2014 Flashcards

Question

A 52-year-old man develops abrupt and severe hypertension. He is poorly controlled with an ACE inhibitor, calcium channel blocker, diuretic, and minoxidil. None of these medications can be safely withheld. Serum creatinine is 1.3 mg/dl. The best way to evaluate for renovascular hypertension is: 1. captopril plasma renin activity test 2. unstimulated plasma renin activity test 3. captopril renography 4. duplex ultrasound 5. diuretic renography.

Answer 1

4 This 52-year-old man is at risk for renovascular HTN. Of the two captopril modulated tests: plasma renin activity (PRA) and captopril renogram, the renogram is a better test than peripheral PRA. Critical to the performance of these tests is appropriate patient preparation. Ideally, patients should be off all medications for two weeks. This is usually not possible clinically. In patients on medications it is critically important to recognize that the use of ACE inhibitors will significantly reduce the sensitivity of captopril stimulated testing and should be discontinued two weeks prior to the test. However, other antihypertensive medications can be used up to the morning of testing. In this clinical setting, duplex ultrasound will give anatomic information on the renal arteries sufficient to determine the need for angiography. Diuretic renography is not generally used as a test for renal artery stenosis.

Answer 2

5 The AUA Ureteral Calculi Guideline states that for newly diagnosed ureteral stone \< 10 mm and whose symptoms are controlled, observation with periodic evaluation is an initial option. Furthermore, such patients may be offered an appropriate medical therapy to facilitate stone passage during this observation period. Metanalysis has shown tamsulosin to be superior to nifedipine in medical expulsive therapy. However, tamsulosin has been described to cause intraoperative floppy iris syndrome (IFIS) and complicates cataract surgery. Therefore, in a patient who is about to undergo cataract surgery, it would be best to avoid tamsulosin. Therefore, the options for this particular patient are observation, SWL, ureteroscopic extraction, or ureteral stent. A 6 mm stone is best treated by ureteroscopic extraction, because more often than not (53% of the time), these stones will not spontaneously pass. An opaque stone implies that the stone is not uric acid and therefore alkalization with sodium bicarbonate would be an incorrect choice.

Answer 3

4 The relatively low incidence of RCC in the general population and the potential risk of identifying clinically insignificant lesions argue against widespread screening. However, several well-defined target populations who are at increased risk of RCC may be suitable for screening efforts. The relative risk of RCC in patients with ESRD has been estimated to be 5-20 times higher than that in the general population. The majority of patients with ESRD will develop acquired renal cystic disease (ARCD) and some of these patients will develop RCC. Cystic disease is associated with time of maintenance dialysis; increasing with duration of therapy. In renal failure patients, a reasonable approach to screening for patients with ESRD without other major comorbidities, is to delay screening until the third year on dialysis. Those with significant comorbidities, and thereby limited life expectancies, are not felt to benefit from screening and thereby should not be screened. Patients undergoing maintenance hemodialysis were previously thought to have a higher incidence of ARCD and thereby a higher risk of renal carcinoma than patients on peritoneal dialysis. However, recent studies have demonstrated similar rates of ARCD in both dialysis subgroups, and thereby suggests both forms of maintenance dialysis would increase the risk of developing renal carcinoma. Obesity and tobacco abuse have been shown to be risk factors for RCC, but these conditions themselves do not necessarily warrant screening efforts in patients with renal dysfunction. Screening for RCC in autosomal dominant polycystic kidney disease (ADPKD) was previously recommended. However, recent studies suggest no significantly increased risk of RCC in ADPKD and imaging is extremely difficult in this population related to the altered intrarenal architecture. Taken together, these considerations suggest that screening for RCC in patients with ADPKD should not be pursued.

Answer 4

3 A metanalysis of patients treated with alpha-blockers for stent discomfort identified 12 randomized controlled trials with 946 patients. It concluded that alpha-blockers were associated with a significant decrease in urinary symptoms and pain, and significant improvement in general health. In contrast, randomized controlled studies failed to demonstrate benefits with oxybutynin, phenazopyridine, or a ketorolac eluting ureteral stent. Periureteral botulinum toxin injection at the time of stent placement has been demonstrated to decrease stent morbidity, however, this would require a secondary cystoscopic procedure, and has not been studied as a rescue procedure after stent placement. Nifedipine and prednisone have not been studied for use in stent pain.

Answer 5

2 This patient has an infected IPG. The bacterial infection of the artificial IPG will result in a bacterial biofilm that will also contaminate the lead. Both the IPG and lead should be explanted. Their risk of infection of a new device or new lead placement at the time of explantation is too high and should not be pursued. The proper management is explantation of all prosthetic material, treatment of the infection, and repeat test stimulation in the future when the patient is completely recovered.

Answer 6

3 The incidental adrenal lesion, or incidentaloma, is an adrenal mass 1 cm or larger in size discovered during radiographic imaging performed for indications other than adrenal disease. They are found in approximately four to six percent of the imaged population. Almost all of incidental adrenal lesions \< 4 cm in size will prove to be benign in a patient without a known history of cancer. In patients with a known history of cancer, up to 50% will represent metastatic malignancy. This patient has an incidentally discovered adrenal adenoma that is probably benign based on its size and the HU of 5. Specifically, a non-contrast CT scan revealing a \< 4 cm adrenal mass with HU \< 10 carries a 98% specificity that the diagnosis is a benign adrenal adenoma. In masses with HU \> 10, a contrast CT scan with early phase wash-out could be obtained to rule-out malignancy; it is, however, not necessary in this instance. Similarly, a gadolinium-enhanced MRI scan is not indicated and is not as good as CT scan when looking for adrenal hypervascularity. The current recommendation for the management of an incidentally discovered adrenal mass \< 4 cm in size with an HU value of \< 10 is a biochemical work-up to include cortisol and catecholamines. In patients with a history of HTN, a hyperaldosteronemia should also be ruled out. Approximately 7% of these incidentalomas are metabolically active, 6% cortisol, and 1% sex or aldosterone secreting. Surgical resection is recommended for all metabolically active adrenal tumors or adrenal tumors \> 4 cm. Of note, in a seven year follow-up study of 231 patients with incidental adrenal tumors \< 4 cm in size and HU \< 10, less than 2% of the metabolically inactive adrenal tumors will either substantially grow or become metabolically active. Therefore, neither observation nor repeat CT scan in three months is appropriate. If the patient had a history of a prior malignancy, higher HU, or larger mass, then biopsy might be indicated.

Answer 7

1 The major clotting protein in semen has been termed semenogelin, which has been shown to be the seminal vesicle-specific antigen. These clotted proteins serve as the substrate for PSA which liquefies the semen. Calcium-binding substances, such as sodium citrate and heparin do not inhibit the coagulation. Blood clotting proteins such as prothrombin, fibrinogen, and factor XII are not present in semen.

Answer 8

1 The clinical picture is consistent with benign urethrorrhagia based on terminal gross hematuria and normal physical examination. UA shows microscopic hematuria only, and the culture is negative. This condition is caused by transient inflammation of the bulbar urethral epithelium. The cause is not known. No further work-up such as calcium to creatinine ratio, non-contrast CT scan, VCUG, or cystoscopy is necessary since this is self-limiting.

Answer 9

4 The radiograph reveals a staghorn stone in the right kidney and several large stones in the Indiana Pouch. SWL or percutaneous extraction of the pouch stones does not address the renal calculi. The staghorn stone needs to be treated as well, an untreated staghorn stone risks urosepsis. Since the right kidney is contributing little to the patient’s adequate renal function, nephrectomy is recommended over stone removal procedures that leave the kidney in place. Though percutaneous extraction of pouch stones is recommended, open surgical extraction is a good alternative with this large stone burden. In a 12 with good continence, pouch revision is not necessary. The patient should be encouraged to catheterize and irrigate the pouch more frequently.

Answer 10

3 Some hydronephrosis is expected after ileal conduit 12. Without a history of malignancy, computed tomography with contrast is not necessary. Loopography is the recommended next step with the new onset of hydronephrosis. It can assess for reflux into the left kidney. If there is free reflux, then obstruction is unlikely. If reflux is absent, then diuretic renal scintigraphy can be used to assess for obstruction. If obstruction is present, percutaneous nephrostomy can drain the kidney and allow the system to be studied. Looposcopy with ureteral catheterization is unlikely to succeed if the system is obstructed, and is unnecessary if it is not obstructed.

Answer 11

3 The patient's evaluation reveals oligoasthenospermia with low ejaculate volume without any obvious cause. Post-ejaculatory UA (PEU) is the best next step in order to identify a correctable cause for this patient's semen abnormalities. Hamster egg penetration test and antisperm antibody testing are useful for prognostic purposes but will not identify a correctable abnormality. Post-coital test is helpful in patients with isolated volume problems but would not be helpful in patients with oligoasthenospermia. Scrotal ultrasonography for subclinical varicocele is not indicated. TRUS may be considered if the PEU is negative but should not be considered first since it is more invasive than a PEU.

Answer 12

5 At the time of radical cystectomy, suspicious lymph nodes can be encountered. Approximately 25% of patients will ultimately have positive lymph nodes at the time of radical cystectomy. If the suspicious node(s) can be safely resected and the volume of suspicious lymph nodes is limited, it is reasonable to continue the cystectomy and continent 12. The patient will benefit from the local control of the lymphadenectomy and cystectomy. There is no evidence that stopping the surgery to treat with neoadjuvant chemotherapy or chemotherapy and radiation therapy is superior to completing the cystectomy. Positive lymph nodes are not a contraindication to continent 12.

Answer 13

1 This patient complains of pain only when the device is inflated during intercourse which may indicate that the cylinders are too large and are buckling, causing pain. MRI scan with the prosthesis inflated is the best imaging modality to prove the possible size discrepancy and buckling is the next step. If the diagnosis is confirmed, revision of the penile prosthesis with placement of smaller cylinders will usually resolve the problem. Penile infection following prosthetic placement usually has associated physical signs of infection (warmth, tenderness, erythema, etc.) that exist in both the flaccid or erect state. An SST deformity (floppy glans) is usually well-described by a patient and can be confirmed by physical examination. It can be repaired by moving the glans onto the distal portion of the cylinders with a glansplasty. Cystourethroscopy is indicated in the presence of voiding symptoms and/or possible infection of the penile prosthesis to rule out urethral erosion, but is not indicated in patients with pain only on inflation. Revision with a lock-out valve would only be useful in cases of autoinflation.

Answer 14

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 15

4 In boys with proximal hypospadias, the prostatic utricle is often enlarged. In a female, this would represent the distal one-third of the vagina. The utricle is of urogenital sinus origin. While an ectopic ureter or bladder diverticulum could have a similar appearance on ultrasound, they generally are not midline in location. Ectopic ureter or bladder diverticulum are not seen commonly with hypospadias. A cecoureterocele would have a bladder deformity in addition to a suburethral extension. A Cowper's duct cyst or syringocele should be confined to the bulbous or prostatic urethra where Cowper's ducts drain.

Answer 16

5 Neoadjuvant platinum-based chemotherapy is indicated for patients with difficult to resect matted or fixed inguinal lymph nodes from metastatic penile cancer. The neoadjuvant chemotherapy should reduce the size of the nodes and enhance their resectability. Following neoadjuvant chemotherapy, the patient should have a bilateral inguinal and pelvic lymphadenectomy. A percutaneous biopsy is not necessary in this setting.

Answer 17

4 Leukocytes are often present in the semen of infertile men. They are seldom due to documentable infection or antisperm antibodies. They do often indicate functional damage from DNA fragmentation to sperm membrane lipid peroxidation from reactive oxygen species released from the leukocytes. Leukocytes can occur with UTIs, but unless urine is in the semen, this is an unlikely source. Sexual transmitted infections can also lead to leukocytes in semen and this does need to be ruled-out, however, even PCR DNA testing for sexual transmitted pathogens are often negative verifying the situation is most commonly idiopathic.

Answer 18

2 The symptoms suggest either a urinoma or vascular injury to the lower pole segment, and is best evaluated with Doppler ultrasound. Pain, fever, and hematuria are common early, but should improve in the first 48-72 hours. Retrograde pyelogram and ureteral stent would be indicated for documented unresolving urinoma. CT angiogram has the disadvantage of radiation exposure without added clinical information that Doppler ultrasound would provide.

Answer 19

1 During placement of an obturator sling, regardless of approach, the trocar should pass through the ischiorectal fossa. It passes through the obturator foramen but not the obturator canal. It does not normally pass through any of the other listed structures. An outside-in transobturator passage traverses the gracilis muscle, adductor longus and brevis muscles, obturator externus muscle, obturator membrane, and obturator internus muscle. The gracilis muscle adducts and flexes the hip. The adductor longus and adductor brevis muscles adduct the thigh. The obturator externus and obturator internus muscles aid with thigh adduction and lateral rotation. Structures that affect medial thigh rotation are not traversed with a transobturator approach.

Answer 20

5 In patients with an acute uncomplicated pyleonephritis, hospitalization is not required if they are able to maintain oral hydration. These patients should have a urine culture and sensitivity obtained and empirical antimicrobial therapy should be initiated immediately. Fluoroquinolones and TMP-SMX are excellent choices. Nitrofurantoin is effective in urine, but does not obtain therapeutic levels in most body tissues and is therefore not preferred for UTIs. Upper tract imaging is not required when uncomplicated pyelonephritis is suspected. However, imaging should be considered if the patient does not respond to antibiotic therapy within 72 hours, or in the presence of specific indications suggestive of a complicated UTI such as diabetes mellitus, immunosuppression, and history of nephrolithiasis or symptoms suggestive of urinary tract obstruction.

Answer 21

4 The Clavien-Dindo classification of surgical complications is largely becoming the standard system for reporting adverse events after surgery that deviate from the normal postoperative course. As the patient required dialysis, due to single organ dysfunction, he would be considered grade IVa. The classification is: Grade I: Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Grade II: Requiring pharmacological treatment with drug other than such allowed for grade 1 complications. (Includes blood transfusion and TPN)Grade III: Requiring surgical, endoscopic or radiological intervention.Grade IIIa: Intervention not under general anesthesia.Grade IIIb: Intervention under general anesthesia.Grade IV: Life-threatening complicationIVa: Single organ dysfunction.Grade IVb: Multiorgan dysfunction.

Answer 22

5 Mid-urethral sling is warranted due to visualization of leak with Valsalva. Additionally, POP-Q exam reveals both posterior (Bp2 notes most distal portion of posterior vaginal wall is 2 cm beyond the hymen) and apical prolapse (C at 0 notes vaginal cuff is at the hymen). The anterior vaginal wall is well supported (Aa and Ba -3). A posterior repair and procedure for apical prolapse is indicated.

Answer 23

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. 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 24

2 When the semirigid ureteroscope will not pass easily over a guidewire in a prepubertal child, the next step is to perform a ureteric orifice dilation using either coaxial dilators or balloon dilator. Studies have demonstrated that ureteric dilation at the time of ureteroscopy is safe in children. After dilation, ureteral access sheath may also be used to minimize trauma. If the dilators do not pass easily, then placing a ureteral stent for passive dilation for several weeks is appropriate, but dilation should be tried first to avoid second anesthesia. Flexible ureteroscope is comparable in size (6.9 Fr) to the 6.5 Fr semirigid scope and may not offer any additional advantage in passing it up the ureter. Furthermore, a smaller working channel may make the stone fragmentation and extraction more difficult. SWL, percutaneous stone extraction, and laparoscopic ureterolithotomy are inappropriate for a distal ureteral stone.

Answer 25

2 Many think that the clinical incidence of Peyronie's disease is increasing. The increase however may be associated and coincide with the increased use of erection-enhancing medications. Phosphodiesterase type 5 (PDE5) inhibitor medications are not contraindicated in the treatment of Peyronie's disease, while intracavernous injection therapy has been linked to the development of penile fibrosis. There has never been any suggestion that PDE5 inhibitors are in any way directly causally related to the development of Peyronie's disease, nor is there suggestion that their use would worsen the course of Peyronie's disease. Data is emerging to suggest that certain endothelial impairment may be reversed with the initiation of PDE5 inhibitor therapy. This patient has erectile dysfunction (ED) and it is reasonable to treat the ED with sildenafil. Reassurance will not improve his ED and surgical correction is not indicated early in the disease course.

Answer 26

3 The image intensifier should be positioned above the patient and the x-ray tube below the patient to minimize radiation exposure (Images A, B, C). The x-ray tube should be positioned as far from the patient as feasible. (Image C) Angulation of the C-arm to a lateral or oblique position (Images B, D) increase the dose rate due to the increased body mass thickness that must be penetrated, and also brings the x-ray tube closer to the patient.

Answer 27

5 Symptomatic lower calyceal stones clear poorly after fragmentation with SWL, especially in horseshoe kidneys. Ureteroscopic fragmentation and stone extraction in these malrotated kidneys can be difficult. Residual stone fragments are unlikely to pass spontaneously and the likelihood of rendering the patient stone-free is limited. Percutaneous renal access can be performed safely through a superior and posterior calyceal puncture. The entry site of the puncture needle is more medial, just lateral to the paraspinous musculature, in comparison to inferior pole punctures in normally positioned kidneys. An inferior calyceal puncture in a horseshoe kidney could be dangerous due to its medial, more anterior and inferior location. Even in thin patients, one may need to utilize longer instruments including flexible cystoscopes, flexible or rigid ureteroscopes, or extra-long nephroscopes. Percutaneous renal access through a superior pole puncture can be performed in a safe fashion and is the most optimal route to render the patient stone free. The only variable identified that decreases the efficacy of PCNL in a horseshoe kidney is the presence of a Staghorn calculus. Stone-free rates are 84% with a primary PCNL and rise to 93% after a second-look nephroscopy.

Answer 28

2 Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, in which it appears to flop over the prosthesis. This deformity may result from inadequate distal dilation, too short cylinders, or in the case of minor deformity, variations in anatomy where the corpora cavernosum does not extend completely under the glans. For a severe deformity, definitive correction involves removing both cylinders, perforating the distal corpora with scissors, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders. For mild defects, like in this patient, dorsal plication of the glans back onto the shaft of the penis (glansplasty) is preferable when there are minor but otherwise bothersome degrees of poor glanular support. Changing to a three-piece prosthesis is not needed and adding a larger cylinder (upsizing) could result in pain and buckling.

Answer 29

4 This patient's persistent, post-obstructive diuresis is most likely iatrogenic. The brisk diuresis that accompanies release of obstruction may represent a physiologic response to the expansion of extracellular fluid volume occurring during the period of obstruction in many patients. This may be perpetuated by overzealous administration of intravenous fluids after relief of the obstruction. It would be safe in this clinically stable, neurologically intact patient to decrease intravenous fluids, allow her free access to fluid, and observe her closely for signs of hypovolemia and electrolyte imbalance. Hydrochlorothiazide is a diuretic and may worsen her diuresis. Vasopressin (ADH) acts to increase water reabsorption at the collecting duct and is not indicated in this scenario.

Answer 30

5 The clinical presentation is that of weakness and lethargy following the course of chemotherapy accompanied by significant hypokalemia and hyperchloremic metabolic acidosis. Despite the acidosis, his urinary pH is alkaline, indicating inability to acidify urine. The most likely diagnosis is a drug-induced renal tubular acidosis (RTA) type I (distal), in which there is a failure of ammonium secretion in the distal tubule. The type II (proximal) RTA represents a defective reabsorption of bicarbonate in the proximal tubule. Although distal RTA can be genetic, this most likely represents an acquired condition due to ifosfamide chemotherapy. The treatment is oral potassium and bicarbonate supplementation. I.V. fluid hydration is unnecessary with no evidence of dehydration, and normal creatinine with no evidence of contraction alkalosis. The use of steroids or diuretics would be detrimental to this patient.

Answer 31

2 This patient has developed a high output (\> 500 ml per day) enterocutaneous (EC) fistula. Management of high output EC fistula when they develop is extremely challenging and complex due to significant fluid and electrolyte loss and coexisting malnutrition. Emergent surgical repair in this patient would be highly technically demanding due to significant perisurgical reactive fibrosis with healing greatly impaired by concurrent malnutrition. Indeed up to 70% of patients with high output fistulae have concurrent malnutrition with documented hypoalbumemia, the latter of which is a significant prognostic factor. The loss of large amounts of fluid in the immediate postoperative period can lead to severe dehydration with oral intake frequently worsening the high output. The immediate step is to discontinue oral intake and initiate TPN. Agents that can decrease bowel motility (loperamide, diphenoxylate/atropine, etc.) can be helpful if the high output continues after the initial steps are taken. Although octreotide can be used to decrease pancreatic secretions, prospective double blinded placebo controlled trials demonstrated no significant reduction in postoperative EC fistula fluid losses nor did they find an increased rate of spontaneous EC closure. It should therefore only be used if high EC fistula outputs continue after initial measures fail.

Answer 32

3 The non-medical use of anabolic steroids by athletes is potentially a significant cause of infertility in male adolescents and adults. It has been estimated that 3-12% of male athletes of high school age in the United States have used steroids. Infertility associated with anabolic steroid use commonly presents as oligospermia or azoospermia along with abnormalities of sperm motility and morphology. As with many of the other steroid side effects, the semen parameter deficits are thought to be reversible and consequently, the discontinuation of all steroids is the first course of therapy. Unfortunately, some steroid abusers develop a chronic anabolic-induced hypogonadism syndrome/state. Successful gonadotropin (hCG) replacement is the best therapy when this occurs. This patient has already been off steroids with no return of sperm after one year, therefore, continued observation is not likely to work at this point and a trial of hCG therapy is indicated. Testosterone supplementation will only continue to suppress the central axis (decrease FSH and LH release) and perpetuate the problem. Clomiphene citrate might work by blocking testosterone and estradiol feedback on the central axis and stimulate LH/FSH release, but will not be as effective as hCG. Testis biopsy is not needed at this time, but might be needed if the patient does not respond to hormonal manipulation and maturation arrest is suspected.

Answer 33

2 Renal venous thrombosis is suggested in the neonate with enlarged kidneys, hematuria, anemia, and thrombocytopenia, often with a history of prolonged delivery and prematurity. Thrombosis is peripheral and initial therapy should be aimed at support and I.V. fluid administration in order to treat the underlying dehydration. Observation would be inadequate with the thrombotic phenomenon likely to escalate in severity with extension of the thrombus. Anticoagulation is indicated if the process extends beyond the renal vein(s). The clinical scenario presented and the imaging reported of bilaterally enlarged kidneys on ultrasound are sufficient to make the diagnosis and no further imaging is necessary.

Answer 34

4 This patient has failed two previous attempts at fistula closure following a complicated surgery. One would expect significant scarring in her pelvis and anticipate a difficult dissection for exposure of the fistula. Although cystoscopy and fulguration of the fistula tract is appealing for its surgical ease and is associated with a high rate of success (\> 66%) for fistula \< 7 mm in size, when used as either a primary or secondary treatment modality, it has no role in the management of large \> 7 mm vesicovaginal fistula. Retrograde endoscopic injection of fibrin glue is a minimally invasive approach that may avoid the morbidity of an open surgery. It has been used to close complex fistulas up to 15 mm in size. Although short term outcomes less than one year are encouraging, approximately 75% successful long-term follow-ups reveal the success of this technique breaks down with time. Whether late break downs can be successfully retreated with fibrin glue injection remains to be clarified. Clearly, with each subsequent surgery, the likelihood of successful repair decreases. Optimal success is achieved with a tension-free primary bladder closure with an interpositional graft between the bladder and vaginal vault. Of the choices, the abdominal approach with rectus muscle graft interposition would provide the best technical option and be considered the gold standard in a patient who has undergone repeated failed attempts at vesicovaginal fistula closure. An ileal conduit is not indicated in this otherwise healthy young woman.

Answer 35

5 The history and physical examination of this patient is highly suspicious for a testis fracture. Immediate exploration is indicated without the need for scrotal imaging for a definitive diagnosis. Indeed, ultrasonography should not deny or delay surgical exploration if the physical examination findings dictate a possible fracture. The overall accuracy of ultrasonography for detection of traumatic testis fracture has been found to be highly operator dependent with both significant false positive and false negative rates found in the published literature. MRI scan has not been extensively studied, is costly, and could delay definitive treatment. Nuclear medicine scan will delay diagnosis and will not add useful information.

Answer 36

2 According to the most recently published AUA Guideline for the Management of VUR, the required step after an open-robotic surgical intervention for VUR is renal ultrasound. Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented. Based on the rigorous meta-analysis performed on the available literature, the use of postoperative VCUG following an open robotic ureteral reimplantation is considered optional. Renal ultrasonography obtained postoperatively will reveal Society of Fetal Urology (SFU) Grade 2 or higher hydronephrosis in approximately 25% of patients one month after a ureteral reimplantation and in 15% of patients three months after a ureteral reimplantation. The exact percentage of patients with postoperative hydronephrosis is dependent upon the percentage of patients with preoperative hydronephrosis, and the percentage of patents with preoperative grade of 4-5/5 VUR. If SFU Grade 2 or higher, hydronephrosis was noted preoperatively, approximately 60% resolve their hydronephrosis by three months, 30% improve, and the remainder are unchanged to slightly worsened. MAG-3 renal scan and VCUG can be obtained in individuals with persistent or worsening hydronephrosis. Evaluation of these patients will reveal persistent VUR in 4-8%, ureteral obstruction and/or bladder dysfunction (noncompliance) noted to be the cause of the hydronephrosis in approximately 1-2%. It is noteworthy that following injection of a bulking agent for treatment of VUR both a VCUG along with a renal ultrasound is recommended. DMSA scan is optional if additional febrile UTI's should occur.

Answer 37

2 Following hysterectomy, a high-riding vesicovaginal fistula (VVF) can often be repaired through a vaginal approach. A simple procedure to augment the repair is harvest of the posterior peritoneum which is often present around the cervical cuff. This can be carried up over the two-layer fistula closure and attached to cover the fistula. Omentum can easily be harvested through a trans-abdominal approach but is difficult with a vaginal incision. Myocutaneous and Martius flaps are used with extensive fistulas and are more challenging to harvest and transpose.

Answer 38

4 Colonic perforation is a rare complication of nephrostomy tube placement, occurring in \< 1% of patients. It most commonly occurs with lower pole nephrostomy tube placement in patients with malrotated kidneys and/or distended colons. Laparotomy is not necessary in the absence of clinical signs of peritonitis. Separate drainage of the colon and urinary system should resolve this problem.

Answer 39

5 Bladder neck injuries in the setting of a pelvic fracture are more common in children than in adults and are frequently associated with injuries to the vagina and rectum. Immediate repair of the bladder neck, urethra, and vagina, and diverting colostomy with rectal repair is recommended. Attempts at management with a temporary suprapubic tube, urethral catheters, and delayed repair is associated with a high incidence of persistent bladder neck incompetence, urinary fistula, pelvic abscess, and osteomyelitis. Thus, in a hemodynamically stable patient, immediate repair of all injuries through a combined suprapubic and perineal approach is recommended. Primary diversion with either percutaneous nephrostomy tubes or externalized ureteral stents and urinary catheters is appropriate when the patient is hemodynamically unstable and blood loss is life threatening.

Answer 40

1 Dysfunctional voiding is characterized by involuntary contraction of the pelvic floor during voiding in a neurologically intact individual. This is clearly demonstrated by the increased EMG activity during voiding seen on this pressure flow urodynamic tracing. Treatment generally starts with conservative measures including pelvic floor physical therapy with biofeedback. Other theoretical options to consider include pharmacologic therapy (Valium or Baclofen) to relax the external sphincter. Some authors have reported success with the use of alpha-blockade, but theoretically, one would not expect an improvement in voiding with a medication that would more likely affect the internal sphincter/bladder neck than the pelvic floor. Urethral dilation is not widely advocated. OnabotulinumtoxinA injection and sphincterotomy, while targeting the proper area, would be very aggressive and certainly not recommended in a neurologically healthy patient as a first line treatment. Bladder neck incision would not treat pelvic floor dysfunction.

Answer 41

2 Calcium homeostasis involves four key components: serum calcium, serum phosphate (binds calcium thereby blocking calcium bioavailability), 1,25-dihydroxyvitamin D3, and parathyroid hormone (PTH). The major target organs for PTH action are the kidneys, skeletal system, and intestine. The primary effect of PTH is in the kidney, where it will act to block phosphate reabsorption in the proximal tubule (i.e., increase phosphate excretion) and promote calcium reabsorption in the ascending loop of Henle, distal tubule, and collecting tubule. PTH promotes bone resorption with subsequent calcium release. The final function of parathyroid hormone (PTH) is by activation of the enzyme 1-hydroxylase in the proximal tubules of the kidney. The enzyme 1-hydroxylase is a key component in the metabolism of vitamin D3 (cholecalciferol). Vitamin D3 (cholecalciferol) is formed in the skin when a cholesterol precursor, 7-dehydroxycholesterol, is exposed to ultraviolet light. Activation of vitamin D3 occurs when the substance undergoes 25-hydroxylation in the liver and 1-hydroxylation in the kidney. The enzyme 1-hydroxylase converts 25-hydroxyvitamin D3 to its most active metabolite, 1,25-dihydroxyvitamin D3. The primary action of 1,25-dihydroxyvitamin D3 is to promote gut absorption of calcium by stimulating formation of calcium-binding protein within the intestinal epithelial cells.

Answer 42

3 In smaller patients with little perivesical fat and less pelvic vascular development, finding the ureter extravesically is fairly straight forward. For older patients and unusual cases, this can be challenging. The ureter courses dorsal to the obliterated umbilical artery, so searching its ventral surface will not be effective. Finding the vas deferens is difficult and may result in damaging it, so this is also not advisable. The ureter may occasionally be adherent to the peritoneum as it is dissected, making this a low yield place to look initially. Extensive dissection of the bladder should be avoided as it may increase the risk of postoperative voiding dysfunction and urinary retention, especially if bilateral reimplant is performed. Dissecting slightly higher up to the level of the iliac vessels, one should be able to find the ureter as it courses on the ventral surface of both the artery and vein. It can then be followed distally to complete the procedure.

Answer 43

2 Rapid short pelvic contractions (termed, quick flicks) have been shown to decrease bladder overactivity and urinary urgency. This treatment is combined with teaching the individual to delay voiding in response to the urge to void. The principles behind these bladder drills are an attempt to retrain the bladder to overcome the voiding urgency. Patients are taught not to void just in case or when the urge hits, but rather to try to delay the void. Slow sustained pelvic floor contractions are utilized in the treatment of stress incontinence and are not as helpful in patients with urinary urgency. With a single negative UA, a repeat UA is reasonable, but a routine culture is not necessary at this point if the UA remains negative. For persistent irritative symptoms, consideration of mycoplasma/ureaplasma cultures, and/or cystoscopy if the patient would have a history of tobacco usage may be reasonable. An anti-incontinence pessary would not be helpful for urgency incontinence and might actually exacerbate the symptoms.

Answer 44

3 Alpha-mercaptopropionylglycine (alpha-MPG) is an oral agent, first introduced in 1968, which reduces cystine stone formation. Approximately 25% of the oral dose appears in the urine and like penicillamine, participates in thiol-disulfide exchange with cystine, thus increasing the latter's solubility. Alpha-MPG appears to be as effective as penicillamine in reducing cystine excretion and significantly reduces the individual stone formation rate, while entailing less significant toxicity. N-acetylcysteine is not effective orally. Tris-hydroxymethyl amino methane is only used for percutaneous dissolution. Acetohydroxamic acid inhibits bacterial urease and is not indicated for cystine stones.

Answer 45

2 Newborns may have a buried penis in which there is poor fixation of the overlying skin at the base of the penis. When they are circumcised with a newborn clamp technique, a trapped penis can develop in which the healing skin edges migrate distally over the glans, which in turn can cause an obstructing cicatrix. Resultant retention of voided urine can cause of ballooning of the penile skin. In severe cases, this can also give rise to significant infections and possible urinary retention. Conservative management with a topical steroid ointment (0.05-0.1% betamethasone) for six weeks will result in resolution of the cicatrix and spontaneous retraction of the overlying skin in up to two thirds of patients. In unresponsive cases or patients with more acute problems such as infection or retention, one can consider use of antibiotics and/or surgical intervention with a dorsal slit. If possible, one should avoid performing a revision circumcision in the acute setting because of the poor results that can result from reconstruction of the inflamed skin. Forced manual retraction should be avoided since there will be a significant risk for increased scarring and recurrence.

Answer 46

5 The possibility of the presence of intrinsic sphincter deficiency (ISD) should be considered in patients with a history of recurrent stress urinary incontinence following anti-incontinence surgery. In the face of urethral hypermobility, a retropubic suspension (e.g. Burch) may be an option, but a pubovaginal sling is more effective and durable for ISD. Injection therapy would also be reasonable, but will likely not be as durable as a sling procedure in this relatively young woman. Pelvic floor muscle therapy is a consideration but is known to be less effective than surgery and is best used in patients with mild leakage. Imipramine is off-label and has the potential to cause cardiac effects. Although it may improve her continence, it is also unlikely to result in complete resolution of her symptoms.

Answer 47

3 Hidradenitis suppurativa is an inflammatory process involving the apocrine glands, most commonly in the groin, axillae, and buttock or below the breasts. They are sterile abscesses. Old scars and sinus tracts are common. Fistulae tracts and perineal abscesses are rare findings in inflammatory bowel disease. Syphilis and chancroid both present with superficial ulcerations. Granuloma inguinale presents with painful lymphadenopathy without abscesses.

Answer 48

4 The femoral nerve is of L2-L4 origin and has both motor and sensory components, providing sensation to the anterior thigh and motor innervation to the extensors of the knee. The femoral nerve travels within the belly and exits through the lateral aspect of the psoas muscle to pass under the ilioinguinal ligament. There are two potential injuries to the femoral nerve during a psoas hitch: the nerve can become entrapped from a suture placed at right angle to the muscle fibers and the direction of the nerve, or if performed by an open approach, the blades of a retractor can compress the psoas muscle and can result in a femoral nerve palsy. The ilioinguinal and genitofemoral nerves are easily identified during exposure for the psoas hitch and are readily mobilized away from the operative field.

Answer 49

4 The primary target of onabotulinumtoxinA treatment is inhibition of acetylcholine release from postsynaptic parasympathetic efferent nerves to the detrusor muscle, resulting in transient paralysis of the detrusor muscle. The efficacy of the treatment, however, exceeds that of pure detrusor paralysis and is associated with a significant reduction in bladder sensation. The decrease in the afferent sensation (urgency) is due to localized inhibition of detrusor muscle ATP, substance P production along with a reduction in activity of afferent axonal capsaicin and purinergic receptors. The overall effect is a profound inhibition of both efferent acetylcholine release (primary) and interference with afferent neuronal mediators and receptors (secondary).

Answer 50

4 This patient has chancroid. According to the CDC, the drug of choice is a single dose of azithromycin (1 gram p.o.). Alternatively, erythromycin 500 mg p.o. q.i.d. for seven days or ceftriaxone 250 mg I.M. once can be effective. The other antibiotics will not be effective to eliminate the organism which is Haemophilus ducreyi. Acyclovir is effective against the herpes virus.

Answer 51

3 Autonomic dysreflexia (AD) is most commonly seen in patients with spinal cord injury levels above T8. It is an exaggerated sympathetic nervous system response to afferent visceral stimulation, manifest with sweating, headache, HTN, reflex bradycardia, and flushing above the level of the spinal cord lesion. The normal BP in para and quadriplegics is low, usually 90-110 mmHg systolic. Elevation with autonomic dysreflexia symptoms classically begin with a 20 mmHg rise above baseline, well within normal range for a neurologic intact individual. If BP is \> 120 mmHg and patient is symptomatic, presumed autonomic dysreflexia is present. Initial therapy should focus on the removal of inciting factors. In this case, that would include emptying of the bladder and removal of all urodynamic catheters. If the symptoms persist and systolic pressure remains elevated but lower than 150 mmHg, then evaluation for and treatment of fecal impaction, the second most common cause of AD after the bladder, is recommended. However, if the systolic pressure remains above 150 mmHg after bladder emptying and catheter removal, then use of a rapid-onset, short-acting antihypertensive is recommended while the cause of AD is investigated. Nitropaste 2%, applied .5-1 inch above the level of the lesion (vasoconstriction occurs below the level of the lesion and may interfere with the drugs absorption) is preferred due to its ability to be wiped free if rebound hypotension occurs. Alternatively, Nitroglycerin 0.4 mg sublingually, are the two first line drugs of choice in the outpatient setting. The physician must make sure the patient has not used a PDE-5 inhibitor for erectile dysfunction in the past 24 hours, due to concern for rebound hypotension. If a sildenafil agent has been used within 24 hours, Captopril 25 mg chewed or given sublingually becomes the drug of choice. Nifedipine used to be recommended as primary treatment or prophylactic agent for AD, however, because of several adverse, rebound hypotensive crisis resulting in stroke or MI after its use, the Joint commission for treatment of High Blood Pressure and National Spinal Cord Injury committees have discouraged its use and it has been banned for treatment or prevention of autonomic dysreflexia in some hospitals. If the blood pressure remains elevated and does not respond to oral therapy I.V., hydralazine is an option, however, BP may be quite labile after its use with both hypotension and/or rebound HTN, the patient will require hospital admission with further monitoring. In the outpatient setting, when autonomic dysreflexia is triggered and successfully treated, it is recommended that the patient should be monitored for resumption of HTN for a minimum of two hours. If AD recurs, hospitalization with monitoring for 24 hours is recommended, if not, the patient can be discharged from the outpatient setting. Recommendations to prevent autonomic dysreflexia preceding cystoscopy or urodynamic evaluations are to use: terazosin 5 mg, prazosin 1 mg, or tamsulosin 0.8 mg the night before the exam, or alternatively at the time of the exam place Nitropaste 2% .5 inch (if not on sildenafil) or Captopril 25 mg sublingually 10-15 minutes prior to exam.

Answer 52

2 The patient’s motor and sensory deficits are classic presentations for femoral neurapraxia, thought to be due to entrapment by the inguinal ligament in patients whose hips are hyperextended during positioning for robotic pelvic procedures. The femoral nerve has both sensory (anteromedial thigh) and motor components essential for hip flexion. The obturator nerve governs adduction of the thigh (motor) and sensation to medial aspect of thigh (sensory). The lateral femoral cutaneous nerve is purely a sensory nerve innervating the lateral thigh. The sciatic nerve has sensory (posterior calf) and motor (posterior thigh muscle groups) branches. The genitofemoral nerve supplies sensation to the scrotal skin and cremaster muscle (motor).

Answer 53

2 If a urethral catheter balloon will not deflate, the first step should be to attempt to place another 2-5 ml of fluid into the balloon and reattempt deflation of the balloon. If that fails, the inflation valve should be cut. This will allow access to the inflation channel. A guide or glidewire passed down the inflation channel will almost always clear the passage and let the water out without breaking the balloon. The other choices listed will result in breaking the balloon, often leaving a floating fragment that cannot be voided or irrigated out and can possibly lead to bladder stone formation. If rupture of the balloon is performed, cystoscopy is recommended to evaluate and retrieve any fragment left behind.

Answer 54

4 This scenario is concerning for UTI with an urea-splitting gram-negative organism in a urinary tract with significant urinary stasis. This can occur in prune belly syndrome children or any other patient with urinary stasis or obstruction. Urea in the urine is split into large amounts of ammonia which is absorbed systemically and may result in encephalopathy or even coma at high levels. Treatment is support, urinary drainage, and antibiotic administration. The vital signs, urine output, and normal hematocrit in the current patient argue for relative normovolemia and are not consistent with sepsis or other illness. Although perturbations of other electrolytes, bicarbonate, or lactate may occur, significant abnormality of one or more of these should lead to hemodynamic instability if severe enough to lead to an obtunded state.

Answer 55

5 Androgen resistance or testicular feminization syndrome presents with a wide range of phenotypes of complete female external genitalia to men with normal genitalia and abnormalities of spermatogenesis. This X linked disorder is due to an abnormality of the androgen receptor. Testosterone production and secretion by the Leydig cells is normal, but the target organs including the pituitary gland do not recognize it due to faulty receptors. Therefore, LH secretion is increased because of the apparent lack of testosterone while FSH is unaffected since it is controlled by inhibin. Puberty would have normal testosterone, LH, and FSH. Klinefelter Syndrome and Sertoli Cell Only Syndrome would have elevated FSH, LH, and low testosterone. Secondary testicular failure can have a multitude of etiologies with the end result being low testosterone. The FSH and LH may be high or low.

Answer 56

1 Following chemotherapy for retroperitoneal metastases from non-seminomatous germ cell tumors, teratoma will be found in approximately 40% of patients. When this is found, complete resection is mandatory for a number of reasons. Although the teratoma may be benign, continued growth of the tumor can lead to significant morbidity and the tumor can become unresectable. Additionally, complete retroperitoneal nodal evaluation will detect foci of residual cancer in up to 20% of patients. Thus, complete RPLND is necessary.

Answer 57

2 The interaortocaval nodes primarily drain the right kidney. The left kidney drains to the interaortocaval nodes only in advanced disease.

Answer 58

5 The use of over-the-counter phytotherapy continues to be a popular therapy for the treatment of male LUTS due to BPH. However, there are a limited number of well done placebo-controlled trials evaluating its efficacy. The vast majority of these trials suggest that Serenoa repens is no more effective than placebo. No differences are seen in regards to AUA-SI or flow rates. There does not appear to be any decrease in prostate size or evidence that suggests that this drug is able to minimize the risk of progression to acute urinary retention. Initial prostate size does not appear to impact the outcome when Serenoa repens is used. Adverse events are mild and appear to be comparable to placebo.

Answer 59

5 Small-cell carcinoma of the prostate carries a very poor prognosis. In most patients, the course is rapidly fatal. Most patients present with rapid onset of symptoms indistinguishable from other causes of bladder outlet obstruction. Systemic constitutional symptoms are reported in about 10% of cases. Chemotherapy in combination with surgery or radiation appears to be the most important component of management. Radiation is ineffective as is surgery alone, since most patients have metastatic disease. These tumors are generally not hormonally sensitive.

Answer 60

5 Of all the potential complications of a large ureterocele, bladder outlet obstruction is the most worrisome because it affects both kidneys, leads to recurrent infection, and progressive renal damage. A key indicator of bladder outlet obstruction in this patient is the presence of contralateral hydroureteronephrosis. Non-function of the upper pole system does not require early intervention unless the patient presents with febrile UTI unresponsive to antibiotic therapy. Initial therapy for reflux either into the ipsilateral or contralateral kidney would be managed with continuous antibiotic prophylaxis as first line therapy. Incontinence occurs in a small percentage of children with ureteroceles, usually due to a congenital defect in the bladder neck due to distortion from the ureterocele, and is best managed in the older child.

Answer 61

2 Patients who are taking PDE5 inhibitors cannot concomitantly use nitrates due to the potential risk of severe hypotension. For the short acting PDE5 inhibitors (vardenafil, sildenafil, avanafil), medical personnel should not use nitrates for at least 24 hours and for 48 hours with the long acting PDE5 inhibitor, tadalafil. Men who have taken PDE5 inhibitors and develop angina during sexual activity (which has a greater risk of bringing on a non-fatal MI) should stop sexual activity and seek emergency medical therapy immediately.

Answer 62

5 Early after continent 12, 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 such as ileus, pouch leak or rupture, or urinary tract obstruction. Patient education on symptoms is paramount to prevent unnecessary interventions.

Answer 63

1 Although ureteral injuries are uncommon during transvaginal suspension procedures, the ureter occasionally can be injured or obstructed by the surgical dissection or suspension suture. If recognized intraoperatively, the suspension suture should be removed and a ureteral stent placed. If this is recognized postoperatively, a retrograde pyelogram will define the extent of the injury and retrograde stent placement attempted. If stenting is not successful, antegrade stenting is advised. Open repair is advised when retrograde or antegrade ureteral stent placement cannot be performed. Ureteroneocystostomy is performed only when significant devitalization of the ureter occurs.

Answer 64

1 Over 85% of patients and 70% of partners rate satisfaction following placement of penile prosthesis as very high. That being said, there are still patients who have significant problems with establishing intimacy following the diagnosis and treatment of prostate cancer. There are also patients who note significant decrease in penile size following radical prostatectomy. In this patient with no problems noted with his implant, evaluation and treatment by a sex therapist would be the best treatment. Combination therapy with a PDE5 inhibitor or alprostadil can increase glanular engorgement but are not FDA-approved and would not necessarily help with partner issues. There is no need to change out the prosthesis for a different device if it has been properly sized and implanted.

Answer 65

4 Under usual circumstances, a peripherally located tumor in a solitary kidney is best managed by partial nephrectomy, both for potential cure and to prevent the need for dialysis. However, the presence of a venous thrombus makes complete tumor excision less likely and is associated with a high likelihood of tumor recurrence and poor prognosis after partial nephrectomy. Given the patient's good health, long life expectancy, and episode of gross hematuria, observation is likely to result in further tumor progression, more bleeding or other local symptoms which may require intervention, and potentially metastatic disease. Laparoscopic cryoablation is best used for smaller tumors and will not control the tumor thrombus. Systemic immunotherapy rarely results in a response in the primary tumor and is unlikely to be curative. Thus, the best choice is radical nephrectomy which will result in the need for dialysis. A prolonged disease-free interval would make the patient eligible for subsequent renal transplantation. Selective angioinfarction of the tumor is another alternative which could be used for palliation of the bleeding, but will not be curative.

Answer 66

4 The incidence of Candidal nosocomia UTIs occurring within neonatal intensive care units is increasing and directly related to the use of parenteral antibiotics. In this select patient population, aggressive treatment of asymptomatic candiduria is required due to a high incidence of subsequent candidemia. Indeed, in some published series, failure to treat asymptomatic candiduria in premature neonates resulted in systemic candidemia in up to 80% of patients. Isolating treatment to the bladder with topical irrigation will not effectively treat the risk of candidemia and parenteral treatment is required. Fluconazole is the treatment of choice in a premature infant when compared to amphotericin because of significantly diminished systemic side effects. Circumcision will not decrease the risk of candidemia.

Answer 67

4 T cell activation requires three signals. First, T cell receptor engages specific antigens presented by MHC molecules on APCs. Without the second signal, the T cell remains functionally inactive. Second, stabilization and costimulation between APC glycoproteins (e.g., CD 40 and CD 80) with their T cell ligands are required. Lastly, cytokine (especially interleukins) stimulation is necessary to complete T cell activation. Although intracellular signal transduction and cell proliferation are integral parts of T cell activation, these steps are not possible without T cell costimulation.

Answer 68

3 An ileal conduit is not a contraindication to having a successful, normal pregnancy. Unless a specific indication exists, the routine obstetrical care of a pregnant woman with an ileal conduit is the same as that for a woman with no previous urinary tract surgery. Antibiotics are only required if the patient experiences a symptomatic urinary tract infection. There is no required need for Cesarean section and amniocentesis should be reserved for fetal indications. Serial renal ultrasounds would likely show progressive physiologic hydroureteronephrosis of pregnancy, and are not indicated in asymptomatic patients.

Answer 69

3 When the testis is more than 2 cm above the internal ring with no vascular redundancy, it is unlikely that the testis will be able to reach the scrotum without dividing the spermatic vessels. In this situation, staged Fowler-Stephens procedure with division of the gonadal vessels at the first stage has a significantly higher success rate than primary Fowler-Stephens procedure. With the high abdominal position of the testis and short spermatic vessels, the testis is unlikely to reach the scrotum with either a laparoscopic or open transabdominal orchiopexy, which would both be limited by the ability to adequately mobilize the vessels. Although hCG has been used to increase testicular vascularity, there are no documented studies to prove that administration of hCG pre-Fowler Stephen orchiopexy improves testicular viability. Indeed, there is concern that acute hCG stimulation could cause damage to the seminiferous tubules.

Answer 70

5 The TOMUS (Trial of Mid-Urethral Slings) study is a multicenter, randomized equivalence trial sponsored by the Urinary Incontinence Treatment Network (UITN) which evaluated 597 women with SUI who were assigned to undergo treatment either with a retropubic or transobturator midurethral sling. At 12 months, the patients in both groups met the prespecified criteria for equivalence with regard to the objective definition of success (negative stress test, negative pad test, and no retreatment) with 80.8% in the retropubic group and 77.7% in the transobturator group having a successful outcome. Subjective definition of success was defined as a self-reported absence of symptoms, no leakage episodes recorded on diary, and no retreatment. Subjectively, the outcomes between the two groups were similar; 62.2% in the retropubic group and 55.8% in the transobturator. Rates of postoperative voiding dysfunction were higher (2.7%) in the retropubic group compared to the transobturator group (0%).

Answer 71

5 Further chemotherapy is not indicated without histologic evidence of residual disease. Although assessment of the retroperitoneal nodes must be considered, removal of the lung mass by thoracotomy is indicated first. Needle biopsy would be an insufficient sampling method and if this is teratoma, excision of the lung mass would be therapeutic.

Answer 72

4 Imperforate anus is accompanied by a high incidence of bony sacral and neurological anomalies that may lead to a neurogenic bladder. On the other hand, diurnal and nocturnal enuresis are common in six year olds. This boy can completely empty the bladder volitionally; i.e., no postvoid residual. There is no evidence of spinal cord tethering with the conus medullaris in the normal position upper border of L-2. A vesico-colonic fistula would be unlikely. The urodynamic study is not suggestive of detrusor-sphincter dyssynergia, and the detrusor overactivity at high volume is unlikely to suggest any serious underlying pathology.

Answer 73

5 The urodynamics are consistent with bladder outlet obstruction. The patient has normal bladder compliance, no evidence of detrusor overactivity, and during the pressure-flow study, elevated detrusor pressures with a low flow. Therefore, treatments aimed at overactive bladder (solifenacin and onabotulintumtoxinA) would not be indicated. This patient does not have a large prostate on exam; thus, dutasteride is not indicated. A TUIP would not be appropriate in light of the enlarged median lobe; therefore, TURP would be the appropriate therapy for this patient’s LUTS.

Answer 74

5 Deletions of the short arm of chromosome 3 are characteristic of clear cell (conventional type) RCCs, 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 75

4 The distal prostatic ducts are lined by transitional (urothelial) epithelium as in the prostatic urethra. Primary urothelial carcinoma of the prostate arising from these glands account for 1.5-4% of all male urethral cancers.

Answer 76

2 If voiding dysfunction persists after stroke, the most common findings include detrusor overactivity, intact sensation, and a synergistic sphincter. However, it is also important to note that non-neurogenic voiding dysfunction may occur as well, especially in this patient population which is often older. The urodynamic findings in this patient are consistent with bladder outlet obstruction so tamsulosin should be started. There is no urodynamic evidence of detrusor overactivity, so therapies directed at that such as mirabegron (beta-3 agonist), SNS, PTNS, and onabotulinumtoxinA would not be the next appropriate step.

Answer 77

4 Due to the high association of subsequent development of overt carcinoma, testicular intratubular germ cell neoplasia may be treated by orchiectomy, radiation therapy, or chemotherapy. Radiation therapy is effective and may maintain Leydig cell function. In cases of bilateral disease, bilateral orchiectomy would be a drastic recommendation. Given the potential toxicities of chemotherapy compared to radiation, this approach would be reserved for contralateral CIS in the setting of metastasis from the primary tumor. Prior to treatment, testicular sperm extraction should be considered as some men with maturation arrest on diagnostic biopsy will have sperm found with a more extensive biopsy.

Answer 78

3 The patient has the urologic finding of incontinence combined with fecal soiling and a foot abnormality. A tethered cord due to occult spinal dysraphism needs to be ruled-out as the cause of his incontinence. Tethered cord syndrome is a stretch-induced functional disorder of the spinal cord with the most caudal part of the cord anchored by inelastic structures. Specific treatment of his bladder instability (timed voids, medication, catheterization, treatment of constipation) is appropriate after a neurologic cause is excluded.

Answer 79

1 This man likely has chronic bacterial prostatitis, which is usually manifested by recurrent UTIs with the same organism. While lower urinary tract bacterial localization is helpful in identifying the prostate as a nidus of infection, localization is useless in the presence of bacteruria, with all isolation specimens having bacterial growth due to contamination. This man is currently symptomatic with documented bacteruria and should not, therefore, undergo localization testing. In this situation, preferred treatment is to obtain a midstream urine culture and treat preferably with nitrofurantoin. Nitrofurantoin will clear the urine of bacteriuria and have little to no effect on intraprostatic bacteria. Once the urine has been documented to be sterile, usually in three to five days, bacterial localization studies with initial voided, mid-stream, expressed prostatic secretions and post-prostatic massage urinary specimens should be obtained. These tests will allow confirmation of chronic bacterial prostatitis. For chronic prostatitis caused by E. coli, four to six week treatment with the fluoroquinolones is superior to the alternative three month therapy with trimethoprim-sulfamethoxazole. Approximately 20% of the patients will fail the initial therapy and a rescue treatment with a second cycle of therapy with an alternative quinolone has been found to rescue the majority of the relapsing patients.

Answer 80

2 Careful selection of the optimal site for a stoma is a critically important part of the preoperative evaluation of the patient. The stomal site should avoid the umbilicus, bony prominences, scars, and folds. It should be placed in a region where the flat abdominal skin measures 5-7 cm in both directions. The stoma for an ileal conduit is usually located in the right lower quadrant. Paraplegics, often with abdominal prolapse and wheel-chair existence pose a special problem for stomal site selection. A right lower quadrant site often results in a stoma that is difficult for the patient to see, with the stoma and appliance squeezed between the abdomen and thigh. For this reason, in the paraplegic patient, the stoma should always, if possible, be placed in the upper abdomen. In addition, in all patients the stoma should be brought through the rectus muscle to minimize the risk of peristomal herniation. All patients should see an enterostomal therapist prior to stomal placement.

Answer 81

5 Bladder calculi develop in 18-30% of children following augmentation cystoplasty. Various factors may contribute to stone formation, e.g., bacteriuria, urinary stasis, hypocitraturia, mucus, etc. The most effective preventive measure for bladder stone formation is regular irrigation to clear the mucus that may serve as a nidus. No studies have demonstrated efficacy of bladder stone prevention using oral potassium citrate, prophylactic antibiotics, urinary acidification, and thiazide.

Answer 82

4 When a metal trocar is placed directly through the skin, the charge surrounding an activated monopolar instrument is conducted back through the metal trocar and dispersed by the abdominal wall. However, placing a metal trocar within a plastic sheath may result in insulation of an electric field from the abdominal wall. The resultant buildup of the electrical field of an activated electrosurgical instrument can then conduct to the exposed metal trocar extending beyond the plastic sheath inside the abdomen resulting in direct conduction to nearby organs such as the bowel. This condition is called capacitance coupling and is one potential cause of electrosurgical injury to the bowel or other internal organs during laparoscopy. As the 8 mm metal trocar is placed within the 12 mm plastic trocar, this would not increase the risk of incisional hernia or trocar site discomfort. As the robotic instrument pivots within a trocar about a fixed remote center point, this avoids any excess inward-outward motion of the trocar thus reducing any risk of trocar dislodgement. Lastly, this unique hybrid trocar arrangement would not itself increase the risk of vascular injury.

Answer 83

1 A number of biochemical tests are available to exclude or confirm the diagnosis of pheochromocytoma. Plasma-free metanephrine testing is the most sensitive test (99%). Because this conversion of catecholamines to metanephrines is an uninterrupted process within pheochromocytomas, the measurement of plasma concentration of metanephrines is a much more sensitive means of tumor detection than the measurement of rises in plasma catecholamines, which may be paroxysmal. Other clinical tests with lower sensitivities include urinary fractionated metanephrines, plasma catecholamines, urinary catecholamines, urinary total metanephrines, and urinary vanillymandelic acid.

Answer 84

4 New onset hydroureteronephrosis found after sphincter/sling placement in patients with a neurogenic bladder may be caused by bladder decompensation (detrusor noncompliance) that was not identified on pre-operative urodynamic studies. Provocative urodynamic studies (occlusion of the bladder outlet while filling), although once recommended to be performed prior to sphincter or sling placement has not been found to be highly accurate in determining the bladders ability to develop or lose compliance following an increase in outlet resistance, and is therefore of equivocal value. Persistent VUR and ureteral atony would not explain rapid decrease in renal function. Surgical obstruction of the ureters due to the sphincter placement would be seen in an acute setting. Six months following reimplantation, obstruction due to ureteral scarring would be unusual and would not be the most likely reason for the increased dilation seen in the upper tracts. Sphincter malfunction would result in incontinence. The most likely source of new onset hydronephrosis in this setting is either the development of detrusor noncompliance, or patient non-compliance with CIC and timed voiding intervals. Complete urodynamic evaluation and maintenance of a voiding-catheterization calendar will help delineate between the two possibilities.

Answer 85

4 Abiraterone irreversibly inhibits the products of the CYP17 gene including both 17,20-lyase and 17-alpha-hydroylase, resulting in a comprehensive block of androgen synthesis within the tumor, testes, and adrenal glands. As a result of inhibition of 17-alpha-hydroxylase, there is a decrease in cortisol synthesis with compensatory rise in ACTH, resulting in increased adrenal mineralocorticoid production. This can lead to HTN, hypokalemia, and fluid retention if concomitant glucocorticoids (such as prednisone) are not administered with abiraterone to attenuate these effects. Therefore, glucocorticoid should be given concurrently with abiraterone. Clinical adrenal insufficiency does not generally occur, likely due to mineralocorticoid precursors which have some glucocorticoid activity. Spironolactone may temporarily address the hypokalemia and HTN respectively, but are not treating the source of the problem. Fludrocortisone is a mineralocorticoid and would not be advisable as the patient is already suffering from mineralocorticoid excess. There is no need to discontinue abiraterone as the patient is responding to the therapy from a cancer perspective. Docetaxel chemotherapy would be reserved for failure of abiraterone therapy, which there are no signs of in this case.

Answer 86

5 Among patients with invasive bladder cancer, M-VAC chemotherapy will result in a complete pathologic response in 20% of patients prior to cystectomy. However, between 20-30% of patients with a clinical response will harbor residual invasive disease at the time of cystectomy. Accordingly, following chemotherapy this patient should undergo a cystoprostatectomy. There is no role for additional intravesical therapy in this patient. In addition, it would be inappropriate to place him on a surveillance protocol.

Answer 87

4 The body has three primary mechanisms to handle physiologic and pathophysiologic acid loads including buffers within the blood, CO2 excretion in the lungs, and intracellular pH. Chronic acidosis is characterized by respiratory compensation of the underlying metabolic process. This leads to an increased respiratory clearance of CO2 and a decreased pCO2 over time. The pH is not as low as in the acute condition, and plasma bicarbonate is less depressed due to the compensation. Compensation includes HCO3 reabsorption within the proximal convoluted tubule and increased hydrogen ion secretion. The anion gap is often normal in the acidosis of chronic renal failure.

Answer 88

4 This patient has congenital penile curvature which is often noticed in the postpubescent time period when the man becomes sexually active. Patients with congenital curvature of the penis can have ventral, lateral (most often to the left), or unusually, dorsal curvature. Photographs of the erect penis demonstrate a smooth curvature of the penile shaft. Patients usually are healthy young men classically presenting between the ages of 18 and 30 years old. Many of these patients have noticed curvature before passing through puberty but have presumed it to be normal. Evaluation is sought by the patient only when the abnormal curvature is brought to their attention from their sexual partner. There is usually no association with penile trauma which may lead to curvature from acute or subacute penile fracture and can cause acquired penile curvature. Peyronie's disease generally occurs in older men and is associated with pain on erection and gradual change in the degree of curvature. Another name for congenital penile curvature is chordee without hypospadias. Surgical repair, when necessary, is usually performed using a plication technique.

Answer 89

1 With regards to prostatic intraepithelial neoplasia (PIN): 1) Low-grade PIN should not be documented in pathology reports due to poor interobserver reproducibility and a relatively low risk of cancer following re-biopsy, 2) The expected incidence of HGPIN on needle biopsy is between 5-8%, 3) Although the diagnosis of HGPIN is subjective, interobserver reproducibility for its diagnosis is fairly high among urological pathologists, 4) The median risk recorded in the literature for finding of cancer sometime in the patient's life following the diagnosis of HGPIN on needle biopsy is approximately 24%, 5) The majority of publications that compared the risk of cancer following a needle biopsy diagnosis of HGPIN to the risk of cancer following a benign diagnosis on needle biopsy show no differences between the two groups, 6) Clinical and pathological parameters do not help stratify which men with HGPIN are at increased risk for a future diagnosis of prostate cancer, 7) A major factor contributing to the decreased incidence of cancer following a diagnosis of HGPIN on needle biopsy in the contemporary era is related to increased needle biopsy core sampling, which detects many associated cancers on initial biopsy, such that re-biopsy following HGPIN, even with good sampling, does not detect many additional cancers, 8) It is recommended that men do not need routine repeat needle biopsy within the first year following the diagnosis of HGPIN. Further studies are needed to confirm whether routine repeat biopsies should be performed several years following a HGPIN diagnosis. In contrast, atypical small acinar proliferation (ASAP) is a small foci of glands that exhibit some features of adenocarcinoma, it is believed this diagnosis is frequently due to insufficient biopsy material to make the diagnosis of prostate cancer and therefore repeat biopsy is recommended.Regarding ASAP: 1) An average of 5% of needle biopsy pathology reports are diagnosed as having ASAP, 2) Cases diagnosed as ASAP have the highest likelihood of being changed to prostate cancer upon expert review and urologists should consider sending such cases for consultation in an attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy, 3) Ancillary pathologic techniques using basal cell markers and AMACR (alpha-methyl-acyl-coenzyme A racemase) can decrease the number of ASAP diagnoses. 4) The average risk of cancer on a subsequent biopsy following a diagnosis of ASAP within a six month time period is approximately 40%, 5) Clinical and pathological parameters do not help predict which men with an atypical diagnosis have cancer on repeat biopsy, 6) Repeat biopsy should include increased sampling of the initial atypical site, and adjacent ipsilateral and contralateral sites with routine sampling of all sextant sites. Therefore, it is critical for urologists to submit needle biopsy specimens in a manner in which the sextant location of each core can be determined, 7) All men with an ASAP diagnosis need re-biopsy within three to six months. It is critical for urologists to distinguish between a diagnosis of HGPIN and that of ASAP on needle biopsy. These two entities indicate different risks of carcinoma on re-biopsy and different recommendations for followup.

Answer 90

2 Magnesium depletion occurs with diuretic use, diabetic ketoacidosis, alcoholism, and prolonged nasogastric suction. The latter is associated with hyperchloremic metabolic acidosis. For reasons that are not clear, this eventually results in hypocalcemia and hypomagnesemia. When hypokalemia is associated with hypomagnesemia, potassium replacement cannot be accomplished until magnesium is replenished. Hypomagnesemia is one of the chief causes of inability to replenish body stores of potassium associated with prolonged nasogastric suction. If not corrected, hypomagnesemia will lead to an alteration in mental status and seizures.

Answer 91

3 Several sodas are acidified by citric acid and contain an amount of citrate equal to or greater than that of lemonade, including Diet Sunkist Orange, Diet 7Up, Sprite Zero, Diet Canada Dry Ginger Ale, Sierra Mist Free, Diet Orange Crush, Fresca, and Diet Mountain Dew. All of the aforementioned sodas have the potential to decrease the risk of kidney stones similar to or greater than lemonade. In contrast, colas, including Caffeine Free Diet Coke, Diet Coke, Diet Coke with Lime, Coke Zero, Caffeine Free Diet Pepsi and Pepsi, are acidified by phosphoric acid, not by citric acid and contain low citrate levels. One randomized study of recurrent stone formers with baseline soda consumption \> 160 ml per day, found that over a three-year period those who abstained from any soft drink consumption had a lower risk of symptomatic stone events (34%) compared to those who continued to drink sodas acidified by phosphoric acid (41%; RR, 0.83).

Answer 92

1 Local recurrence after radical nephrectomy is rare with an incidence of 2.9%. In addition, it is associated with a poor prognosis. Patients with local recurrence treated nonsurgically have a low survival rate. In addition, the presence of synchronous metastasis is associated with a significantly lower survival rate. Best outcomes are reported in those patients treated with surgical resection for isolated local recurrence only. Other factors, including time to local recurrence, location in the ipsilateral adrenal or renal fossa, and size of local recurrence are not independently associated with a worse outcome. Overall, five year survival rates for patients with surgically resected isolated local recurrences are approximately 30%.

Answer 93

4 The best choice for management is a tetanus immunization if he is not up to date, antibiotics, debridement, and primary closure with drainage. 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. 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 94

3 D-penicillamine is used in the management of patients with cystine stones. D-penicillamine is a chelating agent that produces complexes 50 times more soluble than cystine. Side effects include gastrointestinal disturbances, fever and rash, arthralgia, leukopenia, thrombocytopenia, proteinuria with nephrotic syndrome, and polymyositis. It can lead to pyridoxine (Vitamin B6) deficiency and supplementation is recommended with 50 mg/dl.

Answer 95

1 Recent studies on the outcome of 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. The AUA Guidelines for follow-up of clinically localized renal 6s has recently been published. Evidence based recommendations for follow-up should be tailored according to pathologic stage. This patient has stage T1aNo disease. For patients with stage pT1 disease, routine abdominal CT scans are not necessary, however, a yearly chest x-ray for three years is now recommended per AUA Guidelines. For stage pT2 and pT3 patients, it is recommended to obtain chest x-ray and CT scan every six months for three years, then annually to year five.

Answer 96

5 Bladder dysfunction in PUV is common. Three distinct forms of bladder dysfunction have been characterized including detrusor overactivity, decreased capacity/compliance, and myogenic failure. In infants, decreased capacity/compliance predominates which then transitions to detrusor overactivity as the child grows older. In adolescents, myogenic failure is the most common pattern seen which results in a large capacity bladder with decreased sensation and a variable degree of bladder wall compliance. Patients may have incontinence from poor emptying and overflow patterns. Management options include timed voiding, double voiding, alpha-blockers, and CIC. While sphincteric injury can occur, it is uncommon, as is the finding of an occult neurogenic bladder in children with PUV.

Answer 97

1 Due to routine bacterial colonization of struvite calculi, any stone fragments left behind following destruction or removal of struvite calculi places the patient at a high risk of both recurrent UTI and stone disease. Significant efforts should be made to render all patients with struvite stones, stone-free. In patients where this is not possible, Acetohydroxamic acid (AHA), a urease inhibitor may be of benefit. AHA has been shown in randomized controlled studies to decrease growth of residual struvite stone fragments, but does not decrease stone recurrence in patients who were made stone free at the time of their surgical procedure. Adverse reactions have occurred in up to 30% of the patients receiving AHA. Most of these reactions are mild in nature and do not require cessation of treatment. Specifically, about 25% of patients will complain of mild headaches and gastrointestinal symptoms within the first 72 hours of starting the treatment. These symptoms are mild, transitory, and should not result in interruption of treatment. It is noteworthy that numerous patients have noted the development of a nonpruritic macular skin rash of the face and upper extremities when concomitantly consuming alcohol. The rash commonly appears 30-45 minutes after ingestion of alcoholic beverages. It characteristically disappears spontaneously in 30-60 minutes. Patients should therefore be counseled to either avoid using alcohol or use smaller quantities of it.Three clinically significant side effects may result in either temporary cessation of treatment or complete withdrawal: 1) Superficial phlebitis involving the lower extremities has been seen in a number of patients on AHA, rarely will these patients advance to deep vein thrombosis. If this side effect should occur, the medication can be temporarily withdrawn and then restarted almost invariably without ill effects. 2) The most serious side effect of AHA is hemolytic anemia, found in up to 15% of the patients placed on this medication and is more prevalent in patients with renal insufficiency. AHA is a known inhibitor of DNA synthesis and chelates iron. Its bone marrow suppressant effect is probably related to its ability to inhibit DNA synthesis, but anemia could also be related to depletion of iron stores. Subsequently, a decrease in the hemoglobin and hematocrit may arise while on chronic use of this medication. Abnormalities in platelet or WBC have not been noted. Systemic symptoms may be associated with the anemia and are classically described as concurrent malaise, lethargy, and fatigue, and gastrointestinal symptoms (3% of patients with GI symptoms will have concurrent hemolytic anemia). Symptoms and laboratory findings have invariably improved following cessation of treatment. Due to the frequency of this side effect, monitoring patients with quarterly CBC analysis is recommended. 3) Severe depression and or anxiety will arise in 5% of patients. These symptoms are poorly treatable by pharmacologic means and when they develop, interruption or discontinuation of treatment is recommended. AHA is not associated with alterations in liver function, calcium, or magnesium metabolism.

Answer 98

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 99

2 Preservation of the sacral nerve arcs, as indicated by an intact bulbocavernosus reflex, suggests the potential for detrusor-sphincter dyssynergia. While other parameters such as lower extremity movement, spontaneous voiding, and normal anal sphincter tone may also suggest the presence of intact sacral arcs, the bulbocavernosus reflex is the most clinically specific. Unlike spinal cord injury, in lumbosacral spina bifida neural function and urodynamic findings cannot be predicted by the level of the lesion.

Answer 100

4 The patient has suffered a significant burn to the penile shaft. Most genital burns are full thickness with significant tissue sloughing of the penis and urethra in the days following injury. Conservative management, including suprapubic tube placement in the bladder, should be maintained until the full extent of injury is known. Many times, prolonged bladder drainage is required in these patients due to the extent of their injury. Suprapubic cystostomy is preferred over urethral catheterization in order to avoid further urethral damage with catheterization, instrumentation, contrast studies, or endoscopy. Penile debridement is not indicated at this early stage of injury and retrograde urethrogram will not provide useful information four hours after injury.

Answer 101

5 Currently available 5-alpha-reductase inhibitors (finasteride and dutasteride) lower serum PSA in patients with and without prostate cancer. The doubling rule has been used to compensate for PSA reductions in patients on these medications. With growing experience and data from long-term clinical trials using these drugs (e.g. PCPT and PLESS), the effect on PSA and prostate cancer detection has been more clearly defined. Although the doubling rule does accurately reflect the population as a whole, given the wide intra and interindividual variability of serum PSA changes while on these medications, it is relatively inaccurate in the individual patient. While treatment of patients with either finasteride or dutasteride results in a -50% median change in the group as a whole, the 5th to 95th percentile range is -81-20%. Recent analysis of long-term data regarding the change in PSA in men receiving 5-alpha-reductase inhibitors, suggests that in the first year the doubling rule overestimates PSA and can systematically lead to an increased likelihood of prostate biopsy. Beyond 24 months (with further decline in PSA), the doubling rule may underestimate PSA and result in fewer biopsies. As most patients receiving these drugs attain a nadir serum PSA, a sustained increase from nadir can be used to prompt biopsy the same way as it would in untreated patients. Using a 0.3 ng/ml increase from nadir as a trigger for biopsy maintains a sensitivity and specificity similar to an absolute value of 4.0 ng/ml in untreated patients. Free and total PSA ratio should remain unaffected by 5-alpha-reductase inhibitor use. In the absence of infection, there is no indication for use of antibiotics. PCA3 is only FDA-approved for patients with a prior history of a negative biopsy.

Answer 102

3 After brain tumors, neuroblastoma is the most common malignant solid tumor of childhood. More than half of these originate in the abdomen and a palpable abdominal mass is the most common finding. Periorbital metastatic disease is common, causing periorbital edema, proptosis, or raccoon-like ecchymoses. Tuberous sclerosis is associated with facial lesions of adenoma sebaceum in 75% of cases. These lesions are firm, discrete, red or brown telangiectatic papules (facial angiofibromata), and are typically located on the nasolabial folds, chin, and cheeks. Renal angiomyolipomas occur in 40-80% of patients with tuberous sclerosis. Wilms' tumor typically presents as an abdominal mass or with gross hematuria. Hodgkin's disease and leukemia often present with fever, night sweats, or fatigue. Neither Wilms' tumor, Hodgkin's disease, nor leukemia are associated with facial or periorbital lesions.

Answer 103

2 The patient’s presentation is characteristic for scabies. Scabies infestation is associated with overcrowding and poor health conditions. Severe pruritis is the hallmark of scabies and involvement of the external genitalia is very common. The characteristic findings on exam are small erythematous papules and thin grey or white burrows. Treatment of choice for scabies is 5% permethrin cream applied to the entire body overnight with a second application one week later. Clotrimazole is useful for treating candida but the examination is not consistent with candidal infection. Herpes simplex virus does not produce pruritis and there is no need for biopsy.

Answer 104

2 Perioperative mitomycin C is effective in decreasing the chance of recurrence in short term (one to two years), however there is no effect on progression or long term recurrence rate, and no significant differences in complications has been reported when compared to other intravesical therapies.

Answer 105

2 Mesoblastic nephromas are infiltrative tumors not amenable to partial nephrectomy. Rhabdoid tumors are highly malignant and similarly are best treated by radical nephrectomy. Lymphomas are optimally treated with systemic chemotherapy and neuroblastomas rarely involve the kidney. If the neuroblastoma involves the renal hilum, radical nephrectomy is often necessary. In the treatment of Stage V (bilateral) Wilms' tumor, renal preservation is important and hence partial nephrectomy is preferred when appropriate (mass amenable to partial nephrectomy) following chemotherapy.

Answer 106

3 While this patient has depression, this is not specific for testosterone deficiency, and low testosterone should be demonstrated before initiating therapy. The patient has a normal total testosterone but a low free testosterone measured by an analog assay. The gold standard techniques for measurement of free testosterone are ultracentrifugation or equilibrium dialysis. Immunoassays, while convenient and widely available, utilize a testosterone analog and do not give accurate results. Measurement of bioavailable testosterone or free testosterone measured by ultracentrifugation or dialysis should be utilized. Calculated free testosterone which utilizes the total testosterone, sex hormone binding globulin with or without albumin levels, may also be used if the prior tests are not available. Determination of LH and prolactin may be indicated with low total testosterone levels to differentiate between primary and secondary hypogonadism. Since the total testosterone is normal, there is no role for LH or prolactin determination in this patient. While estradiol does increase with obesity, there is no indication for measurement of estradiol in this patient. Aromatase inhibitors are often used off label in patients with elevated estradiol levels and symptomatic gynecomastia. This is second line therapy and should not be initial therapy in most patients since long term safety has not been assessed. Long term use of aromatase inhibitors may result in elevation of liver function tests and affect bone health. Testosterone replacement therapy should not be instituted without demonstrating a low testosterone level.

Answer 107

4 A randomized, placebo-controlled trial Selenium and Vitamin E Cancer Prevention Trial [SELECT] of 35,533 men randomly assigned to four groups (selenium, Vitamin E, selenium/Vitamin E, and placebo) was performed in a double-blind fashion. Baseline eligibility included age 50 years or older (African American men) or 55 years or older (all other men), a serum prostate-specific antigen level of 4 ng/ml or less, and a digital rectal examination not suspicious for prostate cancer. Patients received oral selenium (200 µg/d from L-selenomethionine) and matched Vitamin E placebo, Vitamin E (400 IU/d of all race-alpha-tocopheryl acetate) and matched selenium placebo, selenium/Vitamin E, or placebo/placebo for a planned follow-up of minimum of seven years and a maximum of 12 years. There were no differences in prostate cancer risk between the four groups. However, there were statistically nonsignificant increased risks of prostate cancer in the Vitamin E group (P=.06) and type 2 diabetes mellitus in the selenium group (relative risk, 1.07; 99% CI, 0.94-1.22; P=.16) but not in the selenium/Vitamin E group. The conclusion of the study was that selenium or Vitamin E, alone or in combination at the doses and formulations used, did not prevent prostate cancer in this population of relatively healthy men. Non-GU cancers were unchanged.

Answer 108

2 Combination chemotherapy with or without extirpative surgery has improved the prognosis for patients with rhabdomyosarcoma. The prostate has the worst prognosis as pertains to organ of origin, and radical surgery may be required if there is lack of response to non-operative treatment. The best prognosis in rhabdomyosarcoma has been associated with vaginal origin and embryonal histology.

Answer 109

4 The need for an imaging study to confirm stone/fragment clearance after ureteroscopy with lithotripsy, although controversial, is widely accepted. These imaging studies are performed to document: 1) clearance of the stone/fragments. 2) resolution of preoperative obstructive hydronephrosis, and/or, 3) rule-out the development of obstruction from a ureteral stricture. The need for these follow-up studies in an asymptomatic patient is, however, subject to debate. At the foundation of this controversy is the low incidence of obstruction following ureteroscopic stone extraction, the ability of the patient’s symptoms to predict ureteral obstruction, the unknown time of when a ureteral stricture occurs post-instrumentation, the renal salvage rate following relief of the obstruction, and the cost of a lost kidney versus the need to the need to contain medical costs. Obstruction after ureteroscopic stone extraction has a reported incidence of 1-4%, with the majority of obstructions due to a persistent stone fragment, a ureteral stricture is found to be the cause of the obstruction \< 30% of the time. It is noteworthy, that when obstruction is present the vast majority of patients are symptomatic with the incidence of asymptomatic obstruction reported to range from 0.25-2% of patients undergoing ureteroscopic stone extraction. Stated another way, if obstruction develops post-ureteroscopic stone extraction, the majority of patients will be symptomatic. Indeed, a number of investigators have reported on the safety of selective imaging of only symptomatic patients, as opposed to the use of routine imaging after ureteroscopy. These authors center their recommendation for selective renal imaging based on the facts outlined above and believe that routine imaging to detect the rare case of silent obstruction is not cost-effective. The authors of the AUA Guidelines for imaging in patients with ureteral calculus acknowledge this controversy and note that the Level of Evidence for their recommendation for routine post-operative imaging is low (Grade C). In patients with a preoperative radiopaque calculi who have undergone ureteroscopy and lithotripsy, the Guideline Panel believes that the combination of a KUB and sonogram provides the best means to identify the patient who will require either additional imaging or interventional treatment. (Remember, retained stone fragments are the most common etiology overall for obstruction and may be missed byultrasound alone.) If the patient is asymptomatic and KUB/sonogram show no stones or hydronephrosis, no further imaging is required. If KUB/sonogram demonstrates hydronephrosis and/or residual fragments, further observation with repeat imaging or treatment is indicated. Patients with radiolucent stones or individuals who have undergone ureteroscopy and removal of stone without lithotripsy should undergo a renal ultrasound alone. CT scan is utilized for evaluation if the patient is symptomatic or if hydronephrosis is found on the screening ultrasound. It should be noted that the timing of the follow-up imaging studies is left to the discretion of the treating physician and generally ranges from one to three months post-ureteroscopy. The lack of a specific recommendation regarding a time interval on when to obtain the post-ureteroscopic image is based on inconsistent and limited data regarding rapidity of ureteral stricture development after ureteroscopic stone extraction. Whether the obstruction is incomplete or complete, the impact of pyelolymphatic and pyelovenous back flow on renal preservation and the unknown length of time obstruction needs to be present to cause irreversible renal loss.

Answer 110

3 This lesion likely represents an adenomatoid tumor, however, one cannot rule-out sarcomas. Adenomatoid tumors are the most common tumor of the paratesticular tissues, accounting for approximately 30% of all paratesticular tumors. There has never been a documented case of metastasis. Most occur in individuals in their twenties or thirties. Tumors present as small, solid, asymptomatic masses generally found on routine examination, ranging from 0.5-4 cm in size. They are typically located in the anatomic distribution of the epididymis, testicular tunicae, and rarely, the spermatic cord. Most tumors will arise in or adjacent to the upper or lower pole of the epididymis, with a slightly higher incidence in the lower pole. The definitive treatment is surgical excision through an inguinal incision. Transscrotal incision is contraindicated because malignancy has not been ruled out. Fertility status, and/or semen analysis, and/or fertility preservation should be discussed with the patient prior to the procedure.

Answer 111

4 Exteriorization of the dome of the bladder by the Blocksom technique will prevent prolapse of the bladder. Placement of the vesicostomy cephalad to the urachus immobilizes the peritonealized portion of the bladder dome. None of the other techniques have been shown to adequately immobilize the bladder and prevent the posterior wall of the bladder from extruding through the stoma.

Answer 112

1 The presentation is very strongly consistent with either torsion of an appendix or noninfectious epididymitis. Obtaining a VCUG or uroflow-EMG are unlikely to add any useful information. Neither STD treatment, nor antibiotics should be started without the findings of either a urethral discharge, positive UA, and/or admission of sexual activity. The most appropriate treatment includes NSAIDs as well as rest and scrotal support.

Answer 113

4 Several series have demonstrated that administration of hormonal deprivation therapy prior to radical prostatectomy does not lower the risk of biochemical relapse. Although tumor volume, stage, nodal status, and margin status appear improved in men receiving neoadjuvant hormonal ablation, the risk of biochemical relapse is equivalent to those men who do not receive any neoadjuvant therapy. Gleason scoring can be quite difficult in men who have received hormonal deprivation due to the noted treatment effect in the tissues. Among these men, Gleason score can appear artificially higher and it is recommended that Gleason score not be assigned.

Answer 114

4 Most renal cystic conditions whether congenital, acquired, or sporadic arise from the nephrons and collecting ducts after they have formed. Multicystic dysplastic kidney is an exception in that it arises prior to formation of the nephron. It results from the abnormal differentiation of the metanephric parenchyma during early embryologic development of the kidney. Autosomal recessive polycystic kidney disease occurs during the formation of the nephron and results from mutations in the PKHD1 gene that encodes for a membrane associated receptor like protein known as fibrocystin. Abnormalities in fibrocystin secretion result in dilation of the epithelial line tubules predominantly the renal collecting ducts and the bile ducts. Abnormal fibrocystin secretion, in addition to causing abnormal ductal development, stimulates fibrous connective tissue development resulting in congenital hepatic fibrosis. Autosomal dominant polycystic kidney disease is due to either a defect in the PKD-1 or PKD-2 gene, the former being more common. These genes encode for either polycystin-1 or polycystin-2 respectively. The polycystins function within the calcium channels and disruption of their activity will lead to cyst formation and fibrotic renal stroma and usually begin to become manifest in the second to third decade of life. Medullary sponge kidney is characterized by tubular dilation of the collecting ducts with associated cysts and diverticula. Juvenile nephronophthisis, although rare, is the most common genetic cause of childhood kidney failure and is characterized by fibrosis and cystic dysplasia of renal tubules.

Answer 115

4 In this patient, the best long-term treatment option is urethroplasty with buccal mucosa. It is felt that the use of extragenital tissue, namely buccal mucosa, reduces the risk of lichen sclerosis (LS) induced stricture recurrence as there is a theoretical field change effect of LS involvement of the entire genital skin. Meatotomy is an option, yet this may create a distal hypospadias appearance for this young man along with potential voiding issues if the meatus is cut too proximal on the glans. Meatal dilation is not effective in this setting and the outcomes of CO2 laser use for LS induced urethral meatal stricture disease is unknown.

Answer 116

3 In decreasing order of frequency, the most common sites of origin of extragonadal germ cell tumors are the mediastinum, retroperitoneum, sacrococcygeal region, and pineal gland, although many unusual sites have also been reported.

Answer 117

5 Hematuria after prolonged strenuous exercise is relatively common in individuals who are otherwise free of congenital urinary tract disease. There may be mild proteinuria with the RBCs. Erythrocyte casts are usually not present and the supernatant urine specimen is clear, ruling out significant hemoglobinuria. Hypercalciuria is not related to exercise, and therefore, the urinary calcium to creatinine ratio will be normal. The UA in this benign condition is generally normal 48-72 hours after the exercise. Myoglobinuria is characteristically brown without RBCs. Cystoscopy and CT urogram will be normal.

Answer 118

5 The incidence of Clostridium difficile infection (CDI) is increasing with a preponderance of the NAP1 hypervirulent strain of C. difficile found in recent epidemics. It is believed the NAP1 strain arose due to the widespread use of fluoroquinolone antibiotics. The NAP1 strain is more likely to cause severe and fulminant colitis, characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. While oral vancomycin and oral metronidazole are both considered standard therapies for CDI, recent studies suggest that vancomycin is more effective. Neither I.V. vancomycin nor I.V. metronidazole have been found to be more effective than the oral form of the medications for treatment of CDI. There is no role for fluoroquinolone antibiotics in treatment of CDI. This patient with development of worsening diarrhea, fever, and leukocytosis, demonstrates failure to improve following implementation of standard treatment and is an absolute indication for surgical consultation. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant CD colitis nonresponsive to medications and has been documented to result in improved survival.

Answer 119

5 Patients with high-grade T2 cancer are at a significant risk of occult regional disease or of development of this disease. Studies have shown that patients who have an immediate bilateral inguinal lymphadenectomy have an increased survival than if they develop palpable disease during follow-up. Although this patient currently has no evidence of adenopathy, he has a 59% risk of developing involved lymph nodes. Sentinel lymph node biopsy is gaining popularity, but still lacks sufficient sensitivity and specificity.

Answer 120

3 Radionuclide imaging using cortical scanning agents (DMSA, as opposed to MAG-3 which is filtered and excreted) will demonstrate an area of activity when the suspicious lesion is cortical hyperplasia (column of Bertin). MRI scanning will not differentiate this from other solid lesions. Although arteriography and CT scanning will both help in differentiating malignancy from pseudotumor, they are more invasive and expensive than renal scan and also have higher radiation exposure. They should be utilized only if the radionuclide study does not provide a definitive diagnosis.

Answer 121

5 Candida species are capable of causing severe infection and should be treated as a uropathogen. Suspected UTI should be treated prior to ureteroscopic stone treatment with surgery performed only after culture documented clearance of funguria. Neither irrigation nor intravenous administration of anti-fungals just prior to surgery is sufficient to reduce the risk of postoperative candidemia.

Answer 122

3 If this 6 cm tumor were contained within Gerota’s fascia, the pathologic (p)T stage would be pT1b. However, there is renal vein involvement that is now classified as pT3a (previously pT3b). Tumors with isolated renal vein thrombus are known to have a relatively favorable prognosis, and as a result are now staged as T3a rather than T3b. The margin status is designated as R1, but does not affect primary pathologic tumor stage.

Answer 123

3 Three percent of girls with inguinal hernias have complete androgen insensitivity syndrome. A testicle is found in the hernia sac and a chromosome analysis will reveal a 46 XY karyotype. They should be raised as females. 45 X0/46 XY chromosomal patterns are accompanied by a streak gonad most commonly. Elevated 17-hydroxyprogesterone is seen with CAH, but in this case the gonads would be ovaries. Patients with 5-alpha-reductase deficiency present with either proximal hypospadias or more ambiguous genitalia. Low testosterone with elevated LH and FSH occurs with abnormal testosterone production.

Answer 124

5 This man presents with symptoms of pyelonephritis. While uncomplicated cystitis in a young sexually active male may not require investigation beyond a follow-up urine culture, a complicated UTI in an older male warrants urologic evaluation such as CT urogram and cystoscopy due to the high incidence of associated urologic abnormalities such as obstruction from either urethral or ureteral strictures, tumor, or stones. Observation is incorrect. Localization cultures might be considered as part of a urologic evaluation but are not sufficient as isolated tests in the presence of a complicated febrile UTI. There is no justification for prophylaxis or complete urodynamic studies.

Answer 125

5 Progression while on docetaxel-chemotherapy defines failure of the docetaxel. Cabazitaxel is a novel tubulin-binding taxane drug with anti-tumor activity in docetaxel-resistant cancers. In a large Phase 3 trial, the efficacy and safety of cabazitaxel plus prednisone was compared to that of mitoxantrone plus prednisone. There was a 30% reduction in the risk of death with the cabazitaxel (15.1 months versus 12.7 months). None of the other agents listed have been shown to improve survival in men with castration-resistant prostate cancer. Two additional agents recently approved by the FDA which are abiraterone and enzalutamide, have been shown to also improve survival in this patient population. None of the other regimens have demonstrated a survival difference in this population of patients.

Answer 126

5 This patient is likely suffering from hypokalemia. Patients following vigorous bowel cleansing, even with Go-Lytely or other electrolyte solutions, will often have low potassium. The characteristic signs include muscular weakness with poor respiratory effort causing decreased ventilation in the presence of a normal chest x-ray. Latex allergy may present with itching, erythema, wheezing and coughing, or with anaphylactic shock and hypotension, and severe respiratory distress with or without loss of consciousness. Hypercalcemia may present with excessive thirst, nausea and vomiting, abdominal and joint pain, and lethargy. Muscle cramps, weakness and tremors, and cardiac arrhythmia, may develop in the patient with hypomagnesemia. Common signs and symptoms of pulmonary embolism include shortness of breath, chest pain similar to that experienced with a myocardial infarction, excessive sweating, rapid or irregular heart rate, and in some cases, loss of consciousness.