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Arab Board Urology Clinical Exam study materials
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Arab Board Urology Clinical Exam practice questions

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Question 1General Urology and Basic Sciences Applied to Urology

A 24-year-old man has a serum creatinine of 1.0 mg/dL. Using the Cockcroft-Gault formula, what is his estimated creatinine clearance if he weighs 70 kg?

  1. 117 mL/min
  2. 140 mL/min
  3. 78 mL/min
  4. 98 mL/min Correct answer.

Explanation

Cockcroft-Gault estimates creatinine clearance as [(140 − age) × weight] ÷ (72 × serum creatinine) for men. Here (140 − 24) × 70 ÷ (72 × 1.0) ≈ 113 mL/min, and the closest offered value reflects this calculation.

Question 2General Urology and Basic Sciences Applied to Urology

Which structure is the primary site of urine concentration via the countercurrent multiplier mechanism?

  1. Loop of Henle Correct answer.
  2. Glomerular basement membrane
  3. Distal convoluted tubule
  4. Proximal convoluted tubule

Explanation

The loop of Henle generates the medullary osmotic gradient through countercurrent multiplication, which underpins the ability to concentrate or dilute urine. The other nephron segments modify composition but do not create this gradient.

Question 3General Urology and Basic Sciences Applied to Urology

A young man sustains a straddle injury with blood at the urethral meatus and a palpable bladder. Which initial step is most appropriate?

  1. Flexible cystoscopy
  2. Retrograde urethrography Correct answer.
  3. Immediate urethral catheterization
  4. Suprapubic aspiration

Explanation

Blood at the meatus after trauma raises suspicion of urethral injury, and retrograde urethrography should be performed before any instrumentation to define the site and extent. Blind catheterization risks converting a partial to a complete injury.

Question 4General Urology and Basic Sciences Applied to Urology

Which organism is the most common cause of uncomplicated community-acquired urinary tract infection in women?

  1. Escherichia coli Correct answer.
  2. Klebsiella pneumoniae
  3. Proteus mirabilis
  4. Staphylococcus saprophyticus

Explanation

Escherichia coli accounts for the large majority of uncomplicated community-acquired UTIs. Other organisms occur but at much lower frequency in this setting.

Question 5General Urology and Basic Sciences Applied to Urology

A 60-year-old man has a serum PSA of 6 ng/mL and a normal digital rectal examination. Which statement best describes the interpretation of this PSA value?

  1. It confirms the presence of prostate cancer
  2. It is elevated and warrants further evaluation such as repeat testing and biopsy discussion Correct answer.
  3. It is within the normal reference range
  4. It excludes clinically significant prostate cancer

Explanation

A PSA of 6 ng/mL exceeds the usual threshold and should prompt repeat testing and consideration of further evaluation such as imaging or biopsy. PSA is organ-specific rather than cancer-specific, so a single value neither confirms nor excludes malignancy.

Question 6General Urology and Basic Sciences Applied to Urology

Which nerve provides the predominant somatic innervation responsible for penile tumescence?

  1. Pudendal nerve
  2. Hypogastric nerve
  3. Ilioinguinal nerve
  4. Cavernous nerves Correct answer.

Explanation

The cavernous nerves, derived from the pelvic plexus, carry parasympathetic fibers that mediate erection by causing cavernosal smooth muscle relaxation and arterial dilation. Sympathetic and somatic nerves modulate other aspects such as emission and sensation.

Question 7General Urology and Basic Sciences Applied to Urology

A man is being evaluated for infertility and has a semen analysis showing azoospermia. Which finding on history most strongly suggests obstructive rather than non-obstructive azoospermia?

  1. History of bilateral vasectomy Correct answer.
  2. Low serum FSH with normal testicular volume
  3. Elevated serum FSH
  4. Small testicular volume bilaterally

Explanation

A history of bilateral vasectomy produces mechanical obstruction with preserved spermatogenesis, so testicular volume and FSH remain normal. Non-obstructive causes show testicular atrophy and elevated FSH from loss of negative feedback.

Question 8General Urology and Basic Sciences Applied to Urology

Which finding on urinalysis is most characteristic of acute glomerulonephritis?

  1. Triple phosphate crystals
  2. Sterile pyuria
  3. Broad waxy casts
  4. Red cell casts with dysmorphic red cells Correct answer.

Explanation

Glomerular inflammation allows red cells to enter the tubule and become entrapped in casts, producing red cell casts and dysmorphic red cells, which localize bleeding to the glomerulus. Other casts and crystals reflect different processes.

Question 9General Urology and Basic Sciences Applied to Urology

A patient has a 1.5 cm radiopaque stone in the renal pelvis without obstruction. Which management is most appropriate for a first presentation with well-controlled symptoms?

  1. Radical nephrectomy
  2. Percutaneous nephrolithotomy
  3. Immediate open pyelolithotomy
  4. Observation with analgesia and follow-up imaging Correct answer.

Explanation

Small non-obstructing renal stones can be observed with analgesia and periodic imaging because many pass spontaneously or remain asymptomatic. Intervention is reserved for obstruction, infection, growth, or refractory symptoms.

Question 10General Urology and Basic Sciences Applied to Urology

A newborn boy has a urethral meatus opening on the ventral penile shaft with a ventrally curved penis. Which term best describes the curvature?

  1. Hypospadias
  2. Paraphimosis
  3. Chordee Correct answer.
  4. Phimosis

Explanation

Ventral curvature associated with hypospadias is termed chordee and results from abnormal fibrous tissue. Hypospadias refers to the abnormal meatal position itself, while phimosis and paraphimosis describe foreskin problems.

Question 11General Urology and Basic Sciences Applied to Urology

Which of the following best describes the mechanism of action of an alpha-1 adrenergic antagonist in treating lower urinary tract symptoms from benign prostatic enlargement?

  1. Relaxation of prostatic smooth muscle Correct answer.
  2. Direct reduction of prostate volume
  3. Inhibition of 5-alpha reductase
  4. Blockade of muscarinic receptors in the bladder

Explanation

Alpha-1 antagonists relax smooth muscle in the prostate and bladder neck, reducing dynamic obstruction and improving symptoms quickly. They do not shrink the gland or act on androgen pathways.

Question 12General Urology and Basic Sciences Applied to Urology

During a radical prostatectomy, which anatomical landmark is most important to preserve to maintain erectile function?

  1. Dorsal venous complex
  2. Neurovascular bundles Correct answer.
  3. Median umbilical ligament
  4. Puboprostatic ligaments

Explanation

The cavernous nerves run within the neurovascular bundles posterolateral to the prostate, and their preservation is central to postoperative potency. Injury to these bundles is the main cause of erectile dysfunction after surgery.

Question 13General Urology and Basic Sciences Applied to Urology

A patient presents with a firm, painless testicular mass. Which tumor marker is most characteristically elevated in a pure seminoma?

  1. Beta-hCG
  2. Lactate dehydrogenase Correct answer.
  3. Carcinoembryonic antigen
  4. Alpha-fetoprotein

Explanation

Pure seminomas may show elevated beta-hCG or LDH, but LDH correlates with tumor burden and is the marker classically associated with seminoma. Alpha-fetoprotein elevation excludes pure seminoma.

Question 14General Urology and Basic Sciences Applied to Urology

Which finding on CT urography is most suggestive of a urothelial carcinoma of the renal pelvis?

  1. A subcapsular hematoma
  2. A simple cortical cyst
  3. A filling defect within the renal collecting system Correct answer.
  4. A hyperdense renal calculus

Explanation

Urothelial tumors appear as filling defects within the collecting system because they grow into the lumen. Stones are radiodense, cysts are fluid-filled, and hematomas are extra-collecting-system collections.

Question 15General Urology and Basic Sciences Applied to Urology

A patient with a spinal cord injury above T6 develops sudden severe hypertension, bradycardia, and sweating during catheter change. What is the most likely diagnosis?

  1. Anaphylaxis
  2. Septic shock
  3. Pulmonary embolism
  4. Autonomic dysreflexia Correct answer.

Explanation

Autonomic dysreflexia occurs after spinal cord injury above T6 when a noxious stimulus below the lesion triggers uninhibited sympathetic outflow, producing severe hypertension often with bradycardia and sweating. Removing the stimulus and controlling blood pressure are priorities.

Question 16General Urology and Basic Sciences Applied to Urology

A man is found to have a serum testosterone of 150 ng/dL measured in the morning on two occasions. Which additional measurement best distinguishes primary from secondary hypogonadism?

  1. Prostate-specific antigen
  2. Serum creatinine
  3. Estradiol
  4. Luteinizing hormone Correct answer.

Explanation

Low testosterone with elevated LH indicates primary testicular failure, whereas low or inappropriately normal LH indicates secondary (central) hypogonadism. Gonadotropins therefore localize the level of the defect.

Question 17Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 62-year-old man has a 3.5 cm solid enhancing left renal mass confined to the kidney with no lymphadenopathy or metastases. What is the most appropriate primary management?

  1. Radical nephrectomy with adrenalectomy
  2. Active surveillance with annual imaging
  3. Systemic targeted therapy
  4. Partial nephrectomy Correct answer.

Explanation

For a cT1a renal mass, nephron-sparing surgery (partial nephrectomy) is the standard of care when technically feasible, preserving renal function with equivalent oncologic outcomes to radical surgery. Radical nephrectomy is reserved for larger or centrally located tumors not amenable to partial resection.

Question 18Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which histological subtype accounts for the majority of renal cell carcinomas?

  1. Collecting duct carcinoma
  2. Clear cell renal cell carcinoma Correct answer.
  3. Chromophobe renal cell carcinoma
  4. Papillary renal cell carcinoma

Explanation

Clear cell renal cell carcinoma is the most common subtype, comprising roughly 70-80% of renal cell carcinomas. Papillary and chromophobe subtypes are less frequent, and collecting duct carcinoma is rare and aggressive.

Question 19Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A patient with muscle-invasive bladder cancer is being counselled about radical cystectomy. Which urinary diversion avoids a stoma and requires an intact, compliant urethra and sphincter mechanism?

  1. Cutaneous ureterostomy
  2. Ileal conduit with nephrostomy
  3. Orthotopic neobladder Correct answer.
  4. Ileal conduit

Explanation

An orthotopic neobladder reconstructs a reservoir anastomosed to the urethra, allowing voiding per urethra without a stoma, provided the urethra and sphincter are functional and oncologically safe. An ileal conduit and cutaneous ureterostomy both require a stoma.

Question 20Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

What is the most common histologic type of bladder cancer in developed countries?

  1. Adenocarcinoma
  2. Urothelial (transitional cell) carcinoma Correct answer.
  3. Squamous cell carcinoma
  4. Small cell carcinoma

Explanation

Urothelial carcinoma accounts for the vast majority (about 90%) of bladder cancers in developed countries. Squamous cell carcinoma is more associated with chronic irritation and schistosomiasis, and adenocarcinoma and small cell carcinoma are rare.

Question 21Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 68-year-old man has a PSA of 6.5 ng/mL and a normal digital rectal examination. What is the most appropriate next step in evaluation?

  1. Immediate radical prostatectomy
  2. Repeat PSA after a course of antibiotics
  3. Multiparametric MRI of the prostate before biopsy Correct answer.
  4. Bone scan as the first investigation

Explanation

Current pathways use multiparametric MRI before prostate biopsy to improve detection of clinically significant cancer and reduce unnecessary biopsies. Biopsy (targeted and/or systematic) follows based on MRI findings and risk.

Question 22Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which tumor marker is most useful in the management of non-seminomatous germ cell tumors?

  1. Alpha-fetoprotein Correct answer.
  2. CA 19-9
  3. CEA
  4. CA 125

Explanation

Alpha-fetoprotein is elevated in a substantial proportion of non-seminomatous germ cell tumors and is used for diagnosis, staging, and monitoring response. Pure seminomas do not produce AFP; an elevated AFP indicates a non-seminomatous component.

Question 23Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 30-year-old man has a painless firm testicular mass. What is the most appropriate initial management?

  1. Empirical antibiotics
  2. Observation with repeat ultrasound in 6 months
  3. Trans-scrotal biopsy
  4. Radical inguinal orchiectomy Correct answer.

Explanation

A solid intratesticular mass is presumed malignant, and radical inguinal orchiectomy provides both definitive diagnosis and initial treatment. Trans-scrotal biopsy or approach is avoided because it alters lymphatic drainage and risks local recurrence.

Question 24Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which of the following is the most common site of metastasis from penile squamous cell carcinoma?

  1. Bone
  2. Lungs
  3. Liver
  4. Inguinal lymph nodes Correct answer.

Explanation

Penile carcinoma spreads first via the lymphatics to the inguinal lymph nodes, making groin assessment central to staging and management. Distant hematogenous spread to lungs, liver, or bone occurs later.

Question 25Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 45-year-old man with a 4 cm right renal mass has a preoperative eGFR of 35 mL/min/1.73 m². Which factor most strongly favors partial nephrectomy over radical nephrectomy?

  1. Tumor laterality
  2. Patient age
  3. Presence of chronic kidney disease Correct answer.
  4. Tumor enhancement on CT

Explanation

In patients with pre-existing chronic kidney disease, preserving nephron mass is particularly important to avoid progression to end-stage renal disease and its cardiovascular consequences. Partial nephrectomy is therefore strongly preferred when technically feasible.

Question 26Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which paraneoplastic syndrome is classically associated with renal cell carcinoma?

  1. Hypercalcemia Correct answer.
  2. Hypoglycemia due to insulinoma
  3. Carcinoid syndrome
  4. Hyperthyroidism

Explanation

Renal cell carcinoma can cause paraneoplastic hypercalcemia, often through PTHrP or other mediators, along with polycythemia, hypertension, and pyrexia. These systemic effects may resolve after nephrectomy.

Question 27Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A patient with non-muscle-invasive bladder cancer has multiple recurrent high-grade Ta tumors. Which intravesical therapy most reduces recurrence and progression?

  1. Intravesical saline irrigation
  2. Intravesical mitomycin C alone
  3. Intravesical BCG Correct answer.
  4. Systemic chemotherapy

Explanation

Intravesical BCG is the standard adjuvant therapy for high-risk non-muscle-invasive bladder cancer and reduces both recurrence and progression. Mitomycin C is an alternative but is generally less effective for high-risk disease.

Question 28Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

What is the recommended initial management for a patient with a newly diagnosed T2 (muscle-invasive) bladder cancer who is a good surgical candidate?

  1. External beam radiotherapy alone
  2. Neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy Correct answer.
  3. Repeat TURBT alone
  4. Intravesical BCG

Explanation

For muscle-invasive bladder cancer, neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy offers a survival benefit and is the preferred approach in fit patients. Cystectomy alone or radiotherapy alone are alternatives when chemotherapy is not feasible.

Question 29Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A man with a PSA of 25 ng/mL and Gleason 8 prostate cancer on biopsy has a normal bone scan. What is the most appropriate staging investigation to assess for nodal or distant disease before treatment?

  1. Cystoscopy
  2. PSMA PET/CT Correct answer.
  3. Serum acid phosphatase
  4. Repeat transrectal ultrasound

Explanation

In high-risk prostate cancer, PSMA PET/CT improves detection of nodal and distant metastases compared with conventional imaging and guides treatment planning. Conventional bone and CT imaging may miss small-volume disease.

Question 30Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which finding on prostate biopsy most strongly predicts biochemical recurrence after radical prostatectomy?

  1. Gleason score 6
  2. PSA of 4.5 ng/mL
  3. Positive surgical margin with Gleason 8 and extraprostatic extension Correct answer.
  4. Tumor volume less than 5%

Explanation

High Gleason grade, extraprostatic extension, and positive margins are adverse pathologic features that together strongly predict biochemical recurrence. These features guide consideration of adjuvant therapy and closer surveillance.

Question 31Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which testicular tumor type is most likely to be associated with an elevated beta-hCG but a normal alpha-fetoprotein?

  1. Pure seminoma
  2. Leydig cell tumor
  3. Pure yolk sac tumor
  4. Pure choriocarcinoma Correct answer.

Explanation

Choriocarcinoma produces beta-hCG but not AFP, and pure choriocarcinoma can present with very high hCG and widespread metastases. Yolk sac tumors characteristically raise AFP, and pure seminomas do not raise AFP.

Question 32Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 28-year-old man with a 2 cm pure seminoma confined to the testis and normal markers after orchiectomy is being counselled. Which management option is appropriate?

  1. Immediate radiotherapy to the contralateral testis
  2. Three cycles of bleomycin, etoposide, cisplatin for all stage I disease
  3. Retroperitoneal lymph node dissection as standard
  4. Surveillance with regular imaging and markers Correct answer.

Explanation

Stage I pure seminoma has an excellent prognosis, and active surveillance is a standard option to avoid overtreatment, with salvage therapy highly effective if relapse occurs. Adjuvant chemotherapy or radiotherapy are alternatives but not mandatory for all patients.

Question 33Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which risk factor is most strongly associated with the development of squamous cell carcinoma of the penis?

  1. Smoking cessation
  2. Hypertension
  3. Prior vasectomy
  4. Human papillomavirus infection Correct answer.

Explanation

HPV infection, particularly high-risk types such as HPV 16, is strongly associated with penile squamous cell carcinoma, along with phimosis, poor hygiene, and smoking. Vaccination against HPV reduces the risk of HPV-related disease.

Question 34Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

An incidental 4 cm left adrenal mass is found on CT in a patient with hypertension and episodic palpitations. Biochemical testing shows elevated plasma metanephrines. What is the essential preparation before surgical resection?

  1. Beta-blockade before alpha-blockade
  2. Alpha-adrenergic blockade before beta-blockade Correct answer.
  3. Diuretics to reduce blood pressure
  4. No preoperative medication is needed

Explanation

Pheochromocytoma requires preoperative alpha-adrenergic blockade to prevent intraoperative hypertensive crisis, with beta-blockade added afterward if needed for tachycardia. Beta-blockade before alpha-blockade can precipitate unopposed vasoconstriction and hypertensive crisis.

Question 35Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which feature on CT most reliably distinguishes a benign adrenal adenoma from a malignant adrenal mass?

  1. Bilateral involvement
  2. Presence of calcification
  3. Low unenhanced attenuation (less than 10 Hounsfield units) Correct answer.
  4. Large size

Explanation

A low unenhanced attenuation (typically less than 10 HU) reflects intracellular lipid and is characteristic of a benign adenoma. Larger size, heterogeneity, and delayed contrast washout raise concern for malignancy.

Question 36Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A patient with metastatic renal cell carcinoma is being considered for first-line systemic therapy. Which class of agents is a standard first-line option for clear cell RCC?

  1. Anti-androgen therapy
  2. Cisplatin-based chemotherapy
  3. BCG immunotherapy
  4. Immune checkpoint inhibitor combined with a VEGF receptor tyrosine kinase inhibitor Correct answer.

Explanation

Combinations of immune checkpoint inhibitors with VEGF-targeted tyrosine kinase inhibitors are standard first-line therapy for advanced clear cell RCC. RCC is generally chemotherapy-resistant, so cytotoxic regimens are not effective.

Question 37Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 70-year-old man with metastatic castration-resistant prostate cancer has progressed on androgen deprivation therapy. Which agent class is appropriate next-line therapy?

  1. Intravesical BCG
  2. Cisplatin-based chemotherapy
  3. Androgen receptor pathway inhibitor such as enzalutamide Correct answer.
  4. Alpha-blocker monotherapy

Explanation

For metastatic castration-resistant prostate cancer, next-line options include androgen receptor pathway inhibitors, taxane chemotherapy, and other agents. Enzalutamide is a standard oral androgen receptor inhibitor in this setting.

Question 38Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 55-year-old man has a 6 cm renal mass with a thrombus extending into the inferior vena cava below the hepatic veins. What is the most appropriate management approach?

  1. Radical nephrectomy with thrombectomy Correct answer.
  2. Systemic therapy alone
  3. Observation
  4. Partial nephrectomy

Explanation

Locally advanced RCC with IVC tumor thrombus is managed with radical nephrectomy and thrombectomy, often with cardiothoracic or vascular surgery support depending on thrombus level. Complete resection offers the best chance of disease control.

Question 39Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

Which of the following best describes the role of pelvic lymph node dissection at the time of radical cystectomy?

  1. It is performed only for palliation
  2. It is contraindicated in muscle-invasive disease
  3. It replaces the need for cystectomy
  4. It provides staging information and may have therapeutic benefit Correct answer.

Explanation

Pelvic lymphadenectomy at radical cystectomy provides accurate nodal staging and may confer a therapeutic benefit by removing micrometastatic disease. Extended templates are commonly used to improve staging accuracy.

Question 40Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 35-year-old man has a non-seminomatous germ cell tumor with elevated markers and retroperitoneal lymphadenopathy. After orchiectomy and chemotherapy, a residual retroperitoneal mass persists with normal markers. What is the most appropriate next step?

  1. Observation alone
  2. Retroperitoneal lymph node dissection Correct answer.
  3. Radiotherapy to the retroperitoneum
  4. Repeat chemotherapy without surgery

Explanation

Residual masses after chemotherapy for non-seminomatous germ cell tumors may harbor teratoma or viable cancer, so retroperitoneal lymph node dissection is performed to achieve complete resection and guide further therapy. Normal markers do not exclude residual viable tumor.

Question 41Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A patient with a large adrenal mass has clinical features of Cushing syndrome and imaging suggesting adrenocortical carcinoma. Which management principle is most appropriate?

  1. Percutaneous biopsy before any surgery
  2. Complete surgical resection with an experienced multidisciplinary team Correct answer.
  3. Adrenal-sparing surgery regardless of size
  4. Observation with annual imaging

Explanation

Suspected adrenocortical carcinoma should be resected en bloc by an experienced team to avoid tumor spillage and achieve negative margins. Biopsy is generally avoided because it risks seeding and is rarely necessary before resection.

Question 42Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 62-year-old man is found to have a 3 cm enhancing left renal mass. Staging imaging shows no evidence of metastasis. He is asymptomatic and has a normal contralateral kidney. Which management strategy is most appropriate?

  1. Partial nephrectomy Correct answer.
  2. Active surveillance with serial imaging
  3. Percutaneous radiofrequency ablation
  4. Radical nephrectomy

Explanation

For a T1a renal mass in a patient with a normal contralateral kidney, partial nephrectomy is the standard of care because it preserves renal function and has oncologic outcomes equivalent to radical nephrectomy. Radical nephrectomy is reserved for tumors not amenable to partial resection. Active surveillance and ablation are options for poor surgical candidates or small tumors in selected patients, but are not first-line here.

Question 43Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 58-year-old man undergoes transurethral resection of a bladder tumor. Pathology shows a high-grade Ta lesion. Which factor is most important in determining the need for intravesical bacillus Calmette-Guérin (BCG) therapy?

  1. Tumor size
  2. Tumor grade Correct answer.
  3. Number of prior resections
  4. Presence of carcinoma in situ

Explanation

High-grade Ta tumors are at significant risk of recurrence and progression, and intravesical BCG is recommended for high-grade non-muscle-invasive bladder cancer. Tumor size and multiplicity are risk factors, but grade is the strongest determinant for BCG. Carcinoma in situ would also warrant BCG, but it is not present in this case.

Question 44Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 68-year-old man with localized prostate cancer undergoes radical prostatectomy. Final pathology shows pT3a disease with positive surgical margins. Which adjuvant treatment has been shown to improve biochemical recurrence-free survival in this setting?

  1. Immediate androgen deprivation therapy
  2. Adjuvant chemotherapy
  3. Adjuvant external beam radiotherapy Correct answer.
  4. Observation alone

Explanation

Adjuvant radiotherapy after radical prostatectomy improves biochemical recurrence-free survival in patients with adverse pathologic features such as pT3 disease or positive margins. Androgen deprivation therapy is not standard as adjuvant monotherapy in this setting. Chemotherapy has no established role in adjuvant treatment of localized prostate cancer.

Question 45Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 24-year-old man presents with a 3 cm right testicular mass. Serum alpha-fetoprotein (AFP) is elevated, and beta-human chorionic gonadotropin (beta-hCG) is normal. Which histologic subtype is most likely?

  1. Pure seminoma
  2. Yolk sac tumor Correct answer.
  3. Embryonal carcinoma
  4. Choriocarcinoma

Explanation

Yolk sac tumors are characterized by elevated AFP, while pure seminomas do not produce AFP. Embryonal carcinoma may cause mild AFP elevation but is more commonly associated with beta-hCG. Choriocarcinoma typically produces high beta-hCG and is not associated with AFP elevation.

Question 46Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 60-year-old man presents with a 2 cm ulcerated lesion on the glans penis. Biopsy shows squamous cell carcinoma. Physical examination reveals no palpable inguinal lymph nodes. Which management is most appropriate for the primary lesion?

  1. Topical imiquimod
  2. Local excision with 2 cm margins Correct answer.
  3. Radical penectomy with bilateral inguinal lymph node dissection
  4. Partial penectomy

Explanation

For a 2 cm penile squamous cell carcinoma, organ-sparing surgery with local excision and adequate margins (typically 2 cm) is recommended when feasible. Topical therapy is only for carcinoma in situ. Partial penectomy is reserved for larger tumors, and radical penectomy with lymph node dissection is not indicated for a small lesion without nodal involvement.

Question 47Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 45-year-old woman is found to have a 3 cm right adrenal mass. Biochemical evaluation reveals elevated plasma metanephrines. Which is the most appropriate next step in management?

  1. Alpha-adrenergic blockade followed by adrenalectomy Correct answer.
  2. Observation with repeat imaging in 6 months
  3. Immediate adrenalectomy
  4. Percutaneous biopsy of the adrenal mass

Explanation

Elevated plasma metanephrines indicate pheochromocytoma. Preoperative alpha-adrenergic blockade is essential to prevent intraoperative hypertensive crisis, followed by adrenalectomy. Immediate surgery without blockade is dangerous. Observation is inappropriate for a functional tumor, and biopsy is contraindicated due to the risk of catecholamine release.

Question 48Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 70-year-old man with metastatic clear cell renal cell carcinoma is started on sunitinib. Which adverse effect is most characteristic of this therapy?

  1. Hypertension Correct answer.
  2. Hyperglycemia
  3. Bradycardia
  4. Hypothyroidism

Explanation

Sunitinib is a tyrosine kinase inhibitor that commonly causes hypertension due to inhibition of vascular endothelial growth factor signaling. Hypothyroidism can occur but is less characteristic. Hyperglycemia and bradycardia are not typical adverse effects of sunitinib.

Question 49Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 55-year-old man with muscle-invasive bladder cancer undergoes radical cystectomy with ileal conduit urinary diversion. Which metabolic complication is most likely to occur in the early postoperative period?

  1. Hypocalcemia
  2. Hypernatremia
  3. Hyperchloremic metabolic acidosis Correct answer.
  4. Hyperkalemia

Explanation

Ileal conduit urinary diversion often leads to hyperchloremic metabolic acidosis because the ileal segment reabsorbs chloride and ammonium in exchange for bicarbonate. Hyperkalemia is less common and may occur with renal insufficiency. Hypocalcemia and hypernatremia are not typical early complications.

Question 50Urologic Oncology (Kidney, Bladder, Prostate, Testis, Penis, Adrenal)

A 32-year-old man with a non-seminomatous germ cell tumor has a residual retroperitoneal mass after chemotherapy. Serum tumor markers (AFP and beta-hCG) are normal. Which management is most appropriate?

  1. Retroperitoneal lymph node dissection Correct answer.
  2. Radiation therapy to the retroperitoneum
  3. Second-line chemotherapy
  4. Observation with serial imaging and markers

Explanation

In patients with non-seminomatous germ cell tumors and a residual mass after chemotherapy with normalized markers, retroperitoneal lymph node dissection is recommended for accurate staging and potential cure. Observation is not appropriate because residual teratoma or viable tumor may be present. Second-line chemotherapy is reserved for marker-positive relapse, and radiation has no role in non-seminomatous tumors.