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EAU Entrance Exam study materials
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EAU Entrance Exam practice questions

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Question 1Urological Oncology

A 62-year-old man has a serum PSA of 7.8 ng/mL and a normal digital rectal examination. According to current EAU risk stratification for clinically localised prostate cancer, which category does he fall into?

  1. High risk
  2. Locally advanced risk
  3. Low risk
  4. Intermediate risk Correct answer.

Explanation

EAU defines low risk as PSA below 10 ng/mL together with Gleason score 6 (ISUP grade group 1) and cT1–cT2a, so a normal DRE alone does not exclude intermediate risk once PSA and grade are considered. Intermediate risk requires PSA 10–20 ng/mL or Gleason 7 (ISUP grade group 2–3) or cT2b, and this patient's PSA of 7.8 ng/mL fits only with additional grade information. The key principle is that risk grouping combines PSA, grade and clinical stage rather than relying on a single variable.

Question 2Urological Oncology

Which histological feature is required to diagnose a seminomatous germ cell tumour of the testis rather than a non-seminoma?

  1. Mixed populations of syncytiotrophoblasts and cytotrophoblasts
  2. Schiller-Duval bodies within a reticular pattern
  3. Glandular structures with mucin production
  4. Uniform cells with clear cytoplasm and fibrous septa containing lymphocytes Correct answer.

Explanation

Classic seminoma shows a monotonous population of large cells with clear glycogen-rich cytoplasm, separated by delicate fibrous septa infiltrated by lymphocytes. The other descriptions correspond to choriocarcinoma, yolk sac tumour and adenocarcinoma respectively, which are non-seminomatous patterns. Recognising this architecture is central to deciding between radiotherapy-based and cisplatin-based management.

Question 3Urological Oncology

A 58-year-old smoker presents with painless gross haematuria. Which investigation is the initial reference standard for detecting bladder urothelial carcinoma?

  1. Cystoscopy with histological sampling of suspicious lesions Correct answer.
  2. Serum carcinoembryonic antigen
  3. Urine cytology alone
  4. Renal ultrasound

Explanation

Cystoscopy combined with biopsy or resection of any suspicious lesion remains the diagnostic reference standard for bladder cancer because it allows direct visualisation and histological confirmation. Cytology has low sensitivity for low-grade tumours, and imaging cannot replace endoscopic assessment. The combination of haematuria and smoking history makes urothelial carcinoma the leading concern.

Question 4Urological Oncology

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

  1. Carcinoid syndrome
  2. Cushing syndrome due to ectopic ACTH
  3. Hypoglycaemia due to insulinoma
  4. Hypercalcaemia Correct answer.

Explanation

Renal cell carcinoma frequently secretes parathyroid hormone-related peptide or causes bone metastases, producing hypercalcaemia as a classic paraneoplastic finding. It may also cause polycythaemia, hypertension and pyrexia, but hypercalcaemia is the best-recognised biochemical association. The other options are linked to different neuroendocrine or pancreatic tumours.

Question 5Urological Oncology

A 70-year-old man with metastatic castration-resistant prostate cancer has progressed on abiraterone. Which class of agent targets the androgen receptor directly and is a standard subsequent option?

  1. Radium-223
  2. Docetaxel
  3. Enzalutamide Correct answer.
  4. Zoledronic acid

Explanation

Enzalutamide is a second-generation androgen receptor antagonist that blocks ligand binding, receptor nuclear translocation and DNA binding. It is a recognised option after progression on abiraterone, although cross-resistance occurs. Docetaxel is chemotherapy, radium-223 is a bone-seeking alpha emitter and zoledronic acid is a bisphosphonate for skeletal protection.

Question 6Urological Oncology

Which feature on contrast-enhanced CT most strongly suggests that a renal mass is a benign angiomyolipoma rather than renal cell carcinoma?

  1. Heterogeneous arterial enhancement greater than cortex
  2. Calcification in the lesion wall
  3. Central necrosis with a thick irregular wall
  4. Macroscopic fat density within the lesion Correct answer.

Explanation

The presence of macroscopic fat, typically measured as very low attenuation on unenhanced CT, is the hallmark of angiomyolipoma and allows a confident benign diagnosis in most cases. Necrosis, calcification and hypervascular heterogeneous enhancement are features that raise concern for malignancy. Recognising fat avoids unnecessary nephrectomy.

Question 7Urological Oncology

Which serum marker is most useful for monitoring response to treatment in a patient with a non-seminomatous germ cell tumour?

  1. Prostate-specific antigen
  2. CA 19-9
  3. Beta-2 microglobulin
  4. Alpha-fetoprotein Correct answer.

Explanation

Alpha-fetoprotein is raised in a substantial proportion of non-seminomatous germ cell tumours and correlates with tumour burden and response to chemotherapy. Human chorionic gonadotrophin is also used, but AFP is specifically associated with non-seminomatous elements such as yolk sac tumour. PSA, CA 19-9 and beta-2 microglobulin are markers of other malignancies.

Question 8Urological Oncology

A patient with muscle-invasive bladder cancer is being counselled about radical cystectomy. Which urinary diversion avoids an external stoma while preserving continence via the anal sphincter?

  1. Nephrostomy drainage
  2. Cutaneous ureterostomy
  3. Ileal conduit
  4. Orthotopic neobladder Correct answer.

Explanation

An orthotopic neobladder uses a detubularised bowel segment anastomosed to the urethra, allowing voiding through the native urethra and relying on the anal sphincter for continence. An ileal conduit and cutaneous ureterostomy both require an external stoma, and nephrostomy is a temporary or palliative measure. Patient selection depends on sphincter function, renal function and motivation.

Question 9Urological Oncology

A 55-year-old man has a biopsy showing Gleason score 3+4=7 (ISUP grade group 2), PSA 8 ng/mL and cT2a disease. What is the most appropriate EAU risk category?

  1. Intermediate risk Correct answer.
  2. Metastatic risk
  3. High risk
  4. Low risk

Explanation

ISUP grade group 2 corresponds to Gleason 7, which by itself places the patient in the intermediate-risk group regardless of the otherwise favourable PSA and stage. Low risk requires grade group 1, and high risk requires grade group 4–5, PSA above 20 ng/mL or cT2c–T3a. The grade therefore drives the classification here.

Question 10Urological Oncology

A 45-year-old woman has a 4 cm enhancing renal mass with a level II inferior vena cava thrombus but no distant metastases. What is the most appropriate surgical approach?

  1. Active surveillance with annual imaging
  2. Partial nephrectomy alone
  3. Radical nephrectomy with thrombectomy and caval reconstruction Correct answer.
  4. Percutaneous radiofrequency ablation

Explanation

A tumour thrombus extending into the inferior vena cava requires radical nephrectomy combined with thrombectomy, often under cardiothoracic or vascular support, to achieve complete removal. Partial nephrectomy and ablation are unsuitable for locally advanced disease with venous invasion. Surveillance would allow progression of a potentially curable lesion.

Question 11Urological Oncology

A 68-year-old man with high-risk non-muscle-invasive bladder cancer is being considered for intravesical bacillus Calmette-Guérin. Which condition is an absolute contraindication?

  1. Active systemic infection with fever Correct answer.
  2. Previous transurethral resection
  3. Mild renal impairment
  4. Controlled type 2 diabetes

Explanation

Intravesical BCG is a live attenuated vaccine and must not be given during active systemic infection or in significantly immunocompromised patients because of the risk of disseminated BCGosis. Well-controlled diabetes, prior resection and mild renal impairment are not contraindications. Traumatic catheterisation is a relative reason to postpone instillation.

Question 12Urological Oncology

A 30-year-old man has a 3 cm right testicular mass, markedly raised alpha-fetoprotein and human chorionic gonadotrophin, and multiple lung metastases. What is the initial management after inguinal orchidectomy?

  1. Radiotherapy to the para-aortic field
  2. Systemic cisplatin-based chemotherapy Correct answer.
  3. Retroperitoneal lymph node dissection
  4. Surveillance with monthly markers

Explanation

Poor-prognosis metastatic non-seminomatous germ cell tumour with markedly raised markers and lung metastases is treated with cisplatin-based combination chemotherapy such as BEP. Primary retroperitoneal lymph node dissection and radiotherapy are not the initial approach for disseminated disease. Surveillance is inappropriate once metastases are documented.

Question 13Urological Oncology

A 72-year-old woman has a 2.5 cm upper tract urothelial carcinoma confined to the renal pelvis with normal contralateral kidney function. Which factor most strongly favours endoscopic kidney-sparing management over radical nephroureterectomy?

  1. Concurrent muscle-invasive bladder cancer
  2. Positive urine cytology
  3. Small, low-grade tumour without invasion on biopsy Correct answer.
  4. Hydronephrosis with impaired ipsilateral function

Explanation

EAU guidance supports kidney-sparing surgery for upper tract urothelial carcinoma when the tumour is small, low grade and non-invasive on biopsy, especially in patients with a solitary kidney or impaired renal function. High-grade cytology, concurrent invasive bladder cancer and obstruction with impaired function favour radical surgery. Careful risk stratification is essential because upper tract tumours are prone to recurrence.

Question 14Urological Oncology

Which finding on multiparametric MRI is used in PI-RADS version 2.1 to score a lesion in the peripheral zone as category 5?

  1. Diffuse low signal on T2-weighted imaging with no diffusion abnormality
  2. Focal markedly hypointense on apparent diffusion coefficient with marked hyperintensity on high b-value diffusion-weighted imaging, 1.5 cm or larger Correct answer.
  3. Homogeneous hyperintensity on T2-weighted imaging without diffusion restriction
  4. A well-defined cyst with thin walls

Explanation

In the peripheral zone, diffusion-weighted imaging drives the score, and a focal lesion with marked restricted diffusion measuring 1.5 cm or more is PI-RADS 5. Homogeneous T2 hyperintensity and simple cysts are benign patterns. Diffuse low T2 signal without diffusion restriction does not meet the criteria for a highly suspicious lesion.

Question 15Urological Oncology

A 60-year-old man with a 3 cm renal mass and a solitary kidney is being counselled. Which approach best balances oncological control with preservation of renal function?

  1. Partial nephrectomy with clamping of the renal artery Correct answer.
  2. Bilateral nephrectomy with immediate transplant
  3. Percutaneous cryoablation of the whole kidney
  4. Radical nephrectomy without dialysis planning

Explanation

Partial nephrectomy is the preferred option for a T1 renal mass in a solitary kidney because it preserves functioning parenchyma while achieving oncological clearance. Radical nephrectomy would render the patient anephric and dependent on dialysis. Ablation may be considered in poor surgical candidates but whole-kidney ablation is not appropriate.

Question 16Urological Oncology

Which chemotherapy regimen is standard first-line treatment for metastatic urothelial carcinoma in a fit patient?

  1. Single-agent mitomycin C
  2. Doxorubicin with cyclophosphamide
  3. Cisplatin with gemcitabine Correct answer.
  4. Cisplatin with bleomycin and etoposide

Explanation

Cisplatin-based combination chemotherapy, most commonly gemcitabine plus cisplatin, is the standard first-line regimen for fit patients with metastatic urothelial carcinoma. Carboplatin is substituted in patients unfit for cisplatin. The other regimens are used in different tumour types and are not standard here.

Question 17Urological Oncology

A 50-year-old man has a left testicular mass and a serum human chorionic gonadotrophin of 60,000 IU/L with normal alpha-fetoprotein. Which interpretation is most accurate?

  1. Markedly raised human chorionic gonadotrophin suggests a non-seminomatous element or choriocarcinoma and indicates poor prognosis Correct answer.
  2. The result indicates a benign Leydig cell tumour
  3. The result excludes metastatic disease
  4. The result confirms pure seminoma

Explanation

Very high human chorionic gonadotrophin levels are typical of choriocarcinoma or non-seminomatous germ cell tumours and, in the IGCCCG classification, values above 50,000 IU/L define poor prognosis in non-seminoma. Pure seminoma usually produces only modest elevations. Tumour markers inform prognosis and treatment but do not by themselves exclude metastases.

Question 18Urological Oncology

Which mechanism best explains resistance to androgen deprivation therapy in castration-resistant prostate cancer?

  1. Absence of prostate-specific antigen production
  2. Intratumoural androgen synthesis and androgen receptor amplification Correct answer.
  3. Complete loss of androgen receptor expression
  4. Inability of prostate cells to metastasise to bone

Explanation

Castration-resistant prostate cancer often remains androgen receptor dependent through mechanisms such as intratumoural androgen synthesis, androgen receptor gene amplification and activating mutations. Loss of receptor expression is uncommon and would not explain the typical progression pattern. These mechanisms underpin the use of abiraterone and enzalutamide.

Question 19Urological Oncology

A 65-year-old woman has a 1 cm papillary urothelial lesion in the bladder. Which statement about grading and recurrence is correct?

  1. High-grade tumours never recur after resection
  2. Low-grade tumours recur frequently but rarely progress to muscle invasion Correct answer.
  3. Low-grade tumours rarely recur but often metastasise
  4. Grade has no relationship to progression risk

Explanation

Low-grade papillary urothelial carcinomas have a high recurrence rate but a relatively low risk of progression to muscle-invasive disease. High-grade tumours carry a substantially greater risk of progression and metastasis. This distinction drives the intensity of surveillance and the use of intravesical therapy.

Question 20Urological Oncology

A patient with a 4 cm renal mass has a biopsy showing oncocytoma. Which management strategy is most appropriate if the lesion is asymptomatic?

  1. Immediate radical nephrectomy
  2. Active surveillance with periodic imaging Correct answer.
  3. Adjuvant immunotherapy
  4. Systemic targeted therapy with sunitinib

Explanation

Oncocytoma is a benign renal tumour, and asymptomatic lesions can be managed with active surveillance and serial imaging to confirm stability. Radical nephrectomy and systemic therapies are unnecessary and expose the patient to harm. Biopsy results should be interpreted alongside imaging because hybrid oncocytic tumours exist.

Question 21Urological Oncology

A 40-year-old man has a clinical stage I seminoma after orchidectomy with normal markers and no evidence of metastasis. Which management options are considered acceptable by EAU guidance?

  1. Palliative chemotherapy
  2. Surveillance, single-agent carboplatin or radiotherapy Correct answer.
  3. Immediate four cycles of BEP for all patients
  4. Retroperitoneal lymph node dissection as first-line standard

Explanation

For clinical stage I seminoma, surveillance, adjuvant single-agent carboplatin and adjuvant radiotherapy are all acceptable options, with surveillance increasingly preferred to avoid overtreatment. BEP chemotherapy is reserved for higher-stage or higher-risk disease. Primary retroperitoneal lymph node dissection is not standard for seminoma.

Question 22Urological Oncology

A 70-year-old man with metastatic prostate cancer develops spinal cord compression at T8. What is the most appropriate immediate management?

  1. High-dose corticosteroids followed by urgent surgical decompression or radiotherapy Correct answer.
  2. Oral abiraterone alone
  3. Watchful waiting with serial PSA
  4. Bisphosphonate infusion alone

Explanation

Metastatic spinal cord compression is an oncological emergency requiring immediate high-dose corticosteroids and urgent decompression, either surgically or by radiotherapy, to preserve neurological function. Systemic therapy alone does not relieve the mechanical compression. Delay risks irreversible paraplegia and sphincter loss.

Question 23Urological Oncology

A 55-year-old man with muscle-invasive bladder cancer has a solitary functioning kidney and a creatinine clearance of 45 mL/min. Which neoadjuvant approach is most appropriate before cystectomy?

  1. Standard full-dose cisplatin with gemcitabine
  2. Gemcitabine with carboplatin or split-dose cisplatin Correct answer.
  3. Radiotherapy alone without chemotherapy
  4. No treatment before surgery

Explanation

Neoadjuvant cisplatin-based chemotherapy improves survival in muscle-invasive bladder cancer, but full-dose cisplatin requires adequate renal function, generally a clearance above 60 mL/min. In patients with impaired renal function, split-dose cisplatin or carboplatin with gemcitabine is used. Omitting neoadjuvant therapy deprives the patient of a proven survival benefit.

Question 24Urological Oncology

A 35-year-old man has a non-seminomatous germ cell tumour with a 4 cm retroperitoneal mass and normal markers after orchidectomy. Which statement about post-chemotherapy residual mass management is correct?

  1. Resection is indicated only if markers are markedly elevated
  2. Residual masses larger than 1 cm in non-seminoma are generally resected because they may harbour viable tumour or teratoma Correct answer.
  3. Radiotherapy is the preferred treatment for residual non-seminomatous masses
  4. All residual masses in non-seminoma resolve spontaneously and require no surgery

Explanation

In non-seminomatous germ cell tumours, residual masses after chemotherapy are usually resected when larger than about 1 cm because they may contain viable tumour, teratoma with malignant transformation, or necrosis that cannot be distinguished reliably by imaging. Normal markers do not exclude viable tumour. Radiotherapy is not the standard approach for residual non-seminoma.

Question 25Urological Oncology

A 68-year-old woman has a 6 cm renal mass with renal vein involvement and a solitary pulmonary metastasis. Which sequence best reflects contemporary EAU-aligned management?

  1. Systemic therapy alone without nephrectomy in all patients
  2. Radical nephrectomy alone with no systemic treatment
  3. Palliative radiotherapy to the kidney as first-line treatment
  4. Cytoreductive nephrectomy followed by systemic therapy in selected patients Correct answer.

Explanation

In metastatic renal cell carcinoma, cytoreductive nephrectomy followed by systemic therapy can be considered in selected patients with good performance status and limited metastatic burden, although the sequence is increasingly individualised. Systemic therapy alone may be appropriate for poor-risk disease. Nephrectomy alone does not treat metastatic disease, and palliative radiotherapy to the primary is not first-line.

Question 26Urological Oncology

Which histological subtype accounts for the majority of renal cell carcinomas and typically arises from the proximal convoluted tubule?

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

Explanation

Clear cell renal cell carcinoma is the most common subtype, representing roughly 70-75% of renal cell carcinomas, and is thought to derive from proximal tubular epithelium. It is associated with inactivation of the von Hippel-Lindau gene on chromosome 3p. Papillary and chromophobe subtypes are less frequent, and collecting duct carcinoma is rare and aggressive.

Question 27Urological Oncology

A 62-year-old man is diagnosed with clinical T1a renal mass. According to tumour-node-metastasis staging, which size threshold defines a T1a renal tumour?

  1. Greater than 7 cm
  2. Between 4 and 7 cm
  3. 4 cm or less Correct answer.
  4. 7 cm or less

Explanation

In renal cell carcinoma staging, T1a denotes a tumour confined to the kidney measuring 4 cm or less. T1b covers tumours greater than 4 cm but not exceeding 7 cm, while T2 describes tumours larger than 7 cm still confined to the kidney. This distinction guides the choice between nephron-sparing surgery and radical nephrectomy.

Question 28Urological Oncology

Which serum tumour marker is most characteristically elevated in a pure testicular seminoma when markers are abnormal?

  1. Lactate dehydrogenase only in non-seminoma
  2. Human chorionic gonadotrophin Correct answer.
  3. Alpha-fetoprotein
  4. Carcinoembryonic antigen

Explanation

Pure seminomas may show modest elevation of human chorionic gonadotrophin in about 10-20% of cases due to syncytiotrophoblastic cells, but alpha-fetoprotein is never elevated in pure seminoma; its presence indicates non-seminomatous elements. Lactate dehydrogenase is a nonspecific marker that can be elevated in both but is not diagnostic. Carcinoembryonic antigen is not a germ cell tumour marker.

Question 29Urological Oncology

Which imaging modality is the reference standard for local staging of prostate cancer and guides targeted biopsy when clinical suspicion is high?

  1. Transrectal ultrasound alone
  2. Bone scintigraphy
  3. Multiparametric magnetic resonance imaging Correct answer.
  4. Computed tomography of the pelvis

Explanation

Multiparametric MRI combining T2-weighted, diffusion-weighted and dynamic contrast sequences provides the best soft-tissue resolution for local staging and lesion detection in prostate cancer. It underpins the PI-RADS scoring system and enables MRI-targeted biopsy. CT and bone scan assess nodal and skeletal spread rather than local disease.

Question 30Urological Oncology

A 58-year-old man has a 3 cm renal mass and a normal contralateral kidney. He wishes to preserve renal function. Which management offers the best oncological control with nephron preservation for a T1a tumour?

  1. Percutaneous radiofrequency ablation as first-line for all
  2. Radical nephrectomy
  3. Active surveillance for all T1a tumours
  4. Partial nephrectomy Correct answer.

Explanation

Partial nephrectomy is the standard of care for T1a renal masses when technically feasible, achieving cancer control equivalent to radical surgery while preserving renal function and reducing cardiovascular risk. Active surveillance is reasonable in frail or comorbid patients but not the default for a fit 58-year-old. Ablation is an alternative for poor surgical candidates or small peripheral tumours, not the universal first-line choice.

Question 31Urological Oncology

A 66-year-old man with muscle-invasive bladder cancer undergoes radical cystectomy with an ileal conduit. Which metabolic complication is most likely to arise from urine contact with bowel mucosa over time?

  1. Hyperchloraemic metabolic acidosis Correct answer.
  2. Metabolic alkalosis
  3. Respiratory alkalosis
  4. Hyperkalaemia with hypochloraemia

Explanation

Ileal and colonic conduits reabsorb urinary chloride and ammonium while losing bicarbonate, producing a normal-anion-gap hyperchloraemic metabolic acidosis, especially when renal function is impaired. This is the classic long-term metabolic disturbance after urinary diversion using bowel segments. Alkalosis and hyperkalaemia are not characteristic of ileal conduit physiology.

Question 32Urological Oncology

A 70-year-old man has high-grade non-muscle-invasive bladder cancer with carcinoma in situ. Which intravesical agent is the standard first-line adjunct after transurethral resection to reduce recurrence and progression?

  1. Intravesical gemcitabine
  2. Intravesical bacillus Calmette-Guérin Correct answer.
  3. Intravesical mitomycin C alone
  4. Intravesical epirubicin

Explanation

For high-risk non-muscle-invasive bladder cancer, particularly with carcinoma in situ, intravesical bacillus Calmette-Guérin induction followed by maintenance is the standard adjunct because it reduces both recurrence and progression. Mitomycin C and epirubicin are used mainly for lower-risk disease or as perioperative single instillations. Gemcitabine is generally reserved for BCG-unresponsive disease in combination regimens.

Question 33Urological Oncology

A 28-year-old man has a clinical stage I non-seminomatous germ cell tumour after orchidectomy with normal markers. Which management strategy is a recognised option that avoids unnecessary treatment in patients who may be cured by surgery alone?

  1. Immediate retroperitoneal lymph node dissection in all patients
  2. Surveillance with serial markers and imaging Correct answer.
  3. Adjuvant radiotherapy to the retroperitoneum
  4. Immediate four cycles of bleomycin, etoposide and cisplatin

Explanation

Surveillance is an accepted option for clinical stage I non-seminoma because a substantial proportion of patients are cured by orchidectomy alone, and salvage therapy is highly effective for those who relapse. Adjuvant chemotherapy or nerve-sparing retroperitoneal lymph node dissection are alternatives selected by risk factors and patient preference. Radiotherapy has no role in non-seminoma.

Question 34Urological Oncology

A 74-year-old man with metastatic castration-resistant prostate cancer and symptomatic bone metastases is being considered for a radiopharmaceutical. Which agent targets prostate-specific membrane antigen and delivers beta radiation to PSMA-expressing tumour cells?

  1. Radium-223
  2. Samarium-153 lexidronam
  3. Strontium-89 chloride
  4. Lutetium-177 PSMA-617 Correct answer.

Explanation

Lutetium-177 PSMA-617 is a radioligand that binds prostate-specific membrane antigen and delivers beta-particle radiation to PSMA-expressing prostate cancer cells, with proven survival benefit in metastatic castration-resistant disease after prior therapy. Radium-223, samarium-153 and strontium-89 are bone-seeking agents that target osteoblastic metastases rather than PSMA.

Question 35Urological Oncology

Which parameter from the International Society of Urological Pathology grading system replaced the Gleason score in contemporary prostate cancer reporting and stratifies outcomes into five groups?

  1. Gleason sum alone
  2. ISUP grade group Correct answer.
  3. Tumour volume on biopsy
  4. Percentage of Gleason pattern 4

Explanation

The ISUP grade group system condenses Gleason scores into five prognostic groups, from grade group 1 (Gleason 3+3=6) to grade group 5 (Gleason 9-10), improving discrimination of outcomes over the Gleason sum alone. Percentage of pattern 4 and tumour volume are additional prognostic details but are not the five-tier grouping.

Question 36Urological Oncology

A 60-year-old woman has a 2 cm upper tract urothelial carcinoma of the renal pelvis. Which factor most strongly determines whether kidney-sparing endoscopic management is appropriate rather than radical nephroureterectomy?

  1. Tumour grade and size on ureteroscopy Correct answer.
  2. Patient age alone
  3. Serum creatinine level
  4. Presence of hypertension

Explanation

Kidney-sparing management of upper tract urothelial carcinoma is considered mainly for low-grade, low-stage, small tumours that can be completely resected endoscopically, making grade and size the key determinants. Age alone, renal function and hypertension do not define oncological suitability, though renal function influences the choice of radical surgery and dialysis planning. High-grade or large tumours generally warrant radical nephroureterectomy.

Question 37Urological Oncology

Which paraneoplastic syndrome is classically associated with renal cell carcinoma and results from ectopic production of a hormone-like peptide?

  1. Carcinoid syndrome due to serotonin
  2. Hypercalcaemia due to parathyroid hormone-related peptide Correct answer.
  3. Cushing syndrome due to ectopic adrenocorticotropic hormone
  4. Hypoglycaemia due to insulinoma

Explanation

Renal cell carcinoma can produce parathyroid hormone-related peptide, causing hypercalcaemia in the absence of bone metastases, and this is one of its classic paraneoplastic manifestations. Other recognised paraneoplastic features include polycythaemia from erythropoietin, hypertension from renin and hepatic dysfunction (Stauffer syndrome). Insulinoma, ectopic ACTH and carcinoid syndrome are not typical of renal cell carcinoma.

Question 38Urological Oncology

A 55-year-old man with a 4 cm renal mass has a core biopsy showing a small renal oncocytoma. Which statement best reflects the role of biopsy in this situation?

  1. Biopsy results should always mandate immediate radical nephrectomy
  2. Biopsy cannot fully exclude malignancy because oncocytoma and chromophobe carcinoma overlap, so resection or surveillance is individualised Correct answer.
  3. Biopsy reliably excludes malignancy, so surveillance is always safe
  4. Biopsy is contraindicated in any renal mass

Explanation

Renal tumour biopsy has diagnostic limitations because oncocytoma and the eosinophilic variant of chromophobe renal cell carcinoma can be morphologically and immunohistochemically similar. A biopsy suggesting oncocytoma therefore reduces but does not eliminate the probability of malignancy, so management is individualised based on size, growth and patient factors. Biopsy is not contraindicated and does not mandate radical surgery.

Question 39Urological Oncology

A 68-year-old man with metastatic hormone-sensitive prostate cancer is started on androgen deprivation therapy plus a novel hormonal agent. Which mechanism best describes the action of abiraterone in this setting?

  1. Gonadotrophin-releasing hormone receptor agonism
  2. Direct androgen receptor antagonism
  3. Microtubule stabilisation
  4. Inhibition of CYP17A1, blocking androgen biosynthesis Correct answer.

Explanation

Abiraterone inhibits CYP17A1, blocking the synthesis of androgens in the adrenal glands and within the tumour, and is given with prednisone to suppress mineralocorticoid excess. Androgen receptor antagonists such as enzalutamide act by direct receptor blockade. GnRH agonists suppress gonadal androgen production, and microtubule stabilisers such as docetaxel have a different mechanism.

Question 40Urological Oncology

A 63-year-old woman has a 5 cm renal mass with a level III inferior vena cava thrombus extending above the hepatic veins but below the diaphragm. Which surgical consideration most strongly influences operative planning?

  1. The need for cardiopulmonary bypass and hypothermic circulatory arrest Correct answer.
  2. The choice of laparoscopic approach
  3. The need for neoadjuvant radiotherapy
  4. The likelihood of requiring partial nephrectomy

Explanation

Level III inferior vena cava thrombi extend above the hepatic veins but remain below the diaphragm, and resection often requires mobilisation of the liver and control of the suprahepatic cava, sometimes with cardiopulmonary bypass depending on the upper extent. Level IV thrombi extending above the diaphragm or into the right atrium typically require bypass and circulatory arrest. Laparoscopic approaches and neoadjuvant radiotherapy are not standard for caval thrombus.

Question 41Andrology and Male Sexual Health

A 24-year-old man is evaluated for primary infertility. Semen analysis shows a volume of 0.8 mL, absent fructose, and azoospermia. What is the most likely underlying diagnosis?

  1. Ejaculatory duct obstruction
  2. Hypogonadotropic hypogonadism
  3. Congenital bilateral absence of the vas deferens Correct answer.
  4. Retrograde ejaculation

Explanation

Low-volume azoospermia with absent seminal fructose points to failure of seminal vesicle contribution, classically congenital bilateral absence of the vas deferens, which is strongly associated with CFTR mutations. The absent vas deferens prevents sperm and seminal vesicle fluid from reaching the ejaculate.

Question 42Andrology and Male Sexual Health

Which hormone profile is characteristic of primary testicular failure (hypergonadotropic hypogonadism)?

  1. Low testosterone with low LH and low FSH
  2. Low testosterone with elevated LH and elevated FSH Correct answer.
  3. Elevated testosterone with suppressed LH and FSH
  4. Normal testosterone with low LH and low FSH

Explanation

When the testis fails, negative feedback from testosterone and inhibin B is reduced, so the pituitary raises LH and FSH. The combination of low testosterone with high gonadotropins defines primary hypogonadism.

Question 43Andrology and Male Sexual Health

A 19-year-old presents with acute left scrotal pain of 3 hours duration. Which finding most strongly favors testicular torsion over epididymitis?

  1. Relief of pain with elevation of the scrotum
  2. Gradual onset of pain over several days
  3. Bilateral scrotal swelling
  4. Absent cremasteric reflex on the affected side Correct answer.

Explanation

Loss of the cremasteric reflex on the affected side is a classic sign of testicular torsion and supports immediate surgical exploration. Time-critical presentation with sudden severe pain further raises suspicion for torsion.

Question 44Andrology and Male Sexual Health

Which agent is first-line medical therapy for a man with moderate erectile dysfunction and no contraindications?

  1. Intracavernosal alprostadil
  2. A PDE5 inhibitor such as sildenafil Correct answer.
  3. Testosterone replacement
  4. A vacuum erection device

Explanation

Oral PDE5 inhibitors are recommended first-line for erectile dysfunction because of efficacy, acceptability, and safety in most men. Other options are reserved for non-responders or specific indications.

Question 45Andrology and Male Sexual Health

A man on sildenafil for erectile dysfunction develops chest pain. Which medication is absolutely contraindicated because of the risk of severe hypotension?

  1. Metoprolol
  2. Aspirin
  3. Sublingual nitroglycerin Correct answer.
  4. Atorvastatin

Explanation

Nitrates combined with PDE5 inhibitors cause profound, potentially fatal hypotension through excessive cGMP accumulation. Nitrates must be avoided within 24 hours of sildenafil and 48 hours of tadalafil.

Question 46Andrology and Male Sexual Health

Which parameter on semen analysis is most directly reduced by a prolonged abstinence period beyond the recommended 2–7 days?

  1. Seminal pH
  2. Semen volume
  3. Sperm concentration
  4. Sperm motility Correct answer.

Explanation

Prolonged abstinence increases semen volume and total sperm number but reduces the proportion of motile sperm, so motility is the parameter most affected. Standard abstinence of 2–7 days is recommended to standardize results.

Question 47Andrology and Male Sexual Health

A 35-year-old man has a painless, firm testicular mass. Serum AFP and beta-hCG are elevated. Which tumor type is most consistent with this profile?

  1. Pure seminoma
  2. Leydig cell tumor
  3. Sertoli cell tumor
  4. Non-seminomatous germ cell tumor Correct answer.

Explanation

Elevation of AFP and beta-hCG strongly suggests a non-seminomatous germ cell tumor, since pure seminomas do not raise AFP. Tumor markers guide diagnosis and monitoring of germ cell neoplasms.

Question 48Andrology and Male Sexual Health

Which of the following best describes the mechanism of action of tamsulosin in lower urinary tract symptoms?

  1. 5-alpha-reductase inhibition shrinking prostate volume
  2. Muscarinic receptor antagonism reducing detrusor contractility
  3. Phosphodiesterase-5 inhibition increasing urethral blood flow
  4. Selective alpha-1A adrenergic blockade relaxing prostatic smooth muscle Correct answer.

Explanation

Tamsulosin is a selective alpha-1A antagonist that relaxes smooth muscle in the prostate and bladder neck, improving urine flow. It provides symptom relief without reducing prostate size.

Question 49Andrology and Male Sexual Health

A 28-year-old man reports premature ejaculation with intravaginal ejaculatory latency consistently under one minute. Which first-line treatment is most appropriate?

  1. Daily tadalafil
  2. Bilateral orchiectomy
  3. On-demand topical lidocaine or a delayed ejaculation strategy such as a serotonin reuptake inhibitor Correct answer.
  4. Intracavernosal injection therapy

Explanation

First-line management of lifelong premature ejaculation includes behavioral techniques, topical anesthetics, and off-label SSRIs or the on-demand agent dapoxetine where available. These target ejaculatory control directly.

Question 50Andrology and Male Sexual Health

In a man with acute bacterial prostatitis, which organism is the most common cause?

  1. Escherichia coli Correct answer.
  2. Chlamydia trachomatis
  3. Candida albicans
  4. Staphylococcus saprophyticus

Explanation

Enteric gram-negative bacilli, especially Escherichia coli, account for most acute bacterial prostatitis cases. Empiric antibiotics should cover these organisms and penetrate prostatic tissue.