SASP 2018 Flashcards
In a morbidly obese man with erectile dysfunction, the serum androgen profile is:
A. total testosterone: ↓, estradiol: ↑, sex hormone-binding globulin: ↓.
B. total testosterone: ↓, estradiol: ↓, sex hormone-binding globulin: ↓.
C. total testosterone: ↓, estradiol: ↑, sex hormone-binding globulin: ↑.
D. total testosterone: ↔, estradiol: ↓, sex hormone-binding globulin: ↑.
E. total testosterone: ↑, estradiol: ↓, sex hormone-binding globulin: ↑.
A: “total testosterone: ↓, estradiol: ↑, sex hormone-binding globulin: ↓.”
The majority of testosterone circulates bound to sex hormone-binding globulin (SHBG), with albumin and cortisol binding globulin (CBG) playing lesser roles. Only 1-3% of total testosterone circulates unbound (free). SHBG production in the liver and Sertoli cells are altered by obesity, liver disease, and nephrotic syndrome. Obese males have reduced SHBG, and lower total testosterone, while the free testosterone levels are unchanged. The excess aromatase activity in visceral fat in obese men translates into greater testosterone breakdown to estradiol, which further lowers the total testosterone level.
A 54-year-old man dies the morning following a radical prostatectomy. A decision about an autopsy is determined by:
A. the family. B. hospital policy. C. the coroner/medical examiner. D. the patient's advance directives. E. the attending physician.
C: “the coroner/medical examiner.”
Most legal jurisdictions and hospital regulations require that all deaths be investigated that are either postoperative or related to a medical procedure. An autopsy is not performed as a part of every death investigation. In most cases, the determination of the need to perform an autopsy is a discretionary responsibility of the coroner/medical examiner. If the coroner/medical examiner is unable to determine the cause and manner of death, the law may require an autopsy to establish the cause and manner of death. In this case, the family’s permission is not needed. Additionally, the patient may not elect for this in his advance directives, nor can the attending physician.
A neonatal boy has a solid 4 cm renal mass with no other abnormalities. The contralateral kidney is normal. The next step is:
A. biopsy of mass. B. partial nephrectomy. C. radical nephrectomy. D. radical nephrectomy and chemotherapy. E. radical nephrectomy, chemotherapy, and XRT.
C: “radical nephrectomy.” was the correct answer.
Congenital mesoblastic nephroma is the most common solid renal tumor in infants at a mean age of 3.5 months. There is excellent outcome after radical nephrectomy alone. Occasionally, this extends into the hilum or perirenal soft tissue, so complete excision is important to prevent local recurrence; therefore, biopsy and partial nephrectomy are not advised. Neither chemotherapy nor XRT is routinely recommended.
A 50-year-old man undergoes a radical orchiectomy and is reported to have a pure seminoma. Serum beta-hCG is 342 mlU/mL and AFP is 123 IU/mL prior to orchiectomy. CT scan reveals a 7 cm para-aortic mass. After four cycles of chemotherapy, the para-aortic mass is 1.8 cm and serum markers are normal. The next step is:
A. observation. B. PET scan. C. additional chemotherapy. D. retroperitoneal XRT. E. RPLND.
E: “RPLND.”
The production of AFP is limited to cells of the cytotrophoblast. In cases of testicular germ cell tumor, the presence of an elevated serum AFP confirms the tumor to be at least partially of nonseminomatous origin due to the presence of yolk sac elements. In this case, despite the fact that the histologic evaluation of the primary tumor demonstrates pure seminoma, the cancer must be treated as a NSGCT. In patients with residual mass following chemotherapy for metastatic NSGCT, an RPLND is indicated unless the CT scan normalizes with all lymph nodes < 1 cm. Although helpful for the evaluation of a post-chemotherapy residual mass in pure seminoma, PET scan does not accurately characterize the nature of residual masses following chemotherapy in NSGCT as they may represent residual cancer, teratoma, or necrosis/fibrosis only. Given the serum marker normalization, additional chemotherapy is not necessary. XRT is not indicated in a patient with metastatic NSGCT.
An eight-year-old girl has urinary urgency, urge incontinence, and constant leakage of urine. She is started on timed voiding and has improvement with the urge incontinence but still has constant urinary leakage. Renal and bladder ultrasound are normal. The next step is:
A. MRI urogram. B. MRI scan of the spine. C. VCUG. D. videourodynamics. E. MAG-3 renal scan.
A. MRI urogram.
The clinical history strongly suggests that this girl has an ectopic ureter even though the ultrasound does not show evidence of this. The absence of an abnormality on ultrasound does not rule-out an ectopic ureter. Occasionally, the renal parenchyma from the upper pole of the kidney that is associated with the ectopic ureter is difficult to visualize on ultrasound and may be identified only by alternative imaging studies. In cases in which an ectopic ureter is strongly suspected because of incontinence, yet no definitive evidence of the upper pole renal segment is found on ultrasound, MRI scan will likely demonstrate the small, poorly functioning upper pole segment and ureter inserting beyond the bladder neck. None of the other options will adequately visualize an ectopic ureter.
A 38-year-old woman with a T6 spinal cord injury is treated with an indwelling catheter and oxybutynin for 18 months. She has severe urinary incontinence around the catheter and a patulous urethra at cystoscopy. Videourodynamics performed with a urethral catheter balloon occluding the urethra shows detrusor overactivity, a bladder capacity of 75 mL, and bilateral grade 4 VUR. The next steps are:
A. antimuscarinics and suprapubic tube placement.
B. antimuscarinics, urethral sling placement, and CIC.
C. antimuscarinics, bulking agent injection, and CIC.
D. urethral sling placement, augmentation cystoplasty, and CIC.
E. ileovesicostomy.
D: “urethral sling placement, augmentation cystoplasty, and CIC.”
A T6 spinal cord injury would be associated with detrusor overactivity and detrusor sphincter dyssynergia, in most instances. A suprapubic tube would not help with the stress incontinence that has developed due to sphincteric damage from the long-standing urethral catheter. The patient already has severe detrusor overactivity and reflux, despite antimuscarinic use; therefore, a sling alone will still likely be associated with detrusor overactivity-induced leakage and may intensify the risk of upper tract damage. Ileovesicostomy would likely be associated with ongoing urethral leakage, again due to the damaged sphincter. Bulking agent injection may help improve outlet resistance, but performing CIC repeatedly through the injected area will likely render any beneficial effect meaningless as the bulking agent is molded due to chronic catheterization. An augment, coupled with a sling, will take care of the detrusor overactivity, and the damaged sphincteric unit. The patient would need to perform CIC.
A two-month-old girl has a prenatal history of right hydronephrosis. Neonatal ultrasound images of the right kidney and bladder are shown. The most likely embryologic event to explain this anomaly is:
A. an adynamic distal ureteral segment.
B. a persistence of Chwalla membrane.
C. a cephalad origin of a ureteral bud off the mesonephric duct.
D. a muscular weakness of the trigone of the bladder.
E. early bifurcation of the ureteral bud.
C: “a cephalad origin of a ureteral bud off the mesonephric duct.”
The images demonstrate a duplicated collecting system of the right side with significant hydronephrosis of the upper pole. The bladder image demonstrates a large cystic structure lateral and posterior to the bladder indicative of a largely dilated ureter. The presence of distinct bladder wall between the lumen of the ureter and bladder distinguishes this as an ectopic ureter rather than a ureterocele. This scenario is most commonly explained by a complete duplication of the right system with an ectopic upper pole ureter. The embryology that explains the pathology of an ectopic ureter is a cephalad origin of the ureteral bud on the mesonephric duct. With an abnormally long common excretory duct, the ureter never becomes incorporated into the bladder, and, therefore, remains ectopic. In the female, the most common locations of an ectopic ureter are the bladder neck, urethra, or Gartner’s duct which lies between the urethra and the anterior vaginal wall. An adynamic distal segment would result in a ureterovesical junction obstruction. Persistence of Chwalla membrane would result in a ureterocele. A muscular weakness of the trigone of the bladder would create a diverticulum. Early bifurcation would create a partially duplicated collecting system.
A man with erectile dysfunction, diabetes, and an associated autonomic neuropathy complains of debilitating diplopia with sildenafil despite obtaining an excellent erectile response. He should be advised to discontinue sildenafil and:
A. seek an ophthalmologic consultation. B. use intracavernosal injections. C. use an intra-urethral suppository. D. use vardenafil. E. use tadalafil.
E: “use tadalafil.”
Diplopia, blurred vision, and loss of color vision (chromatopsia) are related to cross activity that some PDE5 inhibitors have for PDE6, the retinal phototransduction enzyme. This is most pronounced with sildenafil and vardenafil and is rarely associated with tadalafil as the latter has very little affinity for PDE6. An ophthalmologic consultation is not required as the adverse event is well-documented. An ophthalmologist should be seen for loss of visual acuity or blindness. The fact that the patient responded well to sildenafil illustrates that his autonomic neuropathy is minimal and the need for more invasive treatments such as a transurethral PGE1 suppository or intracavernosal injection therapy is low. Penile pain due to PGE1 suppository or PGE1 injection monotherapy may be experienced.
A 53-year-old man has atypical small acinar proliferation (ASAP) on prostate biopsy. This suggests that the diagnosis of prostate cancer cannot be made due to insufficient:
A. gland size. B. gland number. C. nuclear atypia. D. basal cells. E. luminal cells.
B: “gland number.”
Atypical small acinar proliferation (ASAP) is noted in 7.6% of men undergoing a prostate biopsy. In these men, small glands, consistent with cancer, are noted, but in an insufficient number to confirm the diagnosis of prostate cancer. Basal cells, identified morphologically or immunohistochemically would suggest benign glands as they are not present in cancer. Nuclear atypia of the luminal cells is generally present in suspicious glands but is not diagnostic in and of itself for invasive adenocarcinoma. For men with atypical small acinar proliferation, repeat biopsy is recommended.
Consumption of 2000 mg/day of Vitamin C will result in:
A. hypercalciuria. B. hyperoxaluria. C. hyperuricosuria. D. hypocitraturia. E. low urinary pH.
B: "hyperoxaluria." Vitamin C (ascorbic acid) is metabolized to oxalate. There is robust evidence that 1 to 2 grams of ascorbic acid administered daily to both normal subjects and calcium oxalate stone-formers result in no urinary pH changes but an increased urinary oxalate excretion; therefore, this practice should not be used in calcium oxalate stone-formers, as it might promote stone activity.
A 70-year-old man has a radical cystoprostatectomy with a right colon continent cutaneous diversion. Twenty-four days postoperatively, his pouch output becomes feculent. He is clinically stable. A CT scan shows a fistula between his pouch and his bowel anastomosis without evidence of distal bowel obstruction. The next step is to place a catheter in the pouch and:
A. start an elemental (low residue) diet.
B. begin TPN with NPO status.
C. place bilateral nephrostomy tubes.
D. perform a diverting ileostomy.
E. perform a re-do ileocolostomy and repair pouch.
A: “start an elemental (low residue) diet.”
The patient has a fistula between his anastomosis and his right colon continent cutaneous diversion without evidence of distal obstruction. This rare complication occurs in less than 5% of patients. In approximately two-thirds of reported cases, the fistula will resolve with conservative management. In a stable patient, a trial of an elemental diet is the initial step, which, if unsuccessful, should be followed by NPO and TPN. Bilateral nephrostomy tubes will not stop enteric content moving from the higher pressure intestine into the low-pressure reservoir. If the fistula was very high volume or the patient was septic, than a diverting ileostomy would be the appropriate step. Redoing the bowel anastomosis and repairing the pouch should be performed in a delayed fashion for fistulas that do not close.
A 33-year-old infertile man has a serum testosterone level of 150 ng/dL and an LH of 1.5 IU/L. The medication most likely responsible is:
A. exogenous testosterone. B. hydrocodone. C. sertraline. D. risperidone. E. finasteride.
B: “hydrocodone.”
This patient has hypogonadotropic hypogonadism which may be caused by chronic opioid use. Exogenous testosterone would increase testosterone levels and decrease LH levels through aromatization to estradiol and inhibition of the hypothalamic release of LH. Sertraline and other SSRIs are associated with anorgasmia and anejaculation. Risperidone and other anti-psychotics affect libido by blocking dopamine release. Finasteride is a 5-alpha-reductase inhibitor which leads to slightly elevated levels of testosterone and depression of LH through aromatization of excess testosterone.
A 52-year-old man with CIS of the bladder undergoes an induction course of intravesical BCG. A biopsy six weeks after completion of induction therapy shows persistent CIS. The next step is:
A. intravesical BCG. B. intravesical valrubicin. C. intravesical mitomycin C. D. intravesical gemcitabine. E. neoadjuvant chemotherapy and radical cystectomy.
A. intravesical BCG.
The 2016 AUA Guideline for the management of non-muscle invasive bladder cancer states that high-risk patients who have persistent CIS after an induction course of BCG should be offered a second course of BCG rather than changing the intravesical agent (such as valrubicin, mitomycin C, or gemcitabine). If a second course also fails, alternative intravesical agents or a clinical trial can be offered to those who are not fit for surgery or refuse surgery. Although primary radical cystectomy in this setting would be an option, in the absence of muscle invasive disease, neoadjuvant chemotherapy is not indicated.
The FDA warning for fluoroquinolone antibiotics states that these agents should be avoided for:
A. treatment of uncomplicated UTIs. B. prophylaxis prior to cystoscopy. C. long-term use (> 7 days). D. male patients. E. patients with fibromyalgia.
A: “treatment of uncomplicated UTIs.” was the correct answer.
The FDA warning states that fluoroquinolones should be reserved for use in patients who have no other treatment options for uncomplicated UTIs because the risks of serious side effects (tendon rupture) generally outweigh the benefits in these patients. Uncomplicated UTIs occur in women who do not have anatomic or urologic abnormalities and do not have recurrent UTIs. All men with UTIs are considered complicated. The warning does not address long term use or fibromyalgia. Quinolones should be avoided in patients with myasthenia gravis.
Fluoroquinolone antibiotics are associated with potentially permanent side effects of the tendons, joints, nerves and central nervous system. Signs and symptoms include joint or tendon pain, muscle weakness, tingling sensations, numbness, confusion, and hallucinations. The FDA does not comment on the use of fluoroquinolones prior to outpatient procedures or the routine use perioperatively; however, due to this warning, it may be prudent to consider switching to a different antibiotic on a case-by-case basis. The FDA warning does not address the length of fluoroquinolone therapy. There is no evidence that the presence of fibromyalgia has an impact on the safety or efficacy of fluoroquinolones.
A 76-year-old man with diabetic neuropathy and normal renal function has cT2 urothelial carcinoma and multifocal CIS of the bladder. The next step is:
A. neoadjuvant M-VAC.
B. neoadjuvant gemcitabine and cisplatin.
C. neoadjuvant paclitaxel and carboplatin.
D. cisplatin plus XRT.
E. radical cystectomy.
E: “radical cystectomy.”
In a recent working group of medical oncologists, the contraindications to cisplatin-based chemotherapy in the setting of urothelial carcinoma of the bladder included poor performance status, creatinine clearance < 60 mL/min, significant hearing loss, significant peripheral neuropathy, or a New York Heart Association Class 3 or higher heart failure. This patient is a poor candidate for cisplatin due to his peripheral neuropathy; therefore, neither M-VAC nor gemcitabine/cisplatin are appropriate. There is no data to support the use of non-cisplatin regimens, such as those using carboplatin, for neoadjuvant chemotherapy prior to cystectomy for bladder cancer. Multifocal CIS is a poor prognostic feature for chemotherapy/XRT in bladder cancer; therefore, this patient is best served by upfront radical cystectomy.
A 33-year-old man with cystinuria is treated with potassium citrate and alpha-mercaptopropionylglycine. Urinary cystine excretion has decreased and urinary pH is between 7 and 7.5. He continues to pass stones. The next step is:
A. add captopril. B. increase potassium citrate. C. increase dietary methionine. D. sodium nitroprusside test. E. stone analysis.
E: “stone analysis.”
Patients with cystinuria may have other metabolic disturbances such as hypercalciuria, hypocitraturia, and hyperuricosuria, and form other types of stones such as calcium oxalate, calcium phosphate, uric acid, or mixed calculi; therefore, a stone analysis should be done to check for non-cystine stones, especially if the patient is on “appropriate” medical therapy. Comprehensive 24-hour urine testing should be done if such patients are forming non-cystine stones. Increasing the dose of potassium citrate may raise urinary pH to a level that would place this patient at risk for calcium phosphate stone formation. Captopril therapy reduces cystine excretion and would be a reasonable addition to this patient’s current regimen if he is currently forming cystine stones. Dietary methionine is a precursor to cystine and should be restricted in patients with cystinuria. The patient has known cystinuria, so he does not require a repeat sodium nitroprusside test.
Evidence based medicine requires prioritization of:
A. etiologic/mechanistic literature. B. studies with significant p values. C. original single studies. D. primary resources of evidence. E. secondary resources of evidence.
E
Twelve weeks following right PCNL for a staghorn calculus, a 64-year-old man has persistent drainage from his flank despite ureteral stent and urethral catheter placement for the past ten weeks. Estimated GFR is 80 mL/min/1.73 m2. Renal scan demonstrates 10% differential function in the right kidney. The next step is:
A. observation. B. placement of a larger stent. C. placement of a percutaneous nephrostomy tube. D. open repair of fistula tract. E. nephrectomy.
E: “nephrectomy.”
Renal fistula following percutaneous nephrostomy is most often due to distal obstruction and can usually be treated with a ureteral stent. Persistent fistula can occur in the setting of a chronic infection such as tuberculosis or xanthogranulomatous pyelonephritis. Changing the stent or putting a percutaneous nephrostomy in this poorly functioning kidney is unlikely to result in closure of the fistula after this long a period; therefore, nephrectomy is the best treatment.
Following a unilateral sacrospinous fixation, a 66-year-old woman has pain radiating down her right leg. It does not improve with conservative measures after one month. The nerve most likely involved is the:
A. obturator. B. femoral. C. sciatic. D. pudendal. E. inferior gluteal.
C: “sciatic.”
The sciatic nerve can be injured with deep placement of sacrospinous fixation sutures, leading to pain radiating down the leg. This may be more common with poor exposure of the ligament and blind placement of sutures. The obturator nerve would be too lateral to catch with sutures. The pudendal nerve can be injured but would cause mostly gluteal pain and not leg pain. The most common cause of gluteal pain after this surgery is injury to the inferior gluteal nerve, and it is typically transient. The femoral nerve would be difficult to injure in this surger
A 32-year-old man with multiple sclerosis underwent 200 U intravesical onabotulinumtoxinA injection two months ago. He reports improved but persistent urgency urinary incontinence despite CIC every four hours. Urinalysis is negative. He also reports that one month ago he had a 75 U onabotulinumtoxinA injection for upper limb spasticity. The next step is:
A. inject 100 U onabotulinumtoxinA.
B. inject 200 U onabotulinumtoxinA.
C. inject 300 U onabotulinumtoxinA.
D. inject 100 U onabotulinumtoxinA in one month.
E. inject 200 U onabotulinumtoxinA in one month.
E: “inject 200 U onabotulinumtoxinA in one month.”
Currently, the total dose of onabotulinumtoxinA should not exceed 400 U in a three month period for all indications, including those outside the urinary tract (i.e., cosmetic, ophthalmologic, etc.). Since this man has had 275 U, he may be eligible for another 200 U dose in one month. If 200 U were not beneficial initially, a dose of 100 U is unlikely to help, while 300 U is not an approved dose for neurogenic detrusor overactivity. As repeated injections of onabotulinumtoxinA have been shown to be effective and safe, most practitioners would attempt additional injections prior to considering ileocystoplasty.
A 32-year-old woman has a blood pressure of 165/100 mm Hg on daily hydrochlorothiazide 25 mg. CT scan demonstrates a “string of beads” appearance of the left renal artery. The next step is:
A. add lisinopril. B. renal function scan. C. renal artery stenting. D. percutaneous transluminal renal artery angioplasty. E. renal artery revascularization.
A: “add lisinopril.”
This patient has medial fibroplasia which occurs predominantly in women 25 to 50 years of age. The lesion is typically described as a “string of beads” and involves the distal half of the main renal artery. The lesions are unlikely to progress to complete occlusion or result in loss of renal function; therefore, a renal function scan is not necessary. Hydrochlorothiazide 25 mg is an appropriate initial treatment and more aggressive medical therapy should now be initiated. Treatment does not usually require surgical intervention (i.e., stenting, angioplasty, or revascularization).
A 43-year-old man who desires a biologic child reports orgasm without antegrade emission for the past two years. Physical exam, testosterone, and FSH assays are normal. The next step is:
A. post-ejaculatory urine. B. transrectal ultrasound. C. spine MRI scan. D. HbA1c. E. pseudoephedrine.
A: “post-ejaculatory urine.”
This condition, in which a patient has an orgasm without the expulsion of an antegrade ejaculate from the urethra, is called “aspermia”, “anejaculation”, or “dry ejaculation.” The differential diagnosis includes failure of a seminal emission (no expulsion of fluid from the vas deferens, seminal vesicles, and prostate into the posterior urethra) and retrograde ejaculation (retrograde flow of semen from the posterior urethra into the bladder). In addition, very low volume ejaculates may be due to ejaculatory duct obstruction or aplasia of the vas deferens and seminal vesicles. In this patient, the likelihood of ejaculatory duct obstruction is low since there is no antegrade ejaculate at all, and transrectal ultrasound would not be an appropriate next step. Post-ejaculatory urinalysis differentiates between the diagnoses of failure of seminal emission and retrograde ejaculation. Patients are counseled to urinate into a specimen container after orgasm, and the urine is centrifuged and inspected for the presence of sperm. Although MRI scan of the spine and HbA1c may help clarify the etiology of the aspermia, post-ejaculatory urine is needed as the next step to determine if the patient has retrograde ejaculation or failure of seminal emission. Pseudoephedrine is a treatment for retrograde ejaculation, but a diagnosis is needed before offering this therapy.
A 45-year-old woman develops Clostridium difficile colitis after antibiotic treatment for uncomplicated cystitis. She is febrile with a WBC of 20,000/mL. The appropriate treatment is:
A. oral metronidazole. B. oral vancomycin. C. oral metronidazole and vancomycin. D. I.V. metronidazole. E. rectal vancomycin.
B: “oral vancomycin.” was the correct answer.
Clostridium difficile is typically present in low numbers in the fecal flora; however, antibiotic therapy may eliminate the normal fecal flora and allow C. difficile to flourish. C. difficile produces toxins which cause diarrhea and mucosal sloughing (pseudomembranous enterocolitis). If left unchecked, the infection can progress to life-threatening toxic megacolon. The diagnosis of C. difficile colitis requires: 1) the presence of diarrhea or radiographic evidence of ileus, and 2) a positive stool test result for the C. difficile organism or its toxins, or colonoscopic/histologic findings of pseudomembranous colitis. Initial treatment of C. difficile colitis includes oral metronidazole or vancomycin. Mild cases can be treated with metronidazole, but patients with evidence of systemic symptoms should be treated with oral vancomycin. The patient in this scenario is febrile with an elevated WBC, and should, therefore, be treated with oral vancomycin. The use of concomitant metronidazole and vancomycin has not been shown to have efficacy above that seen with a single agent. Intravenous metronidazole does result in measurable drug levels in the colon. This treatment can be used in cases where oral medications are not possible but it is not recommended as monotherapy. Similarly, rectal vancomycin can be used in the setting of ileus or as adjunctive therapy, but it is not recommended as monotherapy as it may not reach the entire affected area. Other treatments such as probiotics or fecal transplantation are reserved for cases of recurrent C. difficile infections. Surgical treatment with partial or subtotal colectomy may be required if severe systemic symptoms or colon dilation (megacolon) develops.
An infant has penoscrotal hypospadias, bilateral non-palpable gonads, and a bifid scrotum. Laparoscopy reveals a left intra-abdominal testis and right streak gonad with a right oviduct and rudimentary uterus. The most likely diagnosis is:
A. pure gonadal dysgenesis. B. mixed gonadal dysgenesis. C. hernia uteri inguinale. D. ovo-testicular disorder. E. CAH.
B: “mixed gonadal dysgenesis.”
The combination of a testis and a contralateral streak gonad and incomplete virilization defines mixed gonadal dysgenesis. The chromosomal status is usually that of a mosaic 45 XO/46 XY. The persistence of the Müllerian structures is due to the lack of production of Müllerian inhibiting substance (MIS). This is the second most common etiology of ambiguous genitalia following 46 XX DSD (female pseudohermaphroditism, i.e., CAH). Pure gonadal dysgenesis, defined by bilateral streak gonads, would have either 46 XX or 46 XY genotype. Hernia uteri inguinale (persistent Müllerian duct syndrome) is due to a failure of production of MIS or its receptor and has normal appearing testes in the abdomen with Fallopian tubes and uterus. Ovo-testicular disorder (true hermaphroditism) always has both ovarian and testicular tissue present. CAH does not have testes present.
During an open abdominal sacrocolpopexy, significant bleeding is noted at the time of sacral suture placement. In addition to fluid resuscitation, the next step is:
A. suture ligate sacral vessels.
B. sterile tack placement into sacrum.
C. close retroperitoneum and abandon operation.
D. angioembolization of pudendal vessels.
E. cross clamp iliac vessels.
B: “sterile tack placement into sacrum.”
Presacral bleeding is a serious event that one who performs sacrocolpopexy should be prepared for. The use of a sterile tack placed at the site of sacral sutures may need to be done. Suture ligation of the vessels that would usually cause this type of deep sacral bleeding is rarely successful. Closing the retroperitoneum would not help deep sacral bleeding. Angioembolization and iliac clamping would not help at this presacral venous level. This bleeding is seen more often if the sutures are placed too low in the sacrum (closer to S2/S3/S4).
A prospective, phase 3 randomized controlled trial has demonstrated that the addition of an anti-reflux mechanism to orthotopic urinary diversion:
A. reduces the rate of urinary infection.
B. reduces the rate of renal failure.
C. reduces the risk of urinary retention.
D. increases the overall late complication rate.
E. increases the rate of secondary surgeries.
E: “increases the rate of secondary surgeries.”
A recent prospective, randomized phase 3 trial compared the long-term outcome of orthotopic neobladder with (T-pouch) or without (Studer pouch) an anti-reflux mechanism. The study found no difference in the rates of overall late complications or moderate renal failure, but did demonstrate a higher rate of secondary diversion-related surgeries for those patients randomized to the T-pouch.
A six-year-old girl with urge incontinence demonstrates squatting behavior to try to prevent leakage. The next step is:
A. pelvic floor biofeedback.
B. holding exercises and limiting of fluid intake.
C. laxatives and elimination of caffeine.
D. antimuscarinic medication.
E. posterior tibial nerve stimulation.
D: “antimuscarinic medication.” was the correct answer.
This child has classic symptoms of detrusor overactivity. All of the therapies have a role in the management of urinary incontinence. Antimuscarinics are the gold standard for detrusor overactivity. Often, a course of treatment over several months is effective until the bladder function matures and medication can be stopped. Pelvic floor biofeedback is helpful and can have some inhibitory effect on the overactive detrusor, but it can be time-consuming, difficult to execute at this age, and is most helpful for children with dysfunctional elimination with elevated PVR volume. Holding exercises (delayed voiding) are typically not effective and can promote dysfunctional elimination. Limiting fluid intake is only helpful in children with an excessive fluid intake. Laxatives are helpful in constipated children, but this child’s worsening symptoms dictate therapy more directed at bladder function. Caffeine elimination can also be helpful, but it is rarely an issue at this age. Posterior tibial nerve stimulation can also be effective, but its use is not approved in children and would be used in the adult population after a failure of pharmacologic therapy.
A 15-year-old girl with spina bifida has a sigmoid augmentation and appendicovesicostomy. She catheterizes five times a day and is continent. She has recurrent bladder calculi. The best option for reducing her risk of stone formation is daily bladder irrigation and:
A. thiazide diuretics. B. prophylactic trimethoprim sulfamethoxazole. C. potassium citrate. D. intravesical gentamicin irrigation. E. daily catheterization per urethra.
E: “daily catheterization per urethra.” was the correct answer.
The most common cause of bladder calculi after augmentation cystoplasty is thought to be poor emptying and mucus formation. The majority of stones will be struvite, usually due to chronic bacteriuria. Oral and intravesical antibiotics may transiently lower the risk for bacteriuria but have not been shown to lower stone risk. Thiazide diuretics have no benefit with the types of stones generally formed in an augmented bladder. Hypocitraturia has been shown to be associated with bladder stones in some patients, but the impact of poor emptying and mucus are the more important risk factors. Supplemental potassium citrate will not decrease the incidence of bladder stones in this population. Patients with abdominal wall stomas have a risk of incomplete bladder emptying, with a higher risk of bladder stones compared to those that catheterize per urethra. The best option for this patient would be to add daily bladder irrigation and ensure complete bladder emptying by adding catheterization per urethra.
During laparoscopic left varicocelectomy, several bleeding vessels anterior to the psoas muscle are controlled with electrocautery. Postoperatively, the patient complains of numbness on his anterior thigh and scrotum. The nerve most likely injured is the:
A. iliohypogastric. B. ilioinguinal. C. posterior femoral cutaneous. D. genitofemoral. E. anterior obturator branch.
D: “genitofemoral.”
The genitofemoral nerve runs anterior to the psoas muscle and provides sensation to the anterior thigh (femoral branch), and the cremasteric muscles and anterior scrotum (genital branch). This is the most likely nerve to be injured during laparoscopic varicocelectomy, especially with cautery around the psoas muscle.
The iliohypogastric nerve supplies innervation to the internal oblique and transversus muscles as well as sensation to the lower abdominal wall. The ilioinguinal nerve supplies sensation to the anterior scrotum but not to the thigh. The posterior femoral cutaneous nerve supplies sensation to the posterior scrotum, posterior thigh, and perineum. The obturator nerve supplies sensation to the inner medial thigh and motor supply to the adductors of the thigh.
A 58-year-old obese man is undergoing a planned ileal conduit after radical cystectomy. He has a thick abdominal wall and short mesentery that makes the creation of a properly protruding end ileal stoma difficult. The next step is:
A. move ostomy lateral to rectus fascia. B. create loop ileostomy (Turnbull). C. convert to transverse colon conduit. D. create orthotopic ileal neobladder. E. perform ureterosigmoidostomies.
B: “create loop ileostomy (Turnbull).”
Development of the stoma is perhaps the most important aspect in performing an ileal conduit because the stoma is the most likely site of complications and has a significant impact on a patient’s quality of life. Proper maturation of the stoma and selection of the appropriate site for stomal placement are the most critical factors in determining the success of the ileal stoma and a properly fitting appliance. Ideally, the matured stoma should extend one to two inches above the skin edge for minimizing stomal stenosis, reducing skin problems, and optimizing proper appliance fit. Ideally a nipple or “rosebud” stoma is performed; however, obese patients have a thick abdominal wall and often a thick, short ileal mesentery. This makes the construction of an end ileal stoma extremely difficult, as in this patient. The loop ileostomy obviates some of these problems and is usually easier to perform than the ileal end stoma in the patient who is obese. The so-called Turnbull loop stoma results in a lesser incidence of stomal stenosis but a higher incidence of parastomal hernias. In obese patients with a short mesentery and thick abdominal wall, the loop ileostomy should be considered. All stomas should be placed through the belly of the rectus muscle. Moving the ostomy lateral to the rectus fascia should not be performed as it would significantly increase the risk of a parastomal hernia. Use of transverse colon is unlikely to overcome the difficulties of a thick abdominal wall and short mesentery in this patient, and is, therefore, not recommended. Although in some obese patients, an orthotopic neobladder may be easier to accomplish than the ileal conduit, working with the thickened bowel mesentery remains a challenge. The mesentery may prevent adequate descent of the reservoir into the pelvis compromising the ability to perform the neobladder to urethra anastomosis. Furthermore, since the preoperative plan was to perform an ileal conduit in this patient, primary efforts (including a Turnbull stoma) should be made to perform the ileal conduit if possible. Although the use of ureterosigmoidostomies may avert the need for bowel diversion and may be appropriate in very select patients, it possesses challenges related to fecal incontinence and to potential cancer development. Accordingly, in this patient or any obese patient, this should not represent an initial approach to urinary diversion.
A 28-year-old man is hemodynamically stable after an MVC. CT scan reveals a 1 cm laceration into the right renal parenchyma with no urine extravasation. Two days after injury, he has worsening right flank pain. His hemoglobin is 14 g/dL. The next step is:
A. observation and pain control. B. DMSA scan. C. contrast CT scan. D. renal ultrasound with Doppler. E. retrograde pyelogram.
C: “contrast CT scan.”
Follow-up CT imaging (after 48 hours) is prudent in patients with deep renal injuries (American Association for the Study of Trauma [AAST] grade 4-5) because these injuries are prone to developing troublesome complications such as urinoma or hemorrhage. AAST grade 1-3 injuries have a low risk of complications and rarely require intervention; however, in this scenario, the patient has worsening flank pain which may indicate a potential complication. Routine follow-up CT imaging is not advised for uncomplicated AAST grade 1-3 injuries, because it is unlikely to change clinical management. Routine DMSA or other functional nuclear scans are also not advised. Benefits of forgoing routine follow-up imaging in low-grade renal injuries include simplicity in follow-up, decreased radiation exposure and I.V. contrast complications, patient convenience, and lower cost. Clinicians should not hesitate to perform follow-up imaging studies when a complication of renal injury is suspected. Periodic monitoring of blood pressure up to a year after the injury may uncover the rare instances of post-injury renovascular hypertension. Retrograde pyelogram or renal ultrasound with Doppler are not indicated at this time.
An 11-year-old boy with Lesch-Nyhan syndrome has a history of recurrent stones. He is stone-free after PCNL. Despite allopurinol and high fluid intake, he passes several stones over the next three months. Analysis shows xanthine stones. The next step is:
A. discontinue allopurinol.
B. increase allopurinol.
C. potassium citrate.
D. thiazide diuretic and low sodium diet.
E. evaluate for combined liver and renal transplant.
C: “potassium citrate.”
Stopping allopurinol could lead to high uric acid levels and gout. Increasing allopurinol could lead to hypoxanthine stones. Neither thiazide diuretic nor low sodium diet will affect uric acid stone formation, which is the predominant stone type in patients with Lesch-Nyhan syndrome. Liver and renal transplant are considered for primary hyperoxaluria. Alkalinization of urine, and decreasing the allopurinol dose would be most beneficial in this patient.
