Urologic Surgery

An otherwise healthy $27$-year-old male arrives at the emergency room seeking urgent evaluation for sudden, intense genital pain. Approximately $30$ minutes prior to arrival, he experienced a distinct "cracking" sound during vigorous intercourse, which was immediately followed by rapid detumescence and swelling. He has been in exquisite pain and has intentionally avoided voiding since the event. Triage vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $128/82\text{ mmHg}$, heart rate of $94/\text{min}$, and respiratory rate of $16/\text{min}$. Genitourinary examination demonstrates a markedly edematous and ecchymotic penis that is visibly deviated to the left. A single drop of fresh blood is noted at the external urethral meatus. Scrotal palpation reveals normal testes bilaterally without masses or tenderness. Preliminary laboratory analysis shows a hemoglobin level of $14.2\text{ g/dL}$ and a leukocyte count of $8,500/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

Identify the most appropriate definitive surgical or procedural intervention for each of the described male genitourinary pathologies.

A 15-year-old boy is brought to the emergency department by his parents due to the sudden onset of excruciating left-sided scrotal pain that woke him from sleep 3 hours ago. The pain is constant and accompanied by nausea and one episode of non-bilious emesis. He reports no dysuria, hematuria, urethral discharge, or recent flank pain. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $128/82\text{ mmHg}$, and heart rate is $110\text{ /min}$. On physical examination, the left hemiscrotum is edematous, erythematous, and exquisitely tender to palpation. The left testicle is positioned higher than the right and lies horizontally. The cremasteric reflex is absent on the left side but intact on the right side. Which of the following is the most appropriate next step in management for this patient?

Following a two-day history of escalating groin discomfort, a 54-year-old male with poorly controlled type 2 diabetes mellitus arrives at the emergency department. His spouse notes he has been increasingly lethargic and shivering since this morning. Vital signs demonstrate a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse of $122/\text{min}$, and blood pressure of $86/52\text{ mmHg}$. Genitourinary examination reveals significant edema, poorly defined erythema, and a putrid odor emanating from the perineum. There is palpable crepitus extending from the base of the scrotum to the perianal region. Initial laboratory analysis yields a leukocyte count of $26,000/\text{mm}^3$ with $15\%$ bands. Fluid resuscitation is currently underway. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man comes to the urology clinic after noticing a firm swelling in his left testicle approximately two weeks ago. He reports no pain, dysuria, urinary frequency, or recent trauma. He has no history of sexually transmitted infections. Vital signs are within normal limits. On physical examination, the overlying scrotal skin appears normal. Palpation of the left testicle reveals a $3\text{-cm}$, rock-hard, non-tender nodule located at the lower pole. The lesion does not transilluminate and cannot be separated from the testis. The right testicle and bilateral epididymides are soft and normal to palpation. A scrotal ultrasound confirms the presence of a solid, hypervascular, hypoechoic intratesticular mass. Serum laboratory testing demonstrates an alpha-fetoprotein (AFP) level of $145\text{ ng/mL}$ (normal $< 10\text{ ng/mL}$) and a $\beta$-hCG level of $92\text{ mIU/mL}$ (normal $< 2\text{ mIU/mL}$). Which of the following is the most appropriate next step in management?

A 64-year-old man presents to the clinic with a 3-week history of a left-sided scrotal mass. He reports a dull, dragging sensation in his scrotum but denies acute pain, dysuria, or fever. His medical history is notable for hypertension and a 40-pack-year smoking history. Physical examination reveals a soft, non-tender, tortuous mass superior to the left testis. The mass does not decompress when the patient assumes a supine position. His abdomen is soft and non-tender. Urinalysis demonstrates 4-5 red blood cells per high-power field. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a urologic condition with its most appropriate definitive surgical or procedural management.

A 52-year-old woman is evaluated in the emergency department for a 2-day history of severe left-sided flank pain, nausea, and chills. Her temperature is 39.4°C (102.9°F), pulse is 118/min, and blood pressure is 88/56 mm Hg. Physical examination reveals marked left costovertebral angle tenderness and voluntary guarding. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine of $1.9 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an 8-mm calculus in the proximal left ureter with ipsilateral hydronephrosis and prominent perinephric fat stranding. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

A 35-year-old man is brought to the emergency department complaining of a severely painful and rigid erection that has lasted for 10 hours without any sexual stimulation. He recently began taking trazodone for major depressive disorder. On physical examination, the corpora cavernosa are extremely tense and tender to palpation, while the glans penis and corpus spongiosum remain soft and flaccid. Arrange the following therapeutic interventions in the correct sequential order for managing this patient's condition, proceeding from the initial appropriate step to the most advanced surgical option.

A 28-year-old male is evaluated in the surgical triage area after experiencing sudden, severe genital pain. He reports that approximately two hours ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound from his groin, which was immediately followed by a rapid loss of erection. Since then, he has noticed progressive swelling and discoloration. His vital signs are within normal limits. Physical examination reveals a markedly edematous and ecchymotic penile shaft that is deviated to the left side. The patient states he was able to urinate normally just prior to arrival, and the urine was clear. There is no blood visible at the urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of urothelial carcinoma with its most appropriate definitive surgical or procedural management.