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Oral Board Prep > Oral Board Prep > Flashcards

Oral Board Prep Flashcards

1
Q

Describe the office tests for diagnosing a VVF or UVF.

A

Place a tampon in the vagina. Administer the patient oral phenazopyridine. Instill methylene blue into the bladder. Remove tampon after 10 minutes of walking in the office.

Source: AUA Board Review Manual page 336.

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2
Q

Describe the followup of someone being followed by active surveillance for low grade clincially localized prostate cancer.

A

PSA every 3 - 6 months. DRE once every 6 - 12 months. Repeat biopsy at 12 - 18 months.

Source: NCCN Prostate Guidelines

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3
Q

What artery is a Martius flap based upon?

A

Anteriorly: external pudendal artery.
Posteriorly: posterior labial artery (internal pudendal artery).

AUA Update 2006, lesson 25.

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4
Q

What are the options for repairing a vesicovaginal fistula?

A
  1. Fulguration: short term, small pin point fistula
  2. Fibrin glue: short term, small pin point fistual
  3. Transvaginal repair
  4. Transabdominal
  5. Combined repair
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5
Q

What are the potential consequences of untreated pylenoephritis in a pregnant woman?

A
  1. Prematurity
  2. Low Birth weight
  3. IUGR
  4. Neonatal Mortality

Source: Pregnancy Talk - UAB

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6
Q

What renal function values worrisome in a pregnant woman?

A

BUN > 13 or Cr > 0.8

Source: Pregnancy Talk - UAB, AUA Update - Altomar and Miller

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7
Q

What antibiotics are safe in pregnant women?

A
  1. Nitrofurantoin
  2. Penicillins
  3. Aminoglycosides
  4. Cephalosporins
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8
Q

Who should get a lymph node dissection in penile cancer?

A
  1. Any patient with palpable lymph nodes (after antibiotics).
  2. Patients with High grade T1.
  3. T2 or greater irrespective of palpability.
  4. Positive sentinal node biopsy.

Handbook page 55 + CBLP #60.

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9
Q

What do you do if a superficial groin dissection is positive for cancer in a patient nonpalpable nodes?

A

Proceed to bilateral full node dissection and pelvic lymph node dissection.

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10
Q

What are the boundaries of superficial node dissection for penile cancer?

A
  1. Fascia lata posteriorly
  2. Sartorius laterally
  3. Adductor longus medially
  4. Inguinal ligament superiorly

Handbook page 55

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11
Q

In a patient with T2 penile cancer and bilateral non palpable lymph nodes, what type of lymph node dissection is necessary?

A

Bilateral superficial node dissection.

Handbook page 56.

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12
Q

In any patient with palpable lymph nodes unilaterally, what type of groin dissection is needed for penile cancer?

A

Ipsilateral Complete LND + Contralateral Superficial.

Handbook page 56.

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13
Q

In a penile cancer patient with bilateral palpable nodes, what LND is needed?

A

Bilateral Deep ILND + Pelvic LND.

Handbook page 56.

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14
Q

In a patient with low grade T1 or less penile cancer, what type of followup is required?

A

Followup should be every 3 months with GU exam and nodal exam.

Handbook page 56 and CBLP #60, slide 28.

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15
Q

What staging workup is necessary in a patient with penile cancer?

A
  1. Imaging - abd/pelvis CT + chest imaging
  2. Urine culture prior to surgery
  3. CBC with BMP (hypercalcemia may be present in bulky tumors due to 2 hyperparathyroidism).

CBLP #60.

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16
Q

Name the benign penile lesions.

A
  1. Papilloma (pearly penile papules)
  2. Condyloma acumniatum
  3. Buschke-Lowenstein
  4. Zoon’s balanitis
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17
Q

Name the premalignant penile lesions.

A
  1. Bowenoid Papulosis
  2. CIS
    • erythroplasia of queyrat
    • bowen’s disease
  3. BXO (now LSA)
  4. Leukoplakia
  5. Cutaneous horn

Handbook page 52.

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18
Q

When is a partial penectomy indicated?

A

When tumor is present on the glans and distal penile shaft.

Handbook page 56.

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19
Q

What does the NCCN recommend first if you suspect bladder cancer based on history?

A
  1. H and P
  2. Office cystoscopy
  3. Cytology

NCCN Bladder slide 5

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20
Q

After office cystoscopy, you determine a bladder lesion is worrisome for muscle invasive disease. What would you order next?

A
  1. CBC
  2. BMP + alk phos
  3. Ask about bone pain symptoms
  4. CT urogram
  5. Chest imaging

NCCN BLadder slide 5

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21
Q

On office cystoscopy you note a single tumor. At the time of formal TURBT it appears more worrisome than you originally thought. How does your plan change?

A

You would consider mapping biopsies of the bladder and may consider TUR of the bladder neck or prostate.

NCCN Bladder slide 5.

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22
Q

What must you always include at the time of your formal TURBT for bladder cancer?

A

Exam under anesthesia. Don’t forget this.

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23
Q

What is the typical surveillance regimen for patients with non mucle invasive UCC?

A
  1. Cysto and cytology q 3 mos x 2 years, then q 6 months (high grade Ta, cis and T1)
    - 3 mos, then 6 mos, then annually (Ta low grade)
  2. Upper tract imaging every 1 - 2 years

Handbook page 35 and NCCN Bladder slide 6

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24
Q

Name the minimum nodal areas that should be removed during radical cystectomy and the boundaries of dissection.

A
  1. Common iliac
  2. External Iliac
  3. Hypogastric
  4. Obturator

Boundaries:

  1. Bifurcation (standard) or IMA (extended) - superior
  2. Inguinal ligament (node of Cloquet and take of circumflex iliac vessel) - inferior
  3. Bladder - medial
  4. Pelvic Side wall and genitofemoral nerve - laterally

Handbook page 43, NCCN Bladder slide 12, AUA update 2009 vol 27

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25
Q

How should you follow someone with bladder cancer post radical cystectomy?

A
  1. Cytology, creatinine, and electrolytes every 3 - 6 months for 2 years
  2. If urethra left, do urethral wash every 6 - 12 months
  3. Get chest, abdomen and pelvis imaging every 3 - 12 months

NCCN Bladder slide 16

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26
Q

Who should get immediate intravesical chemotherapy after TURBT?

A
  1. Low grade Ta (according to NCCN)
  2. High grade Ta
  3. T1 lesions (Handbook page 36)

no role in CIS

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27
Q

How should you give post TURBT mitomycin C? What side effects would you expect?

A
  1. Give in a concentrated dose of 40 mg in 20 ml of sterile water.
  2. Leave indwelling x 1 hour.

Chemical cystitis and irritative voiding symptoms.

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28
Q

What patients with non muscle invasive bladder cancer are candidates for intravesical therapy and what is the treatment of choice?

A
  1. Low grade Ta (only if, large tumor > 2 cm, < 1 year recurrence interval, multiple diffuse tumors, incomplete resection).
  2. High grade Ta
  3. Any T1 lesion
  4. CIS

BCG is treatment of choice

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29
Q

What would cause to repeat a TURBT?

A
  1. no muscle in specimen
  2. large multifocal tumor
  3. incomplete resection
  4. Any T1
  5. Any high grade tumor (if even Ta)

NCCN Bladder slide 12

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30
Q

What FDA approved agent is available for BCG refractory CIS?

A

Valrubicin

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31
Q

What is the second line intravesical agent recommended by NCCN for non muscle invasive bladder tumors (excluding CIS)?

A

Mitomycin C

NCCN Bladder slide 6

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32
Q

According the NCCN Bladder cancer algorithm, what is the most important finding in a patient with cT2 - cT4a disease?

A

The presence or absence of positive nodal disease.

Patients with positive nodal disease go straight to chemotherapy or chemotherapy plus RT.

NCCN Bladder Slide 10.

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33
Q

For a patient with cT2 bladder tumor, what treatment options are available?

A
  1. Radical cystectomy +/- neoadjuvant chemo.
  2. Partial cystectomy +/- neoadjuvant chemo (no CIS and well suited lesion with ability to achieve negative margins, must still do a node dissection)
  3. Bladder sparing approach (TURBT + Chemo/RT)
  4. Salvage (sick patients could get TURBT only, Chemo/RT, or Chemo only).

NCCN Bladder slide 8

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34
Q

In what instances would you offer a cystectomy to someone with a tumor less than T2?

A
  1. BCG refractory CIS (after one or two courses)
  2. Residual T1 tumor on repeat TURBT (in what was thought to be a complete resection)
  3. Recurrent Ta,T1 or CIS (must be less than 2 courses)

Handbook page 35 and NCCN Bladder slide 7

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35
Q

What is an extended PLND in prostate cancer patients?

A
  1. External iliac nodes
  2. Hypogastric nodes
  3. Obturator nodes

AUA update 2009 vol 27

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36
Q

How would you decide whether to perform a PLND during radical prostatectomy?

A

Use a nomogram cut point of 2% risk as guided by AUA update 2009 vol 27 and NCCN Prostate guidelines.

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37
Q

What is the minimum metabolic workup for a patient with kidney stones?

A
  1. Serum studies including (BMP, calcium, phos and alk phos).
  2. Stone analysis
  3. UA and Urine culture

Handbook page 131

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38
Q

Who is at high risk for stone disease recurrence or complications?

A
  1. Solitary kidney
  2. Airplane pilots
  3. Gout
  4. Recurrent UTI
  5. GI disorders (Crohn’s)
  6. Family hx of stones
  7. Pediatric patients
  8. Cysteine, uric acid, struvite stone formers
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39
Q

Describe how you would give BCG to a patient. Be specific.

A
  1. Check the patients temperature.
  2. Check a UA for hematuria and or infection.
  3. Have patient void.
  4. Place a catheter and check PVR.
  5. Instill BCG (Tice BCG 1 vial in 50 ml of normal saline).
  6. Retain BCG x 2 hours.
  7. Void in toilet and add bleach.
  8. Wash hands and genitals and refrain from intercourse for 48 hours.

Handbook page 41

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40
Q

What sort of metabolic workup would you do if a stone patient were “high risk”?
What are general diet restrictions for high risk stone formers?

A

Patient needs two 24 hour urine studies (one on a random diet and the other on a restricted diet).

General Diet recs:

  1. Increased hydration
  2. Lowered sodium
  3. Lowered oxalate
  4. 800 - 1000 mg/d of calcium
  5. 0.8 - 1.0 g/kg/d of protein
  6. Limit high doses of Vit C and Vit D

Handbook page 140

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41
Q

Name the absolute contraindications to ESWL?

A
  1. AAA (particularly if > 4 cm)
  2. Pregnancy
  3. Coagulopathy
  4. UTI
  5. Obstruction
  6. Intrarenal vascular calcification

Handbook page 145

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42
Q

What are the relative contraindications to ESWL?

A
  1. Cysteine or matrix stones (resistant to ESWL)
  2. Radiolucent stones
  3. Chronic pancreatitis

Handbook page 145

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43
Q

What are some reasons that ESWL fails?

A
  1. Stone burden > 2.5 cm
  2. Cysteine, matrix or CaOxMono
  3. Obesity (skin distance beyond focal point)
  4. Lower pole location

Handbook page 145

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44
Q

Name 4 situations that you might need to consider acute adrenal insufficiency.

A
  1. Bilateral adrenal surgery (or methachronous retroperitoneal surgeries)
  2. Stressful event in patient on chronic steroids (sepsis after nephrectomy)
  3. Adrenal suppression agents (ketoconazole, mitotane)
  4. Adrenalectomy for functional adrenal adenoma (contralateral side suppressed)

CBLP #67 slide 16

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45
Q

Describe a detailed pelvic exam.

A

The pelvic exam can be completed with a half speculum, first placed on the posterior wall to assess for anterior prolapse as the patient bears down (Valsalva). The blade is then placed anteriorly to assess for a rectocele. A high rectocele can sometimes be distinguished from an enterocele by simultaneous digital rectal exam. As the speculum blade is retracted, the examiner should assess for cervical or vaginal cuff descent. The urethra should be examined for hypermobility and evidence of incontinence with Valsalva maneuvers. To assess for occult SUI, the bladder can be filled, the prolapse reduced, and the patient asked to strain or cough.

CBLP #69 slide 6.

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46
Q

What are the indications for rectocele repair?

A
  1. Bothersome bulge
  2. Splinting to defecate

CBLP #69 slide 14

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47
Q

What are the 3 findings for retroperitoneal fibrosis on IVP or retrograde pyelography?

A

1 .Hydronephrosis with dilation of the proximal ureter

  1. bilateral Medial deviation of the ureter(s) (nonspecific finding by itself)
  2. Narrowing of the middle portion of the ureter(s) due to extrinsic obstruction

CBLP #71 slide 10

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48
Q

Name common causes of RPF>

A
  1. Idiopathic (<50%)
    • caused by periarteritis from AAA
  2. Known
    • 10 - 20% due to retroperitoneal sarcoma, lymphoma, or mets
    • meds: methysergide, LSD, beta blockers
    • sarcoid
    • radiation
    • TB, chronic UTI

CBLP #71 slide 14

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49
Q

Following removal of infected IPP, how soon should replacement be performed?

A

6 - 12 weeks.

Fibrosis is immature at this point and easier to work with.

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50
Q

What is the ddx of a hypoechoic testis mass in a 35 yo male?

A
  1. Germ cell tumor
  2. Sex cord and stromal tumor (leydig, sertoli)
  3. Mixed germ cell and stromal (gonadoblastoma)
  4. Adrenal rest
  5. Non gu tumor (lymphoma, mets)
  6. GU TB
  7. Abscess

CBLP #75 slide 7

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51
Q

In whom are Leydig cell tumors most likely to be malignant?

A

Only in postpubertal adults.

Prepubertal boys don’t demonstrate malignancy.

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52
Q

What is the blood supply to the gracilis muscle?

A

Medial circumflex femoral artery a branch of the profunda femoris.
Proximal additional blood supply comes from the obturator artery.

AUA Update 2006, Lesson 20

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53
Q

List the tests used to assess ED.

A
  1. Nocturnal Penile Tumescence and Rigidity - not sensitive enough to be used as a sole test, can determine if erections are psychogenic
  2. ICI of erectogenic medication - good erection rules out veno-occlusive disease
  3. Penile Doppler -
  4. Cavernosometry - most sensitive test to eliminate veno-occlusive dysfunction
  5. Cavernosography - shows location of venous leak

Handbook page 239 and 240

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54
Q

Describe how to perform a penile doppler for ED.

A
  1. Use 5-10 Hz transducer.
  2. Give erectogenic medication 5 - 10 minutes before.
    • 10 mcg of alprostadil
  3. cavernosal PSV > 30 cm/s to eliminate arteriogenic ed
    • 50 - 60 cm/s bilaterally
  4. cavernosal EDV < 3 cm to eliminate veno-occlusive disease

Handbook page 242

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55
Q

In a man with ED when would you obtain a prolactin level?

A

Get prolactin after checking a testosterone.
T should be low and you check for visual field defects, headaches, and gynecomastia.

Handbook page 239.

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56
Q

Which PDE5 inhibitor has a warning in patients with a prolonged QT interval?

A

Vardenafil.

Handbook page 248.

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57
Q

Describe the WHO parameters for normal semen analysis.

A 
Volume > 2 ml
Sperm Concentration 20 mil/ml
Total Sperm Count > 40 million per ejaculate
Normal morphology > 14%
Motility > 50%

Handbook page 269

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58
Q

What are the contraindications to Btx A injection?

A
  1. Myasthenia gravis
  2. AML
  3. Eaton-Lambert (autoimmune disorder against voltage gated channels, weakness in limbs)
  4. Aminoglycosides (increase the effects of botox and promote greater weakness)
  5. Pregnancy
  6. Breast feeding

CBLP #78 slide 26

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59
Q

What score ranges represent mild, moderate, and severe scores on the AUA SI?

A

Mild 1 - 7
Moderate 8 - 19
Severe 20 - 35

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60
Q

Describe in detail the steps of a prostate biopsy and the potential complications (and treatments) that can occur.

A

Steps:

  1. Stop NSAIDS ten days before
  2. Obtain consent
  3. Give fleets enema morning of procedure.
  4. Give 24 hours of Flouroquinolone (AUA abx best practice statement)
  5. Insert side firing ultrasound probe
  6. Take measurements of the gland
  7. Give 20 cc of 1% lidocaine with epinephrine at apex
  8. Obtain 12 cores sextant + 6 laterally placed cores
  9. Perform DRE to evaluate for hematoma

Complications:

  1. Sepsis –> Admit for IV antibiotics
  2. Bleeding (hematuria, hematochezzia, hematospermia)
  3. Acute prostatitis
  4. Vasovagal episode

AUA Best Practice Antibiotic table, Handbook page 80

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61
Q

What is important about hypoechoic lesions on TRUS?

A

They should be biopsied.

30% of hypoechoic regions harbor cancer.
30 - 50% of palpable nodules have cancer.

Handbook page 80.

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62
Q

What should you do if a TRUS biopsy comes back with something other than cancer free or prostate cancer?

A
  1. Low grade PIN - observe with annual DRE and PSA
  2. HG PIN - rebiopsy in 12 months (10 - 20% with extended strategy will develop cancer, include anteriorly directed transition zone biopsies on repeat)
  3. Atypia - rebiopsy with extended biopsy pattern within 6 months (more worrisome than HGPIN).

NCCN Prostate Early Detection page 33.

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63
Q

Is a creatinine necessary during the initial evaluation of BPH?

A

No. Not recommended.

BPH Best Practice Statement 2010, page 6.

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64
Q

How long should you wait after starting medical therapy for BPH before determining it unsuccessful?

A

alpha blockers = 4 weeks
5-ARI = 3 months

AUA Best practice BPH, page 6.

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65
Q

Describe your initial workup of a man with LUTS.

A
  1. H and P
  2. Urinalysis
  3. DRE

Handbook page 111

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66
Q

What types of LUTS or history would cause you to get a cytology in patient with BPH symptoms?

A
  1. History of bladder cancer
  2. History of smoking
  3. Environmental exposure
  4. Irritative symptoms
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67
Q

What is the overall risk of retrograde ejaculation due to alpha blocker therapy and which has the highest incidence?

A

Overall risk is 2 - 14%.
Tamsulosin has highest incidence while alfuzosin (uroxatrol) seems to have the lowest.

AUA Best Practice 2010, page 10.

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68
Q

What does the AUA BPH BPS 2010 say about 5ARI for prostate bleeding?

A

It is a reasonable option for spontaneous bleeding from the prostate.
No role in reducing potential for prostate bleeding during endoscopic surgery for BPH.

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69
Q

Should 5ARIs be used for men with small glands?

A

No. It is better reserved for men with larger glands.
MTOPS reported best response in men with glands > 40 grams and PSA >4.
CombAT trial recruited only men with glands > 30 or PSA > 1.5.

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70
Q

In the PACU after a TURP you suspect your patient has TUR syndrome. What findings do you look for?

A
  1. Hypertension
  2. Bradycardia
  3. Confusion
  4. Nausea and vomiting

Complications page 292.

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71
Q

During a TURP you notice a large venous sinus has been opened. What are some immediate actions that can be taken?

A
  1. Lower the height of the irrigating fluid to < 60 cm.
  2. Give 80 mg of Lasix.
  3. Change iv fluids to normal saline.

Complications page 292.

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72
Q

What antibiotics would be first line for prophylaxis during a TURBT or TURP?

A

Flouroquinolone or TMP-SMX.

AUA BPS Antimicrobial PPx.

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73
Q

In a man with prostate cancer what characteristics would suggest a CT or pelvic MRI is needed to look for node positive disease?

A
  1. T3 or T4 tumor.
  2. > 10% risk of LN + based on nomogram

NCCN Prostate 2012, slide 6.

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74
Q

Who needs bone scan in the workup for prostate cancer?

A
  1. Any T1 with PSA greater than 20.
  2. Any T2 with PSA greater than 10.
  3. Gleason of 8 or >
  4. Symptomatic T3 or T4.

NCCN Prostate 2012, slide 6.

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75
Q

For open urologic surgery, what is the minimum DVT prophylaxis and possible additional pharmacologic therapy?

A
  1. Minimum compression hose and SCDs.
  2. Consider giving Heparin sc 5000 q12 or Lovenox 40 mg daily after surgery.
    - High risk –> give Heparin 5000 q8 or Lovenox 40 mg bid or SCD if bleed risk is high.
    - Highest risk –> combine scds and pharmacotherapy.

AUA BPS DVT PPX. Page 23.

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76
Q

List all the complications of a radical prostatectomy.

A
  1. Incontinence
  2. Impotence
  3. Bladder neck contracture
  4. Rectal injury
  5. Lymphocele
  6. Intraop bleeding
  7. Oburator nerve injury
  8. Unable to bring down bladder

Choe’s Page 61.

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77
Q

List the absolute and relative indications for BPH surgery.

A

Absolute

  1. Urinary retention.
  2. Renal failure due to BPH.
  3. Refractory hematuria
  4. Recurrent UTI.

Relative

  1. Decreased QOL
  2. Impaired bladder emptying
  3. BOO

Choe’s page 62.

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78
Q

In any man undergoing RP for prostate cancer regardless of stage, what is recommended if adverse features are found and what are the adverse features?

A

Adverse features:

  1. Extracapsular extension
  2. Detectable PSA
  3. SV invasion
  4. Positive margins

Radiation therapy or observation is the treatment of choice.

NCCN Prostate, slide 8.

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79
Q

In any man undergoing RP regardless of stage, what is recommended if positive lymph nodes are found at the time of PLND?

A
  1. Observation
  2. ADT (messing trial showed survival advantage in men with microscopic (N1) nodal disease)
  3. ADT + RT

NCCN Prostate, Handbook page 86.

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80
Q

What are the important aspects of path report on prostate biopsy?

A
  1. Laterality
  2. Gleason score
  3. Presence or absence of perineural invasion
  4. number of cores

Choe’s

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81
Q

What defines intermediate by D’Amico criteria and what treat options are available if LE is > 10 years?

A

Criteria: Any one

  1. T2b or T2c
  2. Gleason 7
  3. PSA 10 - 20

Tx:

  1. RP +/- PLND
  2. RT (81 gy) + adjuvant ADT for 4 - 6 months +/- brachy

NCCN Prostate

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82
Q

Describe the detailed steps of an open radical retropubic prostatectomy.

A
  1. Informed consent with risks and alternatives.
  2. T and C for 2
  3. DVT ppx
  4. Abx ppx
  5. Labs
  6. EKG
  7. Mechanical bowel prep with 90 ml of fleets phosphasoda orally
  8. Infrapubic incision approx 4 cm
  9. Bilateral PLND if required (obturator, external and hypogastric nodes)
  10. enter space of retzius
  11. clear endopelvic fascia and open laterally toward puboprostatic ligaments
  12. ligate the DVC by using an allis clamp and ligating with figure of 8 using 0 chromic.
  13. divid the the urethra anteriorly and bring catheter into the field
  14. divide posterior urethra
  15. take down lateral pedicles with clips
  16. divide prostate and bladder neck
  17. mature bladder neck
  18. insert new foley and create anastamosis
  19. Place pelvic drain
  20. close
    11.
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83
Q

Name the blood supply to the skin overlying the inguinal region.

A
  1. Superficial epigastric
  2. Superficial circumflex iliac
  3. Superficial external pudendal

AUA Update 2008 Lesson 7

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84
Q

What patients with extraperitoneal bladder rupture should be repaired?

A
  1. Vaginal or rectal injury
  2. Pelvic fractures going to the OR for repair
  3. Intravescial bone fragments
  4. bladder neck injury
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85
Q

Describe how you would perform a CT cystogram.

A
  1. Instill 2% contrast by gravity
  2. Fill to 350 ml in intubated patient or to fullness in awake
  3. Perform a single scan through the pelvis.
  4. no need for drainage or early fill images

AUA Update 2008, lesson 25.

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86
Q

Describe your technique for repairing a traumatic bladder injury.

A
  1. Exposure via infrapubic incision
  2. Enter space of retzius
  3. Limit distal extravesical dissection
  4. Open bladder with midline cystotomy
  5. Use dever to expose the trigone, ureters and bladder neck
  6. place ureteral catheters in ureters if necessary
  7. close extraperitoneal injury in 2 layers with 3-0 and 2-0 vicryl from inside
  8. may place spt but not required
  9. close incision
  10. repeat cystogram at 10 days
  11. give < 24 hours of FQ for catheter removal

AUA Update 2008, Lesson 25 and AUA BPS ABX

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87
Q

Describe your approach to assessing a patient with persistent urinary incontinence 3 weeks after a TAH.

A
  1. Tampon test with methylene blue and pyridium.
  2. Office cystoscopy
  3. VCUG
  4. Upper tract imaging with CT Urogram or RGP at the time of formal cysto.

AUA Update 2006, Lesson 25.

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88
Q

Describe the options for surgical and non surgical management of a VVF.

A
  1. Conservative management with foley and anticholinergics for 2 - 3 weeks. (may include fibrin sealant or fulguration, reserved for fistula less than 2 - 3 mm in size).
  2. Latzko repair - inversion of the fistula site with 2 - 3 layers of non overlapping suture lines
  3. Abdominal repair - cystotomy down to fistula, excision of the fistula and closure of the vagina. omental or peritoneal interposition can be used. mobilize the omentum based on the right gastroepiploic artery. useful approach if the ureter needs to be addressed as well.
  4. Combined abdominal and vaginal approach

AUA Update 2006, lesson 25.

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89
Q

What are the complications of a vasectomy?

A
  1. Scrotal hematoma
  2. Infection
  3. Chronic pain
  4. Vas failure
  5. Recanalization

Handbook page 277.

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90
Q

What are the best methods for occluding the vas deferens during vasectomy?

A

(1) Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on
the vas;
(2) MC without FI and without ligatures or clips applied on the vas;
(3) Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end and FI;
OR by the non-divisional method of extended electrocautery.

AUA Guidelines, page 3.

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91
Q

What is the risk of pregnancy with azoospermia or RNMS after vasectomy?

A

1 in 2,000.

AUA guidelines.

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92
Q

What are the characteristics of vasectomy success and when should PVSA be performed?

A
  1. Azoospermia or RNMS (<100,000 per ml)
  2. Obtain at 8 to 16 weeks.

AUA Guidelines vasectomy, page 35.

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93
Q

What should you do if there is unilateral or bilateral absence of the vas deferens on exam working up infertility?

A
  1. Obtain a renal ultrasound.
  2. Unilateral - obtain CFTR testing to determine if patient is a carrier of CF mutation.
  3. Bilateral - w/u patient for CF with chloride sweat test.

Handbook page 280.

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94
Q

Describe an appropriately collected semen analysis.

A
  1. > 48 and < 7 days of abstinence
  2. analyze in one to two hours
  3. get two specimens 1 - 3 weeks apart
  4. wait 3 months after febrile illness
  5. avoid gonadotoxins like alcohol

handbook page 280

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95
Q

What is the minimum endocrine evaluation, what is it and when should it be obtained?

A
  1. Testosterone
  2. FSH

Both drawn in the AM.

Indications include

  1. abnormal semen parameters (esp < 10 million/ml)
  2. decreased libido
  3. findings suggesting and endocrinopathy

Handbook page 269 and AUA BPS Infertility.

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96
Q

What are the indications for endocrine evaluation and what should you do if it is abnormal?

A

Indications include:

  1. abnormal semen parameters especially concentration < 10 million
  2. sexual dysfunction
  3. suspicion of endocrinopathy

If T is low get,

  1. serum prolactin, LH, total and bioavailable testosterone
  2. repeat as necessary.

Handbook page 269.

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97
Q

When is a post ejaculate urine analysis performed in the infertility workup?

A

When ejaculate volume is < 1 ml.

Urine is centrifuged at 300 g x 10 min. Pellet is examined at 400x. Presence of any sperm suggest retrograde ejaculation.

AUA Guidelines, page 13.

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98
Q

When is a TRUS recommended in evaluation of infertility?

A

Men with:

  1. Azoospermia
  2. low ejaculate volumes
  3. palpable vas deferens

AUA BPS Infertility, page 13.

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99
Q

What parameters on TRUS are suggestive of EDO?

A
  1. SV AP diameter > 2 cm
  2. dilated ejaculatory ducts
  3. midline cystic structures

above suggest at least partial EDO

Complete EDO:

  1. pH < 7
  2. Low fructose
  3. reduced coagulation of semen

Handbook page 281.

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100
Q

What patients should be referred for SR + ICSI?

A
  1. Primary testicular failure (hyper, hypo)
  2. Isolated germ cell failure (Sertoli only, High FSH)
  3. Genital duct obstruction

Handbook page 282.

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101
Q

Describe the hormonal profile of hypergonadotropic hypogonadism as well as the causes.

A
  1. Low T
  2. High FSH
  3. High LH

Primary testicular failure

  1. Karyotypic abnormality (Kleinfelter’s, AZFa,b,c deletion on Y chromosome)
  2. Maturational arrest
  3. Gonadotoxins
  4. Varicocele

Handbook page 267 and 274.

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102
Q

Describe the hormone profile in Hypogonadotropic Hypogonadism and the causes.

A
  1. Low T
  2. Low FSH
  3. Low LH

Causes:

  1. Prolactinoma (get Prolactin level and MRI)
  2. Kallman’s
  3. Thyroid disease (increases prolactin)
  4. Prader willi
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103
Q

What are the complications of a varicocele repair and how often should semen analysis be analyzed after repair?

A
  1. Hydrocele
  2. Recurrence
  3. Hematoma (microsurgical repair)
  4. vas transection
  5. testicular atrophy

Check semen analysis q 3 months x one year.

Handbook page 276. Choe’s page 422.

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104
Q

Describe the stress pattern seen on semen analysis in men with varicocele.

A
  1. low sperm count
  2. decreased motility ***** most common
  3. abnormal forms (tapered forms)

Handbook page 275.

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105
Q

What surgeries can you actually do in a patient to potentially correct infertility?

A
  1. Varicocele ligation
  2. TUR EDO
  3. Vas reversal

Choe’s page 425

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106
Q

What patients should undergo a testis biopsy during infertility workup?

A

Men should have

  1. normal testicles (at least one)
  2. azoospermia
  3. normal FSH
  4. at least one palpable vas

AUA BPS Azoospermia, page 14.

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107
Q

Who should be offered a genetic analysis with a karyotype?

A 
All men with:
1. non obstructive azoospermia
OR
2. severe oligospermia (< 5million/ml)
OR
3. non obstructive azoospermia due to primary hyper hypo

AUA BPS Azoospermia, pages, 11 and 17.

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108
Q

What are some conditions that can increase prolactin in the absence of pituitary tumor?

A
  1. renal failure
  2. antipsychotics
  3. hypothyroidism
  4. estrogen exposure
  5. stress

Handbook page 283.

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109
Q

In a man with normal hormone profile and normal sperm on testis biopsy, what do you suspect?

A

Obstructive azoospermia due to genital duct obstruction.

Handbook page 284.

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110
Q

What reasons would prompt you to suggest ICSI over surgical repair of a genital duct obstruction?

A
  1. Female issues (age >37, infertility, will require ART)
  2. > 15 years since vasectomy
  3. success of ICSI > success of surgical repair
  4. ICSI preferred by couple

Handbook page 284.

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111
Q

What is the success rate of ICSI?

A

32% pregnancy rate

Handbook page 289.

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112
Q

What is the most important predictor of ICSI success?

A

maternal age.

As age increases, success decreases.

Handbook page 289.

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113
Q

Describe the imaging modalities for a suspected stone in a pregnant female by trimester.

A

1st trimester: RUS then MRI
2nd/3rd Trimester: RUS then Low dose CT

AUA Ureteral Imaging GUideline, page 3.

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114
Q

Describe the important portions of the reproductive history in the male with infertility.

A

Reproductive history should include

1) coital frequency and timing and lubricants;
2) duration of infertility/prior fertility;
3) childhood illnesses (post pubertal mumps or other orchitis, epididymitis) and developmental history (cryptorhidism)
4) systemic medical illnesses
(e. g., diabetes mellitus and upper respiratory diseases suggesting Kartagener’s or CF)
5) prior surgeries (inguinal hernia)
5) sexual history including sexually transmitted infections
6) gonadal toxin exposure including heat.

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115
Q

In any patient with ambiguous genitalia, what are the first tests you should order?

A
  1. Serum electrolytes and creatinine
  2. Karyotype
  3. Serum 17-OH progesterone (wait until day 3 or day 4 as it may be falsely elevated due to stress of delivery)
  4. T and DHT (early levels may be indicative of 5AR deficiency)

Choe’s page 503.

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116
Q

Name some reasons to give up front chemotherapy for Wilms.

A
  1. Bilateral disease
  2. Unresectable disease
  3. Major vascular involvement
  4. solitary kidney

AUA review guidelines, page 57.

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117
Q

Who gets XRT in Wilms Tumor?

A
  1. Any one with stage III or IV and favorable histology.
  2. Any one with stage I - IV and anaplastic histology.
  3. Stage I - IV CCSK

AUA Review manual, page

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118
Q

Name all the chemotherapy regimens for Wilms tumor.

A
  1. EE-4A - vincristine and actinomycin D
  2. DD-4a V,A + doxorubicin
  3. Regimen 1 - add cyclophosphamide and etoposide
  4. Regimen RTK - carboplatin, etoposide and cyclophosphamide

AUA Review Manual, page 58.

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119
Q

How would you evaluate a small adrenal mass to determine its functionality?

A
  1. Urinary Free cortisol (24 hour urine test, > 80 micg/24 is abnormal)
  2. Overnight Dex Suppression (4 mg Dex at 2300 then AM cortisol, > 5micg/dl abnormal)
  3. Plasma metanephrines
  4. Potassium
  5. Aldo to Plasma Renin Ratio (> 40 is abnormal) (if abnormal, get ARR after sodium loading, confirm the side with aldo sampling by adrenal vein sampling)
  6. Virilized females (17 keto steroids, DHEA)
  7. males with gynecomastia (17 beta estradiol)

AUA Update 2010, lesson 4.

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120
Q

What are the signs of adrenal adenoma on CT scan?

A
  1. homogenous
  2. HU < 10
  3. > 50% washout in 10 minutes

AUA Update 2010, lesson 4.

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121
Q

What are the signs of adrenocortical carcinoma on CT?

A
  1. heterogenous
  2. > 25 HU
  3. < 50% washout in 10 minutes

AUA Update 2010, lesson 4.

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122
Q

Name the different locations of urethral strictures that can occur.

A

Anterior
1. Penile (hypospadias, post urethroplasty)
2. Bulbar (infectious, post urethroplasty, traumatic)
Bulbar
3. Bladder neck (post TURP, post RP)
4. Prostatic

AUA Update 2010, Lesson 20.

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123
Q

Describe the DVIU technique for the various types of urethral stricture.

A
  1. Penile - 12 o’clock (poor success rate usually)
  2. Bulbar - 12 o’clock if < 2 cm (> 2 cm opt for urethral reconstruction)
  3. Bladder Neck post TURP - 5 and 7 o’clock
  4. Bladder Neck post Prostatectomy - 4 and 8 o’clock)
  5. Posterior - postraumatic (if realigned primarily –> radial incisions

AUA Update 2010, Lesson 20.

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124
Q

What FSH measurements and testicular size predicts NOA

A
  1. FSH > 7.6 mIU/mL
  2. Longitudinal length < 4.6 cm

AUA Update 2010, Lesson 38.

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125
Q

Describe the staging of Wilms Tumor. Think extension, spillage, and residual.

A

Stage I - confined to kidney, no spill, total removal
Stage II - extends beyond kidney (renal vein included), local spillage allowed, complete removal
Stage III - gross spillage beyond flank (tumor biopsy), large residual (ie non heme mets, peritoneal implants, positive lymph nodes, positive margins)
Stage IV - heme mets
Stage V - bilateral

Handbook page 23.

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126
Q

Name possible nerve injuries during retroperitoneal surgery.

A
  1. Obturator (L2-L4, M > S, sensory pain in medial thigh + motor defecit with abduction)
  2. Femoral (L2-L4, M > S, motor to most of hip flexors, sensor to anterior medial thigh)
  3. Genitofemoral (L1-L2, S > M, sensory to anterior scrotum and mons, sensory from femoral triangle)

Complications of Urologic Surgery, page 465.

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127
Q

Name some causes of lymphoceles.

A
  1. Low dose heparin
  2. chronic steroid use
  3. poor lymphostasis at time of surgery
  4. prior pelvic irradiation
  5. metastatic nodes

Complications of Urologic Surgery, page 470.

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128
Q

What are the high risk features of RVH?

A
  1. Abrupt onset > 50
  2. Malignant or resistant HTN (> 3 drugs)
  3. severe retinopathy
  4. abdominal bruit
  5. unexplained azotemia
  6. azotemia after starting arb or acei
  7. peripheral vascular disease
  8. unexplained hypokalemia
  9. recurrent unexplained CHF
  10. renal assymetry

AUA Update 2007, lesson 14.

129
Q

What are the screening tests for RVH?

A
  1. Duplex Ultrasound (PSV > 80 or RAA > 3.5)
  2. Captopril renal scan (use DTPA or Mag3, > 11 min time to peak, assymetry, decline in ipsilateral GFR, keep patient off ACEi for 3 - 5 days)
  3. MRA

AUA Update 2007, Lesson 14

130
Q

When to intervene surgically for RVH?

A
  1. > 75% stenosis bilaterally or in solitary kidney
  2. worsening uncontrolled hypertension
  3. declining renal function
  4. recurrent CHF
131
Q

What is the treatment for gonorrhea and chlamydia in non pregnant adults?

A
  1. Ceftriaxone 125 mg IM x 1
  2. Azithromycin 1 gram PO x 1

Handbook page 376

132
Q

How would you treat a pregnant female suspected of having gonorrhea and or chlamydia?

A
  1. Ceftriaxone 125 mg IM x 1
  2. Azithromycin 1 gram PO x 1

Handbook page 374.

133
Q

Which sex partners do you treat in patients with gonorrhea or chlamydia?

A

all with contact in the last 60 days

Handbook page 374.

134
Q

What is the preferred method of diagnosing gonorrhea and chlamydia?

A
  1. Nucleic acid amplification test from urine (obtain > 1 hour after last void).

Handbook page 375.

135
Q

How long should partners wait after GC/C treatment before intercourse?

A

7 days

136
Q

List the vagnitides and the discharge on pelvic exam.

A
  1. Bacterial vaginosis - fishy and thin
  2. Trichomonas - frothy, foul, and green
  3. Gonorrhea - usually asymptomatic
  4. Chlamydia - mucopurulent
  5. Candidiasis - white and curdy

AUA Update 2006 part 2

137
Q

Name the microscopic findings in patients with a vaginitide.

A
  1. yeast or pseduohyphae - Candida
  2. motile flagella - Trich
  3. nothing - chlamydia
  4. diplococci - gonorrhea
  5. clue cells or lack of lactobacilli

AUA Update 2006, part 2

138
Q

What vaginitide can be treated with metronidazole?

A
  1. Trichomoniasis
  2. bacterial vaginosis

500 mg bid x 7 days
pregnant = 2 grams po x 1

AUA Update 2006

139
Q

Which vaginitide has a low pH as characteristic?

A

Candida pH < 4.5

140
Q

Which vaginitide diagnosis is improved by adding 10% KOH to the sample of discharge?

A
  1. Candida –> shows hyphae better
  2. BV –> liberates a fishy odor.

AUA Update 2006

141
Q

List the bacterial mediated nonvaginal STI.

A
  1. Lymphogranuloma venereum –doxy 100^2 or erythromycin 500^4 x 21 days
  2. Chancroid – Azithromycin 1 g PO x 1 or Ceftriaxone 250 mg IM x 1
  3. Granuloma inguinale – doxy 100^2 x 21 days or
  4. Syphyllis - 2.4 million u benzathine penicllin IM x 1

Handbook

142
Q

What is the most common STI worldwide and how does it present?

A

Chancroid

Painful friable ulcer on genitals
Tender lymph adenopathy that may become suppurative and fistulize
yellow-grey exudate

AUA Update 2006, page 12 part 1.

143
Q

How does primary Syphyllis present?

A
  1. nonpainful ulcer that heals without treatment lasting 4 - 6 weeks
  2. non tender regional lymphadenopathy

AUA Update 2006, page 12 part 1

144
Q

How do you screen someone for syphilis and how do you confirm diagnosis?

A
  1. Definitive dx - darkfield microscopy (not widely available) and direct flourescent antibody (much more widely available)
  2. Nontreponemal tests - rapid plasma reagin and VDRL (detect cardiolipin antibodies) (can also be used to measure treatment)
  3. Treponemal serologic tests - FT-ABS or TP-PA

Handbook page 382

145
Q

Describe the Jarisch Herxheimer reaction.

A

symptom complex of fever, malaise, myalgia, headaches, and skin lesion exacerbation due to lysis of spirochetes
occurs 12 - 24 hours after treatment begins.

Handbook page 384

146
Q

What medications could a patient apply for genital warts?

A
  1. Condylox 0.5% BID x 3d, 4d off repeat up to 3 times
  2. Imiquimod 5% cream qhs weekly x 16 weeks

Handbook page 387.

147
Q

What topical treatment can a healthcare provider apply to genital warts?

A
  1. weekly cryotherapy
  2. podophyllin 10 - 25% resin in tincture of benzoin
  3. trichloroacetic acid 80 - 90%

Handbook page 386

148
Q

What is the treatment of urethral meatal warts and intraurethral warts?

A
  1. Urethral meatal –> podophyllin cream
  2. Intraurethral –> laser fulguration with Nd:YAG laser, 5% FU intraurethral for 3 - 8 days (apply after each void)

Handbook page 387.

149
Q

When is surgical intervention warranted for peyronies’ disease?

A

After the acute phase resolves.

Must have no pain and have stable erection for 3 - 6 months.

Handbook page 253.

150
Q

List the options for Peyronies surgery in the order of success.

A
  1. Nesbitt procedure
  2. Coropral plication
  3. Excision and grafting
  4. IPP with modeling or above if has ED.

Handbook page 253.

151
Q

What is the medical therapy for Peyronies during pain and acute phase.

A
  1. Colchcine 0.6 mg TID
  2. Vitamin E 600 - 1200 iU per day

Handbook page 252.

152
Q

What risks should you inform your patient of when treating with colchicine and Vitamin E.

A
  1. Vitamin E linked to heart disease in chronic doses over 400 U.
  2. Colchicine causes diarrhea, N/V, and myelosuppression. check CBC while treating.

Handbook page 253.

153
Q

List the current non surgical therapies for ED.

A
  1. PDE5 inhibitors
  2. Alprostadil
  3. Phentolamine
  4. Papaverine
  5. MUSE
  6. Vacuum erection device

Handbook page 249 - 250.

154
Q

What are the absolute contraindications to PDE5i in men and what are the precautions.

A
  1. Never give with nitrates.
  2. Use caution in men with:
    • alpha blocker therapy (obtain a stable regimen with either drug first and then add the opposite at lowest dose, never give > 25 mg of sildenafil within 4 hours of alpha blocker)
    • men w BP <90/50, cvd, retinitis pigmentosa

Handbook page 252.

155
Q

List the side effects of PDE5i.

A
  1. flushing
  2. headache
  3. blue tint to vision (sildenafil and vardenafil)
  4. back pain (tadalafil)
  5. myalgia (tadalafil)

Handbook page 247.

156
Q

Provide the pharmacokinetics and dosages of PDE5i.

A
  1. Sildenafil - 25, 50, 100,
    • 1/2 life 4 hours
  2. Tadalafil - 5, 10, 20
    • 12 life 17 hours
  3. Vardenafil - 2.5, 5, 10, 20
    • 1/2 life 4 hours

Handbook page 248.

157
Q

What 3 medications are available for intracorporeal injection?

A
  1. Alprostadil
  2. Papaverine
  3. Phentolamine

Handbook page 250.

158
Q

What is the max dose of alprostadil and the side effects.

A
  1. 60 mcg per day start at 2.5.
  2. Penile pain, fibrosis (8%), headache, hypotension, priapism

Handbook page 250.

159
Q

What is significant about phentolamine?

A
  1. Does not cause erections.

2. Limits detumescence

160
Q

What is the dose of papaverine for ICI?

A
  1. start at 3 - 5 mcg

2. max ranges between 20 - 80 mcg

161
Q

Describe the HCG stim test and the possible results.

A
  1. Give 2000 U IM x 4 days.
  2. Measure T, DHT before and after.
  3. Elevated Ratio of T/DHT (> 40)
    • 5ARD –> skin fibroblasts to confirm
  4. Normal Level < 5
    • AIS (T increases)
    • Testicular defect (T does not increase)

Handbook page 295.

162
Q

What medicines prolong the QT interval and would be contraindicated with verapamil?

A
  1. procainamide
  2. sotalol
  3. amiodarone
  4. quinidine

Handbook page 237.

163
Q

What characterisitics make a patient low risk for cardiovascular event and therefore eligible to resume sexual activity?

A
  1. HTN controlled with < 2 medicines
  2. Asymptomatic CAD
  3. < 3 CAD risk factors
  4. stable agina
  5. successful coronary revascularization
  6. uncomplicated MI > 6 weeks ago
  7. Mild valvular heart disease

Handbook page 238.

164
Q

What is bioavailable testosterone?

A

Sum of free testosterone and weakly bound T (bound to albumin)

Handbook page 239.

165
Q

In a male with ED, why would you think to check prolactin levels?

A
  1. gynecomastia
  2. low testosterone
  3. visual field cut
  4. headaches
  5. decreased libido

Handbook page 239.

166
Q

What entitities cause an increase in SHBG and decrease bioavailable T?

A
  1. Liver disease
  2. Hyperthyroidism
  3. elevated estrogens

Handbook page 239.

167
Q

What medical tests might you consider in a male with ED?

A
  1. Cholesterol
  2. Lipids
  3. HbA1c
  4. Thyroid levels (if indicated)

Handbook page 243.

168
Q

What males are at risk by taking supplemental testosterone for low T?

A
  1. cardiopulmonary issues (pulmonary edema, CHF)
  2. cancer (prostate, breast)
  3. desire for fertility
  4. severe dysplipidemia
  5. BOO
  6. liver disease
  7. polycythemia

Handbook page 242

169
Q

What are the characteristics of an abnormal test for cavernosometry?

A
  1. Flow to maintain at 150 mmHg > 3 ml/min.
  2. Pressure decay > 45 mmHg in 30 s with no infusion.
  3. Inability to infuse to the mean arterial pressure.

Handbook page 241.

170
Q

Name some medications that cause ED.

A
  1. Antihypertensives - beta blockers, clonidine, thiazides
  2. Mood stabilizers - lithium, MAOI, TCA, phenothiazines
  3. Sedatives, dilantin, alcohol

Handbook page 236.

171
Q

What are the side effects of ICI for ED?

A
  1. Priapism
  2. Corporal fibrosis
  3. fibrotic nodules
  4. Hematoma
  5. Urethral damage
  6. Penile curvature

Choe’s page 364.

172
Q

Discuss how you would begin injection therapy with ICI or MUSE.

A

General

  1. aseptic preparation of injection site
  2. Inject the test dose laterally on corporal body
  3. Have patient self stimulate
  4. Titrate the dose
  5. Monitor in office until detumescence

Dose:

  1. MUSE - 125 to 250 mg
  2. Caverject - 1.25 (n) to 2.5 9(nn) mcg
  3. Papaverine - 3 (n) to 5 (nn) mg

Choe’s 364 and Handbook page 251.

173
Q

What would you expect to see on arteriogram in a young male with ED v. older male with ED?

A
  1. Young male (usually traumatic) - focal stenosis in bulbar artery
  2. Older male (usually atherosclerotic) - wide spread calcifications
174
Q

Can men on ASA and Coumadin perform ICI?

A

Yes. only a relative contraindication.

175
Q

Name the categories of men with prostate issues that can be considered for TRT.

A
  1. HGPIN
  2. Post RRP (after prudent interval undefined)
  3. Post BT/RT for CaP (low risk)
  4. Post BT/RT for CaP (high risk) (after prudent undefined interval)

AUA Update 2010, lesson 32.

176
Q

In whom is TRT relatively and absolutely contraindicated?

A

Relative: men with elevated PSA
Absolute: men with prostate cancer

AUA Update 2010, Lesson 32.

177
Q

Does TRT increase PSA?

A

Most men see a slight increase. If significant increase seen, evaluate for prostate cancer.

AUA Update 2010, lesson 32.

178
Q

What level of T is considered hypogonadal and what is considered normal?

A

Hypogonadal < 231 ng/dl
Normal > 346 ng/dl

AUA Update 2010, lesson 32.

179
Q

Verbalize the mechanism of erection and detumescence.

A

Parasympathetics from S2 and S3 and the pelvic plexus stimulate the release of NO which in turn stimulates cGMP production. Intracellular calcium levels decrease to allow smooth muscle dilation in the corporal bodies. Increased blood flow allows cavernosal expansion compresses venous return to allow tumescence.

Ejaculatory sympathetic output from the thoracolumbar sympthatetics causes release of norepinephrine. NE stimulates alpha receptors to increase intracellular calcium in smooth muscle cells causing contraction and decreased blood flow.

Choe’s page 361 and Handbook page 235.

180
Q

In what ED patient, would you consider obtaining studies like penile doppler, cavernosometry etc?

A

Young male (<55 y) with new onset ED that is not associated with generalized vascular disease.

Choes page 377.

181
Q

When can nitrates be given for chest pain in a man taking PDE5i?

A

24 hours for sildenafil and vardenafil
48 hours for tadalafil

Sexual activity and cardiovascular disease 2012, page 1064.

182
Q

Describe how you would perform an IPP.

A
  1. Consent
  2. Vanc and Gent (AUA Best Practice Abx PPX)
  3. Place foley, penoscrotal incision
  4. Dissect onto corpora
  5. Place stay sutures and make corporotomy
  6. Dilate proximal and distal with metzenbaum scissors
  7. Dilate with Hegar
  8. Measure cylinder length
  9. Use Furlow insertion tool
  10. Seat cylinders
  11. Place reservoir via nasal speculum at internal ring (pop through fascia)
  12. Place pump in scrotum and separate with layers of dartos
  13. close corporotomy
  14. postoperative antibiotics while in hospital
  15. 7 days oral cephalosporin
  16. leave device inflated overnight partially
  17. deflate the next am
  18. begin inflation daily at 6 weeks
183
Q

Discuss the intraoperative complications of IPP placement.

A
  1. Urethral perforation - stop, leave foley x 7 d, return in 3 months
  2. Crus perforation - rear tip extender sling with 00 NA suture
  3. Septal crossover - place Hegar in that side and go to the opposite side
  4. Difficult dilatation - use metz to cut fibrotic tissu

Choe’s, Handbook

184
Q

Name the postoperative complications of IPP.

A
  1. Infection - pain is infection until proven otherwise, check cbc and esr
  2. Erosion
  3. Mechanical failure
  4. Penile shortening
  5. Floppy glans or SST deformity - can reposition the glans via subcoronal incision with NA suture
  6. penile necrosis

Hernan, handbook, choe’s

185
Q

Who is considered too high risk from a cardiac standpoint to engage in sexual activity?

A
  1. s/p MI with residual symptoms
  2. decompensated CHF or Left heart failure
  3. symptomatic valvular disease
  4. poorly controlled arrhythmias (afib with uncontrolled vent rate, symptomatic SVT, spontaneous V-Tach
  5. symptomatic hypertrophic cardiomyopathy
  6. less than 6 weeks after sternotomy

Sexual Activity and Cardiovascular Disease 2012

186
Q

In a patient scenario with hypertension, what is your differential dx?

A
  1. Pheo
  2. Conn’s Disease - Primary hyperparathyroidism
  3. Cushing’s
  4. RVH

Choe’s page 329

187
Q

What screening tests would you utilize for a patient with recalcitrant hypertension?

A
  1. Plasma metanephrines
  2. Urinary Free cortisol
  3. Serum K
  4. Serum Na
  5. Plasma renin
  6. Plasma aldosterone

Choe’s page 329.

188
Q

Describe the scenario that suggests Aldo producing adenoma (Conn’s) and the series of tests you would order.

A
  1. HTN, weakness

Tests: Screen

  1. Serum potassium - low
  2. 24 hour urine K - high
  3. Plasma Renin - low
  4. Plasma Aldo - high
  5. ARR > 40 abnormal (can vary 15 - 40, high primary aldo)

Confirm: stop all drugs x 6 weeks

  1. 24 hour urine aldo
  2. Captopril suppression test - aldo remains high. Sodium Loading test (2 liters of saline over two hours, plasma aldo remains elevated in 1 Aldo)
  3. Adrenal Vein sampling (Baseline aldo + cortisol + aldo cortisol ratio, ACTH given, repeat serum studies post injection)
  4. CT scan

AUA Update 2010, Lesson 4; Choe’s page 334.

189
Q

What is the difference in treatment of bilateral adrenal hyperplasia with aldosterone production compared to unilateral aldo prodcution?

A
  1. Bilateral - tx with sprionolactone
  2. Unilateral - adrenalectomy

Choe’s page 331.

190
Q

Name all the adrenolytic agents, medical therapies, and adrenocortical carcinoma agents.

A
  1. Spironolactone - potassium sparing diuretic
  2. Ketoconazole - antifungal, inhibits cP450 and 17,20 lyase
  3. Aminoglutethamide - used in cushings disease, blocks aromatase and blocks cholesterol to pregnenolone
  4. Metyrapone - blocks cortisol synthesis by inhibiting 11 b hydroxylase
  5. Mitotane - metastatic adrenocortical carcinoma, poor operative candidate, cytotoxic to adrenal cells
  6. Metyrosine - malignant pheo, inhibits tyrosine hydroxylase and prevents formation of NE

Choe’s, AUA update 2010 lesson 4.

191
Q

How do you recognize someone in adrenal crisis and how do you treat them immediately?

A
  1. Weakness
  2. fatigue
  3. malaise
  4. fever
  5. hyperkalemia
  6. ekg changes
    Choe’s page 14.

Emergent tx: aggressive volume resuscitation with D5NS, Give Hydorcortisone 100mg IV q6 and flornief 0.1 mg qd. (emedicine.com)
Maintenance:

192
Q

Name some infectious causes of adrenal insufficiency.

A
  1. TB
  2. CMV
  3. HIV-related infections
  4. adrenal abcess

Choe’s page 14.

193
Q

Name the most common cause of nongonococcal urethritis and how its treated.

A
  1. Often undetermined.
  2. Most likely Chlamydia or Ureaplasma if testing done.
  3. Tx same as GC/Chlamydia.
  4. Other less common causes include mycoplasma and trichomonas.

Handbook page 358.

194
Q

Name some non-infectious causes of epididymitis.

A
  1. Behçet’s disease - oral/genital ulcers, uveitis, skin lesions
  2. Amiodarone - concentration of the drug in the epididymal head

Handbook page 359.

195
Q

Name the inhibitors of stone formation.

A
  1. Citrate (complexes with calcium)
  2. Tamm Horsfall
  3. Magnesium
  4. Urea (increases solubility of uric acid only)
  5. Glycosaminoglycans

Handbook page 130.

196
Q

Name stones that form in alkaline urine.

A
  1. Matrix
  2. Struvite
  3. Calcium phosphate
  4. calcium carbonate

Handbook page 130.

197
Q

What are the urease producing baceteria.

A
  1. Protues
  2. K. pneumonia
  3. Pseudomonas
  4. Staph
  5. Serratia

Handbook page 130.

198
Q

What does systemic acidosis do to change urine composition?

A
  1. Increases calcium (resorption from bone)
  2. Increases phosphate (resorption from bone)
  3. Decreases citrate

Handbook page 130.

199
Q

What is typically associated with hypocitraturia 2/3 of the time?

A

Hypomagnesuria

Handbook page 138.

200
Q

Name the 5 primary metabolic derangements identified in stone disease and the levels that make them abnormal.

A
  1. Hyperuricosuria (>600 mg/day)
  2. Hyperoxaluria (>45 mg/day)
  3. Hypercalciuria (>200 mg/day)
  4. Hypocitraturia (30 mg/day)

Handbook page 132.

201
Q

What are the main causes of hyperuricosuria?

A
  1. Lesch-nyan (HGPRT -/-)
  2. Chemotherapy - tumor lysis
  3. Gouty diathesis
  4. Chronic diarrhea
  5. glycogen storage disease
  6. myeloproliferative disorder

Handbook page 135.

202
Q

List the maneuvers to gain ureteral length during repair of ureteral injury.

A
  1. Downward renal mobilization
  2. Psoas hitch
  3. Boari flap
  4. Ileal ureter

Complications page 450.

203
Q

Name some helpful adjunctive maneuvers when performing a psoas hitch.

A
  1. Transverse cystostomy
  2. Longitudinal bladder closure
    3, Ligation of the contralateral vascular pedicle.
204
Q

What are some reasons to avoid performing a psoas hitch or Boari flap?

A
  1. History of radiation

2. Neurogenic bladder

205
Q

Which two agents are preferred for increasing urine pH?

A
  1. Potassium citrate
  2. Sodium citrate

AUA Update 2010, lesson 21.

206
Q

Why is potassium citrate preferred over sodium citrate?

A
  1. Monopotassium urate is more soluble than monosodium urate.
  2. Na load can increase urine calcium and decrease urine citrate.

AUA Update 2010, lesson 21.

207
Q

In whom is sodium citrate preferred over potassium citrate?

A

Patients at high risk for hyperkalemia and renal failure.

208
Q

What are the side effects of potassium citrate?

A
  1. Heartburn
  2. Nausea
  3. Diarrhea

AUA Update 2010, lesson 21.

209
Q

What are the doses of Na Citrate and K Citrate?

A

NaCit - 650 - 1300 mg po tid
KCit - 30 - 60 meq per day divided

Goal is pH 6.5. > 7 = calcium phosphate stones.

AUA Update 2010, Lesson 21.

210
Q

In whom is allopurinol recommended for uric acid stones?

A

Patients with:

  1. Hyperuricemia due to IEM or gout
  2. Hyperuricosuria and UA stones

AUA Update 2010, Lesson 21.

211
Q

What is the dose of Allopurinol and what are the side effects?

A

300 mg/day, can cause stevens-johnson.

212
Q

List the complications of a PCNL.

A
  1. Intraoperative bleeding (24 french catheter with balloon inflated)
  2. Postoperative bleeding
  3. UTI/Sepsis
  4. Extraperitoneal colon injury
  5. Duodenal injury
  6. Perforation of the renal pelvis
  7. Pneumothorax/hydrothorax

Handbook page 147.

213
Q

List the complications of ureteroscopy.

A
  1. Avulsion
  2. Stricture
  3. Bleeding
  4. Infection
  5. Perforation
  6. Mucosal injury
  7. lost stone

AUA Update 2008, Lesson 27.

214
Q

What are the appropriate serum studies in a patient with a first stone?

A
  1. Chem7
  2. Ca
  3. Phos
  4. Uric acid
  5. Alk phos

Handbook page 140.

215
Q

What patients should have a PTH drawn during evaluation for stone disease?

A

High risk stone formers.

Handbook page 141.

216
Q

What are the hallmarks of Distal RTA Type 1?

A
  1. Alkalotic urine ph (>6.0)
  2. Hyperchloremic metabolic acidosis (would expect the opposite)
  3. Hypokalemia (potassium always opposite systemic acid balance)

Handbook page 141.

217
Q

What test will discriminate complete Distal RTA from partial Distal RTA?

A

Ammonium chloride loading.

Handbook page 134.

218
Q

What clinical factors might suggest a patient has Distal RTA?

A
  1. Bilateral stones
  2. Calcium phosphate stones
  3. Nephrocalcinosis
  4. Multiple recurrent stones

Handbook page 134.

219
Q

What is the most important cause of stones in Distal RTA?

A

Acidosis induced hypocitraturia.

220
Q

What is the only type of hypercalciuria that has an elevated serum calcium?

A

Resorptive hypercalciuria (Primary hyperparathyroidism)

221
Q

What serum tests would differentiate Absorptive hypercalciuria from renal leak?

A

Absorptive tend to have normal or low PTH while in renal leak it will be elevated.

Handbook page 136.

222
Q

What are the absolute indications for renal exploration in renal trauma?

A
  1. Renal pedicle avulsion
  2. persistent life threatening hemorrhage believed to be from the kidney
  3. pulsatile retroperitoneal hematoma

Handbook page 305

223
Q

What is the minimum volume required for filling during a cystogram for trauma and how should the contrast be diluted?

A
  1. Dilute 6:1 or about 2 - 4%.
  2. Use at least 350 ml or titrate to patient discomfort.

AUA 2010 Review manual page 781.

224
Q

Describe how you would perform a RUG.

A
  1. 16 french foley in fossa navicularis
  2. inflate balloon with 2 - 3 cc of water
  3. place penis on stretch
  4. inject 10 cc at a time of hypaque
  5. use flouroscopy to obtain lateral films.

AUA Review Manual 2010

225
Q

In what patients should vaginal estrogen therapy be used?

A

Postmenopausal women with:

  1. recurrent UTI
  2. vaginal atrophy

AUA Board Review Manual page 332.

226
Q

What are the contraindications to vaginal estrogen therapy?

A
  1. hx of PE or DVT
  2. estrogen induced cancer
  3. undiagnosed genital bleeding
  4. recent stroke or MI
  5. Liver disease

Handbook page 338.

227
Q

What should be performed during a neurologic exam in a female for incontinence?

A
  1. Bulbocavernosus reflex
  2. perineal sensation

AUA Board review

228
Q

What is the standard evaluation of a female with incontinence?

A
  1. Focused history
  2. focused exam
  3. Objective demonstration of SUI
  4. PVR
  5. UA (cx if indicated)

AUA Guidelines SUI

229
Q

What are the surgical treatment options for overactive bladder?

A
  1. Interstim
  2. Botox
  3. Bladder Aug
  4. Denervation neurectomy

AUA Board Review Manual page 333.

230
Q

Describe the definition of asx bacteriuria in men and women.

A

Men: single clean catch w/ > 100K cfu/ml of one strain.
Women: 2 consecutive clean catch w/ > 100k cfu of one srain.

Cath: single specimen containing > 100 cfu.

Handbook page 334.

231
Q

In whom should asx bacteriuria be treated?

A
  1. Pregnant women
  2. People undergoing traumatic GU procedures:
    • TURP
    • urethral dilatation
    • traumatic catheterization.

Handbook page 335.

232
Q

Name some options for preventing recurrence of UTI in patients shown to be susceptible.

A
  1. Topical estrogen
  2. Prophylactic antibiotics
  3. Self Start treatment
  4. Cranberry juice
  5. Intravesical antibiotics
    • 480 mg of gent in 1000 cc of saline (keep refrigerted, discard after 30 days)

Handbook page 339.

233
Q

What is the order of the evaluation for a VVF or UVF?

A
  1. History
  2. Physical
  3. Cystoscopy
  4. Tampon test
  5. IVP or RGP

AUA Board Review Maual page 336.

234
Q

Describe the steps of a Latzko procedure for VVF.

A
  1. Dorsal lithotomy
  2. Antibiotics
  3. DVT ppx
  4. Place weighted vaginal speculum
  5. Place Foley catheter
  6. Denude mucosa from anterior, cuff, and posterior vaginal wall for 3 cm
  7. Place interrupted sutures 1 cm apart to close off cuff
  8. Reinforce with a second row
  9. Close mucosa
  10. leave catheter for 3 weeks

AUA Board Review Manual page 339.

235
Q

In whom is a TUU contraindicated?

A
  1. Nephrolithiasis
  2. Tuberculosis
  3. Abdominal radiation
  4. RPF
  5. UCC
    Handbook page 308
236
Q

When is it necessary to biopsy a fistula tract?

A

In any patient with history of radiation or malignancy.

Choe’s page 309.

237
Q

List the differential diagnosis of periurethral masses in females.

A
  1. Urethral caruncle
  2. Skene’s duct cyst (very distal and lateral typically)
  3. Urethral prolapse (circumferential donut shaped lesion)
  4. Ectopic ureterocele
  5. Urethral diverticulum (mid urethra)
  6. Vaginal wall cyst (Gartner’s duct cyst usually on anterolateral wall)
  7. Vaginal inclusion cyst
  8. Leiomyoma

AUA Board Reveiw manual page 340.

238
Q

Describe the staging for penile cancer.

A 
Tis - carcinoma in situ
Ta - noninvasive verrucous carcinoma
T1 - subepithelial connective tissue
T2 - sponge or caveronsum
T3 - urethra or prostate
T4 - adjacent structures

N0 - none
N1 - single superficial node
N2 - multiple or bilateral superficial nodes
N3 - deep or pelvic nodes

M0 - none
M1 - distant

Handbook page 54

239
Q

Describe the TNM staging for bladder tumors.

A 
Ta - nonivasive papillary tumor
Tis - carcinoma in situ
T1 - lamina propria
T2 - muscularis propria 
	T2a - superficial 
	T2b - deep
T3 - perivesical tissue
	T3a - microscopic
	T3b - macroscopic 
T4 - extravesical organ
	T4a - immediately adjacent (prostate, vagina, uterus)
	T4b - beyond immediately adjacent (abdominal wall, pelvic wall)

N0 - none
N1 - single node < 2 cm
N2 - total node volume > 2 but < 5 cm
N3 - > 5 cm

M0 - none
M1 - distant

Handbook page 52.

240
Q

Give the TNM staging of testicular tumors.

A 
Tis - intratubular germ cell neoplasia
T1 - confined to testis or epididymis without LVI, may invade albuginea
T2 - beyond albuginea into testis or LVI
T3 - Spermatic cord +/- LVI
T4 - invades scrotum

N0 - none
N1 - < 2 cm
N2 - 2 - 5 cm
N3 - > 5 cm

M0 - none
M1 - Distant
M1a - nonreginal node or pulm
M1b - distant (brain)

S0 - normal
S1 - HAL (< 5K, >1K, 50K, > 10K, >10 x)

Handbook page 60.

241
Q

Give the prostate TNM staging.

A 
T1 - clinically inapparent or invisible on imaging
	T1a - < 5% of chips TUR
	T1b - >5% chips
	T1c - elevated PSA with positive biopsy 
T2 - prostate confined
	T2a - < 50% one lobe or less
	T2b - > 50% one lobe
	T2c - both lobes
T3 - Beyond capsule
	T3a - ECE
	T3b - SVI
T4 - Fixed tumor or invades adjacent

N0 - none
N1 - positive

M0 - none
M1 - distant
	M1a - nonregional node
	M1b - bone
	M1c - other +/- bone involvement

Handbook page 82.

242
Q

Describe how you would do an office microscopic analysis of urine.

A
  1. 10 ml of urine
  2. spin at 3000 g x 5 minutes
  3. remove 9 ml of supernatant
  4. resuspend pellet in one ml
  5. place on slide
  6. examine at 400x

Handbook page 123.

243
Q

Describe the options for spontaneous prostate bleeding.

A
  1. 5ARI
  2. TUR
  3. Amicar
  4. Androgen deprivation
  5. Prostate radiation

Handbook page 124.

244
Q

Describe the options for bladder bleeding.

A
  1. Amicar (5g IV then 1g per hour continuous infusion)
  2. Perc nephrostomy
  3. Intravesical agents
  4. HBO
  5. TUR
  6. Emoblization of iliacs
  7. Cystectomy

Handbook page 124.

245
Q

What are the contraindications to Amicar and the side effects?

A

Contraindications:

  1. DIC
  2. Upper tract bleeding (glomerular capillary obstruction)
  3. patients with thrombosis

SE:

  1. Rhabdomyolysis (monitor CPK if tx longer than 24 hours)
  2. Hypotension
  3. Constitutional (HA, N/V, fatigue)

Handbook page 124.

246
Q

List the intravesical agents for hematuria originating from the bladder.

A
  1. Alum 1% (protein precipitation)
    • give as continuous infusion
    • 300 cc per hour
    • use with caution in renal failure
    • monitor ammonia and potassium levels
  2. Silver nitrate 1% (protein precipitation)
    • deliver in water
    • painful, give in OR
    • leave in bladder x 15 min
  3. Formalin (hydrolyzes proteins)
    • 1- 4%
    • rule out reflux with cystogram, occule with fogarty balloons if necessary
    • keep formalin in bladder for 10 min

Handbook page 126.

247
Q

What adverse features on RP would prompt adjuvant XRT? What would the dose be?

A

Adverse features: ECE, SVI, detectable PSA, PSM.

Give 64 -68 gy 9 - 12 months after surgery.

Handbook page 87. NCCN Prostate 2013.

248
Q

List the D’Amico Criteria for Clinically localized prostate cancer.

A
  1. Low: PSA <
  2. Intermediate: PSA 10 - 20, T2b or T2c, Gleason 7
  3. High: PSA > 20, T3, 8 or >

Handbook page 83.

249
Q

What is the definition of BCR after radical prostatectomy?

A

Two consecutive rises in PSA after PSA becomes detectable.

NCCN Prostate 2013.

250
Q

What is the definition of PSA failure after radiaiton according to ASTRO?

A

PSA that rise by 2 ng/ml above the nadir PSA.

NCCN Prostate 2013.

251
Q

What are very low risk criteria for recurrence of prostate cancer?

A
  1. PSA < 10
  2. Gleason < 6
  3. T1c
  4. < 3 cores positive
  5. PSAD < 0.15 ng/mL/g
  6. < 50% of each core positive
    NCCN Prostate 2013.
252
Q

Who is a good candidate for nerve sparing radical prostatectomy?

A

Men with:

  1. T1 or T2
  2. PSA < 10
  3. Gleason < 7
  4. Small volume cancer on biopsy
  5. Good erectile function

Handbook page 86.

253
Q

What are the treatment options for a man with low risk prostate cancer and good LE?

A
  1. RP +/- PLND (use nomogram)
  2. RT 75 gy with 3D or IMRT
  3. Brachy monotherapy (145 gy I125 or 125 gy Palladium)

NCCN Prostate 2013.

254
Q

What are the treatment options for a man with intermediate risk prostate cancer and good LE?

A
  1. RP +/- PLND
  2. EBRT (81 gy) +/- 4- 6 mo adjuvant ADT (optional adt)
  3. EBRT (40 gy) + Brachy boost +/- 4-6 mo ADT (optional adt)

NCCN Prostate 2013.

255
Q

What are the treatment options for a man with high risk prostate cancer?

A
  1. RP + PLND (stop if has fixed pelvic nodes)
  2. EBRT + 2 - 3 years ADT (standard adt)
  3. EBRT (40 gy) + Brachy boost + 2 - 3 years ADT (standard ADT)

NCCN Prostate 2013.

256
Q

What are the treatment options for a man with CaP and positive nodal disease prior to treatment?

A
  1. ADT
  2. EBRT + 2-3 years ADT

NCCN Prostate 2013

257
Q

How do you follow a man after definitive treatment for CaP

A 
PSA 6 months for 5 years. 
DRE yearly (may be omitted if PSA undetectable).

NCCN Prostate 2013.

258
Q

In whom is systemic chemotherapy recommended in men with CaP?

A

Men with castration recurrent prostate cancer.
Docetaxel every 3 weeks is standard.

NCCN Prostate 2013.

259
Q

What free PSA values would suggest the need for prostate biopsy?

A

< 10% = biopsy
>25% = no biopsy
10 - 25% = think about biopsy

NCCN Prostate Early Detection 2013.

260
Q

Describe the use of PSA veleocity.

A
  1. Not helpful in men with PSA over 10.
  2. 3 values taken over an 18 - 24 month period
  3. > 0.35 ng/mL/yr suggests need for biopsy in men with PSA < 4
  4. > 0.75 ng/mL/yr suggests need for biopsy in men with PSA 4 - 10
  5. PSAV > 2 ng/mL/yr = high risk of CaP death

NCCN Prostate 2013.

261
Q

What value for PSAD is concerning for prostate cancer?

A

PSAD > 0.15 ng/ml/g.

Handbook page 120.

262
Q

List the primary and secondary methods of ADT.

A 
Primary 
1. Orchiectomy 
2. LHRH agonists (lupron etc)
5. Non steroidal antiandrogens (flutamide, casodex)
Secondary
1. DES
2. Ketoconazole
3. Aminoglutethamide
4. Steroidal antiandrogens (megace). 
5. AAW
6. High dose bicalutamide
7. Abiraterone + prednisone
8. Enzalutamide (antiandrogen)

NCCN Prostate 2013 + handbook page 84.

263
Q

What is abiraterone?

A

Inhibitor of cyp 17,20 lyase. Decreases testoserone levels.
approved for use in men failing docetaxel and in men with CRPC pre docetaxel.
given in 1000mg daily doses plus prednisone.

NCCN Prostate 2013.

264
Q

What is enzalutmaide?

A

Recently aproved antiandrogen with higher affinity for AR than bicalutamide (5x higher). approved for men with CRPC who have failed docetaxel and in men in pre docetaxel setting.

NCCN Prostate cancer 2013.

265
Q

What are the signs and symptoms of cord compression and what should you do immediately?

A

Si/Sx:
Urinary incontinence
Fecal incontinence
Loss of motor and sensory function below level of lesion.

Immediate treatments:

  1. 100 mg IV dex then 4 mg iv or 25 mg po q 6hours
  2. TLS xrays
  3. Immediate ADT by:
    - orchiectomy (3 hours)
    - ketoconazole (8 hours)
    - DES IV (last resort)
  4. MRI
  5. surgery for unstable spine
  6. XRT

Handbook page 95.

266
Q

Verbalize how you would give a bowel prep for cystectomy or radical prostatectomy?

A

Mechanical:

  1. give clears day before
  2. give 1 gallon golytely beginning 8 am the day before

Antibiotic Nichols prep:
1. Erythromycin base 1 gram
2. Neomycin base 1 gram
GIve at 1, 2, and 11 pm (if surgery at 8 am).

Handbook page 406-407.

267
Q

What patient is highest risk for a DVT following surgery?

A
  1. > 60 years
  2. Major abdominopelvic surgery > 2 hours
  3. Add risk factors:
    - Hx VTE (most critical)
    - malignancy (most critical)

AUA BPS VTE 2008, and Handbook page 411

268
Q

What patient is at lowest risk of VTE after surgery?

A
  1. Age < 40
  2. No additional risk factorsfactors
  3. Nonabdominal or pelvic (ie tur) procedure < 30 min

Handbook page 411.

269
Q

What is recommended for VTE ppx in low risk patients?

A

Early progressive ambulation.

AUA VTE BPS 2008.

270
Q

What is recommended for VTE ppx in highest risk patients?

A
  • Enoxaparin 40 mg. (Cr Cl < 30 ml/min. = 30 mg.) sq daily + SCDs or
  • Heparin 5000 u q8 sq p surgery + scd

AUA VTE BPS 2008.

271
Q

What patient is at moderate risk of VTE following surgery?

A
  1. 40 - 60 years with no additional risk factors

AUA BPS VTE 2008.

272
Q

What patient is at high risk for VTE?

A
  1. 40 - 60 with additional risk factors

AUA BPS VTE 2008.

273
Q

What VTE ppx is recommended for moderate risk patients?

A 
1. SCD and GCS
OR
2. LMWH 40 qd. 
OR 
3. LDUH 5000 q12.

AUA BPS VTE 2008.

274
Q

What VTE ppx is recommended for high risk patients?

A 
1. SCD and GCS
OR 
2. LMWH 40 qd (30 m if CrCl < 30)
OR 
3. LDUH 5000 q 8.

AUA BPS VTE 2008.

275
Q

What are the side effects of brachytherapy?

A
  1. Incontinence (worse in men with prev. TURP).
  2. Retention (worse with prostate > 60 g and or AUASI high)
  3. Same as radiation.

Handbook page 89.

276
Q

What are the side effects of radiation for prostate Ca?

A
  1. ED
  2. Bladder irritation (urgency, frequency, hematuria)
  3. Rectal irritation
  4. Retention (worse with brachy)
  5. Bowel incontinence
  6. Hemorrhagic cystitis
  7. Secondary malignancy
  8. stricture
    Handbook page 90.
277
Q

Describe the initial workup of a man with urinary incontinence after RP?

A
  1. H and P
  2. UA (looking for infection)
  3. PVR (looking for retention)
  4. Cysto if PVR is elevated (looking for stricture)
  5. Dilate or DVIU stricture
  6. If no stricture and minimal PVR –> urodynamics

Handbook page 301.

278
Q

What differentiates good risk from intermediate risk seminoma?

A

Both are any T but
Good = M1a (nonregional nodal or lung mets)
Intermed = M1b (non pulm visceral mets)

Remember: Both MUST have normal AFP.

Handbook page 61.

279
Q

How do you differenitate good, intermediate and poor risk NSGCT?

A 
Good and Intermdiate both have
1. Testicular of RP primary AND M0 or M1a
Good = S1
Intermed = S2
Poor has
1. Mediastinal primary 
OR
2. M1b 
OR
3. S3

Handbook page 62.

280
Q

Why do we care about risk stratification in testis cancer?

A

Risk stratification only important in Stage IIc and III disease.

Decides if you get BEP x 3/EP x 4 if good risk or BEP x 4 if intermed or poor.

281
Q

What is critically different about Stage IA/IB from other stages of testis cancer?

A

No nodal or metastatic disease.
IA = pT1
IB = pT2 - pT4

282
Q

What should you offer a man with IS seminoma?

A

RT with 20 - 30 gy to retroperitoneum.

NCCN Testicular 2012.

283
Q

What is the treatment of choice for pure seminoma with pT1 or pT2 (IA/IB)?

A

Surveillance. Relapse about 15% but can easily be salvaged with XRT if in nodes or chemo if outside nodes.

NCCN Testicular 2012.

284
Q

What is the stage of tumor in a man with spermatic cord involvement or scrotal violation with testis cancer? What treatment should he get?

A

Stage IB.

  1. Surveillance
  2. RT
  3. Upfront carboplatin monotherapy

NCCN Testicular 2012.

285
Q

What stage is a man with >2 cm of LN disease with pure seminoma? >2 but < 5cm? What treatment should they get?

A

Stage IIA
Stage IIB
Both cases should get 30 -35 gray to paraaortics PLUS ipsi iliac nodes.

NCCN Testicular 2012.

286
Q

What is significant about stage IIC in testis cancer?

A

Nodal disease > 5cm.

287
Q

What are the differences between Stage IIIA, IIIB, and IIIC?

A 
IIIA = Any nodes + M1a +/- S1
IIIB = Any nodes + S2 +/- M1a
IIIC = S3 +/- M1b

NCCN Testicular 2012.

288
Q

Who gets upfront chemo in pure seminoma?

A

IIB and III.

NCCN Testicular 2012.

289
Q

What are the critical components of followup for seminoma of any stage?

A
  1. H/P, Tumor markers
  2. Abdominal imaging
  3. Chest xray as indicated

NCCN 2012.

290
Q

What is the most aggressive followup for seminoma patients after treatment?

A

Follow every 3 months with H/P and markers.
Abd imaging every 6 months.

NCCN 2012.

291
Q

In a patient with pure seminoma treated with chemo, what would you do with a retroperitoneal mass and normal markers?

A

If > 3 cm or < 90% shrinkage get a PET. If positive do a RPLND.

If < 3 cm observe.

NCCN Testicular 2012.

292
Q

Who gets upfront RPLND for NSGCT? What template should they get?

A

Stage IB (unilateral modified)
Stage IIA and IIB (bilateral modified)
Should have normal postchemo markers and should have nodal disease in the expected landing zone. otherwise treat with chemo as good risk.

Handbook page 68, NCCN Testicular 2012.

293
Q

Who gets upfront chemo for NSGCT?

A

Stage IIC, IIIA - C

294
Q

Name the components of VHL syndrome (in order of frequency).

A
  1. Retinal angiomas
  2. Pancreatic cysts
  3. Cerebellar hemangioma
  4. Clear cell
  5. Pheochromocytoma
  6. Epididymal cysts

Handbook page 4.

294
Q

After you do a primary RPLND for NSGCT who should get chemo and who should be observed?

A

Men with pN2 should get 2 cycles of EP or BEP and Men with pN3 should 4 of EP or 3 of BEP.

NCCN Testicular 2012.

295
Q

Name paraneoplastic syndromes in RCC.

A
  1. Hypercalcemia
  2. Hypertension
  3. Stauffers (hepatic dysfunction from gm-csf released from tumor)
  4. Elevated Alk phos
  5. Increased ESR.

Handbook page 10.

296
Q

What are the current options for metastatic renal cell carcinoma?

A
  1. RN for systemic therapy plus systemic therapy
  2. Systemic tx includes
    - TKI
    - IL 2
    - IFN
  3. Palliative procedure
    - palliative embolization
    - palliative radiation

Handbook page 13.

297
Q

List the solutions for mulcahy salvage IPP protocol.

A
  1. Kanamycin/bacitracin
  2. 1/2 H2O2
  3. 1/2 Betadine
  4. Pressure w 5 liters vanc and gent
  5. 1/2 Betadine
  6. 1/2 H2O2
  7. Kanamycin/bacitracin
298
Q

If asked to do Urodynamics in patient w spinal cord lesion above T6 what you do?

A
  1. Prophylaxis with 10 mg po q6 w nifedipine.

Treat ADR with nifedipine 10 mg bite and swallow.
Loosen tight clothing.
Check for retention or clogged foley.
Check for fecal impaction.

emedicine.com

299
Q

Name options for treating NGB with high leak point pressures.

A
  1. CIC + anticholinergics
  2. Chronic underling catheter
  3. Bladder aug + CIC
  4. Sphincterotomy + condom cath
  5. Botox injection sphincter

Case scenarios

300
Q

What are the cut points for watchful waiting of BPH symptoms in AUA Guideline?

A

AUA score < 19 without bother.

Guidelines.

301
Q

What would you tell a patient about a renal biopsy for a small clinical T1 renal mass?

A 
20% of clinical T1 masses are benign
False negative rate < 1%
Indeterminate 10 - 15%
Tract seeding - rare
Procedure complications < 2%

AUA Guidelines Renal Mass 2010.

302
Q

What do you know about managing the urethra in patients with bladder cancer?

A

Post cystectomy urethral cancer is about 8%.
Should check frozen section on urethra at time of surgery.
Have a preop conversation about what to do if it comes back positive.
Followup important with washings.
Prostatic stroma is greatest risk factor in men.

Clark and Hall. UrolClinN.America 2005.

303
Q

What is the dose of phenylephrine that should be used for priapism ICI and for how long?

A
  1. 100 - 500 mcg per mL.
  2. Dose every 5 minutes in 1 mL doses for one hour.

AUA Best Practice Guidelines.

304
Q

What are the signs you should watch for when giving sympathomimetic agents for priapism?

A
  1. Headache
  2. Acute hypertension
  3. Reflex bradycardia
  4. palpitations with tachycardia

AUA Best Practice Statement Priapism.

305
Q

What do the guidelines say about sibling screening for VUR?

A

Recommended if:

  1. nonscreened sibling has evidence of scarring on ultrasound
  2. sibling has hx of UTI without workup

AUA VUR Guidelines 2010.

306
Q

In initial visit for child with VUR, what should be obtained?

A
  1. Height
  2. Weight
  3. Blood pressure
  4. Creatinine if bilateral abnormalities
  5. Urine for bacteria and protein (rec not standard)

AUA VUR guidelines.

307
Q

Remember to check LFTs before and during GU TB treatment.

A

.

308
Q

If using stomach for augmentation, what are the metabolic problems and the solution?

A

Loss of acid

  1. Systemic - alkalosis
  2. Potassium - low (intracellular movement, opposite of acid base status, loss in gastric secretions)
  3. Chloride - low (HCl loss)

Tx: H2 blockers.

Handbook page 414.

309
Q

What systemic affects happen in patient with colon or ileum augment?

A

Reuptake of NHCl in the gut from urine. remember NH+ is the main method of renal urinary acidification to control acid base balance.

  1. Systemic - acidosis
  2. K+ - low
  3. Cl - high

Tx: K citrate

Handbook page 414.

310
Q

What are the effects of placing jejunum into the bladder?

A

Loss of NaCl and water. Dehydration. Increased Renin, Angiotensin, Aldosterone. The key to remembering this thinking about the urine that hits the jejunum. Low in salt, high in K+. Gradients support NaCl loss and K+ absorption.

  1. Systemic -acidosis
  2. K+ - high (reabsorption by jejunum)
  3. Na+ - low
  4. Cl - low

Tx: oral salt supplementation.

Handbook page 415.

311
Q

What are the factors obtained by orchiectomy that predict retroperitoneal disease in clinical Stage 1 testicular cancer?

A

Seminoma: mass > 4cm, rete testis involvment.
NSGCT: LVI, embryonal predominance.

CBLP #84.

312
Q

If a prostate biopsy comes back with HG PIN, what are the critical things to know in deciding if and when a repeat biopsy is needed?

A
  1. How many cores
  2. single focus or mutliple foci

CBLP #82.

313
Q

Which is more worrisome, ASAP or HGPIN on prostate biopsy?

A

ASAP is more worrisome. Should prompt a repeat biopsy in one to two months.

HGPIN (even multifocal) can be followed for a period of time with DRE and PSA with repeat biopsy in 12 - 18 months.

CBLP #82.

314
Q

What sorts of things would look for on PE of patient with enhancing renal mass?

A 
Gen: Blood pressure (HTN)
Skin - tubers, ash leaf spots, folliculomas, cutaneous leiomyomas
Lymph - palp nodes
Abd - mass or flank mass
Ext - edema, DVT

CBLP #79.

315
Q

What is the risk of malignancy in a palpable lymph node at the time of nephrectomy for renal tumor?

A

Even if wasn’t visible on imaging, the risk is about 20%.
If you palpate some nodes, take them out regardless.

CBLP #79.

316
Q

What should you make sure you do before you operate on an adrenal lesion?

A
  1. Pheo - usual stuff you know (nitroprusside good during the case)
  2. Aldo producing adenoma - replete the potassium, put them on spironolactone 100 - 400 mg per day
  3. Cortisol producing adenoma - start steroids before surgery
  4. Check ACTH stim test to make sure other side works

CBLP #3.

317
Q

What tests can you do to confirm the presence of testicles in a male with bilateral undescended testis?

A
  1. Karyotype (doesn’t confirm actually)
  2. MIS
  3. Check T, FSH, LH give HCG then recheck T
  4. Check T at 1 - 3 months during puberty of infancy

CBLP #6.

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