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Arab Board Urology Final Written study materials
Arab Board Urology Final Written study resources

Arab Board Urology Final Written practice questions

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Question 1Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 58-year-old man has a 3.2 cm enhancing left renal mass confined to the kidney with no fat invasion or venous involvement. Which of the following best describes the clinical T stage?

  1. T3a
  2. T1b Correct answer.
  3. T1a
  4. T2a

Explanation

T1b is a tumor greater than 4 cm but not exceeding 7 cm, confined to the kidney. T1a is 4 cm or less, T2a exceeds 7 cm but not 10 cm, and T3a involves perinephric fat or renal vein branches.

Question 2Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which histologic subtype accounts for the majority of renal cell carcinomas and typically shows loss of chromosome 3p with inactivation of the VHL gene?

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

Explanation

Clear cell renal cell carcinoma is the most common subtype and classically arises from VHL inactivation with 3p loss. Papillary and chromophobe subtypes have different characteristic genetic alterations.

Question 3Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most appropriate initial management for a patient with a solitary small renal mass who has a strong desire to preserve renal function and is a poor surgical candidate?

  1. Adjuvant systemic therapy
  2. Cytoreductive nephrectomy
  3. Radical nephrectomy
  4. Active surveillance or thermal ablation Correct answer.

Explanation

For small renal masses in patients who are poor surgical candidates, active surveillance or thermal ablation are accepted nephron-sparing options. Radical nephrectomy maximally sacrifices renal function, and systemic therapy has no role in localized disease.

Question 4Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient with metastatic clear cell renal cell carcinoma is being considered for first-line therapy. Which combination represents a current standard first-line option for favorable- or intermediate-risk disease?

  1. Single-agent sunitinib only
  2. Ipilimumab plus nivolumab
  3. Pembrolizumab plus axitinib Correct answer.
  4. BCG intravesical therapy

Explanation

Immune checkpoint inhibitor plus VEGF tyrosine kinase inhibitor combinations such as pembrolizumab plus axitinib are standard first-line options for advanced clear cell RCC. Ipilimumab plus nivolumab is also used but is typically reserved for intermediate- or poor-risk disease, and BCG has no role in RCC.

Question 5Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which paraneoplastic syndrome is most characteristically associated with renal cell carcinoma?

  1. Carcinoid syndrome
  2. Hypercalcemia Correct answer.
  3. Cushing syndrome from ectopic ACTH
  4. Hypoglycemia from insulinoma

Explanation

Hypercalcemia is a well-recognized paraneoplastic manifestation of RCC, often mediated by PTHrP or bone metastases. The other listed syndromes are not characteristic of RCC.

Question 6Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 65-year-old man presents with painless gross hematuria. Which of the following is the most important initial diagnostic step to evaluate for bladder cancer?

  1. Cystoscopy with upper tract imaging Correct answer.
  2. Renal ultrasound alone
  3. Serum PSA measurement
  4. Urine cytology alone

Explanation

Cystoscopy combined with upper tract imaging is the standard initial evaluation for suspected bladder cancer presenting with hematuria. Cytology alone is insufficiently sensitive, and PSA evaluates the prostate rather than the bladder.

Question 7Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient has a Ta high-grade urothelial carcinoma of the bladder. Which of the following is the most appropriate adjuvant intravesical therapy after complete transurethral resection?

  1. Systemic cisplatin-based chemotherapy
  2. Intravesical mitomycin C single dose only
  3. Intravesical BCG induction and maintenance Correct answer.
  4. Intravesical gemcitabine only

Explanation

High-grade Ta tumors are at intermediate to high risk of recurrence and progression, and intravesical BCG induction with maintenance is the standard adjuvant therapy. A single perioperative mitomycin dose is insufficient for high-grade disease, and systemic chemotherapy is reserved for muscle-invasive or metastatic disease.

Question 8Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following best defines muscle-invasive bladder cancer on transurethral resection?

  1. Invasion into the perivesical fat
  2. Invasion into the lamina propria
  3. Invasion into the muscularis propria (detrusor) Correct answer.
  4. Carcinoma in situ only

Explanation

Muscle-invasive bladder cancer is defined by invasion into the muscularis propria (T2 disease). Lamina propria invasion is T1, CIS is Tis, and perivesical fat invasion is T3.

Question 9Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient with muscle-invasive bladder cancer is being counseled on treatment options. Which of the following is the standard treatment associated with the best oncologic outcomes for organ-confined muscle-invasive disease?

  1. Observation with repeat cystoscopy
  2. Partial cystectomy alone
  3. Intravesical BCG
  4. Radical cystectomy with urinary diversion Correct answer.

Explanation

Radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard curative treatment for organ-confined muscle-invasive bladder cancer. BCG is for non-muscle-invasive disease, and observation is inappropriate for invasive cancer.

Question 10Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most common histologic type of bladder cancer in regions where Schistosoma haematobium is endemic?

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

Explanation

In Schistosoma haematobium endemic areas, chronic infection is associated with squamous cell carcinoma of the bladder. Elsewhere, urothelial carcinoma predominates.

Question 11Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 70-year-old man has a PSA of 8 ng/mL and a firm nodule on digital rectal examination. Which of the following is the most appropriate next step in evaluation?

  1. MRI without biopsy
  2. Repeat PSA in 6 months
  3. Observation with annual DRE
  4. Prostate biopsy Correct answer.

Explanation

An elevated PSA with an abnormal DRE is a strong indication for prostate biopsy to diagnose or exclude prostate cancer. Repeat PSA or observation would delay diagnosis.

Question 12Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following Gleason score combinations corresponds to Grade Group 2 in the current ISUP grading system?

  1. Gleason 4+5
  2. Gleason 3+3
  3. Gleason 3+4 Correct answer.
  4. Gleason 4+4

Explanation

Grade Group 2 corresponds to Gleason score 3+4=7. Gleason 6 is Grade Group 1, 4+4 is Grade Group 4, and 4+5 is Grade Group 5.

Question 13Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A man with low-risk localized prostate cancer (PSA <10, Grade Group 1, clinical T1c) is considering treatment options. Which of the following is an appropriate management strategy?

  1. Active surveillance with serial PSA and repeat biopsy Correct answer.
  2. Immediate docetaxel
  3. Immediate radical prostatectomy only
  4. Bilateral orchiectomy

Explanation

Active surveillance is a standard option for low-risk localized prostate cancer to avoid overtreatment while monitoring for progression. Orchiectomy and docetaxel are for advanced disease.

Question 14Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following best describes the role of PSA screening in prostate cancer according to current evidence?

  1. It reduces prostate cancer mortality but carries a risk of overdiagnosis Correct answer.
  2. It is recommended for all men starting at age 30
  3. It has no proven benefit at any age
  4. It reliably distinguishes aggressive from indolent disease

Explanation

Randomized trials show PSA screening reduces prostate cancer mortality but is associated with overdiagnosis and overtreatment, so shared decision-making is recommended. PSA alone does not reliably distinguish aggressive from indolent disease.

Question 15Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 68-year-old man with metastatic castration-resistant prostate cancer has progressed on abiraterone and docetaxel. Which of the following is an appropriate next-line systemic option?

  1. Observation only
  2. Repeat abiraterone alone
  3. BCG intravesical therapy
  4. Cabazitaxel Correct answer.

Explanation

Cabazitaxel is a taxane approved for metastatic castration-resistant prostate cancer after progression on docetaxel. Repeat abiraterone after progression is not standard, and BCG has no role.

Question 16Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most common histologic type of testicular cancer in young adult men?

  1. Seminoma Correct answer.
  2. Yolk sac tumor
  3. Leydig cell tumor
  4. Lymphoma

Explanation

Seminoma is the most common histologic type of testicular germ cell tumor in young adults. Yolk sac tumors are more common in infants, Leydig cell tumors are rare stromal tumors, and lymphoma is the most common testicular tumor in older men.

Question 17Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 25-year-old man has a painless testicular mass. Which of the following is the most appropriate initial step in management?

  1. Radical inguinal orchiectomy Correct answer.
  2. Observation with repeat ultrasound
  3. Scrotal orchiectomy
  4. Testicular biopsy

Explanation

Radical inguinal orchiectomy is both diagnostic and therapeutic for a suspected testicular malignancy. Transscrotal biopsy or scrotal orchiectomy risks tumor seeding and alters lymphatic drainage.

Question 18Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following tumor markers is most characteristically elevated in pure seminoma?

  1. Alpha-fetoprotein (AFP)
  2. Beta-hCG Correct answer.
  3. CEA
  4. CA 19-9

Explanation

Pure seminomas may elevate beta-hCG in a minority of cases, but AFP is never elevated in pure seminoma. An elevated AFP suggests a nonseminomatous component.

Question 19Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient with clinical stage I nonseminomatous germ cell tumor is considering management options. Which of the following is a recognized option?

  1. Immediate retroperitoneal lymph node dissection only
  2. Surveillance Correct answer.
  3. Intravesical chemotherapy
  4. Observation with no follow-up

Explanation

Surveillance is a recognized option for clinical stage I nonseminomatous germ cell tumors, along with nerve-sparing RPLND or adjuvant chemotherapy. Observation without follow-up is unsafe.

Question 20Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most common presenting feature of penile cancer?

  1. Testicular swelling
  2. Painless ulcer or mass on the glans or prepuce Correct answer.
  3. Painless hematuria
  4. Bone pain

Explanation

Penile cancer most often presents as a painless ulcer, nodule, or mass on the glans or prepuce, sometimes with inguinal lymphadenopathy. Hematuria and testicular swelling are unrelated presentations.

Question 21Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most important risk factor for penile squamous cell carcinoma?

  1. Circumcision at birth
  2. Hypertension
  3. Chronic human papillomavirus infection Correct answer.
  4. Smoking cessation

Explanation

Chronic HPV infection, particularly types 16 and 18, is a major risk factor for penile squamous cell carcinoma, along with phimosis and poor hygiene. Neonatal circumcision is protective, and smoking cessation reduces risk.

Question 22Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient with penile cancer has a palpable inguinal lymph node. Which of the following is the most appropriate next step in evaluation?

  1. Radiation to the penis
  2. Inguinal lymph node dissection without further assessment
  3. Fine-needle aspiration or biopsy of the node Correct answer.
  4. Observation for 6 months

Explanation

Palpable inguinal nodes in penile cancer require tissue confirmation, typically by fine-needle aspiration or biopsy, before proceeding to lymphadenectomy. Immediate dissection without confirmation risks unnecessary surgery for reactive nodes.

Question 23Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most common type of adrenal tumor?

  1. Adrenal incidentaloma (benign adenoma) Correct answer.
  2. Adrenocortical carcinoma
  3. Adrenal metastasis
  4. Pheochromocytoma

Explanation

Benign adrenal adenomas, often discovered as incidentalomas, are the most common adrenal tumors. Adrenocortical carcinoma and pheochromocytoma are much less common.

Question 24Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 45-year-old woman has an adrenal incidentaloma with imaging showing low attenuation (<10 Hounsfield units) on unenhanced CT. Which of the following is the most likely diagnosis?

  1. Pheochromocytoma
  2. Adrenocortical carcinoma
  3. Benign lipid-rich adenoma Correct answer.
  4. Adrenal metastasis

Explanation

Low unenhanced attenuation (<10 HU) indicates intracellular lipid and strongly suggests a benign lipid-rich adenoma. Pheochromocytoma, adrenocortical carcinoma, and metastases typically have higher attenuation.

Question 25Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A patient with a suspected pheochromocytoma should undergo biochemical testing before any intervention. Which of the following is the most appropriate initial biochemical test?

  1. Serum aldosterone
  2. Serum cortisol
  3. Plasma renin activity
  4. Plasma free metanephrines or 24-hour urinary fractionated metanephrines Correct answer.

Explanation

Plasma free metanephrines or 24-hour urinary fractionated metanephrines are the recommended initial biochemical tests for pheochromocytoma. Cortisol, renin, and aldosterone assess other adrenal disorders.

Question 26Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 58-year-old man is found to have a 3 cm enhancing mass in the left kidney on CT. He is asymptomatic and has normal renal function. Which of the following is the most appropriate initial management?

  1. Radical nephrectomy
  2. Active surveillance
  3. Percutaneous biopsy
  4. Partial nephrectomy Correct answer.

Explanation

For a clinical T1a renal mass (≤4 cm), partial nephrectomy is the standard of care when technically feasible, as it preserves renal function and has oncologic outcomes equivalent to radical nephrectomy. Radical nephrectomy is reserved for larger or centrally located tumors not amenable to partial resection. Active surveillance is an option for small renal masses in frail patients, but this patient is a good surgical candidate. Percutaneous biopsy is not routinely the initial step for a clearly enhancing mass in a surgical candidate.

Question 27Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 62-year-old man undergoes radical nephrectomy for a 7 cm clear cell renal cell carcinoma. Pathology shows tumor thrombus extending into the renal vein but not beyond. Which of the following is the most important prognostic factor for his outcome?

  1. Presence of sarcomatoid features Correct answer.
  2. Renal vein involvement
  3. Fuhrman nuclear grade
  4. Tumor size

Explanation

Sarcomatoid differentiation is associated with a very poor prognosis and is considered a high-risk feature in renal cell carcinoma, often upstaging the tumor and prompting consideration for adjuvant therapy. While grade and stage (including venous thrombus) are prognostic, sarcomatoid features carry the strongest adverse impact among the listed factors.

Question 28Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 55-year-old woman has a 2 cm enhancing renal mass and a history of breast cancer. She wants to avoid surgery if possible. Which of the following is the most appropriate next step in management?

  1. Repeat imaging in 6 months
  2. Radical nephrectomy
  3. Ablative therapy
  4. Percutaneous renal mass biopsy Correct answer.

Explanation

Percutaneous biopsy of a small renal mass can provide histologic diagnosis, which is particularly useful when metastatic disease is suspected or when the patient wishes to avoid surgery. A history of breast cancer raises the possibility of a renal metastasis, and biopsy can guide management. Ablative therapy and surgery are definitive treatments that may be unnecessary if the mass is metastatic.

Question 29Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

Which of the following is the most common histologic subtype of renal cell carcinoma?

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

Explanation

Clear cell renal cell carcinoma accounts for approximately 70-80% of all renal cell carcinomas. Papillary and chromophobe subtypes are less common, and collecting duct carcinoma is rare and aggressive.

Question 30Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 60-year-old man has a 4 cm renal mass and is scheduled for partial nephrectomy. Preoperative imaging shows a tumor thrombus in the renal vein. Which of the following is the most appropriate surgical approach?

  1. Perform radical nephrectomy without thrombectomy
  2. Abort surgery and refer for systemic therapy
  3. Convert to radical nephrectomy with thrombectomy Correct answer.
  4. Proceed with partial nephrectomy and remove the thrombus

Explanation

Renal vein tumor thrombus is best managed by radical nephrectomy with thrombectomy to ensure complete removal of the tumor and thrombus. Partial nephrectomy is generally contraindicated in the presence of venous thrombus because of the risk of incomplete resection and embolization.

Question 31Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 70-year-old man with muscle-invasive bladder cancer undergoes radical cystectomy. Which of the following is the most important prognostic factor for survival after cystectomy?

  1. Surgical margin status
  2. Tumor grade
  3. Lymphovascular invasion
  4. Pathologic stage Correct answer.

Explanation

Pathologic stage, particularly the presence of lymph node metastasis and depth of invasion, is the strongest predictor of survival after radical cystectomy for bladder cancer. While margin status and lymphovascular invasion are also prognostic, stage carries the greatest impact.

Question 32Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 65-year-old woman presents with painless gross hematuria. She has a history of recurrent urinary tract infections. Which of the following is the most appropriate initial diagnostic test?

  1. Cystoscopy Correct answer.
  2. Renal ultrasound
  3. Urine cytology
  4. CT urography

Explanation

Cystoscopy is the gold standard for evaluating hematuria and is the initial test to visualize the bladder and detect urothelial carcinoma. It allows direct inspection and biopsy of any suspicious lesions. CT urography and urine cytology are adjuncts but not the initial step.

Question 33Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 58-year-old man is diagnosed with non-muscle-invasive bladder cancer (Ta, low-grade). He is treated with transurethral resection. Which of the following is the most appropriate adjuvant therapy?

  1. Radical cystectomy
  2. Intravesical BCG Correct answer.
  3. Systemic chemotherapy
  4. Intravesical mitomycin C

Explanation

For intermediate-risk non-muscle-invasive bladder cancer, intravesical BCG is the standard adjuvant therapy to reduce recurrence and progression. Mitomycin C is an alternative but is generally used for low-risk disease or in combination. Systemic chemotherapy and cystectomy are reserved for higher-risk or muscle-invasive disease.

Question 34Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 72-year-old man with muscle-invasive bladder cancer is being considered for neoadjuvant chemotherapy. Which of the following is the most important prerequisite before initiating chemotherapy?

  1. Liver biopsy
  2. Bone scan
  3. Assessment of renal function Correct answer.
  4. Echocardiogram

Explanation

Neoadjuvant chemotherapy for bladder cancer typically includes cisplatin, which requires adequate renal function. Renal function must be assessed before starting chemotherapy to avoid nephrotoxicity. Bone scan, echocardiogram, and liver biopsy are not routine prerequisites.

Question 35Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 68-year-old man has a rising PSA after radical prostatectomy for prostate cancer. His PSA is 0.5 ng/mL and imaging is negative. Which of the following is the most appropriate management?

  1. Chemotherapy
  2. Observation
  3. Androgen deprivation therapy
  4. Salvage radiotherapy Correct answer.

Explanation

For biochemical recurrence after radical prostatectomy with no evidence of distant metastasis, salvage radiotherapy to the prostate bed is the standard treatment and offers the best chance of cure. Androgen deprivation therapy is reserved for metastatic disease or as an adjunct in high-risk cases. Observation would allow progression.

Question 36Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 70-year-old man with metastatic castration-resistant prostate cancer has progressed on enzalutamide. Which of the following is the most appropriate next-line systemic therapy?

  1. Abiraterone
  2. Docetaxel Correct answer.
  3. Bicalutamide
  4. Observation

Explanation

After progression on enzalutamide, docetaxel is a standard chemotherapy option for metastatic castration-resistant prostate cancer. Abiraterone, another androgen receptor pathway inhibitor, is unlikely to be effective due to cross-resistance. Bicalutamide is a first-generation antiandrogen with limited efficacy in this setting.

Question 37Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 30-year-old man presents with a painless testicular mass. Ultrasound shows a solid intratesticular lesion. Which of the following is the most appropriate next step in management?

  1. Observation with repeat ultrasound
  2. Scrotal exploration
  3. Radical inguinal orchiectomy Correct answer.
  4. Testicular biopsy

Explanation

Radical inguinal orchiectomy is the standard initial treatment for a suspected testicular tumor, providing definitive diagnosis and local control. Testicular biopsy is contraindicated due to risk of tumor spread. Scrotal exploration is not recommended as it may violate oncologic principles.

Question 38Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 28-year-old man is diagnosed with a pure seminoma of the testis. His serum tumor markers are obtained. Which of the following markers is most likely to be elevated?

  1. Human chorionic gonadotropin (hCG)
  2. Carcinoembryonic antigen (CEA)
  3. Lactate dehydrogenase (LDH) Correct answer.
  4. Alpha-fetoprotein (AFP)

Explanation

LDH is often elevated in seminoma and correlates with tumor burden. AFP is never elevated in pure seminoma; its elevation indicates a nonseminomatous component. hCG can be elevated in about 15-20% of seminomas, but LDH is more commonly elevated. CEA is not a testicular tumor marker.

Question 39Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 35-year-old man with a non-seminomatous germ cell tumor undergoes radical orchiectomy. Staging shows no evidence of metastasis. Which of the following is the most appropriate management option?

  1. Retroperitoneal lymph node dissection
  2. Surveillance Correct answer.
  3. Adjuvant chemotherapy
  4. Radiotherapy

Explanation

For clinical stage I nonseminomatous germ cell tumors, surveillance is a standard option, especially for low-risk patients, to avoid overtreatment. Retroperitoneal lymph node dissection and adjuvant chemotherapy are alternatives but carry more morbidity. Radiotherapy is not effective for nonseminomatous tumors.

Question 40Urologic Oncology (kidney, bladder, prostate, testis, penile, adrenal)

A 60-year-old man presents with a painless ulcerated lesion on the glans penis. Biopsy confirms squamous cell carcinoma. Which of the following is the most important prognostic factor?

  1. Lymph node status Correct answer.
  2. Presence of lymphovascular invasion
  3. Tumor grade
  4. Tumor size

Explanation

Lymph node metastasis is the most important prognostic factor in penile squamous cell carcinoma, significantly reducing survival. While grade, size, and lymphovascular invasion are prognostic, nodal status carries the greatest impact on outcome.

Question 41Endourology and Urinary Stone Disease

A 45-year-old man presents with sudden severe left flank pain radiating to the groin, microscopic haematuria, and a 6 mm radiopaque stone at the left pelviureteric junction on CT. He is afebrile with normal renal function. What is the most appropriate initial management?

  1. Open pyelolithotomy
  2. Percutaneous nephrolithotomy
  3. Emergency ureteroscopy with stone extraction
  4. Analgesia with NSAIDs and observation with follow-up imaging Correct answer.

Explanation

A 6 mm stone at the PUJ without obstruction-related infection or renal impairment can be managed with analgesia and observation, as many stones of this size pass spontaneously. NSAIDs provide effective analgesia and reduce ureteric spasm. Intervention is reserved for failure of passage, uncontrolled symptoms, or complications.

Question 42Endourology and Urinary Stone Disease

Which stone composition is characteristically radiolucent on a plain abdominal radiograph?

  1. Struvite
  2. Calcium oxalate monohydrate
  3. Uric acid Correct answer.
  4. Cystine

Explanation

Uric acid stones are the classic radiolucent calculi because they lack sufficient calcium density to attenuate X-rays. Calcium oxalate, struvite, and cystine stones are all radiopaque. CT remains the most sensitive imaging for all stone types.

Question 43Endourology and Urinary Stone Disease

A 30-year-old woman with recurrent calcium oxalate stones has a 24-hour urine study showing hypercalciuria with normal serum calcium and PTH. Which dietary measure most effectively reduces stone recurrence?

  1. Increase dietary sodium to improve hydration
  2. Restrict dietary calcium to below 400 mg/day
  3. Supplement with high-dose vitamin C
  4. Maintain high fluid intake and normal dietary calcium Correct answer.

Explanation

High fluid intake dilutes urine and is the cornerstone of recurrence prevention, while normal dietary calcium binds intestinal oxalate and reduces absorption. Restricting calcium paradoxically increases oxalate absorption and stone risk.

Question 44Endourology and Urinary Stone Disease

Which imaging modality is the first-line investigation for suspected acute ureteric colic in adults?

  1. Intravenous urography
  2. Ultrasound of the kidneys alone
  3. Magnetic resonance urography
  4. Non-contrast CT of the kidneys, ureters, and bladder Correct answer.

Explanation

Non-contrast CT KUB is the gold standard for acute stone disease, with high sensitivity and specificity for all stone types and the ability to identify alternative diagnoses. It is rapid and does not require contrast.

Question 45Endourology and Urinary Stone Disease

A 60-year-old man with a 25 mm right renal pelvic stone and no infection is being counselled. Which treatment offers the highest stone-free rate for a stone of this size?

  1. Retrograde intrarenal surgery
  2. Medical expulsive therapy
  3. Percutaneous nephrolithotomy Correct answer.
  4. Shockwave lithotripsy

Explanation

For renal stones larger than 20 mm, PCNL provides the highest stone-free rates and is the recommended first-line treatment. SWL and RIRS have lower clearance rates for stones of this size.

Question 46Endourology and Urinary Stone Disease

Which organism is most commonly associated with struvite (infection) stone formation?

  1. Ureaplasma urealyticum
  2. Proteus mirabilis Correct answer.
  3. Staphylococcus saprophyticus
  4. Escherichia coli

Explanation

Struvite stones form when urease-producing organisms alkalinise urine, precipitating magnesium ammonium phosphate. Proteus mirabilis is the classic urease producer implicated. E. coli is the commonest urinary pathogen overall but is usually non-urease-producing.

Question 47Endourology and Urinary Stone Disease

A 28-year-old woman at 24 weeks' gestation presents with a 7 mm obstructing ureteric stone and persistent pain despite analgesia. Which management is most appropriate?

  1. Percutaneous nephrolithotomy
  2. Shockwave lithotripsy
  3. Non-contrast CT KUB to localise the stone
  4. Ureteroscopy with stone extraction or ureteric stent placement Correct answer.

Explanation

When intervention is required in pregnancy, ureteroscopy or ureteric stenting is preferred, as these avoid ionising radiation to the fetus. SWL and PCNL are generally avoided during pregnancy.

Question 48Endourology and Urinary Stone Disease

What is the maximum recommended skin-to-stone distance above which shockwave lithotripsy is less likely to succeed?

  1. 5 cm
  2. 15 cm
  3. 10 cm Correct answer.
  4. 20 cm

Explanation

A skin-to-stone distance greater than 10 cm predicts poorer shockwave lithotripsy outcomes because the focal energy is attenuated before reaching the stone. This measurement is obtained on CT planning.

Question 49Endourology and Urinary Stone Disease

A patient develops a fever of 39°C with rigors 24 hours after ureteroscopy and stone extraction. What is the most important immediate step in management?

  1. Urgent resuscitation and drainage of the obstructed system with antibiotics Correct answer.
  2. Increase oral fluid intake and observe
  3. Oral ciprofloxacin and discharge
  4. Repeat ureteroscopy to inspect for residual stone

Explanation

Post-procedural fever with rigors suggests obstructive pyelonephritis or urosepsis, a urological emergency. Immediate resuscitation with intravenous antibiotics and urgent decompression by stent or nephrostomy is required.

Question 50Endourology and Urinary Stone Disease

Which finding on a 24-hour urine study most strongly suggests a primary purine metabolism disorder in a patient with radiolucent stones?

  1. Elevated urinary citrate
  2. Elevated urinary cystine
  3. Elevated urinary oxalate
  4. Elevated urinary uric acid with low urine pH Correct answer.

Explanation

Uric acid stones are radiolucent and associated with hyperuricosuria and persistently acidic urine, which favours precipitation of undissociated uric acid. Alkalinisation of urine is a key treatment.