June Quiz 4

Question 1

A 53-year-old woman has urine leakage with sneezing and exercise despite pelvic floor muscle training. On physical examination, after voiding, she has no significant prolapse and on leakage with cough ro Valsalva. The next step is:

full bladder stress test.
urodynamics
antimuscarinic therapy.
periurethral injection.
midurethral sling.

Answer 1

full bladder stress test.
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This patient has symptomatic stress urinary incontinence (SUI), though none is noted on examination. She should not be treated invasively without documentation of SUI on examination. She should return for a full bladder stress test done supine and repeated standing if necessary. If that remains negative, urodynamics could be offered to try to better delineate her leakage. Antimuscarinics should not be offered in the presence of primarily SUI symptoms.

Question 2

Four weeks after SWL, the best treatment of a persistent, asymptomatic 2 cm steinstrasse is:
medical expulsive therapy.
ureteral stent.
SWL of the lead fragment.
ureteroscopic laser lithotripsy.

percutaneous antegrade ureteroscopy.

Answer 2

ureteroscopic laser lithotripsy.
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Patients with steinstrasse who are asymptomatic can often be observed initially, as spontaneous stone clearance can occur. Medical expulsive therapy with alpha-blockers may be used to augment expectant management and may aid in pain control. Failure of expectant management, though, is an indication for intervention. When intervention is required, a minimally invasive approach is often successful. Ureteroscopic intervention is definitive and predictable, with an immediate success rate approaching 100%. Additional SWL may be successful, but the results are less predictable than with ureteroscopy. A ureteral stent alone will help alleviate obstruction and will improve pain if the patient si symptomatic; however, success of a nephrostomy tube is likely greater than a stent alone when managing a steinstrasse. Percutaneous antegrade ureteroscopy may be used as a salvage procedure.

Question 3

You are performing a retrograde urography on a patient with a completely duplicated ureter on the left with signs of obstruction. What is the position of the ureteral orifice that would most likely reveal an abnormality?
left superior and lateral
left inferior and medial
left superior and medial
left inferior and lateral

Answer 3

left inferior and medial

Question 4

Which is true of hydronephrosis of pregnancy?
Obstruction is the primary factor in its development
Hormonal mechanism is the primary factor in its development
It may extend from the pelvocalyces down to the UVJ
It is expected to resolve 6-8 weeks postpartum

Answer 4

Obstruction is the primary factor in its development

Question 5

A 53-year-old man completes induction and the first maintenance course of intravesical BCG for cT1 urothelial bladder carcinoma with CIS. Bladder biopsies two months after his last BCG course reveal CIS. CT scan is normal. The next step is:

repeat induction with BCG and interferon.
bladder biopsies after next maintenance series.
chemoradiation.
radical cystectomy.
neoadjuvant chemotherapy and cystectomy.

Answer 5

radical cystectomy
This patient has had adequate intravesical therapy for his high risk, non-muscle invasive bladder cancer, defined as induction and at least one course of maintenance BCG, and thus would now be categorized as BCG unresponsive. Given the persistent CIS at this time (within 12 months), which is biopsy-proven, additional salvage intravesical therapies (whether BCG + Interferon or chemotherapy) are not indicated unless the patient is unwilling or unfit for cystectomy. Although bladder preservation with trimodal therapy (i.e., chemotherapy and XRT) can be considered in well-selected patients, it is not appropriate with the finding of CIS alone. Similarly, neoadjuvant chemotherapy has no proven benefit in patients undergoing cystectomy without muscle-invasive bladder cancer.