Urology Practice Questions

Q: What is a potential complication of performing percutaneous nephrolithotomy (PCNL) through the 11th intercostal space?

Pleural effusion. ***Pleural effusion*** - Accessing the kidney through the **11th intercostal space** carries a higher risk of penetrating the **pleural cavity**, leading to **pleural injury** and subsequently a **pleural effusion** or pneumothorax. - This anatomical proximity means breaching the diaphragm which can result in leakage of fluid into the pleural space. *Hematuria* - **Hematuria** is a common and expected complication of PCNL due to direct trauma to the renal parenchyma and collecting system during the procedure. - While it can be significant (e.g., hemorrhage requiring transfusion), it is a direct consequence of kidney access and not uniquely linked to intercostal space entry. *Colon injury* - **Colon injury** is a risk of PCNL, but it is more commonly associated with an overly **medial or anterior trajectory** of the access tract, particularly in cases of bowel malrotation or mobile colon. - It is not specifically increased by using an 11th intercostal space approach, which is a posterior entry point. *Residual stones* - **Residual stones** are a potential outcome of any PCNL procedure if all stone fragments cannot be successfully removed during the initial surgery. - This complication relates to the efficacy of stone clearance and the complexity of the stone burden, not directly to the specific intercostal space chosen for access.

Q: Most common presentation of renal cell carcinoma is

Hematuria. ***Hematuria*** - **Hematuria** (blood in the urine) is the **most common presenting symptom** of renal cell carcinoma, occurring in about 60% of patients [1]. It is often **painless** [2] and can be gross or microscopic. - This symptom occurs due to the tumor eroding into the collecting system of the kidney, causing blood to mix with urine. *Abdominal mass* - While an **abdominal mass** can be a symptom of renal cell carcinoma [1], it is generally less common than hematuria as the initial presentation, occurring in about 45% of cases. - The mass is often **palpable** when the tumor has grown to a significant size [3], indicating a more advanced stage. *Flank pain* - **Flank pain** is another common symptom, but typically ranks third in frequency after hematuria and abdominal mass, presenting in about 40% of patients. - Pain usually arises when the tumor grows large enough to **compress surrounding structures** or invades the renal capsule. *Nocturia* - **Nocturia** (frequent urination at night) is **not a direct symptom** of renal cell carcinoma. - It is more commonly associated with benign conditions like **benign prostatic hyperplasia (BPH)**, urinary tract infections, or bladder overactivity.

Q: A 27-year-old man presents with a left testicular tumor and a 10 cm retroperitoneal lymph node mass. Which of the following is the treatment of choice?

Radical inguinal orchiectomy plus chemotherapy. ***Radical inguinal orchiectomy plus chemotherapy*** - For a suspected testicular tumor, the initial diagnostic and therapeutic step is a **radical inguinal orchiectomy** (high ligation of spermatic cord via inguinal approach) to avoid tumor seeding into the scrotum. - Given the presence of a 10 cm **retroperitoneal lymph node mass**, indicating bulky metastatic disease, **chemotherapy** (typically BEP regimen) is essential post-orchiectomy to address systemic spread. *Radiotherapy* - Radiotherapy may be used for specific stages of **seminoma**, but it is generally less effective for non-seminomatous germ cell tumors and is not the primary treatment for bulky metastatic disease (>5 cm). - It does not address the primary tumor in the testis directly and has higher long-term toxicities compared to chemotherapy for disseminated disease. *Chemotherapy alone* - While chemotherapy is crucial for metastatic testicular cancer, it cannot alone remove the primary tumor in the testis, which would leave a source of ongoing disease. - A **radical orchiectomy** is necessary to confirm the diagnosis, obtain tissue for histopathological staging, and remove the primary tumor. *Immunotherapy with interferon and interleukin* - **Immunotherapy** is generally not a first-line treatment for testicular germ cell tumors. - Standard treatment relies on platinum-based chemotherapy, which has excellent cure rates even in metastatic disease. Immunotherapy has limited role in testicular cancer management.

Q: Which of the following statements about Varicocele is false?

More common on right side. ***More common on right side*** - Varicoceles are significantly **more common on the left side** due to anatomical differences, specifically the longer left testicular vein draining into the left renal vein at a perpendicular angle. - The perpendicular drainage and longer course of the left testicular vein create a higher pressure environment, predisposing to venous incompetence and dilation. *Dilated pampiniform plexus veins* - This statement is **true** because a varicocele is, by definition, an abnormal dilation and tortuosity of the veins of the **pampiniform plexus** within the spermatic cord. - The dilation occurs due to incompetent valves in the spermatic veins, leading to reflux of blood. *Doppler USG is best investigation* - This statement is **true** as **Doppler ultrasonography** is considered the gold standard for diagnosing varicoceles. - It allows visualization of dilated veins, demonstrates reflux with Valsalva maneuver, and helps grade the severity of the varicocele. *Abnormality increases on Valsalva* - This statement is **true** because the **Valsalva maneuver** increases intra-abdominal pressure, which impedes venous return and accentuates the reflux of blood into the testicular veins. - This maneuver helps to confirm the presence of a varicocele on physical examination and during Doppler ultrasonography.

Q: In which of the following conditions is circumcision specifically indicated?

Phimosis (when non-retractable). ***Phimosis (when non-retractable)*** - **Circumcision** is the definitive treatment for **pathological phimosis** where the foreskin cannot be retracted and causes symptoms like pain, dysuria, or recurrent infections. - This is a **primary and specific indication** for circumcision in both children (after conservative measures fail) and adults. - Phimosis can lead to complications like balanitis, urinary retention, and in severe cases, malignancy risk. *Paraphimosis (as primary emergency treatment)* - **Paraphimosis** is a urological emergency requiring **immediate manual reduction** or dorsal slit procedure to relieve strangulation of the glans. - **Circumcision is NOT the primary emergency treatment** - it is performed **electively later** to prevent recurrence after the acute episode is resolved. - The immediate priority is reduction of the paraphimosis, not circumcision. *Balanitis (as first-line treatment)* - **First-line treatment** for balanitis involves **topical antifungals, antibiotics, or corticosteroids** depending on the etiology. - **Circumcision** is indicated for **recurrent or refractory balanitis** after conservative measures have failed, not as initial first-line therapy. - It is a definitive preventive measure but not the primary treatment approach. *None of the above (not indicated)* - This is incorrect because **circumcision has clear medical indications** in urology and pediatric surgery. - Pathological phimosis is a well-established specific indication for the procedure.

Q: A 40-year-old male presented to the casualty with severe pain in the left upper abdomen radiating to the groin. Urine routine examination shows 6-8 pus cells and 15-20 red blood cells. What is the diagnosis based on the CT scan findings?

Left ureteric calculus. ***Left ureteric calculus*** - The combination of severe left flank pain radiating to the groin, along with 6-8 pus cells and 15-20 red blood cells in the urine, is highly suggestive of **renal or ureteric colic** due to a calculus. - A CT scan is the **gold standard** for diagnosing urinary tract stones, definitively identifying their presence, size, and location within the left ureter, confirming the diagnosis. *Aortic Aneurysm* - Aortic aneurysm typically presents with **abdominal or back pain**, but it lacks the characteristic urinary symptoms like hematuria and pyuria seen in this case. - Imaging for an aneurysm would show an **enlarged aorta**, not findings related to the urinary tract. *Acute cholecystitis* - Acute cholecystitis causes **right upper quadrant pain**, often radiating to the right shoulder or back, and is associated with **fever and nausea**. - It does not present with **urinary symptoms** like pus cells and red blood cells in the urine. *Acute Colitis* - Acute colitis typically presents with **abdominal pain**, diarrhea (often bloody), fever, and tenesmus, primarily affecting the colon. - While it can cause abdominal pain, it does not explain the **radiating groin pain** or the specific urinary findings of pus and red blood cells.

Q: During TURP, the surgeon takes care to dissect above the verumontanum to avoid injury to

External urethral sphincter. ***External urethral sphincter*** - The **external urethral sphincter** is located just inferior to the verumontanum, meaning dissecting above the verumontanum helps preserve its function. - Injury to this sphincter is a major cause of **post-TURP incontinence**. *Urethral crest* - The **urethral crest** is a midline ridge on the posterior wall of the prostatic urethra, containing the verumontanum - Dissecting above the verumontanum would still be within the region of the urethral crest, not specifically to protect it. *Prostatic utricle* - The **prostatic utricle** is a small blind-ending pouch located within the verumontanum itself. - Dissecting above the verumontanum would not specifically prevent injury to the utricle, as it is integral to the verumontanum structure. *Trigone of bladder* - The **trigone of the bladder** is located superior to the prostatic urethra, forming the base of the bladder. - TURP primarily involves resection of prostatic tissue, and the trigone is not typically at risk if dissection is confined to the prostatic urethra.

Q: What is the most common type of stone found in the bladder?

Calcium oxalate. ***Calcium oxalate*** - **Calcium oxalate** is the most common type of urinary stone overall, accounting for up to 80% of all stones, and is consequently the most frequent type found in the bladder. - The formation of **calcium oxalate stones** in the bladder is often associated with conditions causing stasis or high calcium excretion, although they can also form in the kidneys and descend [1]. *Ammonium urate* - **Ammonium urate stones** are relatively rare in developed countries but are more common in regions with endemic bladder stones, often linked to chronic urinary tract infections [1]. - These stones are typically soft, friable, and radiolucent, and are often a component of mixed stones. *Uric acid* - **Uric acid stones** are more common in patients with gout, metabolic syndrome, or conditions leading to persistently acidic urine, and are usually radiolucent [1]. - While they can occur in the bladder, they are not as prevalent as calcium oxalate stones in this location. *Struvite* - **Struvite stones** (magnesium ammonium phosphate) are strongly associated with **urinary tract infections** caused by **urea-splitting bacteria** (e.g., *Proteus* spp.) [1]. - They tend to grow rapidly and can form large, staghorn calculi, but are not the most common type of bladder stone overall [1].

Q: Which of the following is NOT a suitable management option for accidental injury of the ureter during an abdominal operation?

Ligation of the ureter. ***Ligation of the ureter*** - **Ligation** of the ureter is generally not a suitable management option as it typically leads to **kidney damage** due to obstruction and hydronephrosis, potentially necessitating **nephrectomy** if renal function is severely compromised. - This approach permanently blocks urine flow, causing **irreversible renal damage** unless the ureter is repaired or diverted very soon after injury. *End-to-end anastomosis through an ureteric catheter* - This is a common and appropriate technique for repairing a **transected ureter**, particularly when the injury is clean and there is minimal tissue loss. - An **ureteric catheter** acts as a stent, maintaining patency and facilitating healing while preventing stricture formation at the repair site. *Implantation into the bladder* - **Ureteroneocystostomy (implantation into the bladder)** is suitable for **distal ureteral injuries** where a sufficient length of ureter remains to reach the bladder without tension. - This procedure re-establishes continuity of the urinary tract directly into the bladder, bypassing the injured segment. *Colonic implantation* - **Colonic implantation** (ureterosigmoidostomy or ureterocolonic anastomosis) is a more complex procedure reserved for specific situations, such as extensive ureteral loss or bladder exstrophy, where direct bladder implantation is not feasible. - It involves diverting urine into the colon, allowing for reabsorption of water, but can lead to complications such as **hyperchloremic metabolic acidosis** and an increased risk of urinary tract infections.

Question 1

What is a potential complication of performing percutaneous nephrolithotomy (PCNL) through the 11th intercostal space?

Accepted Answer

Pleural effusion

Answer

Hematuria

Answer

Colon injury

Answer

Residual stones

Question 2

Most common presentation of renal cell carcinoma is

Accepted Answer

Hematuria

Answer

Abdominal mass

Answer

Flank pain

Answer

Nocturia

Question 3

A 27-year-old man presents with a left testicular tumor and a 10 cm retroperitoneal lymph node mass. Which of the following is the treatment of choice?

Accepted Answer

Radical inguinal orchiectomy plus chemotherapy

Answer

Radiotherapy

Answer

Chemotherapy alone

Answer

Immunotherapy with interferon and interleukin

Question 4

Which of the following statements about Varicocele is false?

Accepted Answer

More common on right side

Answer

Dilated pampiniform plexus veins

Answer

Doppler USG is best investigation

Answer

Abnormality increases on Valsalva

Question 5

A 60-year-old smoker presented with a history of a single episode of painless gross hematuria. The most logical investigation would be.

Accepted Answer

Cystoscopy

Answer

Urine cytology

Answer

X-ray of the kidneys, ureters, and bladder (KUB)

Answer

Ultrasound of the abdomen

Question 6

In which of the following conditions is circumcision specifically indicated?

Accepted Answer

Phimosis (when non-retractable)

Answer

None of the above (not indicated)

Answer

Paraphimosis (as primary emergency treatment)

Answer

Balanitis (as first-line treatment)

Question 7

A 40-year-old male presented to the casualty with severe pain in the left upper abdomen radiating to the groin. Urine routine examination shows 6-8 pus cells and 15-20 red blood cells. What is the diagnosis based on the CT scan findings?

Accepted Answer

Left ureteric calculus

Answer

Acute cholecystitis

Answer

Acute Colitis

Answer

Aortic Aneurysm

Question 8

During TURP, the surgeon takes care to dissect above the verumontanum to avoid injury to

Accepted Answer

External urethral sphincter

Answer

Urethral crest

Answer

Prostatic utricle

Answer

Trigone of bladder

Question 9

What is the most common type of stone found in the bladder?

Accepted Answer

Calcium oxalate

Answer

Ammonium urate

Answer

Struvite

Answer

Uric acid

Question 10

Which of the following is NOT a suitable management option for accidental injury of the ureter during an abdominal operation?

Accepted Answer

Ligation of the ureter

Answer

Colonic implantation

Answer

End-to-end anastomosis through an ureteric catheter

Answer

Implantation into the bladder

Urology — MCQs

Urology — MCQs

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