Urology Practice Questions

Q: In a follow-up case of prostate cancer, what do we need to check?

PSA. ***PSA***- **Prostate-Specific Antigen** is the primary biomarker used for routine surveillance and follow-up after definitive treatment (like prostatectomy or radiation) for prostate cancer. - A sustained rise in PSA levels, known as **biochemical recurrence**, is the earliest sign that prostate cancer may have returned locally or metastasized. *Alkaline phosphatase* - **Alkaline phosphatase (ALP)** levels are primarily followed when there is suspicion of **bony metastasis**, as high ALP reflects increased osteoblastic activity. - It is used to stage and evaluate advanced disease or monitor response to treatment for bone mets, but it is not the primary marker for general recurrence detection. *Testosterone* - **Testosterone** levels are monitored primarily in patients receiving **androgen deprivation therapy (ADT)** to ensure that castrate levels of androgens are being maintained. - Changes in circulating testosterone do not reliably indicate cancer recurrence or progression in patients not undergoing hormonal manipulation. *Acid phosphatase* - **Acid phosphatase (ACP)**, specifically prostatic acid phosphatase (PAP), is a historical tumor marker that has been superseded by PSA in nearly all aspects of follow-up. - Elevated ACP is usually associated with **advanced or metastatic disease** but lacks the sensitivity of PSA for detecting early biochemical recurrence.

Q: Spread of prostate cancer to lumbar vertebra is via?

Venous spread. ***Venous spread***- The most common route for prostate cancer metastasis to the vertebrae is via the **Batson's vertebral venous plexus**, a valveless network.- This plexus allows cancer cells to flow retrograde directly from the deep pelvic veins draining the prostate to the vertebral column, especially the **lumbar vertebrae**.*Arterial spread*- Arterial spread is a route for systemic metastasis but is less significant than the venous route involving **Batson's plexus** for the specific predilection of vertebral spread.- Given the direct connection of the prostate venous drainage to the vertebral system, venous dissemination is the main hematogenous pathway to the axial skeleton.*Local spread*- Local spread refers to the contiguous extension of the tumor to adjacent structures like the seminal vesicles or bladder neck, and it does not explain **distant metastasis** to the bone.- This type of spread dictates local staging but is not the mechanism for tumor cell deposition in the marrow of the spine.*Lymphatic spread*- Lymphatic spread is typically the initial route for spread to **regional lymph nodes** (e.g., pelvic and obturator nodes).- **Bone metastasis**, particularly to the spine, classically bypasses major lymph node groups and utilizes the direct venous connection provided by the Batson's system.

Q: A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Bulbar urethra. ***Bulbar urethra***- Perineal trauma, such as a **straddle injury**, typically compresses the **bulbar urethra** (part of the anterior urethra) against the inferior aspect of the pubic symphysis, leading to rupture or contusion.- The classic presentation of **blood at the external urethral meatus** combined with **urinary retention (inability to void)** following perineal trauma is pathognomonic for a suspected anterior urethral injury, most commonly involving the bulbar segment.*Posterior urethral valve*- This condition is a **congenital anomaly** causing obstruction almost exclusively in male **infants** and neonates, resulting in chronic hydronephrosis.- It is not a traumatic injury and therefore cannot explain the sudden onset of urinary retention in a 22-year-old male following **perineal trauma**.*Intraperitoneal Bladder rupture*- This type of rupture usually occurs due to blunt trauma to the **suprapubic region** when the bladder is full, leading to urine leakage into the abdominal cavity.- Although it causes inability to urinate and hematuria, the history of isolated **perineal trauma** and prominent **blood at the meatus** makes a primary urethral injury significantly more likely.*Membranous urethra*- The **membranous urethra** is part of the posterior urethra and its injury is highly associated with severe blunt trauma causing **pelvic fractures**.- Perineal or straddle injuries typically affect the **anterior urethra** (bulbar segment) because the posterior urethra is protected by the surrounding bony pelvis and supportive ligaments.

Q: Which of the following is the recommended treatment for the ureteric stone shown in the image?

Ureteroscopy. ***Ureteroscopy*** - This procedure involves passing a small, flexible scope through the urethra and bladder into the ureter to directly visualize and treat the stone. - It is a highly effective and preferred treatment for stones located in the **mid and distal ureter**, allowing for either retrieval with a basket or fragmentation with a laser. *Percutaneous nephrolithotomy* - This is an invasive procedure where an instrument is passed directly into the kidney through a small incision in the back. - It is primarily indicated for the removal of **large renal stones** (typically >2 cm) or staghorn calculi located within the kidney, not for ureteric stones. *ESWL* - Extracorporeal Shock Wave Lithotripsy (ESWL) uses focused **shock waves** from outside the body to break the stone into smaller fragments that can be passed in the urine. - While an option for some ureteric and kidney stones, its success rate is lower for stones in the **lower ureter** and for harder stones, making ureteroscopy often more effective. *Wait and watch* - This approach, often combined with **Medical Expulsive Therapy** (e.g., alpha-blockers), is reserved for small, uncomplicated stones (typically **<5 mm**) that are likely to pass spontaneously. - It is not recommended for larger stones, stones causing significant obstruction or severe symptoms, or those that fail to pass after a trial period.

Q: A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?

Tamsulosin. ***Tamsulosin*** - **Alpha-1 adrenergic blocker** that relaxes smooth muscle in the prostate and bladder neck - Provides **rapid symptom relief** within days to weeks for moderate-to-severe LUTS (Lower Urinary Tract Symptoms) - **First-line medical therapy** for symptomatic BPH requiring treatment - Improves urinary flow rate and reduces obstructive symptoms (hesitancy, weak stream, incomplete emptying) *Finasteride* - 5-alpha reductase inhibitor that shrinks prostate size over time - Takes **6+ months** to show clinical benefit, not ideal for initial symptom relief - More appropriate for patients with large prostates (>40g) or as combination therapy *TURP (Transurethral Resection of Prostate)* - **Surgical intervention** reserved for refractory cases, complications, or failure of medical management - Not appropriate as initial management - Indications: recurrent retention, refractory hematuria, bladder stones, renal insufficiency due to BPH *Observation* - Appropriate for **asymptomatic or mildly symptomatic** patients (watchful waiting) - This patient presents with urinary symptoms requiring active management - Not suitable when symptoms are bothersome enough to prompt medical consultation

Q: A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Radical cystectomy. ***Radical cystectomy***- Because this tumor involves the **muscle layer**, it is classified as **muscle-invasive bladder cancer (MIBC)** (T2 stage or higher), for which radical cystectomy is the gold standard treatment for patients who are surgical candidates.- This procedure involves complete removal of the bladder and adjacent pelvic lymph nodes, followed by urinary diversion, offering the best survival and curative rates for localized MIBC.*Intravesical administration of BCG*- This immunotherapy is used primarily for **high-risk non-muscle-invasive bladder cancer (NMIBC)**, particularly carcinoma in situ (CIS) or high-grade T1 tumors, to reduce recurrence.- It cannot achieve adequate penetration or tumor clearance in tumors that have already invaded the **detrusor muscle**.*Radiotherapy*- Radiotherapy is typically used as part of a **bladder-preserving trimodality therapy** (TMT) when the patient is unable or unwilling to undergo surgery.- For fit patients with MIBC, **radical cystectomy** generally provides superior long-term survival rates compared to radiotherapy alone.*Neoadjuvant chemotherapy with Mitomycin C*- **Mitomycin C** is an agent used *intravesically* for NMIBC, similar to BCG, to prevent recurrence after TURBT.- Standard **neoadjuvant chemotherapy** for MIBC (given before cystectomy) consists of **systemic platinum-based regimens** (like Gemcitabine/Cisplatin) and not local Mitomycin C.

Q: Which of the following will have unilateral hydronephrosis?

Retrocaval ureter. ***Retrocaval ureter*** - This is a rare congenital anomaly where the **right ureter** passes behind the inferior vena cava (IVC), causing extrinsic compression and obstruction. - Since only the right ureter is involved in this pathway abnormality, it inherently results in **unilateral hydronephrosis** of the right kidney. *Phimosis* - Phimosis is the inability to retract the foreskin; severe cases can cause distal urinary outflow obstruction. - If obstruction is severe enough to cause hydronephrosis, the resulting high intravesical pressure would be transmitted equally to both kidneys, usually causing **bilateral hydronephrosis**. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are congenital folds in the posterior urethra, causing obstruction distal to the bladder neck. - This obstruction leads to high intravesical pressure, which impairs drainage from both kidneys, inevitably resulting in **bilateral hydronephrosis**. *Urethral strictures* - Urethral strictures are narrowings of the urethra, usually acquired, which obstruct urine flow distal to the bladder. - Significant obstruction at this level causes increased back pressure in the bladder and ureters, usually leading to pressure effects and subsequent **bilateral hydronephrosis**.

Q: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Partial nephrectomy. ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**.

Q: An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Testicular torsion. ***Testicular torsion*** - The sudden onset of **agonizing pain**, a **high-riding testis**, and a **lost cremasteric reflex** are classic signs of testicular torsion. - This condition is an acute surgical emergency that requires prompt intervention to preserve testicular viability. *Epididymo-orchitis* - Typically presents with a more **gradual onset of pain** and symptoms of inflammation, often associated with a urinary tract infection or sexually transmitted infection. - The cremasteric reflex would usually be present, and the testis would not typically be high-riding. *Mumps orchitis* - This condition is preceded by **parotitis (mumps)**, which is not mentioned in the patient's history. - While it causes testicular pain and swelling, it generally occurs several days after the onset of mumps and does not present with a high-riding testis or absent cremasteric reflex. *Idiopathic scrotal edema* - This is characterized by **swelling of the scrotal wall** without significant testicular pain upon palpation. - It usually presents with diffuse, non-pitting edema of the scrotum, with a preserved cremasteric reflex and normal testicular position.

Question 1

In a follow-up case of prostate cancer, what do we need to check?

Accepted Answer

PSA

Answer

Acid phosphatase

Answer

Alkaline phosphatase

Answer

Testosterone

Question 2

Spread of prostate cancer to lumbar vertebra is via?

Accepted Answer

Venous spread

Answer

Local spread

Answer

Arterial spread

Answer

Lymphatic spread

Question 3

A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Accepted Answer

Bulbar urethra

Answer

Intraperitoneal Bladder rupture

Answer

Posterior urethral valve

Answer

Membranous urethra

Question 4

Which of the following is the recommended treatment for the ureteric stone shown in the image?

Accepted Answer

Ureteroscopy

Answer

Percutaneous nephrolithotomy

Answer

ESWL

Answer

Wait and watch

Question 5

A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?

Accepted Answer

Tamsulosin

Answer

Finasteride

Answer

Observation

Answer

TURP-Transurethral resection of prostate

Question 6

A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Accepted Answer

Radical cystectomy

Answer

Radiotherapy

Answer

Neoadjuvant chemotherapy with Mitomycin C

Answer

Intravesical administration of BCG

Question 7

Which of the following will have unilateral hydronephrosis?

Accepted Answer

Retrocaval ureter

Answer

Phimosis

Answer

Posterior urethral valves

Answer

Urethral strictures

Question 8

A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Accepted Answer

Partial nephrectomy

Answer

Partial nephrectomy + neoadjuvant chemotherapy

Answer

Radical nephrectomy + postoperative radiotherapy

Answer

Radical nephrectomy

Question 9

A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?

Accepted Answer

Non-contrast CT KUB

Answer

Ureteroscopy

Answer

Ultrasonography KUB

Answer

Contrast-enhanced CT KUB

Question 10

An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Accepted Answer

Testicular torsion

Answer

Epididymo-orchitis

Answer

Mumps orchitis

Answer

Idiopathic scrotal edema

Urology — MCQs

Urology — MCQs

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