SASP 2012

Question 1

The most common cause of catheter-associated UTI is: A: improper catheterization technique. B: urethral meatal bacteria. C: break in the drainage system. D: urinary drainage bag bacteria. E: bacterial antimicrobial resistance.

Answer 1

B: urethral meatal bacteria

Question 2

A 62-year-old man with a serum creatinine of 4.7 mg/dl has persistent bleeding after TURP. The bleeding time is prolonged, but the PT, PTT, fibrinogen and platelet count are normal. The best treatment is: A: aminocaproic acid. B: Vitamin K. C: fresh frozen plasma. D: desmopressin. E: platelet transfusion.

Answer 2

D: desmopressin

Question 3

A 52-year-old woman has acute onset of right flank pain. She has a long-standing history of diarrhea secondary to laxative abuse. Urinalysis shows numerous RBCs and a pH 6.5. While in the emergency room she passes a small stone. The most likely stone composition is: A: xanthine. B: uric acid. C: struvite. D: ammonium acid urate. E: calcium phosphate.

Answer 3

D: ammonium acid urate

Question 4

A 35-year-old man with C5 quadriplegia has urinary incontinence managed by condom catheter drainage. Urodynamics reveal a detrusor LPP of 60 cm H2O at 150 ml. The next step is: A: observation. B: CIC. C: antimuscarinic medication. D: external sphincterotomy. E: male sling.

Answer 4

D: external sphincterotomy

Question 5

A seven-year-old boy has had multiple repairs for penoscrotal hypospadias. He has recurrent lower UTIs and postvoid dribbling. Renal ultrasound is normal and a pelvic ultrasound is shown. The most likely diagnosis is: A: mesonephric duct cyst. B: ectopic ureter. C: Cowper’s duct cyst. D: prostatic utricle. E: bladder diverticulum.

Answer 5

D: “prostatic utricle.” is correct. In boys with proximal hypospadias, the prostatic utricle is often enlarged due to a lack of androgen action. In the female, this would represent the distal 1/3 of the vagina. The ultrasound demonstrates a midline cystic structure behind the bladder which is consistent with a prostatic utricle. While an ectopic ureter, bladder diverticulum, or mesonephric duct cyst could have a similar appearance, they are usually lateral in location. In addition, the history of proximal hypospadias would make a utricle most likely. A Cowper�s duct cyst should be confined to the bulbous and prostatic urethra.

Question 6

The blood supply to the left adrenal gland is derived from branches from the following arteries: A: aorta and renal. B: renal and splenic. C: renal, splenic, and inferior phrenic. D: aorta, renal, and inferior phrenic. E: aorta, renal, and splenic.

Answer 6

D: “aorta, renal, and inferior phrenic.” was the correct answer. The blood supply for both the right and left adrenal glands is the same. The three sources for each adrenal gland are derived superiorly from branches of the inferior phrenic artery, in the middle directly from the aorta, and inferiorly from the ipsilateral renal artery.

Question 7

Using a monopolar loop, two > 3 cm bladder tumors are endoscopically resected from the bladder dome and left trigone. At the end of the procedure, suprapubic distension is noted. Blood drawn at this point is most likely to reveal: A: anemia. B: high glycine level. C: hyperammonemia. D: hyponatremia. E: elevated BUN.

Answer 7

D: “hyponatremia.” was the correct answer. This patient most likely has bladder perforation related to resection at the base of one of these superficial tumors. The bladder dome is often quite thin and is at high risk for perforation during resection. Also, obturator nerve stimulation can cause muscular spasm during resection of a laterally located tumor and this sudden motion may lead to perforation with the resecting loop. The monopolar current requires glycine or another non-electrolyte containing solution to be used in order to avoid dispersion of the current. Extravasation of the irrigation solution is the likely cause of the suprapubic distension. Glycine is quickly metabolized in the liver after absorption and is unlikely to be detected in the serum. However, the remaining extravesical fluid is free water and will cause acute dilutional hyponatremia as it is absorbed. Ammonia should not be elevated in this circumstance and serum BUN only goes up over a longer period of time if there is extravasation of urine with secondary resorption from exposed tissues. It is unlikely that there has been vessel injury from these superficial resections that is severe enough to cause anemia and suprapubic distension acutely.

Question 8

A 20-year-old man with cystinuria has recurrent calculi despite dietary therapy and hydration. The next step is: A: acetohydroxamic acid. B: Tham-E. C: N-acetylcysteine. D: D-penicillamine. E: alpha-mercaptopropionylglycine.

Answer 8

E: “alpha-mercaptopropionylglycine.” is correct. Cystinuria should be managed initially with hydration and, perhaps, alkali therapy. The solubility of cystine does not significantly increase until the urinary pH reaches 7.5. At this pH, calcium phosphate precipitation may occur. Specific therapy would include use of either D-penicillamine or alpha-mercaptopropionylglycine (Thiola). D-penicillamine is less well-tolerated and approximately 50% of patients stop this therapy due to side effects. Tham-E is an alkalinizing agent used for irrigation. Acetohydroxamic acid is a urease inhibitor used for the management of infection stones. Captopril may be effective in reducing urinary cystine excretion in patients who have not responded to therapy with alpha-mercaptopropionylglycine and D-penicillamine or who are intolerant of these agents.

Question 8

A 22-year-old man sustains a complete T8 spinal cord injury. Four weeks after the injury, the urodynamic profile is best characterized by: A: detrusor overactivity, functional smooth sphincter, guarding reflex present. B: detrusor overactivity, functional smooth sphincter, guarding reflex absent. C: detrusor areflexia, functional smooth sphincter, guarding reflex absent. D: detrusor areflexia, smooth sphincter dyssynergy, guarding reflex absent. E: detrusor areflexia, functional smooth sphincter, guarding reflex present.

Answer 8

C: “detrusor areflexia, functional smooth sphincter, guarding reflex absent.” was the correct answer. Spinal shock after spinal cord injury is the result of absent somatic reflex activity and suppression of somatic and autonomic activity below the level of the injury. It typically lasts six to twelve weeks but can last up to two years. At four weeks after injury, spinal shock continues and is manifested by bladder areflexia, a functional smooth sphincter and an absent guarding reflex (the ability of the striated sphincter to contract during bladder filling). After spinal shock, a T8 SCI patient is likely to have detrusor overactivity, smooth sphincter synergia (because T8 is below sympathetic outflow) and absent guarding reflex.

Question 9

A 32-year-old man has left flank pain. Scout film and retrograde pyelogram are shown (A calyceal diverticum and stone inside). The next step is: A: CT scan without contrast. B: CT scan with I.V. contrast. C: SWL. D: PCNL. E: laparoscopic calyceal diverticulectomy.

Answer 9

A: “CT scan without contrast.” was the correct answer. The image demonstrates an upper calyceal diverticulum. SWL is not recommended for the management of calyceal diverticulum with a narrow diverticular neck, as shown here, as fragments are unlikely to clear. PCNL and laparoscopy are appropriate alternatives for management of a calyceal diverticulum. However, before the choice of procedure can be made, it is important to determine whether the diverticulum is in an anterior vs. posterior location, as well as the relationship of the pleura and adjacent organs. PCNL would be utilized for a posterior diverticulum, while laparoscopy would be utilized for an anterior diverticulum. A CT scan without contrast will provide information for each of these variables. The CT scan will also determine the amount of parenchyma overlying the diverticulum. I.V. contrast would not be necessary as the retrograde pyelogram delineates the calculi within the diverticulum.

Question 10

Homologous natural cycle artificial insemination for couples with male factor infertility due to oligoasthenospermia is: A: only effective if placed intracervically. B: only effective if placed intrauterine. C: no more effective than timed vaginal intercourse. D: most effective in women with tubal disorders. E: most useful with counts of

Answer 10

C: “no more effective than timed vaginal intercourse.” was the correct answer. Natural cycle refers to allowing the woman to ovulate on her own without pharmaceutical induced stimulation of the development of multiple follicles through ovulation induction. In men with male factor infertility due to abnormal semen parameters, natural cycle intracervical or intrauterine insemination (IUI) is no better than timed vaginal intercourse. Those techniques are only useful in infertility caused by mechanical problems such as hypospadias, retrograde ejaculation, or impotence. Natural cycle IUI is useful in pure cervical factor infertility. Pregnancy rates with IUI are increased in couples with abnormal semen parameters if the woman undergoes ovulation induction. Clomiphene citrate and gonadotropins are commonly used medications for ovulation induction. Women with tubal abnormalities are best treated with in vitro fertilization since inseminated sperm still need to ascend through the fallopian tubes. The higher the total motile sperm count the better the pregnancy rate, therefore those with a sperm count > 10 million will fare better than those with

Question 11

A 48-year-old man has an AUA Symptom Score of 26 and a bother score of 4, recurrent UTIs, and significant bladder outlet obstruction documented on urodynamics. He wants to maintain fertility. He has failed medical therapy. The next step is: A: CIC. B: unilateral TUIP. C: bilateral TUIP. D: laser vaporization of the prostate. E: TURP.

Answer 11

B: “unilateral TUIP.” was the correct answer. A frequent complication of bladder outlet surgery for the treatment of obstruction is retrograde ejaculation. While this can be overcome with bladder harvested sperm most men who desire to maintain their fertility want normal antegrade ejaculation. The incidence of retrograde ejaculation is very high after TURP (up to 95%). TUIP has a much lower incidence of retrograde ejaculation (0% to 37%) and in many series is as effective as TURP. With a unilateral incision the incidence of retrograde ejaculation is less than 5%, and with two incisions, it is 15%. Laser vaporization has an associated risk of retrograde ejaculation that may be as high as TURP. While CIC would likely preserve antegrade ejaculation it is less desirable in a healthy young man

Question 12

The principal source of operator radiation exposure during endourologic procedures is: A: the primary radiation beam. B: radiation leakage from the x-ray tube. C: radiation scatter from the patient. D: radiation scatter from endoscopic instruments. E: radiation scatter from the operating room walls and floor.

Answer 12

C: “radiation scatter from the patient.” was the correct answer. Scattering of the primary beam from the patient is the primary source of radiation exposure to the operator during endourologic procedures. For this reason, maximizing the distance between the operator and the patient during fluoroscopy is a very effective method of reducing exposure. This explains why the fluoroscopy source is best placed under the patient to minimize radiation scatter to the operator.

Question 13

A 45-year-old woman has new onset frequency, urgency, and urge incontinence. Urinalysis is negative. Residual urine is 90 ml. CMG reveals phasic detrusor overactivity throughout filling. During volitional voiding, there is simultaneous contraction of the external sphincter. The next step is: A: referral for neurological evaluation. B: cystoscopy and cytology. C: antimuscarinic therapy. D: intradetrusor onabotulinum toxin injections. E: intradetrusor and intrasphincteric onabotulinum toxin injections.

Answer 13

A: “referral for neurological evaluation.” was the correct answer. This patient has detrusor external sphincter dyssynergia (DESD)based on the urodynamic evaluation. By definition, this implies the presence of a lesion between the pons and the lower spinal cord. Multiple sclerosis needs to be strongly considered given this patient’s demographic information and urodynamic findings. Approximately 5-10% of patients with MS present initially with urologic complaints. Cystoscopy is not indicated, and bladder cancer is not likely in the age demographic and with a negative urinalysis. Antimuscarinic therapy may ultimately be helpful, though the residual would need to be monitored closely in the presence of DESD. Patients should be evaluated for possible neurological process due specifically to the finding of DESD. Onabotulinum toxin injections should not be utilized until a definitive diagnosis has been made.

Question 14

A 60-year-old man sustains an avulsion injury of the scrotum. Ninety percent of the scrotal skin is lost. The next step after one week of debridement and local wound care is: A: rotational thigh skin flap. B: full thickness skin graft. C: placement of testicles in thigh pouches. D: split thickness skin graft. E: scrotal skin mobilization and direct closure.

Answer 14

D: “split thickness skin graft.” is correct. Scrotal reconstruction can be performed in many ways depending on the characteristics of the patient, mechanism of injury, and degree of skin loss. Limited skin loss can be managed with mobilization of remaining scrotal skin and direct closure as the scrotal skin is very pliable and will expand to cover relatively large defects. In this case a 90% loss makes this option impossible. More extensive skin loss can be managed with skin grafts, local flaps or tissue expanders. Rotational flaps provide a sensate and hair bearing scrotum but require more extensive dissection and have been generally supplanted by skin grafting. Full thickness skin grafts are reserved for selected cases where small surface areas are required and contraction is especially problematic, but not useful in this case due to 90% scrotal loss. Thigh pouches are acceptable but generally temporizing measures except in the most debilitated patients. Reconstruction is most easily accomplished with the use of split-thickness skin grafts which can cover large areas of skin loss and provide for complete scrotal reconstruction. Advantages of split thickness skin grafts include their high success rate and the fact that, when healed, they mimic the rugate appearance of the normal scrotal skin. Disadvantages include lack of hair and the fact that they may retract. Retraction can be minimized by avoiding expansion of the graft (i.e. 2:1 or 3:1 meshing). Skin grafts should never be placed on an acute injury due to bacterial contamination that will usually result in graft loss. Delayed grafting five to seven days post-injury in the presence of a clean graft bed will result in increased graft take.

Question 15

A 47-year-old woman is undergoing percutaneous test stimulation of a lead for sacral neuromodulation. Plantar flexion and rotation of the foot is noted along with sensation in the buttock. The next step is to: A: maintain lead and discharge home. B: place the lead one foramen higher and re-test. C: place the lead one foramen lower and re-test. D: advance the lead deeper into the foramen and re-test. E: withdraw the lead to a more superficial location in the foramen and re-test.

Answer 15

C: “place the lead one foramen lower and re-test.” was the correct answer. The motor and sensory responses noted are consistent with incorrect placement of the lead into the S2 foramen. The lead should be removed, replaced one foramen lower (S3), and re-tested. Placing more deep or shallow will not result in appropriate stimulation. Correct placement of the lead into the S3 foramen will result in a Bellows reflex, a contraction of the perineal area, and plantar flexion of the ipsilateral great toe.

Question 16

A 65-year-old man has lethargy, malaise, and a markedly diminished urinary stream. After urethral catheterization, he experiences a postobstructive diuresis that is managed by appropriate fluid replacement. Urine output is 1,500 ml daily. Serum creatinine and BUN are 6.8 mg/dl and 95 mg/dl respectively, and unchanged three days later. The next step is: A: continued observation. B: retrograde pyelography. C: dialysis. D: renal ultrasound. E: increased fluid replacement.

Answer 16

D: “renal ultrasound.” was the correct answer. In patients with urinary obstruction and impaired renal function, postobstructive diuresis is not unusual. Typically, urinary catheter drainage produces improvement in the blood levels of creatinine, BUN, and electrolytes to normal levels. If significant improvement does not occur, consideration must be given to inadequate drainage of the upper urinary tract because the bladder is poorly drained (poorly functioning catheter) or because of supravesical obstruction. The latter should be evaluated using renal ultrasound which is less invasive than retrograde pyelography. Since creatinine and BUN have not improved, continued observation is inappropriate until upper tract obstruction is ruled out. No data to suggest the need for immediate dialysis in this patient is provided. There is no evidence the patient is dehydrated, therefore increased fluid replacement is not indicated.

Question 17

A two-year-old boy with hemihypertrophy should undergo: A: twice yearly physical exam of abdomen. B: renal ultrasound every three months. C: twice yearly urinalysis and urinary metanephrine level. D: annual abdominal CT scan. E: abdominal MRI scan every six months.

Answer 17

B: “renal ultrasound every three months.” is correct. Children with hemihypertrophy are at risk for the development of Wilms’ tumor due to alterations in the WTR1 and WTR2 genes. The best screening method to allow early detection of a renal mass, without untoward exposure to radiation or excessive cost, is ultrasound every three months through early childhood. Twice-yearly urinalysis and urinary metanephrine are not indicated in this patient, because they are not predisposed to pheochromocytomas.

Question 18

A 45-year-old man undergoes bilateral end to side vasoepididymostomy. Semen analysis six months later demonstrates azoospermia. The next step is:

A: observation.
B: measurement of FSH.
C: clomiphene citrate therapy.
D: TRUS.
E: testicular sperm retrieval.

Answer 18

A: “observation.” was the correct answer.

The delayed appearance of sperm in the ejaculate of men undergoing vasoepididymostomy (VE) is common. The mean delay in one reported series was six months (range, 3 to 15 months). The ultimate mean sperm count and motility were found to be similar to subjects with sperm present in the initial semen analysis in this study. Therefore, observation would be the best approach in this situation. The epididymal fluid would have been examined for sperm at the time of VE and the procedure only performed if sperm were identified. Determination of the FSH would not be useful since FSH should be normal in patients with obstructive azoospermia. Clomiphene citrate will raise FSH, LH, and testosterone but not correct the obstruction. TRUS is indicated for ejaculatory duct, not epididymal obstruction. Testicular sperm retrieval is not indicated this early after surgery.

Question 19

A one-year-old hypertensive boy has a large, fixed abdominal mass. The most likely diagnosis is: A: congenital mesoblastic nephroma. B: Wilms’ tumor. C: neuroblastoma. D: pheochromocytoma. E: autosomal recessive polycystic kidney disease.

Answer 19

C: “neuroblastoma.” was the correct answer. This boy likely has a neuroblastoma. 50% of these tumors present in children under the age of two. These tumors are usually large, hard, and fixed. Children will often have numerous other paraneoplastic syndromes. Catecholamine release from the neuroblastoma can result in symptoms that can mimic pheochromocytoma including paroxysmal hypertension, palpitations, sweating, and headaches. However, pheochromocytomas tend not to be large masses like this and present in older children. Wilms’ tumor usually presents in children a few years older and the masses are more likely to be smooth and less fixed. Hypertension can also be seen but is less common. Congenital mesoblastic nephroma is possible but is usually seen in infants a few months of age and is the most common renal tumor in children less than six months of age. Autosomal recessive polycystic kidney disease can present at any age with a wide spectrum of symptoms. It involves both kidneys and you should be able to palpate bilateral masses. When it presents early in life, it is usually severe and associated with significant renal insufficiency.

Question 20

A 25-year-old woman has headaches and shortness of breath. Her blood pressure is 160/110 mmHg and serum creatinine is 1.0 mg/dl. She has an abdominal bruit and microscopic hematuria. Renal angiography demonstrates a 6 cm cirsoid arteriovenous fistula and a normal contralateral kidney. The best management is: A: angiotensin converting enzyme inhibitor. B: beta-blocker. C: fistula ligation. D: angio-embolization. E: nephrectomy.

Answer 20

E: “nephrectomy.” was the correct answer. Cirsoid arteriovenous fistulae are generally congenital in nature. This must not be confused with the much more common arteriovenous fistulae that results from iatrogenic kidney needle biopsies. Treatment for the congenital cirsoid lesion is indicated in patients with hypertension, cardiomegaly, heart failure, severe hematuria, or angiographic evidence of expansion of the lesion. ACE inhibitors and beta-blockers are not effective in the treatment of this anatomical defect. Cirsoid fistulas are not like a simple arteriovenous connection where one can just ligate a vessel and the lesion is resolved. Due to the complexity of the lesion, angio-embolization is generally considered difficult if not impossible and the patient is at risk for complications, particularly coil migration. Nephrectomy is the treatment of choice. The importance of this concept is to recognize that cirsoid arteriovenous fistula is a different entity than an iatrogenic arteriovenous fistula from biopsies and thus, the treatment is different.

Question 21

A four-year-old girl voids normally but is continuously wet. A renal ultrasound shows normal appearing kidneys bilaterally. The next step is:

A: MAG-3 renal scan.
B: VCUG.
C: MRI scan
D: cystoscopy and vaginoscopy.
E: retrograde pyelogram

Answer 21

C: “MRI scan” was the correct answer.

The clinical scenario of dribbling despite normal voiding creates suspicion of an ectopic ureter. Often the ectopic upper pole moiety of the duplex kidney is very small and not easily identified on ultrasound. In these cases an MRI scan or MR urogram are the best imaging tests to localize the difficult to identify small, dysplastic upper poles and their ureters. MR urogram is not always required since the T2-weighted images of a standard MRI are particularly suited for finding and defining fluid-filled structures like an ectopic ureter. Sagittal imaging may demonstrate the exact termination of the ectopic ureter. DMSA scan is most useful in the identification of small ectopic kidneys but is unlikely to be useful when the renal US is normal. If the moiety is small, a MAG-3 renal scan and IVP will appear normal because the upper pole has no function and the lower pole will not be deviated. VCUG will sometimes show VUR into an ectopic ureter depending on the location of the orifice. A retrograde pyelogram can identify the ectopic orifice but the orifice is often difficult to identify cystoscopically and is not as sensitive as an MRI scan.

Question 22

In a newborn with penoscrotal hypospadias and nonpalpable testes, the most important test is:

A: serum for 17-hydroxyprogesterone.
B: determination of testosterone:dihydrotestosterone ratio.
C: hCG stimulation test.
D: pelvic ultrasound.
E: genitogram.

Answer 22

A: “serum for 17-hydroxyprogesterone.” was the correct answer.

While this child may be male, consideration of the 46XX disorder of sex development secondary to CAH must be entertained. Laboratory evaluations to assess enzymatic adrenal function is the primary concern. FISH evaluation for the presence of a Y chromosome and chromosome analysis should be done as soon as possible. Many of the patients with CAH will be deficient in mineralocorticoids in addition to corticosteroids. Without prompt diagnosis and treatment life-threatening shock may develop due to dehydration and salt loss. All of the other listed options are reasonable tests for the evaluation of disorders of sex development, but will only be performed after CAH is ruled out.

Question 23

A 28-year-old woman has significantly decreased libido six months after starting oral contraceptive pills. The most likely cause of her decreased sexual desire is:

A: reduced serum estradiol.
B: reduced serum progesterone.
C: reduced serum testosterone.
D: decreased sex hormone binding globulin.
E: increased serum prolactin.

Answer 23

C: “reduced serum testosterone.” was the correct answer.

Oral contraceptive pills (OCPs) significantly increase the production and release of sex hormone binding globulin (SHBG) by the liver. The increased SHBG subsequently lowers serum free testosterone by irreversible binding. Low levels of circulating free testosterone can cause a significant decrease in sexual desire/libido. While estradiol may decrease with OCPs, the effect is less striking on libido than the effect of a lower serum testosterone. Progesterone levels may actually increase with some OCPs.

Question 24

Urinary concentration is primarily the result of which characteristic of the kidney:

A: hypertonic medullary interstitial fluid.
B: absence of ADH.
C: hypotonic medullary interstitial fluid.
D: high levels of ADH.
E: hypertonic proximal tubular fluid.

Answer 24

A: “hypertonic medullary interstitial fluid.” was the correct answer.

Although 65% of sodium chloride and water are reabsorbed in the proximal tubule, the intraluminal fluid remains iso-osmotic. Urinary concentration takes place as the tubular fluid flows through the medullary collecting ducts. The medullary interstitial hyperosmolarity in the presence of normal plasma concentrations of ADH causes water to diffuse out of medullary collecting ducts into the interstitial fluid and then into the medullary blood vessels. High ADH levels produce a more concentrated urine and low levels produce a more dilute urine.

Question 25

A 60-year-old healthy woman with recurrent UTIs has free air in the bladder and a thickened bladder wall adjacent to a loop of thickened colon see on CT scan. Cystoscopy demonstrates erythema in the bladder wall with no clear fistula. The next step is:

A: antibiotic prophylaxis.
B: high pressure cystogram.
C: CT scan with small bowel follow through.
D: MRI scan.
E: general surgery consult/exploratory laparotomy

Answer 25

E: “general surgery consult/exploratory laparotomy.” was the correct answer.

Cross-sectional imaging, especially CT scan, has become the imaging modality of choice to demonstrate a vesicoenteric fistula. CT or MRI scans may localize the fistula track as well as the involved segment of bowel. The triad of findings on CT that are suggestive of colovesical fistula consists of (1) bladder wall thickening adjacent to a loop of thickened colon, (2) air in the bladder (in the absence of previous lower urinary tract manipulation), and (3) presence of colonic diverticula. Cystoscopy has the highest yield in identifying a potential lesion, with some type of abnormality noted on endoscopic examination in more than 90% of cases. However, the findings on cystoscopy are often nonspecific and include localized erythema and papillary or bullous change; a definitive diagnosis by cystoscopy can be made in only 35% to 46% of cases. This patient has clear evidence of a vesicoenteric fistula and further diagnostic studies are not indicated. Should she be a poor surgical risk, long-term antibiotics could be used. Definitive colonic resection of presumed diverticulosis and repair of fistula should occur with exploratory laparotomy. General surgery may wish to proceed with colonoscopy/barium enema to evaluate the extent of the affected segment or rule-out malignancy

Question 26

A four-year-old uncircumcised boy has a two-week history of foreskin swelling with urination. The retained urine under the foreskin drains slowly following completion of voiding. There is no dysuria or hematuria. Physical exam reveals mild erythema of the distal foreskin and a phimotic ring. The meatus cannot be visualized. The next step is:

A: observation.
B: sitz baths.
C: topical steroid ointment.
D: dorsal slit.
E: circumcision.

Answer 26

C: “topical steroid ointment.” was the correct answer.

The patient has pathologic phimosis that does not allow adequate urinary drainage. Observation is only appropriate in the setting of physiologic phimosis in which the foreskin is not retractable due to normal physiologic adhesions, as opposed to pathologic phimosis, which is development of a dense fibrotic ring from chronic inflammation. Treatment of pathologic phimosis with a topical steroid ointment (0.05% betamethasone) is effective in up to 90% of cases in relieving the phimosis and allowing adequate retraction of the foreskin. If the patient had more acute problems such as severe balanitis or more obstructive voiding symptoms then surgical intervention with a dorsal slit or circumcision may be appropriate. Sitz baths alone are unlikely to rectify the problem.

Question 27

A 65-year-old man has been using 20 mg of tadalafil (CialisTM) as needed for treatment of erectile dysfunction. His primary care provider starts him on doxazosin for hypertension. His treatment of erectile dysfunction should include:

A: continue tadalafil 20 mg as needed.
B: decrease tadalafil to 10 mg as needed.
C: start tadalafil for once daily use at 5 mg/day.
D: stop tadalafil.
E: switch to intracorporal alprostadil.

Answer 27

B: “decrease tadalafil to 10 mg as needed.” was the correct answer.

Concomitant use of alpha-blockers and PDE-5 inhibitors can cause hypotension. When tadalafil is coadministered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating treatment with tadalafil, and tadalafil should be initiated at the lowest recommended dose. Conversely, when starting an alpha-blocker the lowest dose of either agent should be used and they should not be taken at the same time. There is no need to stop tadalafil in this patient or switch to intracorporal injections if he has been successful on oral therapy. Of all the choices, decreasing to the lowest effective dose of tadalafil (10 mg for use as needed, or 2.5 mg/day for once daily use) would be recommended for this man.

Question 28

A 40-year-old woman undergoes bilateral adrenalectomy for Cushing’s disease with complete resolution of her symptoms. Her replacement therapy consists of cortisone and fluorocortisone. Three years later, she complains of visual disturbances and has skin hyperpigmentation. The most likely explanation is:

A: Addison’s disease.
B: pituitary adenoma.
C: excessive cortisone replacement.
D: excessive ACTH production.
E: ectopic melanocyte-stimulating hormone secretion.

Answer 28

B: “pituitary adenoma.” was the correct answer.

Approximately 10-20% of patients who have had a bilateral adrenalectomy for Cushing’s Syndrome later develop pituitary tumors that are almost always chromophobe adenomas (Nelson’s syndrome). Progressive hyperpigmentation (due to melanocyte stimulating hormone release by corticotropic releasing hormone), headaches, and visual disturbances are due to the expanding adenoma that is diagnosed by MRI or CT scans of the sella turcica. Pituitary basophilic adenoma that was initially postulated by Cushing as causing the syndrome named for him has, in fact, rarely been a factor. Addison’s disease describes primary adrenal insufficiency not as a result of bilateral adrenalectomy. Excessive cortisone replacement would result in a Cushingoid appearance (purple striae, buffalo hump, central obesity). Excessive ACTH production is not the end result of bilateral adrenalectomy. Although, increased skin pigmentation could be a result of ectopic melanocyte stimulating hormone secretion the other symptoms would not.

Question 29

Hypercoagulability in patients with ESRD secondary to nephrotic syndrome is due to:

A: hypohomocystinenemia.
B: urinary loss of antithrombin III.
C: retention of protein S.
D: retention of protein C.
E: decreased antiphospholipid antibodies.

Answer 29

B: “urinary loss of antithrombin III.” was the correct answer.

A hypercoagulable state can occur in the nephrotic syndrome with urinary loss of the natural anticoagulants: antithrombin III, protein C, and protein S. Hyperhomocysteinemia is common in ESRD, and has been associated with thrombophilia. Antiphospholipid antibodies are found in 30% to 50% of patients with systemic lupus erythematosus, a cause of ESRD. Loss of antithrombin III and increased antiphospholipid antibodies increase the risk of thrombosis of renal allografts, dialysis access devices, and post-operative thromboembolic events. Thus, anticoagulation should be considered in these patients.

Question 30

The most frequent complications associated with the use of mitomycin C for intravesical therapy are:

A: chemical cystitis and rash.
B: myelosuppression and rash.
C: flu-like symptoms and myelosuppression.
D: contracted bladder and chemical cystitis.
E: myelosuppression and chemical cystitis.

Answer 30

A: “chemical cystitis and rash.” was the correct answer.

Rash occurs in 9% of patients receiving mitomycin C instillations, and may represent a contact dermatitis. Chemical cystitis has been reported in 6-41% of patients managed with this agent. The molecular weight of mitomycin C is so high that little is absorbed and myelosuppression is rare. A contracted bladder is also rare after mitomycin C treatment. Flu-like symptoms, which are commonly seen after BCG and interferon therapy, are uncommon after intravesical chemotherapy.

Question 31

A one-year-old boy with a familial bleeding disorder receives I.V. DDAVP prior to a hypospadias repair. Appropriate fluid management would include:

A: 1/4 NS intraoperatively; encourage p.o. fluids postoperatively.
B: 1/4 NS intraoperatively; continue I.V. fluids for four hours postoperatively.
C: 1/4 NS intraoperatively; drink to thirst postoperatively.
D: NS intraoperatively; encourage p.o. fluids postoperatively.
E: NS intraoperatively; drink to thirst postoperatively.

Answer 31

E: “NS intraoperatively; drink to thirst postoperatively.” was the correct answer.

DDAVP causes retention of free water. Intravenous fluids should be iso-osmotic, and oral fluids should not be pushed, but taken according to thirst. Dangerous hyponatremia can otherwise be induced by the administration of hypoosmotic fluids during surgery, or by overencouraging oral fluids postoperatively.

Question 32

A 25 cm segment of ileum is isolated for bladder augmentation and reconfigured into a “U” shape. A sagittal incision of the bladder is made. The most dependent portion of the intestinal patch will not reach the apex of the incision by the bladder neck even after the mesentery is aggressively mobilized. The next step is:

A: reconfigure the intestine into an “S” shape.
B: incise both sides of the peritoneum overlying the mesentery.
C: ligate branching vessels of the vascular arcade.
D: partially close the anterior wall of the bladder.
E: isolate an additional intestinal segment for composite augmentation.

Answer 32

B: “incise both sides of the peritoneum overlying the mesentery.” was the correct answer.

When an intestinal patch will not reach the deep pelvis in a tension free manner, the first step should always be aggressive mobilization of the root of the mesentery. When this fails to achieve the desired length, transverse incisions of the peritoneum should be performed on both sides of the mesentery in a step wise fashion. This can result in significant lengthening of the mesentery. Ligation of vessels should only be done as a last resort to avoid vascular compromise to the bowel segment. Psoas hitch has also been described, but will not help move the apex of the sagittal incision by the bladder neck which is fixed. Reconfiguration will not gain more length and closure of the anterior bladder wall will risk the development of an hourglass deformity.

Question 33

A 67-year-old man develops erythema and mild tenderness in the scrotum six weeks following placement of a three-piece inflatable penile prosthesis. He has no tenderness or erythema in the penile shaft or suprapubic area. The best treatment is:

A: oral antibiotic therapy for six weeks.
B: I.V. antibiotic therapy for six weeks.
C: removal and replacement of the scrotal pump.
D: removal of the entire device and replacement in six months.
E: removal of the device with washout and immediate replacement.

Answer 33

E: “removal of the device with washout and immediate replacement.” was the correct answer.

This patient clearly demonstrates an early prosthetic infection manifested around the scrotal pump. Treatment of a prosthetic infection with antibiotics usually results in clinical improvement but is almost never the definitive treatment and the infection will recur. This is due to microorganisms within a biofilm that is adherent to the device and the inability to sterilize the device or the biofilm once these organisms are present. When a prosthetic infection is present, all components of the prosthesis should be removed. If they are removed a new device should be replaced as soon as is feasible (within six to eight weeks) to decrease the amount of fibrosis and significant penile shortening which will occur. Mulcahy introduced the concept of immediate prosthesis salvage for infection which has been able to salvage as many as 85% of these patients and prevent penile shortening. His protocol involves removal of all prosthetic components followed by irrigation with seven antibacterial solutions. Others have reported on using different numbers and types of solutions. Mechanical irrigation and removal of the biofilm appears to be the key principle of this technique. A new device is implanted immediately after irrigation, and the patient is prescribed antibiotics. When salvage procedures are successful, they maintain penile size and correct the problem with only one operation.

Question 34

When performing urinary diversion, the gastrointestinal segment associated with the highest potassium loss is:

A: stomach.
B: jejunum.
C: proximal ileum.
D: distal ileum.
E: colon.

Answer 34

E: “colon.” was the correct answer.

It is important to know the electrolyte content of the fluid from the various bowel segments in order to replace abnormal fluid losses from these segments. Serum electrolyte complications and the type of electrolyte abnormalities that occur are different, depending on the segment of bowel used. If stomach is employed, a hypochloremic metabolic alkalosis may occur. If jejunum is the segment used, hyponatremia, hyperkalemia, and metabolic acidosis occur. If the ileum or colon is used, a hyperchloremic metabolic acidosis ensues. Hypokalemia and total-body depletion of potassium may occur in patients with urinary intestinal diversion. This is more common in patients with ureterosigmoidostomies than it is in patients who have other types of urinary intestinal diversion. The use of ureterosigmoidostomies has decreased significantly. It has been shown that ileal segments exposed to high concentrations of potassium in the urine reabsorb some of the potassium, whereas colon is less likely to do so. Thus, those with ileum interposed in the urinary tract likely blunt the potassium loss by the kidney, whereas those with colon do not, thus explaining why patients with ureterosigmoidostomies and ureterocolonic diversions are more likely to have total-body potassium depletion.

Question 35

A seven-year-old boy has recurring abdominal pain one to two times per month. Episodes consist of left flank discomfort, nausea, and vomiting. On ultrasound, there is mild left hydronephrosis. A MAG-3 Lasix renal scan shows 50% differential function and a T1/2 of eight minutes bilaterally. Two urinalyses demonstrate 2-5 RBCs/hpf. The test most likely to yield the diagnosis is:

A: non-contrast CT scan.
B: VCUG.
C: MR urogram.
D: ultrasound of kidneys during pain.
E: left antegrade renal perfusion study (Whitaker).

Answer 35

D: “ultrasound of kidneys during pain.” was the correct answer.

The history suggests intermittent UPJ obstruction and the associated “Dietl’s crisis.” Dietl’s crisis is intermittent abdominal pain associated with nausea and vomiting following an episode of high fluid intake. Although a renal scan with Lasix is used in an attempt to prompt the crisis, it may on occasion be falsely negative. In these patients, it is best to repeat a renal ultrasound at the time of pain and compare this to a baseline renal ultrasound taken when the patient was asymptomatic. If increased hydronephrosis at the time of symptoms is present, it is diagnostic and the pyeloplasty will be curative. Placement of a double J stent in this patient population is not usually helpful since the discomfort of the stent will usually preclude its diagnostic usefulness. A Whitaker test is invasive and usually reserved to evaluate for the presence of obstruction in a hydronephrotic kidney with poor renal function, i.e., kidney < 25% differential function, or in a patient where the serum creatinine two times elevated for age or creatinine of greater than or equal to 2 mg/dl in the adult, in these later circumstances, renal scans will usually be falsely positive for obstruction due to poor renal function. A VCUG will not be helpful in this patient. Even if VUR is present, it is not the source of the patient symptoms. MR urogram and a noncontrast CT scan are not effective or useful on asymptomatic patients.

Question 36

A 67-year-old woman is undergoing surgery for repair of a post-hysterectomy vesicovaginal fistula located above the trigone with communication to the vaginal vault. A vaginal repair is selected. The best flap to interpose is:

A: peritoneal.
B: omental.
C: Martius.
D: labial myocutaneous.
E: gracilis.

Answer 36

A: “peritoneal.” is correct.

During a vaginal approach to a high riding post-hysterectomy fistula, a peritoneal flap is preferred. It is relatively easy to raise a well vascularized flap of peritoneum in this location. A Martius flap would be very difficult to mobilize to that location in the vagina without compromising the blood supply. An omental flap is occasionally useful from a vaginal approach if it had previously been secured in the pelvis from prior surgeries. A gracilis flap can be utilized but is typically not necessary for vesicovaginal fistulae. A labial myocutaneous flap can be utilized particularly if there is significant foreshortening of the vagina or loss of vaginal mucosa.

Question 37

The drug that can be reabsorbed by an ileal neobladder and result in toxic serum levels is:

A: phenytoin.
B: trimethoprim-sulfamethoxazole.
C: sildenafil.
D: warfarin.
E: furosemide.

Answer 37

A: “phenytoin.” is correct.

Drugs which are excreted by the kidneys unchanged may be resorbed by the intestinal mucosa in urinary diversions, leading to toxic serum levels. Phenytoin is the only drug listed excreted into the urine unchanged and associated with toxicity in the setting of a urinary diversion. Other commonly used drugs that can be reabsorbed include methotrexate, lithium carbonate, and theophylline

Question 38

Gadolinium based contrast, compared to iodinated contrast, in patients on dialysis have a greater risk of:

A: anaphylactic reaction.
B: nephrotoxicity.
C: itching.
D: systemic fibrosis.
E: congestive heart failure.

Answer 38

D: “systemic fibrosis.” is correct.

Nephrogenic systemic fibrosis (NSF) is a disorder characterized by tissue fibrosis that primarily occurs in dialysis patients following the administration of gadolinium contrast for radiologic studies. The other distractors listed: anaphylactic reaction, nephrotoxicity (patient is already on dialysis), pruritus and congestive heart failure do not occur more frequently following gadolinium than iodinated contrast agent. Studies suggest a strong association between the use of gadolinium based MRI contrast agents and the subsequent development of NSF in patients with renal disease. Gadolinium based MRI contrast agents are chemical chelates with the gadolinium ion bound by a linear or cyclic molecule. Since free gadolinium ions are toxic and poorly excreted, safety completely rests on the ability of the chelate molecule to prevent gadolinium release. The kidneys solely excrete these agents and their half-life prolongs from one to two hours to over 30 hours with severe renal dysfunction. Renal failure allows a situation where gadolinium based MRI contrast agents reside within patients for long periods of time potentially allowing for toxic levels of free gadolinium ions to build-up, deposit in tissues, and subsequently lead to fibrosis. Therefore, patients in ESRD requiring dialysis are at a greater risk of NSF.

Question 39

A six-month-old infant with severe pulmonary hypertension is on I.V. sildenafil at the dose of 1.2 mg/kg every six hours. After two days, he is successfully weaned off inhaled nitric oxide. He develops a sustained erection that has lasted 12 hours. The next step is:

A: observation.
B: discontinue I.V. sildenafil.
C: lower I.V. sildenafil dose.
D: switch to oral sildenafil.
E: re-initiate inhaled nitric oxide.

Answer 39

C: “lower I.V. sildenafil dose.” was the correct answer.

Sildenafil has been very effective in treating pulmonary hypertension in infants and adults and was approved by the FDA in 2005. Many multi-institutional studies have demonstrated its safety and efficacy in this population. Doses for treatment of pulmonary hypertension are much higher than doses used to treat erectile dysfunction (po - 100 mg TID in children and adults, IV 1.2 mg/kg I.V.). This has led to a higher incidence of adverse events including dizziness, headache, flushing, rhinitis and prolonged erection. There have been several reports of prolonged erection in children using high I.V. doses. These patients have responded to simply lowering the dose of sildenafil. This patient has shown an excellent response to treatment with I.V. sildenafil (since he has been successfully weaned off inspired nitric oxide) of his life-threatening pulmonary hypertension and it should be continued. Observation is not appropriate with a prolonged erection of this type. No data is available on either switching to oral administration or to a different PDE5 inhibitor.

Question 40

A 67-year-old man with a clinical stage T2bN0M0 Gleason 6 prostate cancer with a PSA of 7.8 ng/ml is treated with 70 Gy external beam XRT. His PSA nadirs to 0.8 ng/ml six months after therapy. Six months later, he is asymptomatic, has a normal DRE, and a PSA of 6.5 ng/ml. The most likely explanation for the elevated PSA level is:

A: prostatic infarct.
B: persistent prostate cancer.
C: PSA bounce effect.
D: radiation-induced prostatitis.
E: insufficient period of observation after therapy.

Answer 40

B: “persistent prostate cancer.” was the correct answer.

A marked increase in serum PSA after a nadir within six months of external beam XRT is a sign of persistent local or occult metastatic prostate cancer and has a poor prognosis. Radiation induced cellular injury or prostatitis may cause a minor rise in PSA which usually returns to normal within a few weeks. A “bounce” can be defined as a rise greater than 0.2 ng/ml followed by a durable decline and is especially common after brachytherapy, where it is reported to occur in 24% to 35% of men. These can start any time from 9 to 30 months after brachytherapy with the majority of patients having a cumulative PSA rise of not more than 2 to 3 ng/ml. Prostatic infarct is rare following radiation therapy for prostate cancer, and would likely be associated with a significantly elevated PSA.

Question 41

A one-month-old girl with severe congenital heart disease had an episode of urosepsis. She has a solitary kidney with upper pole hydroureteronephrosis. Her renal scan shows 33% function in the upper pole with UVJ obstruction and a massively dilated upper pole ureter. The lower pole system is normal. The VCUG shows no reflux. The next step is antibiotic prophylaxis and:

A: percutaneous nephrostomy.
B: tapered upper pole reimplant.
C: upper pole distal cutaneous ureterostomy.
D: upper pole to lower pole distal ureteroureterostomy.
E: upper pole heminephroureterectomy.

Answer 41

C: “upper pole distal cutaneous ureterostomy.” was the correct answer.

This infant has an obstructed upper pole ureter in a solitary kidney and suffered urosepsis. Surgical intervention is indicated. Her age, severe pulmonary and cardiac disease makes all upper abdominal surgery unattractive. Since she has a significant portion of her renal function in the upper pole a heminephrectomy is incorrect. Anastomosis of the massively dilated upper pole system to the normal lower pole system is technically difficult either at the level of the renal pelvis or the ureter. Percutaneous nephrostomy tubes can be a short term-answer in a critically ill child but they have complications including chronic infection, calculus formation, and displacement. Tapered reimplantation in a child of this age is technically challenging because of the small bladder. The best treatment is a cutaneous ureterostomy that will allow adequate drainage and prevent infection until definitive surgery is safe. It will also allow the dilated upper pole system to decompress and reconfigure the ureter.

Question 42

A three-year-old boy with sickle cell disease has painful priapism for two hours. Initial management should include intravenous hydration, pain management, O2 supplementation and:

A: oral pseudoephedrine.
B: exchange transfusion.
C: aspiration of the corporal bodies with instillation of dilute phenylephrine.
D: Winter’s shunt.
E: cavernosaphenous vein shunt.

Answer 42

A: “oral pseudoephedrine.” was the correct answer.

Priapism occurs in males with all forms of sickle cell anemia but most commonly the sickle cell disease. When presenting in childhood it may be associated with impotence later in life. A precipitating event should be searched for, such as drug usage, medications used for impotence (not in the pediatric population), infection, trauma, or psychoactive medications. Hydration and opioid analgesic are the mainstays of management of all forms of sickle cell pain. Oxygen is indicated when the patient is hypoxic. Erection results from relaxation of the smooth muscles of arterioles and trabeculae in the corpora, and detumescence is the result of smooth muscle contraction, opening emissary veins and increasing venous drainage. Therefore, detumescence should be facilitated by alpha-adrenergic agonists such as pseudoephedrine (a pure alpha-adrenergic agent). These agents induce contraction of the smooth muscle of the trabecular arteries of the cavernosa, forcing blood out of the cavernosa and promoting detumescence. Exchange transfusions are used after conservative methods mentioned above fail. Aspiration/injection or invasive shunts are used only if detumescence is not achieved by pharmacological methods.

Question 43

A three-year-old boy who underwent a surgical correction for a high imperforate anus has inability to toilet train. VCUG reveals a large trabeculated bladder, grade 3 left VUR and incomplete bladder emptying. Ultrasound of the abdomen shows two normal kidneys. The next step is:

A: spinal ultrasound.
B: spinal MRI scan.
C: alpha-blocker.
D: CIC.
E: vesicostomy.

Answer 43

B: “spinal MRI scan.” was the correct answer.

Spinal cord abnormalities, including tethered cord or thickened or fatty filum terminale and lipoma have been noted in 20-50% of patients with imperforate anus. The severity of the lesion is proportional to the severity of the rectal lesion. In this case, the patient has a high-imperforate anus. VCUG reveals trabeculation, VUR into one kidney, and incomplete bladder emptying - a collection of findings for possible neurogenic bladder dysfunction. The best test is an MRI scan to rule-out spinal cord lesions since the kidneys are presently normal and the bladder has some subtle findings. Due to ossification of the spine a spinal ultrasound cannot rule-out a tethered spinal cord after three months of life. Vesicostomy, CIC, and antimuscarinic and alpha-blocker medications are premature at this point without formal diagnosis of neurogenic bladder and urodynamic study.

Question 44

A 53-year-old woman reports leakage with sneezing and exercise. On physical exam, after voiding, she had no significant prolapse or leakage with coughing and strain. A voiding diary reveals three leaks per day over three days, and pad test reveals 40 gram weight gain each day of testing. Pelvic floor muscle training does not help the leakage. The next step is:

A: full bladder supine stress test.
B: VCUG.
C: antimuscarinic therapy.
D: periurethral injection.
E: midurethral sling.

Answer 44

A: “full bladder supine stress test.” was the correct answer.

This patient has symptomatic stress urinary incontinence (SUI), though none is noted on exam. She should not be treated invasively for SUI without documentation on exam. A positive pad test could be the result of urgency leakage, even though she does not report it, as could leaks reported on a voiding diary. She should return for a full bladder stress test done supine and repeated standing if necessary. If that remains negative, urodynamics could be offered to try to better delineate her leakage. VCUG will not add to the diagnostic evaluation in this case, as leakage noted during that test is still not diagnostic of SUI. Antimuscarinics should not be offered in the presence of primarily SUI complaints.

Question 45

A 62-year-old man who seven years earlier received XRT for prostate cancer undergoes TURBT for a pT2 bladder cancer. Metastatic work-up is negative. He desires orthotopic neobladder diversion. At the time of cystectomy, the bowel appears healthy and urethral frozen section is negative. The following diversion should be performed:

A: orthotopic neobladder using right colon.
B: orthotopic neobladder using distal ileum.
C: continent cutaneous diversion.
D: ileal loop conduit.
E: transverse colon conduit.

Answer 45

B: “orthotopic neobladder using distal ileum.” was the correct answer.

Previously, prior pelvic radiation therapy was an absolute contraindication to orthotopic neobladder. However, recent reports have demonstrated that this can be a safe and effective form of diversion in properly selected patients. Astute intraoperative tissue assessment and determination of the condition of the urethra, ureters, and bowel must be done to limit complications and to provide the best possible clinical outcomes. In this case, it would be safe to proceed with orthotopic neobladder. Distal ileum is preferred to right colon in this setting. Right colon is less mobile and more difficult to detubularize than ileum. Preoperatively, the patient needs to be counseled that he is at higher risk for urinary incontinence.

Question 46

A 45-year-old woman undergoes evaluation for recurrent calcium phosphate stones. Serum calciums range from 9.6-10.0 mg/dl ; PTH 62 pg/dl; urine calcium 281 mg/day (normal < 200 mg/day); and urinary citrate 460 mg/day (normal > 320 mg/day). To further elucidate her metabolic diagnosis, she should be placed on a two week course of:

A: thiazide.
B: mercaptoproprinoglycine.
C: sodium cellulose phosphate.
D: orthophosphate.
E: potassium citrate.

Answer 46

A: “thiazide.” was the correct answer.

This patient has a picture equivocal for primary hyperparathyroidism with hypercalciuria, serum calcium at the upper limits of normal and a high, but normal serum PTH value. A “thiazide challenge” would help to differentiate renal hypercalciuria from primary hyperparathyroidism. After treating her with a thiazide diuretic for two weeks, her serum calcium and PTH should remain within normal limits and her urinary calcium should return to normal if she has renal hypercalciuria. If, however, she has true hyperparathyroidism, she would become overtly hypercalcemic and her serum PTH would become elevated with no significant change in the urinary calcium excretion. The other agents will not help elucidate her underlying metabolic abnormalities.

Question 47

After traumatic renal injury, the predictors of persistent bleeding are depth of parenchymal injury, presence of arterial blush, and:
A: urinary extravasation.
B: devitalized fragment.
C: thickness of hematoma.
D: location of laceration.
E: mechanism of injury.

Answer 47

C: “thickness of hematoma.” is correct.

After renal trauma, the likelihood of renal exploration, renorraphy, and nephrectomy is associated with the grade of injury. For example, Grade 4 injuries have a 64 fold higher likelihood of needing nephrectomy than a Grade 1 injury. New literature shows that for grade 3 and 4 injuries, medial hematoma, hematoma > 3.5 cm in thickness and the presence of a vascular contrast blush are associated with increased risk of bleeding and need for intervention. The presence of such findings should alert the urologist to the potential need for angiography and selective embolization of segmental vascular injuries. While urinary extravasation and devitalized fragments increase the risk of urinoma formation, they are not associated with higher rates of bleeding. Neither location of laceration or mechanism of injury predict complications independent of grade.

Question 48

A healthy, ten-year-old girl has several urinalyses that show 2+ proteinuria. The next step is:

A: ASO titer and complement levels.
B: serum BUN and creatinine levels.
C: 24-hour urine for protein and creatinine.
D: spot urine for protein and creatinine.
E: first morning urine for protein and creatinine.

Answer 48

E: “first morning urine for protein and creatinine.” was the correct answer.

All children with > 1+ proteinuria on multiple occasions should be evaluated, starting with a urinalysis and first morning spot protein and creatinine ratio. The child must void before retiring and remain supine until the first morning urine sample is obtained. If the ratio is < 0.2, a diagnosis of orthostatic proteinuria is made and no further studies are needed. If other abnormalities are noted on the urinalysis and/or the first morning protein and creatinine ratio is > 0.2, a complete history and physical, including blood pressure, is suggested. Laboratory evaluations, including serum albumin, creatinine, cholesterol, electrolytes, and a 24-hour urine for protein and creatinine and creatinine clearance are obtained. A renal sonogram should be performed. Complement levels (C3, C4) antinuclear antigen (ANA), and serology for hepatitis B and C are indicated. HIV testing should be considered.

Question 49

In a man with azoospermia and elevated FSH, the best predictor of sperm retrieval from the testicle is:

A: serum FSH level.
B: testosterone level.
C: Y chromosome deletion subtype.
D: seminal volume.
E: presence of the vas deferens.

Answer 49

C: “Y chromosome deletion subtype.” was the correct answer.

In men with azoospermia, 7% will be associated with Y chromosome microdeletions. Classically, these patients will be found to have azoospermia or severe oligospermia with an elevation in FSH. The microdeletions occur in the long arm of the Y chromosome and are designated as AZFa (proximal), AZFb middle, and AZFc distal. The most common deletion is AZFc. About 75% of men with AZFc deletions have sperm on testicular biopsy. Sperm retrieval from men with complete AZFa or AZFb deletions have not been successful. The success of testicular sperm retrieval has not been correlated with FSH or testosterone level. Seminal volume does not reflect spermatogenic potential and has no relationship to the success of sperm retrieval. The absence of the vas deferens may be associated with obstructive azoospermia but these patients should have a normal FSH whereas this patient has an elevated FSH indicating non-obstructive azoospermia.

Question 50

A 76-year-old man has back pain. Seven years ago, he had a bilateral orchiectomy for T3NXM0 prostate cancer. MRI scan of the spine demonstrates a nonpathologic vertebral compression fracture. PSA is undetectable. The next step is:

A: observation.
B: bone scan.
C: DEXA scan (bone densitometry).
D: antiandrogen therapy.
E: local radiotherapy.

Answer 50

C: “DEXA scan (bone densitometry).” was the correct answer.

This man, by virtue of his age and androgen deprivation therapy, is at increased risk for osteoporosis. The consequence of osteoporosis is an increase in bone fragility and a susceptibility to fracture. Androgen deprivation therapy (ADT) increases the risk of osteoporosis and is related to the duration of therapy. Compared to age-matched controls, men on ADT have 6.5% to 17.3% higher bone loss. Furthermore, the risk of non-pathologic fracture with ADT is 4% at five years and 20% at ten years. DEXA scan is the gold standard for diagnosis of osteoporosis, and is reported as compared to young adults (T-score) and age-matched (Z-score) controls. The treatment initially includes increasing physical activity on weight bearing joints and the addition of both Vitamin D and calcium. Since this patient has no clinical evidence of disease progression, there is no indication for additional treatment. MRI scan reveals only a nonpathologic fracture and PSA is undetectable; this combination obviates the need for a bone scan.

Question 51

A 38-week-gestation newborn with a PUV has a serum creatinine of 1.1 mg/dl on day two of life. This child’s serum creatinine value:

A: will not change with a rapid rise in GFR.
B: is a predictor of future poor renal function.
C: will decrease with completion of nephrogenesis.
D: is not reflective of the degree of renal function impairment.
E: will result in increased active sodium absorption from the descending limb of the loop of Henle.

Answer 51

D: “is not reflective of the degree of renal function impairment.” was the correct answer.

The creatinine in a newborn is reflective of maternal renal function and is not necessarily representative of the degree of renal impairment. In usual circumstances, serum creatinine will reflect the child’s renal function by day 7-10. Long term renal function in children with PUV is best predicted by the nadir creatinine at one year of age. If the nadir creatinine is less than 0.8 mg/dl at one year of life, this is a good prognostic sign for retained renal function that will be able to be maintained into adulthood. By 34 weeks gestational age, nephrogenesis is complete and will not affect the level of the creatinine. Sodium reabsorption issues cannot be predicted until the degree of true renal functional impairment is better defined.

Question 52

Ductal carcinoma of the prostate:

A: is best managed with chemotherapy.
B: is associated with high grade disease and recurrence.
C: confers no additional risk.
D: should be graded as Gleason grade 5.
E: commonly arises from the transition zone.

Answer 52

B: “is associated with high grade disease and recurrence.” was the correct answer.

Prostatic ductal carcinoma is an adenocarcinoma that arises in prostatic ducts. It should be graded as a Gleason 4+4 since it shares a cribriform pattern and is associated with high grade disease and recurrence. It should be treated similarly to other high grade adenocarcinomas with combination hormonal therapy/ radiation therapy or radical prostatectomy or cryotherapy or primary hormonal therapy depending on patient age, fitness and preference. Like other carcinomas, ductal carcinoma arises more commonly in the peripheral than the transitional zone.

Question 53

A five-year-old boy has precocious puberty. Scrotal ultrasound reveals a mass in the upper pole of the left testis. FSH and LH are normal prepubertal levels. Testosterone and urinary 17-ketosteroid levels are significantly elevated. The urinary pregnanetriol levels are normal. The next step is:

A: glucocorticoid therapy.
B: biopsy of the mass.
C: enucleation of the mass.
D: simple orchiectomy.
E: radical orchiectomy.

Answer 53

C: “enucleation of the mass.” is correct.

This boy has the classic triad of Leydig cell tumors: precocious puberty, testis mass, and elevated 17-ketosteroid levels. Pituitary lesions may also cause precocious puberty except LH and FSH will be elevated in a prepubertal male. These tumors must be differentiated from hyperplastic nodules of CAH which occur when steroid replacement is inadequate. Although both entities have elevated urinary 17-ketosteroids, only CAH due to the 21-hydroxylase deficiency will cause an elevation in urinary pregnanetriol levels. Glucocorticoid replacement will cause regression of the hyperplastic nodules of CAH. Simple and radical orchiectomy is often performed but not preferred. These tumors are generally benign and preservation of testicular tissue with testis sparing surgery is recommended.

Question 53

Compared to high-level disinfection (CidexTM -glutaraldehyde), sterilization of a flexible cystoscope offers greater protection against contamination by:

A: bacteria.
B: bacterial spores.
C: Mycobacterium tuberculosis.
D: virus.
E: fungi.

Answer 53

B: “bacterial spores.” is correct.

Sterilization, whether by steam under pressure, ozone, ethylene oxide gas or other methods involves the complete destruction of all microbial life, including bacterial spores. Disinfection uses thermal or chemical destruction of pathogenic and other types of microorganisms, and is less lethal than sterilization. High-level disinfection (HLD) cannot kill large numbers of bacterial spores unless they are exposed for an extended time period. Intermediate-level disinfection inactivates M. tuberculosis, vegetative bacteria, most viruses, and most fungi, whereas low-level disinfection cannot be relied upon to kill resistant microorganisms such as tubercle bacilli or bacterial spores.

Question 54

A 55-year-old woman with metastatic RCC has received five months of therapy with sunitinib. She undergoes uneventful right laparoscopic radical nephrectomy for a 5 cm upper pole renal mass. On post-op day one, she is obtunded, febrile, and complains of nausea and diffuse abdominal pain. BP is 80/50 mm Hg, HR 78 bpm, and urine output is 30 ml over four hours. Laboratory studies show a stable hemoglobin of 13.5 g/dl, and normal WBC. Chemistry studies are pending. The next step is normal saline fluid bolus and:

A: I.V. dexamethasone.
B: I.V. desmopressin.
C: CT scan of abdomen and pelvis.
D: angiography.
E: surgical exploration

Answer 54

A: “I.V. dexamethasone.” is correct.

The patient described above has the classic symptoms and signs of acute adrenal insufficiency. The most common symptoms and signs of acute adrenal insufficiency occurring in the setting of clinical deterioration are fever, nausea/vomiting, abdominal or flank pain, hypotension, abdominal distention, lethargy/obtundation, hyponatremia, and hypokalemia. The urologist should have a high index of suspicion for acute adrenal insufficiency following radical nephrectomy and the degree should be heightened in a patient receiving sunitinib as it may contribute to the condition. Physicians are advised to monitor for adrenal insufficiency in patients treated with sunitinib who experience stress such as surgery. As this was an upper-pole mass, the ipsilateral adrenal may have been removed or devascularized as well. Emergency treatment of adrenal crisis is normal saline fluid resuscitation, and dexamethasone sodium phosphate injection (Decadron, 4 mg I.V.). Stat serum electrolytes, glucose, cortisol, and plasma ACTH are obtained. A short ACTH stim test to confirm the diagnosis of adrenal insufficiency is then performed. Supportive measures are provided as needed. Mineralocorticoids are unnecessary and ACTH is not useful. CT scan would be indicated if the patient did not respond to fluid and steroids and adrenal insufficiency is ruled out. Angiography and surgical exploration are also premature given the clinical scenario suggestive of adrenal crisis. I.V. desmopressin would not be first line treatment in this patient with adrenal crisis, but could be indicated if hypotension was refractory to fluid resuscitation and steroids.

Question 55

A patient with an ileal conduit urinary diversion is undergoing renal function tests. The parameter that can be most accurately measured is:

A: creatinine clearance.
B: urinary concentrating ability.
C: fractional excretion of sodium.
D: acid loading.
E: proteinuria.

Answer 55

C: “fractional excretion of sodium.” was the correct answer.

Measuring renal function in patients with intestinal diversion may be difficult. Most parameters of renal function will be affected by the intestinal absorption of various substances in the urine, including creatinine and urea, as well as secretion of alkalinizing substances and alteration in the osmotic content. Sodium handling in ileal segments is not markedly altered as ammonium substitutes for sodium in the Na/H antiporter in the bowel lumen.

Question 56

A 62-year-old man with Klinefelter Syndrome underwent a mastectomy for breast cancer three months ago. He complains of decreased energy and decreased libido. A total testosterone is 210 ng/dl and LH is 15 IU/l. The next step is therapy with:

A: oral phosphodiesterase inhibitors.
B: low dose transdermal estrogen.
C: aromatase inhibitors.
D: testosterone.
E: beta-hCG.

Answer 56

C: “aromatase inhibitors.” was the correct answer.

Men with Klinefelter Syndrome are at increased risk for the development of breast cancer. Approximately 80% of cases are estrogen receptor positive, therefore any treatment that increases estrogen levels is contraindicated unless the patient is cured of breast cancer. This patient has symptomatic hypogonadism which would benefit from an increase in serum testosterone but he was recently treated for breast cancer. In men a portion of testosterone is converted to estradiol, primarily in adipose tissue. Aromatase inhibition will decrease conversion of testosterone to estrogen thereby raising testosterone levels while at the same time decreasing estrogen levels. This is safe in men with breast cancer. Phosphodiesterase inhibitors are indicated for erectile dysfunction which this patient does not complain of. Estrogen therapy has no role in treating these symptoms in men and risks stimulation of breast cancer cell growth. HCG will increase testicular production of testosterone. The increased peripheral testosterone levels from either HCG or testosterone therapy will result in increased estrogen levels due to the peripheral conversion to estrogen. Therefore these are inappropriate therapies in men with breast cancer. In Kleinfelters, patients without breast cancer, standard treatment of hypogonadism with testosterone replacement is safe.

Question 57

A 62-year-old man has a radical prostatectomy for prostate cancer. Histology reveals a Gleason 9, pT3aN1Mx cancer with negative surgical margins. His post-prostatectomy PSA is < 0.1 ng/ml. To minimize his risk of relapse, the next step is:

A: adjuvant docetaxel.
B: external beam XRT.
C: LH-RH agonist therapy for six months.
D: lifelong LH-RH agonist therapy.
E: LH-RH agonist therapy for six months and external beam XRT.

Answer 57

D: “lifelong LH-RH agonist therapy.” was the correct answer.

The treatment of men with isolated lymph node metastasis at the time of prostate cancer surgery has been controversial. The use of adjuvant XRT for adverse pathologic characteristics at the time of prostatectomy has been recently evaluated in two large randomized clinical trials. However, patients with lymph node metastasis, such as patients here, were not included in this trial, and it is generally felt that such individuals are at risk of systemic rather than local recurrence. ECOG 3807 evaluated the use of immediate hormonal ablation versus observation in men with isolated lymph node metastases noted on final pathology after radical prostatectomy. The patients treated with immediate therapy had improved overall and cancer-specific survival relative to men undergoing initial observation. No trial has been performed showing an advantage of any chemotherapy treatment in the adjuvant setting. The advantage of short-term androgen deprivation therapy in this setting has not been established.

Question 58

A 33-year-old woman has dysuria and fever. Urinalysis shows specific gravity of 1.025, leukocyte esterase positive and nitrite negative. There are 10 RBC’s and 30 WBC’s per hpf on microscopy. Urine culture will likely grow:

A: Escherichia coli.
B: Pseudomonas aeruginosa.
C: Serratia marcescens.
D: Klebsiella oxytoca.
E: Proteus mirabilis.

Answer 58

B: “Pseudomonas aeruginosa.” was the correct answer.

Bacteria may convert urinary nitrates into nitrites and this may be used as evidence of UTI. Gram negative bacteria commonly do this, while gram positive species generally do not. One very important exception is Pseudomonas, which does not contain the enzymatic machinery to make this conversion. Thus, a negative nitrite by urinary dipstick in this patient with symptoms and other UA finding suggesting UTI should likely be treated presumptively pending culture and Pseudomonas is one of the very important, aggressive pathogens that must be considered in this circumstance.

Question 59

A 14-year-old girl has primary amenorrhea. She is in the 25th percentile for height and has a webbed neck. Her karyotype is 45 XO. The most likely genitourinary abnormality is:

A: renal agenesis.
B: horseshoe kidney.
C: VUR.
D: UPJ obstruction.
E: vaginal agenesis.

Answer 59

B: “horseshoe kidney.” was the correct answer.

This patient has Turner Syndrome. These girls can be recognized by their typical physical findings including short stature, webbed neck, and shield chest. Girls with the 45 XO karyotype usually exhibit all the stigmata of the syndrome. Patients with the 45 XO/46 XY karyotype are at increased risk for dysgerminoma and gonadoblastoma and require gonadectomy. Horseshoe kidney occurs with increased prevalence in patients with Turner syndrome and a renal ultrasound is warranted. VUR, renal agenesis and vaginal agenesis are not associated with Turner syndrome. UPJ obstruction may occur in association with horseshoe kidney, but is not seen with increased frequency in Turner syndrome

Question 60

A 55-year-old man seeks consultation regarding prostate cancer screening. According to the U.S. Prostate, Lung, Colon, and Ovarian (PLCO) trial, prostate cancer screening increases: A: prostate cancer detection. B: detection of Gleason’s score 8-10 tumors. C: detection of high stage (advanced) tumors. D: prostate cancer survival. E: quality of life in men with elevated PSA.

Answer 60

A: “prostate cancer detection.” was the correct answer. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial randomly assigned 76,693 men to receive either annual screening (38,343 subjects) or usual care as the control (38,350 subjects). Men in the screening group were offered annual PSA testing for six years and DRE for four years. After seven years of follow-up, the incidence of prostate cancer was higher in the screened population; the number of prostate cancers per 10,000 person-years was 116 (2820 cancers) in the screening group and 95 (2322 cancers) in the control group. Prostate cancer survival was similar between study groups; the incidence of death per 10,000 person-years was 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group. The numbers of subjects with advanced (stage III or IV) tumors were similar in the two groups, with 122 in the screening group and 135 in the control group, though the number of subjects with a Gleason score of 8 to 10 was higher in the control group (341 subjects) than in the screening group (289 subjects). Quality of life was not assessed. Thus, in this US trial, screening did improve detection rate; however, at a median follow-up of seven years, there was no difference in survival between the two groups.

Question 61

A 55-year-old man seeks consultation regarding prostate cancer screening. According to the U.S. Prostate, Lung, Colon, and Ovarian (PLCO) trial, prostate cancer screening increases: A: prostate cancer detection. B: detection of Gleason’s score 8-10 tumors. C: detection of high stage (advanced) tumors. D: prostate cancer survival. E: quality of life in men with elevated PSA.

Answer 61

A: “prostate cancer detection.” is correct. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial randomly assigned 76,693 men to receive either annual screening (38,343 subjects) or usual care as the control (38,350 subjects). Men in the screening group were offered annual PSA testing for six years and DRE for four years. After seven years of follow-up, the incidence of prostate cancer was higher in the screened population; the number of prostate cancers per 10,000 person-years was 116 (2820 cancers) in the screening group and 95 (2322 cancers) in the control group. Prostate cancer survival was similar between study groups; the incidence of death per 10,000 person-years was 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group. The numbers of subjects with advanced (stage III or IV) tumors were similar in the two groups, with 122 in the screening group and 135 in the control group, though the number of subjects with a Gleason score of 8 to 10 was higher in the control group (341 subjects) than in the screening group (289 subjects). Quality of life was not assessed. Thus, in this US trial, screening did improve detection rate; however, at a median follow-up of seven years, there was no difference in survival between the two groups.

Question 61

A 32-year-old woman with severe pyelonephritis is receiving ampicillin combined with a single daily dose of tobramycin, 7 mg/kg. After 36 hours, she remains febrile and has persistent flank pain. Following the second dose, a trough serum tobramycin level is 12 mcg/ml (5-10 mcg/ml). The next step is: A: continue current tobramycin regimen. B: continue tobramycin and start n-acetyl cysteine. C: decrease tobramycin dose. D: decrease tobramycin frequency. E: discontinue tobramycin and start aztreonam.

Answer 61

D: “decrease tobramycin frequency.” was the correct answer. When combined with TMP-SMX or ampicillin, aminoglycosides are the first drugs of choice for febrile UTIs. Their nephrotoxicity and ototoxicity are well-recognized; hence, careful monitoring of patients for renal and auditory impairment associated with infection is indicated. Once-daily aminoglycoside regimens have been instituted to maximize bacterial killing by optimizing the peak concentration to minimal inhibitory concentration ratio and reduce potential for toxicity. Administering an aminoglycoside as a single daily dose can take advantage not only of its concentration-dependent killing ability but also of two other important characteristics: time-dependent toxicity and a more prolonged post-antimicrobial effect. The regimen consists of a fixed 7 mg/kg dose of gentamicin or 5-7 mg/kg tobramycin. Subsequent interval adjustments are made by using a single concentration in serum and a nomogram designed for monitoring of once-daily therapy. Antimicrobial doses are given at the interval determined by the drug concentration of a sample obtained after the start of the initial infusion. This regimen is clinically effective, reduces the incidence of nephrotoxicity, and provides a cost-effective method for administering aminoglycosides by reducing ancillary service times and serum aminoglycoside determinations. In this case the serum level of tobramycin is high and requires adjustment. Changing to q 36 hours is indicated. Decreasing the dose may lead to the same reduction in levels but with a reduction in effectiveness. Although the patient continues to have symptoms, this is common during the initial course of pyelonephritis and is not an indication at 48 hours to change antibiotic regimen.

Question 62

A 30-year-old man has persistent hypertension and paroxysmal headaches. Plasma catecholamine levels are 1100 ng/l. Three hours after a single oral dose of clonidine, 0.3 mg, catecholamine levels are 400 ng/l. The most likely diagnosis is: A: renal artery stenosis. B: pheochromocytoma. C: essential hypertension. D: adrenal hyperplasia. E: idiopathic hyperaldosteronism.

Answer 62

C: “essential hypertension.” is correct. Rarely, patients with suspected pheochromocytoma present with normal or mildly elevated plasma catecholamines. When signs and symptoms of pheochromocytoma are present and plasma catecholamines are mildly elevated, it is critical that the cause of hypertension is determined. The best way to distinguish between essential hypertension and pheochromocytoma in this situation is an oral clonidine test. Patients with essential hypertension will experience a significant drop in plasma catecholamines, while those with pheochromocytoma will not. The clonidine test is not useful in assessing for renal artery stenosis, adrenal hyperplasia or idiopathic hyperaldosteronism.

Question 63

A healthy five-year-old boy is evaluated for bloody urethral discharge. VCUG demonstrates a diverticulum of the bulbous urethra. The most likely explanation for the radiographic finding is: A: utricle. B: straddle injury. C: meatal stenosis. D: urethral duplication. E: Cowper’s gland duct cyst.

Answer 63

E: “Cowper’s gland duct cyst.” is correct. A diverticulum of the bulbous urethra in a young male is most commonly related to dilation of a Cowper’s gland duct. The ducts of Cowper’s gland open into the urethra in the bulb and travel to the glands located in the urogenital membrane adjacent to the membranous urethra. These cysts have been found in 2.3% of autopsied males; however, they are rarely diagnosed clinically. Straddle injury usually is associated with stricture formation. Urethral duplication, although a possibility here, is much less common and often associated with infection. A utricle would enter the prostatic urethra.

Question 64

A 25-year-old man is struck by an automobile. He has a left superior and inferior pubic ramus fracture as well as a fracture of the sacroiliac joint. He has a palpable bladder. No blood is noted at the meatus and the prostate is in normal position on DRE. The next step is: A: CT urogram. B: retrograde urethrogram. C: cystogram. D: abdominal ultrasound. E: suprapubic tube.

Answer 64

B: “retrograde urethrogram.” was the correct answer. The most likely genitourinary injury in this patient is a prostatomembranous urethral disruption, as suggested by the type of pelvic fracture. Fractures of the pubic rami, in particular the medial inferior ramus, and pubic diastasis are independent predictors of urethral injuries. In most patients, in the absence of blood at the urethral meatus, catheterization is appropriate as the first step. However, in a high risk patient with a palpable bladder and inferior ramus fracture, a urethrogram is the easiest, most specific, and most rapid way to assess urethral injury. Upper tract imaging is not indicated in patients with pelvic fracture. Cystography may be indicated, but not before the urethra has been determined either by retrograde urethrogram or catheterization, to be intact. CT urogram is not a sensitive or specific test for urethral injury. Abdominal ultrasound may demonstrate intraperitoneal fluid but is unlikely to detect injuries to the urethra. Suprapubic cystostomy is not indicated prior to evaluation of the urethra. A gentle attempt at urethral catheterization may be appropriate prior to imaging in the unstable patient.

Question 65

In a 65-year-old man with RCC, the panel of molecular markers that would be most predictive of good prognosis is: A: high carbonic anhydrase IX, absent vimentin, absent p 53 expression. B: low carbonic anhydrase IX, positive vimentin, absent p53 expression. C: high carbonic anhydrase IX, positive vimentin, positive p53 expression. D: low carbonic anhydrase IX, absent vimentin, positive p53 expression. E: high carbonic anhydrase IX, positive vimentin, positive p53 expression.

Answer 65

A: “high carbonic anhydrase IX, absent vimentin, absent p 53 expression.” is correct. In multivariate analysis of a microarray of multiple RCC, certain molecular markers were independently predictive of survival in patients. Those that were predictive of longer survival included high carbonic anhydrase IX (CAIX), absent vimentin and absent p53 expression. CAIX is a von Hippel-Lindau mediated enzyme. High expression of CAIX predicts favorable prognosis. These factors were predictive independent of clinical variables.

Question 66

The factor most predictive of finding fibrosis only during post-chemotherapy RPLND for germ cell tumor is: A: use of bleomycin chemotherapy regimen. B: size of pre-chemotherapy retroperitoneal mass. C: normal post-chemotherapy CT scan. D: teratoma in primary tumor. E: normal preoperative serum tumors markers.

Answer 66

C: “normal post-chemotherapy CT scan.” was the correct answer. Normal serum tumor markers following chemotherapy are associated with a 10-20% chance of viable germ cell tumor and 30% probability of teratoma. Normal CT scan with no lymph node larger than 8 mm is associated with a greater than 90% chance of fibrosis at the time of RPLND. The presence or absence of bleomycin in the chemotherapy regimen is not associated with probability of response and the prechemotherapy mass size or stage is not a powerful predictor of post chemotherapy histology. Normal pre-chemotherapy tumor markers and the presence of teratoma are not predictive of fibrosis at RPLND.

Question 67

An eight-year-old, 25 kg boy with pyelonephritis has vomiting and diarrhea for three days. Serum electrolytes are: sodium 150 mEq/l, potassium 3.0 mEq/l, chloride 117 mEq/l, bicarbonate 25 mEq/l. The most appropriate I.V. therapy for the first 24 hours is: A: 0.25 NS with 40 mEq/l of KCl at 100 cc/hr. B: D5W with 40 mEq/l of KCl at 200 cc/hr. C: NS with 40 mEq/l of KCl at 100 cc/hr. D: NS with 40 mEq/l of KCl at 75 cc/hr. E: D5W with 10 mEq/l of KCl at 200 cc/hr.

Answer 67

A: “0.25 NS with 40 mEq/l of KCl at 100 cc/hr.” is correct. The child has significant hypernatremia and hypokalemia. Most cases of hypernatremia are due to loss of water or failure to adequately replace water loss. In this case, water loss is due to diarrhea and vomiting. These extrarenal water losses are associated with a decrease in extracellular fluid volume indicating deficits in total body sodium as well as water. The proportionally greater deficiency of water than of sodium leads to the increase in the serum sodium concentration. Initial fluid replacement in this child should replace the water loss and salt losses with a hypotonic salt solution (0.25NS with 40 mEq/l KCl at 100 cc/hr) at a rate 1.5-2.0x maintenance.

Question 68

During open inguinal hernia repair, a 19-year-old man undergoes complete excision of an incidental 2 cm spermatic cord mass. The final pathology shows well-differentiated leiomyosarcoma with negative surgical margins. A metastatic survey is negative. The next step is: A: surveillance. B: inguinal orchiectomy with high ligation of the cord. C: XRT to the inguinal region. D: RPLND. E: systemic chemotherapy.

Answer 68

B: “inguinal orchiectomy with high ligation of the cord.” was the correct answer. Paratesticular leiomyosarcoma occurs most commonly during the first two decades of life. On gross inspection, these tumors appear circumscribed, but on microscopic examination they often extend well beyond the margin seen by the naked eye. Despite achieving a negative margin, local recurrence risk is significant. Because of this, the primary paratesticular tumor should be removed by inguinal orchiectomy with high ligation of the cord. Excision of the inguinal scar is also usually performed at time of orchiectomy to reduce local recurrence. Chemotherapy and radiation are reserved for patients with gross or microscopic residual disease after surgical resection. RPLND for stage I paratesticular leiomyosarcoma is not indicated.

Question 69

During an abdominal surgery, a solid fibrous cord-like structure is encountered, coursing lateral to the bladder and ascending on the posterior aspect of the anterior abdominal wall toward the umbilicus. This structure represents a remnant of the: A: Wolffian duct. B: Müllerian duct. C: urogenital sinus. D: hypogastric artery. E: umbilical vein.

Answer 69

D: “hypogastric artery.” was the correct answer. The fetal hypogastric arteries carry de-oxygenated blood to the umbilical arteries and placenta. When the placental circulation ceases at birth, the part of the hypogastric artery distal to the superior vesical artery is converted into a solid fibrous cord which becomes the medial umbilical ligament (obliterated hypogastric artery).

Question 70

A 35-year-old man has primary infertility. On physical exam, neither vas deferens is palpable, each testis is 34 ml in volume. Semen analysis reveals a 0.3 ml volume and azoospermia. The man and his wife would like to pursue all options for parenthood. The next step is:
A: scrotal ultrasound.
B: Y-chromosome microdeletion analysis and karyotype.
C: cystic fibrosis mutation analysis on both partners.
D: diagnostic testicular biopsy with scrotal exploration.
E: donor sperm intrauterine insemination.

Answer 70

C: “cystic fibrosis mutation analysis on both partners.” was the correct answer.

The majority of patients with congenital bilateral absence of the vas deferens (CBAVD) are found to have mutations or 5T polymorphism of the CFTR (cystic fibrosis transmembrane regulator protein) gene. Men with CBAVD may have subtle pulmonary disfunction such as recurrent bronchitis and other family members may carry CF mutations, therefore the man should be offered CF testing. If the female partner has a CF mutation, the couple’s children have a 50% chance of having mutations in both CF genes and developing clinical cystic fibrosis. CF testing of both partners is ideal if the couple is considering sperm retrieval and ICSI. Diagnostic testicular biopsy is not necessary since CBAVD is associated with obstructive azoospermia. Scrotal exploration will not find the vas deferens. CBAVD patients should have normal karyotypes and will not have AZF deletions of the Y-chromosome. Scrotal ultrasound will not add any useful information. While donor insemination is an option, it is not the next step if the couple is considering all options.

Question 71

A 20 year-old man with stage 1 NSGCT (80% yolk sac, 20% seminoma) without lymphovascular invasion opts for surveillance but is concerned about radiation doses he will receive with CT scans. A reasonable treatment schedule for his CT surveillance would be:

A: chest and abdominal/pelvic CT scans at 3, 6, 9, 12, and 24 months.
B: abdominal/pelvic CT scans at 3, 12, and 24 months.
C: chest and abdominal CT scans at 3 and 24 months.
D: abdominal CT scan at 12 months.
E: chest and abdominal CT scans at 3 and 12 months.

Answer 71

E: “chest and abdominal CT scans at 3 and 12 months.” was the correct answer.

A recent randomized, controlled trial evaluating patients with clinical stage 1 NSGCT concludes that “CT scans at 3 and 12 months after orchidectomy should be considered a reasonable option in low risk patients.” This schedule was compared with CT scans at 3, 6, 9, 12, and 24 months. This less intensive CT scanning regimen is recommended for low-risk patients such as this patient. This patient does not have any high risk features (significant embryonal cell CA component and/or lymphovascular invasion). An alternative strategy to reduce radiation is to use abdominal MRI scan, although this has not been systematically studied.