Surgical Management of Bladder Cancer

Question 1

The administration of neoadjuvant chemotherapy has improved survival in muscle-invasive bladder cancer from:
a. 16 to 42 months.
b. 23 to 54 months.
c. 37 to 51 months.
d. 46 to 77 months.
e. 75 to 85 months.

Answer 1

d. 46 to 77 months. In a seminal randomized trial, Grossman and colleagues compared the treatment of muscle-invasive bladder cancer with radical cystectomy alone or surgery followed by three cycles of MVAC chemotherapy (methotrexate, vinblastine, doxorubicin, and cisplatin). They demonstrated a significant improvement in survival (46 vs. 77 months) in the neoadjuvant chemotherapy arm. This study serves as the basis for current treatment paradigms in muscle-invasive bladder cancer (Grossman etal., 2003).

Question 2

Upper-tract imaging for urothelial carcinoma may include all of the following EXCEPT:
a. renal ultrasound.
b. computed tomography (CT) abdomen and pelvis. c. whole-body positron emission tomography (PET)/CT.
d. magnetic resonance imaging (MRI) abdomen and pelvis.
e. retrograde pyelogram.

Answer 2

c. Whole-body positron emission tomography (PET)/CT. Conventional staging evaluation for upper-tract urothelial carcinoma should include evaluation of both the kidney parenchyma and the urothelial lumen. Although PET/CT can be useful for a staging evaluation, the resolution of imaging within the urinary tract is limited by the excretion of contrast material and lack of granular resolution.

Question 3

MRI-based contrast agents are absolutely contraindicated at which glomerular filtration rate (GFR) level?
a. <15 mL/min
b. <20 mL/min
c. <30 mL/min
d. <35 mL/min
e. <60 mL/min

Answer 3

c. <30 mL/min. Although gadolinium contrast should be administered with caution in patients whose GFR is between 30 and 60 mL/min, it is absolutely contraindicated in those with GFR <30 mL/min. This is due to the risk of nephrogenic systemic sclerosis.

Question 4

The improvement in 5-year survival and median survival when more than 10 lymph nodes are removed is approximately:
a. 15%, 24 months.
b. 10%, 36 months.
c. 20%, 24 months.
d. 5%, 15 months.
e. 15%, 15 months.

Answer 4

e. 15%, 15 months. In a study of surgical factors that influence outcomes in bladder cancer treatment, Herr and colleagues found that a lymph node dissection inclusive of more than 10 nodes was associated with improvement in survival of 15 months (Herr etal., 2004).

Question 5

Which of the following statements is TRUE?
a. Urethral recurrence following radical cystectomy is approximately 8% at 5 years.
b. Even patients with a negative intraoperative urethral frozen section are at high risk for recurrence.
c. The negative predictive value of urethral frozen section is poor.
d. Orthotopic neobladder is protective against urethral recurrence and therefore a positive urethral margin is not a contraindication.
e. Orthotopic neobladder can only be performed after nerve-sparing radical cystectomy.

Answer 5

a. Urethral recurrence following radical cystectomy is approximately 8% at 5 years. Factors that influence the risk of recurrence after radical cystectomy include orthotopic substitution with a positive urethral margin on frozen section analysis. This should be considered a contraindication for such a diversion. In addition, the negative predictive value is useful in the evaluation of urethral margins, and the risk of recurrence is only 8% at 5 years (Freeman etal., 1996).

Question 6

Which of the following statements is FALSE regarding nerve-sparing radical cystectomy?
a. A technique analogous to radical prostatectomy is used.
b. Sexual function is similar for capsular-sparing and conventional nerve-sparing techniques.
c. Age is a strong predictor of the return of erectile function.
d. Nerve sparing does not increase local recurrence rates.
e. Ejaculatory function can be maintained with subtotal prostate resection.

Answer 6

b. Sexual function is similar for capsular-sparing and conventional nerve-sparing techniques. The rate of natural potency after radical cystectomy with conventional nerve sparing is lower than that of analogous prostatectomy series. Studies examining sexual function after subtotal resection (e.g., prostate sparing) have demonstrated improved results (Spitz etal., 1999); however, caution is advised because of the high risk of concurrent occult prostate cancer and potential for increased local recurrence.

Question 7

Anterior pelvic exenteration includes removal of the following EXCEPT:
a. uterus.
b. cervix.
c. ovaries.
d. urethra.
e. vaginal introitus.

Answer 7

e. Vaginal introitus. The vaginal introitus should be maintained for routine anterior exenteration. Satisfactory vaginal capacity can be maintained with both non–vaginal-sparing and vaginal-sparing approaches. In neither instance should a colpocleisis be performed as a matter of routine.

Question 8

Partial cystectomy is appropriate in which of the following settings?
a. 4-cm T2 lesion in the trigone
b. 1-cm T2 lesion in the dome
c. 3-cm T2 lesion in the dome with carcinoma in situ (CIS) in one location
d. 1-cm T2 lesion with pelvic lymphadenopathy on imaging
e. CIS in two locations

Answer 8

b. 1-cm T2 lesion in the dome. In the setting of muscle-invasive bladder cancer, partial cystectomy can be considered in very select patients. In those with small lesions and a lack of concurrent CIS, the results of partial cystectomy approach those of radical cystectomy (Kassouf etal., 2006; Capitanio etal., 2009).

Question 9

Enhanced recovery includes all of the following EXCEPT:
a. alvimopan.
b. neostigmine.
c. pharmacologic thromboembolism prophylaxis.
d. nasogastric suction.
e. early enteral feeding.

Answer 9

d. Nasogastric suction. Postoperative nasogastric suction should be considered in patients with compromised airway protection; however, this has not been demonstrated to enhance recovery and need not be incorporated to facilitate return of bowel function postoperatively. Early enteral feeding, neostigmine, and alvimopan have all demonstrated efficacy in improving return of bowel function following abdominal surgery.

Question 10

Thromboembolism prophylaxis is needed:
a. immediately before incision.
b. postprocedure for 1 day.
c. postprocedure for 1 week.
d. postprocedure for 1 month.
e. both a and d.

Answer 10

e. Both a and d. In addition to the administration of prophylaxis prior to incision, a reduction in postoperative thromboembolic events from 4.6% to 0.8% was observed in patients treated for 4 weeks following abdominal or pelvic surgery (Kakkar etal., 2010).

Question 11

The RAZOR trial demonstrated which of the following:
a. Inferior 2-year progression-free survival for open radical cystectomy
b. Inferior 2-year progression-free survival for robotic radical cystectomy
c. Superior oncologic outcomes for robotic radical cystectomy
d. Noninferior 5-year progression-free survival for robotic radical cystectomy
e. None of the above

Answer 11

e. None of the above. The RAZOR trial was designed as a prospective multiinstitutional noninferiority trial and demonstrated non-inferior progression-free survival at 2 years for robotic radical cystectomy when compared to open radical cystectomy (Parekh etal., 2018).

Question 12

Which of the following statements is supported by level 1 evidence?
a. Robotic radical cystectomy with minimally invasive urinary diversion has a similar complication rate to an open approach.
b. Robotic radical cystectomy results in decreased blood loss when compared to open radical cystectomy.
c. Robotic radical cystectomy and open urinary diversion is oncologically inferior to an open approach.
d. Robotic radical cystectomy and minimally invasive urinary diversion is more costly than an open approach.
e. None of the above.

Answer 12

b. Robotic radical cystectomy results in decreased blood loss when compared to open radical cystectomy. The results of the RAZOR trial (Parekh etal., 2018) and the randomized study performed at Memorial Sloan Kettering Cancer Center (Bochner etal., 2014) demonstrated improvements in blood loss for robotic radical cystectomy. Notably both studies utilized an open technique for the urinary diversion.

Question 13

Before endoscopic treatment of bladder cancer, the patient should have what?

Answer 13

Upper-tract imaging.

Question 14

Initial transurethral resection of a bladder tumor should routinely be performed to include what? There should be a margin of how wide visible on the surface?

Answer 14

Muscle; 2cm

Question 15

Immediately following transurethral resection of bladder tumors, intravesical instillation of what modestly reduces recurrences but has little effect on progression?

Answer 15

Epirubicin or mitomycin C

Question 16

Bacille calmette-Guerin should never be instilled when?

Answer 16

Immediately following bladder tumor resection.

Question 17

Before cystectomy the site of the abdominal stoma should be marked by who with the patient awake so that the proper location may be ascertained?

Answer 17

Enterostomal therapist

Question 18

If prostate- or prostate capsule-sparing techniques are to be used in orthotopic blader construction, preoperative evaluation of what should be performed?

Answer 18

Rule out occult cancer, either transitional cell or prostate adenocarcinoma

Question 19

A radical cystectomy in a female includes complete removal of what?

Answer 19

Urethra, including the meatus

Question 20

Patients amenable to partial cystectomy should have what?

Answer 20

A solitary lesion without associated CiS in which a 2cm margin may be obtained, which is far enough from the ureteral orifices and bladder neck that closure can be accomplished without compromising these structures.

Question 21

What percentage of patients undergoing radical cystectomy have at least one perioperative complication?

Answer 21

64% in the first 3 months; 13% high-grade. Majority of complications are gastrointestinal.

Question 22

What are the boundaries of standard lymph node dissection?

Answer 22

Genitofemoral nerve laterally, internal iliac artery medially, Cooper ligament caudally, crossing of the ureter at the common iliac artery cranially

Question 23

What is the 90-day mortality rate for radical cystectomy?

Answer 23

3%

Question 24

Routine administration of antibiotic prophylaxis should be given in patients undergoing TURBT when?

Answer 24

30-60 minutes before the procedure

Question 25

What techniques may be utilized to reduce the obturator reflex risk of perforation during TURBT?

Answer 25

Minimally distending the bladder, using bipolar cautery, using general anesthesia with paralysis

Question 26

Routine stenting of a resected ureteral orifice with cutting current is?

Answer 26

Not necessary

Question 27

What techniques improve return to bowel function following abdominal surgery?

Answer 27

Early enteral feeding, neostigmine, and alvimopan

Question 28

When a portion of stomach is to be used for augmentation, it should:
a. always be based on the right gastroepiploic artery.
b. include only the antrum.
c. never extend to the pylorus.
d. include a significant portion of the lesser curve.
e. be mobilized with the omentum.

Answer 28

c. Never extend to the pylorus. When a wedge of fundus is used, it should not include a significant portion of the antrum and should never extend to the pylorus or all the way to the lesser curve of the stomach.

Question 29

The ileum differs from the jejunum in that:
a. it has a larger diameter.
b. the mesentery is thinner.
c. it has multiple arcades.
d. the vessels in the mesentery are larger.
e. the mesentery is longer.

Answer 29

c. It has multiple arcades.The ileum, more distal in location, has a smaller diameter. It has multiple arterial arcades, and the vessels in the arcades are smaller than those in the jejunum.

Question 30

When stomach is used for urinary diversion, the electrolyte abnormality that may occur is most commonly what type of metabolic alkalosis?
a. Hyperchloremic
b. Hypochloremic
c. Hyperkalemic
d. Hypernatremic
e. Hypocalcemic

Answer 30

b. Hypochloremic. Complications specific to the use of stomach include the hematuria-dysuria syndrome and uncontrollable metabolic alkalosis in some patients. When stomach is used, a hypochloremic, hypokalemic metabolic alkalosis may ensue.

Question 31

Postoperative bowel obstruction is most common when which of the following segments is used for diversion?
a. Right colon
b. Stomach
c. Sigmoid
d. Ileum
e. Transverse colon

Answer 31

4. d. Ileum. The incidence of postoperative bowel obstruction is 4% to 10%. Colon, stomach, and sigmoid obstruction result in a 4% incidence, less than that occurring with ileum.

Question 32

Mechanical bowel preparation results in a reduction in:
a. bacterial counts per gram of enteric contents.
b. bacterial count in the jejunum.
c. total number of bacteria in the bowel.
d. bacterial counts in the stomach.
e. bacterial counts in the ileum.

Answer 32

c. Total number of bacteria in the bowel. The mechanical preparation reduces the amount of feces, whereas the antibiotic preparation reduces the bacterial count. A mechanical bowel preparation reduces the total number of bacteria but not their concentration.

Question 33

Systemic antibiotics in elective surgery should be given:
a. before the patient is anesthetized.
b. before the skin incision is made.
c. intraoperatively before closure commences.
d. at any time in the perioperative period.
e. postoperatively for 3 to 5 days.

Answer 33

a. Before the patient is anesthetized.Systemic antibiotics must be given before the operative event if they are to be effective.

Question 34

The most common cause of a lethal bowel complication is:
a. use of previously irradiated bowel.
b. lack of mechanical bowel prep.
c. lack of antibiotic bowel prep.
d. placement of a drain adjacent to the anastomosis.
e. failure to give preoperative antibiotics.

Answer 34

a. Use of previously irradiated bowel. In one study of urinary intestinal diversion, 75% of the lethal complications that occurred in the postoperative period were related to the bowel. Eighty percent of these patients had received radiation before the intestinal surgery.

Question 35

When stapled anastomoses are compared with sutured anastomoses, there is/are:
a. fewer leaks.
b. less compatibility with urine.
c. reduced overall operative time.
d. lesser incidence of bowel obstruction.
e. earlier return of bowel function.

Answer 35

b. Less compatibility with urine. In general, anastomoses using reabsorbable sutures or reabsorbable staples are preferable for intestinal segments that are exposed to urine.

Question 36

The use of a nasogastric tube in the postoperative period:
a. hastens the return of intestinal motility.
b. reduces the incidence of bowel leak.
c. reduces postoperative vomiting.
d. increases the risk of aspiration.
e. reduces the incidence of anastomotic leak.

Answer 36

c. Reduces postoperative vomiting. In several studies there was no significant difference in major intestinal complications between those who had postoperative nasogastric tubes and those who did not; however, those who did not have gastric decompression showed a much greater incidence of abdominal distention, nausea, and vomiting.

Question 37

The abdominal stoma for a conduit should be:
a. flush with the skin.
b. placed through the belly of the rectus muscle.
c. made as a loop to reduce parastomal hernia.
d. made with the colon for the lowest complication rate.
e. placed in the right lower quadrant.

Answer 37

b. Placed through the belly of the rectus muscle.All stomas should be placed through the belly of the rectus muscle and be located at the peak of the infraumbilical fat roll.

Question 38

The loop end ileostomy is best used in:
a. the obese patient.
b. the thin patient.
c. when a stoma is revised.
d. in female patients.
e. in spinal cord injury patients.

Answer 38

a. The obese patient. The loop end ileostomy is usually easier to perform than the ileal end stoma in the patient who is obese.

Question 39

Ureteral strictures occurring after an ileal conduit not associated with the ureteral intestinal anastomosis most frequently occur:
a. at the ureteropelvic junction.
b. in the right ureter several centimeters proximal to the ureteral intestinal anastomosis.
c. on the left side where the ureter crosses the aorta.
d. in the mid-ureter.
e. in either ureter within several centimeters proximal to the anastomosis.

Answer 39

c. On the left side where the ureter crosses the aorta. Of importance is that ureteral strictures also occur away from the ureterointestinal anastomosis. This stricture is most common in the left ureter and is usually found as the ureter crosses over the aorta beneath the inferior mesenteric artery.

Question 40

Renal deterioration after a conduit diversion with normal kidneys occurs in what percent of renal units?
a. 20%
b. 40%
c. 50%
d. 70%
e. 80%

Answer 40

a. 20%. Patients who are studied during the long term show a significant degree of renal deterioration. Indeed, 20% of renal units have shown significant anatomic deterioration.

Question 41

The most common cause of death in patients with ureterosigmoidostomies during the long term is:
a. cancer.
b. renal failure.
c. acid–base abnormalities.
d. the primary disease.
e. ammonium intoxication.

Answer 41

b. Renal failure. The most common cause of death in patients who have had a ureterosigmoidostomy for more than 15 years is acquired renal disease (i.e., sepsis or renal failure).

Question 42

The minimal glomerular filtration rate (GFR) in mL/min necessary for a continent diversion is:
a. 70.
b. 60.
c. 35.
d. 25.
e. 20.

Answer 42

b. 60.If the patient is able to achieve a urine pH of 5.8 or less, can establish a urine osmolality of 600 mOsm/kg or greater in response to water deprivation, has a GFR that exceeds 60 mL/min, and has minimal protein in the urine, he or she may be considered for a retentive diversion.

Question 43

The urinary diversion with the fewest intraoperative and immediate postoperative complications is:
a. ileal conduit.
b. colon conduit.
c. Koch pouch.
d. Indiana pouch.
e. neobladder.

Answer 43

a. Ileal conduit. It is the simplest type of conduit diversion to perform and is associated with the fewest intraoperative and immediate postoperative complications.

Question 44

The jejunal conduit syndrome is manifested by:
a. hyperchloremic metabolic acidosis.
b. hypochloremic metabolic alkalosis.
c. hyperkalemic, hyponatremic metabolic acidosis.
d. hypokalemic, hyponatremic metabolic alkalosis.
e. hyperkalemic metabolic alkalosis.

Answer 44

17. c. Hyperkalemic, hyponatremic metabolic acidosis. The early and long-term complications are similar to those listed for ileal conduit except that the electrolyte abnormality that occurs is hyperkalemic, hyponatremic metabolic acidosis instead of the hyperchloremic metabolic acidosis of ileal diversion.

Question 45

The primary advantage of a transverse colon conduit is:
a. its ease of construction.
b. the ability to perform a non-refluxing anastomosis.
c. less likely to be injured by radiation.
d. reduced electrolyte problems.
e. equidistant from each kidney, allowing for short ureteral length on both sides.

Answer 45

c. Less likely to be injured by radiation. The transverse colon is used when one wants to be sure that the segment of conduit used has not been irradiated in individuals who have received extensive pelvic irradiation.

Question 46

Total body potassium depletion is most common in:
a. ureterosigmoidostomy.
b. ileal conduit.
c. colon conduit.
d. sigmoid conduit.
e. gastrocystoplasty.

Answer 46

a. Ureterosigmoidostomy. Hypokalemia and total body depletion of potassium may occur in patients with urinary intestinal diversion. This is more common in patients with ureterosigmoidostomies than it is in patients who have other types of urinary intestinal diversion.

Question 47

In urinary intestinal diversion, serum creatinine may not be an accurate reflection of renal function because of:
a. interfering substances.
b. tubule secretion.
c. tubule reabsorption.
d. bowel reabsorption.
e. decreased renal elimination.

Answer 47

d. Bowel reabsorption.Because urea and creatinine are reabsorbed by both the ileum and the colon, serum concentrations of urea and creatinine do not necessarily accurately reflect renal function.

Question 48

Patients with urinary diversions who have a hyperchloremic metabolic acidosis with time:
a. retain the ability to maintain the acidosis.
b. lose the ability for electrolyte transport in the intestinal segments.
c. compensate for the metabolic acidosis, thus eliminating risk.
d. intermittently absorb ammonia when infection is present.
e. tend to retain potassium.

Answer 48

a. Retain the ability to maintain the acidosis. The ability to establish a hyperchloremic metabolic acidosis appears to be retained by most segments of ileum and colon over time.

Question 49

Bone density abnormalities:
a. are unlikely to occur with ileum.
b. are most likely to occur with colon.
c. are more common in patients with persistent hyperchloremic metabolic acidosis.
d. are common in patients with total body potassium depletion.
e. are unlikely to occur in patients with conduits.

Answer 49

c. Are more common in patients with persistent hyperchloremic metabolic acidosis.Osteomalacia in urinary intestinal diversion may be due to persistent acidosis, vitamin D resistance, and excessive calcium loss by the kidney. It appears that the degree to which each of these contributes to the syndrome may vary from patient to patient.

Question 50

Urinary intestinal diversion in children:
a. increases the need for vitamin D.
b. increases the need for calcium.
c. limits linear growth.
d. decreases epiphyseal growth.
e. results in premature epiphyseal closure.

Answer 50

c. Limits linear growth. There is considerable evidence to suggest that urinary intestinal diversion has a detrimental effect on growth and development.

Question 51

Cancer occurring in urinary intestinal diversion is most likely to occur in:
a. augmentations.
b. colon conduits.
c. ileal conduits.
d. ureterosigmoidostomies.
e. sigmoid conduits.

Answer 51

d. Ureterosigmoidostomies. The highest incidence of cancer occurs when the transitional epithelium is juxtaposed to the colonic epithelium and both are bathed by feces.

Question 52

Reconfiguring the bowel during the long term results in:
a. decreased motor activity.
b. increased volume.
c. decreased metabolic complications.
d. decreased absorption of solutes.
e. increased absorption of solutes.

Answer 52

b. Increased volume. Reconfiguring bowel usually increases the volume, but its effect on motor activity and wall tension over the long term is unclear at this time.

Question 53

The syndrome of severe metabolic alkalosis in patients who have had a gastrocystoplasty is most likely to occur in patients who have:
a. decreased aldosterone levels.
b. jejunum interposed in the urinary tract.
c. total body potassium depletion.
d. elevated gastrin levels.
e. decreased renin levels.

Answer 53

d. Elevated gastrin levels.The syndrome of severe metabolic alkalosis is most likely to occur in patients with high resting gastrin levels who are dehydrated and fail to empty their pouch in a timely manner.

Question 54

There is direct evidence from cystectomy patients that the following can be safely omitted from an enhanced recovery after surgery (ERAS) protocol:
a. preoperative fasting
b. thrombosis prophylaxis
c. mechanical bowel prep
d. pelvic drain
e. preoperative intravenous antibiotics

Answer 54

c. Mechanical bowel prep. There is direct evidence for omission of a mechanical bowel can be safely omitted from cystectomy and urinary diversion patients on an ERAS pathway. Thrombosis prophylaxis (b.) and perioperative antibiotics (e.) should never be omitted. There is evidence that preoperative fasting (a.) and a pelvic drain (d.) may be safely omitted in colorectal surgery patients, but this has not be studied in depth in cystectomy population.

Question 55

Arginine hydrochloride infusion can be used to treat life-threatening complications caused by the following type of conduit:
a. stomach
b. jejunum
c. ileum
d. colon
e. all of the above

Answer 55

a. Stomach. Only urinary diversion consisting of stomach result in metabolic alkalosis. Arginine hydrochloride infusion plays no role in the management of acidosis caused by other bowel segments.

Question 56

Perioperative care. The use of a preoperative mechanical bowel prep, oral antibiotic bowel prep, and postoperative nasogastric tube decompression in patients undergoing bowel surgery is?

Administering intravenous antibiotics 1 h before the surgical incision is not controversial and is supported by many studies. Patients undergoing elective intestinal surgery in the studies that show no advantage to a mechanical and/or antibiotic bowel prep received preoperative intravenous antibiotics. It should be appreciated that the majority of these studies involve isolated anastomoses—not large segments of bowel that are opened, as is the case in urologic procedures.

Answer 56

Controversial and can be safely omitted in appropriately selected patients.

Question 57

Ureteral intestinal anastomotic strictures. Antirefluxing anastomoses have a ? stricture rate; refluxing anastomoses have a ? stricture rate. The ? has the lowest stricture rate.

Answer 57

10%–20%;
3%–10%;
Wallace ureteral intestinal anastomosis

Question 58

Renal function and urinary diversion. Serum creatinine and blood urea nitrogen do not accurately reflect renal function in patients with intestine in the urinary tract because these substances, when excreted by the kidney, are reabsorbed by the bowel. This is more likely to be a problem in ?.

A glomerular filtration rate (GFR) of at least ? and an ability to ? are necessary prerequisites for a continent diversion.

Answer 58

continent diversions;
60 mL/min;
acidify the urine

Question 59

Table 139.1
Syndromes of Electrolyte Disturbances in Patients in Whom the Bowel is Interposed in the Urinary Tract

Answer 59

Question 60

Significant perioperative infectious complications occur in up to ? undergoing cystectomy and urinary diversion.

Answer 60

10% of patients

Question 61

The most common cause of mortality in urologic procedures when the gut is used relates to ?

Answer 61

complications involving the bowel.

Question 62

Complications specific to the use of stomach include the ? and ? in some patients.

Answer 62

hematuria-dysuria syndrome; uncontrollable metabolic alkalosis

Question 63

The incidence of postoperative bowel obstruction is ?. Colon, stomach, and sigmoid obstruction result in a ? incidence, less than that occurring with ileum.

Answer 63

4%–10%; 4%

Question 64

The mechanical preparation reduces ?, whereas the antibiotic preparation reduces the ?

Answer 64

the amount of feces and therefore total bacteria; bacterial count and therefore the concentration of bacteria.

Question 65

If the patient is able to achieve a urine pH of ?, can establish a ?, has a GFR that exceeds ?, and has ?, he or she may be considered for a retentive diversion.

Answer 65

5.8 or less; urine osmolality of 600 mOsm/kg or greater in response to water deprivation; 60 mL/min; minimal protein in the urine

Question 66

Osteomalacia in urinary intestinal diversion may be due to ?, ?, and ?.

Answer 66

persistent acidosis; vitamin D resistance; excessive calcium loss by the kidney

Question 67

In patients with gastric tissue in the urinary tract (usually gastrocystoplasty), the syndrome of ? is most likely to occur in those with high resting gastrin levels who are dehydrated and fail to empty their pouch in a timely manner.

Answer 67

severe metabolic alkalosis

Question 68

A 45-year-old man had an ileal conduit diversion as a child for bladder exstrophy. He requests a continent diversion. Serum creatinine is 2 mg/dL. Loopogram shows bilaterally thin ureters with small kidneys. Which is the best procedure?
a. Ureterosigmoidostomy
b. T pouch using the ileal conduit
c. Abandon continent diversion
d. Penn pouch using the ileal conduit
e. Indiana pouch

Answer 68

c. Abandon continent diversion. A creatinine level greater than 1.8 mg/dL indicates a level of renal function insufficient for continent diversion.

Question 69

A 45-year-old man underwent ileal conduit urinary diversion as a child for bladder exstrophy. He presents requesting continent diversion. Serum creatinine is 2 mg/dL. Loopogram shows bilateral hydronephrosis and a pipestem conduit. What is the best course of action?
a. Mainz II to avoid problems with dilated ureters
b. T pouch abandoning the disease conduit
c. No continent diversion
d. Drain the upper tracts and reassess renal function
e. Proceed to neobladder construction

Answer 69

d. Drain the upper tracts and reassess renal function. The best course of action is to place ureteral cutaneous stents bilaterally (bypassing the pipestem segment) and reassess urinary function. In evaluating the hydronephrotic patient with impaired renal function for continent diversion, upper tract drainage is advised. If necessary, bilateral nephrostomy tubes can be used.

Question 70

A patient undergoing a cystectomy and planned continent cutaneous diversion has positive ureteral margin biopsies up to 2 cm above each iliac artery, at which point negative biopsies are obtained. What is the best course of action?
a. Use the terminal ileum for ureteral implantation and a Mitrofanoff continence mechanism
b. No continent diversion
c. Mobilize the kidneys and stretch the ureters to the reservoir
d. Use a T pouch with a long chimney
e. Cutaneous ureterostomies

Answer 70

a. Use the terminal ileum for ureteral implantation and a Mitrofanoff continence mechanism. The best course of action is to perform a right colon reservoir with anastomosis of the ureters to the terminal ileum. The appendix or other pseudo-appendiceal (Mitrofanoff) mechanisms can be used for continence. The terminal ileum can accommodate short ureters.

Question 71

Preservation of the ileocecal valve can be maintained with which catheterizable pouch?
a. T pouch or Kock pouch
b. Le Bag
c. Indiana pouch
d. Mainz I or II
e. Penn pouch

Answer 71

a. T pouch or Kock pouch. Preservation of the ileocecal valve can be maintained with the T or Kock pouch. All other pouches use the right colon, so that the ileocecal valve is sacrificed.

Question 72

In which procedure to repair a nipple valve would resection of additional bowel be routinely required?
a. Stones on exposed staples
b. Nipple valve slippage
c. Nipple valve atrophy
d. Pinhole leak
e. Anastomotic leak

Answer 72

c. Nipple valve atrophy. Nipple valve atrophy requires that a new nipple valve be made of additional bowel.

Question 73

A 10-year-old child has an ileal conduit for myelomeningocele. The conduit was replaced on two occasions for pipestem conduit development. The conduit is again affected by the same process. The patient’s family wants a continent diversion. Which is the best procedure?
a. Ureterosigmoidostomy
b. Revise the conduit
c. T pouch using the ileal conduit
d. Penn pouch using the ileal conduit
e. Indiana pouch using the ileal conduit

Answer 73

b. Revise the conduit.With significant small bowel compromise, as well as loss of the ileocecal valve in a neurogenic bladder patient, severe diarrhea may ensue.

Question 74

A patient with chronic active hepatitis and invasive bladder cancer associated with intravesical carcinoma in situ is scheduled for a cystoprostatectomy. The serum creatinine concentration is 1 mg/dL. Prostatic urethral biopsy shows mild atypia. What is the best diversion?
a. T pouch
b. Ileal conduit
c. Right colon reservoir
d. Mainz II
e. Cutaneous ureterostomies

Answer 74

b. Ileal conduit. The best approach is cystoprostatectomy and a conduit. Normal hepatic function is mandated in any patient undergoing continent diversion.

Question 75

The highest reoperation rate in catheterizable pouches occurs with what type of sphincter?
a. In situ appendix
b. Imbricated terminal ileum
c. Plicated terminal ileum
d. Nipple valves
e. Transposed appendix

Answer 75

d. Nipple valves. The highest reoperation rate is associated with nipple valve sphincter failure.

Question 76

Which of the Mitrofanoff sphincter deficiencies can be corrected surgically?
a. Length of the appendix
b. Absence of the appendix
c. Stenosis of the appendix
d. All of the above

Answer 76

d. All of the above. The caliber of Mitrofanoff mechanisms, the length of the appendix, stenosis, and even absence of the appendix can be resolved by surgical variations.

Question 77

Hematuria and skin breakdown may occur with what type of pouch?
a. T
b. Gastric
c. Mainz
d. Right colon
e. All of the above

Answer 77

b. Gastric. Hematuria and cutaneous skin erosion may occur with a gastric pouch. With gastric reservoirs or composite reservoirs, the low pH of the urine may lead to hematuria and cutaneous breakdown.

Question 78

Preoperative colonoscopy is indicated in candidates for which reservoir procedures?
a. Ileal
b. Jejunal
c. Rectal
d. Gastric
e. All of the above

Answer 78

c. Rectal. Preoperative colonoscopy is relatively indicated in candidates for any pouch. Any pouch using colon mandates preoperative colonic evaluation.

Question 79

What condition is more common in absorbable stapled ileal pouches?
a. Urine leaks
b. Valve failure
c. Hydronephrosis
d. Ischemic pouch contraction
e. Ureteral stricture

Answer 79

d. Ischemic pouch contraction.Because of the overlap of staple lines in absorbable stapled ileal pouches, ischemic pouch contraction may occur.

Question 80

Anastomotic transitional cell carcinoma develops in a patient who has undergone cystectomy and continent cutaneous urinary diversion. What is the best treatment?
a. Distal ureterectomy and reimplantation
b. Conversion to ileal conduit
c. Ileal ureter interposition
d. Nephroureterectomy
e. Cutaneous ureterostomies

Answer 80

a. Distal ureterectomy and reimplantation. An additional segment of ileum can serve as a proximal limb to the reservoir. If nephrectomy is necessary, careful attention must be paid to the residual renal function.

Question 81

Drainage of mucus is most difficult with which sphincteric mechanism?
a. Kock valve
b. In situ appendix
c. Imbricated ileum
d. Plicated ileum
e. Transposed appendix

Answer 81

b. In situ appendix.The small-diameter catheter used in draining appendiceal sphincter pouches allows for less effective mucus drainage.

Question 82

Which continent cutaneous diversion allows for a refluxing ureteroenteric anastomosis?
a. Mitrofanoff with implantation of the ureters into terminal ileum
b. Mitrofanoff with implantation of the ureters into the colon
c. T pouch
d. Kock pouch
e. Indiana pouch

Answer 82

a. Mitrofanoff with implantation of the ureters into terminal ileum. The implantation of the ureters into the terminal ileum may allow for reflux. The ileocecal valve and the isoperistaltic ileal segment may either prevent or diminish reflux.

Question 83

Three years after radical cystectomy and construction of a Kock pouch, a patient presents with right lower quadrant discomfort and associated spurts of urinary leakage. The test most likely to diagnose the condition is:
a. computed tomography (CT).
b. intravenous pyelogram (IVP).
c. urine culture and sensitivity.
d. cystogram of pouch.
e. urodynamics.

Answer 83

c. Urine culture and sensitivity. The most important diagnostic test is urine culture. The symptoms described are those of pouchitis. This is treated by appropriate antibiotic therapy.

Question 84

17. Three years after cystectomy and Kock pouch for bladder cancer, a patient presents with recurrent episodes of bilateral pyelonephritis. The test most likely to provide the correct diagnosis is:
    a. CT.
    b. IVP.
    c. urine culture and sensitivity.
    d. cystogram of the pouch.
    e. magnetic resonance imaging (MRI).

Answer 84

d. Cystogram of the pouch. The proximal nipple valve may have failed, leading to reflux and pyelonephritis. This is tested by the pouch-o-gram.

Question 85

What is the most important feature in preventing nipple valve slippage?
a. Absorbable staples
b. Length of the intussusception
c. Resecting adequate mesentery
d. Attaching the nipple valve to the side wall of the reservoir
e. Length of staple line

Answer 85

d. Attaching the nipple valve to the side wall of the reservoir. This results in a relative lengthening of the valve rather than a foreshortening of the valve with pouch filling.

Question 86

In a patient with pipestem conduit and bilateral hydronephrosis requesting conversion to continent urinary diversion, nephrostomy drainage results in clearance values of 40 mL/min on the right and 10 mL/min on the left. Serum creatinine is 1.8 mg/dL. The next step in management is:
a. Mainz II to avoid problems with the dilated ureters.
b. T pouch abandoning the disease conduit.
c. no continent diversion.
d. ureterosigmoidostomy.
e. neobladder.

Answer 86

c. No continent diversion.In this case, although the serum creatinine level returns to 1.8 mg/dL, the clearance value measured is less than the 60 mL/min required for continent diversion. Continent diversion should be abandoned, and simple replacement of the conduit considered.

Question 87

A patient with squamous cell cancer of the bladder desires cystectomy and continent diversion. He has lost 20 pounds in the month before surgery. The next step in management is:
a. increased oral intake.
b. conduct preoperative hyperalimentation.
c. conduct postoperative hyperalimentation.
d. proceed directly with surgery.
e. count calories.

Answer 87

b. Conduct preoperative hyperalimentation. The 20-pound weight loss indicates a potential for nutritional depletion or metastatic disease. A careful search for metastatic disease should be undertaken. For the patient with nutritional depletion, preoperative hyperalimentation is suggested to be of value.

Question 88

Preoperative evaluation with an oatmeal enema is required in which procedure?
a. Right colon reservoir
b. Mainz I pouch
c. Mainz II procedure
d. Le Bag pouch
e. Indiana pouch

Answer 88

c. Mainz II procedure.Any procedure that relies on the intact anal sphincter for continence (i.e., the Mainz II pouch) requires an assessment of the sphincter before carrying out the operation. This can be assessed by an oatmeal enema, which mimics the constitution of a combination of the urinary and fecal streams.

Question 89

Follow-up urinary cytology and colonoscopy should be used in which type of continent diversion?
a. Ureterosigmoidostomy
b. Mainz II procedure
c. Right colon reservoir
d. All of the above

Answer 89

d. All of the above.Follow-up urinary cytology and colonoscopy is mandatory with any procedure that combines urinary and fecal streams. Because of an increased risk of malignancy even in the absence of admixture of urine and stool, all large intestinal pouches should be subjected to annual investigation by pouchoscopy and cytology.

Question 90

Nocturnal emptying of the patient’s reservoir is required in which type of diversion?
a. Ureterosigmoidostomy
b. T pouch
c. Right colon reservoir
d. Penn pouch
e. Ileal conduit

Answer 90

a. Ureterosigmoidostomy.Nocturnal reservoir emptying may be required with any of the continent cutaneous reservoirs to prevent overdistention and possible rupture but is mandatory with ureterosigmoidostomy owing to the additional risk of fecal incontinence and metabolic acidosis.

Question 91

The appendix is sacrificed in patients undergoing which pouch construction?
a. Indiana
b. Le Bag
c. Mainz I
d. All of the above

Answer 91

d. All of the above. The appendix is sacrificed in patients undergoing Indiana, Le Bag, and Mainz I pouch reconstruction because it can serve as a nidus for infection and abscess formation.

Question 92

Pouch stone development occurs most commonly with which pouch?
a. T pouch
b. Kock pouch
c. Penn pouch
d. Gastric-ileal composite pouch
e. Le Bag

Answer 92

b. Kock pouch. Pouch stone development occurs most commonly with the Kock pouch. Despite the exclusion of distal staples, the stapling techniques used to secure nipple valves will lead to a higher potential for stone development than in pouches not requiring nipple valves.

Question 93

What is the typical catheter used for appendiceal sphincters?
a. 22-French (Fr) straight-tipped
b. 22-Fr coudé-tipped
c. 14-Fr straight-tipped
d. 14-Fr coudé-tipped
e. 20-Fr coudé-tipped

Answer 93

d. 14-Fr coudé-tipped. Larger catheters will not fit into the appendix. A straight catheter is more difficult to pass.

Question 94

Urinary retention resulting from continent diversion occurs most commonly with what type of sphincter?
a. Appendiceal stoma
b. Benchekroun hydraulic valve
c. Nipple valve sphincter
d. Imbricated Indiana mechanism

Answer 94

c. Nipple valve sphincter.Urinary retention occurs most commonly with nipple valve sphincters. If the chimney of the nipple valve is not near the surface of the abdomen, the catheter can be misdirected into folds of bowel rather than through the nipple valve.

Question 95

Immediate postoperative initial pouch capacity is least in which pouch?
a. T or Kock ileal
b. Right colon
c. Gastric
d. Mainz I
e. Transverse colon

Answer 95

a. T or Kock ileal. Immediate postoperative initial pouch capacity is least in ileal reservoirs (i.e., the T or Kock pouch). Small bowel pouches have initial capacities that are much lower than right colon pouches.

Question 96

Elevated pouch pressures would potentially facilitate the continence mechanism seen with which valve or sphincter?
a. Benchekroun ileal valve
b. Kock valve
c. Appendiceal tunnel
d. Imbricated Indiana mechanism
e. All of the above

Answer 96

a. Benchekroun ileal valve. Because the Benchekroun ileal valve is hydraulic, higher pouch pressures would facilitate continence, whereas lower pouch pressures might lead to incontinence.

Question 97

The long-term failure rate of continence mechanisms is greatest with which mechanism?
a. T pouch valve
b. Appendiceal tunnel
c. Benchekroun hydraulic valve
d. Imbricated terminal ileum

Answer 97

30. c. Benchekroun hydraulic valve. The long-term outcome of Benchekroun hydraulic ileal valve mechanisms is possibly the worst of all reported sphincteric mechanisms.

Question 98

Absorbable staples in continent urinary diversion are best suited to what type of reservoir pouch?
a. Ileal
b. Right colon reservoir
c. Gastric-ileal composite
d. Gastric
e. None of the above

Answer 98

b. Right colon reservoir.The use of absorbable staples is best suited to large bowel pouches. With large bowel pouches there is no problem with staple lines causing subsequent bowel ischemia.

Question 99

When creating a large intestinal reservoir from absorbable staples, why is bowel eversion necessary?
a. Because staples should not be used in reservoir construction
b. To inspect the inside of the reservoir
c. To avoid injury to the mesenteric blood supply
d. To allow application of the second row of staples
e. None of the above

Answer 99

d. To allow application of the second row of staples. In an absorbable-stapled right colon pouch, bowel eversion is required to allow for the application of the second row of staples. Staple lines must not cross because this will prevent the bulky, absorbable staples from seating properly. The bowel is everted, a cut is made beyond the end of the staple line, and the next line of staples is applied.

Question 100

Which of the following conditions make patients unsuitable candidates for continent urinary diversion?
a. Multiple sclerosis
b. Quadriplegia
c. Mental impairment
d. Severe physical impairment
e. All of the above

Answer 100

e. All of the above.Patients with multiple sclerosis, quadriplegia, frailty, or mental impairment will at some point in their lives require the care of family members or visiting nurses, so they are poor candidates for any form of continent diversion.

Question 101

Which of the following sutures should NOT be used in the construction of a reservoir?
a. Chromic catgut
b. Plain catgut
c. Silk
d. Polyglycolic acid (Dexon)
e. Polyglactin (Vicryl)

Answer 101

c. Silk. All sutures used in the urinary tract should be absorbable.

Question 102

Which of the following diversions place the patient at risk for the development of a late malignancy?
a. Ureterosigmoidostomy
b. T pouch
c. Mainz II
d. Indiana pouch
e. All of the above

Answer 102

e. All of the above. Late malignancy has been reported in all bowel segments exposed to the urinary stream, whether or not there is a commingling with feces.

Question 103

Which of the following diversions places the patient at greatest risk for the development of a late malignancy?
a. Ureterosigmoidostomy
b. T pouch
c. Mainz II
d. Indiana reservoir
e. Le Bag

Answer 103

a. Ureterosigmoidostomy.Although late malignancy has been reported in all bowel segments exposed to the urinary stream, whether or not there is a commingling with feces, the mixture of urothelium, urine, and feces poses the greatest risk.

Question 104

Continent urinary diversion has which of the following effects?
a. Results in a psychotic depression
b. Results in an improved psychosocial adjustment
c. Results in violent behavior
d. Bipolar behavior
e. None of the above

Answer 104

b. Results in an improved psychosocial adjustment. Many studies from throughout the world have suggested an improved psychosocial adjustment of the patient undergoing continent urinary and fecal diversion compared with those patients with diversions requiring collecting appliances.

Question 105

According to most randomized studies, which type of urinary diversion is associated with the highest reported quality of life?
a. Ureterosigmoidostomy
b. Continent ileal reservoir (Kock pouch)
c. Ileal conduit
d. Orthotopic neobladder
e. None—no conclusive studies have established higher satisfaction or quality of life with any one specific continent diversion

Answer 105

e. None—no conclusive studies have established higher satisfaction or quality of life with any one specific continent diversion.There are insufficient quality-of-life data from randomized studies comparing continent and incontinent urinary diversions to establish the superiority of any one technique.

Question 106

Which of the following is NOT true of continent urinary diversion?
a. It is the gold standard of urinary diversion.
b. It is a safe and reliable urinary diversion.
c. It is associated with an increased complication rate.
d. It is appropriate for selected individuals.
e. It requires stricter selection criteria than incontinent diversion.

Answer 106

a. It is the gold standard of urinary diversion. Ileal conduit should be considered the “gold standard” of urinary diversion.

Question 107

Which of the following circumstances would contraindicate a rectal bladder?
a. Prior pelvic irradiation
b. Unilateral ureteral dilation
c. Bilateral ureteral dilation
d. Lax anal sphincter tone
e. All of the above

Answer 107

e. All of the above. Dilated ureters, pelvic irradiation, and lax anal sphincteric tone are all contraindications to the procedure.

Question 108

During the construction of a continent cutaneous urinary diversion, the surgeon should:
a. not be concerned about the continence mechanism because the mechanism will mold to the catheter.
b. not test the continence mechanism for ease of catheterization.
c. not be concerned about pouch integrity because the pouch will seal itself.
d. do none of the above.
e. do all of the above.

Answer 108

d. Do none of the above.The continence mechanism must be catheterized intraoperatively to ensure ease of catheter passage. This is an extremely important and crucial maneuver because the inability to catheterize is a serious complication that will often result in the need for reoperation.

Question 109

If the urine in a continent cutaneous reservoir is found to be infected, what should be done?
a. Nothing needs to be done in the absence of symptoms.
b. The urine should always be sterilized with appropriate antibiotics.
c. The infection should be eradicated, and prophylactic antibiotics prescribed.
d. Administer an intravenous pyelogram to check for upper tract damage.
e. Perform a pouch-o-gram.

Answer 109

a. Nothing needs to be done in the absence of symptoms. Most authors would suggest that bacteriuria in the absence of symptomatology does not warrant antibiotic treatment.

Question 110

The most appropriate and conservative care for pouch rupture is:
a. broad-spectrum antibiotic therapy.
b. careful radiologic imaging and antibiotic therapy.
c. surgical exploration for repair of the rupture and broad-spectrum antibiotic therapy.
d. pouch drainage and broad-spectrum antibiotic therapy.
e. bilateral percutaneous nephrostomies.

Answer 110

c. Surgical exploration for repair of the rupture and broad-spectrum antibiotic therapy.In general, these patients require immediate pouch decompression, radiologic pouch studies, and surgical exploration with pouch repair. If the amount of urinary extravasation is small and the patient does not have a surgical abdomen, catheter drainage and antibiotic administration may suffice in treating intraperitoneal rupture of a pouch. Patients managed with this conservative approach require careful monitoring.

Question 111

The first pouch to use the Mitrofanoff principle was the:
a. Mainz I.
b. Penn.
c. Kock.
d. Indiana.
e. Le Bag.

Answer 111

b. Penn. The Penn pouch was the first continent diversion to use the Mitrofanoff principle, wherein the appendix served as the continence mechanism.

Question 112

Which of the following represents the advantage of the gastric pouch?
a. Electrolyte reabsorption is reduced.
b. Absorptive malabsorption is avoided.
c. Acid urine may reduce the risk of infection.
d. All of the above
e. None of the above

Answer 112

d. All of the above. Electrolyte reabsorption is greatly diminished, shortening of the absorptive bowel does not occur, and the acid urine may decrease the likelihood of reservoir colonization.

Question 113

When converting from an ileal conduit to a continent diversion, the conduit should be:
a. discarded because it is older and subject to higher complications.
b. preserved for the ureteroileal anastomosis.
c. incorporated into the continent diversion when possible.
d. discarded because it is a potential nidus of infection.
e. None of the above

Answer 113

c. Incorporated into the continent diversion when possible. The authors prefer to use the conduit in some form whenever possible. The use of an existing bowel segment has the potential to diminish metabolic sequelae and may result in a lower complication rate.

Question 114

Which of the following is TRUE of absorbable staples?
a. Their use has been shown to shorten operative time.
b. They are safe and reliable.
c. Unlike nonabsorbable staples, they must not be overlapped.
d. All of the above.
e. None of the above.

Answer 114

d. All of the above. The use of absorbable staples has substantially reduced the time required to fashion bowel reservoirs and has demonstrated short-term and long-term reliability with respect to reservoir integrity and volume. They must not be overlapped because overlapping will prevent the proper close of the staple.

Question 115

The ability to ? is essential in patients who are to be considered for a continent cutaneous diversion.

Answer 115

self-catheterize

Question 116

All patients should be prepared for the possibility of ? if intraoperative circumstances warrant it.

Answer 116

a traditional ileal conduit

Question 117

A patient should have a minimum creatinine clearance of ? to undergo a continent urinary diversion..

Answer 117

60 mL/min

Question 118

? are used in all continent diversions. The stents are brought out through a separate abdominal stab wound, and a Malecot catheter should be placed into the reservoir and brought out through a separate stab wound as well.

Answer 118

Single J ureteral stents

Question 119

In continent diversions, it is not clear at this time whether antirefluxing ureteral intestinal anastomoses are necessary to preserve the upper tracts; however, antirefluxing procedures are associated with ? over the long term.

Answer 119

a higher incidence of stricture

Question 120

Most patients are satisfied with the type of urinary diversion, irrespective of ?

Answer 120

whether it is continent or not.

Question 121

It is often useful to ? to prevent the reservoir from migrating. This is conveniently done where the Malecot exits the reservoir onto the anterior abdominal wall.

Answer 121

secure the reservoir to the anterior abdominal wall

Question 122

? function must be carefully evaluated before a continent diversion is performed. Significant abnormalities in either are a contraindication to continent diversion. The glomerular filtration rate should be 60 mL/min or greater.

Answer 122

Renal and hepatic

Question 123

Patients with rectal bladders are very prone to the complication of ? and ? . These patients also have an increased incidence of ?

Answer 123

hyperchloremic acidosis; total body potassium depletion; rectal cancer.

Question 124

The ? in patients with neurologic or intestinal disorders subjects the patient to a significant risk of debilitating diarrhea.

Answer 124

loss of the ileocecal valve

Question 125

Any procedure that relies on the intact anal sphincter for continence (i.e., ?) requires an assessment of the sphincter before carrying out the operation. This can be assessed by an oatmeal enema.

Answer 125

the Mainz II pouch;

Question 126

Because of an increased risk of malignancy even in the absence of admixture of urine and stool, all ? should be subjected to annual investigation by ?.

Answer 126

large intestinal pouches; pouchoscopy and cytology.

Question 127

Nocturnal reservoir emptying may be required with any of the continent cutaneous reservoirs to prevent overdistention and possible rupture, but it is mandatory with ? because of the additional risk of fecal incontinence and metabolic acidosis.

Answer 127

ureterosigmoidostomy

Question 128

Small bowel pouches have initial capacities that are much lower than those of ?.

Answer 128

right colon pouches

Question 129

The use of absorbable staples is best suited to ?. With large bowel pouches there is no problem with staple lines causing subsequent bowel ischemia.

Answer 129

large bowel pouches

Question 130

Although late malignancy has been reported in all bowel segments exposed to the urinary stream, whether or not there is a commingling with feces, the juxtaposition of ? poses the greatest risk.

Answer 130

urothelium, urine, and feces