Urologic Surgery

A $32$-year-old man comes to the emergency department due to an unrelenting, painful erection. He states that the condition started $6\text{ hours}$ ago while he was resting and has progressively worsened. The patient recently began taking trazodone for insomnia. His vital signs are stable. On examination, the corpora cavernosa are extremely rigid and tender to palpation, whereas the corpus spongiosum and glans penis remain soft. Diagnostic aspiration of the corpora yields dark, venous-appearing blood. A subsequent cavernosal blood gas analysis demonstrates a $pH$ of $7.15$, a $pO_2$ of $25\text{ mm Hg}$, and a $pCO_2$ of $75\text{ mm Hg}$. Which of the following is the most appropriate next step in management?

A 32-year-old man presents to the emergency department with a severe, painful erection that has persisted for 8 hours without sexual stimulation. He has a history of sickle cell trait. On examination, the corpora cavernosa are extremely rigid and tender, while the glans penis and corpus spongiosum are flaccid. Arrange the following steps in the optimal sequential management of this patient's condition, from the initial diagnostic step to the progressive therapeutic interventions.

Match each clinical presentation with the most appropriate definitive procedural or surgical intervention.

A $58$-year-old male with poorly controlled type 2 diabetes mellitus is evaluated in the emergency department for severe perineal pain and swelling that has progressively worsened over the past $48$ hours. He reports subjective fevers, chills, and generalized weakness. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a tense, swollen, and diffusely erythematous scrotum. There is a central $3\text{-cm}$ area of grayish-purple skin discoloration. Palpation of the perineum and scrotum elicits exquisite tenderness, and a distinct crackling sensation is felt beneath the skin. Laboratory studies demonstrate a leukocyte count of $24,000/\text{mm}^3$ and a serum glucose of $385\text{ mg/dL}$. Intravenous fluid resuscitation and broad-spectrum antimicrobial therapy are initiated. Which of the following is the most appropriate next step in the management of this patient?

During a high school basketball tournament, a 16-year-old boy suddenly drops to the floor, gripping his groin. He is rushed to the nearest acute care center. Upon evaluation, he reports an abrupt onset of agonizing right-sided testicular pain accompanied by nausea and one episode of emesis. He denies any direct trauma to the groin during the game. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $115/\text{min}$. Physical examination reveals a markedly swollen, tender, and erythematous right hemiscrotum. The right testis is significantly elevated compared to the left and rests in a transverse orientation. Stroking the superior medial aspect of the right thigh yields no elevation of the right testis, although the reflex is completely intact on the left side. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old man is brought to the emergency department following a high-speed motorcycle collision. He complains of severe pelvic pain and an inability to void. Vital signs are within normal limits, and he is hemodynamically stable. Physical examination reveals blood at the urethral meatus, a scrotal hematoma, and a 'high-riding' prostate on digital rectal examination. Pelvic radiography confirms a straddle fracture of the pelvis. Arrange the following steps in the most appropriate chronological sequence for the urologic management of this patient.

Match each clinical presentation of genitourinary trauma with the most appropriate next step in management or definitive treatment.

A 75-year-old man is brought to the emergency department by his family due to worsening confusion and severe lower abdominal pain over the past 24 hours. His family reports he has not urinated since yesterday morning. His medical history is significant for benign prostatic hyperplasia (BPH) and bipolar disorder, for which he takes tamsulosin and lithium. On presentation, his blood pressure is $155/95\text{ mm Hg}$, and his heart rate is $98/\text{min}$. Physical examination reveals a firm, tender suprapubic mass extending to the umbilicus.

Laboratory studies reveal:
Blood urea nitrogen: $88\text{ mg/dL}$
Serum creatinine: $4.8\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)
Serum potassium: $6.3\text{ mEq/L}$
Urinalysis: negative for leukocyte esterase and nitrites

A urethral Foley catheter is placed, immediately yielding $1,800\text{ mL}$ of clear urine. He is admitted for monitoring. Over the next 4 hours, his urine output consistently remains between $1,000\text{ mL}$ and $1,200\text{ mL}$ per hour. His repeat blood pressure drops to $84/52\text{ mm Hg}$, and his heart rate increases to $122/\text{min}$. The patient appears pale, and his mucous membranes are severely dry.

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

Match each clinical presentation of a urologic condition to the most appropriate definitive surgical or procedural intervention.

A 72-year-old man presents to the urology clinic with a one-week history of painless gross hematuria. He has a 40-pack-year smoking history. Vital signs are within normal limits, and physical examination is unremarkable. Office flexible cystoscopy reveals a completely normal bladder mucosa and urethra. Urine cytology returns positive for high-grade malignant cells. Arrange the following interventions in the correct chronological order for the definitive evaluation and management of this patient's condition.

Following a mountain biking accident, a 32-year-old man arrives at the emergency department reporting severe perineal pain. He fell forcefully onto the crossbar of his bicycle 2 hours ago and has been unable to void since the incident. Vital signs are temperature 37.0°C (98.6°F), blood pressure 130/80 mm Hg, and pulse 88/min. Inspection of the genital region reveals pronounced swelling and a characteristic butterfly-shaped ecchymosis confined to the perineum. A distinct drop of blood is visualized at the urethral meatus. Digital rectal examination demonstrates a non-tender, normally positioned prostate with intact rectal tone. Which of the following is the most appropriate next step in management?

Match each urologic oncology clinical presentation with the most appropriate definitive surgical or procedural intervention.

Match each clinical presentation of urolithiasis with the most appropriate definitive surgical or procedural management.

A 34-year-old man presents to the emergency department with a painful, persistent erection that began 8 hours ago without sexual stimulation. He has a history of sickle cell trait. Physical examination reveals fully rigid, exquisitely tender corpora cavernosa and a flaccid glans penis. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for managing this acute urologic emergency, progressing from initial evaluation to definitive refractory management.

A $55$-year-old woman is evaluated on postoperative day $4$ following an open low anterior resection for locally advanced rectal cancer. She reports new-onset, constant, right-sided flank pain and mild nausea that began yesterday. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $125/75\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals a clean midline abdominal incision with normal, active bowel sounds. There is distinct right costovertebral angle tenderness, but no rebound tenderness or guarding. A urethral Foley catheter was removed on postoperative day $2$, and the patient has since been voiding spontaneously with an output of approximately $450\text{ mL}$ every $8$ hours. Laboratory studies show a serum creatinine of $0.9\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$) and a leukocyte count of $12,500/\mu\text{L}$. Urinalysis shows $2$-$3$ white blood cells/hpf and no bacteria. Which of the following is the most appropriate next step in management?

A 48-year-old woman is evaluated for right-sided flank pain and nausea on postoperative day 2 following a total abdominal hysterectomy for symptomatic uterine leiomyomata. She reports the pain is constant and severe. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $86/\text{min}$. Physical examination reveals exquisite right costovertebral angle tenderness. The surgical incision is clean, dry, and intact without erythema or induration. Laboratory results are as follows:

Blood urea nitrogen: $28\text{ mg/dL}$
Serum creatinine: $1.8\text{ mg/dL}$ (baseline: $0.8\text{ mg/dL}$)

Urinalysis:
Leukocyte esterase: negative
Nitrites: negative
WBC: $1-2/\text{hpf}$
RBC: $10-15/\text{hpf}$

Renal ultrasonography demonstrates moderate right-sided hydronephrosis. The left kidney appears normal. Which of the following is the most appropriate next step in management?

A 60-year-old man presents to the urology clinic to establish care and discuss prostate cancer screening. He is in excellent health with no lower urinary tract symptoms. Arrange the following interventions in the most appropriate chronological order, representing the standard clinical pathway from initial screening to potential definitive surgical management for localized prostate cancer.

Match the following clinical presentations of urologic pathology with their most appropriate definitive surgical management.

An emergency medical services team brings a $62$-year-old female to the hospital due to excruciating right-sided back pain, rigors, and altered mental status that began $24$ hours ago. Her medical history includes multiple previous episodes of kidney stones. She visited an outpatient clinic $48$ hours prior for pain on urination, where empirical oral nitrofurantoin was prescribed and a urine culture was obtained. Upon arrival today, vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $85/55\text{ mm Hg}$, heart rate of $124/\text{min}$, and respiratory rate of $22/\text{min}$. Physical examination is notable for profound right costovertebral angle tenderness and dry mucous membranes. Blood tests indicate a leukocyte count of $22,000/\text{mm}^3$. A non-contrast computed tomography scan reveals an $11\text{-mm}$ stone lodged in the proximal right ureter causing pronounced hydronephrosis. The outpatient clinic faxes her urine culture results, confirming an infection with Escherichia coli ($>100,000\text{ CFU/mL}$). The organism is susceptible to ceftriaxone and ciprofloxacin, but resistant to ampicillin and nitrofurantoin. Rapid intravenous fluid resuscitation is commenced. Which of the following is the most appropriate next step in management?

A 68-year-old man presents to the emergency department with severe lower abdominal discomfort and an inability to pass urine for the past 14 hours. He reports a two-year history of progressive urinary hesitancy, nighttime awakenings to void, and a weak urinary stream. Vital signs are within normal limits. Physical examination reveals a visibly distended, exquisitely tender suprapubic mass. Arrange the following interventions in the most appropriate sequential order for the standard evaluation and management of this patient's condition, from immediate to definitive.