Urologic Surgery

An obese male patient, aged $58$, with a $15$-year history of poorly controlled type $2$ diabetes mellitus, is evaluated in the emergency department for severe genital pain and progressive swelling that began $24$ hours ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60 \text{ mmHg}$, pulse is $118 \text{ /min}$, and respirations are $22 \text{ /min}$. Physical examination reveals marked erythema, edema, and induration of the perineum extending anteriorly to the scrotum. Palpation of the affected area elicits exquisite tenderness and a distinct crackling sensation beneath the skin. A small area of dark, necrotic-appearing tissue is visible on the right hemiscrotum, exuding a malodorous discharge. Aggressive intravenous fluid resuscitation is immediately initiated. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of genitourinary trauma to its most appropriate definitive management.

A 14-year-old boy is brought to the emergency department by his parents due to sudden-onset, severe left testicular pain that awoke him from sleep 2 hours ago. He reports one episode of nonbilious emesis since the pain started. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mmHg, and heart rate 105/min. Physical examination reveals a swollen, exquisitely tender, and high-riding left testicle with a transverse lie. The cremasteric reflex is absent on the left side but intact on the right. Elevation of the left testicle does not relieve the pain. Which of the following is the most appropriate next step in management?

A surgical team is establishing triage protocols for patients presenting to the emergency department with acute genitourinary symptoms. Match each patient scenario with the most appropriate immediate diagnostic or therapeutic intervention.

A $28$-year-old man comes to the emergency department due to severe penile pain and swelling. $1$ hour ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound followed immediately by a loss of erection and severe pain. He has not attempted to void since the incident. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination shows a significantly swollen and ecchymotic penis that is deviated to the right side. The scrotum is normal. There is a small drop of blood visible at the urethral meatus. Which of the following is the most appropriate next step in management?

A urology team is reviewing the charts of five patients presenting with various manifestations of nephrolithiasis and ureterolithiasis. Each patient requires a highly specific management approach based on stone size, location, concomitant comorbidities, and clinical stability. Match each patient's clinical presentation with the most appropriate definitive management step or surgical intervention.

A $34$-year-old man is brought to the emergency department after a high-speed motorcycle collision. He has a heart rate of $122$/min and a blood pressure of $86/54$ mm Hg. Primary survey reveals an unstable pelvic ring fracture. Genitourinary examination demonstrates blood at the urethral meatus, a large scrotal hematoma, and a high-riding prostate on digital rectal examination. Arrange the following management steps in the optimal sequential order for this patient, proceeding from initial trauma resuscitation to definitive urologic repair.

A 55-year-old woman is evaluated in the intensive care unit for fever and hypotension. She underwent an uncomplicated total abdominal hysterectomy three days ago for symptomatic uterine fibroids. Her temperature is 39.2°C (102.6°F), blood pressure is 85/50 mmHg, and heart rate is 125/min. She complains of severe right-sided flank pain. Physical examination shows exquisite right costovertebral angle tenderness. The abdomen is soft, non-distended, and non-tender, with normal active bowel sounds. Laboratory studies reveal a leukocyte count of 22,000/mm³. A bedside renal ultrasound demonstrates marked right-sided hydronephrosis. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are initiated, but her blood pressure remains 85/50 mmHg. Which of the following is the most appropriate next step in management?

A $49$-year-old woman is brought to the emergency department by her family due to severe right-sided flank pain, shaking chills, and increasing confusion over the past $24$ hours. She has a history of recurrent urinary tract infections but does not take any daily medications. Her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $82/50\text{ mm Hg}$. Physical examination reveals marked right costovertebral angle tenderness and delayed capillary refill.

Laboratory studies show the following:

Following initial intravenous fluid resuscitation and empirical broad-spectrum antibiotic administration, a non-contrast CT scan of the abdomen and pelvis is obtained. The imaging demonstrates a $14\text{-mm}$ calculus lodged in the proximal right ureter with severe ipsilateral hydroureteronephrosis and perinephric fat stranding. Which of the following is the most appropriate next step in management?

A 29-year-old man with a history of sickle cell disease presents to the emergency department with a painful, rigid erection that has persisted for the last 8 hours without sexual stimulation. He has not responded to oral analgesics or warm compresses at home. Arrange the following steps in the correct chronological sequence for the standard step-wise management of this condition, starting with the initial diagnostic step and progressing through escalating medical and surgical interventions.

A 48-year-old female patient is brought to the emergency department experiencing high fever, rigors, and intense right-sided back pain. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate is $118/\text{min}$, and blood pressure is $88/56\text{ mm Hg}$. A noncontrast CT scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis. Arrange the following clinical steps in the most appropriate chronological sequence for managing this patient.

A 62-year-old woman is brought to the emergency department by her family due to a 2-day history of severe left flank pain, high fevers, and worsening confusion. She has a medical history of type 2 diabetes mellitus and hypertension. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $84/52\text{ mmHg}$, and respirations are $24/\text{min}$. Physical examination reveals a lethargic patient with dry mucous membranes and marked left costovertebral angle tenderness. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$, serum creatinine of $2.3\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$), blood urea nitrogen of $48\text{ mg/dL}$, and serum lactate of $4.5\text{ mmol/L}$. Urinalysis is positive for leukocyte esterase, nitrites, and numerous bacteria. A non-contrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ radiopaque calculus in the left proximal ureter with severe hydroureteronephrosis and extensive perinephric fat stranding. Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated, but her blood pressure remains $86/54\text{ mmHg}$. Which of the following is the most appropriate next step in management?

A 42-year-old man presents to the emergency department with a painful, rigid erection that has persisted for 10 hours. He denies any recent sexual activity or use of phosphodiesterase inhibitors, but reports a history of sickle cell trait. Penile blood gas analysis reveals a pO2 of 25 mmHg, pCO2 of 80 mmHg, and pH of 7.15, confirming the diagnosis of ischemic priapism. Non-invasive measures such as systemic analgesia and intravenous hydration have already been initiated.

Arrange the following stepwise interventions in the correct escalating order for managing this patient's condition.

Awakened abruptly by excruciating unilateral pelvic and scrotal pain, a $16$-year-old adolescent is brought directly to the emergency department triage desk at $3:00$ AM. He is visibly distressed, pacing the room, and reports vomiting twice since the onset of symptoms $2$ hours ago. The patient has no past medical history and states he is not sexually active. Vital signs reveal a heart rate of $110$/min and blood pressure of $135/85$ mm Hg, and he is afebrile. Genitourinary examination demonstrates an indurated, highly tender left testicle that is positioned abnormally high in the hemiscrotum with a horizontal axis. Stroking the inner aspect of the left thigh elicits no elevation of the ipsilateral testicle, whereas the reflex remains intact on the right side. Which of the following interventions is most urgently indicated?

During morning rounds on the surgical ward, the care team evaluates a patient recovering from a radical cystoprostatectomy and ileal conduit formation performed $48$ hours ago for high-grade urothelial carcinoma. The patient reports generalized fatigue and mild nausea but no acute distress. Vital signs include a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), heart rate of $95/\text{min}$, blood pressure of $128/78\text{ mmHg}$, and respiratory rate of $18/\text{min}$. Auscultation of the chest reveals faint crackles at both lung bases. Abdominal examination demonstrates mild distension without rigidity or guarding; bowel sounds are absent. The stoma appears pink and healthy. The ostomy appliance contains $180\text{ mL}$ of cloudy, mucus-laden urine collected over the past four hours.

Laboratory studies obtained this morning reveal the following:
Leukocyte count: $11,500/\text{mm}^3$
Sodium: $139\text{ mEq/L}$
Potassium: $4.6\text{ mEq/L}$
Chloride: $110\text{ mEq/L}$
Bicarbonate: $18\text{ mEq/L}$
Blood urea nitrogen: $22\text{ mg/dL}$
Creatinine: $1.1\text{ mg/dL}$

Based on these clinical findings, which of the following is the most appropriate next step in management?

A high school student is evaluated in the surgical assessment unit for sudden-onset, severe right-sided scrotal pain that began two hours ago during a soccer match. The pain is continuous, radiates to the right lower abdomen, and is accompanied by nausea and one episode of emesis. He is not sexually active and reports no preceding genitourinary trauma or urinary symptoms. His vital signs are within normal limits. On physical examination, the right hemiscrotum is swollen, exquisitely tender, and visibly elevated compared to the left. The right testicle lies in a transverse orientation. Stroking the medial aspect of the right thigh elicits no ipsilateral testicular retraction, whereas the left testicle retracts normally. Which of the following is the most appropriate next step in management?

Match each clinical presentation of genitourinary trauma with the most appropriate immediate diagnostic test or intervention.

Match each clinical presentation of nephrolithiasis or ureterolithiasis with the most appropriate surgical or procedural intervention.

A 68-year-old man comes to the urology clinic to discuss the results of a recent procedure. He initially presented with a $2$-month history of painless, intermittent gross hematuria. His past medical history is notable for hypertension, hyperlipidemia, and a $40$-pack-year smoking history. Physical examination is unremarkable. Last week, he underwent cystoscopy which revealed a $4$-cm solid, sessile tumor on the posterior wall of the bladder. A transurethral resection of the bladder tumor (TURBT) was performed. The pathology report from the resected tissue demonstrates high-grade urothelial carcinoma with extensive invasion into the muscularis propria (detrusor muscle). A subsequent staging computed tomography (CT) scan of the chest, abdomen, and pelvis shows no evidence of pelvic lymphadenopathy or distant metastasis. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old graphic designer schedules a clinic appointment after discovering a firm, painless lump in his left testicle while showering. He denies any recent scrotal trauma, dysuria, urethral discharge, or fever. He is otherwise healthy and takes no medications. On physical examination, vital signs are within normal limits. Scrotal examination reveals a 3-cm, hard, non-tender mass within the left testicle that does not transilluminate. The right testicle is normal to palpation, and there is no inguinal lymphadenopathy. A scrotal ultrasound confirms the presence of a solid, hypervascular intratesticular lesion. Serum laboratory testing shows significantly elevated levels of $\beta$-human chorionic gonadotropin ($\beta$-hCG) and $\alpha$-fetoprotein (AFP). What is the most appropriate next step in the management of this patient?