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1

What are the following characteristics of testicular torsion?

  • Risk peaks at which age
  • Torsion is usually in which direction
  • Treatment

  • Risk peaks at which age: Peaks in 15 year olds
  • Torsion is usually in which direction: Torsion is usually toward the midline
  • Treatment: Bilateral orchiopexy

 

[UpToDate: Testicular torsion generally presents with the abrupt onset of severe testicular pain. The testis may lie transversely in the scrotum and be retracted, and the cremasteric reflex is typically absent. Doppler ultrasound of the scrotum is a useful adjunct in equivocal cases but should not delay surgical exploration in cases of suspected testicular torsion. Immediate detorsion is required to maintain viability of the testis. In patients suspected with testicular torsion, we recommend immediate surgical exploration rather than manual detorsion (Grade 1B). If surgical treatment is not immediately available, manual detorsion should be performed. Surgical exploration is necessary even after clinically successful manual detorsion because orchiopexy (securing the testicle to the scrotal wall) must be performed to prevent recurrence, and residual torsion may be present that can be further relieved.]

2

What is the most common urinary tract abnormality and what is the treatment?

  • Ureteral duplication
  • Treat with reimplantation if obstruction occurs

3

What are the following characteristics of tumors of the kidney?

  • Most common tumor in the kidney
  • Treatment for transitional cell carcinoma of renal pelvis
  • Syndrome resulting in angiomyolipomas (hamartomas) of the kidney
  • Syndrome resulting in multifocal and recurrent renal cell carcinoma, renal cysts, CNS tumors, and pheochromocytomas

  • Most common tumor in the kidney: Breast cancer metastasis
  • Treatment for transitional cell carcinoma of renal pelvis: Radical nephroureterectomy
  • Syndrome resulting in angiomyolipomas (hamartomas) of the kidney: Tuberous sclerosis
  • Syndrome resulting in multifocal and recurrent renal cell carcinoma, renal cysts, CNS tumors, and pheochromocytomas: Von-Hippel-Lindau syndrome

4

What are the following characteristics of kidney stones?

  • 4 types of kidney stones
  • Most common type of kidney stone
  • Type of kidney stone that can result in Staghorn calculi (fill renal pelvis)
  • Size above which a kidney stone is unlikely to pass spontaneously

 

  • 4 types of kidney stones:  Calcium oxalate, struvite, uric acid, cysteine
  • Most common type of kidney stone: Calcium oxalate (75% of kidney stones)
  • Type of kidney stone that can result in Staghorn calculi (fill renal pelvis): Struvite stones
  • Size above which a kidney stone is unlikely to pass spontaneously: > 6mm is unlikely to pass

5

What are the following characteristics of a testicular mass?

  • Most testicular masses are what (benign or malignant)
  • Lab markers that should be obtained
  • Percent of testicular masses that are germ cell tumors
  • Most likely tumor to occur in the setting of an undescended testicle
  • What is the most common overall testicular tumor

  • Most testicular masses are what (benign or malignant): Malignant
  • Lab markers that should be obtained: LDH (correlates with tumor bulk), B-HCG, AFP
  • Percent of testicular masses that are germ cell tumors: 90%
  • Most likely tumor to occur in the setting of an undescended testicle: Seminoma
  • What is the most common overall testicular tumor: Seminoma

6

What are the following characteristics of renal cell carcinoma?

  • Risk factor
  • Fraction that have metastatic disease at the time of diagnosis
  • Most common location for metastasis
  • Paraneoplastic syndromes of RCC
  • Treatment

  • Risk factor: Smoking
  • Fraction that have metastatic disease at the time of diagnosis: 1/3 (wedge resection of isolated lung or colon metastases can be performed)
  • Most common location for metastasis: Lung
  • Paraneoplastic syndromes of RCC: Erythropoietin, PTHrp, ACTH, insulin
  • Treatment: Radical nephrectomy with regional nodes, XRT, chemotherapy

 

[UpToDate: Data from the SEER registry covering 2005 through 2011 show the extent of disease at presentation of patients with renal cell carcinoma:

  • Localized disease (ie, confined to the kidney) – 65%
  • Regional disease (ie, spread to regional lymph nodes) – 16%
  • Metastatic disease – 16%
  • Unstaged – 3%

In an analysis of over 29,000 cases from the SEER registry, there has been a steady decrease in the size of tumors at presentation. This is likely due to the greater number of incidental tumors detected on abdominal imaging. For example, data from the National Cancer Database showed that the size of stage I tumors decreased from a mean of 4.1 cm in 1993 to 3.6 cm in 2003. Whether all of the asymptomatic RCCs diagnosed through improved imaging are clinically relevant is uncertain.

The five-year survival rate of patients with kidney cancer has doubled over the last 50 years, from 34% in 1954 to 62% in 1996, and to 73% from 2005 to 2011. The incidence of RCC has risen threefold higher than the mortality rate. This improved survival and case-fatality rate is mostly due to earlier detection of these tumors at smaller sizes (ie, <4 cm) and curative surgical treatment.

For patients with a resectable stage I, II, or III renal cell carcinoma (RCC), we recommend surgery as the primary treatment approach. Radical nephrectomy has been the most widely used approach and remains the preferred procedure when there is evidence of invasion into the adrenal, renal vein, or perinephric fat. Partial nephrectomy (either open or laparoscopic) is an alternative for smaller tumors and is particularly valuable in patients with bilateral or multiple lesions, those with inherited syndromes in whom there is an increased risk of an additional subsequent primary tumor, and those with impaired renal function. For elderly patients and those with significant comorbid disease, ablative techniques (cryoablation, radiofrequency ablation) are an alternative.

Advanced clear cell renal cell carcinoma - For patients who have a good performance status and intact organ function, we suggest high-dose interleukin-2 (IL-2) rather than antiangiogenic targeted therapy (Grade 2B). For patients who will be treated with a molecularly targeted agent, we prefer either pazopanib or sunitinib.

Advanced non-clear cell RCC - For patients with non-clear cell RCC, we suggest molecularly targeted therapy rather than chemotherapy (Grade 2C). However, some types of non-clear cell RCC are reported to be chemosensitive (including collecting duct, sarcomatoid, and medullary RCC).]

7

What are the following characteristics of urologic anatomy?

  • Name of fascia surrounding the kidney
  • Arrangement of renal pelvis, vein, and artery from anterior to posterior
  • Position of right renal artery in relation to the IVC
  • Position of left renal vein in relation to the aorta
  • Position of the ureters in relation to the iliac vessels

  • Name of fascia surrounding the kidney: Gerota's fascia
  • Arrangement of renal pelvis, vein, and artery from anterior to posterior: Vein, artery, pelvis
  • Position of right renal artery in relation to the IVC: Posterior to IVC
  • Position of left renal vein in relation to the aorta: Anterior to aorta
  • Position of the ureters in relation to the iliac vessels: Anterior to iliac vessels

8

What is post-TURP (transurethral resection of the prostate) syndrome?

  • Hyponatremia secondary to irrigation with water
  • Can precipitate seizures from cerebral edema
  • Treat with careful correction of Na with diuresis

 

[Most patients who have TURP have retrograde ejaculation.]

9

What are the following characteristics of testicular seminomas?

  • Percent that have B-HCG elevation
  • Affect on AFP level
  • Sensitivity to XRT
  • Treatment

  • Percent that have B-HCG elevation: 10%
  • Affect on AFP level: Should not be elevated
  • Sensitivity to XRT: Extremely sensitive
  • Treatment: Orchiectomy and retroperitoneal XRT

 

[Chemo reserved for metastatic disease or bulky retroperitoneal disease (Cisplatin, bleomycin, Etoposide {VP-16}).]

 

[UpToDate: For patients with stage I seminoma, orchiectomy is usually curative. For patients who are able to comply with follow-up, we suggest active surveillance rather than chemotherapy or adjuvant radiation therapy (RT). Given the excellent prognosis, active surveillance minimizes the risks of treatment-associated morbidity.

For men who refuse active surveillance and for those who want more aggressive treatment despite their excellent prognosis, we suggest one or two cycles of single-agent carboplatin (dosed at an area under the concentration x time curve [AUC] of 7) rather than adjuvant RT. Single-agent carboplatin is well tolerated and as effective as adjuvant RT in preventing relapse. It is also associated with less morbidity, including lower risks of impaired fertility, second malignancy, or late cardiac disease.

For men who refuse active surveillance and are not candidates for chemotherapy, we suggest adjuvant RT.

Stage II seminoma — Following orchiectomy, the optimal treatment for stage II disease depends upon the extent of lymph node involvement.

Stage IIA – For men with stage IIA disease (ie, diameter of involved nodes ≤2 cm), we suggest adjuvant RT rather than chemotherapy. However, cisplatin-based combination chemotherapy is a reasonable alternative.

Stage IIB or IIC – For men with more extensive retroperitoneal adenopathy (ie, diameter of involved nodes >2 cm), we recommend cisplatin-based chemotherapy.

Elevated beta-hCG – Although uncommon, men with pure seminoma may have associated elevations in serum beta-human chorionic gonadotropin (beta-hCG; >50 international units/L). While its clinical significance is controversial, we suggest treatment using cisplatin-based chemotherapy.

The optimal chemotherapy regimen has not been definitively established. The author's preference is for three courses of bleomycin, etoposide, and cisplatin (BEP), but four courses of etoposide and cisplatin (EP) is an alternative. A choice between them should be based on institutional practice and the predicted ability of the patient to tolerate bleomycin.]

10

A left sided varicocele is worrisome for what?

Renal cell cancer of the left kidney

 

[Left gonadal vein inserts into the left renal vein. Obstruction by a renal tumor causes a varicocele. This could also be caused by another retroperitoneal malignancy.]

11

What are the treatments for the following urologic diseases?

  • Ureteropelvic obstruction
  • Vesicoureteral reflux
  • Ureterocele
  • Hypospadias
  • Horseshoe kidney

  • Ureteropelvic obstruction: Pyeloplasty
  • Vesicoureteral reflux: Reimplantation with long bladder portion
  • Ureterocele: Resect and reimplant if symptomatic
  • Hypospadias: Repair at 6 months with penile skin
  • Horseshoe kidney: May need pyeloplasty

 

[UpToDate: Pyeloplasty is performed for ureteropelvic junction obstruction. It consists of resecting the atretic or stenotic segment, and reattaching the normal ureter to the renal pelvis, thereby relieving the obstruction. If the obstruction is due to an aberrant renal blood vessel, the UPJ is repositioned anatomically above the blood vessel preventing further obstruction.]

12

What is the #1 cause of cancer-related death in men aged 25-35 years old?

Testicular cancer

 

[UpToDate: Testicular cancer is the most common solid malignancy affecting males between the ages of 15 and 35, although it accounts for only 1%of all cancers in men. Germ cell tumors (GCTs) account for 95% of testicular cancers. They may consist of one predominant histologic pattern or represent a mix of multiple histologic types. For treatment purposes, two broad categories of testis tumors are recognized: pure seminoma (no nonseminomatous elements present), and all others, which together are termed nonseminomatous germ cell tumors (NSGCTs). In most series, the ratio of seminoma to NSGCT is about one.

Testicular cancer has become one of the most curable of solid neoplasms because of remarkable treatment advances beginning in the late 1970s. Prior to that time, testicular cancer accounted for 11% of all cancer deaths in men between the ages of 25 to 34, and the five-year survival rate was 64%. In 2017, approximately 400 deaths from testicular cancer are expected in the United States, with a five-year survival rate over 95%.]

13

What is involved in treating ureteral trauma that can be repaired primarily end-to-end?

  1. Spatulate ends
  2. Use absorbable suture to avoid stone formation
  3. Stent the ureter to prevent stenosis
  4. Place drains to idenify and potentially treat a leak
  5. Avoid stripping the soft tissue on the ureter as it will compromise the blood supply

14

Nerve injury at what level of the spinal cord will result in neurogenic obstructive uropathy?

Below T12

 

[Characterized by incomplete emptying. Treatment is intermittent catheterization.]

15

Which renal disorders are associated with the following?

  • WBC casts
  • RBC casts
  • Fever, rash, arthralgias, and urine eosinophils

  • WBC casts: Pyelonephritis and glomerulonephritis
  • RBC casts: Glomerulonephritis
  • Fever, rash, arthralgias, and urine eosinophils: Interstitial nephritis

16

What are the following characteristics of benign prostatic hypertrophy (BPH)?

  • Zone of prostate from which it arises
  • Initial therapy
  • Surgical treatment

  • Zone of prostate from which it arises: Transitional zone
  • Initial therapy: Alpha blockers (Terazosin and Doxazosin) to relax smooth muscle, 5-alpha-reductase inhibitors (Finasteride) to inhibit the conversion of testosterone to dihydrotestosterone (DHT causes hypertrophy)
  • Surgical treatment: Transurethral resection of the prostate (TURP)

17

What is the most common primary tumor of the kidney?

 

Renal cell carcinoma

 

[UpToDate: Renal cell carcinomas (RCCs), which originate within the renal cortex, are responsible for 80% to 85% of all primary renal neoplasms. Transitional cell carcinomas of the renal pelvis are the next most common (approximately 8%). Other parenchymal epithelial tumors, such as oncocytomas, collecting duct tumors, and renal sarcomas, occur infrequently. Nephroblastoma or Wilms' tumor is common in children (5% to 6% of all primary renal tumors), while renal medullary carcinoma is a rare form of RCC seen in sickle cell disease.

Globally, the incidence of renal cell carcinoma (RCC) varies widely from region to region, with the highest rates observed in the Czech Republic and North America. In the United States, there are approximately 64,000 new cases and almost 14,000 deaths from RCC each year. In the European Union, there were approximately 84,000 cases of RCC and 35,000 deaths due to kidney cancer in 2012.

RCC is approximately 50% more common in men compared with women. RCC occurs predominantly in the sixth to eighth decade of life with median age at diagnosis around 64 years of age, according to the 2003 to 2007 National Cancer Institute (NCI) Surveillance, Epidemiology and End Results (SEER) Cancer Statistics Review; it is unusual in patients under 40 years of age and rare in children.]

18

What is the treatment approach to a testicular mass?

Orchiectomy through an inguinal incision (not a trans-scrotal incision because of risk of disrupting the lymphatics)

19

What are the following characteristics of bladder cancer?

  • Most common type
  • Presentation
  • Risk factors
  • Diagnosis
  • Infection associated with squamous cell carcinoma of the bladder

  • Most common type: Transitional cell cancer
  • Presentation: Painless hematuria
  • Risk factors: Smoking, aniline dyes, and cyclophosphamide
  • Diagnosis: Cystoscopy
  • Infection associated with squamous cell carcinoma of the bladder: Schistosomiasis infection

 

[UpToDate: Patients with bladder cancer classically present with painless hematuria (grossly visible or microscopic), although irritative voiding symptoms (frequency, urgency, dysuria) can be the initial manifestation. The diagnosis is often delayed due to the similarity of these symptoms to those of benign disorders (urinary tract infection, interstitial cystitis, prostatitis, passage of renal calculi), and delays can lead to a worsened prognosis due to more advanced stage at diagnosis. There is evidence to suggest that delayed diagnosis accounts for the poorer survival in women diagnosed with bladder cancer compared with men. Furthermore, symptoms are often intermittent. In some patients, metastases will cause the initial symptoms. Incidental bladder cancer is rare at autopsy, suggesting that most cancers eventually become symptomatic.

Cystoscopy is the initial procedure for both the diagnosis and management of urothelial malignancy. Cystoscopy is used to establish the diagnosis, assess whether or not muscle invasion is present, and provide initial therapy for non-muscle-invasive lesions.

Urine cytology is widely used in combination with cystoscopy to assess for the presence of carcinoma in situ and to evaluate for the presence of upper urinary tract lesions. Computed tomography is the preferred imaging procedure to assess the local extent of disease and to further examine the renal pelvis and ureters.

Stage is the most important independent prognostic variable for assessing the probability of progression and survival. The standard approach is the tumor, node, metastasis (TNM) staging system, which requires cystectomy. For patients who will undergo neoadjuvant therapy, clinical staging is appropriate.]

20

What is the pregnancy rate after repair of a vasectomy?

50%

 

[UpToDate: Although vasectomy should be performed only for patients desiring permanent sterility, decisions regarding fertility may change throughout the reproductive years. Vasectomy can be reversed with microsurgical techniques. Vasectomy reversal involves reanastomosis (vasovasostomy) of the reproductive tract, ideally at the site of the previous ligation of the vas deferens. Successful vasectomy reversal has been reported in fifty to seventy percent of men. Rates decline with increasing time between vasectomy and reversal. Patients must be adequately counseled, and vasectomy should be undertaken only in men who intend to have permanent sterility.

Multiple studies have examined the relationship between patient characteristics and the likelihood of a future request for vasectomy reversal. The strongest predictive factor for a vasectomy reversal is a change in marital status. Men without children, and men who were older than 30 years at the time of vasectomy, were less likely to request a reversal in the future. There was no correlation between a patient's religion, number of marriages, or occupation, and the probability of a future request for reversal.

Key determinant of success and patency of reversal are the method of vasectomy and the duration of obstruction. An effort has been made to prevent irreversible damage at the time of vasectomy. This has led to the development of the open-ended vasectomy. The leaked sperm cause an immune response that may result in a sperm granuloma but reduces the risk of concomitant tubular damage. Sealing the testicular side of the cut end of the vas may result in epididymal damage, and decreased vasectomy reversal success.

A large retrospective study found patency rates (sperm present in ejaculate) of >95% and a pregnancy rate of approximately 75% for men who underwent vasectomy fewer than 3 years prior to reversal. Both rates decreased in a linear fashion as the duration of obstruction increased. A patency rate of 71% and pregnancy rate of 30% was reported for men who underwent vasovasostomy 15 years after vasectomy.]

21

What is the treatment for bladder cancer?

T1 (no muscle invasion): Intravesical BCG or transurethral resection

T2 and greater (muscle invasion): Cystectomy with ileal conduit, chemotherapy and XRT

Metastatic disease: Chemotherapy

 

[Chemotherapy regimen with MVAC: Methotrexate, vinblastine, doxorubicin, and cisplatin]

 

[UpToDate: The presence of otherwise unexplained hematuria frequently denotes urinary tract cancer in individuals over the age of 40 until proven otherwise. Flexible cystoscopy and urine cytology are the initial steps in making the diagnosis. Transurethral resection of the bladder tumor (TURBT), along with examination under anesthesia, is required in order to determine histology, depth of invasion, and potential involvement beyond the bladder. Bladder biopsies of normal-appearing mucosa are required in patients with an otherwise unexplained positive urine cytology.

Primary tumors without muscle invasion (Ta and T1 lesions) are generally managed initially with TURBT. Patients at significant risk of recurrence and/or progression may also require intravesical therapy. All patients are at risk for recurrence both in the bladder and elsewhere in the urothelium, and long-term surveillance is required following initial therapy.

For patients with low-risk disease, a single intravesical instillation of chemotherapy is usually sufficient as adjuvant therapy and no further therapy is indicated. For patients with intermediate-risk disease, we recommend an induction course of either intravesical chemotherapy or bacillus Calmette-Guerin (BCG). Following this, maintenance therapy should be continued for one year. For patients with high-risk disease, we recommend an induction course of BCG, and maintenance therapy should be given and continued for three years.

Radical cystectomy with urinary diversion is the treatment of choice for patients with muscle-invasive disease.

  • Neoadjuvant cisplatin-based chemotherapy improves overall survival and should be considered for appropriate patients.
  • Although the benefit of adjuvant chemotherapy has not been established in randomized clinical trials, adjuvant chemotherapy may have a role following cystectomy in patients with high-risk invasive urothelial carcinoma who are otherwise candidates for chemotherapy, although this view remains controversial in view of the published randomized clinical trials.

For patients unable or unwilling to undergo radical cystectomy with urinary diversion for muscle invasive urothelial bladder cancer, complete TURBT combined with radiation therapy plus chemotherapy may offer an alternative bladder-sparing approach.

Combination chemotherapy (using platinum-based regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin [MVAC] or gemcitabine plus cisplatin [GC]) may prolong survival and often provides palliation of symptomatic disease. Checkpoint inhibition immunotherapy has substantial clinical activity in postchemotherapy patients, and ongoing trials are further defining its role.]

22

What are the following characteristics of prostate cancer?

  • Treatment of intracapsular tumors and no metastases (T1 and T2)
  • Treatment of extracapsular tumors or metastatic disease
  • What should happen to PSA after prostatectomy

  • Treatment of intracapsular tumors and no metastases (T1 and T2): XRT or radical prostatectomy + pelvic lymph node dissection (if life span > 10 years) or nothing (depending on health)
  • Treatment of extracapsular tumors or metastatic disease: XRT and androgen ablation (leuprolide, flutamide, or bilateral orchiectomy)
  • What should happen to PSA after prostatectomy: PSA should go to zero after 3 weeks (if not, get a bone scane to check for metastases)

 

[UpToDate: For men with clinically localized, very low-risk prostate cancer and a life expectancy of less than 20 years, we suggest active surveillance rather than immediate definitive therapy (Grade 2C). However, this approach is associated with a need for close follow-up and may create significant anxiety, causing many patients to subsequently choose definitive intervention even in the absence of progressive disease. Radiation therapy and radical prostatectomy are acceptable alternatives for patients preferring immediate definitive therapy.

For men with low-risk prostate cancer and a life expectancy of greater than 10 years, definitive therapy (radical prostatectomy, brachytherapy, or external beam radiation therapy [RT]), or active surveillance may all be appropriate options. The choice of a specific approach requires a consideration of the benefits and risks associated with each approach, taking into account the patient's individual preferences and comorbidities. For patients with a more limited life expectancy (less than 10 years) we suggest active surveillance.

Previously untreated prostate cancer generally is dependent upon androgen for its continued growth. This observation provides the basis for androgen deprivation therapy (ADT) as a component of the initial systemic therapy. Treatments targeting androgenic stimulation of the tumor are also used in several subsequent treatment modalities.

For disseminated prostate cancer, we recommend initial treatment with either medical or surgical orchiectomy (ADT) to suppress serum testosterone levels for all patients requiring systemic therapy (Grade 1A). This approach replaced estrogen therapy, which was associated with increased cardiovascular toxicity in randomized trials. Other modalities that have been shown to prolong survival in men with castration resistant disease have not been evaluated as an alternative for initial therapy and are not indicated in this setting.

For men whose only evidence of disseminated disease is an elevated or rising PSA following definitive locoregional therapy, the optimal timing for initiation of ADT is problematic and involves a consideration of the prolonged natural history of the disease, as well as patient specific factors including age and personal preferences.

For men with overt metastases, we suggest immediate rather than delayed treatment (Grade 2B). This approach has been shown to significantly decrease prostate cancer-related deaths, but the difference in overall survival was not statistically significant.

For men with bone or visceral metastases, we recommend chemohormonal therapy combining ADT with docetaxel chemotherapy rather than ADT alone (Grade 1A). This approach significantly increases overall survival compared with ADT alone as the initial therapy.]

23

Nerve injury at what level of the spinal cord will result in neurogenic bladder?

Above T12

 

[Treatment is surgery to improve bladder resistance.]

24

What are the following characteristics of prostate cancer?

  • Most common site (anterior or posterior lobe)
  • Most common site of metastasis
  • Tests that should be obtained in work up
  • Normal PSA
  • Significance of elevated alkaline phosphatase

  • Most common site (anterior or posterior lobe): Posterior lobe
  • Most common site of metastasis: Bone
  • Tests that should be obtained in work up: Transrectal biopsy, CT chest/abd/pelvis, PSA, alkaline phosphatase, maybe a bone scan
  • Normal PSA: < 4
  • Significance of elevated alkaline phosphatase: Worrisome for metastases or extracapsular disease

 

[UpToDate: Most patients who undergo prostate biopsy do so because of a prostate-specific antigen (PSA) determination, despite the controversy surrounding PSA screening.

Although the risk for having a biopsy positive for prostate cancer increases as the PSA level rises, there are no absolute numbers used as a threshold to determine a need for biopsy.

  • Patient age, prostate volume, digital rectal examination findings, family history, and patient race must all be considered. A PSA level substantially above normal for a certain age may be an indication for biopsy.
  • A change from prior values (more than 0.35 ng/mL/year for a PSA of <4.0 or 0.75 ng/mL if the PSA is >4.0) should be considered suspicious.

An abnormal digital rectal exam, especially asymmetry, nodularity, or induration, should prompt a biopsy regardless of the serum PSA level.

Symptoms are an unusual presentation for men with early prostate cancer and may be difficult to differentiate from symptoms due to benign prostate disease.

The diagnosis of prostate cancer requires tissue. This is usually obtained by biopsy with the guidance of transrectal ultrasound, which should be preceded by measurement of serum PSA.]

25

What are the following characteristics of bladder incontinence?

  • Cause of stress incontinence
  • Treatment of stress incontinence
  • Cause of overflow incontinence
  • Treatment of overflow incontinence

  • Cause of stress incontinence: Hypermobile urethra or loss of sphincter mechanism
  • Treatment of stress incontinence: Kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sling
  • Cause of overflow incontinence: Obstruction (such as BPH) leads to distention and leakage
  • Treatment of overflow incontinence: Transurethral resection of the prostate (TURP)

26

What are the following characteristics of kidney stones?

  • Type of kidney stone that occurs in patients with terminal ileum resection
  • Type of kidney stones that occur with urease-producing infections like Proteus mirabilis
  • Type of kidney stones that occur in patients with ileostomies, gout, and myeloproliferative disorders
  • Type of kidney stones that occur in patients with congenital disorders that inhibit certain reabsorptive functions of the kidney

  • Type of kidney stone that occurs in patients with terminal ileum resection: Calcium oxalate stones
  • Type of kidney stones that occur with urease-producing infections like Proteus mirabilis: Struvite stones (magnesium ammonium phosphate)
  • Type of kidney stones that iccur in patients with ileostomies, gout, and myeloproliferative disorders: Uric acid stones
  • Type of kidney stones that occur in patients with congenital disorders that inhibit certain reabsorptive functions of the kidney: Cysteine stones (Caused by cystinuria)

27

What is the treatment for priapism?

Aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine

 

[May need to create a communication through the glans with scalpel.]

 

[UpToDate: In patients with ischemic priapism, we recommend intracavernosal injection with a sympathomimetic agent (Grade 1B). We prefer phenylephrine (100 to 500 mcg/mL with 1 mL injection) to other agents based on fewer adverse effects. In addition to sympathomimetic injection, we suggest cavernosal blood aspiration (Grade 2C).]

28

What is the most common cause of acute renal insufficiency following surgery?

Hypotension

 

[UpToDate: Acute renal failure occurs in up to 30% of patients who have undergone cardiac surgery, when defined as a 50% increase in the serum creatinine concentration above baseline. It is severe enough to require dialysis in 1% to 5% of patients and it appears to be associated with increased mortality. In a prospective cohort study of 43,642 patients who had undergone coronary artery bypass graft (CABG) or valve surgery, acute renal failure was associated with a 30-day mortality of 64%, compared to four percent without renal failure. More recent data suggest the incidence of renal failure following cardiac surgery has increased, while the associated mortality has decreased. This probably reflects an increase in comorbid disease and improvements in postoperative care.

Risk factors – Postoperative risk factors for acute renal failure include poor cardiac performance and perioperative hemodynamic instability. Risk factors that cannot be controlled postoperatively include advanced atherosclerotic vascular disease, reduced creatinine clearance, a long duration of cardiopulmonary bypass, and the use of radiocontrast agents immediately before surgery.

Mechanism – Mechanisms of perioperative renal failure include renal artery vasoconstriction, hypothermia, loss of pulsatile flow during cardiopulmonary bypass, and atheroembolic disease.

Prevention – The best preventive strategy is to optimize renal perfusion (ie, avoid hypotension and hypovolemia) and to avoid potentially nephrotoxic agents (eg, aminoglycoside antibiotics, angiotensin converting enzyme inhibitors, and radiologic contrast agents) in the immediate postoperative period. There is no clear evidence supporting the efficacy of pharmacologic therapy (eg, low-dose dopamine, loop diuretics) to prevent acute renal failure after major surgery. In addition to lack of proven efficacy, there is some concern about toxicity (eg, arrhythmias, myocardial ischemia, and intestinal ischemia with dopamine).

Treatment – There is no convincing evidence of benefit from early and/or aggressive dialysis, and there is some concern that renal function might be impaired by this approach. Thus, the decision to perform dialysis generally should be based upon the presence of uremic symptoms, fluid overload, or electrolyte abnormalities, rather than a specific blood urea nitrogen or serum creatinine concentration.]

29

What are the following characteristics of nonseminomatous testicular cancer?

  • 4 types
  • Elevated markers
  • Treatment

  • 4 types: Embryonal, teratoma, choriocarcinoma, yolk sac
  • Elevated markers: Alpha fetoprotein and B-HCG
  • Treatment: Orchiectomy and retroperitoneal node dissection

 

[Stage II or greater also should receive chemotherapy with cisplatin, bleomycin and etoposide (VP-16)]

 

[UpToDate: The staging of patients with NSGCT is based on tumor markers following radical orchiectomy, as well as on clinical staging. For those patients whose treatment includes retroperitoneal lymph node dissection (RPLND), pathologic staging may result in further changes in treatment.

Stage IA and IB NSGCT — For men with stage IA and IB NSGCTs, management depends on whether factors associated with an increased risk of relapse are present. These include:

  • Lymphovascular invasion
  • Predominance of an embryonal carcinoma component
  • A T3 or T4 primary tumor

Using these risk factors, our approach to stage I NSGCTs is as follows:

  • Low risk – For men who do not have any risk factors present, we suggest active surveillance.
  • High risk – For men with one or more risk factors, active surveillance, chemotherapy, and RPLND are all options. If technical expertise is available, RPLND is an appropriate treatment option. However, chemotherapy (one or two cycles of BEP) is a reasonable alternative. For men who prefer not to undergo further treatment, active surveillance is a reasonable alternative. However, these men should understand that their risk of relapse, and thus the need for subsequent treatment at a later date, approaches 40%.

Stage IS — Patients with NSGCT limited to the testis on clinical staging but who have persistent elevation of tumor markers following orchiectomy are classified as stage IS. Persistently elevated markers generally indicate the presence of metastatic disease. These patient should be treated with chemotherapy similarly to those with good-risk stage III disease.

Stage II NSGCT — For patients with stage II NSGCTs, treatment depends upon whether disease is documented clinically or pathologically.

Clinical stage IIA NSGCT – For men with radiographically abnormal nodal involvement ≤2 cm and normal serum tumor markers, we suggest RPLND. Further treatment will be based upon the pathologic stage.

Clinical stage IIB and IIC NSGCT – For men with radiographically detected nodal disease ≥2 cm and/or elevated serum tumor markers following orchiectomy, we suggest primary cisplatin-based combination chemotherapy. BEP for three cycles and EP for four cycles are acceptable regimens.

Pathologic stage II NSGCT – Men with NSGCTs with confirmed pathological node involvement following RPLND have pathologic stage II NSGCTs. Treatment following RPLND is based on the extent of nodal:

  • For men with lymph node metastases ≤2 cm in greatest diameter, we suggest surveillance. While adjuvant chemotherapy dramatically reduces the relapse rate, treatment has no significant effect on survival because patients who relapse are treated with chemotherapy for curative intent.
  • For men with nodal involvement >2 cm, we suggest two cycles of adjuvant cisplatin-based combination chemotherapy because the relapse risk is relatively higher.]

30

What are the following characteristics of kidney stones?

  • Percent that are radiopaque
  • Radiopaque stones
  • Radiolucent stones

  • Percent that are radiopaque: 90%
  • Radiopaque stones: Calcium oxalate and struvite stones
  • Radiolucent stones: Uric acid and cysteine stones