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239 Cards in this Set
- Front
- Back
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Hypertensive patient with decreased potassium and metabolic alkalosis is most likely to have?
• Pheochromocytoma • Adrenal adenoma • Renal artery stenosis |
B. ADRENAL ADENOMA conn
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Aldosterone producing adenoma…which is true?
• Distinctly different from cortisol producing tumors • Medullary location • Sodium wasting • Low renin levels |
D. LOW RENIN LEVELS
Adrenal adenomas are located in the cortex and the different types (nonfunctional vs. hyperfunctional) are indistinguishable radiographically. Aldosterone causes sodium and water RETENTION (but only minimal hypernatremia). By definition, aldosteronomas cause suppression of the renin-angiotensin system and thus a LOW renin. |
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MCDK (Multicystic Dysplastic Kidney)
• Cysts communicate • Associated with pelvic and infundibular atresia • Most common associated contralateral abnormality is MCDK |
B. ASSOCIATED WITH PELVIC AND INFUNDIBULAR ATRESIA
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Mesoblastic nephroma … which is false?
• Malignant • Diagnosable on prenatal US • Local extension • Most common solid renal mass of infancy |
A. Malignant (False)
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Renal lymphoma is most commonly
• Multifocal • Hodgkin’s • Hypoechoic mass with increased through transmission • Other lymphoma focal points |
A. MULTIFOCAL
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Which is true about urethral stricture in a male.
• A Catheter induced stricture is at the peno-scrotal junction • B GC causes focal short segment stenosis • C Anterior urethra extends from urethral meatus to the peno-scrotal junction |
• Answer: A (catheter induced stricture is at the peno-scrotal junction) Primer, 3rd Edition, pg 311 and Dunnick Textbook of Uroradiology, 3rd Edition, pg. 421.
• Catheter induced strictures are long, irregular and at the penoscrotal junction. GC strictures are several centimeters long and typically in the anterior urethera. |
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Elderly male with hematuria. Filling defect in the renal collecting system on IVP. Non-contrast CT - mass in the collecting system, HU 75. Likely cause?
• Transitional cell carcinoma • Squamous cell carcinoma • Fungus ball • Urate stone |
Blood clots can have CT densities of 60-90 HU.
This would be the best answer if given as an answer choice. |
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6 hours after renal transplant with reversal of flow in segmental arteries
• Hyperacute rejection • Renal vein thrombosis • ATN |
B. RENAL VEIN THROMBOSIS
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Where do Cowper’s glands insert?
• Prostatic urethra • Membranous urethra • Bulbar urethra • Penile urethra Also recalled as • At what level are Cowper’s glands located? a. prostatic urethra b. membranous urethra c. bulbous urethra d. penile urethra |
C. BULBOUS URETHRA
Glands located at level of membranous urethra. Cowper ducts Insert at bulbous. |
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Pseudo-diverticulosis of urethra
• Associated with TB • Women > men • More common in the distal urethra • Congenital |
B. WOMEN > MEN
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Diverticulum of urethra
• Congenital • Usually posterior • Men > women |
B. Usually posterior LATERAL
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Epidermoid cyst on testicular US
• Hypoechoic with hyperechoic foci • Concentric rings • Can be biopsied transcrotal |
B. CONCENTRIC RINGS
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35-year-old, which testicular CA is most likely?
• Seminoma • Embryonal Cell Carcinoma • Teratoma • Choriocarcinoma • Yolk Sac tumor (Endodermal Sinus tumor) • lymphoma |
• Seminoma – 35-50%
Testicular Tumors by Age Group 1st Decade Yolk Sac tumor / Teratoma 2nd Decade Choriocarcinoma 3rd Decade Embryonal cell carcinoma 4th Decade Seminoma |
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What amount of endometrial thickness should be biopsied in a post-menopausal patient?
• 3 mm • 5 mm • 7 mm • 9 mm • 11 mm |
C. 7 mm
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Which of the following does NOT cause endometrial thickening?
• Polyps • Adenomyosis • Tamoxifen • Hyperplasia |
B. ADENOMYOSIS
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Ovarian torsion
• Eliminated by seeing flow on US • Affected side enlarged • Left more effected than right • Seen most commonly in postmenopausal females • usually associated with malignant mass |
. AFFECTED SIDE ENLARGED
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• What is true about hydrosonography?
• a) used to evaluate cause of endometrial thickening • b) best done transabdominally • c) uses iodinated contrast • d) best performed during the secretory phase of cycle • e) not to be done post menopausal |
• used to evaluate cause of endometrial thickening
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Which is false about para-ovarian cysts?
• a) undergo cyclic change • b) are located in the broad ligament • c) undergo torsion |
• Do not undergo cyclic change.
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• Adenomyosis, what is false?
• a) sharply defined • b) may be focal • c) may be diffuse • d) can get areas of high signal intensity • e) widened junctional zone |
• Ans: A (repeat)
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• What type of stone do you get in bowel resection?
• a) calcium phosphate • b) uric acid • c) calcium oxalate |
• Ans: C. (Repeat)
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Calcification in testicles:
• a) meconium peritonitis • b) trauma • c) tumor |
• Ans: A (repeat)
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• Which of the following is NOT associated with tuberous sclerosis?
a. rhabdomyoma b. astrocytoma c. angiomyelolipoma d. sphenoid dysplasia |
• Answer: D. In TS: Angiomyolipoma (38-89%), Giant Cell Astrocytoma (15%), & Rhabdomyoma (5-30%).
• Sphenoid wing dysplasia never mentioned (is seen with NF1 as per multiple old recalls as reason for pulsitile ophth) |
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• Which ultrasound finding is the most specific for adenomyosis?
a. focal hypoechoic area in myometrium b. cystic area beneath endometrium c. heterogeneous echotexture |
B. Subendometrial cyst
Myometrial cyst was the most sensitive and specific TVUS criterion. In MRI, the presence of a high-signal-intensity myometrial spot was as specific but less sensitive than a maximal junctional zone thickness (JZ(max)) >12 mm and a JZ(max) to myometrial thickness ratio >40%. • Endovaginal US Signs MR Imaging Signs • Abnormal myometrial echogenicity Abnormal myometrial signal intensity • Hypoechoic (75% of cases) Low signal intensity (predominant) • Isoechoic Areas of high signal intensity (subendometrial) • Hyperechoic • Heterogeneous myometrial echotexture Thickening of junctional zone – Focal Focal – Diffuse Diffuse (12 mm thick) • Myometrial cysts Myometrial foci of high signal intensity • Echogenic nodules or linear striations Linear striations of high signal intensity • Pseudowidening of endometrium Pseudowidening of endometrium • Poor definition of endomyometrial junction Poor definition of endomyometrial junction • Relative absence of mass effect Relative absence of mass effect • Poor definition of lesion borders Poor definition of lesion borders • Elliptical myometrial abnormality Elliptical myometrial abnormality |
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• Woman with menorrhagia and 3cm mass in endometrial canal. Low on both T1 and T2
• polyp • endometrial ca • leiomyoma • adenomyosis |
• C Leiyomyoma, dark on t1 and t2 unless degenerates.
polyps are of similar signal |
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• Which of the following is the best way to diagnose Asherman’s syndrome (intrauterine synechiae)?
a. Ultrasound b. MRI c. Hysterosalpingogram d. CT w/ contrast e. PET |
Answer: HSG. Dahnert 5th ed. Pg 1023
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• A patient has extraperitoneal rupture of the bladder with contrast extravasation into the perineum. Likely associated injury?
a. Fx of symphysis pubis b. urethral injury c. fracture of pelvic ring |
Answer: C fracture of pelvic ring
• Extraperitoneal bladder rupture is associated with a pelvic fracture or avulsion tear at fixation points of the puboprostatic ligaments. The Primer says extraperiotoneal bladder rupture accounts for 45% of bladder ruptures, but Dahnert says ithe figure is 80%. Huh??? Who is right? I don’t know. Anyway, extraperitoneal rupture usually occurs at the base of the bladder at the anterolateral aspect. On imaging, you will see a “pear-shaped bladder” or a “molar tooth sign” with fluid around the bladder and displacing bowel loops. Contrast may be seen extending into the thigh or into the anterior abdominal wall. • Intraperitoneal bladder rupture accounts for anywhere from 20-45% of bladder ruptures depending on who you ask. Intraperitoneal bladder rupture occurs with blunt trauma, stab wounds, and invasive procedures. It usually occurs at the dome of the bladder. On imaging, you will see contrast extravasation into the paracolic gutters and outlining small bowel loops and other abdominal viscera. • Source: Primer and Dahnert |
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• Which of the following is accurate regarding Prostate Cancer?.
• on US, most hyperechoic prostate lesions are cancer • PSA in prostate cancer is typically higher than in BPH • appears bright on T2WI • prostate cells (?cancer) produce more PSA than BPH cells. • prostate coil contraindicated after biopsy |
Ans: probably d.
• Most hypoechoic lesions are not cancer. Per Dannert, 35% of hypoechoic prostate lesions are adenocarcinoma. Remainder are BPH, normal prostate tissue, and prostatitis. The peripheral zone in the prostate is normally bright on T2. Cancer is usually in the peripheral zone (70%) and demonstrates decreased signal on T2. BPH is usually in the transition zone. Contraindications to an endorectal coil include “anorectal conditions” including IBD, anorectal surgery, or pelvic irradiation. Prostate biopsy was not included. |
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Regarding prostate cancer: (2000 repeat)
• most lesions are hypoechoic on ultrasound (or most hypoechoic lesions are cancer)? • most lesions are hyperechoic on ultrasound • lesions are hyperintense to normal gland on T2 • lesions are hyperintense to normal gland on T1 • Rectal coil MR is contraindicated post-biopsy/TURP |
• A
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• 22 year-old male with sickle cell trait and a CT scan showing a central renal tumor with local extension and associated satellite nodules as well as multiple lung nodules: diagnosis?
• rhabdomyosarcoma • medullary carcinoma • TCC • lymphoma • sarcomatoid renal tumor |
• A. Medullary carcinoma
• Medullary carcinoma is an infiltrating neoplasm of the kidney highly associated with sickle cell trait and less commonly sickle cell anemia (“seventh sickle cell nephropathy”). It appears to originate from elements of the kidney originally derived from the ureteric bud. Clinically, they are found in pts aged less than 40 years. They are indistinguishable radiographically from other infiltrating neoplasms of the kidney. They tend to be centrally located. Highly aggressive--mean survival 15 weeks from diagnosis.Angiomyolipoma is associated with tuberous sclerosis. RCC is the most common primary renal malignancy. Oncocytoma is a benign neoplasm. Genitourinary Requisites, 115, 81-120; Dähnert 5th p. 926 |
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• Patient has seminal vesicle cyst, what congenital abnormality is associated with this:
• Ipsilateral renal agenesis • Contralateral renal agenesis • Contralateral cryptorchidism • Renal ectopia |
Renal agenesis
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• Which of the following is the cause of Meig’s syndrome?
a. IVC clot b. colon CA c. ovarian fibromas d. ? other bogus answer |
• C. ovarian fibromas
• http://www.emedicine.com/med/topic1422.htm. |
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• A 65 yo male patient has hematuria and a filling defect in the renal collecting system on IVP. Non-contrast CT showed a mass in the collecting system, with HU density of 75. Likely cause?
a. transitional cell carcinoma b. squamous cell carcinoma c. fungus ball d. urate stone |
• A 65 yo male patient has hematuria and a filling defect in the renal collecting system on IVP. Non-contrast CT showed a mass in the collecting system, with HU density of 75. Likely cause?
a. transitional cell carcinoma b. squamous cell carcinoma c. fungus ball d. urate stone e. ? ?blood clot? Not a choice • A. transitional cell CA vs fungal ball. • On CT scans, confusion may occur with a blood clot and a hyperattenuating TCC • The commonly recognized presentations of TCC on CT scans include the following: irregular filling defects of the pelvocalyceal system and ureters, which tend to be associated with obstruction and dilatation of the ureter and pelvis proximal to the lesion; ureteral wall thickening; frondlike growths projecting into the bladder from a fixed mural site; and surface calcification of bladder TCC. • On nonenhanced CT scans, the TCC is hypoattenuating or isoattenuating relative to the normal renal parenchyma, and it is hyperattenuating relative to urine. TCCs demonstrate mild- to-moderate enhancement after the administration of contrast material, and they become hypoattenuating relative to opacified urine |
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• Female on IVP has a dome like impression on the base of the bladder and complains of dribbling. This history suggests the diagnosis of…
• Ectopic ureterocele • Bladder diverticulum • Transitional cell carcinoma • Paraovarian cyst • Urethral diverticulum |
• E. Urethral diverticulum
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• Most frequent complication of Inflammatory Bowel Disease in the GU tract:
• Rectovesical fistula • Stones • TCC • RCC • Obstruction |
• B. Stones.
• In patients with Crohn’s disease, water and electrolyte losses in diarrhea and malabsorption cause changes in the composition of urine leading to stone formation. Nephrolithiasis occurs in 2-10% of this population and has reported to be as high as 18% in patients with ileostomies. Oxalate stones are the most common as a result of active enteritis and malbsorption of fat (increased passive absorption of oxalate occurs because calcium which binds oxalate in the intestine is depleted in combining with unabsorbed fatty acids). Uric acid stones are also common, particularly in patients with ileostomies. The occurrence of nephrolithiasis is roughly proportional to the amount of distal small bowel involvement or resection and degree of malabsorptionRectovesical fistula. Fistulization with the GU tract occurs less commonly than either nephrolithiasis or hydronephrosis. Enterovesical fistulas are the most common with an incidence of 3.9%. Enterovesical fistulas most commonly cause pneumaturia and recurrent UTI’s. Perirenal abscess may also occur. Usually, the distal ileum is the involved segment of bowel. Rectovaginal and ileovaginal fistulas are also common. TCC and RCC. No association between Crohn’s disease and these entities are found in the literature.Obstruction. Obstructive hydronephrosis secondary to ileocecal Crohn’s disease is another complication that may be due to retroperitoneal fibrosis, creeping fat, or abscess formation. Obstruction tends to involve the right ureter at the pelvic brim. Because Crohn’s tends to involve the the terminal ileum, right sided psoas abscesses predominate. The right ureter coarses along the psoas margin and can obstruct at any level. However, it commonly obstructs near the terminal ileum at the pelvic brim. Inflammatory RPF is another complication of Crohn’s and also causes obstruction of the right ureter at the level of the pelvic brim even in the absence of frank infection. The overall incidence of ureteral obstruction is 5-7%. (Gore, Textbook of GI Radiology, p. 2676-7 and Pollack, Clinical Urography, p.962-6, 1686)** Repeat from ’98 ** |
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20 y.o. otherwise healthy female presents with simple 2.0 cm ovarian cyst. What is the next appropriate step in management?
• Nothing further required. • Follow up ultrasound in 4-6 weeks • Contrast enhanced CT • Gynecologic consultation |
• Likely folicular cyst, normally simple 25mm or less, no further workup req pg 565-566
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• Salpingitis isthmica nodosa (SIN) is associated with:
a. Hydrosalpinx b. Endometriosis c. Adenomyosis d. Congenital uterine abnormalities e. uterine hyperplasia |
• B. Endometriosis.
• According to AmershamHealth, Salpingitis Isthmica nodosa is associated with: - #1 Pelvic Inflammatory Disease (in 89% of PID cases) - #2 Endometriosis (28%) - #3 other causes (TB, congenital disorders)SIN, (also called diverticulosis of the Fallopian tubes), inflammation in the isthmic portion of the Fallopian tube: - etiology not fully understood, although chronic inflammation (as in PID or endometriosis) seems to play a role. - no increased incidence of congenital uterine malformations in association with SIN. - diagnosis best achieved with hysterosalpingography - radiological prevalence of SIN is 3.9–7.5%; bilateral (over 50% of cases)* Be aware that previous answers to this question have included hydrosalpinx and adenomyosis, but given currently available references, ‘B’ seems to be the best answer. Dähnert 5th p. 1052 |
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• What is most likely to cause small cystic kidneys (?by ultrasound)
– Multicystic dysplastic kidney – Autosomal dominant polycystic kidney disease – Autosomal recessive polycystic kidney disease – Medullary cystic disease – Acquired renal cystic disease |
• D. Medullary Cystic Disease. (long standing renal failure was not an option)Medullary cystic disease is a spectrum of disease characterized by medullary cysts and tubulointerstitial fibrosis. Patients usually present with azotemia and anemia and subsequently progress to endstage renal failure. Radiographic features include: small kidneys, multiple small cysts in medulla, cortex is thin without cysts, no calcifications.
• HIV nephropathy results in large kidneys. • Medullary sponge kidney is dysplastic dilatation of renal collecting tubules. Results in no change in kidney size. GU requisites p148, Primer, 3rd, 282, 295-296 |
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• What solid renal tumor is most likely to mimic a simple cyst on ultrasound
– Lymphoma – Aml – Mets |
• Lymphoma
• On sonograms, the masses are often hypoechoic, reflecting tissue homogeneity, and they can be misidentified as renal cysts • Emedicine.com |
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• 70 year old man with a long-standing history of HTN. MRI shows an adrenal gland mass which is hypointense on in and out of phase MRI images. The patient most likely has:
• a. Metastases • b. Adrenal adenoma causing his hypertension • c. Adrenal hyperplasia • d. Non-functioning adrenal adenoma and essential hypertension |
• D. Non fxn adrenal adenomawith essential htn
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• A patient has a NORMAL IVP exam. On the follow day he has a BE. The scout film shows bilaterally dense nephrogram. The most likely source of this problem is?
a. Contrast induced renal failure b. Obstruction c. Nephropathy d. The bogus answers keep changing year to year. |
• A. Contrast induced renal failureA delayed, persistent nephrogram at 24 hours has been observed in the majority of patients with contrast nephropathy. see GU Req. p. 3.
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• 25 yo with one year h/o of nephrotic syndrome presents with acute flank pain, gross hematuria, and enlarged kidney and persistent nephrogram on IVP. Most likely dx:
• a. Pyelonephritis • b. Renal vein thrombosis • c. Obstructing UVJ calculus • d. Hemorrhage nephritis |
• B. Renal vein thrombosis.
• a = Pyelonephritis: female>>male, fever, flank pain, equivocal microhematuria, normal or enlarged kidney. • B = Renal vein thrombosis: acute: gross hematuria, enlarged kidney, obstructive nephrogram. Chronic: 80% asymptomatic, nephrotic syndrome. • c = UVJ stone: • d = Hemorrhagic nephritis: (Radiology Review Manual 3rd. ed. Dähnert, pp. 699, 700, 640.) |
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• Regarding Conn’s syndrome, which is NOT seen?
a. Hypernatremia b. Hypokalemia c. Hypertension d. Increased renin e. Increased aldosterone |
• D. Increased renin
• Conn’s syndrome is hyperaldosteronism and causes Na+ reabsorption, K+ secretion, secondary hypertension and supresses renin secretion. Usually secondary to a adrenal adenoma (75%), or hyperplasia (25%); rather than carcinoma (1%) Dähnert . p. 915 |
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• During an IVP a patient becomes tachycardic and hypotensive. Which of the following is NOT an appropriate therapy?
a. atropine b. iv fluids c. epinephrine d. Trendelenburg position e. oxygen |
• C. Atropine
• A patient with hypotension (SBP < 90) and bradycardia (HR<60) is experiencing a VASOVAGAL reaction. According to the ACR manual on contrast reactions, the following should be done for hypotension with bradycardia: 1. monitor vital signs 2. Trendelenburg position or elevate legs more than 60 degrees 3. secure airway (ABCs): give oxygen 6-10L/m by mask 4. secure IV access: rapid fluid replacement with NS 5. Atropine 0.5-1.0mg IV slowly 6. repeat atropine up to total dose of 2-3mg So strictly speaking, the first thing you should do is E-put the person in trendelenburg (although you can’t really “give” trendelenburg). I think C (give the person IV fluids) is a good choice depending on the patient’s degree of hypotension. Atropine is a choice further along if the patient continues to have hypotension dispite the conservative measures (trendelenburg and fluids). Epinephrine is used in patients with hypotension with tachycardia (shock). Epinepherine stimulates adrenergic receptors, producing vasoconstriction, increasing blood pressure and heart rate; Atropine works by blocking vagal nerve discharges and thus increases heart rate. ACLS Provider Manual, copyright 2001, pgs 82, 105, 145-156 and Primer, 647 |
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• Which does not cause bladder wall calcifications?
a. TB b. Schistosomiasis c. Malacoplakia d. Transitional cell carcinoma e. Cystitis |
• C. Malacoplakia.
• Malacoplakia [Greek = soft plaque] is a granulomatous inflammatory process that affects the urinary bladder and lower ureter, in response to a gram negative infection [94% E. coli]. It causes multiple raised but sessile filling defects on cystography. Rare (< 200 cases reported) - CT shows low attenuation lesions Dähnert 5th p. 924.Mnemonic: SCRITTSchistosomiasis, Cytoxan, Radiation, Interstitial cystitis, TB, TCCPrimer, pg 357 and GU Requisites 208-209; Dähnert 5th p. 889 |
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• Which of the following is false concerning varicoceles?
a. is seen in 10-20% of males b. mostly asymptomatic c. more common on the right side d. associated with infertility |
• C. more common on the right side. (False)
• 78-90% occur on the left side (due to drainage of the left spermatic vein into the left renal vein at a right angle). Varicoceles represent dilated veins of the pampiniform plexus. They result from incompetent or absent valves in the spermatic vein. Prevalence: 15% of adult males. If symptomatic, the clinical findings generally are: Infertility, pain, scrotal enlargement. 25% of Varicoceles are bilateral. On US: hypoechoic veins (“bag of worms”), veins easily compressed by transducer, increase in venous size when patient is upright or valsalvas. Primer of Diagnostic Imaging, 3rd ed., pg 327. Dähnert 5th p. 982. |
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• Which is associated with squamous cell cancer:
• a) renal Tb • b) urate nephropathy • c) analgesics • d) infected staghorn calculus |
Staghorn
• Answer: D. Dunnick states that squamous cell cancer of the renal pelvis is frequently associated with leukoplakia or chronic irritation from stones or UTI. Remember that malakoplakia is NOT pre-malignant, however, leukoplakia is pre-malignant. Analgesics predispose to transitional cell ca. |
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• Which of the following is true about Glucophage?
• a. If a patient has had Glucophage in the last 48 hours, iodinated contrast is contraindicated. • b. it causes renal failure if contrast is given • c. it is associated with lactic acidosis in patients with poor renal function |
• C. it is associated with lactic acidosis in patients with poor renal function.
• Metformin (glucophage) is an oral antihyperglycemic agent used in NIDDM. Lactic acidosis is a rare (0.84 cases per 1000) complication with a 50% mortality rate that occurs in patients with concomitant renal or hepatic failure. Recommendations regarding use of iodinated contrast in patients on glucophage, for elective studies: Discontinue metformin for 48 hours before and after contrast study, reevaluate renal function before restarting metofrmin. Recs for urgent studies: obtain serum creatinine, if normal may perform but use nonionic contrast, aggressively hydrate, and hold metformin for 48 hours. If abnormal creatinine, metformin must be held 48 hours before contrast administration. Primer, 945 |
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• CT contrast is excreted by which route?
• glomerular filtration • tubular secretion • biliary excretion |
• glomerular filtration
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• Postmenopausal endometrial bleeding
a. endometrial polyps b. endometrial hyperplasia c. endometrial carcinoma d. endometrial atrophy |
• D. endometrial atrophy.
• Endometrial atrophy causes postmenopausal bleeding in 60-75% of cases: - thin atrophic endometrium is prone to ulceration - In the 75% with endometrial thickness < 4-5 mm, no biopsy needed - in 25% endometrium 6-15 mmOther causes of postmenopausal uterine bleeding: endometrial hyperplasia, polyp, submucosal fibroid, adenomyoma, endometrial carcinoma (7-20%), estrogen withdrawal. Dähnert 5th p. 1004. Primer, 362 and Genitourinary Requisites, 250, 289-291 and 295-300 |
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• A man presents with dysuria , stricture of the penile urethra and dilated glands (of Litrre) on retrograde urethrogram. What is the most likely cause of the stricture?
a. prior gonococcal infection b. prior instrumentation c. neoplasm d. pelvic ring fracture |
• A. prior gonococcal infection
• Infection with Neisseria gonorrhoeae begins in the mucosa and periuretheral glands of Littre. Symptoms of dysuria and urethral discharge occur. Can result in urethral stricture and opacified (dilated) glands of Littre on urethrography due to inflammatory dilatation of duct ostia. 40% of urethral strictures are infectious in etiology. The proximal bulbar urethra is the site of stricture in 70% of patients with gonococcal urethritis because of the high concentration of periurethral glands in this area and the dependent position of this portion of the male urethra. Genitourinary Requisites, 235-236 |
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• Which of the following is false about bladder diverticula?
a. Schistosomiasis is a cause b. Can be congenital c. Associated with stone formation d. can occur in bladder obstruction |
• A. Schistosomiasis is a cause
• Types of bladder diverticulum: • Hutch diverticulum—congenital weakness of musculature near UVJ, usually associated with reflux. • Acquired diverticulum in bladder outlet obstruction—usually multiple, not associated with reflux, complications of: infection, calculi (25%), tumor (3%) • Schistosomiasis: Infected humans excrete eggs in urinary tract which become trapped in mucosa and cause granulomatous reaction. Radiographic findings: extensive calcification in bladder wall (hallmark), inflammatory pseudopolyps, ureteral strictures and/or fistulas, SCC. Genitourinary Requisites 305, 306 |
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• Patient with rapidly progressive inspiratory stridor and hoarseness after contrast
• epi • atropine • ntg • bronchobilator |
• Give Epi
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• Which of the following is true regarding aldosteronomas?
a. often multiple b. low renin c. hyponatremia d. medullary location e. can be histologically differentiated from cortisal secreting adenomas |
• B. low renin
• Approx 70% of primary hyperaldosteronism is caused by a solitary adrenal adenoma (Conn’s syndrome). • Clinically patients present with polyuria, diastolic hypertension, hypernatremia, and signs of total-body potassium depletion (=hypokalemia). - “hypertension secondary to hypernatremia” Dähnert 5th p. 915 - 65-70% of adrenal adenomas are solitary - histologically not distinguishable from cortisol tumors • Aldosterone is produced in the adrenal cortex [zona glomerulosa] and is the location of aldosteronomas. • Renin produced by the kidney in response to dropping GFR. Genitourinary Requisites 366-367 and Nuclear Medicine Requisites, 2nd ed 380-384Remember—“Salt, sugar, sex: the further in you go, the sweeter it gets”. |
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• In a renal duplication which of the following is true?
a. upper pole ureter inserts superior/lateral to inferior pole ureter b. upper pole ureter inserts medial/inferior to lower pole ureter c. the upper pole refluxes and the lower pole obstructs d. occurs more often in males than females. |
• B. upper pole ureter inserts medial / inferior to lower pole ureterWeigert-Myer rule: the upper pole of a kidney drains via the ureter, which inserts inferior and medial to the normal, expected ureteral insertion point. Ectopic ureteroceles occur in 1/3 of patients with duplicated ectopic ureters. The upper pole moiety ureter is subject to obstruction & dysplasia of that portion of the kidney; the lower pole ureter typically refluxes due to its shortened tunnel into the bladder. M:F = 1:2 Genitourinary Requisites, 157; Dähnert 5th p. 977.
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• Which of the following is not associated with Wilms tumor?
a. Beckwith-Wiedemann syndrome b. Hemihypertrophy c. Inherited aniridia d. Nephroblastoma |
• C. Inherited aniridia
• Patients with aniridia who have a positive family history (inherited form) are not at an increased risk for Wilms tumor; however, patients with aniridia without a positive family history (sporadic form) have a 30% chance of developing Wilms tumorWilms tumor (= nephroblastoma) is associated with sporadic anridia (in 33%), hemihypertrophy, Drash syndrome (pseudoherma-phroditism, glomerulonephritis, Wilms’ tumor), Beckwithh-Wiedemann syndrome (macroglossia, omphalocele, visceromegaly), and Nephroblastomatosis. Nephroblastomatosis is a precursor to Wilms. Primer, 839-840; Dähnert 5th p. 984 |
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• Which is true regarding MRI imaging of adrenal adenoma?
a. on gradient echo: increased signal on in phase and out of images b. on gradient echo: decreased signal on in phase/ increased on out of phase c. on gradient echo: iso to slightly increased signal on in phase and decreased on out of phase d. on T1: : iso to slightly increased signal on in phase and decreased on out of phase |
• C. on gradient echo: iso to slightly increased signal on in-phase and decreased on out-of-phase.Nonfunctioning adenomas are isointense with normal adrenal tissue on T1 and T2 weighted images. They are isointense to liver on T1-weighted and isointense-to-slightly hyperintense to liver on T2-weighted images. Chemical-shift imaging has become the standard MR imaging method of characterizing adrenal adenomas: 60-70% of benign adrenocortical tumors have intracytoplasmic fat! Dähnert 5th p. 870With gradient-echo sequences and short echo times, the signal intensity of an adrenal mass can be evaluated by using in-phase and out-of-phase pulse sequences. In-phase, the water and fat in the adenoma combine to give increased signal. Out-of-phase, adenomas have decreased signal. Other adrenal masses do not contain fat and should not demonstrate significant change in signal intensity between in-phase and opposed-phase imaging.
Genitourinary Requisites, 347-349; |
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• Patients with sickle cell trait are increased risk for which of the following renal tumors?
a. Medullary carcinoma b. Angiomyolipoma c. Transistional cell carcinoma d. Oncocytoma e. Renal cell carcinoma |
Medullary carcinomaMedullary
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• Which of the following is not associated with papillary necrosis?
a. oxalosis b. diabetes mellitus c. NSAIDS d. TB e. renal vein thrombosis |
• A. Oxalosis
• Oxalosis is not associated with papillary necrosis; rather, it is associated with medullary nephrocalcinosis.Mnemonic for causes of papillary necrosis: POSTCARD Pyelonephrits, Obstruction (chronic), Sickle cell disease, TB / Trauma, Cirrhosis (ethanol) / Coagulopathy, Analgesics (phenacetin), Renal vein thrombosis, Diabetes (50%) Primer 3rd, 352 |
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• During an IVP a patient becomes bradycardic and hypotensive. Which of the following is NOT an appropriate therapy?
a. atropine b. iv fluids c. epinephrine d. Trendelenburg position e. oxygen |
• C. Epinephrine
• A patient with hypotension (SBP < 90) and bradycardia (HR<60) is experiencing a VASOVAGAL reaction. According to the ACR manual on contrast reactions, the following should be done for hypotension with bradycardia: 1. monitor vital signs 2. Trendelenburg position or elevate legs more than 60 degrees 3. secure airway (ABCs): give oxygen 6-10L/m by mask 4. secure IV access: rapid fluid replacement with NS 5. Atropine 0.5-1.0mg IV slowly 6. repeat atropine up to total dose of 2-3mg So strictly speaking, the first thing you should do is E-put the person in trendelenburg (although you can’t really “give” trendelenburg). I think C (give the person IV fluids) is a good choice depending on the patient’s degree of hypotension. Atropine is a choice further along if the patient continues to have hypotension dispite the conservative measures (trendelenburg and fluids). Epinephrine is used in patients with hypotension with tachycardia (shock). Epinepherine stimulates adrenergic receptors, producing vasoconstriction, increasing blood pressure and heart rate; Atropine works by blocking vagal nerve discharges and thus increases heart rate. ACLS Provider Manual, copyright 2001, pgs 82, 105, 145-156 and Primer, 647 |
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• A renal mass with Hounsfield Units of 60 is seen on CT with IV contrast. What is the most appropriate management?
a. percutaneous biopsy b. partial nephrectomy c. CT without contrast d. Follow up CT in 6 months |
• C. CT without contrast
• Normal attenuation of renal parenchyma is 30-60 HU on noncontrasted scans. Postcontrast, parenchyma HU will increase to 80-120 HU. Recommended protocol to evaluate renal masses include noncontrasted as well as contrasted images. You must be able to compare the mass to the kidney on noncontrasted images and to see if its attenuation changes after contrast administration. Also, there may be a calcification component obscured by the contrasted renal parenchyma. Genitourinary Requisites 25-26, 47 |
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• A young male has an ultrasound examination that shows no kidney in the right renal fossa and a cyst between the bladder and prostate. Most likely diagnosis:
a. pelvic kidney b. renal agenesis c. crossed ectopia |
• B. renal agenesisRenal agenesis is associated with ureteral abnormalities such as absence of the ipsilateral ureter or remnant of the ureter. 20% of cases associated with absence of ipsilateral epididymis, vas deferens, or seminal vesicle, or presence of an associated ipsilateral seminal vesicle cyst.
• The cyst in this question is likely a seminal vesicle cyst. • There’s an image of one on pg 330 of Genitourinary Requisites. Pelvic kidney and crossed ectopia do not have this association. Genitourinary Requisites, pgs 53, 327-328, 330 Primer, 324 |
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• At what level are Cowper’s glands located?
a. prostatic urethra b. membranous urethra c. bulbous urethra d. penile urethra |
• B. membranous urethra
• The accessory sex glands of Cowper are a pair of structures located one on each side of the membranous urethra between the two fascial layers of the urogenital diaphragm. The paired ducts of these glands are 2-3 cm in length and extend forward and medially to enter the proximal bulbous urethra. They are ontogenically homologous to Bartholin’s glands in females. Genitourinary Requisites, 195 |
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• Which of the following is most likely to be unilateral?
a. multicystic dysplastic kidney b. autosomal recessive kidney disease c. autosomal dominant kidney disease d. medullary cystic kidney disease |
• A. Multicystic dysplastic kidney
• Multicystic dysplatic kidney usually presents unilaterally because bilateral MDK is incompatible with life. The autosomal kidney diseases and medullary cystic kidney disease are bilateral. Genitourinary Requisites 66-69, 108-109, 130-131 |
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• A man has microscopic hematuria. Which of the following is the best study to evaluate for bladder cancer?
a. Cystoscopy b. Retrograde cystogram c. MRI d. CT e. US |
I think cystoscopy
• All patients with suspected bladder cancer should undergo cystoscopy and bimanual examination (1). Cystoscopy remains the standard of reference, providing direct visualization of the bladder and an opportunity for cytologic washings, biopsy, or local excision. Retrograde ureterography may also be performed. Cystoscopic biopsies provide invaluable staging information regarding depth of bladder wall invasion. |
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• Which of the following is most likely to cause air in the bladder wall?
a. Candida b. trauma c. e coli |
• C. E. coli
• Emphysematous cystitis caused by infection (most commonly E. coli). Predisposing diseases: diabetes mellitus (most common), long-standing urinary tract obstruction. Radiographic features: gas in bladder wall, gas may enter the ureter, air-fluid level in bladder. Primer 305 |
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• Which of the following is false about bladder diverticula?
a. Schistosomiasis is a cause b. Can be congenital c. Associated with stone formation d. can occur in bladder obstruction |
• A. Schistosomiasis is a cause
• Types of bladder diverticulum: Hutch diverticulum—congenital weakness of musculature near UVJ, usually associated with reflux. Acquired diverticulum in bladder outlet obstruction—usually multiple, not associated with reflux, complications of: infection, calculi (25%), tumor (3%)Schistosomiasis: Infected humans excrete eggs in urinary tract which become trapped in mucosa and cause granulomatous reaction. Radiographic findings: extensive calcification in bladder wall (hallmark), inflammatory pseudopolyps, ureteral strictures and/or fistulas, SCC. Genitourinary Requisites 305, 306 |
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• Where is the most common location for urethral obstruction in young boys?
a. Prostatic urethra b. Membranous urethra c. Bulbous urethra d. Penile urethra |
• A. Prostatic urethra
• Posterior urethral valves occur in 1:5,000 to 8,000 boys; they are the most common cause of urinary tract obstruction + leading cause of end-stage renal disease among boys. They are congenital folds located in the posterior urethra near the distal end of the verumontanum; the verumontanum is located within the prostatic urethra • Causes of bladder outlet obstruction in children: posterior urethral valves (most common in males), ectopic ureterocele (most common in females), bladder neck obstruction, urethral stricture, prune belly syndrome. Genitourinary Requisites, 194-195 and Primer 308, 834-835 |
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• A man presents with dysuria , stricture of the penile urethra and dilated glands (of Litrre) on retrograde urethro gram. What is the most likely cause of the stricture?
a. prior gonococcal infection b. prior instrumentation c. neoplasm d. pelvic ring fracture |
• A. prior gonococcal infection
• Infection with Neisseria gonorrhoeae begins in the mucosa and periuretheral glands of Littre. Symptoms of dysuria and urethral discharge occur. Can result in urethral stricture and opacified (dilated) glands of Littre on urethrography due to inflammatory dilatation of duct ostia. 40% of urethral strictures are infectious in etiology. The proximal bulbar urethra is the site of stricture in 70% of patients with gonococcal urethritis because of the high concentration of periurethral glands in this area and the dependent position of this portion of the male urethra. Genitourinary Requisites, 235-236 |
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• A female with prior GYN surgery has an IVP that shows a smooth defect in the bladder pulled up and pointing to the right sacroiliac joint. Most likely cause:
a. cystitis b. adhesions c. pelvic lipomatosis d. iliopsoas “hitch” procedure |
• D. iliopsoas “hitch” procedure
• Iliopsoas hitch, in conjuction with ureteroneocystostomy, is a surgical repair of a distal ureteral stricture. It is described as follows: ”If a tension-free anastomosis cannot be accomplished by a simple ureteroneocystostomy, a vesicopsoas hitch can be performed. This technique can be used to bridge a 6- to 8-cm defect and is successful in 95% of adults and children. This procedure involves mobilizing the bladder and pulling it superiorly and laterally by fixing it to the psoas tendon with absorbable suture”. This appears to be the best answer to this question.Pelvic lipomatosis is an abnormal amount of pelvic fat that compresses normal structures. It causes elongation and narrowing of the urinary bladder and of the rectosigmoid.Cystitis would give thicken the mucosa of the bladder giving a cobblestone appearance, and could reduce bladder capacity.Adhesions could result in focal narrowing of the bladder or ureters. Adhesions tether the organs and would unlikely move the bladder this far laterally.Ureteral Stricture by Kane, MD, off of www.ask.com and Primer 305, 314 and Genitourinary Requisites 263 |
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• A renal mass is seen on non-contrasted CT that is iso-attenuated to normal renal parenchyma, which is splaying a dual collecting system. The lesion has enhancement similar to normal parenchyma with intravenous contrast. Most likely diagnosis:
a. renal cell carcinoma b. transitional cell carcinoma c. normal tissue d. oncocytoma |
• C. Normal tissue
• Renal cell carcinoma are isointense to renal parenchyma on noncontrasted CT but are hypodense compared to kidney after contrast administration. The are typically lobulated with irregular margins with inhomogeneous internal density. Calcification frequently occurs. Transitional cell carcinoma is a urothelial neoplasm that originates (in the kidney) in the intrarenal collecting system and then (25%) can spread into the kidney parenchyma. When invading the parenchyma they universally spread by infiltration. They are hypodense to renal parenchyma postcontrast.A duplicated collecting system will have normal parenchyma between the two collecting systems.Oncocytoma has similar imaging characteristics with RCC. Look for a central scar on CT or MR or a “spoke wheel” appearance on angiography. Genitourinary Requisites, 89-101, 113-114 |
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• Which of the following is not a germ cell tumor?
a. Choriocarcinoma b. Seminoma c. Leydig cell tumor d. Teratoma |
• C. Leydig cell tumor
• Mnemonic: SECTE • Seminoma, Embryonal cell carcinoma, Choriocarcinoma, Teratoma (70% of germ cell tumors), Endodermal sinus tumors (yolk sac tumors) • Most common non-germ cell tumors of the testicle include the Leydig cell tumor and the Sertoli cell tumor. Genitourinary Requisites, 312-314 and Primer, 77 |
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• Which of the following is true regarding the uterus and adenomyosis?
a. easily differentiated from leiomyomas b. more common in nulliparous females c. premalignant d. adenomyosis is decreased signal on T2 e. endometrial thickness is best measured in the coronal plane f. endometrium is typically hypoechoic |
• D. adenomyosis is decreased signal on T2
• Adenomyosis has primarily low signal on all sequences. It may also have sparse, small, high-intensity foci within it on T1 and T2 images which represent hemorrhage in endometrial islands. Leiomyomas are in the differential for adenomyosis; it is typically found in multiparous women over 30 yrs; it is a benign process, with no malignant association. Measuring endometrial thickness should be performed in the sagittal plane. The endometrium is typically hyperechoic Dähnert 5th p. 1022.; Genitourinary Requisites 16-20, 258-261. |
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• Which of the following is true about Glucophage?
a. If a patient has had Glucophage in the last 48 hours, iodinated contrast is contraindicated. b. it causes renal failure if contrast is given c. it is associated with lactic acidosis in patients with poor renal function |
• C. it is associated with lactic acidosis in patients with poor renal function.
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• Which of the following causes is most often associated with a horseshoe kidney?
a. Wilm’s tumor b. UPJ obstruction c. Nephrolithiasis d. |
• B. UPJ obstruction
• Horseshoe kidneys is the most common renal anomaly whereby the lower poles of the kidneys are fused across the midline and the kidneys are malrotated. Incidence: 1:400 births. Associated anomalies (50%): UPJ obstruction (30%), ureteral duplication (10%), Genital anomalies, Turner syndrome, other anomalies (GI, cardiac, skeletal) 30% Primer, 831 |
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• Which gives intrarenal low resistive index?
a. hydronephrosis b. ATN c. pyelonephritis d. renal artery stenosis |
• D. renal artery stenosis
• RI= (Peak systolic velocity-peak diastolic velocity)/peak systolic velocity • Normally, intrarenal arterial waveforms show an extremely rapid early systolic acceleration that is reflected by an almost vertical upstroke. Renal artery stenosis of the main renal artery produces a slowed systolic upstroke and a delayed time to peak systole. This dampening of the distal arterial waveforms has been referred to as the parvus-tardus effect. (compare images in Ultrasound Requisites, fig 4-78b and fig 4-77, renal artery stenosis vs normal, pgs 111-112).. With diminished systolic waveform and little to no change in diastolic waveform, the RI will be lower in renal artery stenosis. Ultrasound Requisites pg 111-112 |
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• Post menopausal patient has vaginal bleeding. Ultrasound demonstrates 4 mm thick endometrium. What is the most likely cause?
a. endometrial atrophy b. endometrial cancer c. polyps d. cervical cancer e. submucosal fibroid |
• A. endometrial atrophyCauses
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• What is the most likely cause of intermenstrual bleeding?
a. adenomyosis b. endometrial polyp c. endometrial cancer d. cervical cancer e. ovulation |
• B. endometrial polypAs per above (first paragraph), the most common cause of bleeding between menstrual cycles is endometrial hyperplasia or endometrial polyps.
Primer, 362 |
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• An ovarian follicle is likely to rupture after it has obtained which diameter?
a. 10 mm b. 20 mm c. 30 mm d. 40 mm e. 50 mm |
b. 20 mm
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• Following transplant, reversed flow in the renal artery during diastole is most likely due to:
a. ATN b. renal artery stenosis c. renal vein thrombosis d. acute rejection e. urinary obstruction |
• C. renal vein thrombosis
• Renal vein thrombosis can cause reversal of flow in the renal artery during diastole due to hemodynamic pressure from the congested kidney. Renal artery stenosis will have diminished flow but not reversed flow. ATN is the only renal process with normal renal flow but reduced excretion. Acute rejection has both reduced blood flow and reduced excretion. Urinary obstruction can lead to diminished perfusion but not reversal of flow. Primer, 299-301 |
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• A post-menopausal women has 3.5 cm ovarian cyst with single thin septation. What is the appropriate management?
a. surgical excision b. 3 month US follow-up c. laproscopy d. CT scan e. do nothing |
• B. 3 month US follow-up
• Postmenopausal cysts are not physiologic cysts since there is insufficient estrogen. The incidence of malignancy in cysts <5 cm in postmenopausal women is low. Management of postmenopausal cysts: < 5cm—US followup; > 5cm or change in size of smaller lesion--surgery Primer, 340-341 |
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• For a preliminary test, 14 “positive” results are returned in a given population of 100 subjects. Subsequent testing of these 14 “positives” (with the gold standard) shows only 8 of the 14 to be actually diseased. What is the positive predictive value of this test?
a. 92% b. 86% c. 80% d. 57% e. 17% |
• D. 57%(I constructed this question from a “description” of one in the recalls)TP = 8; FP = 14 - 8 = 6PPD = TP / (TP + FP) = 8 / 14 = 57.1%NPD = TN / (TN + FN)
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• If the sensitivity of a test is increased, which of the following is true?
a. false positives will increase b. false positives will decrease c. specificity will increase d. false positives will not change |
• A. false positives will increase Gold Standard “Test A” | normal abnormal (aka “disease”) normal | TN FN abnormal | FP TP sensitivity = TP / (TP + FN) = TP / disease = TP / constant Remember the ROC graph (sensitivity vs. 1 – specificity) for any “real world” test (see Dähnert 5th p. 1119). In summary, if sensitivity is increased, then specificity is decreased.Then, since Specificity = TN / (TN + FP) = TN / (no disease) =
TN / constant = decreased, therefore TN must decrease. but since TN + FP = constant, if TN decreases, FP increases. see also Primer, 1024 |
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• What is the definition of prevalence?
a. number of new cases over a period of time b. number of cases at one point in time c. proportion of nondiseased patients with an abnormal test d. number of correctly identified cases of disease |
• B. number of cases at one point in time
• Prevalence: the number of people in a population at risk who have a particular condition at a specific time. E.g., 1 in 93 women age 45 has breast CA Dähnert 5th p. 551Incidence: the number of people who develop a particular condition within a specific period of time. E.g., 142,000 women per year develop breast CA Dähnert 5th p. 551False-positive ratio: proportion of nondiseased patients with an abnormal test resultAccuracy: number of correctly identified cases in all tests (TP + TN) / Total Review of Radiologic Physics (Huda), pg 207; Dähnert 5th p. 1119 |
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• If a patient has a positive test the likelihood of him having the disease is best related to the test’s:
a. sensitivity b. specificity c. negative predicative value (NPV) d. positive predicative value (PPV) e. kappa |
• D. positive predictive value (PPV)PPV is the possibility that a person with a positive test actually has the disease. PPV = TP / (TP+FP). Note that PPV is a function of disease incidence because if incidence of a disease is low, the FP:TP ratio will be much greater. Dähnert 5th p. 1118-1119.NPV is the probability that a person with a negative test result does not have the disease. NPV=TN/(TN+FN)Sensitivity is is the number of patients with disease that have been correctly detected divided by all patients with the disease. Sensitivity = TP/(TP+FN)Specificity is the number of patients with disease that have been correctly detected divided by all patients with the disease. Specificity=TP/(TN+TP)
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• Varicocele arises from:
a. Pampiniform plexus b. More common on right side c. Occur with normal valves in spermatic vein |
• A. Pampiniform plexus.
• Varicoceles represent dilated veins of the pampiniform plexus. Result from incompetent or absent valves in the spermatic vein. Prevalence: 15%. Clinical Findings: Infertility, pain, scrotal enlargement. Location: 90% occur on the left side (due to drainage of the left spermatic vein into the left renal vein at a right angle). 25% of Varicoceles are bilateral. On US: hypoechoic veins (“bag of worms”), veins easily compressed by transducer, increase in venous size when patient is upright or valsalvas. Primer 3rd ed., pg 327. Dähnert 5th p. 982. |
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• Varicocele arises from:
a. Pampiniform plexus b. More common on right side c. Occur with normal valves in spermatic vein |
• A. Pampiniform plexus.
• Varicoceles represent dilated veins of the pampiniform plexus. Result from incompetent or absent valves in the spermatic vein. Prevalence: 15%. Clinical Findings: Infertility, pain, scrotal enlargement. Location: 90% occur on the left side (due to drainage of the left spermatic vein into the left renal vein at a right angle). 25% of Varicoceles are bilateral. On US: hypoechoic veins (“bag of worms”), veins easily compressed by transducer, increase in venous size when patient is upright or valsalvas. Primer 3rd ed., pg 327. Dähnert 5th p. 982. |
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• A thrombosed ovarian vein in the post purpeural stage may appear as all of the following except?
a. absent ultrasound flow b. A mass at the junction of the right renal vein and the ovarian vein c. soft tissue density anterior to the right psoas d. echolucent linear structure |
• B. A mass at the junction of the right renal vein and the ovarian vein
• This choice is definitely false, because the right ovarian vein drains directly into the IVC. However, the thrombus commonly affects the most cephalic portion of the right ovarian vein and can usually be demonstrated sonographically at the junction of the right ovarian vein with the inferior vena cava, sometimes extending into the inferior vena cava. Rumack 2nd p. 567.Other facts about ovarian vein thrombophlebitis: - right ovarian vein is involved in 80-90% of cases (retrograde through left ovarian vein in the puerperium protects this side) - sonography may demonstrate an inflammatory mass lateral to the uterus and anterior to the psoas - Doppler imaging may demonstrate absence of flow in these veins - ovarian vein may appear as a tubular, anechoic structure containing echogenic thrombus. Incidence 1:600-1:2,000 deliveries; usually presents on 2nd or 3rd postpartum day; palpable mass in ~50%; mortality of 5% reported. Dähnert 5th p. 1050 |
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• Which does not cause bladder wall calcifications?
a. TB b. Schistosomiasis c. Malacoplakia d. Transitional cell carcinoma e. Cystitis |
. Malacoplakia.
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• Which zone of the prostate is removed in TURP?
a. transitional zone b. peripheral zone c. central zone d. |
• A. transitional zone.
• In transurethral resection of the prostate the innermost portion of the prostate, around the urethra, is removed. The glandular tissue of the prostate is divided into three zones. The large peripheral zone is located posteriorly from the base of the verumontanum to the apex of the prostate gland. The central zone is found around the ejaculatory ducts. The transitional zone surrounds the prostatic urethra. Genitourinary Requisites, pg 307 |
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• Regarding MRI of the uterus with adenomyosis:
a. increased T2 signal b. sharp margins c. diffuse prominence of the junctional zone d. focal changes in the junctional zone e. low signal on all sequences |
• E. low signal on all sequences.
• MRI shows a myometrial mass with indistinct margins of primarily low signal intensity on all sequences (due to surrounding reactive dense smooth muscle hypertrophy). Dähnert 5th p. 1022 • C. diffuse prominence of the junctional zone.Diffuse / focal widening of the junctional zone (= inner myometrium) ≥ 12 mm on T2WI, T2-weighted SE images, contrast-enhanced T1WI images. • A. increased T2 signalThere can be central high-intensity spots on T2 (hemorrhagic foci), but in general T2 sequences are low signal. • B. sharp margins (definitely False)leiomyoma has sharp margins, which allows differentiation from adenomyosis • D. focal changes in the junctional zone (?)There can be focal changes within the adenomyosis, but it is unclear if this is within the junctional zone. MRI of the Body 2nd p. 840.Adenomyosis is the presence of ectopic endometrial tissue and stroma in the myometrium which induces an overgrowth of surrounding uterine smooth muscle. There are focal and diffuse forms of adenomyosis. Adenomyosis can be difficult to distinguish from leiomyoma. Genitourinary Requisites 261, 264 (image 7-15) |
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• Salpingitis isthmica nodosa (SIN) is associated with:
a. Hydrosalpinx b. Endometriosis c. Adenomyosis d. Congenital uterine abnormalities e. uterine hyperplasia |
• B. Endometriosis.
• According to AmershamHealth, Salpingitis Isthmica nodosa is associated with: - #1 Pelvic Inflammatory Disease (in 89% of PID cases) - #2 Endometriosis (28%) - #3 other causes (TB, congenital disorders)SIN, (also called diverticulosis of the Fallopian tubes), inflammation in the isthmic portion of the Fallopian tube: - etiology not fully understood, although chronic inflammation (as in PID or endometriosis) seems to play a role. - no increased incidence of congenital uterine malformations in association with SIN. - diagnosis best achieved with hysterosalpingography - radiological prevalence of SIN is 3.9–7.5%; bilateral (over 50% of cases)* Be aware that previous answers to this question have included hydrosalpinx and adenomyosis, but given currently available references, ‘B’ seems to be the best answer. Dähnert 5th p. 1052 |
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• Patient on hormonal therapy with multiple ovarian cystic lesions:
a. Polycystic Ovary Disease b. ovarian overstimulation syndrome |
• B. ovarian overstimulation syndrome
• Ovarian hyperstimulation: ovaries enlarge and contain multiple large lutein cysts. Dähnert 5th p. 1050 • PCOD also has enlarged ovaries with multiple cysts. However, it has a classic clinical presentation: oligoamenorrhea, infertility, and hirsutism.Primer, 348. Genitourinary Requisites, pg 273-275 |
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• Postmenopausal endometrial bleeding
a. endometrial polyps b. endometrial hyperplasia c. endometrial carcinoma d. endometrial atrophy |
• D. endometrial atrophy.
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• Female with mass at the base of the bladder and post-void dribbling,
a. ectopic insertion of the ureter b. ureterocele c. urethral diverticulum |
• C. Urethral diverticulum.
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• Which of the following is false concerning varicoceles?
a. is seen in 10-20% of males b. mostly asymptomatic c. more common on the right side d. associated with infertility |
• C. more common on the right side.
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• Which is false regarding the ovaries in postmenopausal women--
a. the majority of cysts are less than 3 cm b. simple cysts are seen in up to 50% c. if you see a mural nodule, radiologic workup is warranted d. cysts are often associated with hormonal replacement therapy (HRT) |
• B. simple cysts are seen in up to 50%. (False)
• Asymptomatic simple adnexal cysts may be seen in 20-30% of postmenopausal women.A typical post-menopausal ovarian cyst measures 3.0-3.5 cm. (* size cutoff for follow-up is 5 cm).A cyst with a mural nodule is complex (18% malignant), and warrants further workup. - in particular, a cyst with a mural nodule in a peri-/post-menopausal woman raises the suspicion for clear cell carcinoma of the ovary Dähnert 5th p. 1026.Although the exact relationship between HRT and postmenopausal ovarian cysts is unclear, it has been noted that up to 40% of women on HRT have ovarian cysts (vs. only 20-30% of post-menopausal women w/o HRT).Ovaries atrophy after menopause and by age 70 are no greater than 1 cc in volume. Most cysts are less than 3.0 cm in greatest dimension. Most simple cysts in postmenopausal ovaries <5cm are not likely malignant. Genitourinary Requisites 253, 275-276 and Ultrasound Requisites 393-394 |
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• Renal nephroblastomatosis – which is the best way to evaluate it?
a. Computed Tomography b. US c. IVP d. Radiography |
• A. Computed Tomography.
• Contrast-enhanced CT is the preferred study to evaluate renal nephroblastomatosis, as the peripheral low-attenuated nodules show less enhancement than the renal parenchyma. Dähnert 5th p. 931.Nephrogenic rests are foci of metanephric blastema that persist beyond 36 weeks gestation and have the potential for malignant transformation into Wilms’ tumor. Multiple solid, subcapsular mass lesions are virtually diagnostic. By MRI the nodules demonstrate low-signal-intensity foci on both T1W and T2W images. They are hypoechoic by US. Primer 840 |
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• Which of the following will not give you bladder wall thickening?
a. neurogenic bladder secondary to diabetes b. benign prostatic hypertrophy c. schistosomiasis d. lymphoma |
• A. neurogenic bladder secondary to diabetes.
• Diabetic neuropathy usually results in a form of neurogenic bladder called detrusor areflexia. Neurologic damage is focused on the sacral reflex arc, with a loss of perception of bladder distention. Therefore, the bladder just continues to fill until the intravesicle pressure exceeds the intact sphincter mechanisms, and urine just overflow dribbles. There is no functional outlet obstruction here, and the bladder is usually small and thin–walled with an increased capacity. Dunnick 385-392Bladder Wall thickening: > 5 mm nondistended, > 3 mm distended. - Causes: Tumor (TCC, lymphoma), Cystitis (radiation cystitis, infectious cystitis, or resulting from inflammatory bowel dz, appendicitis, focal diverticulitis), Outlet obstruction (benign prostatic hypertrophy, urethral stricture), Neurogenic Primer 356, GU Requisites 205-211, 217-218Schistosomiasis can cause a thick-walled fibrotic “flat-topped” bladder with high insertion of ureters. It results in submucosal bladder wall edema that gives the bladder a blurred contour on cystography. Focal strictures and, of course, calcifications can develop. Dähnert 5th p. 965. |
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• Which of the following will not cause papillary necrosis?
a. regular NSAID use b. diabetes c. oxalosis d. renal vein thrombosis e. TB |
• C. Oxalosis
• Oxalosis is not associated with papillary necrosis; rather, it is associated with medullary nephrocalcinosis. • Mnemonic for causes of papillary necrosis: POSTCARD Pyelonephrits, Obstruction (chronic), Sickle cell disease, TB / Trauma, Cirrhosis (ethanol) / Coagulopathy, Analgesics (phenacetin), Renal vein thrombosis, Diabetes (50%) Primer 3rd, 352 |
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• What is most closely associated with primary megaureter?
a. ipsilateral cryptorchidism b. renal agenesis c. often right-sided d. delayed emptying of ureter e. |
• D. delayed emptying of the ureter.
• Primary megaureter results from inadequate musculature (not aganglionosis) inhibiting peristalsis along a short segment of ureter near the ureterovesical junction. This segment of ureter appears normal radiographically, without stenosis or filling defect. However, inhibition of peristalsis along this segment leads to transient hold-up of urine above the segment, eventually resulting in ureteral dilatation. Note that the calyces remain sharp. GU Req. p. 177. • Associated Disorders: [40% per Dähnert 5th, 5% per Primer 3rd] - Contralateral: UPJ obstruction, reflux, ureterocele, ureteral duplication, renal ectopia or agenesis - Ipsilateral: caliceal diverticulum, megacalicosis, papillary necrosis • Ipsilateral Cryptorchidism is a (not valid) reference to Prune-belly (Eagle-Barrett) syndrome, which does have congenital megaureters as part of the triad. However, note that the cryptorchidism in Eagle-Barrett is required to be bilateral, not ipsilateral. Dähnert 5th p. 941.Left-sided = 3:1; bilateral in 15-40%; M:F = 2-5:1 see also GU Requisites 173, 177-178 and Primer 832, 834 |
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• Horseshoe kidney – what is it related to?
a. UPJ obstruction b. Wilms’ tumor c. Nephrolithiasis |
• A. UPJ obstruction
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• What are seminal vesicle cysts associated with?
a. ipsilateral renal agenesis |
ipsilateral renal agenesis
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• Transplanted kidney: parvus et tardus waveform in renal artery – which of the following would you see it in?
a. renal vein thrombosis b. distal renal artery stenosis c. proximal renal artery stenosis d. rejection |
• C. proximal renal artery stenosis.
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• Transplanted kidney: in the immediate post-transplant period, you see reversed diastolic flow in a segmental renal artery; which of the following is true?
a. renal artery stenosis b. renal vein thrombosis c. acute rejection d. anastomotic leak e. normal |
• B. renal vein thrombosis. Renal vein thrombosis and stenosis is rare (0% to 4%) and usually occurs in the post-operative period. Duplex and color Doppler reveal absent renal venous flow with reversed diastolic arterial flow.Renal artery thrombosis occurs acutely usually within the first month of transplantation and usually results in loss of the graft. It occurs in less than 1% of transplant patients. The most common cause is hyperacute and acute rejections. If thrombosis is complete, duplex and color Doppler will not detect arterial or venous flow distal to the occlusion. If occlusion is incomplete but progressive, serial duplex Doppler may demonstrate decreased, reversed, or absent diastolic flow which eventually progresses to complete absence of both systolic and diastolic flow.Graft rejection can be classified into four types: (1) hyperacute (during surgery); (2) accelerated acute (2 to 3 days); (3) acute (1 to 10 weeks); and (4) chronic (months to years).Hyperacute rejection usually does not require imaging because the diagnosis is evident during surgery. Accelerated acute and acute rejection have similar findings: Gray scale reveals a swollen kidney with loss of corticomedullary differentiation and total renal blood flow is decreased. Chronic rejection often reveals a small kidney with increased cortical echogenicity. Diagnostic Ultrasound, 2nd ed, pgs 385-389
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• Anatomy question about the retroperitoneum:
a. right renal artery is posterior to the IVC |
• A. right renal artery is posterior to the IVC.
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• Which of the following statements is true regarding ureteral jets?
a. do not occur in the third trimester b. used to prove patency of the ureters c. need to evaluate for 5-10 minutes d. used to diagnose obstruction |
• B. used to prove patency of the ureters.
• A. False. Ureteral jets may be reduced during the 3rd trimester (gravid uterus compressing the ureter), but the can and do still occur. • B. True. They prove patency of the ureters when seen. • C. False. Per numerous old questions, jets occur anywhere from every 1-3 minutes to as often as every 20 sec. Definitely faster than 5-10 minutes. • D. False. Absence of a jet does not diagnose obstruction. Ultrasound Requisites, 77-81 and Diagnostic Ultrasound, 2nd ed 1689-1690 |
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• Average size of postmenopausal cysts:
a. 2cm b. 3cm c. 4cm d. 5cm |
• B. 3 cm.
• Most cysts are less than 3.5 (some say 3.0) cm in greatest dimension. Most simple cysts in postmenopausal ovaries <5cm are not likely malignant. Asymptomatic simple adnexal cysts may be seen in 20-30% of postmenopausal women. No clear relationship has been established between the presence of cysts and HRT. These ovarian cysts can disappear or change in size. Surgical exploration is recommended for patients with larger cysts, complex cysts with mural or septal nodules, and cysts with prominent diastolic flow on duplex scanning.(* although only seen in 30% and most are less than 3.5 (or 3.0) cm in size, B is the best answer because the average will be “skewed high” by really large cysts) Genitourinary Requisites 253, 275-276; Ultrasound Requisites 393-394; Primer 340-341; Diagnostic Ultrasound, 2nd ed 546; |
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• The underlying etiology of MCDK is:
a. medullary cystic disease b. medullary sponge kidney c. obstruction d. |
• C. obstruction.
• Multicystic dysplastic kidney is a collection of large, noncommunicating cysts separated by fibrous tissue; there is no functioning renal parenchyma. Results from occlusion (severe UPJ obstruction) of fetal ureters before 10 weeks of gestation. Absent or atretic renal vessels and collecting system. MCDK involute in time. It is associated with UPJ obstruction in contralateral kidney and Horseshoe kidney. Primer 836 |
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• All of the following are associated with renal cysts except--
a. Chronic renal failure b. VHL c. Tuberous sclerosis d. Neurofibromatosis e. Echinococcus |
• D. Neurofibromatosis.
• Renal cystic disease is associated with Von Hippel-Lindau disease and Tuberous Sclerosis. Patients on hemodialysis also develop renal cysts. Most renal cysts are simple cysts, seen in > 50% of the population > 50 years of age. Primer, 279-280 • VHL: 75 % have renal cysts. • Tuberous sclerosis: 15% have renal cysts. • Chronic peritoneal dialysis: 10-20% of patients have acquired renal cysts at three years after the initiation of dialysis; 90% after 5-10 years of dialysis. It is seen equally among patients receiving hemodialysis or peritoneal dialysis. • Echinococcus: 6% have renal cysts. |
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• Captopril blocks--
a. Angiotensin I to Angiotensin II conversion b. Renin to Angiotensin I conversion c. angiotensinogen to Angiotensin I conversion |
• A. Angiotensin I to Angiotensin II conversion.
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• A diagram of coronal and sagittal images of the prostate gland is provided with areas labeled. Select the following:
a. area where majority of carcinomas occur b. area where benign prostatic hypertrophy (BPH) occurs c. area where prostatitis occurs. |
• The prostate consists of multiple zones: the Peripheral zone, the Central zone, the Transitional zone.
• The PZ is located posteriorly from the base of the verumontanum to the apex of the prostate gland. • The CZ is found around the ejaculatory ducts. • The TZ surrounds the prostatic urethra. The anterior fibromuscular stroma contains no glandular tissue. • Prostate cancer: most occur in posterior zone (70%). • BPH occurs in the transitional zone. • Prostatits diffusely involves the gland.Genitourinary Requisites 307, 320-335 and Primer 321-323 |
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• 53 year old male with bladder cancer. CECT demonstrates a 2 cm adrenal lesions measuring 30 HU. What do you do next?
a. Biopsy b. 3 month follow-up scan c. Delayed CT to reassess HU d. NP-59 study e. Call it a met |
• C. Delayed CT to reassess HU
• Assuming that 30 HU is the density on an immediate scan, delayed CT would help in assessing the contrast washout. Both lipid rich and lipid poor adenomas lose contrast much faster than an adrenal met. Adenomas have a >50% washout or < 24 HU density on a 15 min. delayed scan.CECT. Biopsy is not a good option when there are other safer and simpler options available. Adrenal biopsy has up to a 2.8% complication rate. F/U may not be prudent without adequate tumor staging. NP-59 study is useful in differentiating adenomas from non-adenomas but cannot differentiate a met from other non-adenomatous benign lesions. Cannot call it a met without proving it to be one. Uroradiology-Dunnick/Sandler, Dähnert 5th ed p. 910, Primer p. 317-318 |
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• 50 yo female with bladder cancer. CT shows 2.5cm left adrenal mass (-30 HU):
a. metastasis b. adenoma c. hyperplasia d. myelolipoma |
• D. Myelolipoma
• Unlikely tumor to metastasize to the adrenals, more commonly the tumors which have mets in the adrenals are lung, breast, kidney, bowel, ovary, melanoma.B. No, adenomas have HU < 10 and may be up to 35 with contrast.C. Hyperplasia is not usually unilateral.D. Likely, myelolipomas have HU – 20 to - 30, with a unilateral large mass being the common presentation. Primer 317-318, Dähnert p. 930-931(There is a question as to whether the question had a minus sign in front of the 30. If not, adenoma would be the best answer.) |
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• The characteristic of a renal mass that is MOST suggestive of RCC
a. Enhancement of >30 HU on contrast enhanced CT. b. Calcifications c. Size >2 cm d. Other bogus answers that keep changing |
• A. Enhancement of > 30 HU on contrast enhanced CTRenal
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• 55 year old lady with pelvic pain. CECT of the
abdomen/pelvis shows a homogeneous 2.5 cm renal mass, which measures 60 HU. What do you do next? a. Nephrectomy b. Biopsy c. Follow-up in 6 months d. NECT e. DMSA renal scintigraphy f. excision |
• D. NECTNECT
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• Regarding Conn’s syndrome, which is NOT seen?
a. Hypernatremia b. Hypokalemia c. Hypertension d. Increased renin e. Increased aldosterone |
• D. Increased reninConn’s
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• Regarding aldosteronoma which is true?
a. Found in medulla b. Histologically distinct from a cortisol tumor c. low serum renin levels d. low serum sodium/salt wasting e. arises from adrenal medulla f. multiple |
• C. low serum renin levels.
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• Adenomyosis – which is false:
a. more common in nulliparous women b. can have normal appearance on US c. can be mistaken for a fibroid d. a result of invagination of the decidua basalis |
• A. more common in nulliparous women
• Seen in multiparous women >30 years during mestrual life.Most lesions are microscopic and not seen by US. Can be clinically and sonographically difficult to distinguish from a fibroid. It is an invasion of the myometrium by the endometrium. Dähnert 5th ed p. 1022 & US Requisites p. 403. |
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• CT signs of urolithiasis
a. comet tail sign b. tissue rim sign c. perinephric hemorrhage d. lucent center e. seminal vesicle displacement |
• B. tissue rim sign
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• Column of Bertin
a. Technetium b. DTPA, optional treatment with Lasix c. DTPA with captopril d. MAG-3 e. DMSA |
• E. DMSA
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• All of the following regarding mesoblastic nephroma are true except:
a. excellent prognosis following resection b. appearance similar to that of Wilm's tumor on ultrasound c. has a cystic appearance with fine septations d. unlikely to calcify |
• C. has a cystic appearance with fine septations
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• Pelvoinfundibular atresia is associated with which of the following conditions
a. MCKD b. AD-PCKD c. AR-PCKD d. Wilm’s tumor |
• A. MCDKResult of in utero UPJ obstruction. Peds reqs pg 160.Unilateral MCDK: most common form, 80-90%. Secondary to pelvoinfundibular atresia. Dähnert 5th p. 928.
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• Regarding prostate cancer, which is true
a. most hypoechoic lesions are cancer b. increase intensity seen on T2 compare to the peripheral zone c. PSA is higher in cancer than in BPH d. Rectal coil is contraindicated after biopsy e. bone scan indicated after prostatectomy and PSA = 0 |
PSA is higher in cancer than BPH
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• The most likely origin of a prostate carcinoma is?
a. Peripheral b. Central c. Periurethral d. transitional |
• A. peripheral70% cancers in peripheral zonePrimer 322-323
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• In a patient who is S/P TURP, which area is the most likely to contain stricture?
a. bladder neck /prostatic urethra b. membranous urethra c. penile urethra d. bulbous urethra e. fossa navicularis |
• A. bladder neck
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• A patient has benign prostatic hypertrophy. During the TURP procedure, most of the tissue is taken from what zone of the prostate?
a. Transitional b. Central c. Periurethral d. Peripheral |
• A. Transitional
• BPH occurs in transitional zone. Primer 322The largest and most numerous nodules… originate almost entirely within the transitional zone. GU Req. p. 323. |
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• The most common cause of PROSTATIC urethra dilation is?
a. TURP b. Bladder sphincter dyssynergia c. STD d. Previous foley catheter e. Obstruction due to prostatic Ca. |
• A. TURP (* probably—no hard statistics)The prostatic urethra is generally patulous following a TURP, which removes predominantly the transitional zone of the prostate. This enlargement is secondary to a loss of prostatic mass, not downstream obstruction.As previously explained in question #18, detrusor sphincter dyssynergia results in simultaneous detrusor and sphincter contraction, and thus, a functional outlet obstruction, resulting in dilatation of the prostatic urethra. (Remember, both the intrinsic and external sphincter are located just above the urogenital diaphragm, and thus, in the distal most portion of the prostatic urethra. Thus, answer A is also true, but post-TURP is probably more common.Choices C and D are definitely false, as they would more likely cause strictures.
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• The most common etiology of reversed diastolic flow in the segmental arteries in a recently transplanted kidney is:
a. cyclosporin toxicity b. normal c. renal vein thrombosis d. renal artery stenosis e. acute rejection |
• C. Renal vein thrombosis
• Renal vein thrombosis can occur any time after transplant, but most occur in the 1st 3 days.. Findings include a “U-shaped” / plateau-like reversal of diastolic arterial flow. (given the time course, this is probably the best answer).Both renal transplant arterial and vein thrombosis are rare complications (less than 1% of transplants) that occur in the acutepost-operative period. The classic description of renal vein thrombosis is involves renal congestion and reversed diastolic flow in the arterial waveform.Acute rejection of the transplanted kidney can occur at anytime (within 5 days to 6 months). There is increased renal volume from edema. Doppler ultrasound demonstrates initial decrease in resistive index and later increase in resistive index > 0.8 (with increasing severity of rejection). There may be reversal of diastolic flow. [however, this reversal of diastolic flow will not occur until the RI rises, after some amount of time, making this answer less likely]. Source: Dähnert 5th ed. p.955, 958; Primer 3rd p. 301. Dunnick/Sandler pgs.236-252. |
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• The most likely cause of UPJ obstruction is:
a. crossing vessel b. abnormal insertion of the ureter c. intrinsic ureteral abnormality d. some fibrous mass |
• C. intrinsic ureteral abnormalityThe
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• What is the most likely cause for renal vein thrombosis?
a. renal cell carcinoma b. diabetic nephrosclerosis c. glomerulonephritis d. nephritic syndrome |
• C. Glomerulonephritis
D says the same thing |
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• Which of the following is not associated with Kawasaki’s disease?
a. Gallbladder hydrops b. Myocarditis c. Pericardial effusion d. Renal failure e. Cervical adenitis |
• D. Renal failure
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• What is the most common cause of renal AV fistula?
a. blunt trauma b. renal cell carcinoma c. prior biopsy d. VHL e. Angiomyolipoma |
• C. prior biopsy
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• All of the following demonstrate echogenic cortex on renal ultrasound except?
a. Alport’s b. Lymphoma c. Acute pyelonephritis d. HIV nephropathy e. Chronic pyelonephritis |
• B. Lymphoma
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• Cowpers glands are located at the level of:
a. membranous urethra b. prostatic urethra c. bulbar urethra d. glands of Littre |
• A. membranous urethra
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• Fibromuscular dysplasia:
a. typically unilateral b. may cause saccular intracranial aneurysms of the carotid c. more common in males d. responds poorly to angioplasty |
• B. may cause saccular intracranial aneurysms of the carotid
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• The commonest cause of focal scarring and pyelonephritis is?:
a. pyelotubular backflow b. pyelolymphatic backflow c. abscess d. ruptured fornices e. focal ischemia |
• A. pyelotubular backflow
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• Patient on a contrast CT shows decreased enhancement with a faint pyelogram in one kidney. Which is most likely?
a. Renal artery stenosis b. Renal vein thrombosis c. Ureteral obstruction |
• C. ureteral obstruction
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• What is a reason to give lasix during a renal scan ?
a. to differentiate dilated collecting system and ureters from primary megaureter b. Elevated creatinine c. Normal lab values |
• A. to differentiate dilated collecting system and ureters from primary megaureter
• Lasix administration (20-40 mg IV) 20 minutes into exam allows assessment of renal pelvic clearance with accuracy equal to Whitaker test (DDx of obstructed from dilated but nonobstructed pelvicalyceal system). Dähnert p. 1113 |
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• Posterior urethral valves are most commonly found in which portion of the urethra?
a. Prostatic urethra b. Membranous urethra c. Bulbous urethra d. Penile urethra |
• A. prostatic urethra
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• During fetal ultrasound, a urinary tract obstruction is identified. The most common cause of this finding in a male is:
a. obstruction at the membranous urethra b. obstruction at the prostatic urethra c. obstruction at the bulbous urethra d. bladder outlet obstruction |
• B. obstruction at the prostatic urethra
• Posterior urethral valves are congenital thick folds of mucous membrane located in the posterior urethra (prostatic + membranous portion) distal to verumontanum. Most common cause of urinary tract obstruction and leading cause of end stage renal disease among boys (1:5000-8000). • Type I: (most common) mucosal folds (vestiges of Wolffian duct) extend anteroinferiorly from the caudal aspect of the verumontanum, often fusing anteriorly at a lower level. • Type II: (rare) mucosal folds extend anterosuperiorly from the verumontanum toward the bladder neck (nonobstructive normal variant, probably a consequence of bladder outlet obstruction) • Type III: diaphragm-like membrane located below the verumontanum (=abnormal canalization of urogenital membrane) |
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• CT with and without contrast demonstrates a 3 cm mass in the midpole of a kidney with a bifid system. The attenuation of the mass is equal to that of renal parenchyma. The most likely etiology is
a. Normal(column of Bertin) b. Renal cell carcinoma c. Transitional cell carcinoma d. Oncocytoma e. Squamous cell Ca |
• A. normal renal tissueLarge
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• Pt with history of analgesic abuse, now presents with bilateral hydronephrosis and a 3 cm intrapelvic mass.
a. SCC b. RCC c. TCC d. Fungus ball |
• C. TCC
• TCC: 5% bilateral, 85% primary renal pelvic tumors, 8x increased risk of TCC with analgesic nephropathy. • RCC: cause hydro. 1‑3% bilateral. • SCC: 15% urothelial tumors‑UPJ obstruction. • Mycetoma: unilateral caliceal dilation with large irregular filling defect. Phenacetin <<(8X increase) other bladder carcinogens include: aniline dyes, pelvic radiation, tobacco>>. Usually Rx’d as a combo with Dähnert 5th ed p. 971, Primer 3rd ed p. 307 |
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• CT scan in a 50 y/o male (“asymptomatic”) shows a small nodular mass in one limb of the left adrenal gland. What is the most likely diagnosis?
a. Adrenal carcinoid b. Adrenal hyperplasia c. Pheochromocytoma d. Metastasis e. Hyperaldosteronoma |
• D. Metastasis
• Metastasis 30% of adrenal masses - however, “…in the patient with no known history of malignancy, it is unusual for an incidentally discovered adrenal mass to be the initial presentation of a distant primary…” - best answer for pt. history and choices given. see GU Req. p. 350. - a non-functioning adenoma would be the best answer.Incidental discovery of adrenal mass in 1% of all CT! - mass < 3 cm in diameter is likely (in 87%) benign - mass > 5 cm in diameter is likely malignant - Adenoma is the most common cause at 50% of adrenal masses.A. Rare.B. Usually bilateral.C. Pheochromocytoma 10% of adrenal masses; probably functional (symptoms)E. Rare. Should have symptoms. Primer p.315-318, Dähnert p. 871,935 |
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• A patient has a NORMAL IVP exam. On the follow day he has a BE. The scout film shows bilaterally dense nephrogram. The most likely source of this problem is?
a. Contrast induced renal failure b. Obstruction c. Nephropathy d. The bogus answers keep changing year to year. |
• A. Contrast induced renal failureA
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• Multiple T/F: Concerning a paraovarian cyst:
a Usually located in the broad ligament. b Comprise 10% of ovarian cysts c. Remnant of the Wolffian duct d. Remnant of the Müellerian duct e. They usually respond to hormonal therapy |
• A. True. B. True C. True D. False E. False
• Paraovarian cysts are remnants of the Wolffian duct (=mesonephric duct). In the female, the wolffian duct degenerates into the Gartner cyst, while the mesonephric tubules form into the epoophoron and paraophohorn. p. 1050 of Dähnert (5th edition) • This statement is False (and thus the answer)—paraovarian cysts are not part of the ovary, and thus they do not change with the menstrual cycle like ovarian cysts. • Paraovarian cysts are a remnant of wolffian duct, not Müllerian duct; 10% of all pelvic masses; located in broad ligament • Sources: Dähnert 5th p 1051; Primer of Diagnostic Imaging, 3rd ed 340 |
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• Pt with chronic obstruction secondary to stones now presents with mass in left renal pelvis
a. squamous cell b. transitional cell c. fungus ball d. stones |
• A. SCC
• According to the 1997 GU requisites, p. 216, patients with bladder stone disease are prone to develop squamous cell carcinoma secondary to chronic inflammation due to mechanical irritation. |
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• In a duplicated collecting system, which of the following is correct?
a. Upper pole inserts medially and lower pole b. refluxes c. Upper pole inserts posteriorly and refluxes d. Lower pole inserts medial and refluxes e. Lower pole inserts anteriorly and the upper pole refluxes f. Lower pole inserts laterally and usually obstructs. |
• A. upper pole inserts inferior/medially and lower pole refluxes
• Weigert-Myer rule: the upper pole of a kidney drains via the ureter, which inserts inferior and medial to the normal, expected ureteral insertion point. Ectopic ureteroceles occur in 1/3 of patients with duplicated ectopic ureters. The upper pole moiety ureter is subject to obstruction & dysplasia of that portion of the kidney; the lower pole ureter typically refluxes due to its shortened tunnel into the bladder. M:F = 1:2 Genitourinary Requisites, 157; Dähnert 5th p. 977. |
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• Which of the following is NOT in the pararenal space?
a. descending colon b. pancreas c. duodenum d. ascending colon e. adrenal gland |
• E. adrenal gland
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• An oncocytoma is histopathologically classified as what?
a. hamartoma b. metastasis c. hemangioma d. normal parenchyma e. epithelial cell tumor |
• E. epithelial cell tumor
• Oncocytoma = proximal tubular adenoma = benign oxyphilic adenoma. - 1-2-13% of renal tumors - benign, low or no metastatic potential (GU Req p. 99); Dähnert p. 933-934 |
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• The best test for detecting nephroblastomatosis is ?
a. DMSA scan b. CT scan c. MRI d. Ultrasound e. Tc-DTPA |
• B. CT scanDähnert pg 93, Primer p. 840.
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• Which of the following is NOT associated with renal cysts?
a. NF1 b. Tuberous sclerosis c. von Hippel Lindau syndrome d. dialysis e. Rendu-Osler-Weber syndrome |
• A. NF1
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• A 42 year old male has urinary difficulty. RUG is performed and demonstrates a penile urethral stricture and dilation of the glands of Littre. What is the most likely source of his condition?
a. Gonnococcal infection b. Bladder Sphincter dyssynergia c. Prostatic hypertrophy d. Iatrogenic e. Prostatic Cancer |
• A. Gonnococcal infection
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• The ureteral prominence of the trigone is UNILATERALLY edematous. What is the most likely source of this problem?
a. ureterocele b. unilateral seminal vesicle infection c. BPH d. UTI e. recently passed stone |
• E. Recently passed stone
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• What cancer is most prevalent is the undescended testis?
a. Seminoma b. Endodermal sinus tumor c. Sertoli-Leydig tumor d. Teratoma e. Choriocarcinoma |
• A. Seminoma
• Most common tumor in undescended testis. Primer p. 329, Dähnert p. 969 |
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• Which of the following conditions is NOT considered premalignant?
a. Cystitis Glandularis b. Leukoplakia c. Cystitis cystica d. Malakoplakia |
• D. Malakoplakia , Malakoplakia is a chronic inflammatory response to gram – infection, more prevalent in patients with diabetes. Michaelis-Guttman bodies in biopsy specimen are diagnostic. Multiple yellow-brown sub-epithelial plaques are seen in the bladder giving a cobblestone appearance.
• Cystitis cystica = cystitis glandularis premalignant • Leukoplakia = keratinizing squamous metaplasia – result of chronic infection and stones, premalignant Dähnert p. 924, 916, 923 |
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• Unilateral seminal vesicle cyst is most likely associated with?
a. anomalies of the ipsilateral mesonephric duct b. unilateral renal agenesis |
unilateral renal agenesis
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• The least likely associated with bladder diverticulum?
a. congenital b. Adenocarcinoma c. Bladder stones |
• B. Adenocarcinoma
• Bladder diverticuli can be congenital and are associated with calculi, infection, tumor. GU reqs pg 211, Dähnert p. 912-913. |
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• A patient has pyelonephritis with an obstructing stone. The patient need a percutaneous nephrostomy, the ideal approach is
a. Posterior approach through the avascular zone into a posterior calyx b. Posterior approach into an anterior calyx c. Anterior approach into a posterior pole d. Anterior approach into an anterior pole. |
• A. Posterior approach through the avascular zone into a posterior calyxThe puncture should follow Brodel’s Line (an oblique posterior-lateral approach) through the avascular zone of the kidney. Source: Kandarpa, Handbook of IR Procedures 3rd ed p.280
• “The optimal access should enter a posterior calyx on end…”. This is why the patient is prone on the fluoro/angio table! see Ferral p. 263.Puncture above the 10th rib may enter the pleura (pneumothorax). GU Reqs pg 375 |
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• The most common risk factor/predisposing factor for the development of contrast induced renal failure is:
a. pheochromocytoma b. myeloma c. pre-existing renal insufficiency |
• C. preexisting renal insufficiencyAcute
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• Regarding the use of metformin hydrochloride and its interaction with radiographic contrast material, which of the following is true?
a. contrast material should not be given if the medication has been taken within the last 48 hours b. it is directly nephrotoxic c. the combination of the two results in a lactic acidosis that is nephrotoxic |
• C. the combination of the two results in a lactic acidosis that is nephrotoxic
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• Which Does Not Cause A Delayed Nephrogram
• Renal vein thrombosis • Renal Art Stenosis • Hypotension • ATN • Chronic Atrophic Pyelonephritis |
• E. Chronic Atrophic Pyelonephritis
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• Not associated with renal cyst
• Neurofibromatosis • Tuberous sclerosis • VHL • Echinococcal disease • Dialysis |
. Neurofibromatosis
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• Not included in the anterior pararenal space
• Adrenal • Duodenum • Pancreas • Left colon • Right colon |
• Adrenal
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• Patient presents with Varicocoele, what is the treatment
• Permanent occlusion of spermatic vein • Orchiectomy • Alcohol ablation • Temporary occlusion of spermatic vein with gelfoam |
• A. Permanent Occlusion Of Spermatic VeinVaricoceles
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• ACE inhibitors (Captopril) works by:
• To inhibit conversion of angiotensin 1 to angiotensin 2 • To inhibit conversion of angiotensinogen to angiotensin 1 • To inhibit coversion of renin to angiotensinogen • To inhibit conversion of angiotensin 2 to aldosterone |
• A. To Inhibit Conversion Of Angiotensin 1 To Angiotensin 2Angiotensinogen is a glycoprotein produced by the liver. Renin causes the liver to release angiotension I , which is then converted to Angiotension II by Angiotension converting enzyme (yes, ACE) in the lung endothelium. Physiology, Hsu.Renin converts angiotensinogen made in the liver to angiotensin I, which isconverted to angiotensin II in the lungs by ACE. Some angiotensin II is produced locally within the juxtaglomerular apparatus of the kidney as well.Angiotensin II is a powerful vasoconstrictor that, in addition to peripheral vasoconstriction, produces constriction of the efferent arterioles of the glomerulus. This raises filtration pressure and thus maintains GFR when perfusion pressure drops.ACE inhibitors work by blocking the conversion of angiotensin I to angiotensin II. Nuclear Medicine Requisites, 2nd ed, pg 337
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• Patient with a duplicated collecting system
• Upper pole inserts medial and inferior and refluxes, while lower pole inserts superior and obstructs • Upper pole inserts medial and inferior and obstructs, while the lower pole inserts superior and refluxes • Upper pole inserts superior and obstructs, while the lower pole inserts inferior and medial and refluxes • Upper pole inserts superior and refluxes, while the lower pole inserts inferior and medial and obstructs |
• B. Upper Pole Inserts Medial And Inferior And Obstructs, While The Lower Pole Inserts Superior And RefluxesDuplication of the collecting system results from branching of the ureteral bud before it connects with the metanephric blastema. The Meyer-Weigert Law states that the upper moiety/pole ureter enters the bladder inferiorly and medially to the lower ureter. The majority of duplicated systems function normally, with insertion in the general region of the trigone. However, with exaggerated ectopic position, malfunction occurs. The lower pole moiety can insert too superiorly resulting in too direct a course into the bladder lumen. And you recall that the UVJ works because of its tunneled course through the bladder wall and is physically obstructed with bladder lumenal dilatation. The upper pole moiety, when ectopic, inserts distally and is usually extravesical. These insertion sites can vary, but generally result in obstruction and dysplasia of the upper pole. They can insert in the seminal vesicles, vas deferens, vagina, uterus, you name it. Dunnick, p 28-29.
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• Seminal vesicle cysts are ssociated with
• ipsilateral renal agenesis • renal ectopia • contralateral crypto-orchitism |
• A Ipsilateral Renal Agenesis
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• Patient has an IVP which is normal for L sided pain. Next day returns for CT, and on Scout film of belly has dense kidneys?
• Contrast nephropathy • ATN • Glomerulonephritis • Obstruction |
• Contrast nephropathy
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• A 70yr old male with diabetes and scrotal pain has a CT that show scrotal gas, soft tissue swelling with normal epididymis and testes. The likely diagnosis is:
• Fournier’s gangrene • Inguinal hernia • lymphoma |
• Fournier’s gangrene
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• Retrograde urethrography showing contrast extending in dilated glands of Littre and a stricture in the penile urethra
• Gonococcal urethritis • Prior instrumentation • Straddle injury |
• Gonococcal urethritis
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• The best way to diagnose nephroblastomatosis
• Contrast CT • US • Nuclear medicine scan • MRI • IVP |
• Contrast CT
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• Clinicians are ordering percutaneous nephrostomy on a patient with sepsis and acute ureteric obstruction. What would you tell the clinician?
• I’ll do it, but I want you to know the sepsis might get worse. • I’m not doing it until you relieve the obstruction from below. • It’s not indicated. • Attempt the stone removal immediately following the PCN |
• A. I’ll Do It, But I Want You To Know The Sepsis Might Get Worse.In this question, no mention is made of signs of pyonephrosis, such as increased echogenicity noted in the collecting system. However, in cases like this, the obstructed kidney must be assumed as the source of sepsis until proven otherwise. Percutaneous nephrostomy and antibiotics are the standard of care. This is a temporizing measure so the infection can cool down. Surgery on an infected kidney to remove the cause of obstruction can make the patient significantly worse. In fact, percutaneous nephrostomy in this setting has a 28% complication rate of sepsis and hemorrhagic shock. Dunnick, Barbaric 119-123
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• Concerning renal transplants, which of the following does not cause reversed renal artery flow:
• acute rejection • renal vein thrombosis • renal arterial stenosis |
• renal arterial stenosis
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• Most common place for extraadrenal pheochromacytoma – aka extraadrenal paraganglioma
• Lumbar sympathetic chain • Kidney • Thoracic chain • Cervical chain • Organ of Zuckerkandel |
• E. Organ of Zuckerkandel.
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• Unilateral edema at the ureteric ridge is caused by:
• cystitis • calculus • tumor • benign prostatic hypertrophy • prostatitis |
• calculus
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• What is not associated with bladder diverticulum
• Shistosomiasis • Congenital • Bladder stone • Bladder outlet obstruction |
• Shistosomiasis
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• Causes of bladder wall thickening and trebeculation include all except
• Radiation • Cyclophosphamide • Detrusser sphincter dyssnergia • Infectious cystitis • neurogenic bladder secondary to diabetes mellitus • spinal cord injury |
• neurogenic bladder secondary to diabetes mellitus
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• The study of choice in a 1st trimester pregnant patient with symptoms of a urinary stone:
• US • CT • 2- shot IVP • cystoscopy • KUB |
• A. US
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• One can differentiate AIDS nephropathy from other causes end-stage renal disease by:
• renal size • renal echogenicity • doppler waveforms • mass |
• renal size
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• What is the most common cause of enlargement of the prostatic urethra?
• Detrusor dysynergia • stricture • prostatitis • infection • previous TURP |
• previous TURP
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• The most potent vasoactive substance of the following is:
• renin • Angiotensin 1 • Andiogensin II |
• C. Angiotensin II
• Angiotensin-II is the most potent vasoconstrictor of biologic system. Dähnert 5th p902, Weissleder p267 |
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• What is associated with atresia of the renal pelvis and infindibulum (pelvo-infundibular atresia):
• MCDK • hydronephrosis • megacalyces • autoR PCKD • multilocular cystic nephroma • medullary cystic disease |
• MCDK
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• According to the Wygert-myer rule who has increased incontinence with duplication.
• Males • Females • Equal |
• B. FemalesWeigert-Myer rule is seen in ureteral duplication and is that the ectopic ureter drains the upper pole and enters the bladder inferiorly and medially; the ectopic ureter may be stenotic and obstructed. The orthotopic ureter drains the lower pole and enters the bladder near the trigone. The ectopic ureter has a suprasphincteric insertion in males and an infrasphincteric insertion in females, causing increased incontinence in females. Primer p. 772 Dähnert p. 815.
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• What is the most common carcinoma in an undescended testicle (cryptorchidism)?
• Seminoma. • Choriocarcinoma • Yolk sac tumor • Leydig cell tumor • Embryonal cell ca |
• Seminoma.
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• Which of the following is not a germ cell tumor?
• Leydig cell tumor. • Teratoma. • Choriocarcinoma. • Yolk sac tumor. |
• Leydig cell tumor.
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• An oncocytoma is classified as what type of lesion?
• Epithelial cell tumor. • Hamartoma. • Adenocarcinoma. • PNET |
• Epithelial cell tumor.
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• Which component of the prostate gland is involved with benign prostatic hypertrophy?
• Central gland • Central zone • Transitional zone • Peripheral zone |
• Transitional zone
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• In a patient with benign prostatic hypertrophy, which is the largest portion of the gland removed?
• transitional • central • peripheral • periurethral |
• B. If Gland Is After Each Choice;
• A. If Zone Is After Each Choice.BPH is enlargement of the central gland and may contain calcifications. The central gland contains the transitional zone and periurethral zone. The peripheral gland contains the peripheral zone and central zone (confusing!!) Most cancers arise in the peripheral gland. Primer p. 298-299.Dähnert says that the transitional zone enlarges with BPH, but does not say that the periurethral zone does. Dähnert p756 |
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• Which of the following bladder or ureteric pathologies are not premalignant?
• cystitis cystica • Cystitis glandularis • malakoplakia |
• malakoplakia
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• What feature is the most suggestive of malignancy in a renal cyst
• three thick 1 mm septa • hyperdense cyst with HU = 30 • debris that measures HU=50 • a hypodense mass that changes from 10 HU to 45 HU post injection |
• a hypodense mass that changes from 10 HU to 45 HU post injection
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• Which one give you small kidneys
• medullary cystic disease • HIV nephropathy • Medullary sponge kidney • Longstanding renal failure • Lymphoma • Acute obstruction |
• Longstanding renal failure
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• A young women comes in with flank pain, hematuria, and a normal creatinine. You do a IVP which is normal. The next day she comes in for a Ba enema and there is persistence of the renal nephograms
• contrast induced renal failure • cortical necrosis • acute glomerulonephiritis • papillary necrosis • normal varient |
• contrast induced renal failure
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• Causes of a striated nephrogram include all except:
• renal artery stenosis • ureteral obstruction • renal vein thrombosis • medullary sponge kidney • acute pyelonephritis |
• A. Renal Artery Stenosis
• Striated nephrogram = streaky lineer bands of alternating hyper – and hypoattenuation parallel to axis of tubules + collecting ducts during excretory phase due to stasis of contrast material in dilated collecting ducts on background of edematous renal parenchyma Pneumonic: CHOIR BOY Contusion Hypotension (systemic) Obstruction (ureteral) Intratubular obstruction Renal vein thrombosis Bacterial nephritis (acute) Obstruction (ureteral) – twice b\c it’s so common Yes, also cystic diseases i.e. medullary sponge kidney, infantile PCKD, and medullary cystic disease Striated angiographic nephrogram = random patchy densities reflecting redistribution of blood flow from the cortical vasculature to the vasa recta of the medulla. Caused by 1. obliterative diseases of the renal microvasculature including polyarteritis nodosa, scleroderma, necrotizing angitis, and catheter induced vasospasm. 2. acute bacterial nephritis. 3. renal vein thrombosis Dähnert 5th p881 |
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• Corpus luteal cysts usually resolve by how many weeks
• 5 • 10 • 15 • 20 • 25 |
• 20
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• Salpingitis isthmica nordosa is often associated with
• Hydrosalpynx • Endometriosis • Synechia • PID • Adenomyosis |
• PID
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• Persistent nephrogram seen in each except:
• ATN • Renal artery stenosis • Hypotension • chronic atrophic pyelonephritis • Renal v thrombosis |
• chronic atrophic pyelonephritis
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• Most common cause of post-menopausal vaginal bleeding
• endometrial atrophy • endometrial hypertrophy • endometrial polyp • endometrial carcinoma • submucosal fibroid |
• endometrial atrophy
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• Vasoactive agent responsible for hypertension in renal artery stenosis
• aldosterone • renin • AI • AII • Angiotensinogen |
• AII
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• A striated nephrogram is seen in (T/F):
• Infection • Trauma • Infarction |
• a. T
• b. T • c. F • Striated nephrogram shows fine linear bands of alternating lucency and density in the area of tubules and collecting ducts. DDx: systemic hypotension, intratubular obstruction, acute bacterial infection / pyelonephritis, renal contusion (trauma), medullary sponge kidney, medullary cystic disease, ARPCKD, renal vein thrombosis and the big one, acute extrarenal obstruction (e.g., stone disease).Infarction (acute) shows cortical rim enhancement, large kidney with expanded parenchymal thickness (due to edema), attenuated collecting system in case of global infarction (renal artery injury, for example). In focal / segmental infarction, the same findings are seen localized to that segment. Striation is rarely seen.Chronic infarct shows small to normal sized kidney with again diminished / absent contrast enhancement. Ref: Dähnert, 3rd ed., p. 641, 693. |
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• Adrenal mass in single limb found on CT (SBA):
• Adenoma • Hyperplasia • Metastasis • Pheochromocytoma • Hemorrhage |
• Adenoma
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• A man with glomerulonephrosis has a prolonged nephrogram. What is the single most likely etiology?
• renal vein thrombosis • renal artery thrombosis • acute tubular necrosis • urinary obstruction |
• A. Renal Vein Thrombosis:
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• Aldosteronomas are associated with (T/F):
• a) Low renin levels • b) Elevated serum potassium • c) Elevated serum sodium |
• A=T, B=F, C=T
• Adrenal adenomas may secrete excessive hormone and cause one of the endocrine syndromes or be nonhyperfunctional and present as an unsuspected adrenal mass. Nonhyperfunctional adenomas are incidental findings in as much as 3-5% of the population. Function of an adenoma cannot be determined by imaging appearance but is assessed clinically. With aldosterone-secreting adenomas, patients typically present with diastolic hypertension without edema, hyposecretion of renin that fails to increase appropriately during volume depletion, and hypersecretion of aldosterone that fails to suppress appropriately during volume expansion. This hypersecretion of aldosterone leads to the continual renal tubular exchange of sodium and potassium resulting in the hypernatremia and hypokalemia which is characteristic of this disease. GU Requisites, 366-367 and Brandt and Helms, 2nd edition: pg. 770; Harrison’s Principles of Int. Med.: pg. 1366 |
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• 25 yo with one year h/o of nephrotic syndrome presents with acute flank pain, gross hematuria, and enlarged kidney and persistent nephrogram on IVP. Most likely dx:
• a. Pyelonephritis • b. Renal vein thrombosis • c. Obstructing UVJ calculus • d. Hemorrhage nephritis |
Renal vein thrombosis
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• UPJ obstruction is most commonly caused by:
• a. intrinsic functional cause • b. extrinsic compression from crossing blood vessels • c. vesico ureteral reflux • d. adventitial bands |
intrinsic functional cause
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• 35 yo s/p trauma with superior and inferior pubic rami fractures and diastatic right SI joint. No blood at the meatus and prostate is in normal position. The next best step is:
• a. CT scan • b. Retrograde urethrogram • c. Cystogram • d. VCUG • e. IVP |
Retrograde urethrogram
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• A patient with bifid renal pelvis demonstrates a 3 cm mass in the mid kidney which demonstrates the same enhancement and density on pre and post contrast CT as the renal cortex. This is most likely:
• a. RCC • b. Normal • c. Oncocytoma • d. Transitional cell ca • e. Squamous cell ca |
• b. Normal
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• A woman with analgesic nephropathy comes back two years later with a filling defect in the renal pelvis. The most likely cause is (SBA):
• Stone • TCC • Squamous cell carcinoma • RCC |
• TCC
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• Findings associated with the worst prognosis in RCC:
• Contralateral kidney involvement with RCC • IVC tumor thrombus • Adenopathy • Ipsilateral adrenal involvement |
• A. or C.The prognosis of RCC depends on stage. However, the answer depends on how you interpret the choices. If choice (a) is considered as metastatic spread to the contralateral kidney, then this is distant spread (stage 4) and would be the right answer. However, if choice (a) refers to synchronous, bilateral tumors, then the prognosis is good assuming no distant mets. In that case, the answer would be (c). Keep in mind though that in a patient with bilateral RCC, the chances of this being metastatic spread to the contraletral kidney is higher than it being synchronous tumors. Robson Staging:
• Stage I: confined to within renal capsule • Stage II: extension into perinephric fat but confined to Gerota’s fascia • Stage IIIA- renal vein or IVC inolvement • StageIIIB- adenopathy • Stage IIIC- renal vein + lymph nodes • Stage IVA: extension into adjacent organs (other than ipsilateral adrenal) • Stage IVB: distant metsDunnick 2nd, pp. 141-142. Dähnert 4th p. 795-796 Primer, 3rd, 283-284 GU Requisites, 89-99 |
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• IVP on an obstructed kidney demonstrates a crescentic collection of contrast around some or one of the calyces. This is most likely from:
• a. contrast in an incompletely filled distended calyx • b. Back pressure into dilated collecting tubules • c. Distortion of the collecting tubules from dilated calyx |
• A. contrast in an incompletely filled distended calyx.
• Dunbar crescents are small rings or crescents at the interfaces of the calyces and parenchyma. They disappear when the calyces opacify. (Textbook of Uroradiology, 2nd edition, Dunnick, Ames, et al. 1997. pp. 481‑482) |
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• IVP demonstrates a duplex collecting system. A 3cm lesion that displaces a dilated renal collection system enhances during an IVP in a manner similar to renal parenchyma. This mass represents:
• renal cell carcinoma • normal renal tissue • transitional cell carcinoma • onococytoma |
• normal renal tissue
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• Concerning ionic contrast agents, which is true:
• a. completely disassociates in blood • b. partly bound by albumin • c. couldn’t remember the rest of the answers |
• a. completely disassociates in blood
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• Regarding a patient taking glucophage (metformin hydrochloride) and ionic contrast:
• contraindicated within 48 hours of contrast • reacts directly with ionic contrast • associated with lactic acidosis |
• glucophage seems to be associated with lactic acidosis. ACR guidelines are to hold for 48 hours following contrast administration
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• Stage C prostate cancer is defined by (T/F):
• Seminal vesicle involvemnent • Rectal involvement • Capsular invasion • Bladder invasion • Nodal metastasis • Bony metastases |
• Seminal vesicle involvement – True
• Rectal involvement – True • Capsular invasion – True • Bladder invasion – True • Nodal metastasis – False. • Regional node involvement connotes Stage D1 prostate cancer. • Bony metastases – False. Distant metastases connote Stage D2 prostate cancer. • Stage C prostate cancer is defined by unilateral extracapsular extension (T3a), bilateral extracapsular extension ( T3b), invasion of one or both seminal vesicles (T3c), invasion of the bladder neck, external sphincter or rectum (T4a), and invasion of the levator muscles or fixation to the pelvic sidewall (T4b). Primer, 3rd, 322-324 |
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• Concerning bicornuate uterus:
a. It can be distinguished from septate uterus on hysterosalpingogram b. Commonly associated with obstetric complications c. Commonly associated with primary infertility d. |
• B. Commonly associated with obstetric complications.
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• A 40 year old male presents with hypertension, hypokalemia, and metabolic alkalosis. HTN is NOT relieved with captopril (single best answer):
• a. Pheochromocytoma • b. adrenal adenoma • c. bilateral adrenal hyperplasia • d. Carcinoid • e. juxtaglomerular apparatus tumor (JGA tumor) |
• b. adrenal adenoma
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• Bilateral lateral deviation of the ureters above the level of the pelvic inlet (single best answer):
• aortic aneurysm • lymphoma • retroperitoneal fibrosis • retroperitoneal hematoma |
• B. Lymphoma
• Below L1-L2 and above the pelvic brim the ureter normally projects over the transverse processes (nl = pedicle to slightly lateral to the transverse processes). Lateral deviation of the middle and upper third of the ureter is most often caused by lymph node enlargement. Dunnick, et al., Textbook of Uroradiology, p.377 |
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• Bleeding can occur with endometrial thickness less than 4 mm – True\False
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• True.Women with endometria less than 5 mm typically have atrophic endometritis. The majority of women who experience post-menopausal bleeding do not have cancer but have either atrophic endometritis (78%) or hyperplasia. Of those with atrophy, 96% showed an endometrial thickness of 5 mm or less. Uterine curettage is not necessary unless the endometrium is 8 mm or more. Endometrial thickness excludes significant abnormality
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• Concerning acquired renal cystic disease (single best answer):
• one quarter of patients develop cancer • cysts are uniformly less than 1cm in size • cysts are located only in the medulla • increased number of cysts with increased time on dialysis |
• increased number of cysts with increased time on dialysis
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• Concerning the endometrium (multiple true/false):
• The best view for evaluation of the endometrium on endovaginal ultrasound is coronal • Tamoxifen demonstrates an anti-estrogenic effect on the endometrium • Endometrial thickening occurs with unopposed estrogen therapy • Endometrial polyps can mimic endometrial thickening • Bleeding can occur with endometrial thickness less than 4 mm |
• Answer F. Best view for evaluation of endometrium on endovaginal ultrasound is sagittal (Rumack p.528)
• Answer F. Tamoxifen demonstrates antiestrogenic effect on breast, and estrogenic effect of uterus. Tamoxifen is nonsteroidal drug used as adjuvant therapy for breast cancer, competes with estrogen for estrogen receptors. It is associated with increased risk of endometrial cancer, hyperplasia, polyps. Cysts with thick endometrium is frequently seen on ultrasound. • Answer T. Unopposed estrogen causes increased risk of endometrial hyperplasia and cancer. • Answer T. Endometrial polyps can mimic endometrial thickening. 20% are multiple. • Answer T. Bleeding can occur with endometrial atrophy where thickness is < 4 mm. |
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• Matching
1. Vascular nephrogram 2. Tubular nephrogram 3. Early pyelogram 4. Obstruction a. glomerular filtration • b. tubular secretion • c. tubular excretion • d. resorption of water in the collecting tubules • e. resorption of water and salt in the distal tubule |
• 1. Vacsular Nephrogram A: Not sure these next few questions are remembered correctly. For this answer, would put A if he had to choose an answer, although not technically correct. The vascular nephrogram appears within a few seconds of the initial injection and refers to the radiodensity of the kidney caused by blood within the renal circulation, including microvasculature. The vascular nephrogram can be seen up to around 30-40 seconds post-injection
• 2. Tubular Nephrogram A The excretory “tubular” nephrogram is caused by the accumulation of contrast medium within the tubules as a result of glomerular filtration and tubular concentration. This is visualized within the nephon within 30 seconds of injection. • 3. Early Pyelogram: E The early pyelogram is created by resorption of water and salt from the distal tubule, to further concentrate the contrast in the collecting system. • 4. Obstruction: D Obstruction causes an initially reduced density of the nephrogram during the first few minutes of the excretory urogram. However, continued reabsorption of water by the tubules compensates for the elevated hydrostatic pressures within the tubules, and thus glomerular filtration does not cease completely. The net result is contrast in the urine that moves sluggishly forward, with a nephrogram that increases over many hours and calyceal opacification that is delayed.This question is excruciating. Despite numerous searches I could find no definite reference. Pollack (p 179 - 181) discusses the different nephrograms but does not correlate to physiologic processes. A vascular nephrogram describes the first few seconds of contrast administration where the contrast in the in the renal vasculature but not yet filtered through the glomeruli. A tubular nephrogram (AKA excretory tubular nephrogram) causes increased density to the renal parenchyma for the first 3 minutes after contrast administration secondary to water reabsorbtion (it doesn’t state where in the nephron resorption appears). An early pyelogram was not described in the text but may refer to ATN with extravasation of contrast from the disrupted tubules into the surrounding parenchyma and calyces. Finally, an obstructive nephrogram displays an enlarged kidney with slow uptake of contrast and markedly prolonged delay of washout. I could find no physiologic explanation of this however. |
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• Concerning ureteral duplication which is true
• Only the upper pole moiety obstructs • The upper ureter inserts lateral and cephalad to the lower moiety ureter • The lower moiety is associated with reflux • More common in males than females • Ectopic ureterocele is associated with the lower moiety |
• C. Lower pole moiety is associated with reflux
• Collecting system duplications:Most common congenital anomaly of the GU tractPartial dupl.: 1/150 complete: 1/500 • F : M :: 2-5:1Complete duplications are bilateral 10-20% of the timeEmbryology: partial: due to branching of the ureteric bud before it invaginates the metanephric blastemaComplete: 2 separate buds arise from the mesonephric ductWeigert-Meyer rule: Upper pole (moiety) ureter inserts medial and inferior to the normal point: it’s ectopic and is prone to ectopic ureterocele development (seen in 1/3 of pts with duplication)Upper moiety often obstructs (see below)Less commonly see reflux in the ectopic ureterEctopic ureteroceles may obstruct the ipsilateral orthotopic ureter (lower moiety) or the urethra (leading to bilateral ureteromegaly)Ectopic ureteroceles: 4:1 :: F:MEctopic ureter:May insert in the bladder neck, urethra, or vagina in women and is prone to infections—obstructs; also may insert in the uterusMen: may insert in the vas, seminal vesicle, prostate, urethra, or ejaculatory duct, but never below the external sphincter, so it is protected from infection (but it does obstruct)Orthotopic ureter: prone to reflux—often inserts slightly above and lateral to the normal position on the trigone and has a shorter submucosal tunnel, facilitating reflux |
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• Forty-year-old male with hesitancy and diminished urinary stream. Retrograde urethrogram shows a stricture in the penile urethra, with filling of Cowper’s ducts and the glands of Littre. The most likely etiology is (single best answer):
• a. old straddle injury • b. prior instrumentation • c. gonorrhea infection • d. congenital lesion |
• C. Gonorrhea infection.
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• Match the following cystic lesions with their location (matching)
1. Müllerian duct cyst 2. Seminal vesicle cyst 3. Ejaculatory duct cyst 4. Utricular cyst a. Midline • b. Paramidline • c. lateral |
• 1. Mullerian duct cyst A.: -occur in the MIDLINE in the location expected for a dilated utricle but
-DO NOT communicate with the posterior urethra -typically lies posterior and superior to the prostate(in retrovesicle space) -Usually in 3rd to 4th decade -from remnant of Mullerian duct, arises from region of veromontanum -DO NOT contain sperm • 2. Seminal Vesicle cyst C.: -LATERAL -rare, 2/3 rds associated with ipsilateral renal agenesis -congenital in nature -if hemorrhage occurs – may appear as solid mass on CT • 3. Ejaculatory duct cyst B.:-PARAMIDLINE(but can occur midline) , along expected course of ejaculatory duct -intraprostatic cyst in central zone -congenital or acquired due to obstruction -aspirate contains sperm -often has calcification • 4. Utricular cyst A.: -arise in MIDLINE from veromontanum (intraprostatic) -this is a Mullerian Remnant -connects with posterior urethra -typically 8 to 10 mm and does not extend above prostate FYI; Most focal cystic areas in the prostate are found with BPH originating from cystic dilatation of transitional zone glands. Aquired inclusion cysts (not associated with BPH) can occur in any zone. |
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• Point of action of captopril is (single best answer):
• angiotensinogen angiotensin I • angiotensin I angiotensin II • angiotensin I to aldosterone |
• B. the point of action of captopril is: b. angiotensin I angiotensin IIrenin:
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• Postpartum female presents with abdominal pain/left flank pain. Imaging reveals an enlarged left kidney with a long cortical phase and delayed excretion on IVU. Most likely cause is (single best answer):
• ureteral obstruction • ATN • renal artery occlusion • renal vein thrombosis |
• renal vein thrombosis
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• Regarding bladder carcinoma (matching):
1. Squamous cell CA 2. Adenocarcinoma 3. TCC |
• Regarding bladder carcinoma (matching):
1. Squamous cell CA 2. Adenocarcinoma 3. TCC a. schistosomiasis • b. cyclophosphamide • c. exstrophy • D prune belly syndrome • 1. Squamous cell A. carcinoma of the bladder is associated with Schistosomiasis infection, leukoplacia and chronic irritation/stone disease • 2. Adenocarcinoma C.of the bladder is associated with a patent urachus (urachal carcinoma), cystitis grandularis with metaplastic transformation, and bladder extrophy. The tumor is 7 times more frequent in males. Patients present with hematuria (70%), mucus passed per the urethra (25%), or an umbilical discharge (patent urachus). The tumor typically develops within the intra/juxtavesicular segment of the urachus- supravesical, midline, anterior (80%) this is referred to as the "space of Retzuis". On CT the lesion appears as a low attenuation mass which invades the bladder dome. Peripheral psammomatous calcification is found in up to 70% of lesions. • 3. Transitional cell carcinoma B. accounts for over 95% of bladder carcinomas. Patients generally present between the ages of 50-60y with painless hematuria, frequency, and dysuria. An increased risk is for TCCa is associated with: a history of prior TCCa of the upper tracts, aromatic amine exposure, tobacco use, and cyclophosphamide therapy. Common locations for the tumor include the lateral wall (50%), the trigone (25%- produces obstruction), and the bladder dome. Most lesions are superficial (70%) at the time of diagnosis. TCCa of the bladder is associated with a higher risk of developing a subsequent upper tract malignancy. The tumor metastasizes to local lymph nodes initially, then hematogenously to the liver and lungs. Calcification is found in less than 1% of lesions. Transitional cell carcinoma may be papillary (intralumenal) or non-papillary (infiltrative). On IVP the tumor appears as an irregular bladder filling defect or bladder wall thickening. On CT there may be a pedunculated soft tissue mass, or focal or diffuse wall thickening. Perivesicular extension or seminal vesicle involvement can be seen. Necrosis within the lesion may result in calcification rarely. Additionally, urinary salt may be deposited on the surface of the tumors. TCCa may occur within bladder diverticulum. |
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• Regarding findings on IVP examination (matching):
1. Amputated calyx 2. Polygonal multi-faceted calyces 3. Polar cortical thinning a. megacalyx b. TB c. reflux d. obstructive nephropathy e. analgesic abuse |
• Regarding findings on IVP examination (matching):
1. Amputated calyx 2. Polygonal multi-faceted calyces 3. Polar cortical thinning a. megacalyx b. TB c. reflux d. obstructive nephropathy e. analgesic abuse • 1. Amputated calyx B. hallmark of renal TB are multiple ureteral and infundibular strictures. Also called “phantom” calyx. • 2. Polygonal multifaceted calyces A. Congenital megacalices are a nonprogressive caliceal dilatation caused by hypoplastic medullary pyramids. - mosaic-like arrangement of dilated calyces (polygonal + faceted appearance, not globular as in obstruction). Dähnert 5th p. 926. • 3. Polar cortical thinning. C. Reflux of infected urine leads to polar parenchymal scarring because the compound calyces found at the poles have distorted and gaping openings of the ducts of Bellini (normally slit-like). |
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• Regarding HIV nephropathy (multiple true/false):
• May be the earliest manifestation of HIV infection • May be associated with proteinuria and nephrotic syndrome • Similar sonographically to other medical renal diseases • Typically presents as small hyperechoic kidneys on ultrasound • Typically manifests as small focal bilateral renal lesions |
• a. True (difficult to document as the first manifestation, but several sources said it can happen in
asymptomatic HIV patients without AIDS-defining illness) b. True c. False d. False e. False HIV Nephropathy AIDS patients: 38-68% develop azotemia, proteinuria, hematuria, or pyuria at some point HIV nephropathy = proteinuria and rapidly progressive renal failure. Can be in AIDS or in asymptomatic HIV; Not treatable, Fatal in 6 monthsImaging: global enlargement without hydro or scarring CT: +/- increased attenuation of medulla U/S: big kidneys with increased echogenicity usually, but may be normal size and echoesPath: glomerulosclerosis and microcystic dilatation of tubules with proteinaceous castsOther GU dz with HIV: pyelo: large, poorly functioning kidneys with striated nephrogram on CT; U/S—enlarged abscesses pneumocystis: (especially if on aerosolized pentamidine) CT: punctate calcifications in the renal parenchyma (also seen in spleen, liver, LN, adrenals); this also can be seen in MAC and disseminated CMVdisseminated candida: focal microabscesses in liver, spleen, and kidneys. U/S: bullseye lesions CT: low attenuation lesionsNHL: if AIDS and NHL—6-12% will have renal involvement with NHL: solitary or bilateral renal masses, or engulfment of the kidneys by adjacent node massesKS: parenchymal involvement too small to see on imaging (usu postmortem dx) but adjacent bulky LAN may cause hydroSource: Rad Clin NA 9/97“HIV nephropathy may be seen in asymptomatic patients with HIV”—Annals of Int. Med. 1990 |
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• Regarding malakoplakia (multiple true/false):
• a. Associated with E. coli • b. Females greater than males • c. Brunn’s nest seen on histology • d. Pre-malignant condition • e. The most common site is the bladder |
• a: T; b: T; c: F; d: F; e: T. Malakoplakia is a granulomatous inflammatory disease which affects F>M (4:1). Patients present with hematuria and obstructive complaints. The condition is associated with chronic UTI's (E. coli in 94%) and altered immunity status such as post-transplant, lymphoma, carcinoma, or diabetes. The condition most commonly affects the bladder > distal 2/3 of ureters. The ureters, renal pelvis, kidneys, testes, & prostate may also be involved, but less commonly. It is multifocal in 75% of cases and bilateral in 50%. Treatment for renal involvement is nephrectomy for unilateral disease. Bilateral or renal transplant involvement is associated with a poor prognosis. On histologic analysis there are two characteristic findings- the von Hansemann histiocyte (large foamy macrophage) with Michaelis-Gutman bodies (which are intra- & extracytoplasmic inclusion bodies that represent incompletely destroyed bacteria). It is NOT a pre-malignant condition. On contrast examination there are multiple small (5mm) rounded submucosal nodules projecting into the bladder lumen. Renal involvement is characterized by a displaced, but normal appearing pelvoocalyceal system, multiple (or solitary) ill defined, irregular parenchymal masses in the renal cortex, and a decreased nephrogram with poor excretion of contrast. On CT the only finding may be smooth, plaque-like thickening of the bladder wall. The bladder is the most common site for malakoplakia followed by the lower 2/3’s of the ureter, the upper ureter, and the renal pelvis in that order. Multifocal 75%, bilateral 50%Multiple dome shape filling defects – can cause obstruction or mass effect, even diminished or absent nephrogram.DDx: pyeloureteritis cystica
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• Regarding percutaneous nephrostomy (multiple true/false):
• a. On AP view, the posterior calyces are projected on en face • b. Puncture of an anterior calyx ensures entry through the avascular zone • c. The nephrostomy tube should be removed over a wire • d. There is an increased rate of complication with bladder dysfunction • e. Indicated in the treatment of pyonephrosis |
• a. T b. F c. T d. F e. T
• Indications: (1) external drainage of collecting system (a) pyeloureteral obstruction (b) urinary diversion to heal leak/fistula (c) decompression of renal/perirenal fluid collections (d) nondilated obstructive uropathy (2) creation of tract to remove stones, dropsy, stricture dilation and antegrade ureter stenting (3) manage complications from transplant kidneys (4) infusion of antitumor, stone dissolving drugs, antibiotics (5) urinary obstruction of pregnancyRelative contraindications – coagulopathy - the posterior calyces as are- Approach: avoid hilar vessels via an oblique posterolateral approach along Brödels line (near post. axillary line) 2 - 3 cm below 12th rib and direct toward target calix (usually middle or lower pole). Choice of calix depends on procedure and optimal access.- Removal of nephrostomy tube - the locking mechanism (string) is cut from the tube. A guidewire is used to uncoil the loop of catheter and establish access to the renal pelvis. Always remove the tube over a wire. It prevents tube from getting caught or hung up upon removal, and maintains access to the renal pelvis if needed (to tamponade a bleed).Complications - overall (4%) major - massive hemorrhage 1% - Ptx 1% - death <0.2% - peritonitis – rare - (15%) minor - microhematuria: common - pain: common - infxn 1.4 - 21% (45% of patients with struvite stones develop signs of infxn after PCN) - urine extravasation <2% - perirenal bleed (rare) - unnoticed retroperitoneal bleed 13% - catheter related problems 12% |
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• Regarding the placenta and the myometrium (matching):
1. Adherent to the wall of the myometrium 2. Invades into the myometrium 3. Invasion through the myometrium a. creta • b. accreta • c. Percreta • d. Increta • e. myocreta |
• Regarding the placenta and the myometrium (matching):
1. Adherent to the wall of the myometrium 2. Invades into the myometrium 3. Invasion through the myometrium a. creta • b. accreta • c. Percreta • d. Increta • e. myocreta • 1. B. Placenta accreta - underdeveloped chorionic villi in direct contact with myometrium - incidence 1:2500 - 7000 deliveries - 5% of placenta previa patients - increases with number of C-sections • 2. D. Placenta increta - villi invade myometrium • 3. C. Placenta percreta - villi penetrate through serosa of uterus Imaging - thinning or abscence of hypoechoic myometrium between placenta and echogenic serosa or uterine serosa - bladder interface - mass-like protrusions of placenta tissue beyond serosa - > 6 irregular vascular spaces in uterusComplications - uterine bleeding - death - retained placenta Source: Dähnert p. 642 |
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• Regarding Wilms tumor (multiple true/false):
• a. Associated with familial aniridia • b. Encases retroperitoneal vessels • c. The most common malignancy in childhood to invade the IVC • d. Associated with Beckwith-Wiedeman syndrome • e. Associated with hepatoblastoma |
• a: F b: F c: T d: T e: F
• Wilm's tumor is the most common renal neoplasm in children with a peak incidence at age 2 yrs. Nearly 50% of cases occur prior to age 3y and 75% before age 5 years (the tumor is rare in newborns). Patients present with an abdominal mass (90%), HTN (50%), pain, and/or gross hematuria. The tumor is bilateral in 10% of cases. Bilateral tumors are associated with nephroblastomatosis in 100% of the cases. Wilm's tumor is staged: I: Confined to kidney II: Perinephric extension III: (+) Lymph nodes/Vascular Invasion IV: Mets V: Bilateral renal involvementThe tumor metastasizes to para-aortic/renal hilar nodes, lung, bones (less common), & to the liver (hepatic or pulmonary mets are found in 30% of patients at presentation). The lesion may invade vascular but not encase them (Ddx Neuroblastoma). Prognosis depends upon age (under 2 years associated with a good 5 year survival), lesion extent (capsular penetration & mets are associated with a poor prognosis), and tumor histology (well differentiated lesions are associated with a better survival). Syndromes associated with an increased incidence of Wilm's include: Beckwith-Wiedemann syndrome: macroglossia, omphalocele, visceromegaly Hemihypertrophy: Characterized by gross enlargement of a part or half of the body, it may be limited to the musculoskeletal, vascular, or nervous systems. The condition can involve internal organs. Affected patients are at an increased risk for Wilm's tumor, hepatoblastoma, and adrenal cortical tumors. Sporadic aniridia: Wilm's tumor develops in 1/3 of patients. The patients are at an increased risk until about age 5y. The disorder is characterized by bilateral absence of the iris, cataracts, glaucoma, ear deformities, microcephaly, and mental retardation. Drash syndrome: Characterized by pseudohermaphroditism, glomerulonephritis, and nephrotic syndrome. Chromosome 11 deletion: Has been noted in some patients with Wilm'sThe tumor may arise from metanephric blastema (embryonic potential cells). There is usually a pseudocapsule of compressed renal tissue about the tumor. Hemorrhage and necrosis are COMMON, but calcification is uncommon (5-10% of cases) and is usually amorphic or curvilinear. May very rarely note the presence of fat within the mass (by CT), remember that angiomyolipomas are extremely rare in children without tuberous sclerosis!! On US the tumor can appear evenly echogenic, but may see more echolucent areas which represent necrosis. US can also be used to evaluate the renal vein or IVC for tumor extension. On CT the tumor is usually a large, complex renal mass which is typically sharply marginated. The tumor is usually moderately vascular on angiography. |
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• The following are associated with aldosterone secreting tumors of the adrenal gland (multiple true/false):
• Increased plasma sodium • Decreased serum potassium • Histologically very similar to cortisol-secreting tumors • Is located in the adrenal medulla • Serum levels are decreased |
• True hypertension secondary to hypernatremia
• True • True • false • False • Primary hyperaldosteronism (Conn’s Syndrome): 75% due to adenoma, 25% hyperplasia (kids: hyperplasia > adenoma); carcinoma is a rare causeclinically: HTN, hypokalemia, moderate HTN; +/- mild frontal HA; fatigue, weakness; is cause of <1% of HTN caseslab: +/- hypernatremia—one book said yes, the other no; hypokalemia; alkalosis; increased K+ excretion; low plasma renin; increased (nonsuppressible) aldosterone levelsM>F; 30-50 years oldAdrenal cortex: composed of 3 layers—“GFR”—zona glomerulosa, fasciculata, and reticularis, which make aldosterone, cortisol and corticosterone, and androgens, respectively (“salt, sugar, sex; the deeper you go, the better it gets”)Adrenal adenomas: usually <2 cm, will take up I-131 labeled NP-59 asymmetricallyAldosterone: increases resorption of Na+ from urine, sweat, spit, and gastric juice; leads to retention of Na+ in the ECF; at kidney: act on the distal tubule and collecting duct resorbs sodium, secretes K+ and hydrogen ions—hypokalemia and alkalosis Source: Moss, Robbins, Ganong, Dähnert |
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• The most common complication associated with horseshoe kidney (single best answer):
• calculi • infection • hypertension • obstruction • ureteral notching |
• UPJ Obstruction
• D. obstruction. • Horseshoe kidney: Most common renal anomaly—1/400; M:F :: 2:1 Midline connection of developing (blastemal) renal masses in fetus—the midline isthmus may be fibrotic of normal kidney tissue; Vast majority fused caudally; IMA arrests ascent—low position Vascular supply: variable but usually multiple arteriesXray: Incomplete rotation of collecting systems Abnormal axis, Low-lying, May see mild dilatation of collecting systems due to anterior angulation of the ureters—stasisComplications: Stasis—infection and stones; Also obstruction: 30% UPJ obstrxn; Increased incidence of malignancy, esp. Wilms’; More prone to traumatic injuryAssociations: Other organ syst. Anomalies: GI, CV, MSK; Turner synd and Ellis-van Creveld synd Ureteral duplications; Trisomy 18; Other GU anomalies (undescended testes, bicornuate uterus, etc). Source: Zagoria, Amis, Dähnert , Primer p. 278 |
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• GU Thirty-five-year-old female with abdominal pain and negative IVU as an outpatient. Next day scout film performed for barium enema reveals dense kidneys bilaterally. Likely etiology is (single best answer):
• contrast-induced acute renal failure • hypotension • acute cortical necrosis • ureteral obstruction |
• contrast-induced acute renal failure
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• Thirty-year old male with a painful swollen left scrotum. Ultrasound demonstrates a hypoechoic lesion in the left testicle:
• location highly indicative of neoplasm • elevated b-HCG and AFP imply metastatic disease • iliac node likely the first site of spread of disease • ultrasound can distinguish between benign and malignant disease |
• A. location highly indicative of neoplasm
• The location of a scrotal mass is one of the most important determinations to be made, as the vast majority of extratesticular masses are benign, and the majority of intratesticular masses are malignant. Most testicular tumors are germ cell in origin, the seminoma being the most common (mixed are next). Seminomas begin homogeneous and hypoechoic. Mixed germ cell tumors assume a variety of appearances. Other germ cell tumors include teratomas (Ca+), embryonal cell carcinoma, choriocarcinoma. Mnemonic: "YES CT" - Yolk sac tumor (equivalent to endodermal sinus tumor of ovary, childhood, elevated AFP), Embryonal cell carcinoma, Seminoma, Choriocarcinoma, Teratoma. Non-germ cells include Leydig and Sertoli cell tumors (stromal cell tumors) and account for 5-10% of testicular tumors. 60% are pure seminomas, 40% are mixed. Seminomas met via regional lymph nodes (retroperitoneal > mediastinal > supraclavicular) and are very radiosensitive. Nonsemonomatous tumors met via lymphatic & hematogenous routes (lungs > liver > bones) and are radioresistantGerm cell tumors often secrete AFP, HCG, placental alkaline phosphatase, placental lactagen, and lactic acid dehydrogenase. Elevated levels of these markers are most often associated with non-semanomatous tumors. (9% of seminomas, 44% of teratomas, 88% of embryonal cell carcinomas [AFP only], 86% of teratocarcinomas, 75% of yolk sac tumors, and 100% of choriocarcinomas [HCG only].) These markers are used to diagnose, stage following orchiectomy, and monitoring response to therapy. They do NOT imply metastatic disease. Pure seminomas never elaborate AFP, which implies presence of nonsemonomatous element.Testicular tumors have a characteristic mode of spread. In general, retroperitoneal para-aortic nodes are the first to be involved. Subsequent spread may occur to mediastinal and supraclavicular nodes. Hematogenous spread is primarily to the lungs, but liver, brain, and bones may also be involved. The histology of the met may differ from that of the primary.Ultrasound cannot distinguish between benign and malignant disease, which is why stromal tumors and the like are routinely removed.The risk of germ cell tumors in pts with undescended testes is 10X that of the normal population. 10% of testicular tumors are associated with cryptorchidism. The higher the location, the greater the risk to either testes. |
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• Uric acid stones are most likely to be seen in the setting of (single best answer):
• bowel surgery • polyuria • primary greater than secondary gout • aciduria |
• D. Adicuria
• Uric acid exists in urine free or in more soluble salt form NaUrate. Acid urine (pH <5.75) increases concentration of less soluble free form. Increasing urinary excretion of urate increases risk of stone dz (rate > 1gm/day assoc. with 50% incidence of stones; nl < 750 mg/day).Tx for urate stones includes increasing urine output > 2 L/day therefore polyuria is incorrect.Bowel surgery could lead to uric acid stones but the mechanism would be through aciduria (short gut causes chronic diarrhea causes HC03- loss causes aciduria)Secondary gout confers higher risk of uric acid stones than primary gout (42% vs. 22%). |
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• Which of the following is least important in the prognosis of neuroblastoma (single best answer):
• presence of N-myc oncogene • presence of calcification • age at presentation • stage • differentiation |
• B. calcification.
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• Which of the following is not a germ cell tumor (single best answer):
• Leydig cell tumor • choriocarcinoma • embryonal cell carcinoma • Sertoli cell tumor |
• Answer a and d.
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