74 Sexual Function and Dysfunction in the Female

Ervin Kocjancic, Valeio lacoveli, and Ömer Acar

QUESTIONS 7. Which of the following are potential adverse events

1. Sexual health encompasses which of the with supplemental testosterone in wormen? associated
following concepts? a. lirsutism
a. Absence of sexual
b. Mental well-being
dysfunction/problem b. Acne
c. Human development and maturation . Decreased high-density lipoprotein
d. All of the above d. Vaginal bleeding
e. a and c Ler All of the above
2. Which of these molecules is thought to play only a minor role 8. Decreased sexual interest/desire has been associated with
in female genital sexual response? which of the following conditions in wonen?
a. Vasoactive intestinal polypeptide a. Use of antidepressants
b. Life stressors
b. Nitric oxide
c. Hypoestrogen ism
V Acetylcholine
d. Norepinephrine d. Relationship problems
e Allof the above
e. Aquaporins
3. The Female Sexual Function Index (FSFI) assesses all but 9. Education on sexuality is always indicated, which of the fol
which of the following aspects of sexuality? lowing women is likely to also benefit from medical and/or
psychological treatment?
a Sexual distress
a. 24-year-old woman who does not climax with vaginal pen
b. Sexual desire etration but does climax with citoral stimulation
c. Sexual arousal b. 56-year-old woman with vaginal dryness that is well man
d. Sexual pain aged with sexual lubricant
e. Orgasm ve35-year-old woman with bothersome decline ir sexual
desire
4. Which of the following is N T an essential part of the physical d. Allof the above
examination ina woman with sexual concerns?
e. None of the above
a. Vital signs
b. Assessment of vaginal pH 10. Which of the following diagnoses are included in he Diagnas
tic and Statistical Manual of Mental Ilness Fifth E£ition (DSM-5)?
c. Palpation of the levator ani musculature
a. Female orgasmic disorder (FOD)
d. Careful inspection ofthe vulva b. Hypoactive sexual desire disorder
e Biothesiometry . Genitopelvic pain/penetration disorder
5. Which of the following statements is TRUE? a. a and cabove
. . Assessment of the patient's intimate relationship(s) is a key e. All of the above
aspect of treating sexual problems.
b. Women with spinal cord injury cannot experience orgasm. 11. Which of the following conditions has been associated with
lower bioavailable androgen levels in women?
C. Alinear pattern for sexual response is typical for all women.
a. Hormonal contraceptives
d. Survey instruments may take the place of history in evalua
tion of sexual concerns. b. Surgical menopause
e. All women who have sex with women identify as lesbian or c. Elevated prolactin levels
bisexual. vá. All of the above
6. Which of the following statements is FALSE? e. None of the atbove
to be useful
12. Which of the following has N T been shownarousal
a. Hysterectomy may improve or worsen sexual function in problems with sexual in
women depending on the indication. inthe management of
women?
low serum testosterone levels have been dearly linked to
worse sexual function in all women. a. Topical prostaglandins
. Phosphodiesterase type 5 inhibitors are not currently s Muscle relaxants
approved for the management of problems with sexual c. Vaginal lubricants
and/or estro
d. Hormonal supplementation with androgens
arousal response in women.
d. Sexual activity during routine pregnancy is safe. gens

e. Women may have genital arousal responses to erotic mate e. PsychOsocial counseling
rials that they find mentally or emotionally unappealing 275
276 PART VI Reproductive and Sexual Function
13. Which of the following has been
dysfunction in women? definitively linked to sexual 20. Choose the correct statement regarding the DSM-5
of sexual dysfunctions in women: definitions
a. Postmenopausal estrogen replacement a. Alldisorders, including
b. Obesity genitopelvic pain/penetration
disorder, require that the symptoms meet
c. High educational the DSM-5 defini
achievement tions of that condition.
d. Depression b. Symptoms should be present for 3 months
e. Metabolic syndrome C. Symptoms should occur on at least half of the sexual occa
sions
14. Which of the following has the least evidence for
efficacy in we Symptoms should cause clinically significant distress
management of antidepressant-associated sexual dysfunction
in women? e. Symptoms can be a consequence of a severe
a. Use of an distress relationship
adjunctive antidepressant
. . Reassurance 21. Which of the following is the most
sexual dysfunction? prevalent type of female
c. Drug cessation
d. Drug holiday a. Hypoactive sexual desire disorder
e. Sildenail wb Arousal disorder
15. What is the most commonly purported etiology for the C. Orgasmic disorder
sexual
problems that occur in some women using hormonal contra d. Genitopelvic pain/penetration disorder
ception? e. Vaginismus
La Reduction of bioavailable
testosterone 22. Choose the correct statement about the
mechanism of action
b. Reduction of bioavailable of Flibanserin, which is currently the only
estrogen FDA-approved
c. Psychologicaldistress treatment for acquired, generalized hypoactive sexual desire
d. Partner dissatisfaction
disorder.
e.
a. Phosphodiesterase type 5 inhibitor
Alteration of vascular response
b. a-adrenergic antagonist
16. Which of the following is the possible anatomic location of wt. 5-HT1A receptor agonist and 5-HT 2A receptor antagonist
the Grafenberg spot (G-spot), which is particularly
tactile stimulation in some women? sensitive to d. 5-HT1A receptor partial agonist
a. Anterior wall of the vagina at the level of midurethra e. Estrogen receptor modulator
b. Cervical canal 23. Choose the correct statement regarding FOD:
c. Clitoral surface a. Orgasmic disorder almost always occurs as an isolated form
of female sexual dysfunction
d. Posterior vaginal wall
b. Selective serotonin reuptake inhibitors (SSRis) are used to
e. Perianal ring treat FOD
17. ChoOse the correct statement regarding the laboratory evalua c. The information gathered by the questionnaires about
tion for female sexual dysfunction. female sexual funtion is sufficient to arrive at the diagnosis
a. It is mandatory in all cases of FOD
b. Normal range of testosterone levels have been established DSM-5 definition of FOD does not contain the criterion
in women that reqires orgasmic difficulty to occur despite a normal
cAis rarely indicated unless there is suspicion for an under excitement phase
e. Systemic testosterone treatment (either alone or in com
lying conributory medical condition
d. Thyroid dysfunction is the most commonly encountered bination with systemic/local estrogen treatment) has been
hormonal abnormality in female patients with sexual dys approved by the FDA for the treatment for FOD
function 24. Which of the following is one of the criteria that have been
e. Abnormalities in hormone levels provide extensive diag suggested by Leiblum and Nathan and used in the diagnosis of
nostic and prognostic utility in female sexual dysfunction persistent genital arousal disorder in women'
18, Choose the correct statement regarding FSFI. a. Physiologic sexual arousal can be brief and remit on its own
a. Contains 29 items
bSymptoms of sexual arousal can be triggered by no stimu
lus at all
. K Has an abbreviated version thatcan be used for screening. c. Symptoms of sexual arousal are not distressing
pre- and postmenopausal women
d. The signs of physiologic sexual arousal remit with ordinary
c. It is not validated for use in patients with cancer orgasmic experience
d. Maximum total score is 30 e. The signs of physiologic sexual arousal are experienced
e. It is not validated for use in research in the presence of subjective feelings of sexual desire and
arousal
19. Which of the following is the most widely studied, most validated
physiological test used in the assessment of female sexual function? 25. Choose the correct statement regarding provoked vestibulo
dynia (PVD):
a. Laser Doppler imaging
b. Magnetic resonance
imaging a Patientswith primary PVD appear to have greater nerve
fiber density and thicker vulvar vestibule compared to the
c. Thermistor clip secondary group
d. Vaginal photoplethysmography b. Pelvic floor muscles are usually hypotonic in both primary
Doppler urasonography and secondary PVD
 75 Surgical,Radiographic, andEndoscopic Anatomy ofthe
Retroperitoneum
Drew A. Palmer and Alireza Moinzadeh

QUESTIONS 6. The anterior and posterior laminae of Cerota fascia merge later
ally to form:
1. Which of the following structures is NOT in the retroperitoneum? a. transversus abdominis.
a. Kidney
b. Second portion of the duodenum b. lumbodorsal fascia.
C. lateral renal fascia.
c Ascending colon
lateroconal fascia.
d. Adrenal
e. perirenal fascia.
grTransverse coon
2. Which muscle's function is most similar to psoas major? 7. The kidneys are associated with which embryologic structure?
a liacus a. Outer stratum
bAntermediate stratum
b. Quadratus lumborum
C. Inner stratum
. Transversus abdominis
d. Ectoderm
d. External oblique e. Endoderm
e Vastus lateralis
3. Which of the following statements is TRUE? 8. Which of the following statements are TRUE?
a. Small mesenteric defects have a lower risk of internal hernia
The intercostal neurovascular bundle travels between the in compared to large defects.
lernal intercostal and innermost intercostal muscles.
b. Based on current understanding, the mesentery is continuous.
b. The 10th, 11 th, and 12th ribs are floating ribs.
c. In addition to its gastrointestinal (GI) function, the mesentery
c Fracture of the lower ribs does not pose a risk to the retrop has distinct immunologic, endocrine, and vascular functions.
eritoneal structures.
d. a and b.
d. Bony landmarks are not useful for planning surgical inci e. aandc.
SIOns.
e. The iniercostal neurovascular bundle travels within the cos b and c.
tal groove on the cephalad aspect of the rib. 8. a, b, and c.

4. Which ascial layer is immediately deep to the transversus ab 9. The blood supply to the adrenal gland may include branches
dominis muscle? from the:,
a. Lumbodorsal fascia a: inferior phrenic artery.
b. LaterOConal fascia b. aorta.
c Internal oblique fascia C. renal artery.
d. External oblique fascia d. a and b.
lransversalis fascia e. a and c.
5. Despite warnings from his friends and colleagues, a 32-year old ra, b, and c.
urologist purchases a motorcyde. He is involved in an accident 10. Which of the following statements is T'RUE?
and suffers grade 2 renal trauna. Ihe hematomawould most
likely travel in which direcion if it continued to expand? a. The superior nesenteric artery (SMA) may be sacrificed
withoutcausing bowel ischemia.
a. Superior
b. Ligation of the inferior mesenteric artery (IMA) will cause
b. Lateral ischemia to the large bowel but not the small bowel.
. Medial
s Ihe IMA may be sacrificed without colonic ischemia because
d Caudal of collateral circulation via the marginal artery and hemor
e. Cephalad rhoidal arteries.
279
 PART VI Male Genitalia
280
injured during a psoas hitch procedure
because c. It may be the 1.3 to I4
segments
d. The IMA may be sacrificed without colonic ischemia NAt originates from anterior scrotum in males
of collateral circulation via the ileocolic artery. Sensation to the
mescnteric arteries may e. majus in females
the inferior pubic and labium
e. Neither the superior nor ischemia. hypogastric plexuses during
be sacrificed without causing bowel
1. Following colon mobilization for right
troperitoncal sungery, which plane
sided transperitoneal re
should be developed prior to
18. Damage to the
section may
result in:
a. stress incontinence.
b. erectile dysfunction.
retropeitotwal An.
approaching the renal hilum?
a. Medialto the gonadal vein wretrograde ejaculation.
vein
b. Posterior to the gonadal d. varicocele.
c lateral to the gonadal vein e. autonomic dysreflexia.
(IVC)
d. Medial to the inferiorvena cava 19. What is the major function of the muscles innervated ty thy
satements is FALSE? obturator nerve?
12. Which of the following
typically drains into the IVC.
a. The right testicularvein the left renal
X Hip adduction
vein typically drains into
b. The leti testicular b. Hip abduction
vein. left side. c. Hip flexion
are more common on the
c. Unilateral varicoccles should d. Hip extension
unilateral right-sided varicocele
d. A sudden-onset e. Knee flexion
prompiretroperitoneal imaging.
into the IVC.
The left ovarian vein typically drains
TRUE?
13. Which of the following statements is supply medially, and ANSWERS
its blood
a. The proximal ureter receives medially. 1. e. Transverse colon. The contents of the retroperitoneum
:
the distal ureter receives its blood supply the kidneys, ureters, adrenals, pancreas, second and thrt
Na. The proximal ureter receivesblood its blood supply medially, and clude
colr
receives its supply laterally. portions of the duodenum, ascending colon, descending
the distal ureter arterial structures including the aorta and its branches, venox
blood supply laterally, and
c. The proximal ureter receives its structures including the VC and its tributaries, lymphain,
the distal ureter receives its blood supply medially. lymph nodes, sympathetictrunk, and lumbosacral plexus Th
laterally, and intraperitoneal str
d. The proximal ureter receives its blood supply transverse colon is considered to be an
the distal ureter receives its blood supply laterally. ture.
thigh ate
vein? 2. a. Iliacus. Psoas major functions in flexion of the
14. Which of the following is N T a tributary of the splenic hip joint and is innervated by the anterior rami of LI, 2, nd
a. Inferior mesenteric vein
only muscle listed that also functions in flexcit
L3. Iliacus is the
b. Short gastric vein of the thigh at the hip joint.
between the
c. Left gastroepiploic vein 3. a. The intercostal neurovascular bundle travelsmuscles. ira
internal intercostal and innermost intercostal
t. Right gastroepiploic vein
ture of the lower ribs should lead to a high clinical suspiaon
e. Pancreatic veins 11th and 120
injury to the retroperitoneal structures.ribsThebecause
15. What statement best describes the lymphatic drainage of the must be distinguished from the other they have
sternum and are often retertu
right testis? anterior connection with the rib. These nbsa
a. Superficial then deep right inguinal nodes as floating ribs. The 10th rib is not afloating maringoli
b. Lefi para-aoric with some drainage to the interaortocaval nodes of clinical significance during palpation for the
surgical incision. Bony landmarks are of critical impotu
move. Lan
c Only to the interaortocaval nodes do notttypically
surgical incision planning, as theyuseful can changel t
d. Primarily to the interaortocaval nodes with some drainage marks like the umbilicus are less as they patientw
to the right paracaval nodes an obese
tion depending on the positioning (e.g. intercostal
The
Interaortocaval nodes primarily with some drainage to the a large pannus in flank position).Intercostal andinnermost
mag
right paracaval nodes and a small but appreciable amount nerves travel betweenthe internal onthe
caudal
of drainage to the left para-aortic nodes tercostal muscles within the costal groove
of the superior rib. deep!
16 In addition to ranial nerves III, VII, IX, and X, fascialies
parasympathetic 4. e. Transversalis fascia. The transversalis
superficialtothe
pep
nervous system outflow includes:
transversus abdominis muscle and isQ
a. preganglionic fibers from L3 to L4. neal fat and peritoneum. kiicdnev
extraperniok
the
b. preganglionic fibers from T1 to L2. 5. d. Caudal. The perirenal space around the lisu
in Gerou
preganglionic fibers from S2 to S4. shaped and is open at its inferior extent
within the
d. a and c. pelvis. If a hematoma were to form lamine
Posterior
Would be able to travel in a caudal direction.
e. bandc.
f. a, b, and c. 6. d. Lateroconal fascia. The anterior andthe laterocona pi
postenior
form congu
Gerota fascia merge laterally to anterior and o n
17 Which of the tollowing statements is FALSE abou which functions to separate the radiographically
anterolaterallye
itofemoral nerve? nal spaces. It can be visualized
a. One branch provides Ssensation to the tomographic (Cr) Scan and continues
b. The motor component of one upper anterior thigh. the transversalis fascia. arisefrom
abdon
inte

branch
of muscle during the CremastericC reflex.allows for 7. b. Intermediate stratum. The kidneys oftheT h e
conraction The outer stratum covers the epimysiumfascia.
muscles and becomes the transversalis
76 Neoplasms of the Testis
Andrew J. Stephenson and Timothy D. Gilligan

show an AFP level of 1100 ng/ml. (upper limit: <ll ng/ml.) and
QUESTIONS an hCG level of 80 mU/ml. (upper linit: <5 mlI/m.). Left in
1. The following adult male gernm cell tumor (GCI) subtypes arise guinal orchiectomy reveals a mixed CCT with 60% embryonal tera
from germ cell neoplasia in situ (GCNIS) EXCEPT: carcinoma, 30% yolk sac tumor, 5% seminoma, and 5%
toma. The next best management step is:
a. embvonal tumor.
b. choriocarcinoma. a. retroperitoneal lymph node dissection (RPLND).
c. classic seminoma. b. induction chemotherapy with three cycles of bleomycin
etoposide-cisplatin.
d. spermatocytic tumor. of bleomycin
c. induction chemotherapy with four cycles
e. teratoma. etoposide-cisplatin.
levels in 7 days.
2. Which of thefollowing statements is TRUE regarding spermato d. to obtain repeat serum tumor marker
cytic tumor? e. CT-guided biopsy of the para-aortic mass.
a. Cryptorchidism is a risk factor. "poor-risk
7. All of the following patients would be classified asGroup (IGC
b. It may occur as a mixed GCT with other histologic GCT sub by International Germ Cell Cancer Collaborative
with:
types. Mas CCG)classification criteria EXCEPT hose
c. It may contain i(12p) mutations. plment a testicular seminoma with brain metastases.
d. Bilateral testicular involvement may occur in 2% to 3% of cases. b. primary mediastinal NSGCT.
e Metastatic spermatocytic tumor is rare. c. testicular NSGCT with rising postorchiectomy AFP of 15,000
ng/mL (upper limit: <ll ng/mL).
3. Which of the following GCT subtypes is most likely to spread
hematogenously? d. primary retroperitoneal NSGCT with liver metastases.
a. Choriocarcinoma e. testicular NSGCT with rising postorchiectomy hCG of
93,000 mU/mL (upper limit: <5 mu/mL).
b. Embryonal carcinoma
C. Immature teratoma 8. A 34-year-old African American man with a left testicular mass
transformation undergoes inguinal orchiectomy that reveals a l.2-cm pure sem
d. Teratoma with malignant inoma that is confined to the testis with no evidence of lympho
e. Seminoma vascular invasion or rete testis invasion. His postorchiectomy
with a solid, painless, right intrates serum tumor markers are within the normal range. CT of the
4. A 24-vear-old man presents ultrasonography. His left testis chest-abdomen-pelvis reveals no evidence of retroperitoneal
ticular mass confirmed by scrotal lymphadenopathy and no evidence of pulmonary metastases.
markers show a human chorionic gon
is normal. Serum tumor (upper limit: <5 mu/mL) However, on the chest images, there is evidence of bulky hilar
adotropin (hCG) value of 96 mu/mL of 58 ng/mL (upper limit: <l1l adenopathy bilaterally. The next best management step is:
and an a-fetoprotein (AFP) value
histologic finding in+the
feyome)KFA
rght tgstis is: a. induction chemotherapy with four cycles of bleomycin
ng/mL). The most likely yluecei etoposide-cisplatin.
a. pure teratOma.
b. induction chemotherapy with four cycles of etoposide
b. pure seminoma.
carcinoma.
cisplatin.
C. pure embryonal C mediastinoscopy and biopsy.
tumor.
d. pure yolk sac d. close observation.
e. choriocarcinoma. e. bilateral thoracotomy and resection.
acceptable indication for testis
5. Which of the following is an 9. A 43-year-old man with clinical stage IlA left seminoma receives
sparing surgery? dog-leg radiation therapy to the reroperitoneum and ipsilat
with a normal contralateral
13-cm solid intratesticular mass eral pelvis with a boost to his solitary 2-cm para-aortic nass.
testis Six months after completing treatnent, surveillance CT reveals
-aortic mass that has now grown to 2.8 cm. The
testicular lesion a persislen
b. Suspected benign solitary testis
remainder of t
tasIatic IS negative, and his se
evaluation
mass in a rum tumor marker levels are all within normal limits. The next
C. 2.4-Cn solid mass in
with 1.2-cm solid intratesticular best malagement step is:
d. Hypogonadal male
a solitary testis a. RPLND.
"burned
lesion suggestive of anonsepi
e.
Small (<l cm) hyperechoic
patient with disseminated b, CI-guided biopsy of the retroperitoneal mas. patient de
out" primary tumor in a with serum-elevated AFP and bCG C. close observation until the mass regresses or the
nomatous GCT (NSGCT) mass
velops distant metastases.
left testicular induction chemotherapy with three cycles of
bleomycin
presents with a 5-cm para-aortic mass d.
6. A37-year-old man a 6-cm
(CI) reveals Serum tumor markers etoposide-cisplatin.
Computed tomographydistant metastases.
but no evidence of

284
 CHAPTER76 Neoplasms of the Testis 285
e salvage chemotherapy with four cycles of paclitaxel-ifosfa
mide-cisplatin. a. CT-guided biopsy of the paracaval lesion.
b. RPLND.
10. A 41-year-old man has GCNIS discovered on biopsy of an c. two cycles of chemotherapy with bleomycin-etoposide-cis
atrophic right testis during investigations for infertility due to platin.
azoospermia. He has a history of left inguinal hernia repair. Ld. observation.
His left testis is normal in size and consistency, and there is
evidence of normal spermatogenesis on testicular biopsy. Hlis e. cisplatin.
three cycles of chemotherapy with bleomycin-etoposide
serum luteinizing hormone (LH), follicle-stimulating hornone
(ESH), and testosterone levels are within the normal range. The 15.The following factors are associated with the presence of occult dis
most appropriate treatment for the GCNIS in the right testis tant metastases in patients with clinical stage IIA-B NSGCT EXCEPT:
now is:
a. elevated postorchiectomy hCG.
a. inguinal orchiectomy. b. lymphovascular invasion.
b. low-dose radiation therapy. C. retroperitoneal mass size.
c. carboplatin. d. large primary tumor with involvement of the scrotal skin.
d. observation.
e. retroperitoneal lymphadenopathy outside the primary land
e. transscrotalorchiectomy. ing zone.
11. Which of the following factors is NOT associated with the pres 16.The following are independent risk factors for relapse postch
ence of ocult metastases in clinical stage I NSGCT? emotherapy RPLND EXCEPT:
à Lymphovascular invasion a. evidence of viable malignancy in resected specimens.
b. Absence of yolk sac tumor in the primary tumor b. incomplete resection.
c Percentage of embryonal carcinoma in the primary tumor C. rising pre-RPLND serum tumor markers.
d Elevated preorchiectomy AFP level d. poor-risk disease at diagnosis by IGCCCG criteria.
e Advanced primary tumor stage e. prior RPLND.

12. A27-year-old convict at a correctional facility presents for 17. A 34-year-old man with right clinical stage II NSGCT (100%
management of dinical stage Ileft NSGCT. He has a history embryonal carcinoma) with good-risk features by IGCCCG
of enlarging left testicular mass for 12 months that was discov criteria receives induction chemotherapy with three cycles of
ered incdentally during a routine physical examination by the bleomycin-etoposide-cisplatin. At Completion of chemother
limits. On
prison physician. Pathologic examination of the orchiectomy apy, his serum tumor markers are within normal
postchemotherapy CT studies he has a 1.7-cm mass (4.8 cm at
specimen revealed a 1.2-cm mixed GCT (40% seminoma, 40%
embryonal carcinoma, 20% yolk sac tumor) confined to the diagnosis) in the interaortocaval region and a 0.8-cm mass in
testis without evidence of lymphovascular invasion. His pos the para-aortic region (2.3 cm at diagnosis). He also has bilat
torchiectomy serum tumor markers are within normal limits. eral pulmonary nodules in the right lower lobe (0.6 cm; 1.4 cm
He has a history of multiple incarcerations in the past, and his at diagnosis) and left upper lobe (0.8 cm; 1.6 cm at diagnosis).
The most appropriate management is:
viral serology is positive for hepatitis C. The most appropriate
treatment is: a. four cycles of vinblastine-ifosfamide-cisplatin second-line
a. adjuvant radiation therapy to the retroperitoneum and ipsi chemotherapy.
b. resection of the interaortocaval mass.
lateral pelvis.
b. surveillance. Gbilateral postchemotherapy RPLND.
. chemotherapy with one cycle of bleomycin-etoposide-cispl d. bilateral thoracotomy and resection of residual pulmonary
masses.
atin.
d. chemotherapy with two cycles of carboplatin. e. CT-guided biopsy of the pulmonary mass(es).
e. RPLND. 18. Which of the following statements is FALSE concerning late re
T associated with the pres lapse of NSGCT?
13. Which of the following factors is N masses after first-line chem
ence of necrosis/fibrosis in residual a. Surgical resection is the primary treatment modality.
otherapy? b. Yolk sac tumor is the most common malignant histology.
a. Absence of teratoma in the primary tumo. c. The incidence is increasing.
b. Residual mass size. d. The retroperitoneum is the most common site.
early NSGCT re
c. Percentage shrinkage of mass after chemotherapy. e. The outcome is poor relative to those with
d. Prechemotherapy mass size. lapse.
lIC left mixed GCT (50%
e. Lymphovascular invasion. 19. A 35-year-old man with clinical stage sac) with good-risk fea
treatment of a 1.2-cm left tes embryonal, 40% teratoma, l0% yolk
14. A 37-year-old man presents for seminoma, 15% em tures by IGCCCG criteria receives three cycles
of bleomycin
ticular nixed GCT (40% teratoma, 40% to the testis etoposide-cisplatin chemotherapy. At the start of chemotherapy,
tumor) confined
bryonal carcinoma, 5% yolk sac
invasion. His postorchi his AFP was 380 ng/ml (upper limit: <ll ng/mL), and this has
without evidence of lymphovascularare within normal limits. normalized at the end of chemotherapy. Restaging CT shows
ectomy serum tumor marker levels mass has increased from 5.3 cm to 8.9 cm
disease. Abdomin the solid para-aortic
Chest CT shows no evidence of metastatic paracaval location just with displacement of the aorta and left kidney as well as new
7-mm nodule in the common iliac and left obturator
opelvic CT shows a renal hilum. The remainder of the CT study lymphadenopathy in the left
recent onset of left-sided back
inferior to the right is also unremarkable. TIhe region. The patient complains of
medical history
is unremarkable His
is: pain. The most appropriate management is:
most appropriate managenent
286 PART VI Male Genitalia

a. RPLND and pelvic lvmph node

b. CT-guided biopsy of the
dissetion. c. four cycles of bleomycin etoposide cisplatin chemotherapy.
para-aotic mass. d CTof the head
c. four vdes of
paclitaxel-ifosfamide cisplatin as second line e two cycles of bleomycin etoposide-cisplatin followed by
chemotherapy.
d. two res of carboplatin-etoposide high dose chemotherapy and autolo
bleomvin
carboplatin ctoposide highctoposide-cisplatin followed by gous stem cell resCue.
gous stem ell resque.
dose chemotherapy and autolo 25. Which of the following statements is FALSE regarding treat
e. ment-related toxicity?
bleomyrin-etoposide cisplatin plus radiation therapy. a. Two cycles of platin-based chemotherapy do not increase
20. The rationale for single-agent carboplatin as treatment for clini one's risk of developing cardiovascular disease or secondary
cal stagelseminoma is based on all of the malignant neoplasm (SMN)
EXCEPT: following factors
b. Frequent CT body imaging may increase the risk of SMN.
a. absence of teratoma.
c. The risk of cardiovascular disease is highest arnong patients
b. less neurotoxicity compared with cisplatin. receiving mediastinal radiotherapy.
c. less nophrotoxicity compared with cisplatin. d. Exposure to cisplatin-based chemotherapy and history of
d. less ototoxicity compared with cisplatin. cigarette smoking are associated with similar risks of cardio
vascular disease and SMN.
e similar efthcacy to cisplatin.
e. Suprahilar dissection, vascular reconstruction, and hepatic
21. Late complications of infradiaphragmatic dog-leg resection are risk factors for chylous ascites after RPLND.
incdude all the following EXCEPT: radiotherapy 26. Which of the following are N T símilarities between Leydig cell
a. peptic ulcer disease. tumors and GCT?
b. coronary artery disease. i. Both are associated with a history of cryptorchidism.
c. secondary malignancy. ii. Radical inguinal orchiectomy is the initial treatment of
d. ejaculatory dysfuntion. choice.
e impaired spermatogenesis. ii. Bilateral tumors occur in 2% to 3% of cases.

22. The rationale for

iv. Both may be associated with gynecomastia.
surveillance in clinical stage I seminoma is V. The
based on all of the following factors EXCEPT: retroperitoneum is the most common site of metastatic
disease.
a.-itility of serum tumor markers to identify relapse at an early a. i, ii, and ii.
and curable stage.
b. Relapses are cured in virtualy all cases by deferred dog-leg bi and ii.
radiotherapy. C. i, i, ii, and iv.
c. Lack of validated histopathologic prognostic factors to iden d. v only.
tify a high-risk subset. e. All the above.
d. Improved short- and long-term toxicity compared with pri- 27. A54-year-old man presents with an enlarging right inguinal
mary radiotherapy and carboplatin. On examination, a palpable mass is noted in the mass.
e. 159% to 20% of patients are cured by orchiectomy. region that extends into the right hemiscrotum. Theright inguinal
testis cannot
be distinguished from this mass. Staging CT
23. A 44-year-old man with clinical stage IIl left testicular semi
ous, infiltrative area of reveals a heterogene
noma with IGCCCG good-risk features has a discrete 2.4-cm low-intensity mass (-20 Hounsheld units ).
6 x 9 cm, involving the right
residual para-aoric mass (3.8 cm at diagnosis) after receiving
the inguinal canal into the scrotumspermatic cord and extending from
three cycdes of bleomycin-etoposide-cisplatin chemotherapy. with displacement of the right
His pulmonary nodules have regressed completely. His serum testis. There is no evidence of retroperitoneal
tunor markers are within the normal range. The most appropri distant metastases. The most appropriate lymphadenopathy or
management is:
ate management is: ainguinal orchiectomy followed by adjuvant radiotherapy.
postchemotherapy radiation therapy to the residual mass. b. inguinal orchiectomy alone.
b fluorodeoxyglucose-labeled positron emission tomography . transscrotal orchiectomy.
(FDG-PE)at least 4 weeks after completing chemotherapy. d. inguinal
orchiectomy followed by ifosfamide-based adju
eobservaion. vant chennotherapy.
d. postchemotherapy surgical resection of the residual mas. e. inguinal orchiectomy followed by RPLND.
e Four cydes of paclitaxel-ifosfamide-cisplatin as second-line PATHOLOGY
hemotherapy. 1. A 26-year-old man has a
right radical
24. A 42-year-old asyrnptomatic man presents for management of bryonal carcinonma of the testis. A the orchiectomy for an em
right NSGCT (80% embryonal carcinoma, 10% teratoma, 10% Iralateral biopsy is performed and revealstie of surgery, a con
choriocarinoma). His preorchiectomy hCCG value was 15,000 neoplasia (i ig o 1). The patient should beinratubular germ cell
advised that he:
mU/mL (upper limnit <5 mu/mt), and this has risen to 50,800 a. should have a radical
mU/m!. after orchiectomy. Chest CT shows numerous pulmo orchieCOmy.
narv nodules. There is evidence of muliple masses in the inter b. has a signihcant chance of
the left testis. developing a germ cell tumor in
aortocaval region (largest, 4 8 Cm) and masses in the para-aortic
region (largest, 2.6 Cm). The most appropriate management is Cshould not ry to have a child
a three cycdes of bleomycin-etoposide cisplainchemotherapy d. should immediately receive
radiation to the testis.
b. RPLND. e. shoulkd receive salvage chemotherapy.
 CHAPTER 76 Neoplasms of the Testis 287

Fig. 76.1 (From Bostwick DG. Cheng L: Urologic surgical pathology, ed 2. Fig. 76.2 (From Bostwick DG. Cheng L: Urologic surjcal pathology. ed 2.
Edinburgh. 2008, Mostby) Edinburgh, 2008, Mostby:)

2. A 35-vear-old man has an asymptomatic right scrotal mass.

Testicular ultrasonography reveals a 3-cm heterogeneous intrat
esticular mass. A right radical orchiectomy is performed. The
histology is depicted in ig. 76.2 and is reported as seminoma.
Abdominal CT scan is normal. The patient should be advised to:
a. receive radiation to the contralateral testis.
b. receive at least four cycles of chemotherapy.
c be advised that observation is not an option.
d. be advised to have radiation therapy to the retroperitoneum.
e. receive radiation to the abdomen and chest.
3. A32-year-old man has a right radical orchiectomy for a testicu
lar mass. Preoperatively, his AFP value was normal and his hCG
ievel was elevated at 5000 units. The histology is depicted in Fig
76.3 and is reported as seminoma with giant cells. The next step
in management is:
wa. follow markers and check half-life.
b. chemotherapy according to choriocarcinoma protocol.
c. RPLND.
d. radiation therapy to reroperitoneum.
e. thiee cycdes of chemotherapy.
4. A50-year-old man has aright radical orchiectomy for a testicular
mass. The histology is depicted in ig, 764 and is aspermato
cytic tumor. Abdominal and chest CT' are negative. Serum mark
ers ase normal. The patient should be advised to: Fig. 76.3 (From Bostwick DG, Cheng L: Urologc SUgca patholcgy. ed 2,
a. seceive radiation to the reroperioneum. Edinburgh, 2008, Mosby.)
b. teceive one cycle of chemotherapy.
c have a biopsy of the contralateral testis. La. have inducion chemotherapy.
Ld. not have any reatment b. have an RPLND.
e. havea PETCT scan. (. have a PETCT
5. A20-year-old nan has a right radical orchiecomy. The pathol d. receive radiohetapy below the diaphragn.
ogy is depiced in g76 Sand is read as enbryonal carcinoma. e. epeat the hCG and AFP tests in anoher month.
His hCC and AFP values are elevated and a CIof abdomen and
chest reveals no evidence of ietaslaticdisease Three weeks late, 6. A25-year-old man has a right radical orchiectomy. The histol
repeat AFP and hCGtesting show no change in either marker. ogy is depiled in ig 06 and is reported as a mature terato
The patient should be advised to: ma. The palient's AFP is slightly elevated and bHCG is negative:
 288 PART VII Male Genitalia

Fig. 76.4 (From Bostwick DG. Cheng L: Urologic surgical pathology, ed 2,

Edinburgh. 2008, Mosby.)
Fig. 76.6 (From Bostwick DG, Cheng L: Urologic surgical pathology. ed 2.
Edinburgh, 2008, Mosby)

IMAGING
1. A36-year-old man noted a firm left scrotal mass. He was hit in
the groin l month earlier with a tennis ball. Currentlv he has no
pain, fever, or chills. The testicular ultrasound image is depicted
in Fig, 76.7. The most likely diagnosis is:
a. ruptured testis with peritesticular hematoma.
b,testicular neoplasm.
c. epidermoid cyst.
d. dilated rete testis.
e. testicular abscess.

2. A 32-year-old man had a left radical orchiectomy. Pathologic

evaluationreveals a mixed GCT containing seminoma and enm
bryonal cell carcinoma. Tumor markers are negative. The CI
image depicted in ig, 76.8 was obtained 1-day postoperation.
Chest CT is negative. The next step in management is:
a. biopsy.
b. radiationtherapy.
e chenmotherapy.
d. RPLND.
Fig. 76.5 (From Bostwick DG, Cheng L: Urologic surgical pathology, ed 2, e. repeat CT in 1week to conirm a postsurgical intlammawry
response.
Edinburgh, 2008, Mosby.)

however, there is a 3-cm mass in the retroperitoneum on CT:. ANSWERS

He is given chemotherapy and the mass shrinks to J.8 cm. The 1. d. Spermatocytic tumor. GCNIS is the comou prcurot le
patient should be advised to:
sion tor all lypes of adult nale GCT with thc ewepu"
a. have a retroperitoneal lymphadenectomy dissection spermatoytic lumor. Pediatric CCIs do not typically arke
(RPLND). from GCNIS.
b. have salvage chemotherapy. 2. e. Metastatic spermatocytic tumor is rare. Spermatoc
mor ditfers from other GCT subtvpes in that it does not a
C. get an FDG-PET scan. bilaterality has
from GCNIS, Cryptorchidism is not a risk factor, placentalalki
d. receive radiation therapy. not been reported, it does not express si(12p) ormixed C:CL with
e. be observed. line phosphatase, and it does not occur asa
 Surgery of Testicular Tumors
77 Stephen Riggs, Kris E. Gaston, and Peter E Clark

QUESTIONS 7. Which of the following anatomic structures demonstrates the

most predictable and constant anatomy?
1. Which of the following nerves is at risk for injury during radical a. Postganglionic sympathetic nerve fibers
orchiectomy?
a. Genitofemoral nerve bo. Lumbar arteries
c. Lumbar veins
b. llioinguinal nerve
C. Obturator nerve d. Number of nodes in each retroperitoneal packet
d. Lateral femoral cutaneous nerve e. Lymphatic vessels
e. Pudendal nerve 8. The cisterna chylae is located:
2. Which of the following may be an indication to consider partial a. immediately posterolateral to the IVC, just cephalad to the
orchiectomy for a patient with a testicular mass? right renal artery.
a. Apolar tumor less than 2 cm in greatest dimension b. immediately posterolateral to the VC, just inferior to the
right renal artery.
b. A normal contralateral testicle
c. Hypogonadism c. immediately posterolateral to the aorta, just cephalad to the
left renal artery.
d. Suspicion for benign tumor d. immediately posterolateral to the aorta, just inferior to the
e. Infertility left renal artery.
3. Critical elements to clinically staging testicular cancer routinely Lr immediately posteromedial to the aorta, just cephalad to the
include all of the following EXCEPT: right renal artery.
a. radical orchiectomy 9. The most common auxiliary procedure required to ensure com
b. chest radiograph plete resection of residual tumor at postchemotherapy retrop
c. whole-body positron emission tomography (PET) scan eritoneal lymph node dissection (PC)-RPLND is:
a. IVC resection.
d. serum a-fetoprotein (AFP), human chorionic gonadotropin b. retrocrural resection.
(hCG), and lactate dehydrogenase (LDH)
e. contrasted computed tomography (Cr) scan of the abdo Le nephrectomy.
men and pelvis d. pelvic resection.
4. The incidence of perioperative acute respiratory distress syn e. aortic resection.
drome (ARDS) in patients with prior receipt of bleomycin can 10. All of the following are associated with an increased risk of ne
be minimized by allof the following EXCEPT: phrectomy EXCEPT:
raavoidance of the Trendelenburg position a. Left-sided primary testicular tumor
b. keeping the FiO, as low as possible b. Prior receipt of salvage chemotherapy
C. minimization of intraoperative fluid resuscitation C. Larger retroperitoneal mass size
d. minimization of postoperative fluid resuscitation
e. three cycdes of Bleomycin rather than four Presence of ipsilateral accessory lower pole renal arteries
e. Elevated serum tumor markers (STMs) at PC-RPLND
5. Performing the aortic split-and-roll before that of the inferior
vena cava (IVC): 11. The histology encountered most often at resection of residual
a. allows prospective identification of right accessory lower hepatic lesions after chemotherapy is:
pole renal arteries not identified on preoperative imaging. a. viable malignancy.
b. facilitates b. teratoma.
identification of right-sidedpostganglionic
pathetic nerves as they cross over the aorta. sym fibrosis/necrosis.
c. minimizes risk of left ureteral injury. d. somatic-type malignancy.
d. increases risk if injury to the inferior mesenteric e. hemangioma.
artery.
e. should never be performed. 12. All of the following are associated with an increased risk of pel
6. The ureter is typically located: vic germ cell tumor (GCT) metastases EXCEPT:
a. anterior to the ipsilateral renal artery. a. prior groin surgery.
banterior to the ipsilateral retroperitoneal nodal packet. b. late relapse.
C. require repeat RPLND.
we posterior tothe ipsilateral gonadal vein adjacent to the lower vd congenital absence of the vasa deferentia.
pole of the ipsilateral kidney.
d. anterior to the ipsilateral gonadal vein adjacent to the lower e. prior chemotherapy.
pole of the ipsilateral kidney.
e. posterior to the ipsilateral common iliac artery.
293
294
PART VIL Male
13. All of the Gernitalia
ted templatefol oINwing an atient thauu fullriteia for aunilateral uodi
a. nommal STMs. RIND(RhescBetion A. the imary landing zOne is he most ommon site of
tetro
bilteraltemplate) 1X peitonwal ewIenO

blntenational
(IGCCCG), Gem Cell Cancer
good risk only. Collabotive Gtou
bipsilateral pelvi reences ommo
incomplete ipsilateral lumbar vesscl ligation cncountered at
Ieopeative RPUND has been associated with ipsilateral in
.
IGCCCG good or
residual mass less intemediate tisk. ticll r e C e
d.
than 5 (m. d. uresecded ipsilateral gonadalvessels are frequently encoun
e.
welldehnei
fore and
mass contind to the inay
landing zOne be
lewd at reopetative RILNID,
atter chenotherapy. . the reroaotic nd retrocaval regions are frequent sites of
14. With rgand to the tuse oe reCurrence.

chemotherapy in patientspostoperatie adjuvant cisplatin based

demonstrating pathologic stage llA-B 20. Allof the following are true regarding late relapse of CCT EX
disease at primary RPND, all of the following are tnue XCELT CEPT:
a. it spares one to (wo vcles of chemotherapy for thOse pa a. yolk sac tumor is the most common viable histology en
tients destined to Nur on postoperative observation. countered.
b. it nearly eliminates postoperative K. first-line treatment is generally systemic chemotherapy fol
urences. lowed by consolidative PC-RPLND,
Nsiimproves overall and cancer-specitic survival.
d. it results in overtreatment of 50% to 70% ofpatients if given c. patients who are chemotherapy-naive demonstrate superior
to all patients. survival outcomes.
e it is typically given intwo cycles. d. GCT with somatic-type malignancy is seen with increased
frequency in this population.
15. Which of the following characteristics has been associated with e. the retroperitoneum is the most common site of late relapse.
increased recurrence rate when teratoma is encountered at PC
RPLND: 21. What percentage of patientspresenting with GCT have abnor
a. Extranodal extension mal parameters on semen analysis?
b Presence of somatic type malignancy a. Less than 10%
c. Right-sided primary GCT t . 209% to 60%
d. Presence of immature teratoma c. 70% to 80%

e. Number of lymph nodes removed d. Greater than 90%

16. All of the following factors have been associated with worse prog 22. The processes required to ensure antegrade ejaculation of
nosis when viable GCT is encountered at PC-RPLND EXCEPT: sperm-containing semen include all of the following EXCEPT:
a. incomplete resection. a. seminal emission through vasa deferentia.
b. less than 10% viable GCT in resection specimen. b. closure of the bladder neck.
C. smooth muscle contraction of the prostate.
c IGCCCG intermediate or poor risk status.
d. prior receipt of salvage chemotherapy. Vâ. penile erection.
e. immature teratoma in the specimen. e. input from sympathetic fibers arising from Ll to L4.
17. Which of thefollowing criteria is an accepted indication for two 23. All of the following interventions have demonstrated effcacy in
cycles of adjuvant chemotherapy after primary RPLND: managing chylous ascites EXCET:
a. Number of positive nodes relative to the nunmber removed a. medium-chain triglyceride (MCI) diet.
b. Teratoma only nodal metastases b. total parenteral nutrition.
c. Eranodal extension of GCT c. subcutaneous octreotide.
d. pNi disease or higher . limiting fat intake preoperatively.
YpN2 disease or higher e. placement of peritoneovenous shunt.
18. Apatient has an isolated resectable residual retroperitoneal mass 24. Which of the follawing patients is at the greatest risk for neuro
after induction chemotherapy without radiographic evidence of logic compromise due to spinal ischemia?
disease outside the retroperitoneum, but tumor markers have
failed to nomalize. All of the following are reasonable indica a. 32-year-old male undergoing resection of left para-aortic
tions for the consideration of desperation RPLND EXCEPT: mass with apparent aortic invasion who will most likely re
quire resection of the infrahilar aorta and tube graft recon
a. declining AFP after induction chemotherapy. _truction
b. slowly rising AFP after a complete serologic response to in b. 29-year-old male with large-volume left para-aortic and in
duction chemotherapy. teraortocaval masses that extend through the retrocrural re
c. exhausted.
all potentially curative chemotherapeutic options have been gion into the middle visceral mediastinum
c. 27-year-old male with a completed occluded IVC due to
persistentlyrising STMs through induction chemotherapy. large interaortocaval, retrocaval, and right paracaval masses
e. plateauing AFP after induction chemotlherapy. with a tumor thrombus up the interior border of the right
renal vein
19. Reoperative RPLND is thought to indicate a technical failure at d. 31-year-old male wih a large infrarenal left para-aortic mass
prior RPLND. All of the following findings supportive of this that is found to be invading the L2 vertebräl foramina dur
hypothesis have been reported in the literature EXCEPI: ing resection
 78 Laparoscopic andRobotic-Assisted Retroperitoneal
Lymphadenectomy for Testicular Tumors
Mohamad E. Allaf and Louis R. Kavoussi

QUESTIONS 6. I'wo weeks after laparoscopic RPLND, a patient complains of

abdominal distention and emnesis. CT reveals ascites. Diagnostic
1. A
23-year old man presents after undergoing transscrotal orchi paracentesis confirms the diagnosis of chylous ascites. The next
ectomy for presumed hydrocele. I'athologic examination reveals best step is
embryonal carcinoma with vascular invasion. Serum levels of
tumor markers and results of physicalexamination and com a. reassurance and discharge.
puted tomography (CI) of the chest, abdome, and pelvis were b. reoperation to identify andtreat the source of lymphatic
normal. Which of the following approaches is most appropri leak.
ate?
C. placement of a peritoneal drain and initiation of a low-fat
a. Obsevation diet.
b. Retroperitoneal lymph node dissection (RPLND) d. initiation of somatostatin.
RPLND plus excision of scrotal scar and remnant cord e hydration and initiation of a low-fat diet.
d. RPLND plus scrotectomy and inguinal lymph node dissection 7. A20-year-old man undergoes laparoscopic RPLND after right
e. RPLND plus scrotal and inguinal radiation radical orchiectomy for an NSGCT. All of the following regions
2. Late relapse is a feature most commonly associated with
should be dissected clear of all lymphatic tissue EXCEPT which?
a. seminoma. a. Right spermatic cord
b. yolk sac tumor. b. Paracaval region
c. embryonal carcinoma. c. Interaortocaval region
d. choriocarcinoma. d Retrocrural region
VE. teratoma. e. Precaval region
3. A25-year-old man with a stage IlCnonseminomatous germ
8. Potential advantages to laparoscopic compared with open
cell tumor (NSGCT) has completed primary platinum-based RPLND include all of the following EXCET which?
chemotherapy. Tumor marker levels have normalized according a. Improved cosmesis
to appropriate half-life, and he has undergone bilateral post b. Shorter convalescence
chemotherapy RPLND. Final pathologic analysis revealsa focus Improved disease-free survival
of yolk sac tumor. Appropriate therapy at this point is d. Shorter interval tochemotherapy when necessary
a. careful observation.
e. Faster return to normal activities
b. radiation therapy.
Wtwo additional cycles of platinum-based chemotherapy.
d. four additional cycdes of platinum-based chemotherapy. ANSWERS
e. reexploration in 6 weeks. 1. c. RPLND plus excision of scrotal scar and remnant cord. In
4. A20-year-old man with clinical stage I NSGCT undergoes the setting of scrotal contamination and clinical stageldisease,
laparoscopic RPLND. During surgery, a 2-cm lymph node is thepatient is best managed with RPLND and wide excision
encountered. Which of the following is the most appropriate of the scrotal scar. The remainder of the cord should also be
next step? removed. Observation is not optimal because of the presence of
a. Abort the procedure and administer vascular invasion and scrotal contamination.
chemotherapy. 2. e. Teratoma. Late relapse of germ cell tumor (GCT) after
b. Convert to an open prOcedure.
. Perform a unilateral template dissection and administer
definitive therapy is deined as recurrence more than 2years
after completion of therapy and occurring without evidence of
chemotherapy. disease. Teratoma is the most common histologic subtype in
t Coninue the procedure and perform a full bilateral dissection. volved in cases of late relapse. This is likely due to its combina
e. None of the above. tion of prolonged doubling time and chemotherapy resistance.
3. c. Two additionalcycles of platinum-based chemotherapy.
5. The most commmon cause of open The patient's prognosis is related to serum tunmor marker level
scopic RPLND 0s
conversion during laparo
at the tie of RPLND, prior treatment burden, and the patho
a. intraoperative discovery of bulky lymphadenopathy. logic fhndings for the reserted specimen. If viable GCT is present
at any site but all disease is completely resected, two additional
b. failure to progress. cycles provide survival benefit in this subset of patients. Ein
c. bowel injury. hon reported only 2long-tern survivors of 22 patients (9%)
d. hypercapnia. with completely resected viable GCr afier cisplatin, bleomy
cin, and vinblastine chemotherapy if additional postoperative
bleeding. chemotherapy was not given. ox and colleagues reported that
299
79 Tumors of the Penis
Curtis A Pettaway, Juanita M. Cro0k, and Lance C. Pagliaro

QUESTIONS b HIV vaccination

. daily genital hygiene
1. Which of the following penile lesions is not tvpically associ
ated yith viral infection? d. avoiding tobacco products
Balanitis xerotica obliterans e. icuncision before puberty
b Condvlomata acuminatum 8. Which of the following statements regarding penile cancer is
. Kaposi sarcoma FALSE?
d. Bowenoid papulosis a. Cancer may develop anywhere on the penis.
e Erythroplasia of Queyrat wt. Because of the associated discomfort, patients usually
2. Which of the following infections is associated with cervical present to physicians within the first month of noting the
lesion.
dysplasia
c. Phimosis may obscure the nature of the lesion.
a. Human immunodeficieny virus (HIV) infection
b. Herpesvirus infection d. Penetration of the Buck fascia and the tunica albuginea by
the tumor permits invasion of the vascular corpora.
CGonorhea e. Cancer cells reach the contralatera! inguinal region because
Human papillomavius (1HIV) infection of lymphatic cross-communications at the base of the pe
e Lymphogranuloma venereum nis.
3. What is the major difference between Bowen disease and 9. Before a treatment plan for penile cancer is initiated, which of
erythroplasia of Queyrat? the following is TRUE?
a.
Loss of rete pegs a. Adequate biopsies to determine stage are unimportant
b. Keratin staining because all patients should be treated with amputation.
c Viral etiologic agents b. Radiologic studies play no role in decision making.
location c. Tumor HPV status is critical for
determining primary tumor
e Treatment options therapy.
wt Tumor stage, grade, and vascular invasion status all
4. Kaposi sarcoma of the acquired
immunodeficiency syndrome prognostically important information. provide
(AIDS)-related (epidemic) type is associated with which of the e. No disfiguring therapy is indicated,
following etiologic agents? ous remissions have been noted in because spontane
a. HPV type 16 cases. approximately 109% of
B Human herpesvirus (11HV) type 8
10. Which of the following statements is
. HPV type 32
ral history of penile cancer? TRUE regarding the natu
d
Haemophilus ducreyi (chancroid (soft chancre|) a. Metastases from the primary tumor
e often involve lung
Coxsackievirus type 23 liver, or bone as initial sites.
5. Where do penile cancers mnost b. Lymphatic drainage from the primary tumor is ipsilateral
lans
commonly arise! alone in most cases.
b Shaft c.Metastasis often initially involves spread from the corpora
CFtenulum cavernosa to the pelvic lymph nodes.
d. Coronal sulcus Metastasis initially involves inguinal lymph nodes beneath
the fascia lata.
e. Saotum
Metastasis initially involves inguinal lymph nodes above
6. Which of the following is ot the fascia lata.
developnment of squamous cellconsidered
a risk factor for the
carcinona of he penis! Which of the following stalements concerning
a. Cigarette sinoke in patients with penile cancer is TRUE? hypercalcemia
b HPVintection
a. I is more commonly due to massive bone
bulky solt tissue nmetastases. metastases than
. Phimosis
d Gonorrhea b. I is often relaed to uremia due o ureteral
obstruction.
e. Chewing tobacco wlmay be due to the action of parathyroid hormone like
substances ieleased from the tumor.
7. All of the following are preventive strategies to d I is elated to the action of osteoblasts on bone formation.
incidence of penile cancer LXCEPE: decrease the
e. Iis nnanaged with aggressive diuretic administration as
SK ircumcision after 2l years of age first-ine therapy
301
302 PART VII Male Genitalia

12. The following statements are true regarding 18. Which of the following, inguinal staging proxedure(s) isfare
patients with penile cancer EXCEIE imaging tests in considered standard for deteting niroM opir metas144s
while liniting both morbidity and false-neyative fndings!
a. Both ultrasonography and MRIlack sensitivity for the
detection of corpUs cavemosum involvement. a. Sentinel lymph node biopsy
Superfial inguinal dissection
b. computed tomograpby (CT) is notan appropiate test for
determining primary tumor stage. . Dynanic sentinel lyrnph node biopsy
. CT may be benefcial in deteting enlarged inguinal nodes d. All of the abVe
in obese patients or those who have had prior inguinal andc only
therapy. 19. For patients with proVen unilateral rnetastasis involving two or
d. Iymphangiography can detet abnomal architecture in more lynph nodes at presentation, all of the following urgi
normal-sized lymph nodes. cal considerations are true EXCEPI:
e. inguinal palpation is preferred to CT and lymphangiogra a. ipsilateral ilioinguinal lyrnphadenectorry should be per
phy for determining inguinal nodal status.
formed
Com
13. According to the cighth edition of the American Jointmetastases b. a contralateral staging procedure is not indicated
mittee on Cancer Staging System (i.e., tumor, node,
|TNM) for penile cancer, which of the following statements is C. a contralateral staging procedure is indicated
TRUE? d. both a superficial dissection and a deep ipsilateral disser
a. Primary tumor stage is based on the size of the primary le tion are performed
sion.
e. ipsilateral pelvic dissection provides useful prognostic
b. Lymph node stage is based in part on the size of an in information
volved node. 20. Adjuvant or neoadjuvant chemotherapy should be considered
c`tage T2 tumors invade the corpus spongiosum but not the in addition to surgery for all of the following EXCEPT:
cavernosum.
a. single pelvic nodal metastasis
d. Proven pelvic nodal metastases as well as bilateral inguinal b. extranodal extension of cancer
metastases are both designated as stage pN3. c. fixed inguinal masses
e. Stage Tla tumors involve the dartos fascia and exhibit peri
neural invasion in less than 10% of the specimen. . d two unilateral inguinal nodes with focal metastases
e. single 6-cm inguinal lymph node
14. What is the strongest prognostic factor for survival in penile
cancer 21. The majority of penile cancers are histologically:
a. The presence of lymph node metastasis a. melanoma.
b. The grade of the primary tumor b. bowenoid papulosis.
C. The stage of the primary tumor K. squamous cell carcinoma.
d. Vascular invasion presence in the primary tumor d. epidemic Kaposi sarcoma.
erThe extent of lymph node metastasis e. verrucous carcinoma.

15. Criteria for curative surgical resection (>70% 5-year survival) 22. Which of the following chemotherapeutic agents used in com
in patients treated for lymph node metastasis include all of the bination therapy for penile cancer has been associated with
following EXCEPT: significant pulmonary toxicity?
a. no more than two positive inguinal lymph nodes. x Bleomycin
b. no positive pelvic lymph nodes. b. Methotrexate
C. absernce of extranodal extension of cancer. c. Cisplatin
d. unilateral metastasis. d. 5-Fluorouracil (5-FU)
ea single metastasis of only 6 cm. e. Paclitaxel

16. Surgical staging of the inguinal region is strongly considered 23. Indications for radiation therapy as primary treatment tor
penile cancer include which of the following?
under ali of the following conditions EXCEPT:
a. palpable adenopathy. a. Young, sexually active patient with a smalllesion
b. stage Tib or greater primary tumnor. b. Patient refuses surgery
C. presence of vascular invasion in primary tumor. c. Patient with distant or inoperable metastases who requires
local control to the primary tumor
d. presernce of predominantly high-grade cancer in primary d. None of the above
tumor.

stage Ta tumors. sa. b, and c

L
he morbidity of inguinal 24. Primary penile melanoma is thought to be rare for what rea
17. Strategies attemnpting to minimize adenopathy include all son?
staging in patients with no palpable Penileskin is protected from exposure to the sun.
the following EXCEPT:
superficial inguinal lymph node dissection.
b. Keratin content in penile skin is decreased.
dissection. c Penile blood supply precludes such tumor development.
b. modified complete inguinal
Sstandard ilioinguinal dissection. d. Effective topical chemotherapy exists.
dissection. e. None of the above.
robotic inguinal node
d. laparoscopic and
node biopsy.
e. dynamic sentinel
 CHAPTER79 Tumors of the Penis 303
25. Lymphomatous infiltrationof the penis is most likely second
ary to which condition? 4. b. Human herpesvirus (HHV) type 8. HHV type
known as Kaposi 8-also
to be thesarcoma-associated
a. Autoimmune disorder
suspected herpesvirus--is strongly
B. Diffuse disease Kaposi sarcoma. etiologic agent of epidemic (AIDS-related)
c. Metastasis from adistant primary 5. a. Glans. Penile
tumor tumors may
but occur most commonly onpresent anywhere on the penis
d. Chronic infection the glans (48%) and prepuce
e.
Previous venereal infection (21%).
6. d. Gonorrhea. No
26. What is the most frequently ing penile cancer toconvincing evidence has been found link
other factors such as occupation,
involvement of the penis? encountered sign metstatic
of venereal diseases other
or alcohol intake. (gonorrhea, syphilis, herpes), marijuana use,
'a. Pain 7. a.
b. Urethral discharge
Circumcision after 21 years of age. Adult circumcision
appears to offer little or no protection from
c. Ecchymoses velopment of the disease. These data suggest subsequent
that the
de
crucial
d. Priapism period of exposure to certain etiologic agents may have
occurred at puberty and certainly already
by adult age, rendering later
e Preputial swelling circumcision relatively ineffective as a prophylactic
penile cancer. tool for
27. Which of the following features of
Buschke-Löwenstein tumor
characterizes it as different from condyloma
8. b. Because of the associated
discomfort, patients usually
a. Propensity for early distant metastasis
acuminatum? present to physicians within the first month of noting the
lesion. Patients with cancer of the penis, more than patients
b. Disruption of the rete pegs with other types of can cer, seem to delay seeking medical
c. Loss of pigmentation attention. In large series, from 15% to 50% of patients have
been noted to delay medical care for more than a year.
d. Autoamputation 9. d. Tumor stage, grade, and vascular invasion status all
Ve Invasion and destruction of adjacent provide prognostically important information. Confirmation
sion tissues by compres of the diagnosis of carcinoma of the penis, an
the structure(s) invaded, and tumor grade by the assessment of
28. All of the following statements are true combination
regarding the manage of an adequate biopsy, and complete clinical assessment are
ment of bulky inguinal metastases in patients with beneficial before the initiation of definitive therapy. Biopsy can
penile carcinoma EXCEPT: squamous
be performed as a frozen section immediately before definitive
a. cross-sectional imaging plays an important role in estab therapy in some cases.
lishing the extent of disease. 10. e. Metastasis initially involves inguinal lymph nodes above
b. the fascia lata. The lymphatics of the prepuce forn aconnect
neoadjuvant chemotherapy with a cisplatin-containing ing network that joins with the lymphatics from the skin of
regimen is recommended. the shaft. These tributaries drain into the superficial inguinal
c. post-chemotherapy surgical consolidation to achieve nodes (the nodes external to the fascia lata).
disease-free status is recommended following an objective 11. c. It may be due to the action of parathyroid hormone-like
response to chemotherapy. substances released from the tumor. Parathyroid hormone
among patients who progress through chemotherapy, sal and related substances may be produced by both tumor and
vage surgery can often result in prolonged survival. metastases that activate osteoclastic bone resorption.
e. chemo-radiation for tumor cytoreduction prior to surgical 12. a. Both ultrasonography and MRI lack sensitivity for the de
tection of corpus cavernosum involvement. The sensitivity of
resection or as definitive treatment may play a role.
ulrasonogaphy for detecting cavernosum invasion was 1009%
29. Small lesions of erythroplasia of Queyrat may be successfully in one study. This study confirmed the value of ulrasonog
treated with which of the following? raphy in assessing the primary tumor also reported by other
a. Topical 5% 5-FU investigators. For lesions suspected of invading the corpus
cavernosum, both ultrasonography and contrast-enhanced
b. Neodymium:ytrium-aluminum-gamet (Nd-YAC) laser MRI may provide unique information, especially when organ
c. Local excision sparing surgery is considered.
d. Imiquimod 13. c. Stage T2 tumors invade the corpus spongiosum but not the
cavernosum According to the 8th edition, staging system invasion
Allof the above of the corpus cavernosum is now designated T3, indicating a
14.
wose prognosis than tumors involving the spongiosum alone
e. The extent of lymph node metastasis. The presence and
ANSWERS extent of metastasis to the inguinal region are the most impor
tant prognostic factors for survival in patients with squamous
1. a. Balanitis xerotica obliterans. Also known as lichen sclero penile cancer.
sus, manifests as a whitish patch on the prepuce or glans, often 15. e. A single metastasis of only 6 cm. Pathologic criteria associ
involving the meatus and sometimes extending into the fossa ated with long-term survival after attempted curative surgical
navicularis. The cause is unknown but has not been associated resection of inguinal metastases (i.e., >70% 5-year survival)
with known viruses. Condyloma, Bowenoid papulosis, and include (1) minimal nodal disease (up to two involved nodes
evidence of
erythroplasia of (Queyrat are associated with HPV infection in most series). (2) unilateral involvenment, (3) no
while Kaposi sarcoma is associated with HPV 8 infection. extranodal extension of cancer, and (4) the absence of pelvic
2. d. Human papillomavirus (HPV) infection. HPV is recog nodal metastases. A lymph node larger than 4 cm is often as
sociated with extranodal extension of cancer.
nized as the principal etiologic agent in cervicaldysplasia and associated with
cervical cancer. l6. e. Stage Ta tumors. Tumor histologic type patients with pri
3. d. Location. Carcinoma in situ of the penis is referred to by urol little or no risk for metastasis includes those
verrucous
ogists and dermatologists as erythroplasia of Queyrat if it involves mary tumors exhibiting (1) carcinoma in situ or (2)
the glans penis or prepuce and as Bowen disease ifit involves the carcinoma.
remainder of the penile shaft skin, genitalia, or perineal region.
 Tumors of the Urethra
80 Christopher B. Anderson and James M. McKiernan

bRadical urethrectomy is always required.

QUESTIONS c. Transurethral resection and intraurethral bacille Calmette
1. Which of the following is not a possible origin of female ure Guérin (BCG) can be effective for noninvasive tumors.
thral adenocarcinoma? d. Bowel from the neobladder can be reconfigured for a cuta
a. Müllerian tissue neous diversion.
t Cowper glands e. Patients with noninvasive recurrences have a good prog
nosis.
C. Glandular metaplasia
d. Skene glands 8. A 71-year-old man is diagnosed with a primary prostatic
e. Urothelium urothelial carcinoma. Transurethral biopsy demonstrates
invasion into the prostatic stroma, and imaging is negative for
2. The most common histologic subtype of male anterior ure metastasis. The best treatment option is:
thral cancer is:
a. systemic immunotherapy.
a. adenocarcinoma.
b. aggressive transurethral resection of the prostate followed
Lt squamous cell carcinoma. by BCG.
c. urothelial carcinoma. radical cystectomy and urethrectomy with neoadjuvant
d. melanoma. chemotherapy.
e. sarcoma.
d. whole pelvic radiation.
3. The histologic subtype of urethral cancer that is more common e. radical prostatectomy.
in women than in men is:
A adenocarcinoma.
9. When adelayed urethrectomy is performed after radical cystec
tomy in a male, the most important technical consideration to
b. squamous cell carcinona. minimize the risk of a local recurrence is:
C. urothelial carcinoma. A. removal of the entire distal urethra including the neatus.
d. melanoma. b. bilateral groin dissections.
e. sarCOma. . total penectomy.
4. In male pendulous urethral carcinoma: d. intraoperative ultrasound.
a. prognosis depends on histologic cell type. e. neoadjuvant radiation.
b. surgical excision alone is often curative. 10. A condition that does not increase the risk of female urethral
c. prognosis is worse than for bulbomembranous urethral cancer. carcinoma is:
d. a 2-cm margin is always required for penile preserving surgery. a. leukoplakia.
e. biopsy most commonly demonstrates transitional cell bacterial vaginosis.
carcinoma.
c. urethral diverticulum.
5. Atreatment that is NOT indicated in cT3NOMO squamous cell d. urethral stricture disease.
carcinoma of the bulbar urethra is: e. human papillomavirus infection.
a. radical cystectomy with urethrectomy.
b. chemoradiotherapy. 11. The strongest prognostic factor for survival in female urethral
cancer is:
Anguinal lymphadenectomy. tumor stage.
d. pelvic MRI. b. age at presentation.
e. neoadjuvant chemotherapy.
c. histologic subtype.
6. The strongest risk factor for male urethral recurrence after radi d. multimodal treatment.
cal cystectomy is:
e. urinary retention.
carcinoma in situ.
b. bladder tumor multifocality. 12. A 68-year-old man presents with an anterior
urethral
invasive into the corpora cavernosum. His tunor stagetumor
1 prostatic urethral involvement. is:
a. T1.
d. squamnous cell histology. b. T2a.
e. prior nonmuscle invasive bladder cancer. C. T2b.
7. Which of the following is FALSE about urethral . T3.
recurrence
after radicalcystectomy and orthotopic neobladder? e. T4.
a. lIrethral recurrences are more common after radical
cystec
1omy and ileal conduit.
306
 CHAPTER80 Tumors of the Urethra 307
ure.
13. The best treatment fora small, exophytic cT2NO female 4. b. Surgical excision alone is often curative. The prognosis of
thral carcinoma located near the urethral meatus is: male pendulous anteriorurethral cancer is strongly associated
a. excision of the distal 2/3 of the urethra. with stage, is more favorable than bulbomembranous urethral
b. transvaginal biopsy followed by systemic chemotherapy. cancer,
lous
and istumors
unrelated to histologic cell type. Most pendu
urethral are squarmous cell carcinomas. Low-stage
c radical urethrectomy with bladder neck closure and il pendulous anterior urethralcancers can often be cured with
eovesicostomy. surgicalexcision alone, and penile preservation can ofen be
chemoradiation. achieved with margins as little as 5 mm.
e. inguinal lymphadenectomy. 5. c.branous
Inguinal lymphadenectomy. Locally advanced bulbomem
urethral carcinoma requires aggressive treatment. MRI
14. A 76-year-old female presents with a locally invasive proximal is required to fully stage the disease, including the extent of
urethral tumor abutting the pubic symphysis. The treatment local invasion and presence of pelvic nodal metastasis. Oof the
that would be inappropriate is: treatments listed,neoadjuvant chemotherapy, chemoradia
a. radical cystectony with pubectomy. tion, and radical cystectomy with urethrectomy are all reason
b. extemal beam radiation with systemic chemotherapy. able options. The role of inguinal lymphadenectomy for cNO
urethral cancer is controversial, but there is no role for this
c radical cystectomy with intraoperative radiation. in bulbomembranous disease as these tumors are unlikely to
A. radiation monotherapy. drain into the inguinal lymph nodes.
e. chemoradiation followed by surgical consolidation. 6. c. Prostatic urethral involvement. Urethral recurrence after
radical cystectomy occurs in 5% to 10% of patients. Of the
15. Two years after a radical cystectomy and ileal conduit in a male multiple risk factors that have been studied, prostatic urethral
patient, aurethral wash cytology is positive for high-grade involvement, a positive urethral margin, and cutaneous uri
urothelial carcinoma. The next step is: nary diversions have the highest risk of urethral recurrence.
a. repeat urethral wash cytology. 7. b. Radical urethrectomy is always required. Patients with
turethroscopy with biopsy. large or invasive urethral recurrences after radical cystectomy
require aggressive treatment, usually with radical urethrectomy.
C. radical urethrectomy. If a urethral recurrence occurs after an orthotopic neobladder,
d. pelvic MRI. the bowel from the neobladder can be used for a cutaneous
e. urine ytology. diversion in many cases. Patients with noninvasive urethral
recurrences have a favorable prognosis and can often be
16. All of the following are true about the male urethra EXCEPT: managed with transurethral resection and topical BCG, thus
a. the anterior urethra drains into the inguinal lymph nodes. avoiding radical urethrectomy in some cases. Prostatic urethral
b. the glands of Littre line the anterior urethra.
involvement, apositive urethral margin, and cutaneous diver
sions all increase the risk of urethral recurences.
c. the posterior urethra consists of the prostatic and membra 8. c. Radical cystectomy and urethrectomy with neoadjuvant
nous urethra. chemotherapy. The prognosis of primary prostatic urethral
carcinoma is strongly associated with depth of invasion into
t the pseudostratified epithelium of thependulous urethra the prostate. Those with superficial or lamina propria invasion
transitions to glandular epithelium in the fossa navicularis.
e. anterior urethral cancers are more common in the bulbar can often be managed with transurethral resection and BCG;
however, those with tumors invasive into the stroma require
urethra.
aggressive treatment. Radical cystoprostatectomy with urethrec
17. A56-year-old-man presents with an invasive pendulous ure tomy and preoperative chemotherapy is the best choice.
thral squamous cell carcinoma with palpable inguinal lymph 9. a. Removal of the entire distal urethra including the mea
nodes bilaterally. Imaging is negative for distant metastasis. tus. A delayed urethrectomy after radical cystectomy can be a
The best treatment is: challenging procedure. Critically, the entire urethra incuding
the fossa navicularis and urethral meatus should be removed
a. radiation monotherapy to the tumor and lymph nodes. en bloc to eliminate the risk of a distal recurrence, even
tchemoradiation to the penis and groins followed by surgi for proximal tumors. There is no role for routine inguinal
cal consolidation.
lymphadenectomy, and penectomy is not required unless the
C. radical penectomy. urethral tumor is invasive into the deep structures of the penis.
d. dynamic sentinel lymph node biopsy. 10. b. Bacterial vaginosis. rethral carcinoma is most likely
e. distal urethrectomy with 6 weeks of oral antibiotics. caused by conditions that cause intlammation of the urethra,
such as leukoplakia, urethral strictures, and HPV intection.
Female urethral diverticula can increase the risk of urethral
cancers, most commonly adenocarcnomas. Bacterial vaginosis
ANSWERS has no known association with urethral cancer.
1. b. Cowper glands. There are several proposed origins of fenmale 11. a. Tumor stage. The prognosis of temale urethral cancer is
urethral adenocarcinoma, and more than one tissue may be in strongly associated with stage at diagnosis. lumos that arise
volved. Allof he listed tissue types are possible origins with the from the proximalurethra tend to present at a moe advanced
stage.'There is no known association between prognosis and
exception of Cowper glands, which are only present in men. histologic subtype, age at presentation, or presenting symptoms.
2. b. Squamous cell carcinoma. The male anterior urethra is 12. d. T3. Male anterior urethral cancer witth invasion into the
lined by stratified and pseudosuratified columnar epithelium, corpora cavernosun or anterior vagina are classified as T3 by
which transitions to squamous epithelium distally. The major the AJCC8th Edition Staging System. Tumors invasive into
ity of male anterior urethral carcinomas are squamous cell the corpus spongiosum or periurethral tissue are classified as
carcinoma.
3. a. Adenocarcinoma. Gender is not independently 12. The AJCC staging system does not have a'T2a or 12b for
associated
with survival for urethral carcinoma, howeve, there are differences urethral cancer.
in the characteristics of male and female urethral carcinoma, 13. d. Chemoradiation. Smallexophytic distal female urethral
including the distribution of histologic subtypes. Although squa cancers can be effectively treated with surgical excision or
mous cell carcinoma is the predominant form in men, women radiation with or without chemotherapy. Radical urethrectomy
are more likely to have adenocarcinomacompared to men. can usually be avoided for distal tumors. lhe distal 1/3 of the
female urethra can be safely excised without compromising