2008 Flashcards

Question

The medication associated with an increased incidence of renal insufficiency in patients with either bilateral renal artery stenosis or renal artery stenosis in a solitary kidney is: 1. hydrochlorothiazide 2. doxazosin 3. propranolol 4. lisinopril 5. furosemide.

Answer 1

4 Lisinopril causes a pharmacologic blockade of the renin-angiotensin system. Glomerular-capillary hydraulic pressure is determined by the balance between afferent and efferent vascular tone. Efferent arteriolar constriction serves to maintain an effective filtration pressure and glomerular filtration rate when renal arterial perfusion pressure is reduced. In bilateral renal artery stenosis or in renal artery stenosis of a solitary kidney, settings in which total renal blood flow is fixed, failure to autoregulate filtration rate would lead to elevations of the BUN and creatinine. Since evidence suggests that the renin-angiotensin system is responsible for this autoregulation, blockade by captopril would lead to transient renal insufficiency. None of the other drugs listed would produce this effect.

Answer 2

3 Nephrotoxicity is the most common side effect of treatment with cyclosporine and has been observed in as many as 50% of patients. This is preventable by monitoring blood levels of cyclosporine with appropriate dose reduction as needed. Cyclosporine nephrotoxicity is usually reversible and occasionally necessitates complete discontinuation of the drug.

Answer 3

4 This patient manifests the paraneoplastic syndrome of hypercalcemia. The hypercalcemia needs to be controlled promptly, and therapy should begin with hydration with isotonic sodium chloride. Hydration should result in an increase in calcium excretion and lowering of serum calcium levels to acceptable ranges. All other therapies are appropriate and effective if saline hydration is inadequate to return serum calcium to safe levels.

Answer 4

2 Microscopic examination of the urine is the most rapid and inexpensive means to diagnose UTIs and determine the response to therapy. It provides useful information concerning the likely invaders and whether cultures and susceptibility tests might be needed. The urine may be examined with or without staining and with or without centrifugation, depending on the expertise of the examiner. Unstained specimens are useful for rapid diagnosis. Gram stains provide more reliable information about the potential pathogen.

Answer 5

3 In this clinical setting, the most likely diagnosis is chronic urinary infection secondary to a urethral diverticulum. Although many of these lesions can be demonstrated on a VCUG, pelvic MRI is being used with increasing frequency to confirm the diagnosis. Endoscopic examination under general anesthesia with good relaxation and simultaneous digital compression of the anterior vaginal wall may be necessary to satisfactorily demonstrate these lesions. In some cases, a retrograde urethrogram, utilizing the double balloon compression technique, is necessary to demonstrate the diverticulum. Cystogram does not image the urethra. Quantitative urine cultures, although positive in these cases, do not establish the diagnosis. Urodynamics are not indicated in patients with suspected local urethral disease unless there is clinical evidence of co-existent neurogenic disease.

Answer 6

3 Intraoperative IVP is performed in unstable trauma patients who can't undergo a radiographic evaluation in the emergency room. A film is taken ten minutes after contrast is administered intravenously. A 2 ml/kg dose of contrast material is recommended for this study.

Answer 7

2 Early hydronephrosis in this patient suggests recurrent tumor. CT scan and urinary cytology is the best approach to assessing the recurrent cancer in this patient. Urinary cytology from the conduit will be positive with a high grade tumor in greater than 80% of cases and is therefore the next test, as the patient has already had a CT urogram. If urinary cytology is positive, appropriate cancer therapies should be initiated. Assuming the cytology is negative, loopogram, loop endoscopy, and percutaneous nephrostomy can be performed later to aid in surgical planning.

Answer 8

4 The patient has a Stage II penile cancer with invasion of the corpora that is associated with a much higher incidence of positive lymph nodes. Although the lymph node has decreased in size, it is still palpable after six weeks and deserves excision. Since this patient is at high risk for nodal disease, neither a negative needle aspiration nor a negative sentinel node biopsy should dissuade one from lymphadenectomy. Among patients found to have unilateral positive groin nodes, a bilateral lymphadenectomy is indicated due to the high rate of bilateral disease. By comparison, patients who present with unilateral adenopathy beyond one year are treated with ipsilateral lymphadenectomy.

Answer 9

5 Minor degrees of separation of circumcision edges are common. Complete separation as described is uncommon. This incision should be considered contaminated in the baby's diaper. Therefore, immediate closure is not recommended. Skin grafts are not indicated because of the contaminated bed and would have a high risk of infection. Since the length of the skin was adequate at the time of circumcision, observation is the best choice. Usually this complication rapidly heals well and nothing further will be necessary. If an undesirable scar develops, it can be revised or grafted electively at a later time.

Answer 10

5 Lesions apparently representing Wilms' tumor precursors have been recognized for many years. They have been found in 1% of kidneys in infants on postmortem and in 30-40% of kidneys removed for Wilms' tumor. The terminology for these lesions has evolved over the years. These lesions were previously termed persistent nodular renal blastema, Wilms' tumorlet or nephroblastomatosis if there were diffuse lesions. The current preferred term is nephrogenic rest which is defined as foci of abnormally persistent nephrogenic cells that can potentially form a Wilms' tumor. It is has estimated that approximately 1 in 80 nephrogenic rests will develop into a Wilms' tumor.

Answer 11

2 Direct injury to the penile urethra is usually best managed with primary surgical repair. In contrast, partial injuries to the posterior urethra will usually heal well over a urethral catheter if one can be placed atraumatically. While extraperitoneal bladder injuries can usually be managed by urethral catheter drainage of the bladder, indications for primary surgical closure of the bladder and placement of a suprapubic cystostomy include co-existing open pelvic fracture, patients undergoing laparotomy or open surgical repair of pelvic fracture, rectal perforation, and bone fragment projecting into the bladder. Intraperitoneal ruptures require primary surgical exploration and repair.

Answer 12

1 Kaposi's sarcoma is a rare neoplasm of endovascular cells that is seen in men of Mediterranean descent, HIV infected patients, and those on immunosuppression. The lesions are associated with the human herpes virus 8. The lesions are violaceous to light brown. They can cause venous and lymphatic obstruction resulting in local edema.

Answer 13

4 Rates of incontinence can be high in patients undergoing TURP following brachytherapy (at least 18%). The presence of obstructive symptoms at the time of TURP, and a period of at least two years since brachytherapy are associated with a greater likelihood of incontinence. Treatment with Lupron, prostate size, pretreatment IPSS, dosage of brachytherapy, and pre-treatment PSA do not seem to affect the likelihood of incontinence.

Answer 14

2 Multiple series have documented the safety and efficacy of endoscopic management of upper tract TCC. This elderly patient has significant comorbidities and a low grade distal ureteral TCC. Low grade tumors at ureteroscopic biopsy have a strong correlation with noninvasive stage at the time of nephroureterectomy. Similarly, high grade disease identified on ureteroscopic biopsy is very likely to represent invasive disease at the time of final pathologic staging. While optimal therapy for a low grade ureteral tumor in a younger, healthier patient would be distal ureterectomy and reimplantation, this patient would be well-served with endoscopic management. Although upper tract tumors can be ablated with electrocautery delivered through a small Bugbee electrode, the variable depth of penetration and risk of stricture formation have made the use of laser energy for ablation more popular. Follow-up of the patient should include endoscopic evaluation (ureteroscopy) on a periodic basis.

Answer 15

4 The management of ureteral obstruction in association with inflammatory abdominal aortic aneurysms is controversial. Peri-aneurysmal fibrosis has been reported to subside in some cases after aneurysm repair and there have been some who have recommended steroid treatment for this condition. Since the right kidney is functioning normally and there is a long ureteral stricture, left nephrectomy should be strongly considered. Ureterolysis concomitantly with aneurysm repair would likely to require an ileal ureter or autotransplantation which would be ill-advised in this setting.

Answer 16

3 New hydronephrosis after artificial urinary sphincter (AUS) placement is a well described complication. It is usually due to decreased bladder compliance that was unrecognized at the time of AUS placement or has developed subsequent to and as a result of the outlet resistance from the AUS. It is essential to monitor bladder compliance following AUS placement. A changing neurologic lesion (such as tethered cord) is unlikely to occur in a patient who has completed linear growth.

Answer 17

4 The patient has a classic history for a pheochromocytoma. This includes his age, sex, and symptoms. The normal renal Doppler ultrasound rules out most secondary renal causes of HTN. The elevated plasma and urine catecholamine levels document biochemical evidence for a pheochromocytoma. Children have an increased incidence of bilaterality, multifocality, and a greater tendency for familial occurrence. MR imaging is the most sensitive study for localizing adrenal and extra-adrenal tumors. The glucagon stimulation and clonidine suppression tests are used in instances of non-diagnostic plasma and urine catecholamine levels.

Answer 18

3 With loss of the distal half of the ureter and the inflammatory process of the ulcerative colitis, a primary anastomosis with a psoas hitch would not be possible. Because of his bowel disease, creating an ileal ureter would not be ideal. A left auto transplantation is possible but not worth the post operative risks. A cutaneous ureterostomy would only be temporizing and require another open procedure. It would be best to perform a transureteroureterostomy. If the left ureter does not reach to the right, the right ureter can be mobilized, passed to the left and reimplanted into the bladder. A nephrectomy should be avoided as the initial management.

Answer 19

2 Hyperprolactinemia is a common result of hemodialysis. Physical signs of this condition include diminished libido, erectile dysfunction, infertility and gynecomastia. Treatment with cabergoline or bromocriptine reverses the osteoporosis and low testosterone improving libido and erectile dysfunction.

Answer 20

4 The umbilical artery is the first visceral branch of the internal iliac artery and is very commonly a large trunk that in its proximal unobliterated section gives rise to the superior vesical artery as its first branch. The obliterated umbilical artery is an important landmark in the pelvis as it sweeps lateral to the ureter at the pelvic brim. It can be used to mark the peritoneum in pelvic dissections and may be confused with the vas deferens in the male.

Answer 21

5 Urethral recurrence after neobladder is an uncommon but troublesome complication best treated with urethrectomy and some form of urinary diversion. The Studer neobladder affords a reasonable solution to this problem since the non-intussuscepted afferent limb may be detached from the neobladder and converted to a standard ileal loop. A transverse colon conduit would require ureteral reimplantation and continent cutaneous diversion while an operation would have a greater complication rate in an older, previously operated upon patient. Local therapy is inadequate.

Answer 22

4 The rate of clinical understaging in high-risk nonmuscle invasive bladder cancer is as high as 40% among those tumors with involvement of the lamina propria (clinical stage T1). Therefore, to reduce this staging error, the presence of uninvolved muscularis propria should be identified. While the presence of lymphovascular invasion, carcinoma in-situ and high grade tumors are all factors that place the patient at high risk for progression in stage, of the options listed only the absence of muscularis propria would necessitate an automatic restaging by repeat TUR. While muscularis mucosa has been suggested by some to be associated with risk of understaging and progression among T1 tumors, it is not identified in up to one half of TUR specimens and therefore the failure to identify this layer does not justify an automatic repeat resection.

Answer 23

2 This is a typical clinical presentation of delayed hemorrhage from vascular pseudoaneurysm owing to arterial injury during PCNL. A similar injury can occur during partial nephrectomy. The reported incidence of serious arterial injuries in association with percutaneous renal surgery, including arteriovenous fistulas, pseudoaneurysms, and lacerations, ranges from 0.9% to 3%. The diagnosis is presumptive, and therefore therapeutic rather than diagnostic interventions are indicated. Most patients require superselective embolization of bleeding arteries under angiographic control, which is very effective at controlling hemorrhage and preserving renal function. The small number of patients whose bleeding is refractory to embolization may require surgical exploration.

Answer 24

2 Penetrance for all of the manifestations of VHL is incomplete. Pheochromocytoma is found only in certain families with the VHL syndrome, primarily those with a missense mutation of the VHL gene. All of the other manifestations of VHL are found in most families with the syndrome.

Answer 25

5 Reimplantation of the amputated phallus is usually successful even after two hours ischemia without ice. In fact, many organs may be damaged through frost injury if improperly stored in ice. The edges should be debrided and the corpora and urethra re-approximated without attempting reanastomosis of the cavernosal arteries. Microsurgical technique should be employed to re-anastomose the dorsal nerves, arteries and veins. Skin loss frequently occurs but it can be managed later with skin grafting.

Answer 26

2 The most likely diagnosis in this fetus is posterior urethral valves based upon male sex, bilateral hydronephrosis, and a thick walled bladder. The clinical outcome of a child with severe posterior urethral valves is most specifically predicted by the presence or absence of oligohydramnios and when the onset of oligohydramnios was noted to occur. Increased renal echogenicity alone is not predictive, although in the setting of oligohydramnios, it is a poor prognostic indicator. Bladder dilation is not a good prognostic indicator. Urinary electrolytes have been shown to be useful as an indicator of renal salvageability only in the setting of oligohydramnios and in early gestation (18 to 24 weeks). A perinephric urinoma does not predict a poor outcome.

Answer 27

3 Immediate reoperation for fistula closure is not indicated as most fistulae heal with parenteral nutrition. Immediate operative intervention is not indicated unless the patient has signs of peritonitis or an acute abdomen. Parenteral nutrition has significantly improved the prognosis of patients with enterocutaneous fistula and has not only increased the rate of spontaneous fistula closure but also improved nutritional status of patients needing repeated operations.

Answer 28

5 Among pregnant women with a calculus, one-half to two-thirds will pass their stone spontaneously. The average size of a passed calculus is 6 mm (2-11 mm). Among the remaining patients, over 80% will likely be in their third trimester; in this group, placement of an indwelling stent is the most generally accepted next step. The stent can be placed under ultrasonic or fluoroscopic control. If fluoroscopy is used, the fetus should be shielded; however at this time, chances of any adverse developmental effect of radiation to the fetus are low. It is recommended that the stent be changed every 4-8 weeks, although some urologists have reported stent indwell times for the duration of the last trimester with successful retrieval of the encrusted stent. The use of a percutaneous nephrostomy in the third trimester is less acceptable due to the discomfort to the patient, invariable bacterial colonization of the urine, and the frequent problems of encrustation and blockage of the nephrostomy tube necessitating emergency changing of the tube approximately once a month. In this patient, hydration and observation are not reasonable. Spontaneous passage is unlikely given the size of the stone. A surgical procedure also is not indicated, as the goal of therapy is to relieve the stone-induced obstruction. After the patient delivers her child, the stone can be treated with SWL, a less morbid treatment than a percutaneous or ureteroscopic procedure.

Answer 29

1 Myalgia (leg, back, buttock pain) occurs in about 10% of men using tadalafil, due to venous congestion of the large muscle of the body and there is no evidence that it is the result of rhabdomyolysis. Its severity is variable, however it is severe enough in some men that the medication needs to be switched to another PDE5 inhibitor. While, statins can cause rhabdomyolysis, in this patient, his long-standing use of the statin without myalgia and the chronological association between the pain and the commencement of the tadalafil suggest that the latter is to blame.

Answer 30

1 The prostate forms tremendous amounts of citric acid, almost 100 times higher than other soft tissues. The secretory epithelium of the prostate has a special metabolic ability to form citrate from aspartic acid and glucose. Its role in normal prostatic metabolism or reproduction is unknown. Similarly, the seminal vesicles have an increased capacity for fructose production. This production of fructose is the product of glucose metabolism by aldose reduction to sorbitol and a ketone reduction to form fructose.

Answer 31

2 Multi-drug resistant tuberculosis is a form of tuberculosis that is resistant to two or more primary drugs, including isoniazid, pyrazinamide, and rifampin. Multi-drug resistant tuberculosis infection results in increased morbidity, mortality and increased drug-treatment costs. Prevalence rates for multi-drug resistance rates (exceeding 5%) are high in the former Soviet Union, the Baltic States and Peru. Recommended second-line treatment for multi-drug resistant tuberculosis consists of at least 5 drugs including a fluoroquinolone (Ciprofloxacin) and an aminoglycoside (streptomycin, amikacin).

Answer 32

4 Permanent lower urinary tract dysfunction occurs in 15-20% of patients following radical pelvic surgery. The typical pattern is one of detrusor areflexia or hypocontractility in the presence of fixed residual striated sphincter tone. This fixed tone represents a functional obstruction that frequently results in decreased detrusor compliance. Although poor proximal sphincter function can also occur (intrinsic sphincter deficiency), this is often masked by prostate bulk in male patients.

Answer 33

2 Emission is defined as the deposition of seminal fluid into the posterior urethra by the vasa deferentia and the seminal vesicles. Ejaculation is the forceful expulsion of seminal fluid out the urethral meatus by contraction of the bulbospongiosus and ischiocavernosus muscles. Since the vasa and the seminal vesicles are innervated primarily by the sympathetic nervous system, emission is under control of the sympathetic nervous system. Alpha-adrenergic nerve stimulation causes not only contraction of the seminal vesicles and vasa deferentia but also closure of the bladder neck. Ejaculation is the result of somatic nerve stimulation of the periurethral striated musculature. The parasympathetic nervous system is not directly involved with either emission or ejaculation.

Answer 34

4 Skin grafts and placement of the testicles in the thigh are seldom required when half of the scrotal skin remains. Secondary closure for such a recent injury is unnecessary. The best choice for management is a tetanus immunization if he is not up to date, antibiotics, debridement, and primary closure with drainage. If grafting is required, a meshed split thickness graft is preferable because the meshing allows exudate to escape and gives improved cosmesis. Thigh pouches are rarely required as wet to dry dressings of the exposed gonads can be effective in critically ill patients until reconstruction is feasible.

Answer 35

4 The scenario is characteristic of a left multicystic kidney that is nearly always unilateral and is likely to involute. HTN can occur, but is rare. Autosomal dominant polycystic kidney disease is associated with aneurysms and recessive disease is associated with hepatic fibrosis.

Answer 36

3 Approximately 50% of patients with multi-organ metastases from renal cell carcinoma exhibit evidence of skeletal involvement. It has been estimated that between 15% and 30% of such skeletal lesions are solitary. Eighty percent of skeletal metastases occur in the axial skeleton, thoracic/lumbar spine, and pelvis. When long bones are involved, only the proximal portions are characteristic targets for metastatic disease. Surgical treatment of bony metastases is indicated for weight-bearing bones with lytic lesions greater than 3 cm. Internal stabilization or replacement of the destroyed periarticular segment often results in significant pain relief and tremendously improves the patient's quality of life.

Answer 37

1 Severe hemorrhagic cystitis, defined as requiring transfusion of more than six units of packed red blood cells to maintain hemodynamic stability and refractory to conservative measures, is life-threatening. Intravesical administration of silver nitrate or alum is unlikely to be effective following the failure of formalin. Hypogastric artery embolization has been utilized but complications including gluteal claudication and necrosis of the bladder have been reported. Mesna is only effective when administered at the time of cyclophosphamide therapy since it binds to the active metabolite. Bilateral percutaneous nephrostomy tubes divert urine away from the bladder and facilitate application of more aggressive intravesical therapy.

Answer 38

5 According to the AUA Guidelines for the management of clinically localized prostate cancer: 2007 Update, as a standard, patient preferences and functional status with special consideration given to functional outcomes including sexual, urinary, and bowel function should be considered in decision making. Radical prostatectomy, external beam radiation, interstitial radiation, and surveillance are appropriate treatment options with outcome data not providing clear-cut evidence for the superiority of any one treatment. There are trade-offs that must be considered when selecting a treatment for localized prostate cancer and each patient needs to determine based on their preferences which side effect profile is most acceptable to them when making a decision about treatment. The other options listed including prostate volume, PSA velocity, and AUA Symptom Score, may influence treatment decisions but are secondary to patient preference. Bone scan is not indicated in this patient.

Answer 39

1 Although endopyelotomy (antegrade or retrograde) is generally a good choice for salvage of a failed pyeloplasty, incision through an obliterated or intrarenal pelvis may risk significant renal hemorrhage due to incision into renal parenchyma or hilar vessels. Furthermore, repeat open or laparoscopic pyeloplasty will likely be unsuccessful in the face of an intrarenal pelvis. In this case, ureterocalicostomy is the best choice for re-establishing adequate renal drainage.

Answer 40

1 PVR measurement has significant intra-individual variability and does not correlate well with other signs or symptoms of lower urinary tract dysfunction. The VA Cooperative Study Group demonstrated that PVR does not predict the outcome of surgery and the majority of men with large residual urine volume did not require surgery during the three year duration of the trial. Men with significant PVRs should be monitored more closely if they elect no therapy. Medical therapy for BPH is indicated in men who have bothersome symptoms that negatively affect quality of life.

Answer 41

4 In the United States, transmission of HIV by blood transfusion occurs almost exclusively when a recently infected blood donor is infectious but before antibodies to HIV become detectable during the window period. Based on the latest information estimating the risk of HIV transmission, it was estimated that there was a risk of 1 case of HIV transmission for every 2 million donations of screened blood. Surgeons should be aware of this statistic as their patients do ask this important question.

Answer 42

3 Asymptomatic bacteriuria is common in spinal cord injury patients, especially those managed with CIC, and generally does not need to be treated. Symptomatic infections should be treated, but these patients usually do not report the same irritative symptoms as spinal cord intact patients. Symptoms that merit treatment include flank or abdominal discomfort, increased leakage between catheterizations, increased spasticity, and malaise or lethargy. Malodorous urine may be bothersome to the patient but is not an indication for treatment as is increased urinary leakage between catheterizations. The latter indicates a functional impact of the infection while the former is just a social problem. Most patients on CIC will have greater than 10-5^K CFU/ml on urinary culture if there is any bacteriuria. Although increasing bladder distention, as might be expected to occur with a decrease in the frequency of catheterization, is a risk factor for UTI in spinal cord injury patients it does not make treatment more or less necessary.

Answer 43

3 Since turning off the device had no impact on pain, reprogramming it is unlikely to be of any benefit. The device may not need to be completely explanted at this point. A local exploration may obviate a seroma, or perhaps improper location. Relocation would be recommended only if local exploration revealed no abnormalities, and the location was felt to be causative.

Answer 44

2 The principal effect of estrogens is the suppression of LH released from the pituitary, but they also increase the synthesis of sex hormone binding globulin in the liver, thereby, decreasing the amount of bioavailable testosterone. The effect at the level of the anterior pituitary is one of interference with the normal negative feedback mechanism.

Answer 45

4 During pheochromocytoma surgery catecholamines may be released into the circulation making the blood pressure difficult to control. Early ligation of the primary venous drainage, the left adrenal vein, may prevent the release of these vasoactive substances and allow the anesthetic management of the procedure to be simplified.

Answer 46

2 A testis biopsy is not required to establish the diagnosis of spermatogenic dysfunction, as the likelihood of non-obstructive azoospermia in a man with testis longitudinal axis less than 4.6 cm and FSH greater than 7.6 IU/l is 89%. In a recent multicenter trial, over 60% of men with non-obstructive azoospermia demonstrated sperm in their semen analyses after clomiphene citrate administered with mean duration five months. The clomiphene dose should be titrated to increase the serum testosterone levels to 600-800 ng/dl. A third semen analysis is unlikely to aid in the diagnosis, and with LH and FSH levels in the normal range, exogenous hCG and recombinant FSH are unhelpful. Microsurgical reconstruction will not result in ejaculated sperm because non-obstructive azoospermia is caused by impaired spermatogenesis.

Answer 47

2 Orthostatic hypotension is not a contraindication for alpha-blockers providing the blood pressure change is not associated with postural symptoms. The effectiveness of alpha-blockers is independent of prostate size. All surgical interventions may cause retrograde ejaculation. Finasteride will decrease semen volume.

Answer 48

2 The use of fluoroscopic imaging in urological surgery requires a basic knowledge of radiation protection principles so that the dose to the patient, physician, and ancillary staff can be minimized. It is important to remember that with an increase in patient size the dose rate will be greater and accumulate faster. In terms of manipulating the operational factors in fluoroscopy, there is generally a trade off in terms of image quality and radiation dose. Increasing the tube current results in greater image quality and increased dose to the patient and staff. Increasing the tube kilovoltage diminishes image quality (less contrast) but is usually associated with less radiation dose if the tube current is appropriately reduced. Decreasing the image intensifier to skin distance usually increases image quality depending on focal spot size and decreases the dose to the patient without significantly changing the dose to staff. Removing the grid decreases image quality as well as the radiation dose to patient and staff. Increasing the source to skin distance usually improves image quality and decreases the dose to the patient without significantly changing the dose to staff.

Answer 49

3 Approximately 10-20% of patients who have bilateral adrenalectomy for Cushing's syndrome later develop pituitary tumors, almost always chromophobe adenomas (Nelson's syndrome). Progressive hyperpigmentation, headache, and visual disturbances are due to the expanding adenoma that is best seen by cranial MRI. The hyperpigmentation is due to high serum levels of melanocyte stimulating hormone.

Answer 50

3 The administration of a single perioperative dose of intravesical chemotherapy after complete TURBT for Ta-T1 TCC of the bladder significantly reduces the rate of tumor recurrence. This has also been summarized in a large meta-analysis in which patients receiving perioperative chemotherapy had a recurrence rate of 36.7% compared to 48.4% with TUR alone. In all studies where benefit was noted the instillation was given within 24 hours, generally either immediately or within six hours following the TURBT. Several randomized trials have demonstrated significant reductions in recurrence when the intravesical chemotherapy was administered within 24 hours as compared to starting it seven days later. Thus, there is evidence that the instillation should be given on the same day as the TURBT and not later.

Answer 51

2 Although CIC is the treatment of choice for neurogenic bladder patients, in this situation it would be a poor choice. Not only would she potentially be unreliable but there is good possibility that she would physically be unable to catheterize. Therefore, CIC would be contraindicated and augmentation ill-advised. Ureterosigmoidostomy is not an acceptable diversion in the myelodysplastic patient because of the unreliable anal sphincter mechanism. Vesicostomy is usually not an acceptable diversion for the older patient because of the pubic hair and problems with the stoma appliance fit. The colon conduit would be well suited in this clinical situation.

Answer 52

4 This patient has intermediate-risk clinically localized prostate cancer. According to the AUA Guidelines for the management of clinically localized prostate cancer, as a standard, an assessment of the patient's life expectancy, overall health status, and tumor characteristics should be performed prior to making any treatment decisions. Life expectancy, not patient age, is a major factor to consider in treatment selection. When life expectancy is long, localized prostate cancer can be a cause of morbidity and mortality. On the other hand, when life expectancy is relatively short, competing causes for mortality reduce the chance that a man will experience disease progression or die from prostate cancer. Imaging studies including CT scan, bone scan, and Prostascint scans are generally not indicated in the pretreatment evaluation of patients with clinically localized disease. This is especially true in patients with low and intermediate risk disease because the yield is so low to preclude their usefulness. Urodynamics are not indicated.

Answer 53

3 Stress incontinence is the most common type of incontinence after radical prostatectomy. Options include artificial urinary sphincter, sling and periurethral bulking agents. Placement of a sling in this individual (resulting in a fixed urethral resistance) carries a risk of urinary retention due to the Valsalva voiding pattern and the use of cadaveric tissue for male sling does not appear to be as efficacious in the long term as synthetic materials. Periurethral bulking agents are unlikely to provide long term relief of stress urinary incontinence in males. A suprapubic tube will not address the sphincteric incontinence. Sacral neuromodulation is unlikely to have any effect on the sphincteric incontinence.

Answer 54

5 This patient's clinical presentation is typical of pelvic lipomatosis and does not require tissue diagnosis. Treatment of the mass with radiotherapy or excision has not generally been successful. While there have been occasional reports of successful treatment with chronic antibacterial suppression, this in general has not been a successful approach. Steroid therapy has no role in pelvic lipomatosis. Supravesical diversion may be indicated as the ultimate treatment of choice in this man but the immediate therapy of his renal insufficiency can be accomplished by temporary nephrostomy drainage.

Answer 55

2 The use of sildenafil 25 mg has no impact on the type of alpha-blocker used, its dose or the timing in relationship to sildenafil use. Sildenafil doses greater than 25 mg (50 mg or 100 mg), require separation from any alpha-blocker by a period of 4 hours. Tadalafil may be used at any dose with tamsulosin 0.4 mg. The concerns about hypotension induced by concomitant use of sildenafil and alpha-blockers also pertains to vardenafil.

Answer 56

1 Most patients with prolactin-secreting pituitary adenomas respond well to medical therapy consisting of either bromocriptine or cabergoline, which blocks release of prolactin from the pituitary gland and often causes regression of the tumor. Cabergoline is more frequently used now than bromocriptine because of the lower side effect profile and less frequent dosing schedule. Surgery is reserved for patients who are unable to tolerate medical therapy.

Answer 57

3 The cervical mucus is a major barrier to sperm that are poorly motile in the oligospermic man. From a naive viewpoint it would seem that bypassing this biological barrier by intrauterine insemination would be highly successful form of therapy for the subfertile man. Motility and transport though the cervical mucus represent only a small portion of the many complex functions of which sperm must be capable for fertilization and early embryonic development to occur. Therefore, it is not surprising that intrauterine insemination is not effective universally in couples with male factor infertility. The placement of sperm directly into the uterine cavity, carefully timed to ovulation, will not compensate for acrosomal defects and abnormalities of sperm-egg interaction, which are common in men with oligospermia. Nevertheless, sperm processing and intrauterine insemination can have an appropriate role in the management of carefully selected subfertile couples. It is an ideal form of therapy for cervical factor infertility and for men with retrograde ejaculation and significant semen volume abnormalities. Men with significant levels of antisperm antibodies and fewer than 2 million motile sperm after washing are not likely to achieve conception with intrauterine insemination.

Answer 58

3 This patient has hyperkalemia and metabolic acidosis due to obstructive uropathy. In obstructive uropathy, a syndrome of distal renal tubular acidosis can occur due to decreased excretion of potassium and hydrogen. This leads to hyperkalemia, impaired urinary acidification, and metabolic acidosis. The term Type IV renal tubular acidosis is often applied to this disorder. Diuretic abuse and persistent vomiting would produce a metabolic alkalosis. Types I and II renal tubular acidosis are both associated with hypokalemia.

Answer 59

3 In the patient with an initial presentation of a solitary, low grade noninvasive TCC, the only adjuvant therapy to be considered is an immediate postoperative instillation of intravesical chemotherapy. In the metaanalysis reported in the 2007 update of the AUA guideline for the management of nonmuscle invasive bladder cancer, a single perioperative dose of mitomycin C resulted in a 17% reduction (95% CI: 8,28) in recurrences compared to TURBT alone. The panel found no evidence that multiple adjuvant instillations of either BCG or chemotherapy have additional benefit in patients at initial diagnosis of Ta grade 1 bladder cancer.

Answer 60

4 The mechanistic defect in type 1, or distal renal tubular acidosis is the inability of the distal nephron to maintain a proton gradient between tubular fluid and serum. Hallmarks of distal renal tubular acidosis are a hypokalemic, hyperchloremic non-anion gap metabolic acidosis with a urinary pH consistently above 6. Up to 70% of adults with distal renal tubular acidosis have kidney stones, with the most frequent composition calcium phosphate, although oxalate and struvite stones are also observed. Approximately 80% of patients are women. Stone formation results from hypercalciuria, hypocitraturia and high urinary pH.

Answer 61

4 Isolated nocturnal incontinence is sometimes noted in patients who have undergone radical cystectomy and orthotopic neobladder. This is thought to be related to loss of afferent input from the detrusor to the central nervous system. Normally the afferent input causes a reflex rise in urethral pressure during reservoir filling. This reflex is maintained following radical prostatectomy, which explains why isolated nocturnal incontinence is uncommon after this procedure. If there was damage to the rhabdosphincter, the patient would experience incontinence during the day and night, as opposed to isolated nocturnal incontinence. This would also be the case if the neobladder had poor compliance or had contractions. While some authors have suggested that damage to the pelvic and hypogastric plexus contributes to incontinence after cystectomy, this also would not cause isolated nighttime incontinence.

Answer 62

1 Recent studies on the outcome after radial nephrectomy for localized RCC have demonstrated that the risk of recurrence is stage dependent with the risk approximately 7%, 25%, and 40% for T1, T2, and T3 N0 M0 patients respectively. The risk of recurrence is also greatest during the first three years. Based on this data, evidence based recommendations for follow up have been published and surveillance should be tailored according to pathologic stage. For patients with stage 1 disease, routine follow up imaging is not necessary given the low risk of recurrence. In addition to yearly history, physical examination, and laboratory studies, a yearly CXR and a CT scan every two years is recommended for patients with Stage 2 disease. For patients with stage III disease, a history, exam, and CXR is recommended every six months for three years then yearly. In addition, a CT scan is recommended at year one and then every two years.

Answer 63

3 The response of renovascular HTN to surgery or angiographic intervention depends upon the type of lesion and its location. Renin is a mediating substance for renovascular HTN and a search for its origin in helpful. Significantly elevated renin from one renal vein and not the other leads to localization of a candidate for intervention. Further evaluation by imaging and provocative studies involving ACE inhibitors may also confirm the diagnosis and help decide whether surgical treatment is necessary.

Answer 64

3 Mutations in the cystic fibrosis transmembrane conductance regulator gene are responsible for a phenotypic spectrum from overt cystic fibrosis to congenital bilateral absence of the vas deferens. Over 1000 CFTR mutations have been identified and only a portion are detected by routine testing. The man should be assumed to be a CFTR carrier, and his wife needs to be tested to determine the risk of cystic fibrosis in their offspring.

Answer 65

3 Luteinizing hormone and human chorionic gonadotropin have extensive structural homology. Both share a common alpha-subunit and the beta-subunits are 80% homologous. A number of commercially available radio immunoassay kits for beta-hCG will cross react with elevated levels of LH. Elevated LH concentrations may result after orchiectomy if there is inadequate testosterone production from the contralateral testis, thereby producing a spuriously positive elevation of the hCG. This becomes clinically relevant in determining whether individuals with elevated serum beta-hCG require chemotherapy following inguinal orchiectomy for testis cancer. If low testosterone, and secondarily increased LH, is suspected, then administration of exogenous testosterone may normalize the beta-hCG level.

Answer 66

4 Two qualities of radiocontrast agents have been evoked to explain their renal toxicity. First, contrast agents are powerful renal vasoconstrictors and may cause a severe reduction in renal blood flow. Second, in vitro studies have demonstrated that these agents are toxic to renal tubular cells. This toxicity is enhanced by the hypoxia that results from diminished renal blood flow.

Answer 67

3 This patient has an abdominal relapse after observation. Correct management is 3 cycles of BEP (bleomycin, etoposide, cisplatin) for disseminated germ cell tumor in good risk patients. Biopsy of the mass could miss elements of residual cancer and should not be performed. Although the original tumor showed elements of seminoma, radiation would not be the preferred treatment for masses \> 3 cm. Retroperitoneal lymphadenectomy is usually not performed prior to chemotherapy for masses \> 3 cm on CT scan, avoiding double therapy in these patients.

Answer 68

5 The ureter buds from the mesonephric (Wolffian) duct and is absorbed into the bladder base. Incomplete absorption of the upper segment of a duplication may lead to ectopia in those structures of mesonephric origin (seminal vesicle or vas) or into those structures of urogenital sinus origin (bladder, prostatic urethra). Ectopia distal to the verumontanum would not be expected. The development of the distal urethra relates to the development of the penis, not of the urogenital sinus.

Answer 69

1 A small wound dehiscence is likely to heal over time. Since the patient is asymptomatic, immediate surgical intervention is not necessary. Monofilament slings with large pore sizes permit in-growth of fibroblasts and intercalation of macrophages that promote healing. Topical estrogen cream may be beneficial in this postmenopausal female in improving tissue quality and healing. Explantation of the sling is not indicated at this juncture. Timing of primary wound closure is controversial, but drains are not recommended.

Answer 70

3 Three percent of girls with inguinal hernias have testicular feminization. A testicle is found in the hernia sac and a chromosome analysis will reveal a 46XY karyotype. They should be raised as females and will require a gonadectomy. XO/XY chromosomal patterns are accompanied by a streak gonad most commonly. Elevated 17-hydroxyprogesterone is seen with CAH. Low testosterone with elevated LH and FSH occurs with abnormal testosterone production.

Answer 71

2 Parasympathetic postganglionic neurons in the human are located in the detrusor muscle wall as well as in the pelvic plexus. Patients who have cauda equina or pelvic plexus injuries are neurologically decentralized but may not be completely denervated because of this anatomic arrangement.

Answer 72

3 HIV mainly attacks cells with the CD4 protein on it. In the human, this is the T helper cell. HIV may then infect other cells but it infects the T helper cells first and replicates within it.

Answer 73

5 Improved erections with sildenafil treatment were noted in 70% of men with organic erectile dysfunction and in over 80% of men with psychogenic erectile dysfunction. When the response is stratified by specific disease states, the best response rates are noted in the spinal cord injury group (83%). The response rates for the other groups range from 50-70%

Answer 74

3 Recently, a nonapeptide, termed the anti-proliferative factor, was found to be the best discriminator of all the markers tested to discriminate between interstitial cystitis and normal controls. Future strategies at diagnosing and treating interstitial cystitis may revolve around this unique molecule.

Answer 75

2 The venous return from the penis is from the cavernous veins and the deep and superficial dorsal veins. The deep dorsal vein drains the glans penis as well as a major portion of the cavernous spaces of the corpus cavernosum. The vein lies beneath Buck's fascia and proceeds between the suspensory ligament of the penis to enter the urogenital diaphragm between the arcuate and transversus pubic ligament. It empties into the preprostatic plexis.

Answer 76

2 Medical therapy to prevent stone recurrence is indicated in patients with recurrent urolithiasis and first episode urolithiasis associated with a high risk of recurrence, e.g., family history, gout, chronic UTI's, nephrocalcinosis and bone/GI disease. High oral fluid intake with restriction of protein and sodium are the cornerstones of therapy. Dietary calcium restriction is inappropriate and may cause osteoporosis. Increased dietary citrus fruits, and natural fiber cereals are recommended.

Answer 77

1 A mass with Hounsfield units between negative 30 and negative 140 is characteristic of an adrenal myelolipoma. These tumors are benign and are composed of lipid and myeloid tissue. No additional therapy or evaluation is required. As the tumor is benign and it carries no increased risk of spontaneous hemorrhage, no additional radiologic or clinical follow-up is required.

Answer 78

1 Glomerular changes are the last to occur with hydronephrosis. With long term obstruction, other more distal components of the kidney are destroyed first.

Answer 79

4 Recurrent infections and flank pain associated with a complete staghorn calculus in a young Jehovah's Witness patient requires extensive discussions of treatment options and potential outcomes. Chronic antibiotics will not eradicate the UTI. Complications include pyonephrosis, urosepsis, fistula and severe pain. SWL, although appearing benign, can result in steinstrasse, persistent hydronephrosis, pyonephrosis and may ultimately require multiple interventions. Acetohydroxamic acid is associated with numerous side effects and will not be a permanent solution. An anatrophic nephrolithotomy may result in substantial blood loss and may not render the patient stone free. Percutaneous nephrolithotomy can be performed safely. Patients need to be informed of the small risk of blood loss.

Answer 80

5 Nephrogenic adenomas of the bladder are found usually in men and are associated with a prior history of bladder injury or chronic urinary tract infection. It is not associated with viral infection. Nephrogenic adenomas are not associated with cystitis cystica and associated only infrequently with bladder malignancies.

Answer 81

4 Ureterointestinal stricture can occur early or late after urinary diversion. The first step in management is to rule out disease recurrence. Once it has been established that the stricture is not due to recurrent cancer, the most effective approach to management in this setting is open surgical repair. Although various minimally invasive approaches have been employed, including balloon dilatation, cold knife or laser incision and stent placement, open surgical repair has been consistently shown to be the most effective way of addressing this problem, particularly in the setting of a longer stricture and decreased renal function. Minimally invasive approaches may be effective for shorter strictures (1-2 cm or less). Regardless of length, these strictures are usually due to devascularization of the distal ureter and extreme angulation of the left ureter at the level of the inferior mesenteric artery.

Answer 82

3 This patient has urinary incontinence secondary to detrusor overactivity. Urodynamics suggest a component of impaired detrusor contractility as her detrusor contraction pressures are low and the PVR is high. The best initial treatment is prompted voiding with the goal of having the patient void prior to one of the involuntary contractions. Antimuscarinics should probably not be used in this situation without CIC since it will likely increase the PVR. When possible, CIC should be avoided in these settings because it adds to the workload of the caregivers. An indwelling catheter is also to be avoided because of long term risks of infection, stone, urethral erosion, etc. Sacral neuromodulation is technically an option for the treatment of this problem after other conservative therapies have failed.

Answer 83

4 The distal prostatic ducts are lined by transitional epithelium as in the prostatic urethra. Primary TCC of the prostate accounts for 1.5%-4% of all male urethral cancers.

Answer 84

2 The most likely etiology of her new symptomatic UTI’s is a change in the bacterial strain resident in her bladder. This is often due to misdirected efforts to eradicate her asymptomatic bacteruria with antibiotics thus leading to a more virulent bacteria strain. The risk for development of pyelonephritis in a girl over four years of age with untreated asymptomatic bacteruria is small and seems to be associated with a change in bacterial strain.

Answer 85

2 The approach to elderly patients with incontinence should be stepped. Transient causes of incontinence should be addressed first. In this case, it would be most appropriate to eliminate constipation. PSA is unnecessary with a normal rectal exam. Absence of the anal reflex is less significant in elderly patients and invasive testing is not necessary if the symptoms resolve with conservative therapy. Muscarinics may make his symptoms worse and could increase the risk of falling.

Answer 86

5 Early after continent urinary diversion, many patients misinterpret distension of the pouch due to urine and mucus as diffuse abdominal pain. This patient's KUB, normal WBC, normal bowel sounds, and lack of fever do not suggest obstruction or leakage from the bowel reanastomosis or the urinary pouch. The first and simplest measure is to catheterize and drain the pouch to determine if the symptoms are relieved. Only if the pain persists are some or all of the other measures necessary to exclude other postoperative complications.

Answer 87

1 A basic understanding of ultrasound physics is important for optimal diagnostic imaging using this modality. Ultrasonography uses high-frequency sound waves to image anatomic structures. The sound waves as a result of their interaction with tissue are either reflected, refracted, or absorbed. Air reflects sound waves completely; bone absorbs them completely. In diagnostic imaging of the GU system, frequencies between 1 and 10 MHz are typically used. Sound waves have a wave-length between these frequencies of 1.5 to .15 mm which sets a fundamental limit on the potential spatial resolution of the image. Many current ultrasound probes have variable frequency transducers allowing the operator to adjust the frequency in order to optimize imaging characteristics. Increasing the frequency (MHz) increases spatial resolution. However, as the frequency is increased, the depth of penetration decreases as a result of attenuation of ultrasound. Optimum imaging is thus obtained by choosing the highest frequency that will permit adequate penetration to identify the region of interest.

Answer 88

3 Transitional cell carcinoma of the bladder during pregnancy is uncommon. Hematuria during pregnancy may be mistaken for antepartum bleeding. Although hematuria is often due to infection, other causes must be considered. Bladder sonography may detect bladder tumors in pregnant women. Although ultrasound is a good screening technique, it is still not reliable and cystoscopy should be considered in all pregnant patients with documented gross hematuria or persistent microscopic hematuria. The cystoscopic findings in this patient are that of a typical papillary low grade tumor. The endoscopic tumor resection should be performed after delivery. Immediate resection under anesthesia might induce uterine contractions. Bladder tumors in this age group almost always are low grade and noninvasive, and as such do not require immediate removal.

Answer 89

5 Deletions of the short arm of chromosome 3 are characteristic of clear cell (conventional type) renal cell carcinomas, which are seen in sporadic cases of renal cell carcinoma and those associated with von Hippel-Lindau disease. The short arm of chromosome 3 is the location of the VHL gene. Type 1 papillary renal cancers are associated with mutations of the c-met proto-oncogene located on chromosome 7. Type II papillary renal cancers are associated with mutations of the fumarate hydratase gene located on chromosome 1. Oncocytoma can be seen in mutations of the BHD1 gene located on the short arm of chromosome 17.

Answer 90

3 The exotoxins produced by some bacteria can initiate septic shock, but in most cases the bacteria cell wall components are primarily responsible for the development of septic shock. Bacterial cell wall components activate numerous humoral pathways and macrophages and other cells involved in the inflammatory process. The main initiator of gram-negative bacterial septic shock is endotoxin, an lipo-polysaccharide component of the bacterial outer membrane. Circulating endotoxin may be a predictor of poor clinical outcome, but the levels of endotoxin required to trigger septic shock vary greatly.

Answer 91

4 Enuresis is a common problem in five-year-old children. Diurnal enuresis is present in 7-8%, and nocturnal enuresis in 15%. Pharmacologic management may be considered, but the initial treatment should be timed voiding. This will improve the enuresis and decrease the risk for subsequent infection. If timed voiding is not effective, the patient may be treated with either imipramine or oxybutynin. Since nocturnal enuresis is common at that age and the spontaneous resolution rate is 10-15% per year, treatment with DDAVP® is typically reserved for children over seven years of age. Observation leaves the child wet and is not appropriate.

Answer 92

5 Forniceal extravasation is usually associated with a small distal ureteral calculus. These patients should be treated no differently than others with ureteral stones. Intervention should be undertaken when there is an associated fever, nausea/vomiting, or unrelenting pain. Otherwise, conservative observation is appropriate. The AUA guidelines clearly state that a period of observation awaiting spontaneous passage is appropriate.

Answer 93

3 There is a 13% to 45% incidence of anomalies of the lumbosacral spine in imperforate anus, resulting in 7%-18% incidence of neurogenic bladder. This may first become evident after repair of the anal lesion. Children with imperforate anus should be carefully checked for a neurogenic bladder. The pudendal nerve is not involved in bladder function. The other responses are rare.

Answer 94

3 Although hyperuricosuria, low urine pH and low urine volume are all important contributors to uric acid stone formation, a persistently acid urine (pH \< 5.5) is the most important determining factor for uric acid stones. Although hyperuricemia is the hallmark of primary gout, not all patients with uric acid stones have either hyperuricemia or gout. Renal tubular acidosis is associated with high, rather than low, urine pH, hyperchloremia, and hypokalemia.

Answer 95

3 A screening ultrasound of the parents will confirm the diagnosis of a autosomal dominant polycystic disease which is an important cause of renal failure and accounts for 10% of the patients in the United States on chronic hemodialysis. The lesion is an autosomal dominant condition, therefore, 50% of the children of the affected adult will be similarly affected.

Answer 96

4 Intravesical BCG is established as the best agent for intravesical therapy for CIS. However, it is contraindicated in immunocompromised patients because of impaired efficacy and an increased risk of infectious complications. The next most effective agent is mitomycin C, which would be the best choice in this clinical circumstance. Valrubicin is only indicated for BCG refractory CIS.

Answer 97

5 Renal cortical scintigraphy is the most sensitive method of detecting renal scarring. Tc DTPA is commonly used for assessment of renal function but the majority is filtered at the glomerulus and cleared so rapidly that it is not suitable for this purpose. Tc glucoheptonate clears by both tubular secretion and glomerular filtration. About 6% of the dose is retained in the renal cortex by three to four hours after injection. Tc DMSA has much better renal concentration with 30% of activity concentrated in each kidney at six hours after injection. MAG-3 is another renal tubular agent but has much lower tubular secretion. MIBG is used for imaging of the adrenal glands.

Answer 98

3 Diuresis induces ureteral dilation that is the result of elongation and an increase in diameter of the ureter. If prolonged, some hypertrophy of ureteral muscle occurs. Stress relaxation is an intrinsic property of smooth muscle in vitro in response to acute stretch. Treatment of the prolonged diuresis may result in reversal of the ureteral dilation.

Answer 99

2 This patient has an enterovesical fistula due to Crohn's disease. In this disorder, the bladder is indented on the right lateral and/or anterior aspect and air can be seen in the bladder in 90% of cases on CT scan. Carcinoma of the sigmoid colon could cause this picture but the left wall of the bladder would be indented. Carcinoma of the bladder rarely causes enterovesical fistulae. Emphysematous cystitis is a generalized disease involving the entire bladder wall. Clinically significant diverticulitis is unlikely to occur at this patient's age.

Answer 100

3 In pregnancy, glomerular filtration rate increases about 50% as full term approaches. This increase in GFR leads to a decrease in the serum BUN and creatinine. Therefore, the normal values for BUN and creatinine are lower in pregnant women than they are in non-pregnant women.

Answer 101

1 Extended core biopsy schemes have been shown to be superior to traditional sextant biopsy in terms of cancer detection. The schemes generally expand from the traditional sextant template. In one of the largest studies to compare techniques, a total of 483 consecutive patients referred for an abnormal DRE and/or PSA 4.0 ng/ml or greater underwent transrectal ultrasound and systematic biopsy. Lateral biopsies of the peripheral zone at the base and mid gland were added to the routine sextant biopsy regimen for a total of 10 systematic biopsies of the peripheral zone. Detection rates of the various regions were assessed. Various biopsy schemes were then created and cancer detection rates were compared. Of the patients, 42% (202 of 483) had cancer on biopsy. Traditional sextant biopsies missed 20%, while a sextant regimen incorporating lateral peripheral zone biopsies of the mid gland and base along with the apex missed 11% of the cancers. The combination of sextant and lateral peripheral zone biopsies (10-biopsy scheme) detected 194 cancers (96%). The 8 missed cancers were detected by lesion directed (5) or transition zone (3) biopsies. Of the 5 systematic peripheral zone regions the mid lobar base resulted in the lowest and unique cancer detection rates for all stratifications. The unique cancer detection for the traditional sextant sites were as follows: 8.4% apex, 4.0% mid, 1.0% base. For the lateral biopsies, the unique detection rate was 4.5% for the lateral mid and 6.9% for the lateral base. The mid lobar base in essence samples the central zone of the prostate where the fewest cancers would be detected. Thus, eliminating the mid lobar base biopsies from the systematic 10-biopsy peripheral zone regimen resulting in an 8-biopsy peripheral zone regimen decreased detection from 96% to 95%. The 6 systematic biopsies of the peripheral zone are inadequate and a minimum of 8, including the apex, mid lobar mid gland, lateral mid gland and lateral base, should routinely be performed.

Answer 102

1 Patients with AIDS are at risk for various GU infections and initial treatment of this patient with antibiotics is appropriate. In this patient, the initial clinical response does suggest the possibility of an underlying infection at initial presentation, but could also reflect spontaneous resolution of peri-tumoral inflammation from hemorrhage within a tumor. Patients with AIDS may be at greater risk for testicular tumors and the presence of an intraparenchymal testicular mass merits inguinal orchiectomy. Scrotal exploration would likely be non-informative, and intraoperative biopsy is only warranted in cases of solitary testis or those cases in which the surgeon has a very low suspicion of tumor. Transscrotal biopsy or aspiration is not advisable if malignancy is suspected.

Answer 103

4 Breast tenderness and enlargement during hormonal therapy for prostate cancer is due to an altered ratio of serum estrogens and testosterone. Leuprolide inhibits pituitary LH release so there is no rise in serum estrogens. Ketoconazole inhibits androgen and estrogen synthesis. Bicalutamide inhibits both end organ and central androgen receptors so that both LH and androgen levels increase with loss of negative feedback inhibition.

Answer 104

3 Of the tumors listed, neuroblastoma is the only one that is frequently associated with spontaneous regression. Autopsy studies show a much higher rate of incidental neuroblastoma than is seen clinically. Because of the regression (or maturation to ganglioneuroma) some infants with neuroblastoma should not be treated. This is particularly true for those with Stage IV-S, characterized by multiple sites of metastases, including bone marrow, liver and/or skin lesions.

Answer 105

2 The patient is bothered by his symptoms and the very short intravaginal ejaculatory latency time suggests that the patient warrants treatment. The local anesthetic of choice is lidocaine/prilocaine. The absence of a regular partner likely renders sex therapy ineffective. The first line pharmacologic treatment of premature ejaculation is selective serotonin reuptake inhibitors (SSRI). Bupropion is not an SSRI. The use of SSRI is best commenced with daily use and it appears that fluoxetine, sertraline and paroxetine are of approximately similar efficacies. While there is not much literature on on-demand use of SSRI it is generally believed that the daily dosing is more effective.

Answer 106

1 The most frequent error in the diagnosis of fetal uropathy is in distinguishing UPJ obstruction from multicystic dysplastic kidney (MCDK). Since UPJ obstruction and MCDK are a spectrum, all patients with suspected MCDK need to have a confirmatory renal scan to document absence of function. The most sensitive scan is DMSA however a MAG-3 Lasix renogram will also confirm lack of function. Autosomal polycystic kidney disease is characterized by large kidneys greater than two standard deviations above the mean. Ectopic ureterocele is characterized by an upper pole dilated ureter and ureterocele in the bladder. Posterior urethral valves are characterized by a distended bladder and keyhole sign. Finally, on ultrasound a refluxing megaureter has a dilated ureter that is not present in UPJ obstruction.

Answer 107

2 Bacterial vaginosis results from an alteration of normal vaginal flora with a predominance of Lactobacillus species and high concentrations of anaerobic bacteria. Diagnosis can be confirmed with identification of clue cells, a homogenous vaginal discharge, a vaginal pH \> 4.5, and a malodorous fishy vaginal discharge. It is more prevalent in lesbians. Risk factors may include multiple sexual partners, a new sexual partner, use of an intrauterine device, and douching. Treating the patient is as effective as treating the patient and partner. Symptoms may recur in 1/3 of patients after treatment. Metronidazole is the treatment of choice.

Answer 108

1 The MRI scan shows a dilated uterus with no evidence of the vaginal canal consistent with vaginal agenesis. In patients with an imperforate hymen the vaginal canal would be dilated. Androgen insensitivity syndrome would show an absent uterus. The MRI scan does not show an ovarian mass or cyst. Anterior myelomeningocele would not effect menstruation and the spine is normal on this patient's MRI scan. Reconstruction can be complex in complete vaginal agenesis especially when the cervix is also absent.

Answer 109

3 In patients with inherited retinal disorders such as retinitis pigmentosa, sildenafil use is contraindicated. Sildenafil inhibits PDE-VI expression in the retina and exacerbates visual disturbances. Testosterone supplementation is only indicated in the presence of documented hypogonadism. Yohimbine is not a useful treatment. In the presence of documented arterial insufficiency, a penile prosthesis is the best treatment.

Answer 110

2 The most common cause of hypomagnesuria is inflammatory bowel disease associated with malabsorption. Most patients with hypomagnesuria also have hypocitraturia. This loss of inhibitory or complexing activity of magnesium and citrate is responsible for calcium oxalate crystallization in these patients. It has been suggested that magnesium citrate may be reasonable for the treatment of hypomagnesuric calcium nephrolithiasis. The other disorders listed result in recurrent calcium oxalate stones, but as a result of hypercalciuria rather than hypomagnesuria.

Answer 111

4 The immediate repair of a UPJ obstruction is advised in this child because the function in the right kidney is significantly decreased. Neither delay nor removal of this kidney is appropriate since the functional capacity may improve after relief of obstruction, particularly in this age group. Temporary nonintubated cutaneous diversion may provide an acceptable alternative in the very ill or septic infant (not the case here). Prolonged nephrostomy drainage is not recommended in young infants.

Answer 112

5 Absorptive hypercalciuria may be dietary independent, dietary dependent or secondary to a phosphate renal leak. While patients with dietary dependent hypercalciuria may respond to a restricted calcium diet, calcium restriction in patients with dietary independent hypercalciuria may increase urinary oxalate. General recommendations for dietary independent absorptive hypercalciuria include hydration, and restriction of dietary sodium and protein. Thiazides increase calcium resorption in the distal nephron, reducing urinary calcium, and potassium citrate prevents hypokalemia and hypocitraturia. Allopurinol is not indicated unless there is hyperuricosuria.

Answer 113

1 An unrecognized injury to the pancreas may result in a pancreatic fistula. These are usually accompanied by symptoms of pancreatitis with wound drainage of fluid with a high pH and amylase content. Radiologic studies will usually show fluid in the retroperitoneum. When drained adequately, the tract will usually heal spontaneously, but hyperalimentation may be required. Surgical exploration is not yet indicated. A medium chain triglyceride, low fat diet would be useful in the setting of chylous ascites which is characterized by milky fluid high in fat content.

Answer 114

1 Unfortunately, no prostate is the perfect sphere, ellipse, or prolate sphere, rendering calculations somewhat inaccurate. The most accurate means of volume measurement by ultrasound is planimetry, which allows for variation in shape. In this, the probe is mounted on a stepping device and the signal marched through the gland at defined intervals, usually 3-5 mm. At each interval, the surface area of the prostate image is obtained. Volume is calculated by multiplying the sum of the surface areas by the stepping interval. Because of its superior accuracy, this is the method of choice for brachytherapy treatment planning.

Answer 115

5 Approximately 70% of fistulas occurring after needle biopsy of the kidney close spontaneously within 18 months. In the absence of significant related symptoms in such a patient, expectant management is appropriate initially. The clinical manifestations of a renal arteriovenous fistula depend upon the size of the fistula. Congestive heart failure, cardiomegaly, and diastolic HTN are observed in 50% of symptomatic patients. Hematuria is present in about a third, tachycardia is occasionally found, and a palpable flank mass is very rarely encountered. About 75% of patients have an abdominal bruit.

Answer 116

4 Studies into molecular mechanisms of stone formation have identified gene mutations that can affect several organ systems culminating in hypercalciuria. Improved understanding of the molecular and genetic causes of stone disease may change the future of stone management. Idiopathic calcium oxalate nephrolithiasis is thought to be a polygenic disorder, one influenced by several genes. The other entities are monogenic, arising from an abnormality in a single gene.

Answer 117

4 Intravascular fluid absorption can occur with ureteroscopy and percutaneous nephroscopy. This may be massive during percutaneous nephrostolithotomy if a closed irrigation and drainage system is used. Normal saline is both isotonic and non-conductive whereas the other listed fluids do not share both of these properties. There is no advantage using a solution other than normal saline during these procedures unless intrarenal electrosurgery is being performed. Only in this situation is it necessary to change to using glycine or sorbitol as the irrigant.

Answer 118

2 The renal concentrating ability is not abolished in prerenal azotemia. Tubular function is also preserved, thus the urinary sodium concentration decreases. The intact tubular function in prerenal azotemia causes concentration of the urinary nitrogenous wastes. This leads to an elevated urine to plasma creatinine ratio, generally exceeding 40:1. Patients with acute renal failure would have increased fractional excretion of sodium and decreased urine osmolality. These patients frequently have an abnormal urinary sediment with renal tubular epithelial cells and tubular casts. If this patient had myoglobinuria, the dipstick would be positive although the urine would be negative for red cells. Low-dose dopamine is not appropriate in his hypovolemic state.

Answer 119

1 Kaposi's sarcoma is the 2nd most common malignancy of the penis after squamous cancer as a result of the prevalence of HIV infection. It also occurs in patients on immunosuppression for organ transplantation or other indications. In this setting, Kaposi's sarcoma often regresses with modification of the immunosuppressive regimen and this should be the initial approach. If the tumor fails to respond to these efforts, local excision or radiation should be considered. Partial penectomy is not indicated for this tumor type. 5- FU is typically utilized in squamous cell carcinoma of the penis.

Answer 120

2 In a study of 184 radical prostatectomies from previously untreated patients, Bostwick et al found intense cytoplasmic epithelial immunoreactivity for PSMA (prostate specific membrane antigen) in every prostate cancer. The most extensive and intense staining for PSMA was observed in high grade carcinoma (Gleason primary pattern 4 or 5) with immunoreactivity in virtually every cell. Studies have shown that individual cells in poorly differentiated carcinoma produce less PSA than cells in well differentiated and moderately differentiated carcinoma and also normal prostate epithelium.

Answer 121

4 Normal infantile voiding patterns often include frequent small volume, and incomplete voids. Using serial ultrasound, documenting the time and number of voids in neonates and carefully weighing their diapers has confirmed these findings. In the absence of other clinical findings, no specific evaluation should be undertaken. Renal and bladder ultrasound, although non-invasive, is not indicated. The remaining tests are invasive and not indicated in a normal infant.

Answer 122

4 The incidence of prostatic abscess has declined but is still seen in immunodeficient patients such as those with HIV. TRUS is now the imaging modality of choice for the evaluation of patients with suspected prostatic abscess. Antibiotic therapy alone will not be sufficient if an abscess is found. Suprapubic urinary diversion is appropriate in patients with acute bacterial prostatitis without an abscess. Transurethral unroofing is the treatment of choice in patients with an abscess confined to the prostate gland while open drainage is required for patients with more extensive lesions. Transrectal drainage can be used as an alternative when transurethral drainage fails.

Answer 123

4 Normal creatinine excretion at baseline is approximately 20 mg/kg/day. When collecting a 24-hour urine for evaluating stone disease, it is important to index the collection against creatinine, as an incomplete or overcollection would otherwise lead to a false interpretation. It is not possible to determine renal function from urine creatinine alone, since at baseline, the creatinine production and excretion is constant and independent of renal function. To determine glomerular filtration rate, serum and urine creatinine must both be determined.

Answer 124

3 Furosemide (Lasix) is a loop diuretic. Loop diuretics act mainly by inhibiting the Na+-K+-2Cl- cotransport system in the thick ascending limb of Henle's loop. This results in inhibiting sodium reabsorption and produces a solute diuresis.

Answer 125

3 Imipramine has both a strong direct inhibitory action on bladder smooth muscle and a stimulant effect on the bladder outlet. The net result is that it promotes urinary storage by preventing detrusor overactivity and increasing urethral resistance. Phenylpropanolamine, phenylephrine, and ephedrine are sympathomimetic agents. The net result of alpha-adrenergic stimulation is an increase in the resting urethral pressure. On a theoretic basis this should enhance continence due to sphincter abnormalities, but there is no effect on detrusor overactivity. Oxybutynin has antimuscarinic and smooth muscle relaxant effects and has no role in the treatment of stress incontinence. Terazosin would exacerbate this patient's stress incontinence. Bethanechol is a cholinomimetic and would be expected to increase or aggravate detrusor overactivity.

Answer 126

1 This small volume, high pressure bladder may be even worse than urodynamics show, as the bladder volume and pressures are lowered by venting from VUR. The upper tracts are at great risk. Vesicostomy provides immediate and complete relief from high pressures with less subsequent reconstructive trouble than cutaneous pyelostomy. Augmentation of the bladder would be premature at this stage as it increases the complexity of care and starts a clock related to the known and unknown complications of enteric substitution. Even if eventually necessary, augmentation cystoplasty could be safely delayed for several years. Antimuscarinics alone will not benefit this patient. Urethral dilation is of short-term benefit for most patients.

Answer 127

D: "intravaginal estrogen." is correct. The efficacy of estrogen for the prevention of UTI in post-menopausal women has been demonstrated in several studies. There appears to be a higher effectiveness rate in topically applied estrogen in the vagina with an improvement in lactobacillus concentrations, decreased vaginal pH and a decrease in UTI episodes from 5.9 to 0.5 episodes per year. Antimicrobial prophylaxis may be used at low dose if topical estrogen fails. Lactobacillus probiotics, while effective in an investigational setting, have not been subject to the scrutiny of controlled trials.

Answer 128

D: "Multiple System Atrophy (Shy-Drager)." was the correct answer. The cystogram demonstrates an open bladder neck at rest. The urodynamics tracing shows that there was no detrusor activity at the instant the image was obtained. An open bladder neck at rest in a male is highly suggestive of multiple system atrophy (MSA) in the absence of prior prostate surgery. Although other neurological diseases may result in an open bladder neck at rest, none of these are listed except MSA. Erectile dysfunction is often found in MSA, and this finding in concert with the open bladder neck at rest distinguishes this condition from Parkinson's disease which is often clinically similar in many other respects. Other symptoms of MSA may include other autonomic dysfunctions. Bladder neck dyssynergy would have a closed bladder neck with filling. Cervical spinal stenosis and MS would not typically have an open bladder neck at rest.

Answer 129

C: "cardiovascular disease." was the correct answer. The long term toxicity of bleomycin containing chemotherapy regimens includes pulmonary fibrosis however etoposide and platinum does not appear to be associated with this toxicity. There is no chronic increase in risk of systemic infection despite a short term risk of neutropenic sepsis during therapy. Several large scale epidemiologic studies have recently concluded that men treated with either radiation therapy or systemic platinum containing chemotherapy are at significantly increased risk of developing both fatal cardiovascular events as well as secondary malignancy after extended follow-up.

Answer 130

D: "pT1b cN3." was the correct answer. The 2010 AJCC staging for penile cancer made several significant changes. This patient has a pT1 tumor because of his subepithelial connective tissue involvement. Those patients with low grade tumors and without lymphovascular invasion are pT1a. This patient, however, has lymphovascular invasion and as a result is a pT1b. Patients with lymphovascular invasion are in fact at higher risk for metastatic disease. For the first time, nodal staging is divided into both clinical and pathologic staging schemes. With a palpable, fixed nodal mass, regardless of the size or unilateral/bilateral involvement, the clinical lymph node status is cN3.

Answer 131

E: "performing bilateral nerve-sparing surgery." was the correct answer. Factors that may increase leakage in patients with an orthotopic neobladder include: shortened functional urethral length, non-nerve sparing, decreased membranous urethral sensation, and increased time after diversion (as patients age.) Formulation of a funnel-shaped reservoir in fact increases kinking and increases the likelihood of failure of spontaneous voiding. Nerve-sparing may in fact aid in the functionality of the neobladder although exact mechanism is unknown. No data exists for a placement of urethral sling being helpful in maintaining continence and may promote hypercontinence.

Answer 132

A: "pyridoxine." was the correct answer. Pyridoxine reduces oxalate production in up to 50% of patients with mild hyperoxaluria. Pyridoxine, a component of Vitamin B6, is a co-factor for alanine:glyoxylate aminotransferase (AGT), which converts glyoxylate to glycine. In doing so, less glyoxylate is available as a substrate for LDH which leads to a decrease in endogenous oxalate production. The other agents will have no impact on urinary oxalate.

Answer 133

A: "timed voiding." is correct. Voiding dysfunction and incontinence are common in boys with history of PUV. Over 80% will struggle with incontinence at age five. Nocturnal bladder drainage is usually indicated in the presence of high urinary output which can occur in boys with a history of PUV secondary to a concentrating defect. In such patients, significant hydroureteronephrosis is expected, which this patient does not have. Since he is not retaining urine after voiding, urodynamic test will likely demonstrate a pattern of bladder overactivity. However, it is appropriate to try conservative measures such as timed voiding prior to proceeding with more invasive testing such as urodynamics. Oxybutynin must be used with caution since a possible underlying myogenic dysfunction could lead to outright urinary retention. Desmopressin will not affect bladder dysfunction, which is the primary etiology of incontinence in boys with PUV.

Answer 134

C: "timed voiding." was the correct answer. Spina bifida occulta is often identified on spine films. In a child with a normal physical examination the chance of a spinal cord abnormality is very small. These children should be treated the same as other children with urgency and daytime wetting. The initial management is timed voiding and maintenance of a voiding diary. Since it is very likely that this VUR will resolve with behavioral modification surgical management including endoscopic treatment is not indicated. Urodynamics would be reserved for those children that are refractory to medical management. MRI scan of the spine is not indicated.

Answer 135

E: "colon." was the correct answer. It is important to know the electrolyte content of the fluid from the various bowel segments in order to replace abnormal fluid losses from these segments. Serum electrolyte complications and the type of electrolyte abnormalities that occur are different, depending on the segment of bowel used. If stomach is employed, a hypochloremic metabolic alkalosis may occur. If jejunum is the segment used, hyponatremia, hyperkalemia, and metabolic acidosis occur. If the ileum or colon is used, a hyperchloremic metabolic acidosis ensues. 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. The use of ureterosigmoidostomies has decreased significantly. It has been shown that ileal segments exposed to high concentrations of potassium in the urine reabsorb some of the potassium, whereas colon is less likely to do so. Thus, those with ileum interposed in the urinary tract likely blunt the potassium loss by the kidney, whereas those with colon do not, thus explaining why patients with ureterosigmoidostomies and ureterocolonic diversions are more likely to have total-body potassium depletion.

Answer 136

B: "pressure flow urodynamics." was the correct answer. Voiding dysfunction in men with Parkinson's disease can be a result of a multitude of factors, including outlet obstruction related to the prostate, detrusor-striated sphincter pseudodyssynergia, and rarely true dyssynergia. While detrusor overactivity is the most common urodynamic finding in this population, poor detrusor contractility or areflexia may also be seen. Although chronic suppressive antibiotics, tamsulosin, and CIC are not unreasonable options, urodynamics studies should be performed prior to proceeding with any therapy, no matter how simple, to ensure that the proper course is being taken.

Answer 137

B: "spinal MRI scan." is correct. Spinal cord abnormalities, including tethered cord or thickened or fatty filum terminale and lipoma have been noted in 20-50% of patients with imperforate anus. The severity of the lesion is proportional to the severity of the rectal lesion. In this case, the patient has a high-imperforate anus. VCUG reveals trabeculation, VUR into one kidney, and incomplete bladder emptying - a collection of findings for possible neurogenic bladder dysfunction. The best test is an MRI scan to rule-out spinal cord lesions since the kidneys are presently normal and the bladder has some subtle findings. Due to ossification of the spine a spinal ultrasound cannot rule-out a tethered spinal cord after three months of life. Vesicostomy, CIC, and antimuscarinic and alpha-blocker medications are premature at this point without formal diagnosis of neurogenic bladder and urodynamic study.

Answer 138

C: "thickness of hematoma." was the correct answer. After renal trauma, the likelihood of renal exploration, renorraphy, and nephrectomy is associated with the grade of injury. For example, Grade 4 injuries have a 64 fold higher likelihood of needing nephrectomy than a Grade 1 injury. New literature shows that for grade 3 and 4 injuries, medial hematoma, hematoma > 3.5 cm in thickness and the presence of a vascular contrast blush are associated with increased risk of bleeding and need for intervention. The presence of such findings should alert the urologist to the potential need for angiography and selective embolization of segmental vascular injuries. While urinary extravasation and devitalized fragments increase the risk of urinoma formation, they are not associated with higher rates of bleeding. Neither location of laceration or mechanism of injury predict complications independent of grade.

Answer 139

C: "Y chromosome deletion subtype." was the correct answer. In men with azoospermia, 7% will be associated with Y chromosome microdeletions. Classically, these patients will be found to have azoospermia or severe oligospermia with an elevation in FSH. The microdeletions occur in the long arm of the Y chromosome and are designated as AZFa (proximal), AZFb middle, and AZFc distal. The most common deletion is AZFc. About 75% of men with AZFc deletions have sperm on testicular biopsy. Sperm retrieval from men with complete AZFa or AZFb deletions have not been successful. The success of testicular sperm retrieval has not been correlated with FSH or testosterone level. Seminal volume does not reflect spermatogenic potential and has no relationship to the success of sperm retrieval. The absence of the vas deferens may be associated with obstructive azoospermia but these patients should have a normal FSH whereas this patient has an elevated FSH indicating non-obstructive azoospermia.

Answer 140

C: "oral calcium and potassium citrate." was the correct answer. Osteomalacia occurs when mineralized bone is reduced and the osteoid component becomes excessive. Osteomalacia has been reported in patients with all forms of urinary diversion but is most common in colonic continent diversion and especially in postmenopausal women. The metabolic acidosis is buffered by the bone with release of bone calcium. Correction of acidosis and calcium supplementation will result in symptomatic relief and restoration of bone density. Major alterations in serum bicarbonate are not usually present and calcium is usually low normal. Patients who develop osteomalacia generally complain of lethargy; joint pain, especially in the weight-bearing joints; and proximal myopathy. The alkaline phosphatase level is elevated. Although bisphosphonates will decrease bone resorption they do not address the root cause of the problem. Vitamin B12 deficiency is not seen in colonic urinary diversion.

Answer 141

E: "diabetes mellitus." was the correct answer. The decrease in vibratory sensation of the hands and feet, a delayed first sensation at 400 ml on a CMG, and increased residual urine all favor the diagnosis of diabetic cystopathy. Urinary frequency and nocturia may also be due to an osmotic diuresis. The absent bulbocavernosus reflex is unusual but can occur in normal men. Good sphincter tone and voluntary sphincter contraction would suggest there is no abnormality in the sacral reflex. The findings presented are more consistent with undiagnosed diabetes mellitus. These urodynamic findings are not typical for Parkinson's disease which is usually detrusor overactivity and impaired contractility. In contrast, Shy-Drager syndrome would have detrusor overactivity, open bladder neck, and denervation of the external sphincter. Herpes zoster tends to have cutaneous lesions and exhibit a dermatomal pattern, not a symmetrical neuropathy as described in this scenario.

Answer 142

E: "Lactated Ringer's." is correct. This patient has a post-op ileus in which there will be increased fluid losses of isotonic fluid into the bowel lumen. The presence of bilious output is indicative of the ileus and the associated loss of fluids and secretions (including pancreatic) into the bowel lumen. When a post-op ileus occurs, these insensible losses need to be replaced early on in the process to prevent dehydration and secondary vascular compromise. This is best accomplished with a fluid that is isotonic like Lactated Ringer's that also provides replacement with approriate levels of potassium, chloride, and bicarbonate. Saline with KCl supplementation would be more appropriate for replacement of gastric secretions.

Answer 143

C: "VCUG." was the correct answer. The absence of a perinephric fluid collection and late presentation of hydronephrosis accompanied by slowly declining renal function suggests the possibility of significant reflux into the transplant ureter. The most appropriate initial diagnostic study is a voiding cystourethrogram. Although a CT scan of the abdomen and pelvis can demonstrate the anatomy to a better degree than the ultrasound, the findings here with additional definition does not help with diagnosing the rise in creatinine. If a VCUG shows no reflux, a diuretic MAG-3 renal scan would be done to quantify any degree of obstruction at the ureterovesical junction where the anastomosis was performed. A retrograde ureterogram would be helpful but that is a diagnostic procedure that requires anesthesia and also the location of the ureteroneocystostomy is difficult to cannulate especially in the suspicion of ureteric complications such as stenosis. Renal allograft biopsy is not indicated as the first step in an ultrasound finding of significant hydronephrosis. The likelihood of long-term ureteric stenosis is 5-8%, whereas the likelihood of reflux exceeds 50% in the post-transplant population.

Answer 144

B: "potassium citrate." was the correct answer. The treatment of hyperchloremic metabolic acidosis involves administering alkalinizing agents or blockers of chloride transport. Alkalinization with oral sodium bicarbonate is effective in restoring normal acid-base balance if it is tolerated. Sodium citrate and citric acid solution (Bicitra or Shohl's solution) used together is an effective alternative; however, many patients do not care for the taste. Potassium citrate, sodium citrate, and citric acid solution (Polycitra) may be used instead if excessive sodium administration is a problem because of cardiac or renal disease and if potassium supplementation is desirable or at least not harmful. In those patients in whom persistent hyperchloremic metabolic acidosis occurs and in whom excessive sodium loads are undesirable, chlorpromazine or nicotinic acid may be used to limit the degree of the acidosis. These agents used alone do not correct the acidosis, but they limit its development and thus reduce the need for alkalinizing agents. Chlorpromazine and nicotinic acid inhibit cAMP and thereby impede chloride transport, helping to minimize bicarbonate loss.

Answer 145

E: "elevated antistreptolysin-O (ASO) and a decreased complement C3." was the correct answer. This child presents with classic post streptococcal acute glomerulonephritis. The latency period for a beta-hemolytic streptococcal pyoderma is 21 to 30 days. Diagnosis is made by a positive anti-streptolysin-O or streptozyme titer and a decreased serum complement of C3 and C4 concentrations. Elevated anti-neutrophil cytoplasmic antibodies are found in the circulation of patients with necrotizing systemic vasculitis such as polyarteritis nodosa and Wegener's granulomatosis. Anti-glomerular basement membrane antibodies are seen in patients with Good Pasture's Syndrome. Mesangial deposits of IgA occur with IgA nephropathy. Symptoms of post infectious glomerulonephritis is sometimes confused with IgA nephropathy, however, the prodromal period between the two are different. Gross hematuria in-patients with IgA nephropathy occurs during the acute illness compared to the latency seen in post streptococcal glomerulonephritis, seven days for strep pharyngitis 30 days for strep pyoderma.

Answer 146

B: "divide the right colic artery." was the correct answer. Occasionally, surgeons will encounter difficulty approximating an orthotopic urinary diversion to the urethral stump in a patient with a particularly deep pelvis. When the pouch includes the right colon, the surgeon may obtain additional length on the mesentery by dividing the right colic artery. This artery, along with the ileocolic, middle colic, left colic, sigmoid artery and the three hemorrhoidal arteries make up the arc of Drummond and provide considerable leeway when mobilizing the colon. The right colic artery often arises off the superior mesenteric artery, but can sometimes be seen arising directly from the middle colic or ileocolic artery. Division of the right colic artery can be performed safely and will often result in greater length on the mesentery of a neobladder that includes the cecum or distal right colon. Division of the ileocolic artery will result in ischemia and/or necrosis of the neobladder and division of the middle colic artery will not result in any additional length on the mesentery and may also compromise the bowel anastomoses. Alternate diversions should not be considered until all possible options have been exhausted.

Answer 147

A: "increased oxalate and decreased citrate." is correct. After a Roux-en-Y gastric bypass, the primary abnormalities noted that predispose to stone formation include low urine volume, high urine oxalate, and low urine citrate. Urinary sodium and calcium decrease after surgery. Urine volumes are low for the first year following gastric bypass due to the small stomach capacity resulting in decreased oral intake. High urinary oxalate is reflective of the fat malabsorptive component of the surgery which results in saponification of calcium thereby leading to increased oxalate absorption from the gut.

Answer 148

B: "corpus spongiosum." was the correct answer. Rupture of the corpus spongiosum and anterior urethra will be manifest by a perineal "butterfly" hematoma, limited by Colles' fascia. The corpora cavernosa, tunica albuginea, and posterior urethra are unlikely to be involved in a straddle injury. Posterior urethral injuries occur above the pelvic diaphragm are usually associated with a pelvic fracture, and not as a consequence of a straddle injury.

Answer 149

A: "serum testosterone level." was the correct answer. Guidelines for hormone refractory prostate cancer (HRPC) have been established. Patients with evidence of disease progression should have their serum testosterone checked to ensure a castrate level as an initial step. If the testosterone level is not castrate on an LH-RH analogue, then surgical castration should be performed. Once the testosterone is established to be

Answer 150

D: "parasympathetic and pudendal." is correct. The clinical picture is consistent with cauda equina syndrome, which is associated with disc disease (severe central posterior disc protrusion) and other spinal canal pathologies that involve the L4-S2 region. Additional features of the presentation include loss of voluntary control of both anal and urethral sphincters and of sexual responsiveness. The most consistent urodynamic finding is that of a normally compliant areflexic bladder with either normal innervation or incomplete denervation of the perineal floor musculature. Disc protrusions of the lumbar spine interfere with the parasympathetic and somatic innervation of the lower urinary tract, striated sphincter and other pelvic floor musculature, and afferent activity from the bladder and affected somatic segments to the spinal cord.

Answer 151

A: "intracavernous vasoactive injections." was the correct answer. Percutaneous or surgical revascularization of the internal pudendal arteries is not indicated owing to the patient's age and associated atherosclerotic vascular disease secondary to smoking. There is no indication for venous ligation. Owing to the vascular disease, penile injections may not be successful but should be implemented prior to insertion of a penile prosthesis.

Answer 152

C: "ileovesicostomy." was the correct answer. This patient has dangerously elevated intravesical pressures and a continuously draining ileovesicostomy will permit low pressure bladder emptying. An indwelling catheter has the risk of UTI, stones, cancer and urethral erosion. The incompetent outlet of the ileovesicostomy acts as a "pop off" as the bladder fills and therefore the intravesical pressure will remain safe. Bladder neck fascial sling is not necessary as it is unlikely that this individual will have stress incontinence per urethra given her high abdominal LPP and her limited mobility. She is a quadriplegic and catheterization following augmentation cystoplasty through an abdominal stoma or her urethra increases her risks, dependence on a caretaker, and is not practical.

Answer 153

D: "chlorpromazine." was the correct answer. The treatment of hyperchloremic metabolic acidosis requires administration of alkalinizing agents or blockers of chloride transport. In patients in whom excessive sodium loads are undesirable, nicotinic acid or chlorpromazine may be administered to control the acidosis. Nicotinic acid and chlorpromazine inhibit cyclic AMP and thereby impede chloride transport. Furosemide will not correct the metabolic acidosis. Bicitra, sodium bicarbonate, and Polycitra all contain significant amounts of sodium which could potentiate the congestive heart failure.

Answer 154

B: "type II diabetes mellitus." was the correct answer. The prevalence of asymptomatic bacteruria is higher in women with diabetes mellitus. Women with type II diabetes mellitus and asymptomatic bacteruria are at higher risk for developing a symptomatic UTI. However, patients with type I diabetes mellitus and asymptomatic bacteruria are not at higher risk for this occurrence. There are no known risks of developing symptomatic UTIs in hypertension or thyroid disorders

Answer 155

D: "TRUS-guided prostate biopsy." was the correct answer. The normal PSA for a man under 50 is