UROLOGY MCQ
CHAPTER 1: APPLIED ANATOMY OF THE GENITOURINARY TRACT
1. Which of the following structures is not typically encountered in the course of renal surgery through a
flank incision?
A. Internal oblique muscle B. Transversalis fascia C. Rectusmuscle D. Thoracolumbar fascia E. Transversus
abdominis F. Obturator Internus
2. Regarding Gerota’s fascia, which of the following are true?
A. It is part of the inner stratum of retroperitoneal tissue B. Inferiorly there is an open potential space C.
Perinephric fat is outside of it D. It is continuous with Colle’s fascia E. Both A. and C. F. None of the
above
3. Which of the following is not typically a site of normal ureteral narrowing (where stones get caught)?
A. UPJ B. Iliac vessels C. Pelvic ureter D. UVJ E. L4 level F. Entrance to detrusor
4. Normal voiding is dependent on all of the following nerves except? A. Pelvic B. Hypogastric C.
Obturator D. Pudendal
5. Which of the following is true about the prostate? A.Most prostate cancer is fromthe transition zone
B.Most normal volume is in the peripheral zone C. The central zone is primarily distal to the
verumontanum D. The primary blood supply is fromthe superior vesical artery E. The average prostate
volume in a young male is 50cc. F. It has only sympathetic innervation
6. The adrenal glands receive blood supply from all of the following except?
A. Superior phrenic artery B. Inferior phrenic artery C. Adirect branch fromthe aorta D. Abranch off of
the renal artery
7. If one needs to ligate the hypogastric arteries for severe pelvic bleeding it should be done distal to
which area? A. Posterior division B. Umbilical artery C. Inferior vesical artery D. Obturator artery E.
Internal pudendal artery F. Superior vesical artery
8. Which of the following nerves would one suspect was damaged if a patient lost the ability to adduct
the thighs after pelvic surgery? A. Ilioinguinal B. Femoral C. Obturator D. Sciatic E. Genitofemoral F.
Internal pudenal
9. Which of the following structures do not make up part of Hesselbach’s triangle?
A. Inferior epigastric vessels B. Lateralmargin of the rectusmuscle C. Pectinealmuscle D. Inguinal
ligament
10. In women the ureter is in close proximity to and can be damaged during gynecologic surgery on
which of the following structures? A. Ovary B. Uterine artery C. Cervix D. Vaginal wall E. All of the above
Answers
1. C. The typical flank incision does not travel anteromedially to the border of the rectus. All other
structures noted are traversed.
2. B. It is part of the intermediate stratumand the perinephric fat is within it. B. is correct.
3. C. Ureteral caliber is typically narrowest at the UPJ, over the iliacs and at the UVJ. There is no
particular narrow point per se of the pelvic portion of the ureter or at the other sites.
4. C. Obturator nerves allow for thigh adduction. Pelvic and hypogastric nerves carry the autonomic
supply to the bladder and innervation to the external sphincter is via the pudendal.
5. B. A., C. and D. are falsemost cancer is in the peripheral zone, the central zone is proximal to the veru
and the primary blood supply is from the inferior vesical artery.
6. A. The adrenal has a tripartite blood supply and receives blood fromall the options listed except the
superior phrenic artery.
7. A. The posterior division includes the gluteal artery which supplies the gluteus. Ligating proximal to
this pointmay lead to pain in the buttocks.
8. C. The obturator nerve is responsible for thigh adduction.
9. C. Hesselbach’s triangle is borderedmedially by the rectusmuscle, laterally by the inferior epigastrics
and inferiorly by the inguinal ligament.
10. E. All of these structures can be damaged during gynecological surgery.
CHAPTER 2: PEDIATRIC UROLOGY
1. On prenatal US during the third trimester, what are the AP diameter criteria used to classifymoderate
hydronephrosis? A. <7mm B. 7- <9mm C. 10-15mm D. 15-20mm E. >20mm
2. What is the reported incidence of vesicoureteral reflux in children with prenatal diagnosed
hydronephrosis? A. 50-70% B. 40-60% C. 5-20% D. <5% E. 1-2%
3. What is themost appropriate antibiotic used for prophylaxis in a newborn with prenatal
hydronephrosis? A. Amoxicillin B. Suprax C. Bactrim D. Nitrofuratoin E. Ciprofloxacin
4. What ismost common abnormality in renal function associated with posterior urethral valves? A.
Urine Concentration defect B. Increased active sodiumabsorption fromthe descending limb of the loop
of Henle C.Decreased calciumabsorption from ascending limb of the loop of Henle D. The presence of
heavy proteinuria E. None of the above
5. Which of the following is the most important in the treatment of VUR? A. Age of the patients B. Grade
of reflux C. Laterality D. Breakthrough infection E. All of the above
6. At the 30 weeks’gestation, bilateral hydroureteronephrosis, bladder distension and oligohydramnios
were detected. Which of the following ismore likely cause of this condition? A. Ureteropelvic junction
obstruction B. Ureterocele C. Vesico-ureteral Reflux D. Posterior urethral valve E. Ectopic ureter
7. 38-week-gestation newborn with posterior urethral valves has a serumcreatinine of 1.6mg/dl. That
level: A. Is an ominous predictor of future renal function B.Will decrease with completion of
nephrogenesis C. Initially falls with a rapid rise in GFR D.Will result in increased active sodium absorption
fromthe descending limb of the loop of Henle. E. Is not reflective of the degree of renal function
impairment
Answers: 1. C. 2. C. 3. A. 4. A. 5. E. 6. D. 7. E.
The creatinine in a newborn is reflective ofmaternal renal function and is not representative of the
degree of renal impairment or lack thereof due to the obstruction.
CHAPTER 3: PEDIATRIC UROLOGICAL ONCOLOGY
1. Wilms’tumor prognosis is primarily dictated by A. Stage B. Patient age C. Resectability D. Familial
variant E. Histology
2. A3 year old female undergoes right nephrectomy forWilms’tumor. The histology is described as
favorable and the tumor is surrounded by intralobar nephrogenic rests. This suggests A. Incomplete
resectionB. An increased risk of recurrence C. An increased risk of contralateral tumor D.Alikely variant
associated with Tuberous sclerosis E. Likely finding of positive lymph nodes
3. A2 week old newborn with no prenatal screening is found to have a firm right abdominal mass.
Ultrasound confirms this to be solid but heterogeneous right renal mass and it crosses the midline. The
next step is A. Resection B. Obtain VMAand HVA C. Performmetastatic work up D. Consult
ophthalmology because of likely aniridia E. Suggest downstaging with chemotherapy
4. A 7month old boy is found to have a firm testismass. Alpha fetoprotein is normal. Ultrasound reveals
calcific densities surrounded by cysts and heterogeneous solid tissue surrounded by normal appearing
parenchyma. Next step is A. Repeat alpha fetoprotein as this is a likely yolk sac tumor B. Obtain betaHCG as this test is diagnostic of childhood embryonal cancer C. Evaluate withmonthly ultrasounds for
microlithiasis D. Performpartial orchidectomy with frozen section with presumptive diagnosis of
teratoma E. Stage with chest and abdominal CT in order to decide between radical orchidectomy or
chemotherapy.
5. A1month oldmale is being evaluated forenlarged tongue, a large right thigh, and a palpable liver. Your
approach would be to: A. Reassure that this is temporary and will regress B. Screen siblings C.
ObtainMRI D. Suggest serial ultrasounds E. Pursue genetic testing.
Answers:
1. E. Unfavorable histology represents only 10%of all Wilms’tumor but >50%of the fatal cases
2. C. Nephrogenic rests are fetal blastemal remnants that persist and are associated with syndromes
butmost importantly an increased risk of bilaterality. They may be intralobar and hence develop earlier
in nephrogenesis, or may be perilobar and develop later.
3. A. This patient in all likelihood has a congenital mesoblastic nephroma, themost common solid renal
neoplasmof the first 3months of life.Most behave in a benign fashion and hence nephrectomy is the
best choice.
4. D. Newer data suggest that teratoma is themost common childhood testicular neoplasm. Because of
theirmore benign nature, theymay bemanaged with a testicular salvage procedure. The keys in doing so
are the normal alpha fetoprotein and ultrasound suspicion of this lesion. Beta HCG is not important in
prepubertal testicular neoplasm whereas alpha fetoprotein is especially helpful as a marker for yolk sac
(embryonal) tumors.
5. D. This patient has Beckwith-Wiedemann Syndrome and is especially at risk of Wilms’tumor (5%–
20%) in the first 67 years of life. Although overall survival is likely not impacted by ongoing screening,
the probability of diagnosis at an earlier stage or smaller lesion is greater. This is particularly important
as bilateral tumors aremore common, and earlier diagnosismay allow a greater opportunity to spare
nephrons with appropriate chemotherapy and surgery, thus impacting morbidity
CHAPTER 4: GENITAL ABNORMALITIES
1. A 1 year old boy undergoing laparoscopy for a right non-palpable testis is found to have a normal
appearing testis just inside the internal ring. As peritoneum distal to the vas is incised, you notice the vas
leads to and appears to join a midline uterus. The next best step in management is to: A. Stop surgery
and draw serum for 17 hydroxyprogesterone levels B. Stop surgery and obtain a karyotype C. Stop
surgery and biopsy the contralateral descended gonad for ovarian tissue D. Remove the uterus and
perform right orchiopexy E. Proceed with right orchiopexy, splitting the uterus sagitally if the vas is
tethered
2. You are consulted to evaluate a full-termnewbornmale with proximal hypospadias. Your
examconfirms the urethral defect and ventral penile curvature. Genital examination also shows a welldeveloped scrotumwith amidline cleft, and bilateral nonpalpable testes. The next step is to: A. Obtain
FISH to detect a Ychromosome B. Draw serumLH and testosterone levels C. Order retrograde
genitography to detect a utricle D. Schedule repeat examination for testicular descent at age 6months E.
Recommend laparoscopic orchiopexy at age 6months and hypospadias repair at age 1 year
3. A6 year old female presents with bilateral groinmasses notedmostly when she is playing. During
herniorrhaphy, bilateral testes are found. You should next: A. Immediately remove both testes because
of the increased risk for childhood germcell tumors B. Repair the hernias C. Performlaparoscopy to
assess the uterus D. Draw serumformullerian inhibition substance levels E. Obtain a cerebralMRI to rule
out an empty sella
4. A2 year old boy had complete wound dehiscence after a proximal hypospadias repair with preputial
flap urethroplasty. During reoperation you open the right hemiscrotumto obtain tunica vaginalis to
cover over the neourethra,and encounter a dumbbell-shaped ovatestis.
The next step is to: A. Replace the ovatestis and use fibrin glue instead of tunica vaginalis to seal over
the neourethra B. Complete the hypospadias repair and then performlaparoscopic hysterectomy C.
Remove the ovarian portion of the ovatestis and explore the contralateral gonad D. Remove the entire
dysgenic gonad and complete the hypospadias repair E. Remove the ovarian portion and biopsy the
testis for gonadoblastoma
5. An 8 year old girl is referred after a febrile UTI. She brings a CD with a renal ultrasound that shows a
horseshoe kidney and a 2cmheterogenousmass in the region of the right ovary. Notes fromthe
pediatrician’s office indicate.she has been healthy, although her height is more than 2 standard
deviations below normal for her age. During examination you notice her nipples appear wider apart
than usual.Which of the following statements ismost likely true?
A. She is beginning puberty and has a follicular ovarian cyst B. Akaryotype would show a Ychromosome
C. She has an unresolved tubo-ovarian abscess misdiagnosed as a febrile UTI D. AVCUG would show high
grade right reflux E.Vaginoscopy would show an obstructed right hemivagina
6. A5 year old boy presents after hismother noticed he was straining to urinate. His urologic history is
significant for a distal TIP hypospadias repair done in another city at age 8 months. The familymoved
shortly after surgery and so he had no follow-up. He toilet trained over a year ago, butmother is certain
his streamis slowing since then. On examination his penis is circumcised and overall looks normal,
except that themeatus appears small and has a faint white discoloration. Uroflowmetry shows 3 cc sec
peak flow while voiding 35 cc. The best long-termsolution for his problemis: A.Meatotomy B. Optical
urethrotomy C. Reoperative TIP repair D. Reoperation with a flip-flap urethroplasty E.Neourethral
excision with 2-stage buccal graft urethroplasty
7. A6 year old boy is referred for a left undescended testis. Although he has seen the same pediatrician
his entire life, this problemwas first diagnosed on a routine exam1month ago. Atesticular ultrasound
was obtained before referral, reporting both testes are the same size and located in the inguinal canal.
During exam you notice his scrotumis symmetric, and the right testis is easilymanipulated into the
scrotum. The left testes seems higher in the groin, but you can alsomanipulate it into the scrotum,
where is remains a few seconds before reascending. The next step inmanagement is to: A. Schedule
testosterone injections 2mg/kg once amonth for 3months and then reexamine him B. Schedule left
orchiopexy C. Schedule bilateral orchiopexy D. Reassure his parents testicular retraction is common in
this age group E. Repeat ultrasonography since the right testicleseems descended on examination
8. An 8 year old boy presents to the emergency department with a red and swollen scrotumhis mother
found after observing himwalking bow-legged. He is afebrile and seems comfortable lying on the
examtable, but palpation of the scrotumcauses discomfort. The ED physician obtained a testicular
sonogrambefore calling you, reporting “increased left testicularblood flow with a swollen left epididymis
consistent with epididymo-orchitis”. Aurinalysis is normal. You shouldmanage this problemby: A.
Urethral swab and cefixime for 7 days B. Intravenous ceftriaxone until the erythema improves, followed
by oral cefixime for a total of 10 days therapy C. Oral cefixime for 10 days D. Oral cefixime with renal
ultrasound and VCUG when the acute inflammation subsides E. Oral analgesics as needed
9. A7 year old boy presents with urinary incontinence since toilet training. He wears a pull-up that he
changes twice a day. His parents report he can be dry during the night, but wets consistently during the
day, possibly when he is playing too hard and does not go to the bathroom when he should. His urologic
history is otherwise remarkable only for repair of penile epispadias at age 6months. Examination shows
the penis with a glanularmeatus and some upward curvature. The bladder is not palpably distended and
there is no cutaneous back lesion. The treatmentmost likely needed to correct his incontinence is: A.
Timed voiding B. Laxatives for occult constipation C. Oral anticholinergics D.Meatotomy E. Bladder neck
repair
10. A 15 year old teenager was found to have ascrotalmass during sports physical. He has no symptoms.
Your exam confirms Tanner 3pubertal development with a visible left varicocele and symmetric testes,
confirmed by testicular ultrasound. You informhis parents: A. He can play sports and should have
another testicular ultrasound in 1 year B. He should not participate in contact sports because of
increased risk for scrotal hematoma C. He needs a semen analysis to rule out varicocele effect on
spermfunction D. He should undergo left varicocele ligation for a grade 3 varicocele E.He should have
bilateral varicocele ligation, sincemost varicoceles are bilateral
Answers:
1. E. The patient has failure of mullerian inhibition substance,resulting in a male with a uterus. There is
no gender identify issue, and orchiopexy is needed to relocate the intraabdominal testis. The ipsilateral
vas most often fuses into the mullerian structures, making it necessary at times to split the uterus to
gain additional length for the testis to reach the scrotum. Theoretically the patient could have an
ovotesticular disorder of sexual differentiation, although a normal appearing ipsilateral testis and a
contralateral descended gonad make that diagnosis unlikely and does not influence need to proceed
with orchiopexy.
2. A. Although the baby appears virilized, bilateral nonpalpable testes, especially with
hypospadias,mandate evaluation for congenital adrenal hyperplasia in a genetic female. FISH detecting a
Ychromosome would rapidly exclude that potentially lifethreatening diagnosis, since CAH females have a
46 XX karyotype.
3. B. This phenotypic female has complete androgen insensitivity. The testes are at risk germcell tumor
development during or after puberty, and so will eventually need to be removed. However, they can
bemaintained during childhood to assist with secondary sexual development when puberty begins.
Therefore, herniorrhaphy can be completed with or without simultaneous orchiectomy. Although a
minority of patients have a rudimentary uterus, laparoscopy is not needed.
4. C. There is no issue regarding gender identity, but the ovarian portion of the ovatestis should be
removed to prevent breast development during puberty. The testicular portion does not have increased
risk for gonadoblastoma as it is not dysgenetic. The contralateral gonad can be easily exposed to rule
out bilateral ovatestes.
5. B. Short stature, widely spaced nipples and a horseshoe kidney indicate a likely diagnosis of
Turner’ssyndrome. The streak gonads have the potential to develop gonadoblastoma, suggested by the
apparent gonadalmass on ultrasound, when there is Ychromosomalmaterial.
6. E. Bothmeatal stenosis and neourethral stricture are unusual after TIP hypospadias repair. The history
of progressive stranguria and finding of white discoloration around themeatus indicate BXO. BXO in the
urethra after circumcision requires total excision of affected tissues and buccal graft urethroplasty, since
the conditionmay recur if skin flap or graft urethroplasty is done.
7. D. Undescended testes aremost often unilateral and aremost accurately diagnosed during
examinations as a newborn and in the first 6months of life. After that time cremastericmuscular
activitymay retract the testis into the upper scrotum, a normal finding that may continue until puberty.
Ultrasound cannot distinguish between undescended and retractile testes, since the cremaster muscle
contracts and elevates the testis when the gel is applied. In this case the scrotumappears symmetrical
and the left testis can bemoved into the correct position, where it remains a brief time all typical
findings of a retractile testis. This diagnosis is also supported by the negative history of undescended
testis at birth and in the firstmonths of life.
8. E. The history and examination aremost consistent with a torsed appendage testis, which causes
edema of the epididymis that is often reported erroneously as “epididymitis or epididimo orchiditis”.
Epididymitis is rare in otherwise normal, prepubertal males, andmost often presents with fever and
urinainfection. Atorsed appendage resolves spontaneously and so only supportivemeasures are needed,
such as analgesics for discomfort.
9. E. Patients with epispadias often also have bladder neck incompetency, requiring surgical repair.
10. A. Indications for varicocele ligation in teenagers include decreased ipsilateral testicular size or pain.
Semen analysis is not considered useful until pubertal development is completed, typically around age
S17 years.
CHAPTER 7: RENAL PHYSIOLOGY AND PATHOPHYSIOLOGY
1. Which of the following is true about sodium and the kidney? A. By definition, hypernatremia is always
associatedwith elevated total body sodiumconten B.Normal compensation for hyponatremia is
decreased ADH secretion and thirst suppression C.Abnormal elevation of serumlipids can lead to
ameasured false elevation of serum sodium D. If asymptomatic hyponatremia does not improve within
24 hours, intravenous hypertonic saline should be started E. In therapy of symptomatic hyponatremia,
the goal should be a normal serumsodiumof 135 meq/Lwithin 48 hours
2. Which of the following is NOT true about potassium? A. ACE inhibitorsmay be a cause of hypokalemia
B. Potassiumis primarily an intracellular ion C.Acidosis drives potassiumout of the cell into the circulation
D. Ahigh sodiumload in the distal tubule promotes potassiumexcretion E. The upper limit for safe
intravenous potassiuminfusion is 40meq/hr
3. Which of the following is true about acidosis? A. Increasing the blood HCO3 level increases the anion
gap B.Direct bicarbonate loss fromthe kidney would lead tometabolic acidosis and a normal anion gap C.
Lactic acidosis usually presents as a nonunion gapmetabolic acidosis D. Appropriate respiratory
compensation for a metabolic acidosis is decreased respiration with an increased pCO2 E. It is not
possible to have both a respiratory andmetabolic acidosis at the same time
4. All of the following can increase total GFR except: A. Increased RBF B. Increased intraglomerular
(hydraulic) pressure C. Increased glomerular permeability D. Increased efferent arteriolar resistance E.
Increased functioning nephron number
5 Which of the followingmetabolic effects of intestinal segments in the urinary tract is TRUE? A. The
effects are independent of renal function B. Jejunumproduces a hypernatremic metabolic alkalosis C.
Stomach produces an anion gapmetabolic acidosis D. Ileumproduces a non-anion gapmetabolic acidosis
E. Aconduit will bemore likely to lead to a metabolic disorder than a pouch 6. Which of the following is
true about renal tubular acidosis? A. Patients with type 4 usually require potassiumsupplements B. If
urinary pH is high but there is no metabolic acidosis, it can be provoked with a sodiumchloride infusion
test C. Type 1 is themost common formseen in children D. Type 2 patients commonly develop renal
stones E. Type 1 patients commonly have low urinary citrate
Answers
1. B. The physiologic response to hyponatremia is decreased ADH secretion and thirst suppression.
2. A. ACE inhibitorsmay cause hyperkalemia.
3. B.Direct bicarbonate loss is “measured” in the aniongap and therefore leads tometabolic acidosis with
a normal anion gap.
4. C. Glomerular permeability is alreadymaximal under normal conditions for water and small solutes,
so GFR will not increase significantly with increased glomerular permeability. Rather, one sees increased
filtration of larger substances such as albumin.
5.D. Effects aremore pronounced in the face of poor renal function and increased urinary contact time
as would be seen in a pouch rather than a conduit.
6. E. Urinary citrate is low in type 1 which predisposes to renal stones. Type 2 is the most common form
in children and the provocative infusion test is done with ammoniumchloride.
CHAPTER 8: RENOVASCULAR DISEASE
1. Which of the following ismore likely to be associated with renovascular hypertension? A. Positive
family history B.Mild hypertension C. Age of onset of 22 for hypertension D. BPwell controlled with a
diuretic alone E. Kidneys equal size by ultrasound
2. Which of the following does NOT increase the risk of renal artery aneurysmrupture? A. Pregnancy B.
1.5 cmdiameter C. Incomplete calcification D. Size increased from3months ago E. Untreated
hypertension
3. Which of the following increases the likelihood that renal revascularization for ischemic nephropathy
will improve renal function? A.Unilateral disease B.B. Use of a drug eluting stent C.C. Kidney size <7
cmD.D. Cr >5.0mg/dL E.E. Retrograde arterial filling on angiogram
4.Which of the following is TRUE about the Renin Angiotensin System? A.Angiotensin II raises systemic
vascular resistance B. Angiotensinogen is produced by the kidney C. Aldosterone increases urinary
sodiumconcentrations D. The ACE enzymes convert angiotensinogen to angiotensin I E. Angiotensin II
inhibits aldosterone secretion
5.Which of the following is TRUE about renal artery stenosis? A.Atherosclerosis is themost
commonmechanismin children B. Intimal fibroplasia produces the classic "string of beads" appearance
C.Medial fibroplasia is themost common formof fibromuscular disease D. Progression of atherosclerotic
renal arterystenosis is rare E. Perimedial fibroplasia ismore common in elderlymen
6.Which of the following is TRUE about imaging studies for renovascular hypertension? A.Administration
of captopril would be expected to increase GFR in patients with renovascular hypertension B. Duplex
ultrasound is dependent on the degree of remaining renal function C.MRAis ideal for imaging branch
vessel disease D.Apositive captopril renal scan in the best predictor of surgical cure E. Renal vein renin
sampling should be done before any surgical repair
7.Which is the following is true regarding surgical repair of renal artery stenosis A. Artificial grafts are
superior to autologous tissue because they have lower failure rates B. In cases where the abdominal
aorta and all its major branches are heavily diseased with atherosclerosis, the thoracic aorta is often
spared and can be used for a left renal artery repair C. An added risk of autotransplant is the need for
lifelong immunosuppression D.Hepatorenal bypass is a good choice for repair of a left renal artery
stenosis E. Carotid stenosis should be treated after renal artery repair to allow normalization of blood
pressure
Answers 1. C. 2. B. 3. E. 4. A 5. C 6. D 7. B
CHAPTER 9: RENAL TRANSPLANTATION
1. Which of the following factors do not contribute significantly to erectile dysfunction in men after a
kidney transplant? A. Use of both internal iliac arteries withmultiple kidney transplantations B.
Prolonged hypertension C. Diabetesmellitus D. Elevated prolactin levels E. Side effects of hypertension
drugs
2. A54-year-oldmale presents to his 4-year status postrenal transplantation with erectile dysfunction.
The graft is functioning well with a serum creatinine of 1.2.Which of the following recommendations for
his ED would not be appropriate? A. Sildenafil B. Tadalafil C. Intracorporeal prostaglandin injections D.
Placement of penile prosthesis E. Most ED treatments are unsafe in kidney rransplant patients
3. A60-year-oldmale with bladder outlet obstruction due to an enlarged prostate is preparing to
undergo a living-related kidney transplant. He is anuric currently, but worried that he will be unable to
void after the transplant.Which of the following would be an appropriate management strategy? A.
Performa prophylactic TURP, then proceed with transplantation B. Performa TURP at the same time as
the kidney transplant C. Place a suprapubic tube before the kidney transplant D. Start an alpha blocker
posttransplantation, and teach self catheterization if necessary E. Place a prophylactic prostatic stent,
then proceed with transplantation
4. When treating urolithiasis of a transplanted kidney, which of the following treatments is often more
difficult in the transplanted kidney? A. Retrograde ureteroscopy B. Antegrade ureteroscopy C.
Percutaneous nephrolithotomy D. Laser lithotripsy E. Extracorporeal shockwave lithotripsy
5. The placement of prophylactic ureteric stentswith kidney transplantation has been associated with
which of the following? A. High risk of stent encrustation unless removed within 3months of kidney
transplant B. Increased ureteric complications C. Higher overall cost D. More urinary tract infections
unless microbial prophylaxis is added E. Improved patient survival
6. A37-year-old female, 3 days status post kidney transplantation, presents with a ureteric leak. During
open exploration the urologist notes the transplant ureter is entirely necrotic and that there is amobile
bladder and a healthy, wellperfused native ureter available.Which of the following options would be an
appropriate management strategy? A. Cutaneous ureterostomy B. Creation of a colon conduit C. Native
ureteropyelostomy D. Creation of ileal ureter E. Percutaneous nephrostomy for 6 weeks and then reexplore
7. A42-year-oldman who received a kidney transplant 12 years ago is referred because ofnew transplant
hydronephrosis on an ultrasound. The bladder was empty. His serumcreatinine is 1.5mg/dl and has been
stable at this level for years.What would be themost appropriate next study? A. Noncontrast CT scan of
abdomen and pelvis B. DiureticMAG-3 renogram C. Surgical exploration D. Transrectal ultrasound E.
Antegrade nephrostogram
8. Atransplant center is offered a cadaveric kidney froma 53-year-old donor who died from head
trauma. Terminal creatinine was 1.6 mg/dL. Patient had a history of hypertension well controlled with 1
drug for 2 years. It is a left kidney with 2 arteries and 2 ureters. Biopsy shows 30%glomerulosclerosis.
The most likely reason to turn down this kidney is: A. High terminal creatinine B. Donor age C. 2 ureters
D. 30%glomerusclerosis E. 2 renal arteries
9. Which of the following is least likely to cause an elevation of serumcreatinine in a transplant
recipient? A. High sirolimus level B. High cyclosporine level C. Acute rejection D. BK virus infection E.
Ureteral necrosis
10. Atransplant patient has a baseline serumCr of 1.8mg/dLand takes tacrolimus,MMF and steroids.
Because of persistent hypertension, he is started on an ACE inhibitor. 1 week later the Cr is 3.1mg/dL.
Themost likely explanation is: A. Acute rejection B. Renal artery stenosis C. Hypotension and acute
tubular necrosis D. Acute renal vein thrombosis E. Tacrolimus toxicity since the ACE inhibitor raised the
blood levels
11. Which of the following is used to both prevent and treat acute rejection: A. azathioprine B.
Tacrolimus C. Cyclosporine D. Basiliximab E. Thymoglobulin
12. Which of the following would be a contraindication to receiving a kidney transplant? A. Diabetes B.
Primary ureteral reflux C. Untreated tuberculosis D. Ileal conduit E. Bladder augmentation
Answers 1.D. 2. E. 3.D. 4. A.
5.D. 6. C. 7. B. 8. D. 9. A. 10. B. 11. E (the other drugs listed only prevent rejection). 12. C.
CHAPTER 10: URODYNAMICS
1. The indications for performing UDS A. Are supported by high quality, level 1 evidence formost
conditions B. Are better defined formen vs women C. Are best defined by the clinician who has clear-cut
reasons for performing the study and will use the information obtained to guide treatment D. Are clearly
defined for women with stress urinary incontinence E. Both a and b
2. Before performing a UDS study, the clinician should: A. Decide on questions to be answered for a
particular patient B. For consistency, be prepared to perform the study the same way, nomatter what
the circumstances C. Customize the study depending on a patient’s symptoms and condition D. Both a
and b E. Both a and c
3. Which of the following is not true regarding detrusor overactivity? A. It can only be diagnosed by UDS
B. It is often associated with urinary urgency C. It is synonymous with the term“ overactive b
ladder” D. It is classified by whether or not the patient has a known neurological disease E. It can be
provoked by a cough or Valsalva maneuver
4. Detrusor pressure_____________. A. Can bemeasured directly via a transurethral catheter B. Should
remain low (near zero) during bladder filling C. Rises abruptly and returns to baseline with impaired
compliance D. Rises before the external sphincter relaxes in normal voluntarymicturition E. Both a and b
5. Which of the followingmeasures the ability ofthe urethral sphincter complex to resist changes in
abdominal pressure? A. Abdominal leak point pressure B. Detrusor leak point pressure
C.Maximumurethral closure pressure D. All of the above E. Both a and c
6. Which of the following is not a UDS risk factor for upper tract damage? A. Impaired compliance B.
Detrusor-external sphincter dyssynergia C. Poor emptying with high storage pressures D.Ahigh detrusor
leak point pressure (>40cmH2O) E. Ahigh abdominal leak point pressure (>100 cmH2O)
7. Videourodynamics_________________. A. Is themost precisemeasure of lower urinary tract function
and ideally should be used in all cases where UDS is to be performed B. Is the only way to assess
obstruction in a man C. Is the procedure of choice for documenting bladder neck dysfunction inmen and
women D. Is of limited value in patients with neurological disease, such as spinal cord injury, because of
difficulties with patient positioning E. Both c and d
Answers:
1. C. UDS has been used for decades, yet clear-cut, level-1, evidence-based indications for its use are
surprising lacking. There are a number of reasons for this. It is difficult to conduct proper randomized
controlled trials on UDS for conditions where lesser levels of evidence and expert opinion strongly
suggest clinical utility and where empiric treatment is potentially harmful or even life-threatening (eg,
neurogenic voiding dysfunction). Additionally, symptoms can be caused by a number of different
conditions and it is difficult to study pure or homogeneous patient populations. Given the current state
of evidence for UDS studies, what ismost important is that the clinician has clear-cut reasons for
performing the study and that the information obtained will be used to guide treatment of the patient.
Despite having established nomograms for BOO in men, the indications for UDS inmen are nomore
clear-cut than they are in women. UDS probably has its most important role in the diagnosis
andmanagement of patients with neuropathic voiding dysfunction.
2. E. All patients are not alike and therefore each urodynamic evaluationmay be different depending
upon the information needed to answer the questions relevant to a particular patient. Therefore, in
many cases, the study must be customized to answer specific questions for a given patient.
3. C. Detrusor overactivity is an involuntary bladder contraction seen on UDS testing which can be either
neurogenic or idiopathic. It is commonly associated with the symptomof urgency or even urgency
incontinence. It can be provoked by a cough or Valsalvamaneuver (stress-induced detrusor overactivity).
It is not the same as overactive bladder (OAB), which is a termthat describes the syndrome of urinary
urgency usually accompanied by frequency and nocturia, with or without urgency urinary incontinence
in the absence of UTI or other obvious pathology. OAB is a symptomcomplex that does not require UDS
to make its diagnosis.
4. B. Detrusor pressure normally remains low during filling as the bladder is highly compliant. It cannot
be measured directly with a transurethral catheter, but must be obtained via subtraction of abdominal
pressure fromvesical pressure.With impaired compliance, pressure increases with increasing bladder
volume, but does not return to baseline (compliance = change in pressure/change in volume).
5. E. ALPP andMUCP aremeasures of urethral function against stress. The DLPP is ameasure of bladder
function against increased sphincteric resistance.
6. E. Upper tract damage occurs as a result of high intravesical pressures during storage. Abdominal leak
point pressuremeasures outlet resistance and cannotbe demonstrated in continent patients (ie, it is well
over 100 cmH2O).
7. C. Although VUDS provides themost precise evaluation of voiding function and dysfunction and is
particularly useful when anatomic structure and function are important, it is not practical or necessary
for all centers to have VUDS capabilities. VUDS is useful for a number of conditions when an accurate
diagnosis cannot otherwise be obtained (eg, by conventional UDS), including complicated voiding
dysfunction or known or suspected neuropathic voiding dysfunction (adults and children), unexplained
urinary retention in women, prior radical pelvic surgery, urinary diversion, pre- or postrenal transplant,
or prior pelvic radiation. VUDS is the procedure of choice for documenting bladder neck dysfunction
inmen and women.
CHAPTER 11: NEUROPATHIC BLADDER: VOIDING DYSFUNCTIONS
ASSOCIATEDWITH NEUROLOGICAL DISEASE
1. All of the following statements regarding bladder compliance are true, except:
A. Bladder compliance is defined as the change in intravesical or detrusor pressure (Pdet) relative to the
corresponding change in Volume
B.Normal bladder compliance is 12.5mL/cmH2O
C. Is calculated between 2 points: the P(det) with the bladder empty at the start of urodynamic filling
and the Pdet at either the maximalcystometriccapacityorthestartofa
detrusorcontraction(involuntaryorvoluntary)
D. Compliance arises fromthe neuromuscular and biomechanical (collagenous and elastic) components
of the bladder wall.
2. The difference between the detrusor leak point pressure (DLPP) and the abdominal leak point
pressure (ALPP), 2 pressures obtained during urodynamics thatmeasure different aspects of lower
urinary tract function, is the following:
A. Howmuch fluid is in the bladder when the measurements are obtained
B.When the Pdet ismeasured during the filling phase of the urodynamic study in the presence of
increased abdominal pressure
C.When the Pdet ismeasured during the filling phase of the urodynamic study in the presence a detrusor
contraction D. The rate of urodynamic filling of the bladder
3. The following statements regarding the smooth and striated sphinctermuscle of the bladder outlet
and urethra are true, except:
A. The smooth sphincter refers to the smooth musculature of the bladder neck and proximal urethra.
B. The smoothmuscle is a physiologic and an anatomic sphincter and one that is not under voluntary
control.
C. The striated sphincter refers to the striated musculature that is a part of the outer wall of the
proximal urethra in both themale and the female is often referred to as the intrinsic or intramural
striated sphincter.
D. The bulky striated skeletalmuscle group that closely surrounds the urethra at the level of
themembranous portion in the male and primarily themiddle segment in the female is often referred to
as the extrinsic or extramural striated sphincter. E. The extramural portion is the classically described
external urethral sphincter and is under voluntary control.
4. Autonomic hyperreflexia represents which one of the following?
A. An acutemassive disordered autonomic (primarily sympathetic) response to specific stimuli in
patientswith SCI above the cord level of T6 to T8 (the sympathetic outflow).
B.Onset after injury is variable usually soon after spinal shock butmay be up to years after injury.
C. It is more common in cervical (60%) than thoracic (20%) injuries.
D. Distal cord viability is a prerequisite. E. A. and C. F. B. and D. G. D. only H. All the above
5. To differentiate detrusor-sphincter dyssynergia frompelvic floor hyperactivity or dysfunctional
voiding, which one of the following statements must be true?:
A. Failure of the sphincter to relax or stay completely relaxed during micturition must be present.
B.Uninhibited contractions on the filling part of the urodynamicsmust be present
C. Neurologic diseasemust be present.
D. Bladder sensationmust be absent.
E. Bowel dysfunctionmust be present. F. A. and B. G. C. and D. H. E. only I. All of the above
6. Cauda equina syndrome is a termapplied to the clinical picture which typically includes which of the
following criteria:
A. Loss of voluntary control of anal sphincter
B. Perineal sensory loss
C. Loss of voluntary control of the urethral sphincter
D. Loss of sexual responsiveness.
E. Loss ofmotor function of the legs
F. A. and C.
G. B. and D.
H. E. only
I. All of the above
7. Spinal cord shockmay be characterized by which of the following features:
A. It represents a period of decreased excitability of spinal cord segments at and below where the level
of injury occurs B. Itmay be short termor chronic C. It includes suppression of autonomic activity D. It
includes a suppression of somatic activity E. The bladder is acontractile and areflexic
F. A. and C.
G. B. and D.
H. E. only
I. All of the above
8. Lower urinary tract dysfunction in a classic T10 spinal cord level paraplegic patient after spinal shock
has passed would be described as follows:
A. Overactive neurogenic detrusor function
B. Absent bladder sensation
C. Overactiveobstructive urethral function
D. Low bladder capacity
E. Normal bladder compliance
F. A. and C.
G. B. and D.
H. E. only
I. All of the above
9. The voiding dysfunction of a stroke patient with urgency incontinence would best be described as
follows:
A. Overactive neurogenic detrusor function B. Normal bladder sensationC. Normal urethral function
D. Low bladder capacity E. Normal bladder compliance
F. A. and C.
G. B. and D.
H. E. only
I.All of the above
10. Which of the following comments regarding vesicoureteral reflux in the spinal cord injury (SCI)
patients are true:
A.More common in suprasacral injuries
B. Infections are a contributing factor
C. Elevated intravesical pressure during filling and emptying is a contributing factor
D. Persistent reflux can lead to chronic renal damage
E. Risk factor for decreased long termsurvival in SCI patients
F. A. and C.
G. B. and D.
H. E. only
I. All of the above
Answers
1. A.Compliance = change Volume / change Pdet (expressed asmL/cmH2O)
2. B.DLLP is defined by the ICS as the lowest detrusor pressure at which urine leakage occurs in the
absence of either a detrusor contraction or increased abdominal pressure. ALPP is defined as the
intravesical pressure at which urine leakage occurs because of increased abdominal pressure in
theabsence of a detrusor contraction.
3. B.The smooth sphincter refers to the smoothmusculature of the bladder neck and proximal urethra.
This is a physiologic but not an anatomic sphincter and one that is not under voluntary control.
4. H. All of the above. Distal spinal cord viability (incomplete or partial) has to be intact for somatic and
sensory stimuli to enter CNS systemto trigger the sympathetic outflow.
5. F. Failure of the sphincter to relax or stay completely relaxed duringmicturition is abnormal.When it
occurs in patients with neurologic disease, it is termed detrusor-sphincter dyssynergia; this typically
occurs in patients with suprasacral spinal cord injury in which there is an interruption of the
spinobulbar-spinal pathways that normally coordinate the detrusor and the sphincter. In the absence
ofneurologic disease, one cannot use the termdetrusor- sphincter dyssynergia. Instead, the termpelvic
floor hyperactivity or dysfunctional voiding is used.
6. I All of the above. Loss of legmotor function is not typically seen in Cauda equina syndrome. In
addition to all of the above findings, Cauda equina syndrome occurs secondary to disk disease (severe
central posterior disc protrusion) and other spinal canal pathologic processes as well.
7. I.All of the above.
8. I. All of the above. Generally, complete spinal cord lesions above the sacral spinal cord, but below the
area of the sympathetic outflow, result in detrusor overactivity, absent bladder sensation, and striated
sphincter dyssynergia. While normal bladder compliancemay be maintained, reduced bladder capacity is
typically noted.
9. I. All of the above. The most common type of voiding dysfunction after stroke would then be
characterized as a failure to store secondary to bladder overactivity, specifically involuntary bladder
contractions. The dysfunction wouldmost likely be classified as overactive neurogenic detrusor function,
normal sensation, low capacity, normal compliance, and normal urethral closure function during
storage; during voiding the description would be normal detrusor activity and normal urethral function
assuming that no anatomic obstruction existed. Treatment, in the absence of coexisting significant
bladder obstruction or significantly impaired contractility, is directed at decreasing bladder contractility
and increasing bladder capacity.
10. I.
All of the above. Surprisingly little is written about vesicoureteral reflux (VUR) in the SCI patient. The
reported incidence varies between 17%and 25%of such patients and ismore common in those with
suprasacral SCI. Contributing factors include: 1) elevated intravesical pressure during filling and
emptying; and 2)infection.Persistent reflux can lead to chronic renal damage and may be an important
factor in the longtermsurvival of SCI patients. In the series of SCI patients, persistent reflux was present
in 60%of patients of those dying of renal disease. In patients with only transient reflux over a 5- to 15year period, the urogramwas normal in 83%, or calyceal changes were onlyminimal. It should be noted
that high storage and voiding pressures without reflux can be responsible for renal damage. The best
initial treatment for reflux in a patient with voiding dysfunction secondary to neurologic disease or
injury is to normalize lower urinary tract urodynamics asmuch as possible.
CHAPTER 12: FEMALE UROLOGY AND URINARY INCONTINENCE
1. A55-year-oldmultiparous woman has urge incontinence. Urinalysis is normal and physical exam
demonstrates a Grade 3 cystocele. Urodynamics reveal a PVR of 100 cc, involuntary bladder contractions
with incontinence, and a detrusor pressure atmaximumflow(8mL/sec) of 50 cmH2O.When the cystocele
is reduced, no stress urinary incontinence can be elicited. The next step is:
A. Oxybutynin
B. Doxazosin
C. Pubovaginal sling
D. Anterior colporrhaphy
E. Pubovaginal sling and anterior colporrhaphy
2. A61-year-old woman becomes incontinent immediately after a transvaginal repair of Grade III
cystocele. This ismost likely due to:
A. Detrusor instability
B. Partial bladder denervation
C. Underlying urethral deficiency
D. Surgical damage to the urethral sphincter
E. Bladder neck and proximal urethral obstruction
3. A55-year-old woman underwent amidurethral sling for stress incontinence 5months ago. She now has
dysuria, urgency and frequency, despite antibiotic treatment for 2 documented UTIs. Urinalysis reveals
2- 3 RBC/hpf. Pelvic US reveals a 50 cc PVR. The next step is:
A. IVP B. Uroflowmetry C. Filling cystometry D. VCUG E. Cystoscopy
4. A60-year-old woman develops vaginal leakage of urine and is found to have a ureterovaginal fistula 5
days after abdominal hysterectomy. Retrograde shows a fistula 2 -3 cmabove the bladder. Attempts to
pass a stent retro and antegrade are unsuccessful. The most appropriate management is:
A. Observation B. Ureteroneocystostomy C. Ureteroureterostomy D. Perc nephrostomy
5. 3 weeks after anMMK, a 40-year-old woman develops pelvic and suprapubic pain and a fever of
101°F. She experiences difficulty adducting her thighs and has pain to palpation on pubis. The most likely
diagnosis is:
A. Osteitis pubis B. Osteomyelitis pubis C. Obturator nerve injury D. Urinary extravasation
E. Pelvic abscess
6. A62-year-old woman complains of UI and difficulty initiating voiding 12months after a needle
suspension for SUI. Her PVR is 120mLand mid-voiding pressure is 52 cmH2O during an uninhibited
contraction. The best treatment is:
A. CIC B. Ditropan and timed voiding C. Urethral dilation D. Removal of suspension suture E.
Transvaginal urethrolysis
7. A74-year-old female with SUI and DI would like to avoid surgery. The best pharmacologic approach is:
A. Ditropan B. Detrol C. Imipramine D. Terazosin E. Ephedrine
8. A75-year-old woman has recurrent cystitis. PE demonstrates Grade I cystocele and atrophic vaginitis.
PVR 45 cc IVP and VCUG are normal. The bestmanagement is:
A. Vaginal pessary B. Oral estrogen C. Intravaginal estrogen D. Prophylactic antibiotics
9. A54-year-old woman S/PXRT for cervical cancer 2 years ago developsmicrohematuria. TUR of a lesion
2 cmabove the LUO reveals an inverted papilloma. 3 days postop, she develops a vesicovaginal fistula.
The best treatment is:
A. Immediate transvaginal repair B. Transvaginal repair in 6months C. Immediate transabdominal repair
D. Transabdominal repair in 6months E. Urinary diversion
10. A64-year-old female S/PMMK 5 years ago, and transvaginal needle suspension 1 year ago still has
severe urinary incontinence. She leaks with and without physical activity. The best diagnostic test is:
A. Urethral pressure profile B. Video urodynamics C. Cystometry D. VCUG E. CMG EMG
11. A64-year-old woman has a Grade IVcystocele without urinary incontinence. To determine if she
needs a concomitant anti-incontinence surgery with the cystocele repair, she should undergo:
A. PelvicMRI B. Urethral pressure profilometry C. Urodynamics with a pessary D. Cysto E. Uroflow with
PVR
Answers
1. D.This patient suffers frombladder outlet obstruction secondary to a large cystocele, as indicated by a
high voiding pressure and low flow rate. The obstruction secondarily causes detrusor overactivity and
subsequent urge incontinence. Despite reducingthe cystocele, no stress incontinence can be elicited,
indicating good support of the urethrovesical junction.The best treatment is to repair the cystocele with
a technique such as anterior colporrhaphy. The absence of stress incontinence precludes the need for a
pubovaginal sling and, if performed alone, is likely to increase the postvoid residual. Although doxazosin
can be used for female bladder outletobstruction, when possible, the best treatment is to correct the
underlying abnormality.
2. C.Themost common cause of the onset of urinary incontinence after repair of a large cystocele is
underlying urethral dysfunction, which is unmasked by reduction of the cystocele. Cystocele repair
should not cause incontinence due to urethral orbladder denervation or obstruction of the proximal
urethra. Cystocele repair is typically associated with improvement in both bladder emptying and urge
incontinence. Thus, either urethral hypermobility or intrinsic sphincter deficiency is likely to be the
cause of incontinence in this setting.
3. E.Cystoscopy is necessary to exclude the possibility of a foreign body in this setting.
4. B.In a healthy patient, fistula repairmay be undertaken early. Since the attempts to catheterize the
ureter failed, it is unlikely that this will heal withobservation. Themore distal portion of the ureter may
be injured as well and repair should be done with a ureteroneocystostomy.
5. A.These are classic signs and symptoms of osteitis pubis. Occurs in up to 2.5%of patients afterMMK.
Osteomyelitis is possible but far less common than osteitis. Obturator nerve injury (usually secondary to
retractors) can occur but typically does not presentat 3 weeks (present immediately).
6. E.This patient is obstructed, as evidenced by her elevated voiding pressure and elevated PVR.
Ditropan is contraindicated because of the obstruction. CIC will not solve the problemor control the DI.
The suspension should be taken down with urethrolysis.
7. C.Imipramine has both a strong inhibitory action on bladder smoothmuscle and a stimulant effect on
the bladder outlet. The net result is it promotes urinary storage by preventing DI and increasing urethral
resistance.
8. C.Aftermenopause, diminished levels of glycogen are produced as a result of decreased estrogen
production.This alters the vaginal flora, resulting in adecrease in the normally dominant
lactobacilli.Vaginal pH rises, resulting in an overgrowth of enteric organisms. In a randomized doubleblind trial, intravaginal estrogen decreased the incidenceof UTIs in postmenopausal women with
recurrent UTIs.
9. C.In a patient with NO evidence of abscess formation or fluid collection, there is little need to wait
before fixing the fistula. The abdominal approach provides better access to a radiation-induced fistula
and allows for an omental pedicle to be interposed between the bladder and vaginal wall.
10. B. In a patient who has had 2 prior failed surgeries, indepth testing is required. Only UDS will
determine if the patient has involuntary bladder contractions, elevated voiding pressures, low VLLP and
urethral hypermobility.
11. C.Many women develop de novo SUI after cystocele repair due to the poor support of the urethra.
Preop UDS should be performed with a pessary or vaginal packing to assess the competence of the
bladder neck with proper bladder support. Afilling CMG to assess for DI and a VLLP should be
performed.
Medical management of stones diseases
Case 1
A 65-year-old African American female with an 8- year history of recurrent stone formation reports
having spontaneously passed 35 stones. She has required 3 ureteroscopic laser stone fragmentations
and 1 percutaneous nephrolithotripsy. Current radiographs reveal 3 small stones in the left intrarenal
collecting system and 2 in the right. This patient’s medical history is significant for inflammatory bowel
disease. There is a family history of nephrolithiasis in one sibling.
24-hour Urine Collections Normal Range Initial Visit Vol >2,000 mL/d 1,320 pH 5.5 –6.7 5.51 Calcium
<200 mg/d 85 Sodium <200 mg/d 95 Potassium <60 meg/d 45 Uric acid <600 mg/d 375 Oxalate <45
mg/d 78 Citrate >600 mg/d <20 Magnesium >60 mg/d 50 SO4 <20 mg/d 8 Cystine 0 mg/L 0
Serum Values Sodium 135–145 mEq/L 138 Potassium 0.2 –4.8 mEq/L 3.5 Chloride 98 –108 mEq/L 107
Bicarbonate 21 –30 mEq/L 20 Creatine 0.7 –1.4 mg/dL 1.1 Calcium 8.7 –10.2 mg/dL 9.2 Phosphorus 2.3 –
4.3 mg/dL 3.1 Uric acid 2.5 –8.0 4.5 PTH 13 –64 ng/mL 48
1. This condition is best described as: A. Primary hyperoxaluria B. Gouty diathesis C. Distal renal tubular
acidosis D. Enteric hyperoxaluria E. Hyperuricosuria
2. The risk factor most associated with recurrent stone formation secondary to this condition is: A.
Hyperabsorption of oxalate in the jejunum B. Hyperexcretion of calcium from the distal tubule C.
Diminished citrate absorption in the terminal ileum D. Hyperabsorption of calcium in the small bowel E.
Increased colonic absorption of free oxalate
3. The optimum treatment for patients with this disorder would include: A. Calcium supplements,
potassium citrate, increased oral fluid intake B. Dietary restriction of oxalate C. Thiazides and potassium
citrate D. Allopurinol E. Pyridoxine
Case 2
A 50-year-old obese Caucasian male is evaluated for a 2-day history of left flank pain without fevers,
nausea or emesis. He has a prior history of stone disease for 6 years and has spontaneously passed 4 –5
stones. He’s had no prior surgeries for calculus disease and family history is negative for nephrolithiasis,
but positive and family history is negative for nephrolithiasis, but positive for gout. No stones are seen
on the plain abdominal radiographs. Prior stone composition contains mixed calcium oxalate.
24-hour Urine Collections Normal Range Initial Visit
Vol >2,000 mL/d 1,300 pH 5.5 –6.7 5.12 Calcium <200 mg/d 140 Sodium <200 mg/d 170 Potassium <60
mEq/d 35 Uric acid <600 mg/d 285 Oxalate <45 mg/d 35 Citrate >600 mg/d 220 Magnesium >60 mg/d
70 SO4 <20 mg/d 24 Cystine 0 mg/L 0
Serum Values Sodium 135–145 meg/L 140 Potassium 3.2 –4.8 mEq/L 4.2 Chloride 98 –108 mEq/L 102
Bicarbonate 21 –30 mEq/L 27 Creatinine 0.7 –1.4 mg/dL 0.9 Calcium 8.7 –10.2 mg/dL 2.8 Phosphorus
2.3 –4.3 mg/dL 2.8 Uric acid 2.5 –8.0 mg/dL 7.7 PTH 13–64 ng/mL 43
4. The most important factor predisposing patients to this metabolic disorder is: A. Hypercalciuria B. Low
urinary pH C. Hypocitraturia D. Low urine volumes E. Hyperuricosuria
5. The most appropriate medical treatment of this condition is:
A. Allopurinol B. Thiazides C. Increased fluids D. Dietary calcium restriction E. Potassium citrate
Case 3
A 58-year-old Hispanic female is seen by her family physician with a history of recurrent urinary tract
infections treated 3–4 times in the last 18 months. At present, she is asymptomatic. She denies a history
of nephrolithiasis. Renal ultrasound demonstrates moderate left hydronephrosis and a large density
within the renal pelvis with posterior shadowing.KUB with tomography reveals a poorly opacified stone
involving the renal pelvis and lower pole calyces. Prior urine cultures have grown Proteus and Klebsiella
species. Following uncomplicated left percutaneous nephrolithotomy, she returns with the following
metabolic results:
24-hour Urine Collections Normal Range Initial Visit
Vol >2,000 mL/d 1,600 pH 5.5–6.7 6.9 Calcium <200 mg/d 210 Sodium <200 mg/d 120 Potassium <60
mEq/d 40 Uric acid <600 mg/d 360 Oxalate <45 mg/d 20 Citrate >600 mg/d 110 Magnesium >60 mg/d
80 SO4 <20 mg/d 10 Cystine 0 mg/L 0
Serum Values Sodium 135 –145 mEq/L 136 Potassium 3.2 –4.8 mEq/L 3.8 Chloride 98 –108 mEq/L 98
Bicarbonate 21 –30 mEq/L 22 Creatinine 0.7 –1.4 mg/dL 1.6 Calcium 8.7
–10.2 mg/dL 9.5 Phosphorus 2.3–4.3 mg/dL 3.1 Uric acid 2.5 –8.0 mg/dL 6.6 PTH 13 –64 ng/mL 28
6. The stone composition of this patient is most likely: A. Calcium oxalate B. Uric acid C. Magnesium
ammonium phosphate D. Cystine E. Hydroxyapatite
7. The most common cause of recurrent stone disease in a patient having undergone “sandwich”
therapy (PNL followed by
SWL) for a staghorn calculus is: A. Hypomagnesuria B. Hyperoxaluria C. Retained stone fragments D.
Renal tubular acidosis
E. Hypercalciuria
8.
Acetohydroxamic acid contributes to reducing infection stone formation by: A. Reversing associated
metabolic defects B. Preventing recurrent urinary tract infections C. Alkalinization of the urine D.
Irreversibly inhibiting urease E. All of the above
Case 4
A 12-year-old male is seen for evaluation of recurrent nephrolithiasis. He has spontaneously passed 3
stones over the previous 4 years, and has recently undergone shock wave lithotripsy twice without
success. He has been treated in the past with an unknown medication, but was discontinued because
the parents felt it was of no benefit. Family history is negative for stone disease.
24-hour Urine Collections Normal Range Initial Visit
Vol >2,000 mL/d 550 pH 5.5 –6.7 5.4 Calcium <200 mg/d 110 Sodium <200 mg/d 117 Potassium <60
mEq/d 39 Uric acid <600 mg/d 215 Oxalate <45 mg/d 22 Citrate >600 mg/d 260 Magnesium >60 mg/d
80 SO4 <20 mg/d 7 Cystine 0 mg/L/day 1,345
Serum Values Sodium 135 –145 mEq/L 140 Potassium 3.2 –4.8 mEq/L 4.1 Chloride 98 –108 mEq/L 108
Bicarbonate 21 –30 mEq/L 23 Creatinine 0.7–1.4 mg/dL 0.8 Calcium 8.7 –10.2 mg/dL 9.0 Phosphorus
2.3 –4.3 mg/dL 4.0 Uric acid 2.5 –8.0 mg/dL 5.9 PTH 13 –64 ng/mL 43
9. The likely metabolic diagnosis contributing to this patient’s recurrent stone formationis: A.
Hypocitraturia B. Hyperoxaluria C. Low urine volumes D. Gouty diathesis E. Cystinuria
10. Alpha-mercaptopropionylglycine (Thiola®) may be helpful in the management of cystinuria, since it:
A. Acts as a diuretic, further decreasing urinary cystine concentration B. Is significantly more effective
than dpenicillamine C. Can be used as both an oral and intrarenal chemolytic agent D. Has equivalent
efficacy at increasing solubility with reduced toxicity as compared to D-penicillamine F.Adequately
alkalinizes the urine, obviating the need for potassium citrate
Case 5
A 19-year-old Caucasian female with a 6-year history of recurrent stone disease is found to have
multiple bilateral renal calculi by renal ultrasound during an evaluation for recurrent flank pain. She
reports having passed >10 stones in the previous 2 years. Review of the renal ultrasound indicates no
evidence of hydronephrosis. KUB and tomograms demonstrate 5 stones on the left and 8 stones on the
right, all <4 mm in size. She has a strong family history of stones with 3 first-degree relatives and 2
cousins with nephrolithiasis. Stone compositions have been mixed calcium phosphate and calcium
oxalate.
24-hour Urine Collections Normal Range Initial Visit
Vol >2,000 mL/d 1,425 pH 5.5 –6.7 6.94 Calcium <200 mg/d 260 Sodium <200 mg/d 160 Potassium <60
mEq/d 28 Uric acid <600 mg/d 410 Oxalate <45 mg/d 32 Citrate >600 mg/d 140 Magnesium >60 mg/d
66 SO4 <20 mg/d 13 Cystine 0 mg/L 0
Serum Values Sodium 135–145 mEq/L 142 Potassium 3.2 –4.8 mEq/L 3.3 Chloride 98 –108 mEq/L
107Bicarbonate 21 –30 mEq/L 21 Creatinine 0.7 –1.4 mg/dL 0.9 Calcium 8.7 –10.2 mg/dL 9.2 Phosphorus
2.3 –4.3 mg/dL 2.2 Uric acid 2.5 –8.0 mg/dL 4.1 PTH 13 –64 ng/mL 58
11. The most definitive test to identify this disorder would demonstrate: A. Decreased serum
parathyroid hormone levels B. Persistently elevated urine calcium C. Inability to reduce the urine pH
below 5.5 D. Normalization of hypercalciuria E. Marked increase in urinary uric acid levels with initiation
of treatment
Case 6
A 49-year-old Caucasian female with a 4-year history of stone disease has passed 6 stones
spontaneously,3 in the last year. Noncontrast renal CT demonstrates a 2-mm calcification in each kidney
without secondary signs of obstruction. Previousstone analysis has revealed a mixed composition of
calcium phosphate and calcium oxalate. She had been treated with hydrochlorothiazide in the past, but
this medication was discontinued after 3 months of therapy. Her family history is significant for a
brother and grandmother with stones. She is otherwise healthy and has prior surgical history.
24-hour Urine Collections Normal Range Initial Visit Vol >2,000 mL/d 1,800 pH 5.5 –6.7 5.8 Calcium
<200 mg/d 335 Sodium <200 mg/d 230 Potassium <60 mEq/d 38 Uric acid <600 mg/d 472 Oxalate <45
mg/d 29 Citrate >600 mg/d 680 Magnesium >60 mg/d 70 SO4 <20 mg/d 15 Cystine 0 mg/L 0
Serum Values Sodium 135 –145 mEq/L 138 Potassium 3.2 –4.8 mEq/L 4.3 Chloride 98 –108 mEq/L 102
Bicarbonate 21 –30 mEq/L 25 Creatinine 0.7 –1.4 mg/dL 1.3 Calcium 8.7 –10.2 mg/dL 9.1 Phosphorus
2.3 –4.3 mg/dL 2.8 Uric acid 2.5 –8.0 mg/dL 5.1 PTH 13 –64 ng/mL 18
12. The primary defect in this condition is considered to be: A. Primary hyperabsorption of intestinal
calcium B. Hypersecretion of parathyroid hormone C. Renal leak of calcium D. Bone disease E. Excessive
dietary intake of calcium-containing foods
Answers Case 1 1. D.Enteric hyperoxaluria is a disorder most commonly affecting patients with
inflammatory bowel disease, particularly intestinal segments involving the smallintestine. Fat
malabsorption is the hallmark condition predisposing to saponification and sequestering of calcium to
be passed in the stool. Less calcium is available in the GI tract to bind oxalate, thereb allowing more
oxalate to be absorbed with a relative increase in urinary oxalate. Primary hyperoxaluria is an
autosomal-recessive disorder manifest only in the homozygous state. Unless effectively treated early,
primary hyperoxaluria typically runs a malignant course with early death from renal failure.
2. E.Intestinal hyperabsorption of oxalate in patients with enteric hyperoxaluria is the most significant
risk factor leading to recurrent calculus formation.Intestinal transport of oxalate is primarily increased
because of the effects of bile salts and fatty acids on the permeability of colonic intestinal mucosa to
oxalate. The total amount of oxalate absorbed may also be increased because of an enlarged
intraluminal pool of oxalate available for absorption. Intestinal fat malabsorption characteristic of ileal
disease will exaggerate calcium soap formation, limit the amount of “free” calcium to complex to
oxalate, and thereby raise the oxalate pool available for absorption.
3. A.The initial goals of medical management are to rehydrate and reverse metabolic acidosis. Hydration
is at times difficult in some patients as an increase in oral fluids may exacerbate diarrhea.Hydration and
potassium citrate will contribute to the reversal of the metabolic acidosis, as well as enhance the
excretion of citrate to increase its inhibitory effects on stone formation. Calcium supplements will bind
excess oxalate within the intestine thereby reducing intestinal oxalate absorption. Calcium citrate may
offer an ideal calcium supplement in this condition as it should reduce urinary oxalate and increase
urinary citrate. Thiazides may worsen metabolic acidosis and hypokalemia through its diuretic effects
and renal potassium losses. Colon resection may be of benefit in those patients refractory to medical
management, as the primary site of intestinal absorption of oxalate is the large bowel.
Case 2 4. B.Although low urine volumes and hyperuricosuria contribute to the possibility of uric acid
stone formation, the most critical determinant of the crystallization of uric acid remains urinary pH. In
addition, uric acid stones may be formed in patients with primary gout with associated severe
hyperuricosuria and other secondary causes of purine overproduction, such as myeloproliferative states,
glycogen storage disease and malignancy.
5. E. Allopurinol will decrease the production of uric acid by inhibiting xanthine oxidase in the
purinemetabolic pathway, but is most effective in patients with extremely elevated levels of uric acid
(urinary uric acid >1,500 mg/day). In addition, increasing total urine volume will decrease the
concentration of uric acid to assist in preventing stone formation. However, raising the urinary pH above
the dissociation constant of uric acid is the key to prevent recurrent uric acid stone formation and
correcting gouty diathesis. The urine pH should be maintained between 6.0 and 6.5. Thiazides and
calcium restriction have a limited role in the medical treatment of uric acid stone patients.
Case 3 6. C.Ascending urinary tract infections with urea-splitting organisms, such as Proteus species, will
metabolize urea to ammonia. Ammoniuria, in conjunction with a matrix composed of organic
compounds, carbonate apatite, inflammatory cells and bacteria, results in the rapid formation of an
“infection” calculus, eventually progressing into a mineralized, dense stone. Bacteria trapped within the
stone perpetuate the recurrent urinary tract infections and further stone formation, eventually
developing into the classic staghorn calculus.
7. C. After removal of an infected struvite calculus, the most common cause of recurrent stone
formation is failure to completely eradicate the urinary tract infection. Surgical therapy may leave
retained fragments of infected stone within calyces, thus allowing infection to persist. Underlying
metabolic disorders may also contribute to recurrent stone formation, but persistent infection remains
the most important risk factor.
8. D. Acetohydroxamic acid (AHA), a competitive inhibitor of the bacterial enzyme urease, will reduce
the urinary saturation of struvite and retard stone formation. When given at a dose of 250 mg orally TID,
this medication can prevent the recurrence of new stones and inhibit the growth of existing stones in
patients with chronic urea-splitting infections.
AHA can also cause dissolution of small stones. However, up to 30% of patients will experience minor
side effects, including headache, nausea, vomiting, anemia, rash or alopecia. In addition, 15% of patients
have developed deep venous thrombosis while on long-term treatment. Therefore, careful monitoring is
required when using this medication.
Case 4 9. E. Cystinuria is a complex autosomal-recessive disorder of amino acid transport involving
cystine, ornithine, lysine and arginine. Supersaturation of the urine will occur in patients with the
homozygous state. Therefore, it is unusual to see a family history with cystine stones. The age of onset
is often in the 1st or 2nd decade of life.
10. D. d-penicillamine and alpha-mercaptopropionylglycine are equally effective in their ability to
decrease urinary cystine levels. However, studies have demonstrated that alpha-MPG is significantly less
toxic than d-penicillamine. Moreover, the side effects that may occur with alpha-MPG are also
lesssevere. However, if a patient has been doing well on d-penicillamine with no significant
complications, there is no need to switch medications.
Case 5 11. C. Renal tubular acidosis is a clinical syndrome of chronic metabolic acidosis resulting from
renal tubular abnormalities, while glomerular filtration is relatively well preserved. Although patients
may present with many different symptoms and physicalfindings, renal stone formation is a wellrecognized manifestation of distal renal tubular acidosis (dRTA). Patients with the incomplete form of
dRTA are not persistently acidemic despite their inability to lower urinary pH with an acid load. These
patients are able to compensate for their acidification defect and remain in acid-base balance by
increasing ammonia synthesis and ammonium excretion as a buffering mechanism. The initial
identification of incomplete dRTA is often a chance finding. Many of these patients will present with
recurrent nephrolithiasis or may be referred for evaluation after the discovery of nephrocalcinosis after
routine abdominal radiographs. Most patients will have normal serum electrolytes, yet they will have a
high-normal urine pH along with significant hypocitraturia. The diagnosis of incomplete dRTA can be
confirmed by inadequate urinary acidification after an ammonium chloride loading test.
Case 6 12. A.The basic abnormality in absorptive hypercalciuriatype I is the intestinal hyperabsorption of
calcium.The consequent increase in the circulating concentration of calcium enhances the renal filtered
load and suppresses parathyroid function. Hypercalciuria results from the combination of increased
filtered load and reduced renal tubular reabsorption of calcium, a function of parathyroid suppression.
The excessive renal loss of calcium compensates for the high calcium absorption from the intestinal tract
and helps to maintain serum calcium in the normal range.
Surgical magement of stone diseases 1.
Themainmethod of stone fragmentation in SWLis: A. Tensile forces on the leading edge of the stone B.
Cavitationmechanics at the stone surface C. Compressive forces at the stone-fluid interface D. Tensile
forces on the exiting edge of the stone E. All of the above
2. All of the following are true statements except: A. SWLis not recommended for calcium oxalate
monohydrate and cystine stones due to their relative resistance to fragmentation B. Staghorn stones
should not be treated with SWL because they do not fragment well C. Upper ureteral stones <10mmin
diameter can be treated effectively with SWL D. Distal stones >10mmshould not be considered for
SWLas first-line therapy
3. All are true statements regarding SWLexcept: A. Themost common nonurologic injury in the pediatric
population who undergo SWL is lung or pleural injury B. Pre-stenting appears to improve stone-free
rates and reduce hospital re-admissions C. IVP is no longer necessary prior to treatment with SWL. Noncontrast CT suffices as an imaging study D. In situ SWLof ureteral calculi is an acceptable technique for
treating proximal ureteral stones <10mm
4. All of following are true statements regarding post-SWL hematoma except: A. Hypertension, diabetes,
obesity, coronary artery disease are risk factors for development of post-SWLhematomas B. Subclinical
hematomas are common (30%) but clinical post-SWLhematomas are rare (0.2%–4%) C. The most
common presenting sign of a postoperative hematoma is tachycardia and hypotension D. Patients
suspected of having a hematoma should be admitted, placed on bedrest, have serial hematocrits
checked and undergo imaging (CT or renal USN).
5. Patient undergoes a PCNL. Postoperatively, patient develops feca lmaterial in the nephrostomy tube.
Patient is afebrile and abdominal exam is unremarkable. ACT is done of the nephrostomy tube
traversing the colon. All of following are recommended steps except: A. Broad-spectrumantibiotics B.
Immediate exploratory laparotomy and diverting colostomy. C. Make patient NPO, alimentation D.
Placement of a internal ureteral stent, reposition of nephrostomy tube into the colon to act as a
temporary colostomy tube
6. Patient undergoes a PCNLand during the case a large perforation of themedial pelvis is noted. The
next proper course of action is: A. Continue PCNLbutmake sure to use a working sheath andmonitor the
irrigation flow B. Stop the procedure. Place a large nephrostomy tube. Repeat N-gramin 2 –3 days. If
perforation resolves, then continue with PCNL C. Stop the procedure and place a drainage catheter.
Repeat N-gramin 2 –3 weeks to ensure that perforation has adequate time to heal D. Remove the
working sheath and place a JJ ureteral stent 7. Patient undergoes a single-puncture PCNL via a lower
pole for a 2-cmstone and is rendered stone-free. 2 weeks postop, he presents with a brief episode of
gross hematuria after walking at home.What is themost likely cause of his bleeding? A. Perinephric
hematoma B. Bleeding fromthe healing perc site, which is exacerbated by his increased activity C.
Passage of a small stone fragment D. Arteriovenous fistula
Answers 1. E. 2. B. 3. B. 4. C. 5. B. 6. B. 7. D.
CHAPTER 15: RENAL PARENCHYMAL AND UPPER URINARY TRACT UROTHELIAL
NEOPLASMS 1.
Which of the following hereditary renal tumor syndromes is incorrectly paired with its appropriate
gene? A. Von Hippel Lindau – 3p B. Birt Hogg Dube – 17p C. Hereditary Papillary RCC – 7p D. Hereditary
Leiomyoma RCC – 1q E. Tuberous Sclerosis – 9q
2. Which of the following is true regarding the VHLgene and its pathway A.Mutation of VHLis primarily
epigenetic (ie not a sequencemutation) B. The VHLgene is an oncogene C. The VHLprotein is
physiologically overexpressed during times of excess oxygen tension D. HIF proteins are overexpressed
as a function ofmutated VHLgene/protein E. The VHLprotein is a transcriptional factor
3. Which of the following is true regarding the Bosniak classification of renal cysts? A. The Bosniak
classification of renal cysts is an ultrasound based system B.Hyperdense cysts are classified as Bosniak III
C. Simple renal cysts(Bosniak I) are confirmed only on contrast based cross sectional imaging D.
ABosniak IIF has a risk of occult cancer in excess of 65% E. Calciumwithin the wall of a cyst can occur in
Bosniak II, III or IVlesions
4. Which is true regarding Nephrogenic Systemic Fibrosis? A. It typically occurs within 24 hours of
gadoliniumadministration B. It causes a fibromyalgia type syndrome C. It occursmost commonly in
patients with an estimated GFR between 30 and 60 cc/min D. Itmay be fatal E. If is does not happen
after a single dose of gadoliniumit is unlikely to occur with future dose
5. Which is true about infrarenal thrombus incases of IVC involvement? A. Typically the thrombus below
the renal veins is bland and need not be fully resected butmay require anticoagulation or caval
interruption B. Themajority of thrombusmust be assumedmalignant until proven otherwise C. Tumor
thrombus has been known to release IL6 and cause paraneoplastic syndromes D.Malignant infrarenal
tumor thrombus typically stops at the femoral veins E. Infrarenal thrombus is a poor prognostic sign
6. Which is true regarding adrenalectomy during surgery for RCC? A. Routine removal is safe and
recommended B. The adrenal gland is commonly involved in pT2 lesions and should be removed in all
lesions >7cm C. Involvement of the adrenal is now staged as T4 D. Partial adrenalectomy is never
acceptable E. Involvement of the contralateral adrenal is the only indication to preserve the ipsilateral
adrenal
7. Which of the following is true about paraneoplastic syndromes in RCC A. IL-8 is thought to cause
hepatic dysfunction (Stauffer’s syndrome)B.Hyperlipidemia is a common paraneoplastic syndrome
C.Hypertension associated with RCC is always aldosteronemediated D. Hypercalcemiamay be associated
with PTH production E. Hand and foot syndrome is common
8. Which of the following is true of sunitinib? A. It is anmTOR inhibitor B. It is an antibody to VEGF-R C. It
directly inhibits HIF D. It ismediated via blockade of tyrosine kinases E. It is associated with a 6080%overall response rate
9. Regarding the adverse events for targeted therapies, which is paired correctly? A.mTOR
inhibitors – hand and foot syndrome B. VEGFR antibodies – stomatitis C. TKIs – hyperlipidemia D.
TKIs – left ventricular dysfunction E. VEGFR antibodies – hypothyroidism
10. Which of the following is true of cisplatin based chemotherapy for upper tract urothelial carcinoma
A. There are level 1 data to support its use in the neoadjuvant setting B. There are level 1 data to
support its use in the adjuvant setting C. Its primarymode of action is to inhibit DNAcovalent bond and
cross linking D. Its primarymode of action is to inhibit microtubules E. There is little activity when used
as a single agent in urothelial carcinoma
Answers: 1. C. The genetics of renal tumor syndromes have increasinglybeen unraveled using large
familial pedigrees, linkage analysis and ultimately isolation and sequencing of the responsible gene. Of
those listed,C is incorrect – HPRCC is associated with the cMet gene – an oncogene located on the long
armof 7 (7q31). HPRCC is the only hereditary syndrome with no extra-renalmanifestations
2. D. VHLfollows an autosomal dominant inheritance pattern. It is a tumor suppressor gene thatfollows
Knudsen’s two hit hypothesis,meaning both alleles must bemutated for it to function abnormally. The
VHLprotein has been shown to regulate HIF transcription factors which are normally only overexpressed
during hypoxia. However,mutant VHL leads to over expression of HIF under normoxia
3. E. The Bosniak classification is a CT based systemfor categorizing renal cysts. It requires pre and
postcontrast images. That said, a simple cyst has definitivecharacteristics on US (no internal echos, good
through transmission with posterior wall enhancement). Hyperdense (hemorrhagic or proteinaceous)
cysts are Bosniak II. Bosniak IIF cysts do notmeet strict criteria for either II and III and are generally
followed (hence the termF). Their risk of cancer is considered lower than a true Bosniak III. Thin linear
calciumcan occur in BII cysts. Chunky or thick calcium is a more worrisome sign (BIII or IV)
4. D. NSF is a scleroderma like reaction in patients receiving gadoliniumin the setting of severe renal
impairment (eGFR<30). It can occur up to 3mo ormore after exposure and itmay be related to
cumulative exposure, although it has been reported following a single doseand can becan be fatal
5. A. Infrarenal tumor thrombus is typically bland. Clues on anMRImay be seen including lack of
enhancement and flow around the clot. It need not be fully resected but a strategy to prevent
embolimust be employed including caval interruption and/or anticoagulation.
6. C. Adrenalectomy is reserved for large upper pole renal tumors althoughmore recent data suggest
that even in this circumstance routine adrenalectomymay be unnecessary. Adrenal involvement is a
poor prognostic sign and is now considered T4 disease
7. D.Stauffer’s syndrome is thought to be cytokinemediated (IL-6). Hand and foot syndrome and
hyperlipidemia are side effects of targeted therapy. Hypertension associated with RCC is primarily
rennin mediated. Hypercalcemia associated with RCC may be due to bonymetastases or a PTH
paraneoplastic syndrome
8. D. Sunitinib and other tyrosine kinase inhibitors havealtered the therapeutic landscape formRCC.
They work by blocking themessage of the receptor when bound by ligand which decreases cell survival
mechanisms. Overall response rates are 30-40%
9. D. Systemic therapies for RCC are associated with a large number of potential adverse events. Of
those above, TKIs are associated with LVdysfunction and ejection fraction is oftenmeasured prior to
initiating therapy.
10. C. Cisplatin is one of themost potent chemotherapeutic agents for urothelial carcinoma. There are
currently no level 1 data for its use in upper tract UCC. Its mechanismof action is the inhibition of DNA
cross linking
CHAPTER 16: PROSTATE CANCER CHAPTER 17: NON-MUSCLE INVASIVE BLADDER
CANCER 1.
A43-year-old woman whose 55-year-old brother was recently diagnosed with bladder cancer seeks
advice fromyou regarding her own risk. Her history is notable for pelvic radiation 9 years earlier for
cervical cancer. She has smoked 1-1/2 packs per day since age 20, drinks 4-5 cups of artificially
sweetened coffee per day and works as a hair stylist specializing in colorization. She had frequent UTIs
as a child.Which of the following would constitute legitimate risk factors for the development of bladder
cancer in her case? A. Female gender, pelvic radiation, smoking B. Pelvic irradiation, smoking, coffee
consumption, prior UTIs C. Family history, pelvic radiation, smoking, artificial sweetener use D. Pelvic
radiation, smoking, occupation E. Female gender, family history, prior cervical cancer
2. 2 years after resection of a stage T1 highgrade lesion with glandular differentiation fromthe right
lateral wall and BCG therapy withmaintenance X 1 year, a suspicious lesion is found in a similar location
and resected. Histology reveals a nephrogenic adenoma.Which of the following statements best reflects
the clinical significance and implication of this result? A. This is a premalignant lesion that is strongly
associated with the subsequent development of adenocarcinoma. The lesion should be reresected then
closely followed cystoscopically with periodic biopsies. B. This is a variant formof transitional cell
carcinoma associated with a high probability of muscle invasion, lymph node involvement or
distantmetastasis. Radical cystectomy is indicated with possible adjuvant chemotherapy depending on
the findings. C. This is a variant formof bladder carcinoma with a strong predisposition to metastasize
and should be treated with cisplatinum-basedmultiagent chemotherapy. D.While notmalignant, this
lesion is strongly associated with recurrence. A repeat BCG induction course with further maintenance
therapy should be started. E. This is a benign inflammatory lesion. Only routine periodic cystoscopy is
required.
3. Which of the following immunohistochemistry profiles for a bladder tumor would be associated with
themost aggressive tendencies? A.High p53 and Rb staining, low Ki67 and E-cadherin B. High p53 and
Ki67 staining, absent Rb and E-cadherin C. High Rb and E-cadherin, low p53 and Ki67 D.High Ki67 and Rb,
low p53 and E-cadherin E. Low p53, Rb, E-cadherin and Ki-67
4. A65-year-old otherwise healthyman with gross hematuria and negative CT urogram has a 1.5cmlesion found on cystoscopy that is subsequently resected to reveal stage T1, high-grade TCC with
deep invasion of the submucosa but no involvement of the scant muscle present. Themost appropriate
next step would be: A. Bring patient back for circumferential biopsies around the tumor resection bed as
well as randombladder biopsies to determine suitability for a partial cystectomy. B. Begin a course of
BCG therapy 3 weeks later with plans to cystoscope and possibly biopsy 6 weeks after completing the
BCG therapy. C. Strongly advise the patient to consider radical cystectomy at this point given the
aggressive nature of the disease D. Reresect the patient within the next 4 weeks to determine whether
there is residual disease or deeper disease present E. No further treatment at present. Use the results of
the 3-month cystoscopy to determine whether further treatment is indicated
5. A69-year-old otherwise healthy woman has a 2.5-cmtumor identified on cystoscopy for workup of
recurrent painless gross hematuria. An IVP is negative and voided cytology is negative for tumor cells.
The appropriatemanagement plan would be: A. Transurethral resection under anesthesia with
randombladder biopsies B. Transurethral resection with administration of mitomycin within the first few
hours of surgery provided there is no significant bleeding or perforation recognized C. Transurethral
resection with bilateral ureteral wash cytologies D. Transurethral resection with administration of BCG
within the first few hours of surgery provided there is no significant bleeding or perforation recognized
E. Office biopsy of the lesion under local anesthesia to determine grade as a guide for future
management
6. Which of the following is true regarding papillary neoplasms of lowmalignant potential (PUNLMP)? A.
They encompass some formerly described papillomas and grade 1 transitional cell carcinomas. B.
Reresection required with deep biopsies of tumor base and immediate instillation of mitomycin. C.
Begin a full course of BCG therapy 3 weeks later with plans for subsequent maintenance therapy to
reduce progression risk. D. Begin a 6-week course ofmitomycin with no definitive plans formaintenance
at this time. E. Return to operating room for more complete staging evaluation, including random
bladder biopsies, upper tract washes and prostatic urethral biopsies.
7. Which of the following intravesical agents is unlikely to cause local tissue inflammation or necrosis if
administered in the presence of an unsuspected bladder perforation? A. Thiotepa B. BCG C.Mitomycin
D. Doxorubicin E. Epirubicin
8. A64-year-oldman is diagnosed with primary stage Ta low-grade bladder cancer in 3 separate
locations, the largest one of which (3.5 cm) is suggestive of early lamina propria invasion.
Detrusormuscle present and not involved. He currently requires Remicade for severe rheumatoid
arthritis. Because a small bladder perforation was noted at the time of his initial TUR he did not receive
any immediate postoperative intravesical chemotherapy.What would be the best treatment now based
on risk:benefit considerations? A.Observation only with cystoscopic surveillance at 3months. B. Repeat
resection of tumor site within the next 6 weeks. C. Initiate a 6-week course of intravesical chemotherapy
within a few weeks of TUR. D. Provide a single dose of perioperative chemotherapy alone. E. Startmore
aggressive BCG therapy 3-6 weeks frominitial TUR.
9. Apatient calls 6 hours after receiving his fourth scheduled treatment with BCG complaining of
frequency, urgency, light red urine without clots and a temperature of 38.8°C with some chills. Themost
appropriate response to this situation would involve: A. Reassurance that these symptoms are common
with BCG treatment and that they willmost likely clear up on their own B. Informthe patient that he
should immediately report to the emergency room for evaluation and potential admission for 24- hour
observation C. Call in prescriptions for an anticholinergic medication and 7-day course of ciprofloxin to
start immediately with instructions to call back if temperature exceeds 39.5° C, relapses within next 48
hours or is associated with worsening symptoms D. Call in a prescription for isoniazid to take for next 7
days and then for 3 days preceding each subsequent BCG treatment E. Admit to hospital for possible
BCG sepsis with treatment including triple antituberculosis therapy (isoniazid, rifampin, ethambutol) and
steroid therapy
10.A72-year-old woman undergoes TUR of a 4- cmbladder tumor with immediate instillation of
mitomycin C. Pathology report returns 5 days later revealing poorly differentiated transitional cell
carcinoma invasive into the lamina propria with focal areas of micropapillary disease. Detrusormuscle is
present and not involved. Preoperative CT urogramwas negative for any apparent disease outside the
bladder. Treatment at this point should involve: A. Re-resection of the tumor site, which, if negative,
should be followed expectantly with quarterly cystoscopy and cytology B. Re-resection of tumor site,
which, if negative, should be followed by a full 6-week course of BCG therapy with full cystoscopic
restaging at 3months C. Re-resection of the tumor site, which, if positive for residual T1 disease, should
prompt an immediate cystectomy D. Immediate cystectomy presuming remainder ofmetastatic workup
is negative E. Neoadjuvant systemic chemotherapy X 3- 4 cycles, then planned cystectomy
Answers 1. D. Female gender is associated with a lower risk. Coffee consumption, artificial sweetener
use, occasional UTIs and prior cervical cancer are unrelated to risk. Besides pelvic radiation, smoking and
occupational exposure to permanent hair dyes, family history is the only other legitimate risk factor in
this case.
2. E. Nephrogenic adenomas are benign lesions associated with prior trauma, surgery, chronic
inflammation or infection. They do not predispose to further cancers. Answer A. would be appropriate
for cystitis glandularis, answer B. would be appropriate for themicropapillary variant and answer C.
would be appropriate for the small cell variant of bladder cancer.
3. B.High p53 staining is associated with p53mutation, a process that inhibits self-destructive apoptosis
of cancer. Ki67 is amarker of proliferation. High values indicate a faster growth rate. Rb functions as a
cell cycle brake. Loss of Rb promotes cancer cell proliferation. E-cadherin is a cell surfacemolecule that
keeps cells fixed in place. Loss of E-cadherin is associated with increased invasive andmetastatic
potential. The least aggressive profile for comparison would be answer C.
4. D. Essentially all stage T1 high-grade cancers should be re-resected because of the high chance of
both residual disease or unsuspectedmuscle invasion. While BCG therapy is appropriate for
completelyresected and accurately staged T1 high-grade cancer,if the tumor is understaged and actually
T2 this 3-month delay (also found in answer E.) will be potentially harmful. Radical cystectomy or partial
cystectomy is premature unless there are extenuating circumstances (multifocal or bulky T1, associated
lymphovascular invasion for radical; tumor in diverticulumfor partial).
5. B. Asingle dose of intravesical chemotherapy delivered with 6 hours of TUR will significantly
decreasethe risk of recurrence for low-risk bladder cancer at minimal risk to the patient. Choice D.,
giving BCG, is contraindicated for high chance of inducing BCG sepsis. Neither randombiopsies (A.) nor
ureteral cytologies (C.) are indicated in the setting of lowgrade disease with negative voided cytology.
An office bladder biopsy (E.) in this new bladder cancer patient adds nothing to themanagement since
TUR remains themost definitive initial diagnostic and therapeutic maneuver.
6. A. PUNLMPs now include some of the older classified papillomas and low-grade Ta cancers. They do
recur withmoderate frequency but rarely progress. Reresection, use of BCG ormitomycin, andmore
extensive re-staging is simply not indicated.
7. A. Although it will cause transientmyelosuppression, as a non-vesicant agent Thiotepa will not lead to
a severe local tissue reaction if extravasated.Mitomycin and the anthracyclines, doxorubicin
(adriamycin) and epirubicin, are all vesicant drugs with a high potential for local tissue damage. BCG can
also cause a localized or systemic infection in such a circumstance.
8. C. This patient has intermediate-risk bladder cancer based on bothmultifocality and size >3 cm.While
periodic surveillance is required, neither simple observation (A.) nor single dose perioperative
chemotherapy (D.) is sufficient as recurrence risk exceeds 60%with amodest progression rate of 5%15%. A6-week course ofmitomycin (C.) willreduce the relative chance of recurrence by over 30%.
Although perhaps evenmore efficacious, BCG (E.) is contraindicated in patients taking the TNF receptor
blocker Remicade because of the elevated risk of BCG infection. Re-resection (B.) is not unreasonable
but not required in the setting of lowgrade disease, equivocal early lamina propria invasion and clearly
negative detrusor involvement.
9. C. It is unclear at this point whether the patient is having a normal but exaggerated transient immune
reaction to BCG, iatrogenic standard bacterial UTI or early signs of serious BCG infection. Treatment of
irritative voiding symptoms is appropriate but fever >38.5 but <39.5 should prompt additional
treatment. Since fluoroquinolone antibiotics are active againstmost standard bacterial UTIs and BCG,
they are a reasonable first choice until the patient declares himself through either higher fever (≥39.5),
relapsing fever after 48 hours or worsening constitutional symptoms. At that point the patient should
report formedical evaluation, possible inhospital evaluation and institution ofmore specific
antituberculosis drug therapy (B.). Extended outpatient isoniazidmonotherapy is appropriate for milder
forms of BCG infection although it will not prevent the onset of fever and sepsis if administered for 3
days around the time of BCG instillation (D.). Triple-drug antibiotic therapy and steroids would be
appropriate for BCG sepsis with hemodynamic compromise (E.).
10. D. Micropapillary disease is poorly responsive to conservative measures(A.) or to BCG therapy (B.),
resulting in reduced survival. Any delay in therapy (including re-resection) is potentially dangerous (C.).
Neoadjuvant chemotherapy (E.) has not been shown to be of clear benefit in clinically localized disease
for this variant form of bladder cancer.
CHAPTER 18: BLADDER CANCER
1. A52-year-old female with a remote history of CIS and BCG treatment has a new T1G3 tumor
completely resected. There is scant muscularis propria in the TURBT specimen. The next step is: A. Reinduce with BCG plus maintenance BCG B. BCG plus Interferon alpha C. Intravesical chemotherapy with
Valrubicin or Gemcitabine D. Re-resection withmuscularis propria in the specimen E. Radical cystectomy
2. A55-year-old female is found to have a 3-cm nodular lesion in the bladder dome, which on histology is
determined to be small cell carcinoma, deeply invasive into the lamina propria but with
negativemuscularis propria involvement. Randombiopsies and urine cytology are negative. CT scan of
the thorax, abdomen and pelvis are normal. The best initial treatment is: A. Intravesical BCG with
latermaintenance B. Repeat TURBTwithin 6 weeks to assess for residual disease or understaging C.
Partial cystectomy D. Radical cystectomy E. Neoadjuvant systemic chemotherapy
3. A42-year-old potentmale is diagnosed with a 4-cmmicropapillary TCC that extensively invades the
lamina propria.Muscularis propria is present and not involved. Lymphovascular invasion is identified.
The next step is: A. Restaging TURBT and intravesical BCG if muscle invasion is absent B. Partial
cystectomy followed by radiation therapy C.Neoadjuvant cisplatin-based chemotherapy followed by
radical cystectomy D. Nerve-sparing radical cystectomy E. Cisplatin-based chemotherapy and radiation
therapy
4. An orthotopic neobladder in a woman undergoing anterior pelvic exenteration formuscle invasive
bladder cancer is contraindicated in the setting of: A. Age older than 75 B. Nodalmetastases C. Recurrent
UTI D. Bilateral hydronephrosis E. Tumor invading the anterior vaginal wall
5. A65-year-oldmale undergoes 3 cycles of neoadjuvantM-VAC chemotherapy for T3bNxM0 TCC. After
completing chemotherapy, there is no tumor on cystoscopy. The next step should be:a) Observation
with cystoscopy in 3months A. Observation with cystoscopy in 3months B. BCG weekly for 6 weeks C.
Bladder biopsies D. Radiation therapy E. Radical cystectomy
6. Which of the following immunohistochemistry profiles in bladder cancer is associated with the most
aggressive tendencies? A. High p53 and Rb staining, low Ki67 and E-cadherin B.High p53 and Ki67
staining, absent Rb and E-cadherin C.High Rb and E-cadherin, low p53 and Ki67 D. High Ki67 and Rb, low
p53 and E-cadherin E. Low p53, Rb, E-cadherin and Ki-67
7. A53-year-old female with a T2NXM0 bladder TCC undergoes a radical cystectomy and continent
diversion. Final pathology shows pT3a N1 with a singlemicroscopic positive lymph node in the perivesical
fat. The next step thatmay be considered is: A. PET/CT scan B. Adjuvant chemotherapy C. Adjuvant
radiotherapy D. Combined radiotherapy and chemotherapy E. More extensive lymphadenectomy
8. A48-year-old otherwise healthymale has a CT scan and TURBTwhich reveal a T4aNXM0 TCC of the
bladder. The next step should be: A. Neoadjuvant chemotherapy followed by radical cystectomy B.
Radical cystectomy followed by adjuvant chemotherapy C. Radical cystectomy, then check tumor p53
status and, if altered, give chemotherapy D. Preoperative radiotherapy followed by radical cystectomy E.
Neoadjuvant chemotherapy with restaging bladder biopsies and surveillance if no clinical evidence of
cancer
9. A62-year-oldmale has T3b invasive bladder TCC. TUR biopsy of prostatic urethra shows single focus of
CIS. He does not want an external appliance. At the time of cystectomy, he should have: A. Frozen
section of apical urethramargin and, if negative, an orthotopic neobladder B.Urethrectomy and
continent cutaneous diversion C. Urethrectomy and Ileal conduit D. Preoperative radiation therapy
followed by cystectomy E. Bladder salvage with chemoradiation therapy
10. A58-year-oldmale former smoker with a past history of cystectomy for a T3bN1 invasive bladder
cancer has a CT scan 5 years later which reveals a spiculated 1-cmpulmonary lesion. The next step
should be: A. Cisplatin chemotherapy B. Systemic cisplatin-based combination chemotherapy C.
Preoperative radiotherapy followed by removal of the lung lesion D. Radiation therapy to the lung lesion
alone E. Evaluation for possible lung primary carcinoma
11. In aman with good daytime continence following radical cystectomy and orthotopic neobladder,
nocturnal incontinence is due to: A. Damage to the urinary rhabdosphincter B. Neobladder
hypercontractility C. Inadequate compliance of the neobladder D. Loss of afferent input fromthe
detrusor to the central nervous system E. Damage to the inferior hypogastric nerve plexus
12. A62-year-oldmale with bilateral hydronephrosis 4 years after a radical cystectomy and ileal conduit
catheterizes stoma and obtains 100cc urine. Themost likely cause is: A. Stoma stenosis B. Chronic reflux
C. Ureteral obstruction due to cancer D. Ureter obstruction due to fibrosis E. Antiperistaltic orientation
of the conduit
Answers 1. D. Re-resection intomuscularis propria, which is required for accurate staging in T1 cancers.
EAU and AUAGuidelines are consistent regarding the need for routine re-resection of all T1G3 tumors.
Understaging rate of T1 tumors is as high as 40% and is highest when there is nomuscularis propria in
the specimen. Treating with intravesical immunotherapy or chemotherapy prior to accurate staging
risksmissing T2 disease, for which BCG is inadequate therapy and survival probabilities are significantly
reduced compared to cystectomy for <T2 disease. Though radical cystectomymay be appropriate
therapy, salvage intravesical immunotherapy therapy with BCG along or BCG + interferon could be
considered if the re-resection that includesmuscularis propria shows no worse than completely resected
T1 disease. However, upstaging to T2 is associated with a significantly increased risk for cancerspecificmortality.
2. E.Neoadjuvant chemotherapy. Small cell carcinoma isa rare variant of urothelial cancer that can
comprise 100%or a fraction of the tumor. Its biologic behavior appears similar to small cell lung
carcinoma with a high propensity formetastatic disease. Consensus opinion favors neoadjuvant
chemotherapy with etoposide and cisplatin or enrollment on a clinical trial testing novel agents followed
by either radical cystectomy or radiotherapy.
3. A. Kamat et al reported 44 patients withmicropapillary non –muscle-invasive bladder cancer. 67%of
27patients treated with BCG progressed tomuscleinvasive cancer, including 22%withmetastatic disease.
30 patients underwent cystectomy and only 19%remained alive with their bladder in place. On this
basis, the current recommendation is to proceed directly to cystectomy. This patient should be offered
nerve-sparing surgery, which is not associated with an increased risk of local pelvic recurrence.
4. E. The distal two-thirds of the female urethramay serve as an adequate sphinctermechanism,
provided the risk of cancer in the retained urethra is low. Anterior vaginal wall involvement by a
posterior-based bladder tumor or bladder neck or urethra involvement is a contraindication to urethrasparing and orthotopic bladder replacement.
5. E. The pathologic pT0 rate is only 50%in patients with an apparent clinical complete response to
neoadjuvant chemotherapy. There is a highly select group of patients whomay survive long-termwith
chemotherapy only and should be reserved for patients who are notmedically fit or refuse cystectomy.
6. B. High p53 and low Rb suggest altered expression of these gene products, often due tomutation and
associated with increased risk for progression after cystectomy.Ki67 is a proliferationmarker and
increased expression is associated with aggressive pathologic features and decreased long-termsurvival.
E-Cadherin is a cell adhesionmolecule and decreased expression is associated with increased risk of
nodemetastasis and decreased survival.
7. B.Adjuvant cisplatin-based combination chemotherapycan be considered. Randomized trials have
thus far not been definitive in overall survival on this subject. Ameta-analysis suggests a 9%absolute
benefit in overall survival, but the trials represent small numbers of patients, often closed early or due
to pooraccrual and not all of the patients in adjuvant chemotherapy trials are represented.
8. A. The risk of occult nodalmetastases is as high as 50%. Neoadjuvant chemotherapy with
cisplatinbased combination chemotherapy has demonstrated a 9%absolute benefit in overall survival in
ametaanalysis utilizing individual patient data on 3,005 patients from11 randomized trials treated with
neoadjuvant chemotherapy. NCCN guidelines (V 2.2011) recommend neoadjuvant chemotherapywith
gemcitabine and cisplatin orM-VAC.
9. A.Asingle focus of CIS of the prostatic urethra does not increase the risk of a second primary
urothelial tumor of the retained urethra and is therefore not an indication for urethrectomy.
Furthermore, the probability of developing a second primary TCC of the retained urethra is lower with
orthotopic diversion compared to cutaneous diversion.
10. E. Patients with a history of smoking may also develop secondary tumors, such as lung cancer. In
this case,a single lesionmay represent a primary tumor which could be completely resected.
11. D. The loss of afferent input and passive urethral resistance result in the inability to raise urethra
resting pressure during filling of the neobladder. As neobladder pressures rise with filling, this will
overcome urethra resting pressure resulting in incontinence. Patientsmay be able to preempt leakage by
setting an alarmonce or twice at night to void.
12. A. Stomal stenosis results in stasis within the conduit and increased pressures, resulting in
bilateralhydronephrosis.
CHAPTER 19: PENILE AND URETHRAL CANCER
1. Where do penile cancers most commonly arise? A. Shaft B. Prepuce C. Frenulum D. Glans E. None of
the above
2. Which of the following is not a risk factor for invasive SCC? A. Phimosis B. Number of sexual partners
C. Smoking D. Poor hygiene E. Alcohol intake
3. What is the most important prognostic factor for survival in patients with penile cancer? A. Primary
tumor stage B. Extent of lymph node metastasis C. Presence of vascular invasion D. Primary tumor grade
E. Medical comorbidities
4. The following statements pertaining to conservative surgical excision for penile carcinoma are true,
except for which one? A. Glansectomy and circumcision remove the entire contents of the preputial
cavity B. Large defects after glans tumor excision may be covered with a flap of outer preputial skin C.
Frozen section biopsies are usually not needed during these procedures D. Careful postoperative longterm surveillance is necessary E. Circumcision alone may be sufficient to treat certain preputial tumors
5. Which of the following statements about partial penectomy is most accurate? A. It provides for
normal sexual function in over 70% of men B. It is performed less often than total penectomy C.
Postoperative voiding is through a perineal urethrostomy D. It results in local recurrence rates of less
than 10% E. It requires division of the penis at least 3 cm proximal to the tumor
6. Which of the following statements regarding the progression of penile cancer is true? A. Metastasis
initially involves the superficial inguinal nodes B. Metastatic spread from the primary tumor is usually
unilateral C. Metastasis initially is hematogenous to the lung, liver or bone D. Metastasis initially involves
the deep inguinal nodes E. Crossover from the inguinal nodes to the contralateral pelvic nodes is
common
7. Observation of the inguinal regions is reasonable when there is no palpable adenopathy and the
primary tumor demonstrates all of the following, except? A. Tis B. T1, grade II C. Vascular invasion D. Ta
E. T1, grade I
8. All of the following statements pertaining to modified inguinal lymphadenectomy are true, except for:
A. The saphenous vein is preserved B. It is indicated for management of palpable inguinal
lymphadenopathy C. The dissection excludes regions lateral to the femoral artery D. The thigh incision is
shorter than that used for standard ilioinguinal lymphadenectomy E. Both superficial and deep inguinal
nodes are included in the surgical specimen
9. Which of the following statements regarding ilioinguinal lymphadenectomy is true? A. Rotation of the
gracilis muscle is performed to cover the femoral vessels B. It is done only for palliation C. Complications
are few and minor in nature D. The saphenous vein may be preserved in the setting of low volume
metastatic disease E. Pelvic node dissection is necessary even if the unilateral inguinal nodes are
negative
10. What is the most frequent site of urethral cancer in the male? A. Fossa navicularis B. Prostatic
urethra C. Pendulous urethra D. Penoscrotal urethra E. Bulbomembranous urethra
11. Which of the following statements concerning distal urethral cancer in male is true? A. Most
common histologic type is transitional cell carcinoma B. Penectomy is usually indicated for tumors
infiltrating the corpus spongiosum C. Prognosis is worse than for bulbomembranous urethral cancer D.
In the absence of palpable inguinal nodes, early inguinal lymphadenectomy is indicated E. Conservative
surgical therapy is never effective
12. What is the most common histologic type of proximal urethral cancer in women? A. Squamous cell
carcinoma B. Transitional cell carcinoma C. Adenocarcinoma D. Melanoma E. Sarcoma
13. What is the most significant prognostic factor for local control and survival in female urethral
cancer? A. Age at presentation B. Histologic type C. Anatomic location and extent of primary tumor D.
Hematuria E. Presence of urethral diverticulum
Answers 1. D. Penile cancers occur most commonly on the glans penis (48%) followed by the prepuce
(21%).
2. E. There is no evidence linking penile cancer to alcohol intake.
3. B. The presence and extent of inguinal lymph node metastasis are the most important prognostic
factors for survival in patients with SCC penis.
4. C. Frozen section biopsies are often a critical component of conservative surgery for penile cancer to
help ensure complete tumor excision.
5. D. Partial penectomy results in a local recurrence rate of 0%-8%. It provides for adequate sexual
function in a low percentage of men, is performed more commonly than total penectomy, does not
result in a perineal urethrostomy and traditionally is done with a 2 cm tumor margin.
6. A. Metastasis initially occurs to the superficial inguinal nodes, and this may be unilateral or bilateral.
Progression is subsequently to the deep inguinal nodes and then the pelvic nodes. Distant metastasis
occurs late. Pelvic nodes will not be positive if the ipsilateral inguinal nodes are negative.
7. C. Vascular invasion in the primary tumor is an indication for modified inguinal lymphadenectomy in
the setting of clinically negative groins.
8. B. In the setting of palpable adenopathy, more extensive complete ilioinguinal lymphadenectomy is
indicated.
9. D. In the setting of low volume metastatic disease, the saphenous vein may be preserved in order to
try to decrease the risk of postoperative complications. The sartorius muscle is used to cover the
femoral vessels, and the procedure may carry a chance of cure in 30%-60% of cases when pelvic nodes
are not involved.
10. E. In males, urethral cancer occurs most commonly in the bulbomembranous urethra (60%),
followed by the penile urethra (30%) and prostatic urethra(10%).
11. B. Penectomy is indicated for tumors infiltrating the corpus spongiosum. The most common
histologic type is SCC and the prognosis is better than that for bulbomembranous cancers. Early or
prophylactic has not been shown to be advantageous in urethral cancer. Some cases of early or
superficial distal urethral cancer may be managed effectively with conservative surgical therapy.
12. A.SCC is the most common histologic type of proximal urethral cancer in women.
13. C.The most significant prognostic factor for local control and survival in women with urethral cancer
is the location and extent of the primary tumor.
CHAPTER 20: TESTICULAR CANCER
1. Factors associated withmalignant sex cord/gonadal stromal tumors include all of the following except:
A. larger tumor size B. highmitotic rate C. tumor necrosis, D. rete testis invasion E. extratesticular
extension
2. Themost common primary testicular neoplasm inmen over the age of 60 is: A. Classic seminoma B.
Lymphoma C. Spermatocytic seminoma D.Mixed nonseminoma E. Sertoli cell tumor
3. All of the following statements are true regarding the patterns andmechanisms ofmetastatic spread
of primary testis cancers except:
A. “Skip”metastases occur away from the retroperitoneal lymph nodes in 25%of patients. B. The primary
landing zone for left-sided testis tumors is in the left paraaortic location. C. Lymphatic drainage crosses
over fromright to left. Therefore, left paraaortic lymph node involvement occurs commonly in patients
with right testicular primaries. D. Lymphatic drainage above the retroperitoneumis to the cisterna chyli,
thoracic duct, and usually to the left supraclavicular lymph nodes.
4. The propermanagement for a patient with a 0.8-cmnonseminoma with negativemargins, no evidence
for carcinoma in situ and a normal contralateral testicle following partial orchiectomy is: A. Adjuvant
chemotherapy B. Adjuvant radiation C. Completion orchiectomy D. Contralateral testicular biopsies E.
Observation
5. The best recommendation for a compliant patient with a 2-cmclassic seminoma with no evidence for
lymphovascular invasion or rete testis invasion following orchiectomy is: A. Adjuvant radiation to the
paraaortics B. Adjuvant radiation to the paraaortics and to the ipsilateral pelvic lymph nodes C. Single
agent carboplatin for 1 cycle D. Immediate adjuvant BEP x 1 cycle E. Observation
6. Which of the following statements are false regarding postchemotherapy residualmasses in patients
with clinical stage IIImetastatic nonseminoma?
A. Aretroperitoneal residual lymph nodemass >1 cmin size is an indication for a postchemotherapy
RPLND. B. Historically, the likelihood of identifying viable nonteratomatous germcell elements in the
resected lymph node specimen following induction chemotherapy is approximately 10%. C. Histologic
discordance is not uncommon between the resected lymph node specimens and other visceral sites
ofmetastatic disease (ie, liver). D. Resection of residualmasses in the retroperitoneumand in
themediastinum should never be performed in the same operative setting due to cardiopulmonary
toxicity associated with systemic chemotherapy. E.Malignant transformation of teratoma is identified in
approximately 3%of resected residual lymph node specimens.
7.Which of the following statements regarding patients with clinical stage I nonseminoma are
true? A. Patients with clinical stage IS disease are distinguished by lymphovascular invasion in their
primary tumor specimen. B.Most patients with clinical stage IS nonseminoma are treated with singleagent cisplatin x 1 course due to an elevated risk of recurrence following primary RPLND. C. Primary
RPLND alone for clinical stage IB nonseminoma cures 50% –90%of patients with pathologic stage II
(node-positive) disease. D. BEP chemotherapy x 3 courses or EP chemotherapy x 4 courses is an
accepted treatment option for patients with clinical stage IB nonseminoma and normal tumor markers.
8. Which of the following statements are true regarding bHCG as a testicular cancer tumormarker:
A. False-positive bHCG elevationmight be due to other cancers (ie, bladder cancer) as well asmarijuana
use. B. bHCG levels should fall by 50%per week if all of the tumor has been removed with the radical
orchiectomy specimen. C. The beta subunit of HCG is 70%homologous with pituitary LH and, due to
cross reactivity,might cause false elevation of HCG in some patients with hypogonadism. D. Both Aand C.
E. All of the above.
9. Following a primary RPLND for nonseminoma, the risk of an in-field relapse in the retroperitoneumis
reported to be: A. 1% –2% B. 10% –15% C. 20% –25% D. >30%
10. A35-year-old patient has a pure seminoma in the left radical orchiectomy specimen, a 5.5-cm left
paraaortic lymph nodemass and normal tumormarkers. His chest CT is normal. The best management
strategy for this patient includes: A. Concurrent radiosensitizing cisplatin and 40 Gy radiation to the
paraaortics, the left supraclavicular lymph nodes and the ipsilateral pelvic lymph nodes. B. Single-agent
carboplatin x 2 cycles. C. Induction BEP x 3 or EP x 4. D. Primar
Answers: 1. D. Invasion of the rete testis has been reported as a risk factor formicrometastatic disease
in patients with clinical stage I testicular seminoma.
2. B.While it is possible to see all of the listed primary tumors, lymphoma would be the most common
histology in this age group ofmen.
3. A.Distant progression occurs in the absence of retroperitoneal lymph node involvement. Lymphatic
channelsmay bypass the retroperitoneum and communicate directly with the cisterna chili or the
thoracic duct. This pattern of lymphatic drainage and the possibility of direct hematogenous spread
accounts for the small percentage of patients who relapse (most commonly in the lungs) following a
negative RPLND for clinical stage I disease.
4. E.Local recurrence is possible following partial orchiectomy – particularly in patients with CIS
detected in parenchymal biopsies adjacent to tumor.Recurrence is diminished in such patients with
adjuvant testicular radiation. In this case, observation is the best option as biopsies were negative.
5. E.Choices A, B and C are options for the described patient. However, the significantmajority
of patients are cured with orchiectomy alone. There are increasing data addressing the risks of longterm side effects with both chemotherapy and radiation.Most academic centers now favor observation
for this low-risk patient.
6. D. Simultaneous excision of all sites of residual tumor is an accepted option if all of the disease can be
resected through a single incision.While chemotherapy is associated with a higher hazard
of cardiovascular disease, prior chemotherapy is not a contraindication for simultaneous resection.
7. C. Patients with clinical stage IS nonseminoma have persistent elevation of their tumor markers
following radical orchiectomy and no evidence of radiographically detected metastases. For stage IS
patients, primary RPLND is associated with an elevated risk of recurrence following surgery, approaching
80%in some series. Thus, formost patients, standard induction chemotherapy is recommended
consisting of 3 cycles BEP or 4 cycles EP.While primary chemotherapy is an option for patients with
clinical stage IB nonseminoma, BEP x 1 –2 cycles is advocated rather than a standard induction regimen.
8. D. The half-life of bHCG is 24–48 hours. If the entire tumor has been removed, elevatedmarker
levelsshould normalize by 5 –7 days.
9. A. The risk of an in-field relapse is very low in reports of primary RPLNDs fromcenters of excellence.
5% –10%of patients that undergo a negative primary RPLND will relapse out of the field—most
commonly in the lungs.
10. C. Radiation to the supraclavicular lymph nodes is no longer advocated. There is no role for
radiosensitizing chemotherapy and single-agent carboplatin is not utilized in patients with clinical stage
II seminoma. The patient has pure seminoma. Primary RPLND is not an option in this setting.
CHAPTER 21: BENIGN PROSTATIC HYPERPLASIA AND BLADDER CALCULI
1. In a patient with Cushing’s syndrome due to adrenal adenoma, the changes in hormone secretion
following a high dose dexamethasone suppression test are best represented by: A. ACTH:↑Urinary free
cortisol:↓ B. ACTH:↑Urinary free cortisol:↑ C. ACTH:↔Urinary free cortisol:↔ D. ACTH: ↓ Urinary
free cortisol:↓E. ACTH: ↓ Urinary free cortisol:↑
2. Which of the following is themost sensitive biochemical test for confirming the diagnosis of
pheochromocytoma? A. Plasma freemetanephrines B. Plasma catecholamines C. Urinarymetanephrines
D. Urinary vanillylmandelic acid E. Urinary catecholamines
3. Adrenal hemorrhage ismost frequently associated with: A. Heparin-induced thrombocytopenia B.
Trauma C.Warfarin therapy D. Sepsis E. Adrenal adenoma
4. A45-year-old hypertensiveman has an elevated 24-hour urinary aldosterone after a period of salt
loading. CT scan of the adrenals is normal.The best study for localization of a surgically curable lesion is:
A.MRI scans B. Adrenal venography C.MIBG scan D. Adrenal venous sampling E. Iodocholesterol scan
5. A55-year-old obese man with epigastric discomfort is noted to have a 5-cmright adrenal mass on CT
scan. Themassmeasures -40 Hounsfield units.
The next step is: A. Observation B. 24-hour urine formetanephrines C.MRI scans D. Right adrenalectomy
E. Dexamethasone suppression test
6. In the diagnostic evaluation of excess cortisol secretion, the administration of 2mg of dexamethasone
QID (high dose) for 2 days results in: A. No suppression of urinary corticosteroid secretion in normal
patients B. Suppression to less than half the baseline in patients with adrenal hyperplasia C. Suppression
to less than the baseline in patients with benign cortical adenoma D. Suppression to less than half the
baseline in patients with adrenal carcinoma E. Increased urinary secretion in patients with adrenal
carcinoma
7. In a patient with an absent right kidney and a left pelvic kidney, the right adrenal is: A. Absent and
the left is adjacent to the upper pole of the kidney B. Absent and the left is in the normal anatomic
position C. In the normal anatomic position and the left is adjacent to the upper pole of the kidney D. In
the normal anatomic position and the left is in the normal anatomic position E. In the normal anatomic
position and the left is absent 8. A40-year-old woman undergoes bilateral adrenalectomy for Cushing’s
disease with complete resolution of her symptoms. Replacement therapy with cortisone and
fludrocortisone is instituted. 3 years later, she complains of visual disturbances and is noted to have skin
hyperpigmentation. The most likely explanation is:
A. Addison’s diseas B. Pituitary adenoma C. Excessive cortisone replacement D. Excessive ACTH
production E. Ectopicmelanocyte-stimulating hormone
CHAPTER 23A: SEXUALLY TRANSMITTED DISEASES
1. Which statement about erectile dysfunction and AIDS is true? A. Protease inhibitors prolong the
halflife of PDE-5 inhibitors and increase the risk of toxicity. B. Sexually active AIDS patients should carry
postexposure prophylaxis to provide to their partners. C. AIDS patients should not receive treatment for
erectile dysfunction because They might infect their partners. D. Testosterone replacement is
contraindicated due to the high risk of prostate cancer. E. Radical prostatectomy is contraindicated due
to the high risk of erectile dysfunction.
2. Comparing HPV vaccines, Gardasil: A. Targets fewer HPVtypes than Cervarix. B. Is preferred over
Cervarix in the CDC recommendations. C. Ismore effective than Cervarix for patients previously exposed
to HPV. D. Requires fewer injections than Cervarix. E. Is the only HPVvaccine FDAapproved formales.
3. Which of the following STDs is least common among men in the United States? A. Gonorrhea B.
Granuloma inguinale C. Chancroid D. Herpes simplex E. Human papilloma virus
4. At 5:00 PM, a urology resident cuts his finger with a scalpel while doing emergency surgery on a
patient of unknown HIV status. Which statement is true? A. The resident should go to employee health
the nextmorning for evaluation, counseling and possible post-exposure prophylaxis.
B. The patient’s blood cannot be tested for HIVuntil the patient has recovered fromanesthesia, received
counseling and given informed consent. C. The resident should bemore worried about acquiring
hepatitis than HIV. D. Double-gloving does not change the resident’s risk of becoming infected with HIV.
E. Urine and blood are equally likely to transmit HIV.
5. All of the following STDs have readily available, reliable diagnostic tests, except: A. Syphilis B.
Gonorrhea C. Chlamydia urethritis D. Chancroid E. Herpes simplex
Answers 1. A. 2. E. 3. B. 4. C 5. D.
CHAPTER 23B: URINARY TRACT INFECTIONS
1. Which operation for GU tubercuclosis does not require extensive drug therapy first? A. Complete
nephrectomy B. Partial nephrectomy C. Stent for ureteral stricture D. Reimplant ureter for stricture E.
Epididymectomy
2. Which antituberculous agent decreases blood levels of anti-HIVprotease inhibitors? A. Isoniazid (INH)
B. Rifampin C. Pyrazinamine D. Ethambutol E. Cycloserine
3. Which antibioticmay cause severe peripheral neuropathy? A. Nitrofurantoin B. TMP/SMX C.
Amoxicillin/clavulanate D. Levofloxacin E. Cephalexin
4. All of the following are good choices for acute uncomplicated cystitis, except: A. 3 days
fluoroquinolone B. 3 days TMP/SMX C. 3 days trimethoprim D. 3 days ampicillin E. 7 days nitrofurantoin
5. Asymptomatic bacteriuria needs to be treated in which population? A. Patients with indwelling
catheters B. Diabetics C. Elderly people D.Mentally retarded people E. Pregnant women
6. Apatient with invasive Candida pyelonephritis started treatment with amphotericin B and is miserable
with rigors, chills and fever. All of the following are good options for this patient, except: A. Continue
amphotericin B and pretreat with ibuprofen B. Change to the liposomal formof amphotericin B C.
Change to 5-fluorocytosine D. Change to caspofungin E. Change to voriconazole
7. Which of the following is true regarding acute prostatitis (NIH category I Prostatitis)? A. The
pathogenic bacteria are rarely recoverable fromvoided urine B. Prostatemassage and culture of VB3 or
EPS is important to decide on therapy C. The usual route of infection is antegrade fromthe kidneys
D.Most antibiotics will penetrate the prostate well regardless of pKa E. In a patient with urinary
retention, a suprapubic catheter should be avoided
8. Which of the following would be a poor choice to treat a febrile UTI in a neutropenic patient who is
currently on chemotherapy for leukemia? A. Nitrofurantoin B. Ciprofloxacin C. TMP/SMX D. Gentamycin
E. Cephalexin
9. Which of the following suggests that repetitive UTI is due to an anatomic/surgically correctible cause?
A. High counts of Enterococcus spp B.Negative cultures between infections, same bacteria recovered
each time C. Febrile UTI D. Associated with hematuria E. Associated with sexual activity
10. Which of the following is NOT a defense mechanism against UTI? A. Tamm-Horsfall protein B.
Secretory IgAantibody C. Efficient and complete bladder emptying D. Intravaginal lactobacilli E.
Spermicide
Answers 1. C. 2. B. 3. A. 4. D. 5. E. 6. C. 7. D. 8. A. 9. B. 10. E.
1. A1-cmsegment of leftmiddle third ureter is lacerated completely during an elective left colectomy.
The injury is recognized intraoperatively, the tissues appear viable and the patient is stable. The best
choice formanagement is: A. Transureteroureterostomy over a stent B. Ureteroneocystostomy C. Ileal
ureter interposition D. Ureteroureterostomy over a stent E.Ureteral ligation with percutaneous
nephrostomy and delayed repair
2. What is the best technique to evaluate microhematuria in a stable patient with a transthoracic
gunshot wound? A. Abdominal sonography B. Intravenous pyelography C. Intraoperative single shot IVP
D. Immediate abdominal CTwithout IV contrast E. Immediate CTwith intravenous contrast
3. What is the best technique to evaluatemicrohematuria in an unstable patient with amultiple
abdominal gunshot wounds? A. Abdominal sonography B. Intravenous pyelography C. Intraoperative
single shot IVP D. Immediate abdominal CTwithout IV contrast E. Immediate CTwith intravenous
contrast
4. Astab wound victimis found to have a Grade 2 laceration of the lateral left kidney on abdominal
CTwith a small perirenal hematoma. Laparotomy is performed due to bleeding from a concomitant
splenic injury which is easily controlled. The patient has received 2 units of blood and is now
stable.What is the best course of action for the urologist? A. Immediate nephrectomy B. Intraoperative
one-shot IVP C. Cystoscopy with retrograde pyelogram D. Observation E. Renal angiography with super
selective embolization
5. Avictimof a posterior stab wound is found to have an isolatedmedial, lower pole, Grade 4 right renal
laceration on abdominal CT. No other abdominal injuries were identified and he has amoderately large
(4 cm) perirenal hematoma surrounding the renal injury and an otherwise viable kidney. The patient has
received 3 units of blood and now appears stable. What is the next best course of action? A. Immediate
nephrectomy B. Intraoperative one-shot IVP C. Cystoscopy with retrograde pyelogramand possible stent
placement D. Percutaneous nephrostomy tube placement E. Renal angiography with superselective
embolization
6. Contraindications for transureteroureterostomy (TUU) include which of the following? A. Neurogenic
bladder B. Obesity C. History of urolithiasis D. History of abdominal aortic aneurysm E. History of
urethral stricture
7. Avictimof an abdominal gunshot wound presents in shock and is found to have an iliac vein laceration
andmultiple small bowel injuries. He undergoes immediate vascular repair and his bowel injuries are
stapled to prevent ongoing contamination. He has requiredmultiple transfusions and has persistent
acidosis and hypothermia. A complete transaction of the upper ureter is noted. Appropriate urologic
management includes which of the following? A. Transureteroureterostomy over a stent B.
Ureteroneocystostomy with psoas hitch and Boari bladder flap C. Ileal ureter interposition D.
Ureteroureterostomy over a stent with renal mobilization and downward nephropexy E.Ureteral ligation
with long single-J stent placement and delayed repair
8. Ileal ureter interposition is best indicated for which of the following? A. Extensive lower ureteral
injuries B. Extensive upper ureteral injuries C. Patients with bladder outlet obstruction D. Patients with
obstructed ureter due to advanced pelvicmalignancy E. Patients with complete disruption of midureter
due to gunshot wound
Answers 1. D 2. E 3. C 4. D 5. E 6. C 7. E 8. B
CHAPTER 25: BLADDER, URETHRA AND GENITAL TRAUMA
1. Following an automobile accident, a 30-year old comatose man has a blood pressure of 110/70mmHg,
plus of 80/min, CVP of 12 cm H2O and a urinary output of 40ml/hour. There is gross blood in the urine.
Nasotracheal intubation has been performed. The first x-ray obtained should be: A. Skull B. Cervical
spine C. Chest D. IVP E. Cystogram
2. A26-year-old woman has a pelvic fracture, collapsed lung and a severe closed head injury following an
automobile accident. A retrograde cystogramreveals an extraperitoneal bladder rupture. The next step
inmanagement is: A. Catheter drainage B. Immediate surgical repair C. Diagnostic peritoneal lavage D.
Abdominal and pelvic CT scan E. Suprapubic cystotomy
3. An intoxicated 45-year-oldman with a history of chronic alcoholismis evaluated in the emergency
room. Physical examination reveals no abnormalities other than ecchymosis over the lower abdomen.
The blood pressure is 160/80mmHg, pulse 70, respirations 20, temperature 37.5 C and the CVP is 10mm
H2O. Aplain filmof the abdomen shows a ground glass appearance. Initial blood studies reveal: HCT
32%,WBC 15,800/cumm, Na 122mEq/L, K 6.0mEq/L, Cl 109mEq/L, CO2 13mEq/L, BUN 80mg/dLand
creatinine 4.3mg/dL. AFoley catheter is placed but there is no urine output. The next step in
management should be: A. Kayexalate® and furosomide B. Cystogram C. Renogram D. Noncontrast CT
scan E. Tap the abdomen
4. A24-year-oldman is struck by a car and sustainsmultiple injuries including a pelvic fracture. He has
blood at themeatus and a retrograde urethrogramis normal. Acatheter is passed and the bladder is filled
with 200 cc of contrast. Afull and post-drainage filmare normal. The next step should be: A. Evaluation
of the upper tracts by CT scan B. Repeat the cystogram C. Leave catheter and irrigate as needed to clear
clots D. Flexible cystoscopy to exclude a urethral or bladder injury E. Intravenous urogramwith
tomograms
5. A43-year-old woman sustains a single gunshot wound to the abdomen. You are consulted at the time
of emergency laparotomy for an obvious bullet hole in the dome of the bladder. You should: A. Open
the bladder anteriorly and inspect the inside of the bladder B. Performan intraoperative cystogram C.
Debride the bullet hole and close it in 2 layers D. Performan intraoperative IVP E. Place a ureteral stent
B. Urethral Trauma
1. A25-year-old pedestrian is struck by an automobile. On arrival in the emergency room, a plain filmof
the pelvis reveals a left superior and inferior pubic ramus fracture as well as a fracture of the
sacroiliac joint. Examination of the patient reveals a suprapubicmass. No blood is noted at themeatus
and the prostate is in the normal position on digital examination. The most appropriate initial diagnostic
test is: A. IVP B. Retrograde urethrogram C. Cystogram D. Pelvic CT scan E. Peritoneal lavage
2. A26-year-old uncircumcisedman is shot in the penis with a low velocity bullet froma .22 caliber
handgun. He has voided a small amount of grossly bloody urine and is now in urinary retention.
Aurethrogramshows disruption of 1 cmof the penile urethra with extravasation of contrastmaterial. The
best next step is debridement of the wound and: A. Suprapubic tube B. Patch graft urethroplasty C.
Urethral catheter D. Island flap urethroplasty E. End-to-end reanastomosis
3. A14-year-old youngman has a straddle injury to the perineum. Physical examination reveals
ecchymosis limited to the penis and scrotum. The fascia that contains the extravasated blood is:
A.Buck’s B. Dartos C. Colles’ D. External spermatic E. Transversalis
C. Genital Trauma
1. A22-year-oldman sustains a severe burn of his genitalia. There ismarked bullous edema and eschar
formation of the entire penis and much of the scrotum. He has had a Foley catheter in his urethra
tomonitor urine output. The most appropriate initialmanagement is: A. Radical eschar debridement B.
Split thickness skin grafts as soon as possible C. Antibiotic therapy and topical cleansing with water D.
Remove the Foley and insert a suprapubic tube E. Observe until the wound begins to granulate
2. The preferredmanagement of ruptured testis is: A. Orchiectomy B. Closure of the tunica albuginea C.
Orchiectomy and prosthesis infection D. Bed rest, scrotal elevation and ice packs E. Incision and
drainage of scrotum
3. A23-year-oldman suffers severe scrotal, penile and buttock burns. 4 days later the scrotal skin
appears necrotic andmalodorous with the testes visible. After giving antibiotics and performing local
debridement, the next step inmanagement is to: A. Performlocal wound care and delayed
reconstruction B. Performsplit thickness skin grafts to cover testes C. Place testes in subfascial thigh
pouches D. Create lateral subcutaneous flaps to cover the scrotum E. Place testes under subpubic
subcutaneous space
4. A3-year-old boy is seen because his foreskin is caught in his zipper. The best treatment is: A.
Circumcision B. Manipulation of the zipper under general anesthesia C. Manipulation of the zipper under
local anesthesia D. Divide themedian bar of the zipper with a bone cutter E. Excision of the piece of
penile skin caught
5. At the time of a newborn circumcision, the distal one-half of the glans penis is amputated, including
the urethra. The prepuce and glans have been kept in iced saline for 4 hours. The bestmanagement is: A.
Primary anastomosis B. Graft of preputial skin for coverage C. Discard glans tip and allow secondary
healing D. Discard the glans tip and re-configure remaining glans E. Primary anastomosis
withmicrovascular reconstruction
6. A16-year-old uncircumcised youngman is shot in the penis with a low velocity bullet froma .22 caliber
handgun. He has voided a small amount of grossly bloody urine and is now in urinary retention.
Aurethrogram shows disruption of 1 cmof the penile urethra and extravasation of contrastmaterial. The
best next step is debridement of the wound and: A. Suprapubic tube B. Patch graft urethroplasty
C. Urethral catheter D. Island flap urethroplasty E. End-to-end anastomosis
CHAPTER 26: PHYSIOLOGY AND COMPLICATIONS OF LAPAROSCOPY
1. All of the following are properties of nitrous oxide insufflation, except: A. It doesn’t cause
hypercarbia B. It is readily soluble in blood C. Itmay cause bowel distention D. It doesn’t support
combustion E. It does not irritate the diaphragmor peritoneum
2. Which of the following are signs of a gas embolism? A. Sudden hypotension B. Cyanosis C. Increasing
end-tidal CO2 D. “Mill wheel”murmur E. All of the above
3. All of the following maneuversmust be performed immediately if one suspects a gas embolism,
except: a)Release pneumoperitoneum b)Increaseminute ventilation and administer100%oxygen c) Place
patient in a head-down, right lateral d)decubitus position e)Place a central venous line and attempt to
f)aspirate the gas g)Initiate CPR as indicated
4. All of the followingmechanisms account for oliguria during laparoscopy, except:A. Direct compression
of the renal parenchyma B. Compression of renal vasculature C. Decrease in cardiac output D.
Compression of the ureter E. Increased activity of renin-angiotensin access and antidiuretic hormone
release
5. Which of the following is not true about diagnosis and treatment of perioperative rhabdomyolysis?
a)It may present with muscular pain, oliguria and dark urine b)B.Morbid obesity is a risk factor for
developing rhabdomyolysis c)Itmay result in acute renal failure d)Vigorous hydration is a main stay of
therapy e)Urinary alkalinization has been shown to be beneficial in human studies
6. Laparoscopic bowel injury is associated with all of the following, except: A. Peritoneal signs B. High
fever C. Severe nausea and vomiting D. High white blood cell count E. All of the above
7. The nervesmost prone to injury secondary to positioning for laparoscopy are all of the following,
except: A. Brachial plexus B. Lateral popliteal C. Sciatic D. Femoral E. None of the above
8. All of the following confirm correct placement of the Veress needle, except: a)2 pops are heard as the
needle traverses the fascia and the peritoneum b)Inability to aspirate back 5 –10cc of saline c)injected
through the needle d)Low pressure reading at initiation of insufflation e)Adecrease in pressure with
elevation of the abdominal wall f)None of the above
9. Which of the following are true of the laparoscopic diaphragmatic injuries? a)They are usually due to
electrocautery b)They always result in a tension pneumothorax c) and cardiovascular collapse d)They
cannot be repaired laparoscopically e) D.When recognized, theymust be repaired f)immediately g)All of
the above
10. Regarding trocar site hernias, all of the following are true, except: A. To prevent hernias the fascia of
12-mmradially dilating trocar sitesmust always be closed B. They can present as a tender or non-tender
bulge at the trocar site C. They can cause small bowel obstruction D. They can be repaired
laparoscopically E. All of the above
Answers 1. D. Nitrous oxide supports combustion. 2. E.All choices are correct and are common
presenting signs of gas embolus.3. C. Patient should be placed in a head-down, left lateral decubitus
position.
4. D.Ureteral compression has not been shown to be a mechanism of oliguria of pneumoperitoneum.
5. E. Alkalinization was found to be beneficial only in animal studies.
6. E.None of the choices are part of common presentation of laparoscopic bowel injury.
7. E.All of the listed nerves are commonly affected.
8. E. All of the choices indicate correct placement of the Veress needle.
9. A. Diphragmatic injuries are usually secondary to electrocautery.
10. A.Fascia of dilating trocar sites doesn’t need to be closed. The actual diameter of the fascial opening
is about one-half of the trocar size.
CHAPTER 27: EVALUATION AND TREATMENT OFMALE FACTOR INFERTILITY
1. Embryologically, the vas deferens and body of the epididymis are derived from what developmental
structure? A.Müllerian ducts B.Wolffian ducts C. Urogenital ridge D. Gubernaculum testis
E.Metenephros
2. The vastmajority of the fluid in themale ejaculate is derived fromthe: A. Epididymides B. Ejaculatory
ducts C. Seminal vesicles D. Testicles E. Vas deferens 3. The most common and correctable identifiable
problem causingmale infertility is: a)Infection b) Obstruction c)Gonadotoxin exposure d)Varicocele
e)Genetic
4. A25-year-old bodybuilder eschews themerits of natural bodybuilding and cycles and stacks injectable
anabolic steroids regularly tomaximizemuscle bulk. His fertility potential would be expected to be: A.
Normal, because exogenous testosterone does not impair production of endogenous testosterone B.
Low, because exogenous testosterone stimulates pituitary production of FSH and LH C. Low, because
exogenous testosterone inhibits pituitary production of FSH and LH D. Low, because exogenous
testosterone is not as potent as endogenous testosterone at nurturing spermatogenesis E. Normal,
because intratesticular testosterone concentrations are 50x higher than serumlevels, whether or not the
blood contains exogenous testosterone
5. The role of PSAin the ejaculate is: A. To coagulate the ejaculate B. To serve as amarker for prostate
cancer C. To serve as a liquefaction factor D. To give semen its characteristic odor E. To agglutinate the
ejaculate
6. What geneticmutation is involved with congenital absence of the vas deferens (CAVD)?
A. Klinefelter syndrome (47,XXY) B. Reifenstein syndrome C. 3p1 D. CFTR (delta f 508) E. 45XO
7. Low serumtestosterone, LH and FSH characterize what type of hypogonadism? A. Hypergonadotropic
hypogonadism B. Young syndrome C. Hypoprolactinism D. Kallman syndrome E. Klinefelter syndrome
8. How do elevated levels of prolactin influence testosterone production? A. Inhibit GnRH and LH B.
Indirectly inhibit Sertoli cells C. Directly inhibit Leydig cells D. Upregulate inhibin E. Downregulate activin
9. What testicular hormone is themajor feedback inhibitor of LH secretion? a)Testosterone b) Inhibin
c)Activin d)Prolactin e)Sertolin
10. What is the initial evaluation for aman with 1 semen analysis that shows low volume ejaculate? A.
Semen pH B. Postejaculate urinalysis C. Semen fructose D. TRUS E. Repeat semen analysis
11. What is the normal size for adult human testes? A. 5mL B. 10mL C. 20mL D. 30mL E. 40mL
12. In the absence of genital tract infection, round cells in the semen analysis aremost likely what kind of
cell? A. Squamous epithelial cells B. Immature germcells C. Prostatic epithelial cells D. Leydig cells E.
Sertoli cells
13. Hormonal screening of infertility patients below what spermconcentration will pick up most
endocrinopathies? A. <1million/mL B. <5million/mL C. <10million/mL D. <20million/mL E. <60million/mL
14. Vasography is routinely performed by all of the followingmethods EXCEPTwhich one? A. Scrotal B.
Transperineal C. Transrectal D. Transurethral E. Transabdominal
15. Why is performing varicocelectomy at the same time as vasectomy reversal discouraged? a)Venous
congestion b)Arterial compromise c)Increased risk of spermgranuloma d)All of the above e)None of the
above
16. Aman has the following semen analysis profile after vasectomy reversal. This pattern is typical of
what problem? Timepoint Volume Motility after surgery concentration 6 weeks 3.0 45million/mL 45%
3months 3.5 50million/mL 15% 6months 2.5 20million/mL 0% A. Antispermantibodies B. Testicular
injury C. Stricture formation at anastomosis D. Primary hypogonadism E. Ejaculatory duct obstruction
17. What percentage of oligospermic infertile males will have geneticmicrodeletions of the
Ychromosome? A. 1% B. 5% C. 25% D. 50% E. 75%
18. Which of the following has the highest impact on pregnancy rates with in vitro fertilization (IVF)? A.
Oligospermia—male factor infertility B. Tubal obstruction—female factor infertility C. Female age D.
Epididymal sperm E. Testis sperm
19. What patency rates are achievable from contemporary series of microscopic vasovasostomies? A.
90%–99% B. 80% –90% C. 50%–60% D. 40%–50% E. 25% –35%
20. Which fluid characteristic(s) fromthe testis vas deferens predict the best success for vasectomy
reversal? a)Clear with no sperm b)Creamy with spermfragments c)Creamy with no sperm d)Cloudy with
motile sperm e)Cloudy with fragmented sperm
Answers 1.B. Müllerian ducts regress in themale. The indifferent gonadmigrates to the urogenital ridge
to become the testicle. The gubernaculumtestis is responsible for pulling the testis into the
scrotumduring development.
2.C. At least 65% – 70%of ejaculate volume is derived From the seminal vesicles, with the remainder
from the vas deferens (with sperm) and prostatic secretions. Periurethral glandsmay also contribute a
small amount of fluid to the normal ejaculate.
3.D. Infection and obstruction occur in 5% –10%ofmale infertility. The prevalence of gonadotoxin
exposure is not well known. Varicocele occurs in 40%of infertile men.
4.C. Because of negative feedback inhibition thatmaintains homeostatic balance in the pituitarygonadal axis, excess testosterone of any type will cause anterior pituitary production of LH and FSH to
fall. Thisresults in azoospermia inmost ofmen on anabolic steroids, but the effect will vary based on the
dose, frequency and duration of the cycles and stacking regimen
5.E. PSAis a serine protease that enzymatically breaks down the seminal coagulumafter ejaculation.
6.D.CFTRmutations,most commonly delta 508, are involved with CAVD
7.D.Kallmann syndrome, a formof hypogonadotropic hypogonadism
8.A. Hyperprolactinemia causes hypogonadotropic hypogonadism
9.A. Testosterone.
10.E.Low-volume ejaculates are commonly due to collection error.
11. C. 12. B. 13.C. 99%of endocrinopathies will be detected if screening is done inmen with <10million
sperm/mL 14.E. Vasography is not routinely done transabdominally
15.A. With varicocele repair, all venous drainage from thetestis is ligated except for the vasal veins.With
vasectomy reversal, injury to the vasal veins may occur.
16.CAnastomotic strictures after vasectomy reversal typically cause a decrease in spermmotility
followed by a decrease in spermconcentration over time.
17.B.5%. The range is 3% 8%. 18.C. 19.A. 20.D.
CHAPTER 28: ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE AND PRIAPISM
1. The nitric oxide/cyclic GMP (NO/cGMP) systemin the penis is of the utmost importance in the
generation of penile erection. cGMP produced by this cascade is inactivated by which of the following?
(Note: NOS = nitric oxide synthase; PDE = phosphodiesterase) A. PDE 2, 3 and 4 B. PDE 5 C.
Norepinephrine D. Neuronal NOS E. Endothelial NOS
2. Which of the following statements is themost accurate regarding the source of the blood that results
in erection of the corpora cavernosa? A. The blood supply comes from the cavernosal (deep) penile
arteries B. The blood supply comes fromthe deep dorsal arteries C. The blood supply comes from both
the cavernosal and deep dorsal arteries D. The blood supply does not come from the cavernosal or deep
dorsal arteries
3. Which of the following is themost common sexual adverse effect of selective serotonin reuptake
inhibitors (SSRIs)? A. Decreased libido B. Premature ejaculation C. Erectile dysfunction D. Anorgasmia E.
Orchalgia
4. All of the following characteristics in an erectile dysfunction patient’s history suggest a primary
psychogenic problem, except: A. Sudden onset B. Young age C. Sleep erections present D. Varying
degree of dysfunction E. Orgasmis preserved
5. Which of the following agents cause partial inhibition of PDE6? A. Sildenafil B. Tadalafil C. Vardenafil
D. Prostaglandin E1 E. Apomorphine
6. Which of the following erectile dysfunction treatments results in the highest satisfaction rates? A.
Sildenafil B. Intraurethral prostaglandin E1 C. Penile injection therapy with prostaglandin E1 D.
Vacuumconstriction device E. Inflatable penile prosthesis
7. The penoscrotal approach for inflatable penile prosthesis placement offers which of the following
advantages over the infrapubic approach? A. Safer reservoir placement B. Preservation of glans
tumescence C. Less risk of penile contracture D. Less risk of penile sensory loss E. Larger girth implant is
possible
8 Aman presents with Peyronie’s Disease and very significant penile shortening. Intercourse is
impossible due to a 90-degree dorsal deformity. He has firmerections, but is quite upset with how short
the penis has become. Length preservation is the primary goal of the patient. Which of the following
procedures should be avoided to try to help achieve his goals? A. Penile placation procedure (eg, Nesbit)
B. Penile prosthesis placement C. Penile prosthesis placement with amolding procedure D. Plaque
excision with dermal graft E. Plaque incision with pericardial graft
9. A48-year-old-man present with Peyronie’s Disease with a 90-degree dorsal deformity. Erections are
perfectly firmby history. He undergoes a plaque incision and grafting, with elevation of the
neurovascular bundle. Sensation returns to normal, but he is completely unable to achieve erection
following the surgery.Which of the following preoperative testsmight have predicted this complication
fromsurgery? A. Serumtestosterone level B. Nocturnal penile tumescence study C.Duplex Doppler
ultrasound of the penile vessels D. Biothesiometry E. Penile-brachial index
10. Which of the following injectable agents is recommended by the AUAGuidelines on priapism, due to
its pure alpha-adrenergic effect and lack of secondary neurotransmitter release? A. Epinephrine B.
Phenylyephrine C.Metaraminol D. Norepinephrine E. Dopamine
Answers 1. B 2. A 3. D 4. E 5. A 6. E 7. D 8. A 9. C 10. B
Urology MCQ Prometric medical license exam
1. The most ominous sign or symptom of urinary system disease is:
A. Urinary frequency.
B. Pyuria.
C. Pneumaturia.
D. Dysuria.
E. Hematuria.
Answer: E DISCUSSION: While urinary frequency (voiding more than three to five times daily) or dysuria
(painful voiding) may be a sign of malignant disease, they are more commonly associated with
nonmalignant inflammatory disease, neurologic disease, or calculous disease of the urinary tract. Pyuria
(pus in the urine) is most commonly associated with infection and not malignancy. Pneumaturia (air or
gas in the urine) indicates a fistula between bowel and the urinary tract or infection by fermination in
diabetic urine. Hematuria (blood in the urine) is most worrisome. While this may be produced by
infection or by calculous disease, it is most commonly associated with malignant disease in the absence
of associated signs or symptoms such as pyuria, frequency, and dysuria. Thus, of the ones mentioned,
hematuria is the most ominous single sign or symptom.
2. A patient with acute urinary tract infection (UTI) usually presents with:
A. Chills and fever.
B. Flank pain.
C. Nausea and vomiting.
D. 5 to 10 white blood cells per high-power field (hpf) in the uncentrifuged urine specimen.
E. Painful urination.
Answer: E DISCUSSION: Cystitis or infection of the bladder is the most common UTI. Lower UTI, or
cystitis, is an infection in the bladder. Painful urination and frequency are the most common presenting
complaints. Hematuria may occur, but is associated with painful urination and frequency. Flank pain,
fever, chills, nausea, and vomiting usually occur only when the infection involves the kidney. An acute
UTI is identified in unspun urine only when there are more than 10 leukocytes per hpf in the unspun
urine. The normal urine may have as many as 10 WBC/per hpf without being infected
3. Renal adenocarcinomas:
A. Are of transitional cell origin.
B. Usually are associated with anemia.
C. Are difficult to diagnose.
D. Are extremely radiosensitive.
E. Frequently are signaled by gross hematuria.
Answer: E DISCUSSION: Renal adenocarcinomas arise from the renal tubular cells and not from the
transitional cells that line the collecting system of the kidney. Although one fifth of all patients with
renal cancer may present with anemia, the most common presenting symptom is hematuria, either
gross or microscopic. Ultrasonography may confirm that a renal lesion is either cystic or solid but
computed tomography (CT) is probably the most accurate imaging study for diagnosing the disease.
Renal adenocarcinoma is little sensitive to current chemotherapeutic agents. Radiotherapy plays almost
no role in the management of the primary tumor. Operation is the treatment of choice when the disease
is confined to the kidney itself or when it has extended just outside the renal capsule. An operation has
little effect once the disease is extended to adjacent structures or to regional lymph nodes.
4. Ureteral obstruction:
A. Is associated with hematuria.
B. Is associated with deterioration of renal function and rising blood urea nitrogen (BUN) and creatinine
values.
C. Is commonly caused by a urinary tract calculus.
D. Usually requires open surgical relief of the obstruction.
E. Is usually associated with infection behind the obstruction.
Answer: C DISCUSSION: Ureteral obstruction produces loss of renal function when there is only one
renal unit and the ureter is obstructed or when obstruction is bilateral. Ureteral obstruction often is best
identified by either intravenous pyelography (IVP) or retrograde pyelography, which allows one to
identify the specific site of obstruction. Calculous disease is the most common cause of ureteral
obstruction. Ureteral obstruction is not a surgical emergency that requires open surgical intervention,
but it may be relieved by retrograde or antegrade passage of a double-J stent to bypass the obstruction,
permitting orderly nonemergent identification of the cause of obstruction and selection of a treatment
process.
5. Stress urinary incontinence:
A. Is principally a disease of young females.
B. Occurs only in males.
C. Is associated with urinary frequency and urgency.
D. May be corrected by surgically increasing the volume of the bladder.
E. Is a disease of aging produced by shortening of the urethra.
Answer: E DISCUSSION: Stress urinary incontinence is seen principally in older females and is produced
by pelvic floor relaxation with shortening of urethral length. The symptom of stress urinary incontinence
is urinary leakage produced by an increase in intra-abdominal pressure, as with straining to lift or to
laugh. Urgency and frequency are symptoms of urge incontinence, not stress incontinence. Stress
incontinence classically is not seen either in males or in young females who have good pelvic floor
support.
6. Which of the following is/are true of blunt renal trauma?
A. Blunt renal trauma and penetrating renal injuries are managed similarly.
B. Blunt renal trauma with urinary extravasation always requires surgical exploration.
C. Blunt renal trauma must be evaluated by contrast studies using either IVP or CT.
D. Blunt renal trauma requires exploration only when the patient exhibits hemodynamic instability.
E. Any kidney fractured by blunt renal trauma must be explored.
Answer: D DISCUSSION: Blunt renal trauma should be explored. Only those who have gross hematuria
need undergo contrast studies. Microscopic hematuria is no longer an indication for contrast evaluation.
Patients who have blunt renal trauma need to undergo exploration only if they are hemodynamically
unstable. Conservative management in the absence of hemodynamic instability is the current trend. All
penetrating injuries should undergo exploration.
7. Carcinoma of the bladder:
A. Is primarily of squamous cell origin.
B. Is preferentially treated by radiation.
C. May be treated conservatively by use of intravesical agents even if it invades the bladder muscle.
D. May mimic an acute UTI with irritability and hematuria.
E. Is preferentially treated by partial cystectomy.
Answer: D DISCUSSION: Carcinoma of the bladder is primarily of transitional cell origin, arising from the
transitional epithelium that lines the bladder. It may be confused with an acute UTI by producing
urgency, frequency, and hematuria. Bladder carcinoma may be treated conservatively using intravesical
agents if the tumor is intraepithelial in origin and does not invade through the basement membrane.
Neither radiation nor chemotherapy is the treatment of choice for disease that invades the muscle of
the bladder. Partial cystectomy may be chosen only when the disease is focal and there are no mucosal
changes in other parts of the bladder.
8. The major blood supply to the testes comes through the:
A. Hypogastric arteries.
B. Pudendal arteries.
C. External spermatic arteries.
D. Internal spermatic arteries.
Answer: D DISCUSSION: Testes arise from portions of the wolffian bodies on the genital ridge close to
the kidneys; therefore, the major blood vessels from the testes arises from the aorta just below the
renal arteries and are termed the internal spermatic arteries. Secondary blood supply to the testes
comes from the artery of the vas deferens, and a small branch from the epigastric artery termed the
external spermatic artery forms during descent of the testes from the abdomen to the scrotum. The
surgical importance of this phenomenon is that operations involving the region of the renal arteries may
sacrifice the internal spermatic artery. If the two other arteries are intact, the testes will survive;
however, if the patient has had a vasectomy and the artery of the vas has been sacrificed, there is a
possibility of testicular atrophy, since the testicle will have to be totally dependent on the arterial supply
derived from the small external spermatic artery.
9. Patients who have undergone operations for benign prostatic hypertrophy or hyperplasia:
A. Require routine rectal examinations to detect the development of carcinoma of the prostate.
B. Do not need routine prostate examinations.
C. Have a lesser incidence of carcinoma of the prostate.
D. Have a greater incidence of carcinoma of the prostate.
Answer: A DISCUSSION: Patients who have undergone operations for benign prostatic hyperplasia or
hypertrophy have had only the inner portion of the prostate removed, which consists of the periurethral
glandular structures that give rise to hyperplasia and hypertrophy. The posterior segment of the
prostate, which is compressed by the anterior (inner) portion, comprises the surgical capsule and is left
behind. The posterior portion of the prostate gland is the most frequent site of origin of prostate cancer.
There is no difference in the incidence of carcinoma of the prostate in patients with benign prostatic
hypertrophy and those without benign prostatic hypertrophy or those who have and have not
undergone operation for prostatic hypertrophy. Since prostate carcinoma can develop at any time in a
patient's life, routine examinations and prostate-specific antigen assay are the most efficient methods of
detecting this disease.
10. The male contribution to a couple's infertility is approximately:
A. 10%.
B. 25%.
C. 50%.
D. 75%.
Answer: C DISCUSSION: In the United States of America it has been estimated that approximately 15% of
couples have difficulty with conception. Adequate evaluation of the marital unit for infertility demands
assessment of the male partner since infertile status may be attributed to the male as much as 50% of
the time. A full evaluation of the male partner is important to avoid extended fruitless evaluation and
management of the female partner when the male is infertile.
11. To maximize fertility potential, orchidopexy for cryptorchidism should be done before:
A. Age 15 years.
B. Age 12 years.
C. Marriage.
D. Age 2 years.
Answer: D DISCUSSION: The testes are exquisitely sensitive to temperature; therefore there is
progressive deterioration of testes that are not within the scrotum. Cryptorchid testes, whether they be
in the inguinal canal, in an intra-abdominal position, or in an ectopic position, will undergo progressive
spermatogenic failure, although adequate amounts of androgens may be produced and secreted. The
timing of orchidopexy has been moved progressively backward, and now the recommendation is that
orchidopexy should be accomplished before age 2 years, to maximize the possibility of production of
spermatozoa of normal quantity and quality. In cases of unilateral cryptorchidism the matter of surgical
exploration is less critical; however, to provide maximum potential for both testes, the earlier
cryptorchidism is surgically corrected the better are the chances for normal spermatogenesis.
12. Within the age group 10 to 35 years, the incidence of carcinoma of the testis in males with intraabdominal testes is:
A. Equal to that in the general population.
B. Five times greater than that in the general population.
C. Ten times greater than that in the general population.
D. Twenty times greater than that in the general population.
Answer: D DISCUSSION: The incidence of carcinoma of the testis is greater in patients who have
cryptorchidism, whether corrected or not; because of this, routine self-examination by patients who
have undergone operation for cryptorchidism is important. For patients who have uncorrected intraabdominal testes it is estimated that the incidence of the development of carcinoma of the testis in the
age group 10 to 35 years is approximately 20 times greater than that for the general population. If
cryptorchidism is diagnosed after the age of 10 to 12 years, orchiectomy may be the preferred
treatment, since such testes rarely exhibit normal function, despite adequate scrotal placement, and put
the patient at great risk for an intra-abdominal neoplasm that will be difficult to diagnose.
13. The appropriate surgical treatment for suspected carcinoma of the testis is:
A. Transscrotal percutaneous biopsy.
B. Transscrotal open biopsy.
C. Repeated examinations.
D. Inguinal exploration, control of the spermatic cord, biopsy, and radical orchectomy if tumor is
confirmed.
Answer: D DISCUSSION: If, after physical examination, and even scrotal ultrasound, a tumor of the
testicle is still suspected, the appropriate surgical treatment is high inguinal exploration with control of
the cord, delivery of the testicle onto a protected field, biopsy if necessary, and then orchiectomy at the
level of the internal ring if tumor is confirmed. Transscrotal manipulations, whether they be
percutaneous or open, are to be condemned because of the possibility of tumor spillage with the
ultimate necessity for hemiscrotectomy to control local recurrence. Certainly, repeated examinations
over a very short period of time are appropriate, but no time should be lost if there is true suspicion of a
testicular tumor. Before the high inguinal exploration it is helpful to obtain serum levels of the beta
subunit of human chorionic gonadotropin and alpha-fetoprotein, which are important tumor markers.
Surgical exploration should not be delayed until the actual laboratory values are determined, as they are
important to the longitudinal course of the patient and not necessarily to the diagnosis.
14. If torsion of the testicle is suspected, surgical exploration:
A. Can be delayed 24 hours and limited to the affected side.
B. Can be delayed but should include the asymptomatic side.
C. Should be immediate and limited to the affected side.
D. Should be immediate and include the asymptomatic side.
Answer: D DISCUSSION: Torsion of the testicle should be corrected as soon as possible after the
diagnosis is entertained. Incomplete torsion can cause partial strangulation, the effects of which may be
overcome if surgical intervention is accomplished within 12 hours, whereas severe torsion with
complete compromise of the blood supply results in loss of the testis unless surgical intervention occurs
within approximately 4 hours. The contralateral scrotum should also be explored at the time of the
operation, since the primary anatomic defect—insufficient attachment of the testicle to the scrotal
sidewall—most often is a bilateral phenomenon. If the contralateral scrotum is not explored, the patient
runs a very high risk of undergoing torsion on the other side and the possible complication of loss of
both testes.
15. Epididymitis, either unilateral or bilateral, in a prepubertal male:
A. Is a frequent diagnosis.
B. Can be dealt with on an outpatient basis.
C. Is a major scrotal problem in this age group.
D. Is a rare phenomenon.
Answer: D DISCUSSION: Epididymitis can occur in prepubescent males, but it is a rare phenomenon and
usually occurs only in patients with chronic UTI, obstructed urethra, or very high voiding pressure. The
diagnosis of epididymitis in the prepubertal male should be reviewed with suspicion because one of the
more common causes of the clinical situation that presents as epididymitis is torsion of the testicle. If
there is any concern about the validity of the diagnosis, the patient should undergo scrotal exploration.
Epididymitis will not be compromised by surgical exploration, but delay in surgical exploration leads to
loss of the testicle if the problem is torsion.
16. Patients with prostatitis, especially acute suppurative prostatitis:
A. Should have residual urine measured by intermittent catheterization.
B. Should have bladder decompression by urethral catheter.
C. Should have repeated prostatic massage.
D. Should have no transurethral instrumentation if possible.
Answer: D DISCUSSION: Acute suppurative prostatitis should be treated with vigorous antibiotic therapy
with broad-spectrum agents initiated immediately and changed in response to results of culture and
sensitivity studies. Urethral instrumentation and repeated prostate examination should not be done, if
at all possible, since sepsis is not unusual after either diagnostic examination or urethral catheterization.
If the patient does need to have the bladder decompressed, it is beneficial to use a suprapubic catheter
rather than a urethral catheter.
17. Benign prostatic hypertrophy with bladder neck obstruction:
A. Is always accompanied by significant symptoms.
B. Is best diagnosed by endoscopy and urodynamic studies.
C. Is easily diagnosed by the symptoms of frequency, hesitancy, and nocturia.
D. Is always accompanied by residual urine volume greater than 100 ml.
Answer: B DISCUSSION: Benign prostatic hypertrophy with bladder neck obstruction is difficult, in some
patients, to diagnose as they are totally asymptomatic, even if they have residual urines of greater than
1000 ml. or renal compromise consisting of the syndrome of so-called “silent prostatism.”
18. Which of the following statements are true concerning male infertility?
a. Although 15% of couples in the United States are affected by infertility, the male rarely contributes to
the problem
b. A varicocele can be associated with diminished sperm motility and abnormal sperm morphology
c. Complete testicular failure will usually respond to systemic testosterone administration
d. Anti-sperm antibodies are an important cause of infertility which may be treated successfully with
corticosteroid administration
Answer: b, d :Infertility is defined as the inability to conceive a pregnancy within one year of
unprotected intercourse. About 15% of couples in the United States are affected, and in about 25%-50%
of infertility cases, the male contributes to the problem. The cornerstone of male fertility evaluation is
the semen analysis. Oligospermia, or a low sperm count, is an incomplete form of testicular failure due
to a number of causes. A varicocele is found in about 15% of the general male population, but 40% of
infertile men have this finding. Men with a varicocele can exhibit low sperm counts but more often have
diminished sperm motility and abnormal morphology. Surgical ligation or angiographic embolization of
the internal spermatic vein improves the semen parameters in 50%-70% of these men and gives
subsequent pregnancy rates of 25%-50%. Complete testicular failure is diagnosed by a testis biopsy
showing no sperm production or by a markedly elevated serum FSH level, indicating the absence of
negative feedback inhibition induced by spermatogenesis. Complete testicular failure is not remedial by
treatment. Anti-sperm antibodies are found frequently in infertile men and represent an important
cause of infertility. Corticosteroid administration may be helpful if antibodies are present, but the
toxicity of these medications cannot be ignored.
19. A 65-year-old male is diagnosed as having prostatic cancer based on transrectal biopsy of a 1 cm
palpable nodule. Which of the following statement(s) are true concerning his management?
a. If the tumor is confined within the prostatic capsule (stage A or B), radical prostatectomy is an
appropriate option
b. If positive lymph nodes are detected on laparoscopic pelvic lymph node dissection (stage Dl), radical
prostatectomy is indicated
c. Radical prostatectomy is invariably associated with impotence
d. External beam radiation is an appropriate treatment if the tumor is confined to the prostate
e. There is currently no role for orchiectomy in the management of prostatic cancer
Answer: a, d :The treatment of prostatic cancer depends on whether the disease is localized to the
prostate or advanced beyond the gland. Because prostate cancer advances slowly, the morbidity of
therapy may exceed the therapeutic benefit in the elderly and debilitated. Patients who have a limited
life expectancy and low stage disease are frequently treated with observation only. If the tumor is
confined within the prostatic capsule (Stage A or B), options include radical prostatectomy, external
beam radiation therapy, and radioactive implants. Radical prostatectomy is usually carried out through
the retropubic approach. Through this approach a node dissection can be done for further staging, and
the procedure abandoned if the nodes contain tumor. In patients with a high index of suspicion for
positive nodes, a laparoscopic pelvic node dissection can be performed to decrease postoperative
morbidity. The use of the nerve-sparing prostatectomy can be used to preserve penile erection in those
patients who are potent. In this approach, the nerves concerned with penile erection are excluded from
the dissection. The incidence of impotence following traditional radical prostatectomy is l00% but can be
cut in half with the nerve-sparing approach. Hormonal ablation is the initial treatment of choice for
advanced prostatic cancer. Most prostatic cancers are androgen-responsive. Androgen ablation will
cause improvement in 80-90% of patients with regression of tumor in about 40%. The testis is the
primary source of androgen and orchiectomy remains the gold standard and treatment of choice for
advanced prostatic cancer. Estrogen will produce castrate levels of testosterone, but the side effects of
fluid retention and increased incidence of thromboembolic diseases such as heart attacks and strokes
make this hormone a poor choice in this high risk age group.
20. Extracorporeal shock wave lithotripsy (ESWL) has had a dramatic effect on the management of
urinary stones. Which of the following statement(s) are true concerning shock wave lithotripsy of
urinary stones?
a. The basic principle of lithotripsy involves the generation of shock waves which are focused
fluoroscopically on the calculus and are delivered to the patient who is submersed in a water bath
b. The most common complication after lithotripsy is ureteral obstruction secondary to stone fragments
c. ESWL can be associated with stone-free rates ranging between 60%-95% at six months for renal and
proximal ureteral stones
d. The combination of ESWL with percutaneous nephrolithotripsy improves the results for stone
clearance in patients with large or branched stones such as staghorn calculi
Answer: a, b, c, d :The introduction of ESWL has virtually eliminated open surgery for renal and ureteral
lithiasis. The basic principles of all lithotriptors include shock wave generation, focusing of the sound
wave, and imaging of the stone. All lithotriptors produce shock waves by a spark gap electrode or by a
piezoelectric or electromagnetic element. The wave is then focused towards the stone which is localized
either employing fluoroscopy or ultrasonography. The patients are either submersed in a water bath or
“coupled” by a water cushion. The acoustic density of water and body tissues is essentially the same.
Therefore, there is little or no impedance of the shock wave at the water-body interface. Upon striking
the stone, which is of different acoustical density, the shock wave undergoes reflection and refraction,
resulting in compressive and tensile forces which fragment the stone.
Complications of ESWL are rare. The most common complication after ESWL is ureteral obstruction
secondary to stone fragments requiring either additional ESWL, urethroscopic stone retrieval or stent
placement. ESWL is the treatment choice for the vast majority of renal and proximal ureteral stones
with stone-free rates ranging from 60%–95% at six months. Stones larger than 3 cm and branch stones
such as staghorn calculi are best treated with percutaneous nephrolithotripsy alone or in combination
with ESWL. The combination of extracorporeal and percutaneous techniques can result in average dome
clearance rates in excess of 80%.
21. Which of the following statement(s) are true concerning bladder carcinoma?
a. Epidemiologic studies have implicated cigarette smoking as a risk factor
b. If cystoscopy demonstrates a bladder carcinoma as the cause of painless hematuria, no further
evaluation is necessary
c. Multi-focal and recurrent bladder tumors are usually treated with transurethral resection and
intravesical chemotherapy
d. The results of treatment for locally advanced bladder tumors are similar with either radical
cystectomy or radiation therapy
Answer: a, c :A wealth of basic research and clinical data testify to a variety of chemical carcinogens
inducing bladder cancer. Occupational exposure to beta-naphthylamine and para-aminophenyl results in
an increased incidence of bladder cancer. Epidemiologic studies have also indicated cigarette smoke as a
risk factor. Bladder cancer has a strong male prevalence and is almost three times more common in men
than women. The hallmark of bladder cancer is painless, total gross hematuria. The usual diagnostic
tests employed are excretory urography (IVP) and cystoscopy. The former is important because the
upper tracts (renal pelvises and ureters) are also at risk for the development of urothelial neoplasia.
Cystoscopy is not only diagnostic but also therapeutic because superficial tumors are easily excised or
fulgurated through endoscopic instruments. Approximately 70% of patients with bladder cancer will
present with local disease. This is associated with five year adjusted survival rate of 88%. Close vigilance
is important because the recurrence rate exceeds 50%. Ten to 50% of superficial tumors will progress to
invasive disease. Multifocal and recurrent tumors are usually treated with intravesical chemotherapy in
addition to transurethral resection. Agents commonly employed include thiotepa, doxorubicin, and
mitomycin C. Alternatively intravesical immunotherapy has been successfully performed with
installation of BCG (Bacillus Calmette-Guerin). Locally advanced tumors are usually treated with radical
cystectomy and urinary diversion. Radiation therapy has been employed but is associated with a high
rate of local recurrence.
22. The most common malignant neoplasm of the kidney is the hypernephroma or renal cell carcinoma.
Which of the following statement(s) are true concerning renal neoplasms?
a. Renal cell carcinomas can produce a variety of hormone or hormone-like substances
b. Bilateral multifocal renal cell cancers can be associated with the multiple endocrine neoplasia
syndrome
c. A “tumor deformity” on IVP is diagnostic of a renal cell carcinoma
d. Early control of the renal pedicle is an important aspect of surgical management of renal cell
carcinoma
e. Patients with renal cell carcinoma in a solitary kidney will inevitably require total nephrectomy and
long-term dialysis for the resultant renal failure
Answer: a, d :Renal cell carcinoma or hypernephroma account for approximately 2% of all cancers
diagnosed annually. It is most common after the fifth decade of life and has a male to female ratio of
approximately 2:1. No definite etiology has been identified, but a frequent genetic abnormality detected
in renal cell cancer is the loss of heterozygosity of chromosome 3p. Multifocal bilateral tumors are
associated with von Hippel-Lindau disease. Renal carcinomas can produce a variety of hormone or
hormone-like substances (e.g., erythropoietin, renin, and parathormone) and may present with a variety
of symptoms including anemia, hypertension, fever and erythrocytosis. Excretory uroraphy (IVP)
provides a good renal image with superior detail of the collecting system. Renal masses such as benign
cysts or renal cell carcinomas will both appear as “tumor deformities”, distorting the renal outline or the
collecting system. Renal cysts are far more common than renal cell carcinoma and the diagnosis can be
confirmed by renal ultrasound. Surgical excision remains the primary mode of treatment for renal cell
carcinoma. Although the need for radical nephrectomy has recently been questioned, this procedure
remains a gold standard against which less radical procedures must be judged. Radical nephrectomy is
performed through an abdominal or a thoracoabdominal approach and involves early control of the
renal artery and vein. The tumor, together with the kidney and the perirenal fat is excised within
Gerota’s fascia which is not opened. Less radical approaches have been suggested for the treatment of
smaller tumors, including partial nephrectomy. This approach is especially valuable for bilateral tumors
or in patients with a solitary kidney or poor overall renal function.
23. A 28-year-old white male presents with asymptomatic testicular enlargement. Which of the
following statement(s) is/are true concerning his diagnosis and management?
a. Tumor markers, b-fetoprotein (AFP) and ‫ك‬-human chorionic gonadotropin (HCG) will both be of value
in the patient regardless of his ultimate tissue type
b. Orchiectomy should be performed via scrotal approach
c. The diagnosis of seminoma should be followed by postoperative radiation therapy
d. With current adjuvant chemotherapy regimens, retroperitoneal lymphadenectomy is no longer
indicated for non-seminomatous testicular tumors
Answer: c Testis cancer is most common between the ages of 25 and 34 and is rare in blacks. The most
common malignant neoplasm of the testis arise from the germ cells and can represent a variety of
histologic manifestations, e.g, choriocarcinoma, embryonal cell carcinoma, seminoma, and teratoma.
For therapeutic purposes, the tumors can be divided into seminomas and nonseminomas. The usual
presenting symptom is testicular enlargement that may be associated with mild discomfort. Any solid
testicular mass should be considered suspicious for testis carcinoma. The diagnostic and therapeutic
approach for any suspected testis carcinoma is inguinal exploration with orchiectomy if the operative
findings confirm the presence of a testicular mass. The inguinal approach is employed to perform high
ligation of the cord at the inguinal ring and to eliminate potential involvement of the inguinal lymph
nodes which are the primary area of drainage for the scrotum. The tumor markers, a-fetoprotein (AFP)
and the b-human chorionic gonadotropin (HCG) can contribute to both diagnosis and follow-up of testis
cancer. Tumor markers are helpful when obtained prior to and following orchiectomy to help in
assessing the stage of the tumor. Pure seminoma does not cause elevated AFP but can produce a
moderate rise in HCG in 10% of patients. Seminomas are very responsive to radiation. Patients with
minimal to moderate tumor burden (Stage I or II) are usually treated with radiotherapy. The field of
treatment encompasses the para-aortic and para-caval areas below the diaphragm and ipsilateral
inguinal and pelvic areas. When bulky retroperitoneal and/or distant metastases are present, cisplatinbased combination chemotherapy is the preferred treatment. The treatment of non-seminomatous
tumors is more controversial. Stage I tumors are effectively treated with retroperitoneal
lymphadenectomy. If bulky stage II and stage III non-seminomatous tumors are present, initial
treatment includes cisplatin-based chemotherapy. Evidence for residual disease with normalization of
tumor markers is usually an indication for surgical exploration.
24. Which of the following statement(s) is/are true concerning benign prostatic hypertrophy (BPH)?
a. Prostatic size has no consistent relationship to urethral obstruction
b. Renal failure secondary to obstructive uropathy occurs as bladder pressure rises and is eventually
transmitted proximally to the renal pelvis
c. Hormonal treatment for BPH involves treatment with a 5 a-reductase inhibitor which blocks the
conversion of testosterone to the dihydrotestosterone
d. Intermittent catheterization, although a temporizing measure, is not an effective treatment for relief
of symptoms of BPH
Answer: a, b, c :The prototypic bladder outlet obstruction is prostatic hyperplasia, which urologists once
visualized as a progressive encroachment on the urethral lumen related to prostatic growth. It is now
clear that prostatic size has no consistent relationship to obstruction and the diagnosis of obstructive
uropathy cannot be made by endoscopic inspection or by determination of prostatic size or appearance.
Obstruction results in progressive increases in bladder pressure and decreased urine flow rates. If
bladder pressures are high enough and sustained long enough, the ureteral pump mechanism is
overcome, the ureter dilates, and by a hydraulic mechanism, intervesicular pressure is transmitted to
the renal pelvis. At a pressure of 42–50 cm H2O, glomerular filtration ceases. These relatively simple
sequential events lead to renal failure. Prostatic enlargement clearly has an endocrine basis since
treatment with a 5 a-reductase inhibitor, which blocks conversion of testosterone to
dihydrotestosterone (the active male hormone in the prostate) can induce a 30% to 50% regression in
prostatic size. Although surgery or hormone therapy may be effective in initiating reversal of changes
associated with obstructive uropathy, this does not occur invariably. Removal of the hyperplastic
glandular tissue is the most effective treatment in terms of relief of symptoms. Patients who cannot be
subjected to operation, however, show the same response to intermittent catheterization and periodic
bladder emptying in terms of symptoms as well as bladder wall and pressure changes.
25. A 55-year-old male presents with severe flank pain radiating to the groin associated with nausea and
vomiting. Urinalysis reveals hematuria. A plain abdominal film reveals a radiopaque 5 mm stone in the
area of the ureterovesical junction. Which of the following statement(s) is/are true concerning this
patient’s diagnosis and management?
a. A likely stone composition for this patient would be uric acid
b. The stone will likely pass spontaneously with the aid of increased hydration
c. Stone analysis is of relatively little importance
d. Patients with a calcium oxalate stone and a normal serum calcium level should undergo further
extensive metabolic evaluation
Answer: b :It is estimated that 12% of the U.S. population will develop calculus disease during their
lifetime. Males have more than twice the rate of stone formation than females. Caucasians have
between a two to tenfold higher incidence of renal stone disease than Blacks or Asians. The peak
incidence of lithiasis appears to be between the ages of 45 and 64 years. Almost 3/4 of stones are
composed of calcium oxalate in combination with calcium phosphate. Magnesium ammonium
phosphate (struvite) or infection stones make up approximately 12% whereas pure calcium phosphate
and uric acid stones each compromise 7%. The diagnosis of renal stones is made with appropriate
history and performance of urinalysis and a non-contrast abdominal radiograph. Urinalysis of a patient
with a urinary stone will have evidence of either gross or microscopic hematuria in 85%-95% of patients.
Eighty-five to 90% of urinary stones are radio-opaque. Uric acid stones are typically not radio-opaque.
The majority of stones will pass spontaneously with aid of increased hydration and appropriate
analgesics. All stones passed should be retrieved for subsequent analysis. Patients passing their first
stone should have serum calcium and creatinine levels and a urinalysis in addition to stone analysis. If
the stone is calcium oxalate and the serum calcium level is normal, no further evaluation is necessary
other than encouraging the patient to increase fluid intake. Any patient with stones composed of uric
acid, pure calcium phosphate, cystine, or struvite are at high risk for continued stone formation and
should undergo more extensive metabolic evaluation. In addition, those patients with recurrent or
enlarging stones, including those patients with known calcium oxalate stones, should undergo a
metabolic evaluation.
26. Which of the following statements are true concerning male impotence?
a. Psychologic factors account for less than half the cases of male impotence
b. Vascular testing for vasculogenic impotence may include Doppler determination of penile systolic
blood pressure and super selective pelvic arteriography
c. Penile implants are the first line treatment for patients with impotence due to diabetes or vascular
dysfunction
d. Impotence associated with abdominal perineal resection is due to direct trauma to pelvic nerves and
may be improved with papaverine injection
Answer: a, b, d :Erectile dysfunction is a common condition that affects 10 million American men. The
incidence increases with age. By age 55 about 8% of men are affected. By the age of 80 years, the
incidence is 75%. Impotence ensues from interference with the normal vascular, neurologic,
psychological, endothelial, and hormonal mediators of erection. In many cases, the causes are multifactorial. Psychological factors can inhibit as well as stimulate erection and account for less than half of
the cases of impotence. Although a number of systemic diseases can cause impotence, diabetes is the
most common. Impotence may also result from systemic neurologic diseases such as multiple sclerosis.
Direct trauma to the pelvic nerves by pelvic fractures of radical pelvic surgery (radical prostatectomy,
abdominal perineal resection) may also be associated with impotence.
The determination of the effect of vascular disease on impotence can be determined through a number
of techniques. An estimate of penile blood flow can be made through Doppler determination of penile
systolic blood pressure using a penile cuff. Direct corporal injection with papaverine, a smooth muscle
relaxant, bypasses psychogenic and neurologic factors and produces an erection if the blood flow to the
penis is normal. If arterial disease is suspected on the basis of poor response, superselective pelvic
arteriography with injection of vasoactive agents is necessary to document the nature of the disease.
The treatment of impotence depends on both the cause and the patient’s willingness to pursue various
therapeutic approaches. Patients with neurogenic impotence, such as following pelvic nerve injury, can
experience dramatic results with papaverine injection. Penile implants can be used to treat any type of
intractable impotence, but they are usually reserved for patients with diabetes or vascular neurologic
dysfunction who do not respond to conservative measures.
27. Which of the following statement(s) are true concerning the detection and diagnosis of prostatic
cancer?
a. An elevation of prostate specific antigen (PSA) is highly sensitive and specific for prostatic carcinoma
b. American blacks have an increased risk of prostatic carcinoma
c. Autopsy series would suggest that 10% of men in their 50’s will have small latent prostatic cancers
d. Transrectal prostatic biopsy is indicated for a palpable 1 cm prostate nodule
e. Serum prostatic acid phosphatase remains the most useful tumor marker for prostatic carcinoma
Answer: b, c, d:Adenocarcinoma of the prostate is the most common non-cutaneous malignant tumor in
men, accounting for 20% of all male cancers and is the second highest cause of cancer deaths in males.
It is primarily a disease of older men. At autopsy, about 10% of men in their 50’s can be shown to have
small latent tumors, and with this number increasing to 70% of men in their 80’s. However, it is
estimated that only 10% of men over 65 will develop clinically significant prostate cancer. An increased
incidence in American blacks has been reported.
Early prostate cancer has few symptoms. Therefore, early diagnosis requires detection of small tumors
within the prostate gland. Three modalities are used in the early detection of prostate cancer. These
include digital rectal examination, serum prostate specific antigen (PSA), and transrectal ultrasound of
the prostate. Prostate tumors usually arise in the posterior lobe of the prostate an area readily palpable
on digital rectal examination. Early prostatic cancer frequently presents as a small firm nodule within or
at the periphery of the gland. If a 1 cm nodule is detected, it is cancer about 50% of the time. Prostatic
biopsy is readily performed with little morbidity and is often required to confirm the diagnosis.
Transrectal ultrasound of the prostate may also detect prostate cancer often as a smaller more subtle
lesion not easily discernable on rectal examination. However, digital examination will also disclose some
cancers that are not visualized with ultrasound. Serum PSA is used to aid in the early detection of
prostate cancer. PSA is elevated in 68% of men with cancer but 33% of men with benign enlargement of
the gland also have an enlarged PSA. Serum prostatic acid phosphatase is not specific for prostatic
cancer although a significant elevation is usually associated with metastatic disease. Serum acid
phosphatase however has been generally replaced as a tumor marker by the immunoassay for PSA. PSA
is also an extremely sensitive tumor marker for recurrences after surgery because serum levels should
be undetectable if patients are tumor-free
2005 SESAP 5/150
Questions
1. A13-year-old boy falls froma tree and develops gross hematuria. CT scan shows a left renal laceration
extending into the collecting systemwith significant urinary extravasation. Contrast is seen in the distal
ureter. 3 weeks following the injury, he develops a low-grade fever, an ileus and a tender distended
abdomen. CT scan shows a large left urinoma. The next step is: A. Placement of a urethral catheter B.
Percutaneous nephrostomy drainage C. Open surgical drainage and renorrhaphy D. Percutaneous
drainage of the urinoma E. Placement of a ureteral stent
2. A4-year-old boy fell froma second-story window. On examination, his vital signs are stable but he has
right flank and upper quadrant abdominal tenderness and fullness. He does not have peritoneal signs.
Urinalysis is negative. The next step is: A. Observation B. Abdominal paracentesis C. Abdominal and
renal ultrasound D. IVP E. Abdominal CT scan
3. Themost definitive study to rule out traumatic bladder rupture is: A. Pelvic CT scan B. Cystoscopy C.
Pelvic ultrasound D. CT cystogram E. IVP
2004 SESAP 3/150
Questions 1. A20-year-oldman sustains a circumferential avulsion of the skin of themidshaft of the
penis. There is intact skin on both the proximal and distal aspects of the penile shaft, with a denuded
area 4 cmin length. Themost appropriate treatment is: A. Primary approximation of the skin B. Splitthickness skin graft to the denuded area C. Split thickness skin graft and removal of distal penile skin D.
Full thickness skin graft to the denuded area E. Scrotal rotational flap covering the denuded area
2. A23-year-oldman notes a cracking noise and subsequent penile pain during intercourse, followed by
progressive penile swelling and ecchymosis. He is initially embarrassed to seekmedical attention despite
persistent penile pain. 36 hours after the traumatic event, he is a febrile with stable vital signs. A
retrograde urethrogramis normal. The next step is: A. Reassurance and cold compresses B. Cavernosalspongiosal shunt C. Surgical exploration D. Foley catheter splinting E. Corporeal aspiration and Foley
catheter drainage
3. A10-year-old boy has a perineal “butterfly”hematoma following a straddle injury. This suggests
rupture of the: A. Tunica albuginea B. Corpus spongiosum C. Corpus cavernosum D. Posterior urethra E.
Colles’fascia
2003 SESAP 5/150 Questions
1. A42-year-oldman is undergoing laparotomy for intraabdominal injuries and bladder rupture. Bleeding
is noted in the perivesical area. After repair of bladder rupture, pelvic pressure does not stop the
persistent oozing.Multiple blood transfusions are given and his core temperature is 35.5° C. The next
step is: A. Intraoperative arteriography B. Ligation of the hypogastric arteries C. Intravenous
aminocaproic acid D. Close the abdomen and place patient in a MAST suit E. Pack pelvis and close
abdomen
2002 SESAP 5/150 Questions
1. The optimal tissue for early coverage of the perineumfollowing an avulsion skin injury is a(n): A. Island
skin flap B. Musculocutaneous flap C. Full-thickness skin graft D. Split-thickness skin graft E. Dermal graft
2. A23-year-old woman suffers a complex pelvic fracture in amotor vehicle accident. A cystogramreveals
limited extraperitoneal extravasation of contrast at the bladder neck. The bladder is compressed by a
pelvic hematoma and an anterior vaginal laceration is also present. No other injuries are noted and the
patient is hemodynamically stable. Treatment should be: A. Urethral catheter drainage B. Percutaneous
suprapubic cystostomy C. Open bladder repair D. Suprapubic cystostomy and perivesical drainage E.
Repair of vaginal and bladder laceration
2001 SESAP 5/150 Questions
1. A12-year-old prepubertal boy has severe right scrotal pain 1 day after being kicked in the groin. There
is a blue area over the superior portion of the testis, but the examination is difficult due to a hydrocele.
Urinalysis is normal. The next step is: A. Immediate exploration B. Scrotal ultrasound with Doppler C.
Scrotal nuclear scan D. Manual detorsion, exploration E. Observation, anti-inflammatory medications
Answers Bladder Trauma 1. B. 2. A. 3. B. 4. B. 5. A. Urethral Trauma 1. B. 2. E. 3. A. Genital Trauma 1.
B. 2. B. 3. A. 4. D. 5. A. 6. E.
2005 SESAP 5/150 1. D. 2. E. 3. D. 2003 SESAP 3/150 1. C. 2. C. 3. B. 2003 SESAP 5/150 1. E. 2002 SESAP
1/150 1. D. 2. E . 2001 SESAP 5/150 1.
UTI MCQ,S
What was Kass’s proposed criteria for urinary tract infection?
A > 101 bacteria/ml
B > 102 bacteria/ml
C > 103 bacteria/ml
D > 104 bacteria/ml
E > 105 bacteria/ml
2 What was Stam’s proposed criteria for urinary tract infection?
A > 101 bacteria/ml
B > 102 bacteria/ml
C > 103 bacteria/ml
D > 104 bacteria/ml
E > 105 bacteria/ml
3 Which of the following types of adhesion molecules is associated with pyelonephritis in the
general population?
A Type I mannose sensitive
B Dr adhesin
C Type S pili
D Type II mannose resistant
E F adhesin
4 36 year old man has symptoms of prostatitis, his 4 glass localisation test reveals WBC’s in
VB3. What is the type of prostatitis?
A Type IV
B Type IIIa
C Type IIIb
D Type II
E Type I
5 What is the first 10mls of urine collected after prostatic massage known as?
A EPS
B VB3
C VB2
D Midstream urine
E VB1
6 Which of the following is not one of the defining factors of the systemic inflammatory
response syndrome (SIRS)
A Temperature >38 o C
B Respiratory rate >20 breaths/minute
C White cell count > 15000cells/mm3
D Pulse > 90 beats/minute
E PaCO2 < 4.3kPa
7 What is staphylococcus saprophyticus?
A Gram negative cocci
B Anaerobic Gram positive bacilli
C Aerobic Gram negative bacilli
D Gram positive cocci
E Anaerobic Gram negative bacilli
8 What proportion of hospital-acquired UTI’s are caused by E-coli?
A 40%
B 50%
C 65%
D 75%
E 85%
9 Which of the following is not a recognised side-effect of trimethoprim?
A Tendon damage
B Rash
C Worsening hyperkalaemia in patients with renal failure
D Folate deficiency
E Stevens-Johnson syndrome
10 Which of the following is not a recognised cause of epididymo-orchitis?
A E-coli
B Chlamydia trachomatis
C N. gonorrhoeae
D Mycobacterium TB
E Amlodipine
Answers
1 E > 105 bacteria/ml
After measuring bacterial counts in women with pyelonephritis and controls Kass proposed
contamination can be distinguished from true UTI by a threshold of > 105 bacteria/ml
2 B > 102 bacteria/ml
Stam re-evaluated this by examining women with symptoms of UTI and concluded > 102
bacteria/ml was the best criteria with a positive predictive value of 0.88
3 D Type II mannose resistant
Type II mannose resistant pili are associated with pyelonephritis. Type I mannose sensitive are
associated with lower urinary tract infections, Dr adhesion is associated with paediatric UTI and
pyelonephritis in pregnancy, and Type S pili are associated with bacterial dissemination
4 B Type IIIa inflammatory chronic pelvic pain syndrome, according to the NIH classification
5 The first 10mls of urine collected after prostatic massage is known as VB3. The 4 glass Stamey
localisation test includes VB1-1st 10mls of urine, VB2-MSU, VB3-1st 10mls after prostatic
massage and EPS-expressed prostatic secretions
6C SIRS is defined as 2 or more of the following
Temperature >38 o C or <36 o C
Respiratory rate >20 breaths/minute or PaCO2 < 4.3kPa
White cell count > 12000cells/mm3 or <4000cells/mm3
Pulse > 90 beats/minute
7D Staphylococcus saprophyticus causes approx 10% of symptomatic UTI’s in young women
8B E-coli is responsible for 50% of hospital-acquired UTI’s and 85% of community-acquired
UTI’s
9A Tendon damage is a recognised complication of treatment with flouroquinolones
10E Amiodarone not amlodipine is a rare cause of epididymo-orchitis
BPH MCQ,S
1 Which of the following was not defined as clinical progression in the MTOPS study?
A Recurrent haematuria
B Renal failure
C Increase of 4 points in the AUA symptom score
D Urinary incontinence
E Recurrent urinary tract infection
2 In the PLESS study what is the effect of finasteride on acute urinary retention versus placebo?
A Reduces retention by 30%
B Reduces retention by 55%
C Associated with a risk reduction of 57%
D Associated with a risk reduction of 50%
E Reduces rention by 57%
3 Which of the following is not assessed on the IPSS questionaire?
A Incomplete emptying
B Frequency
C Quality of life
D Incontinence
E Straining
4 What proportion of patients with a flow rate of more than 15mls/sec are obstructed?
A 25%
B 30%
C 35%
D 65%
E 40%
5 What is the bladder outlet obstruction index for a man with a voided volume of 310mls, a Qmax of
13mls/sec and a pdet at Qmax of 90cmH20?
A 76
B 72
C 74
D 64
E 82
6 In the development of BPH which of the following is not a growth stimulating factor?
A KGF
B TGFb
C IGF
D EGF
E bFGF
7 :What is the risk of retention in a 70-79 year old with moderate lower urinary tract symptoms?
A 3 per 1000 person years
B 9 per 1000 person years
C 18 per 1000 person years
D 26 per 1000 person years
E 34 per 1000 person years
8 :Regarding the natural history of BPH, what is the average decline in peak urinary flow rate?
A 0.1mls/sec/year
B 0.2mls/sec/year
C 0.3mls/sec/year
D 0.4mls/sec/year
E 0.5mls/sec/year
9: What proportion of men age 61-70 have pathological evidence of BPH?
A 70%
B 65%
C 60%
D 55%
E 50%
10: What proportion of men aged 50-59 with BPH have clinical symptoms?
A 15%
B 20%
C 25%
D 30%
E 35%
11: What is the most important predictor of clinical progression in BPH
A Gland size
B Symptom severity
C PSA
D Age
E High post-void residual
12: What is the risk of erectile dysfunction after TURP?
A 36%
B 30%
C 20%
D 16%
E 6%
13: What is the arterial supply of the prostate?
A Superior vesical artery
B Obturator artery
C Inferior vesical artery
D Inferior epigastric artery
E External iliac artery
14 :What are the arteries seen after middle lobe resection during a TURP?
A Capsular arteries
B Badenoch's arteries
C Floch's arteries
D Branches of the internal pudendal artery
E Branches of the superior vesical artery
15 :What is the embryological origin of the transition zone?
A Mesoderm
B Ectoderm
C Endoderm
D Mullerian duct
E Mesonephric duct
16 :Which alpha-blocker has the strongest association with floppy iris syndrome?
A Alfuzosin
B Indoramin
C Prazosin
D Tamsulosin
E Doxasosin
17: How much is serum dihydrotestosteronedoes reduced by dutasteride?
A 50%
B 60%
C 70%
D 80%
E 90%
18 :Which adrenoreceptor subtype mediates prostatic smooth muscle contraction?
A alpha1-a
B alpha1-b
C alpha2
D alpha1
E alpha1-L
19: What is the risk reduction for clinical progression with combination treatment in the MTOPS study?
A 66%
B 44%
C 39%
D 34%
E 28%
20: What is the change in symptom score in the placebo arm of the PLESS study?
A 3.3 increase
B 1.3 decrease
C 1.0 decrease
D 1.3 increase
E 3.3 decrease
Answers
1:A
Clinical progression was defined in the MTOPS study as
Increase of 4 points in the AUA symptom score
Acute urinary retention
Renal failure
Urinary incontinence
Recurrent urinary tract infection
2:C
99(7%) patients in placebo group compared to 42(3%) in finasteride group suffered acute urinary
retention– Risk reduction of 57%
3:D The following symptoms are assessed
incomplete emptying, frequency, intermittency, urgency, weak stream, straining and nocturia. In
addition there is a quality of life score
4:B <10mls/sec 90% obstructed, 10-15mls/sec 65%, >15mls/sec 30%
5:D BOOI = pdet@Qmax- 2Qmax
6:B Transforming growth factor beta ihibits epithelial cell proliferation, the other growth factors
stimulate cell division and differentiation
7:E This data comes from the Olmstead County Study (required reading) which showed that
men aged 70-79 with moderate/severe symptoms had a retention risk of 34.7 /1000 person years
8:B You are required to be aware of the natural history of BPH and the Olmstead study showed an
average decline of 0.2mls/sec/year in patients with BPH
9:A This figure comes from Barry et al J Urol 1984 which is a useful paper
10:C Garraway et al Lancet 1991 found that 25% of men with a TRUSS volume of >20mls had an IPSS of
>11
11:C A PSA of >1.4ng/ml ids the most important predictor of progression
12:E The national prostatectomy audit quotes a rate of 31% however it appears the risk is much lower.
Wasson's TURP vs watchful waiting study found no difference in the rates of ED between the 2 groups
and Marberger's BJU 1999 meta-analysis indicated a rate of 6.5%
13:A The inferior vesical artery supplies the prostate-as it approaches the gland it divides into urethral
and capsular branches
14:B The arteries seen at 5 and 7 o clock after middle lobe resection are urethral branches of the inferior
vesical artery known as Badenoch's arteries. The smaller arteries seen at 2 and 10 clock are known as
Floch's arteries
15:A Transition zone arises from mesoderm, peripheral zone arises from endoderm and central zone
appears to be embryologically distinct possibly mullerian in origin
16:D Although described as a class effect, the incidence of floppy iris syndrome with tamsulosin is
approx 85%-90%
17:E The dual 5ARI reduces serum DHT levels by 90%, the reduction achieved by finasteride is less but
this does not appear to translate into an increased clinical effect
18:A The alpha1-a subtype predominates in human stroma and therefore mediates prostatic smooth
muscle contraction
19:A The risk reduction for clinical progression is 66% with combination, 39% with doxazosin and 34%
with finasteride
20:B Patients in the placebo arm noticed a 1.3 point improvement/decrease in their symptom score
versus a 3.3 improvement on finasteride. The fact that symptoms improved on placebo is useful to
remember in discussions about treatment in the viva
RADIOLOGY AND TECHNOLOGY MCQ,S
1:1What is the wavelength of a holmium:YAG laser?
A 532 nm
B 2140 nm
C 980 nm
D 1650nm
E 1860 nm
2: Which of the following is not important in determining radio-sensitivity?
A DNA repair
B Re-oxygenation
C Re-accumulation
D Re-assortment
E Re-population
3: What is the unit for the absorbed dose of radiation?
A Gray
B Sievert
C Rad
D Roentgen
E becquerels
4 :Which of the following detects protein on dipstik urinalysis?
A Peroxidase
B Red azo dye
C Indoxyl
D Tetrabromophenol blue dye
E Diazonium salt
5: What is the approximate mortality rate associated with non-ionic contrast media?
A 1/200,000
B 1/100,000
C 1/50,000
D 1/25,000
E 1/10,000
6 :Which of the following types of diuretic renogram curve refers to a system which is dilated without
obstruction?
A Type IV
B Type IIIa
C Type IIIb
D Type II
E Type I
7 :When referring to adrenaline what does a 1 in 10,000 solution equate to?
A 10 mg per 10 ml
B 1 mg per ml
C 10 mg per ml
D 0.1mg per ml
E 1mg per 100ml
8: What frequency of transducer is used during transrectal ultrasound?
A 3.5 MHz
B 4.5 MHz
C 5.5 MHz
D 6.5 MHz
E 7.5 MHz
9: What is the "French" or "Charriere" guage equal to?
A Circumference in mm
B Circumference multiplied by 3 in mm
C Diameter in mm
D Circumference in cm
E Diameter multiplied by 3 in mm
10: Which of the following statements regarding JJ stents is correct?
A Stents aid stone passage
B Stents increase intrarenal pressures
C A nephrostomy is better for the relief of an obstructing stone with infection
D Stents lower intrarenal pressure
E Stents are extremely effective at relieving obstruction from extrinsic compression
11: What stage of chronic kidney disease has a patient with an estimated GFR of 26ml/min/1.73m2?
A Stage 4
B Stage 1
C Stage 3
D Stage 5
E Stage 2
12: What is the 1 year graft survival following living-donor kidney transplantation?
A 95%
B 90%
C 80%
D 70%
E 65%
13: What is the most common new tumour in recipients after transplantation?
A Renal
B Lung
C Lymphoproliferative
D Skin
E Cervical
14 Which of the following immunosuppresive agents is associated with diabetes?
A: Mycophenolate mofetil
B Cyclosporine A
C Tacrolimus
D Azathioprine
E Sirolimus
15: What is the radiation dose in mSv associated with a CTKUB?
A 1.0
B 2.5
C 3.0
D 4.7
E 10
16: Which of the following best describes the thin descending limb of the loop of Henle?
A Impermeable to water
B Permeable to water and less permeable to sodium, chloride and urea
C Impermeable to water, highly permeable to sodium and chloride and slightly permeable to urea
D Permeable to water, sodium, chloride and urea
E Impermeable to water and urea with sodium and chloride actively reabsorbed
17 :What is the typical Hounsfield unit for fat on CT?
A +300
B +40
C0
D -50
E -1000
18: Which drug trial phase primarily assesses the safety of a drug?
A Phase IV
B Phase III
C Phase II
D Phase I
E Phase 0
19: How is leucocyte esterase detected by dipstik urinalysis?
A Peroxidase
B Red azo dye
C The production of indoxyl and oxidation of a diazonium salt
D Tetrabromophenol blue dye
E Double oxidation reaction
20: What is the normal amount of protein excreted by the kidney?
A 50-80 mg/day
B 80-150 mg/day
C 150-200 mg/day
D 200-230 mg/day
E 230-250 mg/day
Answers
1:B
2:C
The "four R's" which determine radiosensitivity are repair, re-oxygenation, re-assortment and repopulation
3:A
In SI units, the activity of a radioactive source is measured in becquerels (symbol Bq). The absorbed
dose of ionizing radiation is measured in grays (symbol Gy) where one gray is equal to one joule of
energy being imparted to one kilogram of matter (the rad is the previously used unit). The dose
equivalent, which is a measure of the effects of radiation on living organisms, is measured in sieverts
(symbol Sv)
4:D
5:A
6:B
Type IV Delayed double peak pattern (Homsey)
Type IIIa Dilated without obstruction
Type IIIb Equivocal
Type II Obstructed
Type I Normal
7:D 1 in 10,000 or 1mg per 10ml adrenaline solution is often used during cardiace arrest in prepared
syringes. A 1 in 1000 or 1mg per ml adrenaline solution is often used IM for anaphylactic reactions.
UrologyUK comment: Although this seems like a fairly non-urological question there are a significant
number of everyday clinical MCQ's and EMQ's in the exam.
8:E A 7.5Mhz biplane probe is used for TRUS
9:EThe French guage is equal to the diameter of the tube multiplied by 3 in mm, not as is often thought
the circumference in mm. However, remember that the circumference is diameter multiplied by Pi
(3.14) so it is nearly correct!!
10:BStents paralyse peristalsis and therefore do not aid stone passage. They increase intrarenal
pressures. Pearle, M; J Urol 1998 demonstrated that there was no difference in recovery between
patients treated with nephrostomy vs JJ stent. JJ stents are less effective at relieving obstruction from
extrinsic compression.
11:A
Stages of CKD
CKD Stage
Description (eGFR
ml/min/1.73m2)
Stage 1
Normal eGFR (>90) With
other evidence of kidney
damage*
Stage 2
eGFR 60 – 90 With other
evidence of kidney
damage*
Stage 3
eGFR 30-59
Stage 4
eGFR 15 – 29
Stage 5
eGFR < 15
* Evidence of chronic kidney damage includes:
persistent microalbuminuria or proteinuria,
12:B
1 year graft survival for living donor nephrectomy is 95% with HLA-identical siblings, 90% for 1haplotype-identical related donor and 80% for cadaveric kidneys
13:D
The approximate distribution of new cancers is renal 5%, lung 5%, lymphoproliferative 11%, skin 40%
and cervical 4%
14:C
Tacrolimus is nephrotoxic and in approximately 20% of patients causes diabetes
15:D
16:B
The thin descending limb is best described by B, the thin ascending limb is best described by C and the
thick ascending limb best described by E
17:D
Substance
Hounsfield Unit
Air
-1000
Fat
-50
Water
0
Soft tissue (eg muscle) +40
Calculus
+100 to +400
Bone
+1000
18:D
Phase IV - Post-launch safety surveillance
Phase III - Randomised control trial
Phase II - Assesses how well the drug works as well as continued safety
Phase I - Assesses safety
Phase 0 - First human trial - does it behave in humans as expected
19:C
Leucocyte esterase catalyses the production of indoxyl which oxidises a diazonium salt leading to a
colour change
20:B Normal excretion is 80-150 mg/day