SASP 2019 Flashcards
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 agonist therapy. E. LH-RH agonist therapy for six months and external beam XRT.
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 any chemotherapy treatment in the adjuvant setting. The advantage of short-term androgen deprivation therapy, with or without XRT, in this setting has not been established.
In a patient with a functionally normal neobladder, typical urodynamic findings during voiding are:
A. Pabd ↑, Pves ↔, Purethra ↑. B. Pabd ↑, Pves ↑, Purethra ↓. C. Pabd ↔, Pves ↓, Purethra ↓. D. Pabd ↔, Pves ↑, Purethra ↑. E. Pabd ↔, Pves ↔, Purethra ↓.
B: “Pabd ↑, Pves ↑, Purethra ↓.”
After orthotopic urinary reconstruction, patients may develop new voiding difficulties or incontinence, and a urodynamic evaluation is appropriate to 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.
28-year-old man receives salvage chemotherapy and a stem cell transplant for metastatic NSGCT. His markers have normalized and his CT scan is shown (?RP mass seen). The next step is: A. observation. B. PET scan. C. XRT. D. percutaneous biopsy. E. RPLND.
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 al, of 121 patients with NSGCT and a residual mass following chemotherapy, the accuracy of PET to 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.
A four-year-old uncircumcised boy has a two-week history of foreskin swelling with urination. The retained urine under the foreskin drains slowly following completion of voiding. There is no dysuria or hematuria. Physical examination reveals mild erythema of the distal foreskin and a phimotic ring. The meatus cannot be visualized. The next step is: A. observation. B. sitz baths. C. topical steroid ointment. D. dorsal slit. E. circumcision.
C: “topical steroid ointment.” is correct.
The patient has a pathologic phimosis that does not allow adequate urinary drainage. Observation is only appropriate in the setting of physiologic phimosis in which the foreskin is not retractable due to normal physiologic adhesions, as opposed to pathologic phimosis, which is development of a dense fibrotic ring from chronic inflammation. Treatment of pathologic phimosis with a topical steroid ointment (0.05% betamethasone) is effective in up to 90% of cases in relieving the phimosis and allowing adequate retraction of the foreskin. If the patient had more acute problems such as severe balanitis or more obstructive voiding symptoms, then surgical intervention with a dorsal slit, preputioplasty, or circumcision may be appropriate. Sitz baths alone are unlikely to rectify the problem.
Vascular reconstruction is recommended in hypertensive patients with:
A. bilateral medial fibroplasia.
B. bilateral ostial atherosclerotic lesions and poorly controlled hypertension on two medications.
C. unilateral 85% renal artery stenosis and a serum creatinine of 1.5 mg/dL.
D. bilateral 70% renal artery stenosis and a serum creatinine of 4.5 mg/dL.
E. bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dL.
E: “bilateral 80% renal artery stenosis and serum creatinine of 2.0 mg/dL.”
Revascularization is typically recommended in renal artery stenosis when greater than 75% occlusion occurs either bilaterally or in a solitary kidney. With severe renal loss (serum creatinine > 4 mg/dL), the likelihood of renal recovery is substantially reduced and revascularization is not recommended. Atherosclerotic renal vascular hypertension should be treated medically, typically with at least three medications, before resorting to revascularization. Medial fibroplasia is not typically progressive; thus, revascularization for this process is rarely required.
Compared to an electrohydraulic lithotriptor, the factor most likely to contribute to decreased pain using an electromagnetic lithotriptor is the:
A. amount of kilovolts (kV) utilized. B. lack of an electrical spark. C. avoidance of a water bath. D. increased entry surface area of the energy. E. decreased size of the focal zon
D: “increased entry surface area of the energy.”
Electromagnetic generators are more controllable and reproducible than electrohydraulic generators because they do not incorporate a variable in their design such as the underwater spark discharge. The introduction of energy into the patient’s body over a large skin area causes less pain. The water bath, the electric spark, and the focal zone size have no direct effects on patient pain. The kilovolt does not impact the amount of pain.
A 27-year-old woman on omeprazole and oral contraceptives has a macular rash on her forearm and joint pain. Urine dipstick reveals 2+ protein and 3+ blood. Urine microscopy shows 20 RBC/hpf and eosinophils. Serum creatinine is 1.9 mg/dL. Renal ultrasound is normal. The next step is:
A. observation. B. stop omeprazole. C. stop oral contraceptives. D. prednisolone. E. lisinopril.
B: “stop omeprazole.”
This patient likely has an acute interstitial nephritis (AIN) caused by the proton pump inhibitor, omeprazole. The findings of microscopic hematuria, proteinuria, and renal failure, along with rash and joint pain are suggestive of AIN. The first step should be to stop the causative agent. Oral contraceptives are not known to induce AIN. Although oral ACE inhibitor (lisinopril) and systemic steroid (prednisolone) are indicated in the treatment of AIN, the first step should be to remove the potential causative agent.
After traumatic renal injury, the predictors of persistent bleeding are depth of parenchymal injury, presence of arterial blush, and:
A. urinary extravasation. B. devitalized fragment. C. thickness of hematoma. D. location of laceration. E. mechanism of injury.
C: “thickness of hematoma.”
After renal trauma, the likelihood of renal exploration, renorrhaphy, and nephrectomy is associated with the grade of injury. For example, grade 4 injuries have a 64 fold higher likelihood of needing nephrectomy than a grade 1 injury. The literature shows that for grade 3 and 4 injuries, medial hematoma, hematoma > 3.5 cm in thickness, and the presence of a vascular contrast blush are associated with increased risk of bleeding and need for intervention. The presence of such findings should alert the urologist to the potential need for angiography and selective embolization of segmental vascular injuries. While urinary extravasation and devitalized fragments increase the risk of urinoma formation, they are not associated with higher rates of bleeding. Neither location of laceration or mechanism of injury predict complications independent of grade.
A 12-year-old girl develops pelvic pain with menarche. Examination reveals a duplicated vagina with an obstructive bulging perineal membrane which is incised with subsequent release of trapped menses from one of the vaginal vaults. Her periods become normal and the pain resolves. The next step is:
A. observation. B. renal ultrasound. C. pelvic MRI scan. D. VCUG. E. vaginoscopy.
B: “renal ultrasound.”
Up to one-third of women with unilateral renal agenesis (URA) have an abnormality relating to Wolffian duct development. Conversely, 43% of women with genital anomalies, like duplicated vagina, will have URA which needs to be further evaluated with a renal ultrasound as in this patient. As such, it is imperative to obtain a renal ultrasound to assess the upper collecting system and kidney on each side. Pelvic MRI scan can further delineate the uterine and vaginal anatomy but would miss renal pathologies. VCUG does not assess for upper tract obstruction or renal agenesis. Vaginoscopy may eventually be needed and consideration made for incising any vaginal septum present, but the initial evaluation in this clinical scenario is to first understand what related anomalies are present.
A newborn child has a normal anus, an enlarged phallus with a single opening at its base, labioscrotal fusion, and a palpable left gonad. Karyotype is 46,XX and genitogram demonstrates a low confluence of the urethra and vagina. The most likely diagnosis is:
A. exogenous androgen exposure in utero. B. mixed gonadal dysgenesis. C. partial androgen insensitivity. D. pure gonadal dysgenesis. E. ovotesticular disorder (true hermaphrodite).
E: “ovotesticular disorder (true hermaphrodite).”
This newborn most likely has true hermaphroditism, known now as ovotesticular disorder of sex development (DSD). This is defined as having the presence of both ovarian and testicular tissue which can be in the form of testis, ovary, or ovotestis. The palpable gonad in this patient very likely represents either testis or ovotestis as these are the gonads that may partially descend. The most common karyotype in ovotesticular DSD is 46,XX though many patients will have a second mosaic cell line with a Y-chromosome present. The degree of sexual ambiguity in these patients varies. All of the other diagnoses here are unlikely. Exogenous exposure to androgens in an XX fetus would be expected to have non-palpable gonads as there are normal ovaries present. Pure gonadal dysgenesis results in normal genitalia and not the appearance described in this patient. Partial androgen insensitivity occurs in 46,XY patients and since these patients do have testes, they produce Müllerian inhibitory substance (MIS) and should not have vaginal development. Mixed gonadal dysgenesis will commonly demonstrate one palpable testis with a streak on the other side, but their karyotype is mosaic, 46,XY/45,XO.
A preventable complication associated with the Trendelenburg position pictured is:
A. weak leg adduction. B. weak hip flexion. C. pain along the dorsum of the foot. D. numbness along the anterior thigh. E. weakness in biceps and wrist extensors.
E: “weakness in biceps and wrist extensors.”
In the Trendelenburg position, shoulder braces should not be used due to the risk of injury to the brachial plexus. This manifests as weakness and tingling in the arms and fingers. In addition, the risk for injury to the brachial plexus is also accentuated by abducting the arms more than 90 degrees from the tucked position. Care should be taken to avoid lowering the robotic arms onto the dorsum of the foot when docking, which may result in pain along the dorsum of the foot. Weak leg adduction may result from injury to the obturator nerve during pelvic lymph node dissection. Injury to the genitofemoral nerve on the psoas muscle results in numbness along the anterior thigh. Hyperextension of the hip to allow docking of the robot in the Trendelenburg position results in compression of the femoral nerve by the inguinal ligament, resulting in weak leg flexion and paresthesias.
In the management of advanced bladder cancer, the substitution of carboplatin for cisplatin in a multi-drug regimen has been shown to:
A. not affect outcome. B. increase renal toxicity. C. improve survival. D. decrease response rate. E. increase duration of therapy.
D: “decrease response rate.”
In a meta-analysis of four randomized trials in 286 patients, Galsky and colleagues have concluded that the substitution of carboplatin for cisplatin resulted in a statistically significant (three fold) decrease in the probability of achieving a complete response and a significant decrease in the overall response rate. Despite the decreased response rate, no significant effect on survival could be documented. In general, the renal safety profile is improved with the use of carboplatin. The duration of therapy is not affected by the substitution of carboplatin.
A 22-year-old woman with a history of nephrolithiasis has left flank pain. She is currently calculus free with a serum creatinine of 1.0 mg/dL. CT urogram demonstrates left hydronephrosis and a 4 cm proximal to mid-ureteral stricture. Diuretic renal scan shows left renal function of 45% and T 1/2 of 23 minutes. The next step is:
A. ureteroscopic incision. B. ureteroureterostomy. C. transureteroureterostomy. D. ureterocalicostomy. E. ileal ureter.
E: “ileal ureter.”
Long, proximal ureteral defects are difficult to manage. The surgeon must be ready to use a variety of approaches depending on the intraoperative findings.
Endopyelotomy is contraindicated with strictures over 2 cm in length because of poor outcomes!!!!
Ureteroureterostomy is ideal for short upper or mid-ureteral strictures but is not possible with long defects as in this case. Transureteroureterostomy is contraindicated in those with nephrolithiasis. Ileal ureter should be considered for long upper ureteral defects in those with serum creatinines of < 2.0 mg/dL. Fallopian tube and appendiceal substitutions are not reliable reconstructive techniques. Other options for this patient include renal mobilization combined with either a long Boari flap (if the bladder is large) or autotransplantation. Ideal patients for ureterocalicostomy have shorter upper ureteral strictures and thin lower pole renal parenchyma. In addition, a nephrectomy may also be considered as a last resort.
A ten-year-old boy with PUV had an ileocystoplasty and appendicovesicostomy two years ago. He has several 1 cm bladder stones. The next step is:
A. SWL and bladder irrigation. B. cystolithotripsy through the urethra. C. cystolithotripsy through the appendicovesicostomy. D. percutaneous cystolithotripsy. E. laparoscopic cystolithotomy.
D: “percutaneous cystolithotripsy.”
It has been reported that up to 50% of children with reconstructed bladders will develop bladder stones in their lifetime. Open cystolithotomy has been the traditional approach to treat bladder stones. In this young child with a significant stone burden, both transurethral and transstomal cystolithotripsy procedures are not ideal due to small caliber channels requiring multiple scope passes. SWL may fragment the stones, but even with irrigation, the fragments will not likely clear. A laparoscopic approach is an option, but due to the previous abdominal procedures, the laparoscopic approach has an increased risk of intra-abdominal organ injury. Percutaneous cystolithotripsy has been shown to be effective with shorter hospital stays, smaller scars, and less indwelling catheter time postoperatively than the traditional open cystolithotomy.
A 64-year-old man with urgency, frequency, and decreased force of urinary stream has an AUA Symptom Score of 18. DRE reveals a benign 35 gram prostate. He has a PVR of 150 mL and a negative urinalysis. PSA is 1.5 ng/dL. He will have cataract surgery in two weeks. The next step is:
A. obtain pressure flow urodynamics. B. tamsulosin. C. finasteride. D. tamsulosin in one month. E. solifenacin.
D: “tamsulosin in one month.”
This patient has bothersome LUTS that would likely benefit from therapy. Based on the findings, evaluation with a pressure-flow study would not be necessary at this point. Based on the Adult Urodynamics Guidelines, pressure-flow urodynamic study should be done to evaluate for urodynamic evidence of obstruction, particularly when invasive or irreversible therapies are being considered. At this point, empiric therapy with an alpha-blocker such as tamsulosin would be appropriate. However, this therapy should be instituted after his cataract surgery to eliminate the risk of floppy iris syndrome, which is a known risk of cataract surgery in patients taking alpha-blockers. Finasteride would not be an appropriate therapy for this patient as it is not recommended for use in men with LUTS that do not have an enlarged prostate. Antimuscarinics would not be primary therapy in a patient with obstructive symptoms and elevated PVR.
A 68-year-old man has a 5 cm partially exophytic (40%) enhancing renal mass with a R.E.N.A.L. nephrometry score of 12. He has a creatinine of 0.8 mg/dL and a normal appearing contralateral kidney. He has moderate COPD and cardiovascular disease. According to the AUA Guidelines, the next step is:
A. active surveillance. B. percutaneous radio frequency ablation. C. percutaneous cryoablation. D. partial nephrectomy. E. radical nephrectomy.
E: “radical nephrectomy.”
The patient has a high complexity (R.E.N.A.L. score 12 and 5.0 cm) mass with normal renal function, and significant co-morbid conditions. According to the most recent AUA Guideline for small renal masses, statement #19: “Physicians should consider radical nephrectomy for patients with a solid…renal mass where increased oncologic potential is suggested by tumor size… In this setting, radical nephrectomy is preferred if all of the following criteria are met: 1) high tumor complexity and partial nephrectomy would be challenging even in experienced hands; 2) no preexisting CKD or proteinuria; and 3) normal contralateral kidney…. (Expert Opinion)”. Therefore, radical nephrectomy is preferred over partial nephrectomy for this patient. Thermal ablation has a much lower success rate for tumors over 3.0 cm in size and the mass is larger than those typically recommended for active surveillance.
A 30-year-old man with an incomplete C6 spinal cord injury has obstructive LUTS. Videourodynamics show a maximum flow of 5 mL/second, a sustained detrusor pressure during voiding of 65 cm H2O and a PVR of 300 mL. During voiding, there is appropriate quieting of his EMG and the bladder neck is closed. The next step is:
A. dantrolene. B. baclofen. C. tamsulosin. D. diazepam. E. phenoxybenzamine.
C: “tamsulosin.”
While neurological disease can cause dyssynergy of the bladder and either the internal or external sphincters (or both), only lesions in the spinal cord above the lower thoracic level of the sympathetic outflow may result in detrusor internal sphincter dyssynergia. Because the internal sphincter is primarily smooth muscle, dantrolene, baclofen, and diazepam, all of which affect skeletal muscle, would not be expected to have much effect. Phenoxybenzamine is a non-selective alpha-antagonist that affects both alpha-1 and alpha-2 receptors. While phenoxybenzamine could be a theoretically appropriate option, the side effect profile that affects 30% of patients and can include orthotopic hypotension, reflex tachycardia, sedation, and emesis, makes it less desirable. Additionally, there has been evidence of mutagenic activity following repeat administration in animals. Tamsulosin, a highly selective alpha-1-antagonist, relaxes the smooth internal sphincter and is the best option of those listed.
A ten-year-old girl has a 1.8 cm renal pelvic stone in a horseshoe kidney with moderate hydronephrosis. The next step is:
A. SWL. B. ureteroscopy and laser lithotripsy. C. PCNL. D. laparoscopic pyelolithotomy. E. open pyelolithotomy.
C: “PCNL.”
Patients with horseshoe kidneys and stone burden > 1.5 cm are best managed with PCNL. If stone burden is < 1.5 cm, both SWL and ureteroscopy have been successful, but the single procedure stone clearance rates are lower than those reported with PCNL. The approach for PCNL is usually through a superior, posterior calyx in a horseshoe kidney. Laparoscopic or open pyelolithotomy would be not be indicated and may be technically difficult due to aberrant vasculature.
The minimal recommended time to delay elective urologic surgery and discontinue clopidogrel (Plavix®) after placement of a drug-eluting cardiac stent is:
A. three weeks. B. six weeks. C. three months. D. six months. E. twelve months.
D: “six months.”
The perioperative management of patients with drug eluting stents (DES) is decided in a multidisciplinary manner by the patient’s cardiologist, surgeon, and anesthesiologist. Surgical hemorrhagic risk and the thrombotic risk of the DES needs to be considered. The risk of stent thrombosis should be weighed against the risk of bleeding. As a general approach, all elective surgical procedures should be delayed by at least six months and ideally, 12 months after DES placement. If surgery cannot be delayed due to urgency, minimizing the time off of dual antiplatelet therapy with aspirin and thienopyridines is important as the risk of stent thrombosis (ST) is significantly increased. Patients undergoing surgical procedures 12 months after percutaneous cardiac intervention are likely at a lower risk of perioperative ST and major cardiac events. Maintaining dual antiplatelet therapy should be continued if the risk of perioperative bleeding is acceptable. Maintaining single antiplatelet therapy with aspirin applies to patients without concomitant risk factors of ST undergoing surgery more than 12 months after percutaneous cardiac stent placement.
During squeezing of the clitoris in a 45-year-old woman with complaints of urinary incontinence, no EMG activity is noted. Coughing demonstrates EMG recruitment. This is most likely representative of a:
A. partial spinal cord disruption at L5-S1. B. demyelinating lesion. C. faulty EMG reading. D. positive bulbocavernosal reflex. E. normal finding.
E: “normal finding.”
The presence of a bulbocavernosus reflex (BCR) indicates an intact sacral arc reflex. A positive BCR would be represented by increased EMG activity and pelvic floor contraction upon squeezing of the clitoris (or gently pulling on an indwelling urethral catheter). It is present in most (70%) but not all neurologically intact women. Therefore, lack of a BCR is not an abnormal finding in a neurologically intact woman. A faulty EMG reading is unlikely since there is appropriate recruitment with coughing.
During prone PCNL of a large volume renal stone, air is injected into the contrast-filled collecting system to delineate the posterior calyces. The patient becomes hemodynamically unstable and hypoxic. The next step is to:
A. remove ureteral catheter.
B. administer hydrocortisone.
C. administer a broad spectrum antibiotic.
D. place patient in supine position.
E. place patient in left lateral decubitus, head-down position.
E: “place patient in left lateral decubitus, head-down position.” is correct.
Venous gas embolism is a rare but potentially fatal complication of percutaneous renal surgery. The gas (in this case, air) enters the venous system and passes through the right heart into the pulmonary circulation, blocking the output of the right heart, which results in hypoxemia, hypercapnia, and depressed cardiac output. Venous gas embolism is indicated by hypoxemia, hypotension, dysrhythmias, and auscultation of a mill-wheel cardiac murmur. Swift response is required and includes positioning the patient head down with the right side up. Removal of the ureteral catheter is not necessary. Administration of hydrocortisone would be indicated in the face of acute allergic reaction, and administration of a broad spectrum antibiotic would be indicated in the face of sepsis. Although returning the patient to a supine position from a prone position can assist in resuscitation measures, this would not be the proper maneuver for a venous gas embolism.
The bacterial organisms most likely to be responsible for the formation of struvite stones are Proteus mirabilis and:
A. Corynebacterium diphtheriae. B. Escherichia coli. C. Serratia marcescens. D. Staphylococcus aureus. E. Streptococcus pneumoniae.
D: “Staphylococcus aureus.”
Proteus species are most commonly associated with struvite stones. However, more than 90% of S. aureus organisms produce urease, and are, therefore, associated with struvite stones. The remainder of the bacteria listed are not associated with urease production
A 41-year-old man has a low velocity gunshot wound to the perineum. Retrograde urethrogram shows extravasation of contrast at the distal bulbar urethra. Cystoscopy reveals an isolated 1 cm defect on the ventral aspect of the distal bulbar urethra. No other injuries are identified. The next step is:
A. urethral catheter realignment.
B. suprapubic tube placement.
C. debridement and primary urethroplasty.
D. debridement and urethroplasty with flap.
E. staged urethroplasty.
C: “debridement and primary urethroplasty.”
All gunshot wounds of the genitalia require surgical exploration to assess and stage the injury, clean the wound, and if appropriate, attempt repair. With a low velocity gunshot wound to the anterior urethra, primary surgical repair is indicated. Catheter realignment is associated with a higher stricture rate than primary repair. Suprapubic diversion is reserved for blunt trauma to the anterior urethra or a high velocity penetrating injury. Primary closure of the urethra is the best option when the defect is small. When the defect is larger, one should consider a staged repair: debride and mature the injured segment to the skin and then return in six months to reconstruct the urethra. Urethroplasty with graft or flap in the compromised tissue of a recent gunshot wound leads to a higher stricture rate as compared to primary repair.
Radiation exposure to the patient during fluoroscopy can be reduced by:
A. allowing the radiology technician to control the fluoroscopy pedal.
B. using continuous imaging over multiple spot images.
C. using boosted images.
D. positioning the radiation source under the operating table.
E. using the last image hold feature.
E: “using the last image hold feature.”
Using the last image hold feature has been shown to reduce radiation exposure by reducing the number of repetitive images. Positioning the radiation source of the C-arm under the operating table reduces exposure to the surgeon by reducing scatter radiation but does not change patient exposure. Boosted images and continuous imaging both increase radiation exposure. Giving the fluoroscopy pedal to the surgeon to limit imaging can reduce patient radiation exposure.
A 47-year-old woman is undergoing percutaneous test stimulation of a lead for sacral neuromodulation. Plantar flexion and rotation of the foot is noted along with sensation in the buttock. The next step is to:
A. maintain lead and discharge home.
B. place the lead one foramen higher and re-test.
C. place the lead one foramen lower and re-test.
D. advance the lead deeper into the foramen and re-test.
E. withdraw the lead to a more superficial location in the foramen and re-test.
C: “place the lead one foramen lower and re-test.” is correct.
The motor and sensory responses noted are consistent with incorrect placement of the lead into the S2 foramen. The lead should be removed, replaced one foramen lower (S3), and re-tested. Placing the lead deeper or in a more shallow position will not result in appropriate stimulation. Correct placement of the lead into the S3 foramen will result in a bellows reflex, contraction of the perineal area, and plantar flexion of the ipsilateral great toe.
A 39-year-old man with a BMI of 40 has a 5 mm distal ureteral calculus on non-contrast CT scan. The stone was not visible on KUB. Four weeks after initial diagnosis, he is asymptomatic but has not passed his calculus. The next step is:
A. renal ultrasound. B. KUB with obliques. C. low-dose non-contrast CT scan. D. non-contrast CT scan. E. ureteroscopy.
D: “non-contrast CT scan.” was the correct answer.
There are many options to image a stone in an asymptomatic patient. For an obese patient, the imaging study with the highest sensitivity is a non-contrast CT scan. Renal ultrasound is less sensitive for stones in the distal ureter, so is not the preferred option. A KUB is utilized in follow-up if the calculus was identified on CT scout film or KUB at time of diagnosis, or if the initial location of the stone was over the sacroiliac area. As such, KUB will not be helpful in this patient. Low-dose non-contrast CT scan is not recommended in patients with a BMI over 30 due to reduced sensitivity. Ureteroscopy should not be performed until a repeat non-contrast CT scan confirms the presence of a persistent stone.
A five-year-old boy with a history of PUV ablation is incontinent day and night. Renal ultrasound shows normal kidneys bilaterally. VCUG shows a mildly trabeculated bladder without VUR and no urethral obstruction. PVR is 10 mL. Urinalysis is normal. The next step is:
A. timed voiding. B. overnight bladder drainage. C. urodynamic study. D. antimuscarinics. E. desmopressin.
A: “timed voiding.”
Voiding dysfunction and incontinence are common in boys with history of PUV. Over 80% will struggle with incontinence at age five. Placing a catheter at night (overnight bladder drainage) is usually indicated in the presence of high urinary output which can occur in boys with a history of PUV secondary to a renal concentrating defect. In such patients, significant hydroureteronephrosis is expected, which this patient does not have. Since he is not retaining urine after voiding, a urodynamic study will likely demonstrate a pattern of bladder overactivity. However, it is appropriate to try conservative measures such as timed voiding prior to proceeding with more invasive testing such as urodynamics. Antimuscarinics must be used with caution since a possible underlying myogenic dysfunction could lead to outright urinary retention. Desmopressin will not affect bladder dysfunction, which is the primary etiology of incontinence in boys with PUV.
According to the AUA Guidelines, sipuleucel-T should be used in men with castration-resistant prostate cancer who have:
A. non-metastatic disease. B. asymptomatic or minimally symptomatic metastases. C. painful bone metastases. D. received docetaxel chemotherapy. E. poor performance status.
B: “asymptomatic or minimally symptomatic metastases.”
Sipuleucel-T immunotherapy is an FDA approved agent in the setting of asymptomatic or minimally symptomatic metastatic castration-resistant prostate cancer (CRPC) based on results of the IMPACT trial, published in 2010. In this randomized double-blind placebo controlled trial, sipuleucel-T was associated with a 22% relative risk reduction of death, and a four month improvement in median survival (25.8 versus 21.7 months). Notably, clinical and radiographic responses are rare with this agent, so patients should be told not to expect a decline in PSA or improvement in bone scan. According to the CRPC AUA Guideline, sipuleucel-T should not be offered to patients with symptomatic metastatic CRPC, those who have received prior docetaxel chemotherapy, poor performance status, or those who do not have metastatic disease.
A 55-year-old woman has persistent voiding symptoms 18 months after radical hysterectomy that were not present prior to her procedure. The most likely urodynamic findings will be:
A. normal compliance, detrusor overactivity, and fixed external sphincter tone.
B. decreased compliance, detrusor underactivity, and fixed external sphincter tone.
C. decreased compliance, detrusor overactivity, and normal external sphincter tone.
D. normal compliance, detrusor overactivity, and normal external sphincter tone.
E. decreased compliance, detrusor underactivity, and normal external sphincter tone.
B: “decreased compliance, detrusor underactivity, and fixed external sphincter tone.” was the correct answer.
Radical pelvic surgery can result in a lower motor neuron lesion and permanent voiding dysfunction. The most common urodynamic findings include an acontractile or underactive detrusor and fixed striated sphincteric tone (which can often lead to obstruction). In addition, this often results in a poorly compliant bladder. The smooth sphincter may be open and non-functional. Voiding dysfunction and a similar urodynamic pattern may be seen after other radical pelvic surgeries as well and the incidence of this occurring is: abdominoperineal resection: 20-68%; radical hysterectomy: 16-80%; anterior resection: 20-25%; proctocolectomy: 10-20%.
During a salvage robotic radical prostatectomy, an inadvertent 1 cm rectal injury is encountered during the apical dissection. The next steps are wound irrigation, broad-spectrum antibiotics, anal dilatation, and primary repair with:
A. TPN. B. omental interposition. C. suprapubic bladder drainage. D. peritoneal interposition. E. diverting colostomy.
E: “diverting colostomy.”
Rectal injuries, although uncommon during primary radical prostatectomy (1-3% incidence), have a higher risk when the prostatectomy is performed in the salvage setting (6-15%). Intraoperative recognition and repair of the injury is crucial. In the previously irradiated pelvis, it is advisable to perform a temporary diverting colostomy at the time of primary repair due to the increased risk of wound breakdown and rectourethral fistula formation. The other options listed involve primary repair only without bowel diversion. TPN should not take the place of a diverting colostomy. Although these may be appropriate alternatives for many patients experiencing a rectal injury (especially primary repair with omental interposition) during primary radical prostatectomy, these are not advisable without a diverting colostomy in the patient who has received prior radiotherapy for prostate cancer.
A 16-year-old girl has severe calf pain and paraesthesia of her foot in the recovery room following a prolonged surgery in the dorsal lithotomy position. The calf pain is exacerbated with palpation and passive dorsiflexion of her foot. She has good capillary refill and palpable pulses in her foot. The next step is:
A. Doppler ultrasound of leg. B. EMG of leg. C. pelvic CT scan. D. lumbar sacral spinal MRI scan. E. intracompartmental pressure measurement.
E: “intracompartmental pressure measurement.”
Patients with prolonged surgery in the lithotomy position are at risk of developing compartment syndrome. This patient is demonstrating many of the early symptoms and signs of compartment syndrome including pain disproportionate to clinical findings, as well as pain on passive stretching of the involved compartmental muscle group, tender and tense calves, and numbness or paraesthesias. Late symptoms include loss of arterial pulses and paralysis. A high index of suspicion and rapid diagnosis and treatment is needed since compartment syndrome is a progressive condition resulting in rhabdomyolysis, nerve damage to the limb, renal failure, and can progress to multi-organ failure and death. Following identification of elevated intracompartmental pressures, immediate fasciotomies are the definitive treatment. Other considerations in this patient include a deep vein thrombosis or a neuropraxia, which can be evaluated with Doppler ultrasound or an EMG; however, given the clinical scenario and timing, compartment syndrome is more likely and if present requires treatment immediately. A CT or MRI scan would not be the initial investigations performed in a patient with this symptom complex.
A 55-year-old woman with urgency urinary incontinence has tried and failed behavioral modifications and Kegel exercises. Urinalysis and physical examination are negative. The next step is:
A. PVR. B. mirabegron. C. urodynamics. D. cystoscopy. E. sacral neuromodulation.
B: “mirabegron.” ]
According to the AUA Overactive Bladder Guidelines, second line therapy (antimuscarinics or beta-3-agonists, such as mirabegron) is considered after failure of first line therapy (behavioral therapy). PVR may provide additional information. but is not part of the necessary next steps according to the Guidelines. The update to the Guidelines in 2014 added beta-3-agonists as part of the new treatment algorithm. It is premature to do urodynamics. Cystoscopy would likely be unremarkable in a patient with a negative urinalysis and is not indicated. Sacral neuromodulation is third line therapy (as is onabotulinumtoxinA and tibial nerve stimulation) and would be considered after second line therapy has failed.
A new medication for treatment of nocturnal enuresis is studied in 1,000 children. Some subjects have daytime urinary incontinence and some have had UTIs. The correct statistical test for assessing efficacy of the medication is:
A. t-test. B. Fisher's exact test. C. analysis of variance (ANOVA). D. multiple linear regression. E. Pearson correlation coefficient.
C: “analysis of variance (ANOVA).”
This is an example of an analysis of variance (ANOVA) multi-variable model where there are two or more independent variables and one dependent variable. Another way of stating this is that ANOVA statistical designs are appropriate when a study compares three or more groups or repeated measures. The t-test is the analysis of independent measures. The most common t-test compares means from two independent or different groups. In the setting of a trial with only a binary variable, a Fisher’s exact test specifically should be used when the number of subjects in any subgroup is less than five. Both the multi-factorial ANOVA and multiple linear regressions are multi-variable models. The ANOVA statistical tests are specific examples of a multiple regression; however, results reported from an ANOVA analysis are generally more intuitive, and for this reason ANOVA models are typically the first choice for analyzing data from group designs. The Pearson correlation coefficient is the appropriate test when assessing the relationship between two variables.
A 61-year-old woman with a continent cutaneous diversion develops cirrhosis. She is admitted with elevated transaminases and lethargy. The next step is:
A. I.V. sodium bicarbonate. B. I.V. hydrocortisone. C. I.V. calcium gluconate. D. pouchogram. E. continuous pouch drainage.
E: “continuous pouch drainage.”
Ammonia excreted in the urine is readily re-absorbed when the urine is in contact with bowel epithelium. In patients with significant liver dysfunction and elevated ammonia levels, this re-absorption can contribute to the associated risk of encephalopathy. Therefore, in this woman with a continent reservoir and probable hepatic encephalopathy, the most appropriate next step is to place a catheter in her reservoir to maximize urinary drainage. Sodium bicarbonate, calcium gluconate, and hydrocortisone will not address hepatic encephalopathy. In the absence of clinical signs suggestive of pouch rupture, a pouchogram is unlikely to be informative.
A 16-year-old girl with a T3 spinal cord injury develops hypotension and tachycardia during PCNL for a staghorn calculus. Preoperative urine culture was negative and she was given perioperative ampicillin and gentamicin. In addition to fluid resuscitation, the next step is:
A. ensure bladder drainage. B. stop the operation. C. place a larger access sheath. D. transfusion. E. decrease irrigation flow.
B: “stop the operation.” was the correct answer.
This patient is demonstrating symptoms of urosepsis. This may occur during fragmentation of a staghorn infectious stone despite a negative urine culture preoperatively. Cultures of”infection stone” fragments obtained from both the surface and inside of the stone have demonstrated that bacteria reside within the stone, thereby causing the stone itself to be infected. Continuation of the PCNL may only liberate more bacteria and endotoxin and result in further bacteremia. Urosepsis may be fatal. The procedure should be aborted immediately. Autonomic hyperreflexia may occur in patients with thoracic spine injuries and distended bladders but presents with hypertension and reflex bradycardia. The patient could have significant bleeding that would result in hypotension and tachycardia, and transfusion may be appropriate, but given the possibility for urosepsis, the next step would be to stop the operation. Placement of a larger access sheath would not be beneficial at this time, but it is important to have an access sheath that permits egress of irrigant. In this situation, the rate of irrigant flow will not affect her hemodynamic state.
An eight-year-old boy with prior ileocystoplasty reports catheterizing six times daily. Ultrasound shows new onset of bilateral moderate hydroureteronephrosis. Videourodynamics demonstrate detrusor pressures of 10 cm H2O at 300 mL and 40 cm H2O at 575 mL without VUR or detrusor overactivity. The next step is:
A. increase catheterization frequency. B. placement of an indwelling catheter. C. diuretic nuclear renal scan. D. antimuscarinics. E. bilateral percutaneous nephrostomy tubes.
B: “placement of an indwelling catheter.”
The urodynamic study demonstrates good bladder capacity and compliance for his age, and there should be no need to begin anticholinergics. In this patient, the most common reason for development of bilateral hydronephrosis after successful ileocystoplasty is poor compliance with his catheterization schedule or technique. With poor catheterization compliance or technique, placement of an indwelling catheter, with subsequent renal ultrasound after a week or two, should demonstrate improved hydronephrosis. It will also permit easier determination of 24-hour urine volume if high urine output is expected. Increasing the frequency of catheterization does not address the concern of poor adherence to a catheterization schedule. If hydronephrosis persists, the next step may involve nuclear renal scan to rule out the unlikely development of bilateral upper tract obstruction.
A 37-year-old man develops an abdominal bruit one week after needle biopsy of his left kidney. Arteriogram demonstrates prompt contrast filling of the left renal vein. Blood pressure and heart rate are normal. The next step is:
A. observation. B. warfarin. C. repeat arteriogram in 48 hours. D. embolization. E. intravascular stent.
A: “observation.” is correct.
Approximately 75% of patients with renovascular fistulae have an abdominal bruit. The management of renal arteriovenous fistulae depend on the cause of the fistula and the associated clinical manifestations. Fistulae due to renal cell carcinoma warrant nephrectomy. Approximately 70% of fistulae occurring after needle biopsy of the kidney close spontaneously within 18 months, thus, expectant management is an appropriate first step. Warfarin is not indicated as this patient does not have a thrombosis. Vascular stent or embolization would not be the appropriate initial step without first observing the fistula in an attempt for spontaneous closure.
A 34-year-old woman has a 3 cm right adrenal mass on ultrasound. Endocrine evaluation is normal. The next step is:
A. repeat ultrasound in six months. B. CT scan without contrast. C. CT scan with contrast. D. gadolinium-enhanced MRI scan. E. biopsy.
B: “CT scan without contrast.”
Ultrasonography is a suboptimal imaging modality for detecting and fully characterizing adrenal lesions. An unenhanced CT scan is the recommended first study to evaluate an adrenal lesion as this imaging modality is easily interpretable and provides perhaps the best assessment of intracellular lipid. Non-contrast CT scan can diagnose an adrenal adenoma in more than 70% of cases (specifically, low attenuation, < 10 Hounsfield units [HU]) on unenhanced CT which corresponds to high intracytoplasmic lipid content and is diagnostic for an adrenal adenoma. 98% of lesions with an attenuation of 10 HU or less on non-contrast CT are adrenal adenomas. Less than 30% of adrenal adenomas are lipid-poor (also known as “atypical adenomas”) and have an attenuation of > 10 HU.
A 78-year-old man has a 3 cm solid enhancing mass at the posterior aspect of his right kidney. Biopsy reveals clear cell RCC, grade 3. His creatinine is 2.1 mg/dL. He is treated with percutaneous cryoablation. Imaging one year later demonstrates persistent central enhancement of the tumor bed. The next step is:
A. observation. B. renal mass biopsy. C. repeat cryoablation. D. partial nephrectomy. E. radical nephrectomy.
C: “repeat cryoablation.”
Local recurrence after tumor ablation represents treatment failure, and occurs in 3-10% after percutaneous cryoablation and 5-20% after radio frequency ablation. Recurrence or persistence of tumor is usually evidenced by persistent central enhancement in the tumor bed. Most local recurrences can be managed by repeat ablative therapy. In this patient with renal insufficiency and tumor location amenable to repeat cryotherapy, that would be the repeat treatment of choice. Observation would be an option, but this tumor is high-grade, and therefore, warrants complete and/or curative treatment. Biopsy is not necessary given the previously positive biopsy and persistent enhancement of the lesion. Partial nephrectomy would be more challenging after cryoablation and would likely result in more renal compromise than repeat cryotherapy, and radical nephrectomy is likely to result in the requirement for dialysis.
During a sacral neuromodulation first stage trial under general anesthesia, a 48-year-old man has a foramen needle placed in S3 under fluoroscopic guidance on both the left and right sides without a motor response. The next step is:
A. use bipolar settings. B. change stimulator pulse width. C. check for neuromuscular blockade. D. move lead to S2. E. abort case.
C: “check for neuromuscular blockade.”
One must assure that this patient has muscle twitches and is not under neuromuscular blockade. Placing the lead in S3 without responses carries the risk of the lead not working or untoward stimulation patterns. Changing pulse width and bipolar settings would not help. Moving the lead to S2 is not standard therapy and would not stimulate the appropriate nerves. Aborting the case would be premature at this point and would not benefit the patient.
An 18-year-old man has gynecomastia. He is tall, thin with poor muscle development, and has sparse facial hair. Both testicles are small and firm. He most likely has:
A. normal estradiol levels.
B. normal LH levels.
C. increased risk of non-germ cell testicular tumors.
D. normal cognitive skills.
E. absence of Leydig cells on testicular biopsy.
C: “increased risk of non-germ cell testicular tumors.”
This patient has Klinefelter’s syndrome based on physical description and testicular exam. The most common karyotype will be 47,XXY. This is associated with hyalinization of seminiferous tubules, leading to small firm testicles and severe subfertility. Leydig cells are present, but testosterone production is abnormally low, with elevated estradiol levels. This leads to poor secondary male sexual development and gynecomastia. These patients are at increased risk of extragonadal germ cell tumors, Leydig and Sertoli cell testicular tumors, and have a marked increased risk of breast cancer, requiring lifelong surveillance after puberty. Recent data has demonstrated decreased verbal skills, and frontal executive function and cognitive skills in Klinefelter’s patients.
Two months after a robotic prostatectomy and lymphadenectomy, a 65-year-old man has progressively increasing urinary frequency. His PVR is 25 mL and his urinalysis shows 0-3 RBC/hpf and leukocytes. He has failed a trial of tolterodine. The next step is to obtain a urine culture and:
A. pelvic floor physiotherapy. B. imipramine. C. empiric antibiotics. D. pelvic CT scan. E. cystoscopy.
D: “pelvic CT scan.”
Patients who present with new onset, worsening irritative voiding symptoms and incontinence following uneventful robotic prostatectomy can often be passed off as experiencing normal postoperative recovery of urinary continence and be prescribed pelvic physiotherapy and anticholinergic medications. However, in the setting of having undergone a pelvic lymphadenectomy, the possibility of a pelvic lymphocele should be ruled-out. Pelvic lymphoceles can cause compression of the bladder resulting in reduced capacity and increased urinary frequency and urgency. Further treatments aimed at his LUTS would be considered if a lymphocele is not found on imaging. Antibiotics would be initiated if the urine culture is positive. There is no indication for cystoscopy at this time.
A 16-year-old girl with a bladder neck reconstruction, augmentation cystoplasty, and appendicovesicostomy is unable to catheterize for 12 hours. A catheter cannot be passed via urethra or appendicovesicostomy. Ultrasound demonstrates a distended bladder. The next step is:
A. percutaneous aspiration of bladder. B. cystoscopy via urethra. C. cystoscopy via appendicovesicostomy under general anesthesia. D. open suprapubic tube placement. E. revision of appendicovesicostomy.
A: “percutaneous aspiration of bladder.”
The flap valve mechanism of the appendicovesicostomy can result in occlusion with over-distention and elevated bladder pressures. Percutaneous aspiration in this patient may result in decompression and subsequently permit catheter passage via the appendicovesicostomy. In some patients, this may be performed under local anesthesia with sedation and avoid the need for general anesthesia. Cystoscopy would likely require general anesthesia and can be difficult after a sling procedure and bladder neck reconstruction. Endoscopy of the appendix in this situation is less likely to be successful with a full bladder and runs the risk of injury to the appendix. Open suprapubic tube placement may be required, but is more invasive than percutaneous aspiration. Revision of the appendicovesicostomy is premature in this patient.
A 54-year-old man has chemoradiation for a cT2 urothelial carcinoma of the bladder. After two cycles of cisplatin and 40 Gy XRT, he has a mid-treatment TURBT. Pathology reveals high-grade T1 urothelial cancer. The next step is:
A. repeat TURBT. B. complete planned chemoradiation. C. change to dose dense M-VAC chemotherapy. D. induction BCG. E. radical cystoprostatectomy.
E: “radical cystoprostatectomy.” was the correct answer.
Bladder preservation strategies with use of either radical TURBT and chemotherapy or tri-modality therapy with TURBT, chemotherapy, and radiation therapy, have been utilized in many clinical scenarios, usually reserved for elderly patients with more comorbidities and limited life expectancy. However, these strategies are being increasingly utilized in the healthier population as the outcomes for bladder preservation in certain subsets appear favorable. Additionally, various strategies of types of chemotherapy and radiation doses have been utilized. The RTOG (Radiation Therapy Oncology Group) has defined various protocols for chemoradiation and bladder preservation. Typically, patients receive two cycles of chemotherapy with concomitant radiation therapy, and then undergo a mid-cycle transurethral resection for response assessment. If there is persistent disease, then the recommendation for cystectomy is given at that time. If there appears to be an adequate response, then completion of chemoradiation therapy is recommended.
In this case, persistent T1 disease at the mid-cycle evaluation indicates an inadequate response to induction therapy and salvage radical cystoprostatectomy is indicated. Repeat transurethral resection after finding T1 disease at mid-cycle is not recommended, nor is changing chemotherapy or increasing planned radiation therapy dosing. Completing standard chemoradiation therapy protocols in the setting of active invasive disease would result in delayed treatment of resistant disease. BCG has been used to treat delayed recurrence of non-muscle invasive bladder cancer after trimodal therapy, but not when this occurs at the mid-treatment evaluation.
A 57-year-old woman has persistent urgency urinary incontinence despite antimuscarinic therapy. Her POP-Q exam shows: Aa: 0; Ba: 0; C: -6; Bp: -2; and Ap: -2. Her PVR is 75 mL and urinalysis is negative. The next step is:
A. pessary trial. B. CIC. C. sacral neuromodulation. D. cystocele repair. E. sacrocolpopexy.
A: “pessary trial.”
Pessary trial is a minimally invasive way to help discern the next step in this patient whose POP-Q examination is consistent with anterior vaginal wall laxity to the hymenal ring. If the urgency urinary incontinence improves, then one can consider continued pessary use or prolapse repair to more definitively correct her problem. If the pessary does not help, one can consider sacral neuromodulation or other options for refractory overactive bladder. Self-catheterization would be premature to consider, especially with a PVR of 75 mL. Since she does not have symptomatic prolapse (bulge, pressure), cystocele repair would be best considered after some assurance that the prolapse correction would result in improvement in her LUTS. Sacrocolpopexy is not indicated as this is for apical prolapse and based on her POP-Q, she does not have apical laxity with a C point of -6.
A three-month-old boy had an unstented dismembered pyeloplasty. One week later, he has continued low-grade fever and modest drainage from his flank incision. Ultrasound demonstrates a large blood clot in the renal pelvis. The next step is:
A. re-evaluate in one week. B. renal scan with Lasix. C. placement of ureteral stent. D. nephrostomy tube placement. E. re-exploration and repair anastomotic leak.
D: “nephrostomy tube placement.”
Persistent urinary drainage after an unstented pyeloplasty is common, and will often require intervention. When this is associated with a large blood clot, and likely edema at the anastomosis, the kidney will need early drainage until the bleeding resolves and edema improves. This is best managed with a nephrostomy tube, as stent placement in this young infant would likely result in stent occlusion from the renal pelvic blood clot. In the majority of cases not associated with an occlusive blood clot, the leak will resolve spontaneously, so observation is the best approach in the early postoperative period in these patients. If the leak is persistent and not associated with a consolidated clot, it would most likely resolve with retrograde stent placement. Renal scan would not change management at one week. Early re-exploration would also not be indicated in this setting that is usually able to be managed with a minimally invasive approach.
An 85-year-old afebrile man with a chronic suprapubic tube has > 105 CFU/mL of Candida on a urine culture. The funguria persists after suprapubic tube change. The next step is:
A. repeat culture in one month. B. renal ultrasound. C. fungal blood cultures. D. oral fluconazole. E. oral flucytosine
B: “renal ultrasound.”
Candiduria is a common condition, particularly in patents with urinary catheters, diabetes, and recent antibiotic use. Candiduria is often asymptomatic and usually follows a benign clinical course. In patients with indwelling catheters, the catheter should be changed and repeat culture should be performed. Persistent candiduria requires work-up for predisposing factors, including PVR assessment to exclude urinary retention, and renal ultrasound to look for hydronephrosis, urolithiasis, fungus balls, and renal abscesses. If no predisposing factors are identified, then observation with repeat culture is appropriate (one to three months). Patients with symptomatic candida cystitis should be treated. Blood cultures for fungi should be obtained in critically ill ICU patients with persistent funguria. First-line therapy is oral fluconazole, 200 mg daily for 14 days. Nearly all urine isolates of Candida albicans and most isolates of Candida glabrata are susceptible to fluconazole. In patients with resistant strains, flucytosine or Amphotericin B may be used.
A 65-year-old man has decreased force of stream, hesitancy, and frequent small-volume voids. DRE reveals a 45 gram benign prostate and urinalysis is negative. Serum PSA is 2.5 ng/mL and AUA Symptom Score is 21. Before starting medical therapy, he should have:
A. no additional work-up. B. cystoscopy. C. uroflowmetry. D. PVR. E. pressure-flow urodynamics.
A: “no additional work-up.”
The following are the recommended tests for basic management of LUTS in men per the AUA BPH Guidelines: relevant medical history, assessment of LUTS severity and bother (i.e., AUA-Symptom Score index), and physical examination including DRE and urinalysis. He has satisfied criteria for being offered treatment options. Flow rate, PVR, and pressure-flow studies are optional tests, and would be helpful for persistent bothersome LUTS after basic management has failed. Assessment of prostate size with cystoscopy or other modalities, such as TRUS and MRI scan, should be done if surgical intervention is to be considered.
