In service assesment 2021

Question 1

What is the value of preoperative urodynamics in the management of urinary incontinence?

1. Grade Severity of incontinence
2. Influence the choice of treatment
3. Predict post-surgical complications
4. Foresee effectiveness of the treatment

Answer 1

2. Influence the choice of treatment

There are no RCT:s ansvering the question whether urodynamics can predict complications of surgery or effectiveness of different treatment methods. Whilst urodynamics will distinguish causes of incontinence, its ability to predict outcome of surgery for incontinence for these men is uncertain.

Question 2

Which medication has been show to be effective and is recommended for intravesical administration in neurogenic detrusor overactivity (NDO)?

1. Capsaicin
2. Resiniferatoxin
3. Oxybuynin hydrochloride
4. Solifenacin

Answer 2

3. Oxybuynin hydrochloride

The efficacy, safety and tolerability of intravesical administraion of 0,1% oxybutynin hydrochloride for treatment of NDO has been demonstrated in randomised controlled studies. Although preliminary data suggested that intravesical vanilloids (Capsaicin and Resiniferatoxin) might be effective for treating neurogenic LUT dysfunction, currentrly, there is no indication for the use of these substances, which are not licensed for intravesical treatmen. Intravesical administration fo Solifenacin in NDO ha not been evaluated.

Question 3

What is considered a significant bacteriuria in patients performing clean intermittent catheterization (CIC)?

1. > 102 cfu/m
2. > 103 cfu/m
3. > 104 cfu/m
4. > 105 cfu/m

Answer 3

1. > 102 cfu/m

Urinary tract infection is the onset of signs and/or symptoms accompanied by laboratory findings of a UTI (bacteriuria, leukocyturia and positive urine culture). There are no evidence-based cut-off values for the quantification of these findings. The published consensus is that a significant bacteriuria in persons performing IC is present with >102 cfu/m, >104 cfu/m in clean-void specimens and any detectable concentration in a suprapubic aspirates. Regarding leukocyturia, ten or more leukocytes in centrifuged urine samples per microscopic field (400x) are regarded as significant.

Question 4

What can be redommended without limitations for the prevention of recurrent UTI in patients with neuro-urological disorder?

1. Low-dose, long-term, antibiotic prophlaxis
2. Cranberry juice
3. L-methionine urine acidificaton
4. There is currently no preventive measure for recurrent UTI in these patients

Answer 4

4. There is currently no preventive measure for recurrent UTI in these patients

Various medical approaches have been tested for UTI prophylaxis in patients with neruo -urological disorders. The benefit of cranberry juice for the prevention of UTI could not be demostrared in RCTs. There is no sufficient evidence to suppport the use of L-methionine for urine acidification to prevent recurrent UTI. Low-dose, Long-term, antibiotic prophylaxis can reduce UTI frequency, but increases bacterial resistance and is therefore not recommended. Based on the criteria of evidence-based medicine, there is currentrly no preventive measure for recurrent UTI in patients wiht neruo-urological disorders that can be recommended without limitations.

Question 5

What is them most typical visual sign when performing a cystoscopy on a patient with schistosomiasis?

Answer 5

Sandy patches

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Question 6

What is the most common diagnosis in a newborn with a 46XY karyotype but normal female phenotype?

1. Mixed gonadal dysgenesis
2. Ovotesticular Disorder of Sex Development
3. Complete androgen insensitivity
4. Congenital adrenal hyperplasia

Answer 6

3. Complete androgen insensitivity

CAIS is one of the three categories of androgen insensitivity syndrome (AIS) since AIS is differentiated according to the degree of genital masculinization: complete androgen insensitivity syndrome (CAIS) when the external genitalia is that of a typical female, mild androgen insensitivity syndrome (MAIS) when the external genitalia is that of a typical male, and partial androgen insensitivity syndrome (PAIS) when the external genitalia is partially, but not fully masculinized. This is genetically male but phenotype is female. The possible mechanisms would be some problem with testosterone synthesis or efficiency. The unresponsiveness of the cell to the presence of androgenic hormones prevents the masculinization of male genitalia in the developing fetus, as well as the development of male secondary sexual characteristics at puberty, but does allow, wthout significant impairment, female genital end sexual development in thes with androgen insensitivity syndrome. In congenital adrenal hyperplasia there is axcessive production of thestosterone and in an XY patient the genitalia will present with much bigger phallus than normal. In all other conditions there will be some masculinization and they will present with ambiguous genitalia including (MAIS) and (PAIS).

Question 7

What is the prevalence of vesicoureteric reflux (VUR) in a newborn with prenatal hydronephrosis?

1. 5-15%
2. 15-25%
3. 25-35%
4. 35-45%

Answer 7

2. 15-25%

The most common etiology of prenatal hydronephrosis is UPJ obstruction. In patients presenting with prenatally diagnosed hydronephrosis the incidence of VUR is 18% in review of the literature. Presence of dilated ureter, cortical pathology are predicting signs on USG.

Question 8

Which statement regarding penile fracture is correct?

1. Most injuries are located at the ventro-lateral aspect of the penis
2. Retrograde urethrography should always be performed to rule out a concomitant urethral injury
3. Circumferential incision is always recommended
4. Obeservation is the first choice

Answer 8

1. Most injuries are located at the ventro-lateral aspect of the penis

When a penile fracture is diagnosed, surgical intervention with closure of the tunica albuginea is recommended; it ensures the lowest rate of negative long-term sequelae and has no negative effect on the psychological wellbeing of the patient. Most injuries are located at the ventro-lateral aspect of the penis. The approach is usually through a circumferential incision proximal to the coronal sulcus which enables complete degloving of the penis. Increasingly, local longitudinal incisions centred on the area of fracture of ventral longitudinal approaches ar currentrly used. Urethrography is not needed unless therei s suspicion about urethral injury. Further localisaton may be gained with a flexible cystoscopy performed prior to incision, if urethral trauma is suspected and eventualla proben. Surgical closure of the tunica should be carried out using absorbable sustures.

Question 9

Congenital abnormalities of the urinary tract can be diagnosed by US during pregnancy. Which findings nearly always indicate a poor prognosis?

1. Bilateral hydro-uretero nephrosis
2. Early oligohydramnios (<20 weeks)
3. Normal amniotic fluid but no bladder filling
4. The finding of a keyhole in the region of the bladder neck

Answer 9

2. Early oligohydramnios (<20 weeks)

Amnion fluid is made from kidneys of the fetur in utero. Reduced amnion fluid is a sign of fetal renal insufficiency. Options 1. and 4. are signs of infravesical obstruction but are not bad prognostic factors if not accompanied with oligohydramnios.

Question 10

What is the best management of a 7 mm long urethral stricture in the midbulbar urethra of a 27-year-old man who previously has had an internal urethrotomy?

1. Repeat internal urethrotomy
2. Urethral dilatation
3. Complete excision of the area of fibrosis with a primary reanastomosis
4. Complete excision of the area of fibrosis with a graft reconstruction

Answer 10

3. Complete excision of the area of fibrosis with a primary reanastomosis

The risk of a new stricture aftera a failed urethrotomy is high as so after dilation. Option 3 has the best result in shorter strictures (less than 1 cm) if not too close to the sphincter wich it is not in this case

Question 11

What is the most common complication after inguinal lymphadenectomy?

1. pain
2. bleeding
3. lymphedema
4. emboli

Answer 11

3. lymphedema

Current guidelines recommend inguinal lymphadenectomy in patients with penile cancer for palpable inguinal lymph nodes or in the event of nonpalpable lymph nodes where pathologic stage T2 or greater, the presence of lymphovascular invasion, or poorly differentiated histology. However, this procedure carries great morbidity and current literature estimates complication rates greater than 50% for radical inguinal lymphadenectomy. The most common complication are lymphedema, deep venous thrombisis (DVT), wound infection, skin necrosis, lymphocele, and seroma. Our aim is to identify complications of inguinal lymphadenectomy that may be minimized with modifications in surgical approach.

Question 12

A 43-year old male patient presents whith a 11 cm right-sided kidney tumour with a tumour thrombisis in the renal vein, enlarged regional lymph nodes and a 5 mm nodule in the left lower lung lobe. What course of actions is recommended?

1. Open nephrectomy, thrombectomy and regional lymphadenectomy
2. Thromobisis prohpylactics and systemic treatment with TKI or immunotherapy
3. Cytoreductive nephrectomy and systemic treatment with TKI or immunotherapy
4. Systemic treatment with TKI and in case of a good response, nephrectomy

Answer 12

1. Open nephrectomy, thrombectomy and regional lymphadenectomy

In a young patient with localized disease who might be cured with radical ssurgery, the lymp nodes can be reactive and the lung nodule can be a benign finding. To this day there are no recommendations for neoadjuvant or adjuvant systemic treatment in RCC.

Question 13

A 23-year-old male patient presents with a left-sided PUJ stenosis and a 14 mm kidney stone in the left pelvis. Renography reveals a decrease in function, left 9% and a high-grade obstruction. cGFR >90. What is the best course of action?

1. Nephrostomy and SWL of the kidney stone
2. Laserlithitripsy of the stone and dilation of the PUJ stricture
3. Open/laprascopic pyeloplasty and stone extraction
4. Laparoscopic nephrectomy

Answer 13

4. Laparoscopic nephrectomy

Renal function of 9% is not worth saving. Saving any differential renal function less than 10% will not bring any benefit for the patient. In small children saving such function may have som chance of further improvement but at the age of 22 this is much less likely to happen.

Question 14

What type and depth of invasion is characteristic of in sity bladder carcinoma?

1. Flat, high-grade tumour invading the lamina propria.
2. Papillary, high-grade tumour confined to the mucosa
3. Flat, high-grade tumour confined to the mucosa
4. Flat, low-grade tumour invading the lamina propria

Answer 14

3. Flat, high-grade tumour confined to the mucosa

Carcinoma in situ is a flat, high-grade, non-invasive urothelial carcinoma. It can be missed or misinterpreted as an inflammatory lesion during cystoscopy if not biopsied. Carcinoma in sity is often multifocal and can occur in the bladder, but also in the upper urinary tract (UUT), prostatic ducts, and prostatic urethra. Carcinom in situ is diagnosed by a combination of cystoscopy, urine cytology, and histological evaluation of multiple bladder biopsies.

Question 15

Adverse prognostic parameters in recurrent renal cell carcinoma are all EXCEPT:

1. Short time interval (<3-12 months) since treatment of the primary tumour
2. Diameter of the primary tumour
3. Sarcomatoid differnetiation of the recurrent lesion
4. Incomplete surgical resection

Answer 15

2. Diameter of the primary tumour

Adverse prognostic parameters in recurrent renal cell carcinoma are all EXCEPT diameter of the primary tumour. Locally recurrent disease can either affect the tumour-bearing kidney after PN, focal ablative therapy such as RFA and cryotherapy, or occur outside the kidney following PN or RN for RCC. After NSS for pT1 disease, recurrences within the remaining kidney occur in about 1.8-2.2% of patients. The limited available evidence suggests that in selected patients surgical removal of locally recurrent disease can induce durable tumour control. Since local recurrences develop early, with a median time interval of 10-20 months after treatment of the primary tumour, a guideline-adapted follow-up scheme for early detection is recommended.

Question 16

Why should post-voiding residual volume be evaluated during the clinical assessment of paitents with lower urinary tract symptoms?

1. If large, it is a contraindication to watchful waiting
2. If large, it is a contraindication to medical therapy
3. Monitoring changes over time may allow to indentify patients at risk for acute urinary retention
4. It allows to distinguish between obstruction and detrusor underactivity

Answer 16

3. Monitoring changes over time may allow to indentify patients at risk for acute urinary retention

Post-voiding residual volume should be evaluated during the clinical assessment of patients with lowerurinary tract symptoms because monitoring changes over time may allow to identify patients at risk for acute urinary retention. Post-void residual (PVR) urine can be assessed by transabdominal US, bladder scan or catheterisation. Post-void residual is not necessarily associated with BOO, since high PVR volumes can be a consequence of obstruction and/or poor detrusor function (detrusor underactivity (DUA)). Using a PVR threshold of 50mL, the diagnostic accuracy of PVR measurements has PPV of 63% and a negative predictive value (NPV) of 52% for the prediction of BOO. A large PVR is not a contraindication to watchful waiting (WW) or medical therapy, although it may indicate a poor response to treatment and especially to WW. In both the MTOPS and ALTESS studies, a high baselin PVR was associated with an increased risk of symptom progression. Monitoring of changes in PVR over time may allow for identification of patients at risk of AUR.

Question 17

During the assessment of lower urinary tract symptoms in male patients, urethrocystoscopy:

1. Should be performed in all patiens
2. Is important for selection of interventional treatment
3. Is mandatory when considering surgical treatment
4. Should be performed in all patients with history of microscopic haematuria

Answer 17

4. Should be performed in all patients with history of microscopic haematuria

During the assessment of lower urinary tract symptoms in male patients, urethrocystoscopy should be performed in all patients with history of microscopic haematuria. Patients with a history of microscopic or gross haematuria, urethral stricture, or bladder cancer, who present with LUTS, should undergo urethrocystoscopy duringdiagnostic evaluation. A prospective study evaluated 122 patients with LUTS using uroflowmetry and urethrocystoscopy. The pre-operative Q max was normal in 25% of 60 patients who had no bladder trabeculation, 21% of 73 patients with mild trabeculation and 12% of 40 patients with marked trabeculation on cystoscopy. All 21 patiens who presented with diverticula had a reduced Q max. Another study showed that there was no significant correlation between the degree of bladder trabeculation (/graded from I to IV), and the pre-operative Q max value in 39 symptomatic men aged 53-83 years.

Question 18

Which lifestyle intervention improves urinary incontinence in adults?

1. Reduction of caffeine intake
2. Alteration of non-incontinence medication
3. Treatment of constipation
4. Weight loss in overweight and obese women

Answer 18

4. Weight loss in overweight and obese women

Obesity is a risk factor for urinary incontinence in women. Non-surgical weight loss in overweight and obese women improves urinary incontinence. Surgical weight loss improves urinary incontinence in obese women. Reduction of caffeine intake does not improve urinary incontinence, but may improve symptoms of urgency and frequency. There is no consistent evidence that alteration of non-incontinence medication can cure or improve symptoms of urinary incontinence.

Question 19

In women with stress urinary incontinence (SUI), what are the adverse effects and the effectiveness in curing SUI with open colposuspension compared to mid-urethral synthetic sling?

1. Both procedures are equally effective.
2. Pelvic organ prolapse is less common after colposuspension
3. Voiding dysfunction occurs more often after colposuspension
4. Morbidity and complications are higher after colposuspension

Answer 19

1. Both procedures are equally effective.

A Cochrane review of open retropubic colposuspension in the treatment on female urinary incontinence was published in 2016. Overall colposuspension is associated with a continence rate of 85-95% at 1 to 5 years post-operatively and about 70% of patients can expect to be dry after five years Comparison of colposuspension vs. mid-urethral synthetic sling showed non difference in subjective or objective evaluation of incontinence rates at any time point (on to fie years and five years and more time points): Adverse events rates were similar for the two treatment groups with Burch 10% and sling 9% although post-operative obstruction was found exclusively in the sling group. In general, open retropubic colposuspension does not seem to be associated with higher morbidity and complications compared to MUS. Pelvic organ prolapse is more common after colposuspension and voiding dysfunction occurs more often after MUS.

Question 20

What are the expected results for women after pelvic organ prolapse surgery?

1. Inferior outcomes for repeat operations for stress urinary incontinence
2. An increase in prolapse recurrence rate if it is combined with surgery for stress urinary incontinence
3. An increase in risk of therapy failure in short term, if it is combined with surgery for stress urinary incontinence
4. A risk of developing de novo stress urinary incontinence

Answer 20

4. A risk of developing de novo stress urinary incontinence

There is conflicting evidence whether prior surgery for stress urinary incontinence (SUI) or prolapse results in inferior outcomes from repeat operations for SUI. Most procedures will be less effective when used as a second-line procedure. Surgery for pelvic organ prolapse (POP) + SUI shows a higher rate of cure of urinary incontinence in the short term than POP surgery alone. There is confilicting evidence on the relative long-term benefit of surgery for POP + SUI versus POP surgery alone. Combined surgery for POP + SUI carries a higher risk of adverse events than POP surgery alone. Continent women with pelvic organ prolapse are at risk of developing SUI post-operatively. The addition of a prophylactic anti-incontinent procedure reduces the risk of post-operative urinary incontinence, but increases the risk of adverse events.

Question 21

Main factors associated with an increase of SHBG circulating levels are all, EXCEPT:

1. Hyperthyroidism
2. Aging
3. AIDS/HIV
4. Cushings disease

Answer 21

4. Cushings disease

Main factors associated with an increase of SHBG circulating levels are all except Cushing Disease. In normal men 60% to 70% of circulating testosterone is bound to the high affinity sex hormone-binding globulin (SHBG), a protein produced by the liver, which prevents its bound testosterone sub-fraction from biological action. The remaining circulation testosterone binds lower affinity, high-capacity binding protein sites, (albumin, alfa-1 acid glycoprotein and corticosteroid binding protein), and only 1%-2% of testosterone remains non-protein bound. There is a general agreement that testosterone bound to lower affinity proteins can easily dissociate in the capillary bed of many organs accounting for so -called “bioavailable” testosterone. It is important to recognise that several clinical conditions and aging itself can modify SHGB levels, thus altering circulating total testosterone levels. Therefore, if not recognised, these factors could lead to an incorrect estimation of male androgen status. Therefore, when indicated SHBG should be tested and free testosterone calculated.

Question 22

Renal mass biopsy has a sensitivity of 90% for detection of renal cell carcinoma (RCC). What does this imply?

1. In those with RCC on biopsy, 90% will have RCC at final pathology
2. In those with RCC at final pathology, 90% will have RCC
3. In those with a benign biopsy, 90% will not have RCC at final pathology.
4. In those withour RCC at final pathology, 90% will have a negative biopsy

Answer 22

2. In those with RCC at final pathology, 90% will have RCC

Sensitivity (also called the true positive rate) measures the proportion of patients with RCC that are correctly identified as such by the biopsy.

Question 23

A patient presents with widespread metastatic clear cell renal cell carcinoma. He underwent a pephrectomy 9 month prior. Prognostic systems are strongly recommended in the metastatic setting. The International Metastatic Renal Cancer Database Consortium (IMDC) proposes several risk factors in metastatic renal cancer. Which is a risk factor in the IMDC system?

1. Neurophil blood count
2. Fuhrman grade
3. Lactate dehydrogenase (LDH)
4. ECOG performance status

Answer 23

1. Neurophil blood count

The IMDC system uses the foloowing risk factors: -Karnofsky performance status (not ECOG performance status). -Delay between diagnosis and treatment. - Corrected calcium. -Haemoglobin. -Neutrophil count. -Platelet count. Lactate dehydrogenase is used in the MSKCC prognostic system. Fuhrman grade is used in prognostic models in localised RCC not in the metastatic setting.

Question 24

Which of the following is the strongest predictor of non-muscle invasive bladder cancer progression according to the EORTC bladder calculator?

1. T1 stage
2. G3 grade
3. Numbers of tumours
4. Concurrent CIS

Answer 24

4. Concurrent CIS

In the EORTC risk calculator, those with concurrent CIS are assigned 6 points, whole lower points are assigned for T stage (Ta: 0 points, T1:4 points), grade (grade 1 or 2: 0 points, grade 3: 5 points), and number of tumours (3 points for 2 or more tumours).

Question 25

What is the recommended first-line systemic treatment for patiens with International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) favourable risk metastatic clear cell ranal cell carcinoma?

1. Ipilimumab plus Nivolumab
2. Pembrolizumab plus Axitinib
3. Avelumab plus Axitinib
4. Atezolizumab plus Bevacizumab

Answer 25

2. Pembrolizumab plus Axitinib

Pembolizumab plus Axitinib is the recommended standard of care for systemic first line treatment. Ipilimumab plus Nivolumab is a standar of care for intermediate and poor risk disease. Data on Avelumab plus Axitinib and Atezolizumab plus Bevacizumab are still immature with regards to the overall survival endpoint.

Question 26

A patient has a 2 cm hyperdense cyst on contrast-enhanced CT. Which follow-up is most appropriate?

1. No follow-up
2. CT in 6 months
3. CT in 12 months
4. CT in 24 months

Answer 26

1. No follow-up

This corresponds to a Bosniak II cyst. Bosnial II cysts are benign. No follow-up is advised. Bosniak category I Simple benign cyst with a hairline-thin wall without septa, calcification , or solid components. Same density as water and does not enhance with contrast medium. Benign II Benign cyst that may contain a few hairline-thin septa. Fine calcification may be present in the wall or septa . Uniformly high-attenuation lesions <3 cm in size, with sharp margins without enhancement. Benign IIF These may contain more hairline-thin septa. Minimal enhancement of a hairline-thin septum or wall. Minimal thickening of the septa or wall. The cyst may contain calcification, which may be nodular and thick, with no contrast enhancement. No enhancing soft-tissue elements. This category also includes totally intra-renal, non enhancing, high attenuation renal lesions ≥ 3 cm. Generally well-marginated. Follow-up, up to five years. Some are malignant. III These are indeterminate cystic masses with thickened irregular walls or septa with enhancement. Surgery or active surveillance (- se Chapter 7). Over 50% are malignant. IV Clearly malignant containing enhancing soft-tissue components. Suregry Most are malignant.

Question 27

A patient undergoes a lymph node dissection for renal cancer. On pathology, 6 out of 7 regional lymph nodes were metastatic. The largest lymph node metastasis was 4 cm. What is the correct stage?

1. N1
2. N2
3. N3
4. M1

Answer 27

1. N1

The TNM classification for renal cell carcinoma does not sub-classify N stage based on teh number of involved regional lymph nodes or lymph node size. All regional lymph node metastases are summarised in teh N1 category. N -Regional Lymph Nodes NX Regional lymph nodes can not be assessed N0 No regional lymph node metastasis N1 Metastais in regional lymph node(s)

Question 28

Which of the following is a predictor of relapse of stage I seminoma?

1. Tumour size > 4 cm
2. Invasion of the spermatic cord
3. Lymphovascular invasion
4. Beta-HCG above upper limit of normal

Answer 28

1. Tumour size > 4 cm

Invasion of the rete testis and tumour size are predictors of relapse for stage I seminoma. Lymphovascular invasion is a prognostic factor for stage I non -seminoma. The level of beta-HCG is not prognostic in non-metastatic seminoma. Invasion of the spermatic cord refers to pT3 disease and is not an established prognostic factor.

Question 29

In patients with new testicular cancer, biopsy of the contralateral testis should be performed in which clinical scenario?

1. Testicular volume 10 mL
2. Alpha-fetoprotein >1000 ng/mL
3. Brain metastasis
4. History of hypospadias

Answer 29

1. Testicular volume 10 mL

A contalateral biopsy should be considered in those with testicular volume < 12 mL and/or a history of cryptorchidism. Contralateral biopsy is not necessary in patients older than 40 years without risk factors.

Question 30

Which of the following is a typical feature of a 5a-reductase deficiency syndrome?

1. Blind ending vagina
2. Atrophic testes
3. Bilateral absent vas deferens
4. Uterus didelphys

Answer 30

1. Blind ending vagina

5a-reductase deficiency is a rare autosomal recessive syndrome. The defective gene (SRD5A2) is located on chromosome 2. These babies are genotypically male (46XY). They often present with severe hypospadias. Gonadal development is not dependent on 5-dihydrotestosterone and hence patients have normal but undescended testes. They lack Mullerian duct structures (cervix, proximal 2/3 of vagina, fallopian tubes). Bilateras absent vas deferens is a sign of cystic fibrosis.

Question 31

Which is the first location of lymphatic drainage in a woman with a tumour located in the proximal end of her urethra?

1. Superficial inguinal lymph nodes
2. Deep inguinal lymph nodes
3. Pelvic lymph nodes
4. Paracaval lymph nodes

Answer 31

3. Pelvic lymph nodes

In women, the lymph of the proximal third drains into the pelvic lymph node chains, whereas the distal two-thirds initially drain into the superficial- and deep inguinal nodes.

Question 32

Which is the recommended treatment for non-invasive urethral carcinoma of the prostatic urethra?

1. Brachytherapy
2. Radical prostatectomy
3. Upfront BCG`instillation therapy followed by external radiotherapy
4. Extensive transurethral resection followed by BCG instillation therapy

Answer 32

4. Extensive transurethral resection followed by BCG instillation therapy

Local conservative treatment with extensive TUR and subsequent BCG instillation is effective in patients with Ta or Tis prostatic urethral carcinoma. Likewise, patients undergoing TUR of the prostate prior to BCG experience improved complete response rates compared with those who do not (95% vs 66%)

Question 33

The negative predictive value (NPV) of a multiparametric-MRI of the prostate showing no abnormalities (PIRADS 1-2) for presence of Gloeason grade group 2 or higher prostate cancer, is closest to:

1. 90%
2. 70%
3. 50%
4. 30%

Answer 33

1. 90%

Although the performance of MRI is dependent on multiple factors related to observer and disesase prevalence, different reviews have presented an NPV for presence of significant prostate cancer of around 90%

Question 34

The following statements regarding Bladder Pain Syndrome (BPS) are correct, EXCEPT:

1. It is far more common among women
2. There is possibly no difference in terms of race or ethnicity
3. According to recent reports, the prevalence of BPS ranges from 0,06% to 30%
4. Children under eighteen are by definition excluded from the diagnosis of BPS

Answer 34

4. Children under eighteen are by definition excluded from the diagnosis of BPS

There is increasing evidence that children under eighteen may also be affected, although prevalence figures are low. Therefore, BPS cannot be excluded on the basis of age.

Question 35

Which is correct regarding a supsicious prostate Digital Rectal Examination (DRE)?

1. It is associated with a lower risk of high Gleason score
2. It is not an indication of prostate biopsy
3. It has a positive predictive value of 5-30% in patients with a PSA level < 2 ng/mL
4. It is always synonymous of pathologically confirmed prostate cancer

Answer 35

3. It has a positive predictive value of 5-30% in patients with a PSA level < 2 ng/mL

Most PCas are located in the peripheral zone and may be detected by DRE when the volume is >0,2 mL. In ~18% of cases, PCa is detected by suspect DRE alone, irrespective of PSA level. A suspect DRE in patients with a PSA level <2 ng/mL has a positive predictive value (PPV) of 5-30%. An abnormal DRE is associated with an increased risk of a higher ISUP grade and is an indication for biopsy.

Question 36

Based on 2nd and 3rd Princeton Consensus, intermediate cardiac risk patients with erectile dysfunction include patients with:

1. Recent myocardial infarction less than 2 weeks ago
2. Recent myocardial infarction between 2-to 6 weeks ago
3. Myocardial infarction more than 6 weeks ago
4. Uncomplicated previous myocardial infarction

Answer 36

2. Recent myocardial infarction between 2-to 6 weeks ago

Based on 2nd and 3rd Princeton Consensus, intermediate risk patients with erectile dysfunction include patients with myocardial infarction between 2-to 6 weeks. Patients who seek treatment for sexual dysfunction have a high prevalence of cardiovascular disease. The Princeton Consensus Conference is dedicated to optimising sexual function and preserving cardiovascular health. Accordingly, patients with ED can be stratified into three cardiovascular risk categories, whick can be used as the basis for a treatmen algorith for initiating or resuming sexual activity. It is also possible for the clinician to estimate the risk of sexual activity in most patiens from their level of exercise tolerance, which can be determined when taking the patient’s history.

Question 37

Topical alprostadil is currently approved at the dose of:

1. 100 µg
2. 200 µg
3. 300 µg
4. 400 µg

Answer 37

3. 300 µg

Topical alprostadil by the use of VITAROSTM is currently approved at the dose of 300 µg. The vasoactive agent alprostadil can be administered per urethra with two different formulations. The first compound is the topical route using a cream that includes a permeation enhancer in order to facilitate absorption of alprostadil (200 and 300 µg) via the urethral meatus. Clinical data are still limited. Significant improvement compared to placebo was recorded for IIEF-EF domain score, SEP2 and SEP3 in a broad ragne of patients with mild-to-severe ED. Side-effects include penile erythema, pneile burning adn pain that usually resolves within two hours of application. Systemic side effects are very rare. Topical alprostadil (VITAROSTM) at the dose of 300 µg is currently approved and it is available in som European countries.

Question 38

Appropriate antibiotic therapy for Fournier’s gangrene include:

1. Cefotaxime (2g every 6h IV) plus clindamycine (600-900 mg every 8h IV)
2. Ciprofloxacine (400mg every 12 h IV).
3. Vancomycin (15mg/kg every 12h)
4. Cefotaxime (2g every 6h IV) plus fosfomycin (5g every 8 h IV)

Answer 38

1. Cefotaxime (2g every 6h IV) plus clindamycine (600-900 mg every 8h IV)

Fournier’s gangrene is an aggressive and frequently fatal polymicrobial soft tissue infection of the perineum, peri-anal region, and external genitalia. It is an anatomical sub-category of necrotisning fasciitis with which it shares a commoon aetiology and management pathway. Immediate empiric parenteral antibiotic treatment should be given that covers all probable causative organisms and can penetrate inflammatory tissue. A suggested regime would comprise a broad-spectrum penicillin or third-generation cephalosporin, gentamicin and metronidazole or clindamycine. This can then be refined, guided by microbiological culture.

Question 39

Which of the following investigations is NOT mandatory to perform in every patient with a bladder stone?

1. Cystourethroscopy
2. Uroflowmetry and postvoid residual volume
3. Metabolic assessment and stone analysis
4. Urine dipstick and pH

Answer 39

1. Cystourethroscopy

Cystourethroscopy is not mandatory in all patients with bladder stones. Bladder stones constitiute only approximately 5% of all urinary tract stones, yet are responsible for 8% of urolithiasis-related mortalities in developed nations. The incidence is higher in developing countries. The prevalence of bladder stones is higher in males, with a reported male:female ratio betseen 10:1 and 4:1. The symptoms most commonly associated with bladder stones are urinary frequency, haematuria (which is typically terminal) and dysuria or suprapubic pain, which are worst towards the end o micturition. All patients with bladder stones should be exdamined and investigated for the cause of bladder stone formation, including: uroflowmetry and post-void residual, urine dipstick, pH +/-culture, metabolic assessment and stone analysis

Question 40

Antibiotic prophylaxis should always be used following:

1. Urodynamics
2. Cystoscopy
3. Extracorporeal shockwave lithotripsy
4. Ureteroscopy

Answer 40

4. Ureteroscopy

To reduce the rate of symptomatic infection, antibiotic prophylaxis should always be used after ureteroscopy. Urological surgeons and the institiutions in which they work should consider and monitor maintenance of a aseptic environment to reduce risk of infection from pathogens within patients (microbiome) and from outside the patient (nosociomial/helathcare-associated). Identifying bacteriuria prior to diagnostic and therapeutic procedures aims to reduce the risk of infectious complications by controlling any pre-operative detected bacteriuria and to optimise antimicrobial coverage in conjunction with the procedure. Based on current evidence, antibiotic prophylaxis to reduce the rate of symptomatic urinary infection following should not be used following: urodynamics, costoscopy, extracorporeal shockwave lithotripsy

Question 41

Staging of muscle-invasive bladder cancer compises evaluation of lymph node involvement. Which is one of the most important parameters used to identify lymph node metasteses with CT or MRI?

1. Laterality
2. Number of nodes
3. Homogeneous contrast enhancement
4. Node size

Answer 41

4. Node size

CT and MRI show similar results in the detection of lymph node metastases in MIBC. Metastases from pelvic cancers frequently produce little, if any, nodal enlargement. Enlarged lymph nodes in the pelvis may be benign, due to reactive hyperplasia or inflammation. The criteria for assessment of nodal involvement include: (1) site , (2) size, (3) shape, (4) number of nodes, (5) nodal characteristics. Round (spherical) nodes are more likely to be malignant than oval nodes acoording to several studies. Nodes > 8 mm and abdominal nodes > 10 mm in maximum short-axis diameter, detected by CT or MRI, should be regarded as pathologically enlarged. A cluster of normal nodes may suggest malignant involvement but asymmetry in the pelvis is common, making this sign less reliable. Pelvic nodal metastases usually have a soft tissue-density, but other features may be helpful in diagnosing metastatic involvement. Nodes frequently anhance with intravenous contrast medium. If inhomogenoeous enhancement of large node is seen, this is more likely to be laignant, but homogeneous anhancementmay be due to benign or malignant disease.

Question 42

What is the most feasible imaging method for biopsy targeting and guiding local salvage treatmen tof recurrent prostate cancer after curative radiotherapy?

1. Choline PET/CT
2. Multiparametric magnetic resonance imaging (mpMRI)
3. Transrectal ultrasonography (TRUS)
4. Prostataspecific membrane antigen PET/CT

Answer 42

2. Multiparametric magnetic resonance imaging (mpMRI)
   Transrectal US is not reliable in identifying local recurrence after RT. In contrast, mpMRI has yielded excellent results and can be used for biopsy targeting and guiding local salvage treatment even if it slightly underestimates the volume of the local recurrence. Detection of recurrent cancer after RT is also feasible with choline PET/CT and Prostate specific membrane antigen PET/CT

Question 43

An 8-month-old male neonate is diagnosed with non-palpable right testicle. What is the next diagnostic step?

1. Abdominal ultrasound having very high accuracy in intraabdominal testicle localization
2. Re-examination under anaesthesia
3. Re-examination after 6 months of hormonal therapy
4. Immediate submission to inguinal canal exploration

Answer 43

2. Re-examination under anaesthesia

Accuracy of any imaging method for undescended testes is limited and only recommended in specific and selected clinical scenarios. The alogrithm in case of unpalpable one side testicle includes re-examination under the anesthesia and in case of unpalpable testicle diagnostic laparoscopy.

Question 44

In patients presenting with metastatic hormone-sensitive prostate cancer (M+HSPC) what would be the LEAST LIKELY agent to start upfront, in addition to androgen deprivation therapy (ADT)?

1. Cabazitaxel
2. Docetaxel
3. Abiraterone
4. Enzalutamide

Answer 44

1. Cabazitaxel

Docetaxel, abiraterone, and enzalutamide have all been assessed in randomized controlled trial in M+HSPC. All have a favourable impact on overall survival when added to standard hormonal therapy. Cabazitaxel has been subject of investigation mainly in castration-resistant prostate cancer (and mainly 2nd and 3rd line).

Question 45

Ketamine is a general anaesthetic. Due to its dissociative effects, short-action, and low cost, it is increasingly used as illegal recreational drug among young people. What is the possible detrimental effect of Ketamine abuse on the urinary tract?

1. Renal carcinoma
2. Prostatitis
3. Urinary stones
4. Ulcerative cystitis

Answer 45

4. Ulcerative cystitis

Ketamine is ageneral anesthetic, introduced for human use in 1970. Dissociative effects, short-action, and low cost led ketamine becoming an illegal recreational drug, widely used among young adults in clubs and parties. Besides psychological effects, ketamine has also demonstrated in long-term abusers detrimental consequences on the urinary tract. Shahani et al first described in 2007 a series of nine daily ketamine abusers with a history of severe urgency, frequency, dysuria and hematuria associated with ulcerative cystitis. Ketamin toxicity was not limited to the bladder, and upper urinary tract involvement was possible. Hydronephrosis was present in several ketamine abusers and is correlated to the contracted bladder, ureteral stenosis, vesicoureteral reflux or impaired peristalsis function of the renal pelvis or ureter. Chronic kidney failure may develop as the final consequence of the ketamine induced uropathy. Stone formation, is gererally not described.

Question 46

In prostate cancer patients suspected of castration resistanc, the definition for castration level of testosterone level is:

1. <100ng/dL (<2 mL/L)
2. <50ng/dL (<1 mL/L)
3. <10ng/dL (<0,2 mL/L)
4. <1ng/dL (<0,02 mL/L)

Answer 46

2. <50ng/dL (<1 mL/L)

The castration level is <50ng/dL (<1.7 nmol/L), wich was defined more than 40 years ago when testosterone testing was less sensitive. Current methods have shown that the mean value after surgical castration is 15 ng/dL. Therefore, a more appropriate level should be defined as < 20 ng/dL (1 nmol/L). This definition is important as better results are repeatedly observed with lower testosterone levels compared to 2. <50ng/dL. However the castrate level considered by the regulatory authorities and in clinical trials addressing castration in a PCa is still the historical 2. <50ng/dL (<1,7mmol/L). For hypogonadism, different testosterone levels are applied.

Question 47

Regarding the embryological development of the urethra in the male which statement is NOT correct?

1. By 18 weeks’ gestation, penile and urethral development is essentially complete.
2. The urethral plate is derived from endoderm and extends into the future glans penis, termination just before the distal tip of the future glans
3. The glanular urethra is formed by ectodermal intrusion growing into the glans and meeting the endodermally derived urethra
4. One of the first signs of masculinization is an increase in the distance between the anus and the genital structures.

Answer 47

3. The glanular urethra is formed by ectodermal intrusion growing into the glans and meeting the endodermally derived urethra

Current evidence supports the view that the glanular urethra form from urogenital sinus epithelium, by direct canalization of the urethra plate with epithelial remodelling within the glans. The ectodermal extrusion theory is outdated.

Question 48

Which would be the best choice for suture material to perform a urinary tract anastomosis?

1. Polypropylene
2. Polyglactin 910
3. Polyester
4. Polyamide

Answer 48

2. Polyglactin 910

Polypropylene(Prolene), Polyester(Mersilene), Polyamide(Nylone) are nonabsorbable sutures. These sutures are not degraded by the body over time and therefore can act as a nidus for infection and stone formation. For these reasons, such sutures are not advised when contact with urine is anticipated (i.e. during urinary tract anastomosis or repair of a genitourinary organ injury). Polyglactin 910 (Vicryl) is an absorbable suture, commonly used in urological surgeries to create ureterovesical, ureteroileal or other anastomoses.