Urologic Surgery

A $34$-year-old male construction worker is brought to the emergency department after falling approximately $6\text{ meters}$ ($20\text{ feet}$) from a scaffold. He is fully alert and reports severe lower abdominal and pelvic pain. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $115/78\text{ mm Hg}$, and pulse is $98/\text{min}$. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal fluid. Pelvic radiography demonstrates an unstable "open book" pelvic ring disruption with significant diastasis of the pubic symphysis. The orthopedic surgery team is preparing the patient for emergent open reduction and internal fixation (ORIF) of the pelvis. A retrograde urethrogram is performed and confirms an intact urethra. A transurethral Foley catheter is placed and drains frankly bloody urine. A subsequent computed tomography (CT) cystogram demonstrates contrast extravasation confined to the perivesical space in a "flame-shaped" pattern, with no contrast outlining the bowel loops. Which of the following is the most appropriate management of this patient's urologic injury?

A $65$-year-old man presents to the clinic complaining of left-sided scrotal swelling and discomfort that he first noticed $1$ month ago. The patient describes a dull, heavy ache in the scrotum that worsens after standing for prolonged periods. Over the past $2$ weeks, he has also experienced intermittent left flank pain and noticed that his urine occasionally appears pink. His medical history is significant for hypertension and a $40$-pack-year smoking history. Vital signs are within normal limits. Physical examination in the standing position reveals a soft, irregular, cord-like mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decrease in size. The testicles are bilaterally smooth, non-tender, and without discrete nodules. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man is evaluated on postoperative day 4 following a robotic-assisted laparoscopic radical prostatectomy for localized prostate adenocarcinoma. A urethral catheter was left in place at the end of the procedure. On postoperative day 2, he developed a fever of 38.8°C (101.8°F), chills, and suprapubic discomfort. Blood and urine cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, the patient is afebrile, and his vital signs are within normal limits. He reports complete resolution of his chills and suprapubic pain. The abdomen is soft and non-tender, and the urethral catheter is draining clear yellow urine. The blood cultures show no growth. The urine culture from postoperative day 2 returns with the following results:

Which of the following is the most appropriate next step in management?

A 28-year-old male is brought to the emergency department after a severe crush injury to his pelvis at a construction site. He is hemodynamically stable. Physical examination reveals a pelvic binder in place, blood at the urethral meatus, and a high-riding prostate on digital rectal examination. A FAST exam is negative. He has a palpable, distended bladder and reports a strong urge to urinate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for the urologic management of this patient.

Following a head-on motor vehicle collision, a $34$-year-old female driver is evaluated in the trauma bay. She complains of worsening diffuse abdominal discomfort and pain radiating to her right shoulder. Her temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $110/70$ mmHg, pulse is $112$/min, and respiratory rate is $18$/min. Physical examination reveals a lap-belt mark across the lower abdomen, generalized abdominal tenderness with guarding, and suprapubic rebound tenderness. After ensuring the urethral meatus is normal, a urinary catheter is inserted and immediately drains frankly bloody urine. A computed tomography (CT) cystography is performed and demonstrates contrast dye extravasation into the peritoneal cavity, outlining the loops of the small bowel. Based on the clinical and imaging findings, which of the following is the most appropriate next step in management?

A $62$-year-old woman is evaluated in the emergency department for right-sided flank pain, nausea, and high fever that began $24$ hours ago. Her past medical history is significant for recurrent urinary tract infections. Temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $80/40\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $26/\text{min}$. Right costovertebral angle tenderness is present. Laboratory tests show a leukocyte count of $24,000/\text{mm}^3$ with $15\%$ bands and a serum creatinine of $2.3\text{ mg/dL}$. Urinalysis reveals $4+$ leukocyte esterase, positive nitrites, and numerous bacteria. A noncontrast CT scan of the abdomen and pelvis shows a $12\text{-mm}$ calculus obstructing the right proximal ureter with associated severe hydronephrosis. Aggressive intravenous fluid resuscitation and broad-spectrum intravenous antibiotics are initiated, and a norepinephrine infusion is started to maintain mean arterial pressure. Which of the following is the most appropriate next step in management?

A $55$-year-old woman is brought to the emergency department due to severe right flank pain, fever, and chills for the past $24$ hours. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/55\text{ mm Hg}$, and pulse is $122/\text{min}$. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. A noncontrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ obstructing calculus in the right proximal ureter with moderate hydronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological order.

An emergency medical crew brings a 61-year-old woman to the hospital after she developed severe left flank pain, nausea, and acute confusion over the past 48 hours. Her medical history is notable for type 2 diabetes mellitus and recurrent cystitis. Vital signs include a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $84/52 \text{ mmHg}$, pulse of $122/\text{min}$, and respirations of $24/\text{min}$. Physical examination reveals marked left costovertebral angle tenderness and a lethargic affect. Laboratory testing demonstrates a leukocyte count of $22,000/\text{mm}^3$. An unenhanced computed tomography (CT) scan of the abdomen and pelvis reveals a $9\text{-mm}$ calculus lodged in the left proximal ureter, accompanied by severe hydroureteronephrosis and perinephric fat stranding. She is immediately given aggressive intravenous fluid resuscitation and broad-spectrum antibiotics (piperacillin-tazobactam). Two hours later, her blood pressure remains $86/54 \text{ mmHg}$ and her urine output is only $10 \text{ mL/hr}$. Which of the following is the most appropriate next step in management?

A $62$-year-old man is evaluated in the surgical intensive care unit for sudden clinical deterioration. Three days ago, he was admitted with septic shock secondary to an obstructing $12$-mm proximal left ureteral calculus. A left percutaneous nephrostomy tube was placed for urgent decompression, and empiric intravenous piperacillin-tazobactam was initiated. The patient initially stabilized and his leukocytosis improved. However, over the past $2$ hours, the nephrostomy tube has stopped draining, and the patient has become confused and diaphoretic. His temperature is $39.4^\circ C$ ($102.9^\circ F$), blood pressure is $78/45$ mmHg, and pulse is $132$/min. Physical examination reveals a new, exquisitely tender and fluctuant swelling in the left flank. Blood and urine cultures from admission are currently growing *Escherichia coli* that is susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, and ciprofloxacin. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is evaluated in the emergency department for a 2-day history of escalating lower abdominal pain, nausea, and fever. Seven days ago, he underwent a transurethral resection of the prostate (TURP) and cystolitholapaxy for severe benign prostatic hyperplasia and concurrent bladder stones. His urethral catheter was removed on postoperative day 2 prior to an uncomplicated discharge. Today, his temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals marked suprapubic tenderness with voluntary guarding. Laboratory studies show a leukocyte count of 18,500/mm³. A CT scan of the abdomen and pelvis with intravenous contrast reveals a 5-cm rim-enhancing fluid collection in the prevesical space (space of Retzius) with adjacent fat stranding. The intraperitoneal cavity has no free fluid. Which of the following is the most appropriate next step in management?

A 29-year-old male with a history of sickle cell trait presents to the emergency department with a painful, rigid erection that has persisted for 8 hours. He denies any trauma or use of erectile dysfunction medications. On physical examination, the corpora cavernosa are tense and tender, while the glans penis and corpus spongiosum remain flaccid. A dorsal penile nerve block is performed for local anesthesia. Cavernosal blood gas analysis reveals a $\text{pO}_2$ of $18\text{ mmHg}$, $\text{pCO}_2$ of $88\text{ mmHg}$, and $\text{pH}$ of $7.05$. Assuming the patient's condition remains refractory to each successive intervention, arrange the following management steps in the correct standard-of-care escalation sequence.

Match each clinical presentation of acute genitourinary trauma with the most appropriate immediate diagnostic or therapeutic next step.

A $62$-year-old man comes to the urology clinic reporting a dull, aching heaviness in his left scrotum that has gradually worsened over the past $3$ months. He denies any dysuria, urethral discharge, fever, or history of sexually transmitted infections. His medical history includes hypertension and a $30$-pack-year history of smoking. Vital signs are within normal limits. Physical examination of the patient in the standing position reveals a palpable, non-tender, tortuous, "bag of worms" mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decompress or reduce in size. Urinalysis shows $15$ red blood cells per high-power field, but is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

Match each clinical presentation to its most appropriate definitive procedural or surgical management.

Match each of the following clinical presentations of urologic pathology with the most appropriate definitive surgical intervention.

Match each presentation of genitourinary trauma or iatrogenic injury with its most appropriate definitive surgical or clinical management step.

A 15-year-old boy is brought to the emergency department by his parents due to severe, sudden-onset right scrotal pain that woke him from sleep 2 hours ago. He reports nausea and has vomited twice. He has no history of trauma, dysuria, or urethral discharge. His temperature is 37.1°C (98.8°F), heart rate is 105/min, and blood pressure is 125/80 mmHg. Physical examination reveals a swollen, exquisitely tender, and high-riding right testicle with a transverse lie. The right cremasteric reflex is absent, while the left is intact. Scrotal elevation does not relieve the pain. Which of the following is the most appropriate next step in the management of this patient?

A 16-year-old boy is brought to the emergency department by his parents due to the sudden onset of severe right scrotal pain that awoke him from sleep 2 hours ago. He has had one episode of vomiting since the pain started. His temperature is 37.1°C (98.8°F), blood pressure is 120/78 mmHg, and pulse is 98/min. Physical examination reveals a swollen, exquisitely tender, and high-riding right testicle with a transverse lie. The right cremasteric reflex is absent. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated on postoperative day 2 following a transurethral resection of the prostate (TURP) for severe benign prostatic hyperplasia. Continuous bladder irrigation was discontinued 4 hours ago, but his indwelling 3-way urethral catheter was left in place. The patient now complains of sudden-onset, severe lower abdominal pain and an intense, constant urge to void. He appears diaphoretic and uncomfortable. His temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, pulse is 118/min, and respirations are 18/min. Physical examination reveals a distended, exquisitely tender suprapubic region. The nursing staff reports that no urine has drained into the collection bag over the last 2 hours. Bedside ultrasonography demonstrates a bladder volume of approximately 850 mL with dependent, heterogeneous echogenic material. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation to the most appropriate initial diagnostic step or definitive procedural intervention.