Treatment of Locally Advanced Prostate Cancer
Identification of patients with high-risk prostate cancer is best achieved by:
a. transrectal ultrasonography.
b. serum prostate-specific antigen (PSA).
c. digital rectal examination.
d. serum PSA, biopsy grade, clinical stage.
e. PSA kinetics.
d. Serum PSA, biopsy grade, clinical stage. Although clinical stage, serum
PSA, and Gleason score all individually predict pathologic stage and
prognosis, the combination of these three variables increases the accuracy of
this assessment.
Regarding perioperative thromboprophylaxis treatment after robot-assisted
radical cystectomy, which of the following is TRUE?
a. Pneumatic compressions and leg stockings are adequate.
b. Low-molecular-weight heparin can be used as a single dose before the
operation.
c. Low-molecular-weight heparin should be continued until 4 weeks after
surgery.
d. Both mechanical and pharmacologic prophylaxes are adequate for 48
hours perioperatively.
e. No prophylaxis.
c. Low-molecular-weight heparin should be continued until 4 weeks after
surgery. Based on 939 patients who underwent robot-assisted radical
cystectomy, the incidence of hematologic and vascular complications was
10%. A survey of urologists who were aware of the American Urological
Association (AUA) Best Practice Statement guidelines revealed that 51%
were likely to use thromboprophylaxis (odds ratio, 1.4, confidence interval,
1.2-1.6). Eighteen percent of urologic oncologists and/or laparoscopic/robotic
specialists and 34% of nonurologic oncologists and/or laparoscopic/robotic
specialists avoided routine thromboprophylaxis in patients undergoing radical
cystectomy. The former were more likely to use thromboprophylaxis
(P < .0001) than other respondents. Urologists graduating after the year 2000
used thromboprophylaxis in high-risk patients undergoing radical cystectomy
more often than did earlier graduates (79.2% vs. 63.4%, P < .0001). Based on
the American College of Surgeons NSQIP (National Surgical Quality
Improvement Program) database from 1307 patients who underwent
radical cystectomy, the mean time to venous thromboembolism diagnosis
was 15.2 days postoperatively; 55% of all venous thromboembolism
events were diagnosed after patient discharge home. It is recommended to
consider extended duration pharmacologic prophylaxis (4 weeks) in this highrisk
surgical population.
The AT1 receptor:
a. has a more pronounced vasoconstriction on the afferent rather than the
efferent arteriole.
b. is the receptor for angiotensin I.
c. protects against ischemia-reperfusion injury by intrarenal dilation.
d. mediates increased release of aldosterone.
e. is not expressed in the kidney.
d. Mediates increased release of aldosterone. AT1, the receptor for
angiotensin II, mediates the release of aldosterone. Intrarenal dilatation is
mediated through AT2.
Laparoscopic ureteral reimplantation can be performed:
a. with a cross-trigonal approach.
b. with a Boari flap or bladder advancement flap.
c. with a psoas hitch.
d. via a traditional laparoscopic or robotic approach.
e. all of the above.
e. All of the above. All of the included answers are correct regarding
laparoscopic ureteral reimplantation. Minimally invasive ureteral reimplant
can be performed in a refluxing or nonrefluxing fashion, and with a crosstrigonal
or tunneled approach if so desired. In cases with larger ureteral loss, a
Boari flap or bladder advancement flap can be utilized, or a psoas hitch can
be performed replicating open techniques. Finally, both a laparoscopic and
robotic approach to ureteral reimplantation has been described.
What is the best option for repair of midureteral transection after a stab
wound?
a. Ureteroureterostomy
b. Transureteroureterostomy
c. Boari flap
d. Nephrectomy
e. Cutaneous ureterostomy
a. Ureteroureterostomy. Ureteroureterostomy, so-called end-to-end repair in
injuries to the upper two thirds of the ureter, is common (up to 32% of one
large series) and has a reported success rate as high as 90%.
Neoadjuvant androgen deprivation (AD) before radical prostatectomy leads
to:
a. improved biochemical-free survival.
b. improved overall survival.
c. reduced positive surgical margins.
d. reduced local recurrence.
e. increased operative morbidity.
c. Reduced positive surgical margins. The randomized and
nonrandomized studies of neoadjuvant androgen deprivation in men
with lower clinical stage (cT1-T2) clearly demonstrate a reduction in the
rate of positive surgical margins; however, this advantage has not been
observed in men with cT3c and has not translated into improved longterm
PSA-free survival.
During robotic-assisted radical cystectomy and intracorporeal urinary
diversion:
a. use of a 30-degree up lens is advantageous for a deep female pelvis.
b. a 0-degree lens can be used for the entire procedure.
c. the camera port is inserted below the umbilicus.
d. the camera can be easily switched to another robotic port.
e. a five-port configuration is used.
b. A 0-degree lens can be used for the entire procedure. The majority of
robot-assisted radical prostatectomy procedures use different lenses for the
procedure. During robot-assisted radical cystectomy, surgeons prefer a 0-
degree lens. Special situations of a narrow, deep pelvis in association with
obesity can require a 30-degree down lens for better visualization, especially
for the proximal portion of the extended lymph node dissection.
Which of the following statements about endothelin is FALSE?
a. Stimulation of endothelin-1 (ET-1) decreases sodium excretion.
b. Endothelin is the most potent vasoconstrictor yet identified.
c. ET-1 release is inhibited by nitric oxide.
d. ET-1 release stimulates aldosterone secretion.
e. ET-1 release reduces renal blood flow.
a. Stimulation of endothelin-1 (ET-1) decreases sodium excretion. Despite
reduction in renal blood flow, stimulation of ET-1 by endothelin increases net
sodium excretion.
All of the following are essential surgical aspects of the Boari flap or bladder
advancement flap EXCEPT:
a. an adequate-sized bladder must be present (200 to 300 mL).
b. the contralateral vesical pedicle may be transected if necessary.
c. the bladder flap should be slightly shorter than anticipated because
bladder tissue can be easily stretched.
d. a tension-free anastomosis is important.
e. typically, a refluxing ureteral anastomosis is created.
c. The bladder flap should be slightly shorter than anticipated because
bladder tissue can be easily stretched. A tension-free anastomosis of the
anterolateral bladder flap based on the ipsilateral vesical pedicle is critical.
The bladder flap should be somewhat longer and wider than anticipated
because the nondistended bladder shrinks in size, thus placing tension on
the anastomosis. Ideally, a flap length-to-breadth ratio of 3:1 ensures
good vascularity of its apex.
When ureteroureterostomy is performed, which of the following is required?
a. Postoperative retroperitoneal Penrose drain
b. Postoperative nephrostomy drain
c. Spatulated, watertight repair
d. Nonabsorbable sutures
e. Intraperitonealization of the ureteral anastomosis
c. Spatulated, watertight repair. Repair ureters under magnification with
spatulated, tension-free, stented, watertight anastomosis and place a
retroperitoneal closed suction drain.
The use of AD in combination with radiation therapy for those with high-risk
cancers is associated with all of the following EXCEPT:
a. improved local control.
b. improved biochemical-free survival.
c. less gastrointestinal toxicity.
d. worsened sexual function.
e. more urinary frequency.
c. Less gastrointestinal toxicity. The longer application (longer than 6 to 9
months) of AD in conjunction with radiation therapy may be associated with
increased rectal morbidity as well as sexual dysfunction.
Before embarking on intracorporeal urinary diversion, it is important to:
a. perform a bowel segment washout.
b. de-dock the robot and change the attachments to the ports.
c. de-dock the robot and reduce the steep Trendelenburg position for both
ileal conduit and neo bladder.
d. de-dock the robot and reposition the port to a new configuration for
urinary diversion.
e. de-dock the robot and reduce the steep Trendelenburg position for
neobladder only.
e. De-dock the robot and reduce the steep Trendelenburg position for
neobladder only. Traditionally, a steep Trendelenburg position has been used
to avoid bowel in the operative field and also to get direct access to the deeper
pelvis. Unfortunately, this works against intracorporeal neobladder, as
urethral-neobladder anastomosis is difficult if the bowel tries to retract back
into the abdominal cavity and is under tension. The ideal solution introduced
by the Karolinska Institute group is reducing Trendelenburg and reversing the
steps by performing the urethra-neobladder anastomosis during the initial part
of the procedure.
Which of the following is a vasodilator of the renal artery?
a. Endothelin
b. Carbon monoxide
c. Atrial natriuretic peptide
d. Norepinephrine
e. Angiotensin II
b. Carbon monoxide. The others are vasoconstrictors.
Which of the following statements is NOT correct regarding laparoscopic
enterocystoplasty?
a. Subtotal cystectomy is not always mandatory.
b. Mesenteric pedicle of the selected bowel segment is wide and broadbased.
c. Mesenteric window is closed.
d. Reestablishment of bowel continuity is a critical step of the operation
and may be performed extracorporeally for added security, if
necessary.
e. Bowel-to-bladder anastomosis is optimally performed with interrupted
serosa-to-serosa sutures.
e. Bowel-to-bladder anastomosis is optimally performed with interrupted
serosa-to-serosa sutures. The technical principles of enterocystoplasty are
identical between open surgical and laparoscopic techniques. Generous
mobilization of the bladder allows creation of an adequate anteroposterior
cystotomy. Subtotal cystectomy is necessary only in patients with severely
symptomatic interstitial cystitis. An optimal segment of bowel based on a
broad, well-vascularized mesenteric pedicle is selected that will reach the
pelvis without tension. The bowel segment is isolated and bowel continuity
reestablished by either intracorporeal or extracorporeal techniques, and the
mesenteric window is closed. The isolated bowel segment is detubularized,
and a bowel plate is created appropriately. A tension-free, watertight, fullthickness,
circumferential, running anastomosis of the bowel segment to the
bladder is created. Adequate urinary drainage is established.
Which maneuver is cited as a cause of ureteral injury during stone basketing?
a. Ureteroscopy without dilating the ureteral orifice first
b. Ureteroscopy in nondilated systems
c. Use of the holmium laser
d. Pulsatile saline irrigation to assist visualization
e. Persistence in stone basketing attempts in the face of a ureteral tear
e. Persistence in stone basketing attempts in the face of a ureteral tear.
One factor cited as a cause of injury was the persistence in stone basketing
attempts after recognition of a ureteral tear. Current recommendations are to
stop and place a ureteral stent.
In men with locally advanced prostate cancer undergoing prostatectomy,
clinical overstaging (i.e., pathologically organ confined disease) occurs in:
a. less than 10%.
b. 15% to 30%.
c. 40% to 60%.
d. 70% to 80%.
e. more than 90%.
b. 15% to 30%. Recent data suggest that clinical overstaging occurs in
approximately 27% of men with clinical stage T3 disease undergoing
prostatectomy, consistent with the range in the literature of 7% to 26%.
During robot-assisted intracorporeal urinary diversion, the benefit of the
marionette stitch is to:
a. identify the distal and proximal ends of the conduit.
b. help in retaining orientation of the bowel.
c. allow free movement of the bowel segment for creation of the conduit.
d. prevent leakage of bowel contents during the creation of the conduit.
e. allow free movement of the bowel segment and prevent inadvertent
movements of the robotic instruments.
c. Allow free movement of the bowel segment for creation of the conduit.
Because of the multiple detailed steps required during intracorporeal urinary
diversion in a narrow operative space, the marionette stitch helps in
controlling the area of focus by acting as a retraction and exposing the correct
surgical space to perform the right and left uretero-ileal anastomosis.
Which of the following statements is FALSE regarding carbon monoxide
(CO) and the enzyme hemoxygenase?
a. Hemoxygenase-2 (HO-2) is a constitutive enzyme.
b. HO-1 is an inducible enzyme.
c. Increased CO increases ischemia-reperfusion injury in the kidney.
d. HO-1 expression helps to maintain renal medullary blood flow.
e. HO-1 produces CO through the catabolism of heme.
c. Increased CO increases ischemia-reperfusion injury in the kidney. CO
is protective against renal ischemia-reperfusion injury.
Which of the following statements is TRUE regarding partial cystectomy?
a. Thirty percent to 40% of patients with bladder cancer are candidates
for a partial cystectomy.
b. Five-year survival rates range from 80% to 90%.
c. Laparoscopic partial cystectomy is now an established procedure.
d. All of the above.
e. None of the above.
e. None of the above. In large series of patients with bladder cancer, fewer
than 10% of the patients are candidates for a partial cystectomy. In the
properly selected patient, 5-year survival rate ranges from 50% to 70%.
Laparoscopic partial cystectomy has only been performed in a few selected
cases and is currently a controversial procedure.
Which of the following statements is TRUE about ureteral injuries during
laparoscopy?
a. The total number of injuries has stayed steady over the years.
b. Surgery for endometriosis greatly increases the risk.
c. Bipolar cautery use during tubal ligation eliminates risk.
d. Most ureteral injuries are recognized immediately.
e. Indigo carmine dye eliminates the risk of injury.
b. Surgery for endometriosis greatly increases the risk. A large percentage
of ureteral injuries after gynecologic laparoscopy occur during electrosurgical
or laser-assisted lysis of endometriosis.
By using the Kattan postoperative nomogram, which of the following
contributes most to the risk of biochemical recurrence after radical
prostatectomy?
a. Positive surgical margin
b. Pretreatment serum PSA of 17 ng/mL
c. Gleason 4 + 3 disease
d. Established capsular penetration
e. Seminal vesicle invasion
b. Pretreatment serum PSA of 17 ng/mL. Despite the trend toward lower
serum PSA at the time of diagnosis, PSA remains an important predictor
of treatment failure, and greater elevations (greater than 8 ng/mL) of
PSA contribute significantly to calculated biochemical recurrence.
During creation of the neobladder, mobilization of the bowel to reach the
urethra can be achieved by all of the following EXCEPT:
a. reducing the Trendelenburg position.
b. using a Penrose drain for gentle traction and stretching.
c. mobilization of the urethra cephalad.
d. incising the peritoneum over the mesentery.
e. dissection of the ileum around the ileocecal junction.
c. Mobilization of the urethra cephalad. Traditionally, a steep
Trendelenburg position has been used to avoid bowel in the operative field
and also to gain direct access to the deeper pelvis. Unfortunately this works
against intracorporeal neobladder because urethral-neobladder anastomosis is
difficult if the bowel tries to retract back into the abdominal cavity and is in
tension. Several options used to reduce tension and ease anastomosis include
reducing Trendelenburg, performing the urethra-neobladder anastomosis at
the beginning of the procedure, incising the peritoneum over the mesentery,
dissection of the ileum around the ileocecal junction, and, finally, using
temporary traction for stretching and holding the bowel in place for
anastomosis.
Which of the following statements regarding erythropoiesis is FALSE?
a. Reduced erythropoiesis and anemia are common in chronic renal
disease.
b. Erythropoiesis is inhibited by low circulating oxygen tension.
c. During chronic inflammation, erythropoiesis is decreased.
d. The kidney makes most of the erythropoietin in the body.
e. There are erythropoietin receptors in many organs of the body.
b. Erythropoiesis is inhibited by low circulating oxygen tension.
Erythropoiesis is increased by low circulating oxygen tension.
Which of the following is a contraindication for laparoscopic radical
cystectomy today?
a. Multiple bladder tumors
b. Nonbulky, invasive bladder cancer
c. T4 disease
d. Moderate obesity
e. Open pelvic surgery
c. T4 disease. Laparoscopic radical cystectomy is an emerging procedure
performed at centers of laparoscopic expertise. At this writing, laparoscopic
radical cystectomy should be offered to nonobese patients with nonbulky,
organ-confined bladder cancer without pelvic lymphadenopathy on
preoperative computed tomography (CT). Various conditions such as morbid
obesity, prior radiotherapy, or pelvic surgery are relative contraindications
because of the increase in laparoscopic technical complexity. Locally
advanced T4 disease should not be approached laparoscopically.
Which imaging technique is most useful for detecting ureteral injuries after
trauma?
a. Computed tomography (CT) without use of contrast material
b. CT with use of contrast agent, obtained immediately after injection of
the contrast agent
c. CT with the use of contrast material, obtained 20 minutes after
injection of the contrast agent
d. Intravenous pyelography
e. Furosemide (Lasix) renography
c. CT with the use of contrast material, obtained 20 minutes after
injection of the contrast agent. Because modern helical CT scanners can
obtain images before intravenous contrast dye is excreted in the urine,
delayed images must be obtained (5 to 20 minutes after contrast material
injection) to allow contrast material to extravasate from the injured collecting
system, renal pelvis, or ureter.