Campbell-Walsh Urology 12th Edition

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Campbell-Walsh-Wein
UROLOGY
TWELFTH EDITION REVIEW
 third edition

Campbell-Walsh-Wein
UROLOGY
TWELFTH EDITION REVIEW
Alan J. Wein, MD, PhD (Hon), FACS Thomas F. Kolon, MD, FAAP
Founders Professor and Emeritus Chief of Urology Howard M. Snyder III MD Chair
Division of Urology in Pediatric Urology
Director, Residency Program in Urology Pediatric Urology Fellowship
Perelman School of Medicine at the University Program Director
of Pennsylvania Children’s Hospital of Philadelphia
Penn Medicine Professor of Urology in Surgery
Philadelphia, Pennsylvania Perelman School of Medicine
at the University of Pennsylvania
Philadelphia, Pennsylvania

Editors
Alan W. Partin, Roger R. Dmochowski, Louis R. Kavoussi, Craig A. Peters,
MD, PhD MD, MMHC, FACS MD, MBA MD
The Jakurski Family Director Professor, Urologic Surgery, Professor and Chair Chief, Pediatric Urology
Urologist-in-Chief Surgery, and Gynecology Department of Urology Children’s Health System Texas
Chairman, Department Program Director, Female Zucker School of Medicine Professor of Urology
of Urology Pelvic Medicine and at Hofstra/Northwell University of Texas
Professor, Departments Reconstructive Surgery Hempstead, New York Southwestern Medical Center
of Urology, Oncology, Vice Chair for Faculty Affairs Chairman of Urology Dallas, Texas
and Pathology and Professionalism The Arthur Smith Institute
Johns Hopkins Medical Section of Surgical Sciences for Urology
Institutions Associate Surgeon-in-Chief Lake Success, New York
Baltimore, Maryland Vanderbilt University Medical
Center
Nashville, Tennessee
Elsevier
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CAMPBELL-WALSH-WEIN UROLOGY TWELFTH EDITION REVIEW,

THIRD EDITION ISBN: 978-0-323-63969-9
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CONTRIBUTORS
Robert Abouassaly, MD Sero Andonian, MD, MSc, FRCS(C), FACS Laurence S. Baskin, MD
Department of Urology Associate Professor Frank Hinman Jr., MD, Distinguished
Glickman Urological and Kidney Institute Department of Urology Professorship in Pediatric Urology
Associate Professor of Surgery (Urology) McGill University Chief of Pediatric Urology
Cleveland Clinic Lerner College of Montreal, Québec, Canada University of California–San Francisco
Medicine Benioff Children’s Hospital
Cleveland Clinic Emmanuel S. Antonarakis, MD Department of Urology
Cleveland, Ohio Professor of Oncology and Urology Mission Hall Pediatric Urology
Johns Hopkins Sidney Kimmel San Francisco, California
Ömer Acar, MD Comprehensive Cancer Center
Department of Urology Baltimore, Maryland Stuart B. Bauer, MD
College of Medicine Professor of Surgery (Urology)
University of Illinois at Chicago Jodi A. Antonelli, MD Department of Urology
Chicago, Illinois Assistant Professor Harvard Medical School
Department of Urology Senior Associate in Urology
Mark C. Adams, MD, FAAP University of Texas Southwestern Medical Department of Urology
Professor of Urologic Surgery Center Boston Children’s Hospital
Division of Pediatric Urology Dallas, Texas Boston, Massachusetts
Department of Urology
Monroe Carell Jr. Children’s Hospital at Joshua J. Augustine, MD Mitchell C. Benson, MD
Vanderbilt Associate Professor of Medicine Herbert and Florence Irving
Vanderbilt University Medical Center Cleveland Clinic Lerner College of Medicine Professor and Chairman Emeritus
Nashville, Tennessee Staff Physician Department of Urology
Glickman Urological and Kidney Institute Columbia University
Riyad Tasher Al Mousa, MD, SSCU, Department of Nephrology and Attending Physician
FEBU, MSHA Hypertension Department of Urology
Consultant Urologist/Neuro-urologist Cleveland, Ohio New York Presbyterian Hospital–
Urology Department Columbia
King Fahad Specialist Hospital–Dammam Paul F. Austin, MD New York, New York
Dammam, Saudi Arabia Professor
Department of Urology Sara L. Best, MD
Mohamad E. Allaf, MD Texas Children’s Hospital Associate Professor
Vice Chairman and Professor of Urology, Baylor College of Medicine Department of Urology
Oncology, and Biomedical Engineering Houston, Texas University of Wisconsin School of
Director of Minimally Invasive and Medicine and Public Health
Robotic Surgery Timothy D. Averch, MD, FACS Madison, Wisconsin
Brady Urological Institute Clinical Professor and Vice Chair for Quality
Department of Urology Department of Surgery Lori A. Birder, PhD
Johns Hopkins University School of Palmetto Health USC Medical Group Professor of Medicine and Pharmacology
Medicine Columbia, South Carolina and Cell Biology
Baltimore, Maryland Renal-Electrolyte Division of Medicine
Gina M. Badalato, MD University of Pittsburgh School of
Christopher L. Amling, MD, FACS Assistant Professor of Urology Medicine
John Barry Professor and Chair Columbia University Vagelos College of Pittsburgh, Pennsylvania
Department of Urology Physicians and Surgeons
Oregon Health and Science University Assistant Attending Jay T. Bishoff, MD
Portland, Oregon New York–Presbyterian Hospital Director, Intermountain Urological
New York, New York Institute
Christopher B. Anderson, MD, MPH Intermountain Health Care
Assistant Professor Daniel A. Barocas, MD, MPH, FACS Salt Lake City, Utah
Department of Urology Associate Professor
Columbia University Irving Medical Center Department of Urology Trinity J. Bivalacqua, MD, PhD
New York, New York Vanderbilt University Medical Center R. Christian Evenson Professor of Urology
Nashville, Tennessee Department of Urology
Karl-Erik Andersson, MD, PhD Johns Hopkins Medicine
Professor Julia Spencer Barthold, MD Baltimore, Maryland
Aarhus Institute for Advanced Studies Principal Research Scientist
Aarhus University Nemours Biomedical Research/Division of Marc A. Bjurlin, DO, MSc
Aarhus, Jutland, Denmark Urology Associate Professor
Professor Alfred I. duPont Hospital for Children Department of Urology
Wake Forest Institute for Regenerative Wilmington, Delaware Lineberger Comprehensive Cancer Center
Medicine Professor of Urology and Pediatrics University of North Carolina at Chapel
Wake Forest University School of Medicine Thomas Jefferson University Hill
Winston-Salem, North Carolina Philadelphia, Pennsylvania Chapel Hill, North Carolina
v
vi CONTRIBUTORS

Brian G. Blackburn, MD, FIDSA Elizabeth Timbrook Brown, MD, MPH, Michael A. Carducci, MD
Clinical Associate Professor of Internal FACS AEGON Professor in Prostate Cancer
Medicine/Infectious Diseases and Assistant Professor of Urology Research
Geographic Medicine Department of Urology Sidney Kimmel Comprehensive Cancer
Stanford University School of Medicine MedStar Georgetown University Center at Johns Hopkins
Stanford, California Hospital Johns Hopkins University School of
Washington, District of Columbia Medicine
Bertil Blok, MD, PhD Baltimore, Maryland
Urologist Benjamin M. Brucker, MD
Department of Urology Associate Professor Maude Carmel, MD
Erasmus Medical Center Director of Female Pelvic Medicine and Assistant Professor of Urology
Rotterdam, the Netherlands Reconstructive Surgery University of Texas Southwestern Medical
Departments of Urology and Obstetrics Center
Michael L. Blute, MD and Gynecology Dallas, Texas
Chief New York University Langone Health
Department of Urology New York, New York Peter R. Carroll, MD, MPH
Walter S. Kerr Jr., Professor of Urology Professor
Massachusetts General Hospital/Harvard Kathryn L. Burgio, PhD Ken and Donna Derr-Chevron
Medical School Professor of Medicine Distinguished Professor
Boston, Massachusetts Division of Gerontology, Geriatrics, and Taube Family Distinguished Professor
Palliative Care Department of Urology
Timothy B. Boone, MD, PhD University of Alabama at Birmingham University of California–San Francisco
Chair, Department of Urology Associate Director for Research San Francisco, California
Houston Methodist Hospital Birmingham/Atlanta Geriatric Research,
Professor and Associate Dean Education, and Clinical Center Clint Cary, MD, MPH
Weill Cornell Medical College and Texas (GRECC) Associate Professor
A&M College of Medicine Birmingham Veterans Affairs Medical Department of Urology
Houston, Texas Center Indiana University
Birmingham, Alabama Indianapolis, Indiana
Stephen A. Boorjian, MD
Carl Rosen Professor of Urology Arthur L. Burnett II, MD, MBA Erik P. Castle, MD
Department of Urology Patrick C. Walsh Distinguished Professor Professor of Urology
Mayo Clinic of Urology Department of Urology
Rochester, Minnesota Department of Urology Mayo Clinic Arizona
Johns Hopkins School of Medicine Phoenix, Arizona
Kristy Borawski, MD Baltimore, Maryland
Clinical Assistant Professor of Urology Toby C. Chai, MD
Department of Urology Jeffrey A. Cadeddu, MD Chair of Department of Urology
University of North Carolina at Chapel Hill Professor of Urology and Radiology Boston University School of Medicine
Chapel Hill, North Carolina Department of Urology Chief of Urology
University of Texas Southwestern Medical Boston Medical Center
Michael S. Borofsky, MD Center Boston, Massachusetts
Assistant Professor Dallas, Texas
Department of Urology Charbel Chalouhy, MD
University of Minnesota Anne P. Cameron, MD, FRCSC, FPMRS Faculty of Medicine
Minneapolis, Minnesota Professor of Urology St. Joseph University
University of Michigan Beirut, Lebanon
Steven Brandes, MD Ann Arbor, Michigan
Given Foundation Professor of Urology Alicia H. Chang, MD, MS
Department of Urology Steven C. Campbell, MD, PhD Medical Director
Columbia University Medical Center Professor of Surgery Department of Public Health,
New York, New York Department of Urology Tuberculosis Control Program
Cleveland Clinic County of Los Angeles
Michael C. Braun, MD Cleveland, Ohio Los Angeles, California
Chief of Renal Service
Texas Children’s Hospital Douglas A. Canning, MD Christopher R. Chapple, MD, BSc,
Professor, Renal Section Chief Professor of Surgery (Urology) FRCS (Urol)
Department of Pediatrics Perelman School of Medicine Professor and Consultant Urologist
Program Director University of Pennsylvania Department of Urology
Pediatric Nephrology Fellowship Program Chief, Division of Urology The Royal Hallamshire Hospital
Baylor College of Medicine Children’s Hospital of Philadelphia Sheffield Teaching Hospitals
Houston, Texas Philadelphia, Pennsylvania Sheffield, United Kingdom

Gregory A. Broderick, MD Paolo Capogrosso, MD Thomas Chi, MD

Professor of Urology IRCCS San Raffaele Hospital Associate Professor
Mayo Clinic Alix School of Medicine Department of Urology Associate Chair for Clinical Affairs
Department of Urology Vita-Salute San Raffaele University Department of Urology
Program Director Milan, Italy University of California–San Francisco
Urology Residency Program San Francisco, California
Mayo Clinic
Jacksonville, Florida
 CONTRIBUTORS vii

John Christodouleas, MD Hillary L. Copp, MD, MS Shubha K. De, MD, FRCSC

Professor of Radiation Oncology Associate Professor, Pediatric Urology Alberta Urology Institute
Urologic Cancer Program Department of Urology Northern Alberta Urology Centre
Penn Medicine University of California–San Francisco Edmonton, Alberta, Canada
Philadelphia, Pennsylvania San Francisco, California
Jean J.M.C.H. de la Rosette, MD, PhD
Peter E. Clark, MD Nicholas G. Cost, MD Professor
Professor and Chairman Associate Professor Department of Urology
Department of Urology Department of Surgery Istanbul Medipol University
Atrium Health Division of Urology Istanbul, Turkey
Chair, Urologic Oncology University of Colorado School of
Levine Cancer Institute Medicine Dirk J.M.K. De Ridder, MD, PhD
Charlotte, North Carolina Aurora, Colorado Professor
Department of Urology
Douglass B. Clayton, MD, FAAP Anthony Costello, MD, AM, FRACS University Hospitals KU Leuven
Associate Professor of Urologic Surgery Professor Leuven, Belgium
Division of Pediatric Urology Department of Urology
Department of Urology Royal Melbourne Hospital Guarionex Joel DeCastro, MD, MPH
Monroe Carell Jr. Children’s Hospital at Parkville, Victoria, Australia Associate Professor, Urology
Vanderbilt Columbia University Medical Center
Vanderbilt University Medical Center Lindsey Cox, MD Department of Urology
Nashville, Tennessee Associate Professor of Urology New York Presbyterian Hospital/Columbia
Department of Urology University
Joshua A. Cohn, MD Medical University of South Carolina New York, New York
Assistant Professor of Urology Charleston, South Carolina
Department of Urology Francisco T. Dénes, MD, PhD
Einstein Healthcare Network Paul L. Crispen, MD Associate Professor
Assistant Professor of Urology Associate Professor Chief, Pediatric Urology Unit
Department of Surgery Department of Urology Division of Urology
Division of Urologic Oncology University of Florida Hospital das Clínicas
Fox Chase Cancer Center Gainesville, Florida Faculdade de Medicina
Philadelphia, Pennsylvania Universidade de São Paulo
Juanita M. Crook, MD, FRCPC São Paulo, Brazil
Michael J. Conlin, MD, MCR Professor
Professor Department of Radiation Oncology Mahesh R. Desai, MS, FRCS,
Department of Urology University of British Columbia FRCS
Portland Veterans Affairs Medical Center Radiation Oncologist Chief Urologist and Managing
Professor Center for the Southern Interior Trustee
Department of Urology British Columbia Cancer Agency Department of Urology
Oregon Health and Sciences University Kelowna, British Columbia, Canada Muljibhai Patel Urological Hospital
Portland, Oregon Nadiad, India
Gerald Cunha, PhD
Christopher S. Cooper, MD, FAAP, FACS Emeritus Professor, Anatomy and David A. Diamond, MD
Professor Urology Urologist-in-Chief
Department of Urology University of California–San Francisco Department of Urology
University of Iowa San Francisco, California Boston Children’s Hospital
Senior Associate Dean of Medical Professor of Surgery (Urology)
Education Douglas M. Dahl, MD, FACS Department of Surgery
University of Iowa Carver College of Associate Professor of Surgery Harvard Medical School
Medicine Harvard Medical School Boston, Massachusetts
Iowa City, Iowa Chief, Division of Urologic Oncology
Department of Urology Heather N. Di Carlo, MD
Kimberly L. Cooper, MD Massachusetts General Hospital Director, Pediatric Urology Research
Associate Professor of Urology Boston, Massachusetts Assistant Professor of Urology
Columbia University Vagelos College of The James Buchanan Brady Urological
Physicians and Surgeons Siamak Daneshmand, MD Institute
Associate Attending Associate Professor of Urology Johns Hopkins Medical Institutions
New York–Presbyterian Hospital Director of Clinical Research Baltimore, Maryland
New York, New York Keck University of Southern California
School of Medicine Colin P.N. Dinney, MD
Lawrence A. Copelovitch, MD Los Angeles, California Chairman and Professor
Assistant Professor of Pediatrics Department of Urology
University of Pennsylvania Perelman Casey A. Dauw, MD University of Texas MD Anderson Cancer
School of Medicine Assistant Professor Center
Attending Physician Department of Urology Houston, Texas
Division of Nephrology University of Michigan
The Children’s Hospital of Philadelphia Ann Arbor, Michigan
Philadelphia, Pennsylvania
viii CONTRIBUTORS

Roger R. Dmochowski, MD, MMHC, FACS Jairam Eswara, MD Reza Ghavamian, MD

Professor, Urologic Surgery, Surgery, and Attending Surgeon Eastern Regional Director of Urology
Gynecology St. Elizabeth’s Medical Center Department of Urology
Program Director, Female Pelvic Medicine Clinical Associate Professor Northwell Health
and Reconstructive Surgery Tufts University School of Medicine Greenlawn, New York
Vice Chair for Faculty Affairs and Boston, Massachusetts Professor of Urology
Professionalism Department of Urology
Section of Surgical Sciences Fernando A. Ferrer, MD, FACS, FAAP Zucker School of Medicine at Hofstra/
Associate Surgeon-in-Chief Surgeon in Chief Northwell
Vanderbilt University Medical Center Department of Pediatric Urology New Hyde Park, New York
Nashville, Tennessee Children’s Hospital Omaha
Professor, Surgery (Urology) Bruce R. Gilbert, MD, PhD
Charles G. Drake, MD, PhD University of Nebraska Professor of Urology
Professor, Medical Oncology and Urology Omaha, Nebraska The Smith Institute for Urology
Department of Medicine Zucker School of Medicine of Hofstra/
Columbia University Neil Fleshner, MD, MPH, FRCSC Northwell
New York, New York Professor of Surgery and Martin Barkin New Hyde Park, New York
Chair Clinical Professor of Urology (Adjunct)
Brian Duty, MD, MBA Department of Urology Department of Urology
Associate Professor University of Toronto Weill Cornell Medical College
Department of Urology Surgeon, Uro-Oncology New York, New York
Oregon Health and Science University University Health Network
Portland, Oregon Toronto, Ontario, Canada Timothy D. Gilligan, MD
Associate Professor of Medicine
James A. Eastham, MD Bryan R. Foster, MD Solid Tumor Oncology
Chief, Urology Service Associate Professor Cleveland Clinic Lerner College of
Department of Surgery Department of Radiology Medicine
Memorial Sloan-Kettering Cancer Center Oregon Health and Science University Program Director, Hematology/Oncology
New York, New York Portland, Oregon Fellowship
Scott Eggener, MD Taussig Cancer Institute
Professor of Surgery and Radiology Richard S. Foster, MD Cleveland Clinic
University of Chicago Professor Cleveland, Ohio
Chicago, Illinois Department of Urology
Indiana University David A. Goldfarb, MD
Mohamed A. Elkoushy, MD, PhD, MSc Indianapolis, Indiana Professor of Surgery
Professor, Urology Cleveland Clinic Lerner College of
Faculty of Medicine Pat F. Fulgham, MD Medicine
Suez Canal University Surgical Director of Oncology Glickman Urological and Kidney
Ismailia, Egypt Services Institute
Chairman, Department of Urology Cleveland Clinic
Jonathan Ellison, MD Texas Health Presbyterian Dallas Cleveland, Ohio
Assistant Professor of Urology Dallas, Texas
Medical College of Wisconsin Marc Goldstein, MD, DSc (hon), FACS
Children’s Wisconsin Arvind P. Ganpule, MS, DNB Matthew P. Hardy Distinguished Professor
Milwaukee, Wisconsin Vice-Chairman of Urology and Male Reproductive
Department of Urology Medicine
Sammy E. Elsamra, MD, FACS Chief, Division of Robotic Surgery Department of Urology and Institute for
Assistant Professor of Surgery (Urology) Muljibhai Patel Urological Hospital Reproductive Medicine
Rutgers Robert Wood Johnson Medical Nadiad, India Weill Cornell Medical College of Cornell
School University
Director of Robotic Surgical Services Kris E. Gaston, MD Surgeon-In-Chief, Male Reproductive
Robert Wood Johnson University Hospital Urologic Oncology Medicine, and Surgery
RWJBarnabas Health Levine Cancer Institute Department of Urology and Institute for
New Brunswick, New Jersey Charlotte, North Carolina Reproductive Medicine
New York Presbyterian Hospital–Weill
Jonathan I. Epstein, MD
John P. Gearhart, MD, FAAP, FACS, Cornell Medicine
Professor of Pathology, Urology, and
FRCS Adjunct Senior Scientist
Oncology
Chief of Pediatric Urology Population Council
The Reinhard Professor of Urological
Professor of Urology Center for Biomedical Research at
Pathology
The James Buchanan Brady Urological Rockefeller University
Director of Surgical Pathology
Institute New York, New York
The Johns Hopkins Medical Institutions
Johns Hopkins Medical Institutions
Baltimore, Maryland
Baltimore, Maryland Leonard G. Gomella, MD, FACS
Carlos R. Estrada, MD, MBA The Bernard W. Godwin Professor of
Associate Professor Matthew T. Gettman, MD Prostate Cancer
Department of Surgery Professor and Vice-Chair Chairman, Department of Urology
Harvard Medical School Department of Urology Sidney Kimmel Cancer Center
Associate in Urology Mayo Clinic Sidney Kimmel Medical College at
Department of Urology Rochester, Minnesota Thomas Jefferson University
Boston Children’s Hospital Philadelphia, Pennsylvania
Boston, Massachusetts

Alex Gomelsky, MD, FACS
B.E. Trichel Professor and Chairman
Department of Urology
Louisiana State University Health
Shreveport, Louisiana
Mark L. Gonzalgo, MD, PhD
Professor and Vice Chairman
Department of Urology
University of Miami Miller School of
Medicine
Miami, Florida
Michael A. Gorin, MD
Assistant Professor
Department of Urology
Johns Hopkins University School of
Medicine
Baltimore, Maryland
Tamsin Greenwell, MD, PhD
Consultant Urological Surgeon
University College London Hospitals
London, United Kingdom
Tomas L. Griebling, MD, MPH
John P. Wolf 33-Degree Masonic
Distinguished Professor of Urology
Department of Urology and The Landon
Center on Aging
The University of Kansas
Kansas City, Kansas
Khurshid A. Guru, MD
Chair of Urology Department
Director of Robotic Surgery
Robert P. Huben Endowed Professor of
Urologic Oncology
Roswell Park Comprehensive Cancer Center
Buffalo, New York
Thomas J. Guzzo, MD, MPH
Associate Professor of Urology
The Hospital of the University of
Pennsylvania
University of Pennsylvania
Philadelphia, Pennsylvania
Jennifer A. Hagerty, DO
Attending Physician
Department of Surgery/Division of Urology
Nemours/AI duPont Hospital for Children
Wilmington, Delaware
Assistant Professor
Department of Urology and Pediatrics
Thomas Jefferson University
Philadelphia, Pennsylvania
Simon J. Hall, MD
Zucker Professor of Urologic Oncology
Smith Institute for Urology
Hofstra/Northwell School of Medicine
Lake Success, New York
Barry Hallner, MD
Associate Program Director, Female Pelvic
Medicine and Reconstructive Surgery
Assistant Professor
Departments of OB/GYN and Urology
Louisiana State University Health
New Orleans School of Medicine
New Orleans, Louisiana
Ethan J. Halpern, MD
Professor of Radiology and Urology
Sidney Kimmel Cancer Center
Sidney Kimmel Medical College at
Thomas Jefferson University
Philadelphia, Pennsylvania
Misop Han, MD
David Hall McConnell Professor of
Urology and Oncology
Department of Urology
Johns Hopkins Medicine
Baltimore, Maryland
Philip Hanno, MD, MPH
Clinical Professor
Department of Urology
Stanford University School of Medicine
Palo Alto, California
Emeritus Professor
Department of Urology
University of Pennsylvania
Philadelphia, Pennsylvania
Siobhan M. Hartigan, MD
Female Pelvic Medicine and Reconstructive
Surgery Fellow
Department of Urology
Vanderbilt University Medical Center
Nashville, Tennessee
Christopher J. Hartman, MD
Chief of Urology, Forest Hills Hospital
Northwell Health
Associate Program Director, Urology
Residency Program
Smith Institute for Urology
Assistant Professor of Urology
Zucker School of Medicine at Hofstra/
Northwell
Hempstead, New York
Hashim Hashim, MD, MBBS, MRCS
(Eng), FEBU, FRCS (Urol)
Consultant Urological Surgeon
Honorary Professor of Urology and
Director of the Urodynamics Unit
Bristol Urological Institute
Southmead Hospital
Bristol, United Kingdom
Dorota J. Hawksworth, MD
Walter Reed National Military Medical
Center
Bethesda, Maryland
Sarah Hazell, MD
Resident Physician
Radiation Oncology and Molecular
Radiation Sciences
Johns Hopkins University School of
Medicine
Baltimore, Maryland
John P.F.A. Heesakkers, MD, PhD
Urologist
Department of Urology
Radboud University Medical Centre
Nijmegen, The Netherlands
CONTRIBUTORS ix
Sevann Helo, MD
Minneapolis Veterans Affairs Medical
Center
Minneapolis, Minnesota
Amin S. Herati, MD
Assistant Professor of Urology
The James Buchanan Brady Urological
Institute and Department of Urology
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of
Medicine
Baltimore, Maryland
C.D. Anthony Herndon, MD, FAAP, FACS
Professor of Surgery
Director of Pediatric Urology
Surgeon in Chief, Children’s Hospital of
Richmond
Division of Urology
Virginia Commonwealth University
Richmond, Virginia
Piet Hoebeke, MD, PhD
Professor of Urology
Dean, Faculty of Medicine and Health
Sciences
Ghent University
Ghent, Belgium
David M. Hoenig, MD
Professor and Chief
North Shore University Hospital
Smith Institute for Urology
North Shore–Long Island Jewish–Hofstra
University
Lake Success, New York
Michael Hsieh, MD, PhD
Associate Professor of Urology and
Pediatrics and Microbiology,
Immunology, and Tropical Medicine
The George Washington University
Director, Clinic for Adolescent and
Adult PedIatric OnseT UroLogy
(CAPITUL)
Children’s National Hospital and the
George Washington University
Washington, District of Columbia
Valerio Iacovelli, MD
Urology Unit
University of Rome Tor Vergata
San Carlo di Nancy General Hospital
GVM Care and Research
Rome, Italy
Stephen V. Jackman, MD
Professor
Department of Urology
University of Pittsburgh
Pittsburgh, Pennsylvania
Joseph M. Jacob, MD, MCR
Assistant Professor
Department of Urology
Upstate Medical University
Syracuse, New York
x CONTRIBUTORS

Micah A. Jacobs, MD, MPH Parviz K. Kavoussi, MD, FACS Ervin Kocjancic, MD
Associate Professor Reproductive Urologist Lawrence S. Ross Professor of Urology
Department of Urology Department of Urology Vice Chairman
University of Texas Southwestern Austin Fertility and Reproductive Medicine Department of Urology College of
Dallas, Texas Adjunct Assistant Professor Medicine
Department of Psychology University of Illinois at Chicago
Thomas W. Jarrett, MD Division of Neuroendocrinology and Chicago, Illinois
Professor and Chairman Motivation
Department of Urology University of Texas at Austin Chester J. Koh, MD
George Washington University Austin, Texas Professor of Urology, Pediatrics, and
Washington, District of Columbia Adjunct Assistant Professor Obstetrics/Gynecology
Department of Urology Baylor College of Medicine
Gerald H. Jordan, MD, FACS, University of Texas Health Sciences Center Division of Pediatric Urology
FAAP (Hon), FRCS (Hon) at San Antonio Department of Surgery
Associate Professor, Urology San Antonio, Texas Texas Children’s Hospital
Eastern Virginia Medical School Houston, Texas
Norfolk, Virginia Miran Kenk, PhD
Scientific Associate Badrinath Konety, MD, MBA
Martin Kaefer, MD Department of Surgical Oncology Chief Executive Officer
Professor of Urology Princess Margaret Cancer Centre University of Minnesota Physicians
Indiana University School of Medicine University Health Network Vice Dean for Clinical Affairs
Indianapolis, Indiana Toronto, Ontario, Canada University of Minnesota Medical School
Professor
Kamaljot S. Kaler, MD, FRCSC Mohit Khera, MD, MBA, MPH Department of Urology
Clinical Assistant Professor Professor of Urology University of Minnesota
University of Calgary Scott Department of Urology Minneapolis, Minnesota
Southern Alberta Institute of Urology Baylor College of Medicine
Calgary, Alberta, Canada Houston, Texas Casey Kowalik, MD
Assistant Professor
Panagiotis Kallidonis, MD, MSc, PhD, Antoine E. Khoury, MD, FRCSC, FAAP Department of Urology
FEBU Walter R. Schmid, Professor of Pediatric University of Kansas Health System
Assistant Professor Urological Urology Kansas City, Kansas
Surgeon Department of Urology
Department of Urology University of California–Irvine Martin A. Koyle, MD, FAAP, FACS,
University of Patras Head of Pediatric Urology FRCSC, FRCS (Eng)
Patras, Greece Children’s Hospital of Orange County Division Head, Division of Pediatric Urology
Orange, California Women’s Auxiliary Chair in Urology and
Steven Kaplan, MD Regenerative Medicine
Professor and Director, The Men’s Health Eric A. Klein, MD Hospital for Sick Children
Program Andrew C. Novick, Distinguished Professor of Surgery
Department of Urology Professor and Chair University of Toronto
Icahn School of Medicine at Mount Sinai Glickman Urological and Kidney Institute Toronto, Ontario, Canada
New York, New York and Cleveland Clinic Lerner College of
Medicine Amy E. Krambeck, MD
Max Kates, MD Cleveland Clinic Michael O. Koch Professor of Urology
Assistant Professor Cleveland, Ohio Department of Urology
Department of Urology Indiana University
Johns Hopkins Medical Institutions Laurence Klotz, MD, FRCSC, CM Indianapolis, Indiana
Baltimore, Maryland Professor of Surgery
University of Toronto Jessica E. Kreshover, MD
Melissa R. Kaufman, MD, PhD, FACS Urologist, Sunnybrook Health Sciences Associate Professor of Urology
Associate Professor Centre The Arthur Smith Institute for Urology
Department of Urology Toronto, Ontario, Canada Zucker School of Medicine at Hofstra/
Vanderbilt University Northwell
Nashville, Tennessee Bodo E. Knudsen, MD, FRCSC New Hyde Park, New York
Associate Professor
Vice Chair Clinical Operations Venkatesh Krishnamurthi, MD
Louis R. Kavoussi, MD, MBA Department of Urology Director, Kidney/Pancreas Transplant
Professor and Chair Wexner Medical Center Program
Department of Urology The Ohio State University Glickman Urological and Kidney Institute
Zucker School of Medicine at Hofstra/ Columbus, Ohio Transplant Center
Northwell Cleveland Clinic Foundation
Hempstead, New York Kathleen C. Kobashi, MD Cleveland, Ohio
Chairman of Urology Chief, Section of Urology
The Arthur Smith Institute for Urology Urology and Renal Transplantation
Lake Success, New York Virginia Mason Medical Center
Seattle, Washington
 CONTRIBUTORS xi

Ryan M. Krlin, MD, FPMRS Sey Kiat Lim, MBBS, MRCS Yair Lotan, MD
Associate Professor of Urology and ­(Edinburgh), MMed (Surgery), Professor
Gynecology FAMS (Urology) Department of Urology
Department of Urology Senior Consultant and Chief University of Texas Southwestern Medical
Louisiana State University Health New Department of Urology Center
Orleans Changi General Hospital Dallas, Texas
New Orleans, Louisiana Adjunct Associate Professor
Duke–National University of Singapore Alvaro Lucioni, MD
Alexander Kutikov, MD Medical School Program Director, Female Pelvic Medicine
Professor and Chief, Urologic Oncology Singapore Reconstructive Surgery Fellowship
Fox Chase Cancer Center Urology and Renal Transplantation
Philadelphia, Pennsylvania W. Marston Linehan, MD Virginia Mason Medical Center
Chief, Urologic Oncology Branch Seattle, Washington
Jaime Landman, MD National Cancer Institute
Professor of Urology and Radiology National Institutes of Health Tom F. Lue, MD, ScD (Hon), FACS
Chairman, Department of Urology Bethesda, Maryland Professor of Urology
University of California, Irvine Department of Urology
Orange, California Richard Edward Link, MD, PhD University of California–San Francisco
Carlton-Smith Chair in Urologic San Francisco, California
Brian R. Lane, MD, PhD Education
Chief, Urology Associate Professor of Urology Nicolas Lumen, MD, PhD
Spectrum Health Director, Division of Endourology and Professor of Urology
Associate Professor Minimally Invasive Surgery Ghent University Hospital
Michigan State University College of Scott Department of Urology Ghent, Belgium
Human Medicine Baylor College of Medicine
Grand Rapids, Michigan Houston, Texas Marcos Tobias Machado, MD, PhD
Professor of Urology
David A. Leavitt, MD Jen-Jane Liu, MD Department of Urology
Assistant Professor Assistant Professor Faculdade de Medicina do ABC
Department of Urology Director of Urologic Oncology Santo Andre, Brazil
Vattikuti Urology Institute Department of Urology
Henry Ford Health System Oregon Health and Science University Stephen D. Marshall, MD
Detroit, Michigan Portland Oregon Attending Physician
Laconia Clinic Department of Urology
Eugene K. Lee, MD Stacy Loeb, MD Lakes Region General Hospital
Associate Professor Professor of Urology and Population Laconia, New Hampshire
Department of Urology Health
University of Kansas Medical Center New York University and Manhattan Aaron D. Martin, MD, MPH
Kansas City, Kansas Veterans Affairs Associate Professor
New York, New York Department of Urology
Gary E. Lemack, MD Louisiana State University Health
Professor of Urology and Neurology Christopher J. Long, MD Sciences Center
Department of Urology Assistant Professor of Urology (Surgery) Department of Pediatric Urology
University of Texas Southwestern Medical Perelman School of Medicine Children’s Hospital New Orleans
Center University of Pennsylvania New Orleans, Louisiana
Dallas, Texas Division of Urology
Children’s Hospital of Philadelphia Laura M. Martinez, MD
Thomas Sean Lendvay, MD, FACS Philadelphia, Pennsylvania Instructor in Clinical Urology
Professor of Urology Department of Urology
University of Washington Roberto Iglesias. Lopes, MD, PhD Houston Methodist Hospital
Professor of Pediatric Urology Assistant Professor Houston, Texas
Seattle Children’s Hospital Pediatric Urology Unit
Seattle, Washington Division of Urology Timothy A. Masterson, MD
Hospital das Clínicas Associate Professor
Herbert Lepor, MD Faculdade de Medicina Department of Urology
Professor and Martin Spatz Chair Universidade de São Paulo Indiana University Medical Center
Department of Urology São Paulo, Brazil Indianapolis, Indiana
New York University School of Medicine
Chief, Urology Armando J. Lorenzo, MD, MSc, FRCSC, Surena F. Matin, MD
New York University Langone Health FAAP, FACS Professor
New York, New York Staff Paediatric Urologist Department of Urology
Department of Surgery Medical Director
Evangelos Liatsikos, MD, PhD Division of Urology Minimally Invasive New Technology in
Professor and Chairman Hospital for Sick Children Oncologic Surgery (MINTOS)
Department of Urology Associate Professor University of Texas MD Anderson Cancer
University of Patras Department of Surgery Center
Patras, Greece Division of Urology Houston, Texas
University of Toronto
Toronto, Ontario, Canada
xii CONTRIBUTORS

Brian R. Matlaga, MD Alireza Moinzadeh, MD, MHL Neema Navai, MD

Professor
James Buchanan Brady Urological
Institute
Johns Hopkins Medical Institutions
Baltimore, Maryland
Kurt A. McCammon, MD
Devine Chair in Genitourinary
Reconstructive Surgery
Chairman and Program Director
Professor
Department of Urology
Eastern Virginia Medical School
Norfolk, Virginia
Devine-Jordan Center for Reconstructive
Surgery and Pelvic Health
Urology of Virginia PLLC
Virginia Beach, Virginia
James M. McKiernan, MD
Chairman and Professor
Department of Urology
Columbia University Irving Medical Center
New York, New York
Chris G. McMahon, MBBS, FAChSHP
Director
Australian Centre for Sexual Health
Sydney, New South Wales, Australia
Kevin T. McVary, MD
Center for Male Health
Loyola University Medical Center
Maywood, Illinois
Luis G. Medina, MD
Research Fellow
Department of Urology
University of Southern California
Los Angeles, California
Kirstan K. Meldrum, MD
Professor
Department of Surgery
Central Michigan University
Saginaw, Michigan
Matthew J. Mellon, MD, FACS
Associate Professor
Department of Urology
Indiana University
Indianapolis, Indiana
Maxwell V. Meng, MD, FACS
Professor and Chief, Urologic Oncology
Department of Urology
University of California–San Francisco
San Francisco, California
David Mikhail, MD, BSc, FRCSC
Endourology Fellow
Smith Institute for Urology
Northwell Health
New Hyde Park, New York
Nicole L. Miller, MD
Associate Professor
Department of Urology
Vanderbilt University Medical Center
Nashville, Tennessee
Chair, Department of Urology Associate Professor
Lahey Hospital and Medical Center Department of Urology
Burlington, Massachusetts University of Texas MD Anderson Cancer
Assistant Professor of Urology Center
Tufts University School of Medicine Houston, Texas
Boston, Massachusetts
Diane K. Newman, DNP, ANP-BC, FAAN,
Robert M. Moldwin, MD BCB-PMD
Professor of Urology Adjunct Professor of Urology in Surgery
The Arthur Smith Institute for Urology Division of Urology
Zucker School of Medicine at Hofstra/ Research Investigator Senior
Northwell Perelman School of Medicine
Lake Success, New York University of Pennsylvania
Co-Director, Penn Center for Continence
Manoj Monga, MD, FACS
and Pelvic Health
Director, Stevan Streem Center for
Division of Urology
Endourology and Stone Disease
Penn Medicine
Department of Urology
Philadelphia, Pennsylvania
Cleveland Clinic
Cleveland, Ohio
Craig S. Niederberger, MD, FACS
Clarence C. Saelhof Professor and Head
Francesco Montorsi, MD, FRCS (Hon)
Department of Urology
Professor and Chairman
University of Illinois at Chicago College of
Department of Urology
Medicine
IRCCS San Raffaele University
Professor
Milan, Italy
Department of Bioengineering
Daniel M. Moreira, MD, MHS University of Illinois at Chicago College of
Assistant Professor Engineering
Department of Urology Chicago, Illinois
University of Illinois at Chicago
Chicago, Illinois Victor W. Nitti, MD
Professor of Urology and Obstetrics and
Allen F. Morey, MD, FACS Gynecology
Professor Shlomo Raz Chair in Urology
Department of Urology Chief, Division of Female Pelvic Medicine
University of Texas Southwestern and Reconstructive Surgery
Dallas, Texas David Geffen School of Medicine at
University of California–Los Angeles
Todd M. Morgan, MD Los Angeles, California
Chief of Urologic Oncology
Department of Urology Samuel J. Ohlander, MD
University of Michigan Assistant Professor
Ann Arbor, Michigan Department of Urology
University of Illinois at Chicago
John J. Mulcahy, MD, PhD, FACS Chicago, Illinois
Clinical Professor
Department of Urology L. Henning Olsen, MD
University of Alabama Professor
Birmingham, Alabama Department of Urology
Section of Pediatric Urology
Ravi Munver, MD, FACS Aarhus University Hospital
Vice Chairman Institute of Clinical Medicine
Chief of Minimally Invasive and Robotic Aarhus University
Urologic Surgery Aarhus, Denmark
Hackensack University Medical Center
Hackensack, New Jersey Aria F. Olumi, MD
Professor of Urology Professor of Surgery/Urology
Hackensack Meridian School of Medicine Department of Urologic Surgery
at Seton Hall University Beth Israel Deaconess Medical Center/
Nutley, New Jersey Harvard Medical School
Boston, Massachusetts
Stephen Y. Nakada, MD, FACS
Professor and Chairman, The David T. Nadir I. Osman, MBChB (Hons), PhD,
Uehling Chair of Urology FRCS (Urol)
Department of Urology Consultant Urologist
University of Wisconsin School of Royal Hallmashire Hospital
Medicine and Public Health Sheffield Teaching Hospitals
Professor and Chairman Sheffield, South Yorkshire
Department of Urology
University of Wisconsin Hospital and Clinics
Madison, Wisconsin
 CONTRIBUTORS xiii

Brandon J. Otto, MD Alan W. Partin, MD, PhD Thomas J. Polascik, MD

Assistant Professor of Urology The Jakurski Family Director Professor of Surgery
University of Florida College of Medicine Urologist-in-Chief Division of Urology
Gainesville, Florida Chairman, Department of Urology Duke Cancer Institute
Professor, Departments of Urology, Durham, North Carolina
Priya Padmanabhan, MD, MPH, FACS Oncology, and Pathology
Professor of Urology Johns Hopkins Medical Institutions Michel Pontari, MD
Pelvic Reconstruction and Voiding Baltimore, Maryland Professor and Vice-Chair
Dysfunction Department of Urology
William Beaumont Medical Center Roshan M. Patel, MD Lewis Katz School of Medicine at Temple
Royal Oak, Michigan Assistant Clinical Professor University
Department of Urology Philadelphia, Pennsylvania
Rodrigo L. Pagani, MD University of California, Irvine
Assistant Professor Orange, California John C. Pope IV, MD
Department of Urology Professor
University of Illinois at Chicago Margaret S. Pearle, MD, PhD Departments of Urology and
Chicago, Illinois Professor Pediatrics
Department of Urology and Internal Monroe Carell Jr. Children’s Hospital at
Lance C. Pagliaro, MD Medicine Vanderbilt
Professor of Oncology University of Texas Southwestern Medical Vanderbilt University Medical Center
Mayo Clinic College of Medicine Center Nashville, Tennessee
Consultant Dallas, Texas
Division of Medical Oncology Jay D. Raman, MD, FACS
Department of Oncology David F. Penson, MD, MPH Professor and Chief
Mayo Clinic Hamilton and Howd Chair in Urologic Division of Urology
Rochester, Minnesota Oncology Penn State Health Milton S. Hershey
Professor and Chair, Department of Urology Medical Center
Ganesh S. Palapattu, MD Vanderbilt University Medical Center Hershey, Pennsylvania
The George F. Valassis and Sandy G. Nashville Tennessee
Valassis Professor and Chair Ranjith Ramasamy, MD
Department of Urology Craig A. Peters, MD Director of Reproductive Urology
University of Michigan Chief, Pediatric Urology Department of Urology
Ann Arbor, Michigan Children’s Health System Texas University of Miami
Professor of Urology Miami, Florida
Drew A. Palmer, MD University of Texas Southwestern
Endourology Fellow Medical Center Ardeshir R. Rastinehad, DO, FACOS
Department of Urology Dallas, Texas Director, Focal Therapy and Interventional
University of North Carolina at Chapel Hill Urology
Chapel Hill, North Carolina Curtis A. Pettaway, MD Associate Professor of Radiology and
Professor Urology
Jeffrey S. Palmer, MD, FACS, FSPU Department of Urology Departments of Urology and Radiology
Director, Genital Reconstruction University of Texas MD Anderson Cancer Icahn School of Medicine at Mount
Cohen Children’s Medical Center of New Center Sinai
York Houston, Texas New York, New York
Associate Professor of Urology and
Pediatrics Janey R. Phelps, MD Yazan F. Rawashdeh, MD
Zucker School of Medicine at Hofstra/ Department of Anesthesia Consultant Pediatric Urologist
Northwell The University of North Carolina at Department of Urology
Long Island, New York Chapel Hill Section of Pediatric Urology
Chapel Hill, North Carolina Aarhus University Hospital
Lane S. Palmer, MD, FACS, FSPU
Chief, Division of Pediatric Urology Aarhus, Denmark
Ryan Phillips, MD, PhD
Cohen Children’s Medical Center of New Resident Physician
York Pramod P. Reddy, MD
Radiation Oncology and Molecular Professor
Professor of Urology and Pediatrics Radiation Sciences
Zucker School of Medicine at Hofstra/ Division Director, Division of Pediatric
Johns Hopkins University School of Urology
Northwell Medicine
Long Island, New York Cincinnati Children’s Hospital
Baltimore, Maryland Cincinnati, Ohio
Meyeon Park, MD, MAS
Phillip M. Pierorazio, MD
Associate Professor W. Stuart Reynolds, MD, MPH
Associate Professor of Urology and Oncology
Medical Director Associate Professor
Brady Urological Institute and
UCSF PKD Center of Excellence Department of Urology
Department of Urology
Department of Medicine Vanderbilt University Medical Center
Johns Hopkins School of Medicine
Division of Nephrology Nashville, Tennessee
Baltimore, Maryland
University of California–San Francisco
San Francisco, California Hans G. Pohl, MD, FAAP Koon Ho Rha, MD, PhD, FACS
Associate Professor Professor
William P. Parker, MD Department of Urology
Assistant Professor Department of Pediatrics
Division of Urology Urological Science Institute
Department of Urology Yonsei University College of Medicine
University of Kansas Health System Children’s National Medical Center
Washington, District of Columbia Seoul, Republic of Korea
Kansas City, Kansas
xiv CONTRIBUTORS

Lee Richstone, MD Eric S. Rovner, MD Rachel Selekman, MD, MS

Chairman of Urology Professor Assistant Professor, Pediatric Urology
Director of Laparoscopic and Robotic Department of Urology Children’s National Medical Center
Surgery Medical University of South Carolina Washington, District of Columbia
Professor of Urology Charleston, South Carolina
Lenox Hill Hospital Abhishek Seth, MD
New York, New York Steven P. Rowe, MD, PhD Assistant Professor, Urology
Assistant Professor of Radiology and Baylor College of Medicine
Stephen Riggs, MD Radiological Science Houston, Texas
Urologic Oncology Johns Hopkins University School of Karen Sandell Sfanos, PhD
Levine Cancer Institute Medicine Associate Professor
Charlotte, North Carolina Baltimore Maryland Department of Pathology
Johns Hopkins University School of
Richard C. Rink, MD, FAAP, FACS Matthew P. Rutman, MD Medicine
Emeritus Professor, Pediatric Urology Associate Professor of Urology Baltimore, Maryland
Riley Hospital for Children Indiana Columbia University Vagelos College of
University School of Medicine Physicians and Surgeons Paras H. Shah, MD
Faculty, Pediatric Urology Associate Attending Assistant Professor of Urology
Peyton Manning Children’s Hospital at New York–Presbyterian Hospital Albany Medical Center
Ascension St. Vincent New York, New York Albany, New York
Indianapolis, Indiana
Simpa S. Salami, MD, MPH Mohammed Shahait, MBBS
Michael L. Ritchey, MD Assistant Professor Consultant of Urology
Professor Department of Urology Department of Surgery
Department of Urology University of Michigan King Hussein Cancer Center
Mayo Clinic College of Medicine Ann Arbor, Michigan Amman, Jordan
Chief Medical Officer Leonard Davis Institute of Health
Phoenix Children’s Hospital Andrea Salonia, MD, PhD Economics
Phoenix, Arizona IRCCS San Raffaele Hospital University of Pennsylvania
Director, Urological Research Institute Philadelphia, Pennsylvania
Claus G. Roehrborn, MD Vita-Salute San Raffaele University
Professor and Chairman Milan, Italy Robert C. Shamberger, MD
Department of Urology Chief, Emeritus
University of Texas Southwestern Medical Edward M. Schaeffer, MD, PhD Department of Surgery
Center Professor and Chair Boston Children’s Hospital
Dallas, Texas Department of Urology Robert E. Gross Professor of Surgery
Northwestern University Feinberg School Harvard Medical School
Ashley E. Ross, MD, PhD of Medicine Boston, Massachusetts
Adjunct Associate Professor Chicago, Illinois
Department of Urology Alan W. Shindel, MD, MAS
Johns Hopkins Brady Urological Institute Bruce J. Schlomer, MD Associate Professor
Baltimore, Maryland Associate Professor Department of Urology
Department of Urology University of California–San Francisco
Sherry S. Ross, MD University of Texas Southwestern San Francisco, California
Department of Urology Dallas, Texas
The University of North Carolina at Aseem R. Shukla, MD
Chapel Hill Michael J. Schwartz, MD, FACS Endowed Chair in Minimally Invasive
Chapel Hill, North Carolina Associate Professor of Urology Surgery
The Arthur Smith Institute for Urology Division of Pediatric Urology
Christopher C. Roth, MD Zucker School of Medicine at Hofstra/ Children’s Hospital of Philadelphia
Associate Professor Northwell Associate Professor of Surgery (Urology)
Department of Urology New Hyde Park, New York Perelman School of Medicine
Louisiana State University Health Sciences University of Pennsylvania
Center Allen D. Seftel, MD Philadelphia, Pennsylvania
Department of Pediatric Urology Professor of Urology
Children’s Hospital New Orleans Department of Surgery Jay Simhan, MD, FACS
New Orleans, Louisiana Cooper Medical School of Rowan Vice Chairman
University Department of Urology
Kyle O. Rove, MD Chief Einstein Healthcare Network
Assistant Professor Division of Urology Associate Professor of Urology
Department of Pediatric Urology Cooper University Health Care Department of Urology
Children’s Hospital Colorado Camden, New Jersey Fox Chase Cancer Center
Assistant Professor Adjunct Professor Philadelphia, Pennsylvania
Department of Surgery Department of Surgery
Division of Urology MD Anderson Cancer Center Brian W. Simons, DVM, PhD
University of Colorado Houston, Texas Assistant Professor
Aurora, Colorado Department of Urology
Johns Hopkins University School of Medicine
Baltimore, Maryland
 CONTRIBUTORS xv

Eila C. Skinner, MD Julie N. Stewart, MD Kae Jack Tay, MBBS, MRCS (Ed), MMed
Professor and Chair Assistant Professor (Surgery), MCI, FAMS (Urology)
Thomas A. Stamey Research Professor of Department of Urology Consultant
Urology Houston Methodist Hospital Department of Urology
Department of Urology Houston, Texas Singapore General Hospital
Stanford University School of Medicine SingHealth Duke–National University of
Stanford, California John Stites, MD Singapore Academic Medical Center
Minimally Invasive and Robotic Urologic Singapore
Armine K. Smith, MD Surgery
Assistant Professor Hackensack University Medical Center John C. Thomas, MD, FAAP, FACS
Brady Urological Institute Hackensack, New Jersey Professor of Urologic Surgery
Johns Hopkins University Division of Pediatric Urology
Assistant Professor Douglas W. Storm, MD Department of Urology
Department of Urology Assistant Professor Monroe Carell Jr. Children’s Hospital at
George Washington University Department of Urology Vanderbilt
Washington, District of Columbia University of Iowa Hospitals and Clinics Vanderbilt University Medical Center
Iowa City, Iowa Nashville, Tennessee
Daniel Y. Song, MD
Professor Douglas W. Strand, PhD J. Brantley Thrasher, MD, FACS
Radiation Oncology and Molecular Assistant Professor Professor Emeritus of Urology
Radiation Sciences Department of Urology University of Kansas Medical Center
Johns Hopkins University School of University of Texas Southwestern Medical Kansas City, Kansas
Medicine Center Executive Director
Baltimore, Maryland Dallas, Texas American Board of Urology
Rene Sotelo, MD Charlottesville, Virginia
Professor of Clinical Urology Li-Ming Su, MD
Department of Urology David A. Cofrin Professor of Urologic Edouard J. Trabulsi, MD, FACS
University of Southern California Oncology Professor and Vice Chair
Los Angeles, California Chairman, Department of Urology Department of Urology
University of Florida College of Sidney Kimmel Cancer Center
Michael W. Sourial, MD, FRCSC Medicine Sidney Kimmel Medical College at
Assistant Professor Gainesville, Florida Thomas Jefferson University
Department of Urology Philadelphia, Pennsylvania
The Ohio State University Chandru P. Sundaram, MD, FACS, FRCS
Columbus, Ohio Eng Chad R. Tracy, MD
Dr. Norbert and Louise Welch Professor of Professor of Urology and Radiology
Anne-Françoise Spinoit, MD, PhD Urology Department of Urology
Pediatric and Reconstructive Urologist Vice Chair (QI) University of Iowa
Department of Urology Director, Minimally Invasive Surgery and Iowa City, Iowa
Ghent University Hospital Residency Program
Ghent, Belgium Department of Urology Paul J. Turek, MD
Indiana University School of Medicine Director
Arun K. Srinivasan, MD Indianapolis, Indiana The Turek Clinic
Division of Pediatric Urology San Francisco, California
Children’s Hospital of Philadelphia Samir S. Taneja, MD
Assistant Professor of Surgery (Urology) The James M. Neissa and Janet Riha Neissa Mark D. Tyson, MD, MPH
Perelman School of Medicine Professor of Urologic Oncology Urologic Oncologist
University of Pennsylvania Professor of Urology and Radiology Department of Urology
Philadelphia, Pennsylvania Director, Division of Urologic Mayo Clinic Arizona
Oncology Phoenix, Arizona
Ramaprasad Srinivasan, MD, PhD Department of Urology
Head, Molecular Cancer Section New York University Langone Health Robert G. Uzzo, MD, MBA, FACS
Urologic Oncology Branch New York, New York Professor and Chairman
Center for Cancer Research Department of Surgery
National Cancer Institute Nikki Tang, MD G. Willing “Wing” Pepper Chair in Cancer
National Institutes of Health Assistant Professor Research
Bethesda, Maryland Department of Dermatology Adjunct Professor of Bioengineering
Johns Hopkins University Temple University College of Engineering
Irina Stanasel, MD Baltimore, Maryland Fox Chase Cancer Center–Temple
Assistant Professor University Health System
Department of Urology Gregory E. Tasian, MD Lewis Katz School of Medicine
University of Texas Southwestern/ Assistant Professor of Urology and Temple University
Children’s Health Epidemiology Philadelphia, Pennsylvania
Dallas, Texas University of Pennsylvania Perelman
School of Medicine Brian A. VanderBrink, MD
Andrew J. Stephenson, MD, MBA, FACS, Attending Physician Associate Professor
FRCS (C) Division of Urology Division of Urology
Professor The Children’s Hospital of Philadelphia Cincinnati Children’s Hospital
Section Chief and Director, Urologic Philadelphia, Pennsylvania Cincinnati, Ohio
Oncology
Rush Medical College
Chicago, Illinois
xvi CONTRIBUTORS

Alex J. Vanni, MD Dana A. Weiss, MD Christopher E. Wolter, MD

Associate Professor Assistant Professor of Urology Assistant Professor
Department of Urology in Surgery Department of Urology
Lahey Hospital and Medical Center University of Pennsylvania Mayo Clinic Arizona
Burlington, Massachusetts Attending Physician Phoenix, Arizona
Children’s Hospital of Philadelphia
David J. Vaughn, MD Philadelphia, Pennsylvania Dan Wood, PhD, MB BS, FRCS (Urol)
Professor of Medicine Consultant in Adolescent and
Division of Hematology/Oncology Jeffrey P. Weiss, MD Reconstructive Urology
Department of Medicine Professor and Chair University College London Hospitals
Abramsom Cancer Center at the Department of Urology London, United Kingdom
University of Pennsylvania State University of New York Downstate
Philadelphia, Pennsylvania Health Sciences University Michael E. Woods, MD
Attending Surgeon Professor of Urology
Vijaya M. Vemulakonda, MD, JD Veterans Affairs New York Harbor Department of Urology
Associate Professor and Director of Research Healthcare System Loyola University Medical Center
Division of Urology Brooklyn, New York Maywood, Illinois
Department of Surgery
University of Colorado School of Robert M. Weiss, MD Hailiu Yang, MD
Medicine Donald Guthrie Professor of Surgery/ Resident Physician
Attending Pediatric Urologist Urology Department of Urology
Children’s Hospital Colorado Department of Urology Cooper University Hospital
Aurora, Colorado Yale University School of Medicine Camden, New Jersey
New Haven, Connecticut
Manish A. Vira, MD Richard Nithiphaisal Yu, MD, PhD
System Chief of Urologic Oncology R. Charles Welliver, Jr., MD Department of Urology
Northwell Health Cancer Institute Department of Urology Assistant Professor of Surgery (Urology)
Smith Institute for Urology Albany Medical Center Boston Children’s Hospital and Harvard
Lake Success, New York Albany, New York Medical School
Associate Professor of Urology Boston, Massachusetts
Zucker School of Medicine at Hofstra/ Hunter Wessells, MD, FACS
Northwell Professor and Nelson Chair Joseph Zabell, MD
Hempstead, New York Department of Urology Assistant Professor
Affiliate Member Department of Urology
Ramón Virasoro, MD Harborview Injury Prevention and University of Minnesota
Associate Professor Research Center Minneapolis, Minnesota
Department of Urology University of Washington School of
Eastern Virginia Medical School Medicine Mark R. Zaontz, MD
Norfolk, Virginia Seattle, Washington Professor of Urology (Surgery)
Fellowship Co-Director Perelman School of Medicine
Department of Urology Duncan T. Wilcox, MD, MBBS University of Pennsylvania
Universidad Autonoma de Santo Domingo Surgeon in Chief, Ponzio Family Chair of Division of Urology
Santo Domingo, Dominican Republic Pediatric Urology Children’s Hospital of Philadelphia
Department of Pediatric Urology Philadelphia, Pennsylvania
Alvin C. Wee, MD Children’s Hospital Colorado
Assistant Professor of Surgery Aurora, Colorado Rebecca S. Zee, MD, PhD
Cleveland Clinic Lerner College of Assistant Professor
Medicine J. Christian Winters, MD, FACS Division of Urology
Director, Kidney Transplant Program H. Eustis Reily Professor and Chairman Children’s Hospital of Richmond
Glickman Urological and Kidney Institute Department of Urology Virginia Commonwealth University
Cleveland Clinic Louisiana State University Health New Richmond, Virginia
Cleveland, Ohio Orleans
New Orleans, Louisiana
Elias Wehbi, MD, MSc, FRCSC
Assistant Professor Anton Wintner, MD
Department of Urology Instructor of Surgery
University of California–Irvine Harvard Medical School
Children’s Hospital of Orange County Associate Residency Program Director
Orange, California Department of Urology
Massachusetts General Hospital
Alan J. Wein, MD, PhD (Hon), FACS Boston, Massachusetts
Founders Professor and Emeritus Chief of
Urology J. Stuart Wolf, Jr., MD
Division of Urology Professor and Associate Chair for Clinical
Director, Residency Program in Urology Integration and Operations
Perelman School of Medicine at the Surgery and Perioperative Care
University of Pennsylvania Dell Medical School of the University of
Penn Medicine Texas at Austin
Philadelphia, Pennsylvania Austin, Texas
HOW TO USE THIS STUDY GUIDE
This study guide is designed to provide the reader with a com-
prehensive review of urology based on the text Campbell-Walsh-
Wein Urology, twelfth edition. Each chapter includes a series of
questions and possible answers, explanations for each answer,
and a collection of chapter review points. Within the answer
explanations, text of particular importance has been indicated
in blue. If the reader knows the blue text and the chapter review
points, he or she will know the majority of important points for
that particular chapter. Moreover, if the questions are understood
and the emphasized points are remembered, then the reader will
have a thorough understanding of the important aspects of each
chapter.
It is important to note that some of the questions are not of the
format used in standardized tests such as the Qualifying Examina-
tion of the American Board of Urology. The proper format for exam-
ination questions is a question that asks for the one best possible
answer out of five. While many questions in this review guide are
in this format, some additional formats are used for teaching pur-
poses. For example, “all of the following are true except” allows the
author to provide the reader with four true statements regarding the
question, and “more than one answer may be correct” also allows
the author to make several points. Both formats serve to broaden
the reader’s knowledge.
We hope that this study guide will be helpful to both the resi-
dent or fellow in training and the practicing clinician in refreshing
knowledge as well as in preparing for a urology examination.
Alan J. Wein, MD, PhD (Hon), FACS
Founders Professor and Emeritus Chief of Urology
Division of Urology
Director, Residency Program in Urology
Perelman School of Medicine at the University of Pennsylvania
Penn Medicine
Philadelphia, Pennsylvania
Thomas F. Kolon, MD, FAAP
Howard M. Snyder III MD Chair in Pediatric Urology
Pediatric Urology Fellowship Program Director
Children’s Hospital of Philadelphia
Professor of Urology in Surgery
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, Pennsylvania
xvii
CONTENTS
PART I Clinical Decision Making 17 Complications of Urologic Surgery, 50
Reza Ghavamian and Charbel Chalouhy
1  valuation of the Urologic Patient: History and
E
Physical Examination, 1 18 Urologic Considerations in Pregnancy, 52
Sammy E. Elsamra Melissa R. Kaufman

2  valuation of the Urologic Patient: Testing and

E 19 Intraoperative Consultation, 55
­Imaging, 5 Michael J. Schwartz and Jessica E. Kreshover
Erik P. Castle, Christopher E. Wolter, and Michael Woods

3  rinary Tract Imaging: Basic Principles of CT, MRI,

U PART III Pediatric Urology
and Plain Film Imaging, 7
Jay T. Bishoff and Ardeshir R. Rastinehad
SECTION A Development and Prenatal Urology
4  rinary Tract Imaging: Basic Principles of Urologic
U 20 Embryology of the Human Genitourinary Tract, 57
Ultrasonography, 11
Laurence S. Baskin and Gerald Cunha
Bruce R. Gilbert and Pat F. Fulgham
21 Urologic Aspects of Pediatric Nephrology, 60
5  rinary Tract Imaging: Basic Principles of Nuclear
U
Michael C. Braun and Chester J. Koh
Medicine, 15
Michael A. Gorin and Steven P. Rowe 22 Perinatal Urology, 64
C.D. Anthony Herndon and Rebecca S. Zee
6 Assessment of Urologic and Surgical Outcomes, 17
David F. Penson and Mark D. Tyson

7 Ethics and Informed Consent, 19

SECTION B Basic Principles
Vijaya M. Vemulakonda 23 Urologic Evaluation of the Child, 67
Rachel Selekman and Hillary L. Copp

PART II Basics of Urologic Surgery 24 Pediatric Urogenital Imaging, 70

Hans G. Pohl
8  rinciples of Urologic Surgery: Perioperative
P
Care, 21 25 I nfection and Inflammation of the Pediatric
Simpa S. Salami Genitourinary Tract, 72
Christopher S. Cooper and Douglas W. Storm
9  rinciples of Urologic Surgery: Incisions and
P
Access, 23 26  ore Principles of Perioperative Management in
C
David Mikhail and Simon J. Hall Children, 77
Sherry S. Ross and Janey R. Phelps
10  rinciples of Urologic Surgery: Intraoperative
P
­Technical Decisions, 26 27  rinciples of Laparoscopic and Robotic Surgery in
P
Manish A. Vira and Christopher J. Hartman Children, 80
Thomas Sean Lendvay and Jonathan Ellison
11 Lower Urinary Tract Catheterization, 28
Joseph M. Jacob and Chandru P. Sundaram
SECTION C Lower Urinary Tract Conditions
12 Fundamentals of Upper Urinary Tract Drainage, 30
Casey A. Dauw and J. Stuart Wolf, Jr. 28  linical and Urodynamic Evaluation of Lower
C
Urinary Tract Dysfunction in Children, 83
13 Principles of Urologic Endoscopy, 36 Duncan T. Wilcox and Kyle O. Rove
Brian Duty and Michael J. Conlin
29 Management Strategies for Vesicoureteral Reflux, 86
14  undamentals of Laparoscopic and Robotic ­Urologic
F Antoine E. Khoury and Elias Wehbi
Surgery, 38
Roshan M. Patel, Kamaljot S. Kaler, and Jaime Landman 30 Bladder Anomalies in Children, 93
Aaron D. Martin and Christopher C. Roth
15 Basic Energy Modalities in Urologic Surgery, 44
Michael W. Sourial, Shubha K. De, Manoj Monga, and Bodo E. 31 Exstrophy-Epispadias Complex, 96
Knudsen John P. Gearhart and Heather N. Di Carlo

16 Evaluation and Management of Hematuria, 46 32 Prune-Belly Syndrome, 103

Stephen A. Boorjian, Jay D. Raman, and Daniel A. Barocas Francisco T. Dénes and Roberto Iglesias Lopes

xviii

33 Posterior Urethral Valves, 106
Aseem R. Shukla and Arun K. Srinivasan
34  euromuscular Dysfunction of the Lower Urinary
N 51
Tract in Children, 110
Carlos R. Estrada and Stuart B. Bauer
35  unctional Disorders of the Lower Urinary Tract in
F 52
Children, 114
Paul F. Austin and Abhishek Seth
36 Management of Defecation Disorders, 117
Martin A. Koyle and Armando J. Lorenzo
37 Lower Urinary Tract Reconstruction in Children, 122
John C. Thomas, Douglass B. Clayton, and Mark C. Adams
SECTION D Upper Urinary Tract Conditions
38 Anomalies of the Upper Urinary Tract, 129
Brian A. VanderBrink and Pramod P. Reddy
39  enal Dysgenesis and Cystic Disease of the
R 55
Kidney, 132
John C. Pope IV
40 Pathophysiology of Urinary Tract Obstruction, 138
Craig A. Peters and Kirstan K. Meldrum
41  ctopic Ureter, Ureterocele, and Ureteral Anomalies,
E
140
Irina Stanasel and Craig A. Peters
42  urgery of the Ureter in Children: Ureteropelvic
S
Junction, Megaureter, and Vesicoureteral Reflux, 144
L. Henning Olsen and Yazan F.H. Rawashdeh
43 Management of Pediatric Kidney Stone Disease, 147
Gregory E. Tasian and Lawrence Copelovitch
SECTION E Genitalia
44  anagement of Abnormalities of the External
M
­Genitalia in Boys, 149
Lane S. Palmer and Jeffrey S. Palmer
45 Hypospadias, 154
Christopher J. Long, Mark R. Zaontz, and Douglas A. Canning
46  tiology, Diagnosis, and Management of
E Charles G. Drake
­Undescended Testis, 160
Julia Spencer Barthold and Jennifer A. Hagerty
47  anagement of Abnormalities of the Genitalia in
M
Girls, 164
Martin Kaefer
48  isorders of Sexual Development: Etiology,
D 63
­Evaluation, and Medical Management, 166
Richard Nithiphaisal Yu and David A. Diamond
SECTION F Reconstruction and Trauma
49  urgical Management of Differences of Sexual
S 65
Differentiation and Cloacal and Anorectal
Malformations, 170
Richard C. Rink
CONTENTS xix
50 Adolescent and Transitional Urology, 172
Dan Wood
 rologic Considerations in Pediatric Renal
U
­Transplantation, 174
Craig A. Peters and Armando J. Lorenzo
Pediatric Genitourinary Trauma, 177
Bruce J. Schlomer and Micah A. Jacobs
SECTION G Oncology
53 Pediatric Urologic Oncology: Renal and Adrenal, 180
Michael L. Ritchey, Nicholas G. Cost, and Robert C. Shamberger
54 Pediatric Urologic Oncology: Bladder and Testis, 184
Fernando A. Ferrer
PART IV Infections and Inflammation
Infections of the Urinary Tract, 187
Kimberly L. Cooper, Gina M. Badalato, and Matthew P. Rutman
56 I nflammatory and Pain Conditions of the Male
Genitourinary Tract: Prostatitis and Related Pain
Conditions, Orchitis, and Epididymitis, 196
Michel Pontari
57 I nterstitial Cystitis/Bladder Pain Syndrome and
Related Disorders, 200
Robert M. Moldwin and Philip M. Hanno
58 Sexually Transmitted Diseases, 206
Kristy McKiernan Borawski
59 Cutaneous Diseases of the External Genitalia, 211
Richard Edward Link and Nikki Tang
60  uberculosis and Parasitic Infections of the
T
­Genitourinary Tract, 218
Alicia H. Chang, Brian G. Blackburn, and Michael Hsieh
PART V Molecular and Cellular Biology
61  asic Principles of Immunology and
B
­Immunotherapy in Urologic Oncology, 224
62 Molecular Genetics and Cancer Biology, 227
Karen Sandell Sfanos and Mark L. Gonzalgo
PART VI Reproductive and Sexual Function
 urgical, Radiographic, and Endoscopic Anatomy of
S
the Male Reproductive System, 233
Parviz K. Kavoussi
64 Male Reproductive Physiology, 236
Paul J. Turek
I ntegrated Men’s Health: Androgen Deficiency,
­Cardiovascular Risk, and Metabolic Syndrome, 239
Neil Fleshner, Miran Kenk, and Steven Kaplan
xx CONTENTS

66 Male Infertility, 242 85  hysiology and Pharmacology of the Renal Pelvis

P
Craig S. Niederberger, Samuel J. Ohlander, and Rodrigo L. Pagani and Ureter, 327
Dana A. Weiss and Robert M. Weiss
67 Surgical Management of Male Infertility, 247
Marc Goldstein 86  enal Physiology and Pathophysiology Including
R
Renovascular Hypertension, 331
68  hysiology of Penile Erection and Pathophysiology
P Thomas Chi and Meyeon Park
of Erectile Dysfunction, 253
Alan W. Shindel and Tom F. Lue 87 Renal Insufficiency and Ischemic Nephropathy, 334
Joshua J. Augustine, Alvin C. Wee, Venkatesh Krishnamurthi, and David
69  valuation and Management of Erectile
E A. Goldfarb
­Dysfunction, 256
Arthur L. Burnett II and Ranjith Ramasamy 88  rological Complications of Renal
U
Transplantation, 338
70 Priapism, 259 Mohammed Shahait, Stephen V. Jackman, and Timothy D. Averch
Gregory A. Broderick

71 Disorders of Male Orgasm and Ejaculation, 264

Chris G. McMahon Upper Urinary Tract Obstruction and
PART IX 
72 Surgery for Erectile Dysfunction, 269 Trauma
Matthew J. Mellon and John J. Mulcahy 89  anagement of Upper Urinary Tract
M
Obstruction, 340
73  iagnosis and Management of Peyronie’s
D
Stephen Y. Nakada and Sara L. Best
Disease, 271
Allen D. Seftel and Hailiu Yang 90 Upper Urinary Tract Trauma, 344
Steven Brandes and Jairam Eswara
74 Sexual Function and Dysfunction in the Female, 275
Ervin Kocjancic, Valerio Iacovelli, and Ömer Acar

PART X Urinary Lithiasis and Endourology

PART VII Male Genitalia 91  rinary Lithiasis: Etiology, Epidemiology, and
U
Pathogenesis, 347
75  urgical, Radiographic, and Endoscopic Anatomy of
S
Margaret S. Pearle, Jodi A. Antonelli, and Yair Lotan
the Retroperitoneum, 279
Drew A. Palmer and Alireza Moinzadeh 92  valuation and Medical Management of Urinary
E
Lithiasis, 352
76 Neoplasms of the Testis, 284
Nicole L. Miller and Michael S. Borofsky
Andrew J. Stephenson and Timothy D. Gilligan
93  trategies for Nonmedical Management of Upper
S
77 Surgery of Testicular Tumors, 293 Urinary Tract Calculi, 358
Stephen Riggs, Kris E. Gaston, and Peter E. Clark
David A. Leavitt, Jean J.M.C.H. de la Rosette, and David M. Hoenig
78  aparoscopic and Robotic-Assisted Retroperitoneal
L 94  urgical Management for Upper Urinary Tract
S
Lymphadenectomy for Testicular Tumors, 299 ­Calculi, 361
Mohamad E. Allaf and Louis R. Kavoussi
Brian R. Matlaga and Amy E. Krambeck
79 Tumors of the Penis, 301 95 Lower Urinary Tract Calculi, 365
Curtis A. Pettaway, Juanita M. Crook, and Lance C. Pagliaro
Arvind P. Ganpule and Mahesh R. Desai
80 Tumors of the Urethra, 306
Christopher B. Anderson and James M. McKiernan

81 Inguinal Node Dissection, 309 PART XI Neoplasms of the Upper Urinary Tract
Rene Sotelo, Luis G. Medina, and Marcos Tobias-Machado 96 Benign Renal Tumors, 369
82  urgery for Benign Disorders of the Penis and
S William P. Parker and Matthew T. Gettman
­Urethra, 312 97 Malignant Renal Tumors, 372
Ramón Virasoro, Gerald H. Jordan, and Kurt A. McCammon Steven C. Campbell, Brian R. Lane, and Philip M. Pierorazio
83 Surgery of the Scrotum and Seminal Vesicles, 320 98  rothelial Tumors of the Upper Urinary Tract and
U
Dorota J. Hawksworth, Mohit Khera, and Amin S. Herati Ureter, 384
Panagiotis Kallidonis and Evangelos Liatsikos

99  urgical Management of Upper Urinary Tract

S
PART VIII Renal Physiology and Pathophysiology Urothelial Tumors, 387
Thomas W. Jarrett, Surena F. Matin, and Armine K. Smith
84  urgical, Radiologic, and Endoscopic Anatomy of
S
the Kidney and Ureter, 324 100 Retroperitoneal Tumors, 389
Mohamed A. Elkoushy and Sero Andonian Timothy A. Masterson, Clint Cary, and Richard S. Foster
 CONTENTS xxi

101 Open Surgery of the Kidney, 391 118 The Underactive Detrusor, 451
Aria F. Olumi and Michael L. Blute Christopher R. Chapple and Nadir I. Osman

102 L
 aparoscopic and Robotic Surgery of the
Kidney, 395
Daniel M. Moreira and Louis R. Kavoussi
103 Nonsurgical Focal Therapy for Renal Tumors, 399
Chad R. Tracy and Jeffrey A. Cadeddu
119 Nocturia, 453
Stephen D. Marshall and Jeffrey P. Weiss
120 P
 harmacologic Management of Lower Urinary Tract
Storage and Emptying Failure, 455
Karl-Erik Andersson and Alan J. Wein

104 Treatment of Advanced Renal Cell Carcinoma, 401 121 C

 onservative Management of Urinary Incontinence:
Ramaprasad Srinivasan and W. Marston Linehan Behavioral and Pelvic Floor Therapy, Urethral and
Pelvic Devices, 463
Diane K. Newman and Kathryn L. Burgio

PART XII The Adrenals 122 E

 lectrical Stimulation and Neuromodulation in
Storage and Emptying Failure, 465
105 S
 urgical and Radiographic Anatomy of the
John P.F.A. Heesakkers and Bertil Blok
Adrenals, 404
Ravi Munver and John Stites 123 R
 etropubic Suspension Surgery for Incontinence in
Women, 469
106 P
 athophysiology, Evaluation, and Medical
Siobhan M. Hartigan, Christopher R. Chapple, and Roger R. Dmochowski
­Management of Adrenal Disorders, 406
Alexander Kutikov, Paul L. Crispen, and Robert G. Uzzo 124 V
 aginal and Abdominal Reconstructive Surgery for
Pelvic Organ Prolapse, 475
107 Surgery of the Adrenal Glands, 413
J. Christian Winters, Ryan M. Krlin, and Barry Hallner
Sey Kiat Lim and Koon Ho Rha
125 S
 lings: Autologous, Biologic, Synthetic, and
­Midurethral, 479
Urine Transport, Storage, and Emptying
PART XIII  Alex Gomelsky and Roger R. Dmochowski

108 S
 urgical, Radiographic, and Endoscopic Anatomy of 126 C
 omplications Related to the Use of Mesh and Their
the Female Pelvis, 416 Repair, 487
Priya Padmanabhan Anne P. Cameron

109 S
 urgical, Radiographic, and Endoscopic Anatomy of 127 A
 dditional Therapies for Storage and Emptying
the Male Pelvis, 419 ­Failure, 489
Jen-Jane Liu, Bryan R. Foster, and Christopher L. Amling Timothy B. Boone, Julie N. Stewart, and Laura M. Martinez

110 P
 hysiology and Pharmacology of the Bladder and 128 Aging and Geriatric Urology, 492
Urethra, 422 Tomas L. Griebling
Toby C. Chai and Lori A. Birder 129 Urinary Tract Fistulae, 496
111  athophysiology and Classification of Lower
P Dirk J.M.K. De Ridder and Tamsin Greenwell
Urinary Tract Dysfunction: Overview, 427 130 Bladder and Female Urethral Diverticula, 502
Elizabeth Timbrook Brown, Alan J. Wein, and Roger R. Dmochowski
Lindsey Cox and Eric S. Rovner
112 E
 valuation and Management of Women With 131 S
 urgical Procedures for Sphincteric Incontinence in
­Urinary Incontinence and Pelvic Prolapse, 431 the Male, 507
Alvaro Lucioni and Kathleen C. Kobashi Hunter Wessells and Alex J. Vanni
113 E
 valuation and Management of Men With Urinary
Incontinence, 436
Riyad Tasher Al Mousa and Hashim Hashim
Benign and Malignant Bladder
PART XIV 
114 U
 rodynamic and Video-Urodynamic Evaluation of Disorders
the Lower Urinary Tract, 439
Benjamin M. Brucker and Victor W. Nitti 132 Bladder Surgery for Benign Disease, 510
Paras H. Shah and Lee Richstone
115 U
 rinary Incontinence and Pelvic Prolapse:
­Epidemiology and Pathophysiology, 442 133 Genital and Lower Urinary Tract Trauma, 513
Gary E. Lemack and Maude Carmel Allen F. Morey and Jay Simhan

116 N
 euromuscular Dysfunction of the Lower Urinary 134 S
 pecial Urologic Considerations in Transgender
Tract, 444 Individuals, 516
Casey Kowalik, Alan J. Wein, and Roger R. Dmochowski Nicolas Lumen, Anne-Françoise Spinoit, and Piet Hoebeke

117 Overactive Bladder, 449 135 Tumors of the Bladder, 518

W. Stuart Reynolds and Joshua A. Cohn Max Kates and Trinity J. Bivalacqua
xxii CONTENTS

136 M
 anagement Strategies for Non–Muscle-Invasive 148 E
 pidemiology, Etiology, and Prevention of Prostate
Bladder Cancer (Ta, T1, and CIS), 526 Cancer, 571
Joseph Zabell and Badrinath Konety Andrew J. Stephenson, Robert Abouassaly, and Eric A. Klein

137 M
 anagement of Muscle-Invasive and Metastatic 149 Prostate Cancer Biomarkers, 574
Bladder Cancer, 530 Todd M. Morgan, Ganesh S. Palapattu, and Simpa S. Salami
Thomas J. Guzzo, John Christodouleas, and David J. Vaughn
150 Prostate Biopsy: Techniques and Imaging, 577
138 S
 urgical Management of Bladder Cancer: Edouard J. Trabulsi, Ethan J. Halpern, and Leonard G. Gomella
­Transurethral, Open, and Robotic, 533
151 Pathology of Prostatic Neoplasia, 581
Neema Navai and Colin P.N. Dinney
Jonathan I. Epstein
139 U
 se of Intestinal Segments in Urinary Diversion,
536 152 Diagnosis and Staging of Prostate Cancer, 583
Stacy Loeb and James A. Eastham
Anton Wintner and Douglas M. Dahl

140 Cutaneous Continent Urinary Diversion, 540 153 A

 ctive Management Strategies for Localized Prostate
Cancer, 586
Guarionex Joel DeCastro, James M. McKiernan, and Mitchell C. Benson
Samir S. Taneja and Marc A. Bjurlin
141 Orthotopic Urinary Diversion, 546
154 Active Surveillance of Prostate Cancer, 590
Eila C. Skinner and Siamak Daneshmand
Laurence Klotz
142 Minimally Invasive Urinary Diversion, 551
155 Open Radical Prostatectomy, 592
Khurshid A. Guru
Edward M. Schaeffer, Alan W. Partin, and Herbert Lepor

156 L
 aparoscopic and Robotic-Assisted Radical
PART XV The Prostate ­Prostatectomy and Pelvic Lymphadenectomy, 597
143 D
 evelopment, Molecular Biology, and Physiology of Li-Ming Su, Brandon J. Otto, and Anthony Costello
the Prostate, 554 157 Radiation Therapy for Prostate Cancer, 600
Brian W. Simons and Ashley E. Ross Ryan Phillips, Sarah Hazell, and Daniel Y. Song
144 B
 enign Prostatic Hyperplasia: Etiology, 158 Focal Therapy for Prostate Cancer, 603
­Pathophysiology, Epidemiology, and Natural Kae Jack Tay and Thomas J. Polascik
­History, 557
Claus G. Roehrborn and Douglas W. Strand 159 Treatment of Locally Advanced Prostate Cancer, 606
Maxwell V. Meng and Peter R. Carroll
145 E
 valuation and Nonsurgical Management of Benign
Prostatic Hyperplasia, 561 160 M
 anagement Strategies for Biochemical Recurrence
Paolo Capogrosso, Andrea Salonia, and Francesco Montorsi of Prostate Cancer, 609
Eugene K. Lee and J. Brantley Thrasher
146 M
 inimally Invasive and Endoscopic Management of
Benign Prostatic Hyperplasia, 566 161 Hormonal Therapy for Prostate Cancer, 611
Sevann Helo, R. Charles Welliver, Jr., and Kevin T. McVary Scott Eggener

147 S
 imple Prostatectomy: Open and Robot-Assisted 162 T
 reatment of Castration-Resistant Prostate
Laparoscopic Approaches, 569 Cancer, 615
Misop Han and Alan W. Partin Emmanuel S. Antonarakis and Michael A. Carducci
 PART
I Clinical Decision Making

1 Evaluation of the Urologic Patient: History and Physical

Examination
Sammy E. Elsamra

QUESTIONS 7. What percentage of patients with multiple sclerosis will pre-

sent with urinary symptoms as the first manifestation of the
1. Pain associated with a stone in the ureter is the result of: disease?
a. obstruction of urine flow with distention of the renal capsule. a. 1%
b. irritation of the ureteral mucosa by the stone. b. 5%
c. excessive ureteral peristalsis in response to the obstructing c. 10%
stone. d. 15%
d. irritation of the intramural ureter. e. 20%
e. urinary extravasation from a ruptured calyceal fornix.
8. What important information is gained from pelvic biman-
2. The most common cause of gross hematuria in a patient older ual examination that cannot be obtained from radiologic
than 50 years is: ­evaluation?
a. renal calculi. a. Presence of bladder mass
b. infection. b. Invasion of bladder cancer into perivesical fat
c. bladder cancer. c. Presence of bladder calculi
d. benign prostatic hyperplasia. d. Presence of associated pathologic lesion in female adnexal
e. trauma. structures
e. Mobility/fixation of pelvic organs
3. The most common cause of pain associated with gross hema-
turia is: 9. With which of the following diseases is priapism most com-
a. simultaneous passage of a kidney stone. monly associated?
b. ureteral obstruction due to blood clots. a. Peyronie disease
c. urinary tract malignancy. b. Sickle cell anemia
d. prostatic inflammation. c. Parkinson disease
e. prostatic enlargement. d. Organic depression
e. Leukemia
4. All of the following are typical lower urinary tract symptoms
associated with benign prostatic hyperplasia EXCEPT: 10. What is the most common cause of cloudy urine?
a. urgency. a. Bacterial cystitis
b. frequency. b. Urine overgrowth with yeast
c. nocturia. c. Phosphaturia
d. dysuria. d. Alkaline urine
e. weak urinary stream. e. Significant proteinuria
5. The most likely cause of continuous incontinence (loss of 11. Conditions that decrease urine specific gravity include all of
urine at all times and in all positions) is: the following EXCEPT:
a. enterovesical fistula. a. increased fluid intake.
b. noncompliant bladder. b. use of diuretics.
c. detrusor hyperreflexia. c. decreased renal concentrating ability.
d. vesicovaginal fistula. d. dehydration.
e. sphincteric incompetence. e. diabetes insipidus.
6. All of the following are potential causes of anejaculation EX- 12. Urine osmolality usually varies between:
CEPT: a. 10 and 200 mOsm/L.
a. sympathetic denervation. b. 50 and 500 mOsm/L.
b. pharmacologic agents. c. 50 and 1200 mOsm/L.
c. bladder neck and prostatic surgery. d. 100 and 1000 mOsm/L.
d. androgen deficiency. e. 100 and 1500 mOsm/L.
e. cerebrovascular accidents.
1
2 PART I Clinical Decision Making

13. Elevated ascorbic acid levels in the urine may lead to false- 21. All of the following are microscopic features of squamous
negative results on a urine dipstick test for: epithelial cells EXCEPT:
a. glucose. a. large size.
b. hemoglobin. b. small central nucleus.
c. myoglobin. c. irregular cytoplasm.
d. red blood cells. d. presence in clumps.
e. leukocytes. e. fine granularity in the cytoplasm.
14. Hematuria is distinguished from hemoglobinuria or myoglo- 22. The number of bacteria per high-power microscopic field that
binuria by: corresponds to colony counts of 100,000/mL is:
a. dipstick testing. a. 1.
b. the simultaneous presence of significant leukocytes. b. 3.
c. microscopic presence of erythrocytes. c. 5.
d. examination of serum. d. 10.
e. evaluation of hematocrit. e. 20.
15. The presence of one positive dipstick reading for hematuria 23. Pain in the flaccid penis is usually due to:
is associated with significant urologic pathologic findings on a. Peyronie disease.
subsequent testing in what percentage of patients?
b. bladder or urethral inflammation.
a. 2%
c. priapism.
b. 10%
d. calculi impacted in the distal ureter.
c. 25%
e. hydrocele.
d. 50%
e. 75% 24. Chronic scrotal pain is most often due to:
a. testicular torsion.
16. The most common cause of glomerular hematuria is:
b. trauma.
a. transitional cell carcinoma.
c. cryptorchidism.
b. nephritic syndrome.
d. hydrocele.
c. Berger disease (immunoglobulin A nephropathy).
e. orchitis.
d. poststreptococcal glomerulonephritis.
e. Goodpasture syndrome. 25. Terminal hematuria (at the end of the urinary stream) is usu-
ally due to:
17. The most common cause of proteinuria is: a. bladder neck or prostatic inflammation.
a. Fanconi syndrome. b. bladder cancer.
b. excessive glomerular permeability due to primary glomeru- c. kidney stones.
lar disease.
d. bladder calculi.
c. failure of adequate tubular reabsorption.
e. urethral stricture disease.
d. overflow proteinuria due to increased plasma concentration
of immunoglobulins. 26. Enuresis is present in what percentage of children at age 5 years?
e. diabetes. a. 5%
18. Transient proteinuria may be due to all of the following EXCEPT: b. 15%
a. exercise. c. 25%
b. fever. d. 50%
c. emotional stress. e. 75%
d. congestive heart failure (CHF). 27. All of the following in the medical history suggest that erectile
e. ureteroscopy. dysfunction is more likely due to organic rather than psycho-
genic causes EXCEPT:
19. Glucose will be detected in the urine when the serum level is a. sudden onset.
above:
b. peripheral vascular disease.
a. 75 mg/dL.
c. absence of nocturnal erections.
b. 100 mg/dL.
d. diabetes mellitus.
c. 150 mg/dL.
e. inability to achieve adequate erections in a variety of cir-
d. 180 mg/dL. cumstances.
e. 225 mg/dL.
28. All of the following should be routinely performed in men
20. The specificity of dipstick nitrite testing for bacteriuria is: with hematospermia EXCEPT:
a. 20%. a. cystoscopy.
b. 40%. b. digital rectal examination.
c. 60%. c. serum prostate-specific antigen (PSA) level.
d. 80%. d. genital examination.
e. >90%. e. urinalysis.
 CHAPTER 1 Evaluation of the Urologic Patient: History and Physical Examination
29. Pneumaturia may be due to all of the following EXCEPT:
a. diverticulitis.
b. colon cancer.
c. recent urinary tract instrumentation.
d. inflammatory bowel disease.
e. ectopic ureter.
30. Which of the following disorders may commonly lead to irrita-
tive voiding symptoms?
a. Parkinson disease
b. Renal cell carcinoma
c. Bladder diverticula
d. Prostate cancer
e. Testicular torsion
ANSWERS
1. a. Obstruction of urine flow with distention of the renal
capsule. Pain is usually caused by acute distention of the renal
capsule, usually from inflammation or obstruction.
2. c. Bladder cancer. The most common cause of gross hematuria
in a patient older than age 50 is bladder cancer.
3. b. Ureteral obstruction due to blood clots. Pain in associa-
tion with hematuria usually results from upper urinary tract
hematuria with obstruction of the ureters with clots.
4. d. Dysuria. Dysuria is painful urination that is usually caused
by inflammation.
5. d. Vesicovaginal fistula. Continuous incontinence is most
commonly due to a urinary tract fistula that bypasses the ure-
thral sphincter or an ectopic ureter.
6. e. Cerebrovascular accidents. Anejaculation may result from
several causes: (1) androgen deficiency, (2) sympathetic den-
ervation, (3) pharmacologic agents, and (4) bladder neck and
prostatic surgery.
7. b. 5%. In fact, 5% of patients with previously undiagnosed
multiple sclerosis present with urinary symptoms as the first
manifestation of the disease.
8. e. Mobility/fixation of pelvic organs. In addition to defin-
ing areas of induration, the bimanual examination allows the
examiner to assess the mobility of the bladder; such informa-
tion cannot be obtained by radiologic techniques such as
computed tomography (CT) and magnetic resonance imaging
(MRI), which convey static images.
9. b. Sickle cell anemia. Priapism occurs most commonly in pa-
tients with sickle cell disease but can also occur in those with
advanced malignancy, coagulation disorders, and pulmonary
disease, as well as in many patients without an obvious cause.
10. c. Phosphaturia. Cloudy urine is most commonly caused by
phosphates in the urine.
11. d. Dehydration. Conditions that decrease specific gravity
include (1) increased fluid intake, (2) diuretics, (3) decreased
renal concentrating ability, and (4) diabetes insipidus.
12. c. 50 and 1200 mOsm/L. Osmolality is a measure of the
amount of solutes dissolved in the urine and usually varies
between 50 and 1200 mOsm/L.
13. a. Glucose. False-negative results for glucose and bilirubin may
be seen in the presence of elevated ascorbic acid concentra-
tions in the urine.
14. c. Microscopic presence of erythrocytes. Hematuria can be
distinguished from hemoglobinuria and myoglobinuria by
microscopic examination of the centrifuged urine; the presence
of a large number of erythrocytes establishes the diagnosis of
hematuria.
3
15. c. 25%. Investigators at the University of Wisconsin found that
26% of adults who had at least one positive dipstick reading
for hematuria were subsequently found to have significant
urologic pathologic findings.
16. c. Berger disease (immunoglobulin A nephropathy). IgA
nephropathy, or Berger disease, is the most common cause of
glomerular hematuria, accounting for about 30% of cases.
17. b. Excessive glomerular permeability due to primary glo-
merular disease. Glomerular proteinuria is the most common
type of proteinuria and results from increased glomerular cap-
illary permeability to protein, especially albumin. Glomerular
proteinuria occurs in any of the primary glomerular diseases
such as IgA nephropathy or in glomerulopathy associated with
systemic illness such as diabetes mellitus.
18. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
cially in the pediatric population, and usually resolves sponta-
neously within a few days. It may result from fever, exercise, or
emotional stress. In older patients, transient proteinuria may
be due to CHF.
19. d. 180 mg/dL. This so-called renal threshold corresponds to
a serum glucose level of about 180 mg/dL; above this level,
glucose will be detected in the urine.
20. e. >90%. The specificity of the nitrite dipstick test for detecting
bacteriuria is greater than 90%.
21. d. Presence in clumps. Squamous epithelial cells are large,
have a central small nucleus about the size of an erythrocyte,
and have an irregular cytoplasm with fine granularity.
22. c. 5. Therefore five bacteria per high-power field in a spun
specimen reflect colony counts of about 100,000/mL.
23. b. Bladder or urethral inflammation. Pain in the flaccid penis
is usually secondary to inflammation in the bladder or urethra,
with referred pain that is experienced maximally at the urethral
meatus.
24. d. Hydrocele. Chronic scrotal pain is usually related to nonin-
flammatory conditions such as a hydrocele or varicocele, and
the pain is usually characterized as a dull, heavy sensation that
does not radiate.
25. a. Bladder neck or prostatic inflammation. Terminal hema-
turia occurs at the end of micturition and is usually secondary
to inflammation in the area of the bladder neck or prostatic
urethra.
26. b. 15%. Enuresis refers to urinary incontinence that occurs
during sleep. It occurs normally in children as old as 3 years
but persists in about 15% of children at age 5 and about 1% of
children at age 15.
27. a. Sudden onset. A careful history will often determine
whether the problem is primarily psychogenic or organic. In
men with psychogenic impotence, the condition frequently
develops rather quickly, secondary to a precipitating event such
as marital stress or change or loss of a sexual partner.
28. a. Cystoscopy. A genital and rectal examination should be
done to exclude the presence of tuberculosis, a PSA assessment
and digital rectal examination should be done to exclude pro-
static carcinoma, and a urinary cytologic assessment should be
done to exclude the possibility of transitional cell carcinoma
of the prostate.
29. e. Ectopic ureter. Pneumaturia is the passage of gas in the
urine. In patients who have not recently had urinary tract
instrumentation or a urethral catheter placed, this is almost al-
ways due to a fistula between the intestine and bladder. Com-
mon causes include diverticulitis, carcinoma of the sigmoid
colon, and regional enteritis (Crohn disease).
30. a. Parkinson disease. The second important example of non-
specific lower urinary tract symptoms that may occur second-
ary to a variety of neurologic conditions is irritative symptoms
resulting from neurologic disease such as cerebrovascular
accident, diabetes mellitus, or Parkinson disease.
4 PART I Clinical Decision Making
CHAPTER REVIEW
1. IPSS score: 0 to 7 mild symptoms, 8 to 19 moderate symp-
toms, 20 to 35 severe symptoms.
2. Renal pain radiates from the flank anteriorly to the respec-
tive lower quadrant and may be referred to the testis,
labium, or medial aspect of the thigh. The pain is colicky
(fluctuates). It may be associated with gastrointestinal
symptoms due to reflex stimulation of the celiac ganglion.
3. Patients with slowly progressive urinary obstruction with
bladder distention often have no pain, despite residual
volumes in excess of a liter.
4. Pain of prostatic origin is poorly localized.
5. Scrotal pain may be primary or referred. Pain referred to the
testicle originates in the retroperitoneum, ureter, or kidney.
6. Hematuria, particularly in adults, should be regarded as a
symptom of malignancy until proven otherwise.
7. Adults normally arise no more than twice a night to void.
Urine production increases at night (recumbent position)
in older patients and those with cardiac disease, particularly
CHF.
8. Postvoid dribbling: Urine escapes into the bulbar urethra
and then leaks at the end of micturition. This may be allevi-
ated by perineal pressure following voiding.
9. Those who present with microscopic hematuria and ir-
ritative voiding symptoms should be suspected of having
carcinoma in situ of the bladder until proven otherwise.
10. Continuous incontinence is most commonly due to ectopic
ureter, urinary tract fistula, or totally incompetent sphincter.
11. Hematospermia almost always resolves spontaneously and
is rarely associated with any significant urologic pathology.
12. When urinary obstruction is associated with fever and
chills, it should be regarded as a urologic emergency.
13. It is always worthwhile to obtain the previous operative
report in patients who are to be operated on.
14. If the patient is uncircumcised, the foreskin must be re-
tracted for inspection of the glans.
15. The testes are normally 6 cm in length and 4 cm in width.
16. If one obtains a stool guaiac test (hemoccult) as a screen
for colon cancer, two subsequent stool specimens must be
obtained for an adequate test. If the hemoccult is positive,
the patient should be on a red meat–free diet for 3 days
before collection of three specimens.
17. A male urologist should always perform a female pelvic
examination with a female nurse in attendance.
18. The bulbocavernosus reflex tests the integrity of this spinal
cord reflex involving S2 to S4.
19. A positive dipstick for blood in the urine indicates hema-
turia, hemoglobinuria, or myoglobinuria. Hematuria is
distinguished from hemoglobinuria and myoglobinuria
by microscopic examination of the centrifuged urine and
identification of red blood cells (more than three red blood
cells per high-power field is abnormal).
20. Hematuria of nephrologic origin is frequently associated
with proteinuria and dysmorphic erythrocytes.
21. Anticoagulation at normal therapeutic levels does not pre-
dispose patients to hematuria.
22. The most accurate method to diagnose urinary tract infection
is by microscopic examination of the urine and identifying
pyuria and bacteria. This is confirmed by urine culture.
23. The chief complaint is the focus of the visit and is the
reason the patient seeks consultation. It should be the lead
sentence in the history and physical (H&P).
24. A family history should always include questions about
renal and prostate cancer, renal cysts, and stone disease.
25. Priapism occurs most commonly in patients with sickle cell
disease but can also occur in those with advanced malig-
nancy, coagulation disorders, or pulmonary disease, as well
as in many patients without an obvious cause.
26. On urine dipstick, false-negative results for glucose and
bilirubin may be seen in the presence of elevated ascorbic
acid concentrations in the urine.
27. Glomerular proteinuria is the most common type of
proteinuria and results from increased glomerular capillary
permeability to protein, especially albumin. Glomeru-
lar proteinuria occurs in any of the primary glomerular
diseases such as IgA nephropathy or in glomerulopathy
associated with systemic illness such as diabetes mellitus.
28. Five bacteria per high-power field in a spun specimen
reflect colony counts of about 100,000/mL.
29. An important example of nonspecific lower urinary tract
symptoms that may occur secondary to a variety of neuro-
logic conditions is irritative symptoms resulting from neu-
rologic disease such as cerebrovascular accident, diabetes
mellitus, and Parkinson disease.
30. The renal threshold for glucose corresponds to a serum
glucose level of about 180 mg/dL; above this level, glucose
will be detected in the urine.
2 Evaluation of the Urologic Patient: Testing and Imaging
Erik P. Castle, Christopher E. Wolter, and Michael Woods

QUESTIONS c. Berger disease (immunoglobulin A nephropathy).

1. What is the most common cause of cloudy urine? d. poststreptococcal glomerulonephritis.
a. Bacterial cystitis e. Goodpasture syndrome.
b. Urine overgrowth with yeast 8. The most common cause of proteinuria is:
c. Phosphaturia a. Fanconi syndrome.
d. Alkaline urine b. excessive glomerular permeability due to primary glomeru-
e. Significant proteinuria lar disease.
2. Conditions that decrease urine specific gravity include all of c. failure of adequate tubular reabsorption.
the following EXCEPT: d. overflow proteinuria due to increased plasma concentration
a. increased fluid intake. of immunoglobulins.
b. use of diuretics. e. diabetes.
c. decreased renal concentrating ability. 9. Transient proteinuria may be due to all of the following
d. dehydration. ­EXCEPT:
e. diabetes insipidus. a. exercise.
b. fever.
3. Urine osmolality usually varies between:
c. emotional stress.
a. 10 and 200 mOsm/L.
d. congestive heart failure.
b. 50 and 500 mOsm/L.
e. ureteroscopy.
c. 50 and 1200 mOsm/L.
d. 100 and 1000 mOsm/L. 10. Glucose will be detected in the urine when the serum level is
above:
e. 100 and 1500 mOsm/L.
a. 75 mg/dL.
4. Elevated ascorbic acid levels in the urine may lead to false- b. 100 mg/dL.
negative results on a urine dipstick test for:
c. 150 mg/dL.
a. glucose.
d. 180 mg/dL.
b. hemoglobin.
e. 225 mg/dL.
c. myoglobin.
d. red blood cells. 11. The specificity of dipstick nitrite testing for bacteriuria is:
e. leukocytes. a. 20%.
b. 40%.
5. Hematuria is distinguished from hemoglobinuria or myoglo-
binuria by: c. 60%.
a. dipstick testing. d. 80%.
b. the simultaneous presence of significant leukocytes. e. >90%.
c. microscopic presence of erythrocytes. 12. All of the following are microscopic features of squamous
d. examination of serum. epithelial cells EXCEPT:
e. evaluation of hematocrit. a. large size.
b. small central nucleus.
6. The presence of one positive dipstick reading for hematuria
is associated with significant urologic pathologic findings on c. irregular cytoplasm.
subsequent testing in what percentage of patients? d. presence in clumps.
a. 2% e. fine granularity in the cytoplasm.
b. 10% 13. The number of bacteria per high-power microscopic field that
c. 25% corresponds to colony counts of 100,000/mL is:
d. 50% a. 1.
e. 75% b. 3.
7. The most common cause of glomerular hematuria is: c. 5.
a. transitional cell carcinoma. d. 10.
b. nephritic syndrome. e. 20.

5
6 PART I Clinical Decision Making
14. All of following is true of uroflowmetry EXCEPT:
a. Qmax >20 mL/s is not consistent with obstruction.
b. Qmax, mean flow rate, and voided volume are parameters
obtained from this study.
c. 80 mL voided volume is adequate for uroflowmetry.
d. the study can be performed in sitting and standing positions.
e. uroflowmetry cannot diagnose the location of obstruction.
15. The following should be given to uncomplicated patients
undergoing simple flexible diagnostic cystourethroscopy:
a. single-dose oral antibiotic following procedure
b. 3 days of oral antibiotics following procedure
c. 3 days of oral antibiotics starting the day prior to procedure
d. nothing
e. single intramuscular injection of ceftriaxone following
procedure
16. What is the most appropriate initial workup for asymptomatic
microscopic hematuria (AMH)?
a. Flexible cystoscopy, urinary cytology, CT urogram, and
UroVysion FISH
b. Flexible cystoscopy and CT urogram
c. CT urogram and NMP22
d. Flexible cystoscopy, urinary cytology, and CT urogram
e. Flexible cystoscopy, renal ultrasound, and urinary cytology
ANSWERS
1. c. Phosphaturia. Cloudy urine is most commonly caused by
phosphates in the urine.
2. d. Dehydration. Conditions that decrease specific gravity
include (1) increased fluid intake, (2) diuretics, (3) decreased
renal concentrating ability, and (4) diabetes insipidus.
3. c. 50 and 1200 mOsm/L. Osmolality is a measure of the
amount of solutes dissolved in the urine and usually varies
between 50 and 1200 mOsm/L.
4. a. Glucose. False-negative results for glucose and bilirubin may
be seen in the presence of elevated ascorbic acid concentra-
tions in the urine.
5. c. Microscopic presence of erythrocytes. Hematuria can be
distinguished from hemoglobinuria and myoglobinuria by
CHAPTER REVIEW
1. A catheterized urine specimen should be obtained in the
female patient with a history of recurrent urinary tract
infections or suspected contaminated specimen.
2. Hematuria should be stratified into glomerular, nonglo-
merular, medical, and surgical causes.
3. A dipstick alone is inadequate for the diagnosis of micro-
scopic hematuria.
4. Asymptomatic microscopic hematuria is defined as three or
greater RBC/HPF on a properly collected urinary specimen
in the absence of an obvious benign cause.
5. Urine dipstick positive for only leukocyte esterase or nitrites
but not both should be confirmed with microscopic analy-
sis and urine culture.
6. Serum creatinine and glomerular filtration rate should be
ordered when renal obstruction of nephrologic disease is
suspected.
7. Prostate-specific antigen is a very sensitive test for prostate
conditions such as BPH and prostatitis and correlates most
often with prostate volume.
8. Urine cytology is not recommended during the initial
microscopic examination of the centrifuged urine; the presence
of a large number of erythrocytes establishes the diagnosis of
hematuria.
6. c. 25%. Investigators at the University of Wisconsin found that
26% of adults who had at least one positive dipstick reading
for hematuria were subsequently found to have significant
urologic pathologic findings.
7. c. Berger disease (immunoglobulin A nephropathy). IgA
nephropathy, or Berger disease, is the most common cause of
glomerular hematuria, accounting for about 30% of cases.
8. b. Excessive glomerular permeability due to primary glo-
merular disease. Glomerular proteinuria is the most common
type of proteinuria and results from increased glomerular cap-
illary permeability to protein, especially albumin. Glomerular
proteinuria occurs in any of the primary glomerular diseases
such as IgA nephropathy or in glomerulopathy associated with
systemic illness such as diabetes mellitus.
9. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
cially in the pediatric population, and usually resolves sponta-
neously within a few days. It may result from fever, exercise, or
emotional stress. In older patients, transient proteinuria may
be due to congestive heart failure.
10. d. 180 mg/dL. This so-called renal threshold corresponds to
a serum glucose level of about 180 mg/dL; above this level,
glucose will be detected in the urine.
11. e. >90%. The specificity of the nitrite dipstick test for detecting
bacteriuria is greater than 90%.
12. d. Presence in clumps. Squamous epithelial cells are large,
have a central small nucleus about the size of an erythrocyte,
and have an irregular cytoplasm with fine granularity.
13. c. 5. Therefore 5 bacteria per high-power field in a spun
specimen reflect colony counts of about 100,000/mL.
14. c. 80 mL voided volume is adequate for uroflowmetry. The
minimum voided volume that is accepted as a requirement for
considering an adequate assessment is at least 100 mL.
15. d. Nothing. For patients undergoing simple diagnostic flexible
cystoscopy no antibiotic prophylaxis is recommended un-
less there are extenuating risk factors for infection or recent
orthopedic implantation of artificial joints. Refer to American
Urological Association (AUA) recommendations on antibiotic
prophylaxis for urological procedures.
16. b. Flexible cystoscopy and CT urogram. For the initial work-
up of AMH, routine urine cytology is not necessary. Cytology
is generally utilized in patients with a history of bladder cancer
undergoing surveillance or the index of suspicion of a high-
grade lesion is present.
evaluation and screening for asymptomatic microscopic
hematuria.
9. Urine cytology is very specific for high-grade urothelial
carcinoma.
10. Uroflowmetry and assessment of postvoid residual should
be ordered when lower urinary tract obstruction is suspect-
ed.
11. Urodynamic studies provide information on disorders of
storage and voiding.
12. Routine use of antimicrobial prophylaxis is not recom-
mended for office cystourethroscopy, urodynamics, or
cystography in the patient without risk factors.
13. Renal ultrasonography can provide basic screening infor-
mation on the presence of hydronephrosis and medical
renal disease but is not an adequate stand-alone study for
the workup of hematuria.
14. CT without contrast of the abdomen and pelvis is the gold
standard for detecting urinary stones.
15. A KUB is a useful and easy test for the follow-up of existing
non-emergent radio opaque urinary stones.
3 Urinary Tract Imaging: Basic Principles of CT, MRI,
and Plain Film Imaging
Jay T. Bishoff and Ardeshir R. Rastinehad

QUESTIONS b. Severe allergic reactions are not dose dependent.

c. Hyperosmolar contrast media are more likely to cause
1. The measure of the potential adverse health effects of ionizing contrast reactions than are iso-osmolar agents.
radiation in sieverts (Sv) is known as:
d. The mechanism of action associated with severe idiosyncratic
a. radiation exposure. anaphylactoid (IA) reactions is an immunoglobulin E (IgE)
b. absorbed dose. antibody reaction to the contrast media.
c. equivalent dose. e. Severe cardiac disease is a risk factor for an adverse reaction
d. effective dose. to contrast media.
e. relative radiation levels. 7. After rapidly assessing airway, breathing, and circulation,
the medical treatment of choice for a severe, life-threatening
2. The relative radiation level associated with abdominal
adverse drug reaction following exposure to contrast
computed tomography (CT) without and with contrast is:
media is:
a. none.
a. subcutaneous injection of epinephrine 0.5 mg of 1:10,000
b. minimal, less than 0.1 mSv. epinephrine.
c. low, 0.1 to 1.0 mSv. b. intravenous injection of 100 mg of methylprednisone.
d. moderate, 1 to 10 mSv. c. 0.01 mg/kg of epinephrine (1:10,000 concentration), given
e. high, 10 to 100 mSv. intramuscularly in the lateral thigh.
3. Bladder filling may precipitate autonomic dysreflexia in d. intravenous diphenhydramine, 50 mg.
patients with a spinal cord injury above: e. 0.01 mg/kg of epinephrine (1:1000 concentration), given
a. S2. intramuscularly in the lateral thigh.
b. L4. 8. Which of the following is NOT a risk factor for developing
c. T10. contrast-induced nephropathy (CIN)?
d. T12. a. Type 2 diabetes mellitus
e. T6. b. Dehydration
c. Hypertension
4. Radiation exposure diminishes as the square of the distance
from the radiation source. An exposure of 9 mSv at 1 foot d. Ventricular ejection fraction less than 50%
from the source would be how much at 3 feet from the e. Chronic kidney disease (CKD) (glomerular filtration rate
source? [GFR] < 60 mL/min)
a. 0.09 mSv 9. Nephrogenic systemic fibrosis (NSF) is:
b. 1 mSv a. a rare genetic condition exacerbated by the use of
c. 3 mSv gadolinium-based contrast medium (GBCM).
d. 9 mSv b. immediately evident after exposure to gadolinium in 10%
e. 27 mSv of exposed patients.
c. fibrosis of the skin, subcutaneous tissue, and skeletal
5. Type 2 diabetics on oral metformin biguanide hyperglycemic muscle seen in patients with chronic hypertension exposed
therapy are at risk for biguanide lactic acidosis after exposure to gadolinium contrast medium.
to intravascular radiologic contrast media if they:
d. not seen in patients with GFR greater than 60 mL/min/
a. discontinue metformin 48 hours before the study. 1.73 m2.
b. have severe renal insufficiency and take metformin the day e. mainly seen in dialysis patients exposed to gadolinium
of the study. contrast medium.
c. are given a saline injection while taking metformin.
10. During a diuretic renal scintigraphy:
d. have normal kidney function and fail to stop metformin 48
hours before the study. a. the diuretic is administered approximately 2 minutes after
peak activity is seen in the collecting system.
e. decrease metformin dose and increase other
antihyperglycemic agents on the day of the study. b. a T½ of greater than 14 minutes is consistent with
obstruction.
6. All of the following are true EXCEPT: c. 99mTc-DMSA is the most sensitive for obstruction and
a. Patients with a history of asthma are at greater risk of determination of GFR.
having an adverse reaction to contrast media.

7
8 PART I Clinical Decision Making
d. intestinal or gallbladder activity should never be seen with
99mTc-MAG3.
e. a T½ of less than 10 minutes is consistent with a
nonobstructed system.
11. Positron emission tomography (PET):
a. has a higher diagnostic accuracy than CT for seminoma and
nonseminoma testis cancer following chemotherapy.
b. is sensitive and specific for detection of postchemotherapy
teratoma.
c. can be used with high positive predictive value within
2 weeks of completion of chemotherapy for bulky lymph
adenopathy.
d. has greater predictive value of primary disease in metastatic
urothelial carcinoma than magnetic resonance imaging (MRI).
e. is able to detect local or systemic recurrence of prostate
cancer in 74% of patients with prostate-specific antigen
recurrence.
12. What is the minimum estimated GFR for use of gadolinium-
based contrast agents?
a. Less than 30 mL/min/1.73 m2
b. Greater than 50 mL/min/1.73 m2
c. Greater than 35 mL/min/1.73 m2
d. Greater than 30 mL/min/1.73 m2
e. There are no restrictions for patients with renal
insufficiency.
13. In magnetic resonance (MR) images using T2-weighted
sequences, fluid appears as:
a. dark.
b. bright.
c. low signal.
d. signal void.
e. indeterminate.
14. What lesions may have a high signal (bright) on T2-weighted
MRI of the adrenal gland?
a. Pheochromocytoma
b. Metastasis
c. Adrenal cortical carcinoma (ACC)
d. None of the above
e. All of the above
15. MR chemical shift imaging (CSI) for adrenal adenoma takes
advantage of which of the following phenomena to aid in the
diagnosis?
a. Water and fat within the same voxel signals are canceled
out in opposed-phase imaging.
b. Opposed-phase imaging will exhibit a high signal (bright).
c. Intracellular lipid content within an adenoma is low.
d. Intravenous contrast is required.
e. All of the above.
16. Oncocytoma typically has been characterized by a central scar.
Which other renal lesion may also exhibit a central scar on T2-
weighted images?
a. Clear cell carcinoma
b. Angiomyolipoma
c. Chromophobe carcinoma
d. Transitional cell carcinoma
e. No other renal masses exhibit a central scar.
17. Which renal mass exhibits signal drop on opposed phase
imaging?
a. Papillary renal cell
b. Chromophobe carcinoma
c. Angiomyolipoma
d. Clear cell carcinoma
e. Transitional cell carcinoma
18. What signal characteristics do kidney stones exhibit on MR
urography?
a. High signal on T2-weighted images
b. Low signal on T2-weighted images
c. Signal void
d. High signal on T1-weighted images
e. Low signal on T1-weighted images
19. Multiparametric imaging of the prostate consists of anatomic
and functional sequences. Match the correct pair.
a. Anatomic: Diffusion-weighted imaging
b. Functional: T1- and T2-weighted images
c. Anatomic: Dynamic contrast enhanced sequences
d. Functional: Apparent diffusion coefficient maps
e. All of the above
ANSWERS
1. d. Effective dose. The distribution of energy absorption in the
human body will be different based on the body part being
imaged and a variety of other factors. The most important
risk of radiation exposure from diagnostic imaging is the
development of cancer. The effective dose is a quantity used
to denote the radiation risk (expressed in sieverts) to a
population of patients from an imaging study.
2. e . High, 10 to 100 mSv. The average person living in the
United States is exposed to 6.2 mSv of radiation per year from
ambient sources, such as radon, cosmic rays, and medical
procedures, which account for 36% of the annual radiation
exposure (NCRP, 2012). The recommended occupational
exposure limit to medical personnel is 50 mSv per year
(NCRP, 2012). The effective dose from a three-phase CT of the
abdomen and pelvis without and with contrast may be as high
as 25 to 40 mSv.
3. e. T6. Autonomic dysreflexia, also known as hyperreflexia,
means an overactivity of the autonomic nervous system
that can result in an abrupt onset of excessively high blood
pressure. Persons at risk for this problem generally have spinal
cord injury level above T6. Autonomic dysreflexia can develop
suddenly, is potentially life threatening, and is considered a
medical emergency. If not treated promptly and correctly, it
may lead to seizures, stroke, and even death.
4. b. 1 mSv. Maintaining the maximum practical distance from
an active radiation source significantly decreases exposure to
medical personnel.
5. b. Have severe renal insufficiency and take metformin
the day of the study. Patients with type 2 diabetes mellitus
on metformin may have an accumulation of the drug after
administering intravascular radiologic contrast medium
(IRCM), resulting in biguanide lactic acidosis presenting with
vomiting, diarrhea, and somnolence. This condition is fatal in
approximately 50% of cases (Wiholm, 1993).a
a Sourcesreferenced can be found in Campbell-Walsh-Wein Urology, 12th Edition,
on the Expert Consult website.
 CHAPTER 3 Urinary Tract Imaging: Basic Principles of CT, MRI, and Plain Film Imaging
Biguanide lactic acidosis is rare in patients with normal
renal function. Consequently in patients with normal renal
function and no known comorbidities, there is no need to
discontinue metformin before IRCM use, nor is there a need
to check creatinine following the imaging study.
6. d
 . The mechanism of action associated with severe
idiosyncratic anaphylactoid (IA) reactions is an
immunoglobulin E (IgE) antibody reaction to the contrast
media. The IA reactions are most concerning because they
are potentially fatal and can occur without any predictable
or predisposing factors. Approximately 85% of IA reactions
occur during or immediately after injection of IRCM and are
more common in patients with a prior adverse drug reaction
to contrast media; patients with asthma, diabetes, impaired
renal function, or diminished cardiac function; and patients
on beta-adrenergic blockers (Spring et al., 1997).
7. e. 0.01 mg/kg of epinephrine (1:1000 concentration), given
intramuscularly in the lateral thigh. Rapid administration
of epinephrine is the treatment of choice for severe contrast
reactions. Epinephrine can be administered intravenously (IV)
0.01 mg/kg body weight of 1: 10,000 dilution or 0.1 mL/kg
slowly into a running IV infusion of saline and can be repeated
every 5 to 15 minutes as needed. If no IV access is available,
the recommended intramuscular dose of epinephrine is 0.01
mg/kg of 1:1000 dilution (or 0.01 mL/kg to a maximum of
0.15 mg of 1:1000 if body weight is <30 kg; 0.3 mg if weight is
>30 kg) injected intramuscularly in the lateral thigh.
8. d. Ventricular ejection fraction less than 50%. The most
common patient-related risk factors for CIN are CKD
(creatinine clearance <60 mL/min), diabetes mellitus,
dehydration, diuretic use, advanced age, congestive heart
failure, age, hypertension, low hematocrit, and ventricular
ejection fraction less than 40%. The patients at highest
risk for developing CIN are those with both diabetes and
preexisting renal insufficiency.
9. d. Not seen in patients with GFR greater than 60 mL/
min/1.73 m2. Patients with CKD but GRF greater than 30 mL/
min/1.73 m2 are considered to be at extremely low or no risk
for developing NSF if a dose of GBCM of 0.1 mmol/kg or less
is used. Patients with GFR greater than 60 mL/min/1.73 m2 do
not appear to be at increased risk of developing NSF, and the
current consensus is that all GBCM can be administered safely
to these patients.
10. e. a T½ of less than 10 minutes is consistent with a
nonobstructed system. Transit time throughout the collecting
system in less than 10 minutes is consistent with a normal,
nonobstructed collecting system. A T½ of 10 to 20 minutes
shows mild to moderate delay and may be a mechanical
obstruction. The patient’s perception of pain after diuretic
CHAPTER REVIEW
1. Absorbed dose for therapy is measured in units called gray
(Gy); 1 rad = 0.01 Gy, or 1 centigray (cGy) = 1 rad.
2. The amount of energy absorbed by a tissue for diagnos-
tic purposes is referred to as the equivalent dose and is
measured in sieverts (Sv). Exposure of the eyes and gonads
to radiation has a more significant biologic impact than
exposure of other parts of the body. The occupational safety
limit is 50 mSv. Exposure time during fluoroscopy should
be minimized by the use of short bursts of fluoroscopy;
positioning the image intensifier as close to the patient as
feasible substantially reduces scatter radiation.
3. There are four basic types of iodinated contrast media: (1)
ionic monomer, (2) nonionic monomer, (3) ionic dimer,
(4) nonionic dimer.
9
administration can be helpful for the treating urologist to
consider when planning surgery in the patient with middle
to moderate obstruction. A T½ of greater than 20 minutes is
consistent with a high-grade obstruction.
11. a . Has a higher diagnostic accuracy than CT for seminoma
and nonseminoma testis cancer following chemotherapy.
There are data on the use of PET/CT in testis cancer, where
PET/CT was found to have a higher diagnostic accuracy
than CT for staging and restaging in the assessment of a
CT-visualized residual mass following chemotherapy for
seminoma and nonseminomatous germ cell tumors (Hain
et al., 2000; Albers et al., 1999).
12. d. Greater than 30 mL/min/1.73 m2. NSF occurs in patients
with acute or chronic renal insufficiency with a GFR less
than 30 mL/min/1.73 m2.
13. b. Bright. High signal on T2-weighted images. Fluid exhibits a
low signal on T1-weighted images.
14. e . All of the above. Traditional teaching reported the lightbulb
sign to be consistent with pheochromocytoma. However,
metastasis and ACC also have a high signal on T2-weighted
images. Furthermore, Varghese and colleagues reported that
35% of pheochromocytomas demonstrated low T2 signal,
contrary to conventional teaching. Therefore the conventional
teaching of the “lightbulb sign” is incorrect.
15. a. Water and fat within the same voxel signals are canceled
out in opposed-phase imaging. MR CSI is performed on T1-
weighted images. Opposed-phase imaging will demonstrate
a low signal (dark) if fat and water occupy the same voxel.
Adrenal adenomas have high intracytoplasmic fat. CSI is
performed without the use of intravenous contrast.
16. c . Chromophobe carcinoma. Chromophobe carcinoma
exhibits a high signal on T2-weighted images.
17. d
 . Clear cell carcinoma. Microscopic intracytoplasmic lipids
have been found in 59% of clear cell carcinomas, which allows
it to be differentiated from other renal cell carcinoma cell types.
18. c . Signal void. Nephrolithiasis/calcification on MR imaging has
no signal characteristics; therefore it appears as a void on imaging.
19. d. Functional: Apparent diffusion coefficient maps.
Multiparametric MRI refers to the use of anatomic sequences
(T1-weighted images, T2 triplanar [axial, sagittal, and
coronal] images) and functional sequences (diffusion-
weighted imaging/apparent diffusion coefficient maps,
dynamic contrast-enhanced MRI, spectroscopy). The
combined approach has reported negative and positive
predictive values to be greater than 90% in detecting
prostate cancer.
4. IA reactions are potentially fatal, are not dose dependent,
and are more common in patients with a history of adverse
reactions to contrast media, those with asthma or diabetes,
those with impaired renal and cardiac function, and those
on β-adrenergic blockers.
5. It is common to have nausea, flushing, pruritus, urticaria,
headache, and occasionally emesis after administration of
contrast media.
6. Patients at high risk for adverse allergic reactions should be
medicated with steroids, given 12 to 24 hours before the
injection of contrast media, as well as antihistamines.
7. For retrograde pyelography, it is useful to dilute contrast
media by half with sterile saline, which facilitates identify-
ing filling defects in the collecting system. There is a low
10 PART I Clinical Decision Making
CHAPTER REVIEW—cont’d
risk of contrast reactions in patients in whom a retrograde
or loopogram is performed.
8. Metformin does not need to be held before contrast admin-
istration in a patient with normal renal function and no
comorbidities.
9. The risk of developing contrast-induced nephropathy is
increased in patients with decreased renal function (GFR <
60 mL/min), diabetes mellitus, dehydration, advanced age,
congestive heart failure, liver disease, and cardiac ejection
fraction less than 40%.
10. TcDTPA is primarily filtered by the glomerulus. It is a good
agent to assess renal function.
11. Because TcDMSA is both filtered by the glomerulus and
secreted by the proximal tubule, it localizes in the renal
cortex and is a good agent for assessing cortical scarring and
ectopic renal tissue.
12. TcMAG3 is cleared mainly by tubular secretion; it has a
limited ability to access renal function.
13. A T½ less than 10 minutes suggests an unobstructed system.
A T½ greater than 20 minutes is consistent with renal ob-
struction.
14. A positive bone scan is not specific for cancer. Moreover,
the volume of cancer cannot be quantitated on bone scan.
Patients with widely metastatic disease may have diffuse
uptake (hyper scan) and no discrete lesions.
15. Glucose, choline, and amino acids have been used as imag-
ing agents for PET scans.
16. 18F-fluorodeoxyglucose (FDG) is used as an imaging agent
in PET scanning and takes advantage of the fact that tumors
have increased glycolysis and decreased dephosphorylation.
This scan is useful in testicular germ cell tumors, particu-
larly seminomas, in determining residual viable tumor
following chemotherapy.
17. The Hounsfield units scale assigns a value of −1000 Houns-
field units for air. Dense bone is assigned a value of +1000
Hounsfield units, and water is assigned 0 Hounsfield units.
18. With the exception of some indinavir stones, all renal and
ureteral calculi may be detected by helical CT.
19. The advantage of MRI is high-contrast resolution of soft tis-
sue on T1-weighted images. Fluid has a low signal and ap-
pears dark on T1-weighted images; on T2-weighted images,
fluid has a high signal and appears bright. Gadolinium
increases the brightness of T1-weighted images. Hemor-
rhage within a cyst results in a high signal on T1-weighted
images. MRI is the imaging modality of choice for patients
with iodine contrast allergies.
20. The risk of developing NSF after gadolinium administration
is increased in patients with GFRs less than 30 mL/min.
21. Adrenal adenomas have high lipid content and may be
differentiated from adrenal cancers or metastatic disease by
specialized CT or MRI scans.
22. Thirty-five percent of pheochromocytomas do not enhance
on T2-weighted images.
23. MRI and CT are excellent imaging studies to determine
the presence and extent of renal vein and vena cava tumor
thrombus. Uptake of gadolinium by the thrombus on MRI
differentiates tumor from bland (blood clot) thrombus.
24. Prostate MRI coupled with an assessment of dynamic con-
trast uptake and washout increases the diagnostic accuracy
for detecting cancer.
25. MR spectroscopy for prostate cancer is based on decreased
citrate levels and increased creatine and choline levels.
26. Bladder filling in patients with spinal cord injuries higher
than T6 may precipitate autonomic dysreflexia.
27. Radiation exposure diminishes as the square of the distance
from the radiation source.
4 Urinary Tract Imaging: Basic Principles of Urologic
Ultrasonography
Bruce R. Gilbert and Pat F. Fulgham

QUESTIONS d. frequency.
e. number of foci.
1. The maximum excursion of a wave above and below the
baseline is known as its: 8. Increasing frequency results in a loss of:
a. wavelength. a. absorption.
b. frequency. b. axial resolution.
c. period. c. lateral resolution.
d. cycle. d. depth of penetration.
e. amplitude. e. mechanical index.
2. The artifact that occurs when an ultrasound wave strikes an inter- 9. When sound waves encounter the interface between two
face at a critical angle and is refracted with limited reflection is: tissues with large differences in impedance, the waves are:
a. reverberation artifact. a. increased in frequency.
b. increased through-transmission artifact. b. decreased in frequency.
c. edging artifact. c. reflected.
d. comet-tail artifact. d. refracted.
e. aliasing artifact. e. reverberated.
3. Which ultrasound mode allows for detection and 10. When a tissue appears darker than the surrounding tissue on
characterization of the velocity and direction of motion? ultrasound it is said to be relatively:
a. Harmonic scanning a. hypoechoic.
b. Color Doppler b. hyperechoic.
c. Power Doppler c. hypodense.
d. Spatial compounding d. isoechoic
e. Gray-scale ultrasonography e. anechoic.
4. If the kidney is less echogenic than the liver, the kidney is
described as: 11. The focal zone represents the area of best:
a. hyperechoic. a. lateral resolution.
b. hypoechoic. b. axial resolution.
c. isoechoic. c. echogenicity.
d. anechoic. d. blood flow.
e. echogenic. e. tissue penetration.
5. The sonographic hallmark of testicular torsion is: 12. Increasing the gain has the effect of:
a. the “blue dot” sign. a. increasing amplitude of the sound waves.
b. epididymal edema. b. increasing acoustic power.
c. paratesticular fluid. c. increasing thermal index.
d. increased epididymal blood flow. d. increasing mechanical index.
e. absence of intratesticular blood flow. e. increasing transducer sensitivity.
6. Ultrasound waves are examples of: 13. One way to improve the visualization of deep structures is to:
a. radio waves. a. increase the frequency.
b. mechanical waves. b. decrease the frequency.
c. electromagnetic waves. c. increase the wave velocity.
d. ionizing radiation. d. decrease the gain.
e. light waves. e. employ Doppler flow.
7. The most important determinant of axial resolution is: 14. The best frequency for performing external renal ultrasound in
a. impedance. most adults is:
b. speed of propagation. a. 3.5 to 5 MHz.
c. acoustic power. b. 6 to 7 MHz.
11
12 PART I Clinical Decision Making

c. 7.5 to 8.4 MHz. 22. Characteristics of prostate cancer as demonstrated on

d. 8.5 to 9.9 MHz. transrectal ultrasound of the prostate may include:
e. None of the above. a. hypoechogenicity.
b. hyperechogenicity.
15. A simple cyst of the kidney would not display which of the
following characteristics? c. prostate asymmetry.
a. Bright back wall d. increased vascularity.
b. Increased through transmission e. all of the above.
c. Anechoic interior 23. The single most important determinant of patient safety in
d. Edging artifact ultrasound utilization is:
e. Hyperechoic internal nodule a. multifrequency probes.
b. good documentation.
16. Which of the following is correct?
c. an informed operator.
a. Measuring bladder volume requires three-dimensional
scanning. d. periodic equipment inspection.
b. A nearly empty bladder is desirable for bladder scanning. e. Doppler capability.
c. A curved array transducer is preferred for bladder ultra- 24. The disinfection level protocol required for transrectal
sound in most patients. ultrasound probes following needle biopsy is:
d. Ureteroceles are usually poorly visualized because the a. low.
membrane is thin. b. moderate.
e. Bladder ultrasound is a sensitive screening exam for sus- c. high.
pected bladder tumors.
d. critical.
17. Which of the following are evaluable by transabdominal e. none of the above.
bladder ultrasound?
a. Urine volume 25. For patient safety it is preferable to maximize and limit:
b. Bladder wall characteristics a. acoustic power, exam duration.
c. Stones or diverticulum b. acoustic power, gain.
d. Dilated ureters c. gain, acoustic power.
e. All of the above d. gain, use of cine function.
e. images, description.
18. Scrotal ultrasound for the evaluation of possible testicular
torsion may include all of the following but must include:
a. B-mode ultrasound. ANSWERS
b. multiple scrotal views.
1. e. Amplitude. In ultrasound physics it is crucial to understand
c. Doppler flow studies. the concept of amplitude. The amplitude of an ultrasound wave
d. simultaneous bilateral views. represents its relative energy state, and it is the amplitude of the
e. harmonic scanning. returning sound wave that determines the pixel brightness to be
displayed on a monitor during real-time gray-scale imaging.
19. The most important limitation of ultrasound in attempting to 2. c. Edging artifact. Echo reflection is the primary mechanism
characterize complex renal cysts as benign or malignant is: whereby sound waves are returned to a transducer. It is
a. refraction. important to understand how the angle of insonation affects
b. inability to evaluate enhancement. the reflection and refraction of sound waves. There is a critical
angle at which waves will travel along an interface rather than
c. lack of axial resolution. being returned to the probe. When this angle is encountered,
d. increased through-transmission with artifact. it provides a dark or hypoechoic “shadow” called an “edging
e. reverberation artifact. artifact.” A reverberation artifact is one caused by multiple
transits of a sound wave between the transducer and the
20. A complete transrectal ultrasound of the prostate should reflecting object. Increased through-transmission artifact is
include an evaluation of: caused by decreased attenuation of sound waves as they travel
a. rectal wall. through a fluid-filled structure. Comet-tail artifact is seen as
the result of the interaction between sound waves and fluid
b. seminal vesicles and ejaculatory ducts.
and gas filled structures such as the bowel. Aliasing artifact is
c. bladder. seen with Doppler ultrasonography.
d. prostate. 3. b. Color Doppler. Doppler ultrasonography is important for
e. all of the above. evaluating motion and flow. The critical difference between
color Doppler and power Doppler is that color Doppler
21. Which of the following would not typically be visible in a is able to evaluate both flow velocity and direction. Power
sagittal midline prostate ultrasound? Doppler evaluates integrated amplitude of the returning sound
a. Middle lobe of the prostate waves. Although gray-scale ultrasonography does permit the
evaluation of motion, it does not permit the characterization
b. Central zone of velocity or direction. Harmonic scanning and spatial
c. Ejaculatory duct compounding are modes that allow the selective evaluation
d. Tip of right seminal vesicle or combination of reflected frequencies in ways that improve
image quality.
e. Apex of the prostate
 CHAPTER 4 Urinary Tract Imaging: Basic Principles of Urologic Ultrasonography
4. b. Hypoechoic. In describing ultrasound images, it is
important to use correct terminology. Descriptive terms
involving echogenicity are relative terms. A hyperechoic
or hypoechoic structure is being described in relation to
the echogenicity of a reference standard. In most cases the
reference standard is the liver. In the adult the normal kidney
is hypoechoic relative to the normal liver in approximately
75% of patients.
5. e. Absence of intratesticular blood flow. The absence of
intratesticular blood flow is the classic sonographic finding in
testicular torsion. However, there are many documented cases
of some preserved intratesticular blood flow even in cases
with significant torsion. Therefore testicular torsion remains a
clinical diagnosis. Epididymal edema, paratesticular fluid, and
increased epididymal blood flow may be seen with testicular
torsion but may also be seen with other clinical conditions.
The blue dot sign is a classic physical finding in torsion of the
appendix testis.
6. b. Mechanical waves: Mechanical waves are represented
graphically as a sine wave alternating between a positive and
negative direction from the baseline. Sound waves as they
propagate through human tissue produce areas of returning
compression and rarefaction.
7. d. Frequency: Axial resolution is directly dependent on
the frequency of sound waves. The higher the sound wave’s
frequency is, the better the axial resolution.
8. d. Depth of penetration: The optimal ultrasound image
requires tradeoffs between resolution and depth of
penetration. High-frequency transducers of 6 to 10 MHz may
be used to image structures near the surface of the body (e.g.,
testis, pediatric kidney) with excellent resolution. However,
deeper structures (e.g., right kidney, bladder) require lower
frequencies of 3.5 to 5 MHz to penetrate. Such images will
have poorer axial resolution.
9. c. Reflected: The shape and size of the object and the angle
at which the advancing wave strikes the object are critical
determinants of the amount of energy reflected. The amount
of energy reflected from an interface is also influenced by the
impedance of the two tissues at the interface. Impedance is
a property that is influenced by tissue stiffness and density. It
is the difference in impedance that allows an appreciation of
interfaces between different types of tissue.
10. a. Hypoechoic: The liver is usually used as a benchmark for
echogenicity. A hypoechoic area is described as “darker” on
B-mode ultrasound.
11. a. Lateral resolution: Lateral resolution refers to the ability
to identify separately objects that are equidistant from the
transducer. Lateral resolution is a function of the focused
width of the ultrasound beam and is a characteristic of the
transducer. The location of the narrowest beam width can be
adjusted by the user. The more focused the beam is, the better
the lateral resolution at that location. Thus image quality can
be enhanced by locating the narrowest beam width (focus or
focal zone) at the depth of the object or tissue of interest
12. e. Increasing transducer sensitivity: The gain control on the
console of the ultrasound machine permits the user to increase
or decrease the sensitivity of the transducer to reflected sound
waves.
13. b. Decrease the frequency: The optimal ultrasound
image requires trade-offs between resolution and depth of
penetration. High-frequency transducers of 6 to 10 MHz may
be used to image structures near the surface of the body (e.g.,
testis, pediatric kidney), with excellent resolution. However,
13
deeper structures (e.g., right kidney, bladder) require lower
frequencies of 3.5 to 5 MHz to penetrate. Such images will
have poorer axial resolution.
14. a. 3.5 to 5 MHz: Deeper structures (e.g., right kidney, bladder)
require lower frequencies of 3.5 to 5 MHz to penetrate.
15. e. Hyperechoic internal nodule: A simple cyst is an example
of a structure that is well circumscribed, with an anechoic
interior and through transmission.
16. c. A curved array transducer is preferred for bladder
ultrasound in most patients: A curved array transducer is
of lower frequency (3.5–6 MHz) and provides greater depth
of penetration but with less axial resolution. It is most often
the transducer of choice for imaging the kidney and urinary
bladder.
17. e. All of the above: Urine volume, bladder wall characteristics,
the presence of calculi or diverticulum, and the presence of
dilated ureters just outside the bladder are all evaluable by
transabdominal bladder ultrasound.
18. c. Doppler flow studies: Caution should be used when
interpreting Doppler flow studies in the evaluation of
suspected testicular torsion. The hallmark of testicular torsion
is the absence of intratesticular blood flow. Paratesticular flow
in epididymal collaterals may appear within hours of torsion.
Comparison with the contralateral testis should be performed
to ensure that the technical attributes of the study are adequate
to demonstrate intratesticular blood flow.
19. b. Inability to evaluate enhancement: Unlike computed
tomography (CT), currently ultrasound cannot evaluate
enhancement. Once it is approved by the US Food and Drug
Administration (FDA) for this purpose, contrast-enhanced
ultrasound will allow the detection of enhancement of renal
masses by ultrasound.
20. e. All of the above: When evaluating the prostate, surrounding
structures need to be assessed. Rectal lesions (including
cancer), dilated seminal vesicles, and/or ejaculatory ducts
as well as bladder pathology should all be evaluated for a
complete examination.
21. d. Tip of right seminal vesicle: In a midline sagittal view the
tips of the seminal vesicles are not normally visualized on
ultrasound. An axial projection needs to be obtained to be
able to measure the length of each seminal vesicle.
22. e. All of the above: Although excellent resolution and tissue
characteristics is possible with transrectal ultrasound a
diagnosis of prostate cancer is not often able to be made with
ultrasound alone.
23. c. An informed operator: The ALARA (as low as reasonably
achievable) principle is intended to limit the total energy
imparted to the patient during an examination. This can be
accomplished by (1) keeping power outputs low, (2) using
appropriate scanning modes, (3) limiting examination times,
(4) adjusting focus and frequency, and (5) using the cine
function during documentation. All of these are dependent
upon an informed sonographer.
24. d. Critical: Any time body fluids or tissues come in contact
with an ultrasound transducer, critical or high-level
disinfection protocols must be strictly adhered to.
25. c. Gain, acoustic power: Unlike gain, which refers to
amplification of the acoustic signal returning to the transducer,
acoustic power is the amount of acoustic energy applied to the
tissue. The biologic effects of ultrasound in terms of power are
in the milliwatt range. High levels generate heat and cavitation,
which might result in tissue damage.
14 PART I Clinical Decision Making
CHAPTER REVIEW
1. One cycle per second is known as 1 hertz (Hz). High-
frequency ultrasonic transducers of 6 to 10 MHz are used to
image structures near the surface. Deeper structures require
lower frequencies of 3.5 to 5 MHz. Axial resolution improves
with increasing frequency, and depth of penetration decreases
with increasing frequency.
2. Resistive index is the peak velocity minus the end-diastolic
velocity over the peek systolic velocity. This is measured using
the color flow Doppler with spectral display and is used to
characterize renal artery stenosis, ureteral obstruction, and
penile arterial insufficiency.
3. By convention, the liver is used as a benchmark for echo-
genicity. By convention, the cephalad aspect of the structure
is to the left of the image.
4. Ultrasonography may produce injury due to mechanical ef-
fects caused by cavitation or by heat generation.
5. With the exception of some indinavir stones, all renal and
ureteral calculi may be detected by helical CT.
6. The advantage of magnetic resonance imaging (MRI) is
high-contrast resolution of soft tissue on T1-weighted im-
ages. Fluid has a low signal and appears dark on T1-weighted
images; on T2-weighted images, fluid has a high signal and
appears bright. Gadolinium increases the brightness of T1-
weighted images. Hemorrhage within a cyst results in a high
signal on T1-weighted images.
5 Urinary Tract Imaging: Basic Principles of
Nuclear Medicine
Michael A. Gorin and Steven P. Rowe

QUESTIONS 7. Which urologic malignancy is poorly imaged with 18F-FDG

positron emission tomography (PET)?
1. 99mTc-diethylenetriaminepentaacetic acid (99mTc-DTPA) a. Bladder cancer
undergoes renal clearance by which mechanism?
b. Penile cancer
a. Glomerular filtration
c. Prostate cancer
b. Active tubular secretion
d. Renal cell carcinoma
c. Anion exchange
e. Seminomatous germ cell tumor
d. Both A and B
e. All of the above 8. What is the half-life of the radionuclide 18F?
a. 20.3 minutes
2. 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) undergoes renal
clearance by which mechanism? b. 109.8 minutes
a. Glomerular filtration c. 68.0 minutes
b. Active tubular secretion d. 4.17 days
c. Anion exchange e. 78.4 hours
d. Both A and B 9. Which of the following PET radiotracers for prostate cancer
e. All of the above imaging is an amino acid analog?
18F-DCFPyL
a. 
3. 99mTc–dimercaptosuccinic acid (99mTc-DMSA) undergoes renal
68Ga-PSMA-11
b. 
clearance and is endocytosed by cells of which part of the
nephron? 11C-choline
c. 
a. Glomerulus d. 68Ga-RM2
b. Proximal tubule 18F-FACBC
e. 
c. Distal tubule 10. Which protein is highly expressed by clear cell renal cell carci-
d. Ascending loop of Henle noma (RCC) but not other renal tumor types and serves as a
e. Collecting duct target for molecular imaging of this malignancy?
a. GLUT1
4. When performing 99mTc-MAG3 renography, the relative function
of each kidney is determined by measuring the area under the b. PSMA
time activity curve between what two time points post injection? c. GRPR
a. 1 to 3 minutes d. CAIX
b. 3 to 5 minutes e. ASCT2
c. 5 to 10 minutes 11. Which radiotracer has the highest specificity for imaging pros-
d. 10 to 15 minutes tate cancer?
e. 15 to 20 minutes a. 18F-DCFPyL

b. 67Ga-citrate
5. Which radiotracer is ideally suited for imaging renal scaring?
99mTc-DTPA c. 11C-choline
a. 
99mTc-MAG3
b.  d. 18F-FDG
99mTc-DMSA e. 18F-FACBC
c. 
d. 67Ga-citrate 12. 18F-FDG PET is recommended for which application in men
99mTc–sulfur colloid
e.  with testicular cancer?
a. Initial cancer staging of patients with elevated postorchiec-
6. 2-Deoxy-2-[18F]fluoro-D-glucose (18F-FDG) is phosphorylated tomy tumor markers
by which glycolytic enzyme, trapping it inside metabolically
active cells? b. Initial cancer staging of patients with negative postorchiec-
tomy tumor markers
a. Hexokinase
c. Postchemotherapy imaging of a residual retroperitoneal
b. Glucokinase mass in men with a seminomatous germ cell tumor
c. Phosphofructokinase d. Postchemotherapy imaging of a residual retroperitoneal
d. Pyruvate kinase mass in men with a nonseminomatous germ cell tumors
e. Phosphoglucose isomerase e. Post-treatment surveillance in patients with negative markers
15
16 PART I Clinical Decision Making
ANSWERS
  
a. Goluerular filtration. 99mTc-DPTA is a single-photon
1. 
radiotracer that is excreted in the urine and can be used to
determine renal split function and to assess for functional
obstruction. 99mTc-DTPA is extracted by the kidneys through
glomerular filtration. The drug then quickly moves through
the renal tubules and is excreted in the urine without being
reabsorbed.
b. Active tubular secretion. 99mTc-MAG3 is a single-photon
2. 
radiotracer that is excreted in the urine and can be used to
determine renal split function and to assess for functional
obstruction. 99mTc-MAG3 is protein bound in circulation and
undergoes clearance exclusively through tubular secretion.
99mTc-MAG3 imaging is therefore not impacted by impaired
glomerular filtration.
b. Proximal tubule. 99mTc-DMSA is cleared from the plasma
3. 
primarily by glomerular filtration. Once within the lumina
10. 
of the renal tubules, 99mTc-DMSA undergoes receptor-medi-
ated endocytosis by the proximal tubular cells. The receptors
responsible for the endocytosis of 99mTc-DMSA are megalin
and cubilin.
a. 1 to 3 minutes. Dynamic renal imaging is performed in
4. 
11. 
two phases. In the first phase, known as the perfusion phase,
renal plasma flow to each individual renal unit is measured
and compared with flow within the aorta. Activity should be
detected in the regions of interest overlying the kidneys within
several seconds of detection in the aorta. The relative function
of each kidney is determined by measuring the area under the
time activity curves between 1 and 3 minutes post injection of
12. 
the radiotracer.
c. 99mTc-DMSA. Because this radiotracer undergoes endocyto-
5. 
sis by the proximal tubular cells, it is ideally suited for imag-
ing cortical processes such as acute pyelonephritis and renal
scaring.
a. Hexokinase. 18F-FDG is a glucose analog that is taken up by
6. 
metabolically active cells via GLUT transporters. Once within
the cell, 18F-FDG is phosphorylated by the glycolytic enzyme
hexokinase, preventing diffusion back across the cell membrane.
The trapped 18F-FDG molecules, which are missing a 2-hydroxyl
CHAPTER REVIEW
1. The most commonly used radiopharmaceutical agents for
nuclear imaging of the kidneys are technetium 99mTc-diethyl-
enetriaminepentaacetic acid (99mTc-DTPA), 99mTc- mercaptoa-
cetyltriglycine (MAG3), and 99mTc–dimercaptosuccinic acid
(DMSA).
2. 99mTc-DTPA and 99mTc-MAG3 are used to measure renal
blood flow, determine differential renal function, and to
evaluate for the presence and degree of renal obstruction.
3. 99mTc-DTPA is cleared by glomerular filtration, whereas
99mTc-MAG3 is cleared by tubular secretion.
4. 99mTc-MAG3 is the preferred at most centers over 99mTc-
DTPA because it has a higher extraction efficiency and is
less impacted by changes in renal function
5. 99mTc-DMSA is retained by cells of the proximal renal tu-
bules and is used to evaluate for infection and the presence
renal scarring.
6. 99mTc-DTPA and 99mTc-MAG3 can also be used to evaluate
renovascular hypertension, transplant graft function, and
vesicoureteral reflux.
7. Molecular imaging of cancer is most commonly performed
group, cannot undergo further glycolytic metabolism and remain
intact allowing for their detection with PET imaging.
c. Prostate cancer. 18F- FDG is taken up by malignant cells,
7. 
which commonly shunt energy production toward anaerobic
metabolism, a phenomenon referred to as the Warburg effect.
A number of genitourinary malignancies, including urothelial
carcinoma, renal cell carcinoma, squamous cell carcinoma of
the penis, and testicular germ cell tumors, can be successfully
imaged with 18F-FDG PET. Prostate cancer is unique in that it
does not show increased levels of glycolysis and therefore is
poorly visualized with 18F-FDG PET.
b. 109.8 minutes. The half-lives of other commonly used
8. 
radionuclides for PET imaging can be found in Table 5.2.
a. 18F-FACBC. This radiotracer functions as a substrate for
9. 
the amino acid transporters LAT1 and ASCT2, which are
overexpressed by multiple malignancies including prostate
cancer.
d. CAIX. This cell surface protein is near universally expressed
by clear cell RCC but not other renal tumor histologies. CAIX
is upregulated following loss of the von Hippel-Lindau (VHL)
gene, which is a defining event in the pathogenesis of clear cell
RCC.
a. 18F-DCFPyL. PET radiotracers targeting prostate-specific
membrane antigen (PSMA) have the highest specificity for
prostate cancer imaging. Of the radiotracers listed, 18F-DCF-
PyL is the only PSMA-targeted radiotracer. A summary of other
radiotracer used for prostate cancer imaging can be found in
Table 5.3.
c. Postchemotherapy imaging of a residual retroperito-
neal mass in men with a seminomatous germ cell tumor.
Guidelines from the European Association of Urology en-
dorse the use of 18F-FDG PET for men with a residual mass
following treatment of a seminoma with chemotherapy.
Using 18F-FDG PET in this manner helps to differentiate
fibrosis from residual active tumor. For patients with non-
seminomatous germ cell tumors, 18F-FDG PET imaging
is not indicated because there appears to be no clinical
benefit for PET in the detection of viable tumor over the
combination of computed tomography (CT) and serum
markers.
using the positron emission tomography (PET) radiotracer
2-deoxy-2-(18F)fluoro-D-glucose (18F-FDG)
8. A number of genitourinary malignancies can be success-
fully imaged with 18F-FDG PET, albeit with varying degrees
of clinical utility beyond conventional anatomical imaging
techniques.
9. Because 18F-FDG is excreted in the urine, imaging with this
radiotracer is typically performed to detect distant sites of
disease.
10. 18F-FDG has little role in imaging prostate cancer and a
number of other radiotracers have been developed for this
purpose.
11. Radiotracers targeting PSMA are the most promising class
of agents for prostate cancer imaging and in many parts of
the world have become the new standard of care for imag-
ing this malignancy.
12. One of the most well-established indications for 18F-FDG
PET imaging is in the detection of residual seminomatous
germ cell tumors following chemotherapy.
6 Assessment of Urologic and Surgical Outcomes
David F. Penson and Mark D. Tyson
QUESTIONS
1. When assessing disease-specific mortality, researchers need to
be aware that this outcome is subject to:
a. detection bias.
b. attribution bias.
c. problems with loss to follow-up.
d. all of the above.
e. b and c.
2. Which of the following is NOT one of the four require-
ments for a valid surrogate endpoint as described by
­P rentice?
a. Treatment is associated with the true endpoint.
b. The surrogate endpoint is associated with the true end-
point.
c. The full effect of treatment on the true endpoint is ex-
plained by the surrogate endpoint.
d. The surrogate endpoint can reliably be measured using
highly objective methods.
e. Treatment is also associated with the surrogate endpoint.
3. With regard to patient-centered outcomes:
a. clinicians can reliably assess these outcomes from the
doctor–patient interaction.
b. there are very few validated and reliable questionnaires
available for use in urology.
c. health-related quality of life is an important outcome to
measure, but only function need be assessed to get a full
portrait of this outcome.
d. patient-centered questionnaires are developed using the
principles of psychometric test theory.
e. none of the above.
4. Which of the following methods has not been suggested as a
technique to assess patient experience of pain?
a. Collect verbal or written descriptions of the pain
b. Query patient’s caregiver regarding patient’s pain level.
c. Have subject rate pain via its effect on observable
­b ehavior.
d. Use analogue techniques in which the patient compares
his/her pain with an experimentally induced stimulus of a
known intensity in a laboratory setting.
e. All of the above can be used to assess pain levels.
5. When a scale has a coefficient α of 0.90, one can be assured
that the scale has high degree of:
a. alternate form reliability.
b. test-retest reliability.
c. internal consistency reliability.
d. intraobserver reliability.
e. interobserver reliability.
6. If a urologist were designing an instrument to measure cancer-
specific quality of life following prostatectomy, how would she
design an experiment to assess test-retest reliability?
a. She could administer the questionnaire before and after the
operation.
b. She could administer the questionnaire to her patients and
a group of age-matched healthy controls.
c. She could use a differently worded questionnaire to obtain
the same information.
d. She could administer the questionnaire to the same patient
twice in the same week and compare the results.
e. She could administer the questionnaire to the same patient
twice at an interval of one year and compare the results.
7. Of the following types of validity, which one often takes
many years of instrument use by numerous investigators to
­adequately assess?
a. Face validity
b. Content validity
c. Concurrent validity
d. Predictive validity
e. Construct validity
8. The use of uroflow results in validating a new survey instru-
ment that measures disease-specific HRQOL in benign pros-
tatic hyperplasia (BPH) patients is an example of:
a. concurrent validity.
b. content validity.
c. construct validity.
d. predictive validity.
e. face validity.
9. A patient undergoes a radical cystectomy. On post-operative day
#2, he aspirates and requires emergent intubation and transfer to
the ICU. He is started on intravenous antibiotics and is extubated
on post-operative day #4. The remainder of his hospital course in
unremarkable and he is discharged on post-operative day #8. The
complication he experienced is a Clavien-Dindo grade:
a. II.
b. IIIa.
c. IIIb.
d. IVa.
e. IVb.
10. A patient with kidney cancer has a single target lesion, a 5-cm
bony metastases. She is treated with a tyrosine kinase inhibitor
(TKI). The lesion is reduced in size and is now 4 cm on imag-
ing. According to the RECIST criteria, this is considered a:
a. complete response.
b. partial response.
c. stable disease.
d. non-CR/non-PD.
e. progressive disease.
17
18 PART I Clinical Decision Making
ANSWERS
1. e. b and c. When assessing disease-specific mortality, research-
ers need to be aware that this outcome is subject to attribution
bias and problems with loss to follow-up.
2. d. The surrogate endpoint can reliably be measured using
highly objective methods. It is not a requirement for a valid
surrogate endpoint that it can reliably be measured using
highly objective methods.
3. d. Patient-centered questionnaires are developed using the
principles of psychometric test theory. For patient-centered
outcomes, patient-centered questionnaires are developed using
the principles of psychometric test theory.
4. e. All of the above can be used to assess pain levels. Col-
lecting verbal or written descriptions of the pain; querying the
patient’s caregiver regarding the patient’s pain level; having
the subject rate pain via its effect on observable behavior; and
using analogue techniques in which the patient compares his/
her pain with an experimentally induced stimulus of a known
CHAPTER REVIEW
1. The effectiveness of health services delivery and treatment
can be measured across three distinct dimensions: structure,
process, and outcomes. Structure and process measures are
easier to assess but outcomes tend to be most meaningful to
clinicians and patients.
2. Mortality is the “hardest” endpoint one can assess in urology.
That being said, it can be subject to bias. Specifically, stud-
ies using overall mortality can still be subject to lead- and
length-time bias, and studies using disease-specific mortality
may be subject to attribution bias.
3. While there are many proxy endpoints in urology, few meet
all four requirements for being a valid surrogate endpoint.
Despite this, urologists routinely use proxy endpoints in
research and clinical practice.
intensity in a laboratory setting are all methods to assess pa-
tient pain.
5. c. Internal consistency reliability. When a scale has a coef-
ficient alpha of 0.90, the scale has a high degree of internal
consistency reliability.
6. d. She could administer the questionnaire to the same
patient twice in the same week and compare the results.
A urologist wishing to measure cancer-specific quality of life
following prostatectomy could design an experiment to assess
test-retest reliability by administering the questionnaire to the
same patient twice in the same week and comparing the results.
7. e. Construct validity. Construct validity often takes many years of
instrument use by numerous investigators to adequately assess.
8. a. Concurrent validity. The use of uroflow results in validat-
ing a new survey instrument that measures disease-specific
HRQOL in BPH patients is an example of concurrent validity.
9. d. IVa. The patient’s complication is Clavien-Dindo grade IVa.
10. c. Stable disease. This is considered stable disease per RECIST
criteria.
4. There are a number of published and widely accepted criteria
for defining disease progression and surgical complications
in urology. While these urologists should use these reporting
systems whenever possible, they should also remember that the
use of these systems does not completely eliminate the poten-
tial for bias in research due to study design and other factors.
5. Frailty, functional status, and comorbidity are important
potential confounders that should be considered in urologic
research. There are numerous standardized tools available to
capture these variables.
6. There are numerous patient-reported outcome tools available
to assess symptoms and quality of life in patients with uro-
logic diseases. Physicians and researchers should always use
validated and reliable patient-centered tools when possible.
7 Ethics and Informed Consent
Vijaya M. Vemulakonda

QUESTIONS c. information that a “reasonable person” would want to

know.
1. The Hippocratic Oath does not include the ethical principle of: d. a written document detailing risks and benefits of the pro-
a. beneficence. cedure.
b. non-maleficence. 8. The element of informed consent that is most often lacking is:
c. patient privacy. a. description of the clinical problem, proposed treatment,
d. patient autonomy. and alternatives.
e. accountability to the profession. b. discussion of the risks and benefits of the proposed treat-
ment.
2. Important events leading to the modern framework of medical
ethics include: c. assessment of the patient’s understanding of the informa-
tion provided by the medical provider.
a. The Nuremburg Trials.
d. solicitation of the patient’s preferences for treatment.
b. The Tuskegee Syphilis Studies.
c. The Milgram Experiments. 9. Exceptions to the informed consent requirement do not in-
clude:
d. all of the above.
a. an unconscious 25-year-old patient who sustained multiple
e. none of the above. gunshot wounds.
3. The most important of the four basic principles of modern b. a 75-year-old patient with Alzheimer dementia who is be-
medical ethics is: ing evaluated for benign prostatic hyperplasia (BPH) and
a. justice. has a previously identified surrogate decision maker.
b. autonomy. c. a 3-year-old patient who is accompanied by his parents for
circumcision evaluation.
c. beneficence.
d. a conscious 25-year-old patient who sustained multiple
d. non-maleficence.
gunshot wounds.
e. none of the above.
e. none of the above.
4. The term bioethics was first coined by:
10. Issues thought to be associated with lack of patient under-
a. Veatch. standing of consent include all EXCEPT:
b. Potter. a. language of the surgical consent form is above the average
c. Beauchamp and Childress. patient reading level.
d. Jonsen, Siegler, and Winslade. b. patients may misunderstand the risks posed by surgery.
e. none of the above. c. patients idealize surgeons and defer to surgeon recommen-
dations.
5. The Four Box Method does not:
d. patients may not recall the information contained within a
a. provide a systematic approach to apply ethical principles to surgical consent form.
specific clinical situations.
e. none of the above.
b. include consideration of medical indications, patient pref-
erences, quality of life, and other contextual features. 11. Use of decision aids have been associated with all of the fol-
c. create a venue for discussion of relative risks and benefits of lowing EXCEPT:
potential treatment options. a. improved knowledge of the procedure.
d. provide definitive answers to ethically challenging situa- b. improved assessment of risk.
tions. c. increased patient participation in the decision-making
e. none of the above process.
6. Clinical informed consent originated in: d. increased decisional conflict.
a. The Hippocratic Oath. e. none of the above.
b. 19th-century negligence laws.
c. The Nuremburg Code. ANSWERS
d. 20th-century battery laws.
1. d. Patient autonomy. Although the Hippocratic Oath includes
7. Under current informed consent requirements, physicians are the concepts of benefiting and avoiding harm to patients as
obligated to provide: well as protecting patient privacy, it does not include the con-
a. information about the most common risks of a procedure. cept of patient autonomy, which emerged in the 20th century.
2. d. All of the above. The Nuremburg trials revealed the involun-
b. information that a “reasonable physician” would provide.
tary experiments of Dr. Josef Mengele and other Nazi doctors
19
20 PART I Clinical Decision Making
on concentration camp detainees, resulting in pain, debilita-
tion, and death of subjects. The trials led to the development of
the Nuremburg code, which reinforced the need for voluntary
consent, need to minimize harm, absence of other methods to
obtain data, and need to terminate studies early if evidence of
potential harm in a clinical research study. The Tuskegee studies
were performed from 1932 to 1972 in Tuskegee, Alabama, to
study the natural history of syphilis, with investigators with-
holding antibiotic treatment even after the discovery of the ef-
ficacy of penicillin to treat the disease. The study raised issues of
adequate knowledge for consent, need to avoid coercion for par-
ticipation, and need to terminate studies early if the investigator
has knowledge of preventable harm. The Milgram experiments,
which were conducted in 1963 at Yale by psychologist Stan-
ley Milgram, encouraged subjects to administer fake electrical
shocks to unseen participants. Recorded responses to the shocks
were played, including screaming and silence suggestive of pos-
sible unconsciousness. Subjects were encouraged to continue
to escalate shocks despite these responses, with the majority of
subjects administering maximal shocks, leading to psychological
trauma in many participants. The study raised concerns about
use of deception in research and lack of adequate safeguards
against harm. All of these events led to heightened scrutiny and
development of heightened standards for medical research.
3. e. None of the above. According to Beauchamp and Childress, the
four basic principles of autonomy, beneficence, non-maleficence,
and justice should be considered equal in weight.
4. b. Potter. Van Rensselaer Potter first coined the term bioethics
in 1970, described as the “study of the moral relationship
between humans and their social and physical world.”
5. d. Provide definitive answers to ethically challenging situ-
ations. Although the Four Box Method allows for systematic
consideration of ethically complex clinical situations and cre-
ates a vehicle for discussions regarding treatment, it may also
oversimplify ethical problems and does not always provide
clear “right” and “wrong” answers to address ethical concerns.
6. d. 20th-century battery laws. Although now considered within
the scope of negligence, informed consent was first described
by state courts in early 20th-century battery cases and was
considered to be grounded in the right to bodily integrity.
The Nuremburg code recommended expansion of the right to
informed consent to medical research.
CHAPTER REVIEW
1. Although the scope of medical ethics continues to evolve, the
basic ethical principles of autonomy, beneficence, non-malef-
icence, and justice remain the foundation of ethical medical
practice.
2. Informed consent is essential to the practice of surgery with
limited exceptions.
7. c. Information that a “reasonable person” would want to
know. Although battery law required disclosure of risks and
early negligence law required disclosure of what a “reason-
able and prudent” physician would do, the current standard is
what a reasonable person would want to know (Canterbury vs.
Spence, 1972). The informed consent process requires both in-
formation from the physician and demonstrated understand-
ing by the patient but does not require written documentation.
8. c. Assessment of the patient’s understanding of the infor-
mation provided by the medical provider. Although all four
elements are needed for a comprehensive informed consent,
the majority of informed consents are incomplete with the
element of assessing patient understanding of the information
provided being the most commonly missed.
9. d. A conscious 25-year-old patient who sustained multi-
ple gunshot wounds. In emergency settings where there is a
significant threat to patient life or well-being, consent is pre-
sumed. However, this waiver of consent does not extend to the
conscious patient even if refusal of treatment is life-threatening
(In re Quackenbush 1978).
10. e. None of the above. All of the options have been posed as
limitations to patient understanding of consent. The informa-
tion provided in consent forms often is above the 12th-grade
level, although the majority of patients have reading levels be-
low the 8th-grade level. Additionally, patients who report read-
ing consent forms may not recall the information contained
in the document. Additionally, patients often underestimate
their risks compared to other people or may use heuristics to
make decisions that lead to a misunderstanding of the risks
involved. Finally, patients often accept surgical recommenda-
tions without meaningful participation in the decision-making
process due to idealization of the surgeon and his or her judg-
ment.
11. d. Increased decisional conflict. Decision aids have been as-
sociated with improved knowledge about procedures, reduced
decisional conflict, improved patient participation in the deci-
sion, and improved assessment of risk.
3. Despite the goal of ensuring adequate understanding of the
nature, risks, benefits, and alternatives of surgery to facilitate
a meaningful decision, the informed consent process is often
incomplete. It is therefore the responsibility of the surgeon
to make every effort to facilitate patient understanding and
participation in the decision-making process.
 PART
II Basics of Urologic Surgery
8 Principles of Urologic Surgery: Perioperative Care
Simpa S. Salami
QUESTIONS
1. A 64-year-old man is found to have an 8-cm left renal mass
and presents to the office for evaluation regarding laparo-
scopic radical nephrectomy. He has a history of hypertension,
non–insulin-dependent diabetes, and 30-pack-year history of
tobacco use, which he quit 10 years ago. He has a strong family
history of heart disease (father died at the age of 55 years from
a myocardial infarction). Further questioning reveals that he
does not regularly exercise but is able to walk up three flights of
stairs without shortness of breath. Before surgery, to minimize
the risk of complications, the patient should:
a. undergo routine preoperative testing with complete blood
count, basic metabolic panel, electrocardiogram, and chest
radiograph.
b. be referred to cardiology consultation to determine if further
testing is necessary.
c. undergo noninvasive cardiac stress testing.
d. undergo pulmonary function testing to determine the need
for preoperative bronchodilators.
e. be started on a perioperative β blocker to reduce the risk of
perioperative myocardial ischemia.
2. With regard to unique patient populations, which of the fol-
lowing statements is TRUE?
a. Although elderly patients have an increased perioperative
risk, recent larger trials have not found age to be an inde-
pendent risk factor for perioperative morbidity and mortality.
b. Morbidly obese patients should undergo open rather than
laparoscopic surgery because of increased risk of pulmonary
complications.
c. In a pregnant patient presenting with urolithiasis, operative
intervention should be delayed, if possible, until the second
trimester.
d. A patient who presents with a 30-pound weight loss over the
previous 3 months should be started on parenteral feedings
immediately postoperatively after elective surgery.
e. In patients with liver disease, the primary determinant of post-
operative risk is degree of liver function enzyme abnormality.
3. A 74-year-old man with muscle-invasive bladder cancer is
scheduled for radical cystectomy and ileal conduit urinary
diversion. Preoperative urine culture shows no growth at 72
hours. The most important factor in the prevention of surgical
site infection in this patient is:
a. preoperative bowel preparation with oral antibiotics (Nich-
ols prep) and sodium phosphate solution (Fleet).
b. administration of 2 g cefoxitin 1 hour before incision.
c. continuation of perioperative antibiotics for 48 hours fol-
lowing surgery.
d. preoperative hair removal with mechanical clippers and
proper sterile preparation of the operative field.
e. optimization of comorbid illness and nutritional status.
4. According to current guidelines in the prevention of thrombo-
embolic complications, a 78-year-old male with a recent history
of colon cancer, medical history of hypertension, coronary
artery disease (postoperative angioplasty with two coronary
stents), and chronic renal insufficiency (creatinine, 2.9 mg/dL)
undergoing laparoscopic transabdominal surgery should have
pneumatic compression stockings and:
a. early ambulation.
b. aspirin and early ambulation.
c. low-molecular-weight heparin.
d. low-molecular-weight heparin and aspirin.
e. unfractionated heparin and aspirin.
5. A 72-year-old woman with a history of asthma, mild congestive
heart failure, and breast cancer is to undergo cystoscopy and
placement of a midurethral sling. Of the following agents, the
best choice for anesthesia induction would be:
a. inhaled halothane.
b. intravenous thiopental.
c. inhaled desflurane.
d. inhaled sevoflurane.
e. intravenous succinylcholine.
6. A 56-year-old man with autoimmune disease is scheduled to
undergo robotic-assisted laparoscopic radical prostatectomy.
Which of the following represents the best choice for managing
his chronic exogenous steroid therapy?
a. Discontinue prior to surgery
b. Discontinue prior to surgery and resume post-operatively
c. Discontinue prior to surgery, administer stress dose steroid
before the induction of anesthesia, and continue post-opera-
tively until home medication is resumed
d. Continue patient’s oral medication at the current dosage
through surgery
e. Increase the dose of patient’s oral medication prior to sur-
gery and reduce back to baseline dose after surgery.
ANSWERS
1. e. Be started on preoperative β blocker to reduce the risk of
perioperative myocardial ischemia. This choice is best given
the patient’s multiple risk factors. Although cardiac stress test-
ing may be considered, the patient’s ability to climb three
flights of stairs indicates a capacity of greater than 4 meta-
bolic equivalents (METs) and therefore a low risk of signifi-
cant coronary artery disease. Although routine preoperative
testing is performed widely, there is no evidence that routine
testing reduces the risk of perioperative complications.
2. c. In a pregnant patient presenting with urolithiasis, op-
erative intervention should be delayed, if possible, until
the second trimester. The second trimester represents the
least anesthetic risk to the mother and fetus with regard to
21
22 PART II Basics of Urologic Surgery
s­ pontaneous abortion and teratogenicity. Although controver-
sy exists as to the exact etiology, several recent trials have found
age to be an independent predictor of morbidity on multivari-
ate analyses. Laparoscopic surgery is the preferred approach
in morbidly obese patients secondary to the reduced risk of
pulmonary and wound complications. Literature suggests that
severely malnourished patients (>20 pounds weight loss in
3 months) significantly benefit from 7 to 10 days of enteral
(not parenteral) feedings before elective surgery. The primary
determinants of the degree of severity in patients with cirrhosis
are hepatic function and severity of clinical manifestations.
3. b. Administration of 2 g cefoxitin 1 hour before incision.
Administration of appropriate antibiotics within 60 minutes of
incision has been shown to significantly decrease the inci-
dence of surgical site infections. Recent meta-analyses from the
colorectal literature indicate that mechanical bowel preparation
does not decrease the risk of postoperative infections. Unless
in the presence of active infection, perioperative antibiotics
should be stopped 24 hours after incision to decrease the
risk of Clostridium difficile colitis. Although preoperative hair
removal and optimization of nutritional status and comorbid
illness improve surgical outcomes, there is no specific evidence
that this reduces surgical site infections.
4. e. Unfractionated heparin and aspirin. The clinical scenario
describes a patient with high to highest risk of venous throm-
CHAPTER REVIEW
1. One must always determine whether a woman in the
childbearing years is pregnant before a surgical procedure.
A urine pregnancy test is a simple method to do this.
2. The American Society of Anesthesiologists’ classification is
a significant predictor of operative mortality.
3. Preoperative cardiac evaluation is meant to identify serious
coronary artery disease, heart failure, symptomatic arrhyth-
mias, and the presence of a pacemaker or defibrillator.
Major clinical predictors of cardiovascular risk are a recent
myocardial infarction (within 1 month), unstable angina,
evidence of an ischemic burden, decompensated heart
failure, significant arrhythmias, and severe valvular disease.
4. A patient’s ability to climb two flights of stairs is a good as-
sessment of adequate functional capacity.
5. Patients with an FEV1 of less than 30% predicted are at high
risk for complications.
6. Smoking must be discontinued at least 8 weeks before
surgery to be effective in reducing risk.
7. Perioperative β blockade is associated with a reduced risk of
death among high-risk patients undergoing major noncar-
diac surgical procedures. However, more recent data bring
this into question.
8. Patients who have a depressed hypothalamic pituitary
adrenal axis due to exogenous steroids should receive 50 to
100 mg of intravenous hydrocortisone before the induction
of anesthesia and 25 to 50 mg every 8 hours thereafter until
the patient’s medication is resumed.
9. In the elderly, delirium can be the first clinical sign of hy-
poxia or of metabolic or infectious complications.
10. In the pregnant patient, postoperative pain is best managed
with narcotic analgesics.
11. A preoperative electrocardiogram should be obtained in all
patients older than 40 years and in those with a significant
cardiac history.
12. It is important to remember that for prophylaxis of venous
thromboembolic disease and the use of antibiotic and
mechanical bowel preps before intestinal surgery, the
studies are often based on data obtained from nonuro-
logic patients. The urologist must consider this when the
procedure being performed is significantly different from
the standard general surgical operation on which the data
boembolism. Such a patient would require both mechanical
and pharmacologic prophylaxis. In a patient with renal insuf-
ficiency, unfractionated heparin is a better choice than low-
molecular-weight heparin. There is no evidence that aspirin is
effective in the prevention of venous thromboembolism, but
in a patient with coronary stents, aspirin is important in the
prevention of stent thrombosis in the perioperative period.
5. d. Inhaled sevoflurane. This is an excellent choice for rapid induc-
tion in this patient secondary to its odorless and bronchodilation
properties. Halothane can adversely affect left ventricular function
and should be used with caution in patients with congestive heart
failure. Desflurane has a pungent odor and is more suitable for
maintenance of anesthesia during prolonged procedures. Intrave-
nous thiopental can increase airway reactivity and is not appropri-
ate in patients with asthma. Succinylcholine is appropriate for
neuromuscular blockade and not commonly used for induction.
6. c. Discontinue prior to surgery, administer stress dose steroid
before the induction of anesthesia, and continue post-opera-
tively until home medication is resumed. Patients who have a
depressed hypothalamic pituitary adrenal axis due to exogenous
steroids should receive 50 to 100 mg of intravenous hydrocorti-
sone before the induction of anesthesia and 25 to 50 mg every
8 hours thereafter until the patient’s medication is resumed.
Simply discontinuing the patient’s steroid medication can result
in adrenal crisis due to adrenal insufficiency post-operatively.
are based. This is particularly true for bowel preparation, as
urologic reconstructive procedures often require opening
the isolated intestinal segment to be used in the procedure,
exposing the entire contents to the operative field.
13. Parenteral antibiotics should be given within 60 minutes
before intestinal surgery.
14. Nitrous oxide inhalation anesthesia results in bowel distention.
15. The half-life of warfarin is 36 to 42 hours, and it is recom-
mended that warfarin be stopped 5 days before the surgical
event.
16. Aspirin and clopidogrel are irreversible inhibitors of plate-
let function and should be discontinued 7 to 10 days before
surgery if bleeding risk is to be minimized.
17. For moderate- to high-risk groups on anticoagulation ther-
apy, a therapeutic bridge is performed using unfractionated
or low-molecular-weight heparin. These may be stopped 4
or 12 hours, respectively, before the procedure and instituted
shortly after its completion.
18. The indications for fresh frozen plasma are immediate rever-
sal of warfarin and replacement of specific clotting factors.
19. The most common cause of transfusion-related fatality is
transfusion-related acute lung injury (TRALI).
20. Hypothermia results in increased blood loss and an in-
creased incidence of wound infection.
21. If hair is to be removed, it should preferably be removed
immediately before the surgical event with mechanical clip-
pers.
22. The need for postoperative parenteral nutrition should be
anticipated in patients undergoing major urologic proce-
dures involving the use of bowel. If it is likely the patient
will not be able to take an adequate caloric intake orally by
7 to 10 days, postoperative parenteral nutrition should be
instituted.
23. The second trimester represents the least anesthetic risk to
the mother and fetus with regard to spontaneous abortion
and teratogenicity.
24. Severely malnourished patients (>20 pounds weight loss in
3 months) significantly benefit from 7 to 10 days of enteral
(not parenteral) feedings before elective surgery.
25. In a patient with renal insufficiency, unfractionated heparin
is a better choice than low-molecular-weight heparin.
Another random document with
no related content on Scribd:
Comme à ce nigaud soutenant sa thèse un autre nigaud objectait :
« Mais comment ? Ce livre que vous tenez à la main, c’est donc une
idée ? » Et l’autre : « Je soutiens que ce n’est qu’une idée ; car qu’y
a-t-il de plus…? etc. » Je les aurais laissés à Molière.
L’Esprit n’aurait été que vengeur. Mais j’avais besoin d’esprit, car
je supportais difficilement les passions. L’oracle heureusement
m’éclaira. « Il n’y a point de connaissance subjective ». J’avais
maintenant de quoi penser. Je pouvais entrer dans la critique de
Kant, malgré les pièges tendus autour par la philosophie d’Institut, et
marcher du fameux théorème de l’Analytique au quatrième
Paralogisme, qui sont les pierres milliaires de l’Esprit. D’autant que
l’oracle jetait d’autres lumières : « La sensation est un abstrait » ; et
d’autres pour rire un peu : « Monsieur Ribot fait de la physiologie a
priori », non moins perçantes. Là-dessus j’écrirais des volumes. Mais
je veux présenter ces vérités à l’état naissant ; car autrement je
devrais ici retrouver ces discussions préliminaires qui n’avançaient
point, et qui revenaient toujours à demander d’un auteur médiocre :
« Que veut-il dire ? » Mais quel intérêt ? Le Maître était faible dans la
discussion et fort dans la conclusion ; et c’est pourquoi la rédaction
de nos cours, que j’avais entreprise autrefois comme un monument
de piété, ne m’a pas paru mériter l’attention des philosophes. Je
ferai mieux connaître l’Homme par ces détours et digressions
auxquels je m’abandonne, et cette manière indirecte et errante
donnera une idée assez exacte de ces leçons surchargées,
confuses, interminables, propres à scandaliser le Pédant.
Ce détour était pour arriver au Pédant. Je nommerai ainsi l’auteur
de manuels réputés en ce temps-là, et qui n’étaient ni meilleurs ni
pires que ceux d’aujourd’hui. Cette philosophie d’Institut, dont je
parlais, laisse encore quelques trous pour respirer ; le manuel n’en
laisse jamais. Ces divisions, ces querelles, ces solutions n’ont
réellement point de sens. Donnez-moi le meilleur manuel de ce
temps-ci ; réellement je n’y comprends rien. En ce temps-là donc, les
éditeurs firent entrer dans notre classe un bon nombre de manuels
du Pédant. Lagneau le sut et, sans autre commentaire, les fit mettre
sous clef. Trois mois après environ, nous vîmes arriver, muni des
pouvoirs de l’Inspection Générale, le Pédant lui-même, et je
considérai avec curiosité la scène qui allait suivre. Elle fut assez
belle. Le Professeur rendait aux élèves une composition sur ce
sujet : « Montrer qu’on ne peut être assuré de rien tant qu’on n’est
pas assuré de l’existence de Dieu. » Le lecteur reconnaîtra ici l’idée
que je rappelais tout à l’heure. Sur quoi le Pédant fit ce préambule,
que c’étaient là sans doute de hautes questions, mais qu’enfin ces
jeunes gens n’étaient peut-être pas en âge de les bien saisir, et qu’il
désirait que M. le Professeur fît expliquer celle-là par un des élèves.
Nous regardions cependant la tête puissante, qui demeurait
immobile et inclinée ; mais de sombres nuées s’assemblaient autour.
Un des élèves, choisi parmi les nouveaux, fut prié de répondre ; et je
vois encore cette jeune tête qui imitait l’autre et se chargeait de
nuages ; mais il ne dit rien. Il fut demandé par le Pédant si M. le
Professeur n’en désignerait pas un autre. Même jeu. Encore un
autre. Même jeu. Sur quoi le Pédant, faisant remarquer que ce
silence justifiait les doutes qu’il avait exprimés tout à l’heure, et la
crainte que l’enseignement du Professeur ne passât bien au-dessus
des élèves, demanda si M. le Professeur voudrait bien à son tour
expliquer comment il entendait que la question fût traitée. Les veines
se gonflèrent un peu plus sur le puissant crâne, mais j’affirme qu’il
n’en sortit pas d’autre signe. Ce fut un silence admirable. Après quoi
d’un ton léger soudainement Lagneau me pria de donner les
explications nécessaires. C’était lâcher le chien sur le visiteur. Je fus
un peu insolent, je le crains, mais brillant comme il fallait. Ce
souvenir me pénètre encore d’une joie délirante. Le Pédant s’en alla
sans répliquer. J’ai su que le jour même Lagneau lui écrivit
demandant un poste dans un collège. J’ai lu la réponse, qui n’était
point d’un sot, abondait en éloges, nommait Lagneau membre de la
commission des livres scolaires, et laissait espérer encore d’autres
faveurs.
Il faut dire que le célèbre Jules Lachelier fut toujours favorable à
Jules Lagneau, qui fut au nombre de ses élèves, à ce point même
que cette faveur s’étendit plus tard jusque sur les fidèles disciples du
maître. Nécessairement j’aurai à comparer, sous le rapport des
doctrines, ces deux hommes éminents. Cela fait trembler. Mais ce
livre enferme bien d’autres difficultés. Pour gagner du temps avec
moi-même, je veux dire une autre histoire assez comique, et qui
concerne encore le Pédant. Cette même année, l’Académie des
Sciences Morales et Politiques ayant mis au concours un exposé de
la philosophie de Spinoza, il y eut deux mémoires sur les rangs dont
on disait qu’ils se partageraient le prix. J’ai lu ces deux mémoires
depuis trop longtemps pour en parler ; Lagneau ne m’en a jamais
rien dit. Comme le prix était ainsi décerné en rumeur, un troisième
larron se jugea assez recommandé pour figurer aussi au partage, et
il rédigea son mémoire un peu vite, ayant coutume de donner plus
de temps à solliciter qu’à réfléchir. Le prix fut donc partagé en trois.
Par un hasard, ce troisième mémoire fut envoyé par le Pédant lui-
même à Jules Lagneau, promu comme j’ai dit aux fonctions de
critique officiel ; ce livre lui arrivant avec un mot de courtoisie, il
répondit au Pédant, après avoir coupé les pages, je cite de mémoire,
mais je réponds de ma mémoire pour le principal : « Je vous
adresserai bientôt un rapport détaillé ; mais un rapide examen m’a
déjà assez instruit. C’est d’une sottise qui désarme l’indignation. » La
réponse arriva promptement : « C’est par erreur, répondit le Pédant,
que ce livre vous a été envoyé ; il est déjà aux mains de M. X…, et je
vous prie de vous épargner la fatigue d’un examen plus
approfondi. » Et de rire.

Lagneau était de Metz ; il fut enfermé à Metz pendant le siège ; et

c’est là qu’il eut le spectacle d’une foule qui venait tous les jours à la
même heure voir dans les vitres d’une vieille maison l’armée de la
délivrance. Il nous l’a conté plus d’une fois. Le philosophe, si jeune
qu’il fût, ne pouvait être ici que spectateur ; car il n’y avait point de
vraisemblance, ni d’autres données que des irisations rouges et
bleues sur de vieux carreaux de vitre. Mais il ne se peut point,
comme dit l’autre, que l’homme n’ait pas de passions. Bien des
années après, Lagneau se hérissait encore en présence de
l’ennemi, et l’on m’a conté qu’un professeur allemand ayant désiré
entendre une de ses leçons, Lagneau ne put prendre sur lui de
parler. Ce récit m’étonna. Je n’approuvais pas davantage une autre
passion vingt fois exprimée devant moi et dans les termes les plus
vifs. Lagneau avait un fort préjugé contre les Juifs. J’objectai un jour
Spinoza et Jésus-Christ, ce qui le fit rire. Jules Lemaître était son
grand ami. D’après tout cela pris ensemble, je me suis demandé ce
qui serait arrivé au cours du procès Dreyfus si Lagneau avait vécu
jusque-là. Quelquefois je l’imagine renfermé dans un silence
farouche ; d’autres fois se jetant sans précaution, et tout entier, dans
le chemin de la justice. Mais il y a une chose dont je suis sûr, c’est
qu’il n’aurait nullement approuvé en aucun cas les passions
politiques qui m’y jetèrent moi-même, non plus que cette
collaboration suivie aux petits journaux qui date de ce temps-là. Non
plus, je le crains, ce que j’ai écrit de la guerre et de la paix. De mon
côté je n’aimerais guère entendre ce qui sera dit solennellement à
Metz quand on honorera sa mémoire dans la maison où il est né.
J’ai connu de sombres méditations sur la route de Metz, entre
Rambucourt et Flirey ; c’était pendant l’hiver de 1914 ; mais apaisons
ces tristes pensées qui sont à peine des pensées.

Apaisons. Mais si je recule aussi devant les seules pensées qui

aient fait en moi une espèce de drame, que dirai-je ? L’opposition
que je sentais en ce temps-là, et que j’ai depuis développée, peut
donner encore une idée du puissant esprit qui ne put, et de bien loin,
me modeler à son image. D’autant qu’il se peut bien que cette
contradiction, qui semble de nature, soit des idées dans le fond, et
qu’elle habitât en cet homme, et qu’elle ait fait en lui cet état violent
dont les lettres que l’on a pu recueillir donnent quelque idée. Mais il
faut revenir à l’homme, et donc aux histoires d’écolier, car mon
expérience ici fut d’un écolier.
J’avais étudié les éléments de la géométrie et de l’algèbre, sans
aucune peine, et avec un plein succès. A vrai dire je ne vis jamais
dans les problèmes, et surtout dans ceux de la géométrie
élémentaire, comme constructions de triangles ou lieux
géométriques, qu’une difficulté de rhétorique, que j’eus toujours
plaisir à surmonter. L’ordre, l’économie, et l’art de tout ramener à la
fin, comme dans la fugue, me donnèrent alors la première idée du
style. Autrement, ces choses ne m’intéressaient pas trop, et il me
semble que j’en appris assez pour mon salut, comme dirait quelque
Pascalien. Les autres exercices scolaires étaient de singerie. Mais
maintenant, éveillé pleinement par le spectacle de cette pensée,
dans le feu et la fumée de cette forge, je montais d’un degré ; je
m’attaquais à des problèmes tout vifs, donnés par la nature elle-
même ; et il me semblait, cette idée ne m’a point trompé, que j’étais
en mesure d’y proposer des démonstrations invincibles sans jamais
me détourner de l’apparence, ni m’écarter du commun langage. Car
il m’était demandé seulement de dire ce que je pensais, comme je le
pensais, sans aller jamais au delà, sans chercher derrière, sans
voyages ni aventures d’aucune sorte. Telle est l’expression en creux
si je puis dire, de cette forte idée qui s’offrait à moi en relief, et à
laquelle le maître revenait toujours, disant qu’il s’agissait de
retrouver toute la pensée dans la moindre de nos pensées, et enfin
d’expliquer en quoi elle était une Pensée. Cette majuscule plaisait ;
mais je n’en fis jamais un réel usage ; ce n’était à mes yeux qu’une
politesse. Et si quelque trait me distingua aussitôt de mes
condisciples, qui certes ne vénéraient pas le Maître moins que moi,
c’est bien ce trait-là. Jamais je n’eus l’idée de quelque objet d’accès
difficile, et caché comme dans des nuages, comme un Sinaï où il
faudrait aller, et d’où il faudrait revenir portant les Tables de la Loi.
Nul mystère à mes yeux, soit dans la variété de la nature, soit dans
les profondeurs de l’âme. Nul passage, nul saut périlleux, entre mes
faibles pensées et la pensée absolue. Au contraire je me trouvai
aussitôt affermi et pour toute une vie sur mon terrain propre, n’ayant
à résoudre jamais que cette seule question : Qu’est-ce que je pense
réellement dans mes pensées les plus naturelles ? On voit ici la
Rhétorique revenir ; car mes pensées sont des pensées, mais
d’abord très mal exprimées ; et bref, je n’eus jamais à débrouiller au
monde que ceci, qui à vrai dire n’est pas peu : Qu’est-ce que je
pense dans chaque concept, comme Espace, Temps, Cause,
Liberté, Nécessité, Force, Droit ? L’idée même de chercher plus
avant et en quelque sorte au dehors (mais voici un exemple : Qu’est-
ce que je pense quand je dis au dehors ?), cette idée-là ne m’est
jamais venue. Je dirais bien aujourd’hui que, du moment que je
pense correctement, je pense absolument. En quoi j’étais et je suis
encore irréligieux, mais dogmatiquement, ce qui peut passer pour
neuf. Le plus étonnant ici, c’est que je n’ai jamais réfléchi au
système de mon Maître sans retrouver aussitôt cette même idée ;
mais c’est la plus cachée aussi ; c’est en Spinoza qu’on peut
l’apprendre ; j’aurai à revenir encore plus d’une fois là-dessus. On ne
se sauve point aisément de Spinoza, mais je m’en suis sauvé, sans
le nier jamais, en le prenant ainsi, et j’ose dire en surface seulement,
occupé seulement de redresser la phrase célèbre : « Ma maison
s’est envolée dans la poule de mon voisin », et autres fautes de
rhétorique. Il me revient à ce sujet un souvenir d’écolier encore, et
bien mince ; mais je fais argent de tout, n’ayant que peu de matière.
Comme Lagneau me parlait au sujet d’un camarade plus jeune, et
que j’ai toujours aimé, plein d’élan et de feu, enfin tel qu’on se
représente le jeune philosophe en ses premières effusions, le Maître
trouva à dire, après un éloge de cœur, que ce garçon manquait de
rhétorique. Le son de cette parole m’étonna. J’en ai vu depuis les
suites, et comment, après avoir trop espéré, on revient à l’Idolâtrie,
c’est-à-dire à prendre les discours mal faits comme ils sont et
l’Apparence comme elle n’est point. Nous ne sommes pas si loin de
la route de Metz ; car plus d’un y est entré avec gloire, mais moi j’en
suis encore à regarder cette route sinistre, m’attachant à bien
penser, à complètement penser cette simple question : « Que
faisais-tu là ? »
On naît homme de troupe. L’homme de troupe creuse où on le
met. Je n’oublierai jamais cette première dissertation où j’écrivis
uniquement ce que je voulais écrire, et exactement ce que je
pensais, sans rien de confus, sans rien d’ambitieux, sans aucune
trace d’imitation ni de flatterie. « Quelles seraient, demandait le
Maître, les impressions d’un aveugle-né à qui une double opération
rendrait successivement, à quelques jours d’intervalle, l’usage des
deux yeux ? » Quelque sot ne manquerait pas de dire qu’il faut ici
faire l’enquête, interroger l’aveugle-né ou le médecin. Or, si quelque
chose me fut évident après trois mois d’attention aux discours
toujours assurés, quoique toujours tâtonnants, que j’entendais sur
ces questions-là, c’est que l’opinion de l’aveugle ou du médecin ne
peut qu’ajouter quelques formules mal venues à celles que l’on
entend ou que l’on lit communément là-dessus, par exemple que les
objets sont vus d’abord sur un même plan, ce que l’on arrive à faire
dire à l’aveugle, ou que les objets doivent d’abord paraître
renversés, ce que l’on n’arrive point pourtant à lui faire dire. C’est
mon affaire, il me semble, de deviner ces fantastiques témoignages,
et même de les trouver au naturel dans mes pensées immédiates,
ou plutôt dans l’expression qui m’en vient d’abord. Les mots
permettent tout et les maisons s’envolent. Quand je vis se présenter
ces impossibilités, et donc ces nécessités, dans nos connaissances
les plus naturelles et les moins travaillées, qu’il faudrait nommer
l’apparence de l’apparence, j’eus un monde devant moi, un travail
sans fin, et une allégresse admirable. Je suis le même encore, et
dans ce travail encore ; et cette attitude m’a valu en toute rencontre
le mépris plus ou moins déguisé, et quelquefois la colère, de tous les
Importants sans exception. C’est ce qu’ils appellent juger sans
vouloir s’informer. Je leur pardonne, et j’espère qu’ils seront quelque
jour battus et contents. Toutefois cela ne m’inquiète guère. Mais que
j’aie saisi le commencement et comme l’esquisse de ce mouvement
dans le seul homme que j’aie vénéré, cela ne peut point aller sans
quelque examen des causes. Après des années de méditation là-
dessus, et celles-là non sans tristesse, j’aperçois que tous les
problèmes de la pratique, et exactement de la politique, sont ici
rassemblés. Il faut, en d’autres termes, que ces pages enferment
aussi les aveux d’un radical impénitent.
Devant mon papier blanc, je ne vis pas si loin. Je m’appliquai
seulement à dire à l’aveugle, en langage correct, ce qu’il aurait voulu
dire mal. Mais quel besoin d’entendre l’aveugle ? N’apprenons-nous
pas à voir à chaque instant ? Pour mieux dire, c’était une expression
du Maître, et il me plaît ici de l’emprunter, voir n’est-il pas à chaque
moment explorer comme fait l’aveugle ? Il n’y a point là de difficulté,
si ce n’est le manque de courage, qui nous porte à aller chercher
d’abord quelque nouvelle relation là-dessus. Je me souviens que
j’eus seulement peine à décrire, au moins par approche, ce que voit
un homme qui ne sait pas encore ce qu’il voit ; car il faut qu’il y ait
quelque affection d’abord, sans lieu ni forme, qui serait mieux
nommée sentiment que sensation ; encore eus-je bien soin de dire
que cette première affection ne peut jamais être sentie que par
souvenir et retour, enfin par comparaison avec un premier essai de
représentation. Ce travail est Bergsonien ; j’indique ici en même
temps, comme l’apercevra le lecteur attentif, comment le moment
Bergsonien est nécessairement dépassé de toutes les façons. Bref
je fus content de moi pour la première fois, hors des mathématiques.
Le Maître dit seulement que c’était bien, et je n’eus pas le premier
rang. Sans doute craignit-il une redoutable facilité, et trop peu de
respect aussi à l’égard des sottises que l’on lit partout. La première
place était occupée, et fortement, par un garçon au large front qui a
fini par douter de tout et de lui-même. Il admirait par dessus tout
Bouvard et Pécuchet, et je gagnai un moment cette maladie. Sans
doute aperçut-il trop d’erreurs à redresser, et prit-il le parti de
s’accommoder à la sottise régnante selon le mode de l’ironie ; cela
mène fort loin. Et voilà une idée qui ne me vint jamais. Au contraire,
puisque je voyais que, dans des questions si simples, le savoir ne
préservait pas de l’absurde, tout m’était clair, et je devinais des maux
incroyables seulement dus à l’infatuation, à l’imitation, au faux
respect. Ce vif mouvement et ce départ sans précaution durent
effrayer le Maître, pour des raisons dont j’ai déjà fait paraître
quelques-unes, et qui sont de morale et de politique.
Lagneau avait la sévérité du saint, mais il ignorait nos existences
aventureuses. Il était seulement en défiance de ce que nous
pouvions faire, laissés à notre seul caprice, et il n’avait pas tort. Il
n’est pas une de nos actions qui ne l’eût indigné ; et sous ce rapport
le garçon dont je parlais, si attentif aux respects de forme, ne valait
pas mieux que moi. Mais ce n’était pas une raison de ne pas vénérer
et craindre le Maître. Aujourd’hui, encore bien mieux qu’en ce temps-
là, j’aperçois comment la doctrine de la Liberté porte celle du Devoir.
Comme je ne me pardonne pas aisément de manquer de courage
dans la spéculation théorique, je voudrais bien aussi n’avoir jamais
été lâche dans le sentiment ni dans l’action. Ainsi, les vertus dont le
Maître donnait l’exemple, je puis les enseigner sans aucune
hypocrisie. Ma piété serait donc sans aucun mélange, si je n’avais
cru discerner en ce Maître de Liberté une disposition étonnante à
confondre les écarts de la vie privée et les hardis jugements de la
vie politique comme résultant d’un même fond de diabolique révolte.
Descartes fait voir partout la même prudence.
Quand Jules bachelier m’écrivait : « Je vous conjure de ne point
vous mêler de politique », je n’en étais pas surpris. Au regard de ce
théologien, l’ordre politique ne pouvait apparaître que comme une
suite de l’ordre universel. Qu’il y eût des pouvoirs, c’était comme une
disposition impénétrable de notre monde humain ; que ces pouvoirs
pussent être aveuglés, c’était un compte entre les hommes
providentiels et la providence elle-même. Toute résistance, et même
toute critique publique, était alors considérée comme l’effet des
désirs et des passions, désordre dans l’État et désordre dans
l’individu. Le devoir d’obéir, et, d’une certaine manière, juste autant
que les opinions sont des actions, le devoir de respecter, rentrait
ainsi dans le devoir envers soi, ce qui n’empêchait nullement ce
grand Administrateur, comme on sait, de gouverner énergiquement
selon sa conscience, selon sa part de pouvoir, et selon la place qu’il
occupait dans l’ordre humain. Je ne trouve pas ici de difficulté.
Chacun fait son métier d’homme, et le reste aux Dieux, comme
Marc-Aurèle aurait dit.
Que Lagneau réglât l’ordinaire de ses actions et toutes ses
pensées politiques selon de tels principes, c’est ce qui paraîtra
évident d’après ses lettres, et j’en puis témoigner d’après cette
crainte qu’il montrait toujours, qu’on ne prît le pouvoir de penser pour
le droit d’oser tout dire. Mais on verra dans la suite que l’idée d’une
existence respectable ou, pour parler autrement, d’un Dieu objet,
n’avait pu tenir dans ses pensées. On a vu déjà dans ses actions,
dès que son propre jugement l’éclairait assez, une méthode qui
pouvait faire scandale, et qui fit scandale en effet. La chose jugée
n’était rien à ses yeux. Petit exemple, je le répète, mais qui n’était
pas petit pour l’écolier. Il est impossible que devant cette conscience
scrupuleuse le problème des pouvoirs ne se soit pas posé. Cet
homme voulait être religieux, et, dans un sens profond, il l’était. Mais
ayant jugé une fois les pouvoirs réguliers, les ayant condamnés et
redressés, pouvait-il promettre une obéissance sans condition, bien
plus une obéissance d’esprit sans condition, comme pourtant il me
paraît qu’il a toujours voulu faire, à l’égard de l’ensemble des
pouvoirs divinisés en quelque sorte sous le nom de la Patrie ?
Nous voici encore une fois sur la route de Metz. Lui-même, un
demi-siècle plus tôt, comme j’ai dit, s’est évadé de Metz et a
combattu en volontaire dans l’armée de Faidherbe ; ces rencontres
réchauffent le cœur. Ici donc, et quant à l’action, nous étions
d’accord et la Grande Ombre était contente. Mais c’est moi qui par
réflexion n’étais pas content. Car cette volonté de croire et en vérité
d’adorer, quels que fussent les chefs, et en prenant la haute politique
comme un mystère impénétrable au commun, c’était bien clairement
à mes yeux la cause responsable de ce massacre machinal auquel
je participais. Or j’admets qu’il faut finalement obéir ; mais qu’il faille
encore plier ses pensées, et approuver pleinement ce que l’on fait,
c’est ce que je ne puis recevoir. Et j’eus dans ces nuits sinistres plus
d’un débat avec la Grande Ombre. J’allai jusqu’au reproche, il me
semble. J’évoquais cette anecdote du professeur prussien, envers
qui il avait manqué au devoir homérique de l’hospitalité. Je me disais
et je lui disais : « Quel exemple pour moi d’une folie adorée ! Toutes
les passions reviennent ici. Quoi ? Mon devoir le plus clair n’est-il
pas maintenant d’aimer à tout risque cet ennemi aveuglé qui à toute
minute cherche à me nuire ? Ce n’est pas dix ans après que je dois
pardonner, mais c’est tout de suite. Quand je ne le pourrais pas, je
sais que je le devrais. Ce sont des hommes ; et, s’ils l’oublient, c’est
à moi de m’en souvenir. Tout m’y invite et jusqu’aux anciennes
traditions de la chevalerie, mal soutenues pourtant par l’idée
théologique du jugement de Dieu. » Dans le fait je reconnaissais
bien le Fanatisme, quoique la religion fût autre. Sur ce coupant, il me
semble qu’on ne peut rester. Dès que l’on pense, il faut tomber d’un
côté ou de l’autre. Ou bien revenir au Dieu objet, ou bien examiner
tout. En ce second parti, nous sommes à l’ouvrage sur le bord du
temps, et en grande incertitude, non pas de ce que nous devons
penser, mais de ce qui sera, sans autre ressource que d’expliquer
tout ce qu’on pourra à soi-même et aux autres, et devant la menace
de l’ignorance et des passions, qui donnent si vite à la liberté un
hideux visage. Mais en quoi la guerre est-elle moins hideuse ? En
n’importe quel cortège révolutionnaire on retrouvera ce mélange de
courage et de colère, cette exaltation et cet avilissement, ces idées
sublimes et cette misanthropie. Avouez seulement que le plus
redoutable cortège, le plus enivré, le plus convulsif, est un petit mal
à côté de ce fossé fulminant et saignant qui dévorait chaque jour des
milliers de victimes. Que les pouvoirs soient absous de ce crime, et
que les chefs de révolte ne soient pas absous de l’autre, voilà qui
suppose un choix absolu concernant l’existence donnée, et une
sorte de sauvage préférence pour l’ordre de fait, quel qu’il puisse
être. Or quand l’esprit a repoussé de croire à l’existence comme à
un absolu, il faut se résoudre, tout au moins, à penser pour le mieux
et à tout dire, et enfin à tuer la formule creuse dès qu’elle paraît.
Sauver cette puissance de penser, ne la soumettre à rien, ne la
déshonorer par aucun genre d’ivresse, n’est-ce point la morale, ô
mon Maître ? Et si je n’ai pu la suivre toujours, est-ce une raison
pour que, d’enthousiasme, j’y manque en ce cas-là ? Ou bien est-ce
ma punition ? N’ai-je plus le droit de tenir ici pour la pensée, quand
je l’ai trahie tant de fois ? Je fais les demandes et les réponses. Et il
le faut bien.
Tel serait peut-être le dernier mot de cet homme bon et
redoutable. Peut-être viendrait-il à me rappeler que la morale n’a pas
pour première fin de juger les autres, mais plutôt de se contrôler soi.
Et qu’enfin c’est le fond de l’injustice si l’on exige paix et justice des
autres en n’apportant au fond commun que mauvaise foi, fantaisie et
guerre. Il me terrasserait ainsi, je le vois bien ; il me condamnerait à
faire la guerre. Aussi l’ai-je faite, et je ne dis pas que je n’aie pas
mérité de la faire. Mais dois-je adorer pourtant le diable et sa
fourche ?
 Je veux pousser encore un peu plus loin ces amères pensées.
J’y reconnais ce gris de la justice, sans agrément, mais sans
confusion aucune, que j’ai imaginé dans cette grande prairie où
Platon nous invite à choisir notre paquet. On peut choisir, mais non
dans le paquet. J’ai mis quelque temps à bien entendre cette fable.
Cela ne veut point dire que tout soit fatal, et que l’on choisisse des
tranches d’avenir, seulement assemblées par la nécessité
extérieure. Cela c’est l’image et l’écorce ; le choix en image ne serait
point un choix ; tout serait mécanique, et on aurait quelque raison
d’accuser Dieu. Mais je ne l’entends pas ainsi ; car ce n’est pas par
une nécessité extérieure que le tyran se cache de chambre en
chambre, sans pourtant pouvoir dormir. Ce n’est pas par hasard
qu’un mensonge marque de mensonge beaucoup de nos pensées,
et peut-être toutes. Ce n’est pas par hasard que le souvenir de la
colère est colère encore, et que paresse est une raison de paresse,
ironie, d’ironie, et ainsi du reste. Si nos fautes revenaient sur nous
avec leur même visage, ce serait encore un avantage, comme
Platon dit, car c’est pénitence ; mais qui ne voit que le châtiment
serait une récompense ? La justice va plus loin, et toujours par des
pensées, non point par des prisons. Quand Platon veut nous dire
que le paquet est fait et qu’il faut le prendre tout, il entend dans le
fond qu’une pensée est toute la pensée ; il nie l’extérieur, et un genre
de suite qui a la forme de l’extérieur.
Je reviens à la guerre. Il est clair que celui qui nie la guerre et la
refuse veut diviser le paquet. Prendre permission pour d’autres
fautes, et la refuser pour celle-là. Mener la vie comme une guerre, et
faire ce qui plaît, on se jette sur ce paquet-là ; on y trouve guerre
enfin à découvert, et l’une des causes que l’on voit le mieux est que
le chef a gouverné comme le fantassin a vécu ; il est bien plaisant
d’accuser le chef. J’apercevais des liens de ce genre dans les
Mémoires du Cardinal de Retz, œuvre de fer. Chacun admirera que
les devoirs d’une charge d’église, toujours présents, toujours suivis,
qu’une piété éclairée et même profonde dans les grandes choses, et
le serment tenu de se décider toujours selon le bien de l’état, que
tout cela se termine naturellement à violence et révolte, et toujours à
des situations telles que « le mieux qu’on y puisse faire est encore
un mal ». Mais il faut regarder à une vie déréglée absolument. De
plus près encore, regardons à ce mépris pour les femmes, qui réduit
l’amour à un jeu sans conséquence ; la riposte est voulue ; on la joue
soi-même, par cette politique d’orgueil, de vengeance, ou seulement
d’humeur, que les femmes mènent selon les passions, et qui
traverse continuellement les meilleurs desseins. Il serait commode
d’attendre que mademoiselle de Chevreuse, madame sa mère et les
autres, rendissent justice contre injustice ; mais elles rendent
injustice et folie, et c’est la justice de Minos, Eaque et Rhadamante.
Je comprends un peu mieux d’après cela ces femmes si
promptement durcies au feu de la guerre, si légères à parler, à
chanter, à célébrer. J’y vis toujours comme une vengeance, mais
bien au-dessus de tout projet ; ce n’est que la dureté masculine
renvoyée à ses œuvres, la guerre paraissant alors, non point du tout
comme la punition de cette autre guerre contre les faibles, et de tout
ce mépris, mais plutôt comme une sorte d’excuse et de justification,
par une nécessité d’obéir auprès de laquelle celle où se trouvent les
femmes n’est presque que douceur. La tendresse était comme
délivrée et rendue ; l’amour baisait ces mains sanglantes. L’Amour
trouvait à être selon une certaine justice qu’il exige toujours. Cet
exemple en éclaire d’autres, quoique le détail nous passe. J’ai
souvent remarqué, et non sans impatience, un mélange étonnant,
dans mes rudes compagnons, de révolte et d’enthousiasme, je dirais
presque de pitié, comme si d’un côté ils réprouvaient, et comme si,
de l’autre, ils reconnaissaient une destinée enfin égale, enfin
commune, des pensées en clair, un accord des volontés seulement
tardif, après cette paix énigmatique. D’où j’arrive à comprendre les
sévères pages où Lagneau a défini le devoir pratique à l’égard du
prochain. Scandale à mes yeux, scandale à nos yeux, que l’amour
ne doive jamais emprunter le détour politique. Et pourtant, qu’est-ce
que le détour politique, sinon un essai de recevoir plus qu’on ne
donne, et enfin d’assurer la paix sans que chacun y sacrifie autre
chose que ce à quoi il ne tient pas ? « Vivons en paix, voulez-vous ?
Mais sans rien changer. » D’où, par cette réflexion, une charité
hautaine, j’entends qui jure de ne point changer l’ordre, parce que
l’ordre, tel quel, n’est que l’exacte expression de ce qui manque en
nos actions réelles. Et si cet ordre est médiocre de toutes façons et
terrible à un moment, par son inhumaine structure, ce n’est que
notre faute exactement renvoyée. Et, comme dit la Voix, Dieu est
innocent. Voilà le tour que je puis faire à l’intérieur de la Sévérité.
Pour le dehors je m’y heurte comme à une porte de fer ; mais la
porte n’est pas fermée.
Saint-Simon le duc connut à la Trappe de Rancé un monsieur de
Saint-Louis qui y faisait retraite après un long service de guerre. Cet
homme s’était crevé un œil d’un coup de houssine, en corrigeant un
cheval. Cette image est digne de Platon. Il n’est pas un homme de
guerre sur qui la guerre pèse comme un crime ; mais je crois plutôt
qu’elle équilibre cette contemplation sans paroles par le juste rapport
des fautes à la punition. « C’est toi qui l’as voulu. » J’ai dit que le
Maître ne traitait point de Morale. Mais il nous lisait Platon comme
une Bible, et souvent La République, où, à mesure que l’on
approche de la fin, et par cette implication des caractères et des
constitutions, par le tableau final de la tyrannie, se règle peu à peu le
compte de l’homme par la Somme intégrale de ses pensées
d’aventure. Le Maître estimait sans doute que c’était bien assez si
nous savions lire, et aussi qu’il faut apprendre à lire en considérant
d’abord l’encrier, le morceau de craie et le cheval de bois. Il y a du
secret dans toutes les grandes âmes, et ce qui est le plus secret est,
par le jeu des passions, ce que nous voudrions savoir d’abord. D’où
cet amour qui refuse pitié. Je ne puis expliquer mieux les nuages
toujours circulant autour de ce front sublime. Et ce n’est pas trop dire
que dire qu’il fuyait et haïssait le clair. Clarum per obscurius, ce fut
sa devise. Car la clarté est comme un refus. Mais la Pensée est
justement le refus du refus. Ici je revois son visage et son geste.
Assurément je ne me trompe pas d’un cheveu. Mais aussi ce visage
est sans doute le seul signe auquel j’aie fait réellement attention.
Il n’est presque point de natures supérieures où l’on ne trouve ce
geste de refus devant ceux qui espèrent changer le dedans par le
dehors ; je citerai Kant et je citerai Proudhon, si différents d’ailleurs,
mais d’accord contre ceux qui ne savent pas bien obéir. Deux effets
de l’action morale, et de l’union pour l’action morale. D’un côté se
rassemblent des cœurs pleins de pitié et des esprits qui cherchent
preuve, sans aucune disposition à adorer cet ordre terrible qui fait
voir l’inégalité, la raison d’état et la guerre comme des faces de
Méduse. Mais de l’autre un petit nombre d’hommes austères, plus
rigoureux encore sur la preuve, plus profondément inventeurs ;
souvent un seul, qui avec une pureté et un scrupule constant de
justice dans sa vie privée, se place à l’égard des pouvoirs dans une
situation qui produit les mêmes effets que la crainte. Platon n’aimait
point trop le peuple en cortège, ni ces ânes, comme il dit, qui portent
si librement la tête. En Gœthe, le même esprit condamnait Fichte.
« Quand ce serait mon propre fils », disait-il. Ce genre d’homme est
inexorable. Ils perdent sentiment et sont comme des pierres dès
qu’ils entrevoient, et ils entrevoient de fort loin, une cohue
d’ignorants qui demandent justice. Ces Maîtres craignent une guerre
d’esclaves. Je soupçonne que l’expérience des passions en eux-
mêmes, et des cohues de l’âme en ces renversements, les font
indulgents d’une certaine manière, mais sévères aussi, à l’égard de
tout mouvement anarchique. Il se peut aussi que l’Esprit leur fasse
peur, par la liberté infinie qu’ils y trouvent, car l’Esprit peut nier tout,
et c’est la démarche propre de toute pensée de se réfugier d’abord
en ce centre de négation, comme Descartes le fait voir à tous les
moments de sa réforme. On comprendra assez que Lagneau avait
touché ce point d’indifférence d’où l’on revient, et même y retournait
toujours ; dans ce mouvement de la réflexion, il n’était que bonté et
grâce, en ce monde d’écoliers, fermé à la politique, ouvert au
monde ; c’était le moment de l’incrédulité et de l’innocence. Il est vrai
aussi que cette enfance du monde n’est possible un moment que
par l’ordre sévère autour. L’autre mouvement, qui fermait la porte,
avait la dureté militaire. Il y avait de la violence dans ces soudains
changements. Violence contre violence, en lui-même d’abord,
comme Platon l’a tant de fois rappelé. La justice n’est point aimable,
mais plutôt redoutable, quand elle commence par le redressement
de soi par soi. Je ne puis comprendre autrement le drame que je
veux appeler physiologique, et qui fatiguait jusqu’à l’épuisement ce
corps vigoureux. J’ai su qu’il avait prédit quelque chose me
concernant. « C’est une violence, dit-il, qui se tournera contre elle-
même. » C’était trop d’honneur. Mais cela donne vue sur cette
puissante nature et sur les flux et reflux de ce sang vif qui colorait
ses lèvres de vermillon pur ; ce signe ne trompe guère.
On verra, d’après ses lettres, qu’il n’était nullement socialiste ; on
devinera même qu’il ne recevait point qu’un homme raisonnable pût
l’être. Cela arrête net ; aussi j’ai voulu, en disant ici tout ce que j’ai
pu saisir de cet homme, préparer le lecteur à ce passage, faute de
quoi l’Académicien y croirait reconnaître sa faiblesse et l’adorer, et
l’autre parti la maudire. La privation n’est rien ; mais de la force
pensante aussi il faut s’arranger au mieux.
Le socialisme est profondément une politique ; en quoi il
s’oppose directement à l’esprit chrétien, qui enferme un mépris à
l’égard de toute politique. Et le fond de la politique est de modifier les
situations, en vue de changer les pensées. Sous quelque forme
qu’on la prenne, dans le cabinet d’un ministre ou dans le grenier
d’un révolutionnaire, toujours elle s’en prend au rapport extérieur ;
cette vue définit entièrement la faveur, qui prétend ramener les
mécontents et y réussit souvent. C’est misanthropie ; car l’esprit est
digne d’être crossé, c’est son droit propre. On voit que la charité
s’entend en deux sens ; et le commun langage le fait bien voir, par
ceci que le plus beau mot peut-être et le plus fort se trouve être
aussi bien le plus faible et le plus avili. Il y a une charité revêche et
comme janséniste ; l’autre est de faveur, et voudrait récolter
sagesse. L’esprit chrétien va tout à la première, qui honore esprit,
courage, volonté, vertu, une même vertu sous ces noms, et qui
n’honore rien d’autre. Je dis esprit chrétien, je dirais aussi bien esprit
stoïcien. Marc-Aurèle laisse chacun à sa place, bonne ou mauvaise,
parce qu’il n’y fait point de différence. Cela est hautain. On
retrouvera ce ton dans les Simples Notes ; mais cela est hautain,
pour les deux, par une idée de l’égalité qui méprise les différences
au lieu de les effacer. Cette vertu est ce qui sauve la guerre où,
comme a dit quelqu’un, l’inégalité est la loi, entendez que la justice
n’y est point du tout dans la rencontre ni dans l’extérieur, mais
uniquement dans une fière simplicité que l’on rencontre quelquefois.
J’ai connu un héros janséniste parfait en ce genre, et à qui il était
impossible de ne pas obéir, par ceci qu’être au-dessus ou au-
dessous n’était point de plus d’importance à ses yeux que pour les
pierres d’un mur. Le pouvoir ainsi gouverné gouverne sans faiblesse.
Ici l’homme répond à l’homme ; et l’on ne va point chercher quelque
égalité de géométrie ou de latin ; cela même instruit. Nous ne
sommes point quittes à l’égard d’une inégalité si belle ; et, pour ma
part, je ne démêle pas sans peine en mes sentiments les plus forts
une égale disposition à la révolte et à l’obéissance.
L’autre charité n’est que flatteuse, dans le sens où Platon le dit
de la rhétorique en son Gorgias. « Donnons-leur trois francs
cinquante », disait un homme d’État assez cynique devant les
gémissements des femmes, au temps où les hommes étaient au
péril. La Raison peut reprendre cette idée et en faire système. Le
système est que tout homme est capable de s’éveiller en esprit
jusqu’à être enfin respectable, mais qu’il faut commencer par
changer la condition extérieure, en adoucissant cet excès de travail,
d’esclavage et de malheur qui hébète l’esprit. Hugo a pensé cette
idée avec force, et l’autre idée aussi, sans pouvoir les joindre.
Toujours est-il que l’essence du socialisme est de subordonner la
vertu aux situations, comme il éclate dans les conceptions de Karl
Marx. Cette idée de regarder d’abord aux droits, et au droit étonnant
d’exister, qui est le principe de tous, est bien une idée, et ainsi va fort
loin. C’est la même chose que de diviniser l’objet, c’est un
Spinozisme mal entendu, et c’est peut-être le Spinozisme. En ce
travail où il faut que je devine presque tout, on me pardonnera ces
détours souterrains, d’où j’arrive à quelques lumières. On trouvera,
dans un article de critique de Lagneau sur une traduction du Court
Traité, une note étonnante sur la Bible, et qui m’éclaire certains traits
du Maître. La note est injuste à première vue, car la terrible religion
de Job ne laisse à l’homme que patience au travail et résignation
héroïque ; et l’on ne peut pas dire que le bonheur soit proposé ici
comme fin. Mais le regard de Lagneau lisait plus loin que le nôtre ; et
sans doute apercevait-il que ce culte presque fanatique de
l’immense existence telle quelle devait conduire à une recherche du
bonheur, en vérité sans espérance, et au fond mécanique, comme
les travaux des fourmis. L’esprit n’étant pas fait pour cela, et portant
mieux tout malheur que la négation de lui-même, peut-être tenons-
nous ici par les causes la colère communiste, et ce paradoxe de
fonder l’extrême paix sur l’extrême guerre. Les socialistes voudraient
bien rester entre deux ; mais leur principe les force, qui est de
changer d’abord la maison, en vue de changer l’habitant. Cela
revient à attendre la justice autour pour être juste. On verra plus loin
que toute la philosophie de Lagneau vise à subordonner
l’Entendement au Jugement. Or c’est une vue d’entendement à
proprement parler de changer l’objet selon la règle, afin de trouver à
appliquer la règle ; au lieu que le Jugement s’exerce sur la situation
maintenant perçue et fait ordre de tout. « Quand l’eau courbe un
bâton, ma raison le redresse », tel est le dernier mot de
l’entendement ; au lieu que le Jugement ne redresse point du tout le
bâton, mais le pense courbé selon le vrai, c’est-à-dire selon l’eau et
selon l’œil, et ainsi pense encore mieux. Bref, au regard d’une
philosophie qui veut penser droitement dans la perception même, et
non point au-dessus ni au delà, ce n’est point demain ou dans dix
ans que l’esprit s’éveillera. Le rêve n’est que de paresse, et la vérité
du rêve c’est la perception. Dieu de chaque moment, tel est le
Jugement ; et il ne demande point que l’objet soit autre ; non, mais
que la pensée soit autre. Sur cette surface du présent, seule à nous,
se tient donc cet Esprit incorruptible, qui n’attend point et qui
n’espère point, assez occupé de passer du chaos à l’ordre, comme à
tout réveil il faut faire. D’où je comprends encore mieux ce geste des
mains, que j’essaie encore d’imiter en mes meilleures réflexions, et
qui refuse de prendre. Aider, c’est donner la main ; mais la confiance
entraînera les deux. Voilà à peu près tout ce que je sais dire de ce
refus de politique. Ainsi me voilà en cette bordure, me défendant d’y
trop croire, et de m’y jeter ; mais il n’est pas défendu d’y regarder.

Lagneau ne traitait jamais de Morale. Sans doute se défiait-il des

passions ; mais je ne crois point du tout qu’il eût été en ces matières
hésitant ou indulgent. Bien plutôt je le vois terriblement clairvoyant et
sévère. Mais quoi ? Nous étions des enfants, et il ne nous
connaissait guère. Dans les circonstances rares où je l’ai vu agir,
dans d’autres qu’on m’a rapportées, il était prompt, hardi, et sans
ménagement pour lui-même. Peut-être estimait-il que la morale en
discours est trop facile. Peut-être aussi était-il naturellement retenu
par d’autres leçons qui se présentent d’elles-mêmes les premières,
et qui l’occupaient toute l’année. Toujours est-il qu’il n’a jamais traité
devant moi que de la Perception et du Jugement. L’inévitable
préambule sur la Méthode de la Psychologie ne faisait que préparer
ces deux leçons principales. Je sais que dans la suite il lui arriva de
traiter de l’existence de Dieu ; j’ai supposé longtemps qu’il n’y avait
eu que le titre de changé ; je ne me trompais guère. Je ne me fie, à
la rigueur, qu’à mes propres souvenirs. Toutes les heures sérieuses
de ma vie ont été occupées à répondre à cette question : « Que
pensait-il ? Que voulait-il dire ? » Il n’y a pas longtemps je revenais à
une formule que j’ai entendue plus d’une fois : « Retrouver dans une
de nos pensées toute la pensée », et je buttais là comme autrefois.
Je ne me plains point de cette lenteur d’esprit ; c’est lui qui m’apprit à
mépriser mes fragiles constructions. Toujours est-il que j’avais assez
de lui pour méditer cent ans. Un ami plus jeune que moi m’avait
entretenu plus d’une fois de cette leçon fameuse, où le Maître allait à
conclure, je résume comme je l’entendis de cet ami, à conclure que
Dieu ne peut être dit exister, puisqu’exister c’est être pris dans le
texte de l’expérience. Nouveau thème pour des méditations
difficiles ; j’y retrouvai un Cartésianisme poussé à bout, et qui certes
n’avait rien de Spinoza ; car, ce que j’ai toujours remarqué en
Spinoza, c’est que l’Immense Existence s’y offre la première, dans
son Idée, il est vrai, et donc tout entière en chaque rencontre, mais
enfin d’abord existence, et de là essence, et finalement pensée, d’où
une liberté murée. J’oserais presque dire que les premières
démonstrations de Spinoza vont plutôt de l’existence à l’essence, au
rebours de Descartes. Mais je prends ce commentaire à mon
compte ; je n’en veux point charger le Maître ; on voit seulement par
quel détour j’essayais de deviner l’essence qui passe l’existence. Au
reste je ne poussais pas bien loin par là, et même j’aurais choisi de
ne rien dire là-dessus si, quelque temps après que j’eus commencé
d’écrire ces mémoires, je n’avais reçu une visite mémorable. Nous
avions annoncé notre projet de rassembler les écrits de Lagneau ;
cette nouvelle avait couru. La réputation où est encore Lagneau,
après une courte vie et si peu de bruit, est quelque chose de
miraculeux, et qui fait honneur à l’espèce. Bref je vis arriver chez moi
un homme de forte structure, à tête chevaline (Diogène disait à
Platon : « Bonjour, cheval ») et de rustique simplicité. Il portait une
valise bourrée de papiers, d’où je vis sortir les leçons déjà connues,
par lui rédigées, à ma grande honte, comme je n’avais su faire, et
enfin les précieux cahiers portant au titre « De l’existence de Dieu ».
Cet homme, que je surnommai aussitôt l’Homme de Dieu, avait été
pêcheur de morue dans sa jeunesse, et puis marin long-courrier,
ensuite étudiant, et, sur la trentaine, élève de Lagneau, justement
après moi ; finalement laboureur et éleveur de bœufs en cette
Normandie, notre commun berceau. Ceux qui ont connu Jules
Lachelier, Normand lui-même, pourront se faire une idée de cette
tête à forte mâchoire, de cette structure tassée et osseuse, de cette
méditation sculpturale d’où remonte le regard bleu, mouvement de
retour et de réveil à ce monde-ci. Lagneau était autre, et, à ce qu’il
me semble, interrogeait l’objet toujours. Imaginez donc cet autre
sage, assis contre sa haie normande, tirant ses cahiers de sa poche,
et trouvant là le dernier mot sur sa destinée, enfin ce qu’il avait
vainement cherché autour du monde, comme il m’a dit. Je me
retrouvai au temps de Solon. L’amitié fut prompte, par ceci de
commun que nous n’avions ni l’un ni l’autre jamais craint ni respecté
aucun être au monde à l’exception de notre commun Maître. Je lus
donc les pages sublimes. La marque y était, mais aussi quelque
chose d’abstrait et de désertique, qui n’était point dans mes
souvenirs d’écolier. Un autre genre d’écolier, un autre genre aussi de
sérieux, avait-il rabattu tous les ornements sur ce pierreux chemin ?
ou bien le Maître sentait-il qu’il était temps de finir ? Ou bien
l’attention dévorante de ce nouveau disciple, qui attendait toujours le
dernier mot, avait-elle insensiblement tiré l’analyse hors de ce
monde jusqu’à l’extrême bord de la réflexion dialectique ? Je me
trouvai d’abord ici comme je fus tant de fois devant les pages les
plus abruptes de Fichte ou de Schelling, cherchant l’objet, qui, dans