SASP 2019

Question 1

A 78-year-old malnourished woman with a history of prior pelvic radiation for cervical cancer has a radical cystectomy and ileal conduit with bilateral ureteral stents for urothelial cancer. Four days postoperatively, her urine output decreases wih a marked increase in output for her abdominal drain. The next step is:

a. TPN
b. placement of a catheter into the ileal stoma
c. bilateral percutaneous nephrostomy tube placement
d. revision of the ureteroileal anastomoses
e. excision of the ileal conduit and replacement with a transverse colon conduit

Answer 1

b. placement of a catheter into the ileal stoma

Leakage and fistula formation from a urinary diversion occur in 2-9% of patients, however, 20-60% of these fistulae close spontaneously. Conservative management can be safely attempted assuming the patient is not septic and that adequate drainage is maintained. Leakage could be from the ureteroileal anastomosis or from the butt end of the conduit. Bilateral ureteral stents are already in place, which should address any concerns about a ureteroileal anastomotic leak. Therefore, the best initial therapeutic maneuver in this patient is placement of a catheter into the ileal loop to facilitate drainage. While TPN is important in malnourished patients and should also be initiated, this would not address the immediate issue of the leak. If the stomal catheter failed to decrease the fistulous output, bilateral percutaneous nephrostomy tubes could be placed to divert the urinary stream. If this failed, surgical intervention would be required to address the problem.

Question 2

A 24-year-old man has a transpubic urethroplasty in the extended lithotomy position. Postoperatively, he has anteromedial thigh paresthesia and right lower extremity weakness. The nerve most likely injured is the:

a. femoral
b. obturator
c. genitofemoral
d. sciatic
e. ilioinguinal

Answer 2

a. femoral

Femoral neuropathy can occur after lithotomy procedures due to hip hyperabduction, or secondary to retractor injury with abdominal/pelvic procedures. The femoral nerve, the largest branch of the lumbar plexus, is formed within the psoas muscle from the fusion of the anterior divisions of L2-L4. It emerges between the psoas major and iliacus muscles just superior to the inguinal ligament and enters the thigh lateral to the external iliac artery. Sensory branches are the anterior and medial femoral cutaneous and long saphenous nerves. Motor supply is to the psoas, iliacus, quadriceps, pectineus, and sartorius muscles. The obturator nerve is a predominantly motor nerve providing adduction of the obturator internus muscle and also originates between L2-L4 nerve roots. The genitofemoral nerve has a genital branch providing motor supply to cremaster muscle and sensation to the anterior scrotum, derived from nerve roots L4-S3 exits the sciatic foramen and provides sensory and motor innervation to the back of the thigh, leg, and foot. The ilioinguinal nerve is a branch of L1 and provides sensory innervation to the upper scrotum and base of the penis (males) or mons pubis and labia majora (females) and motor innervation to the internal oblique and transversus muscles.

Question 3

A 52-year-old man with a history of lung cancer has a 5cm adrenal mass with an attenuation of 45 HU noted on follow-up non-contrast CT scan. Metastatic evaluation is otherwise negative. Metabolic evaluation is normal. The next step is:

a. repeat imaging and metabolic evaluation in six months
b. MRI scan
c. MIBG scan
d. percutaneous needle biopsy
e. adrenalectomy

Answer 3

d. percutaneous needle biopsy

Given the size of a 5cm adrenal mass and a history of lung cancer, observation alone is not acceptable. The CT findings are not consistent with an adenoma (HU <10), and as such, further evaluation is indicated. The primary utility of adrenal mass biopsy is to differentiate the presence of metastatic disease, especially in patients with a separate primary malignancy. In such cases, treatment options might depend on the pathology of the lesion, and, therefore, biopsy would be indicated. Importantly, a metabolic evaluation should be performed prior to biopsy, specifically to establish the absence of catecholamine production, which may be triggered by biopsy. When MRI is used in the evaluation of an adrenal lesion, opposed phase chemical-shift MR imaging is employed to evaluate to evaluate for intracellular lipid content and help distinguish an adenoma from other adrenal lesions. Nevertheless, MRI would not be reliably able to differentiate between adrenocortical carcinoma, which must be considered given the size of the lesion, and an adrenal metastasis, given the patient’s history of lung cancer. Likewise, PET scan would not be able to distinguish between a metastasis and primary adrenocortical carcinoma and so would not be helpful at this point (though it could play a role if metastasis was established). MIBG is an analog of norepinephrine, and as such, MIBG scanning has been used in the evaluation of pheochromocytoma. In a patient with normal metabolic parameters, this scan would be unlikely to impact management, and, therefore, not recommended. To proceed immediately to an adrenalectomy in this setting of a previous primary malignancy, such as lung cancer, is inappropriate until tissue diagnosis is obtained as treatment options may depend upon pathology of the lesion.

Question 4

A 45-year-old hypertensive man with a family history of renal failure is noted to have bilaterally enlarged cystic kidneys and hepatic and pancreatic cysts during an abdominal ultrasonographic examination for abdominal/flank pain and fever. He also complains of marked dysuria. He is admitted with a presumptive diagnosis of pyelonephritis. Urine culture has been sent. Initial antibiotic therapy should be:

a. gentamicin
b. ampicillin
c. cephalexin
d. ciprofloxacin
e. nitrofurantoin

Answer 4

d. ciprofloxacin

Autosomal dominant polycystic kidney disease is a systemic disease with varied renal pathology, including renal cysts, calculi, infection, hemorrhage, and eventual renal insufficiency. Associated gastrointestinal pathology includes hepatic and pancreatic cysts. These patients also have increased incidence of cerebral artery aneurysms. The cysts eventually become isolated structures and standard empiric antibiotics for pyelonephritis penetrate cysts poorly. Lipid soluble antibiotics are required and include trimethoprim, tetracycline, doxycycline, ciprofloxacin, levofloxacin, and chloramphenicol. Ampicillin, aminoglycosides, cephalosporins, and nitrofurantoin are not lipid soluble and thus are poor choices.

Question 5

Five months after cutaneous diversion, a 58-year-old woman has persistent low-grade fevers, malaise, and mild abdominal discomfort over the diversion. Her creatinine is 1.2 mg/dL, and a CT scan shows mild bilateral hydronephrosis. Urine culture is positive for E. coli. After treating the infection, the next step is:

a. urine acidification
b. program of mechanical pouch irrigation
c. prophylactic antibiotic administration
d. increase size of drainage catheter
e. pouchogram to evaluate reflux

Answer 5

b. program of mechanical pouch irrigation

It is not uncommon to develop pouchitis after construction of a urinary reservoir. This is especially true in the early postoperative period when mucous accumulation can be high. A simple program of mechanical irrigation can decrease the incidence of infections, though asymptomatic colonization may not decrease. Using a larger catheter may help urine drainage, but usually does not drain all the mucous. Prophylactic antibiotics or urine acidification are useful in patients who do not respond to simple measures and remain persistently infected. A pouchogram is not the initial step in evaluation of recurrent UTIs in the early postoperative period after continent diversion.

Question 6

A 57-year-old woman has a CT scan for severe flank pain. Pre- and post-contrast CT shows a subcapsular hematoma. The next step is:

a. repeat CT scan in 3 months
b. percutaneous nephrostomy tube
c. percutaneous drainage
d. renal biopsy
e. radical nephrectomy

Answer 6

a. repeat CT scan in 3 months

The image demonstrates a subcapsular hematoma. While subcapsular hematoma can occur in the absence of renal malignancy, the clinician should always be suspicious of an underlying tumor as a cause for the bleeding. In those cases in which an underlying tumor is not evident, delayed imaging is advised as it can allow evaluation for tumor after the hematoma is reabsorbed. A ureteral stent or percutaneous nephrostomy tube is not indicated given the absence of hydronephrosis on the image. Open or percutaneous drainage is not indicated given the risk of underlying tumor and the high likelihood of worsening the bleeding. There is insufficient evidence of a clear tumor to warrant either renal biopsy nor radical nephrectomy until a discernible mass is evident.

Question 7

A debilitated 85-year-old woman with an ileal conduit has recurrent sepsis due to pyocystis despite weekly bladder irrigations with antibiotic solution. Cystoscopy demonstrates no evidence of malignancy. The next step is:

a. prophylactic oral antibiotics
b. intravesical silver nitrate
c. suprapubic cystostomy
d. vaginal vesicostomy
e. cystectomy

Answer 7

d. vaginal vesicostomy

Pyocystis occurs in approximately 20% of patients who undergo supravesical diversion. Patients typically have a malodorous discharge and may develop sepsis. If conservative measures, such as routine bladder irrigations fill, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in women. This is an especially good alternive for an elderly or high risk patient. A stapling device can be used to quickly perform this operation. Absorbable staples should be used if the patient is sexually active. Prophylactic oral antibiotics will not be effective in preventing pyocystis in a defunctionalized bladder. Intravesical silver nitrate will not prevent bladder secretions and is likely to be no more effective than routine bladder irrigations. A suprapubic tube will not facilitate bladder drainage, as well as a vaginal vesicostomy, and would be prone to infectious complications in a defunctionalized bladder. Cystectomy is an effective treatment for pyocystis and would likely be required if the patient was a male or if there was evidence of tumor on the cystoscopy. However, the morbidity of this procedure in this elderly patient is high.

Question 8

A 75-year-old man has severe bleeding from radiation cystitis requiring transfusion. Cystogram reveals no reflux. Previous therapeutic measures have failed including fulguration, clot evacuation, and irrigations with silver nitrate and 1% aluminum. The next step is:

a. ileal loop urinary diversion
b. instillation of 10% formalin
c. instillation of 5% formaldehyde
d. instillation of 2% formalin
e. internal iliac artery embolization

Answer 8

d. instillation of 2% formalin

Formaldehyde is a 37% solution of formaldehyde gas dissolved in water and should not be used intravesically. Formalin solution is made up of 1-10% formaldehyde diluted with normal saline and has been given in bladder instillations to control hemorrhage from advanced bladder tumors or radiation cystitis. Formalin solution is exceedingly irrigating to the bladder, and thus, requires general or regional anesthesia. Because a 10% formalin solution may cause fibrosis and obstruction of the ureteral orifices, formalin instillation should begin with a 1% solution and be repeated with a 5% and then a 10% solution, if necessary. Many begin with a 1-2% solution if other measures (i.e. silver nitrate and 1% aluminum) have failed. A cystogram should be performed before instillation to rule-out vesicoureteral reflux. If reflux is present, Fogarty catheters should be passed up both ureters, and the patient should be tilted into the head-up position to protect the upper tracts from the toxic effects of formalin. Selective internal iliac arterial embolization is more invasive and should be reserved for patients that fail formalin instillation. Ileal loop urinary diversion is the final option for patients with intractable hemorrhage and a nonfunctional bladder.

Question 9

A 38-year-old azoospermic man with secondary infertility has an ejaculate volume of 0.3mL. Post-ejaculate urine contains no sperm. Serum testosterone and FSH are normal, both vasa are palpable, and testicular volume is normal. TRUS reveals a normal prostate, ejaculatory ducts, and dilated seminal vesicles. The next step is:

a. ejaculatory duct cannulation
b. testis biopsy
c. vasography
d. seminal vesicle aspiration
e. renal ultrasound

Answer 9

d. seminal vesicle aspiration

The differential diagnosis of low ejaculate volume azoospermia is ejaculatory duct obstruction, hypogonadism, vasal agenesis, ejaculatory failure, and testicular failure. Hypogonadism was excluded by a normal testosterone level and the patient has palpable vasa. Retrograde ejaculation is not present as sperm were not found in the post-ejaculate urine. This patient has either testicular failure or an obstruction of the ejaculatory ducts. Seminal vesicle aspiration under TRUS guidance will reveal numerous sperm if obstruction is present and is the least invasive method to diagnose this treatable lesion. While vasography would reveal a distal obstruction, it is more invasive than TRUS.Ejaculatory duct cannulation is difficult and, thus may not diagnose the problem. Finally, renal ultrasound is indicated in the work-up of patients with congenital unilateral or bilateral absence of the vas deferens, which this patient does not have based on his examination.

Question 10

After ligation of the adrenal vein during removal of a right adrenal pheochromocytoma, there is a precipitous fall in blood pressure. The next step is:

a. blood transfusion
b. epinephrine
c. norepinephrine
d. dopamine
e. saline bolus

Answer 10

e. saline bolus

Preoperative alpha-blockade is recommended for patients with pheochromocytoma in an attempt to stabilize the patient’s hemodynamic status and expand their intravascular volume. Beta-blockers can also be used preoperatively to decrease the risk of arrythmias. When the blood supply of the tumor has been curtailed, a fall in circulatory catecholamine levels may result in hypotension. Volume replacement with saline is the initial treatment of choice, with careful cardiovascular monitoring. In the absence of bleeding, transfusion is not indicated. Vasopressors are rarely required and may be discontinued once vascular volume approaches normal.

Question 11

The safest chemotherapeutic agent for use in patients who have received extensive prior bone marrow radiation is:

a. cisplatin
b. methotrexate
c. vinblastine
d. bleomycin
e. adriamycin

Answer 11

d. bleomycin

The primary toxicity of bleomycin is pulmonary fibrosis and it has only mild myelosuppressive effects at high doses. All of the other agents listed can have significant bone marrow toxicity. Although cisplatin is most commonly associated with renal toxicity, it can have myelosuppressive side effects as well.

Question 12

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

a. right colic
b. superior hemorrhoidal
c. middle hemorrhoidal
d. sigmoid
e. middle sacral

Answer 12

c. middle hemorrhoidal

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

Question 13

A newborn girl has an abdominal mass. An interlabial bulging mass is also noted. Ultrasound shows a cystic mass anterior to the rectum that does not change with bladder catheterization. The most likely diagnosis is:

a. imperforate hymen
b. rhadbomyosarcoma
c. sacrococcygeal teratoma
d. Gartner’s duct cyst
e. prolapsed ureterocele

Answer 13

a. imperforate hymen

This patient has an imperforate hymen causing obstruction of the vagina. The cervical glands produce mucous in response to maternal hormones. The presentation is that of an interlabial mass. Catheterization of the bladder does not decompress the mass. Ultrasound will confirm the cystic nature of the lesion and its location excludes sacrococcygeal teratoma. Rhabdomysarcoma would be uncommon in this age group and would be solid. Ureterocele can present as an interlabial mass, but the ureterocele is intravesical rather than between the bladder and the rectum. Gartner’s duct cysts usually are found in the walls of the vagina. They can occur with renal anomalies (ectopic ureter or renal hypoplasia), but rarely present with symptoms of abdominal and/or vaginal mass.

Question 14

Calcium oxalate calculi appear on MRI scan as:

a. high intensity T1-weighted image
b. low intensity T2-weighted image
c. low core intensity image
d. poorly visualized image
e. bright bone-like signal image

Answer 14

d. poorly visualized image

MRI scan is unable to reliably identify urinary calculi since it does not visualize calcium. Therefore, stone are noted as filling defects overlying high signal intensity of urine on a T2-weighted image. Stones are not visualized on T1-weighted images. Low core intensity and bright bone-like signal images are not standard findings or terminology for stone disease on MRI scans.

Question 15

A 2-month-old boy has a 4cm right adrenal mass. Biopsy revealed neuroblastoma. There are metastases to the skin, liver, and bone marrow. Skeletal survey is negative. The next step is:

a. observation
b. flank XRT
c. multi-agent chemotherapy
d. right adrenalectomy
e. total body XRT and bone marrow transplant

Answer 15

a. observation

This infant has stage 4-S neuroblastoma. This can include involvement of skin, liver, and bone marrow with bone metastases on skeletal survey. Observation therapy alone in children less than one year of age is usually sufficient and metastases regress spontaneously, and therefore, do not require any of the other options at this time. In older children, or in cases where metastases do not regress, chemotherapy is used. In this patient, there is no role for XRT or adrenalectomy.

Question 16

The antibiotic which can be used in a patient with a history of anaphylactic reaction to penicillin is:

a. ceftriaxone
b. imipinem
c. ceftrazidime
d. aztreonam
e. ampicillin

Answer 16

d. aztreonam

Carbapenems and cephalosporins are immunogenically similar in their ability to effect hypersensitivity reactions in patients who are allergic to penicillin. However, cephalosporins can usually be safely administered to patients with mild allergic reactions to penicillin. Ampicillin is immunogenically very similar to penicillin. These reactions are not seen in patients given aztreonam, although allergic cross-reactivity can occur due to reactivity to its side chain component, which is unrelated to penicillin hypersensitivity.

Question 17

A healthy 60-year-old man is diagnosed with Gleason 9 (4+5) prostate cancer. CT abdomen and bone scan are negative. MRI shows bladder invasion and lymphadenopathy. The next step is:

a. fluciclovine F-18 PET (Axumin)
b. leuprolide acetate and docetaxel
c. leuprolide acetate and XRT
d. radical prostatectomy
e. radical cystoprostatectomy

Answer 17

c. leuprolide acetate and XRT

The patient has evidence of locally advanced (cT4) and N1 prostate cancer based on evidence of bladder invasion and a right lymph node on the MRI scan. However, he does not appear to have metastatic disease (M0). Axumin PET is FDA approved for evaluation of recurrence after treatment and would not be indicated for staging at the time of diagnosis. Although some studies may suggest that the combination of androgen deprivation therapy (ADT) and chemotherapy is beneficial in N1M0 patients, this evidence currently only supports the benefit of ADT and docetaxel in metastatic, hormone-sensitive prostate cancer. The best treatment would be XRT combined with long-term ADT (2-3 years). Even with the significant potential for disease recurrence, treatment of the primary tumor within the prostate may reduce local complications; however, neither radical prostatectomy nor cystoprostatectomy would be indicated.

Question 18

In girls who have suffered sexual abuse, the most frequent finding on physical examination is:

a. no abnormality
b. tear of the labia minora
c. bruising of the inner thigh
d. laxity of the anal sphincter
e. enlargement of the hymenal opening

Answer 18

a. no abnormality

Sexual abuse in children will often leave no physical findings. All of the choices are findings consistent with sexual abuse, but a normal examination is the usual finding. Consequently, one cannot rule-out sexual abuse on the basis of the physical examination alone. A complete history, knowledge of associated risk factors, and a thorough physical examination, combined with a high index of suspicion, may lead to the diagnosis.

Question 19

A 26-year-old man has had four ureteroscopic stone extractions over the past three years. All stones were purely calcium phosphate (brushite). He denies prior UTIs. The most likely etiology for his stone disease is:

a. hyperuricosuria
b. resorptive hypercalciuria
c. phosphate renal leak
d. renal hypercalciuria
e. excess meat consumption

Answer 19

b. resorptive hypercalciuria

Calcium phosphate stones can be classified as brushite (pH 6.6). Recurrent calcium phosphate (100%) brushite stones are unusual and should arouse suspicion for primary hyperparathyroidism (resorptive hypercalciuria). Serum parathyroid and calcium levels should be evaluated. Hyperuricosuric calcium nephrolithiasis is most commonly due to excessive purine intake and can be successfully treated with dietary manipulation. Excess meat consumption is associated with hyperuricosuria. Excessive uric acid production from catabolic states or other metabolic factors can be successfully treated with allopurinol or potassium citrate. Phosphate renal leak hypercalciuria is associated with elevated Vitamin D levels and calcium oxalate or mixed calcium oxalate and calcium phosphate calculi. Renal hypercalciuria is associated with calcium oxalate stones and is successfully treated with hydrochlorothiazides over the long-term.

Question 20

A 55-year-old man has mild right flank pain eight weeks after an aorto-iliac vascular graft. Serum creatinine is 1.4mg/dL, WBC 12,000/cu mm, and urine culture is sterile. Renal ultrasound shows moderate right hydronephrosis and CT scan demonstrates the graft is posterior to the right ureter. The next step is:

a. percutaneous nephrostomy
b. oral steroid therapy
c. transureteroureterostomy
d. nephrectomy
e. ureterolysis

Answer 20

b. oral steroid therapy

Hydronephrosis occurs in 5% of ureters at risk following reconstructive vascular surgery. The cause of ureteral obstruction is anterior graft placement (30%) and localized retroperitoneal fibrosis (70%). Grafts should be placed posterior to the ureter, as in this case. Early ureteral obstruction due to secondary retroperitoneal fibrosis occurring within six months of surgery can resolve with a four-week course of oral steroid therapy. Percutaneous nephrostomy is not indicated with only mild flank pain and a normal serum creatinine. Transureteroureterostomy should be reserved for major loss of ureteral length and nephrectomy is not indicated. Ureterolysis would be reserved for failure of more conservative measures.

Question 21

While performing a videourodynamic study in a three-year-old child, the recommended rate of bladder filling is:

a. 10mL/min
b. 20 mL/min
c. 30 mL/min
d. 40 mL/min
e. 50 mL/min

Answer 21

a. 10 mL/min

The rate of bladder filling (mL/min) is calculated by determining the child’s predicted bladder capacity (average bladder capacity in mL = [age in years + 2] x 30) and dividing the result by 10. In this case, (3 + 2) x 30 = 150 / 10 = 15 mL/min or less. It is important not to fill the bladder too rapidly as it may result in falsely low levels of detrusor compliance and may produce artifactual detrusor contractions. Filling at 10% of the calculated bladder capacity (or less) per minute will minimize this problem.

Question 22

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

a. inadequate cortisone replacement
b. pituitary adenoma
c. excessive cortisone replacement
d. ectopic ACTH production
e. ectopic melanocyte-stimulating hormone secretion

Answer 22

b. pituitary adenoma

After bilateral adrenalectomy, reports have noted that between 8-29% of patients develop Nelson’s syndrome, a condition of increased ACTH secretion due to pituitary adenoma growth. While the pathophysiology remains in some debate, a lack of negative feedback from cortisol after bilateral adrenalectimy and subsequent increase in CRH (corticotropin releasing hormone) production has been hypothesized to be responsible. Local symptoms from tumor growth include headaches and visual field changes, while hyperpigmentation accompanies the increased ACTH levels. Diagnosis can be established with an MRI scan of the brain, measurement of elevated ACTH levels, as well as clinical manifestations. Treatments include radiation (either prophylactic or therapeutic), surgery (transsphenoidal), or pharmacotherapy (octreotide, temozolomide, pasireotide). Prophylactic radiation at the time of bilateral adrenalectomy may prevent the development of Nelson’s syndrome, but its routine use remains controversial. The ACTH overproduction is not likely to result from either excessive or inadequate hormone replacement. Indeed, excessive cortisone replacement would result in a Cushingoid appearance (purple striae, buffalo hump, central obesity).

Question 23

In women with invasive carcinoma of the proximal urethra, the primary lymphatic nodes for metastatic disease are the:

a. superficial inguinal
b. deep inguinal
c. external iliac
d. hypogastric
e. obturator

Answer 23

c. external iliac

Urethral carcinoma is more common in women and may involve either the distal or proximal urethra. The location of the primary tumor will dictate the primary landing zone for lymphatic spread. The distal urethra and labia drain to the superficial and then deep inguinal nodes, while the proximal urethra drains primarily to the external iliac and then secondarily to the hypogastric and obturator lymph nodes.

Question 24

A 24-year-old woman had an ileocystoplasty for neurogenic bladder four years ago. During an emergency cesarean section, the vascular pedicle to the cystoplast segment is divided. The next step is:

a. revascularization of the pedicle
b. excise ileal patch; immediate ileal augmentation
c. excise ileal patch; delated sigmoid augmentation
d. place suprapubic tube and drain
e. observation with follow-up urodynamics

Answer 24

e. observation with follow-up urodynamics

Experimental studies have shown that the augmented bowel segment receives collateral blood flow from the native bladder. Interruption of the vascular pedicle may cause some decrease in the size of the augmented segment, but the augment segment remains intact. Intraoperative assessment of blood flow to the augmented segmented immediately after ligation of the pedicle demonstrates decreased perfusion. However, perfusion returns to normal after eight weeks. Observation of the patient with repeat urodynamic studies is indicated. If this shows a significant decrease in functional capacity, consideration can be given to revision of the ileocystoplasty. Primary revision with sigmoid in this patient would be ill-advised without a bowel prep. There should be no need for a suprapubic tube as extravasation is not likely. Immediate re-augmentation would not be indicated . Subsequent demonstration of a reduction in capacity or compliance would be an indication for re-augmentation.

Question 25

The most common metabolic disturbance that occurs in a patient with an ileal conduit is:

a. hyperkalemic, hyperchloremic, metabolic acidosis
b. hyponatremic, hypochloremic, metabolic acidosis
c. hypochloremic, hypokalemic, metabolic alkalosis
d. hypokalemic, hyperchloremic, metabolic acidosis
e. hyponatremic, hypochloremic, metabolic alkalosis

Answer 25

d. hypokalemic, hyperchloremic, metabolic acidosis

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

Question 26

Renovascular hypertension that is likely to respond to angiographic or surgical intervention is characterized by:

a. marked elevation in plasma renin values
b. elevation of renal vein over inferior vena caval concentrations of renin by at least 25%
c. elevation of ipsilateral renal vein renin by at least 50% over peripheral and contralateral renal vein renin
d. elevation of ipsilateral renal vein renin by 50% over peripheral plasma renin, and by 25% over the contralateral renal vein renin
e. marked elevation of ipsilateral and contralateral renal vein renin as well as peripheral plasma renin

Answer 26

c. elevation of ipsilateral renal vein renin by at least 50% over peripheral and contralateral renal vein renin

The response of renovascular hypertension to surgery or angiographic intervention depends upon the type of lesion and its location. Renin is a mediating substance for renovascular hypertension and a search for its origin is helpful. Significantly elevated renin from one renal vein and not the other leads to localization of a candidate for intervention. Further evaluation by imaging and provocative studies involving ACE inhibitors may also confirm the diagnosis and help decide whether surgical treatment is necessary.

Question 27

A 27-year-old woman at 30 weeks of gestation has gross hematuria. Ultrasound shows a normal fetus and a maternal bladder lesion. Cystoscopy reveals a 3cm pedunculated papillary lesion. The remainder of the bladder is normal. The next step is:

a. immediate transurethral resection
b. early delivery followed by transurethral resection
c. transurethral resection after term delivery
d. remove tumor with cup biopsy forceps at initial cystoscopy
e. immediate tumor ablation with Nd:YAG laser

Answer 27

c. transurethral resection after term delivery

Hematuria during pregnancy may be mistaken for antepartum bleeding and is most commonly caused by an infection; however, other causes must be considered. Urothelial carcinoma of the bladder during pregnancy is uncommon but can present as hematuria. Ultrasound may detect bladder tumors incidentally or as part of a hematuria evaluation. Although ultrasound is a good screening technique, it is still not reliable and cystoscopy should be considered in all pregnant patients with documented gross hematuria or persistent microscopic hematuria. Bladder tumors in this age group almost always are low-grade and non-invasive, which is consistent with the findings on cystoscopy in this case. As such, these low-grade tumors do not require urgent removal. Therefore, immediate biopsy, transurethral resection, laser ablation, or early delivery for subsequent tumor resection are not indicated. In fact, immediate resection under anesthesia or cold cup removal in the office has the potential to induce uterine contractions and precipitate premature labor. The tumor resection should be delayed and performed in the standard fashion after a term delivery.

Question 28

A 31-year-old woman has acute cystitis. The most appropriate treatment is three days of:

a. fosfomycin
b. nitrofurantoin
c. ampicillin
d. ciprofloxacin
e. trimethoprim/sulfamethoxazole

Answer 28

e. trimethoprim/sulfamethoxazole

Practice guidelines from the Infectious Disease Society of America suggest that three days of antibiotics is optimal therapy for acute uncomplicated cystitis in women, except for nitrofurantoin which requires five days of therapy to be equal to other antibiotics. TMP-SMX is the recommended agent since approximately 80% of E. coli are sensitive to this regimen. Fosfomycin may also be used but is single dose therapy. Beta-lactams are less effective in community-acquired organisms with resistance as high as 50% in some communities. Ora fluoroquinolones are not recommended for the treatment of uncomplicated cystitis in women due to the risk of adverse events with these agents.

Question 29

A 67-year-old man with a clinical stage T2bN0M0 Gleason 7 (3+4) prostate cancer with a PSA of 7.8ng/mL is treated with 78 Gy external beam XRT. His PSA nadirs to 0.8ng/mL six months after therapy. Six months later, he is asymptomatic, has a normal DRE, and a PSA of 6.5ng/mL. The most likely explanation for the elevated PSA is:

a. prostatic infarct
b. persistent prostate cancer
c. PSA bounce effect
d. radiation-induced prostatitis
e. insufficient period of observation after therapy

Answer 29

b. persistent prostate cancer

A marked increase in serum PSA after a nadir within 6 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 0.1-0.5ng/mL followed by a durable decline and is especially common after brachytherapy, where it is reported to occur in 24-35% of men. These can start any time from 9-30 months after brachytherapy, with the majority of patients having a cumulative PSA rise of not more than 2-3ng/mL. Prostatic infarct is rare following radiation therapy for prostate cancer and would likely be associated with a significantly elevated PSA. Six months after treatment with XRT is a sufficient time to assess for response. The ASTRO consensus panel defined biochemical failure as three consecutive rises in PSA level after a nadir. The Phoenix definition of biochemical recurrence as a rise of greater than 2 ng/mL above the PSA nadir is a better predictor of clinical outcomes. It is important to remember than PSA failure is not equivalent to clinical failure.

Question 30

A 10-month-old boy with a vesicostomy for posterior urethral valves develops increasing bilateral hydronephrosis and a full bladder on ultrasound. The next step is:

a. diuretic renogram
b. enterocystoplasty
c. calibrate vesicostomy
d. VCUG
e. bilateral cutaneous ureterostomy

Answer 30

c. calibrate vesicostomy

The most common complications of vesicostomy are bladder prolapse and stenosis. Late development of increasing hydronephrosis and a full bladder after vesicostomy would suggest the bladder is not draining well due to stenosis of the vesicostomy. If the vesicostomy is adequate, then consideration of upper tract obstruction would be necessary. Reflux and secondary ureterovesical obstruction may be diagnosed with a VCUG or renogram, respectively, but calibration of the stoma is the first step. Bilateral cutaneous ureterostomy are rarely indicated as the secondary hydroureteronephrosis is usually secondary to a non-compliant bladder.

Question 31

A 24-year-old man is hit in the scrotum with a baseball. Two hours later, physical exam reveals a very firm, smooth, and painful testicle. Ultrasound shows a heterogeneous avascular intratesticular mass. The next step is:

a. serial physical exams and ultrasound
b. needle aspiration of the mass
c. testicular exploration
d. scrotal orchiectomy
e. inguinal orchiectomy

Answer 31

c. testicular exploration

Ultrasound findings suggestive of testicular rupture include heterogeneous echo pattern of the parenchyma and disruption of the tunica albuginea. There is wide variability in the false positive and false negative rate, and the consequences of a missed injury are significant; therefore testicular exploration is the rule. Exceptions include small, minimally symptomatic hematomas, but these patients should be observed with serial exams. Forty percent of patients managed non-operatively for intratesticular hematoma develop infection or infarction. Drainage of the hematoma may salvage the testicle and reduce recovery time. The mechanism of injury and the fact that the mass is avascular makes a tumor unlikely.

Question 32

A patient elects SWL for treatment of a symptomatic, partially obstructing radiopaque 7mm proximal ureteral calculus. The next step is:

a. push back of the stone into the renal pelvis prior to SWL
b. placement of a stent alongside the stone prior to SWL
c. placement of a nephrostomy tube prior to SWL
d. in-situ SWL treatment
e. placement of a ureteral catheter to the level of the stone

Answer 32

d. in-situ SWL treatment

Although it was initially though that SWL was more successful after manipulation of ureteral stones into the kidney or placement of a stent alongside the stone to produce an “expansion chamber” that facilitates SWL fragmentation, subsequent studies showed no difference in stone-free rates in patients treated with or without stone or stent manipulation. Indeed, the AUA Guidelines Panel concluded that there is no advantage to placement of a ureteral stent or a nephrostomy tube for proximal ureteral stones with regard to stone-free rates, and that stents lead to decrease in quality of life. Placement of a ureteral catheter to the level of the stone will only help target the stone, specifically in radiolucent stones.

Question 33

A 58-year-old woman has continuous urinary incontinence two weeks after elective robotic hysterectomy. VCUG is normal and retrograde ureterogram shows a ureterovaginal fistula and ureteral narrowing. The next step is:

a. observation
b. urethral catheter drainage
c. double-J stent placement
d. percutaneous nephrostomy
e. ureteroneocystostomy

Answer 33

c. double-J stent placement

The retrograde pyelogram reveals a ureterovaginal fistula and ureteral narrowing. The initial step should be placement of a double-J stent. If that is successful, that will improve her incontinence and potentially allow for healing of the fistula tract. Nephrostomy tube placement would be considered if a stent could not be placed. A vesicovaginal fistula is not present (normal VCUG); therefore urethral catheter placement alone would not be helpful. Urethral catheter drainage with a ureteral stent may maximize drainage and increase the likelihood of closure of the ureterovaginal fistula. If the fistula does not heal with prolonged stent drainage, the ureteral reimplantantation would be indicated.

Question 34

A 64-year-old man has dysuria, frequency, and hematuria following removal of a urethral catheter after radical prostatectomy. He is allergic to penicillin. A urine culture at the time of catheter removal grew Enterococcus faecalis. The best treatment is:

a. cephalexin
b. gentamicin
c. ciprofloxacin
d. clindamycin
e. nitrofurantoin

Answer 34

e. nitrofurantoin

Most Enterococci are sensitivie to amoxicillin, extended-spectrum penicillin derivative (e.g. piperacillin), nitrofurantoin, and fosfomycin. Fluoroquinolones, clindamycin, aminoglycosides, and cephalosporins are not reliably effective against this organism.

Question 35

A 25-year-old man has a left scrotal exploration and subsequent orchiectomy. Pathologic and staging evaluation reveal a NSGCT clinical stage 2B. After full-dose platinum-based chemotherapy, he has a residual 3cm paraaortic mass. The next steps are RPLND and:

a. scrotal XRT
b. wide excision of the scrotal scar and spermatic cord remnant
c. removal of the spermatic cord remnant
d. left hemiscrotectomy and removal of spermatic cord remnant
e. left hemiscrotectomy, removal of the spermatic cord remnant, and ipsilateral ilioinguinal node dissection

Answer 35

c. removal of the spermatic cord remnant

In patients with low-stage NSGCT undergoing primary RPLND after scrotal violation, the scrotal scar should be widely excised with the spermatic cord remnant at the time of surgery. This patient however, has a higher volume disease and was treated with induction chemotherapy. Given the relative absence of local relapse after systemic treatment, scar excision, hemiscrotectomy, scrotal XRT, and inguinal lymph node dissection are not required for patients such as this who are treated with full-dose platinum-based regimens. Removal of the spermatic cord remnant, containing the gonadal vein, should be performed at the time of RPLND in both the primary and postchemotherapy settings.

Question 36

A 22-year-old woman requests a copy of her medical records. Your office has a right to deny the request if the records:

a. pertain to billing matters
b. pertain to medical information
c. pertain to psychotherapy
d. are electronically stored
e. are more than five years old

Answer 36

c. pertain to psychotherapy

Based on the HIPAA regulations of 1996, a patient has the right to inspect and copy medical information that may be used to make decisions about their care. These request should be submitted in writing. Most commonly they will include medical and billing records. The patient is not entitled to psychotherapy notes or information compiled in a reasonable anticipation of or for use in a civil, criminal, or administrative action or proceedings. If the access to medical information is denied, the patient has the right to request a review by an independent party.

Question 37

A 32-year-old man with inflammatory bowel disease has passed two calcium oxalate stones. Twenty-four hour urine collection reveals elevated oxalate. The next step is:

a. restrict oxalate
b. restrict sodium
c. calcium
d. thiazides
e. potassium citrate

Answer 37

c. calcium

Enteric hyperoxaluria is commonly associated with inflammatory bowel disease or short-gut syndrome. Malabsorption increases the colonic permeability of oxalate by causing fat and bile to bind to intraluminal calcium, leaving oxalate unbound and free to traverse the colonic epithelium. Restricting oxalate is generally insufficient as the cause is not an overabundance of oxalate and compliance is difficult for regimens intending to eliminate all oxalate sources. Oral calcium binds to the free oxalate and prevents its absorption. Thiazide diuretics are most commonly used in hypercalciuria. Potassium citrate is usefil for prevention of stones; however, calcium supplementation is more important in patients with enteric hyperoxaluria without evidence of hypocitraturia on the 24-hour urine collection. Sodium reduction is also useful in general but most useful in patients with hypercalciuria.

Question 38

A two-month-old girl with prenatal hydronephrosis is on antibiotic prophylaxis and has a serum creatinine of 0.3 mg/dL. Bilateral hydroureteronephrosis is identified on ultrasound and VCUG shows no VUR. MAG-3 diuretic renal scan reveals equal function witha T1/2 of 21 minutes on the right and 87 minutes on the left. The next step is:

a. left cutaneous ureterostomy
b. left ureteral reimplantation
c. bilateral uretostomy
d. repeat ultrasound in one month
e. MR urogram

Answer 38

d. repeat ultrasound in one month

Over 90% of antenatally detected megaureters will improve with conservative management. The T1/2, or Lasix washout time, especially in neonatal megaureters isnot a reliable indicator of obstruction, so a normal creatinine and symmetric renal function support initial observation in this child. an end cutaneous ureterostomy is indicated in the neonate with a megaureter and sepsis, ipsilateral reduced function (less tha 35% in a neonate), or in cases of marked or increasing hydroureteronephrosis. A tapered reimplant is almost never indicated in a neonate with a megaureter. MR urography gives improved anatomic detail, but the site of narrowing is fairly constant in megaureters and exact delineation is not required to determine the best management. Conservative management with follow-up ultrasonography is the best next step since this will likely spontaneously improve.

Question 39

A 62-year-old woman with multiple sclerosis has persistent urinary urgency and frequency. Pressure flow urodynamics reveal detrusor overactivity and increased pelvic floor EMG activity during volitional voiding. An MRI scan will most likely reveal evidence of demyelination:

a. of the cerebral cortex
b. of the cerebellum
c. between the pons and sacral spinal cord
d. between the conus medullaris and the cauda equina
e. between the sacral spinal cord

Answer 39

c. between the pons and sacral spinal cord

Multiple sclerosis may involve the central and/or peripheral nervous systems. Depending on the location, level and extent of demyelination, a variety of urodynamic patterns may result. Pelvic floor EMG activity in this individual is increased during voiding which suggests detrusor external sphincter dyssnergia, a urodynamic finding that exists only with neurological lesions between the pons and the sacral spinal cord. Lesions at or distal to the sacral spinal cord would likely result in detrusor areflexia and lesions above the pons result in detrusor overactivity with synergistic activity of the proximal and distal sphincter mechanisms.

Question 40

A 39-year-old man with VHL disease has a 4 cm left upper pole renal mass and several simple appearing lower pole renal cysts. The right kidney also has several cysts as well as two 1.2 cm lower pole solid masses. Renal function is normal. The next step is:

a. radiofrequency ablation of left renal mass
b. staged bilateral radiofrequency ablation
c. left radical nephrectomy
d. left renal exploration with resection of solid mass and renal cysts
e. bilateral partial nephrectomies

Answer 40

d. left renal exploration with resection of solid mass and renal cysts

RCC in von Hippel Lindau (VHL) disease is characterized by both solid renal masses and renal cysts that contain either frank carcinoma or a lining of abnormal clear cells that represent incipient carcinoma. Appropriate surgical treatment of RCC in VHL therefore, requires excision of all solid and cystic renal lesions, preferably through a nephron sparing approach, rather than through radical nephrectomy. Although partial nephrectomy represents effective initial treatment of patients with RCC and VHL disease, it should be withheld until tumor size reaches 3 cm or more. In this scenario, both right renal masses are less than 3 cm and should be observed. This is because most of these patients will develop locally recurrent RCC with the need for repeated surgery. The 3 cm cut point, therefore, reduces the number of surgical intervention to optimize renal function and to minimize the risk of metastatic disease. This 3 cm rule also applies to patients with hereditary papillary RCC and Birt-Hogg-Dube syndrome, but not for patients with hereditary leiomyomatosis RCC. Because repeated partial nephrectomy can be challenging, a number of centers are moving toward thermal ablative treatment techniques in the setting of recurrent disease., though these have the best results when reserved for those with tumors that are less than 3 cm in size.

Question 41

A 43-year-old man desires a biological child with his 38-year-old wife. Both testes are 5 cm in longitudinal axis and firm on physical examination. Two semen analyses show azoospermia with volumes of 2.1 and 2.3 mL. FSH is 2.8 IU/L. The next step is:

a. adoption
b. TRUS
c. evaluation of his wife
d. testicular sperm extraction with ICSI
e. microsurgical scrotal duct reconstruction

Answer 41

c. evaluation of his wife

The likelihood of obstructive azoospermia is 96% with testis longitudinal axis greater than 4.6 cm and FSH less than 7.6 IU/L. However, the most significant predictor of any form of reproductive intervention is maternal age, with female fecundity declining precipitously after age 37. The decision to perform microsurgical scrotal duct reconstruction or to obtain sperm from the testis for in vitro fertilization and ICSI rests on evaluation of the female partner, especially after age 37. Transrectal ultrasound is not necessary if semen volumes are normal (greater than 1.5 mL) as ejaculatory ductal obstruction is unlikely.`

Question 42

A 62-year-old man has a radical prostatectomy for prostate cancer. Histology reveals a Gleason 9 (4+5), pT3aN1Mx cancer with negative surgical margins. His post prostatectomy PSA is <0.1 ng/mL. To minimize the 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 agonis therapy
e. LH-RH agonist therapy for six months and external beam XRT

Answer 42

d. lifelong Lh-RH agonist therapy

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 evaluated in randomized clinical trials. However, patients with lymph node metastasis, such as this patient, were not included in these trials, 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 short term androgen deprivation therapy, with or without XRt, in this setting has not been established.

Question 43

In a patient with a functionally normal neobladder, typical urodynamic findings during voiding are:

a. Pabd ^, Pves < >, Purethra ^
b. Pabd ^, Pves ^, Purethra v
c. Pabd < >, Pves v, Purethra v
d. Pabd < >, Pves ^, Purethra ^
e. Pabd < >, Pves < >, Purethra v

Answer 43

b. Pabd ^, Pves ^, Purethra v

After orthotopic urinary reconstruction, patients may develop new voiding difficulties or incontinence, and a urodynamic evaluation is appropriate t o evaluate storage function and bladder outlet. Micturition following orthotopic neobladder diversion is accomplished through abdominal straining. On a urodynamic study, this would be indicated by increased abdominal and vesical pressure accompanied by a relaxation of the external urinary sphincter and a decrease in urethral pressure.

Question 44

A 28-year-old man receives salvage chemotherapy and a stem cell transplant for metastatic NSGCT. His markers have normalized and his CT scan shows residual retroperitoneal mass. The next step is:

a. observation
b. PET scan
c. XRT
d. percutaneous biopsy
e. RPLND

Answer 44

e. RPLND

This patient has a residual retroperitoneal mass after salvage chemotherapy with stem cell transplant with normalized serum tumor markers. The recommended management is surgical resection in the form of RPLND. The histologic distribution in this setting is notable for a higher rate of viable germ cell tumor (53%) and a lower rate of necrosis (26%) than patients undergoing RPLND after induction chemotherapy. Given this rate of viable disease, observation is not appropriate. The major limitation of fluorodeoxyglucose (FDG) PET for evaluation of NSGCT is that teratoma is not FDG avid. In a prospective study by Oeschle, et all of 121 patients with NSGCT and a residual mass following chemotherapy, the accuracy of PET t o predict tumor viability was 56% which was no better than CT (55%) or serum tumor markers (56%). Thus, PET has no role in the assessment of residual masses in patients with a NSGCT, and should be reserved for use in patients with seminoma who have a residual mass greater than 3 cm after chemotherapy, as teratoma is not a concern in such cases. Similarly, percutaneous biopsy may not be able to sample the mass adequately, particularly given the potential for treatment effect in the tissues and may lead to a false negative. XRT does not play a role in the management of a residual mass in patients with NSGCT.