Genitourinary Section

The following are True False answers

1.

1 T

2 T

3 T

4  F

5  F

Tamoxifen is a estrogen antagonist that functions by binding an estrogen receptor. It is primarily used to fight breast cancer. Despite being an antagonist, it does have weak estrogenic effects. Thus, tamoxifen is associated with increased incidence of endometrial hyperplasia, polyps and cancer. In fact, tamoxifen doubles a woman's risk of endometrial cancer. Typically the post menopausal endometrium measures less than 5mm with thickness up to 8-10 mm acceptable in women taking tamoxifen. It should also be noted tamoxifen will result in uterine enlargement as well as growth of uterine fibroids.

2.

1

2 F

3

3.

1 F

2 T

3 T

4 T

5 T

RETROPERITONEAL FIBROSIS
=ORMOND DISEASE = CHRONIC PERIAORTITIS
Path: dense hard fibrous tissue enveloping the retroperitoneum with effects on ureter, lymphatics, great vessels
Causes:
A. PRIMARY RETROPERITONEAL FIBROSIS (2/3)
Probably autoimmune disease with antibodies to ceroid (by-product of aortic plaque, which has penetrated into media) leading to systemic vasculitis;
Associated with fibrosis in other organ systems (in 8-15%):
mediastinal fibrosis, Riedel fibrosing thyroiditis, sclerosing cholangitis, fibrotic orbital pseudotumor
Age:31-60 years (in 70%); M:F = 2:1
Rx: responsive to corticoids
B. SECONDARY RETROPERITONEAL FIBROSIS (1/3)
(1)Drugs (12%): methysergide, b-blocker, phenacetin, hydralazine, ergotamine, methyldopa, amphetamines, LSD
(2)Desmoplastic response to malignancy (8%): lymphoma, Hodgkin disease, carcinoid, retroperitoneal metastases (breast, lung, thyroid, GI tract, GU organs)
(3)Retroperitoneal fluid collection: from trauma, surgery, infection
(4)Aneurysm of aorta / iliac arteries (desmoplastic response)
(5)Connective tissue disease: eg, polyarteritis nodosa
(6)Radiation therapy
Peak age:40-60 years; M:F = 2:1
weight loss, nausea, malaise
dull pain in flank, back, abdomen (90%)
renal insufficiency (50-60%)
hypertension
leg edema, fever, hydrocele (10%)
claudication (occasionally)

Location:
plaque typically begins around aortic bifurcation extending cephalad to renal hilum / surrounding kidney; rarely extends below pelvic rim, but may extend caudad to bladder + rectosigmoid
IVP
Classic TRIAD:
(1)ureterectasis above L4/5 (interference with peristalsis)
(2)medial deviation of ureters in middle third, typically bilateral
(3)gradual tapering of ureter (extrinsic compression)
usually mild pyelocaliectasis
US:
hypoechoic homogeneous mass in para-aortic region / perinephric space
CT:
periaortic mass of attenuation similar to muscle
may show contrast enhancement (active inflammation)
MR:
low to medium homogeneous signal intensity on T1WI
heterogeneous high signal intensity on T2WI (with malignancy / associated inflammatory edema)
low signal intensity on T2WI (in dense fibrotic plaque)
NUC:
gallium uptake during active inflammation

DDx: lymphoma, retroperitoneal adenopathy
Rx:(1)Withdrawal of possible causative agent
(2)Interventional relief of obstruction
(3)Corticosteroids

4.

1 T

2 T

3 F

4 F

5.

Answer:

1. True

2. False

3. False

4. True

Urinary tract fungus balls are associated with prolonged antibiotic use, diabetes mellitus, steroids, debilitating diseases, and urinary stasis. Also associated with indwelling IV or urinary catheters, AIDS, renal transplant. There is a strong association of Candida fungus balls, DM. Fungus balls do not predispose to malignancy. Candida is the most common organism causing fungus balls, aspergillus, cocci, crypotococcus, torulopsis are reported causes. Fungus balls are usually seen in a systemic debilitating disease.

Renal candidiasis is usually unilateral and is the result of candidemia which usually results from a pulmonary infection. Renal candidiasis results from hematogenous dissemination of the organisms with other major organ involvement like lungs and brain. Another etiology of renal candidiasis is thought to occur without significant hematogenous spread and is higher risk in women and DM-- this is either thru a milder hematogenous spread or ascending from the lower urinary tract.

The radiographic appearance of urinary bladder fungus balls is that of laminated masses containing layered air in sheets. The differential diagnosis would include tumor, blood clot, nonopaque stone, bullous edema, and cystitis of the eosinophilic or glandularis types.

6.

Answer:

5. True

6. False

7. True

8. False

9. True

Two centers control micturition. The first is in the pons, and the second is located in the sacrum. The pontine center is under control of the cerebral cortex. Cerebrovascular accidents and other CNS disease, such as normal pressure hydrocephalus or Parkinsonism, may release control and result in uninhibited bladder contraction. Should a lesion occur below the pons, but above the sacral micturition center (especially above T5), the result is discoordination between voluntary control of the external sphincter by the CNS and the voiding reflex. This is known as bladder-external sphincter dyssynergia. The external sphincter obstructs normal emptying, and the bladder becomes thickened and trabeculated ("Xmas tree" bladder). The upper tracts suffer from high pressure or reflux. Common etiologies include multiple sclerosis, spinal cord tumors, and trauma.

The flaccid or hyporeflexive bladder occurs when the lesion involves the conus medullaris or sacral micturition center. Common causes include disc disease, diabetic neuropathy, pelvic trauma, and surgery.

Successful voiding depends on coordinated activity between the detrusor muscle, bladder neck, proximal urethra, and external sphincter. Dyssynergia, or loss of coordination, occurs at two levels:

Detrusor sphincter dyssynergia can be caused by any entity which interrupts the upper neural pathways inferior to the pons and above L2. It is basically a process caused by injury to the upper neural pathway. Drugs can also be a cause.

Dilatation of the prostatic urethra can be caused by injury to the sympathetic nervous system or alpha blockers.

7.

Answer:

10. True

11. False

12. False

13. True

14. False (on dorsal (upper) side)

Cowper’s glands are two pea-sized glands lying within or at the inferior fascia of the urogenital diaphragm. They empty into the midbulbous urethra inferiorly on both sides of the midline.

The verumontanum is a longitudinal ridge of smooth muscle which extends from the bladder neck almost to the membranous urethra on the posterior wall. The smooth muscle swells about the midpart of the prostatic urethra forming the verumontanum (colliculus). It is approximately 1 cm long and tapers distally within the prostatic urethra to continue as the urethral crest which flattens in the membranous urethra. The verumontanum is within the distal prostatic urethra.

In the male, the normal Mullerian (paramesonephric) duct atrophies at 6 weeks gestation. The vestigial remnants are the prostatic utricle and the appendix of the testes. The appendix corresponds to the fallopian tubes. Nonatrophy of the Mullerian duct can cause cystic dilatations from the vas deferens to the ejaculatory ducts. A utricle cyst can occur close to the prostate in the midline and can cause obstructive symptoms. The cysts lack sperm. Utricle cysts can be associated with hypospadias and undescended testes. This triad raises the possibility of intersexuality. The utricle corresponds to the upper third of the vagina, cervix, and uterus in the female.

The Wolffian (mesonephric) duct (in the male) forms the ureter and renal collecting system, ejaculatory duct, vas deferens, and epididymis. Of course, in the female, only the ureter and renal collecting system are formed.  Gartner's duct cyst and epoophoron are Wolffian.

The glands of Littre are visualized as fine outpouchings on the dorsal (upper) side of the penile urethra. They do not usually fill during retrograde urethrography until inflammatory dilatation occurs.

8.

Answer:

15. true

16. ??true

17. false

18. false

19. true

The posterior urethra extends form the bladder neck to the inf aspect of the urogenital diaphragm and is made up of the prostatic and membranous urethra.

The urogenital diaphragm should be 1-1.5 cm ( the length of the membranous urethra) below the level of the ejaculatory ducts which enter at the verumontanum. This appears to be well above the ischial tuberosities.  Urogenital diaphragm is shown to be above the ischial tuberosities.

The convex symmetric cone shape to the proximal bulbous urethra is the point at the bulbous urethra enters the urogenital diaphragm to continue as the membranous urethra.

Proximal spread of infection can extend as far as the membranous urethra. Instrument strictures produce pressure necrosis in a s-shape. Fixation points are at the penoscotal junction and the membranous urethra. Vast majority of resectoscope injuries occur at the bulbomembranous region with well defined short strictures.

9.

Answer:

20. True (from edema)

21. True

22. True

23. True

10.

Answer:

24. False

25. True

26. True

27. False

28. True

Medullary nephrocalcinosis results from deposition of calcium salts in the distal collecting tubules near the papillae. It is responsible for 95% of all nephrocalcinosis.

Common causes:

                                        - beryllium poisoning.

US examination reveals hyperechoic medullary pyramids with or without posterior acoustic shadowing.

11.

Answer:

29. False

30. False

31. True

32. False

33. True

12.

Answer:

34. occasionally true?

35. true

36.false

37. true

Anomaly occurs from occlusion of fetal ureters before 8-10wks gestation. 41% of fetuses have a contralateral renal anomaly. US is particularly valuable in assessing infants and demonstrates multiple cysts of varying size.

The typical US appearance is a paraspinal mass with macroscopic cysts. Occasionally, sonographic appearance and the size of MCDK can change dramatically on serial examinations as a result of residual glomerular filtration. Any renal disease can lead to oligohydramnios.

13.

Answer:

38. True

39. False

40. True

41. False

42. True

Ionic contrast is a common cause of thrombophlebitis after prolonged contact and is most likely the result of prolonged contact of contrast with venous endothelium..

Contrast has been shown to cause ECG abnormalities which include tachycardia, arrhythmia, ischemic changes. .

Transient increase in pulmonary artery pressure is noted during pulmonary arteriograms.

20% of patients with a history of mild/moderate reaction to prior contrast will have a subsequent reaction. The best single predictor of contrast reaction is prior reaction. 1% of patients with prior contrast study without reaction will have a reaction. Intraarterial administration decreases reaction % by 1/2.

Vasodilation with decrease in peripheral vascular resistance occurs. Systemic effects of Contrast include: increased cardiac output, decreased pressure, decreased peripheral vascular resistance, decrease hematocrit, intravascular blood volume increases. With cardiac , associated Ao , or pulmonary artery injection, the pulmonary artery pressure increases.

14.

Answer:

43. true

44. false

45. true

46. false

Pyelosinus backflow may occasionally be visualized on retrograde pyelograms as occurring when there is rupture of a fornix of the minor calyces. The contrast collects around the renal hilus. Pyelosinus extravasation decompresses the renal pelvis when urine escapes into the perinephric space.

Pyelovenous backflow is thought to occur at the fornices of the calyces where urine enters the venous plexus that surround the calyx. Pyelolymphatic backflow is thought to supplement pyelovenous backflow.

Initially following obstruction there is a rise in renal blood flow that is followed by a rise in ureteral pressure. These decline as obstruction continues. Low osmolar agents has reduced osmotic diuresis. ? increased risk of rupture with high osmolar -ionic agent?

In patients with normal renal function, less than1% of contrast is excreted via the biliary tract and small bowel. Can't usually see on plain radiographs but can see on CT 15-48 hrs post injection. If the pt has depressed renal function, may visualize vicarious excretion on plain film. This is thought to be secondary to increased protein binding in pt with renal insufficiency. Vicarious excretion may also be occasionally seen in acute obstruction.

15.

Answers:

47. True

48. True

49. False

50. False

51. True

Neuro v's nephroblastoma-- neuroblastoma tends to be irregular, ill-defined, calcified. It tends to displace, surround, or encase vessels. Involvement of adjacent LN and prevertebral extension across the midline is frequent.

Neuroblastoma is the most common solid, malignant, extracranial childhood tumor. It is 3rd overall (to leukemia and brain). It is a tumor of neuroblasts and arises along the sympathetic chain. 50% are found in patients < 2 y/o and 75% in patients < 4 y/o. Less than 10% are in patients older than ten. Presentation before 1 year of age carries a more favorable prognosis (60% 2 year survival). Symptoms include abdominal mass, fever, weight loss, and anemia. 70% are disseminated at presentation. Bone, liver and lymph nodes are the most common sites of metastases. Metastases may be localized with I-131 MIBG imaging (82% sensitivity and 88% specificity). 55% have calcification on plain film and 85% on CT (stippled). It typically crosses the midline and encases vessels (SMA, celiac). It may extend into the vertebral canal. It is usually suprarenal or paravertebral. Ultrasound shows inhomogeneous echogenicity. Neuroblastoma may spontaneously mature to ganglioblastoma or ganglioglioma (0.2%).

It is associated with two unusual paraneoplastic syndromes:

and Diarrhea with Hypokalemia syndrome

Wilms tumor is believed to arise from primitive metanephric blastema. It is the most common abdominal malignancy in children (neuroblastoma more common in infancy). 90% present before 8 years of age. Hypertension, attributed to increased renin activity, is present in about 25% (Dahnert says 47-90%) of the cases. It frequently displaces but rarely encases vessels. 5% have calcifications on plain film and 15% on CT (dense clumps or arcs). It frequently invades the IVC. 5% are bilateral and 12-20% have metastases to the lungs at presentation (8-10% have liver metastases, bone metastases are rare). It has an association with hemihypertrophy, aniridia (with or without the Beckwith-Wiedemann syndrome), and Drash syndrome (male pseudohermaphroditism and progressive nephritis), renal anomalies, and genital anomalies.

16.

Answer:

52. true

53. false

54. false

55. false

Neuroblastoma remains clinically silent until it invades or compresses adjacent structures, mets, or produces paraneoplastic syndromes--myoclonic encephalopathy and diarrhea with hypokalemia. Wilms usually presents as a asymptomatic abdominal mass.

Neuroblastoma displaces, surrounds, or frequently encases vessels.

At least 70% present with mets commonly to skeleton, bone marrow, liver, LN, skin. Bone mets are common in kids over 1 y.o. and usually involves the long bones, and orbit. In Resnick, the characteristics of skeletal mets, symmetric involvement, osteolysis, sutural widening, collapse of vertebral bodies. spinal cord compression is frequent.

In children with neuroblastoma, there is greater involvement (2/3rds) below the diaphragm. However, in neuroblastoma with infantile myoclonic encephalopathy, there is slightly greater chest involvement.  Only 2% of pt with neuroblastoma have myoclonic encephalopathy.

17.

Answer:

56. false

57. true

58. false

59. false

60 ???

Although 80% of pt with tuberous sclerosis have AML, only less than 40% with AML have TS. Among pt with TS, AML are usually multiple and bilateral. In pt w/o TS, tumors are usually solitary.

Arteriography can be helpful in dx AML and differentiating it from liposarcoma. If significant vascular components are present, tortuous almost aneurysmally dilated vessels are seen. There is no vascular encasement. Kadir states: most lesions are hypervascular but if fatty elements predominate, it's hypovascular. The arteries supplying the tumor are enlarged and tortuous, neovascularity and aneurysms are present. Arteriovenous shunting is absent. Can be difficult to differentiate from an adenocarcinoma because it has the same features.

Most pt are asymptomatic. Hemorrhage can occur occasionally. Hematuria and HTN are occasionally reported.

18.

Answer:

61. true

62. true

63. true

64. true

Osteomyelitis and septic arthritis is associated with CRI. Effects of parathormone on bone is osseous resorption, brown tumors, periosteal reaction.

Pruritis is a sign of uremia.

Growth retardation is a manifestation of chronic illness.

19.

Answers:

65. True

66. True

67. True

68. False

Horseshoe kidney:

1/3 have associated UPJ obstruction. 1/3 of pt remain asymptomatic . The remainder have symptoms of obstruction, infection, or renal calculus. Ureteral duplication occurs in 10%.

Can get variable blood supply to the kidney; however , increased risk of RAS is not mentioned in Dunnick.

20.

Answer:

69. False

70. True

71. True

72. True

73. True

The differential of a persistent nephrogram is the same as that of an increasingly dense nephrogram:

21.

Answer:

74. False (its the same or greater)

75. False (meglumine is causes more osmotic diuresis)

76. True

77. True

Non-ionic agents have a higher concentration secondary to reduced osmotic diuresis.

The sodium in the sodium agent is partially reabsorbed giving meglumine higher urinary flow secondary to more osmotic diuresis.

Currently used contrast agents are tri-iodinated derivatives of a benzoic acid salt. These salts dissociate in aqueous solution into two ions: an anion (diatrizoate, iothalamate, metrizoate, or iodamide), which contains the three iodine atoms, and a cation, which is either sodium or meglumine, or a combination of both. These compounds are described as "ionic ratio 1.5 monomers" since the three iodine atoms are carried on a molecule that dissociates into two particles in solution. The above ionic monomers have osmolalities 5-6 times that of plasma, in order to have enough iodine to be visible. However, the high osmolality causes endothelial cell disruption, pain, and poor patient tolerance. In 1968, the concept of developing contrast material with lower osmolality was suggested, which could be achieved by increasing the relative number of iodine atoms per particle of contrast material in solution. Ioxaglate meglumine (Hexabrix) is an ionic dimer with 6 iodine atoms for every 2 ions in solution (ratio of 3:1).

"Nonionic" contrast agents were developed in a further effort to reduce complications. Iohexol and iopamidol are also ratio 3 contrast media, by virtue of a polyhydroxylic group on the benzene ring, which allows them to be water-soluble enough to form only one osmotically active particle for every 3 iodine atoms. Therefore, they have the same amount of iodine and only half the osmolality. However, they still have an osmolality twice that of plasma.

Contrast agents such as iodixanol, currently undergoing development, have osmolalities equal to or slightly greater than plasma.

Ionic monomer: Renograffin (diatrizoate meglumine), sinograffin (iopamide meglumine)

Ionic dimer: Hexabrix (ioxaglate meglumine)

Nonionic monomer: Omnipaque (iohexol), Isovue (iopamidol)

Maximal urinary iodine excretion rate is 3 minutes.

22.

Answer:

78. True

79. False

80. True

81. True

82. False

Approximately 15% of patients with renal cell carcinoma without metastases have Stauffer syndrome, which is abnormal liver function in the absence of hepatic metastases.

Polycythemia is seen in 4%, regardless of stage.

Stage I confined within renal capsule

Stage II penetrated beyond capsule but w/in Gerota's fascia

Stage III A- extends to renal v/IVC

Stage  III B- regional LN

Stage  III C- venous and LN

Stage IV A- thru Gerota

Stage IV B- distant mets

23.

Answer:

83. false

84. false

85. ?false

86. ?false

87. true

Growth Hormone is secreted by somatotrophs which make up about 50% of the anterior pituitary.  Growth hormone is a peptide hormone.

Renin is a proteolytic enzyme that is produced and stored in the juxtaglomerular cells. Renin acts on angiotensinogen to form angiotensin I in the lungs. The half life of renin is 10-20 minutes.

Erythropoietin is a glycoprotein and is produced primarily by the kidneys in response to hypoxia and is secreted in the plasma . It acts on erythroid stem cells .

Vasopressin is synthesized in the anterior hypothalamus. Acts on the distal tubular epithelium.. Metabolism/Inactivation of ADH is largely in the liver and kidneys.

Metabolic clearance of hormones is accomplished by several mechanisms. Only small fractions are excreted intact in urine or bile. Degradation and inactivation of the hormone can take place in target tissues or in nontarget tissues such as the liver and kidneys. Peptide hormones are inactivated by proteases, largely in target tissues. Thyroid Hormone is metabolized primarily by the liver. All hormones have one common feature, that alternative pathways exist for catabolism of all hormones described to date. Steroid hormones are also usually degraded in the liver.

24.

Answer:

88. True

89. True

90. True

91. probably False

Pelvic lipomatosis is a nonmalignant overgrowth of adipose tissue with minimal fibrotic and inflammatory components compressing soft tissue structures within the pelvis.

Hypertension is the most commonly reported associated finding.

25.

Answer:

92. True (by 25-30%)

93. False (UP 1/3, LP 2/3)

94. False

95. True (persistence of the renunculae)

26.

Answers:

96. False

97. True

98. prob True

99. False

100. True

101. True

A distended bladder is much more vulnerable to injury than an empty bladder. Cystourography is the examination of choice.

Intraperitoneal bladder rupture (type 2) accounts for approx. 1/3 of major bladder injuries. It occurs when there's a sudden rise in intraabdominal pressure and rupture occurs at the weakest point, the dome where the bladder comes into contact with the peritoneum. Commonly occurs in pt with seat belt or steering wheel injury. 25% occur without a pelvic fracture.

Extraperitoneal bladder injury (type 4) is associated with fracture of the pubic rami/ diastasis of the symphysis. Classically it occurs when there is laceration from a bone fragment. OR it may be a result of stress form the hypogastric wings or puboprostatic ligaments.

27.

Answers:

102. True

103. True

104. True

105. False -has not been proven in humans

106. True

28.

Answers:

107. True

108. True

109. True

Priapism may occur in two ways. Most commonly, it occurs in patients with sickle cell disease, who develop occlusion of the small venous outflow channels, which results in a painful, engorged penis. Another form is "high flow" priapism. It occurs because the arterial inflow has been abnormally increased, often due to trauma or stimulation by cocaine use.

29.

Answer:

110. False

111. False

112. True

113. False

114. True

Typical findings in autosomal recessive polycystic kidney disease:

Typical findings in autosomal dominant polycystic kidney disease:

30.

Answers:

115. False

116. False

117. True

No mention of association of ectopic ureterocele or hypospadias with Hutch diverticulum.

Hutch diverticulum is a congenital deficiency in the musculature adjacent to the UVJ. Associated with ipsilateral VUR.

Answers:

118. True

119. True

120. False

121. True

122. false

123. True

cysteine stones - don't disintegrate with ESWL, they are better treated with percutaneous removal or perc and ultrasonic Rx.

Uric acid stones are the opposite-- better treated with ESWL but resistant to ultrasonic Rx

staghorn calculi - too big for ESWL. Can shatter with ESWL and remove the pieces with perc.

stone greater then 1-2 cm. - use ESWL (limit 2.5 - 3.0 cm.)

stones in child with acute obstruction - ESWL or ureteroscopy 

perc extraction can be applied to ureteral stones as well.

32.

Answers:

124. false

125. True

126. True

127. false

128. False

129. ??? t

130. false

131. false

132. True

Ureteral obstruction is a contraindication to ESWL, as the stone fragments cannot pass. Similarly, UTI is a relative contraindication. Even when the urine clears there is a risk of a nidus of infection in the calculus being released upon fragmentation - therefore, you must treat these patients with caution and often with nephrostomy tube to prevent obstruction by infected material.

Of note, ureteral obstruction is a contraindication but this can be surpassed by placement of a nephrostomy tube for stone passage.

There is a decrease in effective renal plasma flow in the treated kidney. Pt have rise in BP after ESWL which may be secondary to compressive effect of a hematoma resulting in decreased perfusion and compensatory renin release.

Urosepsis, and recurrent infections are only relative contraindications, not true contraindications. A low hemoglobin is also not a contraindication. Morbid obesity is not a contraindication. They will at least try with obesity; however, it is difficult to appropriately set the target of the kidney.

33.

Answer:

133. True

134 . True

135. false--(in normal and neoplastic)

Normal values for prostate specific antigen are around 2 ng/ml and we generally use 4 as our upper range of normal, so 25 ng/ml is definitely elevated.

Benign prostatic hyperplasia (BPH) elevates the level of PSA but at a much lower rate than carcinoma.

PSA is found in normal and neoplastic prostate epithelium and is therefore a differentiation antigen rather than tumor specific.

34.

Answer:

136. True

137. True

138. True

139. True

A striated nephrogram is encountered occasionally as a transitory phenomenon in acute extrarenal obstruction (stone is the most common cause) and in isolated cases of systemic hypotension, intratubular obstruction due to Tamm-Horsfall proteinuria, renal vein thrombosis, acute bacterial nephritis, medullary sponge kidney, and contusion of the kidney.

35.

Answer:

140. False

141. True

142. True?

143. True?

Many risk factors have been cited which predispose to nephrotoxicity, including acute or chronic renal failure, multiple myeloma, older age, proteinuria, and diabetes. The only ones, however, which are supported by the combined literature are (1) chronic renal failure, in which the creatinine level is indeed directly related to the likelihood, severity, and duration of contrast-induced nephrotoxicity, and (2) diabetes mellitus with glomerulopathy. Contrast-induced nephrotoxicity may follow intraarterial or intravenous injection, as well as nonvascular studies such as cholangiography. Additionally, the incidence of contrast-induced nephrotoxicity does not appear to be dose-related, nor does the use of low-osmolality agents prevent its occurrence.

Multiple conflicting studies have shown increased and no risk of ARF following contrast for preexisting renal insufficiency, DM, and dehydration. Other factors in studies have also been implicated which are also controversial--myeloma, contrast induced precipitation of Tamm-Horsfall proteins causing intratubular obstruction, contrast stimulated uricosuria leading to acute urate nephropathy especially seen in pt with myeloproliferative, leukemia following chemo.

Nephrotoxicity usually shows a creatinine peak at 3 days. Urine output, surprisingly, does not usually decrease during this time.

36.

Answer:

144. False

145. True

146. True

147. True

148. True

Mullerian duct cysts (also known as Mullerian duct remnant or prostatic utricle, appendix testicle) occur in males, not females.

37.

Answers:

149. False

150. True

151. False

Consider adrenal hyperplasia in female pseudohermaphroditism

38.

Answers:

152. True

153. False - increase in size not number

154. True

155. False

156. ???

157. ???

158. True

39.

Answers:

159. False

160. True

161. False

162. True 

163. False

In the U.S. approximately 5-10% of all renal stones are composed of uric acid crystals, which are occasionally admixed with sodium and ammonium salts. Although approximately 25% of patients with gout will form uric acid stones, most patients who form uric acid stones have no detectable abnormalities in uric acid metabolism. However, many will have a positive family history of uric stone formation.

Those conditions that predispose to uric acid stone formation include a highly acidic and strongly concentrated urine, excess urinary secretion of uric acid, distal small bowel disease or resection (e.g., regional enteritis), ileostomy, myeloproliferative disorders being treated with chemotherapy, and inadequate caloric or fluid intake. Treatment is directed primarily at increasing urine volume and pH. If hyperuricosuria is present it can usually be corrected with appropriate dietary management and/or administration of allopurinol. Existing uric acid stones can often be dissolved with either systemic or topical alkalinizing agents.

40.

Answers:

164. True

165. ? true ?False - a good time for this to occur but does not usually cause fever unless it's obstructing

166. True

167. False - would have occurred earlier

168. True

Ureteral necrosis is thought to be secondary to compromise of blood supply to the ureter. Necrosis results in a urinoma. This usually occurs before the 6th month post transplant.

Lymphoceles usually occur about 6wks post op. They are largely asymptomatic. If large, can cause ureteral obstruction and impairment of fracture.

41.

Answer:

169. true

170. ??? prob false b/c not likely

171. true

172. true

173. true

Acute bacterial prostatitis usually affects young male adults when it occurs spontaneously, but can also be associated with an indwelling catheter. Usually due to a common urinary pathogen or S. aureus.  Gonococcal is mentioned as causative organism.

In non-bacterial prostatitis, an infectious etiology has not yet been identified. There is non-conclusive evidence for the role of chlamydia or ureaplasm urealyticum. Usually occurs in young sexually active men-- suggests that the organism may be sexually transmitted.

Most common urinary tract infective organisms include E. coli (80%), proteus, klebsiella and occasionally: enterobacter, serratia, pseudomonas.

42.

Answer:

174. True

175.true

176. ?true

177. true

Ureteral manifestations of tuberculosis always occur with evidence of spread from the kidney. There can be filling defects (mucosal granulomas), strictures (giving a "beaded ureter" or "corkscrew ureter"), and a "pipe stem ureter" (rigid aperistaltic short thick and straight ureter) The ureteral orifice (at the UVJ) may become edematous and ulcerated and that ureteral obstruction may follow.

Likewise, schistosomiasis (from S. haematobium) causes calcification, strictures (usually in distal third), and ureteritis cystica, but I could find no evidence of obstruction. Can get a beaded appearance like in TB. Ureteral obstruction is generally produced by fibrosis of the intravesical portion of the ureters. however, abnormalities of ureteral peristalsis may produce these findings.

In retroperitoneal fibrosis , the ureters are encased. There is min-mild ureteral dilatation, but is much less than for the severity of renal failure. This has lead to the supposition that the fibrosis alters peristalsis. The obstruction usually occurs at the middle 1/3 of the ureters.

Chronic cystits should raise the possibility of TB. The possibility of underlying bladder tumor or residual urine due to outlet obstruction or diverticulum should be excluded.

43.

Answers:

178. True

179. False

180. True

181. False

Ureteral jets occur at approximately 1-3 minute intervals.

44.

Answer:

182. True

183. True

184. True

185. ???true

186. False

E. coli and Staphylococcus aureus are responsible for 85%, Gonococcus 12%, and tuberculosis 2%.

Chlamydia and Nisseria gonorrhea are more common in <35 y/o.

E. Coli and Proteus are more common in > 35 y/o

In sexually active men under age 35yo, acute epididymitis is usually secondary to Chlamydia or less likely gonococcus. Usually there is a uretheral d/c.

In older men or following instrumentation, the pathogen is usually gram negatives or urinary pathogens. This group of pt usually don't have urethritis.

For epididymitis in general, the most common organisms include E. coli, and pseudomonas. Can also see in schistosomiasis and TB. Dunnick states that epididymitis is common in middle aged men and adolescents.

45.

Answers:

187. True

188. F

189. True

190. False - it is posterior and medial

191. true

The transversalis fascia inserts into the pubis anteriorly. Posterior to this is the umbilical fascia which is just anterior to the bladder. Therefore, the extraperitoneal space anterior to the bladder can be sub-divided into two spaces. Some texts refer to this entire area as the space of Retzius. Some limit it to just the retropubic space.

Regarding the molar tooth question: when the space of Retzius is filled with fluid, it can have a posterior border which is concave, simulating the appearance of a molar tooth to some observers, so answer this question whichever way you want.

46.

Answer:

192. False???

193. False

194. True

195. True

Prostate carcinoma is the second most common malignancy in males (bronchogenic carcinoma is first). Prostate carcinoma, like prostatic hypertrophy, is androgen dependent. Over 95% of prostate carcinomas are adenocarcinomas, and most originate in the peripheral zone. The Whitmore Jewett staging method is most commonly used:

Approximately 35% of males harbor stage A prostate ca. The origin may be multifocal but by the time they are discovered, the multiple foci have coalesced into a poorly delineated cohesive area of cancer. Stage A had 23% positive LN, B- 18-35%, 50-80% for stage C, and 100% for stage D

47.

Answers:

196. True

197. False

198. True

199. True

200. False

Alport’s (hereditary chronic nephritis) gives increased echogenicity secondary to cortical calcifications

Lymphoma is usually a hypoechoic lesion not limited to the cortex.

In chronic glomerulonephritis you get increased echoes but not necessarily secondary to calcification.

In acute pyelonephritis, usually, but not always, there is normal echogenicity (less likely hypoechoic).

48.

Answer:

201. True

202. True

203. False

204. True

49.

Answer:

205. True

206. True

207. False

208. True

209. False

Reninomas, or juxtaglomerular tumors, occur most frequently in women, with a mean age of about 30. The tumors may be very small, yet hormonally active. They typically arise near the poles of the kidney in a subcapsular location. At discovery, most are 2-3 cm in size. There is usually an elevated plasma renin level and evidence of activation of the renin-angiotensin system; hyperaldosteronism and hypertension frequently bring the patient to attention. Surgery is curative and often provides nearly immediate relief of hypertension.

Ultrasound typically shows the mass to be echogenic, though not of the same intensity as that seen with fat or angiomyolipomas. This is felt to be due to the myriad tissue interfaces that this vascular tumor presents to the ultrasound beam. This vascularity is microscopic, however, and the tumors do not enhance particularly strongly nor does angiography show more than an occasional small feeding vessel. On angio, reninoma is usually hypovascular.

GU

Select the single best answer:

50.

Answer: b

51.

Answer: d

52.

Answer: d

53.

Answer: d. compression of adjacent normal parenchyma

Hypertension is from excess renin production due to crowding of normal parenchyma by cysts. Infection and hemorrhage into the cysts can occur but do not cause hypertension in these patients.

54.

Answer: c. absence of enhancement

55.

Answer: a

On CT the density is variable and depends on the presence of tissue necrosis, hemorrhage, calcification. With contrast, the tumor usually demonstrates inhomogeneous enhancement. Cystic carcinomas are recognized by thick irregular wall.

According to the Bosniak classification, enhancement by at least 10HU, irregular Calcification, irregular wall define a stage III or IV surgical cystic lesion.

56.

Answer: c

Spontaneous renal hemorrhage- 57-63% renal tumor with 30-33% malignant and 24-33% benign- AML lipoma, adenoma, fibroma, ruptured cyst. Less common etiologies include vascular disease( 18-26%)--vasculitis, AVM, aneurysm, and infection(7-10%), coagulopathy

AML are more often in females and the mean age of presentation is 41yo. Most pt are asymptomatic. Hemorrhage can occur.

AVM are congenital and are found more often in women. Are often asymptomatic and not detected until adult life.

RCC is twice as common among men. Can occur at any age but peaks at 6th decade.

57.

Answer: d. adenomyosis

Salpingitis isthmica nodosa (SIN) represents diverticular outpouchings of the midportion of the Fallopian tube. It can be unilateral or bilateral. The etiology is probably infectious - it is associated with infertility and a high incidence of ectopic pregnancy. Tuberculous salpingitis has a similar appearance. Some believe that adenomyosis and SIN are portions on a continuum of the same problem.

58.

Answer: d. stricture

Trauma to the urethra is classified as either posterior or anterior. Posterior urethral trauma can occur in up to 10% of males with pelvic fracture. There are 3 types:

                    Type I:

Surgical repair of these injuries can be immediate (primary) to evacuate the hematoma and to approximate the torn ends of the urethra, or delayed (secondary). In delayed repair, one drains the bladder suprapubically for approximately three months - then a urethroplasty is performed. The general shift has been towards delayed repair which reduces complications. (Incontinence drops from 30% -> ??; impotence drops from 40%-->10%). However, strictures are present in 100% of delayed repairs and in 50-100% of primary repairs.

In anterior urethral injury, the mechanism is either a straddle injury or kick to the groin with the urethra and corpus spongiosum being compressed between a hard object and the inferior pubis. Stricture is the most common complication.

59.

Answer: c

Seminoma is the most common type of pure testicular tumor(30-50% of testicular tumors). >8% of cases of seminoma occur in undescended testes.

60.

Answer: b. Mullerian duct cyst

A cystic midline Mullerian duct remnant can obstruct the bladder and cause hematuria, pain, and infertility.

61.

Answer: ???a

Nephroblastomatosis may either be diffuse or multinodular. It is characterized by persistent nephrogenic blastema which results form an arrest in normal nephrogenesis. In the multifocal form the nodules are microscopic and difficult to image. In the diffuse form , the kidneys are large and the collecting system may be deformed.

The lesions are often hypoechoic but may be iso- or hyper-. Their subcapsular location suggests the dx. The location is also useful for dx on CT. On CT, easily distinguished from normal renal parenchyma by reduced contrast enhancement.

On angio, the renal artery is normal caliber. The nodules are peripheral and don't blush with contrast and the kidney has a scalloped appearance.

62.

Answer: d

Conn's Syndrome is increased aldosterone production either from hyperplasia(20%) or adenoma(80%). Pt usually have Sx of HTN as a result of hypernatremia . AFIP notes also mention muscle wasting. Conns Syndrome adenomas are usually small , less than 2cm. Adrenal hyperplasia is enlargement of the entire gland without a focal mass. Hyperplasia is usually more obvious in pt with Cushings.

Pheochromocytomas can present with headaches, palpitations, diaphoresis. The most common presentation is HTN which is usually labile. Can be associated with MEN, NF, VHL. 90% are located in the adrenal medulla. Dx is made by measuring urinary metanephrines, vanillylmandelic acid. If its intraadrenal, the tumor can be identified on CT with 95% sensitivity.

Nonfunctional adenomas occur in 8% of the general population. Mets are rare in the general pop <1% but common in pt with cancer. Mets are usually larger than 3cm in 80%. With breast , 54% met to adrenal and 36% mets to adrenal with lung ca.  Mets are more likely than a functioning adenoma.

63.

Answer: a or GF with min tubular excretion

In 1960, it was demonstrated that contrast agents- triiodobenzioc acid ( like Conray)-- were excreted by glomerular filtration without a significant component of tubular secretion as opposed to older contrast which had a significant amount of tubular excretion.

64.

Answer: a. it represents slow emptying of the ureter

Primary megaureter, aka primary obstructed megaureter, is a functional obstruction secondary to an aperistaltic segment of the distal ureter. It is more common on the left-- 2/3 of pt have it unilaterally. Like Hirschsprungs of the ureter. Associated with other urinary anomalies such as contralateral UPJ, renal agenesis/ ectopia, ureteral duplication. Adults may present with ipsilateral calculi.

Primary non refluxing, nonobstructive megaureter is uncommon and is associated with Eagle Barrett.

65.

Answer: d

The primitive ureter arises from the Wolffian (mesonephric) duct rather than directly from the bladder. If the ureter fails to separate from the Wolffian duct, the ureter will terminate in a more distal location. In boys, ectopic ureters are less likely to involve duplex systems. Ectopic ureteral openings may be in the posterior urethra, ejaculatory ducts, seminal vesicles, vas deferens, or rectum. Ectopic ureter in males is associated with nonfunctioning renal remnants.

Barriers to UTI include, the bladder, UVJ , and the caliceal structure.

Prostatic ectopic ureter is most likely. Ectopic insertion in to the seminal vesicles, vas, ejaculatory duct usually is associated w/ a nonfunctioning ipsilateral kidney.

66.

Answer: a. pheochromocytoma

Pheochromocytomas (also called paragangliomas) secrete catecholamines which cause episodic hypertension. To make medical diagnosis, check the urine for VMA, catecholamines, and metanephrine. They are associated with MEN IIa and MEN IIb, Neurofibromatosis, von Hippel-Lindau, and multiple cutaneous neuromas. The classic teaching is that 10% are bilateral, 10% are extrarenal, and 10% are malignant (if the pheochromocytoma is extraadrenal, 40% are malignant). Extraadrenal pheochromocytomas occur along the sympathetic chain (including at the organ of Zuckerkandl) On MR pheochromocytomas have intermediate signal on T1 and get extremely bright on T2. If they are small, they have homogenous signal; as they get larger, they can have heterogeneous signal secondary to necrosis. I-131 MIBG scanning is 80-90% sensitive and is highly specific for locating primary and metastatic lesions.

Rule of tens for pheochromocytoma:

Adrenal adenomas are found in 2-8% of patients at autopsy. On MR, they tend to follow normal adrenal gland signal on T1 and T2. We do in- and out-of-phase imaging to demonstrate fat in the adenoma to prove that it is not a metastasis.

Adrenal lipomas follow fat on all sequences.

Adrenal metastases are most commonly from lung or breast carcinoma.

An adrenal cyst is extremely rare. They are predominately endothelial cysts (45%). Pseudocysts (39%) are the most commonly detected cysts clinically - they are usually from prior hemorrhage. They may become large and symptomatic secondary to compression of adjacent structures. Rare echinococcal and true epithelial cysts are seen. If this was a true/false question, this would get a True - it’s just not as bright as pheochromocytoma, so pheochromocytoma was the best answer for this question. On imaging, get septations, debris, calcifications. Adrenal cyst can also get bright on MR T2 wt images. AFIP, 1995

67.

Answer: c. has a cystic appearance with fine septations

The prognosis after complete surgical resection is excellent, so adjuvant chemotherapy and irradiation are not only unwarranted but may produce unnecessary morbidity. Sonographic appearances of both mesoblastic nephroma and Wilms tumor in an older patient are similar to that of a noncalcified uterine leiomyoma - a solid mass with low-level internal echoes. The mass may be relatively hypo or anechoic or mixed echogenicity with anechoic areas. Hemorrhage and necrosis are uncommon. The neoplasm may show gross cystic changes especially at the junction of the tumor and uninvolved kidney. They usually do not calcify.

68.

Answer: a

Unilateral absence of the vas deferens is associated with ipsilateral renal agenesis. The ipsilateral ureter and hemitrigone are gone. Malformations of the lower urinary tract, genitalia, and other organs are not rare in these pts.

Renal ectopia is abnormal position of the kidney without crossover to the other side. The kidney may be dysplastic and subject to reflux because of incompetence of the UVJ. Frequent association with other fusion and rotation anomalies-- crossed ectopia, horseshoe, malrotation.

Pt with partial or incomplete duplication have a frequency of disease similar to patients with nonduplex systems.

Undescended testes commonly occurs as an isolated phenomenon or it may be associated with other urogenital anomalies such as renal agenesis or ectopia, prune belly, and epispadias. Usually secondary to mechanical obstruction or hormonal dysfunction.

69.

Answer: e

Prolonged / increasingly dense nephrogram can be seen with diminished perfusion as in systemic hypotension, RAS, renal v thrombosis, ATN, or in obstruction either intratubular-- uric acid crystals, Bence Jones protein ( myeloma) ,Tamm-Horsfall ( dehydrated children), or extrarenal obstruction- stone.

Pyelonephritis can have a normal urogram in 3/4 of pt. Abnormal findings on urogram include : diffuse renal enlargement, delay in appearance on contrast to collection system, attenuation of calyces secondary to edema, decrease in density of nephrogram in affected portion of kidney.

70.

Answer: b

Cowper's glands lie on either side of the membranous urethra. The ducts empty into the sump (which is the dilation of the proximal half of the bulbous urethra) of the bulbous urethra.

71.

Answer: d. nephrotic syndrome, probably the best answer according to PR

72.

Answer: d. calcium oxalate

Following bypass surgery there is excessive fat within the intestinal lumen leading to steatorrhea. The excess fats bind to intraluminal calcium that would normally combine with oxalate rendering it insoluble. As a result more oxalate is reabsorbed by the intestines and excreted in the kidneys leading to hyperoxaluria.

Also note that there is an increased incidence of uric acid stones or mixed uric acid/calcium oxalate stones in patients with ileostomy due to increased loss of bicarbonate which in turn leads to acidic urine, favoring uric acid stone formation.

73.

sigmoid > cecum

In pt with bladder extrophy, bladder augmentation is performed with a ureterosigmoidostomy which needs f/u for adenoCA.

Ureterosigmoidostomy anastomosis of the ureters into the sigmoid. Antireflux techniques can be performed. There is continence if the rectum has normal function. Latent period for carcinoma at the ureteral anastamosis is 15-20 years.

74.

Answer: d. lymphoma

Possible causes of lateral deviation of both lumbar ureters: (Lateral deviation exists when the ureter is >1 cm lateral to the transverse process in the suprapelvic region):

Possible cause of lateral deviation of the pelvic ureters:

Medial deviation of the lumbar ureters is seen with:

Medial deviation of the pelvic ureters:

The most common cause of lateral displacement of the middle 1/3 of the ureter is retroperitoneal LN enlargement.

75.

Answer: a. bladder neck

76.

Answer: c. transitional zone

Prostate hypertrophy may be diffuse enlargement of the stromal and glandular elements of the transitional zone and periurethral glandular tissue, but more commonly consists of nodular enlargement. Nodules arise in the transitional zone and are vascular fibrous tissue.

77.

Answer: a. RUG

want to determine the patency of the urethra prior to any manipulation

78.

Answer: b. Two shot IVU

79.

Answer: b. transitional cell carcinoma

This constellation of findings suggests analgesic abuse with subsequent development of transitional cell carcinoma. TCC is 8X more common in analgesic abusers.

80.

Answer: a. infection with Staphylococcus aureus

Failure of closure of the urachus at the bladder attachment results in a urachal cyst (there is closure in the supravesicle segment). A patent urachus is failure of closure of the entire length of the urachus. A urachal sinus is a blind-ending dilation at the umbilical end. A vesicourachal diverticulum is a anterosuperior bladder diverticulum.

Urachal cysts may be asymptomatic - when they present in adults it is usually because of infection. Stones rarely occur.

70% of adults retain a minute urachal lumen. 30% of adults have luminal continuity of the bladder with the urachus. Urachal carcinomas are 0.2% of all bladder carcinomas.

81.

Answer: c. papilloma

Benign tumors of the urothelium account for 20% of ureteral neoplasms. The benign papilloma is the most common benign urothelial neoplasm (75% of benign neoplasms). They present as solitary filling defects and some consider them to be low grade malignancies. They are related to the inverted papilloma. They can obstruct, but less commonly than TCC.

The most common nonepithelial tumor is the benign fibrous polyp which presents with hematuria, flank pain, and a variable degree of obstruction.

82.

Answer: a. renal pelvis obstruction

Xanthogranulomatous pyelonephritis is a form of chronic infection which is associated with long-standing obstruction and secondary stone formation (usually due to infection with Proteus). The renal parenchyma is replaced by low-density material (foamy, lipid-laden macrophages that give the cut surface a yellow color), and the inflammatory process frequently extends outside the kidney to involve adjacent tissues. Most cases are associated with gram-negative infection and an obstructing calculus, typically a staghorn. The disease is commonly focal in children, but usually involves the whole kidney in adults. Treatment usually requires surgical resection.

1991 - "mass with multiple calcifications - tumefactive XGP"

The triad of XGP is staghorn, absent / diminished excretion of contrast on IVU, poorly defined renal mass.

83.

answer: b

In XGP, active UTI with E.coli ,proteus, klebsiella, pseudomonas either alone or in combination is present in virtually every case.

84.

Answer: a. ultrasound

85.

Answer: a. seminoma
 

Germ cell tumors of the testis are the most common malignant solid tumors in young men. About 10% arise in cases of cryptorchidism. Roughly two-thirds of germ cell tumors are purely one cell type. The most common primary testicular tumor in the 3rd-4th decades is the seminoma (40%), followed by the teratocarcinoma and embryonal cell carcinoma (each approximately 25% of tumors).

Testicular tumors spread locally to the epididymis and spermatic cord, and distally by hematogenous spread (usually to the lungs) or more commonly via the retroperitoneal lymphatic channels to the renal hila, bypassing the obturator and iliac node chains.

Choriocarcinoma has the worst prognosis, with a 5-year survival of less than 1%. Seminoma, on the other hand, has a high cure rate. The tumor is highly radiosensitive and even large nodal metastases are treatable.

86.

Answer: a epithelial

Another name for oncocytoma is tubular cell adenoma. (An angiomyolipoma is a hamartoma.) It is frequently associated with a central stellate scar. Note, however, that renal cell carcinoma can also cause a stellate central scar.

Oncocytoma arises from the proximal tubule. Oncocytoma contains oncocytes. An oncocyte is a large transformed epithelial cell which has finely granular eosinophilic cytoplasm.

87.

Answer: a. according to MB all are associated with pelvic lipomatosis

Pelvic lipomatosis:

Idiopathic retroperitoneal fibrosis (Ormond disease) accounts for 68% of cases of RPF. When idiopathic, it is most common in middle-aged men. It usually occurs in the abdomen, around the abdominal aorta, causing medial deviation of the midureters and ultimately ureteral obstruction. Even when the aorta is surrounded by fibrosis it is not usually displaced (unlike adenopathy which tends to elevate the aorta off the spine). RPF may also be associated with medications, most notably ergot derivatives. Other potential causes:

88.

Answer: d   bladder external sphincter dyssynergia-- or b. detrusor dyssynergia  is the same thing but have to make sure it's the external sphincter that's affected.

Discoordination between voluntary control of the external sphincter by the CNS and the voiding reflex-- This is known as bladder-external sphincter dyssynergia. The external sphincter obstructs normal emptying, and the bladder becomes thickened and trabeculated ("Xmas tree" bladder). The upper tracts suffer from high pressure or reflux.

Dyssynergia -- can be internal or external sphincter .

The internal sphincter is at the bladder base. The external sphincter is at the membranous urethra. In order to have dilatation of the posterior urethra, have to have dyssynergia with the external sphincter.

Autonomic dysreflexia is with injury above the pons. Get hypertension with voiding.

89.

Answer: d. annual follow-up

With AML if they are asymptomatic you can leave them alone. If the mass is less than approximately 3.5 cm and the patient has symptoms the best answer would be embolotherapy, which is not a choice. If the mass is greater than 3.5 cm, with symptoms, treatment is with a partial nephrectomy.

90.

Answer: d. peripheral zone

Carcinoma of the prostate usually (75%) begins in the peripheral zone, usually as an adenocarcinoma with varying degrees of differentiation. The second most common location is the transitional zone (20%), then the central zone (10%).

91.

Answer: c. decreased peristalsis of ureter

92.

Answer: c. intrinsic ureteral abnormality

94.

Answer: a. hemorrhage

The most common complication of renal biopsy is hemorrhage. If all patients were examined with CT after renal biopsy, it is likely that almost all would have at least a small perirenal hematoma.

95.

Answer: b. pneumothorax or c. hemorrhage

Often, the posterior approach to the adrenal gland crosses the pleura; therefore, the most common complication is pneumothorax.

If an effort is made to avoid the pleura with angled or transhepatic approaches, the risk of pneumothorax can be greatly reduced. In Bernardino’s series of 58 biopsies, hemorrhage occurred in 6 patients (12%)

.

96.

Answer: c. renal vein thrombosis

97.

Answer: b. lymphocele

Lymphocele is the most common (1-15% of cases) - it occurs secondary to inadequate ligation of the lymphatics. It is typically seen 2-4 weeks after the transplant. It is more common in patients with a prior episode of rejection.

98.

Answer: a. stricture

Gonococcal urethritis is the cause of approximately 40% of male urethral strictures in the U.S. Chlamydia and mycoplasma are also frequent causes of urethritis, though stricturing is less common. Tuberculosis and schistosomiasis both may cause urethritis and stricturing, as well as fistula formation.

99.

Answer: d. chronic glomerulonephritis

adult polycystic kidney disease - 10%

Goodpasture’s - a minority

nephrosclerosis - 20-30%

chronic glomerulonephritis - 20-30%. Note that AFIP (8/94) lists chronic glomerulonephritis as the most common cause of end-stage renal disease.

100.

Answer: b. pyelotubular backflow

Parenchymal scarring is actually a result of vesicoureteral reflux and subsequent reflux of urine back into the renal tubules, aka intrarenal reflux.

101.

Answer: prob c. hepatic v thrombosis by tumor or may be hepatic dysfunction secondary to RCC but  toxins? as in answer b

This probably represents Stauffers’ syndrome 15% of RCC.

This question probably refers to Budd-Chiari syndrome secondary to tumor thrombosis. On CT, Budd-Chiari shows hepatomegaly and ascites with poor visualization of the hepatic veins (usually). Contrast enhancement is inhomogeneous with central enhancement first and delayed peripheral enhancement. Abnormal LFTs are associated with Budd-Chiari.

The gold standard for diagnosis is hepatic venography which shows intravascular thrombosis

Causes of Primary Budd-Chiari:

Causes of Secondary Budd-Chiari:

Histologically, 80-95% of renal cell carcinomas are clear-cell type. These are typically hypervascular (65-75%) and are associated with a more aggressive disease. The remainder are papillary cell type, which tend to be more indolent.

CT should detect renal cell carcinoma metastases to the liver

In hepatitis, the liver is usually enlarged.

Hepatic v occlusion by tumor with or without IVC obstruction may lead to hepatosplenomegaly and ascites. Disturbances in LFT 's without demonstrable liver mets are sometimes found and reversed after tumor removal.  Hepatic dysfunction syndrome the liver is hypervascular on angiography. No etiology is noted.

102.

Answer: a. bone metastases

Bone metastases are not usually seen - they are usually lytic and secondary to sarcomatous or anaplastic tumors. Pulmonary metastases are seen in 12-20%; liver metastases are seen in 8-10%. Wilms tumor usually spreads by direct invasion and by lymphatics to the retroperitoneal lymph nodes and hematogenously into the renal vein and IVC.

Staging of Wilms Tumor:

Wilms is the most common solid abdominal mass and the most common renal malignancy of childhood. Its incidence is highest between 30 months and 3 y/o. It usually presents with an asymptomatic abdominal mass.

15% have congenital abnormalities of the GU tract/musculoskeletal system:

Possible Associated Syndromes/findings:

103.

Answer: a. iatrogenic

104.

Answer: a. acute peritonitis

Acute peritonitis is the most common and is usually caused by infection or leak at the site.

105.

Answer: a. zona glomerulosa

The adrenal medulla produces epinephrine and norepinephrine.

The outer cortical layer, the zona glomerulosa, produces mineralocorticoids, principally aldosterone. Conn’s syndrome is primary aldosteronism.

The middle cortical layer, the zona fasciculata, makes cortisol.

The inner cortical layer, the zona reticularis, produces androgens, primarily DHEA.

106.

Answer: no clue

107.

Answer: c. a sedimentation level

This may be a trick question. A fatty mass may have homogeneous low attenuation, and the question does not say what the Hounsfield value is. Almost anything could have a smooth margin. Since the question does not say simple cyst, anything with a sedimentation level is cystic (not necessarily benign) so this is probably the right answer.

108.

Answer: c. prior biopsy

Traumatic arteriovenous fistulae almost always result from penetrating renal injury. The vast majority occur after percutaneus renal biopsy, are not hemodynamically significant, and close spontaneously.

Renal cell carcinoma commonly has neovascularity but rarely has AV fistula.

109.

Answer: c or a

The answer is either oncocytoma (occurs in 30%) or renal cell carcinoma (occurs much less frequently in RCC but RCCs are much more common.)

Oncocytoma makes up 3% of renal neoplasms.

Genitourinary Section

The following are matching questions

110.

111.

1??

2???

3???

112.

1??

2???

3???

4???

113.

Answer:

1. ??? d after the papilla has sloughed?

2. d

3. a

4. c

In TB, the tips of the papilla demonstrate a moth eaten irregular appearance early. As the disease progresses, there is extensive papillary necrosis with formation of frank cavities which may communicate with each other. There is multiple irregular infundibular stenoses and strictures which is the hallmark of renal TB. Infundibular stenosis lead to calyceal clubbing.

Chronic pyelonephritis is thought to be secondary to chronic reflux of infected urine. Radiologic findings include the demonstration of one or more parenchymal scars. with clubbed calyx in area of disease. There may be focal areas of compensatory hypertrophy.

As obstruction continues, there is progressive atrophy of the parenchyma. On urography, see a thin rim of parenchyma surrounding dilated collecting systems. The overall size of the kidney is reduced.

Analgesic abuse is secondary to free radical damage of the kidneys. There is higher concentration of the drugs in the papilla than the cortex. Findings include smaller kidneys, small collections of contrast in the papillary region, sloughed fragments of papilla. . "wavy" renal contour secondary to scarring.

114.

Answer:

5. c

6. b

7. e

Matrix stones are rare, but are found most commonly in patients with urease producing infections like Proteus. They can also be found in patients on dialysis. Matrix stones are composed of mucopolysaccharide and proteins. they are relatively radiolucent (radiolucency depends on the content of calcium coprecipitated in the matrix) on plain films and can be confused with uric acid stones. However, uric acid stones form in acidic urine and matrix stones form in alkaline urine. Davidson states that on CT matrix stones have similar attenuation to soft tissue; whereas all other stones have increased attenuation compared to soft tissue.

Uric acid stones comprise approximately 8-10% of all renal stones. They are usually found in males older than 50 y/o without evidence of gout. Davidson’s text states that 25% of patients with gout will develop uric acid stones. The most important factor in the formation of uric acid stones is acid urine pH; therefore, RTA type I patients don’t make uric acid stones. RTA type I has basic urine with a pH>5.5. In RTA II and IV, the urine pH is <5.5.

Calcium oxalate stones are classically seen in patients with inflammatory bowel disease, malabsorption, and primary hyperoxaluria. However, calcium oxalate stones can form in anyone with hypercalcuria.

115.

Answer:

8. d

9. ??? c or a

10. b

11. e

Cysteine stones are usually seen in pt with cystinuria who have a defect in renal tubular reabsorption of amino acids cystine, ornithine, lysine, arginine. Opacity of cystine stones depend on how much calcium is mixed in . Pure cysteine stones are radioopaque but not as dense and calcium.

Struvite stones form when the urine PH is above 7.2 . Usually seen in light of UTI usually P. mirabilis. Struvite stones are low density but are often found laminated with calcium.

Urate stones are formed in acid urine pH<5.75. Pt usually have hyperuricosuria but not necessarily hyperuricemia. Uric acid stones are poorly radiopaque and can't be seen on plain film. Account for the majority of lucent stones. Can be easily seen on CT.

Calcium oxalate and phosphate stones crystallize when the two ions exceed the solubility product. Hypercalcemia is a common cause. Calcium stones are relatively dense and can be easily seen on plain film.

Triamterene is a diuretic which interferes with sodium reabsorption and K and hydrogen secretion. Associated with stone formation. The stones are usually triamterene mixed with calcium oxalate or uric acid.

116.

prostate ca is most commonly (95%) located in the peripheral zone of the prostate.

BPH usually involves the transitional zone and occasionally the periurethral glandular zone.

There is anatomic controversy as to the common sites of prostatitis. There is a shift of emphasis from the periurethral glands to the peripheral zone and is now the mainly accepted location.

117.

Answers:

15. b

16. c

Hutch Diverticulum:

Hypospadias:

Epispadias (bonus):

118.

Answer:

17. b

18. a ?d

Eagle-Barrett syndrome (prune belly) is associated with dilated laterally placed ureters with functional obstruction (aperistaltic).

40% of patients with cryptorchidism have associated anomalies of the vas and epididymis.

Male pseudohermaphroditism is the presence of testes and feminized genitalia. It is due to decreased androgens and decrease response by target organs.

119.

Answers:

19. b

20. c and e

21. b and e 

22. e

70% of sodium is actively reabsorbed in the proximal convoluted tubule.

Acid base balance is in the distal convoluted tubule and the collecting duct,

Proximal Convoluted Tubule:

- salt/water reabsorbed

- isosmotic tubule fluid

Ascending Limb:

- water impermeable

- salt reabsorption

- hypotonic tubule fluid

- medullary osmolar gradient

Collecting Duct:

- transverse hyperosmolar medulla

- water reabsorption (ADH)

- reduced volume

- hypertonic urine

120.

Answer:

23. b, d

24. c

25. a

26. d

Hydroceles can be idiopathic or can be a result of trauma, infection, infarction, or torsion.

Spermatocele is located in the globus major of the epididymis.

121.

Answer:

27. a

28. c

29. d

Malakoplakia is not premalignant. It is usually due to chronic infection (usually with E. coli). The yellowish plaques (typically umbilicated and surrounded by hyperemia) which appear on the bladder surface are comprised of large histiocytes which contain partially digested bacteria and calcospherules called Michaelis-Gutmann bodies. They look similar to cystitis cystica radiographically.

Leukoplakia is a rare condition in which chronic infection or inflammation transforms the normal uroepithelium into keratinized squamous epithelium, which creates focal or generalized plaques that may desquamate. It is most common in the bladder, but may occur anywhere along the urinary tract. It is most common in the third to fifth decades and has no gender predilection. It is associated with stone disease in half of cases. It is felt to be linked to epidermoid carcinoma, which is present in 20% of patients at the time of diagnosis. Radiographically, the lesions appear as plaques, or thickening, which may become confluent over large areas. Desquamated keratin may produce lacy filling defects. It does not resemble urethritis or pyelitis cystica, which typically produces numerous small, rounded filling defects, which are sharply defined, most commonly in the proximal ureter and renal pelvis. If shed into the distal ureter, this material may obstruct and produce a pattern of renal colic, with hematuria and renal impairment mimicking stone disease.

*