Urology MCQ

1. The most ominous sign or symptom of urinary system disease is:
A. Urinary frequency.
B. Pyuria.
C. Pneumaturia.
D. Dysuria.
E. Hematuria.
Answer: E

DISCUSSION: While urinary frequency (voiding more than three to five times daily) or dysuria (painful voiding) may be a sign of malignant disease, they are more commonly associated with nonmalignant inflammatory disease, neurologic disease, or calculous disease of the urinary tract. Pyuria (pus in the urine) is most commonly associated with infection and not malignancy. Pneumaturia (air or gas in the urine) indicates a fistula between bowel and the urinary tract or infection by fermination in diabetic urine. Hematuria (blood in the urine) is most worrisome. While this may be produced by infection or by calculous disease, it is most commonly associated with malignant disease in the absence of associated signs or symptoms such as pyuria, frequency, and dysuria. Thus, of the ones mentioned, hematuria is the most ominous single sign or symptom.


2. A patient with acute urinary tract infection (UTI) usually presents with:
A. Chills and fever.
B. Flank pain.
C. Nausea and vomiting.
D. 5 to 10 white blood cells per high-power field (hpf) in the uncentrifuged urine specimen.
E. Painful urination.
Answer: E

DISCUSSION: Cystitis or infection of the bladder is the most common UTI. Lower UTI, or cystitis, is an infection in the bladder. Painful urination and frequency are the most common presenting complaints. Hematuria may occur, but is associated with painful urination and frequency. Flank pain, fever, chills, nausea, and vomiting usually occur only when the infection involves the kidney. An acute UTI is identified in unspun urine only when there are more than 10 leukocytes per hpf in the unspun urine. The normal urine may have as many as 10 WBC/per hpf without being infected.


3. Renal adenocarcinomas:
A. Are of transitional cell origin.
B. Usually are associated with anemia.
C. Are difficult to diagnose.
D. Are extremely radiosensitive.
E. Frequently are signaled by gross hematuria.
Answer: E

DISCUSSION: Renal adenocarcinomas arise from the renal tubular cells and not from the transitional cells that line the collecting system of the kidney. Although one fifth of all patients with renal cancer may present with anemia, the most common presenting symptom is hematuria, either gross or microscopic. Ultrasonography may confirm that a renal lesion is either cystic or solid but computed tomography (CT) is probably the most accurate imaging study for diagnosing the disease. Renal adenocarcinoma is little sensitive to current chemotherapeutic agents. Radiotherapy plays almost no role in the management of the primary tumor. Operation is the treatment of choice when the disease is confined to the kidney itself or when it has extended just outside the renal capsule. An operation has little effect once the disease is extended to adjacent structures or to regional lymph nodes.


4. Ureteral obstruction:
A. Is associated with hematuria.
B. Is associated with deterioration of renal function and rising blood urea nitrogen (BUN) and creatinine values.
C. Is commonly caused by a urinary tract calculus.
D. Usually requires open surgical relief of the obstruction.
E. Is usually associated with infection behind the obstruction.
Answer: C

DISCUSSION: Ureteral obstruction produces loss of renal function when there is only one renal unit and the ureter is obstructed or when obstruction is bilateral. Ureteral obstruction often is best identified by either intravenous pyelography (IVP) or retrograde pyelography, which allows one to identify the specific site of obstruction. Calculous disease is the most common cause of ureteral obstruction. Ureteral obstruction is not a surgical emergency that requires open surgical intervention, but it may be relieved by retrograde or antegrade passage of a double-J stent to bypass the obstruction, permitting orderly nonemergent identification of the cause of obstruction and selection of a treatment process.


5. Stress urinary incontinence:
A. Is principally a disease of young females.
B. Occurs only in males.
C. Is associated with urinary frequency and urgency.
D. May be corrected by surgically increasing the volume of the bladder.
E. Is a disease of aging produced by shortening of the urethra.
Answer: E

DISCUSSION: Stress urinary incontinence is seen principally in older females and is produced by pelvic floor relaxation with shortening of urethral length. The symptom of stress urinary incontinence is urinary leakage produced by an increase in intra-abdominal pressure, as with straining to lift or to laugh. Urgency and frequency are symptoms of urge incontinence, not stress incontinence. Stress incontinence classically is not seen either in males or in young females who have good pelvic floor support.


6. Which of the following is/are true of blunt renal trauma?
A. Blunt renal trauma and penetrating renal injuries are managed similarly.
B. Blunt renal trauma with urinary extravasation always requires surgical exploration.
C. Blunt renal trauma must be evaluated by contrast studies using either IVP or CT.
D. Blunt renal trauma requires exploration only when the patient exhibits hemodynamic instability.
E. Any kidney fractured by blunt renal trauma must be explored.
Answer: D

DISCUSSION: Blunt renal trauma should be explored. Only those who have gross hematuria need undergo contrast studies. Microscopic hematuria is no longer an indication for contrast evaluation. Patients who have blunt renal trauma need to undergo exploration only if they are hemodynamically unstable. Conservative management in the absence of hemodynamic instability is the current trend. All penetrating injuries should undergo exploration.


7. Carcinoma of the bladder:
A. Is primarily of squamous cell origin.
B. Is preferentially treated by radiation.
C. May be treated conservatively by use of intravesical agents even if it invades the bladder muscle.
D. May mimic an acute UTI with irritability and hematuria.
E. Is preferentially treated by partial cystectomy.
Answer: D

DISCUSSION: Carcinoma of the bladder is primarily of transitional cell origin, arising from the transitional epithelium that lines the bladder. It may be confused with an acute UTI by producing urgency, frequency, and hematuria. Bladder carcinoma may be treated conservatively using intravesical agents if the tumor is intraepithelial in origin and does not invade through the basement membrane. Neither radiation nor chemotherapy is the treatment of choice for disease that invades the muscle of the bladder. Partial cystectomy may be chosen only when the disease is focal and there are no mucosal changes in other parts of the bladder.


8. The major blood supply to the testes comes through the:
A. Hypogastric arteries.
B. Pudendal arteries.
C. External spermatic arteries.
D. Internal spermatic arteries.
Answer: D

DISCUSSION: Testes arise from portions of the wolffian bodies on the genital ridge close to the kidneys; therefore, the major blood vessels from the testes arises from the aorta just below the renal arteries and are termed the internal spermatic arteries. Secondary blood supply to the testes comes from the artery of the vas deferens, and a small branch from the epigastric artery termed the external spermatic artery forms during descent of the testes from the abdomen to the scrotum. The surgical importance of this phenomenon is that operations involving the region of the renal arteries may sacrifice the internal spermatic artery. If the two other arteries are intact, the testes will survive; however, if the patient has had a vasectomy and the artery of the vas has been sacrificed, there is a possibility of testicular atrophy, since the testicle will have to be totally dependent on the arterial supply derived from the small external spermatic artery.


9. Patients who have undergone operations for benign prostatic hypertrophy or hyperplasia:
A. Require routine rectal examinations to detect the development of carcinoma of the prostate.
B. Do not need routine prostate examinations.
C. Have a lesser incidence of carcinoma of the prostate.
D. Have a greater incidence of carcinoma of the prostate.
Answer: A

DISCUSSION: Patients who have undergone operations for benign prostatic hyperplasia or hypertrophy have had only the inner portion of the prostate removed, which consists of the periurethral glandular structures that give rise to hyperplasia and hypertrophy. The posterior segment of the prostate, which is compressed by the anterior (inner) portion, comprises the surgical capsule and is left behind. The posterior portion of the prostate gland is the most frequent site of origin of prostate cancer. There is no difference in the incidence of carcinoma of the prostate in patients with benign prostatic hypertrophy and those without benign prostatic hypertrophy or those who have and have not undergone operation for prostatic hypertrophy. Since prostate carcinoma can develop at any time in a patient's life, routine examinations and prostate-specific antigen assay are the most efficient methods of detecting this disease.


10. The male contribution to a couple's infertility is approximately:
A. 10%.
B. 25%.
C. 50%.
D. 75%.
Answer: C

DISCUSSION: In the United States of America it has been estimated that approximately 15% of couples have difficulty with conception. Adequate evaluation of the marital unit for infertility demands assessment of the male partner since infertile status may be attributed to the male as much as 50% of the time. A full evaluation of the male partner is important to avoid extended fruitless evaluation and management of the female partner when the male is infertile.


11. To maximize fertility potential, orchidopexy for cryptorchidism should be done before:
A. Age 15 years.
B. Age 12 years.
C. Marriage.
D. Age 2 years.
Answer: D

DISCUSSION: The testes are exquisitely sensitive to temperature; therefore there is progressive deterioration of testes that are not within the scrotum. Cryptorchid testes, whether they be in the inguinal canal, in an intra-abdominal position, or in an ectopic position, will undergo progressive spermatogenic failure, although adequate amounts of androgens may be produced and secreted. The timing of orchidopexy has been moved progressively backward, and now the recommendation is that orchidopexy should be accomplished before age 2 years, to maximize the possibility of production of spermatozoa of normal quantity and quality. In cases of unilateral cryptorchidism the matter of surgical exploration is less critical; however, to provide maximum potential for both testes, the earlier cryptorchidism is surgically corrected the better are the chances for normal spermatogenesis.


12. Within the age group 10 to 35 years, the incidence of carcinoma of the testis in males with intra-abdominal testes is:
A. Equal to that in the general population.
B. Five times greater than that in the general population.
C. Ten times greater than that in the general population.
D. Twenty times greater than that in the general population.
Answer: D

DISCUSSION: The incidence of carcinoma of the testis is greater in patients who have cryptorchidism, whether corrected or not; because of this, routine self-examination by patients who have undergone operation for cryptorchidism is important. For patients who have uncorrected intra-abdominal testes it is estimated that the incidence of the development of carcinoma of the testis in the age group 10 to 35 years is approximately 20 times greater than that for the general population. If cryptorchidism is diagnosed after the age of 10 to 12 years, orchiectomy may be the preferred treatment, since such testes rarely exhibit normal function, despite adequate scrotal placement, and put the patient at great risk for an intra-abdominal neoplasm that will be difficult to diagnose.


13. The appropriate surgical treatment for suspected carcinoma of the testis is:
A. Transscrotal percutaneous biopsy.
B. Transscrotal open biopsy.
C. Repeated examinations.
D. Inguinal exploration, control of the spermatic cord, biopsy, and radical orchectomy if tumor is confirmed.
Answer: D

DISCUSSION: If, after physical examination, and even scrotal ultrasound, a tumor of the testicle is still suspected, the appropriate surgical treatment is high inguinal exploration with control of the cord, delivery of the testicle onto a protected field, biopsy if necessary, and then orchiectomy at the level of the internal ring if tumor is confirmed. Transscrotal manipulations, whether they be percutaneous or open, are to be condemned because of the possibility of tumor spillage with the ultimate necessity for hemiscrotectomy to control local recurrence. Certainly, repeated examinations over a very short period of time are appropriate, but no time should be lost if there is true suspicion of a testicular tumor. Before the high inguinal exploration it is helpful to obtain serum levels of the beta subunit of human chorionic gonadotropin and alpha-fetoprotein, which are important tumor markers. Surgical exploration should not be delayed until the actual laboratory values are determined, as they are important to the longitudinal course of the patient and not necessarily to the diagnosis.


14. If torsion of the testicle is suspected, surgical exploration:
A. Can be delayed 24 hours and limited to the affected side.
B. Can be delayed but should include the asymptomatic side.
C. Should be immediate and limited to the affected side.
D. Should be immediate and include the asymptomatic side.
Answer: D

DISCUSSION: Torsion of the testicle should be corrected as soon as possible after the diagnosis is entertained. Incomplete torsion can cause partial strangulation, the effects of which may be overcome if surgical intervention is accomplished within 12 hours, whereas severe torsion with complete compromise of the blood supply results in loss of the testis unless surgical intervention occurs within approximately 4 hours. The contralateral scrotum should also be explored at the time of the operation, since the primary anatomic defect—insufficient attachment of the testicle to the scrotal sidewall—most often is a bilateral phenomenon. If the contralateral scrotum is not explored, the patient runs a very high risk of undergoing torsion on the other side and the possible complication of loss of both testes.


15. Epididymitis, either unilateral or bilateral, in a prepubertal male:
A. Is a frequent diagnosis.
B. Can be dealt with on an outpatient basis.
C. Is a major scrotal problem in this age group.
D. Is a rare phenomenon.
Answer: D

DISCUSSION: Epididymitis can occur in prepubescent males, but it is a rare phenomenon and usually occurs only in patients with chronic UTI, obstructed urethra, or very high voiding pressure. The diagnosis of epididymitis in the prepubertal male should be reviewed with suspicion because one of the more common causes of the clinical situation that presents as epididymitis is torsion of the testicle. If there is any concern about the validity of the diagnosis, the patient should undergo scrotal exploration. Epididymitis will not be compromised by surgical exploration, but delay in surgical exploration leads to loss of the testicle if the problem is torsion.


16. Patients with prostatitis, especially acute suppurative prostatitis:
A. Should have residual urine measured by intermittent catheterization.
B. Should have bladder decompression by urethral catheter.
C. Should have repeated prostatic massage.
D. Should have no transurethral instrumentation if possible.
Answer: D

DISCUSSION: Acute suppurative prostatitis should be treated with vigorous antibiotic therapy with broad-spectrum agents initiated immediately and changed in response to results of culture and sensitivity studies. Urethral instrumentation and repeated prostate examination should not be done, if at all possible, since sepsis is not unusual after either diagnostic examination or urethral catheterization. If the patient does need to have the bladder decompressed, it is beneficial to use a suprapubic catheter rather than a urethral catheter.


17. Benign prostatic hypertrophy with bladder neck obstruction:
A. Is always accompanied by significant symptoms.
B. Is best diagnosed by endoscopy and urodynamic studies.
C. Is easily diagnosed by the symptoms of frequency, hesitancy, and nocturia.
D. Is always accompanied by residual urine volume greater than 100 ml.
Answer: B

DISCUSSION: Benign prostatic hypertrophy with bladder neck obstruction is difficult, in some patients, to diagnose as they are totally asymptomatic, even if they have residual urines of greater than 1000 ml. or renal compromise consisting of the syndrome of so-called “silent prostatism.”


18. Which of the following statements are true concerning male infertility?

a. Although 15% of couples in the United States are affected by infertility, the male rarely contributes to the problem
b. A varicocele can be associated with diminished sperm motility and abnormal sperm morphology
c. Complete testicular failure will usually respond to systemic testosterone administration
d. Anti-sperm antibodies are an important cause of infertility which may be treated successfully with corticosteroid administration
Answer: b, d

Infertility is defined as the inability to conceive a pregnancy within one year of unprotected intercourse. About 15% of couples in the United States are affected, and in about 25%-50% of infertility cases, the male contributes to the problem. The cornerstone of male fertility evaluation is the semen analysis. Oligospermia, or a low sperm count, is an incomplete form of testicular failure due to a number of causes. A varicocele is found in about 15% of the general male population, but 40% of infertile men have this finding. Men with a varicocele can exhibit low sperm counts but more often have diminished sperm motility and abnormal morphology. Surgical ligation or angiographic embolization of the internal spermatic vein improves the semen parameters in 50%-70% of these men and gives subsequent pregnancy rates of 25%-50%. Complete testicular failure is diagnosed by a testis biopsy showing no sperm production or by a markedly elevated serum FSH level, indicating the absence of negative feedback inhibition induced by spermatogenesis. Complete testicular failure is not remedial by treatment. Anti-sperm antibodies are found frequently in infertile men and represent an important cause of infertility. Corticosteroid administration may be helpful if antibodies are present, but the toxicity of these medications cannot be ignored.


19. A 65-year-old male is diagnosed as having prostatic cancer based on transrectal biopsy of a 1 cm palpable nodule. Which of the following statement(s) are true concerning his management?

a. If the tumor is confined within the prostatic capsule (stage A or B), radical prostatectomy is an appropriate option
b. If positive lymph nodes are detected on laparoscopic pelvic lymph node dissection (stage Dl), radical prostatectomy is indicated
c. Radical prostatectomy is invariably associated with impotence
d. External beam radiation is an appropriate treatment if the tumor is confined to the prostate
e. There is currently no role for orchiectomy in the management of prostatic cancer
Answer: a, d

The treatment of prostatic cancer depends on whether the disease is localized to the prostate or advanced beyond the gland. Because prostate cancer advances slowly, the morbidity of therapy may exceed the therapeutic benefit in the elderly and debilitated. Patients who have a limited life expectancy and low stage disease are frequently treated with observation only. If the tumor is confined within the prostatic capsule (Stage A or B), options include radical prostatectomy, external beam radiation therapy, and radioactive implants. Radical prostatectomy is usually carried out through the retropubic approach. Through this approach a node dissection can be done for further staging, and the procedure abandoned if the nodes contain tumor. In patients with a high index of suspicion for positive nodes, a laparoscopic pelvic node dissection can be performed to decrease postoperative morbidity. The use of the nerve-sparing prostatectomy can be used to preserve penile erection in those patients who are potent. In this approach, the nerves concerned with penile erection are excluded from the dissection. The incidence of impotence following traditional radical prostatectomy is l00% but can be cut in half with the nerve-sparing approach. Hormonal ablation is the initial treatment of choice for advanced prostatic cancer. Most prostatic cancers are androgen-responsive. Androgen ablation will cause improvement in 80-90% of patients with regression of tumor in about 40%. The testis is the primary source of androgen and orchiectomy remains the gold standard and treatment of choice for advanced prostatic cancer. Estrogen will produce castrate levels of testosterone, but the side effects of fluid retention and increased incidence of thromboembolic diseases such as heart attacks and strokes make this hormone a poor choice in this high risk age group.


20. Extracorporeal shock wave lithotripsy (ESWL) has had a dramatic effect on the management of urinary stones. Which of the following statement(s) are true concerning shock wave lithotripsy of urinary stones?

a. The basic principle of lithotripsy involves the generation of shock waves which are focused fluoroscopically on the calculus and are delivered to the patient who is submersed in a water bath
b. The most common complication after lithotripsy is ureteral obstruction secondary to stone fragments
c. ESWL can be associated with stone-free rates ranging between 60%-95% at six months for renal and proximal ureteral stones
d. The combination of ESWL with percutaneous nephrolithotripsy improves the results for stone clearance in patients with large or branched stones such as staghorn calculi
Answer: a, b, c, d

The introduction of ESWL has virtually eliminated open surgery for renal and ureteral lithiasis. The basic principles of all lithotriptors include shock wave generation, focusing of the sound wave, and imaging of the stone. All lithotriptors produce shock waves by a spark gap electrode or by a piezoelectric or electromagnetic element. The wave is then focused towards the stone which is localized either employing fluoroscopy or ultrasonography. The patients are either submersed in a water bath or “coupled” by a water cushion. The acoustic density of water and body tissues is essentially the same. Therefore, there is little or no impedance of the shock wave at the water-body interface. Upon striking the stone, which is of different acoustical density, the shock wave undergoes reflection and refraction, resulting in compressive and tensile forces which fragment the stone.
Complications of ESWL are rare. The most common complication after ESWL is ureteral obstruction secondary to stone fragments requiring either additional ESWL, urethroscopic stone retrieval or stent placement. ESWL is the treatment choice for the vast majority of renal and proximal ureteral stones with stone-free rates ranging from 60%–95% at six months. Stones larger than 3 cm and branch stones such as staghorn calculi are best treated with percutaneous nephrolithotripsy alone or in combination with ESWL. The combination of extracorporeal and percutaneous techniques can result in average dome clearance rates in excess of 80%.


21. Which of the following statement(s) are true concerning bladder carcinoma?

a. Epidemiologic studies have implicated cigarette smoking as a risk factor
b. If cystoscopy demonstrates a bladder carcinoma as the cause of painless hematuria, no further evaluation is necessary
c. Multi-focal and recurrent bladder tumors are usually treated with transurethral resection and intravesical chemotherapy
d. The results of treatment for locally advanced bladder tumors are similar with either radical cystectomy or radiation therapy
Answer: a, c

A wealth of basic research and clinical data testify to a variety of chemical carcinogens inducing bladder cancer. Occupational exposure to beta-naphthylamine and para-aminophenyl results in an increased incidence of bladder cancer. Epidemiologic studies have also indicated cigarette smoke as a risk factor. Bladder cancer has a strong male prevalence and is almost three times more common in men than women. The hallmark of bladder cancer is painless, total gross hematuria. The usual diagnostic tests employed are excretory urography (IVP) and cystoscopy. The former is important because the upper tracts (renal pelvises and ureters) are also at risk for the development of urothelial neoplasia. Cystoscopy is not only diagnostic but also therapeutic because superficial tumors are easily excised or fulgurated through endoscopic instruments. Approximately 70% of patients with bladder cancer will present with local disease. This is associated with five year adjusted survival rate of 88%. Close vigilance is important because the recurrence rate exceeds 50%. Ten to 50% of superficial tumors will progress to invasive disease. Multifocal and recurrent tumors are usually treated with intravesical chemotherapy in addition to transurethral resection. Agents commonly employed include thiotepa, doxorubicin, and mitomycin C. Alternatively intravesical immunotherapy has been successfully performed with installation of BCG (Bacillus Calmette-Guerin). Locally advanced tumors are usually treated with radical cystectomy and urinary diversion. Radiation therapy has been employed but is associated with a high rate of local recurrence.


22. The most common malignant neoplasm of the kidney is the hypernephroma or renal cell carcinoma. Which of the following statement(s) are true concerning renal neoplasms?

a. Renal cell carcinomas can produce a variety of hormone or hormone-like substances
b. Bilateral multifocal renal cell cancers can be associated with the multiple endocrine neoplasia syndrome
c. A “tumor deformity” on IVP is diagnostic of a renal cell carcinoma
d. Early control of the renal pedicle is an important aspect of surgical management of renal cell carcinoma
e. Patients with renal cell carcinoma in a solitary kidney will inevitably require total nephrectomy and long-term dialysis for the resultant renal failure
Answer: a, d

Renal cell carcinoma or hypernephroma account for approximately 2% of all cancers diagnosed annually. It is most common after the fifth decade of life and has a male to female ratio of approximately 2:1. No definite etiology has been identified, but a frequent genetic abnormality detected in renal cell cancer is the loss of heterozygosity of chromosome 3p. Multifocal bilateral tumors are associated with von Hippel-Lindau disease. Renal carcinomas can produce a variety of hormone or hormone-like substances (e.g., erythropoietin, renin, and parathormone) and may present with a variety of symptoms including anemia, hypertension, fever and erythrocytosis. Excretory uroraphy (IVP) provides a good renal image with superior detail of the collecting system. Renal masses such as benign cysts or renal cell carcinomas will both appear as “tumor deformities”, distorting the renal outline or the collecting system. Renal cysts are far more common than renal cell carcinoma and the diagnosis can be confirmed by renal ultrasound. Surgical excision remains the primary mode of treatment for renal cell carcinoma. Although the need for radical nephrectomy has recently been questioned, this procedure remains a gold standard against which less radical procedures must be judged. Radical nephrectomy is performed through an abdominal or a thoracoabdominal approach and involves early control of the renal artery and vein. The tumor, together with the kidney and the perirenal fat is excised within Gerota’s fascia which is not opened. Less radical approaches have been suggested for the treatment of smaller tumors, including partial nephrectomy. This approach is especially valuable for bilateral tumors or in patients with a solitary kidney or poor overall renal function.


23. A 28-year-old white male presents with asymptomatic testicular enlargement. Which of the following statement(s) is/are true concerning his diagnosis and management?

a. Tumor markers, b-fetoprotein (AFP) and ك-human chorionic gonadotropin (HCG) will both be of value in the patient regardless of his ultimate tissue type
b. Orchiectomy should be performed via scrotal approach
c. The diagnosis of seminoma should be followed by postoperative radiation therapy
d. With current adjuvant chemotherapy regimens, retroperitoneal lymphadenectomy is no longer indicated for non-seminomatous testicular tumors
Answer: c

Testis cancer is most common between the ages of 25 and 34 and is rare in blacks. The most common malignant neoplasm of the testis arise from the germ cells and can represent a variety of histologic manifestations, e.g, choriocarcinoma, embryonal cell carcinoma, seminoma, and teratoma. For therapeutic purposes, the tumors can be divided into seminomas and nonseminomas. The usual presenting symptom is testicular enlargement that may be associated with mild discomfort. Any solid testicular mass should be considered suspicious for testis carcinoma. The diagnostic and therapeutic approach for any suspected testis carcinoma is inguinal exploration with orchiectomy if the operative findings confirm the presence of a testicular mass. The inguinal approach is employed to perform high ligation of the cord at the inguinal ring and to eliminate potential involvement of the inguinal lymph nodes which are the primary area of drainage for the scrotum. The tumor markers, a-fetoprotein (AFP) and the b-human chorionic gonadotropin (HCG) can contribute to both diagnosis and follow-up of testis cancer. Tumor markers are helpful when obtained prior to and following orchiectomy to help in assessing the stage of the tumor. Pure seminoma does not cause elevated AFP but can produce a moderate rise in HCG in 10% of patients. Seminomas are very responsive to radiation. Patients with minimal to moderate tumor burden (Stage I or II) are usually treated with radiotherapy. The field of treatment encompasses the para-aortic and para-caval areas below the diaphragm and ipsilateral inguinal and pelvic areas. When bulky retroperitoneal and/or distant metastases are present, cisplatin-based combination chemotherapy is the preferred treatment. The treatment of non-seminomatous tumors is more controversial. Stage I tumors are effectively treated with retroperitoneal lymphadenectomy. If bulky stage II and stage III non-seminomatous tumors are present, initial treatment includes cisplatin-based chemotherapy. Evidence for residual disease with normalization of tumor markers is usually an indication for surgical exploration.


24. Which of the following statement(s) is/are true concerning benign prostatic hypertrophy (BPH)?

a. Prostatic size has no consistent relationship to urethral obstruction
b. Renal failure secondary to obstructive uropathy occurs as bladder pressure rises and is eventually transmitted proximally to the renal pelvis
c. Hormonal treatment for BPH involves treatment with a 5 a-reductase inhibitor which blocks the conversion of testosterone to the dihydrotestosterone
d. Intermittent catheterization, although a temporizing measure, is not an effective treatment for relief of symptoms of BPH
Answer: a, b, c

The prototypic bladder outlet obstruction is prostatic hyperplasia, which urologists once visualized as a progressive encroachment on the urethral lumen related to prostatic growth. It is now clear that prostatic size has no consistent relationship to obstruction and the diagnosis of obstructive uropathy cannot be made by endoscopic inspection or by determination of prostatic size or appearance. Obstruction results in progressive increases in bladder pressure and decreased urine flow rates. If bladder pressures are high enough and sustained long enough, the ureteral pump mechanism is overcome, the ureter dilates, and by a hydraulic mechanism, intervesicular pressure is transmitted to the renal pelvis. At a pressure of 42–50 cm H2O, glomerular filtration ceases. These relatively simple sequential events lead to renal failure. Prostatic enlargement clearly has an endocrine basis since treatment with a 5 a-reductase inhibitor, which blocks conversion of testosterone to dihydrotestosterone (the active male hormone in the prostate) can induce a 30% to 50% regression in prostatic size. Although surgery or hormone therapy may be effective in initiating reversal of changes associated with obstructive uropathy, this does not occur invariably. Removal of the hyperplastic glandular tissue is the most effective treatment in terms of relief of symptoms. Patients who cannot be subjected to operation, however, show the same response to intermittent catheterization and periodic bladder emptying in terms of symptoms as well as bladder wall and pressure changes.


25. A 55-year-old male presents with severe flank pain radiating to the groin associated with nausea and vomiting. Urinalysis reveals hematuria. A plain abdominal film reveals a radiopaque 5 mm stone in the area of the ureterovesical junction. Which of the following statement(s) is/are true concerning this patient’s diagnosis and management?

a. A likely stone composition for this patient would be uric acid
b. The stone will likely pass spontaneously with the aid of increased hydration
c. Stone analysis is of relatively little importance
d. Patients with a calcium oxalate stone and a normal serum calcium level should undergo further extensive metabolic evaluation
Answer: b

It is estimated that 12% of the U.S. population will develop calculus disease during their lifetime. Males have more than twice the rate of stone formation than females. Caucasians have between a two to tenfold higher incidence of renal stone disease than Blacks or Asians. The peak incidence of lithiasis appears to be between the ages of 45 and 64 years. Almost 3/4 of stones are composed of calcium oxalate in combination with calcium phosphate. Magnesium ammonium phosphate (struvite) or infection stones make up approximately 12% whereas pure calcium phosphate and uric acid stones each compromise 7%. The diagnosis of renal stones is made with appropriate history and performance of urinalysis and a non-contrast abdominal radiograph. Urinalysis of a patient with a urinary stone will have evidence of either gross or microscopic hematuria in 85%-95% of patients. Eighty-five to 90% of urinary stones are radio-opaque. Uric acid stones are typically not radio-opaque.
The majority of stones will pass spontaneously with aid of increased hydration and appropriate analgesics. All stones passed should be retrieved for subsequent analysis. Patients passing their first stone should have serum calcium and creatinine levels and a urinalysis in addition to stone analysis. If the stone is calcium oxalate and the serum calcium level is normal, no further evaluation is necessary other than encouraging the patient to increase fluid intake. Any patient with stones composed of uric acid, pure calcium phosphate, cystine, or struvite are at high risk for continued stone formation and should undergo more extensive metabolic evaluation. In addition, those patients with recurrent or enlarging stones, including those patients with known calcium oxalate stones, should undergo a metabolic evaluation.


26. Which of the following statements are true concerning male impotence?

a. Psychologic factors account for less than half the cases of male impotence
b. Vascular testing for vasculogenic impotence may include Doppler determination of penile systolic blood pressure and super selective pelvic arteriography
c. Penile implants are the first line treatment for patients with impotence due to diabetes or vascular dysfunction
d. Impotence associated with abdominal perineal resection is due to direct trauma to pelvic nerves and may be improved with papaverine injection
Answer: a, b, d

Erectile dysfunction is a common condition that affects 10 million American men. The incidence increases with age. By age 55 about 8% of men are affected. By the age of 80 years, the incidence is 75%. Impotence ensues from interference with the normal vascular, neurologic, psychological, endothelial, and hormonal mediators of erection. In many cases, the causes are multi-factorial. Psychological factors can inhibit as well as stimulate erection and account for less than half of the cases of impotence. Although a number of systemic diseases can cause impotence, diabetes is the most common. Impotence may also result from systemic neurologic diseases such as multiple sclerosis. Direct trauma to the pelvic nerves by pelvic fractures of radical pelvic surgery (radical prostatectomy, abdominal perineal resection) may also be associated with impotence.
The determination of the effect of vascular disease on impotence can be determined through a number of techniques. An estimate of penile blood flow can be made through Doppler determination of penile systolic blood pressure using a penile cuff. Direct corporal injection with papaverine, a smooth muscle relaxant, bypasses psychogenic and neurologic factors and produces an erection if the blood flow to the penis is normal. If arterial disease is suspected on the basis of poor response, superselective pelvic arteriography with injection of vasoactive agents is necessary to document the nature of the disease.
The treatment of impotence depends on both the cause and the patient’s willingness to pursue various therapeutic approaches. Patients with neurogenic impotence, such as following pelvic nerve injury, can experience dramatic results with papaverine injection. Penile implants can be used to treat any type of intractable impotence, but they are usually reserved for patients with diabetes or vascular neurologic dysfunction who do not respond to conservative measures.


27. Which of the following statement(s) are true concerning the detection and diagnosis of prostatic cancer?

a. An elevation of prostate specific antigen (PSA) is highly sensitive and specific for prostatic carcinoma
b. American blacks have an increased risk of prostatic carcinoma
c. Autopsy series would suggest that 10% of men in their 50’s will have small latent prostatic cancers
d. Transrectal prostatic biopsy is indicated for a palpable 1 cm prostate nodule
e. Serum prostatic acid phosphatase remains the most useful tumor marker for prostatic carcinoma
Answer: b, c, d

Adenocarcinoma of the prostate is the most common non-cutaneous malignant tumor in men, accounting for 20% of all male cancers and is the second highest cause of cancer deaths in males. It is primarily a disease of older men. At autopsy, about 10% of men in their 50’s can be shown to have small latent tumors, and with this number increasing to 70% of men in their 80’s. However, it is estimated that only 10% of men over 65 will develop clinically significant prostate cancer. An increased incidence in American blacks has been reported.
Early prostate cancer has few symptoms. Therefore, early diagnosis requires detection of small tumors within the prostate gland. Three modalities are used in the early detection of prostate cancer. These include digital rectal examination, serum prostate specific antigen (PSA), and transrectal ultrasound of the prostate. Prostate tumors usually arise in the posterior lobe of the prostate an area readily palpable on digital rectal examination. Early prostatic cancer frequently presents as a small firm nodule within or at the periphery of the gland. If a 1 cm nodule is detected, it is cancer about 50% of the time. Prostatic biopsy is readily performed with little morbidity and is often required to confirm the diagnosis. Transrectal ultrasound of the prostate may also detect prostate cancer often as a smaller more subtle lesion not easily discernable on rectal examination. However, digital examination will also disclose some cancers that are not visualized with ultrasound. Serum PSA is used to aid in the early detection of prostate cancer. PSA is elevated in 68% of men with cancer but 33% of men with benign enlargement of the gland also have an enlarged PSA. Serum prostatic acid phosphatase is not specific for prostatic cancer although a significant elevation is usually associated with metastatic disease. Serum acid phosphatase however has been generally replaced as a tumor marker by the immunoassay for PSA. PSA is also an extremely sensitive tumor marker for recurrences after surgery because serum levels should be undetectable if patients are tumor-free.