2022 Flashcards
A 65-year-old man in urinary retention has post-obstructive diuresis after catheterization and is managed with appropriate fluid replacement. Three days later, urine output normalizes, but serum creatinine and BUN are unchanged at 6.8 mg/dL and 95 mg/dL, respectively. The next step is:
A. observation.
B. increased fluid replacement.
C. renal ultrasound.
D. retrograde pyelography.
E. dialysis.
C. renal ultrasound.
In patients with urinary obstruction and impaired renal function, post-obstructive diuresis is not unusual. Typically, urinary catheter drainage produces improvement in the blood levels of creatinine, BUN, and electrolytes to normal levels. If significant improvement does not occur, consideration must be given to inadequate drainage of the upper urinary tract because the bladder is poorly drained (poorly functioning catheter) or because of supravesical obstruction. The latter should be evaluated using renal ultrasound which is less invasive than retrograde pyelography. Since creatinine and BUN have not improved, continued observation is inappropriate until upper tract obstruction is ruled out. No data is provided to suggest the need for immediate dialysis. There is no evidence the patient is dehydrated; therefore, increased fluid replacement is not indicated.
The vascular supply of an omental wrap is based on the:
A. superior mesenteric artery.
B. gastroduodenal artery.
C. right gastroepiploic artery.
D. short gastric artery.
E. inferior mesenteric artery.
C. right gastroepiploic artery.
The blood supply of the omentum arises from the gastroepiploic arteries. The superior mesenteric, gastroduodenal, short gastric, and inferior mesenteric arteries do not directly supply the omentum and should not be mobilized for omental wraps.
A 46-year-old man with a high velocity GSW to the right lower abdomen has a normal urinalysis. During laparotomy, a small bowel perforation and right iliac vein injury are repaired. Intraoperative IVP reveals prompt bilateral excretion of contrast with no extravasation. The next step is:
A. no further evaluation.
B. ureteral inspection.
C. I.V. fluorescein.
D. bladder filling with methylene blue.
E. retrograde ureteropyelography.
B. ureteral inspection.
The frequency of ureteral injuries from penetrating trauma is low. Given this location, however, there is a high likelihood of ureteral injury, regardless of the appearance of the IVP. These injuries may be difficult to detect because the IVP is either normal or indeterminate in approximately 70% and hematuria may be absent in up to 45%. Retrograde ureteropyelography or injection of dyes (i.e., I.V. fluorescein) may miss such injuries because the blast injury often results in delayed sloughing. Without gross hematuria, a bladder injury is unlikely, and therefore intravesical methylene blue is unnecessary. A high index of suspicion is necessary for diagnosis of a ureteral injury and the most accurate method is ureteral inspection. Given the vein repair, the area of interest is exposed, and inspection should not be difficult.
A 58-year-old man has frequency and nocturia, an AUA Symptom Score of 22, peak urinary flow rate of 8 mL/sec, and PVR of 200 mL. His prostate is 70 grams with a prominent median lobe. Sitting systolic blood pressure is 140 mmHg. An orthostatic blood pressure change of 25 mmHg is not associated with postural symptoms. He is concerned about developing ejaculatory dysfunction. The best treatment is:
A. finasteride.
B. alfuzosin.
C. TUIP.
D. transurethral vaporization of the prostate.
E. UroLift®.
B. alfuzosin.
Orthostatic hypotension is not a contraindication for alpha-blockers providing the blood pressure change is not associated with postural symptoms. Alpha-blockers, such as alfuzosin, are the first-line treatment for men with BPH/LUTS and their effectiveness is independent of prostate size. Alfuzosin has the lowest rate of ejaculatory dysfunction (< 1%) of all the medicines in this class. Finasteride will decrease semen volume and will take several months to take effect. While the rate of retrograde ejaculation with TUIP is low, it still has an approximately 11% rate of ejaculatory dysfunction. Transurethral vaporization of the prostate has a high rate of retrograde ejaculation, similar to TURP. If this man fails to improve on alfuzosin, UroLift® might be an option. However, while UroLift® does not cause retrograde ejaculation, it is not currently recommended for patients with enlarged median lobes. Rezum® is an option for this patient should he fail medical therapy or choose not to undergo a trial of medical therapy.
Two months following closure of a traumatic bladder rupture associated with a pelvic fracture, a 20-year-old man is now voiding but has persistent leakage through his prior suprapubic tube site. The next step is:
A. CT urogram.
B. pelvic MRI scan.
C. fistulogram.
D. cystourethroscopy.
E. UDS.
D. cystourethroscopy.
When faced with a patient with a persistent urinary fistula, the acronym FETID will aid the physician in determining its etiology and management plans: F- Foreign Body, E- Epithelization of the fistula tract, T- Tumor or chronic trauma causing persistence, I- Infection, or chronic inflammation arising from inflammatory bowel disease, XRT, etc., D- Distal obstruction. In this young patient with a history of persistent fistula following closure of a bladder rupture after a pelvic fracture, persistent drainage from a suprapubic tube site is most likely from either a foreign body within the bladder (i.e., bony spicule or bladder calculi formed as a nidus from the prior indwelling suprapubic tube) or bladder outlet obstruction arising from either a bladder neck contracture or urethral stricture. The single best diagnostic study is cystourethroscopy. Pressure flow UDS could demonstrate findings consistent with high-pressure voiding and outlet obstruction. But the source of the obstruction, which is likely a urethral stricture or a bladder neck contracture, would not be able to be determined by this test and this test does not rule-out the possibility of a foreign body within the bladder. A CT scan may allow one to visualize either a foreign body (bone or hardware) or bladder calculi but would not be able to assess the urinary outlet. Similarly, a fistulogram or pelvic MRI scan are unlikely to yield adequate diagnostic information in this situation to result in definitive operative plans.
A 69-year-old woman with hypertension and palpitations has elevated plasma free metanephrines. CT scan is shown. In addition to blood pressure control, the next step is:
A. gallium-68 dotatate PET scan.
B. adrenal venous sampling.
C. iodine-131-MIBG.
D. mitotane.
E. cisplatin and etoposide.
A. gallium-68 dotatate PET scan.
The patient has a clinical presentation, radiographic features, and laboratory studies consistent with a paraganglioma. Initial management should involve alpha-blockade to establish blood pressure control. Staging evaluation for metastases in this setting is recommended, with gallium-68 dotatate PET having emerged as the preferred imaging modality. Dotatate has a high affinity for the somatostatin surface receptor, which is expressed by paragangliomas, and thereby facilitates detection of metastatic disease which may in turn impact management. Iodine-131-MIBG represents a form of systemic therapy that may be utilized for patients with metastatic disease or locally unresectable tumors in whom a prior MIBG scan has been obtained and is positive. Meanwhile, adrenal vein sampling has been reported to have a sensitivity of 95% and a specificity of 100% for detecting lateralized autonomous aldosterone secretion but would not be indicated in the evaluation of a patient with a likely retroperitoneal paraganglioma. Both cisplatin and etoposide as well as mitotane are systemic therapy options for patients with metastatic adrenocortical carcinoma (with cisplatin/etoposide preferred) but would not be indicated here in a functional paraganglioma and without documented metastatic disease.
A five-year-old boy has day and night wetting, constipation, and fecal soiling. Physical examination is normal except for a high-arched right foot. UDS shows detrusor overactivity and normal sphincter function. PVR is 5 mL. The next step is:
A. CIC.
B. timed voiding schedule.
C. spinal MRI scan.
D. antimuscarinics.
E. bowel program.
C. spinal MRI scan.
The patient has the urologic finding of incontinence combined with fecal soiling and a high-arched foot abnormality. A foot abnormality, such as a high-arched foot or abnormal gait, can signify a tethered cord. A tethered cord due to occult spinal dysraphism needs to be ruled out as the cause of his incontinence. Tethered cord syndrome is a stretch-induced functional disorder of the spinal cord with the most caudal part of the cord anchored by inelastic structures. Specific treatment of his detrusor overactivity with timed voids, medication, and/or treatment of constipation is appropriate after a neurologic cause is excluded. CIC would not be needed without evidence of urinary retention.
A 70-year-old woman has intermittent large volume urinary incontinence. Her medical history is significant for a hysterectomy 20 years ago. Urinalysis is normal and PVR is 40 mL. During the CMG, there is no incontinence demonstrated during filling and stress maneuvers, and the end fill pressure is 6 cm H2O at 300 mL. The most likely cause of her incontinence is:
A. overflow.
B. detrusor overactivity.
C. decreased detrusor compliance.
D. intrinsic sphincter deficiency.
E. VVF.
B. detrusor overactivity.
This patient likely has urgency urinary incontinence secondary to detrusor overactivity, as indicated by the random nature of the incontinence. UDS will fail to demonstrate involuntary bladder contractions in approximately 50% of patients with clinical urgency urinary incontinence. SUI occurs during increased abdominal pressure, and she is not describing leakage during these types of events such as coughing, lifting, and exercise. In addition, SUI, including intrinsic sphincter deficiency, is not demonstrated on UDS since urinary leakage did not occur during Valsalva maneuvers. The characteristics of the incontinence are not consistent with a VVF as the urinary leakage is not continuous. She has a normal detrusor pressure at the end of filling, confirming normal compliance (300 mL/6 cm H2O=50 mL/cm H2O). Her PVR of 40 mL demonstrates that she is not in urinary retention and thus rules out overflow incontinence.
The manifestation of the VHL syndrome that tends to cluster within a subset of affected families is:
A. RCC.
B. pheochromocytoma.
C. retinal angioma.
D. cerebellar hemangioblastoma.
E. epididymal papillary cystadenoma.
B. pheochromocytoma.
Penetrance for all of the manifestations of VHL is incomplete. In particular, pheochromocytomas have been found to cluster only in certain families with VHL, primarily those with a missense mutation of the VHL gene. A careful family history and thorough review of preoperative CT scans for potential associated tumors are important in all patients with familial RCC. Indeed, pheochromocytomas are a critical entity to recognize prior to any surgical intervention, given the potential perioperative morbidity of an unrecognized pheochromocytoma. The other listed manifestations of VHL are not as well-characterized by familial clustering.
A 37-year-old woman with a continent cutaneous urinary diversion becomes febrile and develops mental status changes and marked hepatic dysfunction. Previously, her hepatic function had been normal. In addition to prompt urinary drainage and systemic antibiotics, the next step is:
A. lactulose.
B. Vitamin B12.
C. sodium bicarbonate.
D. nicotinic acid.
E. thiamine and folic acid.
A. lactulose.
Urinary ammonium excreted by the kidneys is reabsorbed by the intestinal segment and then returned to the liver via the portal circulation. The liver metabolizes ammonium to urea via the ornithine cycle. The liver usually adapts to the excess ammonia in the portal circulation without difficulty and rapidly metabolizes the urea. In the setting of hepatic dysfunction, the hepatic reserve for ammonium metabolism may be exceeded, resulting in the complication of an ammoniagenic coma. The syndrome, however, also has been described in patients with normal hepatic function. Systemic bacteremia, with endotoxin production, inhibits hepatic function and may precipitate this clinical entity. UTIs with urea-splitting organisms may also overload the ability of the liver to clear the ammonia. If this syndrome occurs in a patient suspected of having near-normal hepatic function, systemic bacteremia or urinary obstruction should be suspected. Prompt urinary drainage with treatment of the offending urinary pathogens along with systemic antibiotics and the administration of oral neomycin or lactulose to reduce the absorption of ammonia in the gastrointestinal tract are the key components to patient management. There is no indication for the use of Vitamin B12, sodium bicarbonate, nicotinic acid, thiamine, and folic acid in this clinical setting.
A 67-year-old man has an IPSS of 25 and a bother score of 5. He has no history of urinary retention, infections or stones, and has normal renal function. DRE reveals a 25 gram benign prostate. The next step is:
A. observation.
B. alpha-blocker.
C. a-alpha-reductase inhibitor.
D. alpha-blocker and 5-alpha-reductase inhibitor.
E. UroLift®.
B. alpha-blocker.
This patient has a high IPSS with a significant bother score, therefore watchful waiting is not appropriate, and he should be offered intervention. A VA study of 1229 patients randomized to placebo, alpha-blocker therapy, finasteride, or combination therapy with alpha-blockers plus finasteride showed the superiority of alpha-blocker therapy alone in improvement of symptoms and peak flow rate. Other than an additional reduction in prostate volume, combination therapy with finasteride did not provide significantly more symptom relief. Combination therapy may be beneficial in a man with an enlarged prostate; however, there is no indication that the prostate is enlarged in this individual, and therefore, the initial cost and potential adverse effects of combination therapy are not justified in this untreated patient. Medical therapy of prostatic symptoms has shown a reduction in BPH progression with combination therapy, though this question focuses on symptomatic relief in a patient without significant prostatic enlargement, which would be best achieved by alpha-blockade alone. This patient has no absolute indication for surgical therapy such as UroLift® although it may be considered if the patient chooses not to undergo medical therapy.
During laparoscopic left radical nephrectomy, minimal placement of clips on the primary branches of the main renal vein is most important to facilitate:
A. lymphadenectomy.
B. en bloc excision with negative margins.
C. adrenalectomy.
D. application of the endovascular stapler onto the main renal vein.
E. dissection and occlusion of the main renal artery(ies).
D. application of the endovascular stapler onto the main renal vein.
Excessive placement of clips when managing the gonadal, adrenal, or lumbar branches of the left renal vein can severely restrict the working space available for safe placement of the endovascular stapler later in the case when the main renal vein is to be addressed. Application of the stapler across a clip can lead to stapler misfire and subsequent hemorrhage and should therefore be avoided. Use of clips is not likely to significantly impact the ability to perform the lymphadenectomy, adrenalectomy, the ability to achieve negative margins, or the ability to control the renal artery.
A 48-year-old man undergoes partial nephrectomy for a 3 cm renal mass. His flank drain is removed on the third postoperative day. Seven days later, he has clear fluid dripping from the flank drain site. He is otherwise asymptomatic. CT scan demonstrates a 5 cm by 10 cm fluid collection adjacent to the kidney with extravasation of contrast from the collecting system. The next step is:
A. observation.
B. urethral catheter.
C. percutaneous drainage of urinoma.
D. PCNT.
E. ureteral stent.
C. percutaneous drainage of urinoma.
Urine leak following partial nephrectomy occurs in up to 15% of cases. If a postoperative drain is left in situ, spontaneous closure of the urinary leak usually occurs within two to four weeks. In the case of an unrecognized or delayed urinary leak, the presence of an adjacent urinoma may prevent fistula closure and predispose the patient to infection/abscess formation. Percutaneous drainage of the urinoma is the preferred method used to control a delayed pyelocutaneous fistula. If the leak does not heal with drainage of the urinoma, consideration should be given to the possibility of either ureteral/bladder obstruction or bladder dysfunction as a cause of the persistent fistula. In these situations, a cystoscopy with a retrograde pyelogram followed by ureteral stent and urethral catheter placement should be pursued. The concomitant urethral catheter is used to aid healing by preventing high-pressure reflux up the ureteral stent and/or to treat bladder outlet obstruction or voiding dysfunction as an etiology for the persistent urinary fistula or urinary leak. PCNT would be considered if a ureteral stent could not be placed.
A 23-year-old addict is treated with I.V. antibiotics and percutaneous drainage for a renal abscess. Forty-eight hours after admission, he continues to have high fever and is found injecting himself with heroin. He physically assaults a security guard and now demands to be discharged against medical advice. The next step is:
A. discharge from the hospital on oral antibiotic therapy.
B. allow discharge against medical advice.
C. sedation, physical restraint, and continue treatment.
D. transfer to a chemical dependency unit.
E. notify legal authorities and continue treatment.
E. notify legal authorities and continue treatment.
The continued use of I.V. street drugs while under treatment directly affects the likelihood of medical success. His abusive and illegal behavior could stem from his underlying social pathology or could indicate alterations in mental capacity from additional infected cerebral sites. The use of street drugs coupled with an assault on the hospital staff should result in turning this patient over to legal authorities, who can mandate and supervise additional diagnosis and treatment. This will provide security for the treating staff and protection of the patient from his own actions.
A 72-year-old man is noted to have a large bladder on a CT scan performed for colonic diverticular disease. He has no LUTS. His prostate is 30 grams and benign. PVR is 350 mL. Urinalysis is negative. The next step is:
A. observation.
B. alpha-blocker.
C. 5-alpha-reductase inhibitor.
D. 5-alpha-reductase inhibitor and an alpha-blocker.
E. Rezum®.
A. observation.
PVR measurement has significant intra-individual variability and does not correlate well with other signs or symptoms of lower urinary tract dysfunction. The VA Cooperative Study Group (which evaluated men with bothersome LUTS secondary to bladder outlet obstruction) demonstrated that PVR does not predict the outcome of surgery and the majority of men with large residual urine volume did not require surgery during the duration of the trial. Men with significant PVRs should be monitored more closely if they elect no therapy. This man would be considered to have low risk chronic urinary retention (PVR > 300 mL) because he has no signs or symptoms of upper tract deterioration or UTIs. Medical therapy for BPH is indicated in men who have bothersome symptoms that negatively affect their quality of life. First-line medical therapies include alpha-blockers, 5-alpha-reductase inhibitors, or a combination of the two. Minimally invasive or surgical therapy, such as Rezum®, is not indicated in men without bothersome symptoms.
One hundred patients undergo abdominal imaging for staging prior to RPLND. Retroperitoneal metastatic disease is confirmed in 50 patients at surgery. With imaging, there were 20 false positives and 10 false negatives. The sensitivity of the imaging is:
A. 50%.
B. 60%.
C. 67%.
D. 75%.
E. 80%.
E. 80%.
A test with high sensitivity (good for screening) reliably finds a disease when it is present and avoids false negatives. A test with high specificity (good for confirmation) reliably excludes a disease when it is absent and avoids false positives. Positive predictive value is the probability a person has disease if test result is positive. Negative predictive value is the probability a person does not have the disease if the test result is negative. The test result can be true positive (TP), true negative (TN), false positive (FP), or false negative (FN). The number with disease = TP + FN = 50. FN = 10; therefore, TP = 40. The number without disease = FP + TN = 50. FP = 20; therefore, TN = 30. The prevalence of disease in this study is 50%. Sensitivity = TP/(TP + FN) = 40/(40 + 10) = 80%. Specificity = TN/(FP + TN) = 30/(20 + 30) = 60%. Positive predictive value = TP/(TP + FP) = 40/(40 + 20) = 67%. Negative predictive value = TN/(FN + TN) = 30/(10 + 30) = 75%.
A 52-year-old man with erectile dysfunction undergoes videourodynamics for voiding dysfunction. A videourodynamic image, taken early in filling (at the point indicated by dotted line in the UDS tracing), is shown. The videourodynamics suggests a diagnosis of:
A. bladder neck dyssynergia.
B. cervical spinal stenosis.
C. Parkinson’s disease.
D. multiple system atrophy (Shy-Drager Syndrome).
E. multiple sclerosis (MS).
D. multiple system atrophy (Shy-Drager Syndrome).
The cystogram demonstrates an open bladder neck at rest. The UDS tracing shows that there was no detrusor activity at the instant the image was obtained. An open bladder neck at rest in a male is highly suggestive of multiple system atrophy (MSA-formerly known as Shy Drager Syndrome) in the absence of prior prostate surgery. Although other neurological diseases may result in an open bladder neck at rest, none of these are listed except MSA. Erectile dysfunction is often found in MSA, and this finding in concert with the open bladder neck at rest distinguishes this condition from Parkinson’s disease (PD) which is often clinically similar in many other respects. Other symptoms of MSA may include other autonomic dysfunctions. Bladder neck dyssynergy would have a closed bladder neck with filling. Cervical spinal stenosis and MS would not typically have an open bladder neck at rest. A further distinction between PD and MSA is that bladder symptoms occur earlier in the course of MSA compared to PD patients.
A 28-year-old man has acute scrotal pain. Ultrasound reveals testicular torsion. The consulting urologist is unavailable and asks that pain medication be withheld until surgical consent can be obtained in one hour. The ER physician should:
A. withhold pain medication.
B. administer appropriate analgesics.
C. transfer to nearest hospital.
D. obtain consent for surgery.
E. give pain medication and obtain consent from a relative.
B. administer appropriate analgesics.
The patient should receive appropriate analgesics, and surgical consent should be obtained only by a member of the surgical team. This surgeon has the common misconception that informed consent is somehow invalidated by the presence of specific medications. Patients who present for surgery may have taken a variety of medications, many of which can have effects on mental function. The issue is not whether the patient has been premedicated, but whether premedication has impaired the patient’s ability to participate in the informed consent process. While it is appropriate to give pain medication, it is not appropriate to obtain consent from another party if the patient still has decision-making capacity. The ethical issues involved in this case include assessment of the patient’s capacity to make decisions and whether the patient is deliberately or otherwise being coerced into consenting for surgery. The patient’s capacity to provide consent is determined not by what recent medications have been given but by whether the patient understands the need for treatment, can listen to and understand treatment options and risks, and can then express a choice regarding their care. Respect for patient autonomy requires that we promote a patient’s ability to make an “unencumbered” choice. Severe pain, by impairing a patient’s ability to listen and understand, is an encumbrance to the informed consent process. Further, withholding pain medication for the purpose of obtaining consent might be coercive.
A 47-year-old woman has SUI and a urethral diverticulum. UDS demonstrates a Valsalva LPP of 50 cm H2O. The best treatment is urethral diverticulectomy and:
A. staged urethral bulking if SUI persists.
B. Martius fat pad.
C. pubovaginal sling.
D. midurethral sling.
E. Burch colposuspension.
C. pubovaginal sling.
A concomitant incontinence procedure should be considered given her SUI symptoms and demonstration of loss of urine with Valsalva on UDS. A pubovaginal fascial sling would treat the SUI without increased risk of urethral erosion. Concomitant placement of a synthetic midurethral sling should be avoided because of the potential risk of infection and erosion into the urinary tract and according to AUA Guidelines is not recommended at the time of urethral diverticulectomy. A Martius fat pad will not treat the incontinence. Her intrinsic sphincter deficiency, as suggested by the Valsalva LPP, is better treated with a sling rather than a Burch procedure.
A 55-year-old man with erectile dysfunction has a 60 degree ventral curvature of his penis of 18 months duration. On duplex Doppler ultrasound, his peak systolic velocities are 40 cm/sec; end-diastolic velocities are 10 cm/sec bilaterally. The next step is:
A. intralesional verapamil.
B. shockwave therapy.
C. penile plication.
D. plaque incision and grafting.
E. placement of a penile implant.
E. placement of a penile implant.
The patient has stable curvature precluding him from having sexual intercourse. His hemodynamic assessment indicates normal arterial inflows (peak systolic velocities > 30 cm/sec). However, there is evidence of veno-occlusive dysfunction (end diastolic velocities > 5 cm/sec). Intralesional injection therapy has not been shown to render men with this severity of curvature functional. Shock wave therapy is only indicated for pain related to Peyronie’s disease. Plication surgery will result in significant loss of penile length because of the degree of curvature and will not address the erectile dysfunction due to venous leakage. According to the AUA Guidelines on Peyronie’s disease, clinicians may offer plaque incision or excision and/or grafting to patients with deformities whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature. In men with this preoperative hemodynamic profile and erectile dysfunction, the procedure will not improve his erectile dysfunction and will render him incapable of having intercourse even with a straight penis. Penile implant surgery is indicated in men with this degree of curvature and erectile function.
An asymptomatic five-year-old boy has gross hematuria two hours after wrestling with his younger brother. Physical examination is normal. The next step is:
A. observation.
B. serial examinations and hematocrit determination.
C. ultrasound of bladder and kidneys.
D. CT scan.
E. cystoscopy.
C. ultrasound of bladder and kidneys.
It is recognized that underlying genitourinary malformations or other pathologies are at least three-fold more common in pediatric patients relative to adults undergoing evaluation for trauma. This is a classic case for raising the concern of an underlying abnormality since the gross hematuria seems out of proportion with the low severity of the trauma. The underlying problems may include hydronephrosis, multicystic kidney, Wilms’ tumor, and various renal fusion anomalies. Therefore, it is appropriate to image with ultrasound to look for such potentially significant problems. A patient should not be considered for admission with serial examinations and hematocrit determination unless there is a documented substantial renal injury. Cystoscopy is not indicated in the initial evaluation of gross hematuria in children. CT scan would only be indicated if there is significant injury or abnormality on ultrasound or if the mechanism of injury was more concerning.
A 32-year-old woman with severe pyelonephritis is receiving ampicillin combined with a single daily dose of gentamicin, 7 mg/kg. After 36 hours, she remains febrile and has persistent flank pain. Following the second dose, a trough serum gentamicin level is 12 mcg/mL (normal is 5-10 mcg/mL). The next step is:
A. continue current gentamicin regimen.
B. continue gentamicin and start n-acetylcysteine.
C. decrease gentamicin dose.
D. decrease gentamicin frequency.
E. discontinue gentamicin and start aztreonam.
D. decrease gentamicin frequency.
When combined with trimethoprim/sulfamethoxazole (TMP-SMX) or ampicillin, aminoglycosides are the first drugs of choice for febrile UTIs. Their nephrotoxicity and ototoxicity are well-recognized; hence, careful monitoring of patients for renal and auditory impairment as well as serum levels is indicated. Once-daily aminoglycoside regimens have been instituted to maximize bacterial killing by optimizing the peak concentration to minimal inhibitory concentration ratio and reduce the potential for toxicity. Administering an aminoglycoside as a single daily dose can take advantage not only of its concentration-dependent killing ability but also of two other important characteristics: time-dependent toxicity and a more prolonged post-antimicrobial effect. The regimen consists of 5-7 mg/kg daily dose of gentamicin or 5-7 mg/kg dose of tobramycin. Subsequent interval adjustments are made by obtaining a single concentration in serum and a nomogram designed for monitoring of once-daily therapy. Antimicrobial doses are given at the interval determined by the drug concentration of a sample obtained after the start of the initial infusion. This regimen is clinically effective, reduces the incidence of nephrotoxicity, and provides a cost-effective method for administering aminoglycosides by reducing ancillary service times and serum aminoglycoside determinations. In this case, the serum level of gentamicin is high and requires adjustment. Changing the dosing interval from every 24 hours to every 36 hours is indicated. Decreasing the dose may lead to the same reduction in levels but with a reduction in effectiveness. Although the patient continues to have symptoms, this is common during the initial course of pyelonephritis and is not an indication at 48 hours to change antibiotic regimen. There are no indications to start aztreonam or n-acetylcysteine.
A seven-year-old boy has had multiple repairs for penoscrotal hypospadias. He has recurrent lower UTIs and postvoid dribbling. Renal ultrasound is normal. Pelvic ultrasound is shown. The most likely diagnosis is:
A. cecoureterocele.
B. ectopic ureter.
C. Cowper’s duct cyst.
D. prostatic utricle.
E. bladder diverticulum.
D. prostatic utricle.
In boys with proximal hypospadias, the
prostatic utricle is often enlarged. In a female, this would represent the distal one-third of the vagina. The utricle is of urogenital sinus origin. While an ectopic ureter or bladder diverticulum could have a similar appearance on ultrasound, they generally are not midline in location. Ectopic ureter or bladder diverticulum are not commonly seen with hypospadias. A cecoureterocele would have a bladder deformity in addition to a suburethral extension. A Cowper’s duct cyst, also known as a syringocele, should be confined to the bulbous or prostatic urethra where Cowper’s ducts drain.
A 65-year-old man uses 20 mg of tadalafil as needed for erectile dysfunction. His primary care provider would like to initiate doxazosin for hypertension. The next step is:
A. continue tadalafil 20 mg as needed.
B. decrease tadalafil to 10 mg as needed.
C. start tadalafil 5 mg daily.
D. stop tadalafil.
E. switch to intracorporal alprostadil.
B. decrease tadalafil to 10 mg as needed.
Concomitant use of alpha-blockers and PDE-5 inhibitors can cause hypotension. When tadalafil is coadministered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating treatment with tadalafil, and tadalafil should be initiated at the lowest recommended dose. Conversely, when starting an alpha-blocker, the lowest dose of either agent should be used, and they should not be taken at the same time. There is no need to stop tadalafil in this patient or switch to intracorporal injections if he has been successful on oral therapy. Of all the choices, decreasing to the lowest effective dose of tadalafil (10 mg for use as needed or 2.5 mg/day for once daily use) would be recommended for this man.
A 58-year-old man has fever, chills, and elevated alanine aminotransferase and aspartate aminotransferase two days after receiving his fourth dose of intravesical BCG for bladder cancer. Urinalysis was notable only for occasional RBCs. In addition to supportive care, isoniazid, and rifampin, the next step is:
A. pyrazinamide.
B. cycloserine.
C. corticosteroids.
D. cyclosporine.
E. gentamicin.
C. corticosteroids.
Disseminated BCG (grade 3 serious complications) presents with systemic signs and symptoms, some of which are due to acute inflammatory response to the bacillus. Thus, systemic steroids are recommended in addition to the standard drug regimen to which a BCG-associated infection usually responds. BCG, an attenuated strain of Mycobacterium bovis, is poorly controlled by pyrazinamide due to uniform resistance. Cycloserine often causes severe psychiatric symptoms and is strongly discouraged. The immunosuppressant cyclosporine has no role in the management of disseminated BCG. There is no clear evidence of a bacterial infection, so the use of gentamicin is not indicated.
A six-year-old boy with a history of neonatally ablated PUV has worsening bilateral hydroureteronephrosis despite timed voiding. He is incontinent at night and occasionally wet during the day. A 24-hour urine collection shows a urine volume of 2 L. UDS shows adequate compliance, no detrusor overactivity, no residual valves, and no VUR. The next step is:
A. decreased fluid intake.
B. dietary salt restriction.
C. DDAVP.
D. CIC.
E. continuous nighttime catheterization.
E. continuous nighttime catheterization.
Patients with a concentrating defect due to obstruction such as PUV may present with worsening incontinence along with upper urinary tract deterioration due to excessive urine production. The urine volume will not decrease significantly with either salt or water restriction. Furthermore, water restriction is dangerous and often counterproductive, as it may lead to dehydration. Patients with a renal concentrating defect typically do not respond to DDAVP. Unless there is evidence of myogenic failure and incomplete bladder emptying, daytime CIC to further eliminate PVR is unlikely to help this patient. It has been suggested that continuous nighttime drainage can improve the fluid dynamics, thus restoring the upper urinary tract (decreasing bilateral hydroureteronephrosis), as well as improving daytime urinary incontinence.
A 65-year-old woman with chronic irritative voiding symptoms has persistent pan-sensitive E. coli UTIs. A renal ultrasound is normal, but cystoscopy shows several raised lesions in the bladder. Transurethral resection is performed. Pathologic study reveals giant cells and histiocytes containing concentrically laminated calcific inclusions. The next step is:
A. trimethoprim/sulfamethoxazole.
B. fluconazole.
C. dimethylsulfoxide.
D. corticosteroids.
E. isoniazid and rifampin.
A. trimethoprim/sulfamethoxazole.
Malakoplakia is an inflammatory process occurring more commonly in women than men (4:1). Irritative voiding symptoms are common, as is hematuria. It is associated with UTIs, most notably those due to E. coli. Most lesions are yellow, raised, and soft. Histologic examination reveals aggregates of large histiocytes (von Hansemann cells) which contain concentrically laminated calcific inclusions (Michaelis-Gutmann bodies). The primary disorder responsible for the disease may be abnormal bacterial digestion by tissue macrophages. Once an accurate diagnosis is made, patients should be treated with antibiotics (such as trimethoprim/sulfamethoxazole or fluoroquinolone). Use of bethanechol or ascorbic acid may enhance phagolysosomal activity. Extensive surgery is rarely necessary, although it may be needed to manage upper urinary tract involvement. The other answers are incorrect: fluconazole is for yeast infection, dimethylsulfoxide (DMSO) is for interstitial cystitis, corticosteroids is not the correct treatment for malakoplakia, and isoniazid and rifampin is for tuberculosis.
Primary idiopathic bladder stones in children form due to high urinary excretion of:
A. ammonia.
B. phosphate.
C. sodium.
D. calcium.
E. oxalate.
A. ammonia.
Primary idiopathic (endemic) calculi are commonly found in children from North Africa, the Middle East, and Asia. With a large immigrant population in the United States, it is important to be aware of this health problem. These children classically rely on a cereal-based diet that is lacking in animal proteins. The lack of protein leads to a dietary phosphate deficiency, low urinary phosphate, and high levels of urinary ammonia. Due to this, the most common stone found in children from these areas is ammonium acid urate. High urinary sodium, calcium, and oxalate are not characteristic findings with endemic bladder stones.
A 25-year-old intoxicated man has abdominal pain and gross hematuria following an MVC. He is hemodynamically stable, and his hemoglobin is 12 g/dL. CT scan with I.V. and oral contrast is shown. There are no pelvic fractures. The next step is:
A. serial hemoglobins and bed rest.
B. place a catheter and perform cystogram.
C. retrograde urethrogram.
D. embolization of segmental renal artery.
E. laparotomy and renorrhaphy.
B. place a catheter and perform cystogram.
Intoxication plus blunt abdominal injury, abdominal pain, and gross hematuria suggest a bladder perforation. The CT scan shows a low-grade renal injury. Although bed rest and serial hemoglobins are the appropriate management of low-grade renal injury, it is insufficient to focus on management of a low-grade renal injury when the bladder has not been completely evaluated. Discovery of a significant bladder injury could alter your decision for bed rest and possibly require surgical exploration. Similarly, renal embolization and renorrhaphy are both not indicated for low-grade renal injury and should not be performed. Therefore, a catheter should be placed and a cystogram performed. It is not necessary to perform a retrograde urethrogram when gross hematuria is present; this is indicated when there is blood at the meatus in the setting of a pelvic fracture or when a catheter cannot be passed into the bladder.
Six months after placement of a sacral neuromodulator, a 35-year-old woman is suddenly unable to sense the stimulation and her urinary urgency symptoms return. Interrogation of the device reveals elevated impedance measurements on two electrodes within the quadripolar lead. The next step is:
A. change pulse width of stimulation.
B. turn the device off and recheck impedances.
C. reprogram using the other two electrodes.
D. surgical exploration to check lead connections.
E. place new leads.
C. reprogram using the other two electrodes.
Impedance refers to the resistance to flow of electrons through a circuit. If there is too much resistance, the flow is limited. In the case of sacral neuromodulation, the circuit includes the neurostimulator circuitry, the extension, leads, patient tissue, and back to the circuitry, including all the connections. If the circuit is disrupted, for example, by a broken lead or a defective connection, impedances may be high. Patients may describe a sudden or gradual loss of sensation of stimulation or change in the character or location of the stimulation. If some electrodes show normal readings, the device should be reprogrammed using those electrodes prior to an exploration or revision. Turning the device off does not provide any helpful information with regards to impedance. Changing pulse width will not be helpful when the problem is too much impedance. Lead replacement is warranted if impedance is abnormal in all electrodes or if symptoms recur despite normal impedances, the latter of which would suggest a current leakage or lead displacement.
Because of the increased risk of adenocarcinoma of the bladder after bladder augmentation cystoplasty, current recommendations for annual monitoring include:
A. urine cytology.
B. urine fluorescence in-situ hybridization (FISH) analysis.
C. serum carcinoembryonic antigen (CEA) level.
D. renal and bladder ultrasound.
E. cystoscopy.
D. renal and bladder ultrasound.
Patients who undergo bladder augmentation with bowel should be counseled on the possible long-term risk of carcinoma formation, renal and bladder calculi, and metabolic abnormalities. The earliest report of tumor formation is four years after bladder augmentation with bowel. Yearly cystoscopic surveillance and cytology have been recommended by the International Children’s Continence Society (ICCS) as soon as 5 to 10 years following augmentation, but the evidence indicating the efficacy of screening protocols in this patient population is insufficient. Recent studies have shown that routine yearly endoscopy is not indicated due to the low incidence of malignancy following a bladder augmentation (approximately 2-4%), lack of proven benefit, and high cost. In the absence of other risk factors, the current recommendation is for annual visits with renal and bladder ultrasound (rule-out stones or the development of hydronephrosis secondary to non-compliance with CIC), electrolytes (rule out metabolic abnormalities), creatinine, serum B12 (rule-out nutritional deficiencies), and urinalysis (assess for hematuria). FISH analysis and CEA levels have not been proven standard of care for monitoring for the development of adenocarcinoma following bladder augmentation. Endoscopy is reserved for individuals with a past medical history of gross hematuria, microscopic hematuria (> 50 RBC/hpf), new onset of hydronephrosis (rule-out tumor obstructing the ureteral orifice), bladder calculi, chronic bladder/perineal pain, or a history of four or more symptomatic UTI per year. Using this screening criteria, > 90% of tumors arising in a bladder augment can be discovered without the use of annual endoscopy.
A 26-year-old man with significant obstructive voiding symptoms has a 3 cm distal bulbar urethral stricture. The next step is:
A. urethral dilation.
B. laser urethrotomy.
C. direct vision internal urethrotomy (DVIU).
D. excision and primary anastomosis.
E. substitution urethroplasty with graft.
E. substitution urethroplasty with graft.
Transurethral manipulation with dilation, DVIU, or laser urethrotomy has little to no success with strictures 3 cm in length. An excision and primary anastomosis of a 3 cm stricture at the distal bulbar urethra would create excessive tension and ischemia at the anastomotic site. This is in comparison to a proximal bulbar urethral stricture where the compliance of the urethral tissue is much greater, and the ability to mobilize the urethra more extensively to create a tension-free anastomosis is possible. Graft or flap interposition is the best option in this clinical scenario.
A 56-year-old man undergoes a radical cystoprostatectomy and orthotopic neobladder. Long-term preservation of renal function is most dependent on:
A. preferential use of ileum over colon.
B. use of > 60 cm of detubularized bowel.
C. performance of an antirefluxing ureteroileal anastomosis
D. intraoperative neobladder capacity of > 500 mL.
E. postoperative avoidance of any bacteriuria.
A. preferential use of ileum over colon.
Reservoirs made of detubularized ileum appear to have the greatest compliance and lowest likelihood of generating intermittent high-pressure contractions. Several clinical studies have demonstrated that the urodynamic characteristics of the ileum appear to be superior to those of the colon and is, therefore, the preferred segment of bowel used for a neobladder. Larger bowel lengths with increased intra-operative volumes are not necessary as all bowel segments effectively stretch over time if there is adequate outflow resistance. In fact, commonly utilized techniques (i.e., Studer, Hauptmann) utilize 40-44 cm of detubularized ileum with resultant intra-operative volumes of 200 mL or less. For ileal neobladders, it has been shown that the capacity increases sevenfold after one year. The true benefits of anti-refluxing anastomosis remain uncertain. It does not appear that conduit pressures are transmitted to the renal pelvis. Also, there is no difference in conduits between those with versus without reflux, with regard to renal function measured two to five years postoperatively. Furthermore, the successful construction of an anti-refluxing anastomosis does not prevent bacterial colonization of the renal pelvis. Many of these patients in fact have no untoward effects and do well despite chronic bacteriuria. Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas, and should therefore be treated in such cases, whereas those with mixed cultures may generally be observed (provided they are not symptomatic).
During vaginal repair of a post-hysterectomy VVF located near the vaginal vault apex, the easiest tissue to interpose as a flap/graft is:
A. buccal mucosa.
B. peritoneum.
C. omentum.
D. Martius fat pad.
E. gracilis.
B. peritoneum.
Following hysterectomy, even a high VVF can often be repaired through a vaginal approach. Note that the literature does not clearly support the need for a graft in a primary VVF repair. However, of the grafts listed, a simple procedure to augment the repair is harvest of the peritoneum which is often present around the vaginal apex. This peritoneal flap can be placed over the two-layer fistula closure. Omentum can easily be harvested through a transabdominal approach but would not be an option transvaginally. Buccal mucosa has been described in case reports but would not offer benefit over more local tissue for a primary repair. Martius flaps are more commonly used for distal fistulas such as a urethrovaginal fistula. Myocutaneous flaps such as a gracilis flap are not appropriate for primary repair of a straightforward fistula.
A 60-year-old man is diagnosed with a single focus of CIS of the bladder. He is treated with six doses of intravesical BCG. One month after his last dose, his cystoscopy is normal, and his cytology is negative. The next step is:
A. bladder biopsy to confirm complete response.
B. observation with regular surveillance cystoscopy and cytology.
C. maintenance BCG with the first of three weekly doses at three months.
D. maintenance BCG with the first of three weekly doses at six months.
E. maintenance BCG single monthly dose for one year.
C. maintenance BCG with the first of three weekly doses at three months.
BCG maintenance therapy is indicated for patients with CIS (even if focal) who achieve a complete response to initial induction treatment. In particular, the Southwest Oncology Group (SWOG) trial reported an estimated median recurrence-free survival of 76.8 months in patients receiving maintenance BCG versus 35.7 months in the no maintenance arm (p < 0.0001). In that study, which has defined the current preferred regimen for maintenance BCG, patients received a six-week induction course followed by three weekly instillations of maintenance at three and six months and then every six months thereafter for three years. This patient is at the three-month point and should therefore receive the first set of maintenance treatments as the next step. Bladder biopsy is not necessary if the patient’s cystoscopy and cytology are negative. Observation alone is not optimal therapy unless the patient has a contraindication or serious complication from BCG. Monthly BCG has been described and is commonly used but has not been tested against the maintenance schedule proven to be effective in the large published SWOG trial. In addition, investigators in a phase III clinical trial (NIMBUS Trial) compared a standard BCG schedule of six-week induction followed by three-week maintenance at three, six, and 12 months (15 instillations) to a reduced frequency BCG schedule of induction at weeks one, two, and six followed by two-weeks (weeks one and three) of maintenance at three, six, and 12 months (nine instillations). Following a data review and safety analysis, patient accrual was halted as the reduced frequency schedule was inferior to the standard schedule regarding the time to first recurrence.
A 45-year-old man has a two-year history of frequency, diminished stream, and perineal discomfort. Examination, urinalysis, localization cultures, and cytology are all normal. Trials of antibiotics and an alpha-blocker have been unsuccessful. Uroflowmetry with EMG reveals a peak flow of 9 mL/sec, a voided volume of 160 mL, synergistic voiding, and a PVR of 100 mL. The next step is:
A. TRUS.
B. videourodynamics.
C. NSAIDS.
D. amitriptyline.
E. pelvic floor physiotherapy.
B. videourodynamics.
Differential diagnosis in this patient includes chronic pelvic pain syndrome or other underlying conditions such as bladder neck obstruction. The information provided and the diagnostic studies done to date are notable for diminished flow rate and incomplete emptying. The synergistic voiding rules out pelvic floor dysfunction. A wide range of studies have documented the prevalence of voiding dysfunction in these patients and the value of UDS evaluation, particularly with simultaneous video evaluation, in diagnosing bladder neck obstruction and guiding treatment. While TRUS, semen culture, and cystoscopy may all be useful in selected patients (when indicated by specific elements of the history or examination), there is no indication for any of them in this instance. The use of NSAIDS as monotherapy has not proven useful. Amitriptyline is a tricyclic antidepressant with both alpha and beta sympathomimetic stimulant effects and will actually worsen voiding symptoms in patients with bladder neck obstruction. Pelvic floor physiotherapy has not been found to be beneficial in patients with primary bladder neck obstruction and use at this time in a patient with presumed bladder neck obstruction is costly and inappropriate.
A 24-year-old man undergoes infertility evaluation. Physical examination reveals bilateral absence of the vas deferens. His semen analysis characteristics should include azoospermia and:
A. an ejaculate volume of 3 mL.
B. a semen pH of 6.3.
C. semen liquefaction within 30 minutes.
D. semen coagulum formation.
E. normal semen fructose.
B. a semen pH of 6.3.
This patient has congenital bilateral absence of the vas deferens (CBAVD). This is mostly associated in men with cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. However, this diagnosis can be reached largely on physical examination and semen analysis prior to genetic testing. These men will have macroscopic semen parameters consistent with a pattern seen with ejaculatory duct obstruction, which includes azoospermia, low semen volume (< 1.0 mL), and acidic semen pH (< 7.0). They will also have an inability to form a semen coagulum and prolonged semen liquefaction. Semen fructose levels are low in men with either CBAVD or ejaculatory duct obstruction due to lack of seminal vesicle contribution to the semen. The remaining fluid comes from the prostate and peri-urethral glands, which is typically acidic and devoid of fructose.
A 70-year-old man has a 2 cm high-grade squamous cell carcinoma of the distal urethra. MRI scan demonstrates invasion of the corpora and no lymphadenopathy. The next step is:
A. partial penectomy.
B. total penectomy with perineal urethrostomy.
C. partial penectomy with bilateral pelvic lymphadenectomy.
D. total penectomy, perineal urethrostomy, and bilateral pelvic lymphadenectomy.
E. partial penectomy with bilateral inguinal lymphadenectomy.
A. partial penectomy.
Squamous cell carcinoma of the distal (pendulous) urethra is managed by distal urethrectomy and penectomy with the goal of achieving a negative margin. If invasive disease involves the proximal penile urethra, total urethrectomy with or without penectomy, may be required. Neoadjuvant chemotherapy has not been tested except with locally extensive lesions to enhance resectability. For advanced distal urethral cancers (T3 +/- N1), chemoradiation has been used with consideration of surgical consolidation. The management of the inguinal region is different compared to primary penile carcinoma in that prophylactic lymphadenectomy for high-grade or high stage primaries without evidence of metastases on exam or imaging, is not indicated. Pelvic lymph node dissection is not indicated in the primary setting of a distal urethral cancer although it can occasionally be utilized after a favorable response to chemotherapy or chemoradiation.
A 50-year-old man has secondary infertility. He has been on tamsulosin and finasteride for three years. Examination is unremarkable and DRE reveals a 40 gram prostate. Semen analysis shows a volume of 0.4 mL, sperm concentration of 9 million/mL, and 30% motility. The next step is:
A. switch tamsulosin to silodosin.
B. discontinue finasteride.
C. discontinue finasteride and tamsulosin.
D. pseudoephedrine.
E. imipramine.
C. discontinue finasteride and tamsulosin.
5-alpha-reductase inhibitors result in decreased dihydrotestosterone (DHT) and semen volume. A variable decrease in sperm concentration and motility may also occur. Alpha-blockers lead to relaxation of the bladder neck, resulting in retrograde ejaculation or anejaculation and decreased ejaculated semen volume. All of these effects are reversible with discontinuation of the medications. Silodosin has a higher rate of retrograde ejaculation than tamsulosin. Pseudoephedrine tightens up the bladder neck and will not cause reduction of semen volume, although it can be used as a treatment for retrograde ejaculation. It would, however, not improve the decreased semen parameters induced by finasteride and may worsen his LUTS. Imipramine is a sympathomimetic medication that was previously used as an anti-depressant. It has been used in cases of retrograde ejaculation, but similar to pseudoephedrine, would be used only if retrograde ejaculation continues following discontinuation of finasteride and tamsulosin (the likely causes in this case). Although not offered as an option here, discontinuation of tamsulosin alone could also have been considered as a first step.
A 50-year-old man has recurrent UTIs and left flank pain. CT scan is shown. The next step is:
A. diuretic renal scan.
B. retrograde pyelogram.
C. ureteroscopy and laser lithotripsy.
D. PCNL.
E. pyeloplasty and pyelolithotomy.
A. diuretic renal scan.
The patient has a possible UPJ obstruction along with the lower pole stone. He has recurrent UTIs that may be due to the UPJ, infected urine, and likely an infected lower pole stone. Observation is not an option in this case. Since the patient has a suspected UPJ obstruction, a diuretic renal scan is needed before initiating a treatment option to determine the degree of possible obstruction. Retrograde pyelogram is invasive and does not quantify the degree of obstruction. If obstruction is confirmed, then a dismembered pyeloplasty with pyelolithotomy to remove the lower pole stone is possible. If obstruction does not exist, then ureteroscopy or PCNL is an option. With a possible tight UPJ, borderline stone size, along with lower pole location, ureteroscopy may require more than one procedure. PCNL would be a better option with or without anterograde endopyelotomy, depending on the result of the renal scan.
The best initial medical treatment for newly diagnosed prostate cancer with painful spinal metastases and new lower extremity weakness is:
A. enzalutamide.
B. abiraterone acetate.
C. relugolix.
D. leuprolide.
E. degarelix.
E. degarelix
LH-RH antagonists, like degarelix or abarelix, bind immediately and competitively to the LH-RH receptors in the pituitary, significantly reducing LH and serum testosterone concentrations by 84% within 24 hours of administration. Hormonally naïve patients with impending spinal cord compression or severe bone pain may uniquely benefit from this class of agents (or surgical orchiectomy). The direct antagonistic activity eliminates the testosterone flare which is characteristic of LH-RH agonists such as leuprolide. Historically, while ketoconazole has been used in this setting, the improved toxicity profile of degarelix makes this a better treatment option. Likewise, surgical orchiectomy may be utilized in this setting. Enzalutamide is a third-generation androgen receptor antagonist but has never been evaluated in this clinical setting. Abiraterone acetate is a CYP-17 inhibitor that lowers androgen synthesis. Relugolix is an oral GnRH receptor antagonist. All three are oral agents and would likely have longer onset of action compared to degarelix and this longer onset makes them inferior choices in this patient with presumed spinal cord compression requiring more urgent treatment.
A 24-year-old man is involved in a high speed MVC. CT scan reveals prompt uptake of contrast in the left kidney with a UPJ disruption. The right kidney is normal. He is hemodynamically stable with a normal hemoglobin. The next step is:
A. ureteral stent.
B. PCNT.
C. PCNT and perinephric drain.
D. flank exploration.
E. transabdominal exploration.
E. transabdominal exploration.
The patient has suffered a UPJ disruption following a rapid deceleration injury. Absolute indications for renal exploration include expanding/pulsatile hematoma, hemodynamic instability, suspected renal pedicle avulsion, and UPJ disruption. Exploration is best carried out through a transabdominal approach (not flank) which allows for better control of the renal vessels and thorough inspection of the bowel and intra-abdominal organs. Observation and minimally invasive approaches such as stent or PCNT, with or without perinephric drain, are not indicated in the presence of an acute UPJ disruption following blunt trauma.
A seven-year-old boy has testes in the upper portion of the scrotum that can be brought down into the dependent portion with some mild tension. They retract into the inguinal canal with body movement but return to their original upper scrotal position with relaxation. The next step is:
A. reassurance.
B. follow-up with annual exams.
C. scrotal ultrasound.
D. beta-hCG.
E. orchidopexy.
B. follow-up with annual exams.
This boy has retractile testes which are felt to be due to an overactive cremasteric reflex. They are commonly seen in boys between the ages of three to seven. In the past, retractile testes were felt to be a variant of normal anatomy and further ascent was rare. However, more recent studies have shown that ascent is fairly common (ascending testis) and can occur in up to 30-50% of cases. The risk of developing an ascending testis is higher in children that present at an older age and those with significant tension along the cord structures. There is some data that suggest that an ascending testis may have some of the similar histologic findings and decreased fertility potential as that of an undescended testis. Thus, close follow-up with annual exams is recommended for children with retractile testes until puberty or when adequate intrascrotal positioning is well documented. In this patient, surgery is not indicated at this time and ultrasound is not adequate to document testis position or presence of a hernia. Human chorionic gonadotropin (hCG) injections have been shown to have some limited efficacy in children with an undescended testis but are not appropriate in the setting of a retractile testes since a response to hCG will not necessarily change the outcome. Close follow-up is still needed since an initial response to hCG may not be permanent.
A 60-year-old woman with weight loss has a 9 cm clear cell RCC with sarcomatoid features and three 1-1.5 cm pulmonary nodules. Hemoglobin is 8.0 mg/dL and remaining laboratory studies are normal. The next step is:
A. avelumab.
B. pembrolizumab.
C. ipilimumab and nivolumab.
D. lenvatinib and everolimus.
E. nephrectomy.
C. ipilimumab and nivolumab.
This patient has metastatic RCC (mRCC). Several prognostic models have been developed to guide therapy for patients with mRCC, most notably the Memorial Sloan Kettering Cancer Center (MKCC) Model and the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) Criteria. Importantly for the patient here, both of these models include anemia. In addition, institutional series have identified the presence of systemic symptoms as an adverse prognostic factor among patients undergoing cytoreductive nephrectomy for mRCC. Further, the presence of sarcomatoid features has in particular been associated with an adverse prognosis for patients with mRCC. Collectively, therefore, the presence of weight loss, sarcomatoid features, as well as abnormal laboratory parameters support an approach to management with initial systemic therapy for this patient. This strategy has the advantage of facilitating assessment of the disease’s responsiveness to systemic therapy – termed a “litmus test” – which may help to select those who might benefit from delayed surgical resection. Indeed, the SURTIME trial randomized patients with mRCC to initial versus delayed cytoreductive nephrectomy, and, although underpowered, reported higher overall survival (albeit as a secondary endpoint of the trial) in the deferred nephrectomy arm. Upfront cytoreductive surgery should in fact rarely be done in any patient with such features, particularly in the absence of local debilitating symptoms such as flank pain and hematuria. The combination of the checkpoint inhibitor medications ipilimumab, an antibody that blocks the interaction of CTLA-4 with its ligands, and nivolumab, an antibody that blocks the interaction between PD-1 with its ligands, was tested in a phase III randomized trial (CheckMate 214) versus sunitinib in patients with advanced RCC. The combination of ipilimumab and nivolumab demonstrated significantly improved objective response rates as well as overall survival. As such, this combination therapy is a preferred regimen by the NCCN Guidelines for the first-line treatment of intermediate and poor risk patients with metastatic clear cell RCC. While pembrolizumab, an immune checkpoint inhibitor, may be utilized in combination with axitinib or lenvatinib for patients with newly diagnosed intermediate or poor risk metastatic clear cell RCC, pembrolizumab monotherapy is not approved for metastatic RCC. Similarly, while avelumab in combination with axitinib represents a first-line treatment option (although not a preferred regimen per the NCCN Guidelines) for patients with intermediate or poor risk metastatic clear cell RCC, avelumab monotherapy is not currently utilized in mRCC. Further, the combination of lenvatinib and everolimus is an option for second-line therapy for patients with mRCC; however, treatment with this regimen is not recommended in the first-line setting.
A 25-year-old woman has a chronic history of intermittent urinary stream and lower abdominal discomfort without significant urinary urgency. Physical examination is normal and PVR is 1 L. MRI scan of the brain and spine is normal, as is cystoscopy. Pressure flow analysis shows an active EMG during voiding. She has failed treatment with biofeedback and prefers not to do CIC. The next step is:
A. vaginal estrogen therapy.
B. alpha-blocker therapy.
C. onabotulinumtoxinA of the sphincter.
D. sacral neuromodulation.
E. sphincterotomy.
D. sacral neuromodulation.
Fowler’s syndrome was first described in 1985. It is a cause of urinary retention in young women that is associated with abnormally increased EMG activity that results in impaired external sphincter relaxation. No neurologic or anatomic abnormality is associated with the condition, though it has been noted that women with Fowler’s syndrome often have polycystic ovaries raising the possibility of a focal hormonal role. That said, neither hormone therapy, onabotulinumtoxinA injection, or alpha-blockade have been found to be successful therapies. Interestingly, however, the condition has been found by several groups to be highly responsive to neuromodulation. Alpha-blockade would relax the bladder neck and smooth muscle but would have no effect on the striated muscle of the external sphincter. A sphincterotomy would not be indicated for Fowler’s syndrome.
A 64-year-old man undergoes a partial penectomy for a high-grade pT1 squamous cell carcinoma of the penis and then chooses surveillance in follow-up. Nine months later, a 2 cm lymph node is palpated in the left inguinal region. CT scan is negative for additional lymphadenopathy or metastatic disease. The next step is:
A. four weeks of antibiotics.
B. left superficial inguinal lymph node dissection.
C. left superficial and deep inguinal lymph node dissection.
D. bilateral superficial and deep inguinal lymph node dissection.
E. excisional biopsy with systemic chemotherapy.
C. left superficial and deep inguinal lymph node dissection.
This patient has likely developed metastatic recurrence in the left inguinal region, consistent with clinical N1 disease. Since this is a delayed development, the patient should have a unilateral superficial and deep inguinal dissection only on the affected side. There are no clinical concerns for infection; therefore, antibiotics are not indicated. In a patient with palpable nodes (or in the setting of clinically negative nodes with a frozen section demonstrating cancer in the superficial nodes), both a superficial and deep lymph node dissection should be performed. Chemotherapy is not indicated without evidence of distant metastatic and/or unresectable disease.
A 35-year-old man with spina bifida has urinary incontinence despite antimuscarinics and CIC every three hours. UDS show detrusor overactivity and a detrusor LPP of 60 cm H2O at 200 mL. Continence is achieved two weeks after intradetrusor injection of 200 U of onabotulinumtoxinA. The next step is:
A. increase time between catheterizations.
B. repeat onabotulinumtoxinA in six months.
C. repeat onabotulinumtoxinA when incontinence returns.
D. repeat onabotulinumtoxinA when UDS evidence of detrusor overactivity returns.
E. repeat UDS now.
E. repeat UDS now.
OnabotulinumtoxinA is indicated for neurogenic detrusor overactivity. However, the concerning UDS finding that can be seen in many patients with spina bifida, including this one, is loss of compliance and an elevated detrusor LPP. Elevated detrusor LPP specifically refers to a loss of compliance. A detrusor LPP > 40 cm H2O places patients at a greater risk for subsequent upper urinary tract damage. While this patient is now continent, that does not mean that his detrusor storage pressure is in a safe range and he should, therefore, undergo a repeat UDS. If the detrusor pressure is in a safe range at appropriate volumes, then increasing the interval between catheterizations can be considered, and he will likely require repeat injection in six to nine months when his symptoms return. If the detrusor pressures are not appropriately lowered with onabotulinumtoxinA, then bladder augmentation should be considered.
During left laparoscopic adrenalectomy, a 3 cm area at the upper medial pole of the kidney becomes pale following complete mobilization of the adrenal gland. The next step is:
A. observation.
B. I.V. fluid bolus.
C. I.V. heparin.
D. I.V. mannitol.
E. partial nephrectomy.
A. observation.
Devascularization of the upper pole of the kidney can occur during adrenalectomy due to inadvertent injury to an unsuspected accessory renal artery or upper pole branch of the main renal artery. If the area fed by the injured vessel is small, it can be ignored; however, larger injuries may require an attempt at revascularization. As the size of the devascularization in this case is small, the patient should be observed. All other listed maneuvers would likely be of no benefit to the small devascularized segment of renal parenchyma. I.V. fluid or I.V. mannitol to increase renal perfusion are incorrect because the arterial supply to the affected part of the kidney has been compromised and these measures will not recover arterial inflow. Similarly, I.V. heparin will not re-establish severed arterial blood supply. Finally, partial nephrectomy is not indicated, as there is no long-term harm caused by a 3 cm ischemic area, and the risk outweighs the benefit.
A 12-year-old boy has a radical orchiectomy for a paratesticular rhabdomyosarcoma confined to the spermatic cord. CT scan of the abdomen and pelvis is negative for metastatic disease. The next step is:
A. observation with CT scan every three months for the next year.
B. ipsilateral retroperitoneal XRT.
C. chemotherapy with vincristine and dactinomycin.
D. chemotherapy with vincristine, dactinomycin, and cyclophosphamide.
E. ipsilateral RPLND.
E. ipsilateral RPLND.
Current Children’s Oncology Group protocols recommend that children ten years of age and older should have an ipsilateral RPLND as part of their routine staging prior to chemotherapy due to their higher risk of retroperitoneal relapse. All children with rhabdomyosarcoma receive chemotherapy, but those older than ten years of age should receive a staging RPLND. Patients under age 10 who are clinical N0 may receive vincristine and dactinomycin without RPLND. Those with metastatic disease or who are clinical N1 will receive additional agents such as cyclophosphamide. XRT is reserved for those with pathologically node-positive RPLND. Observation alone is not an option for rhabdomyosarcoma.
A 58-year-old woman is unable to catheterize her right colon pouch and has increasing right lower quadrant pressure and severe pain. A 14 Fr straight or Coudé-tip catheter can only pass 4 cm and there is no return of urine. The next step is:
A. dilation of stoma.
B. channel cannulation under fluoroscopic guidance.
C. percutaneous drainage of pouch.
D. bilateral PCNT placement.
E. open surgical revision.
C. percutaneous drainage of pouch.
Inability to pass a catheter in spite of multiple attempts is an emergency and the urologist should get involved early. Difficulty with catherization is often due to a narrow stoma at the skin or a tortuous efferent limb that can be more angled with a distended pouch. Initial attempts with a straight catheter should be followed by use of a 16 Fr Coudé-tip catheter with lots of lubrication. Smaller catheters (14 Fr or 12 Fr) can also be useful in navigating a narrow stoma or tortuous efferent limb. Use of a larger catheter (i.e., 20 Fr as is often used for BPH) will unlikely be helpful. Fluoroscopic guidance is also unlikely to aid in cannulation of the efferent limb in such cases and would not be utilized in an emergency situation such as this. Likewise, if the patient was not in pain and the situation was less urgent, then an attempt at endoscopic catheter placement would be a reasonable option. If initial attempts at catheterization fail, a helpful step is to drain the distended pouch. This maneuver will not only relieve the patient’s pain but also may straighten out a kink in the efferent limb. This procedure can safely be done percutaneously a few centimeters to the right and inferior to the stoma, given that the right colon and small bowel usually lie medial to the reservoir. This can be achieved with a long 18- or 16-gauge angiocatheter. The use of a spinal needle (for a test pass) and/or bedside ultrasound can be utilized if the pouch location remains uncertain. Bilateral PCNT may relieve upper tract obstruction but will not necessarily decompress the pouch and avoid the possibility of rupture. Open revision is not warranted at this time, and such procedures are most often used for narrow stomas or tortuous efferent limbs that are refractory to conservative management. Stoma dilation will not solve the immediate problem of a distended pouch, and in addition, this patient is able to pass the catheter beyond the stoma. The patient should be counseled on compliance with a timed catheterization schedule.
A 45-year-old Black man has urinary frequency and microscopic hematuria. CT scan and a T2-weighted MRI scan are shown. The lesion most likely to be found in the bladder is:
A. cystitis cystica.
B. cystitis follicularis.
C. cystitis glandularis.
D. nephrogenic adenoma.
E. malakoplakia.
C. cystitis glandularis.
Pelvic lipomatosis is a benign condition of the pelvis associated with deposition of mature unencapsulated fat in the retroperitoneal pelvic space producing the typical “pear-shaped” appearance of the bladder on CT scan. This condition also causes a straightening and tubular appearance of the rectum. It is more common in Black men and is associated with obesity and with cystitis glandularis of the bladder in up to 40% of cases. The other options (cystitis cystica, cystitis follicularis, nephrogenic adenoma, malakoplakia) are not associated with pelvic lipomatosis.
A 75-year-old man with fatigue has a 3.0 cm renal mass with retroperitoneal and mediastinal lymphadenopathy. Serum creatinine is 1.7 mg/dL, and metastatic evaluation is otherwise negative. The next step is:
A. renal mass biopsy.
B. lymph node biopsy.
C. percutaneous ablation followed by ipilimumab and nivolumab.
D. partial nephrectomy followed by cabozantinib and nivolumab.
E. radical nephrectomy with RPLND followed by axitinib and pembrolizumab.
B. lymph node biopsy.
Lymphadenopathy out of proportion to the size of the renal mass, together with the presence of constitutional symptoms and absence of visceral metastases, should raise concern that the patient may have a diagnosis of lymphoma. Thus, the next step here would be to biopsy a lymph node to establish the histologic diagnosis. The renal mass may represent either renal involvement with lymphoma or a separate primary renal neoplasm. If the biopsy demonstrates RCC, this would not rule-out the presence of concurrent lymphoma; therefore, lymph node biopsy would be the most appropriate next step to determine a diagnosis with potentially one test. If the patient has lymphoma, this diagnosis should be evaluated and managed prior to addressing such a relatively small renal mass in a patient without local symptoms. Moreover, per AUA Guidelines, renal mass biopsy should be performed prior to or at the time of ablation to provide pathologic diagnosis and guide subsequent surveillance.
A 25-year-old man has severe diurnal and nocturnal urinary urgency, frequency, and intermittent gross hematuria. Urine culture is negative. CT urogram reveals a small thick-walled bladder but is otherwise unremarkable. Cystoscopy reveals multiple glomerulations and petechial hemorrhages and no Hunner’s lesions. Bladder biopsy shows severe inflammation and epithelial denudation. The most likely etiology is:
A. ketamine abuse.
B. genitourinary tuberculosis.
C. malakoplakia.
D. herpes simplex virus.
E. cytomegalovirus.
A. ketamine abuse.
Ketamine (also known as: K, Special K, Vitamin K, green, and jet) is a tranquilizer that will induce a trance-like state while providing pain relief, sedation, and memory loss. Heart rate, respiratory function, and airway reflexes will remain functional. Ketamine is most commonly used for pain relief in emergency rooms and intensive care units and/or sedation at the time of anesthetic induction. It has gained popularity as a street drug and has quickly outgrown heroin and methamphetamine as the drug of choice in many parts of the world due to its low cost and easy accessibility. Although ketamine’s recreational use initially blossomed in Asia, its use has spread worldwide. In a recent survey of New York City clubs, 21% of adults aged 18 to 29 have admitted to using ketamine. In 2015, an estimated 2.3 million adults and adolescents in the United States have abused ketamine. Urologists should be aware that the chronic use of ketamine can induce ketamine cystitis. Symptoms, cystoscopic findings, and biopsy findings are highly consistent with non-Hunner’s interstitial cystitis, and without the proper history, distinction between the two diagnoses is almost impossible. Ketamine cystitis will usually lead to a severely fibrotic end-stage bladder that will result in the need for cystectomy. There are, however, successful case reports where the fibrosis has been halted or reversed by the use of intravesical chondroitin sulfate or hyaluronic acid. Tuberculosis of the bladder occurs secondary to tuberculosis of the kidney, and, therefore, upper tract abnormalities would be expected on CT scan. Malakoplakia typically manifests as mucosal plaques or nodules with bladder biopsy demonstrating Michaelis-Gutman bodies. Herpes simplex virus infection causes painful ulcers of the genitalia typically without bladder involvement. Cytomegalovirus may cause hematuria and urinary symptoms but only in immunocompromised individuals.
A 28-year-old man with infertility for two years has a normal physical examination. Semen analysis reveals a volume of 4.0 mL, sperm concentration of 12 million sperm/mL, and motility of 60%. Repeat analysis is similar. The 25-year-old female partner’s evaluation is normal. The next step is:
A. post-ejaculatory urinalysis.
B. genetic testing.
C. scrotal ultrasound.
D. intrauterine insemination.
E. in vitro fertilization/ICSI.
D. intrauterine insemination.
The patient has normal ejaculatory volume and mild oligospermia with a total sperm count of 48 million and a total motile count of 29 million. Post-ejaculate urinalysis is indicated with low volume ejaculates to determine if retrograde ejaculation is present. Genetic testing, including karyotype and Y chromosome microdeletion analysis, should be ordered with sperm densities lower than 5 million/mL. Since no clinical varicoceles or other palpable scrotal abnormalities are noted, scrotal ultrasound is not indicated. Intrauterine insemination (IUI) is appropriate with mild oligospermia in a young couple. If pregnancy does not occur after several IUIs, regular in vitro fertilization may be considered. ICSI is indicated with severe oligospermia.
While using an argon beam electrocoagulator during a laparoscopic partial nephrectomy, poor tidal volumes are noted. The next step is to:
A. obtain deeper sedation.
B. increase ventilation rate.
C. add positive end-expiratory pressure (PEEP).
D. decrease CO2 insufflation flow rate.
E. release pneumoperitoneum.
E. release pneumoperitoneum.
During the use of the argon beam electrocoagulator in a laparoscopic setting, intraperitoneal pressure can rapidly increase, resulting in poor tidal volumes and compromised ventilation. It is important to release the pneumoperitoneum from one of the trocar ports (by “venting”) during the use of an argon beam in order to avoid over-pressurizing the abdomen with the infused argon gas. If unrecognized, this can cause an abrupt increase in intra-abdominal pressure and eventual compromise of ventilation. Due to the amount of argon gas used and the resulting intra-abdominal pressure, obtaining deeper sedation, adding PEEP, or increasing ventilation rate will not help the lungs to clear the argon gas fast enough to mitigate the effects of the excessive argon-related increased intra-abdominal pressure. Decreasing CO2 insufflation rate will not impact intraperitoneal pressure in this setting.
A 41-year-old, morbidly obese man with a low libido and a testosterone of 201 ng/dL is seeking treatment for erectile dysfunction. The next step is:
A. exercise.
B. sildenafil.
C. clomiphene citrate.
D. transdermal testosterone.
E. intramuscular testosterone
B. sildenafil.
Men with erectile dysfunction (ED) should be informed regarding the treatment option of an FDA-approved oral PDE-5 inhibitor, such as sildenafil, including discussion of benefits and risks/burdens unless contraindicated. While diet and exercise may improve his erectile function, this will take time, and in some studies, up to two years. Treatment with PDE-5 inhibitors will be the most expeditious way of addressing his issue. Clomiphene citrate is an estrogen blocker and increases endogenous testosterone levels. Testosterone therapy is not considered first-line therapy for ED. Thus, neither clomiphene citrate nor testosterone cypionate are indicated in this scenario. Although not offered as an option here, if a man with ED has testosterone deficiency (< 300 ng/dL), he should be informed that combination therapy with testosterone and PDE-5 inhibitors may be more efficacious.
While being positioned prone for PCNL access to treat a struvite partial staghorn renal calculus, a morbidly obese patient develops markedly increased airway pressures. After returning the patient to the supine position, airway pressures normalize. The next step is to:
A. terminate the procedure and start acetohydroxamic therapy.
B. convert to ureteroscopy and laser lithotripsy.
C. convert to robotic anatrophic nephrolithotomy.
D. proceed with supine PCNL.
E. perform prone PCNL with increased positive end expiratory pressure.
D. proceed with supine PCNL.
The prone position was described by Goodwin and colleagues (1955) for percutaneous access to the upper urinary tract collecting system, and over time this position became standard. It has the advantage of presenting a large surface area (the patient’s back) that provides many choices of access sites and a stable horizontal working surface. The posterior or posterolateral approach is the most direct one to the desirable posterior calyces and comes closest to approaching the kidney through Brödel’s avascular line. Prone positioning does have some disadvantages. It is associated with a decrease in cardiac index and can also be associated with decreased pulmonary capacity. The anesthesiologist has poor access to the airway with the patient in the prone position, and prone positioning might not be possible in patients with morbid obesity. For the present scenario, acetohydroxamic acid should only be used if surgical therapy is not possible. Given the infected and staghorn nature of the stone, ureteroscopy will be less optimal for complete stone clearance. Supine PCNL is preferred if the patient cannot tolerate the prone position, as in the present scenario, and is the correct choice. There are several different ways to position a patient for a supine PCNL; all of the various scenarios allow for access to the kidney along the mid-axillary line. Prone positioning and increasing positive end expiratory pressure for the entire procedure is not the safest approach in a patient who suffers increased airway pressures on initial prone positioning. Robotic anatrophic nephrolithotomy has been reported, however has potential for increased morbidity, particularly in this morbidly obese patient and increased loss of renal function. Therefore, it is still considered a second-line approach if PCNL is not technically feasible (approach to kidney was unsafe secondary to renal anatomy/surrounding structures or stone was more complex in nature).
A 66-year-old woman has dysuria and light bleeding noted on her underwear and toilet paper after urinating. On examination, she has a 1 cm circumferential urethral prolapse and the tissue is pink and mucosal appearing. PVR is 95 mL and urinalysis shows 0-2 RBC/hpf and 0-2 WBC/hpf. Her last pap smear from one year ago was normal. The next step is:
A. topical estrogen.
B. pelvic ultrasound.
C. pelvic MRI scan.
D. biopsy.
E. excision.
B. pelvic ultrasound.
This patient has a circumferential urethral prolapse with normal-appearing mucosa. The most common symptom of urethral prolapse is vaginal bleeding/spotting with wiping, and voiding symptoms may be present as well. The primary treatment is vaginal estrogen cream. However, in a post-menopausal woman with a uterus, a transvaginal ultrasound should be obtained first to rule out endometrial pathology as a cause for post-menopausal bleeding. Ultrasound is indicated as initial imaging of the uterus, though a pelvic MRI scan might be a necessary follow-up exam if there are abnormal findings. Malignancy is rarely associated with urethral prolapse, but biopsy should be considered if the diagnosis is uncertain. In this patient with normal-appearing mucosal prolapse, a biopsy would not be indicated unless additional features of her exam were concerning. In patients presenting with refractory bleeding or pain, thrombosed or obstructing lesions, earlier surgical excision can be considered versus a trial of vaginal estrogen cream.
A 32-year-old man has a right radical orchiectomy for a pure seminoma in a solitary testicle. Preoperative staging studies are negative for metastasis and tumor markers are normal. Two weeks after orchiectomy, his beta-hCG is 12 mIU/mL. The next step is:
A. exogenous testosterone and repeat markers.
B. CT scan of chest, abdomen, and pelvis.
C. PET-CT scan.
D. brain MRI scan.
E. carboplatin.
A. exogenous testosterone and repeat markers.
The management of testicular cancer involves close monitoring of serum tumor markers such as AFP and beta-hCG. Beta-hCG levels are elevated in 20-40% of low-stage non-seminomas and 40-60% of advanced NSGCT. Additionally, approximately 15-20% of seminomas secrete beta-hCG. The half-life of beta-hCG is 24-36 hours. Consequently, monitoring beta-hCG after the removal of the primary tumor is essential in the initial management of testicular tumors. Immunoassays for hCG are directed at the beta-subunit, and thus there can be some cross-reactivity with LH. This cross-reactivity may lead to false-positive hCG elevations in patients with primary hypogonadism. False elevations will normalize within 48-72 hours after the administration of testosterone. In this patient who has now been rendered anorchid by removal of a solitary testicle, the elevated hCG might be due to this cross-reactivity to LH. In the setting of negative preoperative metastatic studies, it will be quite rare to have progressive disease. Consequently, the administration of exogenous testosterone and a repeat marker test is the correct next step in this case. Immediate treatment with either carboplatin, BEP, or XRT is not indicated until clarification of the source and cause of the mild elevation of his hCG and documentation of the need for active treatment. Repeat imaging this soon after surgery is not necessary unless the tumor marker elevation is ascertained to be tumor related. PET-CT scan is not indicated in seminoma prior to chemotherapy. Brain MRI scan is not indicated unless tumor marker elevation is documented to be of tumor origin. If he has elevation of hCG due to tumor, then it would change his primary management.
Regarding family members of a child with VUR, VCUG screening should be performed in:
A. all siblings.
B. all offspring.
C. any non-toilet-trained sibling.
D. any sibling with prenatal hydroureteronephrosis.
E. any sibling with prenatal bilateral pelviectasis.
D. any sibling with prenatal hydroureteronephrosis.
VCUG is recommended if there is evidence of renal scarring on ultrasound or a history of UTI in the sibling who has not been tested. VCUG is recommended for children with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis (not just pelviectasis), hydroureter, an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a UTI. VCUG is not routinely recommended for all siblings of a child with VUR or for the offspring of a former patient with VUR.
A five-year-old boy has intermittent, painless gross hematuria. Ultrasound and scout film from his VCUG are shown. The next step is:
A. observation.
B. SWL.
C. ureteroscopy and lithotripsy.
D. percutaneous antegrade ureteroscopy and lithotripsy.
E. ureterolithotomy.
E. ureterolithotomy.
This five-year-old boy has a 3 cm distal right ureteral calculus that is relatively asymptomatic. Although there is no associated hydronephrosis or ureteral dilation, a large stone of this size is unlikely to pass spontaneously. Observation would not be an option. The size and location of the calculus in this boy make SWL and endoscopic approaches difficult and unlikely to be successful in achieving a stone-free state. In addition, there would be a significant risk of retained stone fragment(s) and/or ureteral injury with either of these modalities. Open ureterolithotomy via lower abdominal muscle splitting (Gibson) incision or laparoscopic/robotic ureterolithotomy would be most likely to achieve a stone-free state, least likely to cause a complication, such as urethral stricture, and would also allow inspection of the distal ureter for any anatomical abnormality predisposing to stone formation in this location.
A five-month-old boy is treated for his first febrile UTI. Ultrasound of the right kidney and VCUG are shown. The left kidney is normal. Diuretic renal scan with an indwelling catheter shows diminished function in the right lower pole with a T1/2 time of 20 minutes. The next step is antibiotic prophylaxis and:
A. observation.
B. lower pole pyeloplasty.
C. lower pole to upper pole pyeloureterostomy.
D. common sheath ureteral reimplant.
E. lower pole heminephrectomy.
A. observation.
This boy has high-grade VUR into the lower pole of a duplicated system. The reduced renal function that is seen on the renal scan is likely secondary to renal dysplasia. Renal dysplasia is not unique to primary isolated VUR but may also occur in a variety of urologic settings. Duplex renal moieties, prune-belly syndrome, and PUVs may all exhibit reflux-associated renal dysmorphism, particularly when the grade of VUR has been high. The incidence of a concomitant UPJ obstruction in patients with VUR ranges from 1-5%, with the incidence being on the higher end in children with high-grade VUR. When significant hydronephrosis is seen in patients with VUR, one may suspect a UPJ obstruction. However, the hydronephrosis is usually secondary to the VUR as opposed to an obstructive defect. Three radiologic signs on a VCUG that might suggest the existence of UPJ obstruction in the setting of VUR are: 1) if the pelvis shows little or no filling of contrast whereas the ureter is filled with contrast; 2) contrast that does enter into the pelvis is poorly visualized because of dilution of the contrast in a large amount of retained urine; 3) poor drainage of retained contrast in the renal pelvis is seen on a drainage film. In this patient, none of these signs are present; thus, UPJ obstruction is very unlikely. In this boy, there is no dilution of the contrast in the pelvis on the VCUG. The delay that is noted on the drainage portion of the renal scan is more likely due to reduced renal function, as opposed to obstruction. In addition, drainage times on diuresis renography have not been found to directly correlate with obstruction in children. With no clear evidence of obstruction, surgery to promote drainage by either pyeloplasty or ureteropyelostomy would not be appropriate at this time. Lower pole nephrectomy is also not indicated at this age after one UTI. The next best course of action in this boy is to observe him on prophylactic antibiotics. Ureteral reimplantation would be too premature in this setting, especially in light of the patient’s young age and the size of his bladder.
One year after a midurethral sling and anterior repair, a 61-year-old woman with diabetes has hesitancy, frequency, and urgency urinary incontinence. There is no leakage with cough. Her PVR is 150 mL and urinalysis is normal. Her uroflow (voided volume 250 mL) is shown. The next step is:
A. antimuscarinic.
B. CIC.
C. UDS.
D. pessary trial.
E. sling incision.
C. UDS.
The uroflow shows a classic staccato pattern of flow. This may indicate detrusor underactivity or bladder outlet obstruction. UDS should help clarify obstruction versus detrusor underactivity. Antimuscarinics would not be advised in the setting of incomplete emptying with possible outlet obstruction or with detrusor underactivity. CIC may help improve these symptoms in patients with elevated PVRs, however, this would be considered after urodynamic diagnosis of detrusor underactivity is confirmed. A pessary trial would be beneficial for prolapse or SUI, which she does not have. A sling incision may be indicated if bladder outlet obstruction is confirmed on UDS or there is a clear temporal relationship of the sling placement to the onset of her symptoms.
A 26-year-old man has several months of intermittent left lower abdominal pain. CT scan is shown. The next step is:
View Images
A. SWL with stent placement.
B. SWL in the prone position.
C. ureteroscopy.
D. PCNL.
E. laparoscopic pyelolithotom
E. laparoscopic pyelolithotomy.
Per the AUA Guidelines, laparoscopic surgery should not be offered as first-line therapy except in cases of anatomic abnormalities with large or complex stones. This patient has an ectopic, malrotated, pelvic kidney with an anterior facing renal pelvis and stones in the renal pelvis and upper pole region. The bony pelvis prevents a posterior approach to the kidney. Therefore, laparoscopic (or robotic) pyelolithotomy offers the safest, minimally invasive approach with a high success rate and stone-free rate. Since the patient is symptomatic from his stones, observation is not the best option. Based on the anatomy of his kidney and overlying bowel anteriorly and bony pelvis posteriorly, PCNL would not be safe. Additionally, the stone-free rates of ureteroscopy and SWL would be suboptimal compared to laparoscopic pyelolithotomy. SWL (often in the prone position) or ureteroscopy could be considered in select patients with ectopic kidneys and smaller stone burdens.
A 56-year-old woman has intermittent left flank pain. CT images are shown. The lower pole stone size is 2.2 cm with a density of 1100 Hounsfield units and a skin-to-stone distance of 9 cm. The next step is:
View Images
A. staged SWL without ureteral stent.
B. staged SWL with ureteral stent.
C. staged ureteroscopy.
D. PCNL.
E. robotic pyelolithotomy.
C. staged ureteroscopy.
The CT scan demonstrates a large stone in the lower pole of the left kidney, however, access to the lower pole is not straightforward secondary to a retrorenal colon. In this setting, staged ureteroscopy is the safest approach with the highest efficacy, since PCNL has a high risk of injury to adjacent structures. Although the stone parameter of skin-to-stone distance is favorable for SWL, the primary factors of stone location and size are not favorable for SWL, with or without a ureteral stent, when ureteroscopy is an option. Additionally, a stone density of 1100 Hounsfield units is unfavorable for SWL. Robotic pyelolithotomy is an option; however, it is much more invasive than ureteroscopy and would not be considered first-line treatment unless there was a simultaneous need for reconstruction or in cases of larger, more complex stones with aberrant anatomy.
A 38-year-old woman is evaluated for intermittent right flank discomfort and recurrent UTIs. CT scan and endoscopic images of the renal pelvis are shown. The next step is:
A. biopsy and fulguration.
B. balloon dilation and ureteral stent.
C. laser incision and lithotripsy.
D. PCNL with fulguration.
E. laparoscopic treatment and fulguration.
C. laser incision and lithotripsy.
The CT scan shows a stone located within a fluid filled structure in the anterior upper to mid-pole region of the right kidney, likely a calyceal diverticulum. The patient is symptomatic and has recurrent UTIs. If asymptomatic, she could be observed. However, symptoms are present, therefore treatment is recommended. SWL is generally unsuccessful for the treatment of stones within calyceal diverticula. Ureteroscopy is less invasive and can be effective for small volume stones in an upper or mid-pole diverticulum such as this case. Balloon dilation and stent placement through the ostium to the calyceal diverticulum may improve drainage out of the diverticulum but will not address the stone material in the diverticulum. Stenting though the ostium can also be performed after treating the stone in more capacious diverticula to try and improve drainage of the region in the future. PCNL is effective, however, this case is an example when ureteroscopy would be preferred based on the location of the diverticulum, the relatively small size of the diverticulum, and its anterior location. For a larger diverticulum, fulguration may also help obliterate the cavity to reduce the chance for recurrence. For an anterior calyceal diverticulum with thin overlying parenchyma, laparoscopy is the preferred option, but typically in cases where less invasive endoscopic approaches are not reasonable approaches, such as in large volume diverticula and/or larger stone burdens. Partial or heminephrectomy may be an option if the diverticulum was occupying a large portion of the kidney that has atrophied. The CT scan does not show a lesion that requires a biopsy and fulguration.
A 45-year-old woman has bilateral stents for hydronephrosis secondary to retroperitoneal fibrosis. CT scan is shown. She cannot tolerate steroids. The next step is:
A. azathioprine.
B. mycophenolate mofetil (CellCept®).
C. tamoxifen.
D. cyclophosphamide.
E. ureterolysis.
C. tamoxifen.
The clinical presentation is consistent with idiopathic retroperitoneal fibrosis. The CT scan reveals a retroperitoneal mass encasing the aorta, IVC, and bilateral ureters. After initial ureteral stenting to relieve obstruction and consideration for biopsy to rule out malignancy, medical treatment should be considered first prior to ureterolysis. First-line medical treatments include steroids or tamoxifen (a nonsteroidal antiestrogen). Mycophenolate mofetil, azathioprine, or cyclophosphamide can also be used as primary or salvage therapy, but those agents are used in combination with steroids. Their stand-alone efficacy is unknown. Ureterolysis can be undertaken if medical therapy fails.
A 47-year-old man with relapsing remitting multiple sclerosis (MS) has severe urinary frequency and incontinence. He has been treated with tamsulosin for six months with no improvement in his symptoms. Examination reveals a 40 gram smooth prostate. UDS is shown. The next step is:
A. renal ultrasound.
B. videourodynamics.
C. MRI scan of the spine.
D. TRUS.
E. cystoscopy.
A. renal ultrasound.
This UDS documents neurogenic detrusor overactivity and detrusor external sphincter dyssynergia (DESD) in a patient with MS. Male MS patients with DESD appear to be at greatest risk for urological complications including upper tract deterioration and the upper tracts must be assessed early in this patient. At this time, videourodynamics would be redundant and unnecessary, while cystoscopy is unlikely to influence treatment planning and would not be the most appropriate first step. MRI scan of the spine may be indicated in the scenario of unknown pre-existing neurogenic disease but is unnecessary with a diagnosis of MS. His obstruction appears to be secondary to DESD, so there is no reason to size his prostate with a TRUS for a subsequent outlet procedure.
A 64-year-old man has a PSA of 5 ng/mL and a normal DRE. A 12-core biopsy is negative, and his prostate volume is 95 grams. Six months later, his PSA is 6.2 ng/mL. Representative images from a multiparametric MRI are shown (T2 and DWI). The next step is:
A. PSA in three to six months.
B. Decipher® genomic test.
C. targeted biopsy of right peripheral zone.
D. systematic plus targeted biopsy of right peripheral zone.
E. systematic plus targeted biopsy of left peripheral zone.
The T2 and DWI MRI images show no focal lesions within the prostate. As the patient has a low PSA density (0.06 ng/mL), a recent negative 12-core biopsy, and an MRI without a focal lesion, he is at low risk of having a clinically significant prostate cancer. In particular, without a suspicious area on MRI scan, neither targeted biopsies nor an additional 12-core biopsy would be appropriate. The patient should have a repeat PSA in three to six months. The Decipher genomic test is a tissue-based prognostic biomarker used following the diagnosis of prostate cancer.
A 68-year-old woman with a several month history of lower extremity edema has the MRI scan shown. Laboratory studies are normal and CT scan of her chest demonstrates two 4 mm pulmonary nodules. Percutaneous biopsy demonstrates papillary RCC. The next step is systemic anticoagulation plus:
A. cabozantinib.
B. ipilimumab and nivolumab.
C. percutaneous IVC filter placement and renal artery angioembolization.
D. nephrectomy with tumor thrombectomy and intraoperative IVC filter placement.
E. nephrectomy with tumor thrombectomy and IVC ligation.
E. nephrectomy with tumor thrombectomy and IVC ligation.
The patient has a right renal mass with tumor thrombus extending into the suprarenal IVC and bland thrombus (composed likely primarily of platelets and not malignant tissue) in the infrarenal IVC. Tumor thrombus can often (as here) be distinguished from bland thrombus on contrast MRI by the presence of enhancement. The bland thrombus appears to be completely occluding the IVC, consistent with the patient’s history of lower extremity edema. In the setting of bland thrombus, particularly with complete IVC occlusion, systemic anticoagulation is often initiated to prevent further clot extension or embolization and to maintain the patency of collateral vessels. Optimal management of these patients, particular without clear evidence of significant metastatic disease, is with surgical resection. Surgical resection entails nephrectomy with tumor thrombectomy. In addition, for patients with complete occlusion of the infrarenal IVC from bland thrombus, IVC ligation may prevent thrombus extension and embolization postoperatively. Indeed, IVC ligation has been demonstrated to be well tolerated in this setting, as collaterals have developed from the state of complete occlusion. While intraoperative IVC filter placement in the infrarenal IVC has been described for patients following nephrectomy with tumor thrombectomy who have a patent IVC and non-contiguous bland thrombus in the iliac or femoral vessels, such an approach would not be recommended, or likely feasible, in a patient with bulky, occlusive infrarenal IVC clot. Renal artery angioembolization is typically utilized for palliation in patients with symptomatic large renal tumors who are not candidates for surgical resection. While angioembolization may be used preoperatively as well in select circumstances, robust evidence supporting an improvement in perioperative outcomes with this approach is lacking. Importantly, moreover, percutaneous IVC filter placement is not recommended in the setting of a tumor thrombus, as in fact the thrombus may infiltrate into the tines of the filter and significantly complicate surgical resection. While cabozantinib as well as the combination of ipilimumab and nivolumab represent systemic therapy options for patients with metastatic RCC, the bulk of evidence supporting a benefit to treatment with either of the regimens is for patients with predominantly clear cell RCC, and specifically for patients with intermediate or poor risk metastatic disease. This patient: (a) has a non-clear cell histology, (b) would likely be characterized as having favorable risk disease if metastatic, but moreover (c) does not definitively have metastatic disease, as the noted pulmonary nodules are indeterminate based on size/number, and indeed frequently such radiographic findings do not represent metastases.
A 74-year-old man with an orthotopic ileal neobladder (Studer pouch) has had three febrile UTIs in the last six months. PVR is 30 mL and his creatinine has risen to 2.1 mg/dL. Cystogram and MRI scan are shown. The next step is:
A. CIC.
B. gentamicin irrigation.
C. bilateral PCNTs.
D. bilateral ureteral reimplantation.
E. conversion to ileal conduit.
C. bilateral PCNTs.
The Studer pouch is constructed with a U-shaped reservoir and an afferent isoperistaltic tubular segment, or limb, into which the ureters are reimplanted. The imaging here is consistent with afferent limb stenosis, as there is a cut-point of reflux in the afferent limb noted on the cystogram, while images from the MRI scan demonstrate hydronephrosis and an hourglass deformity of the neobladder. While rare, this is thought to occur due to fibrosis of the midpoint of the ileal segment comprising the afferent limb. Stenosis of the limb, in turn, may cause urinary obstruction, leading to hydronephrosis and renal function deterioration, as well as urinary stasis, predisposing patients to infection. Definitive management would require replacement of the afferent limb. At this time, however, renal drainage should be established with bilateral PCNTs. This allows an assessment of subsequent renal function recovery with such drainage and to interrogate the ureteroileal anastomosis, as patency cannot be assured from the imaging provided and bilateral ureteroanastomotic strictures should be ruled out with antegrade nephrostograms once PCNTs are placed. CIC would not address the lack of drainage from the afferent limb, and in particular would not be indicated here with the patient’s low PVR. Similarly, gentamicin irrigation of the neobladder would not correct the likely predisposing factor to the patient’s UTIs - urinary stasis from stenosis of the afferent limb. Ureteral reimplantation may be required if ureteroenteric anastomotic strictures are diagnosed; however, the evaluation provided in the question here does not include assessment of the ureteroenteric anastomoses, and therefore, reimplantation should not be undertaken until further investigation (i.e., antegrade nephrostograms after PCNT insertion) is conducted. Likewise, establishing renal drainage and assessing renal function response after relief of obstruction should be performed prior to consideration of conversion of the neobladder to an ileal conduit. Moreover, the existing, stenotic afferent limb should not be converted to a conduit, but rather a new segment of bowel would be required.
A 51-year-old man with long-standing LUTS develops gross hematuria. CT scan is shown. Cystoscopic biopsy of the mass reveals squamous cell carcinoma and other bladder biopsies are negative. Metastatic evaluation is negative. He prioritizes sexual function. The next step is:
A. complete endoscopic resection.
B. chemotherapy and XRT.
C. neoadjuvant gemcitabine and cisplatin.
D. partial cystectomy.
E. nerve sparing radical cystectomy.
D. partial cystectomy.
The patient has a squamous cell carcinoma (SCC) within a bladder diverticulum. The mouth of the diverticulum arises from the right posterior bladder, and the tumor appears confined to the bladder with preserved perivesical fat planes. Bladder SCC represent about 3-7% of tumors in the U.S. and in this case, is likely associated with urinary stasis and chronic inflammation rather than bilharzial infection. Complete endoscopic resection is likely not feasible given the location within a diverticulum. The outcome of pure bladder SCC is often poor, given the advanced disease at the time of presentation. There is no evidence that neoadjuvant chemotherapy regimens used for urothelial carcinoma are effective with SCC. Likewise, trimodal therapy with chemotherapy and XRT would not be advised given this patient’s LUTS and location of tumor within the diverticulum. In this case, the best treatment is partial cystectomy to excise the bladder diverticulum which would serve to eradicate his tumor, possibly improve his LUTS, and afford him the best opportunity to maintain his sexual function (as compared to nerve-sparing radical cystectomy).
