Urology Practice Questions

Q: A patient is seen on the second postoperative day after a difficult abdominal hysterectomy complicated by ureteral injury during ligation of the left uterine artery pedicle. The patient has developed sepsis. If the ureteral injury had been recognized at the time of surgery, which of the following procedures could have been recommended?

Ureteral reimplantation into the bladder. ***Ureteral reimplantation into the bladder*** - For a **distal ureteral injury** near the bladder, as would likely occur during a hysterectomy involving the uterine artery pedicle, **ureteral reimplantation** directly into the bladder (ureteroneocystostomy) is the reconstructive procedure of choice. - This method provides a **robust and long-lasting repair**, typically performed acutely when the injury is recognized immediately during surgery. *Placement of a ureteral stent without anastomosis* - This is an insufficient intervention for a **frank transection or significant injury** to the ureter; a stent alone cannot repair a severed ureter. - Stents are typically used for **intraluminal obstruction** or to protect an anastomosis, not as a solitary treatment for a complete ureteral injury. *Percutaneous nephrostomy* - This procedure diverts urine from the kidney externally and is primarily used for **temporary drainage** in cases of ureteral obstruction, fistula, or severe sepsis/urosepsis to protect kidney function, often as a temporizing measure before definitive repair. - It does not **repair the ureteral injury** itself, making it an inappropriate direct surgical solution if the injury is recognized and can be repaired at the time of surgery. *Ureteroureteral anastomosis* - This involves **reconnecting the two ends of a severed ureter** but is generally reserved for **mid-ureteral injuries** or when there is sufficient length to achieve a tension-free repair. - Given the injury near the uterine artery pedicle during a hysterectomy, it is more likely to be a **distal ureteral injury**, where reimplantation into the bladder is usually preferred due to shorter mobilized segments and better long-term patency rates.

Q: A patient operated for lower segment uterine fibroid had an uneventful surgery. Post operatively the urine output started to decrease, upto 20 ml/hr. Rapid IV fluid infusions were given with inj. Lasix and output increased to 70 ml/hr. Urine was clear. Patient complained of flank pain which was gradually progressing. Most common cause of such presentation would be:

Unilateral ureteral injury. ***Unilateral ureteral injury*** - A gradual decrease in urine output followed by an increase with fluid and diuretics, combined with **flank pain** after pelvic surgery, strongly suggests **unilateral ureteral obstruction** or injury, as the other kidney is still functioning. - The urine being clear indicates that the problem is not due to hemorrhage into the urinary tract but rather a mechanical blockage or injury affecting urine flow. *Haemorrhage* - Significant **hemorrhage** would typically cause signs of **hypovolemic shock** such as hypotension, tachycardia, and pallor, which are not mentioned. - While hemorrhage can decrease urine output, the subsequent increase with fluids and clear urine, along with flank pain, points away from bleeding as the primary cause of these specific symptoms. *Bladder injury* - A bladder injury would typically present with **hematuria** (blood in urine), inability to void, or leakage of urine into the peritoneal cavity, none of which are described. - While bladder injury can reduce urine output or cause discomfort, it wouldn't explain unilateral flank pain with clear urine in this context. *Acute renal failure* - **Acute renal failure** would typically cause a persistent and significant decrease in urine output despite fluid resuscitation and diuretics, and it would usually affect both kidneys. - The temporary improvement in urine output with fluids and the presence of unilateral flank pain make acute renal failure less likely as the initial cause compared to a localized surgical complication.

Q: True about Latzko technique of genitourinary fistula repair is

Partial colpocleisis.. ***Partial colpocleisis.*** - The Latzko technique involves **denuding the vaginal epithelium** around the fistula and then imbricating the vaginal wall over the defect, effectively performing a **partial colpocleisis**. - This technique achieves fistula closure by sealing the defect without formally excising the tract, relying on tissue apposition and healing. *Lengthens upper vagina.* - The Latzko technique typically involves the **approximation of vaginal walls**, which can lead to a **slight shortening or narrowing** of the vagina, not lengthening. - This is a consequence of the imbrication of vaginal tissue used to close the fistula. *Excision of fistulous tract completely.* - The Latzko technique is a **transvaginal approach** that focuses on **denuding the edges** of the fistula and then **imbricating layers of vaginal tissue** over it, rather than completely excising the fistulous tract. - Complete excision of the tract is more common in more complex or difficult fistula repairs, often requiring an abdominal approach. *Weakens surrounding tissues.* - This technique aims to **strengthen the repair site** by bringing together healthy vaginal tissue and using multiple layers of sutures to create a durable closure. - The goal is to provide a robust repair that supports the weakened area, not to further compromise tissue integrity.

Q: Which surgical procedure has the highest incidence of ureteric injury?

Radical hysterectomy. ***Radical hysterectomy*** - This procedure involves extensive dissection to remove the uterus, cervix, and surrounding parametrial tissue, which places the **ureters at high risk of injury** due to their close proximity to the surgical field. - The **ureter** runs directly through the **parametrium** (cardinal and uterosacral ligaments), which are ligated and excised during a radical hysterectomy, making it the procedure with the highest incidence of ureteral injury. *Vaginal hysterectomy* - While ureteric injury can occur, it is generally less common than in radical hysterectomy due to the less extensive dissection and different angle of approach. - The risk is present during clamping and ligating the **uterosacral and cardinal ligaments** but is typically lower than with a radical approach. *Anterior colporraphy* - This procedure primarily involves the anterior vaginal wall and bladder, usually without deep pelvic dissection that would place the ureters at significant risk. - The main risks are typically related to the bladder itself, rather than the ureters, as the dissection is superficial to the ureteral course. *Abdominal hysterectomy* - While there is a risk of ureteric injury, especially during the ligation of the **uterine arteries** and cardinal ligaments, the dissection is less extensive than in a radical hysterectomy. - Standard abdominal hysterectomy involves less parametrial dissection, thus exposing the ureters to a lower, though still present, risk of injury compared to radical procedures.

Q: The disadvantage of Marshall-Marchetti-Krantz procedure compared with other surgical alternatives for treatment of stress urinary incontinence includes

Osteitis pubis. ***Osteitis pubis*** - **Osteitis pubis** is a known, though rare, complication specifically associated with the Marshall-Marchetti-Krantz (MMK) procedure due to the sutures placed in the periosteum of the pubic symphysis, leading to inflammation. - This complication presents as **groin pain** and tenderness over the symphysis pubis, and it is less common with modern sling procedures or colposuspension techniques. *Increased incidence of urinary tract infections* - While **urinary tract infections (UTIs)** can occur after any pelvic surgery, there is no evidence to suggest that the MMK procedure specifically carries a higher incidence compared to other stress urinary incontinence (SUI) surgeries. - Post-surgical catheterization and manipulation can increase UTI risk universally regardless of the specific surgical approach. *Urinary retention* - **Urinary retention** is a potential complication of many SUI surgeries, including MMK, due to over-correction or urethral obstruction. - However, newer procedures like mid-urethral slings have also been associated with significant rates of transient or persistent urinary retention, suggesting it's not a unique disadvantage of MMK. *High failure rate* - The **failure rate** of MMK, while debated and variable across studies, is generally comparable to or sometimes better than some older SUI procedures. - Modern tension-free vaginal tape (TVT) and other sling procedures have often superseded MMK due to less invasiveness or similar efficacy, not necessarily a universally higher failure rate of MMK.

Q: A 6 year old girl presents with Recurrent E.coli infection in urine. Ultrasound of abdomen shows Hydroureter and Hydronephrosis. Micturating cystourethrogram shows filling defect in urinary bladder. The likely diagnosis is –

Ureterocele. ***Ureterocele*** - A ureterocele is a **congenital dilation** of the distal ureter that protrudes into the bladder, often causing urinary obstruction and reflux. - The imaging findings of **hydroureter**, **hydronephrosis**, and a **filling defect** on MCUG are classic for ureterocele, which can lead to recurrent UTIs. *Duplication of Ureter* - While ureteral duplication can cause issues, it typically presents with two separate ureters entering the bladder or one ectopic ureter, and does not inherently cause a filling defect within the bladder itself unless complicated by an obstructed lower pole ureterocele or ectopic ureter. - The presence of a **filling defect** on MCUG is more characteristic of a ureterocele rather than isolated ureteral duplication. *Vesicoureteric Reflux – grade II* - **Vesicoureteric reflux (VUR)** involves the retrograde flow of urine from the bladder into the ureter and kidney, leading to recurrent UTIs, hydronephrosis, and hydroureter. - While VUR explains the recurrent UTIs and hydronephrosis, it does not account for the **filling defect** observed within the bladder on MCUG, which suggests an anatomical obstruction. *Sacrococcygeal Teratoma* - A **sacrococcygeal teratoma** is a tumor found at the base of the spine, primarily affecting newborns. - While it can cause bladder dysfunction due to mass effect if very large, it does not typically present as a **filling defect within the urinary bladder** itself and is usually diagnosed much earlier in life.

Q: Which among the following simple tests is used to measure/assess urethral hypermobility?

Q tip test. ***Q tip test*** - The **Q-tip test** directly assesses **urethral hypermobility** by measuring the angle of urethral descent during a Valsalva maneuver. - An angle greater than **30 degrees from the horizontal** indicates significant hypermobility. *Voiding diary* - A **voiding diary** is used to record the frequency, volume, and urgency of urination over a specific period. - It helps assess **bladder function** and identify patterns of incontinence, but does not measure urethral mobility. *Office cystometry* - **Office cystometry** measures bladder pressure and volume to evaluate bladder filling and voiding dynamics. - It is primarily used to assess for **detrusor overactivity**, stress incontinence, or outlet obstruction, not urethral hypermobility. *Postvoid residual urine* - **Postvoid residual (PVR) urine** measures the amount of urine left in the bladder after urination. - It helps detect **incomplete bladder emptying**, which can be caused by obstruction or detrusor weakness, but does not assess urethral mobility.

Q: A 36-year-old man presents to his primary care physician complaining of painless enlargement of the testis. Further laboratory studies reveal an increase in serum hCG. Of the following, which is the most likely diagnosis?

Embryonal carcinoma. ***Embryonal carcinoma*** - This highly **malignant tumor** often presents with **elevated hCG** and a **firm, painless testicular mass**. - It frequently consists of mixed germ cell tumors, with embryonal components contributing to the hCG surge. - Among the options provided, this is the most likely diagnosis with elevated hCG (note: choriocarcinoma would show the highest hCG levels but is not listed). *Seminoma* - While it causes **painless testicular enlargement**, seminoma is typically associated with **elevated LDH and placental alkaline phosphatase (PLAP)**, not significant hCG elevation. - Pure seminomas occasionally show mild hCG elevation (~10-15% of cases), but this is not their characteristic tumor marker. *Yolk sac tumor* - These tumors are characterized by significantly **elevated alpha-fetoprotein (AFP)** levels. - While they can cause testicular enlargement, hCG elevation is not its primary tumor marker. *Dysgerminoma* - **Dysgerminomas** are a type of **ovarian germ cell tumor**, primarily found in females, and thus highly unlikely in a male patient. - The male equivalent is a **seminoma**, which does not typically show significant hCG elevation.

Q: Chassar Moir technique is used in

Vesico vaginal fistula. ***Vesico vaginal fistula*** - The Chassar Moir technique is a surgical approach specifically designed for the repair of **vesicovaginal fistulae**, which are abnormal communications between the bladder and the vagina. - This technique primarily utilizes a **transvaginal approach** to close the fistula, often involving excision of the tract and multi-layered closure. *Enterocoele repair* - Enterocoele repair involves addressing a herniation of the **peritoneum and small bowel** into the rectovaginal space. - While it's a pelvic floor repair, it's distinct from fistula repair; various techniques like sacrocolpopexy or colporrhaphy are used, not typically the Chassar Moir. *Urethrocoele* - A urethrocoele (or urethrocele) is a **herniation of the urethra** into the vagina, usually due to weakening of pelvic floor support. - Its repair focuses on supporting the urethra, often through anterior colporrhaphy, and not directly related to the Chassar Moir technique. *Stress incontinence* - Stress urinary incontinence is the involuntary leakage of urine with physical activity, often due to **urethral hypermobility** or **intrinsic sphincter deficiency**. - Surgical treatments include mid-urethral slings or colposuspension, which are entirely different procedures from the Chassar Moir technique for fistula repair.

Q: A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:

Injury to the hypogastric plexi. ***Injury to the hypogastric plexi*** - The **hypogastric plexi** (superior and inferior) contain sympathetic and parasympathetic fibers crucial for bladder control, with parasympathetic fibers primarily responsible for bladder contraction during micturition. - Damage to these nerves during pelvic surgery, such as a hysterectomy, can lead to **detrusor areflexia** or hypocontractility, resulting in urinary retention. *Injury to the bladder neck* - Injury to the **bladder neck** itself typically causes **stress urinary incontinence** or voiding dysfunction due to obstruction, rather than complete retention from inability to contract the bladder. - While it can impact bladder function, it doesn't primarily explain recurrent retention characterized by the inability to empty the bladder. *Atrophic and stenotic urethra* - An **atrophic and stenotic urethra** would primarily cause symptoms of **obstructive voiding**, such as weak stream, hesitancy, or incomplete emptying, but not typically complete, recurrent urinary retention as a direct consequence of a hysterectomy. - This condition is more related to estrogen deficiency or chronic irritation, and would likely pre-date or develop independently from the hysterectomy. *Lumbar disc prolapse* - **Lumbar disc prolapse** can cause urinary retention if it leads to **cauda equina syndrome**, characterized by severe neurological deficits like saddle anesthesia, bowel/bladder dysfunction, and lower extremity weakness. - However, isolated recurrent urinary retention as the *most likely* cause after a hysterectomy, without other neurological signs, points away from a disc issue.

Question 1

A patient is seen on the second postoperative day after a difficult abdominal hysterectomy complicated by ureteral injury during ligation of the left uterine artery pedicle. The patient has developed sepsis. If the ureteral injury had been recognized at the time of surgery, which of the following procedures could have been recommended?

Accepted Answer

Ureteral reimplantation into the bladder

Answer

Placement of a ureteral stent without anastomosis

Answer

Percutaneous nephrostomy

Answer

Ureteroureteral anastomosis

Question 2

A patient operated for lower segment uterine fibroid had an uneventful surgery. Post operatively the urine output started to decrease, upto 20 ml/hr. Rapid IV fluid infusions were given with inj. Lasix and output increased to 70 ml/hr. Urine was clear. Patient complained of flank pain which was gradually progressing. Most common cause of such presentation would be:

Accepted Answer

Unilateral ureteral injury

Answer

Haemorrhage

Answer

Bladder injury

Answer

Acute renal failure

Question 3

True about Latzko technique of genitourinary fistula repair is

Accepted Answer

Partial colpocleisis.

Answer

Lengthens upper vagina.

Answer

Excision of fistulous tract completely.

Answer

Weakens surrounding tissues.

Question 4

Which surgical procedure has the highest incidence of ureteric injury?

Accepted Answer

Radical hysterectomy

Answer

Vaginal hysterectomy

Answer

Anterior colporraphy

Answer

Abdominal hysterectomy

Question 5

The disadvantage of Marshall-Marchetti-Krantz procedure compared with other surgical alternatives for treatment of stress urinary incontinence includes

Accepted Answer

Osteitis pubis

Answer

Increased incidence of urinary tract infections

Answer

Urinary retention

Answer

High failure rate

Question 6

A 6 year old girl presents with Recurrent E.coli infection in urine. Ultrasound of abdomen shows Hydroureter and Hydronephrosis. Micturating cystourethrogram shows filling defect in urinary bladder. The likely diagnosis is –

Accepted Answer

Ureterocele

Answer

Duplication of Ureter

Answer

Vesicoureteric Reflux – grade II

Answer

Sacrococcygeal Teratoma

Question 7

Which among the following simple tests is used to measure/assess urethral hypermobility?

Accepted Answer

Q tip test

Answer

Voiding diary

Answer

Office cystometry

Answer

Postvoid residual urine

Question 8

A 36-year-old man presents to his primary care physician complaining of painless enlargement of the testis. Further laboratory studies reveal an increase in serum hCG. Of the following, which is the most likely diagnosis?

Accepted Answer

Embryonal carcinoma

Answer

Seminoma

Answer

Yolk sac tumor

Answer

Dysgerminoma

Question 9

Chassar Moir technique is used in

Accepted Answer

Vesico vaginal fistula

Answer

Enterocoele repair

Answer

Urethrocoele

Answer

Stress incontinence

Question 10

A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:

Accepted Answer

Injury to the hypogastric plexi

Answer

Injury to the bladder neck

Answer

Atrophic and stenotic urethra

Answer

Lumbar disc prolapse

Urology — MCQs

Urology — MCQs

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