Uro2013-2014All

2013A 34-year-old woman with multiple sclerosis continues to have significant urinary incontinence despite maximal antimuscarinics. Two weeks after intradetrusor injection of 200 units of onabotulinumtoxinA she complains of worsening frequency urgency and urinary incontinence. The next step is: A) PVR. B) cystoscopy. C) urodynamics. D) empiric antibiotic therapy. E) reinject 100 units of onabotulinumtoxinA.

( A PVR.This patient is likely experiencing worsening of symptoms due to incomplete bladder emptying. It appears that approximately 25% of patients with a neurogenic bladder who are not catheterizing at baseline will require CIC after injection of 200 units of onabotulinumtoxinA. UTI could cause her worsening symptoms; however this would be more likely if the patient is already performing catheterization. Urodynamics and cystoscopy would not be helpful in the immediate postoperative period. If a patient requires reinjection this should be done at least two to three months after the initial injection. Recent studies suggest that the 200 U dose is adequate and a higher dose is not beneficial.Andersson KE Wein AJ: Pharmacologic management of lower urinary tract storage and emptying failure Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 68 p 1987.Cruz F Herschorn S Aliotta P et al: Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: A randomized double-blind placebo-controlled trial. EUR UROL 2011;60:742-750. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A seven-year-old boy with a seizure disorder is managed with a ketogenic diet and topiramate has one episode of painless gross hematuria. Renal ultrasound demonstrates 3 mm stones in the lower pole of both kidneys without hydronephrosis. The next step is: A) consult neurologist for alternative seizure treatment. B) urinary alkalinization. C) oral penicillamine. D) SWL. E) ureteroscopic laser lithotripsy.

( A consult neurologist for alternative seizure treatment.Both ketogenic diet and topiramate (Topamax«) can cause calcium phosphate stones. This child with small non-obstructing kidney stones discovered after a single episode of painless gross hematuria does not require surgical intervention at this time. Seeking alternative seizure pharmacotherapy by consulting a neurologist is the best next step. The stone is likely calcium-based and thus medical therapy aimed at uric acid (raise the pH) or cystine (oral penicillamine) stones are not appropriate.Ferrandino MN Pietrow PK Preminger GM: Evaluation and medical management of urinary lithiasis Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 46 p 1320. Pediatric Calculous Disease )

2013A 58-year-old man has frequency and bothersome nocturia with an AUA Symptom Score of 16. History and physical exam are normal Urinalysis is negative. The next step is: A) frequency-volume chart. B) serum creatinine. C) uroflowmetry. D) cystoscopy. E) pressure-flow study.

( A frequency-volume chart.According to the recently updated guidelines on management of BPH by the AUA Practice Guideline Committee recommended components of the diagnostic algorithm for routine evaluation include history assessment of LUTS with an AUA Symptom Score physical examination including DRE and urinalysis. A frequency-volume chart should be obtained if nocturia is a predominant symptom. Urodynamics cystoscopy and serum creatinine are not required as part of the initial evaluation. McVary KT Roehrborn CG Avins AL et al: Update on AUA guideline on the management of benign prostatic hyperplasia. J UROL 2011;185:1795. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 27-year-old woman in the seventh week of pregnancy has right flank pain. Ultrasonography demonstrates a 5 mm calculus at the right UPJ. Urine culture is negative. The next step is: A) hydration and analgesics. B) stone protocol CT scan. C) ureteral stent. D) percutaneous nephrostomy. E) SWL.

( A hydration and analgesics.Between 66% and 85% of women with ureteral colic will spontaneously pass their calculi with hydration and analgesic therapy. If the calculus fails to pass with conservative therapy a ureteral stent should be placed cystoscopically with sonography or minimal radiographic imaging as the first trimester presents the period of greatest risk of teratogenicity and spontaneous abortion. Ureteroscopy is an acceptable alternative. Fluoroscopy should be avoided. Pregnancy is an absolute contraindication for the use of SWL. Ferrandino MN Pietrow PK Preminger GM : Evaluation and medical management of urinary lithiasis Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 46 p 1322. Adult Calculous Disease )

2013A six-week-old boy was born at 27 weeks gestation. His postnatal course has been complicated by respiratory distress bronchopulmonary dysplasia and a patent ductus arteriosus. He has required long-term diuretic therapy. A KUB reveals calcifications in the mid and upper abdominal regions consistent with bilateral renal calculi. The most likely mechanism for the formation of the stones is: A) hypercalciuria. B) hyperuricosuria. C) obstructive uropathy. D) Type I RTA. E) Type II RTA.

( A hypercalciuria.Renal calculi occur in very low birth weight pre-term infants with a history of severe ventilatory problems and bronchopulmonary dysplasia. Many of these infants require long-term treatment with diuretic agents to control heart failure. The diuretic agent used most often is furosemide which increases the rate of urinary calcium excretion up to ten times normal. Chronic hypercalciuria from furosemide therapy has been shown to result in nephrocalcinosis and calculus formation. Loss of calcium from chronic administration of furosemide may lead to secondary hyperparathyroidism and bone changes. Treatment includes switching from furosemide to thiazides. Other etiologies of stone formation do not occur with increased frequency in premature infants requiring diuretic therapyPalmer LS Trachtman H: Renal functional development and diseases in children Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 112 p 3062. Pediatric Calculous Disease )

2013 A 40-year-old newly-diagnosed HIV positive man has a 2.0 cm. painless red nodule on his glans penis. A biopsy confirms Kaposi's sarcoma. The next step is: A) initiate highly active antiretroviral therapy (HAART). B) systemic chemotherapy. C) laser ablation. D) excise the lesion. E) partial penectomy.

( A initiate highly active antiretroviral therapy (HAART).The first step in treatment of Kaposi's sarcoma in patients with HIV is to initiate HAART or to optimize the HAART regimen which generally results in remission of Kaposi's sarcoma. Local treatment can include laser therapy cryotherapy surgical excision application of topical retinoids. Disseminated or visceral Kaposi's sarcoma is treated with combination chemotherapy. The gold standard combination therapy of doxorubicin bleomycin and vincristine has been replaced in recent years with liposomal anthracyclines such as doxorubicin. Kaposi's sarcoma is also often seen in immunosuppressed patients such as renal transplant patients and in this setting the treatment is a reduction of the immunosuppressive regimen. In the current era of immunosuppression the frequency of this is diminished.Heyns CF Groeneveld AE Sigarroa NB: Urologic complications of HIV and AIDS. NAT CLIN PRACT UROL 2009;6:32-43. Adult Neoplasm )

2013 The neurovascular bundles on the prostate travel between the following two layers of fascia: A) levator and prostatic. B) Denonvilliers' and levator. C) Denonvilliers' and prostatic. D) lateral pelvic and prostatic. E) lateral pelvic and levator.

( A levator and prostatic.The prostate is covered with three distinct and separate fascial layers: Denonvilliers' fascia the prostatic fascia and the levator fascia. Denonvilliers' fascia is a filmy delicate layer of connective tissue located between the anterior walls of the rectum and prostate. The neurovascular bundle on the prostate contain the cavernosal nerves and are located between the layers of the levator fascia and prostatic fascia.Schaeffer EM Partin AW Walsh PC: Radical retropubic and perineal prostatectomy Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 102 p 2801. Adult Neoplasm )

2013 A 61-year-old man with a serum creatinine of 1.7 mg/dl has a 5 cm upper pole left renal mass. He undergoes left partial nephrectomy. After complete gross resection of the mass frozen section reveals lymphoma with diffuse infiltration of normal renal parenchyma by lymphoma at the margins. His cold ischemic time was 18 minutes. The next step is: A) no further operative intervention. B) re-excision of tumor bed. C) cryotherapy of margin. D) biopsy of contralateral kidney. E) radical nephrectomy.

( A no further operative intervention.The unexpected finding of renal lymphoma at the time of renal cortical tumor surgery is rare. Ninety percent of these cases are not primary renal lymphoma but rather systemic lymphoma with renal manifestation. Non-Hodgkin's lymphomas are the most common subtype. Multifocal masses bilaterality and regional lymphadenopathy are all more common in renal lymphoma than in renal cortical tumors. In this patient the presence of diffuse renal infiltration by lymphoma will make post-operative systemic therapy necessary. In the setting of compromised renal function every attempt should be made to spare the remaining nephron mass in preparation for systemic chemotherapy. Therefore further surgical intervention is not warranted and completion of the operation and subsequent postoperative discussion regarding systemic therapy is the most logical next step.Campbell SC Lane BR: Malignant renal tumors Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 49 pp 1471-1472. Adult Neoplasm )

2013 A pelvic examination of a 75-year-old woman two years after prior midurethral synthetic sling reveals extrusion of a small amount of mesh along her anterior vaginal wall. She is continent and denies any other urinary or vaginal complaints. She is not sexually active. Urinalysis is normal. The next step is: A) observation. B) removal of extruded mesh. C) removal of entire midurethral sling. D) oral estrogen hormone replacement. E) removal of exposed mesh and simultaneous sling replacement.

( A observation.Intervention is not required for this patient at this time. Removal of the entire midurethral sling is not required for a small exposure of mesh. With partial sling excision continence is maintained in the majority of patients; therefore replacement of another sling would not be indicated. Removal of the entire midurethral sling is challenging unnecessary and would likely lead to recurrent stress urinary incontinence. Transvaginal estrogen is thought to promote vaginal healing and is preferred over oral estrogen therapy due to other potential systemic effects. Extrusions that are larger or symptomatic should be treated. When a midurethral sling is eroded into or involves the urinary tract it should be treated with removal. Dmochowski RR Padmanabhan P Scarpero HM: Slings: Autologous biologic synthetic and midurethral Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL- WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 73 p 2148. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 58-year-old diabetic man with lupus recently discontinued a two week course of ibuprofen for a shoulder injury. Serum creatinine is elevated from a baseline of 0.9 to 2.6 mg/dl. Urinalysis reveals moderate proteinuria and WBC casts without eosinophiluria. Renal ultrasound demonstrates no hydronephrosis. The next step is: A) observation. B) urine culture and antibiotics. C) prednisone. D) cyclosporine. E) percutaneous renal biopsy.

( A observation.Long-term use of NSAIDs such as ibuprofen may result in an acute interstitial nephritis (AIN). Clinically this presents as an acute renal failure with WBC casts. Proteinuria is common. Unlike other types of drug induced AIN; fever and eosinophilia and eosinophiluria are uncommon. Lupus nephritis is characterized by red cell casts. Antibiotics are not indicated for AIN and culture will be negative. Immunosuppressants such as steroids and cyclosporine have no role in the therapy of AIN. Observation is appropriate as discontinuation of the offending agent in this case the NSAID will likely result in resolution of the AIN. Renal biopsy is over aggressive in this patient unless he fails a course of observation. Goldfarb DA Poggio ED: Etiology pathogenesis and management of renal failure Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 43 p 1196. AdultFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013 A 25-year-old man has a solid testes mass. His tumor markers are negative. He has an 8 cm retroperitoneal mass and multiple 1-2 cm. pulmonary metastases. His radical orchiectomy reveals pure seminoma. After chemotherapy his retroperitoneal mass is 2.8 cm and his pulmonary masses have resolved. PET/CT reveals no enhancement of his retroperitoneal mass. The next step is: A) observation. B) percutaneous biopsy of retroperitoneal mass. C) resection of retroperitoneal mass. D) bilateral RPLND. E) salvage chemotherapy.

( A observation.PET imaging is useful to assess post-chemotherapy residual masses after treatment of seminoma. Lesions that are less than 3 cm or non-enhancing can be safely observed as over 90% of seminoma postchemotherapy masses are fibrosis. Percutaneous biopsy is not reliable since the masses can be heterogeneous. Resection of non-enhancing masses is not necessary and resection of seminoma post-chemotherapy masses can be technically difficult or impossible. Resection of the mass and bilateral RPLND would be appropriate for NSGCT post-chemo masses but are not necessary in the post-chemo seminoma setting because of the low risk of cancer or teratoma in the remainder of the retroperitoneum. Salvage chemotherapy is not necessary and is highly toxic.Stephenson AJ Gilligan TD: Neoplasms of the testis Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 31 p 837. Adult Neoplasm )

2013A six-year-old boy has the sudden onset of gross hematuria urgency and frequency. Urinalysis shows 5-10 WBC/hpf and gross blood. Urine culture is negative. Ultrasound shows diffuse bladder wall thickening but no hydronephrosis or renal mass. The next step is: A) observation. B) antibiotics. C) VCUG. D) non contrast CT scan. E) cystoscopy.

( A observation.This boy has typical signs and symptoms of viral cystitis. Adenovirus is the most common virus although viral cultures are infrequently done in this setting. Supportive therapy is the mainstay of management. An ultrasound should be done to rule-out other serious causes of hematuria. Bladder wall thickening is to be expected in the acute phases of a viral infection. Symptoms usually resolve within two to four weeks. Antimuscarinics can be used when the urgency and frequency is more severe. Ribavirin can be considered in highly symptomatic patients especially in those that are immunosuppressed. There is no indication for antibiotics. If his symptoms do not resolve after a few weeks then one can get a VCUG or perform cystoscopy to rule out PUV or other pathology. However doing this in the acute phase is premature since the clinical suspicion for valves is low. If he had valves one would have expected symptoms prior to this time. The clinical suspicion for a stone is also low given the ultrasound findings. Thus getting a CT scan is not indicated especially in light of the unnecessary exposure to radiation which is a significant concern in children.Shortliffe LMD: Infection and inflammation of the pediatric genitourinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 116 p 3117. Pediatric Infection & Inflammatory Disease )

2013 An eight-month-old uncircumcised boy is treated for a febrile UTI. Ultrasound shows a right multicystic dysplastic kidney and a normal left kidney. VCUG shows left grade 3 VUR. DMSA scan shows non-function of the right kidney and a left upper pole cortical defect. The next step is prophylactic antibiotics and: A) observation. B) circumcision. C) left antireflux surgery. D) right nephrectomy. E) left antireflux surgery and right nephrectomy.

( A observation.Up to 25% of children with multicystic dysplastic kidneys will have contralateral vesicoureteral reflux. The scan suggests pyelonephritis in the left upper pole. There is no need to remove the right multicystic dysplastic kidney at this time. Infection in a multicystic dysplastic kidney is extremely rare and not seen in this scenario. In this age child there is still a good chance the reflux will resolve spontaneously. Prophylactic antibiotics and observation is the best treatment. In the absence of breakthrough infections a circumcision is not needed. Khoury AE Bagli DJ: Vesicoureteral reflux Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 122 pp 3286 3288-3290. Pediatric Infection & Inflammatory Disease )

2013 Radiation exposure from a single abdominal CT scan is: A) on average 50 times greater than that from an anterior-posterior abdominal x-ray. B) is less harmful to the digestive organs compared to the brain. C) results in less cancer risk in younger patients. D) increased with automatic exposure-control option. E) the result of non-ionizing radiation.

( A on average 50 times greater than that from an anterior-posterior abdominal x-ray.There are an estimated 60-70 million CT scans performed in the USA perhaps with 33% being unnecessarily performed. CT scans generate ionizing radiation with resulting DNA damage that could result in the induction of cancer. The cancer risk of CT scans is higher in the pediatric population. Furthermore the digestive organs are more sensitive to radiation injury than the brain. Newer CT scans have automatic exposure-control option which will decrease the radiation exposure. An abdominal x-ray results in a dose of 0.25 mSv to the stomach whereas a single CT scan of the abdomen can result in a radiation dose 50 times or greater to the stomach.Brenner DJ Hall EJ: Computed tomography: An increasing source of radiation exposure. NEJM 2007;357:2277-2284. AdultCore Competencies Geriatric Radiation Safety and Ultrasound )

2013During the course of a radical cystectomy a rectal injury is primarily repaired. Three days postoperatively the patient becomes septic. Physical examination reveals a tender surgical wound. The adjacent skin is edematous and has a bronze discoloration. Gram strain of the wound aspirate reveals gram-positive club-shaped organisms. The next steps are surgical drainage I.V. clindamycin and: A) penicillin. B) vancomycin. C) fluconazole. D) cefazolin. E) tetracycline.

( A penicillin.The findings described are characteristic of Clostridium perfringens wound infection. Clostridial infections should be considered in any patient with a wound infection especially if there has been an injury to the colon. The organism is an anaerobe with a positive gram stain and a club shape. Clinically the patient appears toxic and a bronze discoloration of the involved skin is characteristic. Crepitus may be absent. Empirical therapy must cover clostridial infection. As opposed to clostridium difficile in cases of suspected C. perfringens myonecrosis or anaerobic cellulitis and necrotizing polymicrobial infection two drug combination treatment is recommended. I.V. penicillin (2 to 3 million units every 3 hours or 3 to 4 million units every 4 hours) or ampicillin (2 g every 4 hours) plus I.V. clindamycin (0.6 g every 6 to 8 hours) or metronidazole (1 g loading dose followed by 0.5 g every 6 hours) provides coverage of the anaerobic organisms likely to be involved. Vancomycin cefazolin and tetracycline do not provide effective coverage of anaerobic gram positive species. Fungal wound infection is not suspected with the clinical picture and thus fluconazole is not appropriate.Pasternak MS Swartz MN: Cellulitis necrotizing fasciitis and subcutaneous tissue infections in Mandell GL et al: MANDELL DOUGLAS AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES ed 7. Philadelphia Churchill Livingstone Elsevier 2010 pp 1289-1312. Adult Infection & Inflammatory Disease )

2013 An ectopic ureteral insertion into the vagina is the result of the ureteral bud arising or interacting: A) proximally on the mesonephric duct. B) distally on the mesonephric duct. C) on the common excretory duct. D) with ectopic metanephric blastema. E) on the paramesonephric duct.

( A proximally on the mesonephric duct.The ureteric bud arises off of the mesonephric duct. The segment distal to the ureteric bud is called the common excretory duct. The point of origin of the ureteric bud is the ureteral orifice. If the ureteral bud arises more distally than normal the ureteral orifice enters the bladder earlier than usual and migrates cranially and laterally and will likely be associated with reflux. If the bud arises more proximally on the duct the orifice ends up medial and caudal. A very proximal origin leads to a persistent position on the mesonephric duct and termination outside the bladder. In the male this is either in the epididymis vas deferens seminal vesicles and prostate. In the female the mesonephric duct becomes the epoophoron oophoron and Gartner's duct. An ectopic ureter draining into these structures ruptures into the fallopian tube uterus upper vagina or vestibule. Peters CA Schlussel RN Mendelsohn C: Ectopic ureter ureterocele and ureteral anomalies Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 121 pp 3238-3239. GeneralCongenital Anomalies Embryology Anatomy )

2013A five-year-old boy has developed frequent daytime urination voiding at least every 30 minutes. He has no nocturia. Since toilet training at age two he has been continent day and night. His urinalysis is normal. The most appropriate management is: A) reassurance. B) VCUG. C) antimuscarinics. D) glucose tolerance test. E) cystoscopy.

( A reassurance.Excessive urinary frequency in children is occasionally seen. The diagnosis is made by noting that the patient is continent of urine day and night and the urinalysis is normal. The key to the diagnosis is that the frequency does not persist at night. In this child his urinary frequency falls under the category of a nervous habit and may be associated with emotional stress. Urinary frequency generally goes away over time averaging three to six months. It can return in some patients but eventually resolves. Antimuscarinics seldom help these patients whose bladders are normal. Invasive testing such as VCUG and cystoscopy are not indicated since the findings are almost always normal. In the presence of a normal urinalysis glucose tolerance testing is not indicated.MacLellan DL Bauer SB: Neuropathic dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 128 p 3431. PediatricNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A two-day-old 4.5 kg girl has gross hematuria. A right flank mass is palpable. CBC shows thrombocytopenia. The most likely diagnosis is: A) renal vein thrombosis. B) renal artery thrombosis. C) Henoch-Sch÷nlein purpura. D) hemolytic uremic syndrome. E) congenital mesoblastic nephroma.

( A renal vein thrombosis.This is a large infant which may be associated with maternal diabetes. That history and the abdominal mass make the diagnosis of renal vein thrombosis most likely. The thrombocytopenia is characteristic. Renal artery thrombosis is usually associated with an indwelling umbilical artery catheter and can result in a mass and hematuria. Congenital mesoblastic nephroma is the most common solid renal mass in an infant but is not usually associated with hematuria or thrombocytopenia. Henoch-Schonlein purpura is a systemic vasculitis that commonly presents at four to six years of age. The common features are palpable purpuric rash abdominal pain with gastrointestinal bleeding and arthritis. Hemolytic uremic syndrome is defined by the triad of microangiopathic hemolytic anemia thrombocytopenia and acute renal failure that typically occurs after enterocolitis with E. coli (O157:H7). Lee RS Borer JG: Perinatal urology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 114 p 3060. PediatricFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013 A vascular pedicle of the omentum is preferentially based on which artery when using an omental flap for repair of a vesicovaginal fistula: A) right gastroepiploic. B) left gastroepiploic. C) superior mesenteric. D) gastric. E) splenic.

( A right gastroepiploic.An omental flap should be preferentially based on the right gastroepiploic artery. The pedicle is mobilized off the stomach from the left. This will result in a well-vascularized and sufficiently long flap based on the right gastroepiploic. The right gastroepiploic is a larger vessel than the left and its origin is somewhat caudal as compared to the left allowing a shorter course into the deep pelvis.Rovner ES: Urinary tract fistulae Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 77 pp 2237-2241. AdultCongenital Anomalies Embryology Anatomy )

2013A 43-year-old paraplegic man with a neurogenic bladder has gross hematuria. A cystogram shows bilateral grade 2 VUR and a 1 cm papillary filling defect in the mid-right ureter. Cystoscopy shows patulous ureteral orifices but no other abnormalities. Complete ureteroscopic resection of the tumor reveals a low grade non-invasive urothelial carcinoma. The serum creatinine is 1.0 mg/dl. The best management is: A) surveillance with ureteroscopy. B) nephroureterectomy. C) partial ureterectomy. D) ureterectomy and ileal ureter. E) intravesical BCG.

( A surveillance with ureteroscopy.This patient is an ideal candidate for endourologic management of an upper tract tumor. The patulous ureteral orifices will allow easy passage of the ureteroscope for surveillance. The surgical options listed are unnecessary for a completely resected tumor. Intravesical BCG is not indicated for a first-time low grade tumor. Martinez-Pineiro JA Matres MJG Martinez-Pineiro L: Endourologic treatment of upper tract urothelial carcinomas: analysis of a series of 59 tumors. J UROL 1996;156:377-385.Sagalowsky AI Jarrett TW Flanigan RC: Urothelial tumors of the upper urinary tract and ureter Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 53 p 1516. Adult Neoplasm )

2013A 54-year-old man with metastatic clear cell RCC is currently receiving sunitinib. During therapy he should have monitoring of his serum: A) thyroid stimulating hormone and T4. B) testosterone. C) cholesterol. D) cortisol. E) transaminases.

( A thyroid stimulating hormone and T4.Hypothyroidism has been reported in 36% to 46% of patients who took sunitinib in prospective studies. A higher incidence (53% to 85%) has been reported in studies containing both retrospective and prospective data. The mean time to onset of hypothyroidism after initiation of sunitinib therapy ranged from 12 to 50 weeks. The risk of development of hypothyroidism appears to increase with the increasing duration of sunitinib therapy and the condition is likely reversible once therapy has been discontinued. Baseline thyroid function tests should be performed before the initiation of sunitinib treatment. Because hypothyroidism can develop early in the course of therapy thyroid function tests should be monitored frequently throughout the duration of treatment. Possible mechanisms for thyroid dysfunction include impaired thyroid hormone synthesis a destructive thyroiditis preceding the development of hypothyroidism and increased thyroid hormone clearance. If hypothyroidism is identified levothyroxine therapy should be promptly initiated. Sunitinib does not affect testosterone cholesterol cortisol or liver function.Vetter ML Kaul S Iqbal N: Tyrosine kinase inhibitors and the thyroid as both an unintended and an intended target. ENDOCR PRACT 2008;14:618-624. Adult Neoplasm )

2013 A 55-year-old woman undergoes right radical nephrectomy and inferior vena cava thrombectomy for RCC. There is no evidence of metastatic disease. The prognostic factor most predictive of cancer-free survival is: A) tumor stage. B) tumor grade. C) size of caval thrombus. D) tumor size. E) mutant p53 suppressor gene.

( A tumor stage.Important prognostic factors for RCC include specific clinical signs or symptoms such as anemia hematuria and weight loss; tumor-related factors such as grade and histology; and various laboratory findings such as hypercalcemia. Although an integrative approach utilizing nomograms and risk tables combining a variety of factors have proven to be powerful analyses tools the local tumor stage remains the most important single prognostic factor for RCC. The cephalad extent of tumor thrombus has been associated with outcome since a thrombus above the diaphragm increases the stage. However the absolute size of thrombus does not correlate to outcome. Presence or absence of p53 mutation is not prognostic in RCC.Campbell SC Lane BR: Malignant renal tumors Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 49 pp 1443-1444.Glazer AA Novick AC: Long-term followup after surgical treatment for renal cell carcinoma extending into the right atrium. J UROL 1996;155:448.Reissigl A Janetschek G Eberle et al: Renal cell carcinoma extending into the vena cava: Surgical approach technique and results. BR J UROL 1995;75:138.Swierzewski DJ Swierzewski MJ Libertino JA: Radical nephrectomy in patients with renal cell carcinoma with venous venal caval and atrial extension. AM J SUR 1994;168:205. Adult Neoplasm )

2013 An eight-year-old boy was treated for lipomyelomeningocele at birth. He is on CIC every four hours and oxybutynin 5 mg BID. He develops new incontinence. The next step is: A) urodynamics. B) MRI scan of spine. C) increase CIC frequency. D) increase antimuscarinics. E) start imipramine.

( A urodynamics.This patient should undergo urodynamic evaluation to assess the etiology of the incontinence. MRI scan of the spine would be indicated if the urodynamic study shows new abnormal findings or new onset of lower extremity weakness or other alterations on neurologic exam. Implementing any additional treatment at this time without identifying the cause for the incontinence would be premature. Yeung CK Sihoe JDY: Non-neuropathic dysfunction of the lower urinary tract in children Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 127 p 3411. PediatricNeurogenic Bladder Voiding Dysfunction Incontinence )

2013An acutely ill 50-year-old man is in the emergency room. He is unable to give a history. Physical exam reveals severe dehydration. Serum Na is 125 mEq/l and urinary Na is 8 mEq/l (> 20 mEq/l normal spot urine). The most likely cause of his hyponatremia is: A) vomiting. B) diuretic excess. C) renal disease. D) congestive heart failure. E) Addison's disease.

( A vomiting.Congestive heart failure is associated with fluid retention. Therefore a patient with heart failure would not be dehydrated. Renal disease Addison's disease and diuretic excess cause hyponatremia by increased urinary excretion of sodium. Of the choices listed only vomiting would result in hypovolemia hyponatremia and a very low concentration of sodium in the urine. Patients who experience excessive vomiting lose fluid and salt. Therefore they become dehydrated and their kidneys reabsorb almost all of the filtered sodium. Thus the urinary sodium concentration is low.Palmer BF: Hyponatremia in Rakel RE Bope ET (eds): RAKEL: CONN'S CURRENT THERAPY ed 58. Philadelphia: Elsevier Saunders 2006 p 720.Shoskes DA McMahon AW: Renal physiology and pathophysiology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 38 pp 1038-1040. GeneralFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013An 86-year-old man with nocturia times three daytime frequency urinary urgency and occasional incontinence is treated with tolterodine. His incontinence worsens. Urinalysis is normal. The next step is: A) urine culture. B) PVR. C) uroflowmetry. D) videourodynamics. E) cystoscopy.

( B PVR.Transient urinary incontinence occurs in almost one third of ambulatory elderly patients. LUTS in the elderly may be secondary to a number of medical conditions including diabetes immobility congestive heart disease etc. Antimuscarinic agents may cause or worsen urinary incontinence in elderly patients with poor detrusor contractility. This may present with new or worsened incontinence due to overflow after the initiation of an antimuscarinic agent and can be diagnosed with the non-invasive measurement of a PVR. Urine culture is not indicated in the setting of a normal urinalysis. There is no need at this point to proceed to uroflowmetry urodynamics or cystoscopy but these may be useful in further evaluation.Resnick NM Stasa DT Yalla SV: Geriatric incontinence and voiding dysfunction Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 76 p 2205. AdultCore Competencies Geriatric Radiation Safety and Ultrasound )

2013A 35-year-old man with uric acid calculi has a nighttime urinary pH of 5.5 despite potassium citrate 40 mEq TID. The next step is adding: A) allopurinol. B) acetazolamide. C) ascorbic acid. D) sodium citrate. E) hydrochlorothiazide.

( B acetazolamide.Acetazolamide is effective in increasing the urinary pH in patients with uric acid and cystine stone formation who are already taking potassium citrate. However 50% of patients may discontinue the medication due to adverse effects. Acetazolamide a carbonic anhydrase inhibitor leads to an increase in urinary bicarbonate and increased H+ reabsorption. It has been shown to increase overnight urine pH when given at bedtime. Allopurinol is effective for uric acid stones but does not increase pH and might be considered but only if urinary uric acid levels were high. Sodium citrate has been shown to be less effective than potassium citrate therapy. Hydrochlorothiazide may increase urine uric acid. Sterrett SP Penniston KL Wolf JS Jr Nakada SY: Acetazolamide is an effective adjunct for urinary alkalization in patients with uric acid and cystine stone formation recalcitrant to potassium citrate. UROL 2008;72:278-281. Adult Calculous Disease )

2013A 23-year-old man develops chylous ascites after RPLND. He is initially managed with a medium chain triglyceride diet and for the last two weeks with TPN. He still requires periodic paracentesis four weeks postoperatively. The next step is: A) continue current management. B) add somatostatin. C) laparoscopic ligation of the source. D) open surgical ligation of the source. E) peritoneovenous shunt.

( B add somatostatin.After making the patient NPO and starting TPN the next step is the administration of subcutaneous or I.V. somatostatin. Recent reports have shown a beneficial effect leading to drying up of lymphatic fistulas in this setting. Somatostatin works by decreasing the absorption of fats inhibiting gastric intestinal and pancreatic secretions and inhibiting motor activity of the intestines. The net effect is reduced flow within the major lymphatic channels and reduced leakage from the fistula site. Somatostatin is thus recommended prior to proceeding with more invasive measures. Lievovitch I Mor Y Golomb J Ramon J: The diagnosis and management of postoperative chylous ascites. J UROL 2002;167:449-457. Adult Neoplasm )

2013 A ten-year-old girl with a history of bilateral high grade VUR was treated with bilateral cross-trigonal ureteral reimplantation surgery at two years of age. She is evaluated for persistent gross hematuria following treatment of a UTI. Cystoscopy and bladder mass resection demonstrates nephrogenic adenomas. The next step is: A) reassurance. B) antibiotic suppression. C) intravesical BCG. D) laser ablation. E) partial cystectomy.

( B antibiotic suppression.Nephrogenic adenoma is a rare benign metaplastic response of urothelium to tissue injury. Most nephrogenic adenomas occur after an inciting event such as surgery trauma infection and immunosuppression or in response to calculi. The adenomas will develop months to years after a precipitating event and will usually occur within the bladder but may occur on any urothelial surface including transposed bladder mucosal grafts. The main presentation is hematuria and irritative voiding symptoms but patients may also present with obstructive symptoms or be diagnosed incidentally. The endoscopic appearance is that of a papillary exophytic lesion resembling a low-grade urothelial carcinoma. On histological evaluation nephrogenic adenoma appear as subepithelial tubular structures similar to Henle's loops. Although at one time these lesions were considered to be premalignant in nature recent studies have been unable to establish a relationship between nephrogenic adenomas and the subsequent development of malignancy. Even though there is no evidence of malignant potential transurethral resection is recommended together with long-term antibiotic prophylaxis for at least one year after resection. Prolonged antibiotic therapy is suggested due to the frequent finding of UTI as an associated or causative factor. It is controversial regarding whether patients with nephrogenic adenomas should undergo surveillance cystoscopy. Although there is high incidence of recurrence (30-40%) it is feared that repeated cystoscopic evaluations could further traumatize the bladder urothelium leading to an increased incidence of recurrence. Since nephrogenic adenomas are now known to be a benign condition most authorities recommend cystoscopy only if recurrent gross hematuria and/or irritative or obstructive voiding symptoms develop.Frimberger DC Kropp BP: Bladder anomalies in children Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 125 p 3387.Garcia-Penit J Orsola A Parada R et al: Synchronous nephrogenic adenoma in the bladder and neourethra (bladder mucosa) in a boy. BR J UROL INT 1999;84:169-170.Peeker R Aldenborg F Fall M: Nephrogenic adenoma: A study with special reference to clinical presentation. BR J UROL 1997;80(4):539-542. Pediatric Neoplasm )

2013 Berry aneurysms of the circle of Willis are most frequently associated with: A) renal aneurysms. B) autosomal dominant polycystic kidneys. C) autosomal recessive polycystic kidneys. D) horseshoe kidney. E) multicystic dysplastic kidneys.

( B autosomal dominant polycystic kidneys.Ten percent of patients with autosomal dominant polycystic kidney disease have berry aneurysms and subarachnoid hemorrhage can be a lethal consequence. The high incidence of hypertension with autosomal polycystic kidney disease may contribute to the frequency of bleeding from the berry aneurysm. There is no association between renal aneurysms and berry aneurysms. Multicystic dysplastic kidneys have a slight association with hypertension but no extrarenal manifestations otherwise. Horseshoe kidney has a higher incidence of UPJ obstruction and Wilms' tumor but is not associated with berry aneurysms. Autosomal recessive polycystic kidney disease is associated with liver failure but has no known association with berry aneurysms. Pope JC IV: Renal dysgenesis and cystic disease of the kidney Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 118 pp 3170-3176. GeneralFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013A 55-year-old asymptomatic man with a serum PSA of 5.0 ng/ml has a normal DRE. TRUS is normal and prostate biopsy reveals Gleason 3+3 adenocarcinoma in two biopsy cores from the left base and two biopsy cores from the right apex. The remaining biopsies show benign prostate tissue. According to the 2010 AJCC TNM classification the clinical T stage is: A) cT1b. B) cT1c. C) cT2a. D) cT2b. E) cT2c.

( B cT1c.Clinical staging is determined by DRE and TRUS and is not influenced by biopsy location information. This is a common clinical mistake by practicing urologists. The correct clinical stage is cT1c since it is a PSA diagnosed lesion with a normal physical examination and a normal ultrasound. If he had a small nodule on physical examination or consistently present on ultrasound (or other imaging) he would be cT2a. If the nodule was bilateral his clinical stage would be cT2c. If he has a radical prostatectomy his most likely pathologic stage will be pT2c since his disease is bilateral on biopsy. Loeb S Carter HB: Early detection diagnosis and staging of prostate cancer Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 99 pp 2767-2768. Adult Neoplasm )

2013 The ductuli efferentes of the testis enter the: A) seminiferous tubules. B) caput epididymis. C) cauda epididymis. D) vas deferens. E) rete testis.

( B caput epididymis.Seminiferous tubules organized into 200-300 conical tubules drain into 20-30 tubuli recti which enter the rete testis a network of ducts in the testicular mediastinum. At the upper end of the mediastinum the ductuli efferentes emerge from the testis to enter the head (caput) of the epididymis. The cauda epididymis is the most distal portion of this organ from the testis.Chung BI Sommer G Brooks JD: Anatomy of the lower urinary tract and male genitalia Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 2 pp 67-68. GeneralCongenital Anomalies Embryology Anatomy )

2013 Food with high potential renal acid load (PRAL) includes: A) milk. B) cheese. C) yogurt. D) fruit. E) vegetables.

( B cheese.Low urinary pH predisposes to uric acid and calcium oxalate stones. Dietary acid load correlates with increased risk for stone formation. While cheese has one of the highest potential renal acid load (PRAL) milk and yogurt are less acidic and convey only a slight PRAL. The only foods with a net negative PRAL (alkaline load) are fruits and vegetables and should be encouraged in patients with stone disease. While dairy intake is encouraged to decrease the risk of enteric hyperoxaluria cheese should be de-emphasized as the primary source. Penniston K: Role of diet in stone prevention in Pearle MS Nakada S (eds): UROLITHIASIS: MEDICAL AND SURGICAL MANAGEMENT. London Informa Healthcare 2009 chap 4 p 42. General Calculous Disease )

2013 Performance sports drinks may increase urinary: A) sodium. B) citrate. C) calcium. D) uric acid. E) oxalate.

( B citrate.Performance sports drinks may increase urinary citrate and pH; lending a protective effect against urinary lithogenicity. However these drinks have a high fructose and total carbohydrate content so they should not be recommended as the primary means of hydration for stone formers. Though the sodium content may be high in these drinks they do not lead to hypernatruria. Sports drinks have no effect on urinary calcium oxalate and uric acid. Goodman JW Asplin JR Goldfarb DS: Effect of two sports drinks on urinary lithogenicity. UROL RES 2009;37:41-46. Adult Calculous Disease )

2013A 12-year-old boy has severe dysuria and hematuria. Ultrasound shows a bladder mass and mild right hydronephrosis. Urine culture is sterile. Cystoscopy shows a diffuse erythematous bullous mass at the bladder base. Biopsy shows intense inflammation granulomatous reactions and an eosinophilic infiltrate. The best management is: A) laser fulguration. B) corticosteroids. C) long-term antibiotics. D) TUR of lesion. E) cystectomy and diversion.

( B corticosteroids.This patient has eosinophilic granulomatous cystitis. It usually presents as a mass-like lesion with irritative symptoms and hematuria. It may be mistaken for a neoplastic process but is benign and self-limited. If the lesion is focal with minimal symptomatology observation is appropriate. Patients with focal lesions may also be managed with laser fulguration or TUR. In diffuse lesions resection is not indicated. Both antihistamines and steroids may aid in relieving symptomatology. Steroids have been reported to relieve symptoms faster although direct statistical comparisons are not available. Unless infection is also present there is no need to treat with antibiotics. The process is non-specific and often idiopathic although consideration for a causative condition is necessary; e.g. schistosomiasis in a patient at risk. Frimberger DC Kropp BP: Bladder anomalies in children Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 125 p 3387. Pediatric Infection & Inflammatory Disease )

2013In 46 XX female patients with CAH the clitoral nerves at the mid-portion of the enlarged phallic shaft are found: A) ventrally. B) dorsally. C) laterally. D) between the urethra and vagina. E) between the shafts of the corpora cavernosa.

( B dorsally.The clitoral neural anatomy in the masculinized female patients with CAH is similar to that of the normal male or female phallus. At the mid-portion of the enlarged clitoral shaft the nerves are found dorsally. This is the area which must be preserved for possible future genital sensation after the feminizing genitoplasty.Rink RC Kaefer M: Surgical management of disorders of sexual differentiation cloacal malformation and other abnormalities of the genitalia in girls Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 134 p 3652. GeneralCongenital Anomalies Embryology Anatomy )

2013 A 26-year-old man has progressive left flank pain 17 years after an open pyeloplasty. Diuretic renography reveals 28% function from his left kidney with delayed renal pelvic drainage (T1/2 = 40 minutes). Retrograde ureterogram shows a 1 cm narrowing at the UPJ. The best treatment is: A) balloon dilation. B) endopyelotomy. C) nephrectomy. D) pyeloplasty. E) ureterocalycostomy.

( B endopyelotomy.Pyeloplasty may result in early or delayed failure. Failure is most likely secondary to an anastomotic stricture. Transmural endopyelotomy whether performed in a retrograde or antegrade approach is the treatment of choice. Ureterocalycostomy may be considered but only after less invasive treatments. It should be reserved for patients with intrarenal pelvis dilated lower calyces or a lengthy proximal ureteral stricture. Nephrectomy should be reserved for kidneys with minimal renal function. Balloon dilation is suboptimal therapy. Pyeloplasty whether open or laparoscopic should be reserved for endoscopic failures. Nakada SY Hsu THS: Management of upper urinary tract obstruction Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 41 p 1127. AdultObstructive Uropathy Laparoscopy/Robotics )

2013 A 64-year-old man had a TURP six months ago and has an AUA Symptom Score of 5. He has persistent gross hematuria requiring cystoscopy and clot evacuation. Friable prostatic tissue was noted during cystoscopy. He does not wish to undergo further surgical treatment. The next step is: A) tamsulosin. B) finasteride. C) tamsulosin and finasteride. D) bicalutamide. E) antibiotics for one month.

( B finasteride.Finasteride is an effective option for the management of gross hematuria after TURP for BPH. None of the other listed treatments (e.g. tamsulosin and bicalutamide) have efficacy or have been evaluated in this setting. It is known that one of the early effects of finasteride is the intraprostatic suppression of vascular endothelial growth factor. Clinically finasteride has been shown to effectively treat post-prostatectomy hematuria especially in the presence of friable prostate tissue. If hematuria does not resolve with this therapy then evaluation of the upper urinary tract should be considered to rule it out as the source of bleeding. Prolonged antibiotics would only be indicated in the setting of UTI suspected to be of prostatic origin.McVary KT Roehrborn CG Avins AL et al: Update on AUA guideline on the management of benign prostatic hyperplasia. J UROL 2011;185:1798.McNicholas TA Kirby RS Lepor H: Evaluation and nonsurgical management of benign prostatic hyperplasia Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 92 p 2638. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A 45-year-old obese man with untreated sleep apnea develops nocturnal enuresis. He has no daytime incontinence. Physical examination is unremarkable except for mild lower extremity edema. Urinalysis is negative and his PVR is 30 ml. The most likely etiology of the enuresis is: A) decreased secretion of ADH. B) increased secretion of atrial natriuretic peptide. C) detrusor overactivity. D) mobilization of lower extremity edema. E) hypercarbia induced drowsiness.

( B increased secretion of atrial natriuretic peptide.Sleep apnea is a recognized cause of nocturia and secondary or adult-onset nocturnal enuresis. It causes nocturnal diuresis by a cascade of events which are precipitated by hypoxia which occurs during the intermittent occlusion that occurs with obstructive sleep apnea. The hypoxia-induced increase in right atrial transmural pressure leads to elevated atrial natriuretic peptide resulting in increased nocturnal urinary output. Atrial natriuretic peptide secretion is induced by elevated intrathoracic pressures due to diaphragmatic contraction against a closed upper airway. Drake M: Nocturia Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 67 p 1961. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013According to the 2009 AUA Guidelines on Surgical Management of Female Stress Urinary Incontinence (SUI) evaluation of the index patient with SUI should include a focused history physical examination urinalysis PVR and: A) pad test. B) objective demonstration of SUI. C) cystoscopy. D) urodynamics. E) urodynamics and cystoscopy.

( B objective demonstration of SUI.According to the 2009 Update for the Guideline on Surgical Management of Female Stress Urinary Incontinence evaluation of the index patient should include the following components: focused history focused physical examination objective demonstration of SUI assessment of PVR urine volume urinalysis and urine culture if indicated. Additional diagnostic studies are not required but can be performed as needed and include pad testing voiding diary urodynamics cystoscopy and imaging.Appell RA Dmochowski RR Blaivas JM et al: Guideline for the surgical management of female stress urinary incontinence: 2009 update. INCONTINENCE. American Urological Association Education and Research Inc 2009. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/stress2009/page 16 AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 60-year-old man who underwent left total hip replacement one year ago is about to undergo SWL of a 1 cm right renal pelvic stone. Appropriate antimicrobial prophylaxis is: A) none. B) oral ciprofloxacin. C) oral trimethoprim-sulfamethoxazole. D) I.V. ceftriaxone. E) I.V. vancomycin.

( B oral ciprofloxacin.This patient underwent prosthetic joint replacement less than two years prior to a stone manipulation procedure - SWL. According to the AUA Antimicrobial Prophylaxis Best Policy Statement the antimicrobial prophylaxis should be either single dose oral fluoroquinolone or intravenous ampicillin-gentamicin combination.Wolf JS Jr Bennett CJ Dmochowski RR et al: Best practice policy statement on urological surgery antimicrobial prophylaxis. UROLOGICAL SURGERY ANTIMICROBIAL PROPHYLAXIS BEST PRACTICE STATEMENT. American Urological Association Education and Research Inc 2008. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/antibiotic_prophylaxis.pdf General Infection & Inflammatory Disease )

2013 An early manifestation of septic shock is: A) bradycardia. B) respiratory alkalosis. C) high output renal failure. D) decreased cardiac output. E) decrease in plasma norepinephrine.

( B respiratory alkalosis.Respiratory alkalosis is a very early sign of septic shock and is caused by the initial tachypnea stimulated by the sepsis. As hypoperfusion occurs metabolic acidosis develops. Tachycardia oliguria increased cardiac output and increased plasma norepinephrine occur in early septic shock.Schaeffer AJ Schaeffer EM: Infections of the urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 10 p 314. General Infection & Inflammatory Disease )

2013 A 52-year-old man requires six units of packed red blood cells over a 48-hour period five days after a percutaneous nephrolithotomy. He remains hypotensive at 85/50 mmHg. Imaging study is shown. The next step is: A) emergent exploration and repair of kidney. B) selective arterial embolization. C)bedrest blood transfusion and close monitoring. D) insertion of a large-bore percutaneous tamponade catheter in nephrostomy tract. E) insertion of an indwelling ureteral stent and urethral catheter decompression.

( B selective arterial embolization.Delayed bleeding after percutaneous procedures is almost always secondary to pseudoaneurysms or arteriovenous fistulas. Both can present with delayed and intermittent bleeding. Arteriovenous fistula bleeding is more likely to be continuous compared with pseudoaneurysms. Management is renal angiography during active bleeding (with the aid of an arterial vasodilator such as papaverine if necessary) and highly selective angiographic embolization. Continued conservative therapy would be incorrect in the face of hemodynamic instability after appropriate resuscitative efforts. A tamponade catheter may be used as a temporizing measure if the nephrostomy tract is still present. The image presented demonstrates absence of a nephrostomy tube. An indwelling ureteral stent will not address the ongoing hemorrhage. Emergent exploration may lead to need for nephrectomy and a conservative approach is more appropriate.Rastinehad AR Andonian S Siegel DN: Hemorrhagic complications associated with renal surgery in Smith AD Badlani GH Preminger GM Kavoussi LR (eds): SMITH'S TEXTBOOK OF ENDOUROLOGY ed 3. Oxford Blackwell Publishing Ltd 2012 vol 1 chap 30 p 337. Adult Calculous Disease )

2013During ureteroscopic lithotripsy of an impacted 8 mm calcium oxalate stone in the proximal ureter the ureter is cleared but a 3 mm fragment is detected on fluoroscopy 1 cm lateral to the ureter. The next step is: A) observation. B) ureteral stent. C) basket extraction. D) percutaneous nephrostomy. E) retroperinoscopy.

( B ureteral stent.A small stone fragment pushed through the wall of the ureter if completely outside the wall and uninfected is rarely a clinical problem and no intervention such as retroperitoneoscopy or basket extraction needs to be directed towards it. The ureteral perforation through which this fragment passed is managed by ureteral stenting; observation without a stent would lead to extravasation and a higher risk of stricture. Percutaneous nephrostomy and drain placement are not necessary if a stent can be inserted. Johnson DB Pearle MS: Complications of ureteroscopy. UROL CLIN AMER 2004; 31:157-171. Adult Calculous Disease )

2013 A 75-year-old woman with lower limb phlebitis has marked bilateral hydroureteronephrosis on a CT scan performed to screen for an intra-abdominal malignancy. She has had marked uterine prolapse (procidentia) for several years. Stress incontinence of urine is controlled by wearing a pad changed once daily. Residual urine is 100 ml. Serum creatinine is 3.2 mg/dl. Urine culture grows Klebsiella 105 col/ml. The next step in management should be antibiotic therapy and: A) hysterectomy. B) vaginal pessary. C) anterior vaginal repair. D) anterior vesicourethropexy. E) bilateral ureteral stents.

( B vaginal pessary.Complete uterine prolapse (procidentia) can cause bilateral ureteral obstruction. Correction of the prolapse causes relief of the ureteral obstruction. In this case a vaginal pessary to prevent prolapse is the best initial management to allow improvement in renal function and uninterrupted anticoagulant treatment of her phlebitis. Later hysterectomy may be indicated. Neither anterior vesicourethropexy nor anterior vaginal repair will correct uterine prolapse. Cystoscopic manipulation of the upper tracts through an infected bladder will all too often lead to pyelonephritis. All patients with advanced uterine prolapse should have upper tract imaging by ultrasound or pyelography. Lesser degrees of uterine procidentia carry little risk of hydronephrosis (2% in one study).Payne CK: Conservative management of urinary incontinence: Behavioral and pelvic floor therapy urethral and pelvic devices Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 69 pp 2017-2018. AdultObstructive Uropathy Laparoscopy/Robotics )

2013A 66-year-old man has a PSA of 4.1 ng/ml and is diagnosed with a Gleason sum 6 prostate cancer involving less than 5% of a single core from a 12-core biopsy. He elects active surveillance. One year later his PSA is 4.5 ng/ml. The next step is: A) recheck PSA in three months. B) recheck PSA in six months. C) 12-core TRUS-guided prostate biopsy. D) 24-core TRUS-guided saturation biopsy. E) MRI.

( C 12-core TRUS-guided prostate biopsy.Active surveillance is an appropriate management strategy for selected men with localized prostate cancer. Patients who elect this approach should have favorable risk tumors usually consisting of low-volume Gleason sum 6 or less disease. Active surveillance protocols are characterized by close monitoring of PSA kinetics and serial biopsy. Klotz et al from Toronto have suggested that PSAs be measured quarterly for the first two years after diagnosis and then twice annually after that assuming the PSA is stable. A PSA doubling time of less than three years is considered to be an indication for intervention. They have recommended a 10-12 core biopsy at one year after original diagnosis and then every three to five years after that until age 80. If any Gleason sum 7 or higher disease is noted this is considered to be an indication for intervention. In this case the patient is one year removed from his initial diagnosis and a follow-up biopsy is indicated. Reassessment of PSA in three or six months is inappropriate if repeat biopsy is not performed. Saturation biopsy is not indicated in this setting. MRI can be useful in the follow-up for patients but is not a critical element of active surveillance protocols. Klotz L: Active surveillance for prostate cancer: Patient selection and management. AUA UPDATE SERIES 2008 vol 27 lesson 33 p 326. Adult Neoplasm )

2013 A 71-year-old woman has difficulty voiding two hours following injection of a transurethral bulking agent. Residual urine volume is 400 ml. The next step is: A) observation. B) alpha-blockers. C) CIC. D) indwelling urethral catheter. E) suprapubic cystostomy.

( C CIC.Although the majority of patients do not have difficulties voiding following injection of a bulking agent when retention does occur it should be treated with CIC using a small (10- 14 Fr) catheter. Larger catheters indwelling catheters. or large urethral sounds will push the mucosal blebs apart or cause molding of the bulking agent around the catheter. Suprapubic cystotomy can be used if long term catheterization is needed although this is very rare. Herschorn S: Injection therapy for urinary incontinence Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 74 p 2172. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 24-year-old man had a complete T4 spinal cord injury three weeks ago. He is wearing a condom catheter for continuous leakage and examination is significant for suprapubic fullness as well as flaccid muscle paralysis and absent somatic reflexes below the level of injury. The next step is: A) suprapubic catheter. B) suprapubic catheter and urodynamics. C) CIC. D) CIC and urodynamics. E)CIC urodynamics and renal ultrasound.

( C CIC.This patient has classic symptoms of spinal shock which usually lasts 6-12 weeks in complete suprasacral spinal cord lesions. Lower urinary tract function with spinal shock is usually a combination of an acontractile and areflexic bladder and a competent bladder neck. This patient likely has suprapubic fullness due to an elevated residual with leakage secondary to overflow incontinence. This could be managed with either an indwelling catheter or the initiation of regular CIC. As this patient should have normal upper extremity function with this level of injury and therefore should be able to perform CIC there is no reason to place a suprapubic catheter. Urodynamic studies are indicated once spinal shock has resolved and bladder function has stabilized. The resolution of spinal shock is often heralded by the return of deep tendon reflexes.Wein AJ Dmochowski RR: Neuromuscular dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 65 p 1920. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A man with a BMI of 35 (normal 18.5-24.9) complains of left flank and hip pain after undergoing laparoscopic right nephrectomy in the lateral position. The surgery was challenging and required use of the kidney rest for an extended period of time. Postoperatively he appears to have brownish-red urine. Urine dip stick is 3+ for blood but no RBC os seen microscopically. The next step is: A) observation. B) nephrology consultation. C) I.V. hydration and alkalinization. D) radiographic imaging of the hip. E) initiation of patient-controlled anesthesia.

( C I.V. hydration and alkalinization.This patient likely has rhabdomyolysis. The diagnosis is made by measurement of serum creatine phosphokinase (CPK) or a spot test for urine myoglobin. Risk factors for this at the time of laparoscopic surgery include a BMI of 25 or greater male gender prolonged operative time full-table flexion and prolonged use of the kidney rest. Prevention is essential and includes minimizing the use of the kidney rest and intra-operative hypotension. Brownish-red urine suggestive of the hematuria may be noted in patients with rhabdomyolysis however microscopic assessment of the urine will not show RBCs. Treatment at this time should be hydration and alkalinization to minimize the risk of renal failure. Renal function should be monitored. The need for transient dialysis occurs in a minority of patients so nephrology consultation may not be necessary. Radiographs of the hip are not indicated as it is unlikely that an injury to the bony pelvis would occur during a nephrectomy leading to these symptoms.Eichel L Clayman RV: Fundamentals of laparoscopic and robotic urologic surgery Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 9 p 249. AdultObstructive Uropathy Laparoscopy/Robotics )

2013 A man with castrate-resistant prostate cancer and bone metastases is on leuprolide acetate injections and intravenous zoledronic acid injections. He is asymptomatic. Zoledronic acid injections must be stopped if the patient develops: A) fever. B) fatigue. C) a tooth abscess. D) a pathologic fracture. E) severe osteoporosis.

( C a tooth abscess.Zoledronic acid and other bisphosphonates have become an important part of the management of patients with prostate cancer bone metastasis. These compounds reduce bone resorption by inhibiting osteoclastic activity and proliferation. In patients with progressive hormone refractory bone metastatic prostate cancer zoledronic acid has been shown to reduce the incidence of skeletal events in a randomized prospective trial. Adverse events include fatigue myalgias fever anemia and elevations in serum creatinine. Osteonecrosis of the mandibular bone is a severe complication of bisphosphonates usually associated with patients undergoing dental work or who have poor dentition or chronic dental disease. The bisphosphonates should be immediately discontinued in the setting of osteonecrosis or expected invasive dental procedures.Antonarakis ES Carducci MA Eisenberger MA: Treatment of castration-resistant prostate cancer Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 110 p 2954. Adult Neoplasm )

2013 Randomized clinical trials have demonstrated decreased rates of struvite stone growth with the use of: A) urinary acidification. B) suppressive antibiotics. C) acetohydroxamic acid. D) a low protein diet. E) citric acid glucono-delta-lactone magnesium carbonate.

( C acetohydroxamic acid.Acetohydroxamic acid (AHA Lithostat) has been demonstrated in randomized clinical trials to decrease the rate of stone growth in patients with struvite calculi. It is important to note that AHA did not impact the rate of stone recurrence. Urinary acidification has been tested in vitro utilizing L-methionine but has not been studied in humans. Though recurrence rates are higher (62%) in patients with infected urine compared to sterile urine (12%) the use of suppressive antibiotics to decrease stone growth has not been studied in a clinical trial. A low protein diet although effective in feline studies has not been shown to make a difference in human studies. Citric acid glucono-delta-lactone magnesium carbonate (Renacidin«) has been utilized for dissolution therapy of residual fragments. Park S: Pathophysiology and management of infection stones. in Pearle MS Nakada S (eds): UROLITHIASIS: MEDICAL SURGICAL MANAGEMENT. London Informa Healthcare 2009 chap 10 pp 129-130. Adult Calculous Disease )

2013 A 62-year-old woman with multiple sclerosis has persistent urinary urgency and frequency. Pressure flow urodynamics reveal detrusor overactivity during bladder filling that reproduces her symptoms as well as increased pelvic floor EMG activity during voiding. An MRI scan will most likely reveal evidence of demyelination: A) of the cerebral cortex. B) of the cerebellum. C) between the pons and sacral spinal cord. D) between the conus medullaris and the cauda equina. E) between the sacral spinal cord and the bladder.

( C between the pons and sacral spinal cord.Multiple sclerosis may involve the central and/or peripheral nervous systems. Depending on the location level and extent of demyelination a variety of urodynamic patterns may result. Pelvic floor EMG activity in this individual is increased during voiding which suggests striated sphincter dyssynergia a urodynamic finding that exists only with neurological lesions between the pons and the sacral spinal cord. Lesions at or distal to the sacral spinal cord would likely result in detrusor areflexia and lesions above the pons result in detrusor overactivity with synergistic activity of the proximal and distal sphincter mechanisms. Wein AJ Dmochowski RR: Neuromuscular dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 65 p 1920. GeneralNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 66-year-old woman has a polypoid mass at her urethral meatus. Office biopsy demonstrates a non-invasive high-grade squamous cell carcinoma. Radiologic staging reveals no evidence of regional or distant disease. The next step is: A) topical 5-FU cream. B) laser fulguration. C) circumferential excision including excision of anterior vaginal wall. D) XRT with ilioinguinal lymphadenectomy. E) anterior pelvic exenteration with pelvic lymphadenectomy.

( C circumferential excision including excision of anterior vaginal wall.In female urethral cancers treatment recommendations are primarily dependent on tumor location and clinical stage. Local excision may be sufficient for the relatively uncommon small superficial distal urethral tumors and can result in excellent functional results. For more proximal and advanced urethral tumors a more aggressive approach is warranted. Small exophytic superficial tumors arising from the urethral meatus or anterior urethra (as in this case) may be surgically treated with circumferential excision of the distal urethra including a portion of the anterior vaginal wall. The distal third of the urethra may be excised while still maintaining urinary continence. Tumors in the distal urethra tend to be low stage and cure rates of 70% to 90% have been achieved with local excision alone. 5-FU cream has been utilized in the treatment of carcinoma-in situ of the penis but does not have a defined role in female urethral cancers. Although XRT has been effectively used for female urethral cancers the addition of prophylactic lymphadenectomy in this choice makes it incorrect. Recommendations for performing groin dissection have been made only for patients who present with positive inguinal or pelvic lymphadenopathy without distant metastasis or patients who develop adenopathy during surveillance. Anterior pelvic exenteration is employed for patients with proximal urethral cancers often as part of a multimodal approach including chemotherapy and XRT.Sharp DS Angermeier KW: Surgery of penile and urethral carcinoma Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 35 p 934. Adult Neoplasm )

2013 A 64-year-old man undergoes a TURP using glycine irrigation. Vital signs are stable throughout the procedure but at the end of the procedure he is confused and nauseated. The most likely problem is: A) sepsis. B) hyperglycemia. C) dilutional hyponatremia. D) hemolysis. E) hypovolemia.

( C dilutional hyponatremia.The TUR syndrome consists of mental confusion nausea vomiting hypertension bradycardia and visual disturbance. It is secondary to a dilutional hyponatremia from free water overload. Up to 20 ml/minute are absorbed during a resection. The risk increases with the size of the prostate and the length of the resection. Patients become symptomatic when the serum sodium concentration reaches 125 mEq/l. Ammonium intoxication has been suggested when glycine has been utilized as an irrigant. Alternative irrigants such as sorbitol glycine and mannitol are isoosmolar and non-hemolytic whereas water is a cheap irrigant but is hypoosmolar. Sorbitol is an inert sugar and would not lead to hyperglycemia. Sepsis in this scenario would usually be manifested with fever hypotension and tachycardia. Hypovolemia would result in tachycardia and hypotension.Fitzpatrick JM: Minimally invasive and endoscopic management of benign prostatic hyperplasia Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 93 pp 2683-2684. AdultFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013When performing SWL using sedation one should anticipate a need for deeper anesthesia if the patient: A) is a male. B) is older than 50 years. C) has a stone projecting over a rib. D) has never had a prior SWL. E) has a ureteral calculus.

( C has a stone projecting over a rib.There is a greater need for supplemental anesthesia during SWL under sedation if the patient is female or young has a history of anxiety depression or prior SWL or has a rib-projected calculus. Pain during SWL has been shown to be less with ureteral calculi when compared to renal calculi.cVergnolles M Wallerand H Gadrat F et al: Predictive risk factors for pain during extracorporeal shockwave lithotripsy. J ENDO 2009;23:2021-2027. Adult Calculous Disease )

2013 The finding most suggestive of renal artery stenosis on duplex ultrasonography is: A) decreased diastolic flow. B) turbulent systolic flow. C) increased peak systolic velocity. D) renal aortic ratio < 3.5. E) resistive index < 0.8.

( C increased peak systolic velocity.Duplex ultrasound of the renal arteries is a useful noninvasive anatomic study for the diagnosis of renal artery stenosis (RAS). Although an altered flow pattern distal to the stenosis including decreased diastolic flow and a turbulent systolic jet can be suggestive of RAS the most important single indicator is a peak systolic velocity (PSV) > 180 cm/sec. The renal aortic ratio (RAR) is the ratio of renal PSV to the aortic PSV. A RAR > 3.5 indicates > 60% stenosis. The renal resistive index does not directly assess renal artery flow.Fergany A Novick AC: Renovascular hypertension and ischemic nephropathy Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 39 p 1061. GeneralFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013In a patient with muscle invasive urothelial carcinoma the pathologic characteristic that predicts a poor response to neoadjuvant chemotherapy is: A) squamous differentiation. B) lymphovascular invasion. C) micropapillary variant. D) p53 mutation. E) small cell component.

( C micropapillary variant.Patients with histologic variants of urothelial carcinoma including squamous differentiation and small cell component actually appear to respond better to neoadjuvant chemotherapy. Similarly patients with a p53 mutation and lymphovascular invasion are considered higher risk patients with urothelial cancer and are recommended to have neoadjuvant chemotherapy. Micropapillary variant of urothelial carcinoma is the one variant that does not appear to respond to chemotherapy and requires immediate cystectomy.Scosyrev E Ely BW Messing EM et al: Do mixed histological features affect survival benefit from neoadjuvant platinum-based combination chemotherapy in patients with locally advanced bladder cancer? A secondary analysis of Southwest Oncology Group-Directed Intergroup Study (S8710). BJU INT 2011;108:693-699.Kamat AM Dinney CP Gee JR et al: Micropapillary bladder cancer: A review of the University of Texas M. D. Anderson Cancer Center experience with 100 consecutive patients. CANCER 2007;110:62-67. Adult Neoplasm )

2013 A 16-month-old boy is treated for dehydration. He has had no diarrhea or vomiting. He has been drinking excessively over the past several months. The serum sodium is 152 mEq/l. The urine specific gravity is 1.003 and the urine osmolality is 500 mOsm/kg. He is treated with parenteral fluids. The next step is: A) head CT scan. B) renal ultrasound. C) overnight fluid restriction. D) desmopressin (DDAVP). E) salt-restricted diet.

( C overnight fluid restriction.This clinical scenario suggests diabetes insipidus. Infants should undergo overnight fluid restriction in a hospital setting. Body weight and vital signs are monitored until three percent of body weight is lost or the urine osmolality is > 600 mOsm/kg. If this does not produce a concentrated urine fluid is restricted on another day and desmopressin is administered. If the renal response to desmopressin is normal central DI (head CT scan) should be investigated. Salt restriction is not helpful in patients with diabetes insipidus as the primary defect involves free water handling. Renal ultrasound yields no useful information for acute management in this scenario. Shoskes DA McMahon AW: Renal physiology and pathophysiology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 38 pp 1040-1041. PediatricFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013 A 32-year-old man underwent a deceased donor kidney transplant six months ago with a donor kidney with two renal arteries. The lower pole renal artery was anastomosed separately to the distal external iliac artery. He now has a creatinine of 2.1 mg/dl and ultrasound shows hydroureteronephrosis of the transplanted kidney. The next step is: A) CT scan. B) diuretic renogram. C) placement of a indwelling urethral catheter. D) cystoscopy and retrograde stent insertion. E) percutaneous nephrostomy.

( C placement of a indwelling urethral catheter.The first step necessary in assessing the renal transplant patient with new onset of hydronephrosis is the placement of a urethral catheter and obtaining a cystogram to assess for the presence of reflux. In the absence of reflux and if urine output is diminished or if the creatinine does not decrease with urethral catheter drainage (drop in creatinine following placement of catheter indicative of bladder dysfunction) assessment for ureteral stricture would be necessary. If the serum creatinine is above 2 mg/dl or twice normal for age false positive MAG 3 Lasix washout renal scans for obstruction are highly probable due to the decreased renal function. In patients with an elevated creatinine percutaneous nephrostomy placement is both effective for treatment and can be an excellent way to diagnosis ureteric stenosis. The risks for complications of the ureter in renal transplantation is < 3% overall. The most common complications are those related to the vascular viability of the ureter and result in either urinary leakage or ureteral stenosis. Urinary leakage often occurs early after transplantation but ureteral stenosis can be insidious and late in the course. Risk factors for ureteral complications include advance donor age delayed graft function severe graft rejection and kidneys with two or more arteries. Cystoscopy and retrograde pyelography or placement of ureteric stents may be problematic due to the abnormal location of the ureteroneocystostomy following a renal transplant and should be considered only after confirmation that no vesicoureteral reflux is present and following the diagnosis of a ureteral stricture. A CT scan although confirmative for the diagnosis of hydronephrosis does not delineate the etiology for the radiographic finding.Shoskes DS Cranston D: Urological Complications after kidney transplantation in Morris PJ Knechtle SJ (eds): KIDNEY TRANSPLANTATION PRINCIPLES AND PRACTICE ed 6. Philadelphia Elsevier Saunders 2008 pp 465-466. AdultFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013A 71-year-old man previously treated for CIS of the bladder has a positive fluorescence in-situ hybridization (FISH) urine test. Cytology CT urogram and cystoscopy are normal. The next step is: A) observation. B) repeat FISH test. C) random bladder biopsies. D) bilateral upper tract cytology. E) bilateral ureteroscopy.

( C random bladder biopsies.The urinary FISH test identifies intranuclear chromosomal abnormalities that have been associated with bladder cancer. Specifically it detects aneuploidy for chromosome 3 7 and 17 and homozygous loss of chromosome 9p21. This test is currently FDA approved for the evaluation of microscopic hematuria and bladder cancer. In 2007 Yoder and colleagues reported that 35/56 (62.5%) patients with prior urothelial carcinoma who had a normal evaluation by cystoscopy and a positive FISH subsequently were detected to have recurrent disease. The appropriate workup of this patient population remains highly variable however random bladder biopsies are considered the standard of care for patients with a positive urine cytology and negative cystoscopy and should be regarded as a minimum evaluation in this high risk patient. The yield of upper tract endoscopy and cytology in the setting of a normal CT urogram is low and should be discouraged as an initial diagnostic maneuver. Because the patient has a history of bladder cancer the most likely site of recurrence is in the bladder. Repeat FISH will not add anything to the evaluation whether positive or negative. Wood DP: Urothelial tumors of the bladder Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 80 pp 2327-2328.Yoder BJ Skacel M Hedgepeth R et al: Reflex UroVysion testing of bladder cancer surveillance patients with equivocal or negative urine cytology: A prospective study with focus on the natural history of anticipatory positive findings. AM J CLIN PATHOL 2007;127:295-301. Adult Neoplasm )

2013A 30-year-old man is diagnosed with stage 3 NSGCT. He undergoes radical orchiectomy and four cycles of BEP chemotherapy. His tumor markers have normalized. However he has a 10 cm retroperitoneal mass and three 1 cm pulmonary masses (50% size reduction after chemotherapy). After his RPLND the next step is: A) observation with serial imaging. B) PET scan with resection of lung masses if positive. C) resection of lung masses. D) resection of lung masses if retroperitoneum has active tumor. E) resection of lung masses if retroperitoneum has teratoma.

( C resection of lung masses.There is about 75% concordance between retroperitoneal pathology and pulmonary mass pathology however approximately 25% of cases will have discordant pathology (i.e. retroperitoneal fibrosis and active tumor or teratoma in the lung field). Therefore post-chemotherapy thoracotomy yields important prognostic information and is curative in patients with resected teratoma and a subset of patents with viable tumor.PET scanning is a valuable decision making tool for retroperitoneal post-chemotherapy seminoma for residual masses greater than or equal to 3 cm. In this patient population provided the PET scans are performed six weeks after the last chemotherapy cycle (decreased false positives) PET scans have a negative predictive value of 96% and a positive predictive value of 78% for active seminoma. This helps identify patients who merit additional treatment for post-chemotherapy seminoma retroperitoneal masses. PET scans usefulness however for the evaluation of supra-diaphragmatic residual pulmonary nodules or mediastinal masses has not been extensively studied and recommendations for its use in this clinical situation have yet to be determined.Sheinfeld J Bosl GJ: Surgery of testicular tumors Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 32 p 871. Adult Neoplasm )

2013A 56-year-old woman with recurrent symptomatic stress urinary incontinence desires treatment. She had a prior midurethral synthetic sling ten years prior that worked well until recently. Examination reveals loss of urine with cough and minimal urethral hypermobility. Urinalysis is normal. The next best step is: A) urethral bulking agent. B) transobturator transvaginal tape sling. C) retropubic midurethral sling. D) retropubic bladder neck suspension. E) artificial urinary sphincter.

( C retropubic midurethral sling.A repeat midurethral synthetic sling is an appropriate option for a patient with recurrent stress urinary incontinence. Cure rates for redo patients appear to be higher for the retropubic compared to the transobturator approach. This is likely due to a higher rate of intrinsic sphincter dysfunction in patients requiring repeat surgery. Urethral bulking agents would be less likely to lead to a long-term resolution of this patient's symptoms. Placement of an autologous fascial sling would also be a viable option for this patient. A retropubic bladder neck suspension is an inferior procedure to a retropubic transvaginal tape or to an autologous sling. Placement of an artificial urinary sphincter would not be indicated for this patient.Dmochowski RR Padmanabhan P Scarpero HM: Slings: Autologous biologic synthetic and midurethral Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 73 p 2164. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013While performing a videourodynamic study in a patient with neurogenic bladder the patient develops a severe headache. The neurological condition most likely to be associated with this event is: A) hemorrhagic stroke in globus pallidus. B) conus medullaris injury. C) spinal cord infarct at T4. D) astrocytoma displacing the reticulospinal tract at T8. E) multiple sclerosis.

( C spinal cord infarct at T4.Autonomic dysreflexia is a medical emergency caused by over stimulation of the sympathetic nervous system in individuals with spinal cord injuries at or above the 5th thoracic (T5) spinal cord levels although patients with injuries between T6-10 maybe susceptible. Autonomic dysreflexia is classically stimulated by: An overfilled bladder colonic distension (constipation) decubitus ulcer or silent orthopedic fracture. Patients exhibiting autonomic dysreflexia are symptomatic with complaints of a headache flushing and diaphoresis (above the level of the spinal cord lesion) hypertension and bradycardia. Bradycardia occurs due to a reflex stimulated from stretch on the atrial ventricular node by the elevation in blood pressure. When seen in the office setting the first step should be to empty the bladder and remove all noxious stimuli i.e. cystoscope urodynamic catheter from the bladder. If the elevation in blood pressure does not respond the patient should be treated with ? to 1 inch of nitropaste to the chest wall. If rebound hypotension occurs the nitropaste maybe rapidly wiped off of the skin. Other options of pharmacologic therapy for autonomic dysreflexia in the office setting include oral or sublingual nifedipine. However rebound hypotension can be problematic and difficult to deal with. Wein AJ Dmochowski RR: Neuromuscular dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 65 p 1926. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013On prostate ultrasound calcifications within the prostate known as corpora amylacea can be visualized between which zones: A) transitional and anterior. B) central and peripheral. C) transitional and peripheral. D) central and transitional. E) central and anterior.

( C transitional and peripheral.The various zones of the prostate are not always easily distinguished on ultrasound. In glands with large adenoma the transitional zone can often be distinguished from the anterior zone and the peripheral zone because of its more heterogeneous appearance. In addition some patients will develop calcifications along the surgical capsule between the transitional zone and the peripheral zone. These calcifications are known as corpora amylacea and can be used on ultrasound to define the boundaries of these two zones.Trabulsi EJ Halpern EJ Gomella LG: Ultrasonography and biopsy of the prostate Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 97 p 2735. AdultCore Competencies Geriatric Radiation Safety and Ultrasound )

2013 A healthy one-month-old girl has lower abdominal distention. An ultrasound demonstrates a cystic mass behind the bladder. Follow up MRI scan is shown. Physical exam reveals normal appearing genitalia with a single opening in the urethral position with no evidence of a vaginal opening. These findings are most consistent with: A) Mayer-Rokitansky syndrome. B) androgen insensitivity syndrome. C) transverse vaginal septum. D) imperforate hymen. E) CAH.

( C transverse vaginal septum.The MRI scan shows evidence of a distended upper vagina and presence of a uterus which is most consistent with either a transverse vaginal septum or distal vaginal agenesis. Transverse vaginal septa are believed to arise from a failure in fusion or canalization (or both) of the urogenital sinus and M?llerian ducts. Many of the patients present at puberty with primary amenorrhea and a distended upper vagina. A complete transverse vaginal septum may be located at various levels in the vagina but there is a higher frequency in the middle and upper third of the vagina. Transperineal transrectal and abdominal ultrasonography and MRI scan may be beneficial in establishing the diagnosis and determining the location and thickness of a transverse vaginal septum. Vaginal atresia occurs when the urogenital sinus fails to contribute to formation of the lower (distal) portion of the vagina. Mayer-Rokitansky syndrome is characterized by either partial or complete absence of the vagina and coexisting uterine abnormalities with the uterus either partially or completely absent. In Mayer-Rokitansky syndrome the fallopian tubes and ovaries are present but may be either normal or hypoplastic. Two types exist type I that involves only the M?llerian structures (vagina and uterus) and type II that will involve concurrent abnormalities of either the cardiac renal or otologic systems. Androgen insensitivity syndrome is characterized by the absence of a uterus salpinx and upper 2/3 of the vagina these structures regress under the active influence of MIF secreted from the testes. CAH infant will manifest an enlarged clitoris and genital ambiguity with variable lengths of a urogenital sinus present dependent upon the degree of androgen secretion from the adrenal glands. An imperforate hymen should demonstrate a visible bulging membrane at the vaginal introitus. Rink RC Kaefer M: Surgical management of disorders of sexual differentiation cloacal malformation and other abnormalities of the genitalia in girls Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 134 pp 3631-3632. PediatricCongenital Anomalies Embryology Anatomy )

2013 A 55-year-old diabetic woman has new onset pneumaturia. The next step is: A) pelvic CT scan. B) cystoscopy. C) urine culture. D) cystogram. E) barium enema.

( C urine culture.Pneumaturia the passage of gas in the urine may be due to a fistula between the intestine and bladder or due to gas-forming UTI. Common causes of fistula are diverticulitis carcinoma of the sigmoid colon and regional enteritis (Crohn disease). Patients with diabetes mellitus may have gas-forming infections with carbon dioxide formation from the fermentation of high concentrations of sugar in the urine. In the latter situation the microorganism most commonly responsible for cystitis is E. coli. Approximately 60% of cases of emphysematous cystitis occur in diabetics. In the current case a urinalysis and urine culture should be performed first. Additional tests can be performed selectively based on the results of urinalysis and urine culture. Culture results showing multiple organisms is suggestive of a colovesical fistula.Gerber GS Brendler CB: Evaluation of the urologic patient: History physical examination and urinalysis Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 3 p 79. Adult Infection & Inflammatory Disease )

2013A 57-year-old woman reports a vaginal bulge ten years after hysterectomy. On examination she is found to have anterior prolapse with the most distal point noted at her hymenal ring. Her vault and posterior wall show no prolapse. The POP-Q points consistent with her exam are: A)Aa -1 C 0 Ap -3 stage 1. B)Aa -1 C 0 Ap -1 stage 1. C)Aa 0 C -7 Ap -3 stage 2. D)Aa 0 C -7 Ap -1 stage 2. E)Aa +1 C +2 Ap -3 stage 3.

( CAa 0 C -7 Ap -3 stage 2.The POP-Q (pelvic organ prolapse quantification) is a classification system used to quantify the degree of pelvic organ prolapse (POP). Nine points are measured in relation to the hymenal ring which is designated as 0 (zero). Any points located above the hymenal ring are given a negative value corresponding to the number of centimeters (cm) the point is above the hymen whereas points distal to the hymen are given positive values. Aa and Ap correspond to the point three cm up on the anterior and posterior walls respectively and will be -3 if there is no POP. Ba and Bp correspond to the distal-most aspect of the anterior and posterior walls respectively. The well-supported vault (C) should be at about -7 to -9. This patient has a cystocele and no posterior or apical prolapse. The distal-most portion of her anterior vagina is at 0 the level of the hymenal ring. Ap which corresponds to approximately the level of the bladder neck is -3. The vault is supported at -7. This is stage 2 which is defined as the most distal point of the POP being between +1 and -1 or within 1 cm of the hymen. Other points of measurements in POP-Q include the genital hiatus (GH) perineal body (PB) and total vaginal length (TVH). Kobashi KC: Evaluation of patients with urinary incontinence and pelvic prolapse Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 64 pp 1900-1901. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 A 38-year-old woman has intermittent right flank pain. CT scan shows delayed filling of a right upper pole anterior calyceal diverticulum containing an 8 mm stone. The best treatment is: A) observation. B) SWL. C)ureteroscopy incision of the diverticular neck and laser lithotripsy. D) percutaneous nephrostolithotomy and dilation of the infundibular neck. E) laparoscopic ablation of calyceal diverticulum and stone removal.

( Cureteroscopy incision of the diverticular neck and laser lithotripsy.Observation is unacceptable in this symptomatic patient with a diverticular stone. Although SWL may be used successfully to treat a subset of patients with stones in calyceal diverticula that have a broad infundibular neck the overall stone free rates with SWL are unacceptably low. Percutaneous nephrostolithotomy is not only associated with the highest stone-free rate but also the procedure results in resolution of the diverticulum. However anteriorly-located diverticula necessitate percutaneous access through the renal parenchyma with a high risk of bleeding complications. The ureteroscopic approach is ideal for upper pole calyceal diverticula with < 2 cm stones. Laparoscopic ablation would be indicated for an anterior calyceal diverticulum > 2 cm. Canales B Monga M: Surgical management of the calyceal diverticulum. CURR OPIN UROL 2003;13:255-260. Chong TW Bui MHT Fuchs GJ: Calyceal diverticula. Ureteroscopic management. UROL CLIN N AM 2000;27:647-653. Adult Calculous Disease )

2013A six-year-old girl undergoes bilateral ureteral reimplantation. On the first post-operative day she has severe bladder spasms refractory to parenteral opioids and oral antimuscarinic agents. Her urine is clear and the creatinine is 0.4 mg/dl. The next step is: A) oral alpha blocker. B) oral benzodiazepine. C) rectal acetaminophen. D) I.V. ketorolac. E) caudal block.

( D I.V. ketorolac.For post-operative bladder spasms refractory to the conventional pain management using opioids and antimuscarinics intravenous ketorolac (NSAID) administered at 0.25 to 0.5 mg/kg every six hours is effective in reducing bladder spasms following bladder surgery. However significant adverse effects have been reported including renal failure prolonged bleeding and hypersensitivity reactions. It should be avoided in patients with renal insufficiency NSAID sensitivity persistent post-operative bleeding and dehydration. Other treatments such as alpha blocker benzodiazepine rectal acetaminophen and caudal block do not provide any additional benefit. Estrada CR Jr Ferrari LR: Core principles of perioperative management in children Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 119 p 3206. PediatricNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A 66-year-old man undergoes a radical nephrectomy with adrenalectomy for an 8 cm upper pole RCC within the kidney. There is a focus of non-contiguous metastatic RCC in the adrenal gland. No lymph nodes were removed. According to the 2010 TNM AJCC classification pathologic stage is: A) T1bN0Mx. B) T1bNxM1. C) T2aNxM0. D) T2aNxM1. E) T4NxM0.

( D T2aNxM1.According to the 2010 TNM AJCC staging renal cancers greater than 7 cm and less than or equal to 10 cm are now categorized as pT2a. Lesions greater than 10 cm are pT2b. Adrenal gland involvement depends on whether there is contiguous involvement (T4) or non-contiguous involvement (M1). The M1 designation is true even if the adrenal gland is on the ipsilateral side as the nephrectomy. When there are no pathologic lymph nodes available the pathologic staging is designated as NX.Edge SB Byrd D Compton C Fritz A: AJCC Staging Manual ed 7. New York Springer-Verlag 2010 chap 43 pp 479-490. Adult Neoplasm )

2013A 45-year-old woman with prior pelvic radiation for cervical cancer develops severe hemorrhage from the right ureteral orifice during routine exchange of a chronic indwelling 6 Fr ureteral stent. Over the next six hours she continues to bleed but remains stable. The next step is: A) replace stent with 8 Fr stent. B) right percutaneous nephrostomy. C) ureteroscopy with fulguration. D) angiography and placement of endovascular graft. E) open exploration.

( D angiography and placement of endovascular graft.Most cases of ureteroarterial fistulas are reported in patients with a prior history of vascular disease radiation therapy or pelvic surgery especially in the setting of indwelling ureteral stents. In fact ureteroarterial fistulas are highly associated with indwelling stents. The routine urologic and radiologic evaluation of hematuria will not generally provide evidence of ureterovascular fistula. Even in suspected or proven cases preoperative radiologic investigations including nonselective arteriography and pyelography are often nondiagnostic. This is especially true in patients with intermittent hematuria in whom there is no active bleeding at the time of the radiographic investigation presumably because of thrombus over the site of the fistula. Selective or subselective arteriography of the iliac vessels may be more revealing in suspected cases and provocative maneuvers such as stent removal or mechanical friction of the ureteral lumen by manipulation of the stent may be necessary to demonstrate the fistulous connection in patients without active bleeding undergoing angiography. These adjuvant maneuvers should be performed only with extreme caution in an appropriate setting where immediate angiographic or surgical intervention is possible. In a review retrograde pyelography was diagnostic in only 6 of 10 patients in whom it was performed and arteriography diagnosed a ureterovascular fistula in only 4 of 14 cases. Indirect evidence of a ureteroarterial fistula can be found on CT but findings are usually nonspecific and suggestive only in retrospect after a confirmed diagnosis by other means. Nevertheless in a stable patient with a suspected ureterovascular fistula a full radiographic evaluation may be pursued not only for diagnostic purposes but also to evaluate potential reconstructive options and in select cases to perform therapeutic angiographic embolization procedures. As these patients may present in extremis with hypotension and severe hemorrhage surgical intervention must be considered early especially since radiographic evaluation may be nondiagnostic. In this stable patient an attempt at angiography and placement of an endovascular graft is warranted. Open exploration may be needed if hematuria persists. Replacement of the ureteral stent or percutaneous nephrostomy will not stop the hemorrhage. Ureteroscopy with fulguration will be unsuccessful with an arterial-ureteral fistula.Rovner ES: Urinary tract fistulae Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 77 pp 2259-2260. AdultObstructive Uropathy Laparoscopy/Robotics )

2013 A 39-year-old woman has dysuria and frequency. Urinalysis shows 30 WBC/hpf and a few cocci. The midstream urine culture shows 103 coagulase negative Staphylococci/ml. The next step is: A) phenazopyridine. B) repeat midstream culture. C) urine culture for mycobacteria. D) antibiotic therapy. E) catheterized urine culture.

( D antibiotic therapy.The standard definition of significant bacteriuria for a clean voided urine is > 105 CFU/ml) of a uropathogen. This criterion has stood the test of time for screening and epidemiological studies and for entering patients in clinical trials. However there are several important exceptions to its rigid use in clinical practice and one is in patients with a pyuria/dysuria syndrome. In these patients a lower colony count may represent significant bacteriuria.Certain bacterial species such as coagulase negative Staphylococci grow slowly in urine and significant infections may only have counts of 103 CFU/ml. Since the patient has a symptomatic culture-proven UTI treatment with phenazopyridine alone would be inappropriate. Repeat urine culture (midstream or catheterized) is not indicated. Mycobacteria culture is indicated only in sterile pyuria. Schaeffer AJ Schaeffer EM: Infections of the urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 10 p 271-272. Adult Infection & Inflammatory Disease )

2013A 50-year-old man has a large right renal mass with tumor thrombus extending into the atrium. Under hypothermia and circulatory arrest he undergoes nephrectomy with removal of the tumor thrombus. The most frequent significant complication is: A) hepatic dysfunction. B) pulmonary air embolus. C) central nervous system deficit. D) coagulopathy and hemorrhage. E) tumor emboli.

( D coagulopathy and hemorrhage.Hypothermia and circulatory arrest is the treatment of choice for a renal tumor with this level of cephalad extension. This technique has several potential complications such as CNS or hepatic damage yet the most common difficulty associated with this technique is hemorrhage associated with platelet and clotting factor dysfunction. Tumor emboli can occur but are relatively uncommon. Utilization of cardiopulmonary bypass limits the possibility of embolic events.Marshall FF Dietrick DD Baumgartner WA Reitz BA: Surgical management of renal cell carcinoma with intracaval neoplasm extension above the hepatic veins. J UROL 1998;139:1166-1172.Kenney PA Wotkowicz C Libertino JA: Contemporary open surgery of the kidney Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 54 p 1624. Adult Neoplasm )

2013 In the management of advanced bladder cancer the substitution of carboplatin for cisplatin in a multidrug regimen has been shown to: A) not affect outcome. B) increase renal toxicity. C) improve survival. D) decrease response rate. E) increase duration of therapy.

( D decrease response rate.In a meta-analysis of four randomized trials in 286 patients Galsky and colleagues have concluded that the substitution of carboplatin for cisplatin resulted in a statistically significant (three fold decrease) in the probability of achieving a complete response and a significant decrease in the overall response rate. No significant effect on survival could be analyzed and in general the renal safety profile is improved with the use of carboplatin. The duration of therapy is not affected by the substitution of carboplatin.Galsky MD Chen GJ Oh WK et al: Comparative effectiveness of cisplatin-based and carboplatin-based chemotherapy for treatment of advanced urothelial carcinoma. ANN ONCOL 2012;23:406-410. Adult Neoplasm )

2013 The recommended method to prevent postoperative DVT in an otherwise healthy man undergoing TURP under spinal anesthesia is: A) subcutaneous low dose unfractionated heparin. B) low molecular weight heparin. C) aspirin. D) early ambulation. E) obtain preoperative lower extremity duplex studies.

( D early ambulation.The AUA Best Practices Policy on DVT prophylaxis stated that early ambulation is recommended for the vast majority of men undergoing TURP. Those men who are at increased risk for DVT (such as previous DVTs malignancy immobility paresis etc.) may benefit from pneumatic compressive stockings subcutaneous low dose unfractionated heparin or low molecular weight heparin (LMWH). However the use of LMWH is contraindicated in a patient who receives spinal or epidural anesthesia as this is a FDA black box warning due to risk of spinal hematoma. Aspirin and other antiplatelet drugs while highly effective at reducing vascular events associated with atherosclerotic disease are not recommended for DVT prophylaxis in surgical patients. There is no indication for obtaining preoperative LE-duplex studies in an otherwise healthy male.Forrest JB Clemens JQ Finamore P et al: Best practice policy statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. PREVENTION OF DVT AFTER UROLOGIC SURGERY BEST PRACTICE STATEMENT. American Urological Association Education and Research Inc 2008. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/dvt.pdf AdultCore Competencies Geriatric Radiation Safety and Ultrasound )

2013 A 23-year-old man had a successful kidney transplant two weeks ago. He has significant pain below his incision without any leg weakness. The most likely diagnosis is: A) postoperative pain. B) addictive behavior. C) lateral cutaneous nerve injury. D) genitofemoral nerve entrapment. E) femoral nerve damage.

( D genitofemoral nerve entrapment.Nerve injury can be seen after transplantation or a psoas hitch. The genitofemoral nerve arises from the L1-2 ventral primary rami and at the level of L3-4 the nerve pierces the anterior surface of the psoas major muscle and descends past the ureter. It then splits into the genital and femoral branches near the inguinal ligament. The surgeon must not mistake this nerve for a lymphatic vessel as it sometimes crosses the external iliac artery. This nerve supplies the cremaster muscle spermatic cord scrotum and thigh in males. Incisional pain can be common after kidney transplantation but after 2 weeks postoperative pain usually subsides. Although pain to very light touch can suggests addictive behavior the entrapped genitofemoral nerve can indeed present in this manner. More often the pain may be worse with internal or external rotation of the hip and prolonged walking. Lateral cutaneous nerve injury presents with anterior and lateral thigh paraesthesia symptoms of burning and tingling that increase with standing walking or hip extension. Patients with femoral nerve damage complain of difficulty in walking and sometimes knee buckling depending on the severity of the nerve injury.Barry JM Conlin MJ: Renal transplantation Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 44 p 1241. AdultFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013A one-year-old boy with prune belly syndrome has chronic renal insufficiency. He undergoes abdominoplasty and bilateral orchidopexy and develops oliguria post operatively that does not respond to fluid boluses. Serum electrolytes reveal elevated BUN and creatinine metabolic acidosis and hyperkalemia. Sodium polystyrene enemas are given and I.V. sodium bicarbonate is administered. The patient develops abdominal cramping and muscle spasms. This is most likely due to: A) hypokalemia. B) hypophosphatemia. C) hypermagnesemia. D) hypocalcemia. E) hyponatremia.

( D hypocalcemia.This patient has developed acute renal failure (ARF). Children with a history of chronic renal insufficiency secondary to renal dysplasia are at significant risk for ARF after any major surgical procedure. Most cases are reversible. Patients with ARF can develop hyperkalemia metabolic acidosis hyperphosphatemia (from decreased renal excretion) and hyponatremia. The hypocalcemia that develops is due to several causes including hyperphosphatemia decreased intestinal calcium reabsorption and Vitamin D deficiency. The most important acute reason for the hypocalcemia is the hyperphosphatemia. When correcting the metabolic acidosis it is important to monitor the ionized calcium level since this can drop precipitously. Signs and symptoms of hypocalcemia include cramping tetany and prolonged QT interval on EKG.Coplevitch L Kaplan B Meyers K: Acute renal failure in Docimo SG Canning DA Khoury AE (eds): CLINICAL PEDIATRIC UROLOGY ed 5. London Informa Healthcare 2007 pp 363-365.Goldfarb DA Poggio ED: Etiology pathogenesis and management of renal failure Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 43 pp 1203-1208. PediatricFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013A 75-year-old man has severe bleeding from radiation cystitis requiring transfusion. Cystogram reveals no reflux. Previous therapeutic measures have failed including fulguration clot evacuation and irrigations with silver nitrate and 1% alum. The next step in management is: A) ileal loop urinary diversion. B) instillation of 10% formalin. C) instillation of 5% formaldehyde. D) instillation of 5% formalin. E) internal iliac artery embolization.

( D instillation of 5% formalin.Formaldehyde is a 37% solution of formaldehyde gas dissolved in water and should not be used intravesically. Formalin solution is made up of 1-10% formaldehyde diluted with normal saline and has been given in bladder instillations to control hemorrhage from advanced bladder tumors or radiation cystitis. Formalin solution is exceedingly irritating to the bladder and thus requires general or regional anesthesia. Because a 10% formalin solution may cause fibrosis and obstruction of the ureteral orifices formalin instillation should begin with a 1% solution and be repeated with a 5% and then a 10% solution if necessary. Many people begin with a 5% solution if other measures (i.e. silver nitrate and 1% alum) have failed. A cystogram should be performed before instillation to rule out vesicoureteral reflux. If reflux is present Fogarty catheters should be passed up both ureters and the patient should be tilted into the head-up position to protect the upper tracts from the toxic effects of formalin. Selective internal iliac arterial embolization is more invasive and should be reserved for patients that fail formalin instillation.Smit SG Heyns CF: Management of radiation cystitis. NAT REV UROL 2010;7:206-214. Adult Neoplasm )

2013A patient taking chronic thiazide diuretics undergoes nephrectomy. After surgery serum K is 3.0 mEq/l despite adequate fluid replacement. She is normotensive and alert. Attempts to restore her serum K level are hampered by: A) adrenal insufficiency. B) glomerular hyperfiltration. C) normal magnesium levels. D) intracellular shifting of potassium. E) tubular dysfunction.

( D intracellular shifting of potassium.There is no evidence of adrenal insufficiency. Low magnesium levels can contribute to hypokalemia. There is no evidence that thiazides permanently damage the kidneys ability to handle potassium. The glomerulus does not play an important role in potassium homeostasis. When administering potassium for hypokalemia the rise in serum potassium is blunted because about 80% of the potassium enters the intracellular space.Shoskes DA McMahon AW: Renal physiology and pathophysiology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 38 p 1042. GeneralFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013 A 14-year-old boy has a painless mass above the right testis. Radical orchiectomy is performed. Pathology reveals a completely resected paratesticular rhabdomyosarcoma. His abdominal CT scan is normal. The next step is: A) repeat CT scan in three months. B) adjuvant chemotherapy with doxorubicin and alkylating agents. C) retroperitoneal radiation. D) ipsilateral RPLND. E) bilateral RPLND.

( D ipsilateral RPLND.There is a significant rate of false negative imaging of the retroperitoneum on CT scan and microscopic disease may be present in patients with paratesticular rhabdomyosarcoma. Boys ten years of age or younger can be treated with chemotherapy alone. Boys over ten years of age should undergo ipsilateral RPLND since 50% will have microscopic disease. Bilateral RPLND is more morbid and does not improve survival over unilateral surgery. If the lymph nodes are positive for metastasis the patient will require radiation therapy to the retroperitoneum in addition to chemotherapy. Ritchey ML Shamberger RC: Pediatric urologic oncology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 137 p 3709. Pediatric Neoplasm )

2013 A 44-year-old runner experiences the gradual onset of left groin pain. Examination reveals normal genitalia and tenderness over the symphysis pubis. His urinalysis is clear. The most likely cause of his pain is: A) vasitis. B) femoral hernia. C) pubic bone stress fracture. D) osteitis pubis. E) osteomyelitis of the pubis.

( D osteitis pubis.The patient presents with the symptoms of osteitis pubis in the athlete. It is estimated that osteitis pubis accounts for 6-14% of groin pain in athletes and is thought to be a form of overuse injury. The onset of unilateral or bilateral groin pain is gradual and may be accompanied by pain in the lower abdomen hip thigh or testicle. Acutely painful infectious vasitis without associated epididymitis is exceedingly rare. Femoral hernia may cause groin pain but is not typically associated with pain of the symphysis pubis. Pubic stress fractures do occur but are less common than osteitis pubis in athletes. Osteomyelitis of the pubis has been reported in athletes and must be considered in the differential diagnosis. However it is much less common than osteitis pubis. Pelvic MRI scan is used to distinguish between osteomyelitis and osteitis pubis. Treatment for osteitis pubis is anti-inflammatory medications and rest.Johnson R: Osteitis pubis. CURR SPORTS MED REP 2003;2:98-102.Karpos PA Spindler KP Pierce MA et al: Osteomyelitis of the pubic symphysis in athletes: A case report and literature review. MED SCI SPORTS EXCERCISE 1995;27:473-479.Eddy K Piercy GB Eddy R: Vasitis: Clinical and ultrasound confusion with inguinal hernia clarified by computed tomography. CAN UROL ASSOC J 2011;5:E74-76. Adult Infection & Inflammatory Disease )

2013A 30-year-old man on CIC develops urinary incontinence three years after a spinal cord injury. Urodynamic testing demonstrates detrusor areflexia and a detrusor LPP of 60 cm H2O at 200 ml. The next step is: A) tamsulosin. B) ephedrine. C) bethanechol. D) oxybutynin. E) dantrolene.

( D oxybutynin.Detrusor compliance may deteriorate in patients with spinal cord injury and detrusor areflexia. The development of incontinence suggests this occurrence. A detrusor LPP greater than 15 cm H2O indicates that compliance is impaired. In the absence of intervention renal deterioration may occur. The best treatment is an antimuscarinic agent such as oxybutynin. Ephedrine would be contraindicated as it may increase sphincter tone and increase detrusor LPP. An alpha-1-blocker may lower the detrusor LPP but increase the incontinence. Bethanechol would also be contraindicated since it may increase detrusor pressure. Dantrolene is used to treat detrusor external sphincter dyssynergia via relaxation of skeletal muscle. Wein AJ Dmochowski RR: Neuromuscular dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 65 p 1923.Andersson KE Wein AJ: Pharmacologic management of lower urinary tract storage and emptying failure Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 68 pp 1978-1979. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013 Condyloma lata are associated with: A) cervical carcinoma. B) gonococcal urethritis. C) herpes simplex virus. D) secondary syphilis. E) AIDS-related complex.

( D secondary syphilis.Condyloma lata are a cutaneous manifestation of secondary syphilis. They appear as flesh colored or hypopigmented macerated papules or plaques. They most commonly involve genital and anal areas. The lesions are typically smooth and moist. Condyloma lata resemble condyloma acuminata but are distinguished by their smooth flat and moist appearance. Condyloma lata have not been associated specifically with cervical carcinoma gonococcal urethritis herpes simplex or HIV.Deshpande DJ Nayak CS Mishra SN et al: Verrucous condyloma lata mimicking condyloma acuminata: An unusual presentation. INDIAN J SEX TRANSM DIS 2009;30:100-102. Adult Infection & Inflammatory Disease )

2013 The risk factor associated with the highest chance for developing a secondary malignancy and/or cardiovascular disease in patients treated for testis cancer is: A) surveillance imaging. B) smoking. C) BEP chemotherapy. D) subdiaphragmatic and mediastinal radiation therapy. E)cisplatin vinblastine bleomycin (PVB) chemotherapy.

( D subdiaphragmatic and mediastinal radiation therapy.In a multivariate analysis combined subdiaphragmatic and mediastinal radiation has a Hazard's Ratio (HR) of 3.7 for secondary malignancy and/or cardiovascular disease; chemotherapy also increased the risk (HR 1.9) but there is no difference between the chemotherapy regimens. Smoking increased risk 1.7 fold. There is no increased risk of secondary malignancy with surgery. Surveillance imaging is a risk factor for developing secondary malignancy but the magnitude of the risk is much lower than radiation therapy.Haugnes HS Wethal T Aass N et al: Cardiovascular risk factors and morbidity in long-term survivors of testicular cancer: A 20-year follow-up study. J CLIN ONCOL 2010;28:4649-4657.Abouassaly R Fossa SD Giwercman A et al: Sequale of treatment of testis cancer. EUR UROL 2011;60:516-526.Fung C Vaughn DJ: Complication associated with chemotherapy in testicular cancer. NATURE REVIEWS UROL 2011;8:213-222. Adult Neoplasm )

2013 Vesicoureteral reflux is suspected on antenatal ultrasound when: A) there is upper pole hydroureteronephrosis. B) the bladder is noted to be full on serial ultrasounds. C) there is bladder wall thickening. D) the degree of hydronephrosis varies with serial ultrasounds. E) there is a two-vessel umbilical cord.

( D the degree of hydronephrosis varies with serial ultrasounds.On antenatal ultrasound if the fetus has VUR then the degree of fetal bladder fullness at the time of any particular study will determine how much volume is being refluxed and thus how much hydronephrosis is noted. Since bladder fullness differs between studies the varying degrees of hydronephrosis is suggestive of VUR. A fuller bladder should cause an increase in hydronephrosis. Upper pole hydroureteronephrosis suggests an obstructive etiology; bladder wall thickness and persistent bladder fullness suggests bladder outlet obstruction or several other possibilities. A two-vessel cord is unrelated to the risk of reflux.Lee RS Borer JG: Perinatal urology Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 114 p 3054. PediatricCongenital Anomalies Embryology Anatomy )

2013 A 55-year-old man with post-prostatectomy incontinence underwent placement of an artificial urinary sphincter with good results for three years. He now complains of recurrent incontinence. Examination of the device and cystoscopy suggests normal cycling and no cuff erosion. The next step is: A) deactivate device for a two month trial period. B) alpha-blocker therapy. C) antimuscarinics. D) urodynamics. E) surgical exploration for repair or replacement.

( D urodynamics.Urethral atrophy results from chronic compression of the corpus spongiosum by the cuff and is the leading cause of urinary incontinence in this setting. However urodynamic evaluation may reveal involuntary detrusor contractions or decreased bladder compliance. Deactivation will not permit improved sphincter function. Surgical exploration is not indicated if the cause of the incontinence is unrelated to the device (e.g. detrusor overactivity or impaired compliance). Alpha-blockers would not be expected to have any effect on urinary incontinence in this case regardless of the underlying cause. Antimuscarinics would not treat causes of incontinence related to device malfunction. Treatment options for this patient would include downsizing the cuff movement to a more proximal or distal location or the addition of a second cuff placed in tandem.Wessells H Peterson AC: Surgical procedures for sphincteric incontinence in the male: The artificial genitourinary sphincter and perineal sling procedures Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 79 pp 2294-2295. AdultNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A seven-year-old girl has urgency frequency and daytime urinary incontinence. She is wet every day requiring clothing changes twice daily. Physical exam and urinalysis are normal. She is placed on oxybutynin 5 mg bid and timed voiding. She returns two weeks later and reports no change in the daytime urinary incontinence. The next step is: A) MRI scan of the lumbosacral spine. B) add imipramine. C) videourodynamics. D) voiding diary. E) urethral dilation.

( D voiding diary.Daytime urinary incontinence occurs in 5% of seven-year-old children. In most children the underlying problem is infrequent voiding. Timed voiding programs alone will be successful in the majority of children but require several months to be effective. This child has not had enough time to determine if the program will be effective. Changing to another medication or proceeding with urodynamic evaluation at this time is premature. Urethral dilation is not indicated for the treatment of daytime urinary incontinence. Some authors have suggested that an occult tethered cord is responsible for persistent daytime urinary incontinence. However imaging of the spine should be reserved for those children with significant abnormalities on neurologic exam or urodynamic evaluation. MacLellan DL Bauer SB: Neuropathic dysfunction of the lower urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 128 p 3431. PediatricNeurogenic Bladder Voiding Dysfunction Incontinence )

2013If the inferior mesenteric artery is ligated the artery that maintains blood supply to the rectum is: A) superior mesenteric. B) ileocolic. C) middle sacral. D) external iliac. E) hypogastric.

( E hypogastric.Blood supply to the rectum arises proximally from the superior rectal (hemorrhoidal) artery inferior mesenteric artery and distally from the middle (hemorrhoidal) and inferior rectal arteries. When the inferior mesenteric artery is ligated blood supply to the rectum is maintained by the middle hemorrhoidal artery which is a branch of the posterior division of the hypogastric artery and the inferior rectal artery which is a branch of the internal pudendal artery.Sheinfeld J Bosl GJ: Surgery of testicular tumors Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 32 pp 876-880. AdultCongenital Anomalies Embryology Anatomy )

2013 An 11-year-old boy with spina bifida is scheduled for bladder augmentation and implantation of an artificial urinary sphincter. Infection or erosion are more common if sphincter implantation is performed: A) prior to bladder augmentation. B) following bladder augmentation. C) simultaneous with augmentation. D) with sigmoid enterocystoplasty. E) in an area of previous bladder neck surgery.

( E in an area of previous bladder neck surgery.The best treatment for a patient with low bladder compliance small capacity and sphincteric incontinence is the combined use of bladder augmentation and increased bladder outlet resistance. When an artificial urinary sphincter is used in conjunction with augmentation of the bladder the timing of the two procedures does not appear to affect the outcome. More important factors are good bowel preparation intravenous antibiotics sterility of the urine and meticulous surgical technique to avoid entering the previously augmented bladder during sphincter implantation which may predispose to infection and sphincter erosion. Patients who have undergone prior incontinence procedures are also at increased risk for sphincter erosion.Wessells H Peterson AC: Surgical procedures for sphincteric incontinence in the male: The artificial genitourinary sphincter and perineal sling procedures Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 79 pp 2302-2304. PediatricNeurogenic Bladder Voiding Dysfunction Incontinence )

2013A 68-year-old diabetic man has a 1 cm left proximal ureteral non-invasive high grade urothelial carcinoma. His serum creatinine is 0.9 mg/dl. Abdominal CT scan is otherwise normal. The next step is: A)ureteroscopic tumor ablation stent placement and intravesical BCG instillation. B) percutaneous resection and antegrade BCG. C) left partial ureterectomy. D) left ureterectomy with Boari flap. E) left radical nephroureterectomy.

( E left radical nephroureterectomy.Standard therapy for patients with upper tract urothelial carcinoma involving the proximal ureter is nephroureterectomy. Endoscopic treatment of patients with upper tract urothelial carcinoma is generally recommended in those patients with a solitary kidney bilateral disease renal dysfunction or significant intercurrent illness that precludes a major abdominal procedure. Endoscopic management may also be appropriate in selected patients with small low-grade lesions in the presence of a normal contralateral kidney. However most series suggest that recurrence is likely even with frequent reinspection and that progression to invasive disease occurs in a significant number of patients depending on the stage and grade of the initial tumor. Open ureteral resection risks tumor spillage as well as recurrence. This patient has a normal contralateral right kidney. A recent large multi-institutional examination of nephrouterectomy and ipsilateral lymph node dissection did not reveal any survival advantage for patients treated with node dissection with earlier stage upper tract malignancy as is the case with this patient. However in patients with T2-T4 primary tumors pathologic N0 patients did have a longer cancer-specific survival than pathologic Nx patients.Roscigno M Shariat SF Margulis V et al: Impact of lymph node dissection on cancer specific survival in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. J UROL 2009;181:2482-2489.Sagalowsky AI Jarrett TW Flanigan RC: Urothelial tumors of the upper urinary tract and ureter Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 53 p 1516. Adult Neoplasm )

2013A 22-year-old sexually active woman complains of vulvovaginal itching and flu-like symptoms. On physical exam she is afebrile and the only finding is a fissure in the left labia majora with no vaginal discharge. Urinalysis is negative. The treatment that can prevent recurrence of her symptoms is: A) hydrocortisone cream. B) diphenhydramine cream. C) ceftriaxone IM. D) imiquimod cream. E) oral acyclovir.

( E oral acyclovir.This patient has genital herpes (herpes simplex virus HSV) of which 85-90% are caused by HSV-2 and 10-15% are caused by HSV-1. Initial genital herpes infection is often associated with constitutional flu-like symptoms. While vesicular eruptions can be found on physical exam women especially may present with atypical lesions such as abrasions fissures or itching. Empiric treatment may be initiated. Diagnosis can be helped by serology tests for antibodies to HSV-2 and HSV-1. Antiviral creams are not helpful for genital herpes. Oral acyclovir has been shown to prevent recurrence of genital herpes and associated symptoms. Hydrocortisone cream is not recommended for the treatment of genital herpes however recent studies suggest that a combination of topical acyclovir and hydrocortisone cream may reduce the recurrence of herpes labialis. Ceftriaxone is an appropriate treatment for chancroid but not genital herpes. Topical imiquimod is not recommended for treatment of routine genital herpes but is being used to treat recalcitrant cases of acyclovir-resistant herpes in immunocompromised hosts. Frenkl TL Potts JM: Sexually transmitted infections Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 13 p 405.Perkins N Nisbet M Thomas M: Topical imiquimod treatment of aciclovir-resistant herpes simplex disease: Case series and literature review. SEX TRANSM INFECT 2011;87:292-295. Adult Infection & Inflammatory Disease )

2013A 68-year-old woman has nocturia x3 persistent suprapubic pain urgency and daytime frequency after her third BCG instillation for recurrent stage Ta bladder cancer. A urinalysis reveals 5-10 RBC and 10-20 WBC/hpf. A urine culture is negative. The next step is: A) space remaining treatments two weeks apart. B) ciprofloxacin. C) decrease weekly intravesical dose of BCG by 50 percent. D) isoniazid therapy with BCG treatments. E) oxybutynin.

( E oxybutynin.BCG cystitis is a common side effect of BCG therapy. A possible bacterial infection should also always be considered. Quinolone antibiotics are not indicated with a negative urine culture and may have a negative effect on BCG therapy as it is partially tuberculocidal. Similarly antitubercular medications may abrogate the effectiveness of BCG and add the risk of hepatotoxicity. A decrease in dose intensity may hamper therapeutic efficacy. The patient's symptoms are mild to moderate and are best treated symptomatically with an anti-spasmodic agent during the course of therapy.Jones JS Larchian WA: Non-muscle-invasive bladder cancer (Ta T1 and CIS) Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 3 chap 81 p 2345.van der Meijden AD PM Klingeren BV Steerenberg PA: The possible influence of antibiotics on results of bacillus Calmette-Guerin intravesical therapy for superficial bladder cancer. J UROL 1992;147:596-600. Adult Neoplasm )

2013 A 59-year-old man undergoes TRUS biopsy with a PSA of 4.5 ng/ml and a normal DRE. The biopsy reveals BPH and nine months later his PSA has risen to 5 ng/ml and he undergoes a PCA3 urine test. The PCA3 score is 99 (low risk < 35). The next step is: A) 5-alpha reductase inhibitor. B) one month of ciprofloxacin and repeat PCA3. C) free to total PSA ratio. D) prostate MRI. E) repeat TRUS biopsy.

( E repeat TRUS biopsy.The PCA3 urine test is designed to detect the mRNA signal from the DD3 gene which is specific to prostate cancer. This test has now been validated in multiple prospective studies the largest of which was the REDUCE clinical trial. In this study PCA3 scores were measured in 1 072 subjects with a negative prior TRUS biopsy and the results were more closely correlated to the results of the second biopsy than PSA alone or free to total PSA ratio. The higher the level of the PCA3 score the higher the risk of a positive biopsy and a score of under 35 is considered low risk. Therefore a repeat prostate biopsy is warranted in this patient. PCA3 is now FDA-approved for the assessment of patients with a prior negative prostate biopsy. PCA3 is not affected by infection prostate volume or the use of 5-alpha reductase inhibitors.Aubin SM Reid J Sarno MJ et al: PCA3 molecular urine test for predicting repeat prostate biopsy outcome in populations at risk: Validation in the placebo arm of the dutasteride REDUCE trial. J UROL 2010;184;1947-1952. Adult Neoplasm )

2013A five-year-old boy has had two prior failed attempts to repair his penoscrotal hypospadias. His urethral meatus is widely patent and is located at the penoscrotal junction. The distal urethral plate is fibrotic and scarred and is associated with a 15 degree ventral curvature. He has minimal excess preputial and penile shaft skin. The next step is: A) incised plate urethroplasty. B) buccal mucosa onlay graft and corporal body grafting. C) buccal mucosa onlay graft and dorsal corporal plication. D) resection of urethral plate and tubed buccal mucosa graft urethroplasty. E) resection of urethral plate and first stage buccal mucosa graft to urethral bed.

( E resection of urethral plate and first stage buccal mucosa graft to urethral bed.Patients that have had numerous previous attempts at hypospadias repair often have a scarred and poorly vascularized urethral bed. In these situations the best chance for success is resection of the scarred bed with a two-stage buccal mucosa urethroplasty. The minimal degree of residual ventral curvature will likely not be functionally significant and will improve with resection of the fibrotic urethral plate. Single-stage tubed buccal grafts have a higher degree a failure than a two-stage technique.Snodgrass W Elmore J: Initial experience with staged buccal graft (Bracka) hypospadias reoperations. J UROL 2004;172:1720-1724.Snodgrass WT: Hypospadias Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 4 chap 130 pp 3530-3533. PediatricCongenital Anomalies Embryology Anatomy )

2013 Patients with von-Hippel Lindau disease most frequently have: A) renal angiomyolipoma. B) cafe-au-lait spots. C) glioblastomas. D) thyroid carcinoma. E) retinal angiomas.

( E retinal angiomas.Patients with von-Hippel Lindau disease may have hemangioblastomas of the cerebellum renal cell carcinomas and cystadenomas of the epididymis. The diagnosis however can often be made most easily with inspection of the retina with identification of angiomas. Renal angiomyolipomas are commonly seen in tuberous sclerosis complex. Thyroid carcinoma can be seen more commonly in patients with multiple endocrine neoplasia syndrome. Cafe-au-lait spots are pathognomonic of neurofibromatosis.Neumann HP Berger DP Sigmund G Blum U et al: Pheochromocytomas multiple endocrine neoplasia type 2 and von Hippel-Lindau disease. NEJM 1993;329(21):1531-1538.Campbell SC Lane BR: Malignant renal tumors Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 49 p 1423. Adult Neoplasm )

2013A 76-year-old asymptomatic man has castrate-resistant prostate cancer. Bone scan is normal but CT scan of the pelvis demonstrates two new enlarged pelvic lymph nodes. The next treatment is: A) sunitinib. B) zoledronic acid. C) denosumab. D) cabazitaxel. E) sipuleucel-T.

( E sipuleucel-T.This patient has asymptomatic castrate-resistant prostate cancer. The potential next steps are docetaxel chemotherapy or immune therapy with sipuleucel-T. Both are FDA-approved in this clinical situation. Sipuleucel-T is an active cellular immunotherapy that is a type of therapeutic cancer vaccine. It consists of autologous peripheral blood mononuclear cells with antigen presenting cells that have been activated ex vivo with a recombinant fusion protein that consists of prostatic acid phosphatase that is fused to granulocyte-macrophage colony-stimulating factor (an immune-cell activator).In men with asymptomatic or minimally symptomatic castrate-resistant prostate cancer a 4.1 month median overall survival benefit was demonstrated compared to placebo. This patient has asymptomatic castrate-resistant prostate cancer with soft-tissue disease. Sunitinib is a tyrosine kinase inhibitor and although FDA-approved for kidney cancer it has not been approved by the FDA for men with prostate cancer. Zoledronic acid is an I.V. bisphosphonate indicated for patients with metastatic castrate-resistant prostate cancer with bony sites of disease. It has been demonstrated to decrease pain as well as skeletal-related events. No survival advantage has been demonstrated. Although it has been studied for men on long term androgen deprivation therapy this patient has been on therapy for only six months. Denosumab is a RANK-ligand inhibitor and also decreases skeletal-related events and helps to prevent skeletal-related events associated with osteoporosis. Cabazitaxel is FDA-approved for patients with metastatic castrate-resistant prostate cancer who have failed docetaxel. This patient has not had any chemotherapy. Although not listed docetaxel is FDA-approved agent for men with castrate-resistant prostate cancer and may be an appropriate next treatment.Kantoff PW Higano CS Shore ND et al: Sipuleucel-T immunotherapy for castration-resistant prostate cancer. NEJM 2010;363:411-422. Adult Neoplasm )

2013 A 25-year-old woman reports eight afebrile UTIs in the past year. The factor most likely to increase her risk of UTI is: A) tampon use. B) parity. C) douche use. D) daily bicycle riding. E) spermicide use.

( E spermicide use.Studies of risk factors for recurrent UTI demonstrate that spermicide use increases urinary tract infections by decreasing normal vaginal flora and decreasing vaginal pH. Several studies have demonstrated the other four choices are not common risk factors. Toileting after intercourse increasing fluid intake and wiping front to back have not been shown to decrease occurrence of UTIs in adult women. Schaeffer AJ Schaeffer EM: Infections of the urinary tract Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 1 chap 10 p 267. Adult Infection & Inflammatory Disease )

2013A 26-year-old woman has a 2 cm circumferentially calcified saccular aneurysm on renal arteriography. Her blood pressure is 126/82 mm Hg and her creatinine is 1.1 mg/dl. She is newly married and considering pregnancy. The next step is: A) observation. B) serial imaging. C) lisinopril. D) endovascular stent. E) surgical repair.

( E surgical repair.Pregnancy is a risk factor for renal artery aneurysm rupture regardless of size or calcification therefore observation and serial imaging are not recommended. If this was not a woman of child-bearing age the aneurysm could be followed as it is not large and completely calcified. Lisinopril will not reduce the likelihood of rupture or ischemic damage. An endovascular stent is not recommended for someone in this age group due to the risk of lifelong anticoagulation therapy. She should be counseled to undergo surgical treatment of her aneurysm prior to becoming pregnant. Fergany A Novick AC: Renovascular hypertension and ischemic nephropathy Wein AJ Kavoussi LR Novick AC Partin AW Peters CA (eds): CAMPBELL-WALSH UROLOGY ed 10. Philadelphia Elsevier Saunders 2012 vol 2 chap 39 pp 1078-1080. AdultFluid & Electrolyte Transplantation Hypertension Vasc Disease Nephrology )

2013 A 63-year-old woman with metastatic clear cell RCC and a poor performance status has a serum calcium of 11 mg/dl and a hemoglobin of 8 g/dl. The most appropriate treatment is: A) interferon. B) bevacizumab. C) sunitinib. D) sorafenib. E) temsirolimus.

( E temsirolimus.Temsirolimus is an inhibitor of the mammalian target of rapamycin (mTOR) kinase. This is a component of intracellular signaling pathways involved in growth/proliferation of cells. The medication suppresses angiogenesis and is given as a weekly I.V. infusion. Patients with three or more poor risk factors respond better to mTOR inhibitors than other currently used medications. Risk factors include: serum LDH > 1.5 times upper limit of normal hemoglobin below lower limit of normal serum calcium level of more than 10 mg/dl time from initial diagnosis of RCC to randomization of less than one year Karnofsky performance of 60 or 70 or metastases in multiple organs. This patient is considered poor risk and patients who received this regimen were 27% more likely to survive when compared to patients receiving interferon alpha alone. This medication is FDA-approved for advanced RCC. In addition bevacizumab sunitinib and sorafenib have not been proven to have a survival benefit in this high risk subset of patients. Interferon has not demonstrated a consistent survival advantage in the management of metastatic RCC.Hudes G Carducci M Tomczak P et al: Temsirolimus interferon alpha or both for advanced renal-cell carcinoma. NEJM 2007;356:2271-2281. Adult Neoplasm )

2013 A 28-year-old woman awaiting a liver transplant because of primary biliary cirrhosis is symptomatic from a 9 mm proximal ureteral stone. Management should be: A) observation and hydration. B) ureteral stent. C) SWL. D) stent placement and SWL. E) ureteroscopic laser lithotripsy.

( E ureteroscopic laser lithotripsy.A 9 mm stone in the proximal ureter has little chance of spontaneous passage; as such observation is futile. Although SWL and ureteroscopy are both acceptable treatment options for management of a proximal ureteral stone uncorrected bleeding diathesis frequently found in patients with liver dysfunction is a contraindication to SWL. Although it is optimal to correct bleeding diatheses prior to surgical intervention for stones full correction of coagulation parameters often requires administration of multiple blood products and lengthy hospital stays. Ureteroscopy and Holmium:YAG laser lithotripsy has been shown to be safe and effective in patients with uncorrected bleeding disorders.Watterson JD Girvan AR Cook AJ et al: Safety and efficacy of holmium: YAG laser lithotripsy in patients with bleeding diatheses. J UROL 2002;168:442-445. Turna B Stein RJ Smaldone MC et al: Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J UROL 2008;179:1415-1419. Adult Calculous Disease )

2013A 71-year-old healthy uncircumcised man has a 4 cm penile tumor and undergoes partial penectomy. Pathology reveals high grade squamous cell carcinoma invading the corpora cavernosum with negative surgical margins. After four weeks of antibiotic therapy staging evaluation reveals bilateral bulky fixed inguinal adenopathy and bilateral pelvic adenopathy. The next step is: A) pelvic lymph node biopsy. B) sentinel inguinal lymph node biopsy. C) XRT to inguinal nodes. D) bilateral pelvic and inguinal lymph node dissection. E)neoadjuvant cisplatin ifosfamide and paclitaxel.

( Eneoadjuvant cisplatin ifosfamide and paclitaxel.This patient has a T2 (invasion into the corpus spongiosum or cavernosum) N3 (palpable fixed inguinal lymph nodes or nodal mas either bilateral or unilateral) disease. In patients with unresectable primary tumors or bulky regional lymph node metastases neoadjuvant treatment with a cisplatin-containing regimen is the most effective treatment modality and may allow curative resection. A phase 2 study using four courses of neoadjuvant paclitaxel ifosfamide and cisplatin chemotherapy for TxN2-3 disease followed by bilateral inguinal lymph node dissections and unilateral or bilateral pelvic lymph node dissections revealed excellent response with an objective response rate of 55% and complete pathologic response rate of 10% toxicity was acceptable with no treatment-related deaths. This treatment is superior to single agent chemotherapy and has less toxicity than the previous multi-agent chemotherapeutic regimen of cisplatinum bleomycin and methotrexate. The optimal chemotherapy regimen however has yet to be determined. In this patient with bilateral bulky fixed nodes not responding to antibiotics a needle biopsy of the lymph nodes could be considered for pathologic diagnosis. However neither pelvic lymph node biopsy sentinel inguinal lymph node biopsy nor bilateral pelvic inguinal and inguinal lymph node dissection would be curative and would predispose the patient to non-healing surgical incision sites. Similarly XRT to the inguinal nodes would not be curative for this extensive disease.Trabulsi EJ Hoffman-Censits J: Chemotherapy for penile and urethral carcinoma. UROL CLIN N AM 2010;37:467-374.Pagliaro LC Williams DL Daliani D et al: Neoadjuvant paclitaxel ifosfamide and cisplatin chemotherapy for metastatic penile cancer: A phase II study. J CLIN ONC 2010;28:3851-3857. Adult Neoplasm )