Urology Practice Questions

Q: Hyperchloremic acidosis is a common complication of:

Ureterosigmoidostomy. ***Ureterosigmoidostomy*** - This procedure directly connects the ureters to the sigmoid colon, allowing for the **reabsorption of urinary chloride and ammonium** by the colonic mucosa in exchange for bicarbonate secretion. - The mechanism involves **active reabsorption of chloride** from urine coupled with bicarbonate loss into the bowel lumen, leading to **hyperchloremic metabolic acidosis**. - This is the **classic urological cause** of hyperchloremic acidosis and the most specific answer in a surgical context. *Ileostomy* - **Ileostomy** typically leads to significant loss of fluids and electrolytes, including sodium and potassium, through the stoma. - While it can cause dehydration and electrolyte imbalances, it is more commonly associated with **hypokalemia, hyponatremia, and dehydration** rather than hyperchloremic acidosis. *Vomiting* - **Protracted vomiting** primarily results in the loss of gastric acid (HCl), leading to **hypochloremia** and **metabolic alkalosis** (not acidosis). - The loss of hydrogen ions from the stomach causes the kidneys to retain bicarbonate to maintain pH balance, resulting in elevated serum HCO3-. *Diarrhoea* - Severe **diarrhea** causes the loss of **bicarbonate-rich fluids** from the gastrointestinal tract, which can indeed lead to **normal anion gap metabolic acidosis** (hyperchloremic acidosis). - However, in the context of **surgical/urological complications**, **ureterosigmoidostomy** is the more specific and classic answer, as it involves a unique mechanism of **direct chloride reabsorption from urine** rather than simple bicarbonate loss. - Diarrhea-induced acidosis is also typically an acute medical condition rather than a surgical complication.

Q: Urinary bladder can be injured in all of the following operations EXCEPT:

Inguinal hernia repair. ***Inguinal hernia repair*** - While theoretically possible, bladder injury during **inguinal hernia repair** is exceedingly rare, often less than 1% as the bladder is not typically in the direct field of dissection. - The surgical approach for inguinal hernias generally involves layers superficial to the bladder, making direct injury much less common than in pelvic surgeries. - Rare cases occur with **sliding hernias** where the bladder may form part of the hernia sac wall. *Surgery for rectum* - **Anterior resection of the rectum** or abdominoperineal resection involves dissecting close to the bladder's posterior and inferior aspects, particularly the **bladder base** and **ureteral entries**. - Procedures like low anterior resection for rectal cancer pose a significant risk due to the **proximity of the bladder** to the surgical field in the pelvis. *Inguinal lymph node dissection* - **Inguinal lymph node dissection** is primarily a superficial groin procedure involving removal of superficial and deep inguinal nodes. - While bladder injury is **theoretically possible** if dissection extends unusually deep or medially toward the retropubic space, this is **extremely rare** in standard practice. - The risk is significantly lower than pelvic operations but higher than standard inguinal hernia repair due to the extent of dissection. *Hysterectomy* - During a **hysterectomy** (removal of the uterus), the bladder lies anterior and inferior to the uterus and cervix, making it highly susceptible to injury. - The dissection planes for detaching the bladder from the lower uterine segment and cervix pose a substantial risk, especially during **total abdominal hysterectomy** or **vaginal hysterectomy**. - This is one of the **most common** causes of iatrogenic bladder injury.

Q: Intraoperative recognition of ureter is by which of the following features? 1. Transparent tubular appearance 2. Pale glistening appearance 3. Longitudinal vessels on surface 4. Circumferential vessels on surface Select the correct answer using the code given below:

2 and 3. ***2 and 3*** - The ureter has a characteristic **pale, glistening appearance** (often described as "pearly white"), which helps distinguish it from surrounding tissues during surgery. - The presence of **longitudinal vessels** running along its surface is a key anatomical feature for intraoperative identification. - Additional identification feature: The ureter shows **peristaltic waves** when gently stimulated or pinched with forceps. *2 and 4* - While the ureter is indeed **pale and glistening**, the vessels on its surface are **longitudinal**, not circumferential. - **Circumferential vessels** would encircle the structure, which is not characteristic of ureteric vascular anatomy. *1 and 3* - The ureter is a tubular structure, but it is **not transparent**; it has a distinct **opaque, pale coloration**. - Although **longitudinal vessels** are correctly present, the transparency descriptor is inaccurate and not a reliable identification feature. *1 and 4* - The ureter is **not transparent** (it's opaque), and its vessels are **longitudinal**, not circumferential. - Neither of these features accurately describes the intraoperative appearance of the ureter.

Q: A 22-year-old male rugby player presents with acute scrotal pain that began 2 hours ago. Physical examination shows a high-riding, tender left testis with an absent cremasteric reflex. Doppler ultrasound shows decreased blood flow to the left testis. What is the time-sensitive factor most critical to testicular salvage?

Duration of symptoms. ***Duration of symptoms*** - **Testicular torsion** is a medical emergency requiring rapid intervention; the viability of the testicle significantly decreases with prolonged ischemia. - Surgical detorsion within **6 hours** of symptom onset offers the highest chance of testicular salvage. Salvage rates drop drastically after this timeframe. *Age of the patient* - While testicular torsion is more common in adolescents and neonates, the patient's age (22) is not the critical factor determining testicular salvage. - The patient's youth helps with recovery but doesn't change the time-sensitive nature of the condition. *Presence of nausea and vomiting* - Nausea and vomiting are common **sympathetic responses** to severe pain, which often accompanies acute testicular torsion. - These symptoms indicate pain severity but do not directly influence the window for testicular salvage. *Results of Doppler ultrasound* - Doppler ultrasound helps **confirm the diagnosis** of decreased blood flow, but the delay in obtaining and interpreting the results can waste precious time. - Clinical diagnosis is often sufficient to proceed with surgical exploration given the time-sensitive nature of the condition.

Q: Which of the following statements is incorrect regarding vasectomy?

Sterility is achieved 3 weeks after the procedure. ***Sterility is achieved 3 weeks after the procedure*** - Full sterility after vasectomy is not achieved instantly; it typically takes **at least 8-16 weeks** or approximately **20 ejaculations** to clear residual sperm. - Patients are advised to use other birth control methods until a **sperm count of zero** is confirmed by a semen analysis. *The procedure is done under local anesthesia* - Vasectomy is commonly performed using **local anesthesia**, often alongside mild sedation, making it an outpatient procedure. - This approach minimizes patient discomfort and avoids the risks associated with general anesthesia. *The vas deferens is the structure that is divided in the procedure* - The **vas deferens** is indeed the specific anatomical structure that is cut, tied, or sealed during a vasectomy. - This interruption prevents sperm from traveling from the epididymis to the urethra, thus preventing fertilization. *A no-scalpel technique is being widely used now* - The **no-scalpel vasectomy (NSV)** technique is a modern, less invasive approach that uses a puncturing instrument instead of a scalpel incision. - This method typically results in less pain, bleeding, and a quicker recovery compared to traditional incisional techniques.

Q: A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?

Penectomy with deep ilioinguinal node dissection. ***Penectomy with deep ilioinguinal node dissection*** - A **T3 penile lesion** indicates invasion of the corpus cavernosum or corpus spongiosum, which is an aggressive stage requiring **radical local excision (penectomy)**. - **Clinically palpable lymph nodes** alongside a T3 tumor suggest nodal involvement (N1-N3), necessitating a **deep ilioinguinal lymph node dissection** to remove affected deeper lymph nodes that are not readily accessible by superficial dissection. *Penectomy* - While penectomy addresses the primary tumor, it does not manage the **clinically palpable lymph nodes**, which are crucial for staging and prognosis in advanced penile cancer. - This option would be insufficient given the documented **nodal involvement**, leading to likely recurrence and progression of the disease. *Penectomy with superficial node dissection* - This approach is inadequate for **palpable lymph nodes**, especially with a T3 lesion, because such nodes often indicate involvement of **deeper lymphatics (deep ilioinguinal)**. - Superficial dissection alone would likely leave residual disease, failing to properly stage and treat the extent of the cancer. *Chemoradiotherapy* - **Chemoradiotherapy** is typically reserved for patients who are not surgical candidates, or as a neoadjuvant/adjuvant therapy, not as primary treatment for a **T3 lesion with palpable nodes** where surgical intervention is the standard of care for optimal local and regional control. - While it may be used in certain settings, surgery (penectomy with lymph node dissection) offers the best chance for cure in this scenario.

Q: Identify the instrument shown in the image.

Ureteroscope. ***Ureteroscope*** - The image distinctly shows a long, thin, flexible scope with a working channel, consistent with a **flexible ureteroscope**. - The presence of a **guidewire** alongside the scope further indicates its use for navigating the narrow and tortuous ureter. *Nephroscope* - A nephroscope is typically a more rigid and wider instrument used for percutaneous access to the **kidney's collecting system**. - Its design is optimized for procedures within the kidney, not for navigating the ureter. *Cystoscope* - A cystoscope is used to visualize the **bladder** and urethra and is generally shorter and thicker than a ureteroscope. - While it can be flexible or rigid, the instrument shown is too long and thin to be a standard cystoscope. *Laparoscope* - A laparoscope is a rigid instrument used for **abdominal surgery**, inserted through the abdominal wall. - Its design and application are entirely different from the instrument shown, which is designed for internal urinary tract procedures.

Q: A 12-year-old child presents to the OPD with a complaint of scrotal pain and a history of trauma 6 hours ago. On surgical exploration, the following finding is observed. What is the most likely diagnosis?

Testicular torsion with gangrene. ***Testicular torsion with gangrene*** - The combination of **scrotal pain**, history of **trauma**, and the image showing a **dark, necrotic testicle** (implying gangrene) is highly indicative of testicular torsion that has progressed to tissue death due to prolonged ischemia. - Testicular torsion is an emergency where the **spermatic cord** twists, cutting off blood supply; after 6 hours, especially following trauma, the risk of non-viability and gangrene is very high. *Torsion of testicular appendages with gangrene* - While torsion of appendages (e.g., appendix testis) can cause acute scrotal pain, it typically results in a **"blue dot sign"** and is usually a **less severe condition** than testicular torsion. - It would not typically lead to the extensive necrotic appearance of the entire testicle as suggested by the scenario, and surgical exploration revealing gangrene usually points to the whole testis being affected. *Gangrene* - While gangrene is present, this option is **incomplete** as it does not specify the underlying cause, which is critical for diagnosis and treatment. - The context of acute scrotal pain and trauma points to a specific etiology, namely torsion. *Hematoma* - A hematoma would present as a **blood collection**, potentially causing swelling and discoloration, but usually **not the black, necrotic changes** indicative of gangrene from ischemia. - While trauma could cause a hematoma, the description of gangrene points to a more severe vascular compromise.

Q: An 85-year-old male with prostate cancer, Gleason score of 6 , and PSA <8 ng/mL. What is the best management approach?

Active surveillance/Watchful waiting. Androgen deprivation therapy - **Hormonal therapy** is primarily used for advanced, metastatic, or high-risk localized prostate cancer [1], or as an adjunct to radiation therapy. - It is not indicated as a primary first-line treatment for **low-risk, localized prostate cancer** in an elderly patient, as its side effects (e.g., hot flashes, fatigue, bone loss, cardiovascular effects) can significantly impact quality of life without offering a survival advantage in this specific scenario.

Q: A 30-year-old male undergoes varicocele surgery to correct his left-sided varicocele. Following the procedure, the surgeon explains the postoperative changes to the patient. The patient asks, "Through which route does the venous drainage primarily occur after the surgery?" Which of the following is the correct response by the surgeon?

Cremasteric and deferential veins. ***Cremasteric and deferential veins*** - After varicocele surgery, the **internal spermatic veins** (pampiniform plexus) are ligated or embolized, eliminating the primary drainage route. - Venous drainage then shifts to **collateral pathways**: the **cremasteric veins** (which drain to the inferior epigastric vein) and the **deferential/vasal veins** (which drain to the vesical venous plexus). - These provide adequate alternative venous outflow from the testis, preventing venous congestion post-operatively. - This is a well-established anatomical principle in varicocele surgery. *Penile veins* - Penile veins primarily drain the **penis** itself (corpus cavernosum and spongiosum), not the testis. - They are anatomically distinct from the testicular venous drainage system and do not serve as a collateral route after varicocele repair. *Ectopic drainage in the iliac fossa* - This is not a recognized anatomical pathway for testicular venous drainage. - While cremasteric veins eventually drain to the external iliac system via inferior epigastric veins, referring to this as "ectopic drainage in the iliac fossa" is anatomically imprecise and not standard terminology. *At the usual location* - The usual pre-operative drainage is through the **pampiniform plexus → internal spermatic vein** (left side drains to left renal vein, right side to IVC). - This is the pathway that is **surgically interrupted** during varicocele repair (ligation or embolization). - Post-operatively, drainage cannot occur at this location as these vessels are deliberately occluded.

Question 1

Hyperchloremic acidosis is a common complication of:

Accepted Answer

Ureterosigmoidostomy

Answer

Ileostomy

Answer

Vomiting

Answer

Diarrhoea

Question 2

Urinary bladder can be injured in all of the following operations EXCEPT:

Accepted Answer

Inguinal hernia repair

Answer

Surgery for rectum

Answer

Inguinal lymph node dissection

Answer

Hysterectomy

Question 3

Intraoperative recognition of ureter is by which of the following features?

1. Transparent tubular appearance
2. Pale glistening appearance
3. Longitudinal vessels on surface
4. Circumferential vessels on surface

Select the correct answer using the code given below:

Accepted Answer

2 and 3

Answer

2 and 4

Answer

1 and 3

Answer

1 and 4

Question 4

A 22-year-old male rugby player presents with acute scrotal pain that began 2 hours ago. Physical examination shows a high-riding, tender left testis with an absent cremasteric reflex. Doppler ultrasound shows decreased blood flow to the left testis. What is the time-sensitive factor most critical to testicular salvage?

Accepted Answer

Duration of symptoms

Answer

Age of the patient

Answer

Presence of nausea and vomiting

Answer

Results of Doppler ultrasound

Question 5

Which of the following statements is incorrect regarding vasectomy?

Accepted Answer

Sterility is achieved 3 weeks after the procedure

Answer

The procedure is done under local anesthesia

Answer

The vas deferens is the structure that is divided in the procedure

Answer

A no-scalpel technique is being widely used now

Question 6

A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?

Accepted Answer

Penectomy with deep ilioinguinal node dissection

Answer

Penectomy

Answer

Penectomy with superficial node dissection

Answer

Chemoradiotherapy

Question 7

Identify the instrument shown in the image.

Accepted Answer

Ureteroscope

Answer

Nephroscope

Answer

Cystoscope

Answer

Laparoscope

Question 8

A 12-year-old child presents to the OPD with a complaint of scrotal pain and a history of trauma 6 hours ago. On surgical exploration, the following finding is observed. What is the most likely diagnosis?

Accepted Answer

Testicular torsion with gangrene

Answer

Torsion of testicular appendages with gangrene

Answer

Gangrene

Answer

Hematoma

Question 9

An 85-year-old male with prostate cancer, Gleason score of 6 , and PSA <8 ng/mL. What is the best management approach?

Accepted Answer

Active surveillance/Watchful waiting

Answer

Radical prostatectomy

Answer

External beam radiation therapy

Answer

Androgen deprivation therapy

Question 10

A 30-year-old male undergoes varicocele surgery to correct his left-sided varicocele. Following the procedure, the surgeon explains the postoperative changes to the patient. The patient asks, "Through which route does the venous drainage primarily occur after the surgery?" Which of the following is the correct response by the surgeon?

Accepted Answer

Cremasteric and deferential veins

Answer

Penile veins

Answer

Ectopic drainage in the iliac fossa

Answer

At the usual location

Urology — MCQs

Urology — MCQs

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