Gynecologic Surgery

Gynecologic Surgery US Medical PG Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?

• A. Bladder trigone
• B. Uterine artery
• C. Kidney
• D. Ureter (Correct Answer)

Gynecologic Surgery Explanation: ***Ureter*** - The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim. - During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury. *Bladder trigone* - The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice. - It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament. *Uterine artery* - The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament. - While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself. *Kidney* - The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis. - They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.

Gynecologic Surgery US Medical PG Question 2: A 60-year-old post-menopausal female presents to her gynecologist with vaginal bleeding. Her last period was over 10 years ago. Dilation and curettage reveals endometrial carcinoma so she is scheduled to undergo a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During surgery, the gynecologist visualizes paired fibrous structures arising from the cervix and attaching to the lateral pelvic walls at the level of the ischial spines. Which of the following vessels is found within each of the paired visualized structure?

• A. Vaginal artery
• B. Superior vesical artery
• C. Uterine artery (Correct Answer)
• D. Artery of Sampson
• E. Ovarian artery

Gynecologic Surgery Explanation: ***Uterine artery*** - The paired fibrous structures described are the **cardinal ligaments (transverse cervical ligaments)**, which contain the **uterine arteries** as they course towards the uterus. - The uterine artery, a branch of the **internal iliac artery**, crosses over the **ureter** within the cardinal ligament—a critical anatomical relationship during gynecological surgery ("water under the bridge"). - This is the primary vessel within the cardinal ligament and the key vascular structure at risk during hysterectomy. *Vaginal artery* - The vaginal artery typically branches from the **uterine artery** or directly from the **internal iliac artery**, but it is not the main vessel found within the cardinal ligament. - It primarily supplies the **vagina**, not contained within the cardinal ligament support structure. *Superior vesical artery* - The superior vesical artery supplies the **upper part of the bladder** and originates from the **umbilical artery** (a branch of the internal iliac artery). - It is not anatomically associated with the cardinal ligament or uterine support structures. *Artery of Sampson* - The Artery of Sampson is a branch of the **uterine artery** that anastomoses with the **ovarian artery** within the **broad ligament**, not the cardinal ligament. - It is a minor vessel involved in the dual blood supply to the ovaries and uterus, not a primary structure within the cardinal ligament. *Ovarian artery* - The ovarian artery originates directly from the **abdominal aorta** and travels within the **suspensory ligament of the ovary (infundibulopelvic ligament)**, not the cardinal ligament. - It supplies the **ovaries and fallopian tubes**, with a trajectory that is anatomically distinct from structures within the cardinal ligament.

Gynecologic Surgery US Medical PG Question 3: A 42-year-old woman, gravida 3, para 3 comes to the physician because of a 14-month history of prolonged and heavy menstrual bleeding. Menses occur at regular 28-day intervals and last 7 days with heavy flow. She also feels fatigued. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic examination shows a firm, irregularly-shaped uterus consistent in size with a 16-week gestation. Her hemoglobin concentration is 9 g/dL, hematocrit is 30%, and mean corpuscular volume is 92 μm3. Pelvic ultrasound shows multiple intramural masses in an irregularly enlarged uterus. The ovaries appear normal bilaterally. The patient has completed childbearing and would like definitive treatment for her symptoms. Operative treatment is scheduled. Which of the following is the most appropriate next step in management?

• A. Leuprolide (Correct Answer)
• B. Progestin-only contraceptive pills
• C. Tranexamic acid
• D. Levonorgestrel-releasing intrauterine device
• E. Estrogen-progestin contraceptive pills

Gynecologic Surgery Explanation: ***Leuprolide*** - **Leuprolide** is a **GnRH agonist** that creates a hypoestrogenic state, effectively reducing the size of **fibroids** and decreasing blood flow. - Using leuprolide pre-operatively in this patient with **anemia** can improve her **hemoglobin levels**, reduce intraoperative blood loss, and potentially make surgery easier. *Progestin-only contraceptive pills* - While progestins can help with abnormal uterine bleeding, they are generally **less effective** in significantly reducing the size of large **fibroids** like those described. - They may not effectively address the **anemia** or the need for definitive surgical management. *Tranexamic acid* - **Tranexamic acid** is an **antifibrinolytic** that can reduce menstrual blood flow but does not affect the size of **fibroids** or address the underlying cause of heavy bleeding. - It would provide symptomatic relief during menstruation but would not prepare the patient for definitive operative treatment or correct chronic **anemia**. *Levonorgestrel-releasing intrauterine device* - A **levonorgestrel-releasing IUD** is effective at reducing menstrual bleeding by causing endometrial atrophy. - However, it may be difficult to insert or less effective in a significantly enlarged and irregularly-shaped uterus due to multiple large **fibroids**, and it does not reduce fibroid size. *Estrogen-progestin contraceptive pills* - **Estrogen-progestin pills** can regulate menstrual cycles and reduce bleeding but are not typically used to shrink large **fibroids**. - They may not be sufficient for severe bleeding or to prepare for surgery in a patient with significant **anemia** and large fibroids.

Gynecologic Surgery US Medical PG Question 4: A 14-year-old girl presents to the emergency room complaining of abdominal pain. She was watching a movie 3 hours prior to presentation when she developed severe non-radiating right lower quadrant pain. The pain has worsened since it started. She also had non-bloody non-bilious emesis 1 hour ago and continues to feel nauseated. Her temperature is 101°F (38.3°C), blood pressure is 130/90 mmHg, pulse is 110/min, and respirations are 22/min. On exam, she has rebound tenderness at McBurney point and a positive Rovsing sign. She is stabilized with intravenous fluids and pain medication and is taken to the operating room to undergo a laparoscopic appendectomy. While in the operating room, the circulating nurse leads the surgical team in a time out to ensure that introductions are made, the patient’s name and date of birth are correct, antibiotics have been given, and the surgical site is marked appropriately. This process is an example of which of the following human factor engineering elements?

• A. Forcing function
• B. Safety culture
• C. Simplification
• D. Standardization (Correct Answer)
• E. Resilience engineering

Gynecologic Surgery Explanation: ***Standardization*** - The surgical **time-out** is a prime example of **standardization** in healthcare, as it involves a prescribed, uniform procedure followed in every surgery to enhance safety. - It ensures critical safety checks—like patient identification, site marking, and antibiotic administration—are consistently performed, thus reducing variability and the potential for errors. *Forcing function* - A **forcing function** is a design element that makes it impossible to commit an error, such as a specific connector shape that prevents incorrect device attachment. - The time-out, while a critical safeguard, still relies on human compliance and does not physically prevent an error from occurring if the steps are not followed. *Safety culture* - **Safety culture** refers to the shared beliefs, values, and attitudes that employees have about safety within an organization. - While a time-out contributes to a strong safety culture, it is a specific process or tool, not the overarching culture itself. *Simplification* - **Simplification** aims to reduce complexity in a process to minimize cognitive load and potential for error. - The time-out adds a structured step rather than simplifying an existing process; its purpose is to ensure all necessary checks are systematically completed. *Resilience engineering* - **Resilience engineering** focuses on an organization's ability to anticipate, cope with, and recover from failures, maintaining stability in the face of disruptions. - While the time-out promotes safety, it primarily addresses error prevention rather than the broader organizational capacity to adapt and recover from system failures.

Gynecologic Surgery US Medical PG Question 5: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Gynecologic Surgery Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Gynecologic Surgery US Medical PG Question 6: A previously healthy 25-year-old woman is brought to the emergency department because of a 1-hour history of sudden severe lower abdominal pain. The pain started shortly after having sexual intercourse. The pain is worse with movement and urination. The patient had several urinary tract infections as a child. She is sexually active with her boyfriend and uses condoms inconsistently. She cannot remember when her last menstrual period was. She appears uncomfortable and pale. Her temperature is 37.5°C (99.5°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. Abdominal examination shows a palpable, tender right adnexal mass. Her hemoglobin concentration is 10 g/dL and her hematocrit is 30%. A urine pregnancy test is negative. Pelvic ultrasound shows a 5 x 3-cm right ovarian sac-like structure with surrounding echogenic fluid around the structure and the uterus. Which of the following is the most appropriate management for this patient's condition?

• A. Intravenous methotrexate administration
• B. Uterine artery embolization
• C. Emergency exploratory laparotomy (Correct Answer)
• D. Oral doxycycline and metronidazole administration
• E. CT scan of the abdomen

Gynecologic Surgery Explanation: ***Emergency exploratory laparotomy*** - The patient presents with **sudden severe lower abdominal pain**, **hypotension (90/60 mm Hg)**, **tachycardia (110/min)**, **palpable tender right adnexal mass**, and signs of **anemia (Hb 10 g/dL, Hct 30%)**, along with **free fluid** on ultrasound, indicating **hemorrhagic shock due to a ruptured ectopic pregnancy or ovarian cyst**. This is a surgical emergency. - An **exploratory laparotomy** is immediately indicated to identify the source of bleeding, control hemorrhage, and remove the ruptured structure, especially given her unstable vital signs. *Intravenous methotrexate administration* - **Methotrexate** is used for **unruptured ectopic pregnancies** with specific criteria (e.g., small size, stable patient, declining hCG levels), but it is contraindicated in cases of rupture due to the risk of hemorrhage. - The patient's **hypotension** and **anemia** indicate active bleeding and hemodynamic instability, making medical management inappropriate and delaying critical surgical intervention. *Uterine artery embolization* - **Uterine artery embolization** is primarily used for conditions like **uterine fibroids** or **postpartum hemorrhage**. - It is not the appropriate first-line emergency treatment for acute rupture of an ectopic pregnancy or ovarian cyst with hypovolemic shock. *Oral doxycycline and metronidazole administration* - **Doxycycline** and **metronidazole** are antibiotics used to treat **pelvic inflammatory disease (PID)**, which presents with symptoms like fever, vaginal discharge, and lower abdominal pain, but typically not acute hemorrhagic shock. - This patient's presentation is an acute surgical emergency with signs of hemorrhage, not an infection requiring only antibiotic therapy. *CT scan of the abdomen* - While a **CT scan** could provide more detailed imaging, the patient's **hemodynamic instability** (hypotension, tachycardia) requires immediate intervention. - Delaying definitive treatment for further imaging in acute hemorrhagic shock is not appropriate and could worsen her condition.

Gynecologic Surgery US Medical PG Question 7: A 28-year-old woman comes to the physician with a history of bright red blood in her stools for 3 days. She has defecated once per day. She does not have fever, pain on defecation, or abdominal pain. She was treated for a urinary tract infection with levofloxacin around 3 months ago. Menses occur at regular intervals of 28–30 days and lasts 3–4 days. Her father died of colon cancer 4 years ago. Her only medication is an iron supplement. She is 162 cm (5 ft 4 in) tall and weighs 101.2 kg (223 lbs); BMI is 38.3 kg/m2. Her temperature is 36.5°C (97.7°F), pulse is 89/min, and blood pressure is 130/80 mm Hg. Rectal examination shows anal skin tags. Anoscopy shows multiple enlarged bluish veins above the dentate line at 7 and 11 o'clock positions. When asked to exhale through a closed nostril a mass prolapses but spontaneously reduces when breathing normally. Which of the following is the most appropriate next step in management?

• A. Infrared coagulation
• B. Propranolol therapy
• C. Topical diltiazem
• D. Hemorrhoidectomy
• E. Docusate therapy (Correct Answer)

Gynecologic Surgery Explanation: ***Docusate therapy*** - The patient presents with symptoms and signs consistent with **grade II internal hemorrhoids** (prolapses with straining but spontaneously reduces) and a history of constipation (implied by iron supplementation and obesity). - **Conservative management with stool softeners** like docusate is the first-line treatment for grade II internal hemorrhoids, promoting easier bowel movements and reducing straining, which exacerbates hemorrhoids. - Other conservative measures include increased dietary fiber and adequate hydration. *Infrared coagulation* - This is a **procedural treatment** sometimes used for grade I and II internal hemorrhoids that are **refractory to conservative management**. - It is not the most appropriate initial step. Given the patient's presentation, **conservative management should be attempted first** before considering procedural interventions. *Propranolol therapy* - **Propranolol** is a beta-blocker used to manage **portal hypertension** and prevent variceal bleeding in patients with cirrhosis. - There is **no indication of portal hypertension** or liver disease in this patient (normal vital signs, no stigmata of chronic liver disease). - This medication is not used in the management of hemorrhoids. *Topical diltiazem* - **Topical diltiazem** is a calcium channel blocker used to treat **anal fissures** by relaxing the internal anal sphincter and improving blood flow to promote healing. - The patient's symptoms (bright red blood, **no pain on defecation**) are not consistent with an anal fissure, which typically presents with severe pain during and after bowel movements. *Hemorrhoidectomy* - **Hemorrhoidectomy** is a surgical procedure typically reserved for **severe (grade III or IV)** internal hemorrhoids or those unresponsive to less invasive treatments. - The patient's hemorrhoids are grade II, which are likely to respond to conservative management, making surgery an overly aggressive initial approach.

Gynecologic Surgery US Medical PG Question 8: A 25-year-old man presents with pain and a limited range of motion in his right shoulder. He is a collegiate baseball player and says he has not been playing for approx. 1 week because his shoulder hurts when he throws. He also noticed trouble raising his arm over his head. He describes the pain as moderate, dull, and aching in character and worse when he moves his arm above his shoulder or when he lays in bed on his side. He denies any recent acute trauma to the shoulder or other joint pain. The medical history is significant for asthma, which is managed medically. The current medications include albuterol inhaled and fluticasone. He reports a 5-year history of chewing tobacco but denies smoking, alcohol, or drug use. The temperature is 37.0°C (98.6°F); blood pressure is 110/85 mm Hg; pulse is 97/min; respiratory rate is 15/min, and oxygen saturation is 99% on room air. The physical examination is significant for tenderness to palpation on the anterolateral aspect of the right shoulder. The active range of motion on abduction of the right shoulder is decreased. The passive range of motion is intact. No swelling, warmth, or erythema is noted. The sensation is intact. The deep tendon reflexes are 2+ bilaterally. The peripheral pulses are 2+. The laboratory results are all within normal limits. A plain radiograph of the right shoulder shows no evidence of fracture or bone deformities. An MRI of the right shoulder shows increased T1 and T2 signals in the rotator cuff tendon. Which of the following is the best initial course of treatment for this patient?

• A. No further treatment is needed
• B. Acromioplasty
• C. Intra-articular corticosteroid injection
• D. NSAIDs and conservative measures (Correct Answer)
• E. Conservative measures (rest and ice)

Gynecologic Surgery Explanation: ***NSAIDs and conservative measures*** - The patient presents with symptoms and MRI findings consistent with **rotator cuff tendinitis**, common in overhead athletes. Initial treatment should focus on **reducing inflammation** and pain, and promoting healing. - **NSAIDs** combined with conservative measures like **rest from inciting activities** and **ice application** are the mainstay of initial treatment for tendinitis, aiming to alleviate pain and improve function. *No further treatment is needed* - This option is incorrect because the patient is experiencing significant pain, limitation in his sport, and MRI findings of **tendinitis**, which warrants intervention. - Doing nothing would likely lead to worsening symptoms and potentially chronic issues, especially given his athletic demands. *Acromioplasty* - **Acromioplasty** is a surgical procedure typically reserved for cases of **subacromial impingement syndrome** that have failed extensive conservative management, or for larger, more symptomatic tears. - The patient's presentation suggests **tendinitis** without clear evidence of chronic impingement or a full-thickness tear requiring immediate surgical intervention. *Intra-articular corticosteroid injection* - **Corticosteroid injections** can provide temporary pain relief but are generally reserved for cases that have failed conservative therapy with oral NSAIDs and physical therapy. - They also carry risks like **tendon weakening** and potential for rupture, which is particularly concerning in an athlete with tendinitis. *Conservative measures (rest and ice)* - While **rest and ice** are crucial components of conservative management, this option is incomplete as it omits the important role of **NSAIDs** in managing the inflammatory component of tendinitis. - Simply resting and icing might not be sufficient for adequate pain control and inflammation reduction in an active individual with this degree of symptoms.

Gynecologic Surgery US Medical PG Question 9: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

• A. Diagnostic peritoneal lavage
• B. Emergency laparotomy (Correct Answer)
• C. Upper gastrointestinal endoscopy
• D. Close observation
• E. Diagnostic laparoscopy

Gynecologic Surgery Explanation: ***Emergency laparotomy*** - The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch). - This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans. - While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST. *Upper gastrointestinal endoscopy* - This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities. - It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma. *Close observation* - Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings. - This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step. *Diagnostic laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity. - While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.

Gynecologic Surgery US Medical PG Question 10: A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

• A. Intravenous pyelography
• B. External fixation of the pelvis
• C. Cystoscopy
• D. Retrograde urethrography
• E. Retrograde cystography (Correct Answer)

Gynecologic Surgery Explanation: ***Retrograde cystography*** - The presence of **gross hematuria** in a patient with a **pelvic fracture** necessitates ruling out **bladder injury**. A retrograde cystography directly visualizes the bladder and can detect extravasation of contrast if a bladder rupture is present. - This imaging study specifically investigates the bladder using retrograde contrast filling, which is crucial for diagnosing **intraperitoneal** or **extraperitoneal bladder rupture**. *Intravenous pyelography* - This study evaluates the **kidneys** and **ureters** for injury, but the primary concern with gross hematuria and pelvic fracture is the bladder. - An IV pyelogram provides less detailed imaging of the bladder compared to a retrograde cystogram and is less effective for detecting bladder rupture. *External fixation of the pelvis* - While the patient has a pelvic fracture, the immediate priority in a hemodynamically stable patient with gross hematuria is to identify and manage potential **life-threatening urologic injuries** before definitive orthopedic repair. - **Pelvic external fixation** is primarily indicated for **unstable pelvic fractures** or those causing significant hemorrhage, neither of which is explicitly described as an immediate concern requiring intervention before urologic evaluation. *Cystoscopy* - **Cystoscopy** is an endoscopic procedure that allows direct visualization of the bladder's interior. While it can identify bladder injuries, it is generally considered after imaging studies like **retrograde cystography** to confirm findings or address specific issues like clot evacuation or stent placement. - The initial diagnostic step should focus on assessing for rupture via contrast study, which is often less invasive than a direct endoscopic procedure in the acute trauma setting. *Retrograde urethrography* - **Retrograde urethrography (RUG)** is used to evaluate for **urethral injury**, especially when there is blood at the urethral meatus, a high-riding prostate, or an inability to pass a Foley catheter. - The patient's Foley catheter was successfully placed, and there was **no blood at the urethral meatus**, making urethral injury less likely and thus RUG a lower priority as the initial step compared to assessing for bladder injury.

Gynecologic Surgery Flashcard 1 of 7

Question: What surgical procedure involves the en bloc removal of the head/neck of the pancreas, proximal duodenum, and gallbladder?_____

Answer: Whipple procedure

Gynecologic Surgery Flashcard 2 of 7

Question: Anterior urethral injuries are typically caused by a _____ injury

Answer: perineal straddle

Gynecologic Surgery Flashcard 3 of 7

Question: If a patient has a varicocele, consider surgical ligation or _____ if associated with pain or infertility

Answer: catheter embolization

Gynecologic Surgery Flashcard 4 of 7

Question: Testicular tumors present as a firm, painless testicular mass that _____ be transilluminated

Answer: cannot

Gynecologic Surgery Flashcard 5 of 7

Question: Testicular torsion may lead to infertility and thus is treated with urgent _____

Answer: surgery

Gynecologic Surgery Flashcard 6 of 7

Question: If a women undergoes prophylactic mastectomy, can she still develop breast cancer?_____

Answer: Yes, there is a small chance due to small amounts of remaining breast tissue

Gynecologic Surgery Flashcard 7 of 7

Question: A gastrojejunostomy removes the gastric antrum and attaches the gastric body to the _____

Answer: proximal jejunum