SASP 2019 Flashcards

Question

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

Answer 1

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.

Answer 2

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.

Answer 3

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.

Answer 4

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.

Answer 5

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%.

Answer 6

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.

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

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.

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

B: "permanent perineal urethrostomy." was the correct answer. The AUA Guidelines for male urethral stricture call attention to permanent perineal urethrostomy as an option for men with urethral stricture disease who cannot tolerate self-dilation and/or are not good candidates for formal urethroplasty due to comorbidities, advanced age, or urethral disease such as lichen sclerosus. Daily self-dilation would be difficult in this man with Parkinsonian tremor. More complex urethral reconstruction surgeries would offer him little advantage over perineal urethrostomy and expose him to increased perioperative risks and complications.

Answer 26

A. no further testing

Answer 27

E: "dairy products." Urinary uric acid is derived from both endogenous and exogenous sources. Diet-derived purines account for an estimated 30% of urinary uric acid. The typical intake of purines in the United States averages 500-1500 mg/day, including both animal and plant sources, although the latter may account for only 20% of the total in most cases. Uric acid stone-forming patients may benefit from limiting "high" and "moderately-high" purine containing foods. Although the reported purine content of foods varies, "high" purine foods are generally considered those containing more than 150 mg/3-ounce serving. These include, specific fish and seafood (anchovies, sardines, herring, mackerel, scallops and mussels), water fowl, organ meats, glandular tissue, gravies and meat extracts. "Moderately-high" sources of purines include other shellfish and fish, game meats, mutton, beef, pork, poultry, and meat-based soups and broths, and soy. Note that an individual may never or only rarely consume "high purine" foods but may habitually consume large portions of foods in the "moderately-high" category.

Answer 28

D: "dactinomycin, vincristine, doxorubicin, and XRT." was the correct answer. Any tumor spillage increases the tumor stage to at least stage 3. National Wilms' Tumor Study - 3 (NWTS-3) demonstrated that for favorable-histology disease stage 3, 10.8 Gy of abdominal irradiation was as effective as 20 Gy in preventing abdominal relapse if doxorubicin was added to vincristine and dactinomycin. Unfavorable histology with diffuse anaplasia would require additional agents including cyclophosphamide and etoposide.

Answer 29

The classic presentation of vesicoenteric fistula consists of suprapubic pain, urinary frequency, dysuria, and tenesmus. Colonoscopy and barium enema studies are, in general, less likely to demonstrate the fistula. Cystoscopy has the highest yield in identifying a potential lesion, with some type of abnormality noted on endoscopic examination in more than 90% of cases. However, the findings on cystoscopy are often nonspecific and include localized erythema, papillary, or bullous changes. A definitive diagnosis using cystoscopy can be made in only 35% to 46% of cases. CT scan with contrast is the optimal radiographic modality to demonstrate a vesicoenteric fistula and can also often identify the cause of the fistula (e.g., colon cancer, inflammatory bowel disease, diverticulitis), as well. TUR or bladder biopsy in a patient with inflammatory bowel disease could potentially increase the fistula size. Treatment options such as catheter placement and hyperalimentation would be considered after the CT scan is obtained and a diagnosis is made.

Answer 30

``` C: "DNA repair." was the correct answer. PARP inhibitors (poly-adenosine diphosphate [ADP]-ribose polymerase inhibitors) have shown activity in tumors with defects in DNA repair capabilities. Specifically, the PARP inhibitor olaparib is approved for the treatment of ovarian cancer with a BRCA1/2 mutation. PARP inhibitors have produced durable responses in patients with metastatic castration-resistant prostate cancer associated with BRCA2 germline mutations and in the subset of patients with metastatic castration-resistant prostate cancer and somatic gene mutations in DNA repair genes (BRCA1/2, ATM, Fanconi's anemia genes and CHEK2) as detected by next generation sequencing. ```

Answer 31

C: "schizophrenia." is correct. Donors should be healthy individuals, without diseases that would increase the risk of kidney failure, acute symptomatic infections, ongoing substance abuse, and/or psychiatric disorders such as schizophrenia. GFR should be assessed and be > 80 mL/min. Ideally, BMI should be < 30. Donors must be over age 18 years. In recent years, some transplant centers have accepted donors who have hypertension that is well controlled with a single anti-hypertensive medication.

Answer 32

D: "below the left costal margin in the midclavicular line." Palmer's point is used for access when intraperitoneal adhesions are suspected. This is 3 cm below the left costal margin in the midclavicular line. Placement of the Veress needle in the other locations depends on patient position and surgeon preference in patients without prior history of laparotomy. Veress needle placement should not be done in the midline for any patient with a prior midline incision in that area. Veress needle insertion below the right costal margin risks damage to the liver.

Answer 33

B: "decrease the number of false negative dissections." Dynamic radio-guided sentinel node dissection, as opposed to an anatomical or Cabanas sentinel node dissection, when combined with preoperative inguinal ultrasound [and if needed fine-needle aspiration (FNA)] has been found to have a low false negative rate (7%) and less morbidity than an inguinal node dissection when performed in high volume centers. The purpose of performing the initial ultrasound and FNA is to decrease the number of false negative dissections, as in the initial experience dynamic sentinel node dissection failed to identify nodes that were extensively involved with metastatic cancer. The reason for this is that when the sentinel node is extensively involved with cancer, the lymphatic drainage is obstructed so the radio tracer and isosulfan blue drains to an alternate node or does not map at all. The ultrasound and FNA are an effective way to identify these extensively involved nodes but will not identify the microscopically involved sentinel node that the isosulfan blue and radio-colloid locate. The ultrasound and FNA will have no effect on the number of false positive dissections. Ultrasound can evaluate inguinal nodes, but this modality is much less sensitive for the evaluation of pelvic nodes. Pelvic nodes are better staged by cross sectional imaging such as MRI or CT scan. A patient that is identified on preoperative ultrasound-guided FNA to have metastatic cancer in the inguinal nodes would proceed directly to an inguinal node dissection, bypassing sentinel node dissection altogether. If the patient is to have a dynamic sentinel node dissection, the dose of radiotracer injected will not be altered based on the results of the ultrasound.

Answer 34

C: "endometrial biopsy." This patient has bothersome prolapse symptoms; however, the vaginal bleeding also needs to be addressed. While one may assume her vaginal bleeding is due to the prolapse, this may not always be the case and mandates an endometrial biopsy. Uterine preservation in this setting, without preoperative assurance of the absence of uterine pathology, could have major consequences. MRI scan would not be a sufficient evaluation for this. Urodynamics would likely not add much to the clinical scenario as she already has a known history of stress incontinence. The prolapsed compartments would need to be addressed with a sacrouteropexy if she wanted to preserve the uterus, provided she does not have abnormal uterine pathology.

Answer 35

A: "estrogen deficiency." Between 20% and 57% of adolescent and young adult women (< 25 years of age) report pain with intercourse. Sexual pain in older women is most commonly due to vulvovaginal atrophy/genitourinary symptoms of menopause. Estrogen deficiency related to menopause (surgical or natural) is the most common cause of vulvovaginal atrophy in this population. Vaginal atrophy secondary to pelvic radiation has also been reported in the literature. Uterine leiomyoma, endometriosis, and neuroproliferative vestibulodynia are less common causes of dyspareunia.

Answer 36

``` C: "block PD-1 or PD-L1 receptors allowing T-cell activation." Checkpoint inhibitors are a new class of drugs that act through the PD-1 and PD-L1 (Programmed death receptor 1 and Programmed death receptor ligand 1) receptor/ligand complex which normally function to inhibit T-cell response. Inhibition of these receptors allow the immune system to recognize and kill tumor cells more effectively. ``` Tyrosine kinase inhibitors, such as sunitinib and pazopanib, target cell surface receptors that are important for signal transduction leading to activation of cellular growth pathways. Mitotic inhibitors, such as taxanes (docetaxel and paclitaxel), inhibit microtubule formation in the mitotic spindle which interferes with chromosome separation during mitosis. Cytokines, such as interleukin-2 and interferon, are small molecules that stimulate the immune system and T-cell function to more effectively target tumor cells. Poly (ADP-ribose) polymerase (PARP) inhibitors, such as olaparib, cause multiple double strand breaks, and in tumors with BRCA1 and BRCA2 mutations, these double strand breaks cannot be efficiently repaired, leading to apoptosis.

Answer 37

A: "a linear transducer." Linear transducers produce the highest resolution. Sector transducers produce lower resolution but can scan a wide region with a small footprint. Higher frequencies produce better resolution than lower frequency transducers, although the higher frequency has lower tissue penetration and is best for superficial structures. The gain increases the brightness of the image but not the resolution. Pulsed wave Doppler provides velocity information on a timeline from moving objects such as that associated with blood flow.

Answer 38

A: "hepatic cirrhosis." Total testosterone is the recommended initial test to diagnose hypogonadism. Conditions that increase SHBG (aging, hyperthyroidism, and hepatic cirrhosis), or that decrease SHBG (obesity, diabetes mellitus, and glucocorticoid use), affect testosterone bioavailability. There is no indication for SHBG measurement in various forms of priapism or Peyronie's disease.

Answer 39

E: "needle aspiration of the corpora." Oral terbutaline and phenylephrine are not recommended in the management of acute ischemic priapism (> 4 hours) as oral therapies are generally deemed ineffective. Decompression of the corpora cavernosa by aspiration is the recommended initial treatment of ischemic priapism and is the best choice for immediate softening of the erection and pain relief. This treatment alone may be successful in relieving the priapism in 36% of cases and may not only be diagnostic, but therapeutic as well. A corporal blood gas evaluation by aspiration is recommended in the emergency evaluation of priapism and can differentiate ischemic from non-ischemic priapism. Deoxygenated blood with a "crankcase oil" appearance is often observed upon aspiration in ischemic priapism. Blood gas testing will document pH, PO2, and PCO2. If the history suggests penile or perineal trauma, or if the corporal aspirate reveals well-oxygenated blood, penile color duplex Doppler ultrasound (CDU) should be initiated. There is no need for emergent CDU in this case as the findings are consistent with an ischemic presentation

Answer 40

A: "to attempt to conceive by natural means." The couple should be advised to attempt to conceive by natural means. Strict morphology is not a consistent predictor of fertility, and for this reason, the AUA states that strict morphology "should not be used in isolation to make prognostic or therapeutic decisions". While this couple could pursue assisted reproductive techniques, such as intrauterine insemination or in vitro fertilization (without or with ICSI), they might well have success with efforts by natural means. An isolated severely low sperm morphology result is not by itself an indication to proceed to donor sperm.

Answer 41

B: "allows for a smaller incision of the tunica albuginea." was the correct answer. Two-piece inflatable penile implants do not require placement of a separate reservoir, an attribute that may be useful in cases when placement of the reservoir is challenging because of colostomy, ileostomy, kidney transplant, or extensive pelvic surgery. These devices require fewer squeezes of the pump to reach full capacity. A disadvantage is that the pump is very small and hard, making it difficult for patients to manipulate. Although simpler to insert in many respects, two-piece devices paradoxically require a larger tunical incision. Three-piece implants have a more natural feel, being more rigid when full and more flaccid when empty.

Answer 42

B: "exogenous testosterone and repeat markers." was the correct answer. Removal of both testes, with the attendant decline of testosterone production, results in an increased pituitary secretion of LH due to loss of the negative feedback loop. In turn, cross-reactivity of LH with beta-hCG may cause falsely positive detections of beta-hCG elevation. As such, the administration of exogenous testosterone should suppress pituitary gonadotropin secretion, and thereby return the measured serum hCG to normal, if in fact the cause of the noted beta-hCG elevation is LH cross-reactivity. Given the relatively low associated risk, this approach should represent the next step in evaluation for this patient. If the beta-hCG returns to normal after exogenous testosterone, the patient should be considered to have stage 1B seminoma, for which the recommended management is surveillance. Considering the potential toxicities of systemic chemotherapy, determining a potential false-positive elevation in markers would be recommended prior to initiating such treatment. Retroperitoneal radiotherapy, while an option for stage 1B seminoma, should not be initiated prior to investigating the marker elevation further as well, and moreover, surveillance has become the recommended strategy for patients with stage 1A/B seminoma. The role of PET imaging in testicular cancer is restricted to the evaluation of residual masses after chemotherapy for seminoma which are greater than 3 cm. RPLND is currently not indicated for clinical stage 1 seminoma.

Answer 43

A: "intravesical mitomycin C." Two separate trials (one utilizing mitomycin and one utilizing pirarubicin) have demonstrated a significant decrease in the risk of subsequent intravesical recurrence with the use of a single dose of intravesical chemotherapy after nephroureterectomy. Notably, patients from these trials had no prior history of bladder cancer as in this patient. As such, this patient should be offered a dose of intravesical mitomycin C. As BCG has not been reported in such trials, its use in this setting is not recommended. Likewise, adjuvant chemotherapy has not been demonstrated to be of benefit for patients with pT1 urothelial carcinoma. Similarly, radiotherapy is not recommended as there is insufficient data to support a benefit in this setting. Although lymph node dissection may be appropriate at the time of nephroureterectomy for patients with known or suspected high-grade or invasive tumors, a role for delayed lymph node removal has not been established, and therefore, cannot be recommended.

Answer 44

A: "free access to oral fluids." Patients with normal renal function, normal electrolytes, no evidence of fluid overload, and normal mental status should have their vital signs and urine output monitored regularly, and they should be given free access to oral fluids. A 0.45% normal saline at a rate slightly below full replacement may be given if pathologic diuresis occurs. 0.9% normal saline and Lactated Ringer have no role in post-obstructive diuresis and should not be given. COX-2 activity may be increased in the post-obstructive phase and contributes to polyuria, and impaired urine-concentrating ability may be relieved by COX-2 inhibitor, but this intervention is still under evaluation.

Answer 45

C: "clamp the tubing and perform penile modeling." Penile prosthesis surgery is indicated for patients with erectile dysfunction and Peyronie's disease. According to the AUA Guidelines on Peyronie's disease, clinicians may perform adjunctive intraoperative procedures, such as modeling, plication, or incision/grafting, when significant penile deformity persists after insertion of the penile prosthesis. Switching to a larger cylinder will not correct the residual curvature and may cause penile buckling. Correction of the curvature and deformity using inflatable prostheses containing reinforced silicone or the material Bio-Flex® is easier than with semi-rigid devices. The presence of a urethral catheter will not impact the degree of curvature. Plaque excision and grafting for a residual 35 degree curvature is excessive and may result in sensory deficits.

Answer 46

B: "sacral neurologic level of lesion." Studies on sexual function in males with spina bifida have demonstrated that paternity is associated with an L5 or sacral neurologic level. This neurologic level was present in 80% of patients who fathered children. This is in contrast to bladder function, which does not correlate well to the neurologic level of the lesion. The ambulatory status and presence of a ventriculoperitoneal shunt are other important factors associated with paternity. Serum testosterone levels are usually normal. Reflexogenic erections are present in the majority of spina bifida patients and are not predictive of paternity.

Answer 47

D: "apalutamide." was the correct answer. This man has non-metastatic castration resistant prostate cancer (CRPC) since his PSA is rising despite adequate androgen deprivation therapy (ADT) and castrate levels of testosterone with a negative metastatic evaluation. Apalutamide is a next-generation anti-androgen that has been found to significantly improve metastasis free survival when compared to placebo for men with non-metastatic CRPC. Apalutamide or enzalutamide are now recommended as first line therapy in the latest version of the AUA Guidelines for non-metastatic CRPC. Bicalutamide is no longer recommended as first line therapy and ketoconazole is no longer recommended for these patients who do not have metastatic disease. Since the patient has castrate levels of testosterone, switching to a LH-RH antagonist is not indicated. Sipuleucel-T is indicated only in the setting of non-symptomatic or minimally symptomatic metastatic CRPC.

Answer 48

C: "suprapubic tube." In the immediate postoperative period, retention should be managed by placement of a small, transurethral (10 or 12 Fr) catheter for 24 to 48 hours. At four days after surgery, this patient should no longer continue to have a urethral catheter or be performing CIC immediately after cuff placement. Cuff deactivation should be done at the time of the initial surgery and also confirmed to be deactivated if catheter placement is necessary. If the patient fails a voiding trial at 48 hours, suprapubic tube placement under ultrasound or fluoroscopic guidance is recommended to reduce the risk for urethral erosion associated with prolonged urethral catheter drainage. Retention that persists beyond several weeks implies that the cuff may be too small and, in such cases, re-operation and cuff upsizing may be required. Late-onset urinary retention necessitates cystoscopy and urodynamics to rule-out proximal urethral obstruction, cuff erosion, or detrusor failure.

Answer 49

C: "keep implant completely deflated." Maintaining the three-piece implant reservoir completely filled during the healing period will allow capsule formation around a larger space that will allow storage of an adequate volume of saline. Conversely, if the cylinders are partially filled, the reservoir will not be completely full and the capsule formed around the smaller structure may limit its future expansion and lead to autoinflation. Aggressive weight loss will not result in decreased compression of the reservoir or maintenance of a larger reservoir space in the retroperitoneum. Location of the reservoir will not impact the ability of the capsule to form and impact autoinflation. Similarly, avoiding intercourse for three months will not have a positive impact on preventing autoinflation if the cylinders remain partially filled.

Answer 50

B: "check serum sodium in one and four weeks." This patient has bothersome nocturia as her main complaint. She is not complaining of stress incontinence, hence, no therapy is indicated for her at this time. Therapies for stress incontinence would be considered if she complains of this in the future. With desmopressin preparations, one should carefully monitor serum sodium levels and guidelines recommend this be done at one and four weeks after initiation of therapy. If hyponatremia develops, then one should stop this product immediately. There is a greater risk of hyponatremia in elderly patients. There appears to be a lower risk of hyponatremia in patients with the nasal spray as opposed to oral preparations. It is recommended that elderly patients are started on the lower dose of 0.83 mL (1 Noctiva spray).

Answer 51

A: "treatment satisfaction." The ROSETTA trial was a multi-center, open-label, trial randomizing participants to sacral neuromodulation (SNM) and 200 U of onabotulinumtoxinA. Outcomes of a two-year extension trial have been recently published with outcome data available for 87% of 298 clinical responders. There was no difference in decreased mean urgency urinary incontinence (UUI) episodes, urinary frequency, or differences in complete resolution of UUI. Women undergoing onabotulinumtoxinA maintained higher satisfaction with treatment. As expected, onabotulinumtoxinA therapy was associated with more UTIs and an increased need for post procedure CIC; however, the overall incidence of adverse events was statistically similar. No differences were seen in the proportions of participants requesting additional medication or alternative trial therapy off protocol post second injection. SNM revision and removals occurred in 3% and 9% patients, respectively. It should be noted that the 200 U dose in this study is double the FDA-approved dose of 100 U for non-neurogenic UUI.

Answer 52

C: "using a transverse midline fascial incision for extraction." Horizontal skin incision for camera port placement and transverse fascial incision for prostate specimen extraction has been associated with a decrease in the risk of incisional hernia from 5.4% to 0.4%. Fascial closure is required for non-bladed trocar sizes of 10 mm or more. There is no evidence that specimen extraction above versus below the umbilicus affects the likelihood of incisional hernia. Squeezing around the specimen through a minimally-sized incision increases the risk of tearing the fascia and subsequent incisional hernia formation. There is some evidence that interrupted versus continuous closure may result in lower risk of incisional hernia, particularly for midline hand-assisted approaches.

Answer 53

D: "coagulopathy and hemorrhage." Hypothermia and circulatory arrest is the treatment of choice for a renal tumor with this level of cephalad extension. This technique has several potential complications such as CNS or hepatic damage. The most common difficulty associated with this technique is hemorrhage associated with platelet and clotting factor dysfunction. Tumor emboli can occur but are relatively uncommon. Utilization of cardiopulmonary bypass limits the possibility of embolic events.

Answer 54

D: "fertility impairment." was the correct answer. The 2018 AUA Guideline on the evaluation and management of testosterone deficiency states that the evidence is inconclusive at this time regarding a causal link between testosterone therapy in hypogonadal men and the development of stroke, myocardial infarction, venothrombolic events, and prostate cancer. Among the issues listed, only causal links between testosterone therapy and a greater risk of developing fertility impairment (via spermatogenesis impairment) have been conclusively proven.

Answer 55

A: "observation." is correct. Early management and diagnosis of penile prosthesis infections can be facilitated by knowledge about the timeline of presentation. The temptation to prescribe antibiotics at the two-week postoperative interval must be resisted as this may mask a developing infection. In this scenario, if the device is not infected, the patient should experience a clinical improvement within the next 7 to 14 days. Conversely, antibiotics will not be helpful if the implant is infected and may merely delay the diagnosis. Systemic and localized signs, such as fever, erythema, swelling, elevated white blood cell count, and incision drainage typically present later and are usually not observed at this postoperative visit. The diagnosis is not aided by imaging studies such as scrotal ultrasound or CT scanning. Drainage of the hematoma will risk infecting a device that may not be infected. The clinical scenario presented does not provide enough information for definitive diagnosis of an early prosthesis infection, and a salvage procedure is, therefore, not indicated at this juncture.

Answer 56

B: "wide local excision." Extramammary Paget's disease (EMPD) is a rare adenocarcinoma arising from apocrine gland bearing skin. EMPD should be distinguished from the clinically similar appearing squamous carcinoma-in-situ or Bowen's disease. EMPD has been reported to be associated with an underlying abdominal malignancy in up to 45% of cases, so it is recommended that the patient have a CT scan of the chest/abdomen and pelvis. Some centers also recommend a cystoscopy, colonoscopy, and PSA. The treatment of EMPD is wide local excision (some authors recommend a 3 cm margin) with intraoperative frozen section to ensure negative margins as the tumor frequently extends a significant distance into the adjacent normal appearing skin. Histological evaluation of the resected specimen allows for assessment of any areas of invasion which determines the risk of metastatic disease which can occur in the local inguinal nodes. As EMPD frequently extends well into the adjacent normal skin, local excision of the visible lesion is likely to result in a positive margin and the need for re-excision. There are reports of using the CO2 laser, 5-fluorouracil, and imiquimod cream in EMPD. However, there is little data and the reports have been in patients who have failed or are not good candidates for primary surgical excision.

Answer 57

B: "5000 IU of unfractionated heparin every 12 hours starting prior to induction of anesthesia until discharge." Patients undergoing radical cystoprostatectomy and urinary diversion are at significant risk of thromboembolic complications, and there is good evidence that the combination of intermittent pneumatic compression stockings and either unfractionated or low molecular weight (LMW) heparin decreases this risk. The optimal prophylaxis weighs the benefit of decreasing thromboembolic events with the risk of increased bleeding. There is not complete agreement on the optimal choice of drug or duration of therapy. However, there is increasing evidence that suggests that initiating therapy prior to induction of anesthesia is important. The duration of therapy is also controversial with increasing evidence that therapy should be continued for up to four weeks postoperatively. Either unfractionated heparin or low-molecular weight heparin are suitable choices. The advantage of LMW heparin is that it can be administered once daily. LMW heparin can accumulate in patients with a creatinine clearance less than 30 mL/minute, thus, dose adjustment is necessary. The prophylactic dose of the LMW drug enoxaparin is 40 mg once daily. A 40 mg dosage of enoxaparin is double the prophylactic dose and close to the anticoagulation dose for an 80 kg man. Thus, in a patient with renal insufficiency, the best choice is 5000 IU of unfractionated heparin every 12 hours starting prior to induction of anesthesia until discharge.

Answer 58

.52 x 6 x 7 x 7 = 153 cc. SA density = PSA / prostate volume (mL) = 15.3/153 = 0.1 ng/mL/cc. PSA density of greater than .15 ng/mL/cc is associated with a greater risk of detecting prostate cancer on biopsy and may trigger earlier biopsy for patients on active surveillance.

Answer 59

D: "μ-opioid antagonist." is correct. There has been significant interest and study of standardized pathways in patients undergoing radical cystectomy and urinary diversion. The development of ERAS (enhanced recovery after surgery) pathways in urology and colorectal surgery have suggested that preoperative bowel preparation is not necessary, although this has been questioned in recent years. Typical preoperative interventions, which are likely responsible for improved post-surgical recovery, include high carbohydrate diet, omission of a mechanical or antibiotic bowel preparation, and not placing an epidural catheter (replacing an epidural catheter with the use of pain pumps or liposomal bupivacaine). However, these interventions have not been shown to decrease hospital length of stay. The μ-opioid receptor antagonist alvimopan has been shown to accelerate GI recovery and reduce length of hospitalization in patients undergoing radical cystectomy.

Answer 60

B: "in and out catheterization." Urinary retention may happen after bulking agent injection. Usually, an in and out catheterization (with as small a catheter as possible) should be sufficient. The risk of placing an indwelling catheter is that the injectable bulking agent may mold around the catheter, thereby rendering the injection suboptimal. Tamsulosin can be tried, but it may take several days or more to become efficacious. Suprapubic catheter placement or TUR of the bulking agent (rarely indicated) would be premature at this point. If one had to perform TUR for persistent retention, the patient should clearly be informed of the high likelihood of recurrent incontinence.

Answer 61

B: "program of mechanical pouch irrigation." It is not uncommon to develop pouchitis after construction of a continent 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.

Answer 62

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 fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in women. This is an especially good alternative 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.

Answer 63

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.

Answer 64

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.

Answer 65

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 IMA is ligated. The middle sacral artery arises from the posterior aspect of the aorta and gives some blood supply to the rectum.

Answer 66

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. Rhabdomyosarcoma 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 wall 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.

Answer 67

A: "observation." This infant has stage 4-S neuroblastoma. This can include involvement of skin, liver, and bone marrow without 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.

Answer 68

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.

Answer 69

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, the evidence currently only supports the benefit of ADT and docetaxel in metastatic, hormone-sensitive prostate cancer. [OUTDATED ANSWER. Per AUA core curriculum: Men with mCSPC should be treated with traditional ADT combined with another agent including docetaxel, abiraterone, apalutamide, or enzalutamide or external beam radiation therapy depending on the clinical situation and volume of metastatic disease.] 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.

Answer 70

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.

Answer 71

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 adrenalectomy 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 ectopic, but from the pituitary. Likewise, the clinical symptom complex in this setting 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).

Answer 72

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.

Answer 73

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 segment 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.

Answer 74

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.

Answer 75

A ten-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 76

C: "testicular exploration." Ultrasound findings suggestive of testicular rupture include heterogenous 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.

Answer 77

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 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.

Answer 78

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 useful 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.

Answer 79

D: "repeat ultrasound in one month." was the correct answer. Over 90% of antenatally detected megaureters will improve with conservative management. The T 1/2, or Lasix washout time, especially in neonatal megaureters is not 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 than 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.

Answer 80

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 repeat surgery. The 3 cm cut point, therefore, reduces the number of surgical interventions 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.

Answer 81

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 ductal 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.

Answer 82

B: "placement of a catheter into the ileal stoma." Leakage and fistula formation from a urinary diversion occur in 2 to 9% of patients; however, 20 to 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.

Answer 83

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, and the femoral branch provides sensation to the anterior thigh. The sciatic nerve, 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.

Answer 84

D: "percutaneous needle biopsy." Given the size of a 5 cm adrenal mass and a history of lung cancer, observation alone is not acceptable. The CT findings are not consistent with an adenoma (Hounsfield units < 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 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.

Answer 85

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 an 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.

Answer 86

A: "repeat CT scan in three 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.

Answer 87

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 irritating 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% alum) 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.

Answer 88

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 arrhythmias. 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.

Answer 89

D: "poorly visualized image." MRI scan is unable to reliably identify urinary calculi since it does not visualize calcium. Therefore, stones are noted as filling defects overlying the 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.

Answer 90

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.

Answer 91

B: "resorptive hypercalciuria." Calcium phosphate stones can be classified as brushite (pH <6.6) or apatite (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.

Answer 92

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 these problems.

Answer 93

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.

Answer 94

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.

Answer 95

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 (Monurol) 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. Oral fluoroquinolones are not recommended for the treatment of uncomplicated cystitis in women due to the risk of adverse events with these agents.

Answer 96

B: "persistent prostate cancer." A marked increase in serum PSA after a nadir within six months of external beam XRT is a sign of persistent local or occult metastatic prostate cancer and has a poor prognosis. Radiation-induced cellular injury or prostatitis may cause a minor rise in PSA which usually returns to normal within a few weeks. A "bounce" can be defined as a rise greater than 0.1 to 0.5 ng/mL followed by a durable decline and is especially common after brachytherapy, where it is reported to occur in 24% to 35% of men. These can start any time from 9 to 30 months after brachytherapy, with the majority of patients having a cumulative PSA rise of not more than 2 to 3 ng/mL. Prostatic infarct is rare following radiation therapy for prostate cancer and would likely be associated with a significantly elevated PSA. 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 that PSA failure is not equivalent to clinical failure.