3rd Edition

Choe
s
%

SelfAsses
smen
t

Edi
tor
Phi
lip
p
Da
MD,
hm
MHS
,
C,
Co FACS
ndo C.
Delvecchio
, MD Scott
Gilbert,
MD, MS
KhaledS.
Hafez, MD
Gerard
Henry, MD
M. Louis
Moy, MD

ntri
but
ors:
Benja
min
Canal
es,
MD,
MPH
Marc
Cohe
n,
MD,
FACS
Curt
Crane
, MD
Ferna

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M
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Philippe
Spiess, MD,
MS, FACS,
FRCS(C)
John S.
Wiener, MD,
FAAR FACS
Lawrence L.
Yeung, M

TABLE OF CONTENTS
1....................................................... Diseases of the Adrenal Gland
....................................................................................................... 1

2................................................................................................... Benig
n Tumors...................................................................................... 15

3.................................................................. Bladder Outlet Obstruction

........................................................................................................... 35

4................................................................................................... Calcu
lus Diseases.................................................................................. 71

5............................................................................. Bladder Carcinoma

......................................................................................................... 105

6................................................................................. Penile Carcinoma

......................................................................................................... 143

7.............................................................................. Prostate Carcinoma

......................................................................................................... 159

8.......................................................................... Renal Cell Carcinoma

......................................................................................................... 179

9........................................................................... Testicular Carcinoma

..........................................................................................................215

10........................................................ Upper Tract Carcinoma

............................................................................................ 247
11............................................................. Female Urinary Incontinence
..........................................................................................................259

12.

Vesicovaginal & Uretcrovaginal Fistulas 303

13...................................................................................... Hypertension
..........................................................................................................327

14.......................................................................... Erectile Dysfunction

..........................................................................................................359

15............................................................................. Infectious Diseases

..........................................................................................................385

16................................................................................... Male Infertility

..........................................................................................................419

17.............................................................................. Male Incontinence

..........................................................................................................437

18............................................................................. Myelomeningocele
..........................................................................................................459

19........................................................................................... Pediatrics
..........................................................................................................479

20....................................................... Urologic Problems of Pregnancy

......................................................................................................... 535

21........................................................................ Renal Transplantation

......................................................................................................... 547

22................................................................................ Urologic Trauma

..........................................................................................................565

23........................................................................... Ureteral Obstruction

......................................................................................................... 593
Urethral Strictures 605CHAPTER

1 DISEASES OF THE
ADRENAL GLAND

Urology
CASE
I Oral Boards Self-Assessment

I. Diseases of the Adrenal Gland

45 y.o. white female with easy bruising presents for hypertension (HTN) evaluation.
HPI:

State that you would

obtaina detailed

medical

history, beginning

with history of

present illness.

PMH:

HTN

History of headache, blurred

vision,
heart palpitations,
Feeling
sluggish
and lethargic; weight gain in past few months
sweating, and weight gain?
Excessive facial
hair; moon facies
Abnormal hair growth, masculinization,
or irritability?

PSH:

none

Allergies:

none

Medications:

Enalapril
Benadryl

FH:

(-) HTN

SIT:

(-) tob; (-)

ROS:

non-contributory

PE:

ETOH; pharmacist

State that you would examine

the

patient

thoroughly from

headto toe

with the vital signs.

Vitals

T 98.6

BP

GA

WDWN WF 1NAD

HEENT

moon facies; excessive facial hair

Heart

RRR

Lungs

CTA

180/110 P 100

RR12

beginning

/. Diseases of the Adrenal Gland

Spine

Urology Oral Hoard Self-Assessmeni

buffalo hump

Abdomen

obese; soft, NT/ND,

Flank

(-) CVAT

Pelvic

normal female

Rectal

benign

Ext

(-) CCE

Neuro

non-focal

(+) striae

What initial lab tests do you order?

Obtain UA, Chem 7, CBC, PI'/ P IT, and pregnancy test.
UA

->

WNL

Chcm 7

Na 135 meq/L; K 3.0 mcq/L; Cl 100 meq/L;

C02 24 meq/L; BUN 10 mg/dL; Cr 1.0 mg/dL CBC
WNL

PT/PTT

->

Prcgnancy test ->

WNL
negative

What is your differential diagnosis?

The differential diagnosis of uncontrolled HTN includes pheochromocytoma, Conn's Syndrome, renal artery
stenosis, and Cushings Syndrome.
What kinds of screening lab tests do you order now?

Elevated urine cortisol (preferred test: 24-hour urinary free cortisol) implies that she may have Cushings
Syndrome.
What is your next step?
State that you would proceed with low dose dcxamethasone suppression test.
Low dose dexamcthasone suppression test - persistently elevated cortisol
Note:

Positive

dcxamethasone test confirms that she has Cushings

Syndrome and

rules out

Pseudo-Cushings (similar symptoms and elevated cortisol levels due to alcoholism and
8

Urology Oral Boards Self-Assessment

I. Diseases of the Adrenal Gland

depression). Potential causes of Cushings Syndrome include pituitary adenoma (bilateral adrenal
hyperplasia), adrenal adenoma, adrenal carcinoma, and ectopic carcinoma (bronchial carcinoma).
Cushings disease is Cushings Syndrome caused specifically by pituitary adenoma.

What is your next step?

You must distinguish Cushings Syndrome from Cushings disease. Obtain ACTH and perform high dose
dexamcthasone suppression test (DST).
ACTH:

not elevated

High dose DST:

does not suppress cortisol

What is your assessment?

She does not have Cushings disease. Thus, she has either adrenal carcinoma or adrenal adenoma.
What imaging studies would you obtain initially?
Abdominal CT:

evaluate for adrenal adenoma or adrenal carcinoma

Abdominal CT scan:

heterogeneous 5-6 cm (R) adrenal mass; unclear if it enhances

How would you evaluate this adrenal mass?

State that you would obtain MRI scan.
MRI (Tl):

low signal intensity (R) adrenal mass

MRI (T2):

(R) adrenal mass with bright signal intensity, mass appears localized
with no evidence of invasion

Note: Based on MRI findings, she most likely has adrenal carcinoma.

What is your assessment?

45 y.o. WF with adrenal carcinoma.

What is your next step?
Complete staging to rule out metastatic disease: Obtain a CXR or CT scan of the chest; consider bone sain.
If no evidence of metastatic disease, state that you would obtain an informed consent, preoperative lab work.
T&C blood. Give appropriate prcoperative antibiotics and thrombosis prophylaxis.
Danger Point: When embarking on renal or adrenal surgery, the contralateral adrenal gland must be
evaluated. Corticosteroid therapy is not necessary for patients undergoing unilateral
adrenalectomy with a normal contralateral adrenal gland. However, when CT scan
shows contralateral adrenal atrophy or agenesis, supplemental corticosteroids are
required before, during, and after unilateral adrenalectomy.
You re-reviewed the CT scan and MRI. Films showed atrophied contralateral adrenal gland.
9

/. Diseases of the Adrenal Gland

Does this patient need preoperative steroids?

Urology Oral Hoard Self-Assessmeni

Yes, she was given steroids pre- and postoperativcly.

Note:

Patients

with Cushings Syndrome require glucocorticoid therapy before, during,

and after the operation.

Discuss your surgical technique:

The Operation (Radical Adrenalectomy)

1.

Anterior subcostal, Chevron, or thoracoabdominal approach

2.

Minimal manipulation of adrenal mass

Dissect surrounding tissues away from the adrenal glan

What arc alternative approaches?

The role of laparoscopy in treating malignant adrenal masses is evolving. While pure laparoscopic and handassisted laparoscopic adrenalectomy have become standard approaches for benign adrenal masses, open
surgery remains the preferred approach for suspected adrenal carcinoma. These tumors are usually large,
may be locally invasive and the only chance of cure for these patients is complete surgical resection.
Discuss potential complications of adrenal surgery and their management:
1.

During the clamping of adrenal vein, patient bccoincs hypotensive

a.

This is normal response to clamping of adrenal vein

b.

Simply replacing volume with normal saline will restore the BP

c.

Pressors are rarely needed

2.

3.

During dissection, adrenal vein is avulsed from IVC

a.

First, digital compression

b.

Clear the field of blood

c.

Proximal and distal control with sponge sticks

d.

Oversew the hole with 4.0 Prolene

During dissection, IVC is lacerated
1
0

Urology Oral Boards Self-Assessment

a.

Proximal and distal control with sponge sticks

b.

Saiinsky or Allis clamp to oppose the caval edges

c.

Oversew the injury with 4.0 Prolene

I. Diseases of the Adrenal Gland

She tolerates the operation and is returned to the floor.

What is your follow-up?

Check pathology of the specimen and serum chemistries.

Pathology:

metastatic (node positive) adrenal carcinoma

Chem 7:

normal

How do you treat metastatic adrenal carcinoma postoperativcly?

Treatment options are limited. Whenever possible, patients should be referred for participation in
a clinical trial.

1
1

Mitotane (o,p-DDD) is the main drug used to treat metastatic or incompletely resected adrenal carcinoma. Response rates are in
the order of 20 35%. Daily doses of 10-12 grams are necessary and GI and neurological side effects are usually doselimiting.How docs adrenal carcinoma present clinically?
Patients have mixed clinical syndromes such as virilization, feminization, and uncontrolled hypertension.
Approximately 80% are lunctionally active. Most commonly they secrete cortisol (30%), androgen
(20%), estrogen (10%), and aldosterone (1-2%). On physical examination, affected patients may have a
palpable abdominal mass.
What kind of screening labs are pertinent to adrenal carcinoma?
Urine 17KS

>

elevated

17 OH PG

elevated

Urine/plasma estrogen

elevated

Serum ACTH

>

suppressed

What arc appropriate imaging studies for adrenal carcinoma?

Abdominal CT

Abdominal MR1

heterogeneous

adrenal mass,

heterogeneous adrenal

mass;

lymphadenopathy

signal intensity,

local invasion
What is the proper treatment for adrenal carcinoma?
Adrenal resection, if possible. This particular tumor is radio-resistant. You must chcck the pathology for
diagnosis and margins! After surgical resection, additional treatment, i.e., chemotherapy with rnitotane
(o.p-DDD) is needed for metastatic disease.
What would you have done if high dose dexamcthasone suppression test suppressed cortisol?
1. Obtain head CT
2. Inferior petrosal vein sampling if head CT equivocal
(B) Inferior petrosal vein sampling for ACTH
3. Neurosurgery consult if patient had pituitary tumor
4. Trans-sphenoidal hypophysectomy
Surgery of choice for pituitary adenoma
Differential Characteristics of Pituitary and Adrenal Masses:

What is your differential diagnosis of incidental adrenal masses?

1.

Benign adrenal adenoma

2.

Adrenal cyst

> 4 cm >

Solid mass: surgical removal.

Perform fine needle aspiration (FNA) and evaluate the fluid.

FNA - bloody

> resect

CASE 2
55 y.o. white female presents to the clinic complaining of hypertension and weight gain.
HPI:

State that you

would

obtaina detailed medical

history,

beginning with history of

present illness.

Any complaints of obesity, weight gain, or hirsutism?

Large weight gain in past 2 months and

hirsutism on face

1. Diseases of the Adrenal Gland

PMH:

Urology Oral Board Self-Assessment

IITN
asthma (mild)

PSH:

none

Allergies:

none

Medications:

Hytrin
Lipitor
HCTZ

FII:

(-) adrenal disease

SH:

20 pack year smoking; (-) ETOH

ROS:

non-contributory

PE:

State that you

would examine

the patient

thoroughly from

headto toe,

with the vital signs.

Vitals

T 98.6

BP 140/60

GA

Obese WFINAD

IIEENT

Truncal obesity,
moon facies

Heart

RRR

Lungs

CTA

Abdomen

soft; NT/ND; marked striae

Flank

benign

Bimanual pelvic

normal female

Rectal

normal tone; ill BCR; good anal wink

Ext

normal pedal pulses; (-) CCE

Neuro

non-focal

Skin

thin and bruises easily; (+) hyperpigmcntation

buffalo

What initial lab tests do you order?

Obtain UA, CBC, and Chcm 7.

1
7

P90

hump

RR12

beginning

What kinds of screening lab tests do you order now?

State that you would get:
1.

Baseline urine and serum cortisol levels

-

2.

Urine and serum cortisol levels are elevated

Low dose DST suppression test

Urine and serum cortisol do not suppress

Note:

3.

This

means Cushings Syndrome.

ACTH level
-

ACTH level is high (>15 pg/mL)

Note:

This

means Cushings disease or ectopic ACTH producing tumor

ACTH level

4.

High

>

pituitary; ectopic (usu. ectopic)

Normal or moderately high

>

pituitary; ectopic (usu. pituitary)

Low

>

adrenal adenoma/carcinoma

High dose DST suppression test

-

Urine and scrum cortisol are both low

Note: This means Cushings disease.

Suppression

>

pituitary

No suppression

ectopic; adrenal

W'hat type of imaging studies do you order?

You order CT or MRI of head and abdomen as necessary.
Head CT/MRI

mass in the sella turcica

Abdomen CT/MRI

normal adrenal glands

Do you need to order inferior petrosal vein sampling?

No, but if head CT or MRI was normal, bilateral inferior petrosal vein should be sampled for ACTH level.
In this case, head CT revealed pituitary adenoma; thus, this test was not needed.

What is1.your
assessment?
Diseases
of the Adrenal Gland

Urology Oral Board Self-Assessment

55 y.o. WF with Cushing's disease (pituitary adenoma).

What is your recommendation?
1.

Referral to neurosurgeon for trans-sphenoidal hypophyscctomy

a.
b.

Postoperative response to CRH predicts relapse

If successful, patient will demonstrate postoperative hypoadrcnalism. In this case, supplement
with steroids

2.

Pituitary- radiation
a.

If definitive rescction not possible

3.

Chemotherapy
a.

Bromocriptine for intermediate lobe adenoma

b.

Alternative agents include: mitotanc, mctyrapone, aminoglutcthimide, kctoconazole

4.

Bilateral adrenalectomy
a.

Complications of bilateral adrenalectomy include pancreatitis and Nelsons Syndrome

She agrees to trans-spheniodal hypophyscctomy, undergoes uneventful operation by a neurosurgeon, and

thanks you for making the correct diagnosis.
Implications of radiographic findings:
CT scan or MRI Findings
1.

Implication

Sella turcica
Nonnal

Cushings disease, ectopic tumor

or adrenal

Mass

If the mass is microadenoma -Cushings disease

adenoma

If the mass is macroadenoma > Nelsons Syndrome

2.

Abdomen Adrenal mass

Unilateral

Adrenal adenoma or carcinoma

Adrenal enlargement
Bilateral

Pituitary tumor or ectopic

tumor; bilateral adrenal

enlargement without discrete mass implies adrenal hyperplasia

due to pituitary or ectopic tumor Normal adrenal
Pituitary tumor or ectopic
tumor
3.

Chest
1
9

Mediastinal mass

Ectopic tumor

Pancreatic mass

Ectopic tumor

When is inferior petrosal vein sampling performed?

(B) Inferior petrosal vein sampling for ACTH is performed to identify pituitary adenoma.

1.

Do it if head CT is normal and you stil 1 suspcct Cushings disease

2.

Obtain venous sample before and after CRII injection. Check for ACTH level
(+) Response

>

pituitary adenoma

(-) Response

ectopic tumor

1. Diseases of the Adrenal Gland

Urology Oral Board Self-Assessment

CASE 3
58 y.o. white male presents to the clinic complaining of fatigue, malaise, and asthenia (lack of strength).
HPI:

State

that you would obtain a detailed medical history, beginning with history of

present illness.

Does he have any h/o TB, lymphoma, CMV, Cryptococcus, Contracted TB a year ago; off medication
or AIDS?

PMII:

(+)
tuberculosis
fibrillation

PSII:

(-) urologic surgeries

(+)

atrial

IIEENT

benign

Heart

RRR

Lungs

CTA

Abdomen

mild obese; soft; NT/ND benign

Flank

normal circumcised phallus; adequate meatus;

GU

(B) testicles WNL

Prostate

smooth and benign @ 40 g; (-) nodules or induration dark pigmentation (-) CCE
non-focal

Skin

What

initial lab tests do you order?

Ext
Ncuro

2
1

Obtain UA, UCx, Chem 7, and PSA

What is your assessment?

He has hyponatremia, hyperkalemia, and hypcrchloremic metabolic acidosis.
What is your next step?
You need to correct his electrolytes, stabilize him, and get EKG as necessary.
You have corrected his electrolytes and he is stable. You also obtained EKG as a precautionary measure and
EKG was normal.
What do you do now?
At this point you are thinking that he has endocrinologic problem. State that you would order special
biochemical tests, such as urine cortisol, urine ketosteroids, serum cortisol, ACTH level, followed by ACTH
stimulation test.

1.

Urine cortisol

low

2.

Urine 17-01 ICS or 17 KS ->

3.

Serum cortisol

low

4.

ACTH

high

5.

ACTH stim test:

urine and serum cortisol remain low in response

low

to ACTH or cosyntropin stimulation

What is your assessment?

58 y.o. WM with possible Addisons disease.

What imaging studies do you order?

State that you would obtain CT scan or MRI of the abdomen.
CT scan:

(R) adrenal atrophic; (L) adrenal enlarged

1. MRI:
Diseases of the Adrenal
(R) Gland
adrenal atrophic; (L) adrenal enlarged;

Urology Oral Board Self-Assessment

Both adrenals have low signal intensity on T1 and T2 weighted images.

What is your assessment now?
58 y.o. WM with Addisons disease. Left adrenal is atrophic and right adrenal has infarcted. How do you
proceed?

You need to supplement his steroidsglucocorticoid and mincralocorticoid.

You initially gave him cortisol 300 mg/day to get him over his Addisonian crisis and prescribed cortisol 3050 mg QD with Florinef for his maintenance dose.

2
3

What are potential causes of adrenal insufficiency?

1.

Infection of adrenal gland

a.

Tuberculosis, CMV, cryptococcus

b.

AIDS related opportunistic infections (e.g., ftingus)

c.

Adrenal abscess

2.

3.

4.

5.

Iatrogenic surgical removal of adrenal glands

a.

(B) Adrenalectomy

b.

Unilateral radical nephrectomy followed by contralateral adrenalectomy

Drugs
a.

Anti-adrenal
ketoconazole)

drugs

(e.g.,

mitotane,

aminoglutethimide,

b.

Anticoagulant-induced hemorrhage (e.g., Coumadin)

Non-adrenal tumors
a.

Lymphoma

b.

Metastatic brochogenic carcinoma

Spontaneous hemorrhage
a.

Waterhouse-Friedrichsen Syndrome

How do you treat adrenal insufficiency?

1.

Crisis:

Cortisol

300mg QD + Florinef

2.

Maintenance:

Cortisol

30-50 mgQD +

3.

Emergency:

Cortisol

hemisuccinate 100 mg I M/I V

What are metabolic and clinical symptoms of hypoaldosteronism?

1.

Hypcrchloremic acidosis

2.

Hyperkalemia

3.

General weakness/fatigue

4.

Weight loss

5.

Anorexia

6.

Nausea/vomiting

Florinef

metyrapone,

and

1. 7.
Diseases of Muscle
the Adrenal
Gland
palsy
due to hyperkalemia

8.

Urology Oral Board Self-Assessment

Cardiac arrhythmia due to hyperkalemia

What is the difference between primary and secondary hypoaldosteronism?

1.

Primary hypoaldosteronism

2.
Secondary
NSAIDs, diabetes

Congenital or
->
(high)
acquired
>
(low)
deficiency in
Secondary
hypoaldosteronism
aldosterone
>
Florinef
synthesis due
hypoaldosteronism is caused by Type IV RTA,
to aldosteronepyelonephritis, and nephrosclerosis causing juxtaglomerular apparatus damag
synthase
edeficiency.
Renin
>
(low)
In
this condition,
Aldosterone
>
(low)
scrum
renin
level is high
Treatment:
>
Florinef
and
serum
aldosterone
level
is
lowRenin
Aldosterone
Treatment:

2
5

CHAPTER 2 BENIGN

TUMORS

CASEI
56 y.o. mentally challenged
African-Amcrican female with
woozincss and lighthcadcdncss.
HPI:

State that you would

obtain
adetailedmedical
history,beginningwithhistory
of

present illness.

PMH:

N1DDM

PSH:

(B) tubal ligation

Allergies:
e

Medications:

non

FH:
sclerosis

(-)

tuberous

SH:
secretary

(-) tob; (-) ETOH;

ROS:

non-contributory

ASA I tab QD
Glyburide

Danger Point: A woman

with
lighth
eaded
ness
and an
acute
episod
e
of
flank

pain
may
have a
ruptur
ed
angio
myoli
poma.
You
should

ask
about
a
family
histor
y
of
tubero
us
scleros
is.

PE:
State that you would
examine the patient thoroughly
from head to toe, beginning
with the vital signs.
Vitals

98.6

BP 85/40

P120
RR16
GA

WDWN
AAF
INAD

HEENT

multiple

small
adenoma
sebaceum
on
her
cheeks
Heart

RRR

Lungs

CTA

Abdomen

soft;
distended
;
(-)
masses

Flank

mild (R)
CVAT

Pelvic

normal

female
Rectal

benign

Ext

(-) CCE

Neuro

non-focal

What initial lab tests do you order?

Obtain UA, UCx, Chcm 7, CBC,

coagulation panel, urine cytology
.UARBCsHPF; (-) WBC; trace protein; gross hematuria
TNTC

What would you do next?

First you should stabilize the
patient with IVF and
appropriate blood products
as necessary. When she is
stable,
order
specific
imaging studies and special
procedures.

What type of imaging studies and

special procedures do you order?
State that you would obtain
CT scan of abdomen and
pelvis (+/- contrast) followed
by cystoscopy.
CT

scan

(C+/C-):

5 cm lower pole (R) renal

mass; Hounsfield unit > (-)
50 units;
1
cm calcification
(L) kidney; renal
VC, liver, and
nodes
are
Cystoscopy:

within
vein, I
lymph
normal

bleeding efflux from (R)

ureteral orifice; (-) tumors
or stones
Note: MRI is optional if CT
scan is not available.
Danger

Point: Ask for

Ilounsfiel

d units
In
a
renal
mass.
Negative
Hounsfie
ld units
indicate
fat.

What is your assessment?

56 y.o. AAF with
angiomyolipoma
(AML)
and
contralateral renal
calculus. She is
symptomatic from
her AML and has
active hematuria.

How would you advise this patient?

Discuss with her the
potential treatment options
and
make
your
recommendation.
1.

Watchful waiting
a.

This is a poor
option because this

AML is large and

the
patient
is
symptomatic
b.

If this protocol is
chosen,
your
patient may require
emergent
resuscitation
bccausc
your

examiner
make
hypotensive
tachycardic
c.

2.

may
her
and

At this point you

have to discuss
surgery
FNAofAML

a.

This is also a poor

choice because CT
scan in this case is
diagnostic
with
findings consistent
with AML

b.

If you choose this

protocol,
the
examiner
may

cause
more
hemorrhage
and
FNA will be nondiagnostic
c.

3.

At this point you

have to discuss
surgery
Selective arteriala

embolization
a.

This is reasonable
therapy
in
institutions where
interventional
radiology
is
available

b.

However, if this

protocol
is
unsuccessful, you
should be prepared
to perform open
exploration
and
partial
nephrectomy
4.
nephrectomy

Partial

a.

This is probably
the
conservative
procedure of choice
for this patient

b.

Treatment options
for
angiomyolipoma
depend on the size

and symptoms (see

below)
5.
nephrectomy
a.

Radical

This is a BAD
choice since this
patient most likely
has
a
benign

lesion.
Furthermore, she
has mild azotemia,
diabetes, and renal
calculus. Thus, you
should recommend
nephron
sparing
surgery
b.

If you choose this

protocol,
make
sure to send off an
intraoperative
frozen section. If
the frozen scction
comes back as
AML, you should
be
ready
to
perform
partial
nephrectomy

6.

Renal cryotherapy
a.

This is another
BAD choice. There
is no established
role for ablative
forms of therapy at
this time

What are current treatment recommendations for

angiomyolipoma?

Symptomatic AML

Selective embolization,

partial nephrectomy

Asymptomatic AML

>

Observation with
annual/semi-annual

re-

imaging
Indications for treatment of
asymptomatic AML are
controversial and includc
size (> 4 cm), patient age,
compliancc
occupation,
renal reserve, and pregnancy

plans.
Patient agrees to selective
embolization.
What is your next step?
State that you (or the
interventional radiologists)
would obtain an informed

consent, chcck coags and

labs (CBC, Chcm7), confirm
that she has no.contrast
allergy, and give her
prcopcrativc antibiotics and
DVT prophylaxis. Make
sure she stops the ASA.
What are potential complications of selective arterial
embolization that you should

discuss?
1.
Post-embolization
syndrome (up to 85%) with
fever, pain, nausea/vomiting,
leukocytosis
2.
(5%)

Abscess formation

3.
(3%)

Pleural effusion

4.
bleeding

Failure to stop

5.
Angioinfarction of
entire kidney and possible
renal failure

6.
angioinfarction
organs

Inadvertent
of other

She goes down to the

Radiology
suite
and
undergoes a successful
embolization. However, 4
hours later she is noted to be

tachycardic (HR 115) and

hypotensive (85/55).
How do you proceed now?
Discuss emergent surgery
with her and her family and
obtain informed consent.
T&C for at least 2 U of

PRBCs. Post for emergent

surgery with cell saver.
Administer
preoperative
antibiotics
and
DVT
prophylaxis.

Discuss your surgical technique:

The

Operation

(Partial

Nephrectomy)

1.

Flank or anterior

subcostal approach

2.

Kocher maneuver
(Rcflect duodenum
medially)

3.
Early control of
the renal artery and vein
4.
Ice slush around
the kidney

(if the renal artery

is going to be
clamped for more
than 30 minutes)
5.
Mannitol (12.5 g)
before and during renal
manipulation
(To

help

renal

perfusion)
6.
Perform partial
nephrectomy; excise the
mass with 1 cm margin
7.
Intraoperative
frozen
section
to
r/o
carcinoma

8.
Indigo carmine to
assess for collecting system
leak
9.
Perirenal fat or
gelfoam over the defect
10.

Place a drain

Danger Point: You must

ask for the pathology'

report. The specimen is
angiomyolipoma.
She has uncomplicated
intraoperative course. Three
days later, she has increased
fluid output from her JP
drain.

What do you make of this?

At
this
point
your
differential diagnosis of
fluid from JP includes urine
leak,
pancreatic
fluid,
duodenal leak, and chyle.
Note: You could
have injured the head of the

pancreas, duodenum,
thoracic duct

and

during
the
operation or simply
have a renal fistula.
How do you proceed?

HPJ: State that you would obtain a new history and perform a detailed physical examination.

PE:
State that you would reexamine
the patientthoroughly
from head to
toe,
beginning

with the vital signs.

Vitals
AFVSS
GA
Heart

WDWNAAFINAD

RRR
Lungs
CTA
Abdomen
soft;

NT/ND;

(+) BS
Flank
benign
JP
clear yellow fluid

Foley
clear urine
What initial lab tests do you order?
Obtain UA, UCx, Chem 7.
CBC, and fluid Cr from the
JP.

What is your impression?

The patient has urine leak

from her JP drain.

What do you do now?

Obtain KUB to identify the

end of the drain with respect

to the repair.

KUB: The drain is very close

to the repair site.

What would you do next?

Take the suction off the JP

and gently advance the drain
away from the kidney repair

site.

hi spite of this, the urine

continues to leak into the
drain.

What other imaging study could you

obtain?

State that you would obtain

CT scan with contrast to

evaluate for possible renal

fistula.

CT:

(+)

Extravasation

of (R) lower pole kidney

with small urinoma;

(-) Hydronephrosis
What is your assessment?
56 y.o. AAF with renal
fistula
after
partial
nephrectomy.

What arc your options at this point?

Discuss
your
treatment
options and make your
recommendation.
1.

Watchful waiting
a.

This was the best

initial choice since

the
leak
may
spontaneously
close
b.

Taking the drain

off suction should
help expedite this
process.
Suction
can keep the leak

open. You have

followed
this
protocol, but this
did not work
2.

Advance the drain

a.

If the leak persists,

the drain should be

carefully advanced
away from the
closure site. This
protocol was also
performed and did
not work
3.
Percutaneous
nephrostomy tube

a.

This
is
BAD
choice as a first
step. This is too
aggressive
and
dangerous due to
absence
of
hydronephrosis
and recent surgery

b.

4.

However, if the
stent was unable to
be
placed
in
retrograde fashion,
this is the next
logical step

Cystoscopy and stent

a.

If leak persists,

placing
internal
stent is the best
option. The leak
should stop after
internalizing
the
stent
b.

Remember to
remove the stent in
6 weeks

Your partner could not place

a stent cystoscopically. Thus,
interventional
radiologist
placed
a
percutaneous
nephrostomy tube followed
by an internal stent. The leak
stopped.
What is your follow-up?

1.
Remove the stent
in 6 weeks
2.

Monitor serum Cr

3.

Discuss with your

patient
regarding
treatment of (L) renal
calculus on an elective
basis. Dont forget the

left renal calculus!

What further work-up is indicated
in patients with suspected tuberous
sclerosis?
Tuberous sclerosis is an
autosomal
dominant
disease with incomplete
penetrance. It is associated
with the triad of sci/.ures,

mental retardation
adenoma scbaceum.
1.
chest

and

CXR or CT of the

2.
CT or MRI of
brain (r/o astozytoma)
3.

Echocardiography

(r/o cardiac rhabdomyoma)

4.
Fundoscopic
evaluation (r/o macular
hamartoma)
5.

Skin examination

Referral to an internist and/or neurologist should be considered. Patients of reproductive age should be offered genetic
counseling.CASE 2
Urology Oral Hoards Self-Assessment

2. Benign Tumors

45 y.o. African American male presents to the clinic complaining of obstructive voiding symptoms.
HPI:

State that you would

obtain a detailed

medical

history,

beginning with history

of

present illness.

Irritative and obstructive voiding

Difficulty
symptoms;
urinating 2-3
AUA
years;
7 weak stream; AUA score is 15/35; no UTI symptoms
symptoms score; UTI symptoms?

Danger Point: Your examiner is obligated to answer only those questions that you pose to him. He is
not obligated to volunteer any new information.
PMH:

(-) urethral stricture

(-) STDs
prostatitis
HTN

(-)
(+)

PSH:

(-) TURP

Allergies:

none

FH:

(-) prostate cancer

SH:

(-) tob; (-) ETOH

ROS:

non-contributory

PE:

State

Medications:

HCTZ

that you would examine the patient thoroughly from head to toe, beginning

with the vital signs.

Vitals

T 98.6

BP 130/60

GA

WDWN AAM INAD

HEENT

benign

Heart

RRR

Lungs

CTA

Abdomen

mild obese; soft; NT/ND

Flank

benign

GU

normal circumcised phallus; adequate meatus;

(B) testicles WNL
10
1

P90

RR12

Rectal

prostate smooth and benign @ 70 g; (-)

nodules or induration

normal tone; (+) BCR; intact perianal sensation

Ext
Urology Oral
Board Self-Assessment
(-) CCE; normal pedal pulses

2. Benign Tumors

Neuro

non-focal

What initial lab tests do you order?

Obtain UA, Chem 7, PSA.
UA

->

WNL

Chem 7 ->WNL; Cr 1.0 mg/dL

PSA

4.8 ng/mL

Note:

Before drawing a PSA, you should discuss the pros and cons of PSA screening
with him.

What is your assessment?

45 y.o. AAM with obstructive voiding Sx and elevated PSA.

What is your next step?

Perform non-invasive uroflow (Qmax) and postvoid residual (PVR) with bladder ultrasound in the
office during the initial visit.
Qmax

9 mL/s

(low)

Voided volume:

150 mL

PVR

(moderately

200 mL

high)

Note: Minimum voided volume must be at least 150 mL to have an accurate uroflow.
Note: Low flow rate indicates that he has lower urinary tract problem, but you dont know whether he has
obstructing prostate or a weak detrusor. He docs have elevated postvoid residual urine, but he is not
in acute retention. Do not be in a rush to do a TURP. He may need urodynamics (pressure-flow
study). However, he also needs to be evaluated for his elevated PSA.
What are your treatment options for his voiding symptoms?
1.

Watchful waiting with dietary modification

a.

Decreasing dietary stimulants will help alleviate lower urinary tract symptoms (LUTS)
i. Dietary stimulants include caffeine-containing products, spicy foods, alcohol, and carbonatcd
beverages; avoid drugs such as Sudafcd

b.

Decrease fluid intake

i.

Some patients have a tendency to drink lots of water tliroughout the day. So, simply
decreasing their fluid intake will help LUTS
10
2

c.

Neutraceuticals

Urology Oral Hoards

i. Self-Assessment
This may include berry of saw palmetto silodosin (Serenoa rcpens)

2. Benign Tumors

Danger point: These therapies have not demonstrated statistically significant benefits in
placebo, randomized studies. In addition, since these products are not
monitored in the same fashion as prescription drugs for purity, consistency
and contamination issues have been raised.
2.

a-blockcr (e.g., terazosin, doxasozin, tamsulosin)

3.

a-blockcrs (Hytrin, Cardura, and Flomax)

a.

Risks of a-blocker include orthostatic hypotension, dizziness, and fainting

b.

Terazosin and doxasozin are the least expensive of all a-blockcrs but need to be titrated up

c.

Tamsulosin has the least cardiovascular side effects due to its super-sclectivity.Try not to prescribe
cx-blockers to patients whose work may become affected by adverse side effects (i.e., pilots)

4.

5 a-reductase inhibitors (e.g., finasteride, dutescride)

a.

Most useful in large glands (greater than 4.0 cm)

b.

Decrease PSA by 50%

c.

Increase maximal flow rates by approximately 3 mL's in 30% of patients

d.

Increase intracytoplasmic testosterone

e.

Take 6-12 months to be fully effective

f.

Reduce the incidence of prostate cancer 25-27%

5.

TURP
a.

Surgery is too aggressive at this time

Danger Point: Dont forget to evaluate abnormal PSA.

What do you recommend?

Inquire about the degree that he is subjectively bothered by his symptoms.

The patient indicates that he is very bothered by his urinary symptoms, especially the fact that he now needs
to get up at least once a night. He is anxious to do something.
What do you suggest?
You recommend an a-blockcr, e.g., doxazosin and schedule a TRUSBx. You start him at 1 mg/day, which
you titrate up to 4 mg/day. An a-blocker may also reduce his risk of developing urinary' retention.

IIow do you counsel him about the biopsy?

10
3

Transrcctal ultrasound guided prostate biopsy (TRUSBx):

2. Benign Tumors

Urology Oral Board Self-Assessment

1.
Qmax Pdet Qmax complications
Voided
volume
PVR
2.

Discuss

the

procedure,

indications,

potential

risks

and

Prescribe Fleet enema the morning of the procedure

3.

Pcri-biopsy antibiotic prophylaxis -> Ciprofloxacin 500 mg po BID * 3 days

4.

Stop NSAIDS 10 days before the biopsy

He undergoes the biopsy without problems. He returns to your office the following week and wants to know
about the pathology report.
Pathology Report:
Prostate biopsy

(-) CAP; BPH

He is happy about the results of pathology report. But its been 4 weeks since hes been on doxazosin, and
he has not noticcd any improvement in his urinary symptoms. He is still symptomatic and significantly
bothered.
What do you recommend at this point?
Consider urodynamics (prcssure-flow) to document obstniction
.9 mL/s

(normal > 15 cc/s)

90 cm H20

(normal < 40 cm H20)

100 mL
200 mL

(normal < 100 mL)

Note:

Qmax - maximal flow rate; Pdet Qmax ~ detrusor pressure at maximal flow rate.
Low flow, high pressure indicates that he is definitely obstructed and also has good detrusor
function.

What is the minimum evaluation that is needed to diagnose bladder outlet obstruction from
BPH?
For the average patient, only the history, physical examination, non-invasivc flow rate, postvoid residual,
and urinalysis are needed to diagnose bladder outlet obstruction due to BPH. Cystoscopy is not necessary to
make the diagnosis of BPH.
If you arc considering a surgical procedure, urodynamics will clinch the diagnosis and predict a successful
outcome. Consider urodynamics, particularly in patients with unusual presentations (young), confounding
other conditions (neurological systemic, such as diabetes or neurological problems), or at increased risk for
surgery (medical comorbidities, advanced age).
What is your recommendation?
Continued conservative management for another 4-8 weeks. If tolerated, may increase dose to 8 mg/day.
Given the patients prostate size, he may also benefit from finasteride treatment; however treatment benefits
will be delayed.

10
4

The patient agrees to ongoing conservative management with doxazosin. Three weeks later he reftims,
unable to void. You place a Foley catheter and drain 600 cc of clear urine.

Urology Oral Hoards Self-Assessment

2. Benign Tumors

How do you proceed?

You recommend a TURP, to which he agrees. You obtain informed consent, get appropriate prcopcrative
labs, and give preoperative intravenous antibiotics and DVT prophylaxis. He undergoes uneventful TURP.
Discuss the pathophysiology of BPH:
Testosterone is essential for development of BPH. Testosterone is produced by the Leydig cells of testis
(90%). The remaining testosterone (10%) is produced by zona reticularis of adrenal gland. Testosterone
freely diffuses into the cytoplasm of prostate cells because it is lipid soluble. Once in the cytoplasm,
testosterone is converted into DHT by the enzyme 5 tt-reductasc. Dihydrotestostcrone (DHT) is the
principal androgen (90%) found in the prostate. DIIT binds to androgen receptor binding protein within the
cytoplasm. DHT- rcccptor complex enters the nucleus to bind to specific DNA sites. Activation of DNA
results in protein production and cellular proliferation, resulting in BPII. On die other hand, androgen
withdrawal results in decreased protein production and senescence.
W hat else do you do?
Remember to ask for the patients pathology report (consistent with BPH).

10
5

CASE 3
2. Benign Tumors

Urology Oral Board Self-Assessment

One day old infant with an abdominal mass.

HPI:

State thatyou

would

obtain a detailed medical

history, beginning

with history of

present illness.

PMH:

none

PSH:

none

Allergies:

none

FH:

Medications:

none

(-) congenital urological problems (e.g., UPJ, VUR, etc.)

(-) siblings
(-) maternal ingestion of drugs SII:
non-contributory

ROS:
PE:

negative
State

that you would examine the patient thoroughly from head to toe, beginning

with the vital signs.

Vitals

T 98.6

BP 80/60

GA

Healthy appearing newborn male infant

HEENT

normocephalic with soft fontanelles

Heart

RRR without murmur

Lungs

CTA

Abdomen

soft; NT/ND; firm RUQ mass; (-) transillumination of the right side

Back

(-) dimples; (-) hairy patch

GU

normal uncircumcised phallus; (B) testicles descended and palpable

Anus

normal anatomic position; normal gluteal clefts;

Extremities

WNL

10
6

P130

RR24

palpable coccyx

Skin

no rashes or lesions

What
initial
testsSelf-Assessment
do you order?
Urology
Orallab
Hoards

2. Benign Tumors

Obtain UA, UCx, Chem 7, and CBC.

UA

WNL

UCx

->

no growth

Chem 7

->

Cr 0.9 mg/dL

CBC

->

WNL

(high)

Danger Point: Cr 0.9 mg/dL is reflection of maternal Cr. This Cr should be repeated in several days to
allow normalization and reflect muscle mass and renal function of the newborn.
Repeat Cr in few days reveals Cr of 0.4 mg/dL.

What imaging studies do you order?

State that you would obtain renal and bladder ultrasound.

Ultrasound:

cm solid homogeneous (R) renal mass; (L) kidney normal and measures

4.5 cm, normal bladder

Do you need any additional imaging studies?
State that you would obtain CXR to r/o mets (or chest CT)) and abdominal and pclvic CT scan to better
delineate the renal mass.
CXR:

WNL

CT scan (+/-) contrast: enhancing 6 cm solid homogenous (R) renal mass; (L) kidney normal; both
adrenals arc seen and appear to be normal; no adenopathy noted; no
evidence of extra-adrenal metastascs
What is your assessment?
Newborn male with solid renal mass. Differential diagnosis includes congenital mcsoblastic nephroma
(CMN) vs Wilms tumor.
What is your recommendation?

Exploratory laparotomy with probable (R) radical nephrectomy.

IIow do you proceed?

Obtain informed consent, order preopcrative labs, and give prcopcrativc IV antibiotics.
Due to concern for Wilms tumor, you make a transverse incision from the tip of the 10 :h rib.
Note:

Current

protocol mandates visualization and palpation of the contralateral kidney

10
7

so extension of the incision to the contralateral 10 th rib is required. The improved diagnostic
accuracy of newer imaging studies may make this unnecessary in the future.
2. Benign Tumors

Urology Oral Board Self-Assessment

The left kidney is normal, so you move on to the right kidney where you find a large exophytic mass on the
upper pole of (R) kidney. You cannot tell if the mass is malignant or benign.

What are your options?

1.

Perform partial nephrectomy and obtain frozen section

2.

Proceed with simple nephrectomy

3.

Proceed with radical nephrectomy

The mass was too large to do a partial nephrectomy safely. You proceeded with radical nephrectomy. You
obtain a frozen section of the specimen; if it is not a Wilms tumor, there is no need to do a node dissection.

What is your follow-up?

Cheek on the pathology report

Pathology:
Note:

congenital mesoblastic nephroma

If the diagnosis of CMN was made prcoperatively (which you cannot), you could
have performed simple nephrectomy. CMN is the most common benign renal tumor of
childhood.

Danger Point: Ask for the pathology report whenever you remove a specimen.

What is the most common neonatal renal tumor?

Congenital mesoblastic nephroma

1.

Usually occurs in the first year of life

2.

Simple nephrectomy suffices but diagnosis is usually made after radical nephrectomy

3.

There have been 2 3 cases of metastasis

4.

Recommend careful follow-up by US and CT

5.

In contrast, Wilms tumors can occur in newborns but are most common in the 3 ,d year of life

What is the most common abdominal mass in newborns?

Hydronephrosis What are other causes of palpable

kidneys in newborns?

10
8

1.

Multicystic dysplastic kidney (unilateral only; bilateral is incompatible with life)

Urology Oral Hoards Self-Assessment

2.

2. Benign Tumors

Polycystic kidney disease (bilateral; autosomal recessive)

What is another benign renal tumor of childhood?

Multi locular cystic nephromaCASE

45 y.o. white female with recurrent microscopic hematuria.

HPI:

State that you would

obtain a detailed

medical

history,

beginning with

history of

present illness.

PMH:

NIDDM
pyelonephritis kidney stones

PSH:

TVH (uterine fibroids)

Allergies:
e

Medications:

non

FH:

(-) tuberous sclerosis

SH:

(+) tob; (-) ETOH; teacher

ROS:

non-contributory

PE:

State that you would

Glucotrol 1 tab QD
Premarin 1 tab QD

examine the patient

thoroughly from head to toe,

with the vital signs.

Vitals

T 98.6

GA

WDWN WF1NAD

HEENT

benign

Heart

RRR

Lungs

CTA

BP 130/60

10
9

P90

RR16

beginning

Abdomen

soft; distended; (-) masses

2. Benign Flank
Tumors

(-) CVAT

Pelvic

normal female

Rectal

benign

Ext

(-) CCE

Neuro

non-focal

Urology Oral Board Self-Assessment

What initial lab tests do you order?

Obtain UA, Chem 7, CBC, PT/PTT, urine cytology, and urine C& S

What would you do next?

The patient needs a complete hematuria work-up, including an upper tract study. The study of choice is a CT
scan with and without IV contrast.
CT scan (C+/C-):

3.5 cm lower pole (R) renal mass with enhancement

(+80 Hounsfield units); 5 cm calcification within (R) kidney; renal vein, IVC,
liver, and lymph nodes are all within normal limits.

Danger Point: Ask for Hounsfield units in a renal mass. Positive Hounsfield units indicate soft tissue
mass.
What is your assessment?
45 y.o. WF with (R) renal mass and contralateral renal calculus. Differential diagnosis includes renal cell
carcinoma vs xanthogranulomatous pyelonephritis (XGP).
What is your next step?
Perform metastatic work-up of possible renal tumor. Need to obtain CXR and liver function tests (LFTs)
with alkaline phosphatase (alk phos). If LFTs or alk phos is elevated, need to obtain bone scan.
Chest X-ray:

clear without active disease

LFTs:

normal

Alk phos:

normal

Do you need to perform any other procedures?

Need to complete the hematuria work-up with cystoscopy.

Cystoscopy:

benign urothelium; both ureteral orifices arc cffluxing clear urine

11
0

How would you advise this patient?

Urology Oral Hoards Self-Assessment

2. Benign Tumors

Discuss with her potential treatment options and make your recommendation.
1.

Watchful waiting
a.

This is not the best option. An enhancing renal mass (even when associated with calcification) is
renal cell carcinoma until proven otherwise

b.

If you choose this protocol, you should obtain follow-up CT scan in 3 months. If the renal mass
has grown in 3 months, you need to discuss other percutaneous options

2.

FNA of renal mass

a.

If this patient is in relatively good health, this may be an option if non-surgical method (i.e.,
cryosurgery, radiotherapy) is being considered

11
1

2. Benign Tumors
Urology Oral Boards Self-Assessment
2. Benign Tumors

3.

Urology Oral Board Self-Assessment

Right radical nephrectomy

a.

b.
4.

This patient has contralateral renal pathology as well as mild azotemia and diabetes. The mass is a
relatively small renal mass and could be benign. Therefore, radical nephrectomy is not a good
choice
Ideally, nephron-sparing surgery should be performed
Right partial nephrectomy with open left nephrolithotomy

a.

b.
5.

This is also a poor protocol since you arc risking both renal units simultaneously. She may end up
getting dialyzed postopcratively
This protocol is too aggressive
Right renal exploration with partial nephrectomy

a.

This is the procedure of choice for this patient. Indications for partial nephrectomy include small
solid renal masses (< 4 cm in diameter) as well as the following scenarios:
i.

Contraleral renal calculi

ii.

Diabetes mellitus

iii.

Solitary kidney

iv.

Chronic renal insufficiency

v.

Von Hippie Lindau Syndrome

vi.

Recurrent papillary renal cell carcinoma

Patient agrees to renal exploration with partial nephrectomy.

What is your next step?
State that you would obtain an informed consent and appropriate prcopcrative lab work and give her
preoperative antibiotics and DVT prophylaxis. T&C for 2 units PRBCs.
Discuss your surgical technique:
The Operation (Partial nephrectomy)
1.

Extrapcritoneal flank or anterior subcostal incision

2.

Kochcr maneuver

3.

Early control of the renal pedicle (i.e., artery and vein)

4.

Ice slush around the kidney

a.

If the renal artery is going to be clamped for more than 30 minutes

b.
Cover the kidney with ice slush for 10-15 min immediately after occluding the renal artery but
before operating on the kidney
5.

Mannitol (12.5 g) before and during renal manipulation

11
2

6.

Perform partial nephrectomy with adequate margins

Urology 7.
Oral HoardsIntraoperative
Self-Assessmentfrozen section for margins to r/o carcinoma

8.

Close renal capsule with fat or Gel foam bolsters

9.

Place a drain

2. Benign Tumors

Danger Point: You must ask for the pathology report. The specimen is xanthogranulomatous
pyelonephritis (XGP).
What is XGP?
A clironic suppurative infection of the renal parenchyma often associated with renal calculi, obstruction and chronic
urinary tract infections. It is 4 times more common in women than in men. The majority of kidneys arc nonfunctional
at the time of diagnosis. The most commonly associated pathogens are Proteus mirabilis and E-coli.What arc the CT
characteristics of XGP?
1.

Although XGP has been referred to as one of the "great imitators, currently available crosssectional imaging techniques are able to suspect a diagnosis in the majority of cases. Diagnostic
features include:
a.

Enhancing (unilateral) mass

b.

Thickened Gerotas fascia (chronic infection)

c.

Associated kidney stones

d.

Poor renal function

c.
2.

Bear paw sign (patchy areas of debris and stones)

There is no effective medical treatment, and surgical removal is the standard of care.

How do you procccd with your patient?

She docs well from her operation, has uncomplicated postoperative course, and you discharge her to
home.
Two months later she presents to the emergency room with vomiting and Hank pain.
How do you procecd?

PE:
HPI: State that you would obtain detailed history and perform a careful physical exam.
History of complaint?

She has had intermittent (L) flank pain for the past
week

11
3

2. Benign Tumors

Urology Oral Board Self-Assessment

What initial lab tests do you order?

Obtain UA, UCx, Chem 7, and CBC.

UA WNL
UCx

->

Chem 7

>

CBC

protcus mirabulus greater than

100,000 cfu/mL

Cr 1.7 mg/dL
WBC 1 lK/nL; Hgb 12 g/dL

What would you do next?

State that you would obtain non-cnhanccd CT scan and KUB.
CT scan:

1.5 cm

calculus (L) urctcropclvic junction; marked hydronephrosis;

(R) kidney nonnal s/p partial nephrectomy KUB:1.5 cm radio-opaque

calcification (L) ureteropelvie junction
What is your assessment?

45 y.o. WF with obstructing renal calculus.

What is your initial treatment?

State that you would admit her to the hospital for pain control and will place internal stent with antibiotic
coverage. This patient is in severe pain with a large stone stuck in the proximal ureter. This stone will not
pass spontaneously, so watchful waiting is not an option. If you cannot place the stent, have the
interventional radiologist place a percutaneous nephrostomy tube.
You place the stent successfully and her pain is gone.
What are your treatment options at this point?
Discuss your management options and make your recommendation.
1.

Open left nephrolithotomy

a.

This is not the best initial therapy. Open left nephrolithotomy is virtually an outdated procedure
that is now rarely done except in highly selective patients

b.

If you choose this protocol, you need to discuss the surgical technique and will be led down the
11
4

path of discussing the complications of open stone surgery

Urology Oral
Self-Assessment
2. HoardsPercutaneous
nephrolithotripsy (PCNL)

2. Benign Tumors

a.

Although this option is better than open nephrolithotomy, the stone burden is small for PCNL
therapy. Again, this may not be the best initial treatment of choice

b.

If you choose this protocol, be ready to defend your indications for performing PCNL on this
patient with a small stone burden

3.

Extracorporeal shockwavc lithotripsy (ESWL)

a.

Stone burden less than 2 cm is ideal for ESWL

b.

Patient needs to be counseled regarding possible incomplete resolution of stone and need for
repeat or ancillary procedures

4.

Uretheroscopy, laser lithotrophy stone basket manipulation

a.

In the hands of a skilled endoscopist, this procedure may result in high stone free rates as
compared to ESWL with a less invasive procedure than PCNL

Note: The choice of treatment may be influenced by appearance of stone on RUB and Hounsfeld units on
CT.

She undergoes successful shock wave lithotripsy without complications.

W hat is your follow-up?

1.

Have patient strain urine

2.

Stress importance of adequate hydration

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2. Benign Tumors
Urology Oral Board Self-Assessment
2. Benign Tumors

3.

KUB to confirm absence of stone fragments

4.

Remove the stent as outpatient when stone fragments have passed

5.

Send stone fragments off for chemical analysis

6.

Metabolic evaluation for recurrent stone formation

Urology Oral Board Self-Assessment

Danger Point: Be sure to ask for chemical composition of the stone.

Chemical analysis is calcium oxalate dihydrate stone.

What is the proper metabolic evaluation of recurrent stone former?

Metabolic evaluation for recurrent stone formation:

1.

Serum calcium, phosphorus, uric acid, and BMP

2.

Urine calcium, phosphorus, uric acid, oxalate, citrate, magnesium, creatinine, cystine, sodium, pH,
and volume

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