Urology

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
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 Urology
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
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 Urology
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
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 Urology

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
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 Urology
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.
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 Urology

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
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 Urology
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
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 Urology
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.
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 Urology
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.
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 Urology
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
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 Urology
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
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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
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 Urology
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
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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.,
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 Urology
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
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 Urology
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

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This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).
 Urology
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

Asir Surgery MCQs Bank. © 1422H-2002- first impression ©
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This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).
 Urology
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?

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This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).
 Urology
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
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This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).
 Urology
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
Asir Surgery MCQs Bank. © 1422H-2002- first impression ©
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This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).
 Urology
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.

Asir Surgery MCQs Bank. © 1422H-2002- first impression ©

539
This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).