Eval and Mgmt of Hematuria
The likelihood of finding a malignancy in a patient with microhematuria is influenced by all of the following, EXCEPT:
a. age. b. gender. c. use of anticoagulants. d. tobacco use. e. degree of hematuria.
c. Use of anticoagulants. Increasing age, male gender, and tobacco use are risk factors for urologic cancers and specifically for urothelial carcinoma. In addition, although there are few data to distinguish among thresholds of 2, 3, 4, or 5 RBCs/HPF, it is clear that a high level of microhematuria (> 25 RBCs/HPF) is associated with a greater likelihood of malignancy. By contrast, patients using anticoagulant medications or antiplatelet medications have a risk of malignancy similar to that of those who do not use these medications. Therefore, such patients should be evaluated comparably to those who do not use anticoagulants or antiplatelet agents.
Acute pyelonephritis is the most likely diagnosis in a patient with:
a. chills, fever, and flank pain. b. bacteria and pyuria. c. focal scar in renal cortex. d. delayed renal function. e. vesicoureteral reflux.
a. Chills, fever, and flank pain. Acute pyelonephritis is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteriuria and pyuria, a combination that is reasonably specific for an acute bacterial infection of the kidney.
Serum PSA levels vary with which factor?
a. Age b. Race c. Prostate volume d. ACT concentration e. Age, race, and prostate volume
e. Age, race, and prostate volume. In the absence of prostate cancer, serum PSA levels vary with age, race, and prostate volume.
Standard trocar placement for renal surgery may need to be adjusted based on which of the following patient characteristics? a. Obese body habitus b. Prior abdominal surgery c. Renal tumor size d. Robotic assistance e. All of the above
e. All of the above. Trocar placement for renal surgery should be individualized based on patient characteristics and surgical approach planned. Patient body habitus, prior surgical history, intraoperative findings (including adhesions), renal pathology, surgical indication, and surgical approach (transperitoneal vs. retroperitoneal, robotic-assistance vs. conventional laparoscopy vs. laparoendoscopic single-site surgery [LESS]) are all factors to consider to optimize trocar placement.
What is the most accurate imaging study for characterizing a renal mass?
a. Intravenous pyelography b. Ultrasonography c. Computed tomography (CT) with and without contrast enhancement d. Magnetic resonance imaging (MRI) e. Renal arteriography
c. Computed tomography (CT) with and without contrast enhancement. A dedicated (thin-slice) renal CT scan remains the single most important radiographic image to delineate the nature of a renal mass. In general, any renal mass that enhances with administration of intravenous contrast material on CT scanning should be considered a renal cell carcinoma until proved otherwise
The metabolite of oxazaphosphorine chemotherapeutic agents that is responsible for hemorrhagic cystitis is:
a. mesna. b. acrolein. c. formalin. d. gemcitabine. e. methotrexate.
b. Acrolein. Bladder toxicity with oxazaphosphorine chemotherapeutic agents results from renal excretion of the metabolite acrolein, which is produced by the liver and which stimulates bladder mucosal sloughing and subsequent tissue edema/fibrosis. Mesna (2-mercaptoethane sulfonate), which binds to acrolein and renders it inert, has been suggested for prophylaxis against cyclophosphamide-induced hemorrhagic cystitis.
Rates of reinfection (i.e., time to recurrence) are influenced by:
a. bladder dysfunction. b. renal scarring. c. vesicoureteral reflux. d. antimicrobial treatment. e. age.
d. Antimicrobial treatment. Whether a patient receives no treatment or short-term, long-term, or prophylactic antimicrobial treatment, the risk of recurrent bacteriuria remains the same; antimicrobial treatment appears to alter only the time until recurrence.
Which of the following tests has the highest positive predictive value for prostate cancer?
a. PSA b. Digital rectal exam (DRE) c. Transrectal ultrasonography (TRUS) d. Combination of DRE and TRUS e. Human glandular kallikrein (hK2)
a. PSA. PSA is the single test with the highest positive predictive value for cancer.
A laparoscopic renal biopsy is performed for a 53-year-old man with chronic renal insufficiency of unclear etiology and a BMI of 47 kg/m2 . A prior percutaneous approach did not obtain adequate tissue. Using a two-port retroperitoneal approach, copious retroperitoneal fat is encountered and there is difficulty with orientation and localizing the kidney. The best next step is to:
a. abort the procedure. Recommend a repeat percutaneous image-guided approach to the nephrology service. b. advance a biopsy needle under laparoscopic guidance through the fat to the presumed location of the kidney. c. convert to an open retroperitoneal procedure using a mini flank incision. d. intraoperative renal ultrasound to localize the kidney. e. place a third port to aid in dissection.
d. Intraoperative renal ultrasound to localize the kidney. In this case, the patient's obese body habitus and associated retroperitoneal fat pose a challenge in proper orientation and identification of the kidney from the retroperitoneoscopic approach. In obese patients, intraoperative ultrasonography may be required to localize the kidney when copious retroperitoneal or perinephric fat is present. Beyond simply assisting in identification of the kidney, it may allow for precise tissue sampling, particularly in the setting of a failed prior percutaneous biopsy attempt.
The most generally accepted indication for fine-needle aspiration of a renal mass is a suspected clinical diagnosis of:
a. renal cell carcinoma (RCC). b. renal oncocytoma. c. renal cyst. d. renal metastasis. e. renal angiomyolipoma.
d. Renal metastasis. The traditionally accepted indications for needle aspiration or biopsy of a renal mass are when a renal abscess or infected cyst is suspected, or when differentiating RCC from metastatic malignancy or renal lymphoma. Fine-needle aspiration or biopsy is now performed with increased frequency for the evaluation of renal masses in other circumstances, particularly for patients in whom a wide variety of treatment options are under consideration.
A 55-year-old woman presents with intermittent gross hematuria 2 weeks after undergoing a right partial nephrectomy for a 4-cm solid enhancing renal mass. She is afebrile with stable vital signs. She is able to void to completion, and her urine is red without clots. Her creatinine is 1.1 mg/dL. The next step should be:
a. surgical exploration. b. renal angiography. c. continuous bladder irrigation. d. observation. e. noncontrast CT scan of the abdomen/pelvis.
b. Renal angiography. The clinical scenario is consistent with a renal arteriovenous malformation (AVM). Renal angiography is both diagnostic and therapeutic in this scenario, with the ability to coil or embolize this abnormal vascular communication. Observation and bladder irrigation do not address the underlying causative factor, and noncontrast CT imaging fails to delineate the vascular anatomy. Surgical exploration has a high likelihood of renal loss and is reserved for cases refractory to angiographic modalities.
The virulence factor that is most important for adherence is:
a. hemolysin. b. K antigen. c. pili. d. colicin production. e. O serogroup.
c. Pili. Studies have demonstrated that interactions between FimH and receptors expressed on the luminal surface of the bladder epithelium are critical to the ability of many uropathogenic E. coli strains to colonize the bladder and cause disease.
. What pathologic finding or findings at radical prostatectomy are highly predictive of the presence of occult metastatic disease?
a. Positive surgical margins b. Seminal vesicle involvement c. Lymph node involvement d. Both b and c e. Both a and b
d. Both b and c. The finding of seminal vesicle invasion or lymph node metastases on pathologic evaluation after radical prostatectomy is associated with a high risk of distant disease.
On postoperative day 3 following robotic-assisted laparoscopic right partial nephrectomy, a 54-year-old man presents to the emergency room with nausea, low-grade fever, right-sided abdominal pain, and foul-smelling discharge from a right lateral trocar site. CT scan with oral contrast demonstrates extravasation of contrast from the ascending colon with an adjacent fluid collection. The most likely etiology of the injury is:
a. trocar injury. b. blunt dissection. c. sharp dissection. d. bowel ischemia. e. electrocautery scatter.
e. Electrocautery scatter. The clinical scenario described represents a classic presentation of an unrecognized bowel injury. Although blunt dissection, sharp dissection, and transmission of thermal energy from electrocautery are each responsible for approximately equal proportions of bowel injuries, electrocautery scatter is the most frequent cause of unrecognized bowel injury. Delayed necrosis and perforation of the bowel wall from electrocautery may lead to atypical or delayed presentation and most commonly presents between postoperative days 3 and 5. Trocar placement and bowel ischemia are both infrequent causes of bowel injury.
The European Organisation for Research and Treatment of Cancer 30904 study randomly assigned patients to radical versus partial nephrectomy. Which of the following was an inclusion criterion?
a. Clinical T1a tumor (< 4.0 cm) b. Tumor size < 5.0 cm c. Estimated glomerular filtration rate (GFR) > 60 mL/min/1.73 m2 d. No hypertension e. Age < 70 years
b. Tumor size < 5.0 cm. A solitary tumor and a normal contralateral kidney were also required, but criteria for the latter were not well defined.
According to American Urological Association guidelines, the proper initial assessment of a 50-year-old patient with asymptomatic microhematuria includes:
a. blood pressure measurement, serum creatinine level, cystoscopy, and computed tomographic (CT) urogram. b. urine cytology, cystoscopy, and CT urogram. c. urine cytology, blue-light cystoscopy, and any upper tract imaging. d. urine cytology and renal/bladder ultrasound. e. no evaluation unless microhematuria is persistent/recurrent or hematuria is visible.
a. Blood pressure measurement, serum creatinine level, cystoscopy, and computed tomographic (CT) urogram. The AUA suggests that adult patients presenting with asymptomatic microhematuria should undergo evaluation to determine the cause. Blood pressure measurement and serum creatinine level may help identify patients who require concurrent nephrologic workup, and creatinine level also helps determine patient eligibility for contrast imaging. The evaluation of asymptomatic microhematuria includes imaging (preferably with CT urogram) and cystoscopy in patients 35 and older and those under 35 with risk factors for malignancy.
The most reliable urine specimen is obtained by:
a. urethral catheterization. b. catheter aspiration. c. midstream voiding. d. suprapubic aspiration. e. antiseptic periurethral preparation.
d. Suprapubic aspiration. A single aspirated specimen reveals the bacteriologic status of the bladder urine without introducing urethral bacteria, which can start a new infection.
The finding of pathologic perineural invasion of cancer (PNI) on a prostate biopsy specimen suggests:
a. organ-confined disease. b. low-grade disease at radical prostatectomy. c. a greater likelihood of capsular penetration. d. pelvic lymph node involvement.
c. A greater likelihood of capsular penetration. PNI in a prostatectomy specimen has little independent prognostic staging value as initially reported by Byar and Mostofi (1972).* However, in biopsy cores, its presence is associated with a higher chance of non–organ-confined disease at prostatectomy. de la Taille and colleagues (1999) demonstrated that the presence of PNI on a biopsy specimen was closely associated with high PSA values, poorly differentiated tumor, and involvement of multiple cores with cancer, and thus a higher pathologic stage. Approximately 75% of men with PNI on a biopsy specimen will have capsular penetration on examination of the prostatectomy specimen
A 22-year-old woman presents with severe intermittent, positional left flank pain. Her medical and surgical histories are unremarkable, and her body mass index (BMI) is 19 kg/m2 . Renal ultrasound shows no evidence of stones or hydronephrosis. What is the best next step in evaluation?
a. Cystoscopy and retrograde pyelogram b. Computed tomography (CT) urogram c. Flat and upright intravenous pyelogram d. Nuclear renal scan e. Observation
. c. Flat and upright intravenous pyelogram. Ptotic kidneys often present with a history similar to that of a ureteropelvic junction obstruction, with the primary exception that the associated pain is often positional and relieved after a period of lying down. The supine position often eliminates the transient renal ischemia or urinary obstruction that may be the cause of discomfort. The demographic most commonly afflicted with renal ptosis is a young, thin female similar to the patient described. Determining renal descent of approximately two lumbar vertebral bodies with supine and erect intravenous pyelograms makes the diagnosis of a ptotic kidney. A secondary evaluation option is power Doppler sonography performed with the patient in both the supine and erect positions. Nephropexy should not proceed before definitively establishing the diagnosis of a ptotic kidney.
A hyperdense renal cyst may also be termed a:
a. probable malignancy. b. Bosniak II cyst. c. Bosniak III cyst. d. Bosniak IV cyst. e. probable angiomyolipoma.
b. Bosniak II cyst. Category II lesions are minimally complicated cysts that are benign but have some radiologic findings that cause concern. Classic hyperdense renal cysts are small (< 3 cm), round, sharply marginated, and do not enhance after administration of contrast material. Hyperdense cysts that are 3 cm or larger are classified as Bosniak II-F lesions.
A 65-year-old man with a history of BPH has recurrent gross hematuria. The patient is clinically stable, with no transfusion requirement, no clots in urine, and no difficulty with bladder emptying. A hematuria evaluation with CT urogram, cystoscopy, and urine cytology is unremarkable. The best next step in management is:
a. five-alpha reductase inhibitor. b. alpha-blocker therapy. c. angioembolization of internal iliac artery. d. channel transurethral resection of the prostate (TURP). e. trial of antibiotic therapy.
a. Five-alpha reductase inhibitor. Treatment with finasteride is associated with decreased VEGF expression, prostate microvessel density, and prostatic blood flow. Clinically, multiple series have demonstrated the efficacy of finasteride for BPH-related hematuria, with symptom improvement or resolution consistently noted in approximately 90% of patients. Therefore, in otherwise stable patients, finasteride represents a reasonable first-line therapy for BPH-related gross hematuria after the completion of an initial diagnostic evaluation. Channel TURP has typically been used in the setting of prostate cancer, whereas a "standard" TURP or an alternative form of such endoscopic prostate tissue removal/destruction may be used for patients with persistent bleeding from BPH despite conservative therapies and/or endoscopic fulguration, particularly when additional indications for BPH surgery coexist. In cases with persistent bleeding despite TURP, selective angioembolization should be considered.
The most accurate test for evaluation of infection in the kidney is:
a. the Fairley bladder washout test. b. ureteral catheterization. c. gallium scanning. d. computed tomography (CT). e. the antibody-coated bacteria test.
b. Ureteral catheterization. Ureteral catheterization allows not only separation of bacterial persistence into upper and lower urinary tracts but also separation of the infection between one kidney and the other.
As general guidelines regarding PSA levels and pathologic stage, which of the following statements is TRUE?
a. Twenty-five percent of men with a PSA value less than 4 ng/mL have organ-confined disease. b. One hundred percent of men with a PSA value greater than 50 ng/mL have pelvic lymph node involvement. c. Ten percent of men with a PSA value greater than 10 ng/mL have extraprostatic extension. d. Serum PSA has no predictive value for staging. e. Seventy percent or more of men with a PSA value between 4 and 10 ng/mL have organ-confined disease.
e. Seventy percent or more of men with a PSA value between 4 and 10 ng/mL have organ-confined disease. As a general guideline, the majority of men (80%) who have prostate cancer with PSA values less than 4 ng/mL have pathologically organ-confined disease, two thirds of men with PSA levels between 4 and 10 ng/mL have organ-confined cancer, and more than 50% of men with PSA levels more than 10 ng/mL have disease beyond the prostate. Pelvic lymph node involvement is found in nearly 20% of men with PSA levels greater than 20 ng/mL and in most men (75%) with serum PSA levels greater than 50 ng/mL.
Absolute contraindications to laparoscopic partial nephrectomy include: a. aspirin therapy for cardiac stents. b. multiple prior abdominal surgeries. c. prior ipsilateral renal surgery. d. untreated infection. e. body mass index greater than 50 kg/m2 .
d. Untreated infection. Untreated infection is an absolute contraindication for laparoscopic renal surgery, as are uncorrected coagulopathy and hypovolemic shock. Laparoscopic partial nephrectomy has been reported as a feasible, safe approach in appropriately selected patients with intravascular stents on aspirin therapy, multiple prior abdominal operations, history of prior ipsilateral renal surgery (open and laparoscopic), and morbid obesity.
Recommended postoperative radiographic surveillance of the chest after radical nephrectomy for T1N0M0 RCC is:
a. no imaging studies. b. chest radiograph at 1 year. c. chest radiograph annually for 3 years. d. chest CT at 1 year and then chest radiograph annually for 2 years. e. chest radiograph annually for 5 years.
c. Chest radiograph annually for 3 years. Surveillance for recurrent malignancy after radical nephrectomy for RCC can be tailored according to the initial pathologic tumor stage. This patient is low risk (pT1N0M0) and the American Urological Association (AUA) Guidelines recommend an annual chest radiograph for 3 years and only as clinically indicated beyond that time period.