MOKSH USMLE

The answer is A. Genitourinary tuberculosis develops from reactivation of foci in the renal cortex or prostate that were hematogenously seeded during the primary (usually asymptomatic) pulmonary infection. Local spread from the renal and prostatic sites can lead to involvement of the calyx, ureter, bladder, vas deferens, epididymis, and (rarely) the testis. A low-grade inflammatory response results in hematuria or pyuria without bacteriuria. Whenever pus cells are seen on routine urine culture without bacteria on smear or culture plate, genitourinary tuberculosis should be considered. The end result of focal caseation necrosis in the kidney may be scarring and dystrophic calcifica- Urology Answers 293 tion. Genital tract infection often causes an asymptomatic swelling in the epididymis; secondary infection or formation of a sinus tract to the scrotal skin may cause more dramatic signs and symptoms. Epididymal tuberculosis is usually managed by chemotherapy, with surgery reserved for refractory cases. Pneumaturia is associated with a colovesical fistula and not with genitourinary tuberculosis.

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The answer is A. Seminomas tend to grow slowly and metastasize late. They usually present as a nonpainful lump that does not transilluminate. They represent about 40% of malignant testicular tumors; embryonal cell carcinoma and teratocarcinoma each represent about 25%. Because most tumors have mixed elements, they are usually classified according to the most malignant cell type encountered, whatever the predominant cell type. When metastases occur, they are usually along the regional lymphatic drainage pathways to the 292 Surgery iliac, aortic, and renal lymph nodes. Because of their slow growth and radiosensitivity, seminomas are associated with a 90% 5-year survival rate. Therapy generally consists of removing the affected testis and sampling the lymph nodes (usually external iliac) for evidence of metastasis. If metastases are present, radiation therapy is given locally to areas of known involvement. Radiation therapy is highly effective in seminoma, and metastatic disease may be palliated for extended periods.

The answer is A. Initial management should include hydration and analgesics. However, as the stone is larger than 1 cm, it is unlikely to pass spontaneously, though stones smaller than 0.5 cm usually do pass spontaneously. The size of the stone also makes a high-grade obstruction more likely; therefore an intravenous pyelogram (IVP) must be urgently performed. A high-grade obstruction will require nephrostomy or the passage of a ureteral stent. If the stone is completely occluding the lumen of the ureter, the urinalysis may not show microhematuria and thus may be misleading. Approximately 15% of patients will have a recurrence within 1 year, and almost 50% may have a recurrence within 4 years. Elevated BUN and creatinine are expected only in the setting of an obstructed single functioning kidney.

Q.167 A 36-year-old man presents to the emergency room with renal colic. A radiograph reveals a 1.5- cm stone.

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Right Answer(A): Hypospadias is a common congenital anomaly of the penis resulting from incomplete development of the anterior urethra. It occurs in about 1 in 300 live births and is believed to have a multifactorial genetic mode of inheritance. Of those with hypospadias, about 7% have a father with the disorder, 14% a brother, and 20% a second family member. Hypospadias occurs in the corona in about 75% of cases, where it is often accompanied by chordee. Undescended testes occur in about 10% of cases of hypospadias, as do inguinal hernias. Hypospadias in the scrotal area is associated with bilateral undescended testes and infertility and must be differentiated from pseudohermaphroditism and adrenogenital syndrome.

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Right Answer(A): The arteriogram shown demonstrates a left iliac artery occlusion. In a patient with severe symptoms that are interfering with his lifestyle, intervention is indicated. In the young healthy patient with iliac artery occlusive disease, when angioplasty is not a treatment option, femorofemoral and aortoiliac bypasses offer excellent long-term relief. Femorofemoral bypass offers the additional benefit of not disturbing sexual function. Both bypasses provide similar long-term patencies. Aortobifemoral bypass, while clearly the most risky of the treatment options offered, provides the best long-term patency. In the elderly patient with severe COPD, so-called extraanatomic bypasses (femorofemoral or axillofemoral bypasses) offer fair long-term patencies while not subjecting the patient to the risks of general anesthesia.

Q.165

Q.165 The arteriogram below applies to both patients described on the following page.

Right Answer(C): A horseshoe kidney is a fused kidney that occupies space on both sides of the vertebral column. The fusion is ordinarily at the lower poles with the isthmus anterior to the aorta. The ureters run anterior to the isthmus and the kidney frequently has an anomalous blood supply. The arterial supply to the kidney is highly variable with vessels arising not only from the normal position in the aorta but also from a variable number of accessory segmental end-arteries from the lower aorta and iliac arteries. Most cases of abdominal aortic aneurysm associated with a horseshoe kidney can be successfully resected, but these anomalies make the repair challenging. When the horseshoe kidney is recognized preoperatively, an arteriogram helps to define the vascular anatomy. The preferred operative approach is then via a retroperitoneal dissection. This allows the kidney and its collecting system to be swept anteromedially and provides relatively unobstructed access to the aneurysm. All anomalous renal arteries should be implanted into the graft after the aneurysm sac is opened since the proportionate contribution from each may be hard to determine. The renal isthmus and collecting system restrict access to the aneurysm and make the anterior approach less desirable. Though division of the isthmus can be accomplished, there is high risk of calyceal or ureteral injury. Given the numerous arterial, venous, and collecting system anomalies, autotransplantation of the kidney is not a good option. The presence of the fresh intravascular foreign body (aortic graft) contraindicates dialysis because of the excessive risk of infecting the graft.

Q.164 During evaluation for the repair of an expanding abdominal aortic aneurysm, a patient is discovered to have a horseshoe kidney.