Urology — MCQs

A 55-year-old male presented with painless terminal hematuria. Cystoscopic examination revealed a solitary papillary tumor. Histopathological examination of the completely resected tumor is suggestive of grade III transitional cell carcinoma with no muscle invasion. What is the next best step in management?

Q777Easy

Transurethral resection (T.U.R.) syndrome is due to which of the following electrolyte disturbances?

Q778Easy

Fogarty's catheter is used for?

Q779Medium

A patient on warfarin therapy can be taken for elective surgery if the INR is?

Q780Medium

Orchidopexy in an undescended testes decreases all except?

Urology Indian Medical PG Practice Questions and MCQs

Question 771: Which of the following is the treatment of choice for Stage I Wilm's Tumor?

A. Laparoscopic nephroureterectomy
B. Open nephroureterectomy (Correct Answer)
C. Chemotherapy
D. Observation

Explanation: **Explanation:** The treatment of choice for **Stage I Wilms’ Tumor (Nephroblastoma)** is a radical **Open Nephroureterectomy**. **1. Why Open Nephroureterectomy is correct:** In pediatric oncology, the primary goal is complete surgical excision without tumor spillage. An open approach (usually via a wide transperitoneal incision) allows for: * **Thorough Exploration:** Inspection of the contralateral kidney to rule out synchronous tumors. * **Safe Handling:** Minimizing the risk of capsular rupture, which would upstage the tumor to Stage III and necessitate abdominal radiation. * **Lymph Node Sampling:** Essential for accurate pathological staging. **2. Why other options are incorrect:** * **Laparoscopic Nephroureterectomy:** While common in adults, it is generally avoided in Wilms’ tumor due to the high risk of **tumor seeding and spillage** during morcellation or manipulation, which worsens the prognosis. * **Chemotherapy:** While Wilms' is highly chemosensitive (using Vincristine and Dactinomycin), in the **NWTS (National Wilms Tumor Study)** protocol followed in the US, surgery is the *initial* step for Stage I. (Note: The SIOP protocol in Europe uses pre-operative chemo, but surgery remains the definitive treatment). * **Observation:** Wilms’ tumor is a malignant neoplasm; observation is never an option. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (Cannon-ball metastasis). * **Staging:** Stage I is limited to the kidney and is **completely excised** with an intact capsule. * **WAGR Syndrome:** Wilms tumor, Aniridia, Genitourinary anomalies, and mental Retardation (associated with WT1 gene deletion on Chromosome 11p13). * **Prognosis:** Wilms’ tumor has an excellent prognosis, with cure rates exceeding 90% for localized disease.

Question 772: What is the most common site of prostatic carcinoma?

A. Anterior lobe
B. Median lobe
C. Posterior lobe (Correct Answer)
D. Central zone

Explanation: **Explanation:** Prostatic carcinoma primarily originates in the **peripheral zone** of the prostate gland. In the traditional anatomical classification (Lowsley’s lobes), the peripheral zone corresponds most closely to the **posterior lobe**. Approximately 70–80% of prostate cancers arise here, making it the most common site. * **Why Posterior Lobe is Correct:** Anatomically, the posterior lobe is located peripherally and is easily accessible during a **Digital Rectal Examination (DRE)**. Because most cancers start here, DRE is a vital screening tool for detecting firm, irregular nodules. * **Why Other Options are Incorrect:** * **Anterior Lobe:** This is largely fibromuscular stroma and rarely contains glandular tissue; hence, it is an uncommon site for malignancy. * **Median Lobe:** This area, along with the transition zone, is the primary site for **Benign Prostatic Hyperplasia (BPH)**. BPH typically causes obstructive symptoms early, whereas posterior lobe cancers may remain asymptomatic until advanced. * **Central Zone:** This zone surrounds the ejaculatory ducts and accounts for only about 5–10% of prostate cancers. **Clinical Pearls for NEET-PG:** * **Zonal Anatomy (McNeal):** Peripheral Zone (70% Cancer), Transition Zone (Main site of BPH), Central Zone (5-10% Cancer). * **Screening:** The combination of **PSA (Prostate Specific Antigen)** and **DRE** is the gold standard for early detection. * **Diagnosis:** Transrectal Ultrasound (TRUS) guided biopsy is the definitive diagnostic step. * **Metastasis:** Prostate cancer characteristically spreads to the bone (lumbar spine) via **Batson’s plexus**, resulting in **osteoblastic** (sclerotic) lesions.

Question 773: In a child with acute scrotal pain and swelling where testicular torsion is highly suspected, how would you proceed?

A. Immediate scrotal exploration only on the side of swelling
B. Immediate scrotal exploration on the same side and delayed exploration on the other side
C. Immediate scrotal exploration on both sides (Correct Answer)
D. Observation

Explanation: **Explanation:** **1. Why Option C is Correct:** Testicular torsion is a surgical emergency where the "golden period" for salvage is within **6 hours**. The underlying anatomical defect is typically the **"Bell-clapper deformity"** (high investment of the tunica vaginalis), which allows the testis to rotate freely. Crucially, this anatomical predisposition is almost always **bilateral**. Therefore, when one side undergoes torsion, the contralateral side is at high risk for a future event. Immediate exploration of both sides is mandatory: the affected side is detorsed and fixed (orchidopexy), and the unaffected side is fixed prophylactically to prevent future torsion. **2. Why Other Options are Incorrect:** * **Option A & B:** These are inadequate because they leave the contralateral testis at risk. Since the anatomical defect is bilateral, "delayed" or "no" exploration of the normal side invites a secondary emergency that could lead to bilateral testicular loss and infertility. * **Option D:** Observation is contraindicated. Torsion is a clinical diagnosis. If suspected, one should not even wait for a Doppler ultrasound if it delays surgery, as ischemia leads to irreversible necrosis within hours. **3. Clinical Pearls for NEET-PG:** * **Diagnosis:** Primarily clinical. Look for a high-riding testis with a horizontal lie and a **negative Prehn’s sign** (pain is not relieved by lifting the scrotum). * **Reflex:** The **Cremasteric reflex is absent** in torsion (High specificity). * **Golden Period:** Best salvage rate (<90%) if operated within 6 hours; drops to <10% after 24 hours. * **Surgical Procedure:** Orchidopexy is performed using non-absorbable sutures (e.g., Prolene). If the testis is gangrenous, orchidectomy is performed, but the contralateral side **must still be fixed.**

Question 774: Which of the following statements is not true regarding hydrocele?

A. It is an abnormal collection of serous fluid within the tunica vaginalis.
B. It is not possible to get above the swelling on examination of the scrotum. (Correct Answer)
C. Vaginal hydrocele is associated with 5% of inguinal hernias.
D. In a congenital hydrocele, the processus vaginalis is patent and connects to the peritoneal cavity.

Explanation: **Explanation:** In clinical surgery, the ability to **"get above the swelling"** is the hallmark physical examination finding used to differentiate a primary scrotal swelling from an inguinal-scrotal swelling (like a hernia). 1. **Why Option B is the Correct Answer (The False Statement):** In a hydrocele, the swelling is confined to the scrotum. Since the upper limit of the tunica vaginalis does not extend into the inguinal canal, a clinician can palpate the spermatic cord above the mass. Therefore, it **is possible** to get above the swelling. If you *cannot* get above the swelling, it indicates the mass extends from the abdomen/inguinal canal, suggesting an inguinal hernia or a varicocele. 2. **Analysis of Other Options:** * **Option A:** This is the standard definition. A hydrocele is indeed an accumulation of serous fluid between the parietal and visceral layers of the **tunica vaginalis**. * **Option C:** While most vaginal hydroceles are primary (idiopathic), approximately **5-10%** are associated with indirect inguinal hernias or underlying pathology like tumors or epididymo-orchitis. * **Option D:** This correctly describes the pathophysiology of **congenital hydrocele**, where the processus vaginalis fails to obliterate, allowing peritoneal fluid to communicate with the scrotum. **High-Yield Clinical Pearls for NEET-PG:** * **Transillumination Test:** The most characteristic sign of a hydrocele (brilliantly translucent). * **Lord’s Plication:** A surgical technique used for small, thin-walled hydroceles. * **Jaboulay’s Procedure:** The standard surgery (eversion of the sac) for large, thick-walled hydroceles. * **Differential Diagnosis:** Always perform a testicular ultrasound in young men with a sudden hydrocele to rule out an underlying **testicular tumor** (Secondary Hydrocele).

Question 775: A 51-year-old man with a history of passing stones in urine presents with excruciating flank pain and hematuria. Imaging reveals staghorn calculi occupying the right renal pelvis. Which of the following underlying disorders is most likely responsible?

A. Anemia of chronic disease
B. Chronic Proteus infection (Correct Answer)
C. Hyperparathyroidism
D. Hyperaldosteronism

Explanation: ### Explanation **Correct Answer: B. Chronic Proteus infection** **Why it is correct:** Staghorn calculi (large stones that fill the renal pelvis and branch into the calyces) are most commonly composed of **Struvite** (Magnesium Ammonium Phosphate) and Calcium Carbonate. These are known as **"infection stones."** The underlying mechanism involves infection with **urease-producing bacteria**, most notably ***Proteus mirabilis*** (others include *Klebsiella*, *Pseudomonas*, and *Staphylococcus*). The enzyme urease splits urea into ammonia and carbon dioxide. This increases urinary ammonia levels and raises the **urinary pH (>7.2)**, creating an alkaline environment that promotes the precipitation of struvite crystals. **Why the other options are incorrect:** * **A. Anemia of chronic disease:** While chronic renal issues can lead to anemia, it is a consequence of chronic kidney disease (due to decreased erythropoietin), not a cause of stone formation. * **C. Hyperparathyroidism:** This leads to hypercalcemia and hypercalciuria, typically resulting in **Calcium Oxalate** or **Calcium Phosphate** stones. While these can occasionally form large stones, they are not the classic cause of "infection-related" staghorn calculi. * **D. Hyperaldosteronism:** This condition primarily affects blood pressure and electrolyte balance (hypokalemia, metabolic alkalosis) but is not a recognized risk factor for nephrolithiasis. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** Struvite stones are also called **"Triple Phosphate"** stones. * **Radiology:** They are radiopaque and often take the shape of the renal collecting system (resembling deer antlers). * **Treatment of Choice:** **PCNL (Percutaneous Nephrolithotomy)** is the gold standard for managing staghorn calculi. * **Microscopy:** Struvite crystals have a characteristic **"Coffin-lid"** appearance under the microscope. * **Chemical Dissolution:** Suby’s Fluid G (acidic) can be used to dissolve residual fragments.

Question 776: A 55-year-old male presented with painless terminal hematuria. Cystoscopic examination revealed a solitary papillary tumor. Histopathological examination of the completely resected tumor is suggestive of grade III transitional cell carcinoma with no muscle invasion. What is the next best step in management?

A. Follow up
B. Cystectomy
C. Intravesical BCG (Correct Answer)
D. Intravesical chemotherapy

Explanation: ### Explanation **Correct Answer: C. Intravesical BCG** The patient presents with **Non-Muscle Invasive Bladder Cancer (NMIBC)**. According to the histopathology, the tumor is **Grade III (High Grade)** but has **no muscle invasion (Stage Ta or T1)**. In NMIBC, management is based on risk stratification. High-grade tumors are classified as **High-Risk NMIBC**. While the initial step is a Transurethral Resection of Bladder Tumor (TURBT), the standard of care to prevent recurrence and progression in high-risk cases is **Intravesical BCG (Bacillus Calmette-Guérin)**. BCG acts as an immunotherapy, inducing a local immune response that destroys residual malignant cells. **Why other options are incorrect:** * **A. Follow up:** High-grade tumors have a high rate of recurrence (up to 70%) and progression to muscle-invasive disease. Observation alone is inadequate. * **B. Cystectomy:** Radical cystectomy is generally reserved for Muscle-Invasive Bladder Cancer (MIBC, ≥T2) or high-risk NMIBC that fails BCG therapy. It is too aggressive as a first-line step here. * **D. Intravesical chemotherapy:** While agents like Mitomycin-C are used for low-risk NMIBC, they are less effective than BCG for high-grade (Grade III) tumors in preventing progression. --- ### High-Yield Clinical Pearls for NEET-PG * **Hematuria Pattern:** Painless **terminal** hematuria suggests a bladder origin; **total** hematuria suggests ureter/kidney; **initial** hematuria suggests urethra. * **Gold Standard Diagnosis:** Cystoscopy with biopsy. * **BCG Protocol:** Typically started 2–4 weeks after TURBT (to allow the bladder to heal and prevent systemic BCGosis). The standard is the **Southwest Oncology Group (SWOG) regimen**: 6 weekly induction doses followed by maintenance for 3 years. * **Most Common Type:** Transitional Cell Carcinoma (Urothelial Carcinoma) is the most common bladder cancer worldwide. However, in areas endemic for *Schistosoma haematobium*, **Squamous Cell Carcinoma** is more common.

Question 777: Transurethral resection (T.U.R.) syndrome is due to which of the following electrolyte disturbances?

A. Hyponatremia (Correct Answer)
B. Hypokalemia
C. Hypovolemia
D. Hypoxia

Explanation: **Explanation:** **TUR Syndrome** is a life-threatening complication occurring during Transurethral Resection of the Prostate (TURP) due to the systemic absorption of large volumes of non-conductive irrigation fluid (commonly 1.5% Glycine) through opened prostatic venous sinuses. **Why Hyponatremia is correct:** The primary mechanism is **dilutional hyponatremia**. As the irrigation fluid enters the circulation, it expands the intravascular volume and dilutes the serum sodium levels. If Glycine is used, its metabolism into ammonia can further cause neurotoxicity. Clinical features include confusion, seizures, visual disturbances, and bradycardia. **Why the other options are incorrect:** * **Hypokalemia:** While electrolyte shifts occur, potassium levels are generally stable or may even increase (hyperkalemia) if significant hemolysis occurs. It is not the defining feature of TUR syndrome. * **Hypovolemia:** TUR syndrome actually causes **hypervolemia** (fluid overload) due to massive absorption of irrigation fluid, potentially leading to pulmonary edema and hypertension. * **Hypoxia:** While hypoxia can occur secondary to pulmonary edema, it is a late-stage complication rather than the primary electrolyte disturbance. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Irrigation Fluid:** Normal Saline is preferred to avoid TUR syndrome, but it can only be used with **Bipolar Cautery**. * **Classic Triad:** Hypertension (early), Bradycardia, and altered mental status. * **Management:** Stop the procedure, administer diuretics (Furosemide), and in severe symptomatic cases (Na <120 mEq/L), use **3% Hypertonic Saline** at a controlled rate to avoid Central Pontine Myelinolysis.

Question 778: Fogarty's catheter is used for?

A. Urethral catheterization
B. Removal of blood clots from the arteries (Correct Answer)
C. Bladder drainage
D. Total Parenteral Nutrition (TPN)

Explanation: **Explanation:** **Fogarty’s catheter** is a specialized embolectomy catheter primarily used for the **removal of blood clots (emboli or thrombi) from the arterial system**. It consists of a thin, hollow tube with an inflatable balloon at the tip. During a procedure (embolectomy), the catheter is passed beyond the clot, the balloon is inflated, and the catheter is withdrawn, effectively "dragging" the clot out of the vessel to restore distal blood flow. **Analysis of Options:** * **Option B (Correct):** This is the classic use of the Fogarty catheter in vascular surgery to treat acute limb ischemia. * **Option A & C (Incorrect):** Urethral catheterization and bladder drainage typically utilize **Foley catheters** (for indwelling drainage) or **Robinson/Nelaton catheters** (for straight drainage). While both Foley and Fogarty catheters have balloons, the Fogarty is much thinner and designed for vascular lumens, not the urinary tract. * **Option D (Incorrect):** Total Parenteral Nutrition (TPN) requires central venous access via specialized catheters like **Hickman, Broviac, or PICC lines**, which are designed for long-term infusion rather than mechanical clot removal. **High-Yield Clinical Pearls for NEET-PG:** * **Inventor:** Developed by Dr. Thomas J. Fogarty in 1961; it revolutionized vascular surgery. * **Sizing:** Fogarty catheters are sized in **French (F)** units (e.g., 2F to 7F). A common rule of thumb: the French size divided by 3 equals the diameter in millimeters. * **Balloon Inflation:** The balloon should always be inflated with **saline or air** (as per manufacturer) and never over-inflated to avoid arterial rupture or intimal damage. * **Other Uses:** Occasionally used in biliary surgery (to remove gallstones from the common bile duct) or to remove foreign bodies from the airway/esophagus.

Question 779: A patient on warfarin therapy can be taken for elective surgery if the INR is?

A. 1.4
B. 1.6
C. 1.8
D. 2 (Correct Answer)

Explanation: **Explanation:** The management of anticoagulation in the perioperative period is a high-yield topic for NEET-PG. For most elective surgical procedures, the goal is to achieve an **International Normalized Ratio (INR) of <1.5**. However, according to standard surgical guidelines (including Bailey & Love), an **INR of ≤2.0** is generally considered the safe threshold for proceeding with most elective surgeries without a significant risk of spontaneous or uncontrollable bleeding. * **Why Option D is Correct:** An INR of 2.0 is the upper limit of safety. If a patient’s INR is 2 or less, the risk of major surgical hemorrhage is minimized, and the surgery can proceed. If the INR is >2, the surgery is typically postponed, or Vitamin K/Fresh Frozen Plasma (FFP) is administered to bring it down. * **Why Options A, B, and C are Incorrect:** While INRs of 1.4, 1.6, and 1.8 are technically "safer" because they are lower, the question asks for the threshold at which a patient *can* be taken for surgery. Option D (2.0) represents the clinical cutoff point. Options A and B are well within the safe zone, but they do not represent the maximum allowable limit for elective intervention. **High-Yield Clinical Pearls for NEET-PG:** * **Warfarin Cessation:** Warfarin is typically stopped **5 days** before elective surgery to allow the INR to normalize. * **Bridging Therapy:** If the patient is at high risk for thromboembolism (e.g., mechanical heart valves, AFib with high CHADS2 score), they are "bridged" with **Low Molecular Weight Heparin (LMWH)** or Unfractionated Heparin (UFH) once the INR drops below the therapeutic range. * **Emergency Reversal:** If urgent surgery is needed and the INR is high, the fastest way to reverse warfarin is **Prothrombin Complex Concentrate (PCC)** or **Fresh Frozen Plasma (FFP)**. Intravenous Vitamin K takes 6–12 hours to work. * **Minor Procedures:** For very minor procedures (e.g., dental extractions or minor skin surgery), warfarin often does not need to be discontinued.

Question 780: Orchidopexy in an undescended testes decreases all except?

A. Tumour incidence (Correct Answer)
B. Epididymoorchitis
C. Torsion
D. Avoid sexual ambiguity

Explanation: ### Explanation The primary goal of orchidopexy (surgical repositioning of the testis into the scrotum) is to preserve fertility and facilitate clinical monitoring. However, it is a common misconception that the procedure reduces the risk of malignancy. **1. Why "Tumour Incidence" is the Correct Answer:** Orchidopexy **does not decrease the overall incidence** of testicular tumors. A patient with a history of an undescended testis (UDT) remains at a higher risk for germ cell tumors (most commonly **Seminoma**) compared to the general population, regardless of surgery. The main oncological benefit of orchidopexy is **early detection**; by placing the testis in the scrotum, it becomes accessible for regular physical examination and self-palpation, allowing for earlier diagnosis if a tumor develops. **2. Analysis of Incorrect Options:** * **Epididymoorchitis:** Bringing the testis into the scrotum reduces the risk of recurrent infections and inflammatory conditions associated with the abnormal anatomical positioning of UDT. * **Torsion:** UDT is more prone to torsion due to lack of normal gubernacular attachments. Orchidopexy involves fixing the testis to the scrotal wall (e.g., in a sub-dartos pouch), which significantly **decreases the risk of torsion**. * **Avoid Sexual Ambiguity:** In cases of bilateral UDT or associated hypospadias, early surgical intervention helps in establishing a clear male phenotype and prevents psychological distress regarding genital appearance. **Clinical Pearls for NEET-PG:** * **Ideal Age for Surgery:** Orchidopexy should ideally be performed between **6 to 12 months** of age to preserve spermatogenesis. * **Most Common Site:** The **inguinal canal** is the most common location for UDT. * **Malignancy Risk:** The risk of malignancy is higher in abdominal testes compared to inguinal ones. Even after unilateral orchidopexy, there is a slightly increased risk of tumor in the **contralateral** (normally descended) testis. * **Most Common Tumor:** Seminoma is the most common tumor in UDT, but if the testis is left intra-abdominal, the risk of Seminoma is even higher.

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Renal Cell Carcinoma

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Testicular Tumors

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Urinary Incontinence

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