SASP 2010

Question 1

During bladder filling, intraluminal ureteral pressure:

A: increases, and the frequency of contractions increase. B: increases, and the frequency of contractions decrease. C: increases, and the frequency of contractions is unchanged. D: decreases once the frequency of contractions decrease. E: remains stable while ureteral contractions decrease.

Answer 1

A: “increases, and the frequency of contractions increase.” was the correct answer.

As the bladder fills, resting pressure within the intravesical ureter increases. This results in an increase in intraluminal (ureteral) pressure and an increase in the frequency of ureteral contractions. The end result is continued excretion of urine into the filling bladder.

Question 2

A 54-year-old man who underwent a successful open pyeloplasty 20 years ago develops recurrent flank pain. Diuretic renography reveals recurrent UPJ obstruction with 30% ipsilateral renal function. Retrograde pyelogram reveals a 1 cm UPJ stricture. The next step is: A: balloon dilation. B: endopyelotomy. C: re-do pyeloplasty. D: ureterocalycostomy. E: nephrectomy.

Answer 2

B: “endopyelotomy.” was the correct answer. This is an excellent patient for an endopyelotomy. For “secondary” UPJ obstruction, it is reasonable to recommend an open or laparoscopic approach to any patient who has failed a primary endourologic management and an endourologic approach to those who have failed an open or laparoscopic repair. The results of endourologic management in this setting are generally excellent. Ureteral stenting and balloon dilation are not good long-term options and nephrectomy is not necessary at this point.

Question 3

A 47-year-old man with diabetes mellitus has erectile dysfunction, decreased vibratory sensation in his feet and fasting blood sugars over 300 mg/dl. The best treatment of his erectile dysfunction is: A: exogenous testosterone. B: exogenous gonadotropins. C: improved diabetic control. D: a daily Vitamin B complex. E: penile prosthesis.

Answer 3

E: “penile prosthesis.” is correct. Exogenous androgen, gonadotropin and vitamin therapy do not restore potency in the diabetic male. Even with good control of the underlying diabetes, erectile dysfunction usually persists. Alternative therapies such as sildenafil citrate, intracavernous injection therapy, and a vacuum erection device can also be effective in many of these patients. Some diabetic patients will ultimately require a penile prosthesis.

Question 4

A 48-year-old man and his 44-year-old wife wish to have another child. Fifteen years previously, he had a vasectomy and four years ago he failed vasectomy reversal. No sperm were found in the vas at the time of surgery. The wife’s menses are regular. The best chance for pregnancy is: A: open epididymal aspiration with IVF and ICSI. B: needle aspiration of the testicle with IVF and ICSI. C: gynecologic evaluation of wife then bilateral vasoepididymostomy if her evaluation is normal. D: donor eggs and needle aspiration of the testicle with IVF and ICSI. E: re-do microscopic two-layer vasovasostomy.

Answer 4

D: “donor eggs and needle aspiration of the testicle with IVF and ICSI.” was the correct answer. Results of standard IVF or ICSI are extremely poor in women over age 40. Current data demonstrate a 4% live birth rate per cycle in 44 year old women. With donor eggs the pregnancy rate is approximately 50%. The overall rate of pregnancy after vasoepididymostomy is 30-50% but is dramatically lower with a wife of age 40.

Question 5

A three-year-old girl has a febrile UTI. Ultrasound and CT scan are shown. The next step is: A: DMSA scan. B: nephrectomy. C: antibiotics and repeat ultrasound in three months. D: percutaneous aspiration. E: renal ultrasound of parents.

Answer 5

B: “nephrectomy.” was the correct answer. The imaging studies show a large complex cystic lesion that is not the result of an infectious process. The lesion is not typical for inherited cystic disease and parental evaluation is of no value. The differential diagnosis is either a cystic Wilms’ vs. a multilocular cystic nephroma. Diagnosis and treatment should be made based on the pathology following a nephrectomy.

Question 6

The renal artery occlusive disease most likely to be associated with stable renal function is: A: intimal fibroplasia. B: medial hyperplasia. C: medial fibroplasia. D: perimedial fibroplasia. E: atherosclerotic disease.

Answer 6

C: “medial fibroplasia.” is correct. Patients with medial fibroplasia seldom have an increase in serum creatinine, reduction in kidney size, or loss of renal function. Despite the progressive nature of this disease, progressive arterial occlusion is relatively rare. Therefore, renal revascularization for preservation of renal function need not be routinely undertaken even for patients with bilateral disease. Operative intervention or transluminal angioplasty can be limited to those patients with hypertension refractory to control with drug therapy. Progressive ischemic nephropathy leading to loss of function is the end stage of the pathophysiology of perimedial or intimal fibroplasia, medial hyperplasia, and atherosclerotic disease.

Question 7

A 45-year-old woman has a sudden onset of severe right flank pain. CT scan shows a right perirenal hematoma. The most likely underlying cause is: A: renal adenocarcinoma. B: renal angiomyolipoma. C: renal artery aneurysm. D: polyarteritis nodosa. E: complex renal cyst.

Answer 7

B: “renal angiomyolipoma.” was the correct answer. The most common cause of retroperitoneal hemorrhage is rupture of an abdominal aortic aneurysm. Renal and adrenal diseases account for the second and third most common causes respectively. Although both malignant and benign renal tumors may rupture, renal angiomyolipoma is the most common cause of a perirenal hematoma. Follow-up CT imaging after resolution of the hematoma will be necessary to rule-out the presence of an angiomyolipoma or malignant tumor that can be hidden by a retroperitoneal and/or perirenal hematoma.

Question 8

A 45-year-old obese man has hypertension, new onset diabetes and general weakness. Two 24-hour urine collections show elevated cortisol levels. The next step is: A: low-dose dexamethasone test. B: late afternoon plasma corticotrophin and cortisol measurement. C: high-dose dexamethasone test. D: metyrapone test. E: abdominal CT scan.

Answer 8

B: “late afternoon plasma corticotrophin and cortisol measurement.” was the correct answer. Elevated urinary cortisol levels confirm the diagnosis of Cushing’s syndrome but do not provide information about the etiology of the condition. The next step to determine the etiology is to measure late afternoon or midnight plasma corticotrophin and cortisol levels. This will determine if the Cushing’s is ACTH-dependent or ACTH-independent. If ACTH levels are not elevated, then the likely source is adrenal and an abdominal CT scan with attention to the adrenals is appropriate. However, it is preferable and more efficient to determine if ACTH levels are elevated, as the etiology of the Cushing’s is unlikely to be of adrenal origin if ACTH is elevated. High-dose dexamethasone test is indicated if ACTH levels are elevated to determine if the source of the elevated corticotrophin is pituitary. Similarly, the metyrapone test is used to assess whether excess ACTH secretion is pituitary or ectopic in nature and is only appropriate if serum corticotrophin levels are elevated.

Question 9

In a paraplegic man with a T12 spinal cord transection, the major complication of external urethral sphincterotomy is: A: significant hemorrhage. B: acute urinary tract sepsis. C: priapism. D: impotence. E: autonomic dysreflexia.

Answer 9

A: “significant hemorrhage.” was the correct answer. Significant hemorrhage is the major complication to be anticipated in the performance of an external sphincterotomy. Autonomic dysreflexia would not be anticipated to be a major problem because of the level of the lesion. Autonomic dysreflexia is seen with spinal cord lesions that occur above the level of the sympathetic outflow tract (T6). With appropriate antibiotic coverage, acute urinary tract sepsis is usually not a major problem. Likewise, priapism or impotence are rarely if ever encountered during the performance of this operative procedure.

Question 10

A 60-year-old woman complains of peristomal pain three days after undergoing a radical cystectomy and ileal conduit for bladder cancer. A 16 Fr straight catheter is in the conduit; ureteral stents were not utilized. Her stoma was initially dusky, and is now black. The next step is: A: remove conduit catheter. B: loopogram. C: bilateral percutaneous nephrostomies. D: loop endoscopy. E: observation.

Answer 10

D: “loop endoscopy.” was the correct answer. Vascular thrombosis of the intestinal conduit is often related to excessive tension in the mesentery of the chosen bowel segment, a hematoma in the mesentery, or inadvertent ligation of the major blood supply to the conduit. This can lead to necrosis of the stoma or the entire bowel segment. The stoma may normally appear dusky at the termination of the procedure. However, a pink to red appearance of the stoma should develop over the ensuing hours or days. If the stoma worsens in color, the patient develops pain around the stoma, or an obvious urine leak occurs, stomal necrosis is likely. This problem should be corrected on a semi-emergent basis. Loop endoscopy should be performed to determine the extent of ischemia. The extent of ischemia will determine the operative approach. Pressure from a 16 Fr Foley catheter is very unlikely to cause significant ischemia.

Question 11

Temsirolimus treatment in poor risk patients with metastatic RCC is most effective when given: A: oral daily. B: subcutaneously weekly. C: I.V. weekly. D: subcutaneously three times per week. E: I.V. weekly in combination with subcutaneous interferon.

Answer 11

C: “I.V. weekly.” is correct. Temsirolimus acts as an inhibitor of the mammalian target of rapamycin (mTOR). The combination of temsirolimus with interferon alfa was in fact inferior to temsirolimus alone when treating patients with advanced metastatic RCC. The mode of delivery that has been studied and proven effective in this setting is 25 mg administered weekly. This regimen resulted in a survival advantage in poor risk patients with metastatic RCC.

Question 12

A woman with urinary incontinence occurring only during orgasm is best managed by: A: behavioral therapy. B: a bladder neck sling. C: alpha-agonist medication. D: antimuscarinic medication. E: bladder neck collagen injection.

Answer 12

D: “antimuscarinic medication.” was the correct answer. Incontinence during sexual intercourse is not an infrequent problem and is often incorrectly assumed to be due to stress urinary incontinence. Most women respond to antimuscarinic medication, suggesting the etiology is detrusor overactivity. Behavioral therapy is not effective. Since the mechanism is unrelated to stress incontinence, alpha-agonist, sling, and collagen injection are not indicated.

Question 13

A 60 kg, 40-year-old woman with recurrent calcium oxalate nephrolithiasis has normal serum calcium and phosphorus levels. Twenty-four hour urine parameters are: Calcium 350 mg, Creatinine 2200 mg, Oxalate 50 mg, Citrate 1000 mg, Uric Acid 800 mg. The next step is: A: hydrochlorothiazide therapy. B: allopurinol therapy. C: pyridoxine therapy. D: creatinine clearance. E: repeat 24-hour urine collection.

Answer 13

E: “repeat 24-hour urine collection.” was the correct answer. Urinary creatinine provides an assessment of the completeness of a urine collection. In women, it should be 14-21 mg/kg/day and, in men, it should be 20-27 mg/kg/day. This individual over-collected as her urinary creatinine excretion was greater than 30 mg/kg/day. Repeating a urine collection would be the most appropriate step.

Question 14

A one-month-old boy has a history of unilateral prenatal hydroureteronephrosis. An ultrasound of the right kidney is shown. The most likely explanation for the finding is: A: VUR into the upper pole. B: upper pole UPJ obstruction. C: ectopic upper pole ureter. D: renal cyst. E: calyceal diverticulum.

Answer 14

C: “ectopic upper pole ureter.” is correct. The ultrasound demonstrates a duplicated system with upper pole hydronephrosis. The most likely explanation for this finding in a newborn is an ectopic upper pole ureter. The upper pole of a duplex system has a higher incidence of ectopia than the lower pole ureter because the upper pole ureter originates higher on the mesonephric duct and requires absorption of a longer segment of common excretory duct before it becomes incorporated in the bladder. The hydronephrosis results from distal ureteral obstruction as the ureter passes through the sphincteric mechanism of the bladder neck. UPJ obstruction of the upper pole segment is possible but much less common and would not have a dilated ureter. VUR into the upper pole is possible in association with ectopia, although VUR is usually not present with an ectopic upper pole ureter. A renal cyst or a calyceal diverticulum would be contained within surrounding normal renal tissue.

Question 15

The condition that leads to a decrease in circulating blood volume is: A: reduced renal arterial pressure. B: angiotensin II excess. C: catecholamine excess. D: hepatic venous congestion. E: hyperaldosteronism.

Answer 15

C: “catecholamine excess.” was the correct answer. Increased renin with increased aldosterone will lead to an increase in circulatory blood volume. In hepatic venous congestion, aldosterone metabolism is diminished. Adrenal cortical adenoma causes mineralocorticoid excess and increased blood volume. Of all the conditions cited, only catecholamine excess, such as one might see in a patient with pheochromocytoma, is known to be associated with a decreased blood volume. This is the reason that preoperative volume expansion is important in patients with pheochromocytoma.

Question 16

A 53-year-old man with a PSA of 2.7 ng/ml undergoes 12-core TRUS prostate needle biopsy. Pathology reveals focal high-grade PIN and atypical adenomatous hyperplasia (adenosis). The next step is: A: examine multiple deeper tissue sections of current biopsy. B: immediate repeat 12-core TRUS biopsy. C: immediate saturation biopsy. D: repeat PSA in six months. E: delayed TRUS biopsy in six months.

Answer 16

D: “repeat PSA in six months.” is correct. The management of high-grade PIN has changed in the past five years. With the standard biopsy now including 10 to 12 cores, it is no longer considered mandatory for patients to undergo immediate rebiopsy of their prostate. However, in the setting of accompanying atypical small acinar proliferation (ASAP), immediate rebiopsy and/or additional examination of the original biopsy with deeper sections is usually recommended. In this case, however, the patient has atypical adenomatous hyperplasia (adenosis), which is felt to be a benign process and, therefore, does not require immediate rebiopsy. The patient, therefore, should be treated as if he has isolated high-grade PIN and should have serial PSA monitoring. If the PSA is increased in six months, repeat biopsy should be considered. If the PSA remains unchanged, however, rebiopsy should not be undertaken in six months.

Question 17

The validity of a creatinine clearance test can best be determined by simultaneously measuring or calculating the: A: total creatinine excreted. B: total sodium excreted. C: total urea excreted. D: total urine volume excreted. E: average urine osmolality.

Answer 17

A: “total creatinine excreted.” was the correct answer. The total amount of creatinine excreted each 24 hours is dependent upon muscle mass and is generally constant. An incomplete collection is suggested by an incorrect amount of total creatinine in a 24-hour specimen; the normal production of creatinine is 1.0 mg/kg/hr.

Question 18

A 69-year-old man undergoes complete resection of a micropapillary TCC of the bladder with superficial invasion of the lamina propria (T1). Muscularis propria is present and uninvolved; upper tract imaging is normal. The next step is: A: surveillance with cystoscopy and radiographic imaging. B: induction and maintenance Mitomycin C. C: induction and maintenance BCG. D: radical cystectomy. E: neoadjuvant chemotherapy and radical cystectomy.

Answer 18

D: “radical cystectomy.” was the correct answer. Micropapillary bladder carcinoma is a rare variant of urothelial carcinoma. As opposed to the standard form of urothelial carcinoma, intravesical BCG therapy appears to be ineffective against micropapillary variant, and therefore restaging TURBT would not change the management. Recent results suggest that the optimal treatment strategy for nonmuscle invasive micropapillary urothelial carcinoma is radical cystectomy performed before progression.

Question 19

A 40-year-old woman complains of headaches, photophobia, and urinary incontinence. Physical examination reveals lax anal tone and sacral anesthesia. Urinalysis shows greater than 10 RBC/hpf. Urodynamics demonstrates detrusor overactivity. An MRI scan reveals several lesions consistent with hemangiomas within the spinal cord. The most likely diagnosis is: A: lipomeningocele. B: tuberous sclerosis. C: VHL disease. D: diabetes mellitus. E: adult polycystic kidney disease.

Answer 19

C: “VHL disease.” is correct. Forty-four percent of carriers of VHL disease have central nervous system lesions. VHL disease is often associated with headaches and papillary edema due to hemangioblastomas of the cerebellum. In addition, renal tumors are associated with microscopic hematuria. Spinal hemangioblastomas can occur in 24% of patients and are suspected in this individual as a cause for her neurogenic bladder.

Question 20

A 20-year-old man has recurrent gross hematuria and left flank pain related to exercise. Urinalysis reveals microhematuria, RBC casts and 2+ proteinuria. Renal ultrasound is normal. The study most likely to be diagnostic is: A: CT urogram. B: diuretic renography. C: renal angiography. D: ureteroscopy. E: renal biopsy.

Answer 20

E: “renal biopsy.” is correct. Recurrent gross hematuria in young adults occurring after an upper respiratory infection or exercise is the classic presentation of IgA glomerulonephritis (Berger’s disease). Back pain and renal colic due to clots may be associated with the hematuria can persist for days or weeks and may recur. Though the course is chronic, young patients generally have a good prognosis. Renal insufficiency develops in approximately 25% of patients, a poor prognosis is more likely in those with older age, heavy proteinuria, hypertension or abnormal renal function at presentation. The pathology evident on renal biopsy is proliferative and confined mostly to mesangial cells. These changes are usually limited to either some glomeruli or lobular segments of a glomerulus. Though deposits of IgA and IgG may be present on biopsy, these findings are not pathognomonic of the disease as mesangial deposits are found in other forms of glomerulonephritis. Renal imaging or endoscopic intervention is not indicated.

Question 21

A 43-year-old woman has a 3 cm vesicovaginal fistula on the posterior bladder wall 2 cm above the trigone three years following pelvic XRT for cervical cancer. CT urogram demonstrates normal upper urinary tracts without evidence of recurrent disease. The next step is: A: bladder biopsy. B: bilateral percutaneous nephrostomies. C: immediate transvaginal repair with gracilis interposition. D: immediate transabdominal repair with omental interposition. E: delayed transabdominal repair with omental interposition.

Answer 21

A: “bladder biopsy.” is correct. Although less common with improved radiation techniques, radiation-induced fistulas are commonly associated with persistent or recurrent cervical cancer. Fistulas may occur during or shortly following XRT as a result of tumor necrosis in the wall of the vagina or bladder. Fistulas that develop one or more years following XRT are attributed to radiation induced endarteritis obliterans with subsequent necrosis of the vaginal and bladder wall. The most important aspect in the management of a patient with a fistula following XRT is to rule out recurrent cervical cancer. Locally recurrent cervical cancer following definitive XRT is associated with poor survival despite aggressive multimodal management. Fistula repair would not be indicated in the setting of recurrent disease.

Question 22

A 26-year-old woman who is 12 weeks pregnant has a sudden onset of frequency, urgency, and dysuria. She is severely allergic to penicillin. The best antibiotic is: A: cephalexin. B: tetracycline. C: trimethoprim/sulfamethoxazole. D: ciprofloxacin. E: nitrofurantoin.

Answer 22

E: “nitrofurantoin.” was the correct answer. Penicillins have proven to be the safest antibiotics for use during pregnancy. However if the patient is allergic to penicillins, they (and the cephalosporins) should not be used. Nitrofurantoin is usually safe but there is a small risk of maternal neuropathy (with long term use) and hemolysis in the fetus with relative G6PD deficiency. Trimethoprim/sulfamethoxazole is best avoided because folic acid antagonists are known teratogens. Tetracycline is contraindicated because of the adverse effects on the mother (hepatotoxicity) and fetus (tooth discoloration and dysplasia). Ciprofloxacin would be contraindicated because of its adverse effects on developing cartilage.

Question 23

A 61-year-old man had a radical prostatectomy for pT2N0 Gleason 6 disease with negative margins five years ago. His initial PSA was undetectable and remained so until three years after surgery when it was first noted to be 0.08 ng/ml. One year later, his PSA was 0.1 ng/ml and it is now 0.12 ng/ml. The next step is: A: repeat PSA in three to six months. B: biopsy of the prostatic bed. C: bone scan. D: salvage pelvic radiation. E: LH-RH agonist therapy.

Answer 23

A: “repeat PSA in three to six months.” was the correct answer. This patient has a detectable PSA after radical prostatectomy. This is a difficult and controversial topic. Studies have shown that many patients who experience biochemical recurrence after radical prostatectomy never experience clinical symptoms and die of non-prostate cancer related causes. There are certain predictors that allow patients with clinically meaningful recurrences to be differentiated from those who do not require immediate intervention. Specifically, PSA doubling time and Gleason score at the time of prostatectomy, in addition to margin state and pathologic stage, are important predictors of both biochemical and clinical recurrence. In this case, the patient has a low PSA with a long doubling time. In fact, many urologists would not consider this a clinical recurrence. They feel that a biochemical recurrence after radical prostatectomy should be defined as a PSA > 0.2 or 0.4 ng/ml. In addition, there are reports of benign tissue left at the apex causing small rises in PSA that often present like this case. Given the slow doubling time, low Gleason score and favorable pathologic stage, the PSA should continue to be followed, albeit more closely and intervention should be reserved until the PSA doubling time shortens or the total PSA rises to a level unacceptable to the provider and patient. Biopsy of the prostatic bed is not appropriate, as this cannot conclusively rule-out the presence of recurrence and is associated with some morbidity. Bone and/or PET scan add little to the work-up, as it is highly unlikely that there is radiologically measurable metastatic disease at this PSA level. Intervention with either pelvic radiation or hormones should be reserved, as discussed earlier.

Question 24

A nine-year-old boy has urinary frequency and diurnal urinary incontinence without a history of urinary infection. Renal ultrasound is normal. An ultrasound of the bladder is shown. The next step is: A: observation. B: behavioral modification. C: VCUG. D: oxybutynin. E: cystoscopy.

Answer 24

C: “VCUG.” was the correct answer. Persistent voiding dysfunction with urgency, frequency, and diurnal urinary incontinence in this age group warrants screening with ultrasound. This image shows a diffusely thickened bladder with the bladder wall measuring > 5 mm (the upper limits of normal). This is a warning sign for outlet obstruction due to either an anatomic abnormality, neurogenic or non-neurogenic cause. This finding cannot be ignored. Cystoscopy can provide evidence for anatomic obstruction but would not be the recommended next step. The child should undergo a VCUG to rule-out the presence of valves. Observation, behavioral modification, and oxybutynin could be considered first in patients with minimal to mild bladder wall thickening since some degree of bladder wall hypertrophy can result from dysfunctional elimination. However, the degree of bladder wall thickening in this patient is greater than one would expect from dysfunctional elimination alone.

Question 25

A 46-year-old woman with autosomal dominant polycystic kidney disease has mild flank pain, dysuria, urinary frequency, hematuria, and pyuria. Her temperature is 38.1°C. The serum creatinine is 1.8 mg/dl. An ultrasound shows a 4 cm cyst in the left kidney filled with echogenic shadows. Urine culture is negative. The next step is: A: cyst aspiration. B: open renal cystectomy. C: ciprofloxacin. D: ampicillin and gentamicin. E: laparoscopic cyst marsupialization.

Answer 25

C: “ciprofloxacin.” was the correct answer. The course of adult polycystic disease is often complicated by flank pain, hematuria, nephrolithiasis and urinary tract infections. Infected cysts are a major problem because they are difficult to treat and may progress to intrarenal and perinephric abscesses. Fifty to 75% of patients with polycystic disease, mainly females, are said to develop UTIs during the course of their illness. Renal cysts do not communicate with the collecting system; therefore urine cultures may be negative. If the patient is generally well, antimicrobial therapy is the best first step. However, it may be ineffective because of choice of antibiotic which have poor penetration in the diseased kidneys. Most antibiotics, including aminoglycosides, penicillins, cephalosporins and macrolides penetrate polycystic renal cysts poorly. Drugs that penetrate cysts reasonably well include chloramphenicol, trimethoprim-sulfamethoxazole, clindamycin and ciprofloxacin. In this particular case where the patient is not toxic, oral treatment with ciprofloxacin and close observation is warranted. If the patient does not respond and/or her fever persists while on ciprofloxacin, percutaneous aspiration or drainage of the cyst would be indicated.

Question 26

A 60-year-old man has Gleason 7, pT3aN0M0 adenocarcinoma of the prostate with a positive surgical margin after radical prostatectomy. His PSA is 0.2 ng/ml 16 weeks after surgery. He has mild but persistent stress urinary incontinence. The next step is: A: observation. B: high-dose bicalutamide. C: leuprolide acetate. D: postoperative radiation. E: radiation if PSA values reach >1 ng/ml.

Answer 26

D: “postoperative radiation.” was the correct answer. The Southwest Oncology Group (SWOG) trial 8794 demonstrated that adjuvant radiation reduces the risk of biochemical treatment failure by 50% over radical prostatectomy alone. Four hundred thirty-one subjects with pathologically advanced prostate cancer (extraprostatic extension, positive surgical margins, or seminal vesicle invasion) were randomly assigned to postoperative radiotherapy or observation. Three hundred seventy-four eligible patients had a median follow-up of 10.2 years. For patients with a postsurgical PSA of 0.2 ng/mL, radiation was associated with reductions in the 10-year risk of biochemical treatment failure (72% to 42%), local failures (20% to 7%), and distant failures (12% to 4%). Moreover, radiation to the prostate bed reduced the risk of metastatic disease and biochemical failure at all postsurgical PSA levels. It is advisable to wait at least 3-4 months after surgery to allow complete wound healing and return of urinary continence. If salvage radiotherapy is planned, it should be initiated before the PSA level rises much above 0.5 ng/ml. Although some patients with PSA recurrence are better managed with hormone therapy for PSA relapse, the long-term side effects would make adjuvant radiation the best choice particularly at this early post-operative stage.

Question 27

In hypogonadal men, the agent which improves the results of nocturnal penile tumescence testing but does not affect erection in response to erotic films is: A: testosterone. B: L-Dopa. C: sildenafil. D: yohimbine. E: bromocriptine.

Answer 27

A: “testosterone.” was the correct answer. Androgen replacement in hypogonadal men does increase sexual activity and interest. The relationship between androgen replacement and penile erection is not straightforward. When evaluated with nocturnal penile tumescence testing, hypogonadal men demonstrate decreased erectile activity and this abnormality is corrected with testosterone replacement. Laboratory tested erectile responses to erotic films, however, are usually normal in hypogonadal men. These observations are consistent with the conclusion that the major effect of testosterone therapy on sexual function is to enhance libido and not to directly improve penile erection in a sexual setting. None of the other drugs are known to exert these effects.

Question 28

A 42-year-old man is undergoing laparotomy for intraabdominal injuries and bladder rupture. Bleeding is noted in the perivesical area. After repair of the bladder rupture, attempts at suture ligation do not stop the persistent bleeding. Multiple blood transfusions are given and his core temperature is 35.5°C. The next step is: A: intraoperative arteriography. B: ligation of the hypogastric arteries. C: I.V. aminocaproic acid. D: close the abdomen and place patient in anti-shock trousers (MAST). E: pack the pelvis and close the abdomen.

Answer 28

E: “pack the pelvis and close the abdomen.” is correct. Most major bleeding from the pelvis following blunt trauma can be controlled by packing the pelvis and planned re-exploration and/or angiography with embolization in the radiographic suite. Ligation of hypogastric arteries or veins is seldom helpful in management because bleeding occurs from multiple pelvic veins. On-table arteriography is technically difficult, time consuming, and provides poor images and should therefore not be used. The use of a MAST suit in such cases has not been proven to be effective. Bleeding is due to trauma and unlikely to respond to medical therapy.

Question 29

A 53-year-old man with a 2 cm distal penile cancer undergoes partial penectomy revealing low grade T1 squamous cell carcinoma with tumor seen 7 mm from the final surgical margin. The next step is: A: surveillance. B: 5-fluorouracil cream. C: XRT to the penile stump. D: Moh’s surgery of the penile stump. E: additional penile resection to achieve a 2 cm margin.

Answer 29

A: “surveillance.” is correct. An increasing amount of data has accumulated to suggest that a 2 cm margin may not be necessary in all patients undergoing penile cancer resection. Two specific studies have challenged this surgical issue. In a prospective histologic analysis of 64 penectomy specimens, Agrawal and associates concluded that tumor grade highly correlated with microscopic tumor spread. The maximum proximal histologic extent was 5 mm for grade 1 and grade 2 tumors and 10 mm for grade 3 tumors. After performing a retrospective pathologic review of 12 penectomy specimens, Hoffman and colleagues also found seven patients with disease of pathologic stage T1 or greater with microscopic margins measuring less than 10 mm. None of these patients had disease recurrence at a mean follow-up of 32.4 months. The most important factor in determining risk of residual disease in patients with less than a 2 cm margin is tumor grade. This patient is therefore at low risk of recurrence and should be monitored accordingly.

Question 30

Cystine stones form primarily as a consequence of: A: increased concentration of urinary cystine. B: a deficiency of substances other than cystine that inhibit crystal growth. C: an excess of substances that promote crystal growth. D: increased binding of cystine by matrix (mucoproteins). E: excessive urinary acidity.

Answer 30

A: “increased concentration of urinary cystine.” is correct. Cystine stone formation is the only type of metabolic stone disease which can be determined specifically based on the urinary concentration of a specific ionic constituent. In most patients, once the urinary concentration of cystine increases to more than 200 mg of cystine per liter of urine, cystine crystals will precipitate out of solution with subsequent formation of cystine calculi. If one can reduce the cystine concentration below 200 mg per liter, either with increased urinary volume or reductions in cystine excretion, cystine stone disease can be prevented. However, a high percentage of patients with cystine stone disease will also have concurrent metabolic abnormalities and appropriate metabolic evaluation with subsequent treatment should also be instituted.

Question 31

A 70-year-old man with metastatic colon cancer and indwelling ureteral stents develops profuse gross hematuria. Arteriography demonstrates a fistula between the right common iliac artery and ureter. He is hemodynamically stable. The next step is: A: stent removal. B: percutaneous nephrostomy. C: embolize common iliac artery. D: open surgical repair with ligation of the common iliac artery. E: endovascular graft placement.

Answer 31

E: “endovascular graft placement.” is correct. The majority of arterial ureteral fistulas occur in patients who have had extensive pelvic surgery, XRT, and indwelling ureteral stents. Most fistulas involve the common iliac artery but they can also occur in the hypogastric artery. Patients can experience high volume bleeding resulting in hemodynamic instability. Emergency arteriography should be performed if this complication is suspected. While embolization of the common iliac artery will control hemorrhage, a femoral to femoral artery bypass is required to provide adequate circulation to the ipsilateral lower extremity. Placement of an endovascular stented graft or an autologous vein covered stent are less invasive options obviating the need for vascular reconstructive surgery in a patient with limited life expectancy and are the preferred treatment method. The ureteral stent should be removed and a percutaneous nephrostomy placed after this procedure to limit recurrent fistula formation.

Question 32

The optimal tissue for early coverage of the perineum following an avulsion skin injury is a(n): A: island skin flap. B: musculocutaneous flap. C: full thickness skin graft. D: split thickness skin graft. E: dermal graft.

Answer 32

D: “split thickness skin graft.” is correct. A split thickness skin graft takes much more readily than a full thickness skin graft or a dermal graft because capillary ingrowth into the graft is more rapid. Skin flaps and musculocutaneous flaps have no role in the acute management of avulsion injuries.

Question 33

An obese 11-year-old girl with spina bifida is undergoing bladder reconstruction. The appendix is not suitable for construction of a catheterizable abdominal channel. The best channel option is: A: tunneled reconfigured ileum (Monti). B: tunneled tapered ileum. C: intussuscepted ileum. D: incontinent ileovesicostomy. E: tubularized detrusor flap.

Answer 33

A: “tunneled reconfigured ileum (Monti).” was the correct answer. The flap valve or Mitrofanoff principle gives excellent continence with ease of catheterization in most cases. When the appendix is not available, reconfigured ileum (Monti) is preferred because it gives a uniform tube with a small mesentery in the center that facilitates tunneling into the bladder and creation of an abdominal stoma. Tapered ileum leaves a bulky mesentery along the length of the channel and the mucosal folds are oriented transversely potentially making catheterization difficult. An ileal conduit is not ideal long-term management in children because of long-term upper tract deterioration. An incontinent ileovesicostomy requires an appliance has been documented to be problematic in obese patients. The bladder is likely thickened and small; the chance of a detrusor flap reaching the abdominal wall without being complicated by stomal stenosis is small. Intussuscepted ileum historically has a high failure rate with regards to stomal incontinence.

Question 34

The most common acid-base disturbance that occurs in a patient with an ileal conduit urinary diversion is: A: hyperkalemic, hyperchloremic, metabolic acidosis. B: hyponatremic, hypochloremic, metabolic acidosis. C: hypochloremic, hypokalemic, metabolic alkalosis. D: hypokalemic, hyperchloremic, metabolic acidosis. E: hyponatremic, hypochloremic, metabolic alkalosis.

Answer 34

D: “hypokalemic, hyperchloremic, metabolic acidosis.” was the correct answer. In the setting of an ileal conduit urinary diversion, ammonium absorption occurs with chloride in exchange for hydrogen and bicarbonate ions, and may be accompanied by renal potassium wasting. This results in a hypokalemic hyperchloremic metabolic acidosis. Hyponatremic hypochloremic hyperkalemic metabolic acidosis occurs with the use of jejunum due to sodium chloride loss with increased reabsorption of potassium and hydrogen ions. Use of stomach may lead to hypochloremic hypokalemic metabolic alkalosis due to hydrogen and chloride loss with renal oversecretion of potassium to compensate for proton loss.

Question 35

A five-year-old boy has an ectopic ureter associated with a nonfunctional, hydronephrotic, upper pole segment of a duplex system. He undergoes an upper pole partial nephrectomy. The key step in the surgical dissection is: A: mobilization of the lower pole of the kidney. B: mobilization of the adrenal gland. C: reduction of the size of the renal pelvis. D: complete removal of the distal ureter. E: dissection of the ureter from the renal hilum.

Answer 35

E: “dissection of the ureter from the renal hilum.” is correct. The critical step in patients undergoing upper pole, partial nephrectomy, to remove a non functional segment, is dissecting the abnormal ureter from the renal hilum so as not to cause vascular injury to the normal lower pole. The adrenal gland should be left in situ and not disturbed. The distal ureter especially in a male is rarely an issue if not completely removed. The lower pole of the kidney can be mobilized for exposure but is not typically necessary. Reduction of the renal pelvis is not an issue.

Question 36

A 65-year-old man cannot void following an abdominoperineal resection for rectal cancer. He is treated with CIC, and is continent between catheterizations. Three months later he still cannot void and is re-evaluated. He has a normal creatinine and PSA. Cystoscopy reveals occlusive lateral prostatic lobes and a median lobe which projects onto the trigone. A combined CMG-EMG demonstrates a slight decrease in compliance, no definite detrusor contraction is seen. His EMG never silences. Preferred management is: A: continue CIC. B: bethanechol. C: tamsulosin. D: TUIP. E: TURP.

Answer 36

A: “continue CIC.” is correct. Patients who have undergone an abdominoperineal resection are at risk for developing denervation of not only their bladder but also the urethral sphincter mechanisms. Denervation of the smooth muscle in the area of the bladder neck and membranous urethra places these patients at considerable risk for incontinence following transurethral resection of the prostate. Because of the possibility of urinary incontinence following TURP or TUIP, the preferred management of this patient is continued CIC. Bethanechol is not clinically effective in the doses that can be administered orally. Tamsulosin will not be effective in the absence of effective detrusor contractions.

Question 37

A six-year-old boy has severe suprapubic pain with urgency, frequency, dysuria, and fever. Urinalysis and culture are negative after a course of oral antibiotics. WBC count is 12,000/mcl. Renal ultrasound and VCUG are normal. Pelvic CT images are shown. The next step is:

A: I.V. antibiotics and observation.
B: percutaneous drainage and culture.
C: cystoscopy.
D: percutaneous biopsy.
E: partial cystectomy.

Answer 37

B: “percutaneous drainage and culture.” is correct.

The CT is consistent with an infected urachal cyst. Broad spectrum antibiotics without a culture is not prudent. This is not a tumor, therefore biopsy is unnecessary. Excision is definitive therapy but is most appropriate after drainage and treatment of an abscess. Endoscopy may reveal some inflammation at the dome of the bladder but will not be therapeutic or diagnostic.

Question 38

An eight-year-old 30 kg boy with spina bifida has an appendicocecostomy for the antegrade continence enema (ACE) procedure. Postoperatively, he has persistent fecal incontinence and severe constipation with little to no fecal response within two hours of placing 3000 cc of water into the ACE stoma. The next step is:

A: add 1/4 cup of baby shampoo to the colonic irrigations.
B: add a bottle of magnesium citrate to the bowel irrigations.
C: change to polyethylene glycol colonic irrigations.
D: convert to a descending colon stoma or tube for the ACE.
E: diverting colostomy.

Answer 38

D: “convert to a descending colon stoma or tube for the ACE.” was the correct answer.

Two major problems are found to exist with cecal or colon stomas 1) stomal stenosis will develop in up to 30% of patients; this can be managed with either stomal revision or placement of a cecostomy tube through the stenotic channel. 2) washout failure, defined as failure to pass little or any of the enema from the rectum within one to two hours following instillation of irrigation fluid. Approximately 5-10% of patients with washout failure will need a diverting colostomy. The maximum amount of tap water that can be used for ACE irrigations before alterations in serum sodium will occur can be calculated by the formula of body weight (kg) x 0.035 L/kg for example in this 30 kg child. 30 kg x 0.035 liters/kg = 1.05 liters maximum volume. The physician may use water volumes higher than what is calculated but the risk of hyponatremia rises with higher volumes, the onset of hyponatremia and the risk of water intoxication will of course be dependent upon the type of fluid instilled and dwell time within the bowel. If water volumes greater than calculations are used the patients serum electrolytes should be checked at monthly intervals until they can be documented to be stable, after that time electrolytes can be checked with routine follow-up. Alternatives to significantly increasing the volume of calculated instilled fluid involve changing irrigant fluid to polyethylene glycol irrigations, long term use of this substance is however associated with the intermittent development of C. difficile colitis. Magnesium citrate or phosphate enemas may be instilled in the ACE prior to washout to decrease irrigant volume however these maneuvers have been associated with resultant hypermagnesemia, hyperphosphatemia and hypocalcemia. In patients with washout failure following high volume irrigations of a right colonic ACE altering the stomal site/colonic tube to the left colon has been documented to reduce the volume of irrigant; result in successful fecal continence and save the majority of these patients from the need for a diverting colostomy.

Question 39

The most life-threatening electrolyte abnormality that develops during the diuretic phase of acute tubular necrosis is: A: hyponatremia. B: hypomagnesemia. C: hypocalcemia. D: hypokalemia. E: hyperkalemia.

Answer 39

D: “hypokalemia.” was the correct answer. During the massive urinary sodium losses occurring during the diuresis phase of acute tubular necrosis, potassium is also lost resulting in life-threatening hypokalemia. During diuresis the Na+/K+ pump is overwhelmed and exchange fails to occur.

Question 40

A 27-year-old man evaluated for infertility of nine months duration has a normal sperm count and motility, but sperm morphology reveals only round headed sperm. Testis volume is normal bilaterally, serum FSH is within normal limits, and he has a moderate sized left unilateral varicocele. His wife is 25-years-old, and has a normal evaluation. The next step is: A: varicocele repair. B: intrauterine insemination. C: re-evaluation in three months. D: in vitro fertilization. E: ICSI.

Answer 40

E: “ICSI.” was the correct answer. Observation is a reasonable choice in young couples with infertility of less than one year’s duration. However, the finding of round headed sperm is consistent with absence of the acrosome and individuals with this finding are sterile. Standard intrauterine inseminations and in vitro fertilization are unsuccessful because the sperm cannot fertilize an egg without a normal acrosome. Varicocele repair will not improve the morphology. The only method that will induce a pregnancy using the patient’s sperm is in vitro fertilization using intracytoplasmic sperm injection (ICSI). Even regular ICSI has resulted in low pregnancy rates. Current approaches combine assisted oocyte activation with ICSI. The alternative is donor insemination.

Question 41

A 50-year-old man is scheduled for a living related renal transplant. He has a serum creatinine of 5.5 mg/dl and is not yet on dialysis. His noncontrast CT scan shows a 2 cm solid left renal mass. The next step is: A: repeat CT scan with I.V. contrast. B: radical nephrectomy and exclude patient from transplantation. C: simultaneous radical nephrectomy and renal transplantation. D: radical nephrectomy, transplant in two years if no recurrence. E: partial nephrectomy, transplant in two years if no recurrence.

Answer 41

C: “simultaneous radical nephrectomy and renal transplantation.” was the correct answer. Incidentally discovered small asymptomatic renal tumors do not mandate a waiting period prior to transplantation. Repeating the CT scan with contrast risks further nephrotoxic injury with preexisting borderline renal function, and will not change the management of the renal mass. Although partial nephrectomy may carry the advantage of preserving additional renal mass, this is not applicable to this patient. The appropriate management in this setting is simultaneous nephrectomy and transplantation.

Question 42

A 12-year-old boy with blunt abdominal trauma has a CT scan that shows a left renal fracture with a small subcapsular hematoma. He is managed with observation. Six days after injury he has a temperature of 38.4°C and increased hematuria with clots. His hematocrit has decreased from 30 to 24 in the last day. The CT scan on day six is shown. The next step is: A: observation. B: retrograde ureterogram. C: arteriogram. D: percutaneous nephrostomy. E: open surgical exploration.

Answer 42

C: “arteriogram.” was the correct answer. This child likely has a delayed bleed from a renal laceration. The CT demonstrates devitalized areas of the kidney with a collection of blood and urine. This is best managed by embolization after confirmation by arteriogram. Open surgery will more likely result in nephrectomy or heminephrectomy. Percutaneous nephrostomy or retrograde ureterogram will not treat the continued bleeding. A retrograde study would be indicated if one were suspecting a pelvic tear or a UPJ disruption because of medial extravasation.

Question 43

A 28-year-old woman underwent kidney transplantation two weeks ago. Her immunosuppression regimen consists of tacrolimus, prednisone, and mycophenolate mofetil. She exhibits tremors but no fevers. Physical exam reveals no significant tenderness over the transplant. Serum creatinine nadir was 1.1 mg/dl but is now 1.9 mg/dl. Urinalysis is negative, and ultrasonography shows no hydronephrosis or peritransplant collections. The next step is: A: blood sugar level. B: tacrolimus blood level. C: urine culture. D: CT scan of transplant kidney. E: I.V. fluid bolus.

Answer 43

B: “tacrolimus blood level.” is correct. Considerations for apparent early graft dysfunction include infection, renal allograft rejection, urinary or vascular obstruction, cyclosporine or tacrolimus nephrotoxicity, hyperglycemia, and dehydration. A screening work-up consisting of physical exam followed by basic laboratory tests and ultrasound are appropriate. In this case, the prominent physical exam finding of tremor suggests tacrolimus toxicity that can be further evaluated by determining the serum level of the immunosuppressant tacrolimus (calcineurin inhibitor). Mycophenolate mofetil is an antibiotic with immunosuppressive qualities. It is clinically indicated for cardiac and renal transplantation and the treatment of psoriasis and rheumatoid arthritis. Side effects of mycophenolate mofetil include anemia, leukopenia, thrombocytosis, GI bleeding, sepsis, lymphoma, skin cancer, and pulmonary fibrosis. It is not associated with a decrease in renal function. However, its use may result in elevation of tacrolimus and cyclosporin blood levels. The latter may interfere with renal graft function.

Question 44

A 55-year-old man has lower extremity thrombophlebitis and is started on warfarin. Two weeks later, he experiences abdominal pain and has a blood pressure of 84/50 mmHg. His hemoglobin is 13.5 gm/dl and serum potassium 5.8 mEq/l. A CT scan demonstrates bilateral 4 cm adrenal masses. The next step is I.V. fluids and administration of: A: dexamethasone. B: fresh frozen plasma. C: Kayexalate. D: fluorohydrocortisone. E: Vitamin K.

Answer 44

A: “dexamethasone.” was the correct answer. This patient has adrenal insufficiency secondary to bilateral adrenal hemorrhage. This can occur in anticoagulated patients, typically during the first three weeks of therapy. The initial therapy should be administration of I.V. fluids and glucocorticoid therapy. Fresh frozen plasma is not acutely indicated with an adequate hemoglobin level. Kayexalate will help lower a high potassium but not the hypotension from adrenal steroid deficiency. Chronic but not acute adrenal insufficiency is treated with fluorohydrocortisone. Vitamin K will help restore clotting factors depleted by warfarin therapy but is not the initial therapy for this patient.

Question 45

Human papilloma virus is best prevented in a 15-year-old man with use of: A: quadrivalent recombinant vaccine. B: condoms. C: oral acyclovir. D: post-coital acetic acid. E: topical acyclovir.

Answer 45

B: “condoms.” was the correct answer. Quadrivalent Human Papillomavirus vaccine immunizes against types 6, 11, 16 and 18. Types 16 and 18 are associated with 70% of cervical cancer cases. Types 6, 11, 16, and 18 are associated with 90% of cases of genital warts. The vaccine has only been tested in females and is indicated in females age 9-26 for the prevention of cervical cancer, precancerous lesions and genital warts caused by these subtypes. There has been no testing of vaccine efficacy in males (Note: This is from 2010 test. FDA approved use of this vaccine to prevent HPV warts in males 9-26 in 2009)

Question 46

An 80-year-old man has urinary retention. He has bilateral pitting edema, an elevated jugular venous pulse, and a blood pressure of 200/120 mm Hg. His creatinine is 4.0 mg/dl. The serum K+ and Na+ are normal. An ultrasound shows a very distended bladder and bilateral pelvicaliectasis. Three liters of urine is obtained from his bladder when he is catheterized. Urine output over the next two hours is 700 ml. The next step is: A: serial creatinine measurement. B: replace output ml per ml with D5 1/2 NS. C: monitor fluid intake and output every four hours. D: monitor postural BP for two hours. E: spot check urine for osmolality, sodium, and potassium.

Answer 46

E: “spot check urine for osmolality, sodium, and potassium.” was the correct answer.

All patients with an output greater than 200 ml/hr have postobstructive diuresis and should be monitored. High risk patients with chronic obstruction, edema, congestive heart failure, hypertension, weight gain and azotemia are most likely to exhibit a postobstructive diuresis after the release of obstruction. In the high risk patient a spot check urine for osmolality, sodium and potassium will allow for the determination of the type of postobstructive diuresis and will guide in further management. High risk patients should have vital signs, including postural blood pressure and output measured hourly. D5 1/2 NS is an appropriate replacement fluid in the patient with an elevated BUN and creatinine but generally replacement is given at half of the previous hours urine output.

Question 47

Hypertension secondary to acute unilateral urinary obstruction is most likely: A: found in patients with a solitary kidney. B: associated with transient hyperreninemia. C: persistent after relieving the obstruction. D: associated with a demonstrable renovascular lesion. E: due to sodium and water retention.

Answer 47

B: “associated with transient hyperreninemia.” was the correct answer. Renin-mediated hypertension sometimes occurs in acute unilateral renal obstruction and may present a clinical picture suggestive of a renovascular etiology; however, angiographic studies do not show a vascular lesion. A transient hyperreninemia initiates the hypertension and the hypertension is probably sustained by complex volume-vasoconstricting abnormalities that are dependent on the duration of the obstruction and the presence of a contralateral normal kidney. The abnormalities are corrected by relieving the obstruction and the blood pressure in turn reverts to normal. This type of hypertension usually does not occur in a solitary hydronephrotic kidney or bilateral hydronephrosis because of compromised renal function with lowering of renin levels due to impairment of overall sodium and water excretion.

Question 48

A 24-year-old sexually active homosexual man has a solitary erythematous nodule on the penile shaft. He does not have a urethral discharge. Purulent material is expressed from the nodule and culture on Thayer-Martin medium reveals oxidase positive colonies. The most likely diagnosis is: A: primary syphilis. B: gonorrhea. C: chancroid. D: lymphogranuloma venereum. E: Kaposi’s sarcoma.

Answer 48

B: “gonorrhea.” was the correct answer. This patient’s presentation is lacking in the usual signs and symptoms of gonorrhea, but an oxidase positive culture on Thayer-Martin medium is diagnostic of Neisseria gonorrhea. Thayer-Martin media contain various antibiotics (vancomycin, colistin and nystatin) and specific growth-promoting agents with hemoglobin (sheep’s blood) that inhibits or totally suppresses the growth of accompanying bacterial flora while allowing pathogenic Neisseria species to grow normally. Diagnosis of primary syphilis is by darkfield microscopy and direct fluorescence antibody (DFA) test of specimens obtained from the lesion. Alternatively, nontreponemal serologic testing with rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) can be used to diagnosis primary syphilis. Chancroid is caused by Haemophilus ducreyi and this organism is fastidious and difficult to culture. Diagnosis is usually made by gram stain showing gram negative streptobacilli. Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis types L1, L2 and L3. The diagnosis of LGV is primarily clinical as cultures are positive only 30-50% of the time from the cutaneous lesions: and accessory glandular infection may be the only manifestations of active gonorrhea. Kaposi’s sarcoma is caused by HIV.

Question 49

The risk of serious illness or death to a surgeon who suffers a needle stick during the course of surgery is greatest if the patient: A: has asymptomatic untreated HIV infection. B: has a history of clinical hepatitis. C: has AIDS treated with AZT. D: is hepatitis B surface antigen positive. E: is hepatitis A positive.

Answer 49

D: “is hepatitis B surface antigen positive.” was the correct answer. The risk of hepatitis B virus (HBV) developing into clinical infection after a needlestick exposure to hepatitis B surface antigen positive blood ranges from 7% to 30%. Between 5% and 10% of persons with acute HBV infection become chronic carriers; 15% to 25% of carriers will eventually die of liver cancer or cirrhosis. The risk of HIV infection after a needlestick exposure to HIV-infected blood is, on the average, approximately 0.4%. Thus, the death rate may be slightly higher with hepatitis exposure, and the morbidity rate is far higher.

Question 50

Non-gonococcal urethritis not responsive to a full course of tetracycline should be treated with: A: spectinomycin. B: ceftriaxone. C: doxycycline. D: penicillin. E: azithromycin.

Answer 50

E: “azithromycin.” was the correct answer. Nongonococcal urethritis caused by Chlamydia trachomatis or Ureaplasma urealyticum cannot be distinguished clinically, but either tetracycline or azithromycin is usually effective against both. Sexual partners should also be treated. If the signs and symptoms of urethritis do not improve with a tetracycline, infection with tetracycline-resistant U. urealyticum may be present; this usually responds to an azithromycin. Relapse may be due to reinfection by an untreated sexual partner, and the patient and all partners should be retreated. When C. trachomatis causes mucopurulent cervicitis, it usually responds to the same regimen of tetracycline or azithromycin used to treat urethritis.

Question 51

A 45-year-old man with a history of hypertension and significant tobacco use is impotent one year following a crush injury to the pelvis. A penile arteriogram reveals unilateral focal occlusion of the internal pudendal artery. Treatment should be: A: intracavernous vasoactive injections. B: dorsal venous ligation. C: percutaneous angioplasty. D: arterial revascularization. E: penile prosthesis.

Answer 51

A: “intracavernous vasoactive injections.” was the correct answer. Percutaneous or surgical revascularization of the internal pudendal arteries is not indicated owing to the patient’s age and associated atherosclerotic vascular disease secondary to smoking. There is no indication for venous ligation. Owing to the vascular disease, penile injections may not be successful but should be implemented prior to insertion of a penile prosthesis.

Question 52

During inflatable penile prosthesis surgery, the device is inspected for proper inflation and deflation after corporotomy closure. At maximal cylinder inflation, the glans flops ventrally over the distal portion of the cylinders. The next step is: A: complete procedure with cylinders deflated. B: complete procedure with cylinders inflated. C: crural plication. D: fix the glans to the tunica dorsally at the distal ends of the corporal bodies. E: reassess the corporal bodies for cylinder size.

Answer 52

E: “reassess the corporal bodies for cylinder size.” is correct. The description suggests an impending supersonic transport (SST) deformity which is a ventral chordee of the glans whereby the distal aspects of the cylinders inadequately extend distally under the glans creating a floppy appearance. The floppy appearance mimics the drooped nose of the Concorde, a supersonic transport. A likely basis for the problem is inadequate dilatation and sizing of the corporal spaces. If this is identified during prosthesis placement, the corporotomies should be reopened and the corporal bodies inspected to be sure proximal perforation has not occurred. Redilation and remeasurement of corporal bodies are then performed, and the same cylinders can usually be reinserted adding rear-tip extenders to achieve appropriate length. A distal corporal plication (“Ball procedure”) is not generally required during initial prosthesis placement. The device should remain in the deflated position at the completion of surgery until the time of device activation and initiation of use to avoid the risks of an unexpanded cavity space for the reservoir (that is associated with autoinflation), penile pain and distal corporal perforation.

Question 53

The enzyme deficiency that most commonly leads to genital ambiguity in a 46 XX individual with normal ovaries is: A: 20,22-desmolase. B: 17-hydroxylase. C: 21-hydroxylase. D: 3B-hydroxysteroid dehydrogenase. E: 17B-hydroxysteroid dehydrogenase.

Answer 53

C: “21-hydroxylase.” is correct. A deficiency of 20,22-desmolase, 3B-hydroxysteroid dehydrogenase and 17-hydroxylase enzymes occur with congenital adrenal hyperplasia but rarely cause genital ambiguity in a 46 XX female. 17B-hydroxysteroid dehydrogenase is primarily a testicular enzyme. A 21-hydroxylase deficiency will cause CAH in both sexes but in a 46 XX individual with ovaries it will lead to genital ambiguity. Only enzyme defects beyond the 17-hydroxyprogestone stage of steroid biosynthesis will produce excessive androgenic substances

Question 54

A 26-year-old sexually active man has a painful 1.0 cm solitary ulcer on the glans penis which is culture positive for H. ducreyi. The next step is: A: doxycycline. B: azithromycin. C: benzathine penicillin G. D: acyclovir. E: ciprofloxacin.

Answer 54

B: “azithromycin.” was the correct answer. The patient’s findings are classic for chancroid which is due to H. ducreyi. This is the most common sexually transmitted disease worldwide. It affects men three times more than women. It is associated with inguinal adenopathy that is typically unilateral and tender with tendency to become suppurative and fistulize. Single-dose treatment with azithromycin 1 gm orally or ceftriaxone 250 mg intramuscularly is first line therapy. While ciprofloxacin can be a secondary regimen, resistance to ciprofloxacin has been reported in some regions. Patients should be reexamined in five to seven days. Sexual partners should be treated if sexual relations were held within two weeks before or during the eruption of the ulcer.

Question 55

The most important factor responsible for the frequent recurrence of UTIs in an otherwise healthy young woman is: A: adhesive fimbriae of uropathogens. B: specific receptors on urothelial cells. C: presence of pathogenic coliforms in stool. D: feminine hygiene practices. E: method of contraception.

Answer 55

B: “specific receptors on urothelial cells.” was the correct answer.

Properties of uropathogens, sexual activity, feminine hygiene practices and the use of an IUD and/or spermicide may increase the frequency of UTIs in predisposed women, however they are not the most important etiologic factors. Many women have uropathogenic bacteria present in their bowel, use various contraceptive and hygiene methods, and are sexually active without developing infections. E. coli must colonize the peri-urethral area before an uncomplicated infection can occur. Coliform organisms are recovered only rarely from the region of the vaginal vestibule and external urethra in otherwise healthy women who do not have recurrent UTIs. It is postulated by most researchers that host factors rather than specific pathogenicity of the micro-organisms are the prime determinants of colonization. E. coli tend to adhere more to vaginal and buccal epithelial cells obtained from women with recurrent infection than to controls. This explains why certain women are prone to frequent recurrent infections. It would also explain why women with asymptomatic bacteruria are more prone to recurrent infection with marriage and pregnancy and would account for UTIs associated with intercourse, various contraceptive methods, etc., in highly susceptible women.

Question 56

An eight-year-old boy is involved in a MVC. A CT scan confirms a right UPJ disruption. He has had a right ureteral reimplant at the age of four years. The next step is: A: percutaneous nephrostomy. B: primary ureteropyelostomy. C: transureteroureterostomy. D: ileal ureter. E: nephrectomy.

Answer 56

B: “primary ureteropyelostomy.” is correct. Disruption of the ureteropelvic junction in a child secondary to trauma is a prime indicator for operative intervention. His kidney should be salvaged and a percutaneous nephrostomy tube may not be diverting. While the distal blood supply of the ureter has been disrupted due to his previous surgery, his ureter should still have an adequate blood supply from the middle ureteral vessels. A primary repair is the best treatment option. Transureteroureterostomy would potentially put the contralateral renal unit at risk unnecessarily and not likely to be technically feasible.

Question 57

A 67-year-old man had a radical cystectomy and orthotopic diversion ten days ago. He now has feculent material draining from his urinary stents and urethral catheter after an episode of severe post-operative colitis. Within 24 hours, his temperature is 39°C, and his blood pressure is 95/50 mmHg. A CT scan of the abdomen and pelvis reveals an intraperitoneal abscess. Rectal examination is normal. The next step is: A: percutaneous drain placement. B: bowel rest with hyperalimentation. C: bilateral percutaneous nephrostomy tubes. D: fistula repair with bowel diversion. E: proximal bowel diversion.

Answer 57

E: “proximal bowel diversion.” was the correct answer. Nonoperative management is a viable option in selected patients with vesicoenteric fistulas, however, patients chosen for such treatment should be minimally symptomatic with benign fistulas. For those requiring surgical exploration, both one and two stage procedures have been based on clinical circumstances. The decision regarding a one or two stage procedure is influenced by the location and etiology of the fistula, the patient’s general condition, the timing of the exploration relative to the original procedure, the presence of pelvic abscess, the presence of colonic obstruction, and the severity of the inflammatory response. Patients without gross fecal contamination can be treated with a one-stage procedure, whereas those with unprepped bowel, gross fecal contamination, severe inflammatory response, or abscess require a two-stage procedure.

Question 58

Calcium reabsorption in the distal renal tubule is mediated primarily by: A: Vitamin D. B: aldosterone. C: hypocalcemia. D: urinary sodium. E: parathyroid hormone.

Answer 58

E: “parathyroid hormone.” was the correct answer. Parathyroid hormone mediates renal reabsorption of calcium in the distal nephron. More proximally in the nephron, calcium is reabsorbed in concert with sodium. Vitamin D influences calcium homeostasis primarily by enhancing small bowel absorption. Significant hypocalcemia stimulates renal calcium preservation by inducing parathyroid hormone secretion. Aldosterone mediates distal renal preservation of sodium in exchange for available hydrogen and/or potassium, and has no direct effect on calcium reabsorption.

Question 59

A healthy newborn boy has bilateral Grade 4 VUR. This is most commonly associated with: A: low outlet resistance. B: uninhibited detrusor contractions, coordinated voiding. C: poor bladder compliance. D: high pressure voiding with high residual. E: lack of detrusor contractility.

Answer 59

D: “high pressure voiding with high residual.” was the correct answer. Reflux in newborn boys is commonly high grade and associated with uninhibited detrusor contractions during filling, high pressure voiding due to elevated outlet resistence, detrusor-sphincter dyssynergy, and high postvoid residuals. Uninhibited, detrusor contractions associated with coordinated voiding is normal in infants and not associated with high grade VUR. Compliance and contractility are generally within the range of normal for these boys. The best treatment for infant boys with high grade VUR is prophylactic antibiotics and observation. Most of these infants will decrease their outlet resistance and resolve their VUR with neurourologic maturation during the first year of life.

Question 60

A 47-year-old woman with symptomatic stress urinary incontinence develops dyspareunia and postvoid dribbling. A urethral diverticulum is confirmed with a vaginal ultrasound. Videourodynamics demonstrate an open bladder neck at rest, stable filling, and a Valsalva LPP of 70 cm of H2O. The best treatment is urethral diverticulectomy and: A: urethral bulking agent if stress urinary incontinence persists. B: Martius fat pad. C: pubovaginal fascial bladder neck sling. D: a synthetic mid-urethral sling. E: retropubic Burch colposuspension.

Answer 60

C: “pubovaginal fascial bladder neck sling.” is correct. This patient will likely have worsening stress urinary incontinence postoperatively. A concomitant pubovaginal fascial sling would treat the stress incontinence and have no increased risk of infection or urethral erosion. Concomitant placement of a synthetic sling should be avoided because of the potential risk of infection and erosion into the urinary tract. A Martius fat pad will not treat the incontinence. Collagen is unlikely to provide long term relief of stress urinary incontinence. It is unnecessary to perform a retropubic exploration at the time of a vaginal incision for urethral diverticulectomy, in addition, the intrinsic sphincter deficiency as suggested by the open bladder neck is treated better with a sling than a Burch procedure.

Question 61

The earliest clinical manifestation of a tethered spinal cord in children is: A: constipation. B: upward Babinski reflex. C: lower limb weakness, gait abnormality. D: increased deep tendon reflexes of the lower limb. E: urinary incontinence secondary to detrusor overactivity.

Answer 61

E: “urinary incontinence secondary to detrusor overactivity.” is correct. Currently one third of the symptomatic patients undergoing detethering of the spinal cord will present with urologic complaints, 50% will present with the late findings of lower limb weakness/gait disturbance and approximately 15% with back pain. Bowel dysfunction is a rare presenting complaint. Damage from a tethered cord is the result of inadequate oxygen metabolism in the spinal cord. The cord becomes tethered between the site of tethering and where the anterior and posterior nerve roots exit the canal. Repetitive flexion and extension and/or Valsalva activity of any type kinks the arterioles and venules, thereby reducing blood supply to the tethered cord. The clinical findings of tethered cord come from accumulative hypoxemic damage and may occur at any age. The diverse structure of the spinal cord plays a large role in the pathogenesis of this disorder; specifically interneuronal axon connections have the highest oxygen requirements and are the first to become damaged. Clinically, this means the pelvic nerves and the sacral reflex arc will be the first to manifest the hypoxic damage, lower limb weakness and back pain occurring at a later time. Once an MRI scan depicts a tethered or abnormally lying cord, surgical detethering will not correct the MRI picture. Long-term follow up has revealed that up to 20% of tethered cords may redevelop symptomatic findings of re-tethering. The inability of the MRI scan to rule out re-tethering places the urologist and urodynamic testing in a key position. Specifically serial urodynamic tests or electromyography of the muscles involved with the sacral reflex arc are monitored at set intervals usually three months post surgical release of the cord and then again at six to twelve month intervals. Alterations in the urodynamic tests will result in increase attentiveness by the neurosurgeon for the development of re-tethering of the spinal cord.

Question 62

The advantage of a non-refluxing ureterointestinal anastomosis is that it decreases: A: upper tract colonization. B: ureterointestinal stricture. C: pressure transmission to the upper urinary tract. D: metabolic abnormalities. E: stone formation.

Answer 62

C: “pressure transmission to the upper urinary tract.” was the correct answer. Non-refluxing ureterointestinal anastomoses do not prevent upper tract colonization. Virtually all upper tract systems are found to be colonized when urine is aspirated above the non-refluxing anastomoses. Studies which have compared non-refluxing colon conduits to refluxing ileal conduits show similar rates of upper tract deterioration. While a properly functioning non-refluxing ureteral anastomosis does prevent pressure transmission to the upper urinary tract, this benefit is in part offset by a higher incidence of ureterointestinal stricture. This has caused some to question the benefit of creating non-refluxing anastomoses in any form of urinary diversion whether conduit or continent. There is no impact on metabolic issues or stone formation.

Question 63

A 30-year-old man with diabetes insipidus has been NPO for 16 hours. He becomes confused, lethargic, and hyperreflexic. The initial fluids given should be: A: lactated Ringers. B: D5W. C: D5W/.2NS. D: D5W/.45NS. E: 3% saline.

Answer 63

A: “lactated Ringers.” is correct. This patient has symptoms characteristic of hypovolemic hypernatremia. This has occurred due to water loss from his diabetes insipidus without the ability to replace water or electrolytes orally. It is essential to first restore plasma volume with a relatively isotonic solution like lactated Ringers. The hypernatremia should then be corrected slowly with increased free water being given. Correction should decrease serum levels by no more than 10 mEq per day to prevent intracranial swelling and fatal complications. Hypertonic saline is contraindicated.