Professional Documents
Culture Documents
1. Which of the following structures is not typically encountered in the course of renal surgery
through a flank incision?
A. Internal obliquemuscle
B. Transversalis fascia
C. Rectusmuscle
D. Thoracolumbar fascia
E. Transversus abdominis
F. Obturator Internus
the following are true?
2. Regarding Gerota’s fascia, which of the following
A. It is part of the inner stratumof
retroperitoneal tissue
B. Inferiorly there is an open
o pen potential space
C. Perinephric fat is outside of it
D. It is continuous with Colle’s fascia
E. Both A. and C.
F. None of the above
3. Which of the following is not typically a site of normal ureteral narrowing (where stones get
caught)?
A. UPJ
B. Iliac vessels
C. Pelvic ureter
D. UVJ
E. L4 level
F. Entrance to detrusor
6. The adrenal glands receive blood supply from all of the following except?
A. Superior phrenic artery
B. Inferior phrenic artery
C. Adirect branch fromthe aorta
D. Abranch off of the renal artery
7. If one needs to ligate the hypogastric arteries for severe pelvic bleeding it should be done distal to
which area?
A. Posterior division
B. Umbilical artery
C. Inferior vesical artery
D. Obturator artery
E. Internal pudendal artery
F. Superior vesical artery
8. Which of the following nerves would one suspect was damaged if a patient lost the ability to adduct
the thighs after pelvic surgery?
A. Ilioinguinal
B. Femoral
C. Obturator
D. Sciatic
E. Genitofemoral
F. Internal pudenal
10. In women the ureter is in close proximity to and can be damaged during gynecologic surgery on
which of the following structures?
A. Ovary
B. Uterine artery
C. Cervix
D. Vaginal wall
E. All of the above
Answers
1. C.
The typical flank incision does not travel anteromedially to the border of the rectus. All other structures
noted are traversed.
2. B.
It is part of the intermediate stratumand the perinephric fat is within it. B. is correct.
3. C.
Ureteral caliber is typically narrowest at the UPJ, over the iliacs and at the UVJ. There is no particular
narrow point per se of the pelvic portion of the ureter or at the other sites.
4. C.
Obturator nerves allow for thigh adduction. Pelvic and hypogastric nerves carry the autonomic supply to
the bladder and innervation to the external sphincter is via the pudendal.
5. B.
A., C. and D. are false—
false—most cancer is in the peripheral zone, the central zone is proximal to the veru
and the primary blood supply is from the inferior vesical artery.
6. A.
The adrenal has a tripartite blood supply and rece ives blood fromall the options listed except the
superior phrenic artery.
7. A.
The posterior division includes the gluteal artery which supplies the gluteus. Ligating proximal to
this pointmay lead to pain in the buttocks.
8. C.
The obturator nerve is responsible for thigh adduction.
9. C.
the rectusmuscle, laterally by the inferior epigastrics
Hesselbach’s triangle is borderedmedially by the rectusmuscle,
and inferiorly by the inguinal ligament.
10. E.
All of these structures can be damaged during gynecological surgery.
CHAPTER 2: PEDIATRIC UROLOGY
1. On prenatal US during the third trimester, what are the AP diameter criteria used to
classifymoderate hydronephrosis?
A. <7mm
B. 7- <9mm
C. 10-15mm
D. 15-20mm
E. >20mm
2. What is the reported incidence of ve sicoureteral reflux in children with prenatal
diagnosed hydronephrosis?
A. 50-70%
B. 40-60%
C. 5-20%
D. <5%
E. 1-2%
3. What is themost appropriate antibiotic used for prophylaxis in a newborn with prenatal
hydronephrosis?
A. Amoxicillin
B. Suprax
C. Bactrim
D. Nitrofuratoin
E. Ciprofloxacin
4. What ismost common abnormality in renal function associated with posterior urethral
valves?
A. Urine Concentration defect
B. Increased active sodiumabsorption
fromthe descending limb of the loop of
Henle
C.Decreased calciumabsorption from
ascending limb of the loop of Henle
D. The presence of heavy proteinuria
E. None of the above
5. Which of the following is the most important in the treatment of VUR?
A. Age of the patients
B. Grade of reflux
C. Laterality
D. Breakthrough infection
E. All of the above
7. 38-week-gestation newborn with posterior urethral valves has a se rumcreatinine of 1.6mg/dl. That
level:
A. Is an ominous predictor of future renal function
B.Will decrease with completion of nephrogenesis
C. Initially falls with a rapid rise in GFR
D.Will result in increased active sodium absorption fromthe descending limb of the loop of Henle.
E. Is not reflective of the degree of renal function impairment
Answers:
1. C.
2. C.
3. A.
4. A.
5. E.
6. D.
7. E. The creatinine in a newborn is re flective ofmaternal renal function and is not representative of the
degree of renal impairment or lack thereof due to the obstruction.
CHAPTER 3: PEDIATRIC UROLOGICAL ONCOLOGY
1. A 1 year old boy undergoing laparoscopy for a right non-palpable testis is found to have a normal
–appearing testis just inside the internal ring. As peritoneumdistal to the vas is incised,
–appearing
you notice the vas leads to and appears to join a midline uterus. The next be st step in management
is to:
A. Stop surgery and draw serumfor 1 7 hydroxyprogesterone levels
B. Stop surgery and obtain a karyotype
C. Stop surgery and biopsy the contralateral descended gonad for ovarian tissue
D. Remove the uterus and performright orchiopexy
E. Proceed with right orchiopexy, splitting the uterus sagitally if the vas is tethered
2. You are consulted to evaluate a full-termnewbornmale with proximal hypospadias. Your
examconfirms the urethral defect and ventral penile curvature. Genital examination also
shows a well-developed scrotumwith amidline cleft, and bilateral nonpalpable testes. The next step is
to:
A. Obtain FISH to detect a Ychromosome
B. Draw serumLH and testosterone levels
C. Order retrograde genitography to detect a utricle
D. Schedule repeat examination for testicular descent at age 6months
E. Recommend laparoscopic orchiopexy at age 6months and hypospadias repair at age 1 year
3. A6 year old female presents with bilateral groinmasses notedmostly when she is playing.
During herniorrhaphy, bilateral testes are found. You should next:
A. Immediately remove both testes because of the increased risk for childhood germcell tumors
B. Repair the hernias
C. Performlaparoscopy to assess the uterus
D. Draw serumformullerian inhibition substance levels
E. Obtain a cerebralMRI to rule o ut an empty sella
4. A2 year old boy had complete wound dehiscence after a proximal hypospadias repair with preputial
flap urethroplasty. During reoperation you open the right hemiscrotumto obtain tunica vaginalis to
cover over the neourethra,and e ncounter a dumbbell-shaped ovatestis. The next step is to:
A. Replace the ovatestis and use fibrin glue instead of tunica vaginalis to seal over the neourethra
B. Complete the hypospadias repair and then per formlaparoscopic hysterectomy
C. Remove the ovarian portion of the ovatestis and explore the contralateral gonad
D. Remove the entire dysgenic gonad and complete the hypospadias repair
E. Remove the ovarian portion and biopsy the testis for gonadoblastoma
5. An 8 year old girl is referred after a febrile UTI. She brings a CD with a renal
re nal ultrasound
that shows a horseshoe kidney and a 2 cmheterogenousmass in the region of the right ovary.
indicate she has been healthy, although her height is
Notes fromthe pediatrician’s office indicate she
more than 2 standard deviations below normal for her age. During examination you notice her
nipples appear wider apart than usual.Which of the following statements ismost likely true?
A. She is beginning puberty and has a follicular ovarian cyst
B. Akaryotype would show a Ychromosome
C. She has an unresolved tubo-ovarian abscess misdiagnosed as a febrile UTI
D. AVCUG would show high grade r ight reflux
E.Vaginoscopy would show an obstructed right hemivagina
6. A5 year old boy presents after hismother noticed he was straining to urinate. His urologic
history is significant for a distal TIP hypospadias repair done in another city at age 8
months. The familymoved shortly after surgery and so he had no follow-up. He toilet
trained over a year ago, butmother is certain his streamis slowing since t hen. On examination
his penis is circumcised and overall looks normal, except t hat themeatus appears small
and has a faint white discoloration. Uroflowmetry shows 3 cc sec peak flow while
voiding 35 cc. The best long-termsolution for his problemis:
A.Meatotomy
B. Optical urethrotomy
C. Reoperative TIP repair
D. Reoperation with a flip-flap urethroplasty
E.Neourethral excision with 2-stage buccal graft urethroplasty
7. A6 year old boy is referred for a left undescended testis. Although he has seen the same
pediatrician his entire life, this problemwas first diagnosed on a routine exam1month ago.
Atesticular ultrasound was obtained before referral, reporting both testes are the same size
and located in the inguinal canal. During exam you notice his scrotumis symmetric, and the
right testis is easilymanipulated into the scrotum. The left testes seems higher in the groin,
gr oin,
but you can alsomanipulate it into the scrotum, w here is remains a few seconds before reascending.
The next step inmanagement is to:
A. Schedule testosterone injections 2mg/kg once amonth for 3months and then reexamine him
B. Schedule left orchiopexy
C. Schedule bilateral orchiopexy
D. Reassure his parents testicular retraction
ret raction is common in this age group
E. Repeat ultrasonography since the right testicleseems desc ended on examination
8. An 8 year old boy presents to the emergency department with a red and swollen scrotumhis mother
found after observing himwalking bow-legged. He is afebrile and seems comfortable lying on the
examtable, but palpation of the scrotumcauses discomfort. The ED physician obtained a te sticular
sonogrambefore calling you, reporting “increased testicular blood flow with a swollen left
“ increased left testicular blood
epididymis consistent with epididymo-orchitis”.
epididymo- orchitis”. Aurinalysis is
Aurinalysis is normal. You shouldmanage this
problemby:
A. Urethral swab and cefixime for 7 days
B. Intravenous ceftriaxone until the erythema improves, followed by oral cefixime for a total of 10 days
therapy
C. Oral cefixime for 10 days
D. Oral cefixime with renal ultrasound and VCUG when the acute inflammation subsides
E. Oral analgesics as needed
9. A7 year old boy presents with urinary incontinence since toilet training. He wears a pull-up that he
changes twice a day. His parents report he can be dry during the night, but wets consistently during the
day, possibly when he is playing too hard and does not go to the bathroom when he should. His urologic
history is otherwise remarkable only for repair o f penile epispadias at age 6months. Examination shows
the penis with a glanularmeatus and some upward curvature. The bladder is not palpably distended and
there is no cutaneous back lesion. The t reatmentmost likely needed to correct his incontinence is:
A. Timed voiding
D.Meatotomy
10. A 15 year old teenager was found to have ascrotalmass during sports physical. He has no symptoms.
Your exam confirms Tanner 3pubertal development with a visible left varicocele and symmetric testes,
confirmed by testicular ultrasound. You informhis parents:
A. He can play sports and should have another testicular ultrasound in 1 year
B. He should not participate in contact sports because of increased risk for scrotal hematoma
E.He should have bilateral varicocele ligation, sincemost varicoceles are bilateral
Answers:
1. E. The patient has failure ofmullerian inhibition substance, resulting in amale with a uterus. There is
no
gender identify issue, and orchiopexy is needed to relocate the intraabdominal testis. The ipsilateral
vasmost often fuses into themullerian structures, making it nec essary at times to split the uterus to
gain additional length for the testis to reach the scrotum. Theoretically the patient could have an
ovotesticular disorder of sexual differentiation, although a
normal appearing ipsilateral testis and a contralateral descended gonadmake that diagnosis unlikely
and does not influence need to proceed with orchiopexy.
2. A.
Although the baby appears virilized, bilateral nonpalpable testes, especially with hypospadias,mandate
evaluation for congenital adrenal hyperplasia in a genetic female. FI SH detecting a Ychromosome would
rapidly exclude that potentially lifethreatening diagnosis, since CAH females have a 46 XX karyotype.
3. B.
This phenotypic female has complete androgen insensitivity. The testes are at risk germcell tumor
development during or after puberty, and so will eventually need to be removed. However, t hey can
bemaintained during childhood to assist with secondary sexual development when puberty begins.
Therefore, herniorrhaphy can be completed with or without simultaneous orchiectomy. Although a
minority of patients have a rudimentary uterus, laparoscopy is not needed.
4. C.
There is no issue regarding gender identity, but the ovarian portion of the ovatestis should be removed
to prevent breast development during puberty. The test icular portion does not have increased risk for
gonadoblastoma as it is not dysgenetic. The contralateral
gonad can be easily exposed to rule out bilateral ovatestes.
5. B.
Short stature, widely spaced nipples and a horseshoe kidney indicate a likely diagnosis of Turner’s
syndrome. The streak gonads have the potential to develop gonadoblastoma, suggested by the apparent
gonadalmass on ultrasound, when there is Ychromosomalmaterial.
6. E.
Bothmeatal stenosis and neourethral stricture are unusual after TIP hypospadias repair. The history of
progressive stranguria and finding of white discoloration around themeatus indicate BXO. BXO in
the urethra after c ircumcision requires total excision of affected tissues and buccal graft urethroplasty,
since the conditionmay recur if skin flap or graft urethroplasty is done.
7. D.
Undescended testes aremost often unilateral and aremost accurately diagnosed during examinations as
a newborn and in the first 6 months of life. After that time cremastericmuscular activitymay retract the
testis into the upper scrotum, a normal finding that may continue until puberty. Ultrasound cannot
distinguish between undescended and retractile testes, since the cremastermuscle contracts and
elevates the testis when the gel is applied. In this case
the scrotumappears symmetrical and the left testis can bemoved into the correct position, w here it
remains a brief time –
time – all
all typical findings of a retractile testis. This diagnosis is also supported by the
negative history of undescended testis at birth and in the firstmonths of life.
8. E.
The history and examination aremost consistent with a torsed appendage testis, which causes edema of
the epididymis that is often reported erroneously as “epididymitis or epididimo-
epididimo -orchiditis”. Epididymitis
is rare in otherwise normal, pre pubertal males, andmost often presents with fever and urinary infection.
Atorsed appendage resolves spontaneously and so only supportivemeasures are
needed, such as analgesics for discomfort.
9. E.
Patients with epispadias often also have bladder neck incompetency, requiring surgical r epair.
10. A.
Indications for varicocele ligation in teenagers include decre ased ipsilateral testicular size or pain.
Semen analysis is not considered useful until pubertal development is completed, typically around age
S17 years.
Case 5
A 19-year-old Caucasian female with a 6 -year history of recurrent stone disease is found to have
multiple bilateral renal calculi by renal ultrasound during
an evaluation for recurrent flank pain. She reports having passed >10 stones in the previous 2 years.
Review of the renal ultrasound indicates no evidence of hydronephrosis. KUB and tomograms
demonstrate 5 stones on the left and 8 stones on the
right, all <4 mm in size. She has a strong family history of stones with 3 first-degree relatives and 2
cousins with nephrolithiasis. Stone compositions have been mixed calcium phosphate and calcium
oxalate.
24-hour Urine Collections
Normal Range Initial Visit
Vol >2,000 mL/d 1,425
pH 5.5 –6.7
–6.7 6.94
Calcium <200 mg/d 260
Sodium <200 mg/d 160
Potassium <60 mEq/d 28
Uric acid <600 mg/d 410
Oxalate <45 mg/d 32
Citrate >600 mg/d 140
Magnesium >60 mg/d 66
SO4 <20 mg/d 13
Cystine 0 mg/L 0
Serum Values
Sodium 135 –145
–145 mEq/L 142
Potassium 3.2 –4.8
–4.8 mEq/L 3.3
Chloride 98 –108
–108 mEq/L 107
Bicarbonate 21 –30 –30 mEq/L 21
Creatinine 0.7 –1.4
–1.4 mg/dL 0.9
Calcium 8.7 –10.2
–10.2 mg/dL 9.2
Phosphorus 2.3 –4.3 –4.3 mg/dL 2.2
Uric acid 2.5 –8.0
–8.0 mg/dL 4.1
PTH 13 –64
–64 ng/mL 58
11. The most definitive test to identify this disorder would demonstrate:
A. Decreased serum parathyroid hormone levels
B. Persistently elevated urine calcium
C. Inability to reduce the urine pH below 5.5
D. Normalization of hypercalciuria
E. Marked increase in urinary uric ac id levels with initiation of treatment
Case 6
A 49-year-old Caucasian female with a 4 -year history of stone disease has passed 6 stones
spontaneously,3 in the last year. Noncontrast renal CT demonstrates a 2 -mm calcification in each kidney
without secondary signs of obstruction. Previousstone analysis has revealed a mixed composition of
calcium phosphate and calcium oxalate. She had
been treated with hydrochlorothiazide in the past, but this medication was discontinued after 3 months
of therapy. Her family history is significant for a brother and grandmother with stones. She is otherwise
healthy and has prior surgical history.
24-hour Urine Collections
Normal Range Initial Visit
Vol >2,000 mL/d 1,800
pH 5.5 –6.7
–6.7 5.8
Calcium <200 mg/d 335
Sodium <200 mg/d 230
Potassium <60 mEq/d 38
Uric acid <600 mg/d 472
Oxalate <45 mg/d 29
Citrate >600 mg/d 680
Magnesium >60 mg/d 70
SO4 <20 mg/d 15
Cystine 0 mg/L 0
Serum Values
Sodium 135 –145
–145 mEq/L 138
Potassium 3.2 –4.8
–4.8 mEq/L 4.3
Chloride 98 –108
–108 mEq/L 102
Bicarbonate 21 –30 –30 mEq/L 25
Creatinine 0.7 –1.4
–1.4 mg/dL 1.3
Calcium 8.7 –10.2
–10.2 mg/dL 9.1
Phosphorus 2.3 –4.3 –4.3 mg/dL 2.8
Uric acid 2.5 –8.0
–8.0 mg/dL 5.1
PTH 13 –64
–64 ng/mL 18
12. The primary defect in this condition is considered to be:
A. Primary hyperabsorption of intestinal calcium
B. Hypersecretion of parathyroid hormone
C. Renal leak of calcium
D. Bone disease
E. Excessive dietary intake of calcium-containing foods
Answers
Case 1
1. D.Enteric hyperoxaluria is a disorder most commonly affecting patients with inflammatory bowel
disease, particularly intestinal segments involving the small
intestine. Fat malabsorption is the hallmark condition predisposing to saponification and sequestering of
calcium to be passed in the stool.
st ool. Less calcium is available in the GI tr act to bind oxalate, thereb allowing
more oxalate to be absorbed with a relative
increase in urinary oxalate. Primary hyperoxaluria is an autosomal-recessive disorder manifest only in
the homozygous state. Unless effectively treated early, primary hyperoxaluria typically runs a malignant
course with early death from renal failure.
2. E.Intestinal hyperabsorption of oxalate in patients with enteric hyperoxaluria is the most significant
risk factor leading to recurrent calculus formation.
Intestinal transport of oxalate is primarily increased because of the effects of bile salts and fatty acids on
the permeability of colonic intestinal mucosa to
oxalate. The total amount of oxalate absorbed may also be increased because of an enlarged
intraluminal pool of oxalate available for absorption. Intestinal
fat malabsorption characteristic of ileal disease will exaggerate calcium soap formation, limit the
and thereby raise the oxalate pool available for
amount of “free” calcium to complex to oxalate, and thereby
absorption.
3. A.The initial goals of medical management are to rehydrate and reverse metabolic acidosis. Hydration
is at times difficult in some patients as an
increase in oral fluids may exacerbate diarrhea.Hydration and potassium citrate will contribute to the
reversal of the metabolic acidosis, as well as enhance the excret ion of citrate to increase its inhibitory
effects on stone formation. Calcium supplements
will bind excess oxalate within the intestine thereby reducing intestinal oxalate absorption. Calcium
citrate may offer an ideal calcium supplement in this condition as it should reduce urinary oxalate and
increase urinary citrate. Thiazides may worsen met abolic acidosis and hypokalemia through its diuretic
effects and renal potassium
losses. Colon resection may be of benefit in those patients refractory to medical management, as t he
primary site of intestinal absorption of oxalate is the large bowel.
Case 2
4. B.Although low urine volumes and hyperuricosuria contribute to the possibility of uric acid stone
formation, the most critical determinant of the crystallization
of uric acid remains urinary pH. In addition, uric acid stones may be formed in patients with primary
gout with associated severe hyperuricosuria and other se condary causes of purine overproduction, such
as myeloproliferative states, glycogen storage disease and m alignancy.
5. E.Allopurinol will decrease the production of uric acid by inhibiting xanthine oxidase in t he purine
metabolic pathway, but is most effective in patients
with extremely elevated levels of uric acid (urinary
uric acid >1,500 mg/day). In addition, increasing total urine volume will decrease the concentration of
uric acid to assist in preventing stone formation.
However, raising the urinary pH above the dissociation constant of uric acid is the key to preve nt
recurrent uric acid stone formation and correcting gouty diathesis. The urine pH should be maintained
between 6.0 and 6.5. Thiazides and calcium restriction have a limited role in the medical treatment of
uric acid stone patients.
Case 3
6. C.Ascending urinary tract infections with urea-splitting organisms, such as Proteus species, will
metabolize urea to ammonia. Ammoniuria, in conjunction with a matrix composed of organic
compounds, carbonate apatite, inflammatory cells and bacteria,
calculus, eventually progressing into a mineralized, dense
results in the rapid formation of an “infection” calculus, eventually
stone. Bacteria trapped within the stone perpetuate the recurrent urinary tract infections and further
stone formation, eventually developing into
the classic staghorn calculus.
7. C. After removal of an infected struvite calculus, the most common cause of recurrent stone
formation is failure to completely eradicate the urinary tract infection. Surgical therapy may leave
retained fragments of infected stone within calyces, thus allowing
infection to persist. Underlying metabolic disorders may also contribute to rec urrent stone formation,
but persistent infection remains the most important risk fac tor.
8. D. Acetohydroxamic acid (AHA), a competitive inhibitor of the bacterial enzyme urease, will reduce
the urinary saturation of struvite and ret ard stone formation. When given at a dose of 250 mg orally TID,
this medication can prevent the recurrence of new
of new stones and inhibit the growth of existing stones in
patients with chronic urea-splitting infections.
AHA can also cause dissolution of small stones. However, up to 30% of patients will experience minor
side effects, including headache, nausea, vomiting, anemia, rash or alopecia. In addition, 15% of patients
have developed deep venous thrombosis while on long-term treatment. Therefore, careful monitoring is
required when using this medication.
Case 4
9. E. Cystinuria is a complex autosomal-recessive disorder of amino acid transport involving cystine,
ornithine, lysine and arginine. Supersaturation of the
of the urine will occur in patients with t he homozygous
state. Therefore, it is unusual to se e a family history with cystine stones. The age of onset is often in the
1st or 2nd decade of life.
10. D. d-penicillamine and alpha-mercaptopropionylglycine are equally effective in their ability to
decrease urinary cystine levels. However, studies have demonstrated that alpha-MPG is significantly less
toxic than d-penicillamine. Moreover, the side effects that may occur with alpha-MPG are also less
severe. However, if a patient has been doing well on
d-penicillamine with no significant complications, there is no need to switch medications.
Case 5
11. C. Renal tubular acidosis is a clinical syndrome of chronic
of chronic metabolic acidosis resulting from renal
tubular abnormalities, while glomerular filtration is relatively well preserved. Although patients may
present with many different symptoms and physical
findings, renal stone formation is a well-recognized manifestation of distal renal tubular acidosis (dRTA).
Patients with the incomplete form of dRTA are not persistently acidemic despite their inability to lower
urinary pH with an acid load. These patients are able to compensate for their acidification defect and
remain in acid-base balance by
increasing ammonia synthesis and ammonium excretion as a buffering mechanism. The initial
identification of incomplete dRTA is often a chance finding. Many of these patients will present with
recurrent nephrolithiasis or may be refer red for evaluation after the discovery of nephrocalcinosis after
routine abdominal radiographs. Most patients
will have normal serum electrolytes, yet they will have a high-normal urine pH along with significant
hypocitraturia. The diagnosis of incomplete dRTA can be confirmed by inadequate urinary acidification
after an ammonium chloride loading test.
Case 6
12. A. The basic abnormality in absorptive hypercalciuria type I is the intestinal hyperabsorption of
calcium. The consequent increase in the circulating concentration
of calcium enhances the renal filtered load and suppresses parathyroid function. Hypercalciuria results
from the combination of increased filtered load and reduced renal tubular reabsorption of calcium, a
function of parathyroid suppression. The
excessive renal loss of calcium compensates for t he high calcium absorption from the intestinal tract and
helps to maintain serum calcium in the normal range.
Surgical magement of stone diseases
1. Themainmethod of stone fragmentation in SWLis:
A. Tensile forces on the leading edge of the stone
B. Cavitationmechanics at the stone surface
C. Compressive forces at the stone-fluid interface
D. Tensile forces on the exiting edge of the stone
E. All of the above
2. All of the following are true statements e xcept:
A. SWLis not recommended for calcium o xalate monohydrate and cystine stones
due to their relative resistance to fragmentation
B. Staghorn stones should not be treated with SWL because they do not fragment well
C. Upper ureteral stones <10mmin diameter can be treated effectively with SWL
D. Distal stones >10mmshould not be considered for SWLas first-line therapy
3. All are true statements regarding SWLexcept:
A. Themost common nonurologic injury in the pediatric population who undergo SWL
is lung or pleural injury
B. Pre-stenting appears to improve stone-free rates and reduce hospital re-admissions
C. IVP is no longer necessary prior to treatment with SWL. Non-contrast CT suffices
as an imaging study
D. In situ SWLof ureteral
ureter al calculi is an acceptable technique for treating proximal
ureteral stones <10mm
4. All of following are true statements regarding post-SWL hematoma except:
A. Hypertension, diabetes, obesity, coronary artery disease are risk factors for development of post-
SWLhematomas
B. Subclinical hematomas are common (30%) but clinical post-SWLhematomas are rare
(0.2% –4%)
–4%)
C. The most common presenting sign of a postoperative hematoma is tachycardia and
hypotension
D. Patients suspected of having a hematoma should be admitted, placed on bedrest, have
serial hematocrits checked and undergo imaging (CT or renal USN).
5. Patient undergoes a PCNL. Postoperatively, patient develops feca lmaterial in the nephrostomy tube.
Patient is afebrile and abdominal exam is unremarkable. ACT is done o f the nephrostomy tube
traversing the colon. All of following are recommended steps e xcept:
A. Broad-spectrumantibiotics
B. Immediate exploratory laparotomy and diverting colostomy.
C. Make patient NPO, alimentation
D. Placement of a internal ureteral stent, reposition of nephrostomy tube into the colon to act as a
temporary colostomy tube
6. Patient undergoes a PCNLand during the case a large perforation of themedial pelvis is
noted. The next proper course of action is:
A. Continue PCNLbutmake sure to use a working sheath andmonitor the irrigation flow
B. Stop the procedure. Place a large nephrostomy tube. Repeat N-gramin 2 –3 –3 days. If
perforation resolves, then continue with PCNL
C. Stop the procedure and place a drainage catheter. Repeat N-gramin 2 –3 –3 weeks to ensure that
perforation has adequate time to heal
D. Remove the working sheath and place a JJ ureteral stent
7. Patient undergoes a single-puncture PCNL via a lower pole for a 2-cmstone and is rendered stone-
free. 2 weeks postop, he presents with a brief episode of gross hematuria afte r walking at home.What is
themost likely cause of his bleeding?
A. Perinephric hematoma
B. Bleeding fromthe healing perc site, which is exacerbated by his increased ac tivity
C. Passage of a small stone fragment
D. Arteriovenous fistula
Answers
1. E.
2. B.
3. B.
4. C.
5. B.
6. B.
7. D.
CHAPTER 15: RENAL PARENCHYMAL AND UPPER URINARY TRACT UROTHELIAL NEOPLASMS NEOPLASMS
1. Which of the following hereditary renal tumor syndromes is incorrect ly paired with
its appropriate gene?
A. Von Hippel Lindau –
Lindau – 3p
3p
B. Birt Hogg Dube –
Dube – 17p
17p
C. Hereditary Papillary RCC –
RCC – 7p
7p
D. Hereditary Leiomyoma RCC – RCC – 1q
1q
E. Tuberous Sclerosis –
Sclerosis – 9q
9q
2. Which of the following is true regarding the VHLgene and its pathway
A.Mutation of VHLis primarily epigenetic (ie not a sequencemutation)
B. The VHLgene is an oncogene
C. The VHLprotein is physiologically overexpressed during times of excess
oxygen tension
D. HIF proteins are overexpressed
overex pressed as a function ofmutated VHLgene/protein
E. The VHLprotein is a transcriptional factor
3. Which of the following is true regarding the Bosniak classification of renal cysts?
A. The Bosniak classification of renal cysts is an ultrasound based system
B.Hyperdense cysts are classified as Bosniak III
C. Simple renal cysts(Bosniak I) are confirmed only o n contrast based cross sectional
imaging
D. ABosniak IIF has a risk of occult cancer in excess of 65%
E. Calciumwithin the wall of a cyst can occur in Bosniak II, III or IVlesions
4. Which is true regarding Nephrogenic Systemic Fibrosis?
A. It typically occurs within 24 hours of gadoliniumadministration
gadoliniumadministration
B. It causes a fibromyalgia type syndrome
C. It occursmost commonly in patients with an estimated GFR between 30 and 60 cc/min
D. Itmay be fatal
E. If is does not happen after a single dose of gadoliniumit is unlikely to occur with
future dose
5. Which is true about infrarenal thrombus incases of IVC involvement?
A. Typically the thrombus below the renal veins is bland and nee d not be fully
resected butmay require anticoagulation or caval interruption
B. Themajority of thrombusmust be assumedmalignant until proven otherwise
C. Tumor thrombus has been known to release IL6 and cause paraneoplastic syndromes
D.Malignant infrarenal tumor thrombus typically stops at the femoral veins
E. Infrarenal thrombus is a poor prognostic sign
6. Which is true regarding adrenalectomy during surgery for RCC?
A. Routine removal is safe and recommended
B. The adrenal gland is commonly involved in pT2 lesions and should be removed in
all lesions >7cm
C. Involvement of the adrenal is now staged as T4
D. Partial adrenalectomy is never acceptable
E. Involvement of the contralateral adrenal is the only indication to preserve the ipsilateral adrenal
7. Which of the following is true about paraneoplastic syndromes in RCC
A. IL-8 is thought to c ause hepatic dysfunction (Stauffer’s syndrome)
B.Hyperlipidemia is a common paraneoplastic syndrome
C.Hypertension associated with RCC is always aldosteronemediated
D. Hypercalcemiamay be associated with PTH production
E. Hand and foot syndrome is common
8. Which of the following is true of sunitinib?
A. It is anmTOR inhibitor
B. It is an antibody to VEGF-R
C. It directly inhibits HIF
D. It ismediated via blockade of tyrosine kinases
E. It is associated with a 60-80 %overall response rate
9. Regarding the adverse events for targe ted therapies, which is paired correctly?
A.mTOR inhibitors –
inhibitors – hand
hand and foot syndrome
B. VEGFR antibodies –
antibodies – stomatitis
stomatitis
C. TKIs –
TKIs – hyperlipidemia
hyperlipidemia
D. TKIs –
TKIs – left
left ventricular dysfunction
E. VEGFR antibodies –
antibodies – hypothyroidism
hypothyroidism
10. Which of the following is true of cisplatin based chemother apy for upper tract urothelial carcinoma
A. There are level 1 data to support its use in thet he neoadjuvant setting
B. There are level 1 data to support its use in the adjuvant setting
C. Its primarymode of action is to inhibit DNAcovalent bond and cross linking
D. Its primarymode of action is to inhibit microtubules
E. There is little activity when used as a single agent in urothelial carcinoma
Answers:
1. C. The genetics of renal tumor syndromes have increasingly been unraveled using large familial
pedigrees, linkage analysis and ultimately isolation and sequencing of the responsible gene. Of those
listed, C is incorrect –
incorrect – HPRCC
HPRCC is associated with the cMet
gene –
gene – an an oncogene located on the long armof 7 (7q31). HPRCC is the only hereditary syndrome with no
extra-renalmanifestations
2. D. VHLfollows an autosomal dominant inheritance
pattern. It is a t umor suppressor gene thatfollows Knudsen’s two hit hypothesis,meaning both alleles
must bemutated for it to function abnormally. The VHLprotein has been shown to regulate HIF
transcription factors which are normally only overexpressed
during hypoxia. However,mutant VHL leads to over expression of HIF under normoxia
3. E. The Bosniak classification is a CT based systemfor categorizing renal cysts. It requires pre and post
contrast images. That said, a simple cyst has definitive
characteristics on US (no internal echos, good through transmission with posterior wall enhancement).
Hyperdense (hemorrhagic or proteinaceous) cysts are Bosniak II. Bosniak IIF cysts do notmeet strict
criteria for either II and III and are generally followed (hence the termF). Their risk of cancer is
considered lower than a true Bosniak III. Thin linear
calciumcan occur in BII cysts. Chunky or thick calcium is a more worrisome sign (BIII or IV)
4. D. NSF is a scleroderma like reaction in patients receiving gadoliniumin the setting of severe renal
impairment (eGFR<30). It can occur up to 3mo ormore after exposure and itmay be related to
cumulative exposure, although it has been reported following a
single doseand can becan be fatal
5. A. Infrarenal tumor thrombus is typically bland. Clues on anMRImay be seen including lack of
enhancement and flow around the clot. It need not be fully resected but a strategy to prevent
embolimust be employed including caval interruption and/or anticoagulation.
6. C. Adrenalectomy is reserved for large upper pole renal tumors althoughmore recent data suggest
that even in this circumstance routine adrenalectomymay be unnecessary. Adrenal involvement is a
poor prognostic sign and is now considered T4 disease
7. D. Stauffer’s syndrome is thought to be cytokinemediated (IL-6). Hand and foot syndrome and
hyperlipidemia are side effects of targeted therapy. Hypertension associated with RCC is primarily
rennin mediated. Hypercalcemia associated with RCC may be due to bonymetastases or a PTH
paraneoplastic syndrome
8. D. Sunitinib and other tyrosine kinase inhibitors have altered the therapeutic landscape formRCC.
They work by blocking themessage of the receptor when bound by ligand which decreases cell survival
mechanisms. Overall response rates are 30-40%
9. D. Systemic therapies for RCC are associated with a large number of potential adverse events. Of
those above, TKIs are associated with L Vdysfunction and ejection fraction is oftenmeasured prior to
initiating therapy.
10. C. Cisplatin is one of themost potent chemotherapeutic agents for urothelial carcinoma. There are
currently no level 1 data for its use in upper tract UCC. Its
mechanismof action is the inhibition of DNA cross linking
11. B. Penectomy is indicated for tumors infiltrating the corpus spongiosum. The most common
histologic type is SCC and the prognosis is better than that for bulbomembranous cancers. Early or
prophylactic has not been shown to be advantageous in urethral
cancer. Some cases of early
e arly or superficial distal urethral cancer may be managed effectively with
conservative surgical therapy.
12. A. SCC is the most common histologic type o f proximal urethral cancer in women.
13. C. The most significant prognostic factor for local control and survival in women with urethral cancer
is the location and extent of the primary tumor.
1. Embryologically, the vas deferens and body of the epididymis are derived from what developmental
structure?
A.Müllerian ducts
B.Wolffian ducts
C. Urogenital ridge
D. Gubernaculumtestis
E.Metenephros
2. The vastmajority of the fluid in themale ejaculate is derived fromthe:
A. Epididymides
B. Ejaculatory ducts
C. Seminal vesicles
D. Testicles
E. Vas deferens
3. The most common and correctable
cor rectable identifiable problemcausingmale infertility is:
a) Infection
b) Obstruction
c) Gonadotoxin exposure
d) Varicocele
e) Genetic
4. A25-year-old bodybuilder eschews themerits of natural bodybuilding and cycles and stacks injectable
anabolic steroids regularly tomaximizemuscle bulk. His fertility potential would be expected to be:
A. Normal, because exogenous testosterone does not impair production of endogenous testosterone
B. Low, because exogenous testosterone
te stosterone stimulates pituitary production of FSH and LH
C. Low, because exogenous testosterone
te stosterone inhibits pituitary production of FSH and
LH
D. Low, because exogenous testosterone is not as potent as endogenous testosterone at
nurturing spermatogenesis
E. Normal, because intratesticular testosterone concentrations are 50x higher than
serumlevels, whether or not the blood contains exogenous testosterone
5. The role of PSAin the ejaculate
ej aculate is:
A. To coagulate the ejaculate
B. To serve as amarker for prostate cancer
C. To serve as a liquefaction factor
D. To give semen its characteristic
character istic odor
E. To agglutinate the ejaculate
6. What geneticmutation is involved with congenital absence of the vas deferens (CAVD)?
A. Klinefelter syndrome (47,XXY)
B. Reifenstein syndrome
C. 3p1
D. CFTR (delta f 508)
E. 45XO
7. Low serumtestosterone, LH and FSH charac terize what type of hypogonadism?
A. Hypergonadotropic hypogonadism
B. Young syndrome
C. Hypoprolactinism
D. Kallman syndrome
E. Klinefelter syndrome
8. How do elevated levels of prolactin influence testosterone production?
A. Inhibit GnRH and LH
B. Indirectly inhibit Sertoli cells
C. Directly inhibit Leydig cells
D. Upregulate inhibin
E. Downregulate activin
9. What testicular hormone is themajor feedback inhibitor of LH se cretion?
a) Testosterone
b) Inhibin
c) Activin
d) Prolactin
e) Sertolin
10. What is the initial evaluation for aman with 1 semen analysis that shows low volume ejaculate?
A. Semen pH
B. Postejaculate urinalysis
C. Semen fructose
D. TRUS
E. Repeat semen analysis
11. What is the normal size for adult human testes?
A. 5mL
B. 10mL
C. 20mL
D. 30mL
E. 40mL
12. In the absence of genital tract
trac t infection, round cells in the semen analysis aremost likely what kind of
cell?
A. Squamous epithelial cells
B. Immature germcells
C. Prostatic epithelial cells
D. Leydig cells
E. Sertoli cells
13. Hormonal screening of infertility patients below what spermconcentration will pick up
most endocrinopathies?
A. <1million/mL
B. <5million/mL
C. <10million/mL
D. <20million/mL
E. <60million/mL
14. Vasography is routinely performed by all of the followingmethods EXCEPTwhich one?
A. Scrotal
B. Transperineal
C. Transrectal
D. Transurethral
E. Transabdominal
15. Why is performing varicocelectomy at the same time as vasectomy reversal discouraged?
a) Venous congestion
b) Arterial compromise
c) Increased risk of spermgranuloma
d) All of the above
e) None of the above
16. Aman has the following semen analysis profile after vasectomy reversal. This pattern is typical of
what problem? Timepoint Volume Motility after surgery concentration
6 weeks 3.0 45million/mL 45% 3months 3 .5 50million/mL 15% 6months 2.5 20million/mL 0%
A. Antispermantibodies
B. Testicular injury
C. Stricture formation at anastomosis
D. Primary hypogonadism
E. Ejaculatory duct obstruction
17. What percentage of oligospermic infertile males will have geneticmicrodeletions of the
Ychromosome?
A. 1%
B. 5%
C. 25%
D. 50%
E. 75%
18. Which of the following has the highest impact on pregnancy rates with in vitro fertilization (IVF)?
A. Oligospermia—
Oligospermia—male factor infertility
B. Tubal obstruction—
obstruction—female factor infertility
C. Female age
D. Epididymal sperm
E. Testis sperm
19. What patency rates are achievable from contemporary series of microscopic vasovasostomies?
A. 90% –99%
–99%
B. 80% –90%
–90%
C. 50% –60%
–60%
D. 40% –50%
–50%
E. 25% –35%
–35%
20. Which fluid characteristic(s) fromthe testis vas deferens predict t he best success for vasectomy
reversal?
a) Clear with no sperm
b) Creamy with spermfragments
c) Creamy with no sperm
d) Cloudy withmotile sperm
e) Cloudy with fragmented sperm
Answers
1.B. Müllerian ducts regress in themale. The indifferent gonadmigrates to the urogenital ridge to
become the testicle. The gubernaculumtestis is responsible for pulling the testis into the scrotumduring
development.
2.C. At least 65% –70%of
–70%of ejaculate volume is derived From the seminal vesicles, with the remainder from
the vas deferens (with sperm) and prostatic secretions.
Periurethral glandsmay also contribute a small amount of fluid to the normal ejaculate.
3.D. Infection and obstruction occur in 5% –10%ofmale
–10%ofmale infertility. The prevalence of gonadotoxin
exposure is not well known. Varicocele occurs in 40%of infertile
40%of infertile men.
4.C. Because of negative feedback inhibition thatmaintains homeostatic balance in the pituitary-gonadal
axis, excess testosterone of any type will cause anterior pituitary production of LH and FSH to fall. This
results in azoospermia inmost ofmen on anabolic
steroids, but the effect will vary based on the dose, frequency and duration of the cycles and stacking
regimen
5.E. PSAis a serine protease that enzymatically breaks down the seminal coagulumafter ejaculation.
6.D. CFTRmutations,most commonly delta 508, are involved with CAVD
7.D.Kallmann syndrome, a formof hypogonadotropic hypogonadism
8.A. Hyperprolactinemia causes hypogonadotropic hypogonadism
9.A. Testosterone.
10.E. Low-volume ejaculates are commonly due to collection error.
11. C.
12. B.
13.C. 99%of endocrinopathies will be detected if screening is done inmen with <10million sperm/mL
14.E. Vasography is not routinely done transabdominally
15.A. With varicocele repair, all venous drainage from the testis is ligated except for the vasal veins.With
vasectomy reversal, injury to the vasal veinsmay occur.
16.C.Anastomotic strictures after vasectomy reversal typically cause a decrease in spermmotility
followed by a decrease in spermconcentration over time.
17.B. 5%. The range is 3% –
3% –8%.
8%.
18.C.
19.A.
20.D.
CHAPTER 28: ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE AND PRIAPISM
1. The nitric oxide/cyclic GMP (NO/cGMP) systemin the penis is of the utmost importance
in the generation of penile ere ction. cGMP produced by this cascade is inactivated by which of the
following? ( Note: NOS = nitric oxide synthase; PDE = phosphodiesterase)
A. PDE 2, 3 and 4
B. PDE 5
C. Norepinephrine
D. Neuronal NOS
E. Endothelial NOS
2. Which of the following statements is themost acc urate regarding the source of the blood that results
in erection of the corpora cavernosa?
A. The blood supply comes from the cavernosal (deep) penile ar teries
B. The blood supply comes fromthe deep dorsal arte ries
C. The blood supply comes from both the c avernosal and deep dorsal arteries
D. The blood supply does not come from the cavernosal or deep dorsal arteries
3. Which of the following is themost common sexual adverse e ffect of selective serotonin
reuptake inhibitors (SSRIs)?
A. Decreased libido
B. Premature ejaculation
C. Erectile dysfunction
D. Anorgasmia
E. Orchalgia
4. All of the following characteristics in an erectile dysfunction patient’s history suggest a primary
a primary
psychogenic problem, except:
A. Sudden onset
B. Young age
C. Sleep erections present
D. Varying degree of dysfunction
E. Orgasmis preserved
5. Which of the following agents cause partial inhibition of PDE6?
A. Sildenafil
B. Tadalafil
C. Vardenafil
D. Prostaglandin E1
E. Apomorphine
6.
Which of the following erectile dysfunction treatments re sults in the highest satisfaction rates?
A. Sildenafil
B. Intraurethral prostaglandin E1
C. Penile injection therapy with prostaglandin E1
D. Vacuumconstriction device
E. Inflatable penile prosthesis
7. The penoscrotal approach for inflatable penile prosthesis placement offers which of the following
advantages over the infrapubic approach?
A. Safer reservoir placement
B. Preservation of glans tumescence
C. Less risk of penile contracture
D. Less risk of penile sensory loss
E. Larger girth implant is possible
8. Aman presents with Peyronie’s Disease and very
and very significant penile shortening. Intercourse is
impossible due to a 90-degree dorsal deformity. He has firmerections, but is quite upset with how short
the penis has become. Length preservation is the primary goal of the patient. Which of the following
procedures should be avoided to try to help achieve his goals?
A. Penile placation procedure (eg, Nesbit)
B. Penile prosthesis placement
C. Penile prosthesis placement with amolding procedure
D. Plaque excision with dermal graft
E. Plaque incision with pericardial graft
9. A48-year-old-man
A48-year-old-man present with Peyronie’s Disease
Peyronie’s Disease with a 90-degree dorsal deformity.
Erections are perfectly firmby history. He undergoes a plaque incision and grafting, with
elevation of the neurovascular bundle. Sensation returns to normal, but he is completely
unable to achieve erection following the surger y.Which of the following preoperative
testsmight have predicted this complication fromsurgery?
A. Serumtestosterone level
B. Nocturnal penile tumescence study
C.Duplex Doppler ultrasound of the penile vessels
D. Biothesiometry
E. Penile-brachial index
10. Which of the following injectable agents is recommended by the AUAGuidelines on priapism, due to
its pure alpha-adrenergic effect and lack of secondary neurotransmitter release?
A. Epinephrine
B. Phenylyephrine
C.Metaraminol
D. Norepinephrine
E. Dopamine
Answers
1. B
2. A
3. D
4. E
5. A
6. E
7. D
8. A
9. C
10. B