 9 to 30 months after brachytherapy, with the majority of patients having a cumulative PSA rise of not more than 2 to 3 ng/mL. Prostatic infarct is rare following radiation therapy for prostate cancer and would likely be associated with a significantly elevated PSA. Six months after treatment with XRT is a sufficient time to assess for response.
The ASTRO consensus panel defined biochemical failure as three consecutive rises in PSA level after a nadir. The Phoenix definition of biochemical recurrence as a rise of greater than 2 ng/mL above the PSA nadir is a better predictor of clinical outcomes. It is important to remember that PSA failure is not equivalent to clinical failure.
A ten-month-old boy with a vesicostomy for posterior urethral valves develops increasing bilateral hydronephrosis and a full bladder on ultrasound. The next step is:
A. diuretic renogram.
B. enterocystoplasty.
C. calibrate vesicostomy.
D. VCUG.
E. bilateral cutaneous ureterostomy.
C: “calibrate vesicostomy.” is correct.
The most common complications of vesicostomy are bladder prolapse and stenosis. Late development of increasing hydronephrosis and a full bladder after vesicostomy would suggest the bladder is not draining well due to stenosis of the vesicostomy. If the vesicostomy is adequate, then consideration of upper tract obstruction would be necessary. Reflux and secondary ureterovesical obstruction may be diagnosed with a VCUG or renogram, respectively, but calibration of the stoma is the first step. While the child may eventually require an enterocystoplasty, this is not the next step. Bilateral cutaneous ureterostomy are rarely indicated as the secondary hydroureteronephrosis is usually secondary to a non-compliant bladder.
A 24-year-old man is hit in the scrotum with a baseball. Two hours later, physical exam reveals a very firm, smooth, and painful testicle. Ultrasound shows a heterogeneous avascular intratesticular mass. The next step is:
A. serial physical exams and ultrasound.
B. needle aspiration of the mass.
C. testicular exploration.
D. scrotal orchiectomy.
E. inguinal orchiectomy.
C: “testicular exploration.” is correct.
Ultrasound findings suggestive of testicular rupture include heterogenous echo pattern of the parenchyma and disruption of the tunica albuginea. There is wide variability in the false positive and false negative rate, and the consequences of a missed injury are significant; therefore, testicular exploration is the rule. Exceptions include small, minimally symptomatic hematomas, but these patients should be observed with serial exams.
Forty percent of patients managed non-operatively for intratesticular hematoma develop infection or infarction. Drainage of the hematoma may salvage the testicle and reduce recovery time. The mechanism of injury and the fact that the mass is avascular makes a tumor unlikely.
A patient elects SWL for treatment of a symptomatic, partially obstructing radiopaque 7 mm proximal ureteral calculus. The next step is:
A. push back of the stone into the renal pelvis prior to SWL.
B. placement of a stent alongside the stone prior to SWL.
C. placement of a nephrostomy tube prior to SWL.
D. in-situ SWL treatment.
E. placement of a ureteral catheter to the level of the stone.
D: “in-situ SWL treatment.” is correct.
Although it was initially thought that SWL was more successful after manipulation of ureteral stones into the kidney or placement of a stent alongside the stone to produce an “expansion chamber” that facilitates SWL fragmentation, subsequent studies showed no difference in stone-free rates in patients treated with or without stone or stent manipulation. Indeed, the AUA Guidelines Panel concluded that there is no advantage to placement of a ureteral stent or a nephrostomy tube for proximal ureteral stones with regard to stone-free rates, and that stents lead to decrease in quality of life. Placement of a ureteral catheter to the level of the stone will only help target the stone, specifically in radiolucent stones.
A 58-year-old woman has continuous urinary incontinence two weeks after elective robotic hysterectomy. VCUG is normal and retrograde ureterogram is shown. The next step is:
A. observation.
B. urethral catheter drainage.
C. double-J stent placement.
D. percutaneous nephrostomy.
E. ureteroneocystostomy.
C: “double-J stent placement.” is correct.
The retrograde pyelogram reveals a ureterovaginal fistula and ureteral narrowing. The initial step should be placement of a double-J stent. If that is successful, that will improve her incontinence and potentially allow for healing of the fistula tract. Nephrostomy tube placement would be considered if a stent could not be placed. A vesicovaginal fistula is not present (normal VCUG); therefore, urethral catheter placement alone would not be helpful. Urethral catheter drainage with a ureteral stent may maximize drainage and increase the likelihood of closure of the ureterovaginal fistula. If the fistula does not heal with prolonged stent drainage, then ureteral reimplantation would be indicated.
A 64-year-old man has dysuria, frequency, and hematuria following removal of a urethral catheter after radical prostatectomy. He is allergic to penicillin. A urine culture at the time of catheter removal grew Enterococcus faecalis. The best treatment is:
A. cephalexin.
B. gentamicin.
C. ciprofloxacin.
D. clindamycin.
E. nitrofurantoin.
E: “nitrofurantoin.” is correct.
Most Enterococci are sensitive to amoxicillin, extended-spectrum penicillin derivatives (e.g., piperacillin), nitrofurantoin, and fosfomycin. Fluoroquinolones, clindamycin, aminoglycosides, and cephalosporins are not reliably effective against this organism.
A 25-year-old man has a left scrotal exploration and subsequent orchiectomy. Pathologic and staging evaluation reveal a NSGCT clinical stage 2B. After full-dose platinum-based chemotherapy, he has a residual 3 cm para-aortic mass. The next steps are RPLND and:
A. scrotal XRT.
B. wide excision of the scrotal scar and spermatic cord remnant.
C. removal of the spermatic cord remnant.
D. left hemiscrotectomy and removal of spermatic cord remnant.
E. left hemiscrotectomy, removal of the spermatic cord remnant, and ipsilateral ilioinguinal node dissection.
C: “removal of the spermatic cord remnant.” is correct.
In patients with low-stage NSGCT undergoing primary RPLND after scrotal violation, the scrotal scar should be widely excised with the spermatic cord remnant at the time of surgery. This patient, however, has higher volume disease and was treated with induction chemotherapy. Given the relative absence of local relapse after systemic treatment, scar excision, hemiscrotectomy, scrotal XRT, and inguinal lymph node dissection are not required for patients such as this who are treated with full-dose platinum-based regimens. Removal of the spermatic cord remnant, containing the gonadal vein, should be performed at the time of RPLND in both the primary and postchemotherapy settings.
A 22-year-old woman requests a copy of her medical records. Your office has a right to deny the request if the records:
A. pertain to billing matters.
B. pertain to medical information.
C. pertain to psychotherapy.
D. are electronically stored.
E. are more than five years old.
C: “pertain to psychotherapy.” is correct.
Based on the HIPAA regulations of 1996, a patient has the right to inspect and copy medical information that may be used to make decisions about their care. These requests should be submitted in writing. Most commonly they will include medical and billing records. The patient is not entitled to psychotherapy notes or information compiled in a reasonable anticipation of or for use in a civil, criminal or administrative action or proceedings. If the access to medical information is denied, the patient has the right to request a review by an independent party.
A 32-year-old man with inflammatory bowel disease has passed two calcium oxalate stones. Twenty-four hour urine collection reveals elevated oxalate. The next step is:
A. restrict oxalate.
B. restrict sodium.
C. calcium.
D. thiazides.
E. potassium citrate.
C: “calcium.” is correct.
Enteric hyperoxaluria is commonly associated with inflammatory bowel disease or short-gut syndrome. Malabsorption increases the colonic permeability of oxalate by causing fat and bile to bind to intraluminal calcium, leaving oxalate unbound and free to traverse the colonic epithelium. Restricting oxalate is generally insufficient as the cause is not an overabundance of oxalate and compliance is difficult for regimens intending to eliminate all oxalate sources. Oral calcium binds to the free oxalate and prevents its absorption. Thiazide diuretics are most commonly used in hypercalciuria. Potassium citrate is useful for prevention of stones; however, calcium supplementation is more important in patients with enteric hyperoxaluria without evidence of hypocitraturia on the 24-hour urine collection. Sodium reduction is also useful in general but most useful in patients with hypercalciuria.
A two-month-old girl with prenatal hydronephrosis is on antibiotic prophylaxis and has a serum creatinine of 0.3 mg/dL. Bilateral hydroureteronephrosis is identified on ultrasound and VCUG shows no VUR. MAG-3 diuretic renal scan reveals equal function with a T 1/2 of 21 minutes on the right and 87 minutes on the left. The next step is:
A. left cutaneous ureterostomy.
B. left ureteral reimplantation.
C. bilateral ureterostomy.
D. repeat ultrasound in one month.
E. MR urogram.
D: “repeat ultrasound in one month.” is correct.
Over 90% of antenatally detected megaureters will improve with conservative management. The T 1/2, or Lasix washout time, especially in neonatal megaureters is not a reliable indicator of obstruction, so a normal creatinine and symmetric renal function support initial observation in this child. An end cutaneous ureterostomy is indicated in the neonate with a megaureter and sepsis, ipsilateral reduced function (less than 35% in a neonate), or in cases of marked or increasing hydroureteronephrosis. A tapered reimplant is almost never indicated in a neonate with a megaureter. MR urography gives improved anatomic detail, but the site of narrowing is fairly constant in megaureters and exact delineation is not required to determine the best management. Conservative management with follow-up ultrasonography is the best next step since this will likely spontaneously improve.
A 62-year-old woman with multiple sclerosis has persistent urinary urgency and frequency. Pressure flow urodynamics reveal detrusor overactivity and increased pelvic floor EMG activity during volitional voiding. An MRI scan will most likely reveal evidence of demyelination:
A. of the cerebral cortex.
B. of the cerebellum.
C. between the pons and sacral spinal cord.
D. between the conus medullaris and the cauda equina.
E. between the sacral spinal cord and the bladder.
C: “between the pons and sacral spinal cord.” is correct.
Multiple sclerosis may involve the central and/or peripheral nervous systems. Depending on the location, level and extent of demyelination, a variety of urodynamic patterns may result. Pelvic floor EMG activity in this individual is increased during voiding which suggests detrusor external sphincter dyssynergia, a urodynamic finding that exists only with neurological lesions between the pons and the sacral spinal cord. Lesions at or distal to the sacral spinal cord would likely result in detrusor areflexia and lesions above the pons result in detrusor overactivity with synergistic activity of the proximal and distal sphincter mechanisms.
A 39-year-old man with VHL disease has a 4 cm left upper pole renal mass and several simple appearing lower pole renal cysts. The right kidney also has several cysts as well as two 1.2 cm lower pole solid masses. Renal function is normal. The next step is:
A. radiofrequency ablation of left renal mass.
B. staged bilateral radiofrequency ablation.
C. left radical nephrectomy.
D. left renal exploration with resection of solid mass and renal cysts.
E. bilateral partial nephrectomies.
D: “left renal exploration with resection of solid mass and renal cysts.” is correct.
RCC in von Hippel Lindau (VHL) disease is characterized by both solid renal masses and renal cysts that contain either frank carcinoma or a lining of abnormal clear cells that represent incipient carcinoma. Appropriate surgical treatment of RCC in VHL, therefore, requires excision of all solid and cystic renal lesions, preferably through a nephron sparing approach, rather than through radical nephrectomy. Although partial nephrectomy represents effective initial treatment of patients with RCC and VHL disease, it should be withheld until tumor size reaches 3 cm or more. In this scenario, both right renal masses are less than 3 cm and should be observed. This is because most of these patients will develop locally recurrent RCC with the need for repeat surgery. The 3 cm cut point, therefore, reduces the number of surgical interventions to optimize renal function and to minimize the risk of metastatic disease. This 3 cm rule also applies to patients with hereditary papillary RCC and Birt-Hogg-Dube syndrome, but not for patients with hereditary leiomyomatosis RCC. Because repeated partial nephrectomy can be challenging, a number of centers are moving toward thermal ablative treatment techniques in the setting of recurrent disease, though these have the best results when reserved for those with tumors that are less than 3 cm in size.
A 43-year-old man desires a biological child with his 38-year-old wife. Both testes are 5 cm in longitudinal axis and firm on physical examination. Two semen analyses show azoospermia with volumes of 2.1 and 2.3 mL. FSH is 2.8 IU/L. The next step is:
A. adoption.
B. TRUS.
C. evaluation of his wife.
D. testicular sperm extraction with ICSI.
E. microsurgical scrotal ductal reconstruction.
C: “evaluation of his wife.” is correct.
The likelihood of obstructive azoospermia is 96% with testis longitudinal axis greater than 4.6 cm and FSH less than 7.6 IU/L. However, the most significant predictor of any form of reproductive intervention is maternal age, with female fecundity declining precipitously after age 37. The decision to perform microsurgical scrotal ductal reconstruction or to obtain sperm from the testis for in vitro fertilization and ICSI rests on evaluation of the female partner, especially after age 37. Transrectal ultrasound is not necessary if semen volumes are normal (greater than 1.5 mL) as ejaculatory ductal obstruction is unlikely.
A 62-year-old man has a radical prostatectomy for prostate cancer. Histology reveals a Gleason 9 (4+5), pT3aN1Mx cancer with negative surgical margins. His post-prostatectomy PSA is < 0.1 ng/mL. To minimize the risk of relapse, the next step is:
A. adjuvant docetaxel.
B. external beam XRT.
C. LH-RH agonist therapy for six months.
D. lifelong LH-RH agonist therapy.
E. LH-RH agonist therapy for six months and external beam XRT.
D: “lifelong LH-RH agonist therapy.” is correct.
The treatment of men with isolated lymph node metastasis at the time of prostate cancer surgery has been controversial. The use of adjuvant XRT for adverse pathologic characteristics at the time of prostatectomy has been evaluated in randomized clinical trials. However, patients with lymph node metastasis, such as this patient, were not included in these trials, and it is generally felt that such individuals are at risk of systemic rather than local recurrence. ECOG 3807 evaluated the use of immediate hormonal ablation versus observation in men with isolated lymph node metastases noted on final pathology after radical prostatectomy. The patients treated with immediate therapy had improved overall and cancer-specific survival relative to men undergoing initial observation. No trial has been performed showing an advantage of any chemotherapy treatment in the adjuvant setting. The advantage of short-term androgen deprivation therapy, with or without XRT, in this setting has not been established.
In a patient with a functionally normal neobladder, typical urodynamic findings during voiding are:
A. Pabd ↑, Pves ↔, Purethra ↑.
B. Pabd ↑, Pves ↑, Purethra ↓.
C. Pabd ↔, Pves ↓, Purethra ↓.
D. Pabd ↔, Pves ↑, Purethra ↑.
E. Pabd ↔, Pves ↔, Purethra ↓.
B: “Pabd ↑, Pves ↑, Purethra ↓.” is correct.
After orthotopic urinary reconstruction, patients may develop new voiding difficulties or incontinence, and a urodynamic evaluation is appropriate to evaluate storage function and bladder outlet. Micturition following orthotopic neobladder diversion is accomplished through abdominal straining. On a urodynamic study, this would be indicated by increased abdominal and vesical pressure accompanied by a relaxation of the external urinary sphincter and a decrease in urethral pressure.
A 28-year-old man receives salvage chemotherapy and a stem cell transplant for metastatic NSGCT. His markers have normalized and his CT scan is shown. The next step is:
A. observation.
B. PET scan.
C. XRT.
D. percutaneous biopsy.
E. RPLND.
E: “RPLND.” is correct.
This patient has a residual retroperitoneal mass after salvage chemotherapy with stem cell transplant with normalized serum tumor markers. The recommended management is surgical resection in the form of RPLND. The histologic distribution in this setting is notable for a higher rate of viable germ cell tumor (53%) and a lower rate of necrosis (26%) than patients undergoing RPLND after induction chemotherapy. Given this rate of viable disease, observation is not appropriate.
The major limitation of fluorodeoxyglucose (FDG) PET for evaluation of NSGCT is that teratoma is not FDG avid. In a prospective study by Oeschle, et al, of 121 patients with NSGCT and a residual mass following chemotherapy, the accuracy of PET to predict tumor viability was 56% which was no better than CT (55%) or serum tumor markers (56%). Thus, PET has no role in the assessment of residual masses in patients with a NSGCT, and should be reserved for use in patients with seminoma who have a residual mass greater than 3 cm after chemotherapy, as teratoma is not a concern in such cases. Similarly, percutaneous biopsy may not be able to sample the mass adequately, particularly given the potential for treatment effect in the tissues and may lead to a false negative. XRT does not play a role in the management of a residual mass in patients with NSGCT.
A four-year-old uncircumcised boy has a two-week history of foreskin swelling with urination. The retained urine under the foreskin drains slowly following completion of voiding. There is no dysuria or hematuria. Physical examination reveals mild erythema of the distal foreskin and a phimotic ring. The meatus cannot be visualized. The next step is:
A. observation.
B. sitz baths.
C. topical steroid ointment.
D. dorsal slit.
E. circumcision.
C: “topical steroid ointment.” is correct.
The patient has a pathologic phimosis that does not allow adequate urinary drainage. Observation is only appropriate in the setting of physiologic phimosis in which the foreskin is not retractable due to normal physiologic adhesions, as opposed to pathologic phimosis, which is development of a dense fibrotic ring from chronic inflammation. Treatment of pathologic phimosis with a topical steroid ointment (0.05% betamethasone) is effective in up to 90% of cases in relieving the phimosis and allowing adequate retraction of the foreskin. If the patient had more acute problems such as severe balanitis or more obstructive voiding symptoms, then surgical intervention with a dorsal slit, preputioplasty, or circumcision may be appropriate. Sitz baths alone are unlikely to rectify the problem.
Vascular reconstruction is recommended in hypertensive patients with:
A. bilateral medial fibroplasia.
B. bilateral ostial atherosclerotic lesions and poorly controlled hypertension on two medications.
C. unilateral 85% renal artery stenosis and a serum creatinine of 1.5 mg/dL.
D. bilateral 70% renal artery stenosis and a serum creatinine of 4.5 mg/dL.
E. bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dL.
E: “bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dL.” is correct.
Revascularization is typically recommended in renal artery stenosis when greater than 75% occlusion occurs either bilaterally or in a solitary kidney. With severe renal loss (serum creatinine > 4 mg/dL), the likelihood of renal recovery is substantially reduced and revascularization is not recommended. Atherosclerotic renal vascular hypertension should be treated medically, typically with at least three medications, before resorting to revascularization. Medial fibroplasia is not typically progressive; thus, revascularization for this process is rarely required.
Compared to an electrohydraulic lithotriptor, the factor most likely to contribute to decreased pain using an electromagnetic lithotriptor is the:
A. amount of kilovolts (kV) utilized.
B. lack of an electrical spark.
C. avoidance of a water bath.
D. increased entry surface area of the energy.
E. decreased size of the focal zone.
D: “increased entry surface area of the energy.” is correct.
Electromagnetic generators are more controllable and reproducible than electrohydraulic generators because they do not incorporate a variable in their design such as the underwater spark discharge. The introduction of energy into the patient’s body over a large skin area causes less pain. The water bath, the electric spark, and the focal zone size have no direct effects on patient pain. The kilovolt does not impact the amount of pain.
A one-month-old girl with a history of glucose-6-phosphate dehydrogenase deficiency has a febrile UTI. Urine culture grows Enterococcus and she is treated with amoxicillin. VCUG shows bilateral grade 4 VUR. The most appropriate prophylactic antibiotic is:
A. amoxicillin.
B. amoxicillin/clavulanate K (Augmentin®).
C. trimethoprim/sulfamethoxazole.
D. nitrofurantoin.
E. cephalexin.
E: “cephalexin.” is correct.
Prophylactic antibiotics should ideally have low serum and high urinary concentrations as well as minimal effect on the fecal flora. All of the listed antibiotics are reasonable prophylactic agents other than Augmentin which has too wide a spectrum. In this child, amoxicillin is not a good choice since the greatest risk of recurrent infection is in the first few weeks after the initial infection, and the fecal flora may be resistant to the therapeutic antibiotic that was used. Nitrofurantoin cannot be used in children with G6PD deficiency and, like trimethoprim/sulfamethoxazole, should be avoided in the first few months of life since it can cause neonatal hyperbilirubinemia. Therefore, cephalexin is the best choice.
A 35-year-old man has primary infertility. On physical examination, neither vas deferens is palpable and each testis is 34 mL in volume. Semen analysis reveals a 0.3 mL volume and azoospermia. The man and his wife would like to pursue all options for parenthood. The next step is:
A. scrotal ultrasound.
B. Y-chromosome microdeletion analysis and karyotype.
C. cystic fibrosis mutation analysis on both partners.
D. diagnostic testicular biopsy with scrotal exploration.
E. donor sperm intrauterine insemination.
C: “cystic fibrosis mutation analysis on both partners.” is correct.
The majority of patients with congenital bilateral absence of the vas deferens (CBAVD) are found to have either a mutation or a 5T polymorphism of the CFTR (cystic fibrosis transmembrane regulator protein) gene. Men with CBAVD may also suffer from subclinical or mild pulmonary or pancreatic dysfunction arising from the same CFTR gene mutation or polymorphism.
In this scenario, the next step is cystic fibrosis mutation analysis on both partners. Genetic testing that does not detect a mutation does not necessarily rule out the presence of a CFTR mutation, and therefore, both the male and female partner should undergo this testing. If both the male and female partner have a CFTR mutation, the couple’s children have a 25% chance of having mutations in both inherited CFTR genes, and thus, developing clinical cystic fibrosis. Diagnostic testicular biopsy is not necessary since CBAVD is associated with obstructive azoospermia. Scrotal ultrasound and scrotal exploration will not result in detection of the vas deferens; absence of the vas deferens is diagnosed by physical examination. Patients with CBAVD characteristically have normal karyotypes and do not have AZF deletions of the Y-chromosome. While donor insemination is an option, it is not the next step for this couple that “would like to pursue all options.”
The starting dose of a PDE5 inhibitor should be lowered in a patient taking:
A. indinavir.
B. fluconazole.
C. warfarin.
D. doxycycline.
E. tacrolimus.
A: “indinavir.” is correct.
The cytochrome P450 (CYP3A4) pathway is the principle metabolic system for the metabolism of sildenafil, tadalafil, avanafil, and vardenafil. Potent CYP3A4 inhibitors like the protease inhibitors, indinavir and ritonavir, ketoconazole, and macrolide antibiotics can increase serum levels of PDE5 inhibitors. The initial dose of PDE5 inhibitor should be lowered in patients taking potent CYP3A4 inhibitors. Indinavir is the only potent CYP3A4 inhibitor listed. Warfarin and tacrolimus are not CYP3A4 inhibitors. Doxycycline is a moderate CYP3A4 inhibitor.
During PCNL, a collecting system perforation is noted. The first sign of significant extravasation of irrigant into the peritoneal cavity is:
A. hypotension.
B. hypercarbia.
C. abdominal distension.
D. narrowed pulse pressures.
E. increasing ventilatory pressures.
D: “narrowed pulse pressures.” is correct.
Narrowed pulse pressures (rise in diastolic pressure) precede difficulty with ventilation, hypercarbia, and a rise in central venous pressure. Extravasated irrigant increases abdominal pressure leading to decreased venous return, and thus, narrowing the pulse pressure. Distension is not appreciated in the prone position until later in the course. Hypotension would signal the possibility of significant hemorrhage. Increasing ventilatory pressures is a later sign when there is significant fluid in the peritoneal cavity and when the patient is returned to the supine position.
A 30-year-old man has persistent hypertension and paroxysmal headaches. Plasma catecholamine levels are 1100 ng/L. Three hours after a 0.3 mg single oral dose of clonidine, catecholamine levels are 400 ng/L. The most likely diagnosis is:
A. renal artery stenosis.
B. pheochromocytoma.
C. essential hypertension.
D. adrenal hyperplasia.
E. idiopathic hyperaldosteronism.
C: “essential hypertension.” is correct.
Patients with suspected pheochromocytoma rarely present with normal or mildly elevated plasma catecholamines. When signs and symptoms of pheochromocytoma are present and plasma catecholamines are minimally elevated, it is critical that the cause of hypertension is determined. The best way to distinguish between essential hypertension and pheochromocytoma in this situation is an oral clonidine test. Patients with essential hypertension will experience a significant drop in norepinephrine due to suppression of production by the sympathetic nervous system, while those with pheochromocytoma will not. The clonidine test is not useful in assessing for renal artery stenosis, adrenal hyperplasia, or idiopathic hyperaldosteronism.
In penile reconstruction after amputation, microsurgical re-anastomosis of the dorsal artery and vein is most important in preventing:
A. glans atrophy.
B. urethral stricture.
C. erectile dysfunction.
D. skin loss.
E. penile numbness.
D: “skin loss.” is correct.
In the case of traumatic amputation of the penis, reconstruction with simple urethral and corporal re-anastomosis should be attempted. Reconstruction alone can preserve erectile function, glans vascularity, and urethral continuity. Prompt macroscopic reconstruction is preferred over delayed surgery for microsurgical re-anastomosis. Microvascular re-anastomosis is required for preservation of skin (dorsal artery and vein re-anastomosis) and sensation (dorsal nerve re-anastomosis). Erectile function results are similar with macroscopic and microscopic approaches.
The paired dorsal arteries travel along the dorsum of the corpora cavernosa. They give branches to the circumflex arteries which supply the corpus spongiosum; the dorsal arteries then arborize to the glans penis. While the dorsal arteries do give perforators to the corpora cavernosa, their contribution to erectile function is not consistent. It is the arborization in the glans penis which, through retrograde flow, helps supply the distal shaft skin.
A 22-year-old sexually active woman complains of vulvovaginal itching and flu-like symptoms. On physical examination, she is afebrile and the only finding is a fissure in the left labia majora with no vaginal discharge. Urinalysis is negative. The treatment that can prevent recurrence of her symptoms is:
A. hydrocortisone cream.
B. diphenhydramine cream.
C. intramuscular ceftriaxone.
D. imiquimod cream.
E. oral acyclovir.
E: “oral acyclovir.” is correct.
This patient has genital herpes (herpes simplex virus, HSV), of which 85-90% are caused by HSV-2 and 10-15% are caused by HSV-1. Initial genital herpes infection is often associated with constitutional flu-like symptoms. While vesicular eruptions can be found on physical exam, women especially may present with atypical lesions, such as abrasions, fissures, or itching. Empiric treatment may be initiated. Antiviral creams are not helpful for genital herpes. Oral acyclovir has been shown to prevent recurrence of genital herpes and associated symptoms. Hydrocortisone cream is not recommended for the treatment of genital herpes; however, recent studies suggest that a combination of topical acyclovir and hydrocortisone cream may reduce the recurrence of herpes labialis. Ceftriaxone is an appropriate treatment for chancroid but not genital herpes. Topical imiquimod is not recommended for treatment of routine genital herpes but is being used to treat recalcitrant cases of acyclovir-resistant herpes in immunocompromised hosts.
A 58-year-old man has a weak urinary stream. There is no history of lower urinary tract instrumentation or trauma. Retrograde urethrogram is shown. The next step is:
A. antegrade urethrogram.
B. direct vision urethrotomy (DVIU).
C. excision and primary anastomosis.
D. urethroplasty with graft or flap.
E. perineal urethrostomy and two stage repair.
D: “urethroplasty with graft or flap.” is correct.
This retrograde urethrogram is an adequate study and does not require an antegrade study. The study shows a 5 cm mid- to proximal bulbar urethral stricture. The next step is urethroplasty with graft or flap. Some evidence would support extended excision and primary anastomosis in this patient; however, only in the most experienced of hands. The stricture is too long (> 1.5 cm) for endoscopic manipulation. Perineal urethrostomy and two stage repair would be a more morbid approach for this stricture which could be successfully repaired in a single stage.
A two-month-old boy is noted to have an asymmetrical skin dimple over his upper sacrum on a physical examination. The next step is:
A. observation.
B. spinal ultrasound.
C. VCUG.
D. spinal MRI scan.
E. urodynamic study.
B: “spinal ultrasound.” is correct.
The finding of a skin dimple or cleft, discoloration, hemangioma, hair tuft, or other cutaneous malformation over the sacrum raises the question of an underlying spinal cord problem, such as tethering or lipoma involving the distal spinal cord. It is important to diagnose this promptly as there commonly will be progressive neurological impairment over time which will not be reversible with later intervention. Early treatment of tethered cord may preserve full neurological abilities. Spinal ultrasound is very useful in assessing the lower spinal cord in children under four months, as there is not full ossification of the bony structures, and thus, image quality is excellent. In addition, ultrasound holds the advantage over MRI scan in that it will not require general anesthesia and it is also much less costly. There is good correlation of ultrasound findings with MRI scan in this age group. If the ultrasound is normal, then no further imaging is needed. However, if there is an abnormality on spinal ultrasound, further evaluation with an MRI scan may be needed for clinical decision-making. Invasive lower urinary tract evaluations such as VCUG and urodynamic studies are premature, unless there is a diagnostic finding of a spinal abnormality.
A three-year-old boy with spina bifida and a neurogenic bladder has early filling bilateral grade 2 VUR. His bladder capacity is 170 mL with low detrusor pressure. DMSA shows bilateral renal scars. He is on CIC four times daily and has recurrent febrile UTIs while on prophylactic antibiotics. The next steps are to change prophylaxis and:
A. begin dual antibiotic prophylaxis.
B. start antimuscarinic medication.
C. increase frequency of CIC.
D. vesicostomy.
E. surgical repair of VUR.
E: “surgical repair of VUR.” is correct
This child with a neurogenic bladder has chronic bacteruria secondary to CIC. Most children on CIC do not have symptomatic infections, but this boy has developed renal scarring in spite of prophylaxis. This is an indication for a more aggressive approach to eliminate ascending infection. Surgical repair of VUR is the most appropriate choice. In the presence of scarring, observation (no change in therapy) is inappropriate. Increasing the frequency of CIC will not decrease the incidence of bacteruria and will not decrease the risk to the upper tracts since he has a low pressure bladder. Antimuscarinics will not be beneficial in what is already a low pressure bladder. A change in prophylaxis risks future infections and additional renal injury. Vesicostomy would be difficult to manage in a three-year-old and require continuous diaper dependency.
A 72-year-old man with metastatic prostate cancer complains of back pain. MRI scan reveals multiple spinal lesions without spinal cord involvement. The best immediate treatment is:
A. LH-RH antagonist.
B. LH-RH agonist.
C. anti-androgen monotherapy.
D. oral estrogen.
E. combination LH-RH agonist and anti-androgen.
A: “LH-RH antagonist.” is correct
In this patient with symptomatic metastatic disease and no evidence of spinal cord compression, prevention of testosterone surge and potential symptomatic flare is the best therapy. Leuprolide monotherapy is associated with an initial temporary testosterone increase and bicalutamide (an anti-androgen) would not cause immediate improvement of symptoms. Although estrogen would bring about testosterone decline, degarelix (a LH-RH antagonist) would bring about quicker castrate levels (within three days) and would accomplish this faster than combination LH-RH agonist and anti-androgen. Ketoconazole and bilateral orchiectomy are other options to rapidly reduce testosterone levels and can do so within 12 hours. The time to achieve castrate levels of testosterone is one to two weeks with estrogen, and three to four weeks for LH-RH agonists.
A 33-year-old woman has dysuria and fever. Urinalysis is leukocyte esterase positive and nitrite negative. There are 10 RBC and 30 WBC/hpf on microscopy. Urine culture will likely grow:
A. Escherichia coli.
B. Pseudomonas aeruginosa.
C. Serratia marcescens.
D. Klebsiella oxytoca.
E. Proteus mirabilis.
B: “Pseudomonas aeruginosa.” is correct.
Bacteria may convert urinary nitrates into nitrites and this may be used as evidence of UTI. Gram-negative bacteria commonly do this, while Gram-positive species generally do not. One very important gram-negative exception is Pseudomonas, which does not contain the enzymatic machinery to make this conversion. Thus, a negative nitrite by urinary dipstick in this patient with symptoms and other urinalysis findings suggestive of UTI should likely be treated presumptively pending culture, and Pseudomonas is one of the very important, aggressive pathogens that must be considered in this circumstance.
A 27-year-old man and his 27-year-old wife have not conceived after four months of attempts. A semen analysis is normal while a sperm DNA fragmentation test reveals high levels of DNA fragmentation. She has been cleared by her gynecologist and his evaluation is unremarkable. The next step is:
A. timed intercourse.
B. karyotype of the man.
C. intrauterine insemination with ovulation induction.
D. ICSI with ejaculated sperm.
E. counsel regarding high risk of congenital anomalies.
A: “timed intercourse.” is correct.
Sperm DNA integrity has garnered much interest over the last decade as a possible source of pathology for couples trying to conceive. Sperm DNA is complexed with protamines, resulting in a DNA structure that is six times more compact than the DNA found in somatic cells. Some investigators hypothesize that abnormally high levels of sperm DNA fragmentation are associated with abnormal reproductive outcomes, including lower fertilization, pregnancy, live birth rates, and higher rates of miscarriage.
The literature on outcomes associated with abnormally high sperm DNA fragmentation levels is divided and inconsistent. Some studies have reported that elevated levels of sperm DNA fragmentation are associated with lower rates of pregnancy by intercourse, but many couples still conceive via intercourse despite elevated sperm DNA fragmentation.
At this time, the World Health Organization categorizes sperm DNA integrity tests as “research procedures”. Given the conflicting nature of the literature regarding elevated DNA fragmentation levels and reproductive outcomes, the AUA states, “Currently, the tests have inadequate sensitivity and specificity to be of value as screening tests for pregnancy by intercourse”. Additionally, there are no therapies at this time that have been proven to correct an abnormal DNA fragmentation result. Since this couple has only attempted conception for four months, they should continue with intercourse for a total of 12 months. If no pregnancy results after 12 months of timed intercourse, then intrauterine insemination with ovulation induction or ICSI with ejaculated sperm could be considered. At this time, there is no evidence that men with elevated sperm DNA fragmentation rates have an increased risk of offspring with congenital abnormalities, so this line of counseling is not indicated. Finally, karyotype of the man is not indicated given that his semen analysis was normal.
A 65-year-old healthy man with bothersome LUTS (AUA Symptom Score 15) has a non-invasive uroflow as shown. His PVR is 100 mL. Based on these results, the:
A. study is inconclusive due to a low voided volume.
B. patient has bladder outlet obstruction.
C. patient has underactive detrusor.
D. cause of his LUTS cannot be identified.
E. patient should undergo a pressure-flow urodynamic study.
D: “cause of his LUTS cannot be identified.” is correct.
Uroflow is a screening tool for patients with lower urinary tract symptoms. A peak flow rate less than 15 mL/sec is considered abnormal. However, this study is unable to differentiate between bladder outlet obstruction and detrusor underactivity. If the bladder volume is less than 125-150 mL, the flow rate measurements are inconclusive. The bladder volume is the voided volume plus PVR. This patient may benefit from a pressure-flow urodynamic study to further elucidate the cause of his LUTS. However, this would usually be considered after a failed trial of medications.
A preventable complication associated with the Trendelenburg position pictured is:
A. weak leg adduction.
B. weak hip flexion.
C. pain along the dorsum of the foot.
D. numbness along the anterior thigh.
E. weakness in biceps and wrist extensors.
E: “weakness in biceps and wrist extensors.” is correct.
In the Trendelenburg position, shoulder braces should not be used due to the risk of injury to the brachial plexus. This manifests as weakness and tingling in the arms and fingers. In addition, the risk for injury to the brachial plexus is also accentuated by abducting the arms more than 90 degrees from the tucked position. Care should be taken to avoid lowering the robotic arms onto the dorsum of the foot when docking, which may result in pain along the dorsum of the foot. Weak leg adduction may result from injury to the obturator nerve during pelvic lymph node dissection. Injury to the genitofemoral nerve on the psoas muscle results in numbness along the anterior thigh. Hyperextension of the hip to allow docking of the robot in the Trendelenburg position results in compression of the femoral nerve by the inguinal ligament, resulting in weak leg flexion and paresthesias.
