Urology

Question 1

All of the following form a covering layer over the kidney, except:
A. Gerota’s fascia (peri-renal fascia)
B. Peri-renal fat
C. Liver
D. Para-renal fat
E. Fibrous capsule

Answer 1

C. Liver

Moving outwards the covering layers of the kidneys are as follows;

• fibrous capsule
• peri-renal fat
• peri-renal/Gerota’s fascia – a layer of connective tissue that
surrounds the kidneys and adrenal glands. It is continuous with the
fascia transversalis laterally.
• para-renal fat – the outermost covering layer of the kidney and
forming part of the retroperitoneal fat.

The right lobe of the liverforms the superior border of the right kidney, but does not form a covering layer of the kidney itself.

Question 2

The posteromedial aspect of the kidneys is related to which one of the following
structures:
A. Psoas muscle
B. Ilio-inguinal nerve
C. Diaphragm
D. Pancreas
E. 12th rib

Answer 2

A. Psoas muscle

anatomical relations of the kidney:

Question 3

In its course from the kidney to the bladder, the ureter runs on the top of which
muscle?
A. Quadratus lumborum
B. Transversus abdominis
C. Psoas
D. Iliacus
E. Latissimus dorsi

Answer 3

C. Psoas

The Psoas muscle (C) seperates the ureters from the trasverse processes of the lumbar vertebrae.

Quadratus lumborum (A) arises from aponeurotic fibres of the iliolumbar ligament and the iliac crest. It produces lateral flexion and extension of the vertebral column and fixes the ribs in forced expiration. It forms the posteriolateral border of the kidney.

Transversus abdominus (B) is a muscle of the abdominal wall that also forms the posteriolateral border of the kidney.

Iliacus (D) is a muscle of thigh flexion and lateral rotation found in the iliac fossa, lateral to Psoas.

Latissimus dorsi (E) is a back muscle

Question 4

The renal arteries arise at intervertebral level:
A. T11/T12
B. T12/L1
C. L1/L2
D. L2/L3
E. L3/L4

Answer 4

C. L1/L2

The renal arteries are branches of the abdominal aorta, they arise immediately below the superior mesenteric artery at L1, so classically described as being at the level of L1/2 (C)

Question 5

In a non-exercising individual, the proportion of cardiac output supplied to the
kidneys is approximately:
A. 5 per cent
B. 10 per cent
C. 15 per cent
D. 20 per cent
E. 25 per cent

Answer 5

D. 20 per cent

Question 6

A 34-year-old father of five children attends the family planning clinic for advice
on birth control. After discussing the various options available, he requests a
vasectomy. Which of the following structures lies most proximal to the vas
deferens (ductus deferens)?

A. Superficial scrotal fascia (Dartos fascia)
B. Internal spermatic fascia
C. Tunica vaginalis
D. External spermatic fascia
E. Preperitoneal fat

Answer 6

C. Tunica vaginalis

The vas deferens are the ducts that connect to the testis through the epididymis and conveys sperm. In vasectomy this is ligated, but it is important to counsel the patient that active sperm can remain in the duct for up to 12 weeks.

The layers to be dissected during the procedure (from superficial to deep) are:

• skin
• superficial scrotal fascia (Dartos fascia)
• external spermatic fascia
• cremasteric fascia and muscle
• internal spermatic fascia
• preperitoneal fat
• tunica vaginalis.

Question 7

With regard to the male urethra, which one of the following segments is the
narrowest?
A. Pre-prostatic
B. Prostatic
C. Membranous
D. Bulbar
E. Penile

Answer 7

C. Membranous

The male urethra is around 20 cm long and has five
components. These are:
• Pre-prostatic or intramural urethra – approximately 0.5–1.5 cm in
length (varies according to bladder fullness).
• Prostatic urethra – approximately 3 cm in length and the
widest/most dilatable part of the urethra. The vas deferens and
prostatic ducts (contributing sperm and seminal fluid) open into
this portion.
• Membranous urethra – approximately 2 cm long portion of the
urethra piercing the urogenital diaphragm. It is also the narrowest
part of the urethra.
• Bulbar urethra.
• Penile urethra – runs along the ventral surface of the penis and is
the longest portion, comprising most of the urethral length.

Question 8

A 40-year-old office executive presents with a 4-hour history of excruciating left
loin pain radiating to the groin. The pain has been constant with short spells of
more severe pain every 30–40 minutes. He informs you that his father has gout
and has had similar pains in the past. A KUB and IVU confirm the presence of a
radio-opaque stone in the left ureter, measuring approximately 4 mm in diameter.
What type of stone is most likely to be present in this patient?
A. Xanthine
B. Uric acid
C. (Triple) phosphate
D. Calcium oxalate
E. Cysteine

Answer 8

D. Calcium oxalate

Risk factors for renal calculi development include increased calcium slats, increased urinary concentration, and urinary stasis.

They can arise anywhere in the urinary tract and lead to colicky loin to groin pain, nausea and vomiting, and lower urinary tract symptoms.

60% of stones are formed of calcium oxalate (D)

33% of stones are formed of magnesium/calcium/ammonium phosphate, known as triple phosphate stones (C)

Other stones form the remainder and are rarerr and usually formed as a result of an aquired or genetic biochemical abnormality, they are generally rasdiolucent.

Question 9

A 29-year-old PhD student presents with acute-onset colicky left loin pain and
describes a history suggestive of urinary calculi. Which one of the following would
be the initial investigation of choice to determine the presence of a calculus in the
renal tract?
A. Dimercaptosuccinic acid (DMSA) scan
B. KUB (kidney ureter bladder) radiograph
C. Intravenous urogram/pyelogram
D. Flexible cystoscopy
E. Diethylene triamine pentaacetic acid (DTPA) scan

Answer 9

B. KUB (kidney ureter bladder) radiograph

This patient is experiencing renal colic which is spasming of the ureters secondary to stone impaction within the tract. The stones can impact at sites of pathological strictures or the three anatomical stricture sites; The plvi-ureteric and vesico-uriteric junctions and the crossing of the pelvic inlet.

Several methods of imaging the urinary tract exist but the more traditional first line is KUB (B) although this has been widely superseeded by CT techniques. It is the best answer here.

An IV urogram/pyelogram (C) requires a KUB film for comparison, but this hasn’t yet been taken.

A DMSA/DTPA (A)(E) scans are used to image the cortex and can give an indication of renal function, they are not a first line modality for calculi.

Flexi Cystoscopy (D) is used commonly as a minimally invasive method of stone removal.

Question 10

A 30-year-old housewife presents to her GP with a week-long history of dysuria,
frequency and extremely strong smelling urine. A urine dipstick test confirms the
presence of leucocytes and nitrites. She has previously suffered from multiple
urinary tract infections that have resolved with a short course of antibiotics. To
rule out further complications of the urinary tract, an ultrasound scan is
performed, which suggests the presence of a large calculus within the left
pelvicalyceal system. Which one of the following microorganisms is not associated
with the formation of such stones?
A. Proteus
B. Klebsiella
C. Pseudomonas
D. Mycoplasma
E. Mycobacteria

Answer 10

E. Mycobacteria

Repeated UTI’s can predispose to a type of ureteric stone, ‘infection stones’, they account for approximately 10% of stones. They are as a result of infection with organisms such as Proteus, Pseudomonas, Staphylococcus, Mycoplasma and Klebsiella. These organisms are known as urea-splitting organisms and hydrolyse urea to ammonium which alkalises the urine, resulting in deposition of various ions leading to struvite stones (magnesium ammonium phosphate).

These stones often have a shape that resembles deer antlers, leading to thier name of staghorn calculi.

Mycobacteria (E) species are not usually involved in the formation of struvite stones.

Question 11

A 75-year-old man presents to the surgical unit with a 24-hour history of acuteonset
left loin pain, which seems to worsen intermittently and has not settled with
regular simple analgesia. He suffers from mild dementia and is unable to recall the
details of his past medical history. The foundation year 2 doctor on call suspects
that a urinary calculus is the cause of this man’s pain and spots an old pathology
report in the patient’s notes showing the presence of negatively birefringent
crystals in a synovial fluid aspirate. Which one of the following substances is likely
to make up the majority of this man’s calculus?
A. Xanthine
B. Uric acid
C. (Triple) phosphate
D. Calcium oxalate
E. Cysteine

Answer 11

B. Uric acid

Negatively bifringent crystals in synovial fluid is diagnostic of gout, which is a purine metabolism disorder (exacerbated by dehydration, and diet) that leads to acute reccurent attacks of synovitis due to hyperuricaemia leading to urate crystal deposition. It predominantly affects the large joints.

The hyperuricaemic state also predisposes patients to urate and calcium oxalate stones. This makes option (B) the answer here. Treatment is as per other stones but allopurinol and dietery modification will help prevent reccurence.

It is important in a man of this age to exclude important differentials such as a ruptured AAA.

Question 12

A 24-year-old sexually active medical student is diagnosed as having a urinary
tract infection by her GP. Which one of the following organisms is most commonly
associated with community acquired urinary tract infection?
A. Escherichia coli
B. Pseudomonas
C. Staphylococcus saprophyticus
D. Staphylococcus aureus
E. Streptococcus faecalis

Answer 12

A. Escherichia coli

• E.coli* accounts for around 90% of all community aquired UTIs, it is a gram negative organism. Furthermore it accounts for around 50% of UTIs in hospital patients.
• Pseudomonas* (B) infection is associated with foreign body contamination, such as a catheter or a calculi.
• S.saprophyticus* (C) occurs more commonly in sexually active women and is the second commenest cause of community UTI.
• S.Aureus* (D) is associated with recent surgery
• S.faecalis* (E) is an Enterobacter (much like Proteus and Klebsiella), these are urea-splitting organisms and can lead to the formation of struvite (staghorn) stones. They are uncommonly the cause of UTI.

Question 13

A 40-year-old female lawyer is referred to the urology outpatient clinic with a history of multiple urinary tract infections over the preceding 10 years, which have required increasingly longer courses of antibiotics to treat. She also reports feeling more lethargic of late, despite leading a relatively active lifestyle. An ultrasound
scan of this patient’s renal tract indicates chronic pyelonephritis. Which of the following sonographic features would be diagnostic of her condition?
A. Absent kidney
B. Hydronephrotic kidney
C. Multiple renal stones
D. Atrophic kidney
E. Poor urinary concentration

Answer 13

D. Atrophic kidney

Pyelonephritis is an infection situated in the renal pelvis and the parenchyma of the kidney. Acute pyenephritis arises as a result of an ascending UTI or scepticaemia, classically this leads to fever, rigors, and loin pain.

Urine dip and MC&S, and blood cultures are used to establish any bacterial cause. Radiological assessment such as KUB and ultrasound demonstrate obstructive points indicating renal stones, and finally a renal IVU can indicate kidney enlargement and poor urine concentration.

Chronic pyelonephritis is a result of reccurent UTO and vesico-ureteric reflux. It is diagnosed on radiological findings of a small, contracted, scarred and atrophic kidney (D). Patients can also present more late stage with chronic renal failure. Treatmetn is to correct the underlying cause, correcting any electrolyte/biochem abnormalities, antibiotics and if necessary nephrectomy.

Question 14

A 28-year-old student presents with a 2-day history of dysuria and mucopurulent urethral discharge. He reports recently having had unprotected sex while on holiday in the Mediterranean. A urethral discharge smear inoculated into Thayer–Martin medium confirms infection with Neisseria gonorrhoeae and appropriate antibiotics are started. What type of organism is N. gonorrhoeae?
A. Lactose-fermenting Gram-negative rod
B. Maltose-fermenting Gram-negative coccus
C. Coagulase-positive Gram-positive coccus
D. Glucose-fermenting Gram-negative coccus
E. Lactose-non-fermenting Gram-negative rod

Answer 14

D. Glucose-fermenting Gram-negative coccus

N.gonorrhoeae is a glucose fermenting gram-negative diplococcus (D), it is the cause of Gonorrhoea, which is a common STI. There can be extra urogenital manefestations, including the joints, and in the urinary tract it presents with dysuria and prfuse purulent discharge (especially in males). It can also cause newborn conjunctivitis.

Treatment is with broad spectrum antibiotics, in order to also cover Chlamydia, and the encouragement of safe sex practice.

Lactose fermenting gram-negative rods (A) include Klebsiella, E.coli, enterobacter, citrobacter and serratia species.

N.meningitides is a maltose, sucrose and glucose fermenter, it is a gram-negative coccus (B).

S.aureus is a coagulase positive gram-positive coccus (C)

finally the lactose non-fermenting gram-negative rods (E) include; Shigellla, Salmonella, and proteus species, as well as the oxidase positive Psudomonas species.

Question 15

A 69-year-old diabetic man presents to the acute surgery unit with a 5-day history of mild dysuria, frequency and feeling generally unwell. On examination, he is found to be pyrexial and tachycardic. A genital examination reveals both the penis and the scrotum to be swollen, red and tender to touch, with erythema also extending into the groin bilaterally. Of note, the examining surgeon believes that there is palpable crepitus in the perineum. Routine bloods and cultures are taken (which later grow both aerobic and anaerobic organisms), and fluid resuscitation
and broad-spectrum antibiotics are commenced. Following further discussion with a urologist, he is taken promptly into the operating theatre for definitive management. The likely diagnosis in this patient is:
A. Fournier’s gangrene
B. Epididymo-orchitis
C. Testicular tumour
D. Testicular torsion
E. Prostatitis

Answer 15

A. Fournier’s gangrene

nasty stuff… Fournier’s gangrene (A) is a relatively rare condition where there is necrotising fascitis of perineal, perianal and genital areas (it is secondary to infection). It predominantly affects middle aged and elderly men with pre-existing co-morbidities, particularly diabetes.

It is a urological emergency that often presents with swelling, pain and erythema of the genital region alongside systemic infective features. There will often be a preceeding history of several days of pruritis and discomfort of the area. There may be no signs of necrotic tissue externally, although the crepitations indicate bacterial gas production within the tissue plains and is almost diagnostic. Given the rapid progress of this condition speed of diagnosis and debridment is paramount.

Prostatitis (E) is an inflammation of the prostate gland, usually due to bladder outflow obstruction. It presents with fever. frequency, urgency, dysuria and occasional haematuria as well as haemospermia and occasionally a tender prostate and pain on ejaculation. Treatment is with antibiotics and investigation to exclude an abcess and to treat any underlying cause.

The other answers here are discussed elsewhere

Question 16

A 29-year-old railway worker is admitted following crush injury to his left leg. He is talking in full sentences and complaining of pain in his leg. Further examination reveals a blood pressure of 90/58 mmHg, pulse of 99 beats/min, and a swollen and bruised left leg. Intravenous access is gained, routine blood samples are taken and fluid resuscitation is commenced. In addition, the patient is catheterized for monitoring purposes and passes only a small of red-brown urine, which, on microscopy, is confirmed to contain myoglobin. The admitting physician makes
a working diagnosis of rhabdomyolysis. Which one of the following metabolic abnormalities is not associated with this condition?
A. Hypocalcaemia
B. Hyperkalaemia
C. Hypernatraemia
D. Hyperphosphataemia
E. Hyperuricaemia

Answer 16

C. Hypernatraemia

Rhabdomyolysis is the destruction of striated muscle, as a result of injury of any aetiology.

Commonly it is caused by’ crush injury, ischaemia, prolonged epileptic seizures, heavy physical exercise (more likely with dehydration) and alcohol withdrawal.

More rarely it is caused by; infection, inflammatory myopathy, drugs (such as statins), hypothyroidism, snake bites, malignant hyperthermia and electrocution.

Given the specrum of causes presentations are variable, but the various metabolic disturbances are a hallmark.

The classic disturbances are hyperkalaemia, hyperuricaemia and raised creatinine, hypocalcaemia (calcium binds to necrotic muscle), hyperphosphataemia (reaction to hypocalcaemia), raised creatinine kinase and occasionaly deranged LFTs. Urine dip may reveal blood which microscopy will confirm as myoglobin not haemoglobin.

Initial management consists of stabilising the patient, and then fluid resuscitation (for rehydration and prevention of myoglobin deposition that can lead to acute tubular necrosis), and then catheterization.

Urine alkalisation can also be used to increase the solubility of myoglobin, but evidence of benefit is limited.

The hyperkalaemia needs urgent correction with insulin+glucose, calcium resonium to chelate and calcium gluconate to protect the myocardium from arrythmias. Dialysis may be indicated in severe cases.

Question 17

A 45-year-old man presents to the emergency department with a severe headache that started suddenly following a weight-training session. He is treated appropriately and further examination some days later reveals a palpable lump in
the left loin. An ultrasound scan confirms multiple kidney cysts and hepatomegaly, suggestive of adult polycystic kidney disease. On further questioning, he reports that his father died of brain haemorrhage at the age of 35. Adult polycystic kidney
disease is most commonly inherited by which one of the following modalities.
A. Autosomal recessive gene chromosome 16
B. Autosomal dominant gene chromosome 16
C. Autosomal dominant gene chromosome 8
D. Autosomal recessive gene chromosome 4
E. Autosomal dominant gene chromosome 4

Answer 17

B. Autosomal dominant gene chromosome 16

Adult polycystic kidney disease is an autosomal dominant disease caused by a defect on chromosome 16 (B) affecting the PKD1 gene (in 85% of cases, the majority of the remainder are due to a chromosome 4 abnormality). THe condition is charecterised by multiple kidney cysts which are present at birth with progressive enlagement and reduced renal function in affected adults.

Patients my present with feature of renal dysfunction such as loin pain, haematuria (bleeding into a cyst), renal failure, hypertension and UTI. There are also many systemic effects of the disease such as;

• intracranial haemorrhage – especially subarachnoid haemorrhage
due to rupture of berry aneurysms of the circle of Willis
• liver, breast and pancreatic cysts
• mitral valve prolapse
• aortic root dilatation
• thoracic aorta dissection
• abdominal wall hernias.

There may also be a family history of unexplained intracranial bleeds or renal failure, with the development of end-stage disease by age 60.

Treatment is with dialysis and renal transplantation, Genetic counselling and testing should also be offered.

Question 18

A 6-week-old boy presents with his parents to the specialist paediatric urology outpatients department. The family is Jewish and at the time of the boy’s
circumcision were told by their rabbi that the urethral meatus was not in the normal position. On examination, the meatus is on the ventral surface just below the glans penis. What is the most likely diagnosis?
A. Hypospadias
B. Epispadias
C. Phimosis
D. Chordee
E. Perineal urethra

Answer 18

A. Hypospadias

Hypospadias (A) is a term for an abnormal opening of the urethral meatus along the ventral surface of the penis. The opening can be anywhere along the urethral groove between the glans and the scrotum or even perinium. It occurs in around 1:125 births, in the majority of cases the meatus opens on the glans penis(first-degree hypospadias) and usually causes little functional loss. In other cases the meatus opens on the shaft or perinum/scrotum (second, and third degree hypospadias respectively), this can cause problems with urination, fertility and psycosocial issues, and so is repaired at a young age (usually 9-18 months).

Epispadias (B) is a condition in which the urethral meatus opens on the dorsum of the penis. It results from a failure of mid-line structures below the umbilicus to fuse, there can also be a split pubic symphasis, low umbilicus, undescended testes, bladder exstrophy, and cloacal exstrophy. The equivalent in females is a bifid clitoris.

Phimosis (C) is contraction of the foreskin preventing its retraction over the glans penis. It can be physiological in infants. Pathological phimosis is seen in older children and is the result of a disease process or infection. Treatment is usually by circumcision.

Paraphimosis occurs when the foreskin is not replaced after being rolled back (such as after a catheter insertion), it results in a tight irreducable band.

Chordee (D) is a congenital condition in which the head of the penis curves downwards, it is usually surgically corrected in childhood.

Perineal urethra (E) refers to a perineal opening of the urethra, more commonly seen in women.

Question 19

A young girl presents to her GP with a 2-day history of fever and swelling on the left side of her abdomen. Examination confirms a raised temperature and left loin
swelling extending into the mid-line. In addition, microscopic haematuria is found on a urine dipstick test. She is referred to the local hospital where an ultrasound
scan of the abdomen and biopsy confirm Wilm’s tumour (nephroblastoma). Which one of the following statements regarding Wilm’s tumour is true?

A. The tumour may be associated with anophthalmia
B. 5-year survival in stage IV disease is approximately 65 per cent
C. Children most commonly present at the age of 8–10 years
D. Some cases are associated with a gene mutation on chromosome 13
E. It commonly metastasizes to the brain

Answer 19

B. 5-year survival in stage IV disease is approximately 65 per cent

Wilm’s tumour is a malignant nephroblastoma (embryological origin), it most commonly affects children 3-4 years old. It is linked to a mutation on chromosome 11 that leads to the loss of WT-1 (a tumour suppressor gene). Occasionally, wilm’s tumour can be part of a syndromic abnormality. Examples include; WAGR syndrome (Wilm’s tumour, Anirirdia, genito-urinary abnormalities and mental retardation), and Denys-Drash syndrome (associated with hemi-hypertrophy), but most patients have Wilm’s tumour in isolation. These patients present with Fever, abdominal swelling, and haematuria.

The four stages of Wilm’s tumour are;

• Stage I – disease is limited to the kidney and can be completely
excised. It does not breach the renal capsule.
• Stage II – disease extends beyond the kidney but can be excised
with no residual beyond the excision margin.
• Stage III – there is an unresectable primary tumour with lymph
node metastasis.
• Stage IV – distant metastases are present especially to the lung.

Treatment is by resection, potentially with pre-operative chemotherapy to shrink the tumour. Post-operative chemotherapy may be needed dependant on the tumour stage.

Disseminated disease may be treated with radiotherapy. 5-year survival is dependant of tumour stage but prognosis is excellent.

With stage i/II (the most common presentation), there is greater than 90% 5-year survival. With stage III this falls to >80%, and with stage IV there is around 65% 5-year survival.

Question 20

A 65-year-old hypertensive man attends the preoperative assessment clinic 7 days before he is due to undergo a transurethral resection of prostate for benign prostatic hypertrophy. He is currently taking furosemide for blood pressure control but no other regular medication. A routine set of bloods is taken, the results of
which show a potassium level of 2.7 mmol/L. On the basis of this an electrocardiogram is requested. All of the following electrocardiographic changes are characteristic of hypokalaemia, except:
A. Left bundle branch block
B. Flattened T waves
C. U waves
D. ST segment depression
E. Prolonged QT interval

Answer 20

A. Left bundle branch block

Hypokalaemia is when serum potassium is below the reference range of 3.5-5.0 mmol/l. It may be due to;

• Loop diuretics such as furosemide and bumetanide.
• D and V
• Pyloric stenosis
• villoius adenoma of the rectum
• intestinal fistula
• Cushings syndrome/disease
• Conn’s syndrome
• Alkalosis

Hypokalaemia may present asymptomatically or with muscle weakness, hypotonia, cramp, tetany and potentially fatal cardiac arrhythmias (also seen in hyperkalaemia)

in hypokalaemia the ECG changes are; small or inverted T waves (B), prominent U waves(C), prolonged PR interval, ST segment depression (D) and a prolonged QT interval (E).

LBBB (A) is not classically associated with hypokalaemia.

Important to note that the ECG changes in hyperkalaemia include tall (tented) T waves, small p waves and wide QRS complexes.

Question 21

Which one of the following statements regarding renal cell carcinoma is true?
A. It is an incidental finding in approximately 30 per cent of patients
B. Women are more commonly affected than men
C. Approximately 2 per cent of cases are familial
D. Renal cell carcinoma accounts for around 3 per cent of adult cancers
E. Metastases are poorly visualized by standard imaging techniques

Answer 21

D. Renal cell carcinoma accounts for around 3 per cent of adult cancers

Renal cell (adeno)carcinoma is a malignant cancer of proximal renal tubule cells accounting for around 3% of all adult cancers. It is a highly vascular tumour with a slight predisposition in men. Risk factors include:

• acquired renal cystic disease (affects 90 per cent of patients on
dialysis)
• smoking
• exposure to lead
• asbestos
• polycarbons

The majority of cases are sporadic but a small proportion of around 2% are familial and associated with Von Hippel-Lindau disease, haemangioblastomas of the cerebellum and spine, retinal haemangiomas, phaeochromacytoma and islet cell tumours.

Patients can present with the classic triad of pain, palpable loin mass and haematuria. In the majority of patients the disease is an incidntal finding (in about 50% of cases) or associated with signs of systemic disease or paraneoplastic syndromes. This syndromes can present with the release of renin, erythropoietin, ACTH or para-thyroid hormone. Metastatic spread is by local extension into the paranephric fat, fascia, and into the renal vein/IVC, or it can spread in a haematogenous fashion, resulting in cannonball mets in the lung, brain and bone.

Treatment primarily involves radical nephrectomy, either with a curative or palliative intention depending on the stage at presentation, chemo/radiotherapy and immunotherapy may be used in disseminated disease.

5-year survival ranges from 90% to 2% dependant on tumour stage and grade.

Question 22

With regard to carcinoma of the bladder, which one of the following statements is
not correct:
A. Epithelial tumours account for the majority of bladder tumours
B. It accounts for 1 in every 5000 new cases of cancer in the UK
C. Males are more commonly affected than females
D. There is a strong correlation with exposure to industrial dyes
E. It frequently presents with painful haematuria

Answer 22

E. It frequently presents with painful haematuria

Carcinoma of the bladder is seen more commonly in middle aged and elderly individuals, and more frequently in males. It represents 1 in 5000 cancers in the UK and has predisposing factors including; smoking, chemical exposure (aromatic amine and aniline dyes, chemicals used in printing, processing and rubber industry), drugs such as phenacetin and cyclophosphamide , and chronic inflammation associated with conditions such as schistosomiasis/Bilharzia.

90% of of bladder cancer is transitional cell carcinoma. the rarer cases can be squamous cell carcinoma, adenocarcinoma and sarcoma. Squamous cell carcinomas arise from metaplastic areas, often following chronic inflammation, Adenocarcinomas arise from urachal remnants.

Bladder cancer usually present with painless haematuria and occasionally symptoms of renal failure secondary to obstruction. In more advanced disease patients can present with dysuria, frequency, urgency, clot formation and urinary retention.

Question 23

A 69-year-old retired canal engineer who has previously worked in north Africa
presents to the urology outpatients department with a 2-month history of
intermittent painless haematuria. A cystoscopy is performed showing a sessile
mass on the posterior abdominal wall. A biopsy is taken of this mass, which
confirms transitional cell carcinoma invading the bladder muscle but no local
nodes are involved. A further staging computed tomography scan shows no distant
metastases. According to the TNM classification, the tumour stage in this
individual is:
A. Tis Nx Mx
B. T2 N0 M0
C. T2 N1 M0
D. T3 N1 M1
E. T3 N0 M1

Answer 23

B. T2 N0 M0

T2 refers to the tumour having invaded the muscle, and not being in situ (Tis), Papillary carcinoma (Ta), or only extending through the lamina propria (T1). N0 and M0 refer to there being no nodal involvement or metastatic disese, respectively.

Treatment of bladder carcinoma depends on tumour stage:
• Superficial disease (i.e. Tis, Ta and T1) is treated with transurethral
resection of bladder tumour (TURBT) ± intravesical input. Patients
are followed up with regular cystoscopy as there is a risk of
developing invasive disease.

• Intravesical therapy consists of mitomycin C or BCG for 6 weeks.
• Radical therapy is reserved for patients with extensive disease and
those who fail to respond to intravesical treatment. Intervention
includes radical cystectomy (with bladder reconstruction surgery)
and radiotherapy.
• Metastatic disease can be treated with platinum-based
chemotherapy.• Intravesical therapy consists of mitomycin C or BCG for 6 weeks.
• Radical therapy is reserved for patients with extensive disease and
those who fail to respond to intravesical treatment. Intervention
includes radical cystectomy (with bladder reconstruction surgery)
and radiotherapy.
• Metastatic disease can be treated with platinum-based
chemotherapy.

Question 24

Which one of the following statements regarding testicular tumours is true?
A. They account for 5–10 per cent of male malignancy in the UK
B. Seminomas are more common than non-seminomatous germ cell tumours
C. Teratomas commonly present between the ages of 30 and 50 years
D. Seminomas secrete a-fetoprotein and b-human chorionic gonadotrophin
E. 5-year survival for seminomas is approximately 90 per cent

Answer 24

E. 5-year survival for seminomas is approximately 90 per cent

Testicular malignancy is the commonest solid malignancy in young men, but only accounts for 1-2% of all male cancers in the UK. Undescended testes, and previous contralateral malignancy are risk factors.

Testicular tumours can be divided into three broad groups; Stromal tumours, lymphomas and germ cell tumours. Stromal tumours arise from Leydig’s cells (they secrete androgens and can lead to infantile hercules syndrome) and Sertoli cells (these secrete androgens and can present with testicular feminization). Around 10% are malignant. Lymphomas account for less than 10% of testicular tumours, mainly occuring in elderly men, and have a poor prognosis.

Around 80-90% of testicular tumours arise as germ cell tumours, of which there are seminimas and non-seminomatous germ cell tumours. Seminomas arise form germinal cells in the testes and are solid and slow growing, they account for around 42% of germ cell toumours and have an excellent prognosis (5-year survival of around 90%) as they are very radiosensitive. The NSGCTs account for around 60% of germ cell tumours with teratomas being the most common subtype.

The presentation of testicular malignancy tends to be a painless lump (although there is pain in a small proportion), occaisionally there will be haematospermia and gynecomastia (due to beta hCG production).

On occasion patients will present with signs of disseminated disease; such as shortness of breath, bone pain, and a palpable abdominal mass (para-aortic nodes).

Tumours may produce AFP and beta hCG.

Question 25

A 36-year-old carpenter is diagnosed with a seminoma. To which lymph nodes
does a seminoma most commonly spread first?
A. Para-aortic lymph nodes
B. Superficial inguinal lymph nodes
C. Anterior cervical chain
D. Posterior cervical chain
E. Deep inguinal lymph nodes

Answer 25

A. Para-aortic lymph nodes

Seminomas are germ cell tumours, predominantly affecting individuals aged 20-40. Vascular supply is from the testicular artery and so lymph drainae is along this route, meaning that any lymphatic spreas will go to the para-aortic nodes.

The anterior cervical chain (C) of nodes lies above and below the
sternocleidomastoid muscle in the neck and drains the throat, posterior
pharynx, tonsils and thyroid gland. Meanwhile, the posterior cervical
chain (D) lies posterior to the sternocleidomastoid muscle (and anterior to the
trapezius) and can become enlarged during upper respiratory tract
infections. The superficial inguinal lymph nodes (B) drain lymph from the
scrotum, while the deep nodes can become enlarged as a result of spread
from anal and vulval malignancies. The deep nodes (E) drain to the external
iliac, pelvic and finally para-aortic lymph nodes.

Question 26

All of the following statements regarding carcinoma of the penis are true, except:
A. It is a squamous cell carcinoma
B. Incidence is lower in men infected with the human papilloma virus
C. Incidence is lower in men circumcised at birth
D. Staging of disease is by the TNM (tumour node metastasis) system
E. 5-year survival in patients with localized disease is around 80 per cent

Answer 26

B. Incidence is lower in men infected with the human papilloma virus

Carcinoma of the penis is a rare squamous cell carcinoma (A) arising in the glans or foreskin and accounts for around 1% of male malignancy.

It is extremely rare in men circumcised at a young age (C)

HPV (particularly 16, 18 and 31) are particularly carcinogenic and there is a higher incidence of carcinoma of the penis in affected men. Therefore option (B) is the incorrect statement here.

Answers (D) and (E) are correct statements.

Question 27

A 55-year-old solicitor presents to the urology outpatients department with a 6-
month history of abnormally angulated penis on erection. This has made sexual
intercourse particularly difficult and painful and has been affecting his
relationship with his wife. After further questioning, a diagnosis of Peyronie’s
disease is offered. All of the following statements regarding Peyronie’s disease are
true, except:
A. It is a connective tissue disorder of unknown origin
B. Around 1 per cent of men are affected
C. It is the result of a gene mutation on chromosome 5
D. Surgical treatment is considered only 1 year after initial presentation
E. There is an association with Dupuytren’s contracture

Answer 27

C. It is the result of a gene mutation on chromosome 5

Peyronie’s disease is a connective tissue disorder of unknown origin (A)(C) resulting in the development of fibrous plaques in the tunica albuginia and corpus cavernosum. It results in abnormal curvature and pain on erection and affects approximately 1% of middle aged men (B). The condition is associated with Dupuytren’s contracture (E) and plantar fascia contractures.

Treatment is initially conservative for a year (D) in order to allow for the disease process to stabilise.

Surgical management after 1 year will generally be one of three procedures;

• Nesbit’s operation – tunica albuginea on the opposite side of the
offending plaque is excised, leading to return of normal curvature
but also penile shortening.
• Plaque excision and patching – can lead to softer erections.
• Implantation of penile prosthesis – straightens penis in men with
pre-existing erectile dysfunction.

Question 28

Which of the following vessels contributes to the blood supply of the prostate
gland?
A. Coeliac plexus
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Internal iliac artery
E. External iliac artery

Answer 28

D. Internal iliac artery

The prostate gland is supplied by branches of the inferior vesical and middle rectal arteries, which are two of branches of the internal iliac artery (D).

Venous drainage is via the prostatic venous plexus, lymphatic drainage is via the internal iliac nodes.

Question 29

An 80-year-old man presents to his GP with a 6-month history of increasing
urinary frequency. He passes urine approximately eight times during the day and
six times each night but feels that he has not completely voided. In addition, he
reports that his stream is very slow and finds it hard to stop, with micturition
prolonged due to terminal dribbling. He is otherwise fit and healthy with no other
symptoms reported. On rectal examination, the prostate is found to be smoothly
enlarged with no other significant findings on systemic examination. Which of the
following layers of the prostate gland is likely to be enlarged in this man?
A. Transition zone
B. Central zone
C. Peripheral zone
D. Anterior fibromuscular stroma
E. All of the above

Answer 29

A. Transition zone

In benign prostatic hypertrophy (the case in this scenario) there is benign enlargement of the stromal and glandular tissue within the inner transitional zone (A), it is believed to be as a result of steroid hormone imbalance. It affects most males over the age of 80 and presents with lower urinary tract symptoms;

• Voiding symptoms, e.g. hesitancy, straining, poor stream, terminal
dribbling and strangury (the sensation of incomplete voiding).
• Storage symptoms, e.g. frequency, urgency, nocturia, overflow
incontinence.
• Other symptoms – UTI, bladder stones due to stasis, occasional
haematuria.

Examination will reveal a smothly enlarged prostate, Medical treatment is with a-blockers such as alfuzosin and tamsulosin, which relax prostatic and bladder neck smooth muscle to increase urine flow, or with 5-a-reductase inhibitors, e.g. finasteride or dutasteride, which prevent the formation of dihydrotestosterone and reduce prostate size. Surgical management is reserved for those with ongoing symptoms despite medical intervention and most commonly involves TURP to
reduce prostatic volume.

Question 30

A 75-year-old man presents to the urology outpatients clinic with a 6-month
history of urinary frequency associated with difficulty initiating micturition,
dribbling on reaching the end of his stream and nocturia. A digital rectal
examination reveals a hard prostate gland. Core biopsy is performed on the gland
and the pathology report indicates presence of a tumour involving most of the
right lobe. According to the TNM classification, the tumour stage is:
A. T2 N1 M0
B. T3 Nx Mx
C. T3 N1 M0
D. T2 Nx Mx
E. T1 N1 M0

Answer 30

D. T2 Nx Mx

There is no mention of any lymph nodes or any investigations of possible metastatic disease in this case so it must be described as Nx Mx. That leaves only options (B) or (D). We know from the case that the tumour has not extended beyond the prostate as it is not described as being irregular, this makes the answer here (D).