SASP 2011 Flashcards
A 66-year-old diabetic man with peripheral neuropathy and a 25 gm palpably normal prostate has urinary frequency, urgency, and urge incontinence. He voided 300 ml with a PVR of 380 ml. Urodynamic studies reveal a maximum uroflow of 8 ml/sec, a voiding pressure of 88 cm H2O, and a bladder capacity of 850 ml with decreased bladder sensation. Cystourethroscopy reveals mild trilobar prostatic enlargement. The most effective treatment is: A: CIC. B: CIC and oxybutynin. C: neuromodulation. D: tamsulosin. E: TURP.
E: “TURP.” was the correct answer.
Typically described urodynamic findings in diabetics include: impaired bladder sensation, increased cystometric capacity, decreased bladder contractility, impaired uroflow, and later, increased residual urine. The main differential diagnosis in men is the presence or absence of bladder outlet obstruction. In this patient, urodynamic data document bladder outlet obstruction as well as probable diabetic cystopathy. Cystourethroscopy excluded urethral stricture; thus, prostatic obstruction is the likely etiology. CIC with or without medications, is an acceptable treatment but in the face of prostatic obstruction, TURP will alleviate the symptoms provided the patient does timed voiding to prevent overdistention. Neuromodulation is not indicated in a patient with bladder outlet obstruction. Given the degree of bladder outlet obstruction and the amount of residual urine, tamsulosin is unlikely to be as effective as TURP.
Placement of a ureteral stent in an unobstructed system will result in:
A: increase in ureteral contractility.
B: decrease in ureteral contractility.
C: atrophy of the ureteral mucosa.
D: atrophy of the ureteral smooth muscle.
E: decrease in intrapelvic pressure.
B: “decrease in ureteral contractility.” was the correct answer.
A number of changes occur after placement of a ureteral stent including: hyperplasia and inflammation of the urothelium, smooth muscle hypertrophy, increased intrapelvic pressure, a decrease in ureteral contractility and vesicorenal reflux. Decreased ureteral contractility does contribute to vesicorenal reflex, which may have implications in infected systems in the setting of bladder outlet obstruction.
A 25-year-old man has a thickened, indurated fat mass excised from his spermatic cord at the time of inguinal hernia repair. Final pathology reveals low grade liposarcoma with negative margins. The next step is:
A: observation.
B: inguinal orchiectomy.
C: inguinal orchiectomy and RPLND.
D: inguinal orchiectomy and hemiscrotectomy.
E: inguinal/abdominal radiation.
B: “inguinal orchiectomy.” was the correct answer.
Liposarcoma of the paratesticular structures is most often associated with the spermatic cord. it is a rare tumor that is usually well-differentiated. As with all sarcomas of the paratesticular region, inguinal orchiectomy with high ligation of the spermatic cord with inguinal orchiectomy is generally advised to minimize the chance of local recurrence. Because of the low likelihood of hematogenous or lymphatic spread in a low grade sarcoma, additional radiation or chemotherapy would not likely be necessary. This tumor has a low likelihood of complete response to primary radiotherapy and therefore it is not a reasonable option. Hemiscrotectomy is unnecessary with no violation of the scrotum.
Serum osmolality is determined by utilizing a formula which involves the sum of which three osmotically active substances in the blood: A: sodium, potassium, glucose. B: sodium, chloride, urea nitrogen. C: sodium, glucose, urea nitrogen. D: albumin, glucose, creatinine. E: albumin, globulin, urea nitrogen.
C: “sodium, glucose, urea nitrogen.” was the correct answer.
Osmolality is estimated by computing the sum of serum sodium (mEq/l) x 2, glucose (mg/dl)/18 and urea (mg/dl)/3. These three solutes are the major contributers to osmolality with creatinine, magnesium, phosphate and potassium contributing less. The chloride contribution is taken into account by doubling the sodium concentration.
A 22-year-old man involved in an MVC is evaluated for multi-system trauma. CT scan shows complete enhancement of both kidneys, a 2 cm laceration in the lower pole of the left kidney, and a left perinephric hematoma. A 3 cm splenic laceration that does not extend to the hilum is also seen. He is managed with observation. Ten days later, he develops acute abdominal pain. On physical examination, he is diaphoretic and has a rigid abdomen. His temperature is 38.5°C, pulse 120/min, and blood pressure is 90/70 mm Hg. This clinical condition is most likely due to: A: delayed sepsis. B: persistent urinary extravasation. C: delayed renal hemorrhage. D: delayed splenic hemorrhage. E: missed bowel injury.
D: “delayed splenic hemorrhage.” was the correct answer.
Associated organ injury is common in patients with renal trauma. Nonrenal trauma accounts for the majority of the morbidity and mortality that occurs in such patients. As in the case described, CT allows staging of renal injury and detection of associated organ injury. Nonoperative management of both splenic and renal injury is possible in selected patients with renal injuries associated with limited extravasation and bleeding. Development of delayed bleeding, infection, or hypertension (related to the renal injury) is unlikely. Those cases where there are nonviable renal segments are more likely to require delayed laparotomy. Although splenic lacerations may be managed nonoperatively, up to 40% of those with Type II injuries (splenic laceration not extending to hilum) may require operative intervention. Although either injury described in the case presented may require delayed laparotomy, the splenic injury is more likely. The finding of the rigid abdomen suggests an intraperitoneal process. A missed bowel injury would present within the first several days after injury.
A 24-year-old man with azoospermia and an ejaculate volume of 0.5 ml has a palpably normal left vas deferens, a nonpalpable right vas deferens, and a normal DRE. Both testes measure 30 ml. The most useful diagnostic study for infertility is: A: TRUS. B: serum testosterone. C: post-ejaculatory urinalysis. D: testicular biopsy. E: seminal fructose.
A: “TRUS.” is correct.
The differential diagnosis for low ejaculate volume azoospermia is vasal agenesis, ejaculatory duct obstruction, and ejaculatory dysfunction. The presence of unilateral vasal agenesis on physical examination strongly suggests the presence of a congenital anomaly with contralateral segmental vasal atresia. TRUS will help differentiate between a potentially treatable ejaculatory duct obstruction and, more likely, absence or hypoplasia of the contralateral seminal vesicle and ampullary vas deferens. Patients with vasal agenesis do not require either a serum FSH or testicular biopsy unless they have testicular atrophy or another historical risk factor. Seminal fructose does not help differentiate between these two disorders; it is absent in both.
A 47-year-old man has palpable right inguinal adenopathy following partial penectomy for a 4 cm T2 squamous cell cancer. Needle biopsy of a right inguinal lymph node reveals metastatic cancer. The pelvic lymph nodes are radiologically normal. The next step is:
A: antibiotic therapy and reexamination.
B: pelvic node dissection.
C: right superficial inguinal node dissection.
D: right superficial and deep, left superficial inguinal node dissection.
E: bilateral superficial and deep inguinal node dissection.
D: “right superficial and deep, left superficial inguinal node dissection.” was the correct answer.
Men with invasive penile cancer are at high risk of inguinal metastasis. Those men who present with palpable inguinal lymph nodes often have an inflammatory or infectious etiology due to poor hygiene. In these patients, two approaches can be employed. Patients can be treated with a two to four week course of antibiotic therapy to assess for resolution of lymphadenopathy. Alternatively, fine needle aspirate of suspicious nodes can be performed at presentation. If positive, this removes the need for delayed therapy due to antibiotics. Men with palpable nodes proven positive for metastatic disease should undergo superficial and deep inguinal node dissection as those with limited nodal disease are found to have up to an 80% five year disease-free survival with complete resection of nodal disease. Owing to the high rates of cure achieved with aggressive resection in limited nodal disease, many have advocated early dissection in men with invasive penile cancer and no palpable lymphadenopathy. In these men, dissection can be limited to nodes superficial to the fascia lata unless positive on evaluation. In men with palpable disease on one side, contralateral superficial dissection is mandatory owing to the high rate of lymphatic cross-over. In these cases, contralateral metastasis is noted in 50% of patients.
The best predictor of immediate graft function following living donor renal transplantation is:
A: warm ischemia time.
B: cold ischemia time.
C: renal revascularization time.
D: total ischemia time.
E: donor kidney urine output just prior to nephrectomy.
E: “donor kidney urine output just prior to nephrectomy.” was the correct answer.
While both cold (storage) and warm (anastomotic) ischemic times have important roles in determining immediate function for deceased donor renal transplant recipients, these times are negligible in living donor transplantation and rarely affect immediate graft function. The single best determinant of immediate function in live donor transplantation is the functional status of the kidney at the moment it is removed from the donor.
A 10 Fr nephrostomy tube was placed uneventfully to drain a pyonephrotic kidney. Follow-up nephrostogram reveals a 6 cm staghorn calculus. The percutaneous nephrostomy tube enters directly into the renal pelvis. At time of percutaneous nephrolithotomy, optimal access is obtained via:
A: dilating the established nephrostomy tract.
B: a new percutaneous tract - middle anterior calyx.
C: a new percutaneous tract - middle posterior calyx.
D: a new percutaneous tract - inferior anterior calyx.
E: a new percutaneous tract - inferior posterior calyx.
E: “a new percutaneous tract - inferior posterior calyx.” is correct.
Percutaneous renal access into the collecting system should be as peripheral as possible to help avoid serious hemorrhage. Direct puncture into an infundibulum or into the renal pelvis substantially increases the risk of hemorrhage. The temptation to utilize a previously placed nephrostomy tube in a suboptimal location should be abandoned. A new percutaneous access should be established. Staghorn calculi are best approached through polar access. Inferior or superior pole entry optimizes access to most of the collecting system. An interpolar puncture hinders entry into the superior or inferior calyceal groups. A posterior calyceal puncture decreases the need to torque instruments into the collecting system and helps reduce hemorrhage and eases stone extraction.
The most useful parameter to assess the malignant risk of an incidental adrenal mass is tumor: A: grade. B: histology. C: isointensity on MRI scan. D: metabolic activity. E: size.
E: “size.” was the correct answer.
Incidentally discovered adrenal masses have been reported in up to 4.4% of abdominal CT scans, most commonly in female patients between the ages of 50 and 70 years. A small minority of adrenal masses will be malignant, most often due to adrenocortical carcinoma or metastases to the adrenal gland. The primary indication for surgery is suspicion of malignancy based on size criteria, radiographic findings, or interval growth documented on follow-up imaging. The most useful parameter for assessing risk of malignancy is size; 5-6 cm is generally considered worrisome enough for surgical excision. Tumor histology and grade do not readily predict metastatic behavior. A high signal intensity ratio on T2 weighted MRI images suggests that the lesion is not a benign adenoma. Metabolic activity is common in both benign and malignant adrenal masses.
In patients with androgen-independent metastatic prostate cancer, the median improvement in overall survival of docetaxel + prednisone every three weeks compared to mitoxantrone + prednisone is: A: 2.5 months. B: 4.5 months. C: 6 months. D: 12 months. E: 18 months.
A: “2.5 months.” was the correct answer.
Docetaxel is currently the only FDA-approved agent that has been shown to prolong survival in men with androgen-independent metastatic prostate cancer. In the pivotal trial of docetaxel, patients who received an every three week administration of the drug had a median survival of 18.9 months, as opposed to a 17.3 month median survival for patients who received docetaxel on a weekly basis and 16.4 months (difference of 2.5 months) for those who received mitoxantrone. The p-value comparing docetaxel every three weeks to mitoxantrone (which does not prolong survival but improves quality of life) was p=0.009. These findings led the FDA to approve docetaxel for use in these patients.
One month after L5 laminectomy, a 30-year-old woman develops lower extremity weakness, a residual urine of 300 ml, and an intermittent urinary stream. Videourodynamics demonstrates detrusor-sphincter dyssynergia. The most likely explanation is: A: pseudodyssynergia. B: recurrent lumbar disk herniation. C: cauda equina syndrome. D: undiagnosed multiple sclerosis. E: permanent nerve injury from disk.
D: “undiagnosed multiple sclerosis.” was the correct answer.
The urodynamic finding of detrusor external sphincter dyssynergia (DESD) indicates that a suprasacral spinal lesion is present. This cannot be explained by a recurrent hernia or permanent injury to L5. The most likely supraspinal lesion in a woman this age is multiple sclerosis.
Bacterial biofilms forming on implants and foreign bodies in the urinary tract are comprised of a(an):
A: surface film of compact microorganisms.
B: conditioning film comprised of carbohydrate molecules.
C: linking film from which plank-tonic organisms can arise and spread.
D: accumulation of microorganisms and their extracellular products forming a structured community.
E: layer of mucopolysaccharide excreted by bacterial cells to protect them from WBC infiltration.
D: “accumulation of microorganisms and their extracellular products forming a structured community.” was the correct answer.
Bacterial biofilms arise from bacterial adherence and growth of bacteria on solid surfaces and foreign bodies in the urinary tract. Bacteria form biofilms in a variety of environments, particularly on implants and stents in the urinary tract. A biofilm is defined as the accumulation of microorganisms and their extracellular products to form a structured community on a surface. Factors that influence bacterial adhesion to devices include the biomaterial surface characteristics, bacterial surface features, and the presenting clinical condition.
A 25-year-old man has inadequate erections since sustaining a pelvic fracture in a MVC two years ago. After a successful urethral stricture repair, he denies any difficulty with orgasm and ejaculation. Intracavernosal injection of 15 ug of prostaglandin E1 produces a soft erection. The next step is:
A: infusion cavernosography.
B: pelvic/pudendal arteriography.
C: infusion cavernosometry.
D: intracavernosal injection of 30 ug of prostaglandin E1.
E: color Doppler study of penile arteries.
E: “color Doppler study of penile arteries.” was the correct answer.
This patient most likely has either an arterial or a neurologic injury to explain his erectile difficulty. A neurologic lesion is less likely because of his failure to respond with an erection to a reasonable dose of prostaglandin E1. Patients with neurogenic injuries frequently respond to very low doses of intracavernosal agents. The major clinical question which needs to be answered is whether or not this patient has an arterial injury. Infusion cavernosography and infusion cavernosometry are studies which demonstrate the extent and site of corporovenous leakage. Fifteen ug of prostaglandin E1 is a reasonable dose of drug to administer and increasing the dose to 30 ug would likely not produce more information. The study of choice to determine the presence of arterial disease in this clinical situation is a color Doppler study of the penile arteries before and after the intracavernosal injection of vasoactive drugs. Only after arterial disease has been diagnosed and only when operative revascularization is under consideration should pelvic/pudendal arteriography be performed.
A 19-year-old woman is treated with ampicillin for a UTI and develops a pruritic groin rash. Physical examination reveals poorly marginated, red patches on her inner thighs, inguinal folds, and labia. Satellite papules and pustules are scattered at the periphery of the inflammatory process. The most likely diagnosis is: A: fixed drug reaction. B: contact dermatitis. C: candidiasis. D: molluscum contagiosum. E: lichen planus.
C: “candidiasis.” is correct.
Infection of the crural folds with Candida albicans and other Candida species is a very common condition. In women, Candida species are normal inhabitants of the gastrointestinal tract and are commonly present asymptomatically in the vagina. With a constant source of these organisms so nearby, it is not surprising that they frequently spread to the cutaneous aspects of the groin. The hallmark of cutaneous candidiasis is that of bright red inflammation. The initial changes occur at the apex of the crural fold; subsequently, the inflammatory plaque expands in a radial fashion to all surrounding skin. Generally small pustules overlying the red plaques can be identified, and sometimes, satellite lesions are found as solitary papulopustules separate from, but adjacent to the larger primary plaque. The degree to which pruritus is present varies greatly, but itching can be quite severe at times. A clinical diagnosis can be confirmed by culture. Alternatively, a KOH examination is useful if intact pustules are present. Fixed drug eruptions are typically circular hyperpigmented lesions. Contact dermatitis would not be expected to be bilateral. Molluscum contagiosum occurs primarily in children and has a different appearance, although a sexually transmitted form exists. Lichen planus has violacious flat topped papules and small white lesions on the genitalia.
A 63-year-old woman has lethargy and joint pain four years following sigmoid neobladder creation. Serum studies reveal bicarbonate 20 mEq/l, calcium 9.1 mg/dl, alkaline phosphatase 249 U/l, hematocrit of 34%. The next step is: A: oral calcium and Vitamin D. B: oral magnesium and Vitamin D. C: oral calcium and potassium citrate. D: intramuscular Vitamin B12. E: oral bisphosphonate.
C: “oral calcium and potassium citrate.” is correct.
Osteomalacia occurs when mineralized bone is reduced and the osteoid component becomes excessive. Osteomalacia has been reported in patients with all forms of urinary diversion but is most common in colonic continent diversion and especially in postmenopausal women. The metabolic acidosis is buffered by the bone with release of bone calcium. Correction of acidosis and calcium supplementation will result in symptomatic relief and restoration of bone density. Major alterations in serum bicarbonate are not usually present and calcium is usually low normal. Patients who develop osteomalacia generally complain of lethargy; joint pain, especially in the weight-bearing joints; and proximal myopathy. The alkaline phosphatase level is elevated. Although bisphosphonates will decrease bone resorption they do not address the root cause of the problem. Vitamin B12 deficiency is not seen in colonic urinary diversion.
The most appropriate perioperative management of a patient undergoing adrenalectomy for Cushing’s syndrome is:
A: hydration, alpha-blockers, and stress-dose steroids.
B: beta-blockers, stress-dose steroids and careful glycemic control.
C: potassium sparing diuretics and stress-dose steroids.
D: stress-dose steroids and careful glycemic control.
E: potassium sparing diuretics, stress-dose steroids, and careful glycemic control.
D: “stress-dose steroids and careful glycemic control.” was the correct answer.
Patients undergoing adrenalectomy for Cushing’s syndrome have an excess of corticosteroids from an adrenal adenoma or carcinoma. These patients need stress-dose steroids and careful glycemic control as they often have obesity and diabetes. Alpha-blockers and hydration are indicated perioperatively for patients with pheochromocytoma. Beta-blockers may also be necessary preoperatively for patients with pheochromocytoma if they are tachycardic after alpha-blockade. Potassium sparing diuretics are important for the perioperative management of patients with hyperaldosteronism (Conn’s disease) as they often have significant hypokalemia.
In chronic ureteral obstruction, the glomerular filtrate exits the renal pelvis primarily by: A: pyelosinus backflow. B: pyelolymphatic backflow. C: extravasation from the renal pelvis. D: reabsorption from renal pelvis. E: pyelovenous backflow.
E: “pyelovenous backflow.” was the correct answer.
Following acute ureteral obstruction, the renal pelvic pressure is initially elevated but gradually returns to normal. Glomerular filtrate exits the renal pelvis by extravasation into the perirenal spaces, pyelolymphatic backflow and pyelovenous backflow. It is believed that 80-90 percent of the filtrate in chronic hydronephrosis is reabsorbed in the tubules and exits via the renal veins.
A 47-year-old uncircumcised married man is diagnosed with high grade Ta squamous cell carcinoma of the foreskin. His wife should undergo: A: observation. B: HPV vaccination. C: Pap smear. D: imiquimod therapy. E: cervix biopsy.
C: “Pap smear.” was the correct answer.
HPV infection is associated with the development of penile cancer. Wives or ex-wives of men with penile cancer have a threefold higher risk of cervical carcinoma. The male partners of women with cervical intraepithelial neoplasia have a significantly higher incidence of penile intraepithelial neoplasia. Therefore, screening with Pap smear and pelvic exam is prudent in this setting. HPV vaccination is inappropriate because it is only effective prior to exposure. More aggressive therapy such as biopsy or topical therapy is inappropriate unless a diagnosis of cervix cancer is suspected on physical exam and Pap smear.
A 36-year-old woman with cerebral palsy on CIC develops urgency, incontinence with severe perineal skin ulceration. Urodynamics show a 200 ml capacity bladder with overactive contractions and no stress urinary incontinence. She has failed antimuscarinics. Due to her body habitus, CIC is difficult per urethra. The best management is:
A: detrusor myomectomy.
B: ileal conduit.
C: Indiana pouch.
D: bladder augmentation with catheterizable abdominal channel.
E: bladder augmentation with fascial sling.
D: “bladder augmentation with catheterizable abdominal channel.” was the correct answer.
Bladder augmentation represents the best solution to this complex problem; however, this will commit the patient to CIC. In selected circumstances such as this, a continent catheterizable abdominal channel in conjunction with a bladder augmentation is appropriate. The urethral sphincter is intact in this patient as evidenced by a very high abdominal leak pressure. In a patient desiring a continent solution, an ileal conduit would not be indicated. Use of an Indiana pouch would require ureteral-enteric reanastomosis and a small but definitive risk for upper tract obstruction at the anastamosis. Detrusor myomectomy has not been shown to improve capacity long-term.
A 47-year-old man with relapsing remitting multiple sclerosis has severe urinary frequency and incontinence. He has been treated with tamsulosin for six months with no improvement in his symptoms. Examination reveals a 40 gm smooth prostate. CMG, pressure-flow study is shown. The next step is: A: renal ultrasound. B: videourodynamics. C: MRI scan of the spine. D: TRUS. E: cystoscopy.
A: “renal ultrasound.” was the correct answer.
This urodynamic study documents neurogenic detrusor overactivity and detrusor external sphincter dyssynergia in a patient with MS. Videourodynamics would be redundant and unnecessary. Male MS patients with detrusor sphincter dyssynergia appear to be at greatest risk for urological complications including upper tract deterioration. The upper tracts must be assessed early in a male patient with dyssynergia. Cystoscopy is unlikely to influence treatment planning, and would not be the most appropriate first step. MRI scan of the spine would be indicated in the scenario of unknown pre-existing neurogenic disease, but is unnecessary with a diagnosis of MS. A TRUS would be unnecessary as a TURP would not be recommended treatment in the scenario of neurogenic voiding dysfunction.
A four-year-old boy with a PUV has a vesicostomy. Serum creatinine is 0.6 mg/dl. Ultrasound shows minimal hydronephrosis. Videourodynamics show a bladder capacity of 30 cc with a pressure of 14 cm H2O when leakage occurs from the vesicostomy with no reflux. Undiversion is considered. The best management is resection of the posterior urethral valves and:
A: ileal augmentation cystoplasty.
B: ileal augmentation with appendicovesicostomy.
C: bladder cycling via the vesicostomy.
D: primary closure of the vesicostomy.
E: autoaugmentation cystoplasty.
D: “primary closure of the vesicostomy.” was the correct answer.
There was at one time concern that a cutaneous vesicostomy caused permanent loss of bladder volume and compliance. However, recent studies show that it does not significantly affect either. Preoperative videourodynamics showing a small bladder capacity do not predict eventual functional bladder capacity. Approximately 75% of children will have normal bladder function after vesicostomy closure. The need for bladder augmentation is more related to the effects of the primary pathological condition on the detrusor. Augmentation cystoplasty is rarely needed after undiversion in patients with a PUV. The eventual need for augmentation should be assessed with sequential follow-up after the vesicostomy has been closed.
A 28-year-old man with Kallmann's syndrome is treated with hCG and FSH injections over two years. His serum testosterone and FSH levels are normal. His semen volume is 1.0 ml, sperm count is six million sperm/ml, and sperm motility is 90%. Well-timed sexual intercourse has not resulted in pregnancy for his wife, whose evaluation is normal. The next step is: A: intrauterine insemination. B: color Doppler scrotal ultrasound. C: ICSI. D: transrectal ultrasound. E: testis biopsy.
A: "intrauterine insemination." was the correct answer. Intrauterine insemination (IUI) is a highly effective treatment for men with normal semen parameters, especially normal sperm motility. IUI involves placing processed sperm via a catheter inserted through the cervix into the uterine cavity. This bypasses cervical mucous and higher numbers of motile sperm will be able to reach the fallopian tubes. Semen volume and sperm production is limited in men with Kallman's syndrome, because prostate, seminal vesicle and testicular size are affected. However, sperm quality tends to be completely normal. In vitro fertilization is not required at this point, and ICSI is unnecessary. Testis biopsy will not be helpful since the patient is not azoospermic. TRUS is useful to evaluate ejaculatory duct obstruction which is usually associated with azoospermia. It is not associated with Kallmann's syndrome.
A 74-year-old man has a 2 cm lower pole renal mass that enhances on CT scan. His medical history includes hypertension, congestive heart failure, and renal insufficiency with a creatinine of 1.8 mg/dl. The next step is:
A: renal mass biopsy. B: cryoablation. C: radiofrequency ablation. D: partial nephrectomy. E: radical nephrectomy.
A: “renal mass biopsy.” is correct.
Renal mass biopsy should now be considered in select patients with small renal masses to help stratify oncologic risk and offer the optimal treatment intervention. Most studies suggest that biopsy has an accuracy of over 90% in distinguishing benign vs. malignant histology and an associated 70-80% accuracy in assessing tumor histology and grade. Needle tract seeding is exceedingly rare. This patient has comorbidities that might encourage surveillance of his small renal mass, but a minimally invasive treatment would also be appropriate for an aggressive histology given the favorable tumor size and location. Knowing the histology could assist in counseling this patient, particularly since ~20% of small renal masses are benign. Radical nephrectomy would be inappropriate in treating a small exophytic lesion in a patient with renal insufficiency. Given the patient comorbidity and the potential morbidity of partial nephrectomy, a less invasive approach is favored in this setting. This patient is also a reasonable candidate for observation.
A 28-year-old woman in her third trimester of pregnancy has a cervical culture positive for Neisseria gonorrhoeae. She developed a skin rash and urticaria after taking penicillin previously. A skin test for penicillin allergy is negative. The most appropriate treatment is:
A: procaine penicillin G. B: tetracycline. C: erythromycin. D: ceftriaxone. E: spectinomycin.
D: “ceftriaxone.” is correct.
Ceftriaxone is the drug of choice for Neisseria urethritis and cervicitis. It is safe to administer during pregnancy. Tetracycline and spectinomycin should be avoided. Although erythromycin may be given, it is not the preferred antibiotic in this situation. The decision to administer penicillin to a patient with a history of allergy is dependent on the severity of the reaction and the availability of alternative drugs. Only one-fourth of those with a history of allergic reactions to penicillin have an adverse effect when re-challenged with the drug. Desensitization techniques may be of value to those with a history of major allergic reaction and where there is a strong need to give the drug. Ceftriaxone can be administered to women in their 3rd trimester.
The maximum yearly whole-body exposure to radiation recommended by the National Council on Radiation Protection is:
A: 1 rem. B: 5 rem. C: 10 rem. D: 50 rem. E: 100 rem.
B: “5 rem.” is correct.
Urologists may have significant occupational radiation exposure. It is important to wear radiation protection for the body, thyroid and eyes. Place the fluoroscopy beam under the table if possible and use the principle ALARA or “as low as reasonably achievable”. The maximum yearly dose recommended by the National Council on Radiation Protection is 5000 mrem or 5 rem.
Administration of I.V. mannitol prior to renal artery occlusion for partial nephrectomy helps prevent tissue damage by:
A: increasing cellular pH. B: preventing cellular edema. C: inhibition of Na/K ATPase. D: preventing lactic acidosis. E: limiting intracellular calcium influx.
B: “preventing cellular edema.” is correct.
Renal ischemia will deplete ATP energy stores, decreasing activity of active transport via Na+/K+ and Ca++/Mg++ ATPases. As a result, intracellular influx of Na+, Ca++, Cl- and water occur. The influx of water causes cellular swelling and tissue damage. The use of solutions containing impermeable solutes, such as mannitol, help reduce cellular edema. Additionally, mannitol infusion results in improved renal hemodynamics and an osmotic diuresis.
During a left laparoscopic pyeloplasty the inferior mesenteric artery is accidentally ligated. Blood supply to the left colon will be primarily maintained by:
A: left colic artery.
B: left colic artery and inferior hemorrhoidal arteries.
C: middle colic artery and superior hemorrhoidal arteries.
D: marginal artery and superior hemorrhoidal arteries.
E: middle colic and middle hemorrhoidal arteries.
E: “middle colic and middle hemorrhoidal arteries.” was the correct answer.
The inferior mesenteric artery supplies the main blood supply to the left colon via the left colic artery and superior hemorrhoidal arteries. When this is injured or ligated, blood supply is maintained proximally via the middle colic artery which is a branch of the superior mesenteric artery and distally via the middle and inferior hemorrhoidal arteries. The middle colic and hemorrhoidal arteries connect with each other via the marginal artery of Drummond. This artery runs parallel to the wall of the colon. It is important to maintain this artery during any dissection of the left colon in cases where injury to the inferior mesenteric artery may occur.
A 62-year-old man undergoes a TURBT at the dome. Final pathology reveals muscle-invasive small cell carcinoma. Metastatic work-up is negative. The next step is:
A: restaging TURBT. B: neoadjuvant cisplatin-based chemotherapy. C: XRT. D: partial cystectomy. E: radical cystoprostatectomy.
B: “neoadjuvant cisplatin-based chemotherapy.” was the correct answer.
Small cell carcinoma of the bladder is a relatively rare tumor of the bladder that may arise in combination with urothelial carcinoma. It is usually biologically aggressive with early vascular and muscular invasion. These malignancies usually respond to, but are not cured by, cisplatin-based chemotherapy regimens. Neither partial cystectomy nor intravesical chemotherapy is appropriate in this setting. Radiation or extirpative surgery alone may result in cure rates of 5 to 20%. However, neoadjuvant chemotherapy followed by surgery or radiation therapy results in cure rates of 40 to 65%. Therefore, the best treatment is cisplatin-based chemotherapy followed by an aggressive local treatment such as surgery or radiation if the patient does not progress.
Beta-lactamase inhibitors are useful for treating UTIs because they:
A: enhance entry of a second antimicrobial agent into bacteria.
B: protect a penicillinase-susceptible agent from hydrolysis.
C: are bactericidal.
D: are active against methicillin-resistant staphylococcus.
E: antagonize the bactericidal effect of penicillin-like drugs.
B: “protect a penicillinase-susceptible agent from hydrolysis.” was the correct answer.
Bacteria that make beta-lactamase (penicillinase) are resistant to penicillin because the beta-lactamase hydrolyzes the penicillin. The beta-lactamase inhibitors bind to beta-lactamase to make it unavailable for causing enzymatic hydrolysis of penicillinase-susceptible penicillin. In this way, clavulanic acid and sulbactam, inhibitors of microbial beta-lactamases, will allow hydrolysable penicillins to continue to be active against resistant organisms. These inhibitors do not enhance drug entry into bacteria, nor are they active against the bacteria on their own. They are used in combination with a penicillin-like antimicrobial agent such as: ticarcillin-clavulanic acid (Timentin), ampicillin-sulbactam (Unasyn), amoxicillin-clavulanic acid (Augmentin). Methicillin itself is a penicillinase-resistant penicillin, and as such the addition of a beta-lactamase inhibitor is not useful in treating bacteria already resistant to methicillin.
A 30-year-old woman complains of a vaginal discharge and odor. She has no itching, burning, or soreness. On physical examination, she has a malodorous, gray-yellow discharge. Microscopic examination of the discharge shows clue cells. A whiff test is positive. The etiology her vaginitis is:
A: Candida albicans. B: Gardnerella vaginalis. C: Trichomonas vaginalis. D: Chlamydia trachomatis. E: mucorrhea.
B: “Gardnerella vaginalis.” was the correct answer.
The presence of clue cells (vaginal epithelial cells whose borders are obscured by bacteria) and a positive whiff test (fish odor after adding potassium hydroxide to the discharge) are diagnostic of a Gardnerella vaginalis infection. The organism is not a tissue pathogen, so local symptoms are absent. Treatment with oral metronidazole is the standard. New molecular techniques have identified a biofilm containing mostly Gardnerella and Atopobium vaginae, which can persist after treatment; thus suppressive treatment with metronidazole gel can prevent recurrence. Candida vaginitis and Trichomonas vaginalis are diagnosed by finding the organisms that cause these infections on microscopic examination. Chlamydia causes a cervicitis, and mucorrhea (a clear or cloudy discharge) is normal.
Compared to primary penile prosthesis insertion, prosthesis revision is associated with an increased risk of: A: infection. B: mechanical failure. C: erosion. D: persistent penile pain. E: hemorrhage.
A: “infection.” was the correct answer.
Overall infection rates following initial penile prosthesis insertion range from 1 to 3%. This rate is considerably higher for revision surgery (7-18%). Antibiotic impregnation of prostheses components has reduced the risk of infection. Risk of mechanical failure, erosion, penile pain, and hemorrhage are not higher after repeat prosthesis insertion. Loss of penile size has been associated with delayed reimplantation, and so early replacement has been advocated for patients considering replacement.
The most likely neurologic deficit following nerve injury at the time of laparoscopic varicocelectomy is:
A: numbness on the base of the penis and anterior scrotum.
B: numbness on the anterior thigh.
C: numbness on the lateral thigh.
D: inability to extend the knee.
E: inability to adduct the thigh.
B: “numbness on the anterior thigh.” was the correct answer.
Laparoscopic varicocelectomy is a minimally invasive option for management of varicoceles. The genitofemoral nerve lies directly atop the psoas muscle. Approximately 4-5 % of patients undergoing laparoscopic varicocelectomy will complain of either temporary or permanent alterations in the sensory innervation of the anterior thigh consistent with injury to the genitofemoral nerve. The genitofemoral nerve arises from L1-L2, emerges from the psoas, passes posterior to the ureter and divides into the genital and femoral branches above the inguinal ligament. The femoral branch then passes behind the inguinal ligament and enters the femoral sheath. The genital branch enters the inguinal canal close to the internal inguinal ring to supply the cremaster muscle and the scrotal skin. The ilioinguinal nerve (numbness on the base of the penis and anterior scrotum) and lateral femoral cutaneous nerve (numbness on the lateral thigh) run at least 3 cm lateral to the internal ring and, therefore, should be at little risk during routine laparoscopic varicocelectomy. The obturator nerve (inability to adduct the thigh) is medial and caudal to the iliac vessels and should not be injured during varicocelectomy. The femoral nerve (inability to extend the knee) is deep in the psoas muscle. It can be injured during open surgery with retraction but injury is unlikely during laparoscopy.
A 54-year-old woman underwent radiation therapy for cervical cancer two years ago now has microscopic hematuria. TUR of a lesion 2 cm above the left ureteral orifice reveals an inverted papilloma. Three days post-operatively, she develops a vesicovaginal fistula. The best treatment is: A: immediate transvaginal repair. B: transvaginal repair in six months. C: immediate transabdominal repair. D: transabdominal repair in six months. E: urinary diversion.
C: “immediate transabdominal repair.” was the correct answer.
In a woman with no evidence of abscess formation or a fluid collection, there is little need to wait an extended period of time before fistula repair. The abdominal approach provides better access to a radiation induced fistula and allows an omental pedicle flap to be interposed between the bladder and vaginal wall. Obliteration of dead space, good bladder drainage, control of infection and interposition of healthy tissue are critical elements to fistula closure.
Primary hyperaldosteronism caused by bilateral adrenal hyperplasia is best managed by:
A: salt restriction.
B: spironolactone administration.
C: captopril administration.
D: unilateral adrenalectomy of the larger adrenal.
E: bilateral adrenalectomy.
B: “spironolactone administration.” is correct.
Patients with bilateral adrenal hyperplasia are best treated medically. Bilateral adrenalectomy will sacrifice glucocorticoid and mineralocorticoid function. Moreover, either partial or unilateral adrenalectomy will not correct the hypertension accompanying this disorder. While patients become hypokalemic with hyperaldosteronism, neither potassium supplementation nor salt restriction will correct the etiology of the hypertension. Captopril may be indicated in a subset of primary hyperaldosteronism patients in whom aldosterone production is not completely autonomous from angiotensin II stimulation.
A six-year-old boy has a history of a PUV treated with endoscopic resection. He now has worsening bilateral hydronephrosis and his serum creatinine has increased from 0.6 to 1.0 mg/dl over the past nine months. He is dry and has no voiding complaints. Videourodynamics reveal no reflux, near complete emptying without outflow obstruction and filling pressures of 20 cm H2O at 220 ml and 32 cm H2O at 280 ml. The initial plan should be:
A: voiding diary. B: start oxybutynin. C: start alpha-blocker. D: nocturnal indwelling catheter. E: initiate CIC every four hours.
A: “voiding diary.” was the correct answer.
Children with correction of severe obstructive uropathy will sometimes demonstrate a persistent decrease in renal concentrating ability. This tends to worsen with growth and may lead to very high obligate urine output. This output can, at times, be so high that children cannot void frequently enough to maintain safe intravesical pressures; hydronephrosis and rising creatinine will ensue. This boy appears to void without obstruction. He does have reduced bladder compliance (as many valve patients do), but his pressures only reach 32 cm H2O by 280 ml - which should be an average six-year-old bladder capacity. However, if his urine output is very high, then he will reach this capacity very quickly after voiding. While he may eventually need timed voiding, antimuscarinic medication, CIC, or use of a nocturnal indwelling catheter, none of them can be used in a logical way without first knowing more about the patient’s daily urine output volume. An alpha-blocker is not indicated in this patient.
The urine sample that should be collected for pH testing to establish the diagnosis of RTA is:
A: fasting. B: postprandial. C: diurnal. D: nocturnal. E: hydrated.
A: “fasting.” was the correct answer.
Distal RTA (Type I) is commonly associated with urinary calculi, primarily calcium phosphate stones. The hallmark of RTA is an inability to acidify the urine. Initial screening for RTA can be done by measuring the pH of the second voided morning urine specimen after the patient has fasted overnight. The second voided specimen is better than the first because the first voided specimen may have an elevated pH as a result of pre-fasting food intake.
A six-year-old girl has a palpable abdominal mass. CT scan demonstrates a 5 cm mass in the lower pole of the left kidney and a 2 cm lesion in the upper pole of the right kidney. Biopsy of the left renal mass shows Wilms’ tumor. The next step is:
A: chemotherapy.
B: chemotherapy and XRT.
C: bilateral partial nephrectomies.
D: left radical nephrectomy and right partial nephrectomy.
E: left radical nephrectomy and chemotherapy.
A: “chemotherapy.” was the correct answer.
There is current controversy as to whether patients with Wilms’ tumor should undergo primary surgical exploration or initial pre-operative chemotherapy. However, there is general consensus that there are several instances when surgical therapy should not be undertaken, other than biopsy. This includes vena caval extension of the tumor above the hepatic veins, inoperable tumor, and bilateral disease. Bilateral disease is seen in about 5% of cases. In these cases, therapy is directed towards preservation of renal tissue since there is high incidence of renal failure, especially when a primary nephrectomy is undertaken. Thus, primary chemotherapy is indicated in patients with bilateral disease with a subsequent surgical exploration following completion of the first course of chemotherapy.
An oligospermic man who takes 25 mg of clomiphene citrate a day will usually have a:
A: low serum LH. B: low serum FSH. C: low serum estradiol. D: high serum testosterone. E: high prolactin.
D: “high serum testosterone.” is correct.
Clomiphene citrate is an antiestrogen that blocks the negative feedback of estrogen on the hypothalmus and pituitary. It will raise the serum FSH, LH, and testosterone. Estradiol may also rise because of peripheral conversion of testosterone through the action of aromatase. When used for idiopathic oligospermia, the majority of (but not all) controlled studies show no effect on pregnancy rates. Clomiphene citrate does not affect prolactin levels.
An eight-year-old girl has urinary urgency, urge incontinence, and constant leakage of urine between voids. She is started on timed voiding and has improvement with the urge incontinence but still has constant urinary leakage. An ultrasound does not show any evidence of hydronephrosis or bladder wall thickening. The next study that will most definitively diagnose her problem is:
A: MRI scan of the abdomen. B: MRI scan of the spine. C: VCUG. D: videourodynamics. E: MAG-3 renal scan
A: “MRI scan of the abdomen.” was the correct answer.
The clinical history strongly suggests that this girl has an ectopic ureter even though the ultrasound does not show evidence of this. The absence of an abnormality on ultrasound does not rule out an ectopic ureter. Occasionally, the renal parenchyma from the upper pole of the kidney that is associated with the ectopic ureter is difficult to locate and may be identified only by alternative imaging studies. In cases in which an ectopic ureter is strongly suspected because of incontinence yet no definite evidence of the upper pole renal segment is found, magnetic resonance imaging (MRI or CT scanning) will likely demonstrate the small, poorly functioning upper pole segment and ureter. None of the other options will adequately visualize the ectopic ureter.
Stage III prolapse in the Pelvic Organ Prolapse Quantification (POPQ) system occurs when the most distal portion of the prolapse is:
A: 1 cm or less proximal or distal to the hymenal plane.
B: 1 cm or less proximal or distal to the introitus.
C: > 1 cm below the hymen; entire vagina has not prolapsed.
D: > 1 cm below the introitus; entire vagina has not prolapsed.
E: associated with complete vaginal eversion.
C: “> 1 cm below the hymen; entire vagina has not prolapsed.” was the correct answer.
The International Continence Society has established a standardized system to quantify pelvic organ prolapse, this classification is known as the POPQ system an acronym that is short for pelvic organ prolapsed quantification. The system uses the hymenal ring as its central identification point, the hymen was chosen over the vaginal introitus because it can be more precisely located within the vaginal vault, all measurements are based from this location. This classification avoids the use of the terms cystocele or rectocele, recognizing that the actual organ prolapsing may be unable to be determined by a physical examination. The examination to determine POPQ stage is performed in a dorsal lithotomy position with the patient straining. The POPQ staging system has excellent inter-observer and intra-observer reliability and has become the standard for reporting outcomes following prolapsed repair. The staging system is however not perfect and can be significantly affected by patient positioning, with the degree of the prolapsed being more severe if the patient is examined with the head of the table raised to 45 degrees or higher. In addition, it fails to assess for unilateral or asymmetric defects. The POPQ staging systems is defined as: Stage 0 - no prolapsed Stage I - the most distal portion of the prolapse is more than 1 cm above the hymen. Stage II - the most distal portion of the prolapse is +/-1 cm above or below the hymen. Stage III - the most distal portion of the prolapsed protrudes > 1 cm below the hymen and the total vagina has not prolapsed. Stage IV - the entire vagina everts-complete prolapse.
A 45-year-old man with congestive heart failure develops epididymitis. His current medications include digoxin, enalapril and amiodarone. The next step in management is:
A: administer ciprofloxacin. B: discontinue enalapril. C: discontinue amiodarone. D: discontinue digoxin. E: administer doxycycline.
C: “discontinue amiodarone.” was the correct answer.
The incidence of epididymitis during amiodarone therapy is reported to be as high as 11%. Epididymitis usually resolves with discontinuation of this medication, which should be done under the supervision of the treating cardiologist. Dose reductions of amiodarone may also improve symptoms. This condition has been associated with high serum or epididymal levels of amiodarone or its metabolites. The development of anti-amiodarone antibodies may play a role in the pathophysiology of this disorder. Lymphocytic infiltration and fibrosis of the epididymis are seen on histologic analysis. There is no bacterial etiology and thus antibiotics are not indicated.