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Campbell Walsh Urology 12Th Edition Review 3E Mar 2 2020 - 0323639690 - Elsevier Alan W Partin Online Ebook Texxtbook Full Chapter PDF
Campbell Walsh Urology 12Th Edition Review 3E Mar 2 2020 - 0323639690 - Elsevier Alan W Partin Online Ebook Texxtbook Full Chapter PDF
Review, 3e (Mar 2,
2020)_(0323639690)_(Elsevier) Alan W.
Partin
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Campbell-Walsh-Wein
UROLOGY
TWELFTH EDITION REVIEW
Alan J. Wein, MD, PhD (Hon), FACS Thomas F. Kolon, MD, FAAP
Founders Professor and Emeritus Chief of Urology Howard M. Snyder III MD Chair
Division of Urology in Pediatric Urology
Director, Residency Program in Urology Pediatric Urology Fellowship
Perelman School of Medicine at the University Program Director
of Pennsylvania Children’s Hospital of Philadelphia
Penn Medicine Professor of Urology in Surgery
Philadelphia, Pennsylvania Perelman School of Medicine
at the University of Pennsylvania
Philadelphia, Pennsylvania
Editors
Alan W. Partin, Roger R. Dmochowski, Louis R. Kavoussi, Craig A. Peters,
MD, PhD MD, MMHC, FACS MD, MBA MD
The Jakurski Family Director Professor, Urologic Surgery, Professor and Chair Chief, Pediatric Urology
Urologist-in-Chief Surgery, and Gynecology Department of Urology Children’s Health System Texas
Chairman, Department Program Director, Female Zucker School of Medicine Professor of Urology
of Urology Pelvic Medicine and at Hofstra/Northwell University of Texas
Professor, Departments Reconstructive Surgery Hempstead, New York Southwestern Medical Center
of Urology, Oncology, Vice Chair for Faculty Affairs Chairman of Urology Dallas, Texas
and Pathology and Professionalism The Arthur Smith Institute
Johns Hopkins Medical Section of Surgical Sciences for Urology
Institutions Associate Surgeon-in-Chief Lake Success, New York
Baltimore, Maryland Vanderbilt University Medical
Center
Nashville, Tennessee
Elsevier
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material herein.
Printed in China
Brian G. Blackburn, MD, FIDSA Elizabeth Timbrook Brown, MD, MPH, Michael A. Carducci, MD
Clinical Associate Professor of Internal FACS AEGON Professor in Prostate Cancer
Medicine/Infectious Diseases and Assistant Professor of Urology Research
Geographic Medicine Department of Urology Sidney Kimmel Comprehensive Cancer
Stanford University School of Medicine MedStar Georgetown University Center at Johns Hopkins
Stanford, California Hospital Johns Hopkins University School of
Washington, District of Columbia Medicine
Bertil Blok, MD, PhD Baltimore, Maryland
Urologist Benjamin M. Brucker, MD
Department of Urology Associate Professor Maude Carmel, MD
Erasmus Medical Center Director of Female Pelvic Medicine and Assistant Professor of Urology
Rotterdam, the Netherlands Reconstructive Surgery University of Texas Southwestern Medical
Departments of Urology and Obstetrics Center
Michael L. Blute, MD and Gynecology Dallas, Texas
Chief New York University Langone Health
Department of Urology New York, New York Peter R. Carroll, MD, MPH
Walter S. Kerr Jr., Professor of Urology Professor
Massachusetts General Hospital/Harvard Kathryn L. Burgio, PhD Ken and Donna Derr-Chevron
Medical School Professor of Medicine Distinguished Professor
Boston, Massachusetts Division of Gerontology, Geriatrics, and Taube Family Distinguished Professor
Palliative Care Department of Urology
Timothy B. Boone, MD, PhD University of Alabama at Birmingham University of California–San Francisco
Chair, Department of Urology Associate Director for Research San Francisco, California
Houston Methodist Hospital Birmingham/Atlanta Geriatric Research,
Professor and Associate Dean Education, and Clinical Center Clint Cary, MD, MPH
Weill Cornell Medical College and Texas (GRECC) Associate Professor
A&M College of Medicine Birmingham Veterans Affairs Medical Department of Urology
Houston, Texas Center Indiana University
Birmingham, Alabama Indianapolis, Indiana
Stephen A. Boorjian, MD
Carl Rosen Professor of Urology Arthur L. Burnett II, MD, MBA Erik P. Castle, MD
Department of Urology Patrick C. Walsh Distinguished Professor Professor of Urology
Mayo Clinic of Urology Department of Urology
Rochester, Minnesota Department of Urology Mayo Clinic Arizona
Johns Hopkins School of Medicine Phoenix, Arizona
Kristy Borawski, MD Baltimore, Maryland
Clinical Assistant Professor of Urology Toby C. Chai, MD
Department of Urology Jeffrey A. Cadeddu, MD Chair of Department of Urology
University of North Carolina at Chapel Hill Professor of Urology and Radiology Boston University School of Medicine
Chapel Hill, North Carolina Department of Urology Chief of Urology
University of Texas Southwestern Medical Boston Medical Center
Michael S. Borofsky, MD Center Boston, Massachusetts
Assistant Professor Dallas, Texas
Department of Urology Charbel Chalouhy, MD
University of Minnesota Anne P. Cameron, MD, FRCSC, FPMRS Faculty of Medicine
Minneapolis, Minnesota Professor of Urology St. Joseph University
University of Michigan Beirut, Lebanon
Steven Brandes, MD Ann Arbor, Michigan
Given Foundation Professor of Urology Alicia H. Chang, MD, MS
Department of Urology Steven C. Campbell, MD, PhD Medical Director
Columbia University Medical Center Professor of Surgery Department of Public Health,
New York, New York Department of Urology Tuberculosis Control Program
Cleveland Clinic County of Los Angeles
Michael C. Braun, MD Cleveland, Ohio Los Angeles, California
Chief of Renal Service
Texas Children’s Hospital Douglas A. Canning, MD Christopher R. Chapple, MD, BSc,
Professor, Renal Section Chief Professor of Surgery (Urology) FRCS (Urol)
Department of Pediatrics Perelman School of Medicine Professor and Consultant Urologist
Program Director University of Pennsylvania Department of Urology
Pediatric Nephrology Fellowship Program Chief, Division of Urology The Royal Hallamshire Hospital
Baylor College of Medicine Children’s Hospital of Philadelphia Sheffield Teaching Hospitals
Houston, Texas Philadelphia, Pennsylvania Sheffield, United Kingdom
Barry Hallner, MD John P.F.A. Heesakkers, MD, PhD Joseph M. Jacob, MD, MCR
Associate Program Director, Female Pelvic Urologist Assistant Professor
Medicine and Reconstructive Surgery Department of Urology Department of Urology
Assistant Professor Radboud University Medical Centre Upstate Medical University
Departments of OB/GYN and Urology Nijmegen, The Netherlands Syracuse, New York
Louisiana State University Health
New Orleans School of Medicine
New Orleans, Louisiana
x CONTRIBUTORS
Micah A. Jacobs, MD, MPH Parviz K. Kavoussi, MD, FACS Ervin Kocjancic, MD
Associate Professor Reproductive Urologist Lawrence S. Ross Professor of Urology
Department of Urology Department of Urology Vice Chairman
University of Texas Southwestern Austin Fertility and Reproductive Medicine Department of Urology College of
Dallas, Texas Adjunct Assistant Professor Medicine
Department of Psychology University of Illinois at Chicago
Thomas W. Jarrett, MD Division of Neuroendocrinology and Chicago, Illinois
Professor and Chairman Motivation
Department of Urology University of Texas at Austin Chester J. Koh, MD
George Washington University Austin, Texas Professor of Urology, Pediatrics, and
Washington, District of Columbia Adjunct Assistant Professor Obstetrics/Gynecology
Department of Urology Baylor College of Medicine
Gerald H. Jordan, MD, FACS, University of Texas Health Sciences Center Division of Pediatric Urology
FAAP (Hon), FRCS (Hon) at San Antonio Department of Surgery
Associate Professor, Urology San Antonio, Texas Texas Children’s Hospital
Eastern Virginia Medical School Houston, Texas
Norfolk, Virginia Miran Kenk, PhD
Scientific Associate Badrinath Konety, MD, MBA
Martin Kaefer, MD Department of Surgical Oncology Chief Executive Officer
Professor of Urology Princess Margaret Cancer Centre University of Minnesota Physicians
Indiana University School of Medicine University Health Network Vice Dean for Clinical Affairs
Indianapolis, Indiana Toronto, Ontario, Canada University of Minnesota Medical School
Professor
Kamaljot S. Kaler, MD, FRCSC Mohit Khera, MD, MBA, MPH Department of Urology
Clinical Assistant Professor Professor of Urology University of Minnesota
University of Calgary Scott Department of Urology Minneapolis, Minnesota
Southern Alberta Institute of Urology Baylor College of Medicine
Calgary, Alberta, Canada Houston, Texas Casey Kowalik, MD
Assistant Professor
Panagiotis Kallidonis, MD, MSc, PhD, Antoine E. Khoury, MD, FRCSC, FAAP Department of Urology
FEBU Walter R. Schmid, Professor of Pediatric University of Kansas Health System
Assistant Professor Urological Urology Kansas City, Kansas
Surgeon Department of Urology
Department of Urology University of California–Irvine Martin A. Koyle, MD, FAAP, FACS,
University of Patras Head of Pediatric Urology FRCSC, FRCS (Eng)
Patras, Greece Children’s Hospital of Orange County Division Head, Division of Pediatric Urology
Orange, California Women’s Auxiliary Chair in Urology and
Steven Kaplan, MD Regenerative Medicine
Professor and Director, The Men’s Health Eric A. Klein, MD Hospital for Sick Children
Program Andrew C. Novick, Distinguished Professor of Surgery
Department of Urology Professor and Chair University of Toronto
Icahn School of Medicine at Mount Sinai Glickman Urological and Kidney Institute Toronto, Ontario, Canada
New York, New York and Cleveland Clinic Lerner College of
Medicine Amy E. Krambeck, MD
Max Kates, MD Cleveland Clinic Michael O. Koch Professor of Urology
Assistant Professor Cleveland, Ohio Department of Urology
Department of Urology Indiana University
Johns Hopkins Medical Institutions Laurence Klotz, MD, FRCSC, CM Indianapolis, Indiana
Baltimore, Maryland Professor of Surgery
University of Toronto Jessica E. Kreshover, MD
Melissa R. Kaufman, MD, PhD, FACS Urologist, Sunnybrook Health Sciences Associate Professor of Urology
Associate Professor Centre The Arthur Smith Institute for Urology
Department of Urology Toronto, Ontario, Canada Zucker School of Medicine at Hofstra/
Vanderbilt University Northwell
Nashville, Tennessee Bodo E. Knudsen, MD, FRCSC New Hyde Park, New York
Associate Professor
Vice Chair Clinical Operations Venkatesh Krishnamurthi, MD
Louis R. Kavoussi, MD, MBA Department of Urology Director, Kidney/Pancreas Transplant
Professor and Chair Wexner Medical Center Program
Department of Urology The Ohio State University Glickman Urological and Kidney Institute
Zucker School of Medicine at Hofstra/ Columbus, Ohio Transplant Center
Northwell Cleveland Clinic Foundation
Hempstead, New York Kathleen C. Kobashi, MD Cleveland, Ohio
Chairman of Urology Chief, Section of Urology
The Arthur Smith Institute for Urology Urology and Renal Transplantation
Lake Success, New York Virginia Mason Medical Center
Seattle, Washington
CONTRIBUTORS xi
Ryan M. Krlin, MD, FPMRS Sey Kiat Lim, MBBS, MRCS Yair Lotan, MD
Associate Professor of Urology and (Edinburgh), MMed (Surgery), Professor
Gynecology FAMS (Urology) Department of Urology
Department of Urology Senior Consultant and Chief University of Texas Southwestern Medical
Louisiana State University Health New Department of Urology Center
Orleans Changi General Hospital Dallas, Texas
New Orleans, Louisiana Adjunct Associate Professor
Duke–National University of Singapore Alvaro Lucioni, MD
Alexander Kutikov, MD Medical School Program Director, Female Pelvic Medicine
Professor and Chief, Urologic Oncology Singapore Reconstructive Surgery Fellowship
Fox Chase Cancer Center Urology and Renal Transplantation
Philadelphia, Pennsylvania W. Marston Linehan, MD Virginia Mason Medical Center
Chief, Urologic Oncology Branch Seattle, Washington
Jaime Landman, MD National Cancer Institute
Professor of Urology and Radiology National Institutes of Health Tom F. Lue, MD, ScD (Hon), FACS
Chairman, Department of Urology Bethesda, Maryland Professor of Urology
University of California, Irvine Department of Urology
Orange, California Richard Edward Link, MD, PhD University of California–San Francisco
Carlton-Smith Chair in Urologic San Francisco, California
Brian R. Lane, MD, PhD Education
Chief, Urology Associate Professor of Urology Nicolas Lumen, MD, PhD
Spectrum Health Director, Division of Endourology and Professor of Urology
Associate Professor Minimally Invasive Surgery Ghent University Hospital
Michigan State University College of Scott Department of Urology Ghent, Belgium
Human Medicine Baylor College of Medicine
Grand Rapids, Michigan Houston, Texas Marcos Tobias Machado, MD, PhD
Professor of Urology
David A. Leavitt, MD Jen-Jane Liu, MD Department of Urology
Assistant Professor Assistant Professor Faculdade de Medicina do ABC
Department of Urology Director of Urologic Oncology Santo Andre, Brazil
Vattikuti Urology Institute Department of Urology
Henry Ford Health System Oregon Health and Science University Stephen D. Marshall, MD
Detroit, Michigan Portland Oregon Attending Physician
Laconia Clinic Department of Urology
Eugene K. Lee, MD Stacy Loeb, MD Lakes Region General Hospital
Associate Professor Professor of Urology and Population Laconia, New Hampshire
Department of Urology Health
University of Kansas Medical Center New York University and Manhattan Aaron D. Martin, MD, MPH
Kansas City, Kansas Veterans Affairs Associate Professor
New York, New York Department of Urology
Gary E. Lemack, MD Louisiana State University Health
Professor of Urology and Neurology Christopher J. Long, MD Sciences Center
Department of Urology Assistant Professor of Urology (Surgery) Department of Pediatric Urology
University of Texas Southwestern Medical Perelman School of Medicine Children’s Hospital New Orleans
Center University of Pennsylvania New Orleans, Louisiana
Dallas, Texas Division of Urology
Children’s Hospital of Philadelphia Laura M. Martinez, MD
Thomas Sean Lendvay, MD, FACS Philadelphia, Pennsylvania Instructor in Clinical Urology
Professor of Urology Department of Urology
University of Washington Roberto Iglesias. Lopes, MD, PhD Houston Methodist Hospital
Professor of Pediatric Urology Assistant Professor Houston, Texas
Seattle Children’s Hospital Pediatric Urology Unit
Seattle, Washington Division of Urology Timothy A. Masterson, MD
Hospital das Clínicas Associate Professor
Herbert Lepor, MD Faculdade de Medicina Department of Urology
Professor and Martin Spatz Chair Universidade de São Paulo Indiana University Medical Center
Department of Urology São Paulo, Brazil Indianapolis, Indiana
New York University School of Medicine
Chief, Urology Armando J. Lorenzo, MD, MSc, FRCSC, Surena F. Matin, MD
New York University Langone Health FAAP, FACS Professor
New York, New York Staff Paediatric Urologist Department of Urology
Department of Surgery Medical Director
Evangelos Liatsikos, MD, PhD Division of Urology Minimally Invasive New Technology in
Professor and Chairman Hospital for Sick Children Oncologic Surgery (MINTOS)
Department of Urology Associate Professor University of Texas MD Anderson Cancer
University of Patras Department of Surgery Center
Patras, Greece Division of Urology Houston, Texas
University of Toronto
Toronto, Ontario, Canada
xii CONTRIBUTORS
Eila C. Skinner, MD Julie N. Stewart, MD Kae Jack Tay, MBBS, MRCS (Ed), MMed
Professor and Chair Assistant Professor (Surgery), MCI, FAMS (Urology)
Thomas A. Stamey Research Professor of Department of Urology Consultant
Urology Houston Methodist Hospital Department of Urology
Department of Urology Houston, Texas Singapore General Hospital
Stanford University School of Medicine SingHealth Duke–National University of
Stanford, California John Stites, MD Singapore Academic Medical Center
Minimally Invasive and Robotic Urologic Singapore
Armine K. Smith, MD Surgery
Assistant Professor Hackensack University Medical Center John C. Thomas, MD, FAAP, FACS
Brady Urological Institute Hackensack, New Jersey Professor of Urologic Surgery
Johns Hopkins University Division of Pediatric Urology
Assistant Professor Douglas W. Storm, MD Department of Urology
Department of Urology Assistant Professor Monroe Carell Jr. Children’s Hospital at
George Washington University Department of Urology Vanderbilt
Washington, District of Columbia University of Iowa Hospitals and Clinics Vanderbilt University Medical Center
Iowa City, Iowa Nashville, Tennessee
Daniel Y. Song, MD
Professor Douglas W. Strand, PhD J. Brantley Thrasher, MD, FACS
Radiation Oncology and Molecular Assistant Professor Professor Emeritus of Urology
Radiation Sciences Department of Urology University of Kansas Medical Center
Johns Hopkins University School of University of Texas Southwestern Medical Kansas City, Kansas
Medicine Center Executive Director
Baltimore, Maryland Dallas, Texas American Board of Urology
Rene Sotelo, MD Charlottesville, Virginia
Professor of Clinical Urology Li-Ming Su, MD
Department of Urology David A. Cofrin Professor of Urologic Edouard J. Trabulsi, MD, FACS
University of Southern California Oncology Professor and Vice Chair
Los Angeles, California Chairman, Department of Urology Department of Urology
University of Florida College of Sidney Kimmel Cancer Center
Michael W. Sourial, MD, FRCSC Medicine Sidney Kimmel Medical College at
Assistant Professor Gainesville, Florida Thomas Jefferson University
Department of Urology Philadelphia, Pennsylvania
The Ohio State University Chandru P. Sundaram, MD, FACS, FRCS
Columbus, Ohio Eng Chad R. Tracy, MD
Dr. Norbert and Louise Welch Professor of Professor of Urology and Radiology
Anne-Françoise Spinoit, MD, PhD Urology Department of Urology
Pediatric and Reconstructive Urologist Vice Chair (QI) University of Iowa
Department of Urology Director, Minimally Invasive Surgery and Iowa City, Iowa
Ghent University Hospital Residency Program
Ghent, Belgium Department of Urology Paul J. Turek, MD
Indiana University School of Medicine Director
Arun K. Srinivasan, MD Indianapolis, Indiana The Turek Clinic
Division of Pediatric Urology San Francisco, California
Children’s Hospital of Philadelphia Samir S. Taneja, MD
Assistant Professor of Surgery (Urology) The James M. Neissa and Janet Riha Neissa Mark D. Tyson, MD, MPH
Perelman School of Medicine Professor of Urologic Oncology Urologic Oncologist
University of Pennsylvania Professor of Urology and Radiology Department of Urology
Philadelphia, Pennsylvania Director, Division of Urologic Mayo Clinic Arizona
Oncology Phoenix, Arizona
Ramaprasad Srinivasan, MD, PhD Department of Urology
Head, Molecular Cancer Section New York University Langone Health Robert G. Uzzo, MD, MBA, FACS
Urologic Oncology Branch New York, New York Professor and Chairman
Center for Cancer Research Department of Surgery
National Cancer Institute Nikki Tang, MD G. Willing “Wing” Pepper Chair in Cancer
National Institutes of Health Assistant Professor Research
Bethesda, Maryland Department of Dermatology Adjunct Professor of Bioengineering
Johns Hopkins University Temple University College of Engineering
Irina Stanasel, MD Baltimore, Maryland Fox Chase Cancer Center–Temple
Assistant Professor University Health System
Department of Urology Gregory E. Tasian, MD Lewis Katz School of Medicine
University of Texas Southwestern/ Assistant Professor of Urology and Temple University
Children’s Health Epidemiology Philadelphia, Pennsylvania
Dallas, Texas University of Pennsylvania Perelman
School of Medicine Brian A. VanderBrink, MD
Andrew J. Stephenson, MD, MBA, FACS, Attending Physician Associate Professor
FRCS (C) Division of Urology Division of Urology
Professor The Children’s Hospital of Philadelphia Cincinnati Children’s Hospital
Section Chief and Director, Urologic Philadelphia, Pennsylvania Cincinnati, Ohio
Oncology
Rush Medical College
Chicago, Illinois
xvi CONTRIBUTORS
xvii
CONTENTS
PART I Clinical Decision Making 17 Complications of Urologic Surgery, 50
Reza Ghavamian and Charbel Chalouhy
1 valuation of the Urologic Patient: History and
E
Physical Examination, 1 18 Urologic Considerations in Pregnancy, 52
Sammy E. Elsamra Melissa R. Kaufman
xviii
CONTENTS xix
43 Management of Pediatric Kidney Stone Disease, 147 59 Cutaneous Diseases of the External Genitalia, 211
Gregory E. Tasian and Lawrence Copelovitch Richard Edward Link and Nikki Tang
81 Inguinal Node Dissection, 309 PART XI Neoplasms of the Upper Urinary Tract
Rene Sotelo, Luis G. Medina, and Marcos Tobias-Machado 96 Benign Renal Tumors, 369
82 urgery for Benign Disorders of the Penis and
S William P. Parker and Matthew T. Gettman
Urethra, 312 97 Malignant Renal Tumors, 372
Ramón Virasoro, Gerald H. Jordan, and Kurt A. McCammon Steven C. Campbell, Brian R. Lane, and Philip M. Pierorazio
83 Surgery of the Scrotum and Seminal Vesicles, 320 98 rothelial Tumors of the Upper Urinary Tract and
U
Dorota J. Hawksworth, Mohit Khera, and Amin S. Herati Ureter, 384
Panagiotis Kallidonis and Evangelos Liatsikos
101 Open Surgery of the Kidney, 391 118 The Underactive Detrusor, 451
Aria F. Olumi and Michael L. Blute Christopher R. Chapple and Nadir I. Osman
102 L
aparoscopic and Robotic Surgery of the 119 Nocturia, 453
Kidney, 395 Stephen D. Marshall and Jeffrey P. Weiss
Daniel M. Moreira and Louis R. Kavoussi
120 P
harmacologic Management of Lower Urinary Tract
103 Nonsurgical Focal Therapy for Renal Tumors, 399 Storage and Emptying Failure, 455
Chad R. Tracy and Jeffrey A. Cadeddu Karl-Erik Andersson and Alan J. Wein
108 S
urgical, Radiographic, and Endoscopic Anatomy of 126 C
omplications Related to the Use of Mesh and Their
the Female Pelvis, 416 Repair, 487
Priya Padmanabhan Anne P. Cameron
109 S
urgical, Radiographic, and Endoscopic Anatomy of 127 A
dditional Therapies for Storage and Emptying
the Male Pelvis, 419 Failure, 489
Jen-Jane Liu, Bryan R. Foster, and Christopher L. Amling Timothy B. Boone, Julie N. Stewart, and Laura M. Martinez
110 P
hysiology and Pharmacology of the Bladder and 128 Aging and Geriatric Urology, 492
Urethra, 422 Tomas L. Griebling
Toby C. Chai and Lori A. Birder 129 Urinary Tract Fistulae, 496
111 athophysiology and Classification of Lower
P Dirk J.M.K. De Ridder and Tamsin Greenwell
Urinary Tract Dysfunction: Overview, 427 130 Bladder and Female Urethral Diverticula, 502
Elizabeth Timbrook Brown, Alan J. Wein, and Roger R. Dmochowski
Lindsey Cox and Eric S. Rovner
112 E
valuation and Management of Women With 131 S
urgical Procedures for Sphincteric Incontinence in
Urinary Incontinence and Pelvic Prolapse, 431 the Male, 507
Alvaro Lucioni and Kathleen C. Kobashi Hunter Wessells and Alex J. Vanni
113 E
valuation and Management of Men With Urinary
Incontinence, 436
Riyad Tasher Al Mousa and Hashim Hashim
Benign and Malignant Bladder
PART XIV
114 U
rodynamic and Video-Urodynamic Evaluation of Disorders
the Lower Urinary Tract, 439
Benjamin M. Brucker and Victor W. Nitti 132 Bladder Surgery for Benign Disease, 510
Paras H. Shah and Lee Richstone
115 U
rinary Incontinence and Pelvic Prolapse:
Epidemiology and Pathophysiology, 442 133 Genital and Lower Urinary Tract Trauma, 513
Gary E. Lemack and Maude Carmel Allen F. Morey and Jay Simhan
116 N
euromuscular Dysfunction of the Lower Urinary 134 S
pecial Urologic Considerations in Transgender
Tract, 444 Individuals, 516
Casey Kowalik, Alan J. Wein, and Roger R. Dmochowski Nicolas Lumen, Anne-Françoise Spinoit, and Piet Hoebeke
136 M
anagement Strategies for Non–Muscle-Invasive 148 E
pidemiology, Etiology, and Prevention of Prostate
Bladder Cancer (Ta, T1, and CIS), 526 Cancer, 571
Joseph Zabell and Badrinath Konety Andrew J. Stephenson, Robert Abouassaly, and Eric A. Klein
137 M
anagement of Muscle-Invasive and Metastatic 149 Prostate Cancer Biomarkers, 574
Bladder Cancer, 530 Todd M. Morgan, Ganesh S. Palapattu, and Simpa S. Salami
Thomas J. Guzzo, John Christodouleas, and David J. Vaughn
150 Prostate Biopsy: Techniques and Imaging, 577
138 S
urgical Management of Bladder Cancer: Edouard J. Trabulsi, Ethan J. Halpern, and Leonard G. Gomella
Transurethral, Open, and Robotic, 533
151 Pathology of Prostatic Neoplasia, 581
Neema Navai and Colin P.N. Dinney
Jonathan I. Epstein
139 U
se of Intestinal Segments in Urinary Diversion,
536 152 Diagnosis and Staging of Prostate Cancer, 583
Stacy Loeb and James A. Eastham
Anton Wintner and Douglas M. Dahl
156 L
aparoscopic and Robotic-Assisted Radical
PART XV The Prostate Prostatectomy and Pelvic Lymphadenectomy, 597
143 D
evelopment, Molecular Biology, and Physiology of Li-Ming Su, Brandon J. Otto, and Anthony Costello
the Prostate, 554 157 Radiation Therapy for Prostate Cancer, 600
Brian W. Simons and Ashley E. Ross Ryan Phillips, Sarah Hazell, and Daniel Y. Song
144 B
enign Prostatic Hyperplasia: Etiology, 158 Focal Therapy for Prostate Cancer, 603
Pathophysiology, Epidemiology, and Natural Kae Jack Tay and Thomas J. Polascik
History, 557
Claus G. Roehrborn and Douglas W. Strand 159 Treatment of Locally Advanced Prostate Cancer, 606
Maxwell V. Meng and Peter R. Carroll
145 E
valuation and Nonsurgical Management of Benign
Prostatic Hyperplasia, 561 160 M
anagement Strategies for Biochemical Recurrence
Paolo Capogrosso, Andrea Salonia, and Francesco Montorsi of Prostate Cancer, 609
Eugene K. Lee and J. Brantley Thrasher
146 M
inimally Invasive and Endoscopic Management of
Benign Prostatic Hyperplasia, 566 161 Hormonal Therapy for Prostate Cancer, 611
Sevann Helo, R. Charles Welliver, Jr., and Kevin T. McVary Scott Eggener
147 S
imple Prostatectomy: Open and Robot-Assisted 162 T
reatment of Castration-Resistant Prostate
Laparoscopic Approaches, 569 Cancer, 615
Misop Han and Alan W. Partin Emmanuel S. Antonarakis and Michael A. Carducci
PART
I Clinical Decision Making
13. Elevated ascorbic acid levels in the urine may lead to false- 21. All of the following are microscopic features of squamous
negative results on a urine dipstick test for: epithelial cells EXCEPT:
a. glucose. a. large size.
b. hemoglobin. b. small central nucleus.
c. myoglobin. c. irregular cytoplasm.
d. red blood cells. d. presence in clumps.
e. leukocytes. e. fine granularity in the cytoplasm.
14. Hematuria is distinguished from hemoglobinuria or myoglo- 22. The number of bacteria per high-power microscopic field that
binuria by: corresponds to colony counts of 100,000/mL is:
a. dipstick testing. a. 1.
b. the simultaneous presence of significant leukocytes. b. 3.
c. microscopic presence of erythrocytes. c. 5.
d. examination of serum. d. 10.
e. evaluation of hematocrit. e. 20.
15. The presence of one positive dipstick reading for hematuria 23. Pain in the flaccid penis is usually due to:
is associated with significant urologic pathologic findings on a. Peyronie disease.
subsequent testing in what percentage of patients?
b. bladder or urethral inflammation.
a. 2%
c. priapism.
b. 10%
d. calculi impacted in the distal ureter.
c. 25%
e. hydrocele.
d. 50%
e. 75% 24. Chronic scrotal pain is most often due to:
a. testicular torsion.
16. The most common cause of glomerular hematuria is:
b. trauma.
a. transitional cell carcinoma.
c. cryptorchidism.
b. nephritic syndrome.
d. hydrocele.
c. Berger disease (immunoglobulin A nephropathy).
e. orchitis.
d. poststreptococcal glomerulonephritis.
e. Goodpasture syndrome. 25. Terminal hematuria (at the end of the urinary stream) is usu-
ally due to:
17. The most common cause of proteinuria is: a. bladder neck or prostatic inflammation.
a. Fanconi syndrome. b. bladder cancer.
b. excessive glomerular permeability due to primary glomeru- c. kidney stones.
lar disease.
d. bladder calculi.
c. failure of adequate tubular reabsorption.
e. urethral stricture disease.
d. overflow proteinuria due to increased plasma concentration
of immunoglobulins. 26. Enuresis is present in what percentage of children at age 5 years?
e. diabetes. a. 5%
18. Transient proteinuria may be due to all of the following EXCEPT: b. 15%
a. exercise. c. 25%
b. fever. d. 50%
c. emotional stress. e. 75%
d. congestive heart failure (CHF). 27. All of the following in the medical history suggest that erectile
e. ureteroscopy. dysfunction is more likely due to organic rather than psycho-
genic causes EXCEPT:
19. Glucose will be detected in the urine when the serum level is a. sudden onset.
above:
b. peripheral vascular disease.
a. 75 mg/dL.
c. absence of nocturnal erections.
b. 100 mg/dL.
d. diabetes mellitus.
c. 150 mg/dL.
e. inability to achieve adequate erections in a variety of cir-
d. 180 mg/dL. cumstances.
e. 225 mg/dL.
28. All of the following should be routinely performed in men
20. The specificity of dipstick nitrite testing for bacteriuria is: with hematospermia EXCEPT:
a. 20%. a. cystoscopy.
b. 40%. b. digital rectal examination.
c. 60%. c. serum prostate-specific antigen (PSA) level.
d. 80%. d. genital examination.
e. >90%. e. urinalysis.
CHAPTER 1 Evaluation of the Urologic Patient: History and Physical Examination 3
29. Pneumaturia may be due to all of the following EXCEPT: 15. c. 25%. Investigators at the University of Wisconsin found that
a. diverticulitis. 26% of adults who had at least one positive dipstick reading
for hematuria were subsequently found to have significant
b. colon cancer. urologic pathologic findings.
c. recent urinary tract instrumentation. 16. c. Berger disease (immunoglobulin A nephropathy). IgA
d. inflammatory bowel disease. nephropathy, or Berger disease, is the most common cause of
glomerular hematuria, accounting for about 30% of cases.
e. ectopic ureter.
17. b. Excessive glomerular permeability due to primary glo-
30. Which of the following disorders may commonly lead to irrita- merular disease. Glomerular proteinuria is the most common
tive voiding symptoms? type of proteinuria and results from increased glomerular cap-
a. Parkinson disease illary permeability to protein, especially albumin. Glomerular
proteinuria occurs in any of the primary glomerular diseases
b. Renal cell carcinoma such as IgA nephropathy or in glomerulopathy associated with
c. Bladder diverticula systemic illness such as diabetes mellitus.
d. Prostate cancer 18. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
cially in the pediatric population, and usually resolves sponta-
e. Testicular torsion neously within a few days. It may result from fever, exercise, or
emotional stress. In older patients, transient proteinuria may
be due to CHF.
ANSWERS 19. d. 180 mg/dL. This so-called renal threshold corresponds to
a serum glucose level of about 180 mg/dL; above this level,
1. a. Obstruction of urine flow with distention of the renal glucose will be detected in the urine.
capsule. Pain is usually caused by acute distention of the renal 20. e. >90%. The specificity of the nitrite dipstick test for detecting
capsule, usually from inflammation or obstruction. bacteriuria is greater than 90%.
2. c. Bladder cancer. The most common cause of gross hematuria 21. d. Presence in clumps. Squamous epithelial cells are large,
in a patient older than age 50 is bladder cancer. have a central small nucleus about the size of an erythrocyte,
3. b. Ureteral obstruction due to blood clots. Pain in associa- and have an irregular cytoplasm with fine granularity.
tion with hematuria usually results from upper urinary tract 22. c. 5. Therefore five bacteria per high-power field in a spun
hematuria with obstruction of the ureters with clots. specimen reflect colony counts of about 100,000/mL.
4. d. Dysuria. Dysuria is painful urination that is usually caused 23. b. Bladder or urethral inflammation. Pain in the flaccid penis
by inflammation. is usually secondary to inflammation in the bladder or urethra,
5. d. Vesicovaginal fistula. Continuous incontinence is most with referred pain that is experienced maximally at the urethral
commonly due to a urinary tract fistula that bypasses the ure- meatus.
thral sphincter or an ectopic ureter. 24. d. Hydrocele. Chronic scrotal pain is usually related to nonin-
6. e. Cerebrovascular accidents. Anejaculation may result from flammatory conditions such as a hydrocele or varicocele, and
several causes: (1) androgen deficiency, (2) sympathetic den- the pain is usually characterized as a dull, heavy sensation that
ervation, (3) pharmacologic agents, and (4) bladder neck and does not radiate.
prostatic surgery. 25. a. Bladder neck or prostatic inflammation. Terminal hema-
7. b. 5%. In fact, 5% of patients with previously undiagnosed turia occurs at the end of micturition and is usually secondary
multiple sclerosis present with urinary symptoms as the first to inflammation in the area of the bladder neck or prostatic
manifestation of the disease. urethra.
8. e. Mobility/fixation of pelvic organs. In addition to defin- 26. b. 15%. Enuresis refers to urinary incontinence that occurs
ing areas of induration, the bimanual examination allows the during sleep. It occurs normally in children as old as 3 years
examiner to assess the mobility of the bladder; such informa- but persists in about 15% of children at age 5 and about 1% of
tion cannot be obtained by radiologic techniques such as children at age 15.
computed tomography (CT) and magnetic resonance imaging 27. a. Sudden onset. A careful history will often determine
(MRI), which convey static images. whether the problem is primarily psychogenic or organic. In
9. b. Sickle cell anemia. Priapism occurs most commonly in pa- men with psychogenic impotence, the condition frequently
tients with sickle cell disease but can also occur in those with develops rather quickly, secondary to a precipitating event such
advanced malignancy, coagulation disorders, and pulmonary as marital stress or change or loss of a sexual partner.
disease, as well as in many patients without an obvious cause. 28. a. Cystoscopy. A genital and rectal examination should be
10. c. Phosphaturia. Cloudy urine is most commonly caused by done to exclude the presence of tuberculosis, a PSA assessment
phosphates in the urine. and digital rectal examination should be done to exclude pro-
11. d. Dehydration. Conditions that decrease specific gravity static carcinoma, and a urinary cytologic assessment should be
include (1) increased fluid intake, (2) diuretics, (3) decreased done to exclude the possibility of transitional cell carcinoma
renal concentrating ability, and (4) diabetes insipidus. of the prostate.
12. c. 50 and 1200 mOsm/L. Osmolality is a measure of the 29. e. Ectopic ureter. Pneumaturia is the passage of gas in the
amount of solutes dissolved in the urine and usually varies urine. In patients who have not recently had urinary tract
between 50 and 1200 mOsm/L. instrumentation or a urethral catheter placed, this is almost al-
13. a. Glucose. False-negative results for glucose and bilirubin may ways due to a fistula between the intestine and bladder. Com-
be seen in the presence of elevated ascorbic acid concentra- mon causes include diverticulitis, carcinoma of the sigmoid
tions in the urine. colon, and regional enteritis (Crohn disease).
14. c. Microscopic presence of erythrocytes. Hematuria can be 30. a. Parkinson disease. The second important example of non-
distinguished from hemoglobinuria and myoglobinuria by specific lower urinary tract symptoms that may occur second-
microscopic examination of the centrifuged urine; the presence ary to a variety of neurologic conditions is irritative symptoms
of a large number of erythrocytes establishes the diagnosis of resulting from neurologic disease such as cerebrovascular
hematuria. accident, diabetes mellitus, or Parkinson disease.
4 PART I Clinical Decision Making
CHAPTER REVIEW
1. IPSS score: 0 to 7 mild symptoms, 8 to 19 moderate symp- 18. The bulbocavernosus reflex tests the integrity of this spinal
toms, 20 to 35 severe symptoms. cord reflex involving S2 to S4.
2. Renal pain radiates from the flank anteriorly to the respec- 19. A positive dipstick for blood in the urine indicates hema-
tive lower quadrant and may be referred to the testis, turia, hemoglobinuria, or myoglobinuria. Hematuria is
labium, or medial aspect of the thigh. The pain is colicky distinguished from hemoglobinuria and myoglobinuria
(fluctuates). It may be associated with gastrointestinal by microscopic examination of the centrifuged urine and
symptoms due to reflex stimulation of the celiac ganglion. identification of red blood cells (more than three red blood
3. Patients with slowly progressive urinary obstruction with cells per high-power field is abnormal).
bladder distention often have no pain, despite residual 20. Hematuria of nephrologic origin is frequently associated
volumes in excess of a liter. with proteinuria and dysmorphic erythrocytes.
4. Pain of prostatic origin is poorly localized. 21. Anticoagulation at normal therapeutic levels does not pre-
5. Scrotal pain may be primary or referred. Pain referred to the dispose patients to hematuria.
testicle originates in the retroperitoneum, ureter, or kidney. 22. The most accurate method to diagnose urinary tract infection
6. Hematuria, particularly in adults, should be regarded as a is by microscopic examination of the urine and identifying
symptom of malignancy until proven otherwise. pyuria and bacteria. This is confirmed by urine culture.
7. Adults normally arise no more than twice a night to void. 23. The chief complaint is the focus of the visit and is the
Urine production increases at night (recumbent position) reason the patient seeks consultation. It should be the lead
in older patients and those with cardiac disease, particularly sentence in the history and physical (H&P).
CHF. 24. A family history should always include questions about
8. Postvoid dribbling: Urine escapes into the bulbar urethra renal and prostate cancer, renal cysts, and stone disease.
and then leaks at the end of micturition. This may be allevi- 25. Priapism occurs most commonly in patients with sickle cell
ated by perineal pressure following voiding. disease but can also occur in those with advanced malig-
9. Those who present with microscopic hematuria and ir- nancy, coagulation disorders, or pulmonary disease, as well
ritative voiding symptoms should be suspected of having as in many patients without an obvious cause.
carcinoma in situ of the bladder until proven otherwise. 26. On urine dipstick, false-negative results for glucose and
10. Continuous incontinence is most commonly due to ectopic bilirubin may be seen in the presence of elevated ascorbic
ureter, urinary tract fistula, or totally incompetent sphincter. acid concentrations in the urine.
11. Hematospermia almost always resolves spontaneously and 27. Glomerular proteinuria is the most common type of
is rarely associated with any significant urologic pathology. proteinuria and results from increased glomerular capillary
12. When urinary obstruction is associated with fever and permeability to protein, especially albumin. Glomeru-
chills, it should be regarded as a urologic emergency. lar proteinuria occurs in any of the primary glomerular
13. It is always worthwhile to obtain the previous operative diseases such as IgA nephropathy or in glomerulopathy
report in patients who are to be operated on. associated with systemic illness such as diabetes mellitus.
14. If the patient is uncircumcised, the foreskin must be re- 28. Five bacteria per high-power field in a spun specimen
tracted for inspection of the glans. reflect colony counts of about 100,000/mL.
15. The testes are normally 6 cm in length and 4 cm in width. 29. An important example of nonspecific lower urinary tract
16. If one obtains a stool guaiac test (hemoccult) as a screen symptoms that may occur secondary to a variety of neuro-
for colon cancer, two subsequent stool specimens must be logic conditions is irritative symptoms resulting from neu-
obtained for an adequate test. If the hemoccult is positive, rologic disease such as cerebrovascular accident, diabetes
the patient should be on a red meat–free diet for 3 days mellitus, and Parkinson disease.
before collection of three specimens. 30. The renal threshold for glucose corresponds to a serum
17. A male urologist should always perform a female pelvic glucose level of about 180 mg/dL; above this level, glucose
examination with a female nurse in attendance. will be detected in the urine.
2 Evaluation of the Urologic Patient: Testing and Imaging
Erik P. Castle, Christopher E. Wolter, and Michael Woods
5
6 PART I Clinical Decision Making
14. All of following is true of uroflowmetry EXCEPT: microscopic examination of the centrifuged urine; the presence
a. Qmax >20 mL/s is not consistent with obstruction. of a large number of erythrocytes establishes the diagnosis of
hematuria.
b. Qmax, mean flow rate, and voided volume are parameters 6. c. 25%. Investigators at the University of Wisconsin found that
obtained from this study. 26% of adults who had at least one positive dipstick reading
c. 80 mL voided volume is adequate for uroflowmetry. for hematuria were subsequently found to have significant
d. the study can be performed in sitting and standing positions. urologic pathologic findings.
7. c. Berger disease (immunoglobulin A nephropathy). IgA
e. uroflowmetry cannot diagnose the location of obstruction.
nephropathy, or Berger disease, is the most common cause of
15. The following should be given to uncomplicated patients glomerular hematuria, accounting for about 30% of cases.
undergoing simple flexible diagnostic cystourethroscopy: 8. b. Excessive glomerular permeability due to primary glo-
a. single-dose oral antibiotic following procedure merular disease. Glomerular proteinuria is the most common
type of proteinuria and results from increased glomerular cap-
b. 3 days of oral antibiotics following procedure illary permeability to protein, especially albumin. Glomerular
c. 3 days of oral antibiotics starting the day prior to procedure proteinuria occurs in any of the primary glomerular diseases
d. nothing such as IgA nephropathy or in glomerulopathy associated with
systemic illness such as diabetes mellitus.
e. single intramuscular injection of ceftriaxone following 9. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
procedure cially in the pediatric population, and usually resolves sponta-
16. What is the most appropriate initial workup for asymptomatic neously within a few days. It may result from fever, exercise, or
microscopic hematuria (AMH)? emotional stress. In older patients, transient proteinuria may
be due to congestive heart failure.
a. Flexible cystoscopy, urinary cytology, CT urogram, and
10. d. 180 mg/dL. This so-called renal threshold corresponds to
UroVysion FISH
a serum glucose level of about 180 mg/dL; above this level,
b. Flexible cystoscopy and CT urogram glucose will be detected in the urine.
c. CT urogram and NMP22 11. e. >90%. The specificity of the nitrite dipstick test for detecting
d. Flexible cystoscopy, urinary cytology, and CT urogram bacteriuria is greater than 90%.
12. d. Presence in clumps. Squamous epithelial cells are large,
e. Flexible cystoscopy, renal ultrasound, and urinary cytology have a central small nucleus about the size of an erythrocyte,
and have an irregular cytoplasm with fine granularity.
13. c. 5. Therefore 5 bacteria per high-power field in a spun
ANSWERS specimen reflect colony counts of about 100,000/mL.
14. c. 80 mL voided volume is adequate for uroflowmetry. The
1. c. Phosphaturia. Cloudy urine is most commonly caused by
minimum voided volume that is accepted as a requirement for
phosphates in the urine.
considering an adequate assessment is at least 100 mL.
2. d. Dehydration. Conditions that decrease specific gravity
15. d. Nothing. For patients undergoing simple diagnostic flexible
include (1) increased fluid intake, (2) diuretics, (3) decreased
cystoscopy no antibiotic prophylaxis is recommended un-
renal concentrating ability, and (4) diabetes insipidus.
less there are extenuating risk factors for infection or recent
3. c. 50 and 1200 mOsm/L. Osmolality is a measure of the
orthopedic implantation of artificial joints. Refer to American
amount of solutes dissolved in the urine and usually varies
Urological Association (AUA) recommendations on antibiotic
between 50 and 1200 mOsm/L.
prophylaxis for urological procedures.
4. a. Glucose. False-negative results for glucose and bilirubin may
16. b. Flexible cystoscopy and CT urogram. For the initial work-
be seen in the presence of elevated ascorbic acid concentra-
up of AMH, routine urine cytology is not necessary. Cytology
tions in the urine.
is generally utilized in patients with a history of bladder cancer
5. c. Microscopic presence of erythrocytes. Hematuria can be
undergoing surveillance or the index of suspicion of a high-
distinguished from hemoglobinuria and myoglobinuria by
grade lesion is present.
CHAPTER REVIEW
1. A catheterized urine specimen should be obtained in the evaluation and screening for asymptomatic microscopic
female patient with a history of recurrent urinary tract hematuria.
infections or suspected contaminated specimen. 9. Urine cytology is very specific for high-grade urothelial
2. Hematuria should be stratified into glomerular, nonglo- carcinoma.
merular, medical, and surgical causes. 10. Uroflowmetry and assessment of postvoid residual should
3. A dipstick alone is inadequate for the diagnosis of micro- be ordered when lower urinary tract obstruction is suspect-
scopic hematuria. ed.
4. Asymptomatic microscopic hematuria is defined as three or 11. Urodynamic studies provide information on disorders of
greater RBC/HPF on a properly collected urinary specimen storage and voiding.
in the absence of an obvious benign cause. 12. Routine use of antimicrobial prophylaxis is not recom-
5. Urine dipstick positive for only leukocyte esterase or nitrites mended for office cystourethroscopy, urodynamics, or
but not both should be confirmed with microscopic analy- cystography in the patient without risk factors.
sis and urine culture. 13. Renal ultrasonography can provide basic screening infor-
6. Serum creatinine and glomerular filtration rate should be mation on the presence of hydronephrosis and medical
ordered when renal obstruction of nephrologic disease is renal disease but is not an adequate stand-alone study for
suspected. the workup of hematuria.
7. Prostate-specific antigen is a very sensitive test for prostate 14. CT without contrast of the abdomen and pelvis is the gold
conditions such as BPH and prostatitis and correlates most standard for detecting urinary stones.
often with prostate volume. 15. A KUB is a useful and easy test for the follow-up of existing
8. Urine cytology is not recommended during the initial non-emergent radio opaque urinary stones.
3 Urinary Tract Imaging: Basic Principles of CT, MRI,
and Plain Film Imaging
Jay T. Bishoff and Ardeshir R. Rastinehad
7
8 PART I Clinical Decision Making
d. intestinal or gallbladder activity should never be seen with 17. Which renal mass exhibits signal drop on opposed phase
99mTc-MAG3. imaging?
e. a T½ of less than 10 minutes is consistent with a a. Papillary renal cell
nonobstructed system. b. Chromophobe carcinoma
11. Positron emission tomography (PET): c. Angiomyolipoma
a. has a higher diagnostic accuracy than CT for seminoma and d. Clear cell carcinoma
nonseminoma testis cancer following chemotherapy. e. Transitional cell carcinoma
b. is sensitive and specific for detection of postchemotherapy
teratoma. 18. What signal characteristics do kidney stones exhibit on MR
urography?
c. can be used with high positive predictive value within
2 weeks of completion of chemotherapy for bulky lymph a. High signal on T2-weighted images
adenopathy. b. Low signal on T2-weighted images
d. has greater predictive value of primary disease in metastatic c. Signal void
urothelial carcinoma than magnetic resonance imaging (MRI). d. High signal on T1-weighted images
e. is able to detect local or systemic recurrence of prostate e. Low signal on T1-weighted images
cancer in 74% of patients with prostate-specific antigen
recurrence. 19. Multiparametric imaging of the prostate consists of anatomic
and functional sequences. Match the correct pair.
12. What is the minimum estimated GFR for use of gadolinium-
a. Anatomic: Diffusion-weighted imaging
based contrast agents?
b. Functional: T1- and T2-weighted images
a. Less than 30 mL/min/1.73 m2
c. Anatomic: Dynamic contrast enhanced sequences
b. Greater than 50 mL/min/1.73 m2
d. Functional: Apparent diffusion coefficient maps
c. Greater than 35 mL/min/1.73 m2
e. All of the above
d. Greater than 30 mL/min/1.73 m2
e. There are no restrictions for patients with renal
insufficiency.
ANSWERS
13. In magnetic resonance (MR) images using T2-weighted
sequences, fluid appears as: 1. d. Effective dose. The distribution of energy absorption in the
human body will be different based on the body part being
a. dark. imaged and a variety of other factors. The most important
b. bright. risk of radiation exposure from diagnostic imaging is the
c. low signal. development of cancer. The effective dose is a quantity used
to denote the radiation risk (expressed in sieverts) to a
d. signal void. population of patients from an imaging study.
e. indeterminate.
2. e . High, 10 to 100 mSv. The average person living in the
14. What lesions may have a high signal (bright) on T2-weighted United States is exposed to 6.2 mSv of radiation per year from
MRI of the adrenal gland? ambient sources, such as radon, cosmic rays, and medical
a. Pheochromocytoma procedures, which account for 36% of the annual radiation
exposure (NCRP, 2012). The recommended occupational
b. Metastasis
exposure limit to medical personnel is 50 mSv per year
c. Adrenal cortical carcinoma (ACC) (NCRP, 2012). The effective dose from a three-phase CT of the
d. None of the above abdomen and pelvis without and with contrast may be as high
e. All of the above as 25 to 40 mSv.
15. MR chemical shift imaging (CSI) for adrenal adenoma takes 3. e. T6. Autonomic dysreflexia, also known as hyperreflexia,
advantage of which of the following phenomena to aid in the means an overactivity of the autonomic nervous system
diagnosis? that can result in an abrupt onset of excessively high blood
pressure. Persons at risk for this problem generally have spinal
a. Water and fat within the same voxel signals are canceled cord injury level above T6. Autonomic dysreflexia can develop
out in opposed-phase imaging. suddenly, is potentially life threatening, and is considered a
b. Opposed-phase imaging will exhibit a high signal (bright). medical emergency. If not treated promptly and correctly, it
c. Intracellular lipid content within an adenoma is low. may lead to seizures, stroke, and even death.
d. Intravenous contrast is required. 4. b. 1 mSv. Maintaining the maximum practical distance from
e. All of the above. an active radiation source significantly decreases exposure to
medical personnel.
16. Oncocytoma typically has been characterized by a central scar.
Which other renal lesion may also exhibit a central scar on T2- 5. b. Have severe renal insufficiency and take metformin
weighted images? the day of the study. Patients with type 2 diabetes mellitus
on metformin may have an accumulation of the drug after
a. Clear cell carcinoma administering intravascular radiologic contrast medium
b. Angiomyolipoma (IRCM), resulting in biguanide lactic acidosis presenting with
c. Chromophobe carcinoma vomiting, diarrhea, and somnolence. This condition is fatal in
approximately 50% of cases (Wiholm, 1993).a
d. Transitional cell carcinoma
e. No other renal masses exhibit a central scar.
a Sourcesreferenced can be found in Campbell-Walsh-Wein Urology, 12th Edition,
on the Expert Consult website.
CHAPTER 3 Urinary Tract Imaging: Basic Principles of CT, MRI, and Plain Film Imaging 9
Biguanide lactic acidosis is rare in patients with normal administration can be helpful for the treating urologist to
renal function. Consequently in patients with normal renal consider when planning surgery in the patient with middle
function and no known comorbidities, there is no need to to moderate obstruction. A T½ of greater than 20 minutes is
discontinue metformin before IRCM use, nor is there a need consistent with a high-grade obstruction.
to check creatinine following the imaging study.
11. a . Has a higher diagnostic accuracy than CT for seminoma
6. d
. The mechanism of action associated with severe and nonseminoma testis cancer following chemotherapy.
idiosyncratic anaphylactoid (IA) reactions is an There are data on the use of PET/CT in testis cancer, where
immunoglobulin E (IgE) antibody reaction to the contrast PET/CT was found to have a higher diagnostic accuracy
media. The IA reactions are most concerning because they than CT for staging and restaging in the assessment of a
are potentially fatal and can occur without any predictable CT-visualized residual mass following chemotherapy for
or predisposing factors. Approximately 85% of IA reactions seminoma and nonseminomatous germ cell tumors (Hain
occur during or immediately after injection of IRCM and are et al., 2000; Albers et al., 1999).
more common in patients with a prior adverse drug reaction
to contrast media; patients with asthma, diabetes, impaired 12. d. Greater than 30 mL/min/1.73 m2. NSF occurs in patients
renal function, or diminished cardiac function; and patients with acute or chronic renal insufficiency with a GFR less
on beta-adrenergic blockers (Spring et al., 1997). than 30 mL/min/1.73 m2.
7. e. 0.01 mg/kg of epinephrine (1:1000 concentration), given 13. b. Bright. High signal on T2-weighted images. Fluid exhibits a
intramuscularly in the lateral thigh. Rapid administration low signal on T1-weighted images.
of epinephrine is the treatment of choice for severe contrast 14. e . All of the above. Traditional teaching reported the lightbulb
reactions. Epinephrine can be administered intravenously (IV) sign to be consistent with pheochromocytoma. However,
0.01 mg/kg body weight of 1: 10,000 dilution or 0.1 mL/kg metastasis and ACC also have a high signal on T2-weighted
slowly into a running IV infusion of saline and can be repeated images. Furthermore, Varghese and colleagues reported that
every 5 to 15 minutes as needed. If no IV access is available, 35% of pheochromocytomas demonstrated low T2 signal,
the recommended intramuscular dose of epinephrine is 0.01 contrary to conventional teaching. Therefore the conventional
mg/kg of 1:1000 dilution (or 0.01 mL/kg to a maximum of teaching of the “lightbulb sign” is incorrect.
0.15 mg of 1:1000 if body weight is <30 kg; 0.3 mg if weight is
>30 kg) injected intramuscularly in the lateral thigh. 15. a. Water and fat within the same voxel signals are canceled
out in opposed-phase imaging. MR CSI is performed on T1-
8. d. Ventricular ejection fraction less than 50%. The most weighted images. Opposed-phase imaging will demonstrate
common patient-related risk factors for CIN are CKD a low signal (dark) if fat and water occupy the same voxel.
(creatinine clearance <60 mL/min), diabetes mellitus, Adrenal adenomas have high intracytoplasmic fat. CSI is
dehydration, diuretic use, advanced age, congestive heart performed without the use of intravenous contrast.
failure, age, hypertension, low hematocrit, and ventricular
ejection fraction less than 40%. The patients at highest 16. c . Chromophobe carcinoma. Chromophobe carcinoma
risk for developing CIN are those with both diabetes and exhibits a high signal on T2-weighted images.
preexisting renal insufficiency. 17. d
. Clear cell carcinoma. Microscopic intracytoplasmic lipids
9. d. Not seen in patients with GFR greater than 60 mL/ have been found in 59% of clear cell carcinomas, which allows
min/1.73 m2. Patients with CKD but GRF greater than 30 mL/ it to be differentiated from other renal cell carcinoma cell types.
min/1.73 m2 are considered to be at extremely low or no risk 18. c . Signal void. Nephrolithiasis/calcification on MR imaging has
for developing NSF if a dose of GBCM of 0.1 mmol/kg or less no signal characteristics; therefore it appears as a void on imaging.
is used. Patients with GFR greater than 60 mL/min/1.73 m2 do
not appear to be at increased risk of developing NSF, and the 19. d. Functional: Apparent diffusion coefficient maps.
current consensus is that all GBCM can be administered safely Multiparametric MRI refers to the use of anatomic sequences
to these patients. (T1-weighted images, T2 triplanar [axial, sagittal, and
coronal] images) and functional sequences (diffusion-
10. e. a T½ of less than 10 minutes is consistent with a weighted imaging/apparent diffusion coefficient maps,
nonobstructed system. Transit time throughout the collecting dynamic contrast-enhanced MRI, spectroscopy). The
system in less than 10 minutes is consistent with a normal, combined approach has reported negative and positive
nonobstructed collecting system. A T½ of 10 to 20 minutes predictive values to be greater than 90% in detecting
shows mild to moderate delay and may be a mechanical prostate cancer.
obstruction. The patient’s perception of pain after diuretic
CHAPTER REVIEW
1. Absorbed dose for therapy is measured in units called gray 4. IA reactions are potentially fatal, are not dose dependent,
(Gy); 1 rad = 0.01 Gy, or 1 centigray (cGy) = 1 rad. and are more common in patients with a history of adverse
2. The amount of energy absorbed by a tissue for diagnos- reactions to contrast media, those with asthma or diabetes,
tic purposes is referred to as the equivalent dose and is those with impaired renal and cardiac function, and those
measured in sieverts (Sv). Exposure of the eyes and gonads on β-adrenergic blockers.
to radiation has a more significant biologic impact than 5. It is common to have nausea, flushing, pruritus, urticaria,
exposure of other parts of the body. The occupational safety headache, and occasionally emesis after administration of
limit is 50 mSv. Exposure time during fluoroscopy should contrast media.
be minimized by the use of short bursts of fluoroscopy; 6. Patients at high risk for adverse allergic reactions should be
positioning the image intensifier as close to the patient as medicated with steroids, given 12 to 24 hours before the
feasible substantially reduces scatter radiation. injection of contrast media, as well as antihistamines.
3. There are four basic types of iodinated contrast media: (1) 7. For retrograde pyelography, it is useful to dilute contrast
ionic monomer, (2) nonionic monomer, (3) ionic dimer, media by half with sterile saline, which facilitates identify-
(4) nonionic dimer. ing filling defects in the collecting system. There is a low
10 PART I Clinical Decision Making
CHAPTER REVIEW—cont’d
risk of contrast reactions in patients in whom a retrograde 17. The Hounsfield units scale assigns a value of −1000 Houns-
or loopogram is performed. field units for air. Dense bone is assigned a value of +1000
8. Metformin does not need to be held before contrast admin- Hounsfield units, and water is assigned 0 Hounsfield units.
istration in a patient with normal renal function and no 18. With the exception of some indinavir stones, all renal and
comorbidities. ureteral calculi may be detected by helical CT.
9. The risk of developing contrast-induced nephropathy is 19. The advantage of MRI is high-contrast resolution of soft tis-
increased in patients with decreased renal function (GFR < sue on T1-weighted images. Fluid has a low signal and ap-
60 mL/min), diabetes mellitus, dehydration, advanced age, pears dark on T1-weighted images; on T2-weighted images,
congestive heart failure, liver disease, and cardiac ejection fluid has a high signal and appears bright. Gadolinium
fraction less than 40%. increases the brightness of T1-weighted images. Hemor-
10. TcDTPA is primarily filtered by the glomerulus. It is a good rhage within a cyst results in a high signal on T1-weighted
agent to assess renal function. images. MRI is the imaging modality of choice for patients
11. Because TcDMSA is both filtered by the glomerulus and with iodine contrast allergies.
secreted by the proximal tubule, it localizes in the renal 20. The risk of developing NSF after gadolinium administration
cortex and is a good agent for assessing cortical scarring and is increased in patients with GFRs less than 30 mL/min.
ectopic renal tissue. 21. Adrenal adenomas have high lipid content and may be
12. TcMAG3 is cleared mainly by tubular secretion; it has a differentiated from adrenal cancers or metastatic disease by
limited ability to access renal function. specialized CT or MRI scans.
13. A T½ less than 10 minutes suggests an unobstructed system. 22. Thirty-five percent of pheochromocytomas do not enhance
A T½ greater than 20 minutes is consistent with renal ob- on T2-weighted images.
struction. 23. MRI and CT are excellent imaging studies to determine
14. A positive bone scan is not specific for cancer. Moreover, the presence and extent of renal vein and vena cava tumor
the volume of cancer cannot be quantitated on bone scan. thrombus. Uptake of gadolinium by the thrombus on MRI
Patients with widely metastatic disease may have diffuse differentiates tumor from bland (blood clot) thrombus.
uptake (hyper scan) and no discrete lesions. 24. Prostate MRI coupled with an assessment of dynamic con-
15. Glucose, choline, and amino acids have been used as imag- trast uptake and washout increases the diagnostic accuracy
ing agents for PET scans. for detecting cancer.
16. 18F-fluorodeoxyglucose (FDG) is used as an imaging agent 25. MR spectroscopy for prostate cancer is based on decreased
in PET scanning and takes advantage of the fact that tumors citrate levels and increased creatine and choline levels.
have increased glycolysis and decreased dephosphorylation. 26. Bladder filling in patients with spinal cord injuries higher
This scan is useful in testicular germ cell tumors, particu- than T6 may precipitate autonomic dysreflexia.
larly seminomas, in determining residual viable tumor 27. Radiation exposure diminishes as the square of the distance
following chemotherapy. from the radiation source.
4 Urinary Tract Imaging: Basic Principles of Urologic
Ultrasonography
Bruce R. Gilbert and Pat F. Fulgham
QUESTIONS d. frequency.
e. number of foci.
1. The maximum excursion of a wave above and below the
baseline is known as its: 8. Increasing frequency results in a loss of:
a. wavelength. a. absorption.
b. frequency. b. axial resolution.
c. period. c. lateral resolution.
d. cycle. d. depth of penetration.
e. amplitude. e. mechanical index.
2. The artifact that occurs when an ultrasound wave strikes an inter- 9. When sound waves encounter the interface between two
face at a critical angle and is refracted with limited reflection is: tissues with large differences in impedance, the waves are:
a. reverberation artifact. a. increased in frequency.
b. increased through-transmission artifact. b. decreased in frequency.
c. edging artifact. c. reflected.
d. comet-tail artifact. d. refracted.
e. aliasing artifact. e. reverberated.
3. Which ultrasound mode allows for detection and 10. When a tissue appears darker than the surrounding tissue on
characterization of the velocity and direction of motion? ultrasound it is said to be relatively:
a. Harmonic scanning a. hypoechoic.
b. Color Doppler b. hyperechoic.
c. Power Doppler c. hypodense.
d. Spatial compounding d. isoechoic
e. Gray-scale ultrasonography e. anechoic.
4. If the kidney is less echogenic than the liver, the kidney is
described as: 11. The focal zone represents the area of best:
a. hyperechoic. a. lateral resolution.
b. hypoechoic. b. axial resolution.
c. isoechoic. c. echogenicity.
d. anechoic. d. blood flow.
e. echogenic. e. tissue penetration.
5. The sonographic hallmark of testicular torsion is: 12. Increasing the gain has the effect of:
a. the “blue dot” sign. a. increasing amplitude of the sound waves.
b. epididymal edema. b. increasing acoustic power.
c. paratesticular fluid. c. increasing thermal index.
d. increased epididymal blood flow. d. increasing mechanical index.
e. absence of intratesticular blood flow. e. increasing transducer sensitivity.
6. Ultrasound waves are examples of: 13. One way to improve the visualization of deep structures is to:
a. radio waves. a. increase the frequency.
b. mechanical waves. b. decrease the frequency.
c. electromagnetic waves. c. increase the wave velocity.
d. ionizing radiation. d. decrease the gain.
e. light waves. e. employ Doppler flow.
7. The most important determinant of axial resolution is: 14. The best frequency for performing external renal ultrasound in
a. impedance. most adults is:
b. speed of propagation. a. 3.5 to 5 MHz.
c. acoustic power. b. 6 to 7 MHz.
11
12 PART I Clinical Decision Making
4. b. Hypoechoic. In describing ultrasound images, it is deeper structures (e.g., right kidney, bladder) require lower
important to use correct terminology. Descriptive terms frequencies of 3.5 to 5 MHz to penetrate. Such images will
involving echogenicity are relative terms. A hyperechoic have poorer axial resolution.
or hypoechoic structure is being described in relation to 14. a. 3.5 to 5 MHz: Deeper structures (e.g., right kidney, bladder)
the echogenicity of a reference standard. In most cases the require lower frequencies of 3.5 to 5 MHz to penetrate.
reference standard is the liver. In the adult the normal kidney 15. e. Hyperechoic internal nodule: A simple cyst is an example
is hypoechoic relative to the normal liver in approximately of a structure that is well circumscribed, with an anechoic
75% of patients. interior and through transmission.
5. e. Absence of intratesticular blood flow. The absence of 16. c. A curved array transducer is preferred for bladder
intratesticular blood flow is the classic sonographic finding in ultrasound in most patients: A curved array transducer is
testicular torsion. However, there are many documented cases of lower frequency (3.5–6 MHz) and provides greater depth
of some preserved intratesticular blood flow even in cases of penetration but with less axial resolution. It is most often
with significant torsion. Therefore testicular torsion remains a the transducer of choice for imaging the kidney and urinary
clinical diagnosis. Epididymal edema, paratesticular fluid, and bladder.
increased epididymal blood flow may be seen with testicular 17. e. All of the above: Urine volume, bladder wall characteristics,
torsion but may also be seen with other clinical conditions. the presence of calculi or diverticulum, and the presence of
The blue dot sign is a classic physical finding in torsion of the dilated ureters just outside the bladder are all evaluable by
appendix testis. transabdominal bladder ultrasound.
6. b. Mechanical waves: Mechanical waves are represented 18. c. Doppler flow studies: Caution should be used when
graphically as a sine wave alternating between a positive and interpreting Doppler flow studies in the evaluation of
negative direction from the baseline. Sound waves as they suspected testicular torsion. The hallmark of testicular torsion
propagate through human tissue produce areas of returning is the absence of intratesticular blood flow. Paratesticular flow
compression and rarefaction. in epididymal collaterals may appear within hours of torsion.
7. d. Frequency: Axial resolution is directly dependent on Comparison with the contralateral testis should be performed
the frequency of sound waves. The higher the sound wave’s to ensure that the technical attributes of the study are adequate
frequency is, the better the axial resolution. to demonstrate intratesticular blood flow.
8. d. Depth of penetration: The optimal ultrasound image 19. b. Inability to evaluate enhancement: Unlike computed
requires tradeoffs between resolution and depth of tomography (CT), currently ultrasound cannot evaluate
penetration. High-frequency transducers of 6 to 10 MHz may enhancement. Once it is approved by the US Food and Drug
be used to image structures near the surface of the body (e.g., Administration (FDA) for this purpose, contrast-enhanced
testis, pediatric kidney) with excellent resolution. However, ultrasound will allow the detection of enhancement of renal
deeper structures (e.g., right kidney, bladder) require lower masses by ultrasound.
frequencies of 3.5 to 5 MHz to penetrate. Such images will 20. e. All of the above: When evaluating the prostate, surrounding
have poorer axial resolution. structures need to be assessed. Rectal lesions (including
9. c. Reflected: The shape and size of the object and the angle cancer), dilated seminal vesicles, and/or ejaculatory ducts
at which the advancing wave strikes the object are critical as well as bladder pathology should all be evaluated for a
determinants of the amount of energy reflected. The amount complete examination.
of energy reflected from an interface is also influenced by the 21. d. Tip of right seminal vesicle: In a midline sagittal view the
impedance of the two tissues at the interface. Impedance is tips of the seminal vesicles are not normally visualized on
a property that is influenced by tissue stiffness and density. It ultrasound. An axial projection needs to be obtained to be
is the difference in impedance that allows an appreciation of able to measure the length of each seminal vesicle.
interfaces between different types of tissue. 22. e. All of the above: Although excellent resolution and tissue
10. a. Hypoechoic: The liver is usually used as a benchmark for characteristics is possible with transrectal ultrasound a
echogenicity. A hypoechoic area is described as “darker” on diagnosis of prostate cancer is not often able to be made with
B-mode ultrasound. ultrasound alone.
11. a. Lateral resolution: Lateral resolution refers to the ability 23. c. An informed operator: The ALARA (as low as reasonably
to identify separately objects that are equidistant from the achievable) principle is intended to limit the total energy
transducer. Lateral resolution is a function of the focused imparted to the patient during an examination. This can be
width of the ultrasound beam and is a characteristic of the accomplished by (1) keeping power outputs low, (2) using
transducer. The location of the narrowest beam width can be appropriate scanning modes, (3) limiting examination times,
adjusted by the user. The more focused the beam is, the better (4) adjusting focus and frequency, and (5) using the cine
the lateral resolution at that location. Thus image quality can function during documentation. All of these are dependent
be enhanced by locating the narrowest beam width (focus or upon an informed sonographer.
focal zone) at the depth of the object or tissue of interest 24. d. Critical: Any time body fluids or tissues come in contact
12. e. Increasing transducer sensitivity: The gain control on the with an ultrasound transducer, critical or high-level
console of the ultrasound machine permits the user to increase disinfection protocols must be strictly adhered to.
or decrease the sensitivity of the transducer to reflected sound 25. c. Gain, acoustic power: Unlike gain, which refers to
waves. amplification of the acoustic signal returning to the transducer,
13. b. Decrease the frequency: The optimal ultrasound acoustic power is the amount of acoustic energy applied to the
image requires trade-offs between resolution and depth of tissue. The biologic effects of ultrasound in terms of power are
penetration. High-frequency transducers of 6 to 10 MHz may in the milliwatt range. High levels generate heat and cavitation,
be used to image structures near the surface of the body (e.g., which might result in tissue damage.
testis, pediatric kidney), with excellent resolution. However,
14 PART I Clinical Decision Making
CHAPTER REVIEW
1. One cycle per second is known as 1 hertz (Hz). High- 4. Ultrasonography may produce injury due to mechanical ef-
frequency ultrasonic transducers of 6 to 10 MHz are used to fects caused by cavitation or by heat generation.
image structures near the surface. Deeper structures require 5. With the exception of some indinavir stones, all renal and
lower frequencies of 3.5 to 5 MHz. Axial resolution improves ureteral calculi may be detected by helical CT.
with increasing frequency, and depth of penetration decreases 6. The advantage of magnetic resonance imaging (MRI) is
with increasing frequency. high-contrast resolution of soft tissue on T1-weighted im-
2. Resistive index is the peak velocity minus the end-diastolic ages. Fluid has a low signal and appears dark on T1-weighted
velocity over the peek systolic velocity. This is measured using images; on T2-weighted images, fluid has a high signal and
the color flow Doppler with spectral display and is used to appears bright. Gadolinium increases the brightness of T1-
characterize renal artery stenosis, ureteral obstruction, and weighted images. Hemorrhage within a cyst results in a high
penile arterial insufficiency. signal on T1-weighted images.
3. By convention, the liver is used as a benchmark for echo-
genicity. By convention, the cephalad aspect of the structure
is to the left of the image.
5 Urinary Tract Imaging: Basic Principles of
Nuclear Medicine
Michael A. Gorin and Steven P. Rowe
b. 67Ga-citrate
5. Which radiotracer is ideally suited for imaging renal scaring?
99mTc-DTPA c. 11C-choline
a.
99mTc-MAG3
b. d. 18F-FDG
99mTc-DMSA e. 18F-FACBC
c.
d. 67Ga-citrate 12. 18F-FDG PET is recommended for which application in men
99mTc–sulfur colloid
e. with testicular cancer?
a. Initial cancer staging of patients with elevated postorchiec-
6. 2-Deoxy-2-[18F]fluoro-D-glucose (18F-FDG) is phosphorylated tomy tumor markers
by which glycolytic enzyme, trapping it inside metabolically
active cells? b. Initial cancer staging of patients with negative postorchiec-
tomy tumor markers
a. Hexokinase
c. Postchemotherapy imaging of a residual retroperitoneal
b. Glucokinase mass in men with a seminomatous germ cell tumor
c. Phosphofructokinase d. Postchemotherapy imaging of a residual retroperitoneal
d. Pyruvate kinase mass in men with a nonseminomatous germ cell tumors
e. Phosphoglucose isomerase e. Post-treatment surveillance in patients with negative markers
15
16 PART I Clinical Decision Making
CHAPTER REVIEW
1. The most commonly used radiopharmaceutical agents for using the positron emission tomography (PET) radiotracer
nuclear imaging of the kidneys are technetium 99mTc-diethyl- 2-deoxy-2-(18F)fluoro-D-glucose (18F-FDG)
enetriaminepentaacetic acid (99mTc-DTPA), 99mTc- mercaptoa- 8. A number of genitourinary malignancies can be success-
cetyltriglycine (MAG3), and 99mTc–dimercaptosuccinic acid fully imaged with 18F-FDG PET, albeit with varying degrees
(DMSA). of clinical utility beyond conventional anatomical imaging
2. 99mTc-DTPA and 99mTc-MAG3 are used to measure renal techniques.
blood flow, determine differential renal function, and to 9. Because 18F-FDG is excreted in the urine, imaging with this
evaluate for the presence and degree of renal obstruction. radiotracer is typically performed to detect distant sites of
3. 99mTc-DTPA is cleared by glomerular filtration, whereas disease.
99mTc-MAG3 is cleared by tubular secretion. 10. 18F-FDG has little role in imaging prostate cancer and a
4. 99mTc-MAG3 is the preferred at most centers over 99mTc- number of other radiotracers have been developed for this
DTPA because it has a higher extraction efficiency and is purpose.
less impacted by changes in renal function 11. Radiotracers targeting PSMA are the most promising class
5. 99mTc-DMSA is retained by cells of the proximal renal tu- of agents for prostate cancer imaging and in many parts of
bules and is used to evaluate for infection and the presence the world have become the new standard of care for imag-
renal scarring. ing this malignancy.
6. 99mTc-DTPA and 99mTc-MAG3 can also be used to evaluate 12. One of the most well-established indications for 18F-FDG
renovascular hypertension, transplant graft function, and PET imaging is in the detection of residual seminomatous
vesicoureteral reflux. germ cell tumors following chemotherapy.
7. Molecular imaging of cancer is most commonly performed
6 Assessment of Urologic and Surgical Outcomes
David F. Penson and Mark D. Tyson
5. When a scale has a coefficient α of 0.90, one can be assured 10. A patient with kidney cancer has a single target lesion, a 5-cm
that the scale has high degree of: bony metastases. She is treated with a tyrosine kinase inhibitor
(TKI). The lesion is reduced in size and is now 4 cm on imag-
a. alternate form reliability. ing. According to the RECIST criteria, this is considered a:
b. test-retest reliability. a. complete response.
c. internal consistency reliability. b. partial response.
d. intraobserver reliability. c. stable disease.
e. interobserver reliability. d. non-CR/non-PD.
e. progressive disease.
17
18 PART I Clinical Decision Making
CHAPTER REVIEW
1. The effectiveness of health services delivery and treatment 4. There are a number of published and widely accepted criteria
can be measured across three distinct dimensions: structure, for defining disease progression and surgical complications
process, and outcomes. Structure and process measures are in urology. While these urologists should use these reporting
easier to assess but outcomes tend to be most meaningful to systems whenever possible, they should also remember that the
clinicians and patients. use of these systems does not completely eliminate the poten-
2. Mortality is the “hardest” endpoint one can assess in urology. tial for bias in research due to study design and other factors.
That being said, it can be subject to bias. Specifically, stud- 5. Frailty, functional status, and comorbidity are important
ies using overall mortality can still be subject to lead- and potential confounders that should be considered in urologic
length-time bias, and studies using disease-specific mortality research. There are numerous standardized tools available to
may be subject to attribution bias. capture these variables.
3. While there are many proxy endpoints in urology, few meet 6. There are numerous patient-reported outcome tools available
all four requirements for being a valid surrogate endpoint. to assess symptoms and quality of life in patients with uro-
Despite this, urologists routinely use proxy endpoints in logic diseases. Physicians and researchers should always use
research and clinical practice. validated and reliable patient-centered tools when possible.
7 Ethics and Informed Consent
Vijaya M. Vemulakonda
on concentration camp detainees, resulting in pain, debilita- 7. c. Information that a “reasonable person” would want to
tion, and death of subjects. The trials led to the development of know. Although battery law required disclosure of risks and
the Nuremburg code, which reinforced the need for voluntary early negligence law required disclosure of what a “reason-
consent, need to minimize harm, absence of other methods to able and prudent” physician would do, the current standard is
obtain data, and need to terminate studies early if evidence of what a reasonable person would want to know (Canterbury vs.
potential harm in a clinical research study. The Tuskegee studies Spence, 1972). The informed consent process requires both in-
were performed from 1932 to 1972 in Tuskegee, Alabama, to formation from the physician and demonstrated understand-
study the natural history of syphilis, with investigators with- ing by the patient but does not require written documentation.
holding antibiotic treatment even after the discovery of the ef- 8. c. Assessment of the patient’s understanding of the infor-
ficacy of penicillin to treat the disease. The study raised issues of mation provided by the medical provider. Although all four
adequate knowledge for consent, need to avoid coercion for par- elements are needed for a comprehensive informed consent,
ticipation, and need to terminate studies early if the investigator the majority of informed consents are incomplete with the
has knowledge of preventable harm. The Milgram experiments, element of assessing patient understanding of the information
which were conducted in 1963 at Yale by psychologist Stan- provided being the most commonly missed.
ley Milgram, encouraged subjects to administer fake electrical 9. d. A conscious 25-year-old patient who sustained multi-
shocks to unseen participants. Recorded responses to the shocks ple gunshot wounds. In emergency settings where there is a
were played, including screaming and silence suggestive of pos- significant threat to patient life or well-being, consent is pre-
sible unconsciousness. Subjects were encouraged to continue sumed. However, this waiver of consent does not extend to the
to escalate shocks despite these responses, with the majority of conscious patient even if refusal of treatment is life-threatening
subjects administering maximal shocks, leading to psychological (In re Quackenbush 1978).
trauma in many participants. The study raised concerns about 10. e. None of the above. All of the options have been posed as
use of deception in research and lack of adequate safeguards limitations to patient understanding of consent. The informa-
against harm. All of these events led to heightened scrutiny and tion provided in consent forms often is above the 12th-grade
development of heightened standards for medical research. level, although the majority of patients have reading levels be-
3. e. None of the above. According to Beauchamp and Childress, the low the 8th-grade level. Additionally, patients who report read-
four basic principles of autonomy, beneficence, non-maleficence, ing consent forms may not recall the information contained
and justice should be considered equal in weight. in the document. Additionally, patients often underestimate
4. b. Potter. Van Rensselaer Potter first coined the term bioethics their risks compared to other people or may use heuristics to
in 1970, described as the “study of the moral relationship make decisions that lead to a misunderstanding of the risks
between humans and their social and physical world.” involved. Finally, patients often accept surgical recommenda-
5. d. Provide definitive answers to ethically challenging situ- tions without meaningful participation in the decision-making
ations. Although the Four Box Method allows for systematic process due to idealization of the surgeon and his or her judg-
consideration of ethically complex clinical situations and cre- ment.
ates a vehicle for discussions regarding treatment, it may also 11. d. Increased decisional conflict. Decision aids have been as-
oversimplify ethical problems and does not always provide sociated with improved knowledge about procedures, reduced
clear “right” and “wrong” answers to address ethical concerns. decisional conflict, improved patient participation in the deci-
6. d. 20th-century battery laws. Although now considered within sion, and improved assessment of risk.
the scope of negligence, informed consent was first described
by state courts in early 20th-century battery cases and was
considered to be grounded in the right to bodily integrity.
The Nuremburg code recommended expansion of the right to
informed consent to medical research.
CHAPTER REVIEW
1. Although the scope of medical ethics continues to evolve, the 3. Despite the goal of ensuring adequate understanding of the
basic ethical principles of autonomy, beneficence, non-malef- nature, risks, benefits, and alternatives of surgery to facilitate
icence, and justice remain the foundation of ethical medical a meaningful decision, the informed consent process is often
practice. incomplete. It is therefore the responsibility of the surgeon
2. Informed consent is essential to the practice of surgery with to make every effort to facilitate patient understanding and
limited exceptions. participation in the decision-making process.
PART
II Basics of Urologic Surgery
21
22 PART II Basics of Urologic Surgery
s pontaneous abortion and teratogenicity. Although controver- boembolism. Such a patient would require both mechanical
sy exists as to the exact etiology, several recent trials have found and pharmacologic prophylaxis. In a patient with renal insuf-
age to be an independent predictor of morbidity on multivari- ficiency, unfractionated heparin is a better choice than low-
ate analyses. Laparoscopic surgery is the preferred approach molecular-weight heparin. There is no evidence that aspirin is
in morbidly obese patients secondary to the reduced risk of effective in the prevention of venous thromboembolism, but
pulmonary and wound complications. Literature suggests that in a patient with coronary stents, aspirin is important in the
severely malnourished patients (>20 pounds weight loss in prevention of stent thrombosis in the perioperative period.
3 months) significantly benefit from 7 to 10 days of enteral
(not parenteral) feedings before elective surgery. The primary 5. d. Inhaled sevoflurane. This is an excellent choice for rapid induc-
determinants of the degree of severity in patients with cirrhosis tion in this patient secondary to its odorless and bronchodilation
are hepatic function and severity of clinical manifestations. properties. Halothane can adversely affect left ventricular function
and should be used with caution in patients with congestive heart
3. b. Administration of 2 g cefoxitin 1 hour before incision. failure. Desflurane has a pungent odor and is more suitable for
Administration of appropriate antibiotics within 60 minutes of maintenance of anesthesia during prolonged procedures. Intrave-
incision has been shown to significantly decrease the inci- nous thiopental can increase airway reactivity and is not appropri-
dence of surgical site infections. Recent meta-analyses from the ate in patients with asthma. Succinylcholine is appropriate for
colorectal literature indicate that mechanical bowel preparation neuromuscular blockade and not commonly used for induction.
does not decrease the risk of postoperative infections. Unless
in the presence of active infection, perioperative antibiotics 6. c. Discontinue prior to surgery, administer stress dose steroid
should be stopped 24 hours after incision to decrease the before the induction of anesthesia, and continue post-opera-
risk of Clostridium difficile colitis. Although preoperative hair tively until home medication is resumed. Patients who have a
removal and optimization of nutritional status and comorbid depressed hypothalamic pituitary adrenal axis due to exogenous
illness improve surgical outcomes, there is no specific evidence steroids should receive 50 to 100 mg of intravenous hydrocorti-
that this reduces surgical site infections. sone before the induction of anesthesia and 25 to 50 mg every
8 hours thereafter until the patient’s medication is resumed.
4. e. Unfractionated heparin and aspirin. The clinical scenario Simply discontinuing the patient’s steroid medication can result
describes a patient with high to highest risk of venous throm- in adrenal crisis due to adrenal insufficiency post-operatively.
CHAPTER REVIEW
1. One must always determine whether a woman in the are based. This is particularly true for bowel preparation, as
childbearing years is pregnant before a surgical procedure. urologic reconstructive procedures often require opening
A urine pregnancy test is a simple method to do this. the isolated intestinal segment to be used in the procedure,
2. The American Society of Anesthesiologists’ classification is exposing the entire contents to the operative field.
a significant predictor of operative mortality. 13. Parenteral antibiotics should be given within 60 minutes
3. Preoperative cardiac evaluation is meant to identify serious before intestinal surgery.
coronary artery disease, heart failure, symptomatic arrhyth- 14. Nitrous oxide inhalation anesthesia results in bowel distention.
mias, and the presence of a pacemaker or defibrillator. 15. The half-life of warfarin is 36 to 42 hours, and it is recom-
Major clinical predictors of cardiovascular risk are a recent mended that warfarin be stopped 5 days before the surgical
myocardial infarction (within 1 month), unstable angina, event.
evidence of an ischemic burden, decompensated heart 16. Aspirin and clopidogrel are irreversible inhibitors of plate-
failure, significant arrhythmias, and severe valvular disease. let function and should be discontinued 7 to 10 days before
4. A patient’s ability to climb two flights of stairs is a good as- surgery if bleeding risk is to be minimized.
sessment of adequate functional capacity. 17. For moderate- to high-risk groups on anticoagulation ther-
5. Patients with an FEV1 of less than 30% predicted are at high apy, a therapeutic bridge is performed using unfractionated
risk for complications. or low-molecular-weight heparin. These may be stopped 4
6. Smoking must be discontinued at least 8 weeks before or 12 hours, respectively, before the procedure and instituted
surgery to be effective in reducing risk. shortly after its completion.
7. Perioperative β blockade is associated with a reduced risk of 18. The indications for fresh frozen plasma are immediate rever-
death among high-risk patients undergoing major noncar- sal of warfarin and replacement of specific clotting factors.
diac surgical procedures. However, more recent data bring 19. The most common cause of transfusion-related fatality is
this into question. transfusion-related acute lung injury (TRALI).
8. Patients who have a depressed hypothalamic pituitary 20. Hypothermia results in increased blood loss and an in-
adrenal axis due to exogenous steroids should receive 50 to creased incidence of wound infection.
100 mg of intravenous hydrocortisone before the induction 21. If hair is to be removed, it should preferably be removed
of anesthesia and 25 to 50 mg every 8 hours thereafter until immediately before the surgical event with mechanical clip-
the patient’s medication is resumed. pers.
9. In the elderly, delirium can be the first clinical sign of hy- 22. The need for postoperative parenteral nutrition should be
poxia or of metabolic or infectious complications. anticipated in patients undergoing major urologic proce-
10. In the pregnant patient, postoperative pain is best managed dures involving the use of bowel. If it is likely the patient
with narcotic analgesics. will not be able to take an adequate caloric intake orally by
11. A preoperative electrocardiogram should be obtained in all 7 to 10 days, postoperative parenteral nutrition should be
patients older than 40 years and in those with a significant instituted.
cardiac history. 23. The second trimester represents the least anesthetic risk to
12. It is important to remember that for prophylaxis of venous the mother and fetus with regard to spontaneous abortion
thromboembolic disease and the use of antibiotic and and teratogenicity.
mechanical bowel preps before intestinal surgery, the 24. Severely malnourished patients (>20 pounds weight loss in
studies are often based on data obtained from nonuro- 3 months) significantly benefit from 7 to 10 days of enteral
logic patients. The urologist must consider this when the (not parenteral) feedings before elective surgery.
procedure being performed is significantly different from 25. In a patient with renal insufficiency, unfractionated heparin
the standard general surgical operation on which the data is a better choice than low-molecular-weight heparin.
Another random document with
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The Project Gutenberg eBook of Married or
single?, Vol. 2 (of 3)
This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
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laws of the country where you are located before using this
eBook.
Author: B. M. Croker
Language: English
IN THREE VOLUMES
VOL. II.
LONDON
CHATTO & WINDUS, PICCADILLY
1895
CONTENTS OF VOL. II.
CHAPTER PAGE
XIV. A Social Godmother 1
XV. Mr. Jessop does his Duty 10
XVI. Two Visits and a Letter 40
XVII. Gone to Ireland 67
XVIII. Wanted—a Reason 82
XIX. A Disagreeable Interview 102
XX. Not “A Happy Couple” 115
XXI. An Interruption 132
XXII. Mr. Wynne’s Visitor 148
XXIII. A Bold Step 172
XXIV. An Unexpected Honour 185
XXV. Plain Speaking 196
XXVI. Mr. Wynne makes a Statement 219
XXVII. A Promise Postponed 227
XXVIII. A Portière which Intervened 241
MARRIED OR SINGLE?
CHAPTER XIV.
A SOCIAL GODMOTHER.
The next day Lord Tony’s only sister, Lady Rachel Jenkins, arrived
to call—but not for the first time—upon Miss West. She was an
extremely vivacious and agreeable little woman, with dark eyes and
flashing teeth. She took Madeline out with her in her own brougham,
and—oh, great favour!—introduced her to her pet dressmaker. This
august person viewed Miss West’s stone-coloured costume with an
air of amused contempt; it was not good style; the cut of the skirt
was quite “out,” and she finally wound up by uttering the awful
words, “Ready made.” It was not what Madeline liked, or even
thought she would like, but what Lady Rachel suggested and
Madame Coralie approved, that was selected.
“Your father, my dear,” patting the girl’s hand confidentially, “met
me on the stairs, and we had a few words together. I’m going to
show you what we do in London, and what we wear, and whom we
know; and what we don’t wear, and whom we don’t know, my little
country mouse!”
So the country mouse was endowed with half a dozen fine
dresses chosen entirely by Lady Rachel—dresses for morning,
afternoon, and evening.
“I only order six, my dear,” said her chaperon cheerily, “as the
season is getting over, and these will carry you on till August, if you
have a good maid. Madame Coralie, we can only give you five days,”
rising as she spoke.
But Madame Coralie threw up eyes and hands and gesticulated,
and volubly declared that it was absolument impossible! She had so
many gowns for Ascot and the royal garden party. Nevertheless,
Lady Rachel was imperious, and carried her point.
“The opera mantle is to be lined with pink brocade, and you will
line the cloth skirt with shot sulphur-coloured silk; and that body I
chose is to be almost drowned in chiffon and silver.”
She was to be female bear-leader to this young heiress, and was
resolved that her appearance should not disgrace her, and that “the
old squatter,” as she called him, should be taken at his word, and
made to pay and look pleasant.
The succeeding visit was to a milliner’s; the next to a shoe shop,
when the same scene was rehearsed. Madeline looked on and said
nothing, but made an angry mental note that she would never again
go out shopping with this imperious little lady. Why, even the poorest
had the privilege of choosing their own clothes! Why should this little
black-browed woman, barely up to her shoulder, tyrannize over her
thus? Simply because, my dear, unsophisticated Madeline, she has
promised to bring you out—to be your social godmother, to introduce
you to society, such as your father loveth, and to be friendly. Besides
all this, she has already decided in her own mind that “you will do
very well,” and are not nearly as rustic as she expected; and she has
made up her mind—precisely as she did about your satin dinner-
dress—that you are to marry her brother. Oh, happy prospect!
Lady Rachel was Lord Anthony’s only sister—a woman of five and
thirty, who, thirteen years previously, had married a rich parvenu—
plain, homely, much older than herself—for his money. She had no
fortune as Lady Rachel Foster, and she was not particularly pretty;
so she made the best available use of her title, and changed it for
twenty thousand a year and the name of Jenkins. Mr. Jenkins liked
being announced as “Lady Rachel, and Mr. Jenkins;” to be asked in
a loud voice, in public places, “How is your wife—Lady Rachel?” For
her part, she liked her fine house, servants, carriages, and jewels;
and both were, to a certain extent, satisfied with their bargain.
Perhaps of late years there had been a certain amount of
disappointment. Lady Rachel went more and more into society, and
drifted widely apart from Mr. Jenkins and his city friends. Mr. Jenkins
was not considered an acquisition in her circles, which were a little
rapid. He was given to understand—by deeds, not words—that he
was rather a bore, and that he must not always be expecting to be
tied to the tail of his brilliant, fashionable, frivolous little wife—and
then, Mr. Jenkins was jealous!
It was quite time that Anthony was married, thought his sister. He
was not prepossessing in appearance. He was well known in society,
and especially in her own set, as a fellow with an empty head, empty
pockets, and a roving nature. He was not popular. She was aware
that he had been rejected by heiress after heiress. He would not be
modest and content with a plain girl, or an elderly widow, or even a
faded spinster on the shady side of forty! No; Lord Anthony Foster
must have beauty and money to boot, and there was no bidding for
his coronet in the quarters these came from. Prudent mammas had
set a mark against his name, and where his attentions would have
been welcomed, he turned up his nose, and talked in a high moral
manner about the sin of marrying one’s grandmother. His
affectionate sister had vainly suggested one or two ladies that she
had thought suitable, but until now Lord Tony had been too difficile,
and her pains had gone for nothing!
But now, oh, joy at last, he had found a girl almost, as one might
say, to order—young, accomplished, ladylike, very pretty, and very
rich.
Lady Rachel already considered Madeline her sister-in-law, and
had already selected her own gown for the wedding, so far ahead do
some active, imaginative natures throw their mental life. There was
nothing to wait for. Tony was willing—the old squatter was willing—
and the girl—well, she was willing, of course.
Madame Coralie’s dresses came home punctually, and were all
that the most fastidious could desire, in fit, style, colour, and cut.
Madeline spent the whole afternoon, in the retirement of her own
room, slowly trying on all six, one after the other, with ever-
increasing approbation. The climax was an oyster-white satin, with a
turquoise velvet and silver bodice—a dream of a dress, to quote the
enraptured Josephine.
Madeline had an æsthetic appreciation of herself as she stood
before a glass and contemplated the slim figure, white rounded
arms, the rich glistening skirt, the exquisitely moulded bodice. Could
this apparition be the same young woman who had humbled herself
before Mrs. Kane, and carried up her own coals? What a difference
dress made—in self-respect and self-importance! Dress, as she now
realized it, was a powerful engine in cultivating one’s own self-
esteem. Yes, a silk-lined skirt could impart a surprising amount of
confidence! She glanced over one shoulder, then over the other,
then looked full at her reflection, and said to herself, with a smile, “I
do love pretty clothes!”
CHAPTER XV.
MR. JESSOP DOES HIS DUTY.
“Laurence Wynne.
“Do not think that I am complaining that you have not been
down here. I fully understand that your father, having no
occupation, is much at home, perhaps too much at home, and
can’t bear you out of his sight—which is natural, and that to
come and go to the Holt Farm would take four hours—hours
for which you would be called on to account. And you dared
not venture—dared not deceive him. Deceive him no longer in
any way, Maddie. Send me a wire, and he shall know all
before to-morrow night.”
Madeline read this letter over slowly, with rapidly changing colour.
Some sentences she perused two or three times, and when she
came to the last word, she recommenced at the beginning—then she
folded it up, put it into its envelope, thrust it into her dressing-case,
and turned the key.
She was a good deal disturbed; you could read that by her face,
as she went and stood in the window, playing with the charms on her
bangle. She had a colour in her cheeks and a frown upon her brow.
How impatient Laurence was! Why would he not give her time?
What was three months to prepare papa? And was it really three
months? It seemed more like three weeks. Yes, April; and this was
the beginning of July.
Her eyes slowly travelled round the luxurious apartment, with its
pale blue silk hangings, inlaid satin-wood furniture, and Persian
carpet, her toilet-table loaded with silver bottles and boxes, a large
silver-framed mirror, draped in real lace, the silver-backed brushes,
the cases of perfume; and she thought with a shudder of the poor
little room at No. 2, with its rickety table, shilling glass, and jug
without a handle. Deliberately, she stood before the dressing-table,
and deliberately studied her reflection in the costly mirror. How
different she looked to poor, haggard, shabby Mrs. Wynne, the slave
of a sick husband and a screaming baby, with all the cares of a
miserable home upon her young shoulders; with no money in her
purse, no hope in her heart, no future, and no friends!
Here she beheld Miss West, radiant with health and beauty, her
abundant hair charmingly arranged by the deft-fingered Josephine,
her pretty, slim figure shown off by a simply made but artistic twenty-
guinea gown; her little watch was set in brilliants, her fingers were
glittering with the same. She had just risen from a dainty lunch,
where she was served by two powdered footmen and the clerical
butler. Her carriage is even now waiting at the door, through the
open window she can hear the impatient stamping of her six-
hundred-guinea horses.
She was about to call for an earl’s daughter, who was to
chaperone her to a fête, where, from previous experience, she knew
that many and many a head would be turned to look after pretty Miss
West; and she liked to be admired! She had never gauged her own
capacity for pleasure until the last few months. And Laurence
required her to give up all this, to rend the veil from her secret, and
stand before the world once more, shabby, faded, insignificant Mrs.
Wynne, the wife of a briefless barrister!
Of course she was devoted to Laurence. “Oh,” angrily to her own
conscience, “do not think that I can ever change to him! But the
hideous contrast between that life and this! He must give me a little
more time—he must, he must! I must enjoy myself a little!” she
reiterated passionately to her beautiful reflection. “Once papa knows,
I shall be thrust out to beggary. I know I shall; and I shall never have
a carriage or a French gown again.”
And this was the girl who, four months previously, had pawned her
clothes for her husband’s necessaries, and walked miles to save
twopence!
Sudden riches are a terrible test—a severe trial of moral fibre,
especially when they raise a girl of nineteen, with inherited luxurious
tastes, from poverty, touching starvation, to be mistress of
unbounded wealth, the daughter, only child and heiress of an open-
handed Crœsus, with thousands as plentiful now as coppers once
had been.
“I will go down and see him. I must risk it; there is no other plan,”
she murmured, as she rang her bell preparatory to putting herself in
the hands of her maid. “Letters are so stupid. I will seize the first
chance I can find, and steal down to the Holts, if it is but for half an
hour, and tell Laurence that he must wait; he must be patient.”
And so he was—pathetically patient, as morning after morning he
waited in the road and waylaid the postman, who seldom had
occasion to come up to the farm; and still there was no letter.
Madeline was daily intending to rush down, and day followed day
without her finding the opportunity or the courage to carry out her
purpose. And still Laurence waited; and then he began to fear that
she must be ill. A whole week and no letter! He would go to town and
inquire. No sooner thought of than done. Fear and keen anxiety now
took the place of any other sensation, and hurriedly making a
change in his clothes, and leaving a message for Mrs. Holt, he set
off to the station—three miles—on foot, and took a third-class return