SASP 2010 (2)

Question 1

A 38-year-old woman with stress urinary incontinence and recurrent UTIs undergoes urethral diverticulectomy. One month following removal of the catheter, she has constant dribbling incontinence. Examination reveals a 5 mm urethrovaginal fistula in the proximal urethra. The next step is:

A: topical estrogen therapy and suprapubic cystostomy.
B: place urethral catheter and obtain VCUG in three to six weeks.
C: transurethral fulguration of the fistula tract and placement of a urethral catheter.
D: urethrovaginal fistula repair.
E: urethrovaginal fistula repair and midurethral polypropylene sling.

Answer 1

D: “urethrovaginal fistula repair.” was the correct answer.

Proximal urethrovaginal fistulae may present with constant dribbling incontinence. A large (5 mm) urethrovaginal fistula is unlikely to close with urinary drainage or fulguration. The safety of synthetic materials is not established in the setting of urinary fistula or prior urethral diverticulectomy. Surgical repair of the fistula should be undertaken two to three months post-operatively, and re-evaluation of the SUI done once the fistula is repaired. Long term indwelling urethral catheter is not recommended due to the development of chronic bacteruria and chronic inflammation.

Question 2

The vessel at greatest risk for injury during laparoscopic placement of an umbilical trocar is the:

A: right common iliac vein.
B: vena cava.
C: abdominal aorta.
D: right common iliac artery.
E: inferior mesenteric artery.

Answer 2

D: “right common iliac artery.” was the correct answer.

Major vascular injury is a rare but serious complication that occurs in 0.11-2% of cases. The right common iliac artery lies close to the mid-line at the inferior umbilicus. Therefore, with placement of an umbilical trocar, the right common iliac artery is the most commonly injured vessel, followed by the aorta. In contrast, the IVC is less frequently involved because of its lateral location in relation to the aorta. The common iliac veins are rarely involved given their posterior location in relation to the common iliac arteries.

Question 3

A 71-year-old man with a history of aortoiliac reconstruction has left flank pain. A noncontrast CT scan reveals obstruction of the left ureter at the pelvic brim. The most likely cause of the obstruction is:

A: compression from an anteriorly placed graft.
B: pseudoaneurysm formation.
C: retroperitoneal fibrosis.
D: ligation of the ureter.
E: ischemia of the ureter.

Answer 3

C: “retroperitoneal fibrosis.” was the correct answer.

Ureteral obstruction is a recognized complication of reconstructive vascular procedures. The incidence of temporary, asymptomatic hydronephrosis is 12-30%, and mild or moderate permanent ureteral obstruction is seen in 2-14% of patients. Most patients develop ureteral obstruction within one year following the procedure; however, delays up to 14 years have been reported. Retroperitoneal fibrosis secondary to the surgical procedure is the most common cause of ureteral obstruction and is believed to be secondary to bleeding or excessive periureteral dissection. The other choices are all causes of obstruction, but not the most common.

Question 4

Renal ultrasound reveals an echogenic mass with speed-propagation artifact. The most likely diagnosis is:

A: simple renal cyst.
B: acute focal pyelonephritis (lobar nephronia).
C: intrarenal abscess.
D: angiomyolipoma.
E: RCC.

Answer 4

D: “angiomyolipoma.” was the correct answer.

Ultrasonography is a very useful imaging modality for distinguishing kidney masses. Specifically, it is able to use the acoustic properties of the renal parenchyma to aid in diagnosis. The presence of an echogenic mass immediately eliminates the diagnosis of simple cyst, as these are usually echo-free. In addition, while lobar nephronia may appear like a mass on ultrasound, it is usually echo-poor or echo-free as well. RCCs, intrarenal abscesses and angiomyolipoma all may be echogenic. Angiomyolipomas are usually echogenic, while RCCs and intrarenal abscesses have variable echogenicity. The key here is the speed-propagation artifact, which is due to the presence of fat in the tumor. In this case, the speed of sound in the fat is significantly slower than that in the soft tissue, which causes the unique artifact that confirms the diagnosis of angiomyolipoma.

Question 5

Vascular reconstruction is recommended in hypertensive patients with:

A: bilateral medial fibroplasia.
B: bilateral ostial atherosclerotic lesions and poorly controlled hypertension on two medications.
C: unilateral 85% renal artery stenosis and a serum creatinine of 1.5 mg/dl.
D: bilateral 70% renal artery stenosis and a serum creatinine of 4.5 mg/dl.
E: bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dl.

Answer 5

E: “bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dl.” was the correct answer.

Re-vascularization is typically recommended in renal artery stenosis when > 75% occlusions occur either bilaterally or in a solitary single kidney. With severe renal loss (serum creatinine > 4 mg/dl), the likelihood of renal recovery is substantially reduced and revascularization is not recommended. Atherosclerotic renal vascular hypertension should be treated medically, typically with at least three medications before resorting to revascularization. Medial fibroplasia typically is not progressive and revascularization for this process is rare.

Question 6

A 35-year-old man with new onset hypertension has a serum K+ of 2.9 mEq/l, a serum aldosterone of 80 ng/dl (normal 2-9 ng/dl) and a low peripheral renin level. An abdominal CT scan shows no adrenal masses. Adrenal venous localization studies show aldosterone levels of 6000 ng/dl and 8 ng/dl from the left and right, respectively. The next step is:

A: MIBG scan.
B: MRI scan with T2 weighted images.
C: left adrenalectomy.
D: ACE inhibitor and K+ supplement.
E: spironolactone.

Answer 6

E: “spironolactone.” was the correct answer.

Hypokalemia, an elevated serum aldosterone level and a normal peripheral renin level suggest primary hyperaldosteronism. The CT shows no adrenal mass suggesting adrenal hyperplasia. An MRI with T2 weighted images is useful in cases of a pheochromocytoma but this is not suggested by the biochemical data. An MIBG scan lacks sensitivity. Venous localization studies are most useful in this case. Venous localization studies demonstrate convincingly the pathology is from the left adrenal, suggesting unilateral hyperplasia. Spironolactone would be the first treatment. If the hypertension and hyperkalemia are not corrected, a left adrenalectomy would be indicated.

Question 7

The inferior mesenteric artery is ligated during a RPLND for testis cancer. Blood supply to the sigmoid colon is now derived from which artery:

A: right colic.
B: superior hemorrhoidal.
C: middle hemorrhoidal.
D: sigmoid.
E: middle sacral.

Answer 7

C: “middle hemorrhoidal.” is correct.

The main arterial supply of the sigmoid colon is from the sigmoid and superior hemorrhoidal branches of the inferior mesenteric artery (IMA). The major collateral vessels are the middle and inferior hemorrhoidal arteries which arise from the internal iliac artery. They anastomose freely with the superior hemorrhoidal branches. It is distributed to the rectum, anastomosing with the inferior vesical artery, superior rectal artery, and inferior rectal artery. The right colic artery arises from the superior mesenteric artery and does not have collaterals to the distal colon. The superior hemorrhoidal arteries and sigmoid arteries are continuations of the IMA and is filled retrograde when the IMA is ligated. The middle sacral artery arises from the back of the aorta and gives some blood supply to the rectum.

Question 8

A 75-year-old man is scheduled to undergo cataract surgery. He is currently taking tamsulosin, doxazosin, and metoprolol. The medication(s) associated with intra-operative floppy iris syndrome is/are:

A: tamsulosin.
B: doxazosin.
C: metoprolol.
D: tamsulosin and doxazosin.
E: tamsulosin and metoprolol.

Answer 8

D: “tamsulosin and doxazosin.” is correct.

While tamsulosin had been the most widely publicized alpha-1a blocker to be associated with intra-operative floppy iris syndrome (IFIS) during cataract surgery, other alpha-blockers have as well (including super-selective and less selective agents). Although not eliminating the risk of IFIS, discontinuing these medications one to two weeks prior to surgery lowers the incidence.

Question 9

A 35-year-old Cushingoid woman undergoes left adrenalectomy for a small adrenal adenoma. Postoperative cortisol levels remain high. Her serum ACTH is low and an MRI scan of the brain is normal. The best therapy is:

A: aminoglutethimide.
B: right adrenalectomy.
C: ketoconazole.
D: ortho-para DDD.
E: metyrapone.

Answer 9

E: “metyrapone.” is correct.

Excess circulating glucocorticoids may be due to adrenal adenoma or carcinoma, or to ectopic secretion of ACTH or CRH. This patient has no evidence of Cushing’s disease or ACTH dependent disease. She most likely has a contralateral adrenal source and glucocorticoid suppression with metyrapone is the most appropriate next step. Agents include aminoglutethimide, which blocks the conversion of cholesterol to pregnenolone; metyrapone, which blocks the conversion of 11-desoxycortisol to cortisone. Patients given aminoglutethimide are prone to develop adrenocortical insufficiency because aldosterone production is also impaired. Metyrapone does not normally result in salt wasting because of increased production of desoxycorticosterone, a potent mineralocorticoid. A right adrenalectomy in a patient with a solitary adrenal gland would commit the patient to lifelong steroid replacement.

Question 10

A four-year-old boy is undergoing salvage cystoprostatectomy for rhabdomyosarcoma after failing chemotherapy and XRT. The best urinary diversion is:

A: ileal loop.
B: Kock pouch.
C: ileocolonic pouch.
D: sigmoid conduit.
E: transverse colon conduit.

Answer 10

E: “transverse colon conduit.” is correct.

In patients with prostatic rhabdomyosarcoma who have failed chemotherapy and XRT, the best form of diversion, with the lowest complication rate is a transverse colon conduit. Once the patient has completed additional chemotherapy and no recurrence of malignancy has occurred for a minimum of two years, conversion to a continent urinary diversion can be considered.

Question 11

A 27-year-old quadriplegic woman has urinary incontinence. Videourodynamics reveal a detrusor LPP of 65 cm H2O at 100 ml without VUR. Abdominal LPP is 105 cm H2O. The best management is:

A: indwelling urethral catheter.
B: intradetrusor botulinum toxin injection.
C: ileovesicostomy.
D: augmentation cystoplasty and pubovaginal fascial sling.
E: appendicovesicostomy and augmentation cystoplasty.

Answer 11

C: “ileovesicostomy.” is correct.

This patient has dangerously elevated intravesical pressures and a continuously draining ileovesicostomy will permit low pressure bladder emptying. An indwelling catheter has the risk of UTI, stones, cancer and urethral erosion. The incompetent outlet of the ileovesicostomy acts as a “pop off” as the bladder fills and therefore the intravesical pressure will remain safe. Bladder neck fascial sling is not necessary as it is unlikely that this individual will have stress incontinence per urethra given her high abdominal LPP and her limited mobility. She is a quadriplegic and catheterization following augmentation cystoplasty through an abdominal stoma or her urethra increases her risks, dependence on a caretaker, and is not practical.

Question 12

A 50-year-old woman undergoes radical nephrectomy. Pathology reveals collecting duct carcinoma with invasion of the perinephric fat and microscopic involvement of one hilar node. Her metastatic evaluation is otherwise negative. The next step is:

A: observation.
B: XRT to the flank.
C: cisplatin and 5-FU.
D: tyrosine kinase inhibitor.
E: M-VAC chemotherapy.

Answer 12

A: “observation.” was the correct answer.

Collecting duct carcinoma is an unusual and aggressive type of renal tumor. While this patient is at risk for disease recurrence and progression, she is at this time without evidence of disease and no further therapy is indicated. There are no data that demonstrate efficacy of any form of adjuvant therapy.

Question 13

A 50-year-old man who underwent radical cystoprostatectomy and orthotopic bladder reconstruction five years ago develops congestive heart failure. The best treatment for his persistent hyperchloremic metabolic acidosis is:

A: furosemide.
B: citric acid and sodium citrate.
C: sodium bicarbonate.
D: chlorpromazine.
E: potassium citrate.

Answer 13

D: “chlorpromazine.” was the correct answer.

The treatment of hyperchloremic metabolic acidosis requires administration of alkalinizing agents or blockers of chloride transport. In patients in whom excessive sodium loads are undesirable, nicotinic acid or chlorpromazine may be administered to control the acidosis. Nicotinic acid and chlorpromazine inhibit cyclic AMP and thereby impede chloride transport. Furosemide will not correct the metabolic acidosis. Bicitra, sodium bicarbonate, and Polycitra all contain significant amounts of sodium which could potentiate the congestive heart failure.

Question 14

The chemotherapeutic agent most likely to be associated with increased toxicity because of reabsorption from an ileal neobladder is:

A: methotrexate.
B: gemcitabine.
C: vincristine.
D: doxorubicin.
E: cisplatin.

Answer 14

A: “methotrexate.” is correct.

Toxic metabolic effects secondary to drug reabsorption of methotrexate from intestinal mucosa used in urinary tract reconstruction can occur. Vigorous hydration, alkalinization of the urine, and catheter drainage can prevent this complication. The other agents given do not display a significantly increased toxicity because of intestinal reabsorption. Methotrexate is the smallest molecule of those listed, and therefore most likely to be absorbed.

Question 15

A 12-year-old boy complains of intermittent right scrotal pain two weeks after being kicked in the groin. Both physical examination of the scrotal contents and urinalysis during an episode of pain are normal. Doppler ultrasound of the testis demonstrates normal flow, and a 5 mm subtunical cystic lesion in the lower pole of the right testes without internal echoes or calcification. The next step is:

A: radical orchiectomy.
B: scrotal exploration and biopsy of the lower pole lesion.
C: repeat physical examination and urinalysis in three months.
D: repeat ultrasound in three months.
E: bilateral orchiopexy.

Answer 15

D: “repeat ultrasound in three months.” is correct.

The questions for this peripubertal boy with intermittent testicular pain are whether he has intermittent torsion and whether the lesion in the testis requires excision. With a normal physical examination; i.e., no horizontal lie to the testis, it is difficult to diagnose intermittent torsion especially since the problem has been evident for only two weeks. The lesion in the right testis is clearly a cyst by ultrasound and treatment for this would be observation with follow-up ultrasound in three months. True simple cysts of the testis are usually non-palpable, usually subtunical near the mediastinum of the testis, and rarely change on follow-up ultrasound. Complex cysts or cysts with calcification tend to be more associated with malignancy and require more aggressive management.

Question 16

A 62-year-old man with bothersome LUTS has an AUA Symptom Score of 26, despite an adequate trial of an alpha-blocker and finasteride. DRE reveals a 40 gm benign prostate. PSA six months ago was 2.3 ng/ml. Prior to KTP laser prostatectomy, the next step is:

A: urinalysis.
B: repeat PSA.
C: uroflowmetry
D: cystoscopy.
E: pressure flow urodynamics.

Answer 16

A: “urinalysis.” was the correct answer.

The only recommended test prior to surgery, beyond those already mentioned, is a urinalysis. A positive urinalysis may trigger other testing. PSA was normal within the last year and need not be repeated. Cystoscopy, uroflowmetry, and postvoid residual testing are all optional. Cystoscopy may be appropriate if the size of the prostate is in doubt, particularly if it may be too large for endoscopic management. Uroflowmetry, although not specific, may be a reasonable indicator of bladder outlet obstruction. Pressure flow testing is the best assessment for outlet obstruction but is costly, invasive, and not recommended routinely unless the diagnosis is in doubt - for example, younger men with small prostates and severe LUTS, or if there is concern for neurogenic detrusor dysfunction.

Question 17

Deletions or mutations on chromosome 3 are most common in which histologic subtype of RCC:

A: clear cell.
B: chromophobe.
C: collecting duct.
D: medullary cell.
E: papillary.

Answer 17

A: “clear cell.” was the correct answer.

Genetic alterations on chromosome 3 are common in the clear cell variant of RCC but are uncommonly found in the other histologic variants, suggesting distinct pathways to tumorigenesis. The VHL tumor suppressor gene located at chromosomal locus 3p25 is mutated in approximately 50% of clear cell type RCC. The mutations of this gene result in decreased expression of hypoxia inducible factor 1 (HIF1) and increased expression of vascular endothelial growth factor 1 (VEGF1), thereby resulting in increased angiogenesis.

Question 18

A four-year-old boy has renal failure due to membrano-proliferative glomerulonephritis. He has undergone a bilateral orchiopexy and proximal hypospadias repair as an infant. He is at greatest risk for development of:

A: gonadoblastoma.
B: NSGCT.
C: Sertoli cell tumor.
D: Wilms' tumor.
E: RCC.

Answer 18

D: “Wilms’ tumor.” was the correct answer.

A number of recognizable syndromes are associated with an increased incidence of Wilms’ tumor. Three syndromes that are well known to be at high risk for Wilms’ tumor development include Denys-Drash syndrome (male pseudohermaphroditism manifested by proximal hypospadias and cryptorchidism, membrano-proliferative glomerulonephritis, and nephroblastoma), Beckwith-Wiedemann syndrome (macroglossia, nephromegaly, hepatomegaly) and WAGR syndrome (Wilms’ tumor, aniridia, gonadoblastoma, and mental retardation. In patients with Denys Drash syndrome, the kidneys need to be monitored carefully and removed as renal failure occurs.

Question 19

The urodynamic finding most predictive of new onset hydronephrosis in a 32-year-old T10 spinal cord injured man managed with antimuscarinic medication and CIC is:

A: bladder compliance 100 cm H2O.
C: detrusor LPP 100 cm H2O.
E: detrusor areflexia at bladder capacity.

Answer 19

A: “bladder compliance 12. Patients with decreased bladder compliance are at great risk for development of upper tract deterioration. The amplitude of phasic involuntary bladder contractions is of little prognostic value due to their transient nature. Detrusor LPP of > 40 cm H2O is a risk factor for upper tract deterioration however it is not as significant as poor bladder compliance. Neither detrusor areflexia nor increased urethral closure pressures are independent risk factors for hydronephrosis unless associated with elevated storage pressures.

Question 20

A 38-year-old man has diarrhea and loses two liters of isotonic fluid. He drinks two liters of water for fluid replacement. These fluid shifts result in:

A: decreased renin secretion.
B: decreased aldosterone secretion.
C: two liters of water added to the extracellular fluid.
D: decreased ADH secretion.
E: water moving from intracellular fluid to extracellular fluid.

Answer 20

D: “decreased ADH secretion.” was the correct answer.

The entire two liters of isotonic fluid are lost from the extracellular fluid (ECF). Since the loss is isotonic, the osmolality of the ECF did not change and no water moved out of the cells. The two liters of ingested pure water are distributed throughout the entire body water compartment; one-third remains in the ECF, and two-thirds move into the cells. The addition of pure water lowers the osmolality. Even though the decreased ECF volume would stimulate ADH secretion, the reduced osmolality would inhibit it via the hypothalamic osmoreceptors. Osmoreceptor input usually predominates during such “conflicts” unless the ECF volume depletion is very large. Renin and aldosterone secretions would increase because of the decreased ECF volume.

Question 21

A patient complains of lack of erectile efficacy with 20 mg of tadalafil. He has used it six times and always takes it with dinner. The next step in treatment is:

A: continue 20 mg of tadalafil.
B: take on an empty stomach.
C: increase the dose of tadalafil.
D: change to vardenafil.
E: change to intracorporal alprostadil.

Answer 21

E: “change to intracorporal alprostadil.” was the correct answer.

The pharmacokinetic profile of the PDE5 inhibitors differs mainly in terms of the half life, with tadalafil having a significantly longer half life (17.5 hours) than vardenafil or sildenafil (4-6 hours). The other principle difference is in absorption with a concomitant fatty meal. Both vardenafil and sildenafil have decreased absorption with a high fat meal while the absorption of tadalafil is not affected by food consumption. Many studies show that at least four to six attempts may be needed to demonstrate that a patient will respond to PDE5 inhibitors. This patient has had an adequate trial of tadalafil and taking it on an empty stomach would not improve its efficacy. He has already been given the maximum FDA approved dose of tadalafil and increasing his dose will only increase the incidence of side effects. No level one evidence exists that switching PDE5 inhibitors will improve efficacy. Initiating treatment with intracorporal alprostadil would be a reasonable next step to efficaciously treat his erectile dysfunction.

Question 22

A 22-year-old man treated with bleomycin, etoposide, and cis-platinum for a Stage II mixed germ cell tumor of the testis has a residual abdominal mass. Preoperative pulmonary function testing discloses a mild reduction in forced vital capacity. The most important factor in minimizing the risk of post-operative pulmonary problems after RPLND is limitation of:

A: inspired oxygen concentration.
B: the extent of resection.
C: perioperative steroids.
D: I.V. fluids.
E: the length of the incision.

Answer 22

D: “I.V. fluids.” was the correct answer.

Current literature has challenged the classical teaching that oxygen exposure increases the likelihood of pulmonary toxicity in patients treated with bleomycin. In this study the factors associated with postoperative pulmonary problems were positive fluid balance, amount of blood transfused, surgical time, estimated blood loss, and forced vital capacity, while the fraction of inspired oxygen was not a predictor of adverse outcome. Avoiding overhydration was the most important factor in limiting pulmonary problems.

Question 23

The most significant difference between ureteroscopy and SWL in the treatment of a 1 cm lower pole kidney stone is:

A: stone free rate.
B: need for stenting.
C: length of stay.
D: postoperative complication rate.
E: return to work.

Answer 23

E: “return to work.” was the correct answer.
One study identified the major difference between SWL and ureteroscopy for lower pole stones was return to work, specifically 3.3 days following SWL compared to 8.5 days following ureteroscopy. Although SWL arguably provides acceptable first line therapy for stones 1 cm or less based on the initial randomized trial, ureteroscopy has been touted as a promising alternative that can improve the stone free rate with little additional morbidity over SWL. However, in this small trial investigators were unable to validate the hypothesis that ureteroscopy was superior to SWL. The stone free rate after ureteroscopy and SWL for lower pole stones of less than or equal to 1 cm was remarkably low and not statistically different between the two modalities. While the results of the study support that either SWL or ureteroscopy may be used in this situation, practitioners and patients must be cognizant of the limitations of treatment modalities that rely on spontaneous fragment passage to achieve a stone-free state.

Question 24

Compensatory renal growth in a child with a multicystic dysplastic kidney is most likely completed by:

A: first trimester.
B: birth.
C: age two.
D: adolescence.
E: one year after the multicystic dysplastic kidney is removed.

Answer 24

C: “age two.” was the correct answer.

Although the kidney contralateral to a multicystic dysplastic kidney does exhibit compensatory hypertrophy at birth, this occurs rapidly after birth, and by age two years, the hypertrophied kidney exhibits a GFR significantly greater than one normal sized kidney. This is not correlated with the removal of the multicystic kidney. Studies have demonstrated that compensatory renal growth can begin prenatally. Because the placenta provides the excretory function for the fetus, an increased excretory burden on the kidney is not required to initiate compensatory growth. Rather, alterations in growth factors or inhibitors presumably modulate the prenatal changes. Compensatory increase in renal mass in the adult is largely due to cellular hypertrophy. Neonatal glomerular hypertrophy results also from increased glomerular basement membrane surface area and proliferation of mesangial matrix.

Question 25

In well-controlled diabetic patients, which class of drug should be stopped 48 hours prior to elective major surgery: ``` A: glargine. B: insulin. C: rosiglitazone. D: chlorpropamide. E: metformin. ```

Answer 25

D: "chlorpropamide." was the correct answer. To stabilize glycemic control in patients taking insulin, frequent glucose monitoring should be performed, with insulin dosages adjusted appropriately. On the day before surgery, long-acting insulin can be continued throughout the day if the patient's control is good, particularly if the patient is using glargine. Oral agents are generally discontinued before surgery. Long-acting sulfonylureas (e.g., chlorpropamide [Diabinese]) are stopped 48 to 72 hours before surgery, while short-acting sulfonylureas, other insulin secretagogues, and metformin [Glucophage] can be withheld the night before or the day of surgery. No recommendations exist for discontinuation of thiazolidinediones (e.g. rosiglitazone [Avandia], pioglitazone [Actos]) before surgery; their extremely long duration of action probably indicates no rationale for stopping them at all.

Question 26

The normal epithelium of the distal bulbar urethra in the adult male is: A: transitional. B: stratified squamous. C: pseudostratified columnar. D: columnar.

Answer 26

C: "pseudostratified columnar." was the correct answer. Pseudostratified columnar epithelium lines the urethra from the membranous area to the fossa navicularis where stratified squamous epithelium becomes predominant. Transitional cell epithelium lines the prostatic urethra to the membranous area. Neither columnar nor keratinized squamous epithelium is normally present in the male urethra.

Question 27

Cystoscopy in a man often induces an increase in: ``` A: free PSA. B: complexed PSA. C: complexed/total PSA ratio. D: PSA velocity. E: prostate volume. ```

Answer 27

A: "free PSA." was the correct answer. Complexed PSA represents the fraction of total PSA that is circulating bound to other serum proteins, including antichymotrypsin and alpha-1 macroglobulin. Prostate manipulation including biopsy, cystoscopy, catheterization, and vigorous massage generally result in a transient increase in serum total PSA. Most of the rise in total PSA is contributed by the free (non-bound) component. In general, complexed PSA is the most stable component and relatively little rise occurs following prostate instrumentation. Complexed to total PSA ratio would decrease upon disproportionate free PSA increase. Due to the transient nature of PSA rise with prostate manipulation, PSA velocity is generally not affected.

Question 28

A five-year-old boy with hepatosplenomegaly develops progressive azotemia and a renal concentrating defect. Ultrasound of the kidneys demonstrates slight enlargement with multiple small (1-2 mm) cortical cysts. An uncle died of renal disease. The most likely diagnosis is: A: familial juvenile nephrophthisis. B: autosomal recessive polycystic kidney disease. C: autosomal dominant polycystic kidney disease. D: tuberous sclerosis. E: renal-retinal dysplasia.

Answer 28

B: "autosomal recessive polycystic kidney disease." is correct. The presence of autosomal recessive polycystic kidney disease varies depending on age. In older children, hepatosplenomegaly due to portal hypertension may be prominent and associated with renal interstitial fibrosis and cortical cystic disease. Autosomal dominant polycystic disease does not usually cause renal insufficiency at such an early age; the cysts are variable in size and occur throughout the kidney. Familial juvenile nephrophthisis and renal-retinal dysplasia are associated with renal cysts which are typically located in the medulla but the kidneys are usually shrunken and scarred. Renal cysts do occur in tuberous sclerosis but renal failure is usually attributed to multiple solid angiomyolipomas.

Question 29

The boundaries of the femoral triangle are the inguinal ligament: ``` A: adductor longus, and vastus medialis. B: pectineus, and iliopsoas. C: pectineus, and sartorius. D: adductor longus, and pectineus. E: adductor longus, and sartorius. ```

Answer 29

E: "adductor longus, and sartorius." is correct. The femoral triangle, also known as Scarpa's triangle, is bounded laterally by the medial margin of the sartorius. The medial boundary is the adductor longus and the inguinal ligament is superior. The floor of the triangle is composed of the pectineus muscle medially and the iliopsoas laterally. The location of the saphenofemoral junction is estimated to be at a point two fingerbreadths lateral and two fingerbreadths inferior to the pubic tubercle. These landmarks are important in a lymphadenectomy for penile cancer.

Question 30

An oliguric patient has a spot urine sodium of 8 mEq/l. The condition most consistent with this laboratory finding is: ``` A: prerenal azotemia. B: acute tubular necrosis. C: chronic pyelonephritis. D: renal tubular acidosis. E: acute urinary obstruction. ```

Answer 30

A: "prerenal azotemia." is correct. Urine volume is the difference between GFR and amount of water resorbed. If a normal adult has a GFR of 180 liters/day then 179 liters must be reabsorbed to have a urine volume of one liter. Anuria is described as urine volume that is virtually nil, i.e., less than 50 ml/day. Oliguria is substantially reduced urine volume (less than 30 ml/hour). Urine sodium concentration is usually below 25 mEq/l in volume depletion and above 40 mEq/l with normovolemia or acute tubular necrosis. A urinary sodium of only 8 mEq/l is most suggestive of prerenal azotemia. RTA and chronic pyelonephritis would not generally lower urinary sodium concentrations.

Question 31

A 33-year-old man has active genitourinary tuberculosis. His community has a 12% incidence of isoniazid resistant (INH) Mycobacterium. The initial treatment is INH and: ``` A: rifampin. B: rifampin, pyrazinamide. C: rifampin, ethambutol, pyrazinamide. D: rifampin, streptomycin. E: pyrazinamide, streptomycin. ```

Answer 31

C: "rifampin, ethambutol, pyrazinamide." was the correct answer. The best initial treatment of genitourinary tuberculosis is triple drug treatment for two months followed by two drugs for four months. The best combination is INH, rifampin, and pyrazinamide. If the INH resistance is above 4% in the patient's community, addition of ethambutol or streptomycin to the three drugs is advised. In 1991, resistance to one or more antituberculosis drugs was noted in 14.2% of patients with tuberculosis in the United States; 9.5% of patients had resistance to isoniazid or rifampin. Drug resistant tuberculosis has an increased prevalence in patients who are HIV-positive and among people who counsel HIV patients . Isolated isoniazid- resistant tuberculosis infections should be treated with rifampin, pyrazinamide, and ethambutol for six months. For patients who have tuberculosis strains that are resistant to rifampin, an alternate regimen of isoniazid and ethambutol for 18 months or isoniazid, pyrazinamide, and streptomycin for nine months are recommended.

Question 32

A 45-year-old man develops irritative symptoms and a fever of 39°C after beginning induction intravesical BCG therapy. The fever persists for three days despite administration of acetaminophen. Urinalysis reveals microscopic hematuria. After stopping BCG, the next step is: A: one week of fluoroquinolone antibiotic. B: one week of fluoroquinolone antibiotic followed by suppressive antibiotic therapy. C: isoniazid for three months. D: isoniazid and rifampin for six months. E: isoniazid, rifampin, and ethambutol for six months.

Answer 32

C: "isoniazid for three months." was the correct answer. Intravesical BCG is generally well-tolerated, but patients should be monitored for systemic infection with BCG and treated appropriately. In the absence of bacteruria, patients with persistent (> 24 hours) high fevers (> 38.5°C) that do not respond to antipyretic therapy, should have BCG treatment discontinued and INH therapy started. This may be an early sign of a systemic BCG infection. Double and triple therapy is reserved for patients who present with pulmonary or hepatic involvement with BCG.

Question 33

A 24-year-old infertile man has a normal physical examination, serum testosterone of 340 ng/dl and isolated oligospermia with normal volume on two semen analyses. His wife's evaluation is normal. The next step is: ``` A: repeat semen analysis. B: antisperm antibody testing. C: scrotal ultrasound. D: intrauterine insemination. E: adoption. ```

Answer 33

D: "intrauterine insemination." was the correct answer. The patient has oligospermia. No correctable abnormalities are present. Further evaluation with ultrasonography for a subclinical varicocele is not helpful. Since two semen analyses show the same defects, a repeat semen analysis will be of no value. If the two analyses were discrepant, another specimen would be useful. No indication for antisperm antibody testing is present. Intrauterine insemination is most effective for cervical-factor infertility or isolated oligospermia.

Question 34

An increased risk of genitourinary abnormality in the neonate is associated with: A: newborn serum creatinine of 1.2 mg/dl. B: maternal insulin-dependent diabetes. C: maternal hypertension. D: no urine from infant in first 20 hours. E: maternal history of multicystic kidney.

Answer 34

B: "maternal insulin-dependent diabetes." was the correct answer. The neonatal serum creatinine of 1.2 mg/dl reflects maternal creatinine and is not a matter of concern. Maternal diabetes mellitus (insulin-dependent) poses an increased risk for sacral agenesis and bladder dysfunction in the infant. Maternal hypertension is associated with some risk of renal vein thrombosis. Some infants do not pass urine in the first 24 hours. At 20 hours, no studies are indicated in the absence of other problems. Multicystic kidney is congenital, but not hereditary.

Question 35

A 62-year-old man with minimal LUTS prior to treatment develops urinary retention three weeks after undergoing 125I brachytherapy for prostate cancer despite tamsulosin 0.8 mg daily. Over the next nine months, he fails repeated voiding trials, refuses to perform CIC and has an indwelling urethral catheter. His prostate volume is 25 gm. The next step is: ``` A: finasteride. B: leuprolide acetate. C: suprapubic catheter. D: TUMT. E: TURP. ```

Answer 35

E: "TURP." was the correct answer. LUTS are common following brachytherapy and often seem to coincide with the half-life of the isotope (60 days for iodine-125 and 17 days for palladium-103). Usually these symptoms improve over time and respond to alpha-blocker therapy. Patient selection for brachytherapy is extremely important to avoid severe voiding dysfunction and urinary retention. Patients with significant pretreatment symptoms despite medical therapy are poor candidates for an implant as they are much more likely to have severe post-implant LUTS and a higher risk for urinary retention. In brachytherapy series, 2-8% of patients require TURP often within the first six months postimplant because of urinary retention. TURP should be delayed at least three months after the initial seed implantation. The resection should not be aggressive with preservation of apical tissue. Prior to three months, retention is best managed by CIC. Finasteride and leuprolide acetate would require months before any possible benefit and would not be effective in a patient with a small gland. A suprapubic catheter would provide drainage but has the associated problems of infection and bladder irritation. TUMT is contraindicated following radiation therapy.

Question 36

A 34-year-old man has azoospermia with a seminal volume of 2 ml and pH of 8.3. Physical exam shows small soft testicles each with a normal vas and epididymis. FSH is elevated to 3.5 times normal. The next step is: A: semen fructose determination. B: karyotype and Y chromosome microdeletion assay. C: fine needle testicular aspiration. D: scrotal exploration with testis biopsy and vasography. E: testicular microdissection and cryopreservation of sperm.

Answer 36

B: "karyotype and Y chromosome microdeletion assay." was the correct answer. Azoospermic men have an increased incidence of chromosomal abnormalities. Patients thought to have non-obstructive azoospermia should have both a karyotype and Y-chromosome microdeletion analysis. Of the three types of Y chromosome deletions, types a and b rarely if ever have sperm production in the testicles. Type c deletions have patchy sperm production in the testicles some of the time. The latter may benefit from testicular sperm retrieval but the types a and b deletions will likely not. With an FSH three times normal this patient will not have obstructive azoospermia and thus scrotal exploration and a vasogram are not indicated. Fine needle testicular aspiration for diagnosis is unnecessary. Both needle aspiration and testicular microdissection and cryopreservation of sperm are premature without prior genetic testing. In addition needle aspiration is less successful in retrieving sperm from non-obstructed azoospermic patients than open testicular sperm extraction. Semen fructose determination may demonstrate a low fructose concentration in patients with ejaculatory duct obstruction or congenital bilateral absence of the vas deferens. Both of these conditions are associated with low volume acidic semen specimens which are not present in this patient.

Question 37

A five-day-old boy has vomiting and dehydration. His serum CO2 is 12 mEq/l, K+ 5.5 mEq/l, and creatinine 2.2 mg/dl. A VCUG demonstrates posterior urethral valves and bilateral Grade 4 vesicoureteral reflux. The next step is: ``` A: percutaneous cystostomy. B: percutaneous nephrostomies. C: valve ablation. D: urethral catheter drainage. E: cutaneous vesicostomy. ```

Answer 37

D: "urethral catheter drainage." was the correct answer. The management of the infant with a PUV depends on the severity of the obstruction and the degree of any renal dysplasia present. The main problems arise in management of the infant with severe obstruction and compromised renal function with dehydration, acidosis, and sepsis. Initially, a small infant feeding tube, placed transurethrally, can provide bladder drainage. Once stabilized, valve ablation can be undertaken. Vesicostomy is reserved for infants who cannot undergo primary valve ablation because of the inadequate size of their urethra or for very small, unstable infants. If initial bladder level drainage does not result in satisfactory clinical improvement, temporary supravesical diversion may be considered, however the vast majority of these patients will be found to have renal dysplasia, not urethral vesical obstruction as the etiology the penile of the persistently elevated creatinine.

Question 38

The optimal stoma site for the of an ileal conduit is: A: 2 cm superior and lateral to the umbilicus. B: 5 cm lateral to the incision at the belt line. C: in the mid-axillary line lateral to the umbilicus. D: through the rectus muscle at the peak of the fat roll. E: lateral to the rectus muscle at the peak of the fat roll.

Answer 38

D: "through the rectus muscle at the peak of the fat roll." was the correct answer. The site of the stoma should be selected preoperatively. This is done with the patient in a sitting and supine position. Care is taken to place the stoma over the rectus muscle at least 5 cm from the planned incision line. The point chosen should be well away from any skin creases, scars, the umbilicus, belt lines or bony prominences. All stomas should be placed through the belly of the rectus muscle located at the peak of the infraumbilical fat roll. If the stoma is placed lateral to the rectus sheath, a parastomal hernia is likely to occur.

Question 39

The radionuclide that has the best tissue to background ratio is: ``` A: 99mTc-DTPA. B: 99mTc-MAG-3. C: 99mTc-DMSA. D: 99mTc-glucoheptonate. E: 123 I-iodohippuran. ```

Answer 39

C: "99mTc-DMSA." is correct. DMSA is bound to renal proximal tubule cells in progressive amounts over three to six hours. Over time, there will therefore be less background activity and a higher tissue to background ratio. This is particularly important with poorly functioning kidneys. MAG-3, DTPA and Hippuran are all excreted. Functional assessment is done in the first three minutes after injection, during which time there is considerable background activity. Glucoheptonate is a hybrid that is both excreted and bound.

Question 40

When comparing post-prostate biopsy hemorrhage to prostate cancer, the signal intensity of prostate cancer on T1 and T2 weighted MRI images is: ``` A: high T1 and high T2. B: low T1 and high T2. C: high T1 and low T2. D: low T1 and low T2. E: intermediate T1 and high T2. ```

Answer 40

D: "low T1 and low T2." was the correct answer. Prostate MRI scan, especially with combined endorectal and phase-array coils, is used in prostate cancer staging with up to 82% accuracy. The T1- and T2-weighted images are helpful in differentiating between postbiopsy hemorrhage, which presents as a high T1 and a low T2 lesion, and prostate cancer, which presents as a low T1 and low T2 lesion.