2015 Flashcards

Question

Two months following closure of a traumatic bladder rupture associated with a pelvic fracture, a 20-year-old man has persistent urinary leakage through the suprapubic cystostomy site despite voiding. The diagnostic test most likely to diagnose the etiology of the problem is: 1. CT urogram 2. pelvic MRI scan 3. fistulogram 4. cystourethroscopy 5. urodynamics.

Answer 1

4 When faced with a patient with a persistent urinary fistula, the acronym FETID will aid the physician in determining its etiology and hence management plans: F- Foreign Body, E- Epithelization of the fistula tract, T- Tumor or chronic trauma causing persistence, I-Infection or chronic inflammation arising from inflammatory bowel disease, radiation therapy, etc. D-Distal obstruction. In this young patient with a history of persistent fistula, following closure of a bladder rupture after a pelvic fracture, persistent drainage from a suprapubic tube site is most likely from either a foreign body within the bladder, i.e., bony spicule or bladder calculi formed as a nidus from the prior indwelling suprapubic tube or bladder outlet obstruction arising from either a bladder neck contracture or urethral stricture. The single best diagnostic study is cystourethroscopy. Pressure flow urodynamic studies could demonstrate findings consistent with high pressure voiding and outlet obstruction. But the source of the obstruction, which is likely a urethral stricture or a bladder neck contracture, would not be able to be determined by this test and this test does not rule-out the possibility of a foreign body within the bladder. A CT scan may allow one to visualize either a foreign body or bladder calculi to be present, but would not be able to assess the urinary outlet. Similarly, a fistulogram or pelvic MRI scan are unlikely to yield adequate diagnostic information in this situation to result in definitive operative plans.

Answer 2

5 The patient has peritoneal signs, which dictate exploration and intestinal diversion. If the patient did not have peritoneal signs, then repositioning the tube in the colonic lumen and placing a ureteral stent would be an optimal approach to prevent a nephrocolonic fistula.

Answer 3

3 Alvimopan, a peripherally acting µ-opioid receptor antagonist, is indicated to accelerate upper and lower GI recovery following surgeries that include a bowel resection. In October 2013, the U.S. Food and Drug Administration (FDA) authorized an expanded indication on the basis of a Phase 4 randomized multicenter clinical trial. In this trial, patients receiving alvimopan experienced more rapid bowel recovery and had a shorter hospital stay compared with those who received placebo. There were no differences with regard to early (\< 7 day) post-op ileus (POI) or 30-day all cause readmission rates between the two groups. Alvimopan has been associated with the potential for increased cardiac toxicity in patients with chronic narcotic use, and is therefore contraindicated in this patient population. In the aforementioned trial, such patients were excluded, and there were no differences in cardiac adverse events between the alvimopan and placebo groups. In a preplanned economic analysis of this study, alvimopan use decreased hospitalization costs by reducing health care services associated with POI and decreasing hospital length of stay; total costs were $2,640 lower per patient for alvimopan compared with placebo. The study did not address opiate consumption, but it is unlikely that a µ-opioid receptor antagonist should affect opioid intake. Instead, it would be expected to affect the peripheral effects of opioids on bowel motility.

Answer 4

3 There is no consensus as to whether transplanted ureters should be reimplanted into a recipient's native bladder with an antirefluxing technique. However, there is certainly a concern that reflux of infected urine and/or reflux associated with elevated detrusor pressures can be damaging to the transplanted kidney. This patient does not have any LUTS and there is no evidence of elevated storage pressures on her urodynamic study (i.e., no detrusor overactivity and normal compliance); thus, there is no reason to initiate therapy for OAB with either oxybutynin or mirabegron. She does abdominally recruit with some degree of Valsalva voiding at the end of her micturition, but that is unlikely related to bladder infections or pyelonephritis because she empties effectively. Decreasing her immunosuppression would not address the issue of her infections, would not minimize risk of future episodes of pyelonephritis, and would only place the kidney at possible risk for rejection. Low dose suppressive antibiotic therapy would be the appropriate next step to minimize future episodes of pyelonephritis. If this is not effective then revision of her ureteral reimplant with a non-refluxing neocystostomy should be considered.

Answer 5

4 The option with the best stone-free rate for larger ureteral stones is ureteroscopy. While SWL is acceptable, the best option is ureteroscopy for stones \> 1 cm according to the data extracted in the AUA/EAU Ureteral Stone Guidelines. A stone this large would likely not pass. Percutaneous stone removal would be definitive, but should only be considered when the patient already has a pre-existing nephrostomy tube or has failed a retrograde ureteroscopic approach or SWL.

Answer 6

4 Prostatic duct adenocarcinomas arise in the periurethral prostatic ducts, and usually grow as an exophytic lesion in the urethra. They can give rise to either hematuria or obstructive symptoms, and often both are present. These tumors are often underestimated clinically because serum PSA levels and DRE are often normal. Consequently, many ductal adenocarcinomas are at an advanced stage at presentation and have an aggressive course. They are graded as 44=8 because of their cribriform morphologic features. These tumors should be treated aggressively and approached surgically. There is no indication that ductal adenocarcinomas are more sensitive to radiation, and similarly, chemotherapy is not indicated in this situation.

Answer 7

3 Arterioureteral fistula (AUF) is a rare but acute condition that predominantly affects women (\> 70%) with a wide time range between the initial placement of the ureteral stent to fistulization, ranging from 2 to 25 years. Factors that should raise suspicion of an AUF include history of hematuria in a patient with indwelling ureteral stents especially in patients with a past medical history of prior abdominal or pelvic irradiation, pelvic surgery or aortoiliac or aortofemoral grafts. Although 55% of patients will present with a history of persistent gross hematuria plus or minus shock, 45% of patients present with herald bleeding (gross hematuria occurring from the ureteral orifice during a ureteral stent exchange.) When herald bleeding occurs as in the patient in this question, treatment should be pursued to prevent a possible exsanguinating emergent fistula complication. The diagnostic goal in these patients is to identify the specific location of the fistula. In patients with bilateral indwelling stents, the side in which the gross hematuria is found is helpful for locating the side involved but is nonspecific in nature. Computed tomographic angiography will document the location in \< 40% of patients. However, it may be useful because it can identify a concurrent periarterial abscess, aneurysmal enteric communication, aneurysmal dilation, significant arterial calcification, and concomitant thrombus. Diagnostic provocative angiography with selective iliac views remains the gold standard and is 90% diagnostic. Provocative angiography will require exchange of the double-J ureteral stent for a straight ureteral catheter. This will allow the interventionalist the ability to manipulate the ureteral stent at time of angiography to induce bleeding and identify the site and location of the fistula. While exchanging the stent, it is imperative not to lose access to the ureter; this procedure is best done in an endovascular suite with an operative team immediately available. It should be noted that a minority of patients, 10% will be empirically treated for an AUF without identification of the exact AUF location. These individuals will have a history of herald hematuria with predisposing factors for AUF and no other identifiable source of urinary bleeding. Prior studies have documented that once the AUF has developed, simple removal of the stent is inadequate for fistula closure. Previously, open repair of the fistula (often with vascular bypass procedure of the affected vessel and percutaneous nephrostomy tube placement) was the standard therapy. However, recent advances in endovascular stents have made this the least morbid procedure and the best initial therapeutic option. It is noteworthy that after placement of an endovascular graft, greater than 60% of the patients are still treated by chronic ureteral stent drainage along with chronic antibiotic prophylaxis, while the remaining 40% are managed by either permeant ipsilateral nephrostomy tube drainage or nephrectomy.

Answer 8

4 Drug-induced renal calculi represent 1-2% of all renal calculi. They include two categories: those resulting from the urinary crystallization of a highly excreted, poorly soluble drug or drug metabolite, and those due to the metabolic effects of a drug. Four drugs that can induce calculi through precipitation of the medication or its metabolite include: 1) Indinavir, a protease inhibitor used to treat HIV infections, 2) Magnesium Trisilicate, an antacid used to treat gastroesophageal reflux, 3) Triamterene, a potassium sparing diuretic used to treat edema and HTN, 4) Ephedrine used in a variety of nutritional or energy supplements for its stimulant properties, can when used alone or in combination with guaifenesin, the combination used as an expectorant, induce calculi containing either ephedrine, or both ephedrine and guaifenesin. Five commonly used medications may induce physiologic changes that can lead to metabolic abnormalities that facilitate the formation of calculi these include: 1) Loop diuretics (Furosemide, Lasix), it is noteworthy that up to two thirds of low-birth-weight infants who have received furosemide therapy will develop precipitation of calcium crystals, 2) Carbonic anhydrase inhibitors, drugs such as acetazolamide (Diamox), used to treat glaucoma, altitude sickness, and epilepsy, and 3) topiramate (Topamax), an anticonvulsant medication used to treat refractory seizures, can produce severe hypocitraturia and high urinary pH, and will induce calcium phosphate calculi in up to 2% of patients on long-term therapy, 4) Zonisamide (Zonegran), a sulfonamide anticonvulsant will result in the formation of calcium phosphate calculi in 4% of the patients on this mediation, 5) potential laxative abuse should be considered when ammonium acid urate calculi are found in the absence of UTI or bowl disease. Carbamazepine (Tegretol) used to treat seizure disorders, nerve pain and bipolar disorder is not known to be associated with urolithiasis.

Answer 9

1 Every reasonable effort should be made to obtain a negative proximal margin before re-implantation when a frank tumor is encountered at the margin. However, the findings of CIS at the ureteral margin (either at the time of frozen section or on final pathology) is more uncertain. The group at Memorial Sloan Kettering has questioned the value of achieving a negative margin because this did not alter the risk of development of subsequent upper tract tumor and CIS of the ureter is not independently associated with a worse outcome following cystectomy. Cancer recurrence at the anastomosis is rare even with a positive margin showing CIS, but a positive margin is a risk factor for developing a second primary tumor of the ureter or renal pelvis. Schumacher and colleagues demonstrated that upper tract recurrences occur in 3% to 5% of patients, and they are usually at sites distant from the anastomosis. However, they found no correlation between frozen and permanent section findings in their cohort.Accordingly, the data would suggest that patients with CIS at the ureteral margin may have a mildly increased risk of an upper tract recurrence (often remote from the margin, either on the ipsilateral or contralateral side). As a result, such patients (like all patients with invasive bladder cancer) require close follow-up with upper tract surveillance. Although the most commonly performed method of upper tract surveillance is with imaging (e.g., CT urogram), the most sensitive means involves surveillance ureteroscopy, and this can be used in patients with a very high degree of suspicion for upper tract recurrence. The median time to occurrence in one recent series was 53 months. Pre-emptive antegrade brush biopsy is not indicated at this time in the absence of obstruction or other abnormalities in imaging. BCG is also not indicated, as the finding of CIS at the margin only suggests a slightly increased incidence of recurrence, and often this recurrence is at a location remote from the margin site. Similarly, pre-emptive re-implantation or ipsilateral nephroureterectomy are not indicated or warranted as most patients will not have a local recurrence or ipsilateral upper tract recurrence.

Answer 10

4 During laparoscopic surgery, electrosurgically induced thermal injury may occur via one of four mechanisms: inappropriate direct activation, coupling to another instrument, capacitive coupling, and insulation failure. Intraoperatively, thermal injuries of the bowel may present as whitish spots on the serosal lining. In severe cases, the muscularis mucosae or the intestinal lumen may be seen. However, in many patients, thermal injury of the bowel is not realized at the time of the procedure. Postoperatively, the patient with unrecognized bowel trauma may not develop fever, nausea, or signs of peritonitis for three to seven days; the full extent of the bowel necrosis may take up to 18 days to fully develop. Therefore, the problem often does not become manifest until the patient has been discharged. Accordingly, bowel injury must be ruled-out for any patient who develops a fever beyond postoperative day one or who complains of increasing abdominal discomfort. Abdominal radiographs are notoriously inaccurate because the carbon dioxide from the laparoscopy may remain as free air for more than two weeks after the procedure; however, an ileus pattern is usually present. An abdominal ultrasound will similarly be nonspecific and may detect loops of bowel or free fluid. The more sensitive test is an abdominal CT scan with oral contrast and delayed films. Minor postoperative thermal injuries of the bowel may be managed conservatively, aided by administration of antibiotics and an elemental diet. However, if the patient does not respond rapidly or develops worsening peritonitis, open surgical exploration is mandatory. Thermal injury caused by monopolar cautery often results in tissue damage that extends beyond the visible area of necrosis. With this in mind, the surgeon should perform a bowel resection with a safety margin of 6 cm on either side before completing an end-to-end anastomosis. Thermal injury caused by bipolar electrosurgery is more confined to the visible area of damage; thus, if the injury is small, it can be managed by simple excision of the defect and closure of the bowel wall. Injuries that involve more than half of the circumference of the bowel should be treated by excision of the affected bowel segment and end-to-end anastomosis.

Answer 11

5 Decreasing the rate of shock wave administration from 120 to 60 shocks per minute results in improved stone-free rates. A slower treatment rate of proximal ureteral stones reduces the need for additional SWL or more invasive treatments to render patients stone-free without any increase in morbidity and with an acceptable increase in treatment time. The hypothesized mechanism of this effect is due to the formation of cavitation bubble cloud around the stone, which may shield the stone from subsequent shock waves. This effect is most pronounced at higher shock wave frequency.

Answer 12

1 Bosniak classifications of renal cysts are:1) Simple hairline thin cyst wall, Hounsfield units \< 102) Simple hairline thin cyst wall, few hairline thin septa within cyst, short, thin areas of calcification maybe present, septa and wall do not enhance, Hounsfield units \< 10. The patient described in the question has a Bosniak 2 cyst. No follow-up evaluation is indicated for a class 1 or 2 Bosniak cyst.2F) Thickened cyst wall, multiple septa that may be thickened or contain calcium, Hounsfield units of 10-15 no significant enhancement with contrast. Follow-up is indicated due to an increased risk of malignancy (5-10%). These cysts should therefore undergo periodic surveillance with no set time limit; evaluations every 6-12 months have been purposed. Biopsy is not indicated due to poor reliability in sampling areas of concern.3) Cystic mass with thickened wall, thick irregular septum, cyst wall or septa enhance with contrast, Hounsfield units \>15.4) Cystic mass with thickened wall, thick irregular septum, cyst wall, septa, and areas within cyst, not associated with the wall or septa enhance, Hounsfield units \>15.Both Bosniak 3 and 4 cysts should at a minimum be considered for a biopsy or alternatively surgical excision.

Answer 13

5 BPH is a histological diagnosis. This patient has not had a biopsy. Benign prostatic obstruction is a urodynamic diagnosis made on the basis of the relationship between pressure and flow. The poor flow rate in this case may be due to either detrusor underactivity or bladder outlet obstruction and is not diagnostic of either entity. Detrusor overactivity and detrusor underactivity are urodynamic diagnoses that cannot be made in the absence of a urodynamic study. LUTS is a generic term describing LUTS and does not imply an underlying pathology or pathophysiology.

Answer 14

2 The patient presented here is Index Patient 2 of the AUA Guidelines and should be considered for sipuleucel-T immunotherapy. This patient is only minimally symptomatic (not requiring narcotics) and thus is a candidate for sipuleucel-T, which has demonstrated a survival advantage in this patient population. Abiraterone acetate is also an option but is not listed here. The other treatment options are not appropriate for Index Patient 2. Cabazitaxel is indicated for patients who have failed prior docetaxel chemotherapy. Radium-223 in general is reserved for patients with symptomatic bone metastases. Mitoxantrone has not been shown to provide a survival advantage and in general has been used for palliative purposes in symptomatic patients.

Answer 15

1 This patient has a persistent mass following hormonal therapy for endometriosis invading the bladder. She had an adequate trial of GnRH agonist therapy. The next step is upper tract imaging; this test should be obtained in all patients with pelvic endometriosis prior to and following hormonal therapy, and again prior to surgical intervention due to the potential for silent upper urinary tract obstruction which can occur in 10-20% of these women. Repeat biopsy of the bladder mass, endoscopically or percutaneously, is unlikely to be helpful as it will show either fibrosis or persistent endometriosis. Partial or radical cystectomy is overly aggressive and certainly not indicated until the upper tracts have been evaluated. An anatomic study with CT urogram will provide more information than nuclear renography and will complete the hematuria workup.

Answer 16

2 Thiazide diuretics will lose their effectiveness in the treatment of hypercalciuria in up to 25% of patients on long-term management. The loss of effectiveness is due to increased serum calcium levels which stimulate the C cells in the thyroid to produce more calcitonin. Increased calcitonin leads to increased urinary calcium excretion. Increased dietary calcium, decreased patient compliance, increased GI absorption or increased PTH could all lead to hypercalciuria, but are not the proposed mechanisms for tachyphylaxis with thiazides.

Answer 17

2 In women with recurrent symptomatic UTI, continuous low-dose antibiotic prophylaxis or if the recurrent UTI can be related to intercourse post-coital antibiotics are indicated. Appropriate antibiotics include: trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. Fluoroquinolones should be reserved for instances of bacterial resistance or allergy. Therapy is usually continued for six months followed by a trial period off prophylaxis. Other strategies such as post-coital voiding, changing to cotton underwear, wiping away from the urethra and avoidance of hot tubs have not been shown to decrease the rate of infections. Cystoscopy is not indicated for recurrent simple cystitis in women.

Answer 18

1 ANOVA (analysis of variance) is used when comparison is being made between the mean of more than two groups. A t-test is used to make comparison between the mean of two groups. Chi-square test is used to compare differences in proportions. Pearson r test is used to evaluate the strength and direction of an association. Spearman rank order correlation is used to compare ordinal data.

Answer 19

3 It is very unlikely that this patient, who is in complete urinary retention one month after a retropubic mid-urethral sling, will resume normal voiding. If the patient had undergone an autologous sling, it would be appropriate to wait three months before intervening as spontaneous sling loosening may occur with resorption of the sling. In this patient with a synthetic sling, if she desires to void spontaneously, she will need to have the sling loosened or cut. Sling loosening may be attempted within the first week to ten days after surgery, but this must be done surgically by exposing the sling and attempting to loosen it and not by urethral dilation. If loosening is not selected or is ineffective, the sling will need to be cut. Incision of the synthetic sling will restore voiding in approximately 90% of patients; however, recurrent stress incontinence may occur in 15-20% of patients. Transvaginal urethrolysis is indicated when an incision does not work or if the urethra is felt to be fixed to the underside of the pubic symphysis. Suprameatal urethrolysis is unnecessary following mid-urethral sling procedures, as there is very little scarring immediately anterior to the urethra, and the obstruction is presumablye due to excessive obstruction from the suburethral sling. Classically, suprameatal urethrolysis is indicated for obstruction following a Marshall-Marchetti-Krantz procedure, or for persistent obstruction following sling incision and/or transvaginal (submeatal) urethrolysis.

Answer 20

4 The need for ventriculo-peritoneal shunting was found in approximately 70% of the infants in the prenatal-surgery group and 98% of those in the postnatal-surgery group. Prenatal surgery also resulted in improvement in the composite score for mental development and motor function at 30 months (p=0.007) and an improvement in several secondary outcomes, including ambulation by 30 months. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at delivery. There has been no documentation of a positive effect on the incidence of spinal cord tethering, urinary continence or bowel function with in utero myelomeningocele repair. In non-randomized, controlled studies, prenatal surgery has not been shown to result in improved bladder dynamics nor function compared to historical controls.

Answer 21

3 Urologists frequently obtain imaging studies utilizing I.V. contrast agents that are often performed in the office under their direct supervision. Since use of these agents is associated with adverse events including potentially life-threatening anaphylactic-like reactions, an appreciation of the risk factors predisposing to these adverse events is essential. Adverse reactions to radiocontrast media are classified as either systemic allergic-type reactions or chemotoxic-type reactions. Chemotoxic events arise as a result of the physiochemical properties of radiocontrast agents, and include contrast-induced renal failure and seizures. Individuals with poor renal function, diabetes and intravascular volume depletion are predisposed to these events. Obesity, due to its association with metabolic syndrome and diabetes, is a known risk that increases the patient's susceptibility to a chemotoxic event.System allergic-type reactions occur due to the release of active cellular mediators that can result in urticaria, bronchospasm, laryngeal edema, hypotension, and anaphylaxis-like reactions. Patients who have a history of multiple systemic allergies (drug or nutritional allergies) or a history of asthma account for an inordinately large percentage of patient with allergic reactions. In point of fact a history of asthma results in a 3-5x increased risk of a systemic allergic type of reaction to radiocontrast media. Allergy to Betadine is a type of contact dermatitis and not associated with increased risk. There does not appear to be any racial differences in risk to either type of event.

Answer 22

5 Autonomic dysreflexia (AD), a syndrome of unopposed sympathetic discharge classically occurs in patients with a complete spinal cord injury (SCI) at or above T-6 (above the T10-L2 sympathetic outflow. This dysreflexic response will typically occur secondary to, visceral distension (bladder or bowel), or pain stimulation below the level of the lesion. Symptoms classically are sweating and diaphoresis above the level of the lesion, a blood pressure rise of \> 20 mm Hg over baseline levels, headache and bradycardia. In the treatment of AD, it should always be assumed that the bladder is distended and/or the urethral catheter malpositioned. Drainage of the bladder, placement of a urethral catheter, or verification that an indwelling catheter is functional and in the correct position, should always be the first step in management. All clothing should subsequently be loosened and the patient's upper torso should be elevated. If these maneuvers do not result in a decrease in blood pressure, topical or oral nitroglycerin is the recommended first line medical therapy. Topical nitroglycerin is preferred due to the ability to wipe off the medication from the skin if rebound hypotension should occur. Prior to nitroglycerin use, it must be verified that the patient has not taken a PDE-5 inhibitor within the prior 24 hours, the combination of NTG and a PDE-5 inhibitor increases the risk of severe rebound hypotension. If the patient has used a PDE-5 inhibitor, captopril 25 mg given sublinguinally or chewed is the drug of choice. Sublingual nifedipine once routinely recommended for this complication is no longer the drug of choice due to variable absorption, and episodic rebound hypotension that has resulted in strokes or myocardial infarction. If the blood pressure does not improve rapidly or rebound, HTN develops the patient should be examined for other causes of AD including fecal impaction, renal or bladder calculi, decubitus ulcers and asymptomatic broken bones.

Answer 23

1 Parenteral testosterone injection therapy (testosterone enanthate or cypionate) will cause significant peaks and valleys in serum testosterone levels which can cause mood swings and variations in libido and potency (roller-coaster effect). Oral, subcutaneous, and transdermal preparations do not have this roller-coaster effect. The alkylated oral androgens, e.g., fluoxymesterone, methyltestosterone, have serious liver toxicity and adverse effects on serum lipids (increased LDL, decreased HDL) and should not be used

Answer 24

1 A presumptive diagnosis of testicular teratoma can often be made based on testicular ultrasound findings. When a prepubertal testicular teratoma is expected it should be approached via an inguinal incision with vascular control of the spermatic cord. Juvenile testicular teratomas may be treated by either partial orchiectomy or orchiectomy depending upon the size of the mass. This prepubertal boy had a unilateral mature testicular teratoma that has been completely resected with radical orchiectomy. In a prepubertal boy, this is a benign lesion and can be followed with serial annual examinations if an orchiectomy was performed, or serial annual testicular ultrasound evaluations if a partial orchiectomy or enucleation was performed. Follow-up should be through puberty to verify adequate hormonal function of the contralateral testis. In a patient with a prepubertal testicular teratoma there is no need for further CT scans, tumor markers, surgery, or chemotherapy. However, mature teratoma in the pubertal child or postpubertal adolescent has a clinical behavior similar to adults and should be managed with a standard post-orchiectomy protocol for NSGCT.

Answer 25

1 The overall success rate for obtaining an erection with intraurethral alprostadil is approximately 55%. If it is successful in producing an erection, the most common side effect is penile pain that can include the scrotum and extremities. No treatment is needed for this pain, but it can be dose limiting in some patients. Terbutaline, methylene blue and Neo-Synephrine are useful for the treatment of priapism, which this patient does not have. No data is available for the use of ibuprofen with PGE-1 induced pain and it is unlikely to work based on ibuprofen's mechanism of action.

Answer 26

2 The horseshoe kidney is positioned more inferior, anterior and medial than a normal kidney. The upper pole is typically subcostal and superficial, making it the best option for percutaneous access. The medial position of the kidney often requires a percutaneous tract that passes through the paraspinous musculature.

Answer 27

4 The right adrenal vein enters the IVC directly on its posterolateral aspect. It does not enter other veins between the adrenal gland and the IVC as occurs on the left side. The left adrenal vein joins with the left phrenic vein and enters the cranial aspect of the left renal vein. The lumbar vein and left gonadal vein enter the left renal vein but do not receive the adrenal vein.

Answer 28

5 This patient has progressive urologic symptomatology that is refractory to a therapeutic modality that was once effective. When the physician encounters a patient with progression of the severity of symptoms, particularly in conjunction with new neurologic symptoms, a neurologic diagnosis such as multiple sclerosis should be considered. Performance of MRI (below the neck) is important in establishing the diagnosis of a neuropathic disease, and is contraindicated in patients with a sacroneuromodulation device in place. Therefore, it must be removed to allow this patient to proceed with the diagnostic MRI scan. Although evaluation of the position of the lead, consideration of reprogramming of the device, surgical revision of the device (pending the effects of reprogramming), or change in treatment modality might all be reasonable, in a patient without progressive neurologic deterioration they are not reasonable alternatives in this clinical scenario.

Answer 29

5 Hyperparathyroidism should be suspected in patients with renal calculi and serum calcium levels over 10.1 mg/dl. In patients with suspected hyperparathyroidism, a thiazide challenge may unmask subtle primary hyperparathyroidism by increasing proximal tubular resorption of calcium resulting in a significant rise in serum calcium. The treatment of patients with primary hyperparathyroidism and renal calculi is parathyroidectomy, with over 90% improvement in calculus recurrence. In patients who present with symptomatic or obstructive renal calculi and who are not in hypercalcemic crisis, the calculi should be treated prior to the parathyroid gland.

Answer 30

4 The t-test is the most commonly used method for comparison of means between two groups. Chi-square analysis is the most important nonparametric test and is used to compare proportions. ANOVA is the appropriate test when more than two groups are being compared. Pearson's r test is used to evaluate strength and direction of the relationship between two interval variables. Spearman's rank order test is used to test for an association between ordinal positions in rankings.

Answer 31

5 Indications for autologous sling include a severely dysfunctional urethra, as indicated by low LPP (0-60 cm H2O), loss of urethral tissue (e.g., following synthetic mesh erosion into the urethra, urethral diverticulectomy, or urethrovaginal fistula repair), and multiple previous anti-incontinence procedures. While the other options listed are reasonable options to discuss with patients, this patient's low LPP and her history of previous surgery make autologous sling the best option of those listed.

Answer 32

4 Pyocystitis may be a complication following supravesical diversion in individuals with a neurogenic bladder when a cystectomy is not performed. The failure of irrigation therapy to permanently suppress recurrent pyocystitis is an indication for surgical intervention. Vesicovaginostomy allows the bladder to drain and usually results in symptomatic improvement in patients who have pyocystitis unresponsive to standard treatment. In this woman, vesicovaginostomy would be a significantly less morbid option than simple cystectomy.

Answer 33

2 The incidence of renal calculi in patients with UPJ obstruction is nearly 20%. Husmann and colleagues reported a 70-fold increased risk of stone formation in the pediatric population with UPJ obstruction. Although the obstruction plays a role in stone formation, several studies have demonstrated that patients with UPJ obstruction and concurrent renal calculi carry the same metabolic risks as other stone formers. Correction of UPJ obstruction did not prevent recurrent stones in most patients, and thus metabolic evaluation, rather than annual UA alone, is the correct next step. Based on the findings of the metabolic evaluation, treatments such as dietary changes, potassium citrate, or hydrochlorothiazide may be appropriate, but not until the work-up is completed. Despite the fact that this was discovered during the evaluation of a UTI, antibiotic prophylaxis is not indicated.

Answer 34

3 Repair of vesicovaginal fistula, whether via an open or minimally invasive technique, requires adherence to basic principles of fistula repair. These include: adequate excision of the fistula, use of healthy tissues for repair, performance of a tension free anastomosis with multi-layered closure, interposition with omentum, and adequate bladder drainage. However, the challenge of a minimally invasive approach is losing pneumoperitoneum after the fistula is excised. Techniques such as packing gauze in the vagina and clamping the urethral catheter are helpful but they do not seal the opening adequately to maintain pneumoperitoneum and thus can make suturing more difficult. If pneumoperitoneum is maintained, exposure and ease of suturing should be no different. Risk of ureteral injury and port site complications should not differ between the procedures.

Answer 35

2 Streptococcal and Clostridial wound infections are characteristically invasive, painful, and occur within 24 hours after surgery. A thin, watery purulent discharge without frank abscess formation or foul smell is characteristic for Streptococcal infections. Clostridial infections are usually associated with intraoperative fecal contamination; the discharge is gray or reddish brown and foul smelling, and associated with wound crepitus and necrosis. Treatment should include systemic high dose penicillin. Opening of the surgical wound with debridement and drainage is necessary only if there are signs of crepitus or wound fluctuance or wound margin necrosis. Staphylococcal infections usually occur \> 24 hours postoperatively, and are characterized by a localized indurated area of cellulitis with associated abscess formation with a thick yellow or cream-colored pus. Postoperative wound infections caused by enteric bacilli have a longer incubation period than those caused by staphylococcus.

Answer 36

1 Primary idiopathic (endemic) calculi form in children, most commonly from North Africa, the Middle East and Far East. With a large immigrant population in the United States, it is important to be aware of this health problem. These children rely on a cereal-based diet that is lacking in animal proteins. This leads to a dietary phosphate deficiency, low urinary phosphate and high peaks of ammonia. Due to this, the most common stone is ammonium acid urate. Though chronic dehydration can lead to calcium oxalate and uric acid stones, high urinary sodium, calcium and oxalate are not characteristic findings with endemic bladder stones.

Answer 37

3 This patient would benefit from mesh excision and closure of the defect. Patients with asymptomatic vaginal mesh exposure can be observed. However, if symptomatic or desiring definitive treatment, the exposed mesh should be removed. Factors responsible for mesh exposure include poor vaginal tissue quality, excessive sling tension, infection, and type of graft material. Multifilament products appear to have greater risk for exposure compared to monofilament products and larger pore sizes in the graft decrease the risk of exposure. It is unlikely an exposure of this size would heal secondarily or with the use of topical estrogens. The majority of patients undergoing removal of exposed mesh do not have recurrent stress urinary incontinence postoperatively; thus, a concomitant sling is unnecessary.

Answer 38

1 Cushing's syndrome may be caused by an adrenal tumor, ectopic ACTH production, and by excessive pituitary ACTH secretion (Cushing's disease). The basis of the high dose dexamethasone suppression test is that ACTH secretion in patients with Cushing's disease is not completely, but only partially, resistant to glucocorticoid feedback inhibition. Therefore, by increasing the dose of dexamethasone, pituitary secretion of ACTH is suppressed in patients with Cushing's disease and glucocorticoid production is reduced. In contrast, dexamethasone has no effect in patients with adrenal tumors and ectopic ACTH production, since their pituitary glands are already suppressed. Serum cortisol may be used instead of urinary parameters.

Answer 39

1 At this stage of gestation, 90% of the amniotic fluid volume is derived from the fetal urine production. Oligohydramnios early in pregnancy nearly always predicts a poor renal outcome. Echogenicity is more subjective and may be indicative of dysplasia, but is not always predictive of a poor renal outcome. Although concerning, a kidney with thinned renal cortex may have normal function. The thinned cortex may simply be an anatomical or physical reflection of the severity of the obstructive process. A distended bladder may be normal or may only be indicative of VUR, and the cycling of refluxed urine that over time will cause stretching and expansion of the bladder. The magnitude of renal pelvic dilation may predict the degree of obstruction but does not correlate with renal function.

Answer 40

4 The most frequently selected insufflation pressure for laparoscopy is 15 mmHg. If insufflation pressures of \> 20 mmHg develop, three major systems are affected: 1) a decreased venous return and cardiac output occurs results in tachycardia, 2) an increase in pressure on the renal parenchyma results in a decrease in GFR and oliguria, 3) expanded abdominal pressure results in a decrease in diaphragmatic movement, decreased pulmonary insufflation, hypercarbia, and respiratory acidosis. When faced with the classic triad of tachycardia, oliguria and hypercarbia, the next step is to increase the respiratory rate and decrease the insufflation pressure. Although increasing the PEEP is advisable in patients with lung disease, this would not address the multiple systemic problems seen with elevated intraabdominal pressure. The steep Trendelenburg can cause a decrease in heart rate and systemic vascular resistance and a rise in mean arterial pressure and cardiac output. I.V. fluid bolus would not alter the physiologic condition and is not necessary to address the mild oliguria associated with pneumoperitoneum.

Answer 41

2 The key abnormalities in this evaluation are the two semen analyses demonstrating all normal parameters except for a markedly decreased volume. The history of HTN is incomplete and should include medications since many anti-hypertensives interfere with bladder neck closure and ejaculation. TRUS is not required because the semen pH is normal implying that ejaculatory duct obstruction is unlikely. The next most useful test would be examination of a post-ejaculate urine specimen. The correct diagnosis can be made by finding large numbers of sperm (10-15/hpf) in the urine.

Answer 42

5 The incidence of urethral injuries following a pelvic facture are directly related to the number pubic rami-factures, the degree of the separation of the pubic symphysis, and the presence of diastasis of the sacroiliac joint. When any of these injuries are found to occur in conjunction with blood at the penile meatus or blood at the vaginal introitus, a urethral injury must be ruled-out. While a retrograde urethrogram is the preferred modality to assess urethral integrity in males, cystoscopy and vaginoscopy under general anesthesia is preferred in pre- and post-adolescent females. It is important to note that in this patient population concurrent rectal injuries must also be ruled-out. DRE once the mainstay to rule out a concurrent rectal injury has been found to have a large false negative rate and currently rectal endoscopy or other imaging modalities must also concurrently be performed to rule out a concomitant rectal injury.

Answer 43

1 Subcutaneous emphysema can develop intraoperatively from CO2 gas leakage around trocars and diffusion into the subcutaneous space. This is more common in cases where the trocar sites are made too large, lengthy cases, or use of high intra-abdominal insufflation pressures. Trocars should be directed toward the organ of interest so as to minimize forceful redirection of the trocar and instruments, resulting in enlargement of the trocar tract and gas leakage into the subcutaneous tissues. In obese patients, trocar length limits may result in the trocar pulling back into the subcutaneous tissues and causing gas leakage. In such cases, an extra-long trocar may be necessary. In assessing this patient's particular case, the first step is to ensure that all trocars are properly positioned within the intraperitoneal cavity, and that widening of the tracts has not occurred. Simply relocating the gas insufflation without ensuring proper trocar placement would not correct the problem. Although adjusting ventilator settings may help compensate for the hypercarbia, the initial problem has not been solved. Lastly, converting to an open operation just because of subcutaneous emphysema would be too extreme a measure.

Answer 44

1 While studies of empirical treatment of idiopathic oligospermia have shown improvement in sperm parameters, this occurs in a minority of men. Oral agents such as clomiphene citrate, as well as gonadotropins, have been used. Treatment with human chorionic gonadotropin does not generally achieve consistent improvement in sperm concentration, sperm motility, or pregnancy rate. Seminal volume does not increase in men with normal testosterone levels. Testosterone levels do rise because of the stimulation of testosterone production by Leydig cells. Some testosterone is converted to estradiol by the enzyme aromatase.

Answer 45

4 The descended testis is not hypertrophied (\> 2 cm in length in a prepubertal boy) implying that the undescended testis is present and located in an abdominal position. None of the imaging studies would eliminate the need for diagnostic laparoscopy to exclude an intra-abdominal testicle. Scrotal exploration would be a reasonable option only if the descended testis was hypertrophied, as approximately 90-95% of the cases will have documented gonadal vessels in the inguinal canal. However, it should be noted that hypertrophy of the contralateral testis, if present, is neither perfectly sensitive nor specific for the presence of vanishing testis. Therefore, surgical exploration is indicated in all children with a nonpalpable testis, regardless of the size of the contralateral testis. In 5% of cases with unilateral hypertrophy, the testicle will have torsed intra-abdominally, and laparoscopy or retroperitoneal dissection will be necessary to visualize the blind-ending vessels proximal to the internal ring. There is no role for hormonal therapy to induce testicular descent due to its low efficacy.

Answer 46

5 Any issues of obstruction should be resolved before proceeding with AUS placement. Opening the bladder neck contracture with either dilation or resection and simultaneous AUS placement would not be recommended. It is unknown if the bladder neck contracture will remain open with either therapy, and this issue needs to be resolved prior to AUS placement, as treatment of a bladder neck contracture with an AUS in place can be very challenging. Steroid injection into the resection site is not indicated and would not alter the treatment strategy. This patient should have his bladder neck contracture opened and then undergo repeat cystoscopy in the office. If the bladder neck remains patent over time (at least three months) then AUS placement can proceed. Simultaneous sphincter placement in the setting of a less severe bladder neck contracture has been advocated.

Answer 47

1 The major advantages of fluoroscopy for stone location are: a short learning curve, a wide range of indications for in situ treatment, and multifunctional use of x-ray. The localizing problems for fluoroscopy consist chiefly of stones close to the vertebral column and radiolucent calculi. The advantages of ultrasound for stone location are: low purchase costs and maintenance, no x-ray exposures, the possibility of continuous real-time monitoring, and location of radiolucent calculi. Calculi in the middle ureter are almost impossible to localize with ultrasound. Multiple calculi may be problematic for ultrasonic stone localization.

Answer 48

4 VCUG is recommended if there is evidence of renal scarring on ultrasound or if there is a history of UTI in the sibling who has not been tested. VCUG is recommended for children with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis (not just pelviectasis), hydroureter or an abnormal bladder on ultrasound (late term prenatal or postnatal), or who develop a UTI on observation. VCUG is not routinely recommended for all siblings of a child with VUR, or for the offspring of a former patient with VUR.

Answer 49

2 UTI in patients with spinal cord injury on CIC is commonly seen but can be a challenge to diagnose. Almost all urine collections will show bacteriuria, and pyuria may occur solely due to the irritative effects of catheterizations, and may not always be related to the presence of infection. The usual symptoms of UTI such as urinary frequency, urgency, and dysuria will not be noted in patients with a complete neurologic injury who have no bladder sensation. Typical UTI symptoms in a patient with a spinal cord injury may include urinary incontinence between catheterizations, increased spasticity (as seen in this patient), malaise, lethargy, persistent cloudy or malodorous urine, and discomfort at the level of the flank, back, or abdomen. Bacteria levels are problematic to interpret and are classically only treated if they are greater than or equal to 100 cfu/ml and the patient is symptomatic. Due to the symptomatic complaint of increased spasticity and positive urine culture, this patient should be given antibiotics. If the spasticity is not resolved after treatment, the patient should be carefully examined for any physical injury below the level of his lesion, such as obstipation, decubitus ulcer, ingrown toe nail, developing syrinx, etc. Baclofen is a commonly used treatment for spasticity in spinal cord injury (SCI) patients, and should be considered for use if the spasticity is not resolved after treatment of the UTI, and additional patient evaluation fails to reveal an underlying cause. Elevated storage pressures do place a patient at increased risk of symptomatic UTI, and urodynamics should be considered if this patient continues to experience recurrent symptomatic infections.

Answer 50

3 It must be decided whether this woman has recurrent E. coli infections or a persistent source of infection. One of the causes of surgically correctable bacterial persistence in the urinary tract is a unilateral infected atrophic kidney. To prove that this woman has bacterial persistence, however, upper tract bacterial localization cultures with bilateral ureteral catheterization need to be performed before nephrectomy is considered to treat her infections. If the kidney is not infected, these infections are the result of frequent E. coli reinfections, in which case a right nephrectomy would not be helpful in treating her. An indium-labeled WBC scan may not be helpful if the kidney is inflamed but not the source of recurrent E. coli infections.

Answer 51

3 Neoadjuvant chemotherapy is indicated: in children at risk for tumor recurrence (syndromes such as Beckwith-Wiedemann), in very large tumors or with tumor in the IVC above the hepatic veins making primary resection difficult, and in synchronous bilateral tumors. In bilateral tumors, nephron-sparing surgery is the goal, and repeat CT scan is indicated after chemotherapy to assess tumor shrinkage for timing of partial nephrectomies. Percutaneous or open renal mass biopsy will upstage the tumor and are not required for initiation of therapy.

Answer 52

5 Clinical studies reveal that that up to half of the patients with the combination of LUTS and oliguria will have significantly improved symptoms after transplantation and the resolution of the oliguria, thereby rendering surgical treatment unnecessary. It is noteworthy that oliguric men undergoing surgical intervention for BPH have a significantly higher risk of developing either a bladder neck contracture, a prostatic fossa obliteration, or a urethral stricture if surgical treatment is performed before transplantation. To avoid these complications, it is recommended that treatment of bladder outlet obstruction in patients with oliguria be delayed until after the transplant is performed.If the physician elects to perform a TURP or TUIP in an oliguric or anuric patient the establishment of normal voiding cycles for a period of six weeks post-surgery has been shown to decrease the postoperative complications of urethral obstruction. To allow for normal voiding, either a SP tube is placed or CIC is done, and water or saline is instilled into the bladder four to five times daily with the patient instructed to void per urethra. These maneuvers prevent the dry urethra and aid in prevention of bladder neck or obliterative urethral strictures. Finasteride would be indicated for a patient with a larger prostate with an elevation in residual urine. OnabotulinumtoxinA would be indicated for detrusor overactivity unresponsive to medical therapy with anticholinergics. Treatment of this patient now with onabotulinumtoxinA may improve his bladder capacity, but could lead to urinary retention and the need for CIC.

Answer 53

4 Improved patency and pregnancy after vasectomy reversal are correlated with a short time interval between vasectomy and reversal. It has been demonstrated that a proximal vas segment in excess of 2.7 cm predicts the presence of vasal fluid with whole sperm. It is generally believed that the presence of a granuloma and a smaller luminal diameter are favorable, as pressure below the level of the vasectomy may be less. Testicular specimens obtained after vasectomy reveal increased thickness of the seminiferous tubules, reduction in the number of Sertoli cells and spermatids, and an increase in the cross-sectional tubular area. The presence of interstitial fibrosis has an adverse effect on post-vasovasostomy fertility. The type of microscopic anastomosis (multi or one-layer) does not correlate with patency rates.

Answer 54

2 This child has balanoposthitis. In mild cases, simple removal of irritating agent (such as soaps and detergents) can lead to improvement, but this child has had significant symptoms for over 24 hours and is having difficulty voiding. The correct next step is topical antibiotic rather than observation. If the topical antibiotic is ineffective, then topical or oral antifungal agents may be tried next. Unlike with balanitis xerotica obliterans (BXO), topical testosterone is inappropriate. In cases of severe swelling, topical corticosteroid may be tried. Performance of a dorsal slit is too aggressive for this benign condition.

Answer 55

5 It is unlikely that a man with ED not using any erectogenic medications will develop ischemic priapism. Moreover, his ABG does not suggest ischemic, nor non-ischemic priapism. Cavernosal blood gas in men with ischemic priapism typically has a PO2 of \< 30 mmHg, a PCO2 of \> 60 mmHg, and a pH \< 7.25. Cavernous blood gases in men with nonischemic priapism are similar to the blood gases of arterial blood. Normal flaccid penis cavernous blood gas levels are approximately equal to those in normal mixed venous blood. The findings in this patient, blood gas values equal to normal mixed venous blood are most consistent with priapism secondary to metastatic prostate cancer to the corpora and corpora biopsy is indicated. In view of the blood gas finding the use of oral terbutaline, sympathomimetic cavernosal injections or shunting would be inappropriate.

Answer 56

3 Cushing's syndrome implies glucocorticoid excess, while Cushing's disease is glucocorticoid excess specifically due to a pituitary adenoma. Approximately 80% of patients with Cushing's syndrome have HTN at the time of presentation. Glucocorticoids have weak mineralocorticoid effects resulting in retention of salt and water. With excessive glucocorticoid production these weak mineralocorticoid effects can cause HTN. Plasma catecholamines are typically not elevated.

Answer 57

4 Patients who undergo bladder augmentation with bowel should be counseled on the possible long-term risk of carcinoma formation, renal and bladder calculi and metabolic abnormalities. The earliest report of tumor formation is four years after bladder augmentation with bowel. Yearly cystoscopic surveillance had been recommended in the past, though the timing of when to start the surveillance was not well-defined. Recent studies have shown that routine yearly endoscopy is not indicated due to the low incidence of malignancy following a bladder augmentation (approximately 1.5-2.5% of patients per decade), lack of proven benefit, and high cost. In the absence of other risk factors, the current recommendation is for annual visits with renal and bladder ultrasound (rule-out stones or the development of hydronephrosis secondary to noncompliance with CIC), electrolytes (rule out metabolic abnormalities), creatinine, serum B12 (rule-out nutritional deficiencies), and UA (assess for hematuria). Endoscopy is reserved for individuals with a past medical history of gross hematuria, microscopic hematuria (\> 50 RBC/hpf), new onset of hydronephrosis (rule-out tumor obstructing the ureteral orifice), bladder calculi, chronic bladder/perineal pain or a history of four or more symptomatic UTI per year. Using this screening criteria, \> 90% of tumors arising in a bladder augment can be discovered without the use of annual endoscopy.

Answer 58

3 Residual urine volumes have a large intraindividual variability, are not associated with renal or bladder damage, are not well-correlated with symptoms, and are not predictive of surgical outcome. In addition, an elevated PVR has not been associated with recurrent pyelonephritis. Therefore, the test is of limited clinical value and, in fact, the AUA Guidelines classify the test as optional in the initial diagnostic evaluation and subsequent assessment of men with bothersome LUTS.

Answer 59

1 Prostatic granulomas are recognized with increasing frequency in men following intravesical BCG therapy. Although long-term outcome is uncertain, the granulomas are generally asymptomatic and no therapy is recommended. This patient had a prior normal digital rectal exam of the prostate and his serum PSA is normal. Thus, it is unlikely he has prostate cancer and further biopsies are no more indicated in him than in any other age matched male patient.

Answer 60

5 The horseshoe kidney involves anteriorly oriented renal pelves and a low-lying kidney mass with the isthmus sitting just below the inferior mesenteric artery takeoff from the aorta. This makes a transperitoneal, laparoscopic approach to this large stone very attractive. With moderate hydronephrosis, a simple transmesenteric exposure of the renal pelvis followed by pyelotomy can allow intact removal of the large stone. Simple lap suturing can close the pyelotomy incision. The option of percutaneous lithotripsy is appropriate to consider; however, access should be through the upper pole because of calyceal anatomy. The lower pole of a horseshoe kidney will be too medial and anterior for optimal access. Ureteroscopic treatment using a holmium laser is not a good option with a stone of this size as the duration of procedure and failure rate will both be high. ESWL will also carry a high failure rate due to stone size. A double J stent does not offer an advantage in treating the stone in this scenario.

Answer 61

1 This patient is likely experiencing worsening of symptoms due to incomplete bladder emptying. Approximately 5% of patients with idiopathic overactive bladder will have issues of incomplete bladder emptying/urinary retention requiring CIC after injection of 100 units of onabotulinumtoxinA. Determination of her PVR would allow for proper evaluation for incomplete bladder emptying and guide the initiation of CIC as needed. Mirabegron is a beta-3-adrenergic receptor agonist and is indicated for OAB; this would only be considered once the possibility of incomplete bladder emptying has been ruled-out. Urodynamics is unnecessary to rule out urinary retention. However, if this patient is emptying adequately, urodynamics may then be considered for diagnostic purposes. If a patient requires reinjection, this should be done at least three months after the initial injection. In addition, studies suggest that the 100 unit dose is adequate for OAB, and a higher dose is not beneficial and maybe associated with an increased incidence of urinary retention.

Answer 62

3 Chemotherapy-naive relapses occur in men with clinical stage (CS) I NSGCT managed with either surveillance or RPLND, and in the men with CS IIA-B NSGCT treated with RPLND alone. In general these patients are treated with induction chemotherapy, with the specific regimen and duration of therapy determined by risk, and cure rates exceed 95%. This patient has an abdominal relapse after observation. Correct management is three cycles of BEP for disseminated germ cell tumor in good risk patients. Biopsy of the mass could miss elements of residual cancer and should not be performed. XRT is not indicated for mixed germ cell tumors of the testis. Retroperitoneal lymphadenectomy is usually not performed prior to chemotherapy for masses \> 3 cm on CT scan, avoiding double therapy in these patients.

Answer 63

5 DDAVP, similar to ADH, exerts its effects on the collecting ducts to absorb water. DDAVP is often used for the treatment of nocturnal enuresis in children and polynocturia in adults. Side effects, although rare, do exist and may result in hyponatremia, headaches, and on extremely rare occasions, hyponatremic-induced mental confusion and seizures. If this medication is chronically administered, the urologist should consider obtaining intermittent serum electrolyte evaluations to observe for the development of hyponatremia. DDAVP should not be used to treat nocturnal polyuria in the adult with a history of CHF or renal insufficiency.

Answer 64

5 Persistent or recurrent LUTS may occur after TURP. Since \< 20% of these men have any evidence of recurrent or persistent bladder outlet obstruction, assessment with pressure-flow studies are particularly useful to make determinations regarding the appropriateness of further surgical intervention. Many of these patients' symptoms are due to poor bladder contractility or detrusor overactivity. Uroflowmetry alone may be used for screening purposes, although it may be misinterpreted in the presence of high-flow, high-pressure voiding. Cystoscopy will rule-out a stricture or bladder neck contracture but the presence of visually obstructing prostatic tissue does not correlate with bladder outlet obstruction. Neither residual urine nor creatinine (even if abnormal) sheds light on the etiology of the emptying disorder.

Answer 65

5 It was previously believed that scrotal surgery markedly increased the risk of local recurrence and inguinal node metastases. Further evidence now suggests that this risk has been overestimated and a formal hemiscrotectomy or prophylactic inguinal lymph node dissection is rarely indicated. A meta-analysis of all evaluable reported series (1182 total cases, 206 with scrotal violation) found that the risk of local recurrence increased from 0.4% to 2.9% with scrotal violation, but there was no difference in the distant recurrence or survival rates. In patients with low-stage NSGCT, the scrotal scar should be widely excised with the spermatic cord remnant at the time of RPLND. The inguinal nodes should be preserved.

Answer 66

3 According to the American Society of Anesthesia guidelines, NPO after midnight is no longer advisable or safe for children. Recommendations for fasting prior to anesthesia include: clear liquids - 2 hours, breast milk - 4 hours, formula or solid food - 6 hours, and fatty foods - 8 hours.

Answer 67

5 Spinal shock is defined as the loss of motor, sensory, reflex, and autonomic neurologic function below the level of spinal cord injury. It is a temporary physiologic disorganization of spinal cord that classically starts within one hour after the neurologic injury. Resolution of spinal cord shock classically begins with the initial return of the bulbocavernosus reflex followed by the eventual restoration of the deep tendon reflexes (DTR) below the level of spinal cord injury. Resolution of spinal cord shock may be defined by either the recurrence of the bulbocavernous reflex or by return of the DTR, the latter of which usually occurs at four to six weeks post injury. Return of the DTR, will be followed by a progressive increase in muscle spasticity and the development of detrusor over activity. The severity of muscle spasticity and/or detrusor dysfunction increases during the first year post injury due to a combination of neuronal sprouting, done by the neurons in an attempt to make neural connections below the spinal cord injury, combined with the up regulation of neural receptors within the target organs. The full extent of the neurogenic bladder dysfunction may take one to two years to become completely manifested. Significant surgical intervention, for example, formation of continent catheterizable stoma or determining if the patient would need a bladder augmentation should therefore be delayed for at least one year following injury to allow the severity of the neurourologic injury to be revealed. The timing for the initial urodynamic study should not arbitrarily be based on the time since the injury, but rather on the clinical findings of the patient. Specifically, the return of DTR associated with the strength of these reflexes following minimal stimulation should dictate when to perform the initial urodynamic evaluation. Since the initial in-patient rehabilitation stay is usually no more than two to three weeks, a study at this time only reflect the finding of detrusor underactivity due to the manifestations of spinal cord shock. The initial findings of urinary incontinence are often a consequence of a UTI due to the initiation of CIC and are not necessarily an indication to perform the initial urodynamic evaluation. On the other hand, new onset of urinary incontinence in a patient with neurogenic bladder who has been stable on their bladder management for greater than six months and is not actively infected would be a reason to evaluate the patient with urodynamic studies.

Answer 68

3 Patients with a NSGCT who have a \> 90% reduction in the size of the retroperitoneal mass with chemotherapy and have no teratomatous elements in their tumor (such as this patient who had a pure embryonal tumor) uncommonly have either viable cancer or teratoma in the residual mass at the time of retroperitoneal lymph node resection. In an early study, Donohue and colleagues (1987) reported that none of 15 patients without teratoma in the primary tumor and who achieved a 90% or greater reduction in the size of the residual mass with chemotherapy had any evidence of viable malignancy or teratoma at postchemotherapy surgery. In contrast, seven of nine patients (78%) with teratoma in the primary tumor experiencing a similar reduction in the size of the metastasis with chemotherapy had evidence of viable malignancy and/or teratoma. Predictors of necrosis in post-chemotherapy surgery specimens include the absence of teratoma in the primary tumor, significant percentage reduction (e.g. 90%) in the retroperitoneal mass with chemotherapy, and the size of the residual mass. However, despite statistical modeling using these and other factors, a consistent false-negative rate for necrosis (of up to 20% in some studies) has been reported, largely due to the presence of teratoma. Thus, the presence of necrosis only in the retroperitoneum cannot be predicted with sufficient accuracy to safely obviate the need for surgery in patients with residual masses. Normalization of the serum markers does not predict the presence of fibrosis.

Answer 69

5 Patients with a concentrating defect due to obstruction such as PUV may present with worsening incontinence along with upper urinary tract deterioration due to excessive urine production. The urine volume will not decrease significantly with either salt or water restriction. Furthermore, water restriction is dangerous and often counterproductive, as it may lead to dehydration and worsening renal function. Patients with a renal concentrating defect typically do not respond to DDAVP. Unless there is evidence of myogenic failure and incomplete bladder emptying, daytime CIC to further eliminate post void residual is unlikely to help this patient. It has been suggested that continuous nighttime drainage can improve the fluid dynamics, thus restoring the upper urinary tract (decreasing bilateral hydroureteronephrosis), as well as improving daytime urinary incontinence.

Answer 70

3 Preoperative bladder volume may be the most important predictor of success. If a significant increase in bladder volume capacity is needed, autoaugmentation is not likely to be as useful as other reconstructive techniques. Autoaugmentation usually increases bladder compliance, and operative time is shorter than for bowel augments without a high risk of perforation. Studies have shown no increased complication rate from subsequent enterocystoplasty, if needed.

Answer 71

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

Answer 72

4 Fowler's syndrome was first described in 1985. It is a cause of urinary retention in young women that is associated with abnormally increased EMG activity that results in impaired external sphincter relaxation. No neurologic or anatomic abnormality is associated with the condition, though it has been noted that women with Fowler's syndrome often have polycystic ovaries raising the possibility of a focal hormonal role. That said, neither hormone therapy nor onabotulinumtoxinA injection or alpha-blockade have been found to be successful therapies. Interestingly, however, the condition has been found by several groups to be highly responsive to neuromodulation.

Answer 73

2 The deep dorsal vein is occasionally ligated, dissected, and excised during a dorsal penile plication and the plication sutures are then placed in the venous bed. Thus, there is no need to salvage, convert, or abort the procedure. Excision and grafting is becoming less favorable due to the possible development of erectile dysfunction as a result of veno-occlusive dysfunction.

Answer 74

5 Cycloserine inhibits BCG growth within 24 hours. The other drugs listed require two to seven days to inhibit BCG growth. Because of its relatively rapid action, cycloserine can be lifesaving in patients with BCG sepsis. Isoniazid, rifampin, and ethambutol all have slower onset of action and are less useful in the immediate management of life threatening BCG sepsis.

Answer 75

3 Cystine stones occur in patients homozygous for a complex autosomal recessive disorder of amino acid transport involving cystine, ornithine, lysine, and arginine. Onset is usually in the first or second decades. Cystine crystals are hexagonal and cystine stones are very dense making them difficult to treat by lithotripsy. Medical therapy, by increasing the solubility of cystine, is the mainstay of treatment. This disorder is noted to be of increased incidence in the Japanese population.

Answer 76

3 All exogenous testosterone products serve as a natural contraceptive, and thus, should not be given to men who are trying to achieve a pregnancy. Human chorionic gonadotropin is an LH analog and will increase endogenous testosterone, as well as potentially improve semen parameters. A scrotal ultrasound may be indicated if there was a suspicion for varicoceles although this patient's exam was normal. A testis biopsy would not be indicated in this situation.

Answer 77

4 Breast tenderness and enlargement during hormonal therapy for prostate cancer is due to an altered ratio of serum estrogens and testosterone. Leuprolide inhibits pituitary LH release so there is no rise in serum estrogens. Ketoconazole inhibits androgen and estrogen synthesis. Bicalutamide inhibits both end organ and central androgen receptors so that both LH and androgen levels increase with loss of negative feedback inhibition. Increased androgen is converted to estradiol, which can cause painful gynecomastia. Although finasteride can cause gynecomastia, the most likely cause is bicalutamide monotherapy.

Answer 78

1 This situation describes retractile testes. The cremasteric reflex is responsible for the superior retraction of the testes, and this reflex becomes more pronounced in many boys between two and eight years of age. The principal diagnostic characteristic is that the testis will remain without tension in a scrotal position after fatiguing (holding the testis manually in the scrotum for approximately 30 seconds and releasing the testis) until the reflex is once again stimulated. Some testes may retract into a higher position than others and require more persistent exam to evaluate and diagnose. Retractile testes have been shown to grow normally over time and be associated with normal paternity rates, thus requiring no immediate intervention. There is an associated phenomenon of secondary ascent in 2-4% of boys that may be associated with deterioration of germ cells. For this reason, it is appropriate to examine boys with retractile testes annually until either puberty arrives or the testis becomes non-retractile. hCG injection will consistently cause retractile testis to become intrascrotal and may be used in some cases where the diagnosis of retractile vs. undescended is uncertain. The testicles will, however, frequently retract once the hormonal stimulation is complete. In the case described, retractility is the clear diagnosis; therefore, neither further hormonal studies nor surgery are required.

Answer 79

3 The use of quick connectors for AUS allows for a secure and watertight connection between the reservoir, cuff, and pump in a freshly placed device. However, studies show they are associated with suboptimal results when they are used for revision surgery. Presumably, the decrease in success is due to the formation of the biofilm on pre-existing devices. Studies suggest that the biofilm interferes with the tubing connection using the quick connectors, and thus leads to a suboptimal connection that is at greater risk of leaking. Hand-tie connectors should be used in all AUS revision procedures. If the entire device is removed and replaced, the quick connectors may be used.

Answer 80

2 Penetrance for all of the manifestations of VHL is incomplete. Pheochromocytoma is found only in certain families with the VHL syndrome, primarily those with a missense mutation of the VHL gene. All of the other manifestations of VHL are found in most families with the syndrome. A careful family history and thorough review of preoperative CT scans for potential associated tumors is important in all patients with familial RCC. Pheochromocytomas in particular are a critical entity to recognize prior to any surgical intervention.

Answer 81

4 Plastic bag specimens are unreliable and unacceptable for diagnosis of UTI in high-risk populations and infants. Generally, if a UTI is suspected in a child who is not yet toilet trained, only a catheterized or needle-aspirated specimen is acceptable for diagnosis because bagged urinary specimens have an unacceptably high false-positive rate. Under special collection circumstances when the perineum is cleaned well and the bag removed and processed promptly after voiding, a bagged specimen or even a diaper specimen that shows no growth is useful in eliminating bacteriuria as a diagnosis. In this infant, the UA is equivocal and the risk of UTI is increased. Thus, a more definitive diagnosis with a catheterized urine specimen is needed prior to the initiation of any type of antibiotic therapy. She would likely be treated with oral antibiotic therapy as an outpatient (not observed or managed with I.V. antibiotic) only after a catheterized specimen has been obtained. Repeat ultrasound might be indicated if she has not responded to antibiotic therapy.

Answer 82

5 OnabotulinumtoxinA is indicated for neurogenic detrusor overactivity. However, the concerning urodynamic finding that can be seen in many patients with spina bifida, including this one, is loss of compliance and an elevated detrusor LPP. Elevated detrusor LPP specifically refers to a loss of compliance. A detrusor LPP \> 40 cm H2O places patients at a greater risk for subsequent upper urinary tract damage. While this patient is now continent, that does not mean that his detrusor storage pressure are in a safe range and he should, therefore, undergo a repeat urodynamic study. If the detrusor pressures are in a safe range at appropriate volumes, then increasing the interval between catheterizations can be considered, and he will likely require repeat injection in six to nine months when his symptoms return. If the detrusor pressures are not appropriately lowered with onabotulinumtoxinA, then bladder augmentation should be considered.

Answer 83

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

Answer 84

2 Following valve ablation, upper tract changes may take months or even years to resolve. However, in most cases, a trend towards improvement is noted in the first three to six months after valve ablation. When there are persistent upper tract changes, the first step is to perform a VCUG to determine if the valves are adequately ablated and whether or not reflux is present. Endoscopic valve ablation can be a technically challenging procedure in infants, and it is not always clear following initial surgery as to whether adequate ablation has occurred. In cases where the follow-up VCUG is unclear as to whether adequate valve ablation has occurred, repeat endoscopy is warranted. If there is no evidence of residual valves on the VCUG, then a careful assessment of bladder function is needed to determine if there is bladder dysfunction that is impairing upper tract drainage. Urodynamics can be performed to help tailor bladder management. In some patients CIC and/or pharmacotherapy may be needed. It is uncommon for upper tract dilation to be secondary to a true ureterovesical obstruction in this setting. Vesicostomy is usually reserved for patients in which initial valve resection cannot be performed due to urethral anatomy or in cases where CIC is needed and cannot be performed reliably. Although the role of supravesical diversion (bilateral cutaneous ureterostomy) is controversial, it is generally limited to those patients that continue to do poorly despite bladder level drainage. Observation is warranted only after the possibility of residual valves and bladder dysfunction has been adequately assessed. Changing prophylactic antibiotics will not lead to clinical improvement if there is persistent valve obstruction. MR urogram would simply confirm upper tract dilation, but would not be helpful in evaluating for persistent bladder outlet obstruction and is contraindicated in the setting of compromised renal function.

Answer 85

5 The first communication from the FDA regarding vaginal mesh occurred in October 2008 and focused on the risk of complications of surgically placed vaginal mesh to treat both stress urinary incontinence and pelvic organ prolapse (POP). In July 2011, the FDA published an updated safety communication regarding the use of transvaginal mesh placement for POP. These communications do not state that these techniques should not be done. In addition, while the communication does recommend that each surgeon obtain specialized training for each technique they use and be aware of the risks involved with that technique, it does not state that these procedures should only be done by physicians who are board certified in the specialty of Female Pelvic Medicine and Reconstructive Surgery. The statement does note that serious complications associated with transvaginally placed mesh for POP are not rare. The FDA summary of the literature also notes that the use of mesh in transvaginal POP repair introduces possible risks that would not be seen in a repair without mesh, lower mesh-related complication rates are seen with transabdominal mesh use compared to transvaginal repairs and that mesh augmented transvaginal POP repairs may result in a better objective outcome that does not translate into a better symptomatic outcome.

Answer 86

3 The finding of a papillary lesion at the ureteral margin needs further evaluation to fully ascertain the extent of tumors in the system prior to planning the correct therapy. An on-the-table flexible ureteroscopy would thus be useful in detecting more proximal tumors which if present may necessitate more extensive surgery. If only CIS or dysplasia is present, intraoperative endoscopy is not indicated, because visual identification of CIS is unlikely. Presuming that on-the-table ureteroscopy shows no additional tumors, you would then resect until negative margins are obtained. Nephroureterectomy and extensive ureteral resection would only be performed if the ureteroscopy demonstrated tumors at more proximal location. BCG is not indicated for a low grade ureteral tumor.

Answer 87

3 The flow rate is abnormal but there is no anatomic obstruction. This boy has primary bladder neck dysfunction since the bladder contraction precedes the onset of urine flow by a significant period of time. The treatment of choice would be alpha-1 receptor blockade for a period of several weeks to months followed by re-evaluation clinically, and repeat uroflow with EMG. External sphincter dyssynergia can be treated with botulinum toxin injection or pelvic floor retraining (biofeedback). Double voiding may decrease his PVR and improve his continence, but this will not address the primary problem. CIC would 'bypass' the blockage but would not be the preferred primary treatment.

Answer 88

1 Classically, cryoablation is used to treat tumors \< 4 cm in size, with the laparoscopic approach used being dependent on the location of the tumor. Posterior and lateral tumors are usually approached retroperitoneally, and anterior or anterolateral tumors were approached transperitoneally. Theoretically, hilar tumors are more difficult to treat than peripherally located tumors due to the heat-sink effect caused by the renal blood flow within the renal hilar vessels. As such, target temperatures may be more difficult to achieve consistently throughout the entire tumor located near the renal hilum. Specific measures required to optimize tumor destruction during laparoscopic renal cryoablation include: 1) use of real-time intraoperative ultrasound to guide and confirm probe placement during laparoscopic insertion, 2) use of the ultrasound probe to monitor progression of the cryo lesion, 3) placement of the cryo probe tip at or just beyond the deepest or inner margin of the tumor, 4) obtaining target temperatures below -40 degrees Celsius during treatment, 5) extending the cryo lesion approximately 1 cm beyond the margin of the tumor, 6) performing an active double freeze-thaw cycle, as opposed to single cycle.

Answer 89

1 Urethral recurrence following radical cystectomy and orthotopic neobladder is a rare event with a reported incidence of 2-3%. While invasive tumors are an indication for total urethrectomy and ileal conduit, noninvasive tumors can be managed initially with conservative therapy. For papillary tumors, TUR alone may be curative for low grade recurrences. Intraurethral chemotherapy and immunotherapy have been used for high grade noninvasive recurrences. In this patient with CIS, an initial attempt at preservation of the urethra and neobladder is warranted. For this reason, intraurethral BCG is the most appropriate choice.

Answer 90

2 The cremasteric reflex implies an intact reflex arc in the genital branch of the genitofemoral nerve. Both the iliohypogastric and ilioinguinal nerve supply motor function to the internal oblique and transversus abdominis. The obturator nerve is the motor nerve for muscles in the medial thigh compartment. The femoral nerve supplies motor function for the anterior thigh compartment. The lateral femoral cutaneous nerve does not have a motor function and supplies sensation to the lateral aspect of the thigh.

Answer 91

3 For patients with chronic bicarbonate losses due to diarrhea, citrate should be employed to correct the resulting acidosis. It is recommended that a liquid preparation of potassium citrate be used rather than the slow-release tablet preparation because the slow-release medication may be poorly absorbed due to trapid intestinal transit time. Lemonade therapy is unlikely to normalize citrate levels, and the volume of fluid required will exacerbate the patient's diarrhea. Sodium citrate is not preferred, due to the sodium load which can promote hypercalciuria. Magnesium oxide and pyridoxine are useful treatments for hyperoxaluria, but not for hypocitraturia.

Answer 92

3 In a randomized clinical try, observation alone after successful BCG induction has been associated with a high recurrence rate when compared to three weekly maintenance BCG treatments at three months, six months and then every six months for two years. Prior randomized trials using other maintenance schedules have not been associated with a significant decrease in recurrence rates and, therefore, intravesical BCG on a monthly basis is not correct and there is no indication to initiate repeat induction BCG therapy. Monthly mitomycin maintenance has not been evaluated following BCG response in the setting of CIS.

Answer 93

4 Congenital abnormalities of the urachus include a urachal sinus, urachal cyst, patent urachus, vesicourachal diverticulum, and omphalomesenteric cyst/duct. Urachal abnormalities occur equally between boys and girls and present more often in adulthood with umbilical drainage followed by an umbilical mass and periumbilical pain. Staphylococcus aureus is the most common bacteria cultured from an infected sinus tract or cyst. An important aspect of treatment is initial antibiotic therapy. Incision and drainage or percutaneous drainage should be considered for a loculated abscess, particularly when it is non-responsive to antibiotic therapy. Omphalomesenteric ducts may connect the midgut to the umbilicus. Ultrasound will demonstrate a periumbilical mass and a sinogram will reveal communication of the umbilical sinus to the ileum. Definitive treatment centers on excision that should be delayed for a few weeks following the initial antibiotic therapy in order to decrease the inflammatory response. This will help limit the amount of bladder that may need to be resected and will reduce the risk of injury to adjacent intra-peritoneal structures.

Answer 94

2 Semen pH is alkaline (pH \> 7.2). This is due to the larger amount of alkaline fluid from the seminal vesicles (SVs) over the smaller volume of acidic fluid from the prostate. Very little alkaline fluid is provided by the vas, testes, or epididymides. Alkaline pH of semen is needed for correct function of sperm. The knowledge of semen volume and pH is very important because it is diagnostic, and can determine ejaculatory duct obstruction (EJDO) and congenital bilateral absence of the vas deferens (CBAVD) from other obstructive causes of azoospermia. Both EJDO and CBAVD have low volume acid pH semen due to obstruction and absence of the SVs respectively. Bilateral vasectomy or epididymal obstruction would result in normal semen volume and pH with azoospermia since the SVs are not obstructed.

Answer 95

3 The size of residual masses is an important predictor of viable malignancy; 27% to 38% of discrete residual masses larger than 3 cm contain viable malignancy compared with 0% to 4% for masses \< 3 cm. Moreover, surgical resection is technically difficult due to severe fibrosis, and often incomplete. The recommended management for this situation (small tumor \< 3 cm) is observation with serial physical exam, serum markers, and CT scans. Recently, FDG-PET has been found to be a useful adjunct to CT to select patients for post-chemotherapy surgery. Thus, patients with discrete residual masses \> 3 cm should be evaluated further with FDG-PET and those who are PET positive should undergo surgery. PET-negative residual masses \> 3 cm and masses \< 3 cm (as above) should be observed. This management should be distinguished from individuals with mixed germ cell tumors or non-seminomatous germ cell tumors in whom RPLND is indicated for the vast majority of residual masses within the retroperitoneum.

Answer 96

1 Children who initially fail an alarm system in the treatment of nocturnal enuresis will benefit from combination therapy e.g., enuretic alarm with pharmacological treatment. Comparison of estimated bladder capacity (age in years x 30 ml 60 ml = bladder capacity) divided by the mean of the voided diurnal urine volumes obtained on a voiding diary can guide combination therapy. Patients with values of \> 70% (estimated bladder capacity/mean diurnal voided volume) will have a better response to the combination of a enuretic alarm and DDAVP. Response to enuretic alarm and anticholinergic medication is better in patients with \< 70% (estimated bladder capacity/ mean diurnal voided volume).

Answer 97

1 Cystic fibrosis (CF) is a progressive, lifelong condition in which the glands that produce mucus, sweat, and intestinal secretions produce abnormally high amounts of NaCl. The abnormal functioning of the epithelial cells result in thick mucus accumulation in the lungs, leading to breathing difficulty and repeated respiratory infections, impaired digestion due to thick mucus blocking the pancreatic ducts with failure of pancreatic enzymes secretion, and infertility (\> 98% of affected men are infertile) due to vasal atrophy and dissolution. Vasal dissolution presumably occurs secondary to mucus build-up within the vasal lumen and pressure induced atrophy. Due to the thick build-up of mucous within the lungs and recurrent pulmonary infections, many of the patients with CF are exposed to prolonged antibiotic use resulting in the loss of the intestinal bacteria, Oxalobacter formigenes. This bacteria normally metabolizes intestinal oxalate, reducing the amount of oxalate available for systemic absorption. Due to the lack of digestive pancreatic enzymes, cystic fibrosis patients will frequently have intestinal malabsorption resulting in diarrhea, caloric deficiencies and deficiencies in the absorption of Vitamins A, D, E, and K and the minerals of calcium, magnesium, iron, sodium chloride, and zinc. To combat these deficiencies, CF patients are encouraged to eat a diet high in calories, fat, and salt. The elevation in salt intake is critical in CF patients due to the high salt content (\> 10 fold normal) found in the sweat of affected patients. Individuals with cystic fibrosis will, therefore, not have absorptive hypercalciuria; indeed, they have a failure to absorb calcium from their GI tract due to saponification of calcium by the high fat content of their stools. They will have elevated levels of urinary sodium due to increased sodium intake. CF patients do have diarrhea with resultant hypocitraturia and hypomagnesuria; however, replacement of citrate or magnesium have not been found to reduce stone formation within this patient population.The chief cause of stones in patients with CF is the excess oxalate absorbed due to absence of Oxalobacter formigenes, the saponification of calcium within the intestine, and low urinary volume secondary to fluid depletion from diarrhea.

Answer 98

1 Primary hyperaldosteronism (Conn's Syndrome) due to adrenal hypersecretion of aldosterone causes HTN and hypokalemia in non-edematous patients. Conn's syndrome accounts for about 1% of hypertensive patients, usually women between the ages of 30-50 years. Patients typically have HTN, muscle weakness, polyuria, hypokalemia, and mild metabolic acidosis. However, essential HTN treated with diuretics is the most common cause of hypokalemia in patients with HTN. Secondary hyperaldosteronism can be due to renal artery stenosis, cardiac failure, hepatic cirrhosis, pregnancy and Bartter's Syndrome (due to juxtaglomerular cell hyperplasia).

Answer 99

3 Stranguria and gross hematuria in a child with a normal ultrasound suggests a possible urethral abnormality, such as congenital urethral polyp, or urethral stricture. A VCUG will likely be diagnostic. CT scan and MRI are unlikely to add useful information in a patient with a normal renal and bladder ultrasound and urine cytology is not indicated. Cystoscopy may be indicated based on the findings of the VCUG.

Answer 100

5 Asymptomatic bacteriuria has not been demonstrated to cause harm in most adults. While these patients are at risk for developing symptomatic UTIs, treatment of the asymptomatic bacteriuria does not result in fewer symptomatic UTIs. In contrast, treatment of asymptomatic bacteriuria is indicated in pregnant women and patients undergoing urologic procedures because they are at increased risk of developing adverse outcomes if left untreated. The presence of diabetes is not an indication to screen for or treat asymptomatic bacteriuria. Neither imaging studies nor cystoscopy is indicated if the bacteriuria is asymptomatic. In this setting, a culture should not be sent because it will not affect management.

Answer 101

1 Cytoreductive nephrectomy as part of a multidisciplinary approach to metastatic RCC has been shown to prolong survival in two randomized clinical trials. However, its use is controversial and proper patient selection is crucial. The following inclusion criteria have been suggested for selecting patients for cytoreductive nephrectomy: 1) ability to resect more than 75% of the tumor volume, 2) no brain metastases, 3) adequate pulmonary and cardiac reserve, 4) ECOG performance status of 0 or 1, and 5) predominantly clear cell histology. Although sarcomatoid cell histology has been associated with poor prognosis it is not a contraindication to cytoreductive nephrectomy. Patients with brain metastasis should be treated with stereotactic radiation or CNS surgery prior to consideration for cytoreductive nephrectomy.

Answer 102

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

Answer 103

3 The main purpose of the one shot IVP is to assess for the presence of a functioning contralateral kidney and to assess the degree of damage to the ipsilateral kidney and ureter when a non-expanding, non-pulsatile retroperitoneal hematoma is encountered during abdominal exploration for a GSW in the absence of preoperative imaging. Ultrasound cannot delineate parenchymal lacerations, vascular injury, or collecting system or ureteral injuries in the acute setting. Renal arteriography is not indicated in the acute, intra-operative setting. Expectant management has been advocated as long as there is not an expanding or pulsating hematoma and renal pelvic or ureteral injury can be excluded by pre-operative CT scan or pre- or intra-operative one-shot IVP. Because of the risk of renal loss with exploration, a conservative approach is advocated and has been associated with a lower nephrectomy rate. In the presence of an expanding or pulsatile retroperitoneal hematoma, renal exploration is indicated.

Answer 104

2 This patient has low risk clinically localized prostate cancer (normal DRE, PSA \<10, Gleason score \< 7, and minimal core involvement). Although there is no clinical or biochemical evidence at this point of disease progression, a repeat prostate biopsy within 18 months is an essential component of active surveillance and can provide important information useful in management. This is especially true for men electing active surveillance who have a life-expectancy \> 10 to 15 years and are otherwise candidates for definitive therapy. A repeat biopsy may provide information that would lead one to consider local therapy. This includes grade progression and an increase in the percentage of the biopsy specimen involved with cancer. MRI remains investigational as a tool for monitoring patients on active surveillance. Bone scan and ProstaScint scan are not indicated at this point in time.

Answer 105

3 This baby has a clinically and functionally significant right distal ureterovesical junction obstruction associated with decreased renal function. The diagnostic parameters indicate that treatment is needed. Observation is inappropriate and may result in further loss of renal function and/or severe infection in this obstructed system. Definitive treatment would entail ureteral reimplantation with tapering. However, this is technically challenging in this age group and better deferred for a child older than one year of age. A percutaneous nephrostomy tube requires external drainage which is not practical when required longer than several weeks. The most appropriate temporizing procedure is a distal cutaneous ureterostomy. Another option to be considered is an anastomosis of the distal ureter to the bladder in a refluxing manner.

Answer 106

2 Urethral rest involves a period of several weeks where the urethra is not instrumented. This rest period allows inflammation to decrease within the lumen and facilitates accurate identification of severely fibrotic segments of the stricture which will eventually require focal or complete excision. Suprapubic tube urinary diversion, removal of a urethral catheter after recent instrumentation, or cessation of CIC all accomplish urethral rest. The median duration of urethral rest is reported as three months in this study; however, repeat urethral staging can be repeated at four to six weeks. Urethroplasty following recent dilation, CIC, or DVIU may not accurately assess the location and severity of fibrotic urethral segments thus understaging the disease and placing the patient at a higher risk for recurrence following urethroplasty. DVIU is not indicated in any situation for a urethral stricture \> 1.5 cm. The urethroplasty technique will depend on the degree and length of fibrotic urethra following urethral rest.

Answer 107

2 Similar to retroperitoneal lymph node dissection for testicular cancer, chylous leak can occur after regional lymphadenectomy at the time of renal surgery. Care must be taken to ligate small lymphatic vessels, particularly those close to the cisterna chyli below the right crus. In a setting where a drain is left in place, the fluid will have a milky white appearance and will have elevated fat and total protein levels. While pancreatic injury and fistula needs to be considered in the setting of a resection of a large left-sided upper pole tumor, this is not as likely on the right side. In addition, the clinical presentation is not consistent with a pancreatic leak, as pancreatic fluid is usually clear. Similarly, a urine leak would present with clear fluid. Finally, an unrecognized bowel injury resulting in enterocutaneous fistula is unlikely given the appearance of the fluid. Therefore, an activated charcoal test would not be helpful.

Answer 108

2 Maintenance fluids are based on body weight. One formula is: 4 ml/kg/hr for the first 10 kg and 2 ml/kg/hr for the second 10 kg, then 1 ml/kg/hr for the remainder. Hence, for a 14 kg child, 48 ml/hr is appropriate (or approximately 50 ml/hr). Infants under six months are generally given 1/4 NS because of their high water needs per kg, but older than 6 months should receive 1/2 NS.

Answer 109

4 The patient has suffered a significant blunt bulbar urethral injury. Dilation and DVIU would have a much lower success rate in this situation as compared to non-traumatic strictures, as traumatic strictures have significant spongiofibrosis. The best treatment is excision of the strictured urethral segment and primary anastomosis of healthy urethral mucosa and spongiosum. A patch graft could be considered, but the outcomes with a nearly obliterated urethra and significant spongiofibrosis would be inferior to excision and primary anastomosis. Mitomycin injection may be indicated in recurrent bladder neck contractures but is not indicated in this situation.

Answer 110

4 Bladder preservation with chemoradiation can be effective in well-selected patients. The use of radical TURBT and concurrent radiosensitizing chemotherapy has achieved 50% five year survival. The most well-studied and effective chemotherapeutic agent used in this setting is cisplatin. Methotrexate, vinblastine, and doxorubicin are all important systemic agents with efficacy against bladder cancer; however, they do not have significant roles as concurrent treatments along with radiation therapy. Paclitaxel may have a selected role as a radiosensitizer, but to a much lesser degree than cisplatin.

Answer 111

3 Approximately 1% of children with unilateral Wilms' tumor develop contralateral disease. Children younger than 12 months diagnosed with Wilms' tumor who also have nephrogenic rests, in particular perilobar nephrogenic rests, have a markedly increased risk of developing contralateral disease. These children require frequent and regular surveillance for several years. They are not at higher risk for renal disease (other than that usually associated with nephrectomy, chemotherapy, radiation therapy), nor is she at greater risk for local or distant recurrence.

Answer 112

5 Proximal and large ureteral defects are difficult to manage. The surgeon must be ready to use a variety of approaches depending on the intraoperative findings. Due to poor long term outcomes, endopyelotomy is contraindicated in strictures over 2 cm. Ureteroureterostomy is ideal for short upper or mid-ureteral strictures but is not possible with large defects. Transureteroureterostomy is contraindicated in those with nephrolithiasis. Ureterocalicostomy is reserved for individuals with UPJ and proximal 2-3 cm stricture with a dilated lower pole calyx, this patient has a length ureteral stricture to amenable to this procedure. Ileal ureter should be considered for long, \> 4 cm upper ureteral defects, in patients with serum creatinines of \< 2.0 mg/dl. Fallopian tube and appendiceal substitutions although described, are not reliable reconstructive techniques and are associated with recurrent stricture on long-term follow-up. Other options for this patient include autotransplantation or nephrectomy. Nephrectomy is usually considered as a last resort and is reserved for patients with a normal serum creatinine and poor function (classically \< 20% on renal flow scan).

Answer 113

3 Approximately three quarters of urine specimens from ileal conduits are culture positive. Most adult patients show no untoward effects when exposed to chronic bacteriuria. Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas, and thus, these patients should receive antibiotic therapy to reduce the incidence of stone formation. Those patients with mixed cultures may generally be observed, provided they are not symptomatic. Further imaging in this asymptomatic patient is not indicated.

Answer 114

1 Post-traumatic HTN can occur in the setting of renal ischemia, development of an arteriovenous (AV) malformation, or kidney compression from a hematoma. The ultrasound rules out infarction, venous thrombosis and global scarring. The nuclear scan rules out infarction and segmental and global scarring. In this case of delayed development of HTN, the most likely cause is an AV fistula secondary to penetrating trauma. Diagnosis can be made with an MRI or CT angiogram. Successful treatment is usually achieved with angiographic embolization. In contrast to blunt or penetrating traumatic AV fistula, those occurring after a needle biopsy will often close spontaneously.

Answer 115

2 This patient has sustained a high velocity urethral injury. The best treatment is suprapubic tube placement followed by staged urethroplasty. The blast effect of the high velocity missile will cause significant collateral tissue damage which will evolve over the next several days. Suprapubic urinary diversion is the best course of action as compared to a urethral catheter which may compound the injury, followed by restaging the injury and eventual staged urethroplasty. Penile urethroplasty with or without graft immediately following a high velocity injury is not indicated as the full extent of the urethral injury is not known. The patient will eventually require a urethroplasty; however, this should be performed following suprapubic urinary diversion and restaging of the injury.

Answer 116

4 Failure to empty occurs more commonly in female than in male patients. Uniquely, females may develop hypercontinence that is likely due to a mechanical issue in which the orthotopic diversion falls back into a wide pelvic cavity. This in turn results in an acute angulation of the posterior pouch-urethral junction. Various maneuvers including omental packing behind (posterior) to the reservoir, suspending the dome of the reservoir to the rectus muscle and suspension of the vaginal stump to the preserved round ligaments have been described to prevent this angulation. Nerve-sparing techniques and increased intestinal length have been described as risk factors for retention. Suspension of the pouch to the back of the rectus muscle at the time of surgery is the most effective way to prevent angulation and hypercontinence.

Answer 117

1 Boys with urethral valves often have problems with bladder training because of a combination of factors. Often these patients will have persistent tubular concentrating defects resulting in polydipsia and polyuria combined with small bladders capacities, detrusor overactivity with or without poor detrusor compliance. The low capacity bladder associated with large urine volume production results in significant urinary frequency, urgency, urge incontinence and primary nocturnal enuresis. The most useful studies to define the anomalies are a 24-hour collection for volume and urodynamics. Diuretic renography and antegrade pressure perfusion study are not indicated in this patient with stable hydronephrosis and normal creatinine. Cystoscopy would not be indicated with normal voiding phase of the VCUG. Antimuscarinics are not indicated unless bladder overactivity is documented on urodynamic study.

Answer 118

3 Mutations in the CFTR are responsible for a phenotypic spectrum from overt cystic fibrosis to congenital bilateral absence of the vas deferens. Over 1,000 CFTR mutations have been identified and only a portion are detected by routine testing. The man should be assumed to be a CFTR carrier despite a negative CFTR gene test. Therefore, his female partner needs to be tested prior to any assisted reproductive techniques to determine the risk of cystic fibrosis in their offspring.

Answer 119

2 Multiple series have documented the safety and efficacy of endoscopic management of upper tract urothelial carcinoma (TCC). This elderly patient has significant comorbidities and a low grade distal ureteral TCC. Low grade tumors at ureteroscopic biopsy have a strong correlation with noninvasive stage at the time of nephroureterectomy. Similarly, high grade disease identified on ureteroscopic biopsy is very likely to represent invasive disease at the time of final pathologic staging. In a younger, healthier patient, distal ureterectomy and reimplantation would be another option; however, this older patient would be better served with endoscopic management. Although upper tract tumors can be ablated with electrocautery delivered through a small Bugbee electrode, the variable depth of penetration and risk of stricture formation have made the use of laser energy for ablation more popular.

Answer 120

1 The half-life of AFP is approximately five days and the fall in AFP levels described in this patient would be considered abnormal and suspicious of metastatic disease in any patient \> 18 months of age. However, in infants (\< 18 months of age) with a yolk sac tumor the physician should see a precipitous drop in the AFP levels post-orchiectomy but persistent elevations in the AFP (\> 10 ng/dl) are a normal finding. The reason behind the persistent elevation in AFP is its production in the fetal and neonatal liver. Indeed, AFP is the chief serum protein (instead of albumin) for the first six months of life. The persistent elevation in AFP in a neonate is a normal finding with the AFP levels reaching normal adult values (\< 10 ng/dl) at approximately eighteen months of age. In infants undergoing resection of a yolk sac tumor serial AFP levels are obtained with evidence of persistent or recurrent disease noted by serial elevations of the AFP level above the nadir value.

Answer 121

3 All five drug classes have been used for the pain relief of acute renal colic. NSAIDS and narcotics are most commonly used; however, meta-analysis and comparative studies show that NSAIDS are superior to narcotics for the acute relief of renal colic. NSAIDS treat the inflammatory basis of pain and reduce collecting system pressure as compared to narcotics. Narcotics are also associated with more side effects as compared to NSAIDS. Alpha-blockers, calcium channel blockers, and steroids are used more commonly for medical expulsive therapy.

Answer 122

4 Ureterointestinal stricture can occur early or late after urinary diversion. The first step in management is to rule-out disease recurrence. Once it has been established that the stricture is not due to recurrent cancer, the most effective approach to management is open surgical repair. Although various minimally invasive approaches have been employed, including balloon dilation, cold knife or laser incision and stent placement, open surgical repair has been consistently shown to be the most effective way of addressing this problem, particularly in the setting of a longer stricture and decreased renal function. Minimally invasive approaches may be effective for shorter strictures (1-2 cm or less). Early ureteroenteric strictures (\<1 yr postoperative) are usually due to devascularization of the distal ureter or extreme angulation of the left ureter at the level of the inferior mesenteric artery. Late strictures are usually due to a fibrotic response at the ureteroenteric junction. Nephrectomy is not indicated in this kidney with 25% shared function. In younger patients, a chronic ureteral stent is not indicated.

Answer 123

5 Approximately 70% of arteriovenous fistulas occurring after needle biopsy of the kidney close spontaneously within 18 months. In the absence of significant related symptoms, expectant management is appropriate initially. The clinical manifestations of a renal arteriovenous fistula depend upon the size of the fistula. Congestive heart failure, cardiomegaly, and diastolic HTN are observed in 50% of symptomatic patients. Hematuria is present in about a third, and tachycardia is occasionally found. Flank pain, embolic events, and HTN are less common. In contrast, AVF following blunt renal trauma is much less likely to resolve spontaneously.

Answer 124

4 The genitofemoral, ilioinguinal, and lateral femoral cutaneous nerve can be seen during the performance of a psoas hitch. Although this patient has suffered an injury to the femoral branch of the genitofemoral nerve, visualization of three nerves will usually result in sparing injury to these structures. Indeed, some studies have revealed the most common nerve injured during the performance of a psoas hitch is the femoral nerve running in the undersurface or belly of the psoas muscle. Sutures placed horizontally in the psoas muscle increase the risk of injury to this nerve. Sutures for a psoas hitch should be placed longitudinally, e.g., in the direction that the muscle is running and superficially to prevent this complication.As noted, this patient has suffered an injury to the femoral branch of L1, L2 as a result of the psoas hitch. This nerve branch is responsible for sensation to the anterior thigh. The genital branch of L1, L2 is motor to the cremasteric muscles and scrotum. The lateral femoral cutaneous nerve is responsible for sensation to the lateral aspect of the thigh, and the ilioinguinal nerve provides sensation to the anterior pubis and scrotum. The obturator nerve provides sensation to the medial thigh.

Answer 125

2 The presence of even a small amount of fat within a renal lesion on CT scan (confirmed by a value of -20 HU or lower) virtually excludes the diagnosis of RCC and is diagnostic of angiomyolipoma (AML). There are very rare cases of fat containing kidney cancer, but most of those will have calcified areas. Approximately 20% to 30% of AMLs are found in patients with tuberous sclerosis syndrome (TS), an autosomal dominant disorder characterized by mental retardation, epilepsy, and adenoma sebaceum, a distinctive skin lesion.Most patients with acute or potentially life-threatening hemorrhage require total nephrectomy if it is explored; and if a patient has TS, bilateral disease, preexisting renal insufficiency, or other medical or urologic disease that could affect renal function in the future, selective embolization should be considered. In such circumstances, selective embolization can temporize and in many cases prove definitive.This patient is hemodynamically stable and may not require transfusion if selective embolization is successful. There is no role for radio frequency ablation or cryotherapy for a large AML that is acutely bleeding. A partial nephrectomy may be possible or desirable in the future; however, in the setting of acute bleeding, most explorations will result in nephrectomy, which would be undesirable for this woman with renal insufficiency.

Answer 126

2 When infradiaphragmatic urinary extravasation extends through Buck's fascia, it is limited only by Colles' fascia which attaches posteriorly at the triangular ligament and laterally at the fascia lata of the thigh. Colles' fascia is continuous anteriorly with Scarpa's fascia which extends superiorly to the thoracoclavicular fascia. Therefore, both Colles' and Scarpa's fascia limit such an extravasation. Such an extravasation, particularly when associated with infection (periurethral phlegmon), can result in edema and necrosis of the skin of the penis, scrotum, and anterior body wall. Denonvillier's fascia does not connect with Colles', Scarpa's, or dartos fascias. Colles' is contiguous with dartos fascia.