Urology Flashcards
60yo man sees a urologist for what he describes as bloody urine. a urine sample is positive for cytologic evidence of malignancy. cystoscopy confirms the presence of superficial TCC. which of the following is the recommended treatment for stage A (superficial & submucosa) TCC of the bladder?
a. topical (intravesicular) chemotherapy
b. radical cystectomy
c. radiation therapy
d. local excision and topical (intravesicular) chemotherapy
e. systemic chemotherapy
D
Superficial –> transurethral rsection of visible lesions & intravesicular local chemotherapy
36yo man presents to the ED with renal colic. his VS are normal and UA shows microscopic hematuria. a radiograph reveals a 1.5cm stone. which of the following is the most appropriate management of this pt?
a. hydration and analgesics
b. alpha-adrenergic blocker
c. extracorporeal lithotripsy
d. percutaneous nephrostomy tube
e. open surgery to remove the stone
C
> 1cm ==> lithotripsy
8yo boy is seen by a pediatrician for the first time. the physician notes that there are no testes in the scrotum. which of the following is the optimal management of b/l undescended testicles in an infant?
a. immediate surgical placement into the scrotum
b. chorionic gonadotropin therapy for 1 mo; operative placement into the scrotum before age 2 if descent has not occurred
c. observation until age 2; operative placement into scrotum if descent has not occurred
d. observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school
e. no therapy, reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend
B.
if 1 –> cryptorchidism
–> wait until 1yo; then removal of testicle for risk of cancer.
if 2 –> concerns about low DHT
- -> 1 mo of endocrine therapy w/ chorionic gonadotropin
- -> if persistent = surgical intervention w/ inguinal orchidopexy (before age 2)
Complications of b/l undescended testes
- reduced spermatogona
- malignant degeneration
32yo man presents with a asymptomatic mass in the R testicle. on exam, the mass cannot be transilluminated. US shows a solid mass in the R testicle. which of the following is the most accurate method in obtaining a diagnosis of testicular cancer
a. serum levels of alpha-fetoprotein and beta-hCG
b. percutaneous biopsy of the testicular mass
c. incisional biopsy of the testicular mass through a scrotal incision
d. excisional biopsy of the testicular mass through a scrotal incision
e. radical inguinal orchiectomy
e
not transilluminated = likely cancer
dx & tx = radical inguinal orchiectomy + high ligation o the spermatic cord near the internal inguinal ring
==> avoid damage of the scrotum (even if biopsy) –> b/c can affect the lymphatic drainage of the remaining testis
non-seminomatous tumor = high AFP, hCG
10yo boy presents to the ED with pain in the L testicle. the pain was acute in onset and began 1h ago. on exam, he is noted to have a high-riding, firm and markedly tender left testis. the R testicle is normal. UA is unremarkable. which of the following is the most appropriate management of this pt?
a. manual detorsion of the L testicle with external rotation toward the thigh; orchipexy if the condition recurs
b. manual detorsion of the L testicle with internal rotation toward the thigh; orchipexy if the condition recurs
c. orchiopexy of the L testicle
d. orchiopexy of b/l testicles
e. orchiectomy of the L testicle
D
testicular torsion
tx = open rotation of the affected testicle, with orchipexy (tether it down) on both the affected & unaffected testicle.
+/- orchiectomy if the affected testicle is nonviable.
Sxs = acute onset of testicular pain and/or swelling
Dx = Tc-99m, Doppler
45 yo woman presents with a 7cm RCC with radiologic evidence of abdominal LN involvement with no distant metastases. which of the following is the most appropriate management of this pt?
a. radical nephrectomy
b. radiation
c. chemotherapy
d. radiation, followed by nephrectomy
e. chemotherapy, followed by nephrectomy
A
there is local spread
RCC does not respond to chemo or radiation.
tx = nephrectomy + nodal dissection.
58yo man is found to have high serum PSA conc. with normal prostate examination. a biopsy of the prostate confirms low grade carcinoma. the pt wishes to avoid therapy involving any risk for impotence. which of the following is the most appropriate management of this pt?
a. observation
b. chemotherapy
c. prostatectomy
d. radiation therapy
e. hormonal therapy
A. early prostate cancer –> can always watch and wait with these slow growing tumors.
active surveillance = q3-6 mo visits, with DRE for any new changes, blood tests for rising PSA, and imaging if concerns for spread of cancer.
the rest puts him at risk for impotence
60yo man seeks medical attention b/c of recurrent UTI. the pt also reports a hx of increasing difficulty in urination (decreased flow, straining, hesitancy) over the last several months. a PSA level is mildly elevated and a prostate biopsy proves benign. which of the following is the most appropriate initial management of this pt with BPH?
a. alpha-adrenergic blocker
b. 5-alpha reductase inhibitor
c. alpha-adrenergic blocker and 5-alpha reductase inhibitor
d. transurethral resection of the prostate (TURP)
e. open prostatectomy
D
uncomplicated BPH
1) tamsulosin = alpha blocker
2) finaseride = 5-alpha reductase inhibitor (prevent testosterone from being turned into DHT)
complicated BPH = recurrent UTI; urinary retention refractory to meds, upper tract dilation, post-renal renal insufficiency, bladder stones
1) TURP
2) open prostatectomy = very large prostates, positional contraindication to TURP
the L ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill pt. which of the following would be the most appropriate management of this injury given the pt’s unstable condition?
a. placement of an external stent thru the proximal ureteral stump with delayed reconstruction
b. ipsilateral nephrectomy
c. placement of a catheter from the distal ureter thru an abdominal wall stab wound
d. placement of a closed suction drain adjacent to the injury
e. bringing the proximal ureter up to the skin as a ureterostomy
A
1) pt that is unstable ==> placement of catheter into proximal ureter into proximal ureter ==> to allow reconstruction to be performed later.
2) pt is stable ==> primary ureteral reconstruction
a pedestrian is hit by a speeding car. radiologic studies obtained in the ED, including a retrograde urethrogram (RUG) are consistent with a pelvic fracture with rupture of the urethra superior to the urogenital diaphragm. which of the following is the most appropriate next step in this pt’s management?
a. immediate percutaneous nephrostomy
b. immediate placement of a Foley catheter through the urethra into the bladder to align and stent the injured portions
c. immediate reconstruction of the ruptured urethra after initial stabilization of the pt.
d. immediate exploration of the pelvis for control of hemorrhage from pelvic fracture & drainage of pelvic hematoma
e. immediate placement of a suprapubic cystostomy tube.
E
Ureteral damage
1) retrograde ureterogram
2)
incomplete ureteral damage ==> Foley
complete ureteral damage ==> suprapubic cystostomy
hematoma should resolve within 4-6 mo
–> then definitive ureteral reconstruction
55yo man presents with fever and pain in the perineal regon. upon further questioning, he also complains of frequency, urgency, dysuria, and is soft, nondistended and nontender. digital rectal examination demonstrates exquisite tenderness on the anterior aspect. Labs reveal leukocytosis and findings on UA are consistent with a bacterial infection. which of the following is the most likely diagnosis?
a. UTI
b. BPH
c. prostatitis
d. pyelonephritis
e. nephrolithiasis
C
UTI –> leading to prostatitis
