Genitourinary Interventions — MCQs
Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?
What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?
Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:
A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?
What is the modality of the test shown in the image?
All of the following are true regarding renal trauma, except which of the following?
Irregular scarred kidney with pelvic dilatation is seen with?
Which article of the Indian Constitution allows the state to intervene in cases of hunger strikes to protect the right to life?
What is the primary purpose of interventional studies in clinical research?
Emergency management for Tension pneumothorax is:
Genitourinary Interventions Indian Medical PG Practice Questions and MCQs
Question 1: Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?
- A. Retrograde pyeloplasty
- B. ESWL
- C. PCNL (Correct Answer)
- D. Antegrade pyeloplasty
Explanation: ***PCNL*** - **Percutaneous nephrolithotomy (PCNL)** is the gold standard treatment for large renal stones (>2 cm) due to its high stone-free rates in a single procedure. - For a 3 cm renal pelvis stone, PCNL provides the best clearance rate (~95%) with minimal need for repeat procedures. - It involves direct percutaneous access to the kidney, allowing fragmentation and removal of large stone burden efficiently. *ESWL* - **Extracorporeal shock wave lithotripsy (ESWL)** has limited efficacy for stones >2 cm, with stone-free rates dropping to 50-60% for 3 cm stones. - Multiple sessions are typically required, with increased risk of steinstrasse (stone street) formation and residual fragments. - While non-invasive, ESWL is not the optimal choice for this stone size. *Retrograde pyeloplasty* - This option appears to reference **retrograde endoscopic approaches** (such as retrograde intrarenal surgery - RIRS or ureteroscopy). - While retrograde ureteroscopy can treat renal stones, it is generally reserved for stones <2 cm due to longer operative time and lower stone-free rates for larger stones. - True "pyeloplasty" is a reconstructive procedure for ureteropelvic junction obstruction, not a stone removal technique. *Antegrade pyeloplasty* - This option likely refers to **antegrade endoscopic access** to the renal pelvis. - While antegrade access is used in PCNL, "pyeloplasty" specifically means surgical reconstruction of the UPJ for obstruction, not stone treatment. - Antegrade ureteroscopy alone (without nephroscopy) would be less effective than PCNL for a 3 cm stone.
Question 2: What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?
- A. Antibiotic prophylaxis alone
- B. Immediate ureterolithotomy
- C. Endoscopic ureteral stenting (Correct Answer)
- D. Urinary alkalization
Explanation: ***Endoscopic ureteral stenting*** - **Endoscopic ureteral stenting** is the primary intervention for **acute symptomatic ureteral obstruction** requiring urgent decompression when the obstruction causes **hydroureter**. - This minimally invasive procedure provides immediate drainage from the kidney to the bladder, preventing further renal damage, managing pain, and relieving obstruction. - **Indications for urgent stenting** include: infected hydronephrosis, impaired renal function, intractable pain, solitary kidney with obstruction, or bilateral obstruction. - Alternative to stenting is **percutaneous nephrostomy**, particularly when retrograde stent placement fails or in infected systems. *Antibiotic prophylaxis alone* - While antibiotics are essential when infection complicates obstruction (pyonephrosis), **antibiotics alone cannot relieve the mechanical obstruction**. - The physical blockage must be addressed to prevent progressive renal damage and sepsis. *Immediate ureterolithotomy* - **Open ureterolithotomy** is a definitive surgical treatment but is **not first-line** for acute obstruction. - It is more invasive and typically reserved for failed endoscopic management, large impacted stones, or anatomical abnormalities preventing endoscopic access. - Modern approach favors initial decompression followed by definitive treatment (ureteroscopy, ESWL, or surgery). *Urinary alkalization* - **Urinary alkalization** may help dissolve **uric acid stones** over time but does not provide immediate relief of acute obstruction. - This is an adjunctive measure for specific stone types, not an emergency intervention for symptomatic hydroureter.
Question 3: Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:
- A. Percutaneous nephrostomy
- B. Wait and watch
- C. Surgical exploration and repair
- D. Double-J stent (Correct Answer)
Explanation: ***Double-J stent*** - A persistent urinoma for 12 days, even in a stable, afebrile patient, suggests ongoing urine leakage from the renal laceration. A **double-J stent** can bridge the laceration, **diverting urine flow** from the injury site into the bladder, which promotes healing and resolves the urinoma. - This minimally invasive procedure allows the kidney to drain properly, preventing further accumulation of urine and reducing the risk of complications such as infection or fibrosis without the need for open surgery. *Percutaneous nephrostomy* - While a percutaneous nephrostomy can drain urine, it usually involves external drainage and does not directly address the *internal* diversion of urine flow to promote healing of the laceration effectively. - This option is more commonly used for **obstructive uropathy** or in cases where the urinoma is infected and requires drainage which is not seen here as the patient is afebrile. *Wait and watch* - Waiting and watching for 12 days has already shown that the urinoma persists, indicating that the laceration is not healing spontaneously. - Continued persistence of a urinoma increases the risk of complications such as infection, obstruction, or fibrosis, so intervention is warranted. *Surgical exploration and repair* - **Surgical exploration and repair** is a more aggressive open surgical intervention, generally reserved for cases with ongoing hemorrhage, escalating infection, or significant tissue damage that cannot be managed by less invasive means. - Given the patient's stability and absence of fever, a less invasive approach like stenting is preferred before considering more extensive surgical repairs.
Question 4: A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?
- A. Urine culture and sensitivity
- B. Repeat USG
- C. Hysterosalpingography (Correct Answer)
- D. Endometrial biopsy
Explanation: ***Hysterosalpingography*** - Given the history of **pelvic inflammatory disease (PID)**, there is a significant risk of **tubal blockage** or damage, which is a common cause of **infertility**. - **Hysterosalpingography (HSG)** is the gold standard investigation to assess the patency and morphology of the **fallopian tubes** and uterine cavity. *Urine culture and sensitivity* - This test is used to detect **urinary tract infections**. While important in general health, it is rarely the primary cause of infertility in the absence of urinary symptoms. - The patient's history of **PID** points towards gynecological causes rather than urinary ones as the likely source of infertility. *Repeat USG* - The initial **ultrasound (USG)** has already shown normal organs, indicating no obvious uterine or ovarian structural abnormalities. - Repeating the same investigation without new symptoms or findings is unlikely to provide additional diagnostic information regarding infertility, especially not **tubal patency**. *Endometrial biopsy* - An **endometrial biopsy** is typically performed to assess the health of the **uterine lining** for conditions like chronic endometritis or abnormal uterine bleeding. - While helpful in specific scenarios, it does not evaluate **fallopian tubal patency**, which is a crucial step in assessing infertility after **PID**.
Question 5: What is the modality of the test shown in the image?
- A. Hysterosalpingography (Correct Answer)
- B. Hysteroscopy
- C. Laparoscopy
- D. Saline infusion sonography
Explanation: ***Hysterosalpingography*** - The image shows a **contrast-filled uterus and fallopian tubes**, characteristic of a **hysterosalpingogram (HSG)**. - An HSG uses **X-rays** and **radiopaque contrast media** to visualize the uterine cavity and assess fallopian tube patency. *Hysteroscopy* - **Hysteroscopy** involves direct visualization of the uterine cavity using a **fiber optic endoscope** inserted through the cervix. - It does not produce an X-ray image with contrast filling the fallopian tubes. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure that involves inserting a **laparoscope** through an incision in the abdominal wall to view pelvic organs externally. - This image clearly depicts an internal view of the uterus and tubes through contrast, not an external, endoscopic view. *Saline infusion sonography* - **Saline infusion sonography (SIS)**, also known as sonohysterography, uses **ultrasound** imaging during the infusion of saline into the uterus. - While it assesses the uterine cavity, it is an ultrasound-based technique and does not involve X-ray contrast passing through the fallopian tubes, as seen in the image.
Question 6: All of the following are true regarding renal trauma, except which of the following?
- A. Observation is best
- B. Exploration indicated in all cases (Correct Answer)
- C. Haematuria is a cardinal sign
- D. CECT is the investigation of choice
Explanation: ***Exploration indicated in all cases*** - This statement is incorrect because not all renal traumas require **surgical exploration**. Many low-grade renal injuries can be managed **conservatively** with observation. - The decision for exploration depends on the **grade of injury**, hemodynamic stability, and associated injuries. **Absolute indications** for exploration include: hemodynamic instability despite resuscitation, expanding/pulsatile perirenal hematoma, and renal pedicle avulsion. - Approximately **80-90% of renal traumas** are managed non-operatively. *Observation is best* - This is true for **low-grade renal injuries (Grade I-III)**, especially in hemodynamically stable patients. - **Conservative management** with bed rest, fluid resuscitation, serial hemoglobin monitoring, and close observation is the preferred approach for most renal traumas that do not involve major vascular injury or ongoing hemorrhage. *CECT is the investigation of choice* - **Contrast-Enhanced CT (CECT)** is the **gold standard** imaging modality for evaluating renal trauma in hemodynamically stable patients. - It provides detailed information about the **grade of injury**, renal parenchymal damage, collecting system involvement, urinary extravasation, and vascular injuries. - CECT helps in **injury grading** (AAST classification) and guides management decisions regarding conservative vs. operative management. *Haematuria is a cardinal sign* - **Hematuria (blood in the urine)** is indeed a cardinal sign of renal trauma and is present in **over 90% of cases**. - The presence of gross or microscopic hematuria after blunt or penetrating abdominal trauma warrants investigation for potential renal injury. - **Important:** The degree of hematuria does NOT correlate with the severity of injury. Severe injuries like renal pedicle avulsion may present with minimal or absent hematuria.
Question 7: Irregular scarred kidney with pelvic dilatation is seen with?
- A. Chronic pyelonephritis (Correct Answer)
- B. Polycystic kidney
- C. Renal artery stenosis
- D. Tuberculosis of kidney
Explanation: ***Chronic pyelonephritis*** - Characterized by irregular scarring of the kidney and often leads to **pelvic dilatation** due to recurrent infections and obstruction [1]. - The damage from inflammation results in **cortical scarring** and can affect kidney function significantly over time [1]. *Renal artery stenosis* - Typically presents with **hypertension** and may lead to ischemic atrophy, but does not cause significant **pelvic dilatation**. - The kidney appears small and often asymmetric, but not typically irregular and scarred. *Tuberculosis of kidney* - Can cause damage to the kidney, but usually leads to **caseating granulomas** and can cause abscesses, not specifically irregular scarring with pelvic dilation. - Often presents with systemic symptoms such as fever and night sweats, along with hematuria. *Polycystic kidney* - Characterized by multiple cysts in both kidneys leading to enlarged kidneys, but does not typically present as **irregularly scarred kidneys**. - Usually associated with **hemodynamic issues** and hypertension but not pelvic dilatation in the sense of scarring or fibrosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 937-939.
Question 8: Which article of the Indian Constitution allows the state to intervene in cases of hunger strikes to protect the right to life?
- A. Article 21 (Correct Answer)
- B. Article 35
- C. Article 48
- D. Article 52
Explanation: ***Article 21*** - This article guarantees the **right to life and personal liberty**, a fundamental right that the state is obligated to protect. - The Supreme Court has interpreted this right to include the right to a dignified life, which obliges the state to intervene to prevent self-harm, such as in cases of a **prolonged hunger strike**. *Article 35* - This article deals with the **power of Parliament to make laws** to give effect to certain provisions of Part III (Fundamental Rights) of the Constitution. - It does not directly provide a right to life or allow for state intervention in hunger strikes based on this right. *Article 48* - This article is part of the **Directive Principles of State Policy** and deals with the organization of **agriculture and animal husbandry**. - It focuses on promoting modern and scientific methods for these sectors and does not relate to the right to life or hunger strikes. *Article 52* - This article states that there shall be a **President of India**. - It defines the office of the President and does not relate to fundamental rights or state intervention in cases of hunger strikes.
Question 9: What is the primary purpose of interventional studies in clinical research?
- A. Confirming Hypotheses
- B. Testing Hypotheses (Correct Answer)
- C. Manipulating Hypotheses
- D. Formulating Hypotheses
Explanation: ***Testing Hypotheses*** - Interventional studies, such as **randomized controlled trials**, are specifically designed to **test cause-and-effect relationships** by actively intervening. - They aim to determine if a specific intervention (e.g., a drug, a therapy) produces a hypothesized outcome. *Confirming Hypotheses* - While interventional studies can confirm hypotheses, their primary role is not just confirmation but the initial **rigorous testing** of a hypothesis under controlled conditions. - Confirmation often implies that previous evidence already strongly supports the hypothesis. *Manipulating Hypotheses* - Hypotheses themselves are not "manipulated"; rather, the **variables** within the study design (e.g., treatment groups, dosages) are manipulated to test the hypothesis. - This option incorrectly applies the concept of manipulation to the hypothesis. *Formulating Hypotheses* - Hypothesis formulation usually occurs during the **observational research phase** or through literature review, *before* interventional studies are designed. - Observational studies or descriptive research are more typically used for generating new hypotheses.
Question 10: Emergency management for Tension pneumothorax is:
- A. Tracheostomy
- B. Insertion of a chest tube
- C. Needle decompression (Correct Answer)
- D. Thoracotomy
Explanation: ***Needle decompression*** - This is the immediate, **life-saving intervention** for tension pneumothorax, as it rapidly relieves the pressure on the heart and lungs. - It involves inserting a large-bore needle into the **second intercostal space** in the midclavicular line or the fourth/fifth intercostal space in the anterior axillary line to convert the tension pneumothorax into a simple pneumothorax. *Tracheostomy* - This procedure creates an opening in the trachea to secure an **airway**, primarily used for upper airway obstruction or long-term ventilation. - It does not address the underlying pathology of accumulated air in the pleural space, which is causing mediastinal shift and hemodynamic compromise. *Insertion of a chest tube* - While essential for definitive management of a pneumothorax, a chest tube requires more time to set up and insert compared to needle decompression. - In an acute tension pneumothorax, the priority is immediate pressure relief, which needle decompression provides more rapidly. *Thoracotomy* - This is a major surgical procedure involving opening the chest wall, typically reserved for **life-threatening conditions within the chest** that require direct surgical intervention, such as severe trauma or uncontrollable bleeding. - It is not the appropriate initial emergency management for tension pneumothorax, as it is too invasive and time-consuming for immediate pressure relief.
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