2016

Question 1

Secretion of aldosterone is primarily mediated by:

1. ACTH
2. renin
3. serum potassium level
4. sodium concentration in the proximal tubule
5. sodium concentration in the collecting duct.

Answer 1

2

ACTH and serum potassium may increase aldosterone secretion but the effect is much less pronounced than that achieved by renin . The primary echanism for control of aldosterone production resides in a feedback system involving the kidney and its juxtaglomerular apparatus. In the presence of ppropriate stimuli (i.e., decreased renal perfusion pressure), juxtaglomerular cells release renin which results in the increased production of angiotensin II . ngiotensin II is a potent stimUlator of aldosterone output from the zona glomerulosa of the adrenal cortex. Sodium concentration in the thick ascending Loop of enle (not the proximal tubule or collecting duct) an also be sensed by the macula densa which can stimulate the re lease of renin.

Question 2

A 55-year-old man undergoes a left lower pole partial nephrectomy for a 3.5 cm solid renal mass. The contralateral kidney is normal. Two days postoperatively, his serum hematocrit drops from 32% to 28% over 24 hours. Urine is dark burgundy in color. Vital signs are stable. The next step is:

1. angiography and embolization of bleeding vessels
2. reoperation with suture ligation of bleeding vessels
3. reoperation with nephrectomy
4. bed rest, serial monitoring, and transfusions as needed
5. ureteral stent placement.

Answer 2

4

Complications of partial nephrectomy include hemorrhage, urinary fistu la formation , ureteral obstruction, renal insufficiency, and infection. Significant intraoperative bleeding can occur in patients who are undergoing partial nephrectomy. The need for early control and ready access to the renal artery is emphasized . Postoperative hemorrhage may be self-limiting if confined to the retroperitoneum with or without associated gross hematuria. The initial management of postoperative hemorrhage is expectant with bed rest, serial hemoglobin and hematocrit determinations, frequent monitoring of vital signs, and blood transfusions as needed. Angiography may be helpful if bleeding persists, to localize actively bleeding segmental arteries, which may be controlled by angioinfarction. Severe intractable hemorrhage may necessitate re-exploration with early control of the renal vessels and ligation of the active bleeding points. Ureteral stent is not indicated.

Question 3

Five years after a radical cystectomy and ileal conduit for bladder cancer, a 65-year­ old man has a serum creatinine of 3.0 mg/di, BUN 40 mg/di, sodium 146 mEq/I, potassium 4.6 mEq/I, and bicarbonate 16 mEq/I. A loopogram shows a 35 cm long moderately dilated conduit with grade 4 reflux into dilated upper tracts. The most appropriate treatment is:

1. sodium citrate
2. injection of bulking agent into the ureteroenteric anastomosis
3. revision of conduit length and stoma
4. excision of ileal conduit and conversion to a non-refluxing colon conduit
5. bilateral nephrectomies and placement on transplant list.

Answer 3

3

Despite improvement in surgical techniques, stomal stenosis is still the most likely cause of the elongated dilated conduit with hydronephrosis and hyperchloremic acidosis. Therefore, the most appropriate treatment is revision of the stoma and shortening of the conduit. Administration of electrolytes is symptomatic treatment only and does. ot addres th.e anatomic cause of the acidosis. Conversion to a non-refluxing colon.conduit 1s not rqired 1.n this setting where a simpler procedure, shortening of the ileal cndu1t and. stom I rev1s1on, .w l suffice. Treatment of high grade vesicoureteral reflux by a bulking agent in a 1leal conduit is not indicated· the high grade reflux is a direct sign of distal obstruction and 1s usually due tc either stomal or mid-ileal loop stenosis. Although this patient may event lly need a ren transplant, a functional loop is necessary for transplantat on, tereore, rev1s1on of the loop 1 indicated. No indications are currently present for proceeding with bilateral nephrectomy.

Question 4

A seven-year-old, neurologically normal boy with recurrent UTls and worsening diurnal incontinence has a normal renal ultrasound and VCUG. His bowel function is normal. Urodynamic evaluation reveals detrusor overactivity and increased sphincter activity during voiding. His initial treatment should be

1. maintenance of voiding diary and timed voiding
2. biofeedback
3. pelvic floor muscle retraining
4. oxybutynin
5. prazosin

Answer 4

1

Dysfunctional voiding syndrome is frequently manifested by worsening diurnal incontinence posturing when voiding, with or without primary nocturnal enuresis, recu:re.nt UTls, anc encopresis. Classically , urodynamic studies will reveal poor cerebral appreciation of sudden detrusor contractions. Voluntary sphincter contraction 1s thought to be a reponse to udder detrusor contraction. This can arise from either delayed neurourlogic .maturation o inappropriately learned voiding behavior. Initial treatment should be with maintenance of voiding and stooling diary , timed voiding every two hours while awake, and treatment of constipation issues if present. Approximately 80-85% of patients will resolve their symptoms o this treatment. Individuals failing the conservative management outlined above may be treat by either the addition of antimuscarinics, such as .oybutynin or alternatively, behavioral modification with biofeedback pelvic floor muscle retraining. Use of a sacral nuromodulatc should only be considered after the patient has failed the mar conseat1ve treamer modalities outlined above. Prazosin, an alpha-1- receptor blocker, 1s potentially useful in thsetting of bladder neck dysfunction but not in the patient described above.

Question 5

Two grams of oral ascorbic acid (Vitamin C) per day will:

1. decrease urinary calcium
2. increase urinary oxalate
3. decrease urinary magnesium
4. decrease urinary acidity
5. decrease urinary citrate

Answer 5

2

Approximately 10-20% of dietary ascorbate is metablized into oxalic a.cid that is ten excret into the urine. Ascorbic acid in doses of 2 grams daily was shown to increase urinary oxala by 20-30%, but had no effect on urinary pH, citrate, calcium, or magnesium.

Question 6

A one-month-old girl with prenatal hydronephrosis underwent postnatal imaging as shown. The most likely cause of findings in the bladder and kidney is:

1. VUR
2. UPJ obstruction
3. ureterocele
4. bladder diverticulum
5. ectopic ureteral insertion into the vagina.

Answer 6

3

Ureteral duplicaion is one of the most common renal abnormalities with approximately 1% of the population diagnosed as having a duplication anomaly during their lifetime with 10% of the affected indiiduals ill have a bilatral duplicatio anomaly. In individuals with a duplication anmaly, 10 Yo are diagnosed following an evaluation for a UTI, another 10% are discovered dnng an evluatio for p:enatal h.ydronephrosis , and the remainders are incidentally d1s ove:ed during rad1ograph1c evaluations. Severe upper pole hydronephrosis of a duplicated moiety 1s com?nly associated with either a ureterocele or ureteral ectopy, while lower pole hyronephros1s 1s common ly associated with vesicouretera l reflux or a UPJ obstruction. In this patient, the ulrasoud. (US) images are classic for obstruction of the upper pole due to a ureterocele. D1fferent1at1on of a ureterocele from an ectop ic ureter can at times be problematic. Indeed, te term “pseudourete:ocele” has been coined for enlarged ectopic ureter that protrudes into the bladder. Classically , a tip off that it is an ectopic ureter and not a ureterocele is found in the thickness of the ureterocele membrane. Presence of a thin-wall membrane is almost invariably associated with a ureterocele. In contrast, a thick-walled “ureterocele” or cystic structure may indicate a ectopic ureter with the thick wall being attenuated detrusor muscle. Inadvertent endoscopic incision of a pseudoureteroce le has led to the creation of detrusor-ureteral-vaginal f istulas that may be highly problematic to repair in a neonate. To differentiate. an ectoic uretr (pseudoureterocele) from a ureterocele, a VCUG may be helpful. If the ectopic reer insert into t.he bladder neck or urethra, reflux into the upper system may be faun? confirming the d1agnos1s of an ectopic ureter. If no reflux is noted and the physician has a high degree of suspicion that the diagnosis is truly an ectopic ureter, a pelvic MRI or CT scan may be of benefit.

Question 7

A newborn girl had moderate left hydroureteronephrosis on prenatal ultrasound. Ultrasound at one month of age demonstrates normal kidneys bilaterally. Physical examination is normal. The next step is

1. observation
2. VCUG
3. MAG-3 renal scan
4. repeat ultrasound in three months
5. MR urogram.

Answer 7

2

It is not uncommon for children with prenatally recognized hydronephrosis to have normal renal. ultrsou.nd after bi · Man of these represent patients with insignificant prenatal phys1olog1c d1lat1on. Spec1f1cally , in patients with a history of mild to moderate fetal hydronephro!s and a noral postnatal ultrasound , the latter obtained one to two months post­ art.um; add1t1onal evaluations are deemed unnecessary . The exception to this rule is the f1nd1ng of moderate to severe hydroureteronephrosis found on the prenatal evaluation with a normal post-partum ultrasound. The presence of ureteral dilation on the prenatal ultrasound has been ound to be associated.with a significant increased risk for neonatal UTls and high grade ves 1coureteral reflux despite a normal postpartal renal ultrasound. Documentation of ureteral dilation on the fetal ultrasound, therefore , results in the recommendation that a neonatal VCUG be obtained. Observation alone may miss the opportunity to diagnose high grade VUR and place this infant at significant risk. Repeat ultrasound at such a short interval is not indicated and, if normal, would not obviate the need for a VCUG. MAG-3 renal scan should be considered if the neonatal follow-up ultrasound evaluations demonstrate perslstenl hydroureteronephrosis and the VCUG reveals absence of reflux .. Antibiotic prophylaxIs IS recommended for infants found on neonatal ultrasound to have a dilated ureter and/or VUR. Unless the renal ultrasound reveals a structural abnormality, i.e ., poorly defined duplication anomaly, magnetic resonance urogram would not be indicated. Serial observation without the need for antibiotic prophylaxis would be indicated in the presence of hydronephrosIs alone without evidence of prenatal ureteral dilation. In these latter infants, a MAG-3 renal scan with a diuretic washout phase wou ld be indicated at two to three months of age.

Question 8

A 16-year-old boy passes a stone composed of 100% cystine. This condition is characterized by:

1. excessive jejunal absorption of cystine
2. excessive tubular resorption of arginine and lysine
3. inadequate tubular resorption of ornithine and cystine
4. excessive metabolic production of cystine, ornithine and lysine
5. impaired conversion of cystine to ornithine.

Answer 8

3

Cystinuria is the result of inadequate renal tubular resorption of cystine, ornithine, lysine, arginine, and is also associated with inadequate intestinal absorption of these amino acids. Stones result from increased concentrations of cystine in the urine which precIpitate In aCldl1 urine. The other amino acids do not crystallize to form stones.

Question 9

A 42-year-old infertile man has a semen volume of 2 ml, sperm density of 5 million/ml, and decreased sperm motility. Physical examination demonstrates a grade 3 left varicoce le and grade 1 right varicocele. His partner’s evaluation is normal. The next step is

1. transrectal ultrasonography
2. clomiphene citrate (Clomid™)
3. intrauterine insemination
4. left varicocelectomy
5. bilateral varicocelectomy.

Answer 9

5

Semen parameters improve to a greater extent after bilateral varicocelectomy as compared to just repairing the dominant varicocele in patients with a grade .’I-III varicoele and contralateral grade I varicocele. This approach does not extend to patients with a subclinical varicocele (those only detected by Doppler ultrasound). Transrectal ultrasonography all clomiphene citrate (Clomid) are not indicated in this setting. Intrauterine insemination ~another alternative but varicocelectomy is more cost effective. Intrauterine Insemination is not indicated because sperm concentration is too low. Age of the female partner is also an important consideration ; if partner is older, in vitro fertilization should be considered as treatment option.

Question 10

A 14-year-old boy with myelodysplasia and a ventriculo-peritoneal shunt has acute abdominal pain. He underwent a sigmoid bladder augmentation six months ago. His pulse is 100 bpm and blood pressure is 100/70 mmHg. He has diffuse abdominal tenderness . Urine output over the past six hours is 70 ml. Cystogram shows no extravasation. The best management is l.V. hydration, broad spectrum antibiotics, and:

1. abdominal CT scan
2. CT cystogram
3. continuous catheter drainage
4. placement of large-bore (24F), percutaneous suprapubic tube
5. exploratory laparotomy .

Answer 10

2

It is noteworthy that up to 50% of cystogram studies in cases of a ruptured augmented bladder may be negative for the injury; therefore, a negative cystogram does not rule out a bladder rupture. With this patient having clear clinical signs of acute peritoneal inflammation the differential diagnosis is . cystitis with peritoneal irritation (treated by antibiotic therapy’ and continuous bladder drainage and not requiring surgery), a loculated infected ventriculoperitoneal shunt (requiring a neurosurgical consultation), or a missed bladder rupture (requiring emergent surgery). Confirmation of suspected perforation of an augmented bladder is best achieved by performing a CT cystogram with a minimum of 300 ml of contrast placed in the bladder with a CT phase taken with the bladder distended and emptied. An abdominal CT without a cystogram may show a significant increase in peritoneal fluid if an infected VP shunt is present (false positive for bladder rupture) or, alternatively, a high false negative rate for rupture if a small bladder perforation is present and occluded by either small bowel or omentum. The performance of a CT cystogram with a minimum of 300 ml of contrast has been shown to dislodge the omentum or small bowel that would be plugging the bladder laceration and diagnosis of extravasated contrast is more readily found on the CT evaluation than the plain cystogram. Placement of a large bore suprapubic tube will not sufficiently divert urine or drain infected urine from the peritoneal cavity if a bladder rupture is present. Continuous catheter drainage along with I.V. antibiotics may be of benefit for severe cystitis but should only be pursued after documentation of the absence of a bladder perforation. Exploratory laparotomy would be indicated without a CT cystogram if the patient was clinically unstable and not responsive to fluid resuscitation.

Question 11

A 26-year-old man has bilateral gynecomastia . Testicular examination is normal. Free testosterone is elevated and LH is decreased. The next step is:

1. cranial MRI scan
2. abdominal CT scan
3. testicular ultrasound
4. serum prolactin
5. serum estradiol.

Answer 11

3

Gynecomastia occurs in the male when there is an alteration of the testosterone-estradiol ratio which may be due to either reduced testosterone or elevated estradiol . The ddx of gynecomastia in an adult includes prolactin-secreting pituitary tumor, estrogenic drugs, exogenous testosterone, testicular tumors, and idiopathic. The elevated testosterone level with low gonadotropin levels in this patient is most suggestive of either exogenous testosterone or a testicular tumor. Exogenous testosterone will usually result in a reduction in the size and softening of the consistency of the testes. The most likely etiology is a testicular tumor despite his normal testicular physical examination. Leydig cell tumors are one of the more common non pa lpable testicular tumors and with their inherent abi lity to secret testosterone is the most likely diagnosis. If it had been a prolactin secreting tumor, the LH and the testosterone would be low. The MRI scan is not needed since the pituitary is responding normally and prolactinoma is not suspected. Gynecomastia in these patients is caused by the conversion of excess (unregulated) testosterone to estradiol by aromatase.

Question 12

The characteristic that distinguishes primary hypoadrenalism from secondary (pituitary) hypoadrenalism is:

1. hypotension
2. metabolic alkalosis
3. cutaneous hyperpigmentation
4. hypernatremia
5. hypokalemia.

Answer 12

3

Since the amino acids of ACTH are identical to the terminal amino acids of melanocyte stimulating hormone (MSH), over-production of ACTH results in cutaneous hyperpigmentation. Adrenal loss results in lack of negative feedback and over-production of ACTH. Pituitary failure , on the other hand, results in a lack of ACTH. Vitiligo may also be seen in these patients. Primary hypoadrenalism (or Addison’s disease) is notable for hyponatremia (not hypernatremia) and hyperkalemia (not hypokalemia). Hypotension can be present In primary or secondary hypoadrenalism.

Question 13

A two-year-old girl has a large abdominal mass. Chest and abdominal CT scans show clear lung fields with a 12 cm tumor arising from the center of the right kidney and two 3 cm exophytic tumors of the mid- and lower poles of the left kidney. The next step is:

1. initiate chemotherapy
2. bilateral percutaneous needle biopsy
3. exploration and bilateral open renal biopsy
4. right nephrectomy and partial left nephrectomy
5. bilateral nephrectomy.

Answer 13

1

There is a high probability that this two-year-old girl has bilateral Wilms: tumor. The current Children’s Oncology Group Wilms’ Tumor protocol recommends 6 weeks of chemotherapy without the need for renal biopsy in patients with highly probable bilateral Wilms’ tumor. The response to the chemotherapy is assessed after six weeks of chemotherapy by CT or MRI scans. Imaging at this time will quantify any reduction in tumor volume and allow the surgeon to assess the feasibility of renal sparing surgery. Tumors responding to chemotherapy may receive a second round of medications in an attempt to further reduce the size of the tumor allowing the surgeon to maximally salvage non-involved renal parenchyma. Tumors not responding to therapy will require bilateral open renal biopsy and lymph node sampling in order to both determine histopathology and guide further treatment. Although right nephrectomy and partial left nephrectomy may eventually be the ultimate outcome for this patient, chemotherapy is the initial step in management with renal preservation the primary goal.

Question 14

During a laparoscopic donor nephrectomy, a 2 cm laceration is made in the splenic flexure of the colon. The most appropriate action is to:

1. abandon the operation
2. close the laceration , administer broad-spectrum antibiotics to the donor and continue with the transplantation
3. close the laceration, irrigate wound with neomycin, and proceed with the transplantation
4. close the laceration, administer broad-spectrum intravenous antibiotics to the donor and recipient , and proceed with the transplantation
5. close the laceration, irrigate wound with neomycin, administer broad-spectrum ant1b1ot1c to the donor and recipient, and proceed with the transplantation.

Answer 14

1

Infection transmitted from a cadaver donor to an immunocompromised recipient can be rapidly fatal. Gross bacterial contamination of the operative site gives the surgeon only one single safe option which is to abandon the procedure.

Question 15

A 24-year-old man is shot in the right flank and sustains a grade 5 renal injury and extensive liver and bowel injury. During exploration, his liver and bowel injuries are stabilized and a nonpulsatile right retroperitoneal hematoma is identified with no intervention . One week after exploration, he develops increased drainage from a perihepatic drain. Creatinine of the drainage fluid is 8 mg/di. CT scan and retrogradepyelogram are shown. The next step is:

1. ureteral stent
2. ureteral stent and urethral catheter
3. percutaneous nephrostomy
4. exploration, debridement, and renal repair
5. nephrectomy.

Answer 15

2

The patient has a delayed urine leak following high velocity penetrating renal trauma. CT scan and retrograde pyelogram reveal a urine leak. The next step is ureteral stent and urethral catheter drainage to prevent reflux of urine retrograde into the stent which may potentiate the leak and result in infection of the retroperitoneal hematoma. Ureteral stent placement may allow for resolution of the leak without operative intervention. The patient’s recent history of shattered kidney along with liver and bowel injury placement of a percutaneous nephrostomy tube would result in increased risk for infection of the perinephric hematoma and maybe difficult to place and maintain in the proper position due to the renal injury. Exploration of the right kidney is not ind icated at this time.

Question 16

Antenatally diagnosd marked bilateral hydronephrosis is confirmed postnatally in a newborn girl. VCUG 1s normal. The next step is:

1. magnetic resonance urogram
2. MAG-3 renal scan
3. DMSA renal scan
4. CT urogram
5. repeat ultrasound in two months.

Answer 16

2

In this setting, one must determine if the hydronephrosis is causing significant obstruction and, if so at what level in the urinary tract. The ultrasound may show ureteral dilation which suggests obstruction at the ureterovesical junction, but the MAG-3 renal scan will determine the differential function and the degree of obstruction. The ideal timing for performing this study is during the second month of life when the GFR has increased several fold. DMSA scan would not provide information regarding degree or level of obstruction. The MR urogram may be useful after the first week of life, but does not provide dlfferenlial renal function. Antegrade studies are not needed at this point and should not be performed prior to the less invasive MAG-3 renal scan. CT urogram does not provide quantitative data and exposes the infant to unnecessary radiation and anesthesia.

Question 17

18. Reflex bladder and urethral activity are coordinated by a reflex center located in the:
19. sacral cord
20. thoracic and sacral cord
21. pons
22. medulla
23. basal ganglia.

Answer 17

3

The center for integration and coordination of bladder and urethral activity is in the pons (pontine micturition center). Suprasacral spinal cord injury disrupts the. necessary communication between the pontine micturition center and the sacral cord. This results In detrusor overactivity and detrusor external sphincter dyssynergia. Patients with this issue may have urinary incontinence, incomplete bladder emptying, and their upper tracts may be at risk.

Question 18

Nephrocalcinosis of infancy:

1. should be treated by thiazide diuretics
2. results in a high incidence of renal calculi in childhood
3. is associated with distal renal tubular acidosis
4. may completely disappear after stopping furosemide
5. should be treated by increased calcium and phosphate in the neonatal diet.

Answer 18

4

Nephrocalcinosis of infancy has been found in up to 64% of low birth weight < 1500 g) Dr premature infants (gestational age of 32 weeks or less). Specifically, neonates who require oxygen for greater than four weeks of life, undergo dietary supplementation with high calonc formula (increased calcium and phosphate), and infants receiving loop diuretics are at the highest risk. The largest risk factor for nephrocalcinosis is in infants who have received looP diuretics (furosem ide) to treat fluid overload, improve pulmonary oxygenation, and Increase card iac output. Indeed, 70% of the patients with nephrocalcinosis will have a history of prolonged loop diuretic exposure. The normal hypercalciuric effect of furosemide found In adults is enhanced in infants by the reduced glomerular filtration rate and the decrease hepatic filtration/metabolism function associated with infancy. The reduction in GFR and decreased systemic clearance of loop diuretics by the liver will significantly prolong the half-life of this drug, resulting in excesslve hypercalciuria. In infants with clinically documented nephrocalcinosis, approximately 15% will develop renal calculi by five years of age. The calculi isolated from these patients are composed exclusively of calcium oxalate. The vast majority of these infants (85%) will completely resolve their nephrocalcinosis following stopping the use of loop diuretics. Although neonatologists will frequently replace the use of loop diuretics by using thiazides for fluid management issues in these critically ill infants, it is noteworthy that resolution of nephrocalcinosis has not been found to be significantly enhanced by the use of thiazides. Treatment of. infants diagnosed with nephrocalcinosis should be with stoppage of the loop diuretiCs and Interval follow-up with renal ultrasound until the nephrocalcinosis has resolved or alternatively renal calculi have been documented to develop and necessary treatment has been accomplished. There is no association of nephrocalcinosis of infancy to renal tubular acidosis. Increased dietary calcium and phosphate in the diet routinely found in infant high caloric formula supplements may at times actually

Question 19

The initial nephrostomy tube puncture site in a horseshoe kidney compared to that in a normally positioned kidney is more:

1. medial and through a posterior calyx
2. lateral and through an anterior calyx
3. medial and through an anterior calyx
4. lateral and through a posterior calyx
5. inferior and through an anterior calyx.

Answer 19

1

Horseshoe kidneys may develop renal calculi, possibly as a result of high insertion of the ureter and relative stasis of urine. Patients with small, nonobstructing calculi in nondependent locations may be treated with SWL. However, obstructing calculi or those that are large or in dependent locations, are best treated with percutaneous techniques. The initial puncture is more medial than that for normally positioned kidneys and should be placed through a posterior calyx.

Question 20

A newborn boy has a left-sided abdominal mass. Ultrasound reveals an infiltrative mass replacing the lower third of the left kidney. The right kidney appears to have a slightly increased echogenicity , but is otherwise normal. The next step is:

1. bilateral needle biopsy of the kidneys, then chemotherapy
2. exploratory laparotomy and bilateral biopsy
3. left nephrectomy followed by chemotherapy
4. left lower pole partial nephrectomy followed by chemotherapy
5. left nephrectomy and surveillance.

Answer 20

5

This disease process is most likely a congenital mesoblastic nephroma (CMN) and should be distinguished from a Wilms’ tumor by the patient’s age and the fact that CMN is typically infiltrative on imaging, whereas Wilms’ tumors displace and compress renal architecture. CMNs are the most common tumor in infants greater than four months of age, with a median age at the time of diagnosis of three months. In contrast, the median age for diagnosis of a Wilms’ tumor is 3.5 years. Two types of mesoblastic nephroma exist, the classic type which is far more common, and, provided surgical margins are negative, rarely recur and the cellular variant. The cellular variant consists of atypical spindle cells with frequent mitotic figures (25-30/10 hpf) and necrosis and is considered a variant of a fibrosarcoma. This. variant is associated with both local recurrence and widespread metastasIs. Surveillance by Interval SIX month abdominal ultrasounds for the first two years is usually recommended for the classIc variant and more aggressive follow-up with interval CT or MRI scans of the lungs and abdomen are recommended at three to six month intervals for the first two years for the cellular variant. Normal newborn kidneys are slightly echogenic, hence, the right kidney is normal in the boy presented here.

Question 21

The factor most likely to increase the risk of a perirenal hematoma after SWL is:

1. hypertension
2. stone size > 2 cm
3. > 2,000 shocks
4. UTI
5. diabetes mellitus.

Answer 21

1

Preoperative HTN, especially uncontrolled HTN, and bilateral application of SWL are risk factors for the development of perirenal bleeding. Patient size or weight, or stone size location and number do not correlate with this complication. Clinically significant peri-renal hemtomas occur in approximately 0.2-0.4 % of patients undergoing SWL. Most such patients can be managed with surveillance, although a third may require transfusion.

Question 22

During transvaginal repair of a high vesicovaginal fistula, a Martius flap is harvested, but is of insufficient length to reach the fistula site. The next step is:

1. myocutaneous gracilis flap
2. gluteal flap
3. omental flap
4. peritoneal flap
5. myocutaneous labial flap.

Answer 22

4

Uncomplicated vesicovaginal fistulas can be closed using meticulous technique and a multi· layer closure. Repair of more complex fistulae often requires the . use of well-vascularized tissue flaps positioned between the bladder and vaginal repair sites. The use of Martlus (fibrofatty tissue), myocutaneous labial (skin and fibrofatty tissue) or: more rarely, gluteal skin flaps can be used to repair low fistulas. Such flaps may not be of sufficient length to reach high fistulae. Peritoneal flaps can be harvested through the vaginal incision and are In close proximity to such fistulas. Use of peritoneum obviates the morbidity of an abdominal incision (necessary for harvesting the omentum) or an incision along the Inner thigh (necessary for harvesting the gracilis muscle).

Question 23

A 26-year-man undergoes orchiectomy for seminoma. Abdominal CT scan and tumor markers are negative. He elects surveillance. The most accurate statement regarding his outcome over the next two years is:

1. similar risk of relapse as patients treated with XRT
2. 5% risk of visceral relapse
3. 5% risk of relapse with non-seminomatous elements
4. 15% risk of retroperitoneal relapse
5. 15% risk of pulmonary relapse.

Answer 23

4

The standard of care for decades in a patient with clinical stage I seminoma (negative CT scan and negative tumor markers) was retroperitoneal XRT. In patients receiving XRT for stage I seminoma, the risk of overall relapse is 5% or less and it would be extremely uncommon for such a patient to relapse with nonseminomatous elements. The major concern regarding the routine use of XRT In these patients was the risk of secondary malignancy, usually leukemias and lymphomas found in approximately 18% of patients 25 years after radiation therapy. To reduce the risk of secondary malignancy, surveillance may be a reasonable option. In a patient with stage one seminoma, there IS an approximately 15% risk of relapse of the tumor to retroperitoneal lymph nodes; almost all are salvaged provided they were reliable candidates for serial surveillance and were not lost to follow-up. Visceral and pulmonary relapse of seminoma or alteration to non-seminomatous elements is extremely uncommon in patients with stage I seminoma. Single agent carboplatln IS the other option in place of either XRT or observation for clinical stage I seminoma and is associated with a 3-5% relapse rate in reported series.

Question 24

A five-year-old boy has a two-week history of severe daytime urinary frequency . There is no history of UTI and urinalysis is negative. Physical and neurological examination are normal. The next step is voiding diary and:

1. reassurance
2. oxybutynin
3. tamsulosin
4. ultrasound
5. VCUG.

Answer 24

1

This is a typical presentation of pediatric benign urinary frequency syndrome and is best managed expectantly. Reassurance is all that is necessary with the expectation that the symptoms will resolve in .one to three months. It is important to confirm that both the physical examination and UA are normal with no evidence of neurologic abnormalities such as a spinal dimple or lower extremity weakness or UTls. In most instances, pharmacological therapy and invasive investigation or therapy have proven to be unsuccessful and may actually worsen symptoms. In almost all cases, these symptoms resolve spontaneously within a few months and the family should be reassured.

Question 25

A 74-year-old man with a Studer ileaI neobladder develops invasive urothelial carcinoma of the proximal urethra three years post-cystectomy. A metastatic evaluation is negative. The next step is: 1. BCG instillation in the urethra and neobladder 2. urethrectomy and transverse colon loop construction 3. urethral laser fulguration 4. urethrectomy and continent cutaneous diversion 5. urethrectomy and use afferent limb for cutaneous diversion.

Answer 25

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

Question 26

A 23-year-old woman has dull, persistent, bilateral flank pain. A scout CT image without contrast is shown. Serum calcium is 9.4 mg/di and urine calcium on an unrestricted diet is 300 mg/day (normal \< 250 mg/day). Urine culture is negative. The next step is: 1. observation 2. thiazides 3. potassium citrate 4. percutaneous nephrolithotomy 5. parathyroidectomy.

Answer 26

2 The radiograph demonstrates the typical "bunches of grapes" or "bouquet of flowers" appearance of medullary sponge kidney. The charactenstlc anatomic feature .of medullary sponge kidney is dilation of the distal portion of the collecting ducts associated with numerous cysts and diverticula. If symptomatic, most patients (60%) present with flank pain, followed by UTI (25%) and gross hematuria (15%). For patients with renal lithiaSIS and hypercalcluria, thiazides should be administered as they arrest stone growth and prevent new stone formation. Parathyroidectomy is not indicated in this patient with normal serum calcium and no measurement of serum parathormone. In the absence of an obstructing stone, PCNL IS not indicated.

Question 27

A 16-year-old phenotypic girl undergoes evaluation for primary amenorrhea. Testes are found on laparoscopic examination. Karyotype is 46 XY. If the gonads are not removed, the tumor most likely to develop is: 1. seminoma 2. Leydig cell tumor 3. gonadoblastoma 4. embryonal cell carcinoma 5. teratoma.

Answer 27

1 The syndrome of complete androgen insensitivity (CAIS), previously known as testicular feminization syndrome is due to absence of a functional androgen receptor. All affected individuals will have a 46 XY genotype and approximately 80% will have "normal" appearing external female genitalia. These patients currently present by one of five different means: fe tal karyotype (46 XY) incongruent with newborn infant's phenotype (5% of patients), relative or family member with CAIS with patient diagnosed due to recommendation for genetic screening (15% of patients), ambiguous genitalia at bIrth, i.e. , female phenotype with ralpablegonads or mild to moderate clitorimegaly (20% of patients), primary amenorrhea 0 (30 Yo of patients),. and testicle found within a inguinal hernia at the time of surgical repair (30 Yo. of patients). Patients with complete androgen insensitivity syndrome will have a substantial Increased risk of developing a testicular seminoma and if the testis is left in situ , approximately 20% of the patients will have developed a testicular malignancy by the age of 30. Removal of the testicles are, therefore, strongly recommended either prior to or Immediately following pubescence. Gonadoblastoma is a tumor that is associated with disorders of sex development. Specifically, it is found in infants noted to have partial or pure gonadal dysgenesis (46 XY or 46 .XY/XO genotypes) and is not associated with complete androgen insensitivity syndrome. IndiVidualswith complete androgen insensitivity syndrome are at no higher risk of Leydig cell tumors, embryonal cell carcinoma, and teratomas than the normal population.

Question 28

A 36-year-old man with ejaculatory duct obstruction and a left varicocele has persistent azoospermia despite normalization of ejaculatory volume following TUR of the ejaculatory duct. The next step is: TRUS 2. repeat TUR of the ejaculatory duct 3. scrotal exploration and testis biopsy 4. varicocelectomy 5. donor insemination.

Answer 28

3 Persistent azoospermia following resection of the ejaculatory ducts may be due to persistent obstruction, concomitant epididymal obstruction, or testicu lar failure. The restoration of normal ejaculate volume rules out persistent ejaculatory duct obstruction, therefore, neither a repeat TUR-ejaculatory duct nor a TRUS is indicated. Scrotal exploration is necessary to differentiate between epididymal obstruction and testicular fa ilure. Donor insemination is not necessary with obstructive azoospermia unless the obstru ction is uncorrectable and the couple refuses ICSI. Varicocelectomy may be indicated in some instances of non-obstructive azoospermia but it is not helpful with obstructive azoospermia.

Question 29

A 17-month-old boy has a firm, smooth testicular mass. Testicular ultrasound shows a2 cm upper pole intratesticular cyst with preservation of the parenchyma. Tumor markers are negative. The next step is: 1. transscrotal enucleation 2. radical inguinal orchiectomy 3. inguinal exploration with cyst enucleation 4. cyst aspiration for cytology 5. simple orchiectomy with placement of prosthesis.

Answer 29

3 The differential diagnosis of cystic testicular lesions includes: epidermoid cyst, dermoid cyst, prepubertal te ratoma, Juvenile granulosa ce ll tumor, cystic dysplasia of the rete testis lymphangioma, simple cyst, and cyst degeneration after torsion. The patient's age, physical examination, and ultrasound findings suggest an epidermoid cyst or simple cyst. Since these lesions are clinica lly indistinguishable from neoplasms, preoperative tumor markers should be drawn. In this age group, if preoperative tumor markers are negative and a benign lesion is suspected on imaging, testiCUlar sparing surgery via an ingu inal incision with the use of frozen section histopathology for confirmation, should be attempted when possible. Cyst aspiration for cytopathology IS neither diagnostic nor ind icated, and worst, would upstage a malignant tumor and potentially seed the needle tract. Placement of a prosthesis is usually delayed until adolescence when an appropriate size prosthesis can be used, as well as involve the adolescent or young adult patient in preoperative discussion as to thei r desire for a prosthesis.

Question 30

A three-year-old boy has a 48-hour history of abdominal pain, fever, vomiting, bloody diarrhea, hematuria, and oliguria. Physical examination reveals mild peripheral edema. Laboratory evaluation demonstrates hemoglobin of 5 g/dl, thrombocytopenia, and serum creatinine of 3.2 mg/di. The most likely etiology is infection caused by: 1. streptococcus 2. E. coli 3. cytomegalovirus 4. Clostridium difficile 5. hepatitis C virus.

Answer 30

2 This patient has hemolytic uremic syndrome. This is most frequently due to E. coli infection, 70% due to the 0157:H7 serotype. In recent years, many large outbreaks have occurred due to eating uncooked hamburger meat, cheese made from unpasteurized dairy products,. and unpasteurized apple cider. With aggressive management of the acute renal failure, the majority of patients will recover normal renal function. The presentation IS classIc, with a prodrome of enterocolitis with bloody diarrhea, fever, gross hematuria , and oligurlc renal failure. Treatment is supportive. Although hemolytic uremic syndrome classically arises following an E. coli enterocolitis, it can develop as a consequence of streptococcus pneumonia, post-bone marrow transplant, and Vitamin B12 metabolic disorders.

Question 31

A 35-year-old man has persistent retroperitoneal lymphadenopathy after platin-based chemotherapy for NSGCT. The parameter most predictive of finding only fibrosis in the retroperitoneum is: 1. pre-chemotherapy lymph node size 2. 75% reduction in size of the mass on CT scan 3. pure embryonal cell carcinoma in the primary tumor 4. pre-chemotherapy marker levels 5. teratoma in the primary tumor.

Answer 31

3 Patients with fibrosis/necrosis, only in the post-chemotherapy specimens, have a favorable prognosis with relapse rates of 10% or less in most series. Investigators have sought to identify factors that reliably predict for a high probability of fibrOSis/necrosIs In a postchemotherapy residual mass. The absence of teratoma in the primary tumor, the percentage reduction in the retroperitoneal mass with chemotherapy (usually cited as 90% or greater), and the size of the post-chemotherapy residual mass have consistently been identified as predictors of fibrosis/necrosis in the post-chemotherapy specimens. In this question, pure embryonal carcinoma would be the best predictor of fibrosis only in the retroperltoneum. Neither pre-chemotherapy lymph node size nor pre-chemotherapy serum tumor marker levels are predictive for fibrosis and the percent reduction has been cited as 90% or greater to predict fibrosis. The absence of teratoma in the primary would predict for fibrosis, not the presence of teratoma.

Question 32

A ten-year-old boy with acute lymphoblastic leukemia has right flank pain, nausea, and vomiting after chemotherapy. Urinalysis shows pH 5.5, 10-20 RBC/hpf, and 5-10 WBC/hpf, platelet count is 50,000/cu mm, and WBC is 3,500/cu mm. Ultrasound images are shown. The next step is: 1. observation and antibiotics 2. urine alkalinization 3. SWL 4. percutaneous nephrostomy 5. ureteral stent.

Answer 32

5 This child has an obstructing lower ureteral calculus. His immune status is depressed due to his recent chemotherapy, including a low platelet and WBC count. He is symptomatic and requires decompression of his kidney before he becomes septic. Considering his hematologic state, the best option is ureteral stent placement. Although observation, antibiotiCS, and/or alkalinization with a distal uric acid stone may be appropriate in an asymptomatic patient, In this scenario immediate decompression is necessary. Ureteral stent is a better option than percutaneous nephrostomy due to the thrombocytopenia. SWL is not appropriate for a distal ureteral stone in a child.

Question 33

A 42-year-old man had a right radical nephrectomy two yers ago for a \_stage pT3aNOMx RCC. He now has right hip pain. Bone scan shows intnse \_uptake in the right hip area and plain films of the right femur show a 3.5 cm lyt1c lesion. The next step is: 1. external beam radiation to the femur 2. strontium-89 3. internal fixation of the femur 4. pain management 5. systemic targeted therapy.

Answer 33

3 Approximately 50% of patients with multi-organ metastases from RCC exhibit evidence of skeletal Involvement. It has been estimated that between 15% and 30% of such skeletal lesions are solitary. Eighty percent of skeletal metastases occur in the axial skeleton, thoraCic/lumbar spine, and pelvIs. When long bones are involved, only the proximal portions are characteristic targets for metastatic disease. Surgical treatment of bony metastases is ind icated for weight-bearing bones with lytic lesions \> 3 cm. Internal stabilization or replacement of the destroyed periarticular segment often results in significant pain relief and tremendously Improves the patient's quality of life. For a lesion this large, XRT or strontium are likely to be Ineffective. This patient needs surgery to prevent fracture as a priority over systematic treatments or pain management alone

Question 34

A three-year-old boy with thoracolumbar myelomeningocele has diurnal and nocturnal urinary incontinence. Renal ultrasound is normal and VCUG shows no VUR. Urodynamic study reveals total fill noncompliance with end-fill detrusor pressures of 50 cm H20 at 150 ml. In addition to the poor compliance, there is intermittent detrusor overactivity beginning at 50 ml, with intermittent urge incontinence noted to be associated with the overactivity. Tonic external sphincter activity is noted with the leakage. The next step is: 1. timed voiding 2. antimuscarinics 3. antimuscarinics and CIC 4. onabotylinumtoxinA to the external urinary sphincter 5. onabotylinumtoxinA into the detrusor muscle and CIC.

Answer 34

3 This boy has findings consistent with a neurogenic bladder associated with high storage pressures, detrusor overactlvlty, and tonic sphincter activity. In this scenario, if the physician is seeking to gain both urinary continence and provide safe storage pressures, treatment of the detrusor to Improve compliance, decrease overactivity, and CIC to empty the bladder must be the mainstay of treatment. Injection of onabotulinumtoxinA into the external urinary sphincter would decrease detrusor LPP but would not aid in urinary continence. Although the combination of onabotulinumtoxinA into the detrusor and CIC would work, this would require general. anestheSia to accomplish In a pediatric-aged patient and should not be pursued unless the patient has failed more conservative measures such as oral antimuscarinics and CIC. Enterocystoplasty could be considered as an option if medical therapy fails.

Question 35

During laparoscopic left radical nephrectomy, jud icious placement of clips on the primary branches of the main renal vein is most important to facilitate: 1. lymphadenectomy 2. en bloc excision with negative margins 3. adrenalectomy 4. application of the endovascular stapler onto the main renal vein 5. dissection and occlusion of the main renal artery(ies).

Answer 35

4 Excessive placement of clips when managing the gonadal, adrenal, or lumbar branches can severely restrict the working space available for safe placement of the endovascular stapler later in the case when the main renal vein is addressed. Application of the stapler across a clip can lead to intraoperative or postoperative hemorrhage and must be avoided. Use of clips should have no effect on the ability to perform the lymphadenectomy, adrenalectomy, or the ability to achieve negative margins, or ability to control renal artery.

Question 36

37. During laparoscopic live donor nephrectomy, the kidney becomes visibly pale with loss of turgor after 15 minutes of hilar dissection. The next step is: 1. reduce insufflation pressure 2. fluid bolus 3. intraarterial papaverine 4. systemic heparin 5. convert to open nephrectomy.

Answer 36

1 Renal artery vasospasm may occur during renal hilar dissection, leading to reduced renal perfusion. The first step shou ld be to simply reduce the insufflation pressure. This maneuver will allow improved renal perfusion and no additional steps are necessary in the majority of patients. If renal perfusion continued to be suboptimal, topical papaverine applied to the renal hilar vessels would be the next step. A fluid bolus in the presence of increased intraperitoneal pressure from the pneumoperitoneum is usually of little to no benefit. There is no role for systemic heparinization in this patient.

Question 37

38. A 54-year-old man with prostate cancer has skeletal metastases. Three months after beginning LH-RH agonist therapy, his PSA is undetectable. The likelihood of developing further bone pathology is best reduced with: 1. enzalutamide 2. abiraterone 3. bicalutamide 4. estramustine 5. denosumab.

Answer 37

5 Use of denosumab or bisphosphonate therapy in men with prostate cancer has demonstrated two outcomes: prevention of osteoporosis and reduction of skeletal-related events. Denosumab and zoledronic acid both reduce analgesic use and the time to a skeletal event compared to placebo in this setting. However, these changes do not influence survival. None of the other listed agents will prevent bone events. The use of other agents such as enzalutamide or abiraterone have been shown to increase progression-free survival after the development of castrate resistant prostate cancer, but their immediate use in the hormone-sensitive setting is unknown. Estramustine can be associated with thromboembolic events and should not be used in this setting.

Question 38

39. Following a snowboarding accident, a 13-year-old girl has gross hematuria and a renal injury. Eight days later, she has a persistent ileus and a low-grade fever. CT scan is shown. The next step is: 1. urethral catheter placement 2. ureteral stent and urethral catheter placement 3. percutaneous nephrostomy 4. percutaneous drain placement 5. selective angiographic embolization.

Answer 38

2 The CT image demonstrates a great for renal laceration with extravasation of urine into the. Africa matoma. the patient's symptoms of a low-grade fever in ileus are consistent with potential irritation from the parametric urinoma and treatment is indicated. Options for management would be retrograde stent placement, with or without concurrent urethral catheter drainage, percutaneous nephrostomy or drain placement. Retrograde stent placement for the patient with the faster return to ambulation and normal activities with less concern for infection of the perinephric hematoma. The disadvantage of place in the ureteral stent in children is the need for anesthesia replacement and removal. Specifically if there is a large amount a clot in the renal pelvis the clock make lewd a ureteral stent. in this radiograph there is no evidence of significant blood clot in the renal pelvis and the urinal it is small, therefore, percutaneous nephrostomy is not indicated. There is no significant hematoma and therefore no need for Selective embolisation. The best treatment is ureteral stent placement with concurrent drainage of bladder.

Question 39

40. A 52-year-old man with erectile dysfunction has a penile curvature less than 30° that developed spontaneously 18 months ago and is unresponsive to oral Vitamin E. Doppler ultrasound reveals normal bilateral cavernous arterial flow, mild venous leak, and dorsal penile plaque. The next step is: 1. oral PDE-5 inhibitor 2. intracavernous pharmacotherapy 3. corporal plication 4. plaque incision and grafting 5. penile prosthesis surgery.

Answer 39

1 The clinical picture is consistent with Peyronie's disease. While the criteria for surgery include the presence of a stable and mature disease of at least 12 months from onset surgical correction is not warranted given minimum degree of angulation. The process is not indicated in this patient due to the fact he is adequate blood flow to the penis. initial therapy may be best directed to improving erectile function using non-invasive oral pharmacotherapy such as PDE5

Question 40

A 65-year-old man is treated with goserelin acetate and bicalutamide for a rising serum PSA following definitive XRT for Gleason 8 prostate cancer. Bone scan and CT scan are negative. In addition to the hormone therapy, he should have annual bone density scans and: 1, observation 2. monthly zoledronate (Zometa) 3. weekly alendronate (Fosamax) 4. calcium and Vitamin D 5. denosumab.

Answer 40

4 Osteoporosis is a recognized risk of long-term androgen ablation and has been shown to have significant clinical impact. Men started on LH-RH agonists should receive annual bone density scans and regular calcium and Vitamin 0 supplements. Treatment of osteoporosis, if it develops, may be done with bisphosphonates, but the ideal type of therapy is not proven. Prophylactic monthly zoledronate (Zometa) or denosumab are cost prohibitive agents that have been shown to prevent bone-related events only in men with documented bony metastases.

Question 41

Bladder relaxation during filling is accomplished by: 1. stimulation of beta-3 adrenergic receptors via the hypogastric nerve 2. stimulation of alpha-1 d receptors via the hypogastric nerve 3. stimulation of alpha-1 a receptors via the hypogastric nerve 4. inhibition of sympathetic input from the spinal cord 5. inhibition of nicotinic receptors via the pelvic nerve.

Answer 41

1 The accommodation of the bladder to increasing volumes of urine is primarily a passive phenomenon dependent on the intrinsic properties of the vesical smooth muscle and the quiescence of the parasympathetic efferent pathway. Stimulation of alpha-receptors do not initiate bladder relaxation. Stimulation of beta-2 and beta-3 adrenergic receptors in the detrusor muscle results in the direct relaxation of the detrusor smooth muscle. Mirabegron, a beta-3 agonist, takes advantage of this pathway to improve symptoms of overactive bladder.

Question 42

45. A 32-year-old man has a weak urinary stream and recurrent UTls. He has a known urethral stricture and has undergone three dilations in the past. Retrograde urethrography is shown. The next step is: 1. cystoscopy 2. urethral ultrasound 3. VCUG 4. excision and primary anastomosis 5. urethroplasty with graft or flap.

Answer 42

3 The retrograde urethrogram (RGUG) provided in the image is an incomplete study. Two major problems exist with this image. First, the patient is not tipped far enough laterally; this can be identified by the visible obturator ring. If either or both of the obturator rings are visible, a distortion of the urethra is produced due to an improper pelvic angle and the length of the stricture will appear shorter than it actually is. Second, not enough contrast passed through the stricture to delineate its proximal extent. A repeat RGUG would most likely not reveal any additional information. A voiding urethrogram would provide an antegrade study that will allow the physician to determine the proximal extent of the urethral stricture. To perform this study, the urologist may need to pass a glide wire through the stricture followed by a 6 Fr ureteral catheter. This will allow the bladder to be filled with contrast and not dilate or destroy the stricture. The patient is subsequently asked to void and the proximal location of the stricture identified. If you can combine the VCUG with a simultaneous RGUG, a so-called up and downogram can be obtained that will delineate the length of the stricture. Cystoscopy or urethral ultrasound would not add additional information as to the extent of the stricture. Urethral ultrasound has been shown to determine the degree of spongiofibrosis yet would not add additional information over an antegrade study regarding the length of the stricture. Urethroplasty with incomplete staging information should not be performed In order to prevent unnecessary buccal mucosa harvest, and/or added operative time in the lithotomy position while a graft is unexpectedly harvested.

Question 43

Renal medullary carcinoma is characterized by: 1. occurrence predominately in the left kidney 2. relatively indolent clinical course 3. good response to cisplatin-based chemotherapy 4. typically amenable to partial nephrectomy 5. metastatic disease at presentation.

Answer 43

5 Renal medullary carcinoma was first described in 1995 and, to date, less than 100 cases have been reported in the literature. It is an extremely aggressive disease with nearly all patients presenting with metastatic disease. Mean survival IS less than SIX months and only two longterm survivors are reported in the literature. It has not been shown to respond to standard chemotherapy and/or immunotherapy regimens. Interestingly, approximately three-fourths of cases have been reported to involve the right kidney. Recent studies have reported amplification of the ABL gene and increased expression of ABL protein in the absence of BCRABL translocation characteristic of chronic myeloid leukemia. Medullary carcinoma IS more common in patients with sickle cell trait. It tends to be central and infiltrative.

Question 44

A 48-year-old man undergoes partial nephrectomy for a 3 cm renal mass. His flank drain is removed on the third postoperative day. Seven days later, he has clear fluid dripping from the flank drain site. He is otherwise asymptomatic. CT scan demonstrates a 5 cm by 10 cm fluid collection adjacent to the kidney with extravasation of contrast from the collecting system. The next step is: 1. observation 2. urethral catheter 3. percutaneous drainage of fluid collection 4. percutaneous nephrostomy 5. ureteral stent.

Answer 44

3 Urine leak following partial nephrectomy occurs in up to 15% of cases. Provided a postoperative drain is left in situ , spontaneous closure of the urinary leak occurs within 2-4 weeks. In the case of an unrecognized or delayed urinary leak, the presence of an adjacent urinoma will prevent fistula closure and predispose the patient to Infectlon/abscess formation. Percutaneous drainage of the urinoma is the preferred method used to control a unrecognized or delayed pyelocutaneous fistula. If the leak does not heal with drainage of the urinoma consideration should be given to the possibility of either ureteral/bladder obstruction or bladd'er dysfunction as a cause of the persistent fistula. In these situations, a cystoscopy with a retrograde pyelogram followed by ureteral stent and urethral catheter placement should be pursued. The concomitant urethral catheter IS used to aid healing by preventing high pressure reflux up the ureteral stent and/or to treat bladder outlet obstruction or vOiding dysfunction as an etiology for the persistent urinary fistula.

Question 45

For dosimetry planning for brachytherapy, the most accurate method to estimate prostate volume by ultrasound is based on: 1. planimetry 2. a sphere 3. an ellipse 4. a prolate ellipse 5. a prolate sphere.

Answer 45

1 Unfortunately, no prostate is the perfect sphere, ellipse, or prolate sphere, rendering calculations somewhat inaccurate. The most accurate means of volume measurement by ultrasound IS planlmetry, which allows for variation In shape. In this, the probe is mounted on stepping device and the signal marched through the gland at defined intervals, usually 3-5 mm. At each Interval, the surface area of the prostate image is obtained. Volume is ca lcu lated by multiplYing the sum of the surface areas by the stepping interval. While a prostate ellipsoid is the calculation typically used In TRUS of the prostate, it is not as accurate as planimetry. Because of ItS superior accuracy, planlmetry IS the method of choice for brachytherapy treatment planning.

Question 46

A 61-year-old man has a T1c, Gleason 7 prostate cancer with a PSA of 9.1 ng/ml. He has moderate LUTS and prostate volume of 42 ml. Before any treatment decisions are made, he should undergo: 1. CT scan of abdomen and pelvis 2. bone scan 3. urodynamics 4. assessment of life expectancy 5. molecular testing.

Answer 46

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

Question 47

In a man who has good daytime continence following radical cystectomy and orthotopic neobladder, nocturnal incontinence is due to: 1. damage to the urinary rhabdosphincter 2. neobladder hypercontractility 3. inadequate compliance of the neobladder 4. loss of afferent input from the detrusor to the central nervous system 5. damage to the inferior hypogastric nerve plexus.

Answer 47

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

Question 48

A 24-year-old man with a T4 complete spinal cord injury has. urinary .incontinence despite CIC and maximal anticholinergic therapy. His urodynam1 study 1.s shown. He would like to be dry. He was injected with 300 units of onabotullnumtox1nA for lower extremity spasticity one month ago. The next step is: 1. increase frequency of catheterization 2. immediate injection of 200 units onabotulinumtoxinA 3. injection of 200 units onabotulinumtoxinA in two months 4. sacral neuromodulation 5. artificial urinary sphincter.

Answer 48

3 The urodynamic study is consistent with detrusor overactivity. This patient has failed medical therapy so the next option, if he would like to improve hiS continence, would be bladder augmentation or onabotulinumtoxinA. Pelvic floor physical therapy would not be helpful In a patient with a complete spinal cord injury. Sacral nerve stimulation does not have an FDA indication for the treatment of neurogenic bladder. Artificial unnary sphincter would be indicated for stress urinary incontinence which would be unlikely with this level of injury and was not demonstrated on the urodynamic study. Doses of onabotullnumtoxlnA should not exceed 360 units every 12 weeks. Since this patient was injected for .his spasticity last month, he would be best treated in two months and not immediately. In addition, further treatment of both his detrusor overactivity and lower extremity spasticity with onabotulinumtoxinA should be coordinated between his urologist and physiatrist to eliminate the potential for over dosage over a period of time. Regarding the treatment of neurogenic bladder with onabotulinumtoxinA, 200 units is an efficacious starting point with the dose increased to 300 units for refractory cases. Studies comparing injections of onabotylinumtoxinA into the detrusor only, compared to a combined injection, with two-thirds of the volume injected into the detrusor and one-third of the volume injected into the trigonal areas, have found that the combination Injection had better relief of symptoms, improved compliance, and no increased nsk of veslcoureteral reflux compared to detrusor-only injections.

Question 49

A 43-year-old man has a 4 cm micropapillary urothelial cacinoma. th.at extensively invades the lamina propria near the bladder dome. Musculans propna 1s present and uninvolved. The next step is: 1. restaging TURBT 2. partial cystectomy 3. neoadjuvant chemotherapy followed by radical cystectomy 4. radical cystectomy 5. chemotherapy.

Answer 49

4 T1 tumors with aggressive features (tumor size \> 3 cm, micropapillary histology, and Iymphovascular invasion) have an increased risk of progression and should undergo definite cystectomy that is highly effective for early stage tumors. While intravesical BCG IS an option for the treatment of T1 bladder cancer, the high risk features of this tumor leave the patient at very high risk of relapse and progression. This IS Inappropnate given hiS young age and excellent health. Partial cystectomy is not the best choice for tumor control given the high risk of muilifocal recurrences Within the remaining bladder. Prophylactic radiotherapy and systemic chemotherapy have not been shown to reduce the risk of recurrence in individuals with T1 disease. Micropapillary urothelial carcinoma is unlikely to respond to intravesical therapies. The use of neoadJuvant chemotherapy In non-muscle invasive disease is unproven , so Immediate cystectomy is most appropriate.

Question 50

Three years after radical cystectomy and orthotopic ileal neobladder, a 61-year-old man has chronic and severe diarrhea. The next step is: 1. fluid restriction 2. Metamucil 3. loperamide 4. Vitamin B12 replacement 5. cholestyramine.

Answer 50

5 The etiology of diarrhea following urinary diversion is related to the type and amount of bowel used in the diversion. Many patients initially suffer from diarrhea after the procedure, but this usually resolves dunng the postoperative period. A small number of patients suffer chronic and bothersome diarrhea that necessitates treatment. In the case of diversions that require ileal resection of \>40 cm but \< 100 cm, the diarrhea is thought to be due to decreased ileal bile salt absorption that leads to increased bile salt delivery to the co lon. This in turn leads to colonic irritation and .increased bicarbonate and water secretion. This is effectively a secretory diarrhea. The Initial treatment should be decreased fat intake and initiation of cholestyramine. In contrast, diversions in which the ileocecal valve or colon is resected result in decreased bowel transit time and an osmotic diarrhea. This is best treated with oral bulking agents and loperamlde. VitamlnB12 replacement is usually indicated in patients who have had significant portions of terminal Ileum removed , but this will not impact the diarrhea. Fluid restriction is not advisable in the setting of a urinary diversion.

Question 51

65-year-old woman undergoes ureteroscopic biopsy and laser ablation of a single nght m1d-ureteral tumor. Histology reveals a low grade Ta urothelial carcinoma. The next step is: 1. CT urogram and urine cytology 2. quarterly upper tract surveillance, urine cytology, and cystoscopy 3. ureteral stent placement and BCG instillation 4. nephrostomy and antegrade administration of BCG 5. partial ureterectomy and Boari flap.

Answer 51

2 The management of upper tract urothelial carcinoma has changed significantly in the past decade as endoscopIc technologies have Improved. Many of these tumors, which previously would have been managed by open surgical excision, can now be safely managed with endoscopIc ablation: Patients With low volume, low grade, and low stage disease can be safely managed With minimally Invasive techniques. Other factors that should lead to strong consideration of minimally invasive management include renal insufficiency or other abnormalities. In this case, the patient has a single non-invasive, low grade tumor which favors a minimally invasive nephron-sparing approach. While ureterectomy would spare the involved likely adequate initial treatment of the ureteral tumor. Follow-up for these tumors must include evaluation of both the upper tract and the bladder, as there is increased risk of bladder tumors in these patients. Therefore, quarterly upper tract surveillance with imaging or ureteroscopy, cystoscopy, and urine cytology is the best surveillance strategy In this patient. BCG for high grade upper tract UC is occasionally used in patients with a solitary kidney or similar circumstances, but there is no definitive data to support a benefit. With BCG instillation might be indicated for higher grade or stage disease managed endoscopically, It Iis unnecessary in this situation.

Question 52

A 73-year-old woman with high-grade muscle invasive bladder cancer in the bladder neck and dome of the bladder as well as CIS desires an orthotopic urinary diversion. The strongest relative contraindication to this type of diversion would be: 1. age 2. multifocal disease 3. presence of CIS 4. preoperative unilateral hydronephrosis 5. bladder neck involvement.

Answer 52

5 The incidence of tumor involving the urethra in women undergoing cystectomy for bladder urothelial carcinoma is approximately 12%. The urethral recurrence rate in properly selected patients is low at less than 4%. Bladder neck tumor involvement in women, however, may be seen in approximately 22% of patients and is a risk for a urethral tumor in about half (1 2%). Preoperative involvement of the bladder neck with tumor in women is not. an absolute contraindication as long as full-thickness, intraoperative, frozen section analysIs reveals no tumor involvement of the proximal urethra (distal surgical margin). Age, tumor grade and pathological stage do not appear to be significant risk factors or contraindications to orthotopic diversion in women. CIS and multifocality also increase the risk of urethral occurrence, but not to the same degree as bladder neck involvement.

Question 53

During an inguinal approach to a pediatric hernia, the ilioinguinal nerve can be separated from the cord structures by entering the: 1. external oblique fascia 2. cremaster 3. internal spermatic fascia 4. processus vaginalis 5. Scarpa fascia.

Answer 53

2 The ilioinguinal nerve runs in the cremaster layer, and can be effectively spared by opening the cremaster and separating it from the remainder of the cord. The nerve does not have to be individually dissected.

Question 54

A 32-year-old man with bilateral congenital absence of the vas deferens (CBAVD) is most likely to have: 1. unilateral renal agenesis 2. a brother with vasal agenesis 3. hypospermatogenesis 4. low semen volume 5. Y chromosome microdeletion.

Answer 54

4 Congenital bi lateral absence of the vas deferens (CBAVO) is associated with cystic fibrosis gene mutations In 85 Yo of patients. ApproXimately 7% of brothers will have also vasal agenesis. Only 10-15% of men with CBAVO will have unilateral renal agenesis and most of these are in patients with no identifiable cystic fibrosis gene mutation. There is no association with Y microdeletions. Semen is almost always of low volume and acidic due to hypoplasia or absence of the seminal vesicles, which provide alkalinity.

Question 55

A three-month-old boy with a history of incised PUVs has a febrile illness. There is difficulty passing a catheter per urethra into the bladder to obtain a urine specimen . The most likely cause is: 1. urethral stricture 2. residual valve leaflet 3. external sphincter spasm 4. bladder neck hypertrophy 5. false passage from previous catheterization.

Answer 55

4 Consequences of PUV are detrusor hypertrophy and bladder neck hypertrophy. The outlet obstruction will result in elongation and dilation of the prostatic urethra due to the relative lack of musculature of the prostatic urethra. The hypertrophy of the bladder neck causes an upward course of the prostatic urethra and a high riding bladder neck which can make urethral catheterization difficult. During cystoscopy of such a posterior urethra, the cystoscope must be angled directly anterior In order to gain access to the bladder. All of the other options may also make catheterization difficult, but they are less likely to occur than bladder neck hypertrophy in the setting of a history of PUV.

Question 56

A 37-year-old woman with recurrent stones is taking topiramate for migraine headaches. To minimize the risk of stones, the next step is: 1. amiloride 2. allopurinol 3. potassium citrate 4. calcium carbonate 5. carbonic anhydrase inhibitor.

Answer 56

3 In this clinical scenario, the use of topiramate creates a chronic intracellular acidosis. This in turn creates a urinary milieu similar to distal renal tubular acidosis with hyperchloremic acidosIs, high urine pH , extremely low urinary citrate, and hypercalciuria. Treatment may be potassium citrate or cessation of the medication if possible. Amiloride will reduce urine calcium when used in conjunction with thiazide but is not indicated in this situation. Allopurinol is the preferred treatment for hyperuricosuria. Calcium carbonate has no role in the medical management of kidney stones. Topiramate acts as a carbonic anhydrase inhibitor and addition of a similar agent would be counterproductive.

Question 57

A 34-year-old man has priapism for more than 48 hours. He continues to have a firm, indurated penis despite a corporal-glanular shunt followed by a proximal corpora spongiosum shunt. The next step is: 1. penile Doppler ultrasound and corporal blood gas determination 2. continuous irrigation with an alpha-adrenergic agent 3. systemic baclofen 4. selective embolization of cavernosal artery 5. penile prosthesis.

Answer 57

1 Ischemic priapism presenting in a significantly delayed fashion (\> 48-72 hours) may predictably fail to resolve with intracavernous treatment as well as surgical shunting and suggests that erectile dysfunction will be the inevitable outcome. Even if a successful shunt IS performed, woody induration of the penis may persist. To confirm the presence of persistent hypoxemia, a penile Doppler ultrasound to assess for vascular flow and a corporal blood gas determination should be performed. If these evaluations confirm poor vascular flow and continued Ischemia, experts have advocated immediate placement of a penile prosthesIs. The recommendation is based in part on the knowledge that placement of a penile prosthesIs at a later time, after significant fibrosis has evolved, is extremely difficult and fraught with hlghercompllcatlon rates. Based on the duration of priapism , it is unlikely that continuous Irrigation with an alphaadrenergic agent or systemic baclofen would be effective. Selective embolization of the cavernosal artery is a consideration for treatment of high flow priapism, not Ischemic Induced priapism.

Question 58

A 63-year-old man has an incidentally discovered 3.8 cm left adrenal mass with a negative endocrine evaluation. The test most likely to differentiate between malignant and benign histology is: 1. MRI scan 2. duplex Doppler ultrasound 3. CT scan with and without contrast 4. MIBG 5. fluorodeoxyglucose PET.

Answer 58

3 Lesion size is the most reliable clinical means to differentiate benign from malignant incidental adrenal tumors. Tumors \< 4 cm in size are malignant in only 2% of cases. All of the listed radiographic techniques have been applied to adrenal tumor diagnosis, however, CT scan without and with contrast with measurement of contrast washout IS the most reliable indicator for malignant mass. On non-contrast images, lipid-rich adrenal adenomas will be homogenous and will have \< 10 Hounsfield units. For lesions with\> 10 Hounsfleld units, a washout contrasted CT scan is necessary to distinguish benign lipid-poor adenomas versus malignant masses. Malignant masses will have delayed washout of contrast maintaining an average of 30 Hounsfield units higher signal intensity at ten minutes following contrast administration when compared to benign lesions which washout rapidly.

Question 59

6-week-old asymptomatic boy has intermittent drainage from the umbilicus. A f1stulogram with contrast injected through the umbilicus is shown. The next step is: 1. topical silver nitrate to umbilical stump 2. VCUG 3. CT scan 4. immediate excision with bladder cuff 5. observation, excision at six months if symptoms persist.

Answer 59

5 This child has a patent urachus. 50% of radiographically confirmed patent urachus will spontaneously close in the first six months of life and observation IS warranted . Topical sllver nitrate is a reasonable treatment modality for small urachal cysts, but the physIcian should be aware of the increased risk of bladder or bowel injury with silver nitrate used in the presence of a patent urachus or omphalomesenteric duct (connection of the umbilicus to small bowel). Treatment of a patent urachus or mesonephric duct (i.e., omphalomesenteric duct) by silver nitrate IS contraindicated due to possible injury to the bladder or small bowel. A CT or MRI scan is sometimes obtained on these children to exclude a patent omphalomesenteric duct. In this case, the CT scan is not necessary because the diagnosis of patent urachus IS confirmed by slnogram. A VCUG is usually not necessary if a sinogram confirms the diagnosis unless history suggests the presence of a bladder outlet obstruction that could be the etiology of urachal patency.

Question 60

The most common cause of hyperuricosuria is: 1. gout 2. excess Vitamin C intake 3. dietary purine excess 4. decreased urinary volume 5. myeloproliferative disorders.

Answer 60

3 The most common cause of hyperuricosuria is excessive dietary purine intake. Gout, metabolic syndrome (obesity,. HTN, hyperlipidemia, and hyperglycemia) and myeloproliferative is orders are significant but less common risk factors. Decreased urinary volume and decreased citrate Intake are not typical causes of hyperuricosuria. Excess Vitamin C intake is associated with hyperoxaluria.

Question 61

A 60-year-old man has a 3 cm squamous cell carcinoma of the penile urethra (3 cm from the meatus) and a palpable 2 cm right inguinal lymph node. Metastatic survey is otherwise negative. The next steps are partial penectomy and: 1. right inguinal XRT 2. right inguinal lymphadenectomy 3. bilateral inguinal lymphadenectomy 4. cisplatin-based chemotherapy 5. 5-FU and bilateral inguinal XRT.

Answer 61

2 Partial penectomy with an adequate surgical margin is the treatment of choice for urethral tumors localized to the distal half of the penis. Palpable inguinal lymph nodes occur in about 20% of cases and almost always represent metastatic disease, in contrast to pen ile cancer, in which a substantial percentage of palpable nodes may be inflammatory. Lymphatics from the male anterior urethra drain Into the superficial and deep inguinal lymph nodes and occasionally into the external Iliac nodes. Ilioinguinal lymphadenectomy is indicated in the presence of palpable inguinal lymph nodes without evidence of metastatic disease. Unlike penile cancer, benefit from prophylactic contralateral inguinal node dissection or XRT has not been demonstrated in urethral cancer. Although some instances of tumor control by radiation have been reported, In general, XRT has been reserved for patients with early-stage lesions who refuse surgery. The combination of chemotherapy and radiation has shown some success in a small number of patients, however, squamous cell cancers respond poorly to the M-VA regimen.

Question 62

An asymptomatic five-year-old boy develops gross hematuria two hours after wrestling with his younger brother. Physical examination is normal. The next step is: 1. observation 2. serial examinations and hematocrit determination 3. ultrasound of bladder and kidneys 4. CT scan 5. cystoscopy.

Answer 62

3 It is recognized that underlying GU malformations or other pathologies are at least three-fold more common in pediatric patients relative to adults undergoing evaluation for trauma. This is a classic case for raising the concern of an underlying abnormality since the gross hematuria seems out of proportion with the low severity of ~he trauma. The underlying problems may include hydronephrosIs, multlcystlc kidney, Wilms tumor, and vanous renal fusion anomalies. Therefore, it is appropnate to Image with ultrasound to look for such potentially significant problems. A patient should not be considered for admission with serial examinations and hematocrit determination unless there IS a documented substantial renal injury. Cystoscopy is not indicated in the initial evaluation of gross hematuria in children. CT scan would only be indicated if there is significant injury or abnormality on ultrasound, or If the mechanism of injury was more concerning.

Question 63

A six-year-old boy with a history of myelomeningocele has two febrile UTls six months after a bladder neck sling and appendicovesicostomy. An ultrasound shows normal upper tract$ and VCUG shows new grade llN bilateral VUR. The next step is: 1. increase CIC frequency 2. add antimuscarinic therapy 3. urodynamics 4. MRI scan of spine 5. endoscopic correction of VUR.

Answer 63

3 This child has new onset reflux and febrile UTls after a surgical procedure that increased his bladder outlet resistance. Of concern in this situation is that approximately 15% of patients with a neurogenic bladder will develop a poorly compliant bladder after increasing urinary outlet resistant. New onset of vesicoureteral reflux in this situation may be due to either noncompliance with CIC, thus resulting in an overdistention of the bladder,or the development of detrusor non-compliance. Urodynamics are first required to see If the bladder has deteriorated and to better direct treatment. If compliance and capacity are unchanged, then attention to the frequency of catheterization, with or without the addition of antimuscarimc therapy, should be the primary consideration. Treatment of reflux in a patient with a neurogemc bladder is not appropriate without an understanding of bladder dynamiCs since high storage pressures doom correction to failure. A spinal MRI scan can be conSidered If the urodynamlcs are abnormal, although a change in bladder function IS likely related to the sling and not a tethered cord.

Question 64

Eight weeks following placement of a mid-urethral polypropylene sling, a 73-year-old woman has no leakage but reports difficulty voiding. Her urinalysis shows large numbers of RBCs and WBCs, and PVR is 300 ml. She is started on antibiotics. The next step is to teach her CIC and: 1. pressure flow urodynamics 2. urethral dilation 3. tamsulosin 4. cystoscopy 5. incise sling.

Answer 64

4 The patient appears to be obstructed following mid-urethral sling placement and should be considered for sling incision. Urodynamic data can be useful In select cases,. but If the symptoms began after the sling was placed, she will likely need to have the sling incise regardless of urodynamic findings. Cystoscopy is necessary, however, to evaluate for urethral or bladder mesh perforation and other bladder pathology, as well as hypersuspenslon, should be done before planned sling incision . Cystoscopy is of particular importance in the patient with hematuria. Sling incision will like ly be necessary but only after cystoscopy has ruled-out overt urethral erosion or other bladder/urethra l pathology. Office urethral dilation is not recommended at such a late period of time after sling surgery as the synthetic mesh is likely scarred In at this time.

Question 65

A 55-year-old man has bothersome LUTS poorly respons ive to medical therapy. Pressure-flow urodynamics are shown. He refuses therapy that may result in retrograde ejaculation. The next step is: 1. TUIP 2. TUMT 3. prostatic urethral lift (Urolift™) 4. photoselective vaporization of the prostate (PVP) 5. Holmium laser enucleation of the prostate (HOLEP).

Answer 65

3 The urodynamics are consistent with BOO with a voiding pressure close to 100 cm H20 and a maximal flow close to 9 mllsec. All of the options address bladder outlet obstruction, however, only th e prostatic urethral lift does not cause retrograde ejaculation. TUIP, TUMT, PVP, and HOlEP al l place patients at risk for retrograde ejaculation with the risk ranging from 9.2-67%. The prostatic lift obtained FDA approval in 2013 for the treatment of symptomatic BPH. The procedure does not invo lve cutting or resection of prostate tissue instead re lying on an implant to "lift" or pull the prostati c tissue away and open the prostatic urethra. To date, there have been no reports of erectile dysfunction or retrograde ejaculation in patients treated with th is modality

Question 66

A 51-year-old man with a solitary kidney has multifocal high grade T1 urothelialcarcinoma in the left upper pole and multifocal CIS in the left ureter three years after cystectomy and ileal conduit. The next step is: 1. retrograde upper tract BCG 2. percutaneous resection followed by antegrade BCG 3. partial nephrectomy followed by retrograde upper tract BCG 4. nephroureterectomy 5. nephroureterectomy with conduit excision.

Answer 66

4 The best answer involves nephrouretectomy in th is sett ing with hemodialysis and possible future renal transplantation. The use of BCG in patients with ileal conduit urinary diversion is associated with up to a 10% risk of sepsis due to absorption . Partial nephrectomy in the setting of multlfoca llty IS associated With an unacceptable recurrence rate. Systemic chemotherapy would be poorly tolerated in the setting of a solitary kidney and not effective for CIS. The ileal conduit should be left in-situ and could be used in the future if renal transplantation is planned.

Question 67

In a patient with Fournier's gangrene, the factors found to improve patient survival are early recognition of the diagnosis, aggressive surgical debridement, and: 1. transfer to a tertiary care center 2. broad-spectrum antibiotic therapy 3. hyperbaric oxygen 4. aggressive glycemic control 5. placement of a suprapubic tube.

Answer 67

2 Early recognitions of the diagnosis, aggressive surgical debridement and use of antibiotics are most essential for stopping rapidly progressing Fourniers gangrene. Transfer to a tertiary facility may delay care.

Question 68

A 26-year-old man with complete C7 spinal cord injury managed by CIC has recurrent episodes of vague abdominal pain, severe headache, and diaphoresis. Imaging reveals a 12 mm obstructing radiolucent UPJ stone and urinalysis shows a pH of 5.0, 25-50 RBC/hpf, 0-5 WBC/hpf, and no bacteriuria. The next step is: 1. urinary alkalinization 2. urinary alkalinization and tamsulosin 3. stent placement 4. ureteroscopic intervention 5. percutaneous nephrolithotomy .

Answer 68

3 The pateint presented with symptoms of autonomic dysreflexia that have temporarily subsided but are likely to recur. This represents a life-threatening situation. Stent placement will avert recurrent obstruction and dysreflexia

Question 69

Six months following an uneventful transobturator mid-urethral sling, a 63-year-old woman with previous hysterectomy has a slightly bloody vaginal discharge, but no mesh is visible. Urinalysis is normal. The next step is: 1. repeat examination in three months 2. vaginal estrogen and repeat examination in three months 3. cephalexin and reevaluate in one month 4. cystoscopy 5. complete sling excision.

Answer 69

2 Even though mesh is not directly palpable on exam, the patient should be presumed to have an extrusion based on the bloody vaginal discharge 6 months out from surgery. Observation may be reasonable early on, but it is unlikely to lead to resolution of the extrusion at this point. Vaginal estrogen is reasonable for a small exposure, such as this one, and failing that, partial sling excision is reapproximation of the vaginal edges may be necessary. Alternatively, one may wish to go straight to partial excision with reapproximation. Complete sling excision would not be required in the case of small extrusion such as this one. If the patient had not had prior hysterectomy, then evaluation for vaginal bleeding (particularly uterine pathology) should be considered. If this patient had blood in the urine or severe new onset urinary symptoms, then cystoscopy would be warranted.

Question 70

A 13-month-old girl has a fever of 38.5° C. A bagged urine specimen is positive for leukocyte esterase, negative for nitrites, and has no growth on culture at 24 hours. The next step is: 1. observation 2. empiric antibiotics for UTI 3. catheterized urine specimen 4. suprapubic aspiration 5. renal bladder ultrasound .

Answer 70

1 Bagged collection of urine for evaluation in infants is notoriously non-specific for true urinary infection. The usual conundrum is that a bagged specimen will include many bacteria which were perineal and not within the urinary tract; this leads to many false positive results. However, when a bagged specimen shows no growth on culture, it can be seen as being a strong indicator with a \> 99% probability that no urinary infection is present. Basically, a bagged culture is helpful to rule out infection if negative, but not very helpful to rule in infection; indeed studies have revealed that if the bag specimen is positive for\> 100,000 co lonies of a single organism, up to 80% of the specimens will be false positive compared to simultaneously obtain catheterized urine specimen . Leukocyte esterase was positive, but this finding only indicates that the urine came into contact with inflamed tissues and is not at all very specific for a true UTI. Urinary nitrite is produced when bacteria that reduce urinary nitrate to nitrite have been in contact with the urine. Classically, this signifies that the urine has come into contact with a member of the bacterial family of Enterobacteriaceae , e.g., Escherichia coli, Klebsiella, Proteus, Enterobacter, Serratia, or Citrobacter. It is noteworthy that clinically symptomatic UTls with streptococcus, enterococcus, pseudomonas, and Candida will turn urine nitrite positive in \< 5% of infections. The combined findings in this patient highly suggest that this girl is very unlikely to have a UTI; negative bagged urine cu lture, negative urine nitrite. She should not be treated for UTI and repeat culture in this circumstance is li ke ly a waste of resources. Another source for the possible febrile illness should be sought.

Question 71

74. A 60-year-old man with bothersome LUTS undergoes a non-invasive uroflow which is shown. He has a PVR of 100 ml. Based on these results: 1. the study should be repeated until the total voided volume is greater than 180 ml 2. he would likely be obstructed if he was ten years older with the same uroflow results 3. he has a high likelihood of moderate to significant bother based on his AUA Symptom Score 4. the cause of this patient's LUTS cannot be differentiated between obstruction and underactive bladder 5. he would have a poorer outcome after prostatectomy compared to patients with a peak flow rate greater than 15 ml/sec.

Answer 71

4 Uroflow evaluation with the determination of PVR is an important screening tool for patients with LUTS. Normal values vary depending on age, sex, and volume voided. In men, urine flow declines with age while women will have minimal alterations with age. In general, in pre-pubertal M+F, the average peak flow rates range from 10-15 ml/sec. Post-puberty until age 45 years, the average peak uroflow rate in M = 21 ml/sec; F = 18 ml/sec. Between the ages 46 - 65 years, the average peak uroflow rate for males will decrease to 12 ml/sec. The average peak uroflow rate for females will remain at 18 ml/sec. Between 66 to 80 years of age, the average peak uroflow rate for males will further decrease to 9 mllsec. The average peak uroflow rate for females remains at 18 mllsec. In general, provided the patient vOids a minimum of 125-150 ml, urologists will find a peak flow rate of \< 15 ml/sec in one third of patients of evaluated (1 SD below the mean) and a peak flow rate of \< 12 ml/sec In 5 Yo (2 SD below the mean). In using the uroflow to evaluate patients, it is critical to note the following: 1) The uroflow represents the combined dynamics of the outflow tract and detrusor contractility, a decrease in peak uroflow may be due to either the obstruction of the outflow tract, poor detrusor contractility, or both. 2) There is minimal to no correlation of the peak uroflow to prostate symptom scores. Specifically, pharmacological. therapy for BPH will frequently document significant improvement in symptom scores with minimal to no ncrease In peak uroflow. 3) Studies have found that patients with a peak uroflow of \> 15 ml/sec have significantly less improvement in prostate symptoms scores following TURP compared to patients with a peak uroflow of \< 15 ml/sec. The uroflow, being. of prognostic value In this circumstance, enables the surgeon to determine how well surgical intervention will Improve the patient's symptoms.

Question 72

Endemic bladder stones in children form due to high urinary excretion of: 1. ammonia 2. phosphate 3. sodium 4. calcium 5. oxalate .

Answer 72

1 Primary idiopathic (endemic) calculi form in child ren are commonly found in children from North Africa, the Middle East, and the Far East. With a large immigrant population in the United States, it is important to be aware of this health problem. These children classically re ly on a cereal-based diet that is lacking in animal proteins. The lack of protein leads to a dietary phosphate deficiency, low urinary phosphate, and high levels of urinary ammonia. Due to this, the most common stone found in children from these areas IS ammonium aCid urate. High urinary sodium, calcium, and oxalate are not characteristic findings with endemic bladder stones.

Question 73

A 50-year-old man with multiple endocrine neoplasia II has hypertension resistant to three antihypertensives . An MRI scan shows a 3 cm adrenal mass. A plasma-free metanephrine is elevated, and he is placed on phenoxybenzamine which is increased to the maximal dose. Despite this, he continues to have episodic hypertensive crises associated with sweating and palpitations. The next step is: 1. switch phenoxybenzamine to metyrapone 2. addition of prazosin 3. addition of metyrosine 4. addition of clonidine 5. immediate surgical removal.

Answer 73

3 In patients with a suspected pheochromocytoma, it is critical to achieve adequate alpha blockade prior to surgery. This is typically accomplished with phenoxybenzamlne. In patients in whom blockade with phenoxybenzamlne IS Inadequate, the addition of metyroslne, a tyrosine hydroxylase inhibitor, has been recommended to prepare the patient for anesthesia or surgery. An alternative to metyrosine would be to continue the phenoxybenzamine and add a beta-blocker, but in this setting of inadequate alpha-blockade, the addition of a beta-blocker has on occasion been found to be associated with increased alpha-receptor stimulation and furthering HTN. Therefore, the addition of metyroslne would be a better choice in patients who have their HTN poorly-controlled by phenoxybenzamine. Weak alpha-blockers, such as prazosln, have been used, however, a majority of patients still appear to have hypertensive crises prior to or dUring surgery while on these drugs. Immediate surgical removal would be dangerous without pre-surgical medical stabilization which has not been accomplished in this patient. Clonldlne and metyrapone do not play a role in the medical management of pheochromocytoma.

Question 74

A man with castration-resistant metastatic prostate cancer receives oral abiraterone acetate and prednisone . The toxicity most likely to require dose reduction ordiscontinuation is: 1. hypertension 2. fluid retention 3. hypokalemia 4. hepatotoxicity 5. nephrotoxicity .

Answer 74

4 Abiraterone acetate is an oral Cyp-17 lyase and hydroxylase inhibitor indicated for the treatment of men with castration-resistant metastatic prostate cancer post-docetaxel treatment. The blockade of Cyp~17 inhibits androgen biosynthesis at all sites as well as inhibiting the biosynthesIs of corticosteroids and can cause upregulation of ACTH and resultant hypersecretion of mineralocorticoids. Increased mineralocorticoids can cause HTN, fluid retention, and hypokalemia. It is co-administered with prednisone. The most serious adverse event associated with its administration is hepatotoxicity, that can be severe and potentially life threatening. Liver enzymes as well as electrolytes must be checked frequently (every two weeks for the first three months) when initiating the medication. There is no associated renal toxicity. Fatigue, hypokalemia, and fluid retention are relatively common side effects but typically do not require dose reduction.

Question 75

The most common complication associated with laparoscopic RPLND is: 1. retrograde ejaculation 2. bowel injury 3. intraoperative bleeding 4. chylous ascites 5. prolonged ileus.

Answer 75

3 Laparoscopic RPLND has become a feasible technique compared to the open approach: The laparoscopic complications seem to compare favorably to the historic open RPLND series with the exception that an increased blood loss with the laparoscopic technique over the open technique has been reported. This complication appears to be related to the surgeon's experience and is more common during the initial learning curve. That stated, this complication is still the most commonly reported complication of the laparoscopic procedure. The adequacy of the laparoscopic lymph node dissection In an experienced surgeon's hands is similar to open surgery with no Increase In tumor recurrence noted. The observed frequencies in retrograde eJaculation, chylous ascites, and prolonged ileus are no different compared to the open approach.

Question 76

A six-month-old girl has a fever of 39° C, lethargy, and poor oral intake. Catheterized urine specimen demonstrates 2+ leukocyte esterase, positive nitrite, and few bacteriaon microscopic examination. A urine culture is sent. The next step is: 1. hold antibiotic treatment until the culture is finalized 2. oral nitrofurantoin 3. lV ceftriaxone 4. renal and bladder ultrasound 5. DMSA renal scan.

Answer 76

3 This child has clinical signs and symptoms of severe UTI (high fever, lethargy, and poor oral intake). Although culture results are not avai lable, the UA findings are suggestive oof a UTI. Specifically, if both a positive leukocyte esterase and positive nitrite are present, 75% of the patients will have a positive culture result, i.e., a single bacterial organism at \>50,000 colonies of bacteria per ml of urine. If bacteria are seen on a catheterized urine specimen, It is 70% sensitive for a UTI for a positive culture result: i.e ., a single bacterial organism at \> 50,000 CFU/ml of urine. The combination of these findings along with the patient's clinical symptoms strongly suggests that treatment should be instituted while awaiting the culture results. Nitrofurantoin achieves a low serum concentration, and is, therefore, inappropriate for severe systemic UTI. Imaging studies,. such as ultrasound, CT, or MRI evaluation are indicated to rule out anatomic abnormalities If a child does not respond to treatment after 72 hours of I.V. appropriate antibiotics. A OMSA scan may be used to determine if the febrile infections is due to pyelonephritis, however, it should not be done prior to the institution of antibiotic therapy in this setting. The correct step is to begin a broad spectrum antibiotic therapy, such as IV ceftriaxone.

Question 77

A four-year-old girl with spina bifida is wet between urethral catheterizations. Her detrusor LPP is 50 cm H20 and her Valsalva LPP is 70 cm H20. She is started on oxybutynin. A repeat urodynamic study will reveal: 1. unchanged detrusor LPP; unchanged Va IsaIva LPP 2. unchanged detrusor LPP; increased Valsalva LPP 3. decreased detrusor LPP; increased Valsalva LPP 4. decreased detrusor LPP; decreased Valsalva LPP 5. decreased detrusor LPP; unchanged Valsalva LPP.

Answer 77

1 The LPP is determined by the resistance of the external sphincter. Antimuscarinic medication, such as oxybutynin, does not affect the external sphincter which IS a striated muscle. Therefore there should be no change in the LPP (detrusor or Valsalva). The effect of the antimuscarinic medication on the detrusor may increase bladder compliance by increasing the volume of urine stored at a given pressure, and thereby, increase the patient's bladder capacity. The closing pressure of the proximal urethra will not be affected

Question 78

To reduce post-operative pulmonary morbidity in smokers to the same level as non­ smokers, patients should discontinue smoking for a minimum of: 1. one month 2. two months 3. three months 4. six months 5. one year.

Answer 78

2 Regarding operative risks for major urologic procedures, epidemiologic studies have shown that postoperative morbidity is fourfold and mortality is up to tenfold higher in smokers compared to nonsmokers. To decrease the risk of pulmonary complications to the level of a non-smoker, the smoking must be discontinued for at least two months preoperatively.

Question 79

82. A 60-year-old man is diagnosed with a single focus of CIS of the bladder. He is treated with six doses of intravesical BCG. A month after his last dose, his cystoscopy is normal and his cytology is negative. The next step is: 1. bladder biopsy to confirm complete response 2. observation with regular surveillance cystoscopy and cytology 3. maintenance BCG with the first of three week ly doses at three months 4. maintenance BCG with the first of three week ly doses at six months 5. maintenance BCG single monthly dose for one year.

Answer 79

3 BCG maintenance therapy is indicated for patients with CIS, even if focal, who achieve a complete response. The Southwest Oncology Group (SWOG) reported the most significant Impact of maintenance therapy. Patients received a six-week induction course followed by three weekly In stillations at three and SIX months and every six months, thereafter, for three years. This patient is at the three month point and should receive the first set of maintenance treatments as the next step. Estimated median recurrence-free survival was 76.8 months in the maintenance arm and ~5 . 7 months in the control arm (P = .0001). Bladder biopsy is not necessary If the patient s cystoscopy and cytology are negative. Observation alone is not optimal therapy unless the patient has a contraindication or serious complication from BCG. Monthly BCG has been described and is commonly used, but has not been tested against the maintenance schedule proven to be effective in the large published SWOG trial.

Question 80

68-year-old man has a posterior bladder injury during a low anterior resection for locally advanced colon cancer that is repaired primarily with a two layer repair. Postoperative ly, a urethral catheter is left indwelling. Serial postoperative cystograms obtained at three, six, and nine weeks following surgery reveal persistent extraper itonea l extravasation from the posterior bladder wall. A CT scan reveals no pelvic masses and no evidence of ureteral injuries. The next step is: 1. repeat cystogram in three weeks 2. cystoscopy and fulguration 3. cystoscopy and biopsy 4. primary repair and omental interposition 5. suprapubic cystostomy.

Answer 80

3 Persistent drainage nine weeks following a repaired bladder injury would indicate issues related to poor healing such as foreign body, inadequate drainage from an indwelling catheter or recurrent/persistent malignancy. This injury .is unlikely to heal with further catheter drainage following nine weeks of observation and waiting an additional three weeks and repeating a cystogram would be of little to no merit. The next step should be a cystoscopy and biopsy to rule out recurrent/persistent malignancy before proceeding with definitive therapy. Assuming the urethral catheter IS working appropriately, suprapubic drainage will not be any more efficient and not resolve the issue. Fulguration of a fistula tract and/or injection of fibrin glue pursued in large or persistent fistula. Surgical intervention , however, should not be pursued until persistent or recurrent malignancy has been ruled have been shown to be of benefit in fistula \< 5 mm in size with definitive repair of fistula

Question 81

A stone measures 15 mm on CT imaging. When estimating the stone size, ultrasound and KUB will respectively: 1. overestimate, overestimate 2. overestimate, underestimate 3. underestimate, overestimate 4. accurately estimate, underestimate 5. underestimate,·accurately estimate.

Answer 81

4 There is an increased awareness of the radiation risks of CT imaging. In view of this US is an attractive alternative to measure stone size. The clinician should be aware of the limitations on ultrasound imaging of urolithiasis. Ultrasound Will correlate approximately two thirds of the time with the stone size determined on CT scan. Specifically, the US will overestimate the size of one third of the stones smaller than 10 mm, and underestimating the size of one third of stones, \> 10 mm. KUB underestimates\> 90% stones, \> 10 mm due in part to its inability to measure in three dimensions.

Question 82

64-year-old man requires CIC to empty his bladder six months after a lumbar laminectomy. He denies incontinence between CIC. Urodynamics are shown. The next step is: 1. continue CIC 2. antimuscarinics 3. alpha-blocker 4. onabotulinumtoxinA 5. lumbar to sacral nerve re-routing ("Xiao procedure").

Answer 82

1 This can be a challenging study to interpret due to the excessive activity from the rectal catheter. This results in artifactual activity in Pdet that is not a true change In this patients detrusor pressures. In interpreting this study, it is important to look atall of the tracings on the study. Aside from a few pressure spikes due to cough, the Pves tracing IS essenlially flat to a filled volume of more than 1000 ml. This patient wi ll be best treated with continued CIG. Therapies aimed at decreasing detrusor pressure (antimuscarinics and onabotullnumtoxmA) are not needed. Use of alpha-blockers would not be helpful in this patient who appears to have an areflexic bladder with only a small, short-lived rise in his vesical pressure at capacity. Lumbo-sacral re-routing was initially reported to be an option for spina bifida patients that were unable to void spontaneously; however, subsequent reports have not shown this to be overly beneficial and this procedure has not been evaluated in patients with urinary retention following laminectomy.

Question 83

The baseline sexual and ejaculatory function of a man with a complete L1 spinal cord injury is: 1. reflex erection, no emission, and no ejaculation 2. no erection , normal emission, and retrograde ejaculation 3. no erection, no emission, and no ejaculation 4. reflex erection, normal emission, and normal ejaculation 5. reflex erection, normal emission, and retrograde ejaculation.

Answer 83

1 Three neural pathways are necessary for complete sexual function. They are: sympathetic (T10-L2), parasympathetic (S2-S4), and motor function to the perineal muscles from the somatic motor neurons (S2-S4). Erections may be either cerebrally or directly induced by penile stimulation, ie, reflexlc erections. Cerebral induced erections occur in response to visual or sensory erotic stimulation to the cerebral cortex. Erections by this method occur via central Innervation .of the parasympathetic pathway, through the S2-S4 nerve routes and require an Intact spinal cord. The parasympathetic pathway can also be stimulated by direct penile stimulation through S2-S4 sensory fiber stimulation to cause erections, i.e., reflexic Induced erections. The three phases necessary for semen production are: emission, closure of the bladder neck, and ejaculation. In response to cerebral stimulation, signals are conducted down the thoracolumbar sympathetic nerves, resulting in sympathetic induce contraction of prostatic smooth muscle, seminal vesicles, and the vas deferens and allowing pre-ejaculatory fluid to be deposited Into the prostatic urethra, a process called emission . Bladder neck closure occurs concurrently. with emission in response to alpha-sympathetic stimulation by the sympathetic innervations. Emission will result in swelling of the bulbar urethra, the distension of the bulbar urethra stimulating rhythmic contractions of the bulbocavernosus, and pelvic floor muscles under somatic control through S2-S4 nerve roots (Onuf's nucleus). Semen is then projected In an antegrade fashion. Disruption of the sympathetic nerve fibers that travel through these plexuses with a complete spinal cord injury between T12-L2 can, therefore, cause loss of seminal vesicle emission and/or failure of bladder neck closure. Distention of the prostatic urethra will not occur, i.e., failure of emission, and the somatic controlled periurethral and pelVIC muscles Will not be stimulated to contract resulting in anejaculation . Reflexic erections, however, Will be maintained since the parasympathetic and penile sensory S2-S4 nerve plexuses are intact.

Question 84

68-year-old man has received intravesical BCG therapy for bladder cancer. He is asymptomatic, but a new firm area in the prostate gland is noted on DRE. The serum PSA is 3.1 ng/ml. A TRUS-guided biopsy reveals a caseating granuloma. The next step is: 1. observation 2. isoniazid for six months 3. cycloserine for six weeks 4. isoniazid and rifampin for three months 5. isoniazid, rifampin, and cycloserine for six months.

Answer 84

1 This asymptomatic patient has developed granulomatous prostatitis. This is a common condition following intravesical BCG therapy that requires no further intervention. If the patient is on maintenance BCG, it can be continued in this scenario. Isoniazid, rifampin, and cycloserine are used for systemic BCG toxicity and are not indicated in this case. The other more common side effect associated with intravesical BCG therapy is bladder irritability. This symptom complex includes dysuria (91 %), urinary frequency (90%), hematuria (46%), fever (24%), malaise (18%), nausea (8%), chills (8%), arthralgia (2%), and pruntus (1%)

Question 85

An eight-year-old boy with a history of incised posterior urethral valves has worsening hydroureteronephrosis. His creatinine is 1.3 mg/di. He is on a timed void interval, with a voiding calendar revealing he voids 400-500 ml every three hours. He has overnight urine output of 1000 ml and remains continent throughout the day and night. Videourodynamics reveals no urethral obstruction or reflux, with detrusor pressures of 40 cm H20 at volumes 500 ml and end-fill detrusor pressures of 60 cm H20 at volumes 700 ml. He voids with pressures generated from the noncompliant bladder with residual urines of 200 ml. The next step is: 1. fluid restriction 2. oral anticholinergics 3. CIC 4. onabotulinumtoxinA 5. bladder augmentation.

Answer 85

3 This patient has the valve bladder syndrome with progressive hydroureteronephrosis developing secondary to nephrogenic diabetes insipidus, obligatory high unne output, and a poorly compliant bladder at capacities of \> 500 ml. With approximately 125-150. ml of urine output per hour, he would stay in fairly safe volume/pressure anges If CIC was Instituted every three hours. If hydroureteronephrosis persisted, then ovemlght cathetenzatlon would also be an option. Bladder augmentation wou ld be too aggressive without an aggressive trial of medical management. Oral anticholinergics or onabotullnumtoxlnA, If instituted without concurrent use of CIC would be insufficient therapy due to already large PVR urine. Timed voiding every two hours while awake would also be reasonable option, however, this would not address his large residuals and mayor may not address his hydroureteronephrosls and would demand strict follow-up to verify compliance with medical directives. Fluid restriction would not benefit this patient with nephrogenic diabetes insipidus and would only lead to relative dehydration and possibly worsening renal failure.

Question 86

31-year-old man undergoes bilateral testicular biopsy during evaluation for infertility. Left testicular biopsy reveals intratubular germ cell neoplasia (ITGCN). Scrotal ultrasound is normal except for a moderate left varicocele. The next step is: 1. in vitro fertilization/intracytoplasmic sperm injection 2. left varicocele repair 3. low dose XRT to the left testis 4. left radical orchiectomy 5. single-dose carboplatin chemotherapy.

Answer 86

4 Intratubular Germ Cell Neoplasia (ITGCN) is diagnosed by testicular biopsy performed for the investigation of infertility, by biopsy of the contralateral testis in a patient with germ cell tumor (GCT), or by biopsy within the affected testis in a patient undergoing testls-spanng surgery. The rationale for treatment of ITGCN is based on the high risk of developing invaSive germ cell tumor in at least 50% of patients. Treatment options include, orchiectomy, low-dose radiotherapy, and close observation. The choice of therapy should be individualized based on the patient's desire for future paternity, the presence or absence of a normal contralateral testis, and the patient's desire to avoid testosterone replacement therapy. Radical orchiectomy is the most definitive although lOW-dose radiotherapy (20 Gy) IS associated with Similar rates of local control with' the prospect of preserving testicular endocrine function owing to the relative radioresistance of Leydig cells compared with germinal epithelium. For patients who do not desire future paternity XRT is the preferred option, although radical orchiectomy and testosterone replacement, therapy is a reasonable alternat.ive. For patients with a normal contralateral testis who desire future paternity (as is the case with this patient who IS pursuing evaluation for infertility), radical orchiectomy is preferred because scatter to the contralateral testis from radiotherapy may impair spermatogenesis. For patients with semen parameters that are abnormal but sufficient for assisted reproductive techniques, close surveillance witheasonable strategy with deferred therapy until successful pregnancy. Another option for these patients is exploration of the testis, sperm harvesting, and cryopreservatlon for assisted reproductive techniques, and radical orchiectomy followed by testosterone replacement therapy. Left varicocele repair alone does not address the concerns for malignant transformation of ITGCN. Single-dose carboplatin chemotherapy has been used In patients with stage I seminoma, but has no defined role in ITGCN. If no intervention is taken, close follow-up, as noted above, is still warranted.

Question 87

23-year-old man has buckling and pain during intercourse. On examination, he has minimal penile tenderness and swelling with no ecchymosis or hematoma. Urinalysis is normal. The next step is: 1. Doppler ultrasound 2. MRI scan 3. infusion cavernosography 4. flexible urethroscopy 5. surgical exploration .

Answer 87

2 Penile fracture can usually be diagnosed by history and physical examination and imaging is unnecessary In the majority of patients. However, the clinician should be aware that differential diagnosis includes a false penile fracture and/or rupture of a penile vein with a subsequent penile hematoma. These latter patients may clinically present with the classic history of a typical snap-pop sensation and immediate detumescence as in this case. In cases in which the physical examination is not classic for a penile facture, imaging with a penile-perineal MRI scan is the most accurate test to prevent unnecessary surgical exploration. Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture. Obtaining a UA to rule-out a concurrent urethral injury: found in up to 10-20% of patients with a penile fracture is absolutely necessary. In patients With a confirmed penile fracture, imaging of the urethra prior to exploration is mandatory and can be performed with either a retrograde urethrogram or cystoscopy at the time of the procedure. If a urethral injury is found , this should be repaired concurrently with the penile fracture.

Question 88

A 58-year-old man with bothersome LUTS undergoes urodynamics as shown. His PVR urine is 0 ml. The likely etiology of his LUTS is: 1. dysfunctional voiding 2. detrusor-external sphincter dyssynergia 3. benign prostate enlargement 4. multiple sclerosis 5. Hinman syndrome.

Answer 88

3 The pressure flow urodynamic study reveals detrusor overactivity (DO), coexisting with urodynamlc eVidence of bladder outlet obstruction. In this study, external sphincter activity is noted With each episode of DO. This is a normal guarding response to an uninhibited bladder contraction and will occur in an attempt to prevent urge incontinence. When given permission to void, EMG activity, which measures the electronic potential of the external sphincter, appropriately quiets and the patient is able to void. Patients with multiple sclerosis (MS) may have do which is seen in the urodynamic tracing. However, if high-pressure voiding was due to voiding dysfunction secondary to MS then the EMG would be active throughout the voiding phase. Hinman Syndrome (also termed non-neurogenic neurogenic bladder) and dysfunctional voiding are similar entities and would be characterized by simultaneous bladder emptying and voluntary striated sphincter contraction. Detrusor-external sphincter dyssynergia (DESD) is also characterized by silmutaneous detrusor and involutnary striated sphincter contraction. The likely etiology of this patient's UDS findings is BPH with secondary DO. BOO on a UDS may be determined by use of either detrusor pressure flow rate nomograms or alternatively may be diagnosed when tow of the following 4 criteria are met: 1) flow rate \<12ml/sec, 2) detrusor pressure at peak flow \>50cm/H2O, 3) elevated urethral resistance (Pdet at Qmax divided by 2x Qmax \>0.2), or 4) significant residual urine (\>100-150ml) in the presence of high detrusor voiding pressures (ie detrusor pressure \>50cm H2O at maximum flow rate.) This patient has detrusor pressures at peak flow \>50cm/H2O, an elevated urethral resistance of approximately 0.3 and peak uroflow at the cut off level

Question 89

A medication associated with an increased risk of C. difficile in hospitalized patients is: 1. lansoprazole (Prevacid™) 2. metoclopramide (Reglan M) 3. dicyclomine (Benty!™) 4. diphenoxylate and atropine (Lomotil™) 5. alvimopan (Entereg™).

Answer 89

1 Lansoprazole is a proton pump inhibitor (PPI). It is noteworthy that all PPls have been found to be significantly associated with an increased risk of C. difficile colonization and infection. This has been attributed to their attenuation of acid secretion by the stomach and elimination of th iS barrier to bacterial colonization. None of the other medications has been associated with C. difficile colonization or infection.

Question 90

Erythropoietin production in the kidney is regulated primarily by: 1. angiotensin 2. high oxygen tension 3. renin 4. hypoxia-inducible factor 1-alpha 5. testosterone.

Answer 90

4 Production of erythropoietin (EPO) is closely associated with circulating oxygen levels. During conditions of hypoxia, hypoxia-i nducible factor-1-alpha (HIF-1-a) is upregulated increasing EPO transcription. HIF-1-a is then rapidly degraded by proteases upon restoration of normal oxygen tension. Renin does not directly influence EPO production. Testosterone and angiotensin II induce erythrocytosis through proposed mechanisms, Including stimulation of EPO, however, these are thought to be less significant than HIF-1-a. Mutation of the VHL gene such as in patients with von Hippel-Lindau syndrome results in constitutive production of HIF-1-a increased EPO with resultant polycythemia. HIF-1-a also upregulates production of vascular endothelial growth fa ctor (VEGF), which is the primary angiogenic factor responsible for the neovascularity associated with RCC.

Question 91

54-year-old woman is diagnosed with CIS of the bladder. She is currently taking methotrexate and prednisone for severe rheumatoid arthritis. The next step is: 1. intravesical BCG 2. intravesical valrubicin 3. intravesical gemcitabine 4. taper off methotrexate and prednisone then administer BCG 5. radical cystectomy.

Answer 91

1 Immunocompromised patients are generally considered to be contraindicated to receive intravesical BCG therapy due to the theoretical concerns of loss of efficacy and increase in toxIcity. However, there exists little evidence to support or refute such claims. A recent report from Herr and Dalbagnl demonstrate the safety and efficacy of intravesical BCG in Immunocompromisedpatients including patients with autoimmune disease, transplant patients, and patients undergOing systemic chemotherapy. The authors demonstrated that intravesical BCG is safe and effective in immunologically compromised patients with bladder cancer with the majority of patients (91 %) having an initial complete response. Transplant patients fared worse but stili demonstrated a response to BCG with acceptable tolerability. Therefore, an Initial tnal of BCG therapy can be considered in this patient following appropriate counseling about nsks, benefits, and safety issues. Valrubicin was approved by the FDA in 1998 for the treatment of BCG refractory CIS of the bladder in patients who are medically unfit or refuse a cystectomy, with modest efficacy observed in this setting. It is not indicated in this setting and Its role. In the Immunocompromised patient is uncertain. Although thiotepa is the only Intravesical chemotherapeutic agent FDA-approved for papillary bladder cancer, it may result in significant myelosuppression which would be of particular concern in the immunocompromised patient. Furthermore, its efficacy in CIS is limited and it has not been studied in this setting. Intravesical gemcitabine has been shown to have activity in non-muscle invasive bladder cancer in high-risk patients. Although early results are promising in the second line or salvage setting, the limited patient population evaluated supports the need for additional phase II and phase III stUdies. Moreover, its efficacy in the immunocompromised patient IS unknown. Radical cystectomy is a reasonable option, but may be too aggressive for this patient as a first line option with untreated CIS.

Question 92

A four-month-old uncircumcised boy is hospitalized for a febrile UTI. He has persistent fevers after 24 hours of appropriate l.V. antibiotic therapy. Renal and bladder ultrasound is normal. The next step is: 1. continue current antibiotic regimen 2. repeat urine and blood cultures 3. VCUG 4. CT scan 5. circumcision.

Answer 92

1 In the treatment of pyelonephritis, persistence of fever for 72 hours following initiation of IV appropriate antibiotics is within the range of normal and no additional studies should be done at this time. Guidelines from the American Academy of Pediatrics recommend further radiologic testing in this age group only if the initial renal bladder ultrasound is abnormal or for occurrence of a second febrile UTI. Acute DMSA scanning may be helpful In situations where the diagnosis regarding the etiology of the fever is unclear and the physicians desire to document the presence of pyelonephritis. CT or MRI scans may be considered If the renal bladder ultrasound is abnormal or if fever persists beyond 72 hours. Persistent fever\> 72 hours is best evaluated with either a CT or MRI scan, with repeat ultrasonography having an unacceptable false negative rate for documenting the presence of a perinephric abscess. A VCUG is not indicated in the acute setting but can be considered once the child IS afebrile. Repeat cultures or broadened coverage is not required when initial sensitivities are available but should be considered for a temperature persisting \> 72 hours. CircumcIsion at this age usually requires a general anesthetic and is not needed for a first UTI.

Question 93

A 26-year-old man is shot with a high velocity rifle in the lower abdomen. Exploration reveals a rectal injury which is repaired. Inspection of the left distal ureter reveals a 2 cm contusion. l.V. administration of methylene blue does not reveal a ureteral leak. He is hemodynamically stable. The next step is: 1. observation 2. ureteral stent placement 3. percutaneous nephrostomy 4. ureteroureterostomy 5. ureteral reimplant.

Answer 93

5 The patient has suffered a ureteral contusion from a high velocity weapon, and many times the extent of the injury is underestimated at initial exploration. Following a high velocity Injury, the patient is at high risk for subsequent ureteral stenosis, or tissue necrosIs from delayed microvascular injury to the ureter. The best option for a distal ureteral contusion from a high velocity injury is ureteral reimplantation. A ureteroureterostomy should not be performed In the distal ureter. Observation, ureteral stent, and percutaneous nephrostomy drainage will not alter the eventual tissue damage from the blast effect and, thus, would not be helpful in this situation.

Question 94

A 62-year-old man with an ileal neobladder has a serum chloride of 114 mEq/I, potassium of 3.8 mEq/I, creatinine of 1.8 mg/ml, and bicarbonate of 16 mEq/I, despite low urinary residuals, normal upper tracts, and timed voiding every three hours. He has a history of hypertension and diabetes mellitus. The next step is: 1. sodium bicarbonate 2. sodium citrate 3. potassium citrate 4. chlorpromazine 5. nicotinic acid.

Answer 94

3 Following ileal or colonic urinary reconstruction, patients are prone to the develop hyperchloremic, metabolic acidosis due to the exchange .of ammonium Ions (ammonium chloride) for carbonic acid and water. Treatment of chroniC aCidOSIS Involves reduction of urinary contact time to ensure minimization of ammonium absorption. In the event the aCidosis persists despite frequent catheterization, alkalinizing agents or Inhibitors of chloride transport may utilized. Inhibitors of chloride transport, such as ch lorpromazine or nicotinic acid, are generally not effective alone in the treatment of acidosis, but they may be used In conjunction with alkalinizing agents. In this case, the use of sodium bicarbonate and sodium citrate should be discouraged given the history of HTN and the desire to limit sodium intake. As such, potassium citrate is the ideal first choice for treatment.

Question 95

A 60-year-old woman has chronic dysuria and suprapubic discomfort when her bladder is full and during voiding. She has a normal physical exam and urinalysis. Flow rate reveals a total volume voided of 100 ml, peak of 14 ml/sec, average of 8 ml/sec, and a postvoid residual urine of 0 ml. Cystoscopy reveals a focal ulceration on the right lateral wall. Cytology is normal. The next step is: 1. antihistamines (loratadine) 2. tricyclic antidepressants (amitriptyline) 3. oral sodium pentosan polysulfate (Elmiron) 4. intravesical dimethyl sulfoxide (DMSO) 5. biopsy and fulguration.

Answer 95

5 Interstitial cystitis (IC) is a clinical diagnosis characterized by diurnal and nocturnal frequency and urgency, lower abdominal or suprapubic pain with bladder distension and relief or improvement of pain with voiding. Symptoms should be present in the absence of identifiable pathology, e.g., UTI, and persisting for \>9 months. Urodynamic evaluations will typically show a bladder capacity \< 350 ml. The International Continence Society (ICS) prefers the term "painful bladder syndrome" (PBS) to describe this symptom complex, and reserves the diagnosis of IC for patients with "typical cystoscopic and histological features following hydrodistention". Classic cystoscopic findings are glomerulations and bladder wall petechial hemorrhage found following hydrodistention. The urologist must be aware, however, that these cystoscopic findings can also be seen upon hydrodistention in patients without IC and other diagnostic criteria, as noted above, must be met. In addition to glomerulations, Hunner originally described a characteristic lesion or "ulcer" in some patients With IC which has led to the classification of IC into 2 types: ulcerative and non-ulcerative. Approximately 15% of patients with IC will have extremely painful areas of inflammation in the bladder, well known as Hunner's lesions (formerly, Hunner's Ulcers). The detection of a Hunner lesion is best possible at cystoscopy following hydrodistension. In patients with PBS, the hydrodistension is best done under general, epidural, or local anesthesia due to the exquisite pain it will often invoke within the patient. A Hunner's lesion or "ulcer" is a distinctive inflammatory lesion presenting a characteristic deep rupture through the mucosa and submucosa provoked by bladder distension. Despite the name that has been commonly used, the lesion is not a pathologic ulcer and hence, the term, Hunner's lesion is gradually being adopted worldwide. A Hunner's lesion presents as a circumscript, reddened mucosal area withsmall vessels radiating towards a central scar. This site ruptures with increasing bladder distension, resulting in petechial oozing of blood from the lesion in a waterfall manner. Biopsy of the lesion classically shows inflammatory cystitis, often with epithelial denudation. AUA Treatment Guidelines outline current treatments for Hunner's lesions to include: fulguration, laser therapy, and/or the injection of triamcinolone into the center of the ulcer. Although longterm outcomes regarding injection of triamcinolone are currently unavailable, fulguration andlaser therapy have been found to be associated with slightly \> 50% of patients having complete resolution of their symptoms, with another 25% having \> 50% improvement of their symptoms following treatment. Unfortunately, long-term follow-up reveals approximately 1/3 of the patients that symptomatically improved or resolved their symptoms following fulguration will have a clinical recurrence of their disease process. It is noteworthy that polymyxa viruses have recently been found to be present within Hunner's lesions suggestive that antiviral medications or topical agents with an antiviral effect (Clorpactin) may be of benefit to this class of IC patients.

Question 96

A two-month-old girl with urosepsis has an ectopic ureterocele associated with moderate left upper pole hydroureteronephrosis and bilateral VUR, grade 2 reflux to left lower pole, and grade 3 reflux to a right solitary collecting system. She has defervesced on l.V. antibiotics. The next steps are prophylactic antibiotics and: 1. observation with repeat renal ultrasound and VCUG at one year of age 2. transurethral incision of ureterocele 3. left upper pole partial nephrectomy 4. left upper to left lower pole ureteroureterostomy 5. ureterocele excision and left common sheath ureteral reimplant and right ureteral reimplant.

Answer 96

2 The obstruction of the upper urinary tract by a ureterocele, resulting in moderate hydroureteronephrosis associated with bilateral vesicoureteral reflux, is the most concerning element found on diagnostic imaging. The findings of associated bilateral ureteral reflux suggest the ureterocele may be obstructing the bladder neck resulting in high pressure voiding and secondary reflux. Intravenous antibiotics followed by transurethral inCISion of the ureterocele would be the most prudent course of action in this young Infant. All of the other options listed would be associated with increased risk of morbidity in an infant of this age: \<10% of cases will incision of the ectopic ureterocele completely resolve the clinical findings on repeat VCUG in three to six months. Frequently a repeat VCUG will reveal decompression of the ureterocele, but wil l have either persistent or new onset of reflux to the left upper pole. Prior to definitive surgical intervention, the latter usually performed at one year of age, assessment of the function of the left upper pole with a DMSA scan is performed along with repeat renal ultrasound and VCUG. Definitive treatment could Include any of the surgical options listed; the type of surgery performed would be dependent upon radiographic findings.

Question 97

A 50-year-old woman with a T4 complete spinal cord injury has been managed with an indwelling catheter since her injury ten years ago. She currently complains of constant leakage of urine around her 18 Fr urethral catheter. Examination reveals a patulous urethral meatus with a diameter of two fingers and a urethral length less than 1 cm. The next step is: 1. 22 Fr catheter with 30 ml balloon 2. peri-urethral calcium hydroxylapatite (Coaptite™) injection 3. suprapubic tube 4. bladder neck closure and suprapubic tube 5. autologous fascia! sling.

Answer 97

4 This patient has the classic findings of an eroded urethra secondary to long-term indwelling catheter use. She has essentially lost almost all of her urethral length and has a patulous Wide open bladder neck and meatus. Placement of a larger catheter with a larger balloon will only worsen the erosion and would likely not improve the incontinence. A minimum of 1 cm urethral length is believed to be needed to allow for obstruction of the urethra by bulking agents or by sling placement. Although one could attempt urethral lengthening and then proceed with either bulking agents or sling placement, use of these procedures following urethral reconstruction has been found to be fraught with complications. A suprapubic (SP) tube alone would not be sufficient as urine would still leak per her incompetent bladder neck and urethra. This patient would be best served with a bladder neck closure (which could be done via a vaginal or transabdominal approach) and SPT placement. Other options which could be considered would be bladder neck closure and construction of a continent urinary stoma If she is Willing to perform CIC, bladder neck closure and ileovesicostomy, or supra-vesical non-continent urinary diversion.

Question 98

A 30-year-old man with primary infertility has a semen analysis that shows a 2.5 ml ejaculate volume, 50 million sperm/ml, and 1% motility. The morphology score and round cell concentration are normal. A repeat semen analysis is similar. The next step is: 1. post-ejaculate urine analysis 2. sperm viability testing 3. transrectal ultrasound 4. cystic fibrosis mutation screening 5. semen white blood cell stain.

Answer 98

2 Ultrastructural flagellar defects result in motilities of less than 5-10%. In these samples, most of the non-motile sperm are viable. Most cases of ultrastructural fl agellar defects are associated with normal sperm densities. Since the semen volume is normal, there is no reason to look for retrograde ejaculation with a post-ejaculate UA. While a partial ejaculatory duct obstruction has been reported to be associated with low motility, this should only be considered If the sperm are viable and thus would not be the next step. Cystic fibrosis mutations are associated with congenital absence of the vas deferens and azoospermia. Semen WBC staining is indicated only if increased numbers of round ce lls are noted in the semen.

Question 99

A 12-year-old boy has daytime urinary incontinence five years following transurethral incision of PUV. The preoperative VCUG and the current VCUG images are shown. The next step is: 1. CIC 2. oxybutynin 3. biofeedback 4. transurethral incision of PUV 5. diverticulectomy.

Answer 99

4 VCUG image is concerning for the persistence of (residual) PUV tissue with persistence of a dilated posterior urethra and a filling defect noted at the transition point from the prostatic to membranous urethra. Due to these findings, cystourethroscopy and repeatevaluation for possible repeat transurethral incision of PUV is mandatory. He may at some point benefit from biofeedback, oxybutynin, or CIC; however, these treatment modalities should not be employed until after there is documentation of valvular destruction. Radiographic studies do document bilateral bladder diverticula; however, these mayor may not be clinically relevant to. hiS VOiding dysfunction and. their treatment should only be pursued following documentation of valve destruction and failure of conservative treatment modalities.

Question 100

A 53-year-old woman has POP-Q stage 3 anterior compartment prolapse and urinary incontinence. No stress urinary incontinence is noted during urodynamics with cough or Valsalva maneuver performed at a maximum bladder capacity of 400 ml with or without reduction of pelvic organ prolapse by physical manipulation. The next step is: 1. fill the bladder to 100 ml beyond maximal capacity and repeat stress maneuvers 2. repeat urodynamic study with prolapse reduction performed by a vaginal pessary 3. remove urethral catheter and repeat stress maneuvers 4. proceed with prolapse repair with no anti-incontinence procedure 5. proceed with prolapse repair with sling

Answer 100

3 The AUA/SUFU Urodynamics Guidelines suggest that clinicians should repeat stress testing with the urethral catheter removed in patients suspected of having stress incontinence (SUI) who do not demonstrate SUI with the catheter in place. Filling the bladder to a higher volume than maximum capacity would not be indicated. Changing the prolapse reduction method would not be expected to change the findings. It should be noted the guidelines on urodynamic assessment of stress incontinence states that there is no standardized method with which to reduce prolapse during a urodynamic study. Patients with marked vagina l prolapse are at a high risk for concomitant stress incontinence and presence of a urethral catheter may prevent manifestation of the stress incontinence during urodynamics. Removal of the catheter (with continued reduction of prolapse) allows for complete evaluation and is the next step prior to proceeding with surgical planning.

Question 101

An 11-year-old girl undergoes bilateral inguinal hernia repairs. Gonads measuring 3.5 cm are found at the internal rings. Biopsies show seminiferous tubules with few germ cells, interstitial fibrosis, and no ovarian follicles. The external genitalia is female, and she has not yet started menses. The most likely diagnosis is: 1. 45 XO Turner syndrome 2. 46 XX congenital adrenal hyperplasia 3. 46 XY complete androgen insensitivity syndrome 4. 45 X/46 XY mixed gonadal dysgenesis 5. 46 XY pure gonadal dysgenesis.

Answer 101

3 Histology in this disorder of sex development patient demonstrates seminiferous tubules with no ovarian stroma. This finding is consistent with testicular differentiation, thus ruling out Turner syndrome (bilateral streak gonads), pure gonadal dysgenesis (bilateral streak gonads), mixed gonadal dysgenesis (one streak gonad, one testis), and congenital adrenal hyperplasia (two ovaries). Based on the histology and the normal external female genitalia, the patient has 46 XY complete androgen insensitivity syndrome (CAIS). It is not uncommon in AIS patients for the seminiferous tubules to demonstrate a paucity of germ ce ll s, indeed many biopsies are found to contain Sertoli cells only.

Question 102

69-year-old woman has a 2.2 cm, biopsy-proven , grade 2, clear cell RCC and elects active surveillance. The next step is: 1. renal ultrasound in six months 2. CT scan in six months 3. CT scan in one year 4. fluorodeoxyglucose-PET imaging 5. repeat biopsy in one year.

Answer 102

2 The AUA Guidelines for Follow-up of Renal Masses recommends that patients undergo crosssectional abdominal scanning (CT or MRI , but not ultrasound) within six months of active surveillance initiation to establish a growth rate. The Panel further recommends continued imaging at least annually thereafter. Data on long-term growth patterns of renal masses are limited, although there is a suggestion that masses show linear growth on axial imaging rather than logarithmic. Thus, serial axial imaging as early as six months after the in itiation of surveillance will establish an expected growth rate for subsequent comparison. After this initial scan, subsequent imaging, which then can include ultrasound, can be performed yearly un less the pace of growth is concerning. Fluorodeoxyglucose PET scans have no utility in staging for RCC, and there is no indication for a functional renogram study. There is no indication for repeat biopsy for surveillance of renal masses.

Question 103

67-year-old man with a history of multifocal CIS is on maintenance BCG after a six­ week induction course 18 months ago. He has positive voided urine cytologies with negative bilateral upper tract imaging and washings, normal appearing bladder, and normal random bladder biopsies. The next step is: 1. fluorescent in situ hybridization (FISH) testing 2. intravesical induction mitomycin C 3. repeat induction BCG 4. prostatic urethral biopsy 5. ureteroscopy with biopsy.

Answer 103

4 In patients with high-risk non-muscle-invasive disease, there is high risk of secondary tumor involvement of the prostatic urethra and ducts. Prostatic urethral involvement may be detected in 20-40% of these patients within 10 years of diagnosis. In patients with refractory disease, the incidence of extravesical recurrence in the prostatic fossa may be as high as 33% and a substantial portion may be fatal. In this patient, persistently positive cytologies with no clear upper tract or bladder source would warrant biopsy of the prostatic urethra to investigate the source of abnormal cytologies. FISH or other molecular markers would NOT provide additional information over clearly positive mailgnant cytology. Intravesical topical therapies (mitomycin/BG) will not treat the prostatic urethra adequately and are not indicated for cytology alone diagnosis. Ureteroscopy is not indicated with negative upper tract washings.

Question 104

50-year-old man has autosomal dominant polycystic kidney disease, hypertension, and normal renal function. The best medication for his hypertension is a(n): 1. alpha-blocker 2. beta-blocker 3. calcium channel blocker 4. angiotensin receptor antagonist 5. thiazide diuretic.

Answer 104

4 HTN is a very common presenting sign in patients with ADPKD. The mechanism appears to be compression of the intra-renal vessels from the cysts causing ischemia and thus, renin-mediated HTN. Early recognition and treatment is important to avoid hypertensive-related renal deterioration. Because this mechanism is renin-mediated, the most logical choice in anti-hypertensive medication is either ACEi/ARB.

Question 105

A 63-year-old man underwent a partial penectomy. Pathologic evaluation of the specimen reveals a grade 1, pT1 penile cancer without lymphovascular invasion. Physical examination reveals no palpable inguinal lymph nodes, the next step is: 1. observation 2. bilateral superficial inguinal lymph node dissection 3. bilateral superficial and deep inguinal lymph node dissection 4. diagnostic sentinel node biopsy 5. prophylactic XRT to both groins.

Answer 105

1 In patients with low-grade pT1 penile cancer w/o LVI, the rate of inguinal mets is \<10% and thus these patients should be ovserved. In this low-risk patient, there is no indication for sentinal LN biopsy, prophylactic radiation or lymphadenectomy. In general, bilateral inguinal lymphadenectomy is reserved for patients wiht pT2 or HG disease. In addition, consideration for immediate bilateral prophylactic node dissection can be given for low-grade pT1 tumors that harbor findings that are highly indicative of occult metastasis, such as LVI. It is notworthy that in the setting of palpable LN, abx administration and delayed reassessment is not indicated if there are clinical indications for proceeding wiht a LN dissection, namely pT1 high-grade or pT2 or greater tumors

Question 106

The form of testosterone most commonly associated with erythrocytosis and an increased risk of thrombotic events is: 1. topical gel 2. transdermal patch 3. oral 4. sublingual 5. intramuscular injection.

Answer 106

5 Testosterone stimulates eryth ropoiesis with a direct correlation between hemoglobin and hematocrit levels and testosterone levels. Injection of testosterone IS associated with higher potential for secondary erythrocytosis than topical or oral preparatlons. High Ievels of testosterone are associated with polycythemia (hematocrit over 51%). Due to the Increased risk of clotting complications with an elevated hematocrit, it is recommended that the testosterone dose is adjusted and/or periodic ph lebotomy be performed to keep the hematocrit below 52-55%. All patients placed on testosterone should have periodiC CBC assessments with the initial evaluation for erythrocytosis occurring three months follOWing Inillation oftreatment.

Question 107

A ten-year-old boy has persistent dysuria. Serial urinalysis reveals a pH of 7.2, specific gravity of 1.025, protein is negative, 0-2 WBC/hpf , 20-30 RBC/hpf, and a negative urine culture. A renal bladder ultrasound and a VCUG are normal. Thediagnosis is best made by: 1. KUB 2. serum calcium-to-creatinine ratio 3. 24-hour urinary calcium collection 4. CT scan 5. renal biopsy.

Answer 107

3 This boy has a typical presentation for hypercalciuria. The diagnosis is best made by a 24-hour urine colle ction with calcium excretion exceeding 4 mg/kg/day being diagnostic. Often, a UA will reveal a high specific gravity\> 1.020 and an abnormal spot urine ca lcium-to creatinine ratio (\> 0.21). Although these findings are helpful to prove dehydralion and hypercalciuria as a cause of the dysuria, the best true diagnostic assay IS the 24-hour uri ne collection checking for both 24-hour urinary volume and calCium excretion. Patients with documented hypercalciuria and low urinary volume are at higher risk for urolithiaSIS. Treatment should be with liberalization of fluids and repeat urine assessment. Identlflcalion of calculusdisease via plain x-ray or CT scan would not be diagnostic of hypercalciuria and, in view of the normal ultrasound, would place the patient at needless risk of radiation exposure. In the absence of proteinuria, there is no need for renal biopsy.

Question 108

58-year-old man has asymptomatic non-metastatic castration-resistant prostate cancer demonstrated by a rising PSA on LH-RH agonist therapy. The next step is: 1. observation 2. bicalutamide 3. sipuleucel-T 4. abiraterone and prednisone 5. enzalutamide .

Answer 108

1 This patient represents index patient 1 in the AUA Guideline for Castration-Resistant Prostate Cancer (CRPC). The guidelines make a primary recommendation for observation for this patient. The gUidelines also make the recommendation that clinicians should not offer systemic chemotherapy or Immunotherapy to patients with non-metastatic CRPC outside the context of a clinical trial: thus, making the use of sipu leucel-T, abiraterone with prednisone, and enzalutamlde Incorrect In thiS patient. As an option , the guidelines state that clinicians may offer treatment with flrst- generation anti-androgens (flutamide, bicalutamide and nilutamide) or first generation androgen syntheSIS inhibitors (ketoconazole with prednisone) to select patients with non-metastatic CRPC who are unwilling to accept observation. However, given the lack of data suggesting any clinical benefjt and given the potential side effects of therapy, the panel only recommended the use of anti-androgens in this patient population only if patients are unWilling to accept the recommendation of observation. There is no statement that this patient IS unwilling to accept observation , and , accordingly, observation should be the initial step andrecommendation.

Question 109

A 35-year-old man with Crohn's disease and recurrent calcium oxalate stone formation should be counseled to restrict intake of dietary oxalate and: 1. restrict intake of animal protein 2. restrict intake of omega-3 fatty acids 3. increase intake of calcium 4. Dincrease intake of pyridoxine 5. initiate cholestyramine therapy.

Answer 109

3 Urinary oxalate is modulated by calcium intake which influences intestinal oxalate absorption. Large cohort studies have demonstrated an increased risk of stone formation with lower calcium diets and have also found that diets higher in calcium are associated with reduced oxalate excretion. Of note, patients with enteric hyperoxa luria and high levels of urinary oxalate, such as those With malabsorptive conditions (e.g., inflammatory bowel disease or Roux-en-Y gastric bypass), may benefit from more restrictive oxalate diets as well as from higher calCium Intakes, which may include supplements, specifically timed with meals. In such cases, calcium will serve as an oxalate binder so that a significant proportion will appear in the stool. However, 24-hour urine monitoring can be used to ensure that hypercalciuria does not result. Animal protein restriction is not correct as that recommendation would be most appropriate for those with hyperuricosuria. A role for nutritional supplements, such as, omega- 3 fatty acids, pyridoxine , and cholestyramine has been suggested, but at present the evidence is not suffiCient to guide recommendations.

Question 110

63-yearold man has. partial penectomy for squamous cell carcinoma invading the glans penis (pT2). Pelvic CT scan demonstrates a 1.5 cm right inguinal lymph node that cannot be palpated. The next step is: 1. antibiotics and repeat CT scan in six weeks 2. CT-guided aspiration of the suspicious node 3. right sentinel node biopsy 4. right inguinal node dissection 5. bilateral inguinal node dissection.

Answer 110

5 This patient has pathologic stage T2 disease and is at high risk for occult inguinal node metastases. Regardless of inguinal lymph node status (palpable or not), these patients should undergo inguinal lymph node dissection. In this setting, antibiotics decrease the risk of inguinal wound infection, but response of lymph nodes to antibiotic treatment should not Influence the decision for surgical staging . Whether inguinal nodes are palpable unilaterally or not palpable, bilateral inguinal node dissection is indicated. In this case, superficial inguinal dissection is indicated on the left and superficial and deep dissection on the right.

Question 111

An 18-year-old man with primary nocturnal enuresis is managed with oral DDAVP 0.6 mg/day. He has worsening nocturnal enuresis after starting college and increases his dose t? mg every night. He presents for a follow-up examinat ion requesting another prescription for DDAVP. He is asymptomatic and a routine check of his serum sodium reveals a value of 129 mEq/I. After withdrawing the DDAVP, the next step is: 1. water restriction 2. oral furosemide 3. oral sodium bicarbonate 4. lV 0.5 NS and furosemide 5. 1.V. 3% hypertonic saline and furosemide.

Answer 111

1 This patient has hyponatremia due to SIADH from self-medicating with DDAVP. He has a chronic condition (\> 48 hours) with no symptoms and modest hyponatremia that can be corrected slowly over time. Removing the inciting agent (DDAVP) together with water restriction would be the optimal treatment. In the absence of symptoms, the addition of diuretics and saline replacement are not necessary. There is no role for oral sodium bicarbonate in this setting

Question 112

A 65-year-old woman has recurrent metastatic RCC after undergoing radical nephrectomy for a pT4 papillary RCC. She has poor prognostic features by Memorial Sloan Kettering risk criteria. The next step is: 1. interleukin-2 2. bevacizumab 3. sorafenib 4. temsirolimus 5. pazopanib.

Answer 112

4 The patient has advanced RCC with predominantly non-clearcell histology. Additionally, she is now presenting with poor prognostic features. Prognostic sconng systems have been developed in advanced RCC and have been shown to have Important correlations to response to therapies and to overall survival. The most commonly used prognostic model is from MSKCC and includes performance status, serum LDH, serum calcium, hemoglobin, and interval from diagnosis to treatment. Although the majority of clinical trials have focused on patients with clear cell histologies, data exists indicating that targeted therapies may have benefits in patients with non-clear cell histologies. According to the NCCN Kidney Cancer Panel, temsirolimus is a category 1 recommendation for the treatment of patients with non-clear cell histology and poor prognostic features. These recommendations by the panel are based primarily on the retrospective analysis of the global ARCC trial which evaluated temsirolimus in both clear cell and non-clear cell patients. In fact, this is one of the only phase III trials that included patients with non-clear cell histologies. Tyrosine kinase inhibitors (TKls) (sunitinib, sorafenib) have been shown to have some effect In phase II trials In non-clear cell patients and are both are a category 2A recommendation by the NCCN pa nel. There are ongoing trials examining the potential benefits of pazopanlb and aXltlnlb as flrst-time therapies in non-clear cell patients, but data are limited and both drugs receive a category 2A recommendation based on extrapolation of results from other TKls. Bevaclzumab has been studied in a small phase II study of papillary renal cell carcinoma patients but the study was closed early due to slow accrual. The NCCN guideline panel has provided a category 2A recommendation for bevacizumab in these patients. The use of cytoklne therapies (IFN-50 and IL-2) have not been shown to have significant benefits in non-clear cell patients. In the aforementioned ARCC tnal, temslrolimus was compared to interferon-alpha. Overall survival was significantly better in the temsirolimus subgroup, thereby, justifying the recommendation of temslrolimus. Interferon is not recommended by the NCCN panel

Question 113

The antibiotic of choice for a three-week-old girl with a febrile UTI and mild jaundice is: 1. ampicillin 2. ceftriaxone 3. trimethoprim-sulfamethoxazole 4. nitrofurantoin 5. ciprofloxacin.

Answer 113

1 Neonates and young infants should be covered for enterococcus species when choosing empiric antibiotics since the inCidence of infections with this uropathogen is higher in early Infancy than at a later age. Enterococcus is frequently sensitive to ampicillin and first generation cephalosponns. Ceftnaxone and trimethoprim-sulfamethoxazole are specifically contraindicated In neonates With Jaundice. Nitrofurantoin would not provide systemic treatment and IS both contraindicated In Infants with jaundice and in infants less than one month of age due to an Increased nsk for hemolytic anemia arising from the interactions of an immature liver and the medication. Ciprofloxacin typically would not cover the most common infectingorganism, enterococcus, and is contraindicated in this age group.

Question 114

A 25-year-old man is referred from the drug and alcohol rehabilitation center. He complains of severe diurnal and nocturnal urinary urgency, frequency, and intermittent gross hematuria. Urine culture is negative. CT urogram reveals a small thick-walled bladder but is otherwise unremarkable. Cystoscopy reveals multiple glomerulation s and petechial hemorrhages and no Hunner's lesions. Bladder biopsy shows severe inflammation and epithelial denudation. The most likely etiology is: 1. ketamine abuse 2. genitourinary tuberculosis 3. malacoplakia 4. herpes simplex virus 5. cytomegalovirus.

Answer 114

1 Ketamine is a tranquilizer that will induce a trance-like state while providing pain relief, sedation, and memory loss. Heart rate, respiratory function, and airway reflexes will remain functional. Ketamine is most commonly used for pain relief In emergency rooms and intensive care units and/or sedation at the time of anesthetic Induction. Beginning in the late 1990's, it has gained popularity as a street drug and has quickly outgrown heroin and methamphetamine as the drug of choice in many parts of the world due to ItS low cost and easy accessibility. Ketamine has joined the ranks of PCP, Ecstasy (MDMA), GHB (Gamma Hydroxybutyrate), and Rohypnol as popular club drugs. It is frequently mixed with Rhobypnol or GHB to create the "date rape" drug. Ketamine, when used alone, will give a floating out of the body sensation combined with a mild hallucinogenic effect. Within the US, 1-2% of individuals \< 21 years of age admit to having tried ketamine and 10% of these individuals will become habitual users. Ketamine is currently the leading street drug used In Hong Kong and other parts of Asia. Indeed, drug and alcohol rehabilitation clinics within Hong Kong and other select Asian locations have found up to 80% of the individuals admitted for rehabilitation to be abusing the medication. Urologists should be aware that the chronic of ketamine will induce ketamine cystitis. Symptoms, cystoscopic, and biopsy findings are highly cansistent with n.on-Hunner's interstitial cystitis, and w/o the proper history, distinctian between the two diagnoses is almost impossible. Ketamlne cystitis will usually lead to a severely fibrotic end-stage bladder that will result In the need for cystectomy. There are, however, successful cases where the fibrosis has been halted or reversed by the use of intravesical chondroitin sulphate or hyaluronic acid. Tuberculosls of the bladder occurs secondary to tuberculosis of the kidney, and, therefare, upper tract abnormalities would be expected on CT scan. Malacaplakia typically manifests as mucosal plaques or nodules with bladder biopsy demonstrating Michaelis-Gutman bodies. HSV causes painful ulcers of the genltaha typically with aut bladder invalvement. CMV may cause hematuria and urinary symptams but only in immunacampromised individuals.

Question 115

A 25-year-old woman has mild abdominal pain and distension two weeks after left laparoscopic donor nephrectomy. She is afebrile with normal vital signs. CT scan is shown. Paracentesis is most likely to show elevated: 1. bacteria 2. RBCs 3. creatinine 4. triglycerides 5. amylase.

Answer 115

4 The clinical presentatian and CT scan is highly consistent with chylous ascites. Patients with postoperative chylous ascites classically have abdominal distention wlthout significant pain or fevers and will have normal bowel habits. This complication results from disruption of the major para-aortic lymphatics channels leading to the cisterna chyli and is predominantly noted after left-sided procedures (i.e. , radical and donar nephrectomy) or retroperltoneal Iymphadenectamy. Chylous ascites is diagnosed by paracentesIs with ascitic fluid found to have classically white and turbid appearence with fluid analysIs showlng elevated Iymphocytes, associated with a high cholesterol and triglyceride content. Initial treatment is to reduce the flow of chyle into the lymphatics by a low-fat medium-chain triglyceride diet. If chylous ascites persist despite dietary management, the next step should involve bowel rest and the institution of total parenteral nutrition with the concurrent use of octreatide, a somatastatin analog. Somatostatin has been documented to significantly decrease postprandial increases in triglyceride levels by inhibiting lymphatic flow. Open or laparoscopic treatment of chylous ascites, using suture ligatian and fibrin glue to control the leak, can be pursued if conservative management fails. Intraoperative locatian of the lymphatic leakage can be challenging and the combined use of preoperative lymphangiography and consumption of "fatty" meal immediately before surgery has been documented to be beneficial in helping the surgeon locate the site of the leak

Question 116

A 68-year-old ma with history of superficial bladder cancer develops a severe anaphylactic\_ reaction while undergoing surveillance flexible cystoscopy. The most llikely causative agent is: 1. glutaraldehyde 2. ortho-phthalaldehyde (OPA) 3. peracetic acid 4. hydrogen peroxide 5. ethylene oxide.

Answer 116

2 All of the substances listed may be used to disinfect flexible cystoscopies. Orthaphthalaldehyde (OPA), however, is the only one associated with anaphylactic reaction followlng repeated patient exposure. Consequently, it is recommended that OPA not be used to sterilize cystoscopies in patients requiring repetitive cystoscopy such as a patient with a hx of bladder cancer.

Question 117

A 43-year-old w?man wi\_th autosomal dominant polycystic kidney disease has fever and _ left flank par n. She r s treated with ciprofloxacin but after four days she remains fbrrle. A CT scan deonstrates that one of the cysts in the left kidney is 7 cm in diameter an? \_has.a thickened wall which enhances after contrast administration. Herserum cratr nrne rs 1.2 mg/di and her current urinalysis is within normal limits. The next step rs: 1. continue treatment 2. add gentamicin 3. add vancomycin 4. percutaneous cyst drainage 5. partial nephrectomy.

Answer 117

4 Patients with ADPKD can develop cyst infections. Signs and symptoms may include fever and flank or abdominal pain with normal UA and sterile urine cultures. Therapy with lipid soluble antibiotics such as a fluoroquinolone agent is indicated If this dlagnosls is suspected. Patients should defervesce within 72 hrs. Persistent symptoms should prompt an abdaminal CT scan to seek for infected cysts. Studies have shown that symptomatic infected cysts are typically larger than neighboring cysts, have thickened walls, are of higher attenuatian, and enhance after contrast administration. This patient has not responded to appropriate antibiotic therapy. Therefore, the cyst should be drained and a percutaneaus approach is preferred. Partial or simple nephrectamy is not indicated nor are additional antibiotics. A tagged indium-111 WBC scan can help lacalize theinfection in patients without a dominant infected appearing cyst an CT scan.

Question 118

A 35-year-old paraplegic man on CIC is referred for recurrent UTls. Review of the patient history reveals that these are asymptomatic in nature and diagnosed by the family physician obtaining intermittent urine cultures. All cultures are positive for E. coli. CT urogram and cystoscopy are unremarkable. The next step is: 1. observation 2. change to antibiotic-coated catheters 3. sterile CIC 4. suppressive antibiotics 5. gentamicin bladder irrigation.

Answer 118

1 The finding of asymptomatic bacteriuria in patients an CIC has been reparted to occur in up to 50% of individuals. Treatment in asymptomatic individuals is not required; in fact, treatment will predispose these patients to develop resistant organisms and significantly increases the risk for C. diff colitis. Changing to antibiotic coated catheters or sterie CIC are not indicated in this setting.

Question 119

A 44-year-old woman with an lnterStim 11™, sacral neuromodulation device, needs to undergo an MRI scan of the brain. The next step is: 1. proceed with MRI scan 2. reprogram battery to MRI compatible setting 3. remove lead 4. remove battery 5. remove lead and battery.

Answer 119

1 Performance of an MRI scan in patients with a sacral neuromodulation device in-situ has been considered to be a potential hazard secondary to the interaction of the MRI magnet with the metal leads or implanted pulse generator (IPG). Specifically, there. IS concern that this interaction could result in tissue damage arising from motion, dislocation or torquing of the implanted pulse generator (IPG), heating of the leads, and/or permanent damage to the IPG. In April 20.12 , the FDA approved the use of head (brain) MRI scans In patients implanted with the newer (InterStim II) lPG, the latter stimulation device has been In use since 2007. Since a head MRI scan is needed, this patient can proceed with the MRI scan. The MD should be aware that an FDA warning still exists regarding performing an MRI scan of the spine In the setting of an implanted neurostim device and removal of the sacral neuromodulatlon device maybe requested by the radiologist prior to performing the study. However, multiple studies currently exist that document that a 1.5 Tesla MRI scan of the spine may be safely performed provided the sacral neuromodulation is out of the isocenter of the MRI scanner (remote site). To date, multiple patients positioned with the IPG outside of the magnet bore have undergone remote site MRI with minimal or no complications reported In 97% of the patients. Complications, when they occurred, were device-related problems, such as malfunction or failure, with minimal to no patient-related problems. Most radiologists now consider remote site MRI scan of the spine to be a safe option following implantation of an InterStlm II deVice.

Question 120

A 78-year-old man undergoes an artificial urinary sphincter for severe stress urinary incontinence following radical prostatectomy and adjuvant radiation treatment for prostate cancer. He has a 4 cm cuff placed around the distal bulbar urethra. The riskfactor which places him at highest risk for urethral erosion is: 1. age 2. cuff size 3. cuff location 4. pelvic radiation exposure 5. history of radical prostatectomy.

Answer 120

4 Urethral erosion is a devastating complication of artificial urinary sphincter (AUS) placement which requires explantation. Patients classified as high risk for cuff erosion following AUS placement are defined as patients that have undergone: radiation therapy, a prior urethroplasty, multiple endoscopic treatments for bladder neck contracture or urethral stricture prior urethral stent placement, or have a history of erosion or infection in a previous AUS: There is also a much lower but still significant increased risk of erosion with a prolonged postoperative cathetenzatlon Interval (\> 48 hours), or use of either a 3.5 cm or transcorporal cuff compared to a standard 4 cm cuff. No increased risk of erosion has been found related to age, proximal or distal bulbar urethral placement of the AUS, or prior radical prostatectomy.

Question 121

A significant limitation of CT imaging for renal trauma is an inability to fully assess a: 1. renal pelvis injury 2. renal vein injury 3. renal artery injury 4. parenchymal laceration \< 1 cm 5. renal contusion.

Answer 121

2 CT scan remains the gold standard for radiologic staging of renal trauma. One major limitation of CT scan, however, is the inability to define a renal venous injury adequately. A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury. A renal contusion is defined as normal urologic imaging with the presence of hematUria. Parenchymal lacerations are clearly defined, and extravasation of contrast-enhanced urine can easily be detected which has led to an enhanced ability to manage many injuries non-operatively. Repeated/delayed scanning of the kidneys ten minutes after injection of contrast identifies parenchymal lacerations and urinary extravasation accurately and reliably. It is important to note that ureteral injuries can be difficult to diagnose on CT scan. If the urinary extravasation from the ureteral injury is contained by Gerota's fascia, the extent of medial leakage can be minimal. It is also known that ureteral injuries do not show contrast in the ureter on delayed images. Tracing both ureters throughout their entire course on a CT scan is mandatory to fully evaluate urogenital injuries. Delayed images should be obtained 5 to 20. minutes after contrast injection to allow contrast to extravasate from the collecting system injury.

Question 122

An FDA approved clinical trial for placement of a sacral nerve stimulation device, exists for which clinical scenario: 1. medication resistant urinary incontinence secondary to multiple scleros is 2. bladder underactivity following a spinal cord injury 3. bladder underactivity following pelvic surgery such as a low anterior resectionor hysterectomy 4. chronic prostatitis - pelvic pain failing traditional treatment modalities 5. medical refractory urinary and fecal incontinence associated with spina bifida.

Answer 122

4 Sacral nerve stimulation (SNS) has FDA approval for treatment of: non-obstructive urinary retention , urinary urge incontinence, urinary urgency-frequency syndrome, and for the GI indication of chronic fecal incontinence. Clinical trials are ongoing for its use ininterstitial cystitis, chronic prostatitis (i.e., chronic pelvic pain), and idiopathic constipation failing traditional treatment modalities. It has not been cleared by the FDA to be used In patients with urologic or gastrointestinal symptoms arising from a known neuropathy, such as multiple sclerosis, Parkinson's disease, a congenital neuropathic anomaly, post-traumatic spinal cord injury, and/or pelvic nerve injury arising from pelvic surgery.

Question 123

A 48-year-old man has undergone extensive penile skin debridement secondary to Fournier's gangrene. Reconstruction for the penile shaft should include the use of a(n): 1. local skin flap 2. meshed split thickness skin graft 3. unmeshed split thickness skin graft 4. meshed full thickness skin graft 5. unmeshed full thickness skin graft.

Answer 123

3 The highest probability of 100% graft take and best cosmetic results occur with penile skin reconstruction using an unmeshed thick (0.012 - 0.015 inch) split thickness skin (STS) graft. Meshed or thinner STS grafts have more of a tendency to contract which compromises penile functionality and cosmesis. Local skin flaps from the abdomen or thigh generally do not produce the same cosmetic outcomes. Full thickness skin grafts may provide adequate cosmesis but are associated with a higher incidence of failure of the graft to take.

Question 124

Prior to surgery for uncomplicated stress incontinence in women , urodynamics is: 1. necessary for all patients having sling surgery 2. useful in determining which type of sling procedure (transobturator versus retropubic) to perform 3. useful in determining prognosis following sling surgery 4. able to determine prognosis following an autologous fascia sling only 5. no better than a basic office evaluation in determining surgical outcomes.

Answer 124

5 The VALUE trial assessed the utility of urodynamics versus basic office evaluation in the uncomplicated patient with stress incontinence (SUI). Uncomplicated patients with SUI are those with demonstrable SUI on physical exam, no overactive bladder symptoms, normal bladder emptying, no prior surgery for SUI , and no signs, symptoms, or past medical history consistent with a possible neurologic etiology for their urinary incontinence. This study documented that within the uncomplicated patient population, the addition of urodynamlc studies did not improve the surgical outcome following incontinence surgery compared to women who had a basic office evaluation alone. A basic office evaluation includes a pelvic exam with supine stress test with a full bladder, assessment of PVR, and UA.

Question 125

While mobilizing the spleen during a left laparoscop ic adrenalectomy, a 1.5 cm diaphragmatic injury is noted with entry into the pleural cavity. The patient remains hemodynamically stable. The next step is: 1. pack defect, decrease insufflation pressure , and continue operation 2. place chest tube in the second anterior intercostal space and continue operation 3. repair diaphragm laparoscopically, aspirate pleural cavity, and continue operation 4. continue procedure and repair diaphragm through specimen extraction site 5. convert to open surgery, repair diaphragm, and complete adrenalectomy .

Answer 125

3 Diaphragmatic injury is a rare complication of laparoscopic upper tract urinary surgery. It is important to note that this injury has occurred early in the operation in a stable patient. The injury is large enough that it must be repaired and placement of a chest tube to vent the pleural cavity alone would be Inadequate treatment and could result in persistent loss of the pneumoperitoneum and/or inadequate pulmonary re-expansion. There is no need for open conversion; the injury can be repaired laparoscopically with aspiration of air from the pleural cavity and continuation of the .operation. Placement of a chest tube is not routinely necessary following surgical repair. Packing the diaphragmatic injury or repairing the injury at the end of the operation risks continued filling of the pleural cavity with carbon dioxide leading to poor ventilation and high peak airway pressures.

Question 126

While using an argon beam electrocoagulator during a laparoscopic partial nephrectomy, poor tidal volumes are noted. The next step is: 1. obtain deeper sedation 2. increase ventilation rate 3. add positive end-expiratory pressure (PEEP) 4. decrease C02 insufflation flow rate 5. release pneumoperitoneum

Answer 126

5 During use of the argon beam electrocoagulator in a laparoscopic setting, it is important to "vent" from one of the trocar side arm ports during its use in order to avoid over-pressurizing the abdomen with the infused argon gas. If unrecognized, this can cause an abrupt increase in intra-abdominal pressure and eventual compromise of ventilation. All other listed maneuvers and ventilatory changes would not address the primary problem of increased intraperitoneal pressure.

Question 127

When compared to women undergoing a retropubic mid-urethral sling, women undergoing transobturator slings are more likely to experience: 1. improved continence 2. UTls 3. urinary retention 4. bladder perforations 5. neurologic complications.

Answer 127

5 The TOMUS trial compared the outcomes of retropubic sling to transobturator mid-urethral slings for treatment of stress urinary incontinence. In the original trial, success rates were statistically equivalent between the two groups. However, in long-term analysis (one versus five years), several differences were noted. Specifically, transobturator sling patients were more likely to manifest neurologic complications. It is believed these complications arose due to injury of small nerve branches from either the pudendal or obturator nerves occurring either at the time of trocar passage or alternatively due to long-term compression of the nerves from the obturator sling. Transobturator slings were also statistica lly less effective in preventing long-term urinary incontinence compared to retropubic urethral slings. Patients undergoing a retropubic urethral sling, however, had more bladder dysfunction, including higher postvoid residual urines, increased incidence of recurrent UTls, and increased risk of delayed sling erosion into the bladder compared to patients undergoing a transobturator sling

Question 128

A ten-month-old boy has persistent right hydroureteronephrosis with a negative VCUG. The right kidney contributes 35% of the total renal function and the T 1/2 is 30 minutes on MAG-3 renal scan after diuretic. The next step is antibiotic prophylaxis and: 1. observation with repeat MAG-3 diuretic scan in one year 2. percutaneous nephrostomy 3. creation of a freely refluxing ureterovesical junction 4. distal end cutaneous ureterostomy 5. tapered ureteral reimplantation.

Answer 128

5 This child has a primary obstructive megaureter associated with diminished renal function. Although many children with a primary obstructive megaureter will show gradual progressive improvement in the degree of dilation and rapidity of washout with age, the decision to observe without surgical intervention is dependent upon the renal function and the absence of symptoms. In the presence of significantly impaired function (differential function of \< 40%), surgical intervention is indicated. Since the child is otherwise healthy and uninfected, primary reconstruction with a tapered ureteral reimplantation is the method of choice. Temporary diversion by a distal cutaneous ureterostomy or alternatively creation of a widely refluxing ureterovesical junction may be considered in the presence of extremely poor renal function and or a premature or young, less than six- to eight-month-old infant, where a tapered reimplantation may be technically challenging. Placement of a percutaneous nephrostomy tube is mainly used in the severely ill infant with a severe urinary infection who is not responding to parenteral antibacterials.

Question 129

A 71-year-old woman has persistent bothersome stress incontinence six months following a transobturator mid-urethral sling. Videourodynamics show a Valsalva LPP of 55 cm H20 with minimal urethral mobility and an open bladder neck at rest. The next step is: 1. neurology evaluation 2. Kegel exercises 3. radiofrequency of bladder neck suspension 4. autologous fascia sling 5. artificial urinary sphincter.

Answer 129

4 This patient has minimal urethral mobility with stress maneuvers and a low abdominal LPP consistent with intrinsic sphincter deficiency (LPP \< 60 cm H20). The treatment of choice with persistent incontinence secondary to intrinsic sphincter deficiency following a failed sling procedure is placement of an autologous rectus fascia sling. In and of itself, the postoperative findings of an open bladder neck on a videourodynamic study is not suggestive of a neurologic disorder (such as Shy-Drager syndrome). A neurologic consultation is, therefore, not indicated unless concurrent neurologic findings are present. Kegel exercises in a postoperative patient with these urodynamic findings would be of extremely limited benefit. Radiofrequency bladder neck suspension has not been shown to be of significant benefit in patients with recurrent stress incontinence following surgical repair and/or in patients with intrinsic sphincter deficiency (Valsalva LPP \< 60 cm H20). Artificial urinary sphincter placement may beconsidered an option but should be considered only after the patient had failed an autologous fascial sling.

Question 130

A 55-year-o ld woman with multiple sclerosis has worsening urinary incontinence threeweeks after undergoing an onabotulinumtoxinA injection. The next step is: 1. start an antimuscarinic 2. obtain a PVR 3. perform a complete urodynamic study 4. repeat onabotulinumtoxinA with higher dose 5. initiate sacral neuromodulation.

Answer 130

2 Approximately 5% of patients undergoing bladder onabotulinumtoxinA injections may develop urinary retention. Accordingly, patients with worsening urinary incontinence post-injection should undergo a PVR assessment to rule-out overflow incontinence. Antimuscarinics would not be advisable if her residual were high. Urodynamics would be premature at this early stage after injection. Repeating onabotulinumtoxinA injections may be an option at some point if she is not retaining urine. Sacral neuromodulation, wh ile an option, is not recommended in the presence of known neurologic conditions and would only be considered after an elevated residual has been ruled-out.

Question 131

A healthy 26-year-old man undergoes urethroplasty with buccal mucosa for a 5 cm bulbar urethral stricture. The most common form of sexual dysfunction he may experience postoperatively is: 1. loss of libido 2. erectile dysfunction 3. ejaculatory dysfunction 4. anorgasmia 5. penile curvature.

Answer 131

3 Permanent ejaculatory dysfunction may occur in as high as 20% of men following urethroplasty. Complaints are usually related to pooling of semen within the urethra and/or loss of force with ejaculation. The etiology is poorly defined but is presumed to be due to either tortuosity of the neourethra and/or dysfunction of the bulbocavernosal muscle. Temporary erectile dysfunction is found in up to 20% of individuals undergoing an anterior urethroplasty. This incidence is similar between all types of anterior urethroplasties, e.g., excision and primary anastomosis, vascularized or graft urethroplasties. The erecti le dysfunction symptoms classically resolve within six months with \< 3-4% of patients reporting a permanent alteration in their erectile capabilities. New onset of penile curvature may occur usually following an overaggressive attempt at excision and primary anastomosis performed in the distal bulbar region. Loss of libido and anorgasmia are very rare complaints following urethroplasty and are predominately due to a psychological component.

Question 132

Treatment with tadalafil 5 mg daily for the signs and symptoms of BPH and erectile dysfunction may result in improvements in: 1. urinary flow rates and International Prostate Symptom Score (IPSS) 2. urinary flow rates and International Index of Erectile Function (llEF) 3. IPSS and llEF score 4. IPSS if baseline evaluation score is \> 18 5. llEF if baseline evaluation score is \< 12.

Answer 132

3 Daily tadalafil is FDA approved for the signs and symptoms of BPH and erectile dysfunction. Improvements may be seen with both erectile dysfunction and urinary symptom scores such as the International Prostate Symptom Score (IPSS). Use of once daily tadalafil (or other phosphodiesterase inhibitors) does not improve urinary flow rates. There is no evidence that a certain degree of baseline bother, as measured by the IPSS or International Index of Erectile Function (liEF), are necessary to predict success with this therapy. In addition, there is evidence that suggests that combination therapy with phosphodiesterase inhibitors and alphablockers work together synergistically; however, this combination may also result in symptomatic hypotension . Phosphodiesterase inhibitors are not presently part of the AUA Guidelines for the Management of BPH.

Question 133

A 31-year-old man desires a biological child. His physical exam is normal with 30 ml testes. He is azoospermic and has a semen volume of 3.5 ml with a pH of 7.6 . His FSH is 3.6 IU/1. The next step is: 1. clomiphene citrate 2. seminal fructose level 3. post-ejaculate urine 4. transrectal ultrasound 5. testicular biopsy with sperm retrieval.

Answer 133

5 This patient has normal seminal volume and normal seminal pH. This rules out ejaculatory duct obstruction or congenital bilateral absence of the vas (CBAVD) which are both associated with low volume, acidic semen specimens. A low normal FSH of 3.6 mlU/ml indicates spermatogenesis is likely intact and that obstructive azoospermia is present. A testicular biopsy is warranted during which sperm retrieval and cryopreservation should be considered . If the testicular biopsy is normal , then a post-testicular obstruction is present and either an epididymovasostomy or a vasovasostomy can be performed at the time of biopsy. Clomiphene will increase serum FSH but will not correct obstructive azoospermia. Seminal fructose is absent in ejaculatory duct obstruction or CBAVD. A transrectal ultrasound is not indicated because seminal volume is normal. Post-ejaculate urine analyses are useful in cases of low volume semen specimens or cases with dry ejaculates to rule out retrograde ejaculation.

Question 134

A 67-year-old man has erectile dysfunction after a myocardial infarction four months ago. He has retinitis pigmentosa and takes clopidogrel (Plavix). His testosterone is 195 ng/dl. The next step is: 1. sildenafil 100 mg on demand 2. daily tadalafil 5 mg 3. daily testosterone gel 4. intracavernous prostaglandin injection 5. intraurethral alprostadil suppository.

Answer 134

5 An FDA warning exists that recommends against the use of phosphodiesterase type 5 inhibitors in patients with a recent history of a myocardial infarction (less than six months) and in patients with known hereditary degenerative retinal disorders such as retinitis pigmentosa. Thus the use of tadalafil or sildenafil in this patient would not be advised. Testosterone therapy is not considered first-line therapy for erectile dysfunction. Intracavernous injection is relatively contraindicated in men with a history of coagulopathy (c lopidogrel) or unstable cardiovascular disease and thus would not be a good option for this patient. The best option for this patient would be intraurethral alprostadil suppository.

Question 135

A 43-year-old asymptomat ic woman returns three days after an uncomplicated outpatient vaginal sling surgery with a vaginal pack still in place. The next step is to administer 1. IV antibiotics 2. call your malpractice insurer 3. notify the insurer of the outpatient surgical center 4. notify Joint Commission of Health (JCAHO) 5. report as a SERS (serious event reporting system) event.

Answer 135

5 Retention of vaginal packs for \> 24 hours post-surgery does place the patient at risk for toxic shock syndrome, however, antibiotic therapy is not indicated in an asymptomatic patient. In the clinical situation described, treatment should be with outpatient observation of the individual and with notification of the hospital SERS (Serious Event Reviews System) program. This system will review the process by which this complication occurred and recommend steps to prevent its recurrence. The Joint Commission on the Accreditation of Health Care Organizations (JCAHC) is a national association existing since 1951 that accredits and certifies more than 20,000 health care organizations and programs in the United States. Commission accreditation and certification is performed to verify that the health care organization undergoing review meets or exceeds current national standards of care, and is recognized nationwide as a symbol of quality. Accreditation is necessary for financial reimbursement of the institution by select insurers and other third parties and may be required in select states to care for patients. JACHO recognizes and rewards hospitals for running quality improvement projects, such as SERS, but does not establish or maintain the quality improve project; the latter is a function of the individual hospital or surgical center involved. There is no need to notify your malpractice insurer or the insurer of the outpatient surgical center regarding this finding unless a serious consequence of its action should occur or comments from the patient are a concern.

Question 136

A 63-year-old man with idiopathic thrombocytopeni c purpura (ITP) requires pelvic exenteration. His platelet count prior to surgery was 50,000/cu mm. Venous thromboembo lic prophylaxis should consist of: 1. oral low dose aspirin 2. oral warfarin 3. oral pentoxifylline (Trental™) 4. subcutaneous heparin 5. subcutaneous enoxaparin (Lovenox™).

Answer 136

4 This patient is at high risk for venous thromboembolic event (VTE) because of his cancer diagnosis, age, surgery, and prolonged immobility. Thus, guidelines indicate the need for full precautions. His idiopathic thrombocytopenic purpura may put him at increased risk of perioperative bleeding, but does not protect him from the risk of VTE. Thus, subcutaneous heparin is the standard prophylaxis, although it should be used cautiously in patients with severe thrombocytopenia. Enoxaparin should be used only with extreme caution in patients with thrombocytopenia. In either case, close monitoring of the platelet count is indicated to detect any heparin-induced thrombocytopenia. Warfarin does not provide immediate protection, and is, therefore, reserved for long-term anticoagulation. Pentoxifylline has not been shown to prevent VTE.

Question 137

Radiofrequency renal artery denervat ion for the treatment of medically refractory hypertension causes a(n): 1. increase in plasma renin activity 2. decrease in renal blood flow 3. increase in renal efferent arterial tone 4. decrease in sympathetic activity 5. increase in parasympathetic activity.

Answer 137

4 Endovascular radiofrequency ablation (RFA) of the renal artery results in destruction of the renal sympathetics and is being increasingly utilized for management of pharmacologically resistant HTN. Sympathetic innervation to the kidneys run in the adventitial wall of the renal arteries. Stimulation of the renal sympathetics results in a decrease in renal blood flow, an increase in renin secretion, retention of sodium and water, and HTN. Circumferential RFA of the renal sympathetics occurs by introduction of a 6 Fr catheter by the femoral vein; the therapeutic catheter has a steerable tip and is connected to a console that delivers radiofrequency energy. The level of energy delivered is monitored with a sensor at the tip of the catheter so that excessive tissue injury is avoided . Ablation of the renal sympathetics results in dilation of the renal efferent arteries, decreased plasma renin activity, and increased renal blood flow. In addition, it is postulated that renal artery sympathetic ablation results in stimulating an inhibitory regulatory feedback mechanism that decreases the overall sympathetic outflow. Renal artery RFA has no effect on parasympathetic nerve activity. It has been associated with rare intimal dissections of the renal artery and renal artery aneurysms that may require emergent nephrectomy.

Question 138

A 45-year-old man with a T6 spinal cord injury managed with an indwelling urethral catheter is diagnosed with a 6 cm T2 high grade urothelial carcinoma with squamous differentiation . The tumor is located near the dome and random biopsies are negative. The metastatic evaluation is negative. The next step is: 1. partial cystectomy 2. cisplatin-based neoadjuvant chemotherapy 3. AdriamycinTM based neoadjuvant chemotherapy 4. chemotherapy and XRT 5. radical cystoprostatectomy.

Answer 138

2 A recent secondary analysis of the SWOG neoadjuvant chemotherapy trial testing M-VAC followed by cystectomy vs. cystectomy alone for muscle invasive bladder cancer showed that the survival benefit to chemotherapy in patients with mixed histology including squamous or glandular differentiation was actually superior to that seen in patients with pure urothelial cancer. Partial cystectomy is not appropriate for large urothelial carcinomas regardless of their location. Radical cystoprostatectomy and ileal conduit will be appropriate after chemotherapy or if the patient cannot safely have chemotherapy due to comorbidities or other constraints such as poor renal function. Adriamycin-based chemotherapy is used for pure squamous cell carcinoma of other primary sites but has no role in urothelial carcinoma. Chemotherapy and XRT are not preferred in a patient that is otherwise a surg ical candidate. If the patient had pure squamous cell carcinoma, immediate radical cystoprostatectomy would be appropriate.

Question 139

A 47-year-old man has a dorsal penile nodule for three months. There is a painful hourglass deformity upon erection. The next step is: 1. anti-inflammatories 2. vacuum erection device 3. intra-lesional collagenase 4. ESWL of penile plaque 5. plaque incision and grafting.

Answer 139

1 This patient is currently in the active phase of Peyronie's disease. The vacuum erection device and the penile traction device have not been adequately studied as primary treatment therapies dUring the acute phase of this disorder and should not be recommended at this time. The role of ESWL to treat Peyronie's disease has been shown to decrease penile pain but does not sign ificantly Improve the penile curvature or resolve the hourglass deformity. Intraleslonal collagenase IS recommended to be used in patients in the active phase and with patients with a minimum of 30 degree curvature. Collagenase has not however been tested in patients with an hourglass deformity. Incision and grafting or plication should only be performed in patients in the quiescent phase. The best option at this time is anti-inflammatories and observation.

Question 140

A 38-year-old man develops a 5 mm ureteral stricture overlying the iliac vessels six months following ureteroscopy and stone basketing. The next step is: 1. retrograde balloon dilation 2. percutaneous nephrostomy and antegrade balloon dilation 3. ureteroscopic endoureterotomy 4. ureteroureterostomy 5. ureteral reimplantation with psoas hitch.

Answer 140

3 The best management for ureteral strictures less than 2 cm with no previous intervention is an endoscopic approach. Balloon di lation has been reported with some short-term success but long-term outcomes are unfavorable. Should balloon dilation fail , a much longer stricture may develop requiring more invasive intervention. Ureteroscopic ureterotomy, such as with laser incision, provides a more durable long-term outcome. Care must be taken to place the endoureterotomy incision away from the iliac vessels medially (anteromedial incision). Cautery wire IncIsion does not offer any advantage over ureteroscopic endoureterotomy, and ureteroureterostomy is reserved for recurrent ureteral strictures or strictures \> 2 cm upon presentation.

Question 141

One da-X following his first injection of his first cycle of .intra-lesioal cllagenase (Xiaflex M) for Peyronie's disease, a 54-year-old-man experiences penile pain, edema, and ecchymosis after sex. The next step is: 1. anti-inflammatory 2. pressure dressing 3. delay the second collagenase injection to greater than 72 hours 4. cystoscopy 5. penile exploration.

Answer 141

5 A known complication of intra-Iesional collagenase is a penile fracture. Thus, patients are advised not to engage in sexual activity for two weeks after the injection in order to mitigate the risk of penile fracture. In this case, it is highly likely that he has experienced a penile fracture and he should be surgically explored. A cystoscopy would be warranted at the time of penile exploration to rule out a concurrent urethral injury. Delaying the second injection to \> 72 hours, using anti-inflammatories or applying a pressure dressing, would be appropriate if the penile pain would have occurred following the injection only, but wou ld not be the best option in treating a patient who developed symptoms during or following coitus.

Question 142

An antibiotic is being studied to test its ability to prevent UTI. The binary outcome measurement is the development of a UTI. Analysis of this binary variable would not include: 1. t-tests 2. chi-square 3. Fisher's exact test 4. logistic regression 5. point-biserial correlation.

Answer 142

1 T-tests as well as analysis of variance, correlation coefficients, and linear multiple regression are used to compare results of a dependent variable that is measured as a continuous variable. These tests can compare groups that have means and standard deviations. When the dependent variable is measured as a binary variable, then statistics such as the frequency are able to be determined, but means and standard deviations or variance are not. In that case, the types of statistical procedures used are chi-square, Fisher's exact test, point-biserial correlation coefficients, and logistic regression.

Question 143

A seven-year-old boy with two 5 mm renal pelvis stones undergoes ureteroscopy and basket extract ion of one stone. During reinsertion of the ureteroscope, a small ureteral perforation is identified. The next step is: 1. remove ureteroscope and stop operation 2. placement of a ureteral stent 3. basket extraction of remaining stone and stent placement 4. fragment stone into 1 mm fragments and stent placement 5. stent and percutaneous nephrostomy tube placement.

Answer 143

2 Identification of a ureteral perforation is an indication for immediate discontinuation of the procedure and passage of a ureteral stent. Persistence of the operation may lead to further shear force injury on the ureter or extravasation of irrigant or urine. If a ureteral stent is placed, percutaneous drainage is not necessary.

Question 144

A 22-year-old woman with ESRD and spina bifida undergoes pre-op transplant evaluation. Renal bladder ultrasound reveals moderate bilateral HUN associated with a full bladder. VUDS reveals atotal fill poorly-compliant bladder with detrusor pressures of 50 cm H20 at 100 ml, associated with bilateral grade 2 VUR, and end fill detrusor pressure of 85 cm H20 at 280 ml with overflow incontinence. She leaks urine several times a day despite CIC four times daily and obtains 250-300 ml/catheterization . The next step is: 1. proceed with kidney transplant, then re-evaluate bladder 2. bladder augmentation after kidney transplant 3. bladder augmentation prior to kidney transplant 4. bilateral native nephrectomies and augment prior to kidney transp lant 5. recommend against kidney transplant.

Answer 144

3 The patient has poor bladder compliance with bilateral grade 2 VUR, elevated pressures of \> 40 cm at 100 ml, and end fill detrusor pressure with overflow at system LPP of 85 cm at 280 ml. These urodynamic findings are highly suggestive of high detrusor pressures being related to her loss of renal function. She can undergo kidney transplant, however, to reduce risk ofdamage to the transplant, she would be best treated with pre-transplant bladder augmentation. This wou ld lower her detrusor storage pressures and probably minimize or resolve her low grade VUR. It is noteworthy that this patient does not have oliguric renal failure. Poor detrusor compliance is frequently found on a urodynamic study in oliguric or anuric pre-transplant patient due to disuse detrusor atrophy. In the latter patients, the bladder will almost invariably develop normal compliance post-transplant and no preoperative intervention is required. If there is concern that the bladder is really noncompliant in a patient with oligouric renal failure, Individuals may be started on CIC with increasing volumes of fluid placed in the bladder over a series of weeks and the urodynamic study repeated. This patient does not have any of the criteria necessary to consider pre-transplant nephrectomy. Indications for pre-transplant nephrectomy are: renal lithiasis, renal mass, chronic pyelonephritis, uncontrollable HTN, and excessive proteinuria. Occasionally in a patient with ADPKD, a nephrectomy may be performed due to inadequate space for a renal transplant.

Question 145

A healthy 55-year-old woman with rheumatic heart disease and a systolic murmur is about to undergo urodynamic testing. Urinalysis is negative . Appropriate antimicrobial prophylaxis includes : no antimicrobials 2. amoxicillin 3. fluoroquinolone 4. trimethoprim-sulfamethoxazole 5. gentamicin .

Answer 145

1 The American Heart Association does not recommend the administration of prophylactic antibiotics to prevent bacterial endocarditis associated with urodynamic testing or other GU procedures presuming a negative UA and sterile technique. Infectious endocarditis is more likely to result from random bacteremias associated with daily activities than from those caused by GU procedures. Prophylaxis may prevent only a very small number of cases of infectious endocarditis, if any, in individuals undergoing GU procedures. Overall , the risk of antimicrobial-associated adverse events exceeds the benefit from prophylactic antimicrobial therapy so lely to prevent infectious endocarditis in patients undergoing GU procedures.

Question 146

A 67-year-old man with a history of radical prostatectomy , cardiovascular disease, osteoporosis , and diabetes is planning to initiate testosterone therapy. Prior to initiating testosterone therapy, he should be counseled about an increased risk of: 1. myocardial infarction and stroke 2. prostate cancer recurrence 3. insulin resistance 4. anemia 5. osteoporos is progression.

Answer 146

1 Recently, the FDA has issued a warning and label change with testosterone products for the potential increased risk of cardiovascular disease in men taking testosterone. Patients should be counseled on this potential cardiovascular risk prior to starting therapy. Testosterone therapy has been shown to improve insulin resistance and osteoporosis. Patients on testosterone therapy can develop erythrocytosis, not anemia. There is no data to support that testosterone causes prostate cancer or increases incidence of recurrence.

Question 147

The use of fluorescence ("bluelight") cystoscopy has been shown to: 1. decrease utilization of intravesica l therapies 2. decrease progression rates 3. decrease cystectomy rates 4. increase detection of CIS 5. increase tumor detection after BCG.

Answer 147

4 Hexaminolevulinate hydrochloride was approved in the U.S. by the FDA in 2010 as an optical imaging agent indicated for use in the cystoscopic detection of non-muscle invasive bladder cancers. It is used with a cystoscopic photodynamic detection system to perform so-called fluorescent, or "blue light" cystoscopy to aide in the detection of bladder tumors. According to the pivotal phase III North American multicenter trial , fluorescence cystoscopy improved the detection of both CIS and of papillary tumors as compared to conventional white light cystoscopy. As of yet, these pivotal trials have not demonstrated a reduction in progression rates, cystectomy rates, or use of intravesical therapies. Of note, it is contraindicated in patients who have received BCG within 90 days of treatment and , therefore, is not commonly utilized at this time for the tumor detection post-BCG.