Urologic Surgery

A 72-year-old man is brought to the emergency department by his daughter due to increasing confusion and lethargy over the past 24 hours. The daughter reports that the patient has not urinated since yesterday morning. For the past several years, he has had progressive difficulty initiating urination, a weak stream, and nocturia. His temperature is 37.1°C (98.8°F), blood pressure is 168/92 mm Hg, pulse is 96/min, and respirations are 16/min. Physical examination reveals a dull, suprapubic mass extending to the umbilicus that is mildly tender to palpation. Digital rectal examination demonstrates a symmetrically enlarged, smooth prostate without nodules. Laboratory studies show a blood urea nitrogen of 78 mg/dL and serum creatinine of 5.2 mg/dL. A renal ultrasound demonstrates bilateral hydronephrosis and a markedly distended urinary bladder. Which of the following is the most appropriate initial step in the management of this patient?

A 28-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He has a severe pelvic fracture. On physical examination, there is blood at the urethral meatus, a scrotal hematoma, and a high-riding prostate on digital rectal examination. He is unable to void despite a strong urge. Arrange the following management steps in the most appropriate chronological order for this patient.

A $34$-year-old man is evaluated in the trauma bay following a high-velocity motorcycle collision. He is hemodynamically stable. Examination reveals lower abdominal guarding, diffuse tenderness, and a displaced pelvic ring fracture. Retrograde urethrography demonstrates an intact urethra, allowing for the safe placement of a urethral catheter, which yields $300\text{ mL}$ of frankly bloody urine. A subsequent retrograde CT cystography demonstrates contrast extravasation into the paracolic gutters and outlining loops of small bowel.

Arrange the following surgical management steps in the most appropriate chronological sequence for this patient.

An emergency medicine physician is evaluating a 54-year-old woman complaining of severe right-sided back pain, rigors, and vomiting that began 12 hours ago. Her temperature is 39.2°C (102.6°F), blood pressure is 88/55 mmHg, and pulse is 115/min. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory testing shows a leukocyte count of 18,000/mm³. Arrange the following management steps in the most appropriate chronological sequence for this patient.

During a routine health maintenance examination, a 64-year-old African American male reports waking up twice a night to urinate but denies any dysuria, gross hematuria, or bone pain. His past medical history is notable for hypertension managed with lisinopril. Vital signs are within normal limits. Digital rectal examination reveals a distinctly firm, irregularly shaped nodule on the left posterior lobe of the prostate gland. Laboratory studies show a serum prostate-specific antigen (PSA) level of 7.8 ng/mL. Which of the following is the most appropriate next step in the management of this patient?

During a high school basketball game, a $16$-year-old adolescent boy suddenly experiences excruciating left-sided scrotal pain and collapses on the court. He is immediately transported to the hospital by his coach. The patient reports severe, unrelenting pain radiating to his lower abdomen and has vomited twice in the triage area. He is otherwise healthy and takes no medications. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $130/85\text{ mm Hg}$, and a pulse of $110/\text{min}$. Physical examination reveals a swollen, exquisitely tender left hemiscrotum. The left testicle is firm, positioned higher than the right, and lies in a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. There is no relief of pain upon manual elevation of the scrotum. Which of the following is the most appropriate next step in the management of this patient?

A rapid response is called for a $65$-year-old man on the medical ward due to acute hemodynamic deterioration. Two days prior, he was admitted for severe right flank pain. A non-contrast computed tomography (CT) scan at admission demonstrated a $9$-mm calculus in the proximal right ureter with moderate hydroureteronephrosis. At that time, he was afebrile and hemodynamically stable. A urine culture was obtained, and he was started on intravenous normal saline and empirical ceftriaxone.

Currently, his temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $82/50$ mm Hg, and pulse is $128$/min. He is lethargic, diaphoretic, and minimally responsive. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bandemia. The admission urine culture has just resulted, demonstrating $>10^5$ CFU/mL of *Escherichia coli*. Susceptibility testing indicates the organism is sensitive to cefazolin, ceftriaxone, and ciprofloxacin, but resistant to ampicillin. He is receiving aggressive intravenous fluid resuscitation.

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

Match each patient's genitourinary trauma presentation to the most appropriate definitive management strategy or next required intervention.

Match each clinical presentation to the most appropriate urologic diagnosis.

A primary care physician refers a $65$-year-old retired chemical worker to the urology service due to alarming urinary changes. Over the preceding four weeks, the patient noted three distinct episodes where his entire urinary stream was bright red. He reports no associated pain during urination, flank discomfort, fever, or weight loss. He has a history of essential hypertension and smoked one pack of cigarettes daily for $40$ years before quitting recently. In the clinic, his vital signs are stable. Examination of the abdomen and external genitalia shows no abnormalities, and digital rectal examination reveals a smooth, non-enlarged prostate. A catheter-free urinalysis demonstrates $>50$ red blood cells per high-power field, with absent leukocyte esterase. A multiphasic computed tomography urogram is subsequently performed, which outlines normally functioning kidneys and pristine ureters without any solid masses or nephrolithiasis. Which of the following is the most appropriate next step in management?

A $52$-year-old man comes to the urology clinic to discuss the results of recent imaging. Two weeks ago, he presented to the emergency department with mild left lower quadrant abdominal discomfort. A CT scan of the abdomen and pelvis with contrast was performed to evaluate for diverticulitis; the colon appeared normal, but an incidental $3.4$-cm solid, heterogeneously enhancing, exophytic mass was discovered in the lower pole of the left kidney. He has a history of well-controlled hypertension and hyperlipidemia. His BMI is $28$ kg/m $^2$. Vital signs are within normal limits. Physical examination reveals a soft, non-tender abdomen without palpable masses. Serum creatinine is $0.9$ mg/dL, and urinalysis shows no abnormalities. There is no evidence of lymphadenopathy or vascular involvement on the imaging. Which of the following is the most appropriate next step in management?

A 28-year-old man is brought to the trauma center following a high-speed motorcycle collision. His airway is intact, and his hemodynamics are stabilized with intravenous fluids. A pelvic binder is applied for a complex pelvic ring fracture. Physical examination reveals a scrotal hematoma and fresh blood at the urethral meatus. Digital rectal examination demonstrates a high-riding, nonpalpable prostate. He reports lower abdominal discomfort and a strong urge to void, but has not urinated since the accident. Arrange the following urologic interventions in the most appropriate chronological order for the evaluation and definitive management of this patient's genitourinary injury.

A $44$-year-old woman is evaluated on postoperative day $3$ following a complicated total abdominal hysterectomy for severe endometriosis. She reports new-onset right-sided flank pain and nausea. Her temperature is $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$). Physical examination reveals right costovertebral angle tenderness. The pelvic surgical drain has abruptly started outputting a high volume of clear, watery fluid. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for managing this patient's suspected urologic complication.

A 64-year-old man is evaluated in the emergency department for severe perineal and scrotal pain that has progressively worsened over the past 3 days. He has a history of poorly controlled type 2 diabetes mellitus and hypertension. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $118/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $88/54\text{ mmHg}$. Physical examination reveals a markedly swollen, tense, and erythematous scrotum with areas of dusky discoloration. Palpation of the scrotum and perineum elicits exquisite tenderness, and distinct crepitus is felt within the subcutaneous tissues. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ and a serum glucose of $310\text{ mg/dL}$. Which of the following is the most appropriate next step in the management of this patient?

Match the following distinct clinical presentations of urologic conditions to their most appropriate definitive surgical management.

A $59$-year-old man is brought to the emergency department by his partner due to severe, worsening perineal pain and fever for the past $24\text{ hours}$. He has a $15$-year history of type 2 diabetes mellitus complicated by peripheral neuropathy and nephropathy. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $84/52\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked edema, erythema, and induration of the perineum extending to the scrotum. There are several dark, necrotic bullae on the scrotal skin. Palpation of the affected area elicits exquisite pain and a crackling sensation beneath the skin. Laboratory evaluation reveals a leukocyte count of $26,000/\text{mm}^3$ and serum glucose of $480\text{ mg/dL}$. Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Which of the following is the most appropriate next step in management?

An ambulatory 61-year-old man presents to his primary care provider reporting a persistent feeling of heaviness and a dull ache in his right scrotum that he first noticed three weeks ago. He denies any history of scrotal trauma, dysuria, gross hematuria, urgency, or fevers. His medical history includes essential hypertension and hyperlipidemia, both well-controlled with medication. He has a 40-pack-year smoking history. His temperature is 37.1°C (98.8°F), blood pressure is 138/86 mmHg, and pulse is 76/min. Physical examination of the genitalia reveals a soft, irregular, tortuous mass in the right hemiscrotum that feels like a 'bag of worms.' When the patient is asked to lie in the supine position, the mass does not decrease in size. Both testicles are palpable, symmetric, and without firm nodules. Transillumination of the scrotum is negative. Which of the following is the most appropriate next step in management?

An $18$-year-old man is brought to the emergency department due to severe, sudden-onset left scrotal pain that woke him from sleep $4$ hours ago. The pain is continuous and radiates to his left lower abdomen. He reports one episode of vomiting and significant nausea. One month ago, he had a similar episode of left-sided scrotal pain that resolved spontaneously after $30$ minutes. He has no significant past medical history and is not sexually active. His temperature is $37.2^\circ$ C ($99.0^\circ$ F), blood pressure is $135/85$ mm Hg, and pulse is $108$/min. On physical examination, the left hemiscrotum is swollen, erythematous, and exquisitely tender to palpation. The left testis is positioned higher in the scrotum compared to the right and has a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. Elevation of the left testis exacerbates the pain. Urinalysis reveals $8$ WBCs/hpf, $0$ RBCs/hpf, and negative leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

Various urologic conditions present with specific symptoms and physical findings that dictate precise clinical algorithms. Which surgical intervention or initial operative management is most appropriate for each of the following patient profiles?

A 54-year-old woman is brought to the emergency department for severe right flank pain, nausea, and chills over the past 24 hours. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $86/52 \text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked right costovertebral angle tenderness. Laboratory studies reveal a leukocyte count of $19,500/\text{mm}^3$ and a serum creatinine of $1.8 \text{ mg/dL}$. A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis and perinephric fat stranding. Arrange the following management steps in the most appropriate chronological sequence for this patient.