Urology Question Bank

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1. What was the principal finding of the Prostate Cancer Prevention Trial (PCPT) of finasteride?

PCPT randomised about 18,000 men aged 55 or older with normal examination and PSA of 3 ng/mL or less to finasteride or placebo for 7 years. Finasteride reduced prostate cancer period prevalence by about 25%, mainly low-grade tumours, and the initially reported excess of high-grade cancer was largely explained by detection bias from gland shrinkage. Long-term follow-up (18 years) showed no difference in overall or prostate cancer-specific survival. Therefore claims of reduced mortality or improved survival are incorrect, and the reduction in detection was clearly significant. Pearl: REDUCE showed a similar ~23% reduction with dutasteride; neither agent is licensed for prevention.

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2. In Burch colposuspension, sutures placed in the paravaginal fascia at the level of the bladder neck are anchored to which structure?

Burch colposuspension elevates and supports the bladder neck and proximal urethra by suturing the paravaginal fascia to the ipsilateral iliopectineal (Cooper's) ligament via open or laparoscopic retropubic access. Long-term cure rates are about 70–80% and comparable to retropubic mid-urethral slings, with more voiding dysfunction and later posterior compartment prolapse. Suturing to the pubic periosteum is the Marshall–Marchetti–Krantz procedure, abandoned because of osteitis pubis. Attachment to the arcus tendineus defines paravaginal repair. Sacrospinous fixation treats apical prolapse. Pearl: colposuspension is a key non-mesh option in current NICE guidance.

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3. Which patient most clearly warrants a full metabolic evaluation, including 24-hour urine collection, after the first stone episode?

EAU guidelines recommend a basic evaluation for all stone formers: stone analysis, urinalysis, and serum creatinine, calcium and uric acid. A specific metabolic evaluation with 24-hour urine collections is reserved for high-risk patients. These include children, recurrent stone formers, those with a solitary kidney, bilateral or large stone burden, nephrocalcinosis, and cystine, uric acid, brushite or infection stones. They also include patients with bowel disease, hyperparathyroidism, RTA, medullary sponge kidney or a strong family history. A solitary kidney makes any recurrence dangerous. A first small passed stone, or a single calcium oxalate stone with no risk factors, is low-risk. Pearl: occupations such as pilots are also considered in risk stratification.

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4. A 3-month-old boy presents with fever of 39 °C and irritability, with no focus on examination. A urine bag specimen shows leucocyte esterase and nitrite positive, and the laboratory reports mixed growth. Before starting antibiotics, what is the most appropriate step to confirm the diagnosis?

Bag specimens have contamination rates as high as 60–85%, so a positive or mixed-growth bag culture cannot confirm UTI. In a febrile infant who is not toilet trained and requires antibiotics, the AAP recommends obtaining urine by catheterisation or suprapubic aspiration before treatment; clean-catch is an alternative when feasible (NICE). A negative bag urinalysis can help exclude UTI, but a positive one must be confirmed. Repeating a bag specimen retains the contamination problem. Ultrasound can support but does not establish the diagnosis of UTI.

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5. A 45-year-old woman with ACTH-independent Cushing syndrome from a 3 cm right adrenal adenoma undergoes laparoscopic right adrenalectomy. Her left adrenal gland appeared atrophic on CT. What is the most appropriate perioperative endocrine management?

Chronic autonomous cortisol secretion suppresses ACTH, causing atrophy of the contralateral adrenal gland and of normal tissue on the same side. After removal of the adenoma, patients develop secondary adrenal insufficiency that can last months to over a year. Perioperative stress-dose hydrocortisone, followed by physiological replacement tapered according to recovery of the hypothalamic–pituitary–adrenal axis (checked with morning cortisol or an ACTH stimulation test), is required. Patients need sick-day rules. Omitting cover risks adrenal crisis. Mineralocorticoid function is preserved via the renin–angiotensin system, so fludrocortisone alone is inappropriate. A single dexamethasone dose is insufficient. Pearl: the same applies to mild autonomous cortisol secretion.

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6. A 9-year-old girl with lumbosacral myelomeningocele is continent of urine on clean intermittent catheterisation and an antimuscarinic. She has faecal soiling most days despite 2 years of a supervised bowel programme with oral laxatives, scheduled toileting and daily retrograde transanal irrigation, which she cannot perform independently. She is motivated to achieve independent bowel care. What is the most appropriate next step?

Neurogenic bowel dysfunction is common in spina bifida and faecal soiling severely affects quality of life. Management is stepwise: diet, laxatives, scheduled toileting and retrograde transanal irrigation. When these fail or cannot be managed independently, the Malone antegrade continence enema (MACE), usually an appendicocaecostomy, allows the child to flush the colon antegradely through a catheterisable stoma, achieving continence in about 70–90%. It can be created at the same operation as a Mitrofanoff channel, splitting the appendix if needed. A colostomy is a last resort. Escalating laxatives worsens soiling in a child with sphincter denervation. Sacral neuromodulation requires intact sacral reflex pathways and is not effective in myelomeningocele.

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7. A 3-year-old boy presents with acute urinary retention and haematuria. Ultrasound and MRI show a 5 cm lobulated, solid, enhancing mass arising from the bladder base and prostate, with bilateral mild hydronephrosis and no distant metastases on staging. What is the most appropriate initial management?

Rhabdomyosarcoma is the most common paediatric bladder and prostate tumour, usually embryonal (including botryoid) histology with a relatively favourable prognosis. After tissue diagnosis, preferably by transurethral or needle biopsy, management follows cooperative group protocols (COG, EpSSG): multi-agent chemotherapy such as vincristine, actinomycin D and cyclophosphamide or ifosfamide first, followed by local control with radiotherapy and/or conservative surgery, aiming at bladder preservation, which is achieved in a majority. Primary radical cystoprostatectomy is reserved for residual or recurrent disease. Radiotherapy alone is inadequate systemic treatment.

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8. A 45-year-old office worker has a 6 mm non-obstructing stone in a lower pole calyx found incidentally on CT for abdominal pain later attributed to gastritis. He has no history of stones, no infection and normal renal function, and he has no occupational requirement to be stone-free. What is the most appropriate management?

Small asymptomatic, non-obstructing calyceal stones can be managed with active surveillance. EAU guidelines advise periodic follow-up imaging (for example at 6 months and then yearly), with intervention if the stone grows, causes symptoms, obstruction or infection, or if the patient prefers treatment. The annual risk of a symptomatic event is modest, and lower pole stones are less likely to migrate. Shock wave lithotripsy, flexible ureteroscopy and PCNL all carry procedural risks that are not justified for a small incidental stone. Pearl: occupations such as pilots, and patients with a solitary kidney or who travel to remote areas, may justify earlier treatment.

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9. An 8-year-old girl has recurrent afebrile UTIs, daytime wetting and constipation. Uroflowmetry shows a staccato (fluctuating) curve with prolonged voiding time, simultaneous pelvic floor EMG shows increased activity during voiding, and post-void residual is 45 mL on repeated measurements. Neurological examination and spine imaging are normal. After starting laxatives, what is the most appropriate specific treatment?

Dysfunctional voiding is habitual contraction of the external sphincter or pelvic floor during voiding in a neurologically normal child, producing a staccato flow curve, pelvic floor EMG activity during voiding, incomplete emptying, UTIs and constipation. Treatment is urotherapy and bowel management combined with pelvic floor relaxation training, particularly animated biofeedback using flow and EMG displays, with good success rates. Antimuscarinic monotherapy may worsen residual urine. Bladder neck incision is inappropriate because the obstruction is functional at the sphincter. Detrusor botulinum toxin treats refractory detrusor overactivity, not sphincter overactivity.

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10. After relief of chronic high-pressure urinary retention, post-obstructive diuresis is conventionally defined by which urine output?

Post-obstructive diuresis occurs in a proportion of patients after relief of bilateral obstruction or high-pressure chronic retention, due to excretion of retained urea, sodium and water, impaired tubular concentrating ability and natriuretic factors. It is usually defined as urine output above 200 mL/h for two consecutive hours or above 3 L in 24 hours. Most cases are physiological and self-limiting, but a pathological phase can cause hypovolaemia and electrolyte disturbance. Management includes monitoring vital signs, urine output and electrolytes, and replacing a proportion of losses intravenously when the patient cannot keep up orally. The other thresholds do not match the accepted definition. Pearl: raised creatinine, oedema and confusion predict risk.