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FEBU Part 1 study materials
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FEBU Part 1 practice questions

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Question 1General urology and andrology

Which event within the preceding 48 hours can cause a transient rise in serum prostate-specific antigen (PSA) and should be avoided before repeat testing?

  1. Ejaculation Correct answer.
  2. Fasting
  3. A short walk
  4. Finasteride use

Explanation

Ejaculation can transiently increase serum PSA, so many laboratories advise abstinence for about 48 hours before measurement. Prostate biopsy, urinary retention, and prostatitis are stronger causes of elevation. Finasteride lowers PSA rather than raising it.

Question 2General urology and andrology

A 15-year-old boy presents with sudden severe left scrotal pain, nausea, and a high-lying transverse testis. What is the most appropriate immediate management?

  1. Urgent scrotal exploration Correct answer.
  2. Oral antibiotics and outpatient review
  3. Scrotal ultrasound before any intervention
  4. NSAIDs and reassessment in 6 hours

Explanation

Testicular torsion is a surgical emergency, and typical history and examination should prompt immediate scrotal exploration rather than delay for imaging. Detorsion and bilateral orchidopexy are performed to preserve the testis and prevent recurrence. Time-dependent testicular salvage is the key concern.

Question 3General urology and andrology

Which drug class relieves lower urinary tract symptoms in benign prostatic hyperplasia mainly by relaxing smooth muscle in the prostate and bladder neck?

  1. Alpha-1 adrenergic antagonists Correct answer.
  2. 5-alpha-reductase inhibitors
  3. Loop diuretics
  4. Muscarinic receptor antagonists

Explanation

Alpha-1 adrenergic antagonists relax prostatic and bladder neck smooth muscle, producing relatively rapid improvement in lower urinary tract symptoms. 5-alpha-reductase inhibitors reduce prostate volume more slowly, while muscarinic antagonists are used for overactive bladder symptoms. Loop diuretics may worsen urinary frequency.

Question 4General urology and andrology

A 40-year-old man has a 6 mm distal ureteral stone, well-controlled pain, no fever, and normal renal function. What is the preferred initial management?

  1. Immediate extracorporeal shock wave lithotripsy
  2. Observation with NSAIDs and hydration Correct answer.
  3. Percutaneous nephrostomy
  4. Emergency ureteroscopy

Explanation

Small distal ureteral stones often pass spontaneously, so observation with analgesia and hydration is appropriate when pain is controlled and there is no infection or renal impairment. Urologic intervention is reserved for failure of passage, uncontrolled symptoms, sepsis, or obstruction with deteriorating renal function.

Question 5General urology and andrology

Which exposure is the strongest established risk factor for urothelial carcinoma of the bladder?

  1. Long-term statin use
  2. Cigarette smoking Correct answer.
  3. High dietary calcium intake
  4. Neonatal circumcision

Explanation

Cigarette smoking is the most important established risk factor for urothelial carcinoma of the bladder, largely through exposure to aromatic amines and other carcinogens. Occupational exposures such as aniline dyes and rubber manufacturing are also recognized. Dietary calcium, statins, and neonatal circumcision are not established bladder carcinogens.

Question 6General urology and andrology

A 58-year-old man reports erectile dysfunction but has normal libido and consistent morning erections. Which diagnosis is most likely?

  1. Bilateral cavernous nerve injury
  2. Psychogenic erectile dysfunction Correct answer.
  3. Prolactin-secreting pituitary adenoma
  4. Severe cavernosal arterial insufficiency

Explanation

Preserved morning erections and normal libido suggest intact nocturnal erectile physiology, making a psychogenic contribution more likely than severe organic disease. Cavernous nerve injury and severe arterial insufficiency usually impair nocturnal tumescence as well. Hyperprolactinemia typically reduces libido.

Question 7General urology and andrology

Why is varicocele much more common on the left side?

  1. Higher metabolic rate of the left testis
  2. Left spermatic vein valve incompetence Correct answer.
  3. Greater length of the left vas deferens
  4. Compression by the left renal artery

Explanation

The left internal spermatic vein drains into the left renal vein, often at a right angle and with less competent valves, predisposing to venous reflux and varicocele. The right internal spermatic vein drains more directly into the inferior vena cava. This anatomic difference explains the left-sided predominance.

Question 8General urology and andrology

A 32-year-old man has a painful erection lasting 5 hours after intracavernosal alprostadil. Corporal aspiration returns dark hypoxic blood. After aspiration, what is the next appropriate treatment?

  1. Oral tadalafil
  2. Immediate penile prosthesis insertion
  3. Warm scrotal compresses
  4. Intracavernosal phenylephrine Correct answer.

Explanation

This is ischemic priapism, and corporal aspiration followed by intracavernosal phenylephrine is the standard initial treatment. Phenylephrine is an alpha-adrenergic agonist that promotes cavernosal smooth muscle contraction and venous outflow. Surgical shunting is considered if aspiration and repeated phenylephrine fail.

Question 9General urology and andrology

A hemodynamically stable patient has a grade IV renal laceration with urinary extravasation after blunt trauma. What is the preferred management?

  1. Immediate ureteral reimplantation
  2. Immediate open nephrectomy
  3. Nonoperative observation with repeat imaging Correct answer.
  4. Routine renal artery embolization

Explanation

Hemodynamically stable patients with high-grade renal trauma and urinary extravasation are usually managed nonoperatively with observation, serial examination, and repeat imaging. Angiography with embolization is reserved for active bleeding, and surgery is reserved for hemodynamic instability or other urgent indications. Many grade IV injuries heal without operative repair.

Question 10General urology and andrology

A 30-year-old man has low serum testosterone, elevated LH, and elevated FSH. Which condition best explains these results?

  1. Pituitary macroadenoma
  2. Kallmann syndrome
  3. Klinefelter syndrome Correct answer.
  4. Exogenous testosterone use

Explanation

Low testosterone with elevated LH and FSH indicates primary hypogonadism, reflecting failure of testicular steroidogenesis and spermatogenesis with loss of negative feedback. Klinefelter syndrome is a common cause of primary hypogonadism. Kallmann syndrome and pituitary disease cause central hypogonadism with low or inappropriately normal gonadotropins.

Question 11General urology and andrology

A 12-month-old boy is brought for a routine visit. His right testis is not palpable in the scrotum and has never descended. According to current guidelines, by what age should orchidopexy ideally be performed to reduce the risk of infertility and malignancy?

  1. After 5 years of age, when the child can cooperate
  2. At puberty, after hormonal therapy has been tried
  3. Immediately after birth, within the first 2 weeks
  4. Between 6 and 18 months of age Correct answer.

Explanation

Current guidelines recommend orchidopexy by 18 months of age, ideally between 6 and 12 months, because early placement into the scrotum reduces the risk of impaired spermatogenesis and testicular malignancy. Surgery after puberty has little benefit for fertility and increases the risk of cancer. Hormonal therapy is not a substitute for timely surgical correction.

Question 12General urology and andrology

A 22-year-old sexually active woman presents with burning on urination, urinary frequency, and suprapubic discomfort. She has no fever or flank pain. Which organism is the most common cause of uncomplicated cystitis in this setting?

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

Explanation

Escherichia coli causes approximately 75-95% of uncomplicated cystitis in women. Staphylococcus saprophyticus is a distant second in young sexually active women, while Proteus and Klebsiella are more often associated with complicated infections or structural abnormalities.

Question 13General urology and andrology

A 55-year-old man with a history of gout passes a kidney stone. Which stone composition is most likely to be radiolucent on a plain abdominal radiograph?

  1. Struvite (magnesium ammonium phosphate)
  2. Calcium oxalate monohydrate
  3. Uric acid Correct answer.
  4. Cystine

Explanation

Uric acid stones lack calcium and therefore appear radiolucent on plain radiography, although they are visible on non-contrast CT. Calcium oxalate, struvite, and cystine stones contain calcium or sufficient density to appear radiopaque.

Question 14General urology and andrology

A 65-year-old man with benign prostatic hyperplasia starts finasteride. His lower urinary tract symptoms do not improve after 2 weeks, and he asks why. What is the best explanation for the delayed response?

  1. It relaxes prostatic smooth muscle but needs dose escalation
  2. It blocks alpha-1 receptors and requires four weeks to reach steady state
  3. It raises serum testosterone and temporarily worsens symptoms
  4. It shrinks the prostate by inhibiting 5-alpha reductase over months Correct answer.

Explanation

Finasteride is a 5-alpha reductase inhibitor that lowers dihydrotestosterone and gradually shrinks the prostate over 3 to 6 months. Symptom improvement therefore lags behind that of alpha-1 blockers, which relax smooth muscle within days.

Question 15General urology and andrology

A 58-year-old man with poorly controlled diabetes presents with fever, severe scrotal pain, and crepitus on examination of the perineum. What is the most appropriate immediate management?

  1. Oral antibiotics and outpatient follow-up in 48 hours
  2. Scrotal elevation and warm compresses alone
  3. Hyperbaric oxygen therapy as the sole treatment
  4. Urgent surgical debridement combined with broad-spectrum intravenous antibiotics Correct answer.

Explanation

Fournier's gangrene is a necrotizing fasciitis of the perineum and requires emergency surgical debridement together with broad-spectrum intravenous antibiotics. Delay in surgery increases mortality. Hyperbaric oxygen may be used as an adjunct but is never the sole treatment.

Question 16General urology and andrology

A 60-year-old woman with overactive bladder has not responded to behavioral therapy and cannot tolerate antimuscarinics because of dry mouth. Which medication acts by relaxing detrusor smooth muscle through beta-3 adrenergic receptor agonism?

  1. Oxybutynin
  2. Mirabegron Correct answer.
  3. Tamsulosin
  4. Solifenacin

Explanation

Mirabegron is a beta-3 adrenergic agonist that relaxes the detrusor muscle and increases bladder capacity. Solifenacin and oxybutynin are antimuscarinics, and tamsulosin is an alpha-1 blocker used for benign prostatic hyperplasia.

Question 17General urology and andrology

A prostate biopsy reports a Gleason score of 4+3=7. How does this differ prognostically from a Gleason score of 3+4=7?

  1. The 3+4 score has a worse prognosis because pattern 3 is more aggressive
  2. The two scores have identical prognosis because the total is 7
  3. The 4+3 score has a better prognosis because pattern 4 is less aggressive
  4. The 4+3 score has a worse prognosis because the primary pattern is 4 Correct answer.

Explanation

In the Gleason system, the primary pattern carries more prognostic weight. A score of 4+3=7 has a higher proportion of pattern 4 and a worse prognosis than 3+4=7, despite the same total score.

Question 18General urology and andrology

A 32-year-old man with a T4 spinal cord injury suddenly develops a severe pounding headache, profuse sweating, and blood pressure of 210/110 mmHg during bladder catheterization. His heart rate is 48 bpm. What is the most likely cause?

  1. Septic shock from a urinary tract infection
  2. Anticholinergic toxicity from bladder medication
  3. Autonomic dysreflexia triggered by bladder distension Correct answer.
  4. Pheochromocytoma crisis

Explanation

Autonomic dysreflexia occurs in patients with spinal cord injury above T6 when a noxious stimulus, commonly bladder distension, triggers a sympathetic surge below the injury. This causes severe hypertension, headache, sweating, and reflex bradycardia. Immediate bladder drainage and antihypertensive treatment are required.

Question 19General urology and andrology

A 30-year-old man has a testicular mass. After radical orchiectomy, pathology confirms pure seminoma. Which serum tumor marker is expected to be normal in this condition?

  1. Lactate dehydrogenase (LDH)
  2. Beta-human chorionic gonadotropin (beta-hCG)
  3. Alpha-fetoprotein (AFP) Correct answer.
  4. Placental alkaline phosphatase (PLAP)

Explanation

Pure seminomas do not produce alpha-fetoprotein; an elevated AFP suggests a non-seminomatous component or mixed germ cell tumor. Beta-hCG can be elevated in about 10-20% of seminomas, and LDH and PLAP may also rise.

Question 20General urology and andrology

A 34-year-old man is evaluated for infertility. Semen analysis shows a volume of 0.8 mL, pH 6.2, and no sperm. Fructose is absent. Serum FSH is normal. What is the most likely diagnosis?

  1. Hypogonadotropic hypogonadism
  2. Klinefelter syndrome
  3. Maturation arrest of spermatogenesis
  4. Bilateral absence of the vas deferens Correct answer.

Explanation

Low ejaculate volume, acidic pH, absent fructose, and normal FSH point to obstruction at the ejaculatory ducts or congenital bilateral absence of the vas deferens. Non-obstructive causes such as Klinefelter syndrome or maturation arrest typically have elevated FSH and normal semen volume and fructose.

Question 21Uro-oncology

Which histological subtype accounts for approximately 75% of renal cell carcinomas?

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

Explanation

Clear cell renal cell carcinoma is the most common subtype, accounting for roughly 70–80% of sporadic renal cell carcinomas. Papillary carcinoma accounts for about 10–15%, chromophobe carcinoma for about 5%, and collecting duct carcinoma is rare and aggressive. Subtype matters because prognosis, hereditary associations, and systemic therapy options differ.

Question 22Uro-oncology

In a man with a testicular germ cell tumour, elevation of which serum marker establishes that the tumour has a non-seminomatous component?

  1. Alpha-fetoprotein Correct answer.
  2. CA 19-9
  3. Lactate dehydrogenase
  4. Human chorionic gonadotrophin

Explanation

Alpha-fetoprotein is not produced by pure seminoma, so its elevation indicates yolk sac or other non-seminomatous elements. Human chorionic gonadotrophin can be raised in both seminoma and non-seminoma, and lactate dehydrogenase is nonspecific. Correct marker interpretation influences stage and treatment selection.

Question 23Uro-oncology

A prostate biopsy shows Gleason pattern 3+4=7. According to the ISUP 2019/WHO grading system, what is the grade group?

  1. Grade group 4
  2. Grade group 1
  3. Grade group 2 Correct answer.
  4. Grade group 3

Explanation

Gleason 3+4=7 corresponds to ISUP grade group 2, whereas 4+3=7 is grade group 3, Gleason 8 is group 4, and Gleason 9–10 is group 5. Grade group 2 is an intermediate-risk category and is managed accordingly. Accurate grading is essential because it drives risk stratification and treatment decisions.

Question 24Uro-oncology

What was the principal outcome of the European Randomized Study of Screening for Prostate Cancer (ERSPC) comparing PSA screening with no screening?

  1. Lower all-cause mortality but unchanged cancer mortality
  2. A large mortality reduction without overdiagnosis
  3. No difference in mortality at any follow-up
  4. A modest cancer mortality reduction with overdiagnosis Correct answer.

Explanation

ERSPC reported a relative reduction in prostate cancer mortality of about 20% with PSA screening, but the absolute benefit was small and came at the cost of considerable overdiagnosis and overtreatment. The PLCO trial, in contrast, did not show a significant mortality benefit. These results underpin risk-adapted, shared decision-making approaches to early detection.

Question 25Uro-oncology

A 66-year-old man has a serum PSA of 7.5 ng/mL and a normal digital rectal examination. He has not had a previous prostate biopsy. According to current European guidelines, what is the most appropriate next step?

  1. CT of the pelvis and bone scan for staging
  2. Repeat PSA in 12 months without further investigation
  3. Multiparametric MRI of the prostate before any biopsy Correct answer.
  4. Immediate transrectal ultrasound-guided 12-core biopsy

Explanation

European guidelines recommend multiparametric MRI before prostate biopsy to improve detection of clinically significant cancer and reduce unnecessary biopsies. A suspicious lesion is targeted, and systematic biopsy is added according to risk. Staging imaging is not indicated before a cancer diagnosis has been established.

Question 26Uro-oncology

Which patient with non-muscle-invasive bladder cancer has the clearest indication for intravesical bacillus Calmette–Guérin (BCG) induction and maintenance therapy?

  1. A 55-year-old with a single, low-grade pTa tumour and no recurrence at 3 months
  2. A 65-year-old with a pTa G1 tumour completely resected and negative cytology
  3. A 70-year-old with carcinoma in situ of the bladder Correct answer.
  4. A 60-year-old with a single, low-grade pTa tumour less than 3 cm

Explanation

Carcinoma in situ is a high-risk non-muscle-invasive lesion and is an absolute indication for BCG, which reduces recurrence and progression. Low-risk tumours such as single small pTa G1 lesions are managed with complete resection and early single-instillation chemotherapy rather than BCG. Risk stratification therefore determines whether BCG is appropriate.

Question 27Uro-oncology

A 58-year-old woman has a 3.2 cm enhancing mass in the left kidney and a normal contralateral kidney. She is fit for surgery. What is the preferred surgical management?

  1. Active surveillance with repeat imaging in 12 months
  2. Radical nephrectomy with ipsilateral adrenalectomy
  3. Partial nephrectomy with negative margin Correct answer.
  4. Percutaneous radiofrequency ablation as first-line therapy

Explanation

For a T1a renal mass, partial nephrectomy is the standard of care when technically feasible, preserving renal function without compromising oncological control. Radical nephrectomy is reserved for larger or centrally located tumours where partial resection is not feasible. Ablation is generally reserved for small masses in patients who are poor surgical candidates.

Question 28Uro-oncology

A 68-year-old man has a 2 cm tumour in the right renal pelvis with hydronephrosis and cytology positive for high-grade urothelial carcinoma. There is no evidence of metastasis. What is the standard surgical treatment?

  1. Endoscopic laser ablation of the tumour
  2. Right partial ureterectomy and reimplantation
  3. Right radical nephrectomy alone
  4. Right nephroureterectomy with excision of a bladder cuff Correct answer.

Explanation

High-risk upper tract urothelial carcinoma is managed by radical nephroureterectomy with removal of the bladder cuff to eradicate the whole urothelial tract and reduce recurrence. Kidney-sparing surgery is reserved for low-risk, small, solitary tumours with normal cytology. High-grade cytology and hydronephrosis indicate aggressive disease requiring radical surgery.

Question 29Uro-oncology

A 62-year-old man has a 2.5 cm squamous cell carcinoma of the glans penis. Biopsy shows pT1b, grade 2, and there are no palpable inguinal lymph nodes. What is the most appropriate management of the inguinal lymph nodes?

  1. Dynamic sentinel node biopsy Correct answer.
  2. Bilateral inguinal lymph node dissection in all cases
  3. Prophylactic inguinal radiotherapy
  4. Observation with clinical examination every 3 months

Explanation

In penile cancer, patients with pT1b or high-grade tumours and non-palpable inguinal nodes are at significant risk of occult nodal metastasis, and invasive staging with dynamic sentinel node biopsy is recommended. Inguinal lymphadenectomy is reserved for node-positive disease, and radiotherapy is not given prophylactically. Risk-adapted nodal staging improves survival by identifying occult metastases early.

Question 30Uro-oncology

In metastatic castration-resistant prostate cancer, which molecular finding best predicts benefit from a PARP inhibitor such as olaparib?

  1. Pathogenic BRCA2 mutation Correct answer.
  2. PTEN loss
  3. AR-V7 splice variant expression
  4. ERG gene rearrangement

Explanation

PARP inhibitors exploit synthetic lethality in tumours with homologous recombination repair defects, and BRCA2 mutations are the strongest predictive biomarker. PTEN loss and ERG rearrangement are common in prostate cancer but do not confer the same sensitivity. AR-V7 predicts resistance to androgen receptor-targeted agents rather than response to PARP inhibition.

Question 31Uro-oncology

Which histological type accounts for the majority of bladder cancers diagnosed in Europe and North America?

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

Explanation

Urothelial carcinoma accounts for approximately 90% of bladder cancers in non-schistosomal regions. Squamous cell carcinoma is more frequent where Schistosoma haematobium is endemic, and adenocarcinoma and small-cell carcinoma are uncommon.

Question 32Uro-oncology

A 72-year-old man with newly diagnosed prostate cancer asks where the disease most often spreads first when it metastasizes. Which site is most typical?

  1. Bone Correct answer.
  2. Liver
  3. Lung
  4. Brain

Explanation

Prostate cancer metastasizes most commonly to the axial skeleton through the valveless Batson venous plexus. Liver, lung, and brain metastases occur but are less frequent as the initial site of spread.

Question 33Uro-oncology

A 24-year-old man presents with a painless, firm left testicular mass. What is the most likely diagnosis?

  1. Acute bacterial epididymo-orchitis
  2. Testicular germ cell tumour Correct answer.
  3. Varicocele of the pampiniform plexus
  4. Idiopathic hydrocele

Explanation

A painless, firm intratesticular mass in a young man is a germ cell tumour until proven otherwise. Epididymo-orchitis is painful, hydrocele transilluminates, and varicocele feels like a bag of worms above the testis.

Question 34Uro-oncology

A 68-year-old man has a 3 cm high-grade T1 urothelial carcinoma that was completely resected at TURBT; the specimen contains no muscularis propria. What is the most appropriate next step?

  1. Intravesical BCG alone
  2. Repeat TURBT Correct answer.
  3. Immediate radical cystectomy
  4. Cystoscopy in 3 months

Explanation

A T1 high-grade tumour with no muscle in the specimen is incompletely staged, so repeat TURBT is required to exclude muscle invasion. Immediate cystectomy is reserved for selected very-high-risk disease, and BCG alone before restaging risks undertreatment.

Question 35Uro-oncology

A 59-year-old man with clear-cell renal cell carcinoma has a serum calcium of 3.1 mmol/L, a suppressed PTH, and no bone metastases. Which mechanism best explains the hypercalcaemia?

  1. Ectopic PTH secretion
  2. PTHrP secretion Correct answer.
  3. Osteolytic bone metastases
  4. Primary hyperparathyroidism

Explanation

Humoral hypercalcaemia from tumour PTH-related peptide is the commonest mechanism in RCC and explains the suppressed PTH without bone lesions. Ectopic PTH secretion is very rare, and osteolytic metastases are excluded by imaging.

Question 36Uro-oncology

A 64-year-old man underwent radical prostatectomy for pT3a N0 prostate cancer. Eighteen months later his PSA rises from 0.02 to 0.25 ng/mL and imaging is negative. What is the most appropriate management?

  1. Repeat radical prostatectomy
  2. Observation until PSA exceeds 2 ng/mL
  3. Androgen deprivation therapy alone
  4. Prostate-bed salvage radiotherapy Correct answer.

Explanation

Biochemical recurrence after radical prostatectomy is best managed with early salvage radiotherapy to the prostate bed, which offers the chance of cure. Androgen deprivation alone is not curative, and delaying treatment until PSA exceeds 2 ng/mL reduces the likelihood of durable control.

Question 37Uro-oncology

A 60-year-old man has a 1.5 cm pT1G1 squamous cell carcinoma of the glans penis and no palpable inguinal nodes. What is the recommended management of the inguinal regions?

  1. Bilateral inguinal lymph node dissection
  2. Observation Correct answer.
  3. Sentinel node biopsy
  4. Prophylactic inguinal radiotherapy

Explanation

pT1G1 penile cancer carries a low risk of occult inguinal metastasis, so surveillance is appropriate when nodes are impalpable. Invasive nodal staging is reserved for higher-risk tumours such as pT1G2 or greater.

Question 38Uro-oncology

A 70-year-old man undergoes radical nephroureterectomy for a pT3N0 high-grade urothelial carcinoma of the renal pelvis. Which adjuvant treatment has been shown to improve disease-free survival?

  1. External-beam radiotherapy to the renal bed
  2. Interferon-alpha immunotherapy
  3. Intravesical bacillus Calmette–Guérin
  4. Gemcitabine–cisplatin chemotherapy Correct answer.

Explanation

The POUT trial showed that adjuvant gemcitabine–cisplatin improves disease-free survival after nephroureterectomy for high-risk upper tract urothelial carcinoma. Intravesical BCG treats the bladder lumen, not the retroperitoneal field, and renal-bed radiotherapy and interferon are not standard adjuvant options.

Question 39Uro-oncology

A 35-year-old man has metastatic non-seminomatous germ cell tumour with a testicular primary, an AFP of 5,000 ng/mL, an hCG of 10,000 IU/L, and lung metastases only. According to the IGCCCG, which risk group applies?

  1. Intermediate risk Correct answer.
  2. Unclassifiable without LDH
  3. Good risk
  4. Poor risk

Explanation

The IGCCCG assigns non-seminoma to intermediate risk when AFP is 1,000–10,000 ng/mL or hCG is 5,000–50,000 IU/L without non-pulmonary visceral metastases. This patient's AFP and hCG both fall in the intermediate range, and lung-only spread does not make the disease poor risk.

Question 40Uro-oncology

A 65-year-old man with cT2N0M0 muscle-invasive bladder cancer is fit for cisplatin and proceeds to radical cystectomy. Which neoadjuvant regimen is standard?

  1. Gemcitabine plus cisplatin Correct answer.
  2. Single-agent carboplatin
  3. Mitomycin plus fluorouracil
  4. Intravesical BCG

Explanation

Neoadjuvant gemcitabine plus cisplatin, or dose-dense MVAC, improves overall survival before radical cystectomy for muscle-invasive bladder cancer. Carboplatin is used when cisplatin is unsuitable but is not the standard neoadjuvant choice in fit patients.

Question 41Stone disease and endourology

A 45-year-old man has a 9 mm renal stone that is not seen on plain abdominal radiography but is clearly demonstrated on non-contrast CT with a density of about 300 Hounsfield units. Which stone composition is most likely?

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

Explanation

Uric acid stones are typically radiolucent on plain radiography because they contain little or no calcium, yet they are well seen on non-contrast CT. Calcium oxalate stones are usually radiopaque, cystine stones are faintly radiopaque, and struvite stones often contain enough calcium to be visible.

Question 42Stone disease and endourology

A 62-year-old woman presents with a temperature of 39°C, flank pain, and an 8 mm obstructing proximal ureteral stone with hydronephrosis. What is the most appropriate immediate management?

  1. Intravenous antibiotics alone without drainage
  2. Urgent decompression plus intravenous antibiotics Correct answer.
  3. Elective ureteroscopy after urine culture results are available
  4. Oral tamsulosin and outpatient review in one week

Explanation

An obstructed infected urinary tract is a urological emergency because it can progress to sepsis. Immediate drainage by ureteral stent or percutaneous nephrostomy, together with broad-spectrum antibiotics, is required; definitive stone treatment is deferred until the infection is controlled.

Question 43Stone disease and endourology

Which finding is an absolute contraindication to extracorporeal shock wave lithotripsy for a renal stone?

  1. A previously placed ureteral stent
  2. An uncorrected bleeding diathesis Correct answer.
  3. A body mass index of 32 kg/m²
  4. A 1 cm lower-pole stone

Explanation

Uncorrected coagulopathy is an absolute contraindication to shock wave lithotripsy because of the risk of uncontrolled retroperitoneal or renal bleeding. Lower-pole location, moderate obesity, and an indwelling ureteral stent are relative or technical considerations rather than absolute contraindications.

Question 44Stone disease and endourology

A 35-year-old man has a 6 mm distal ureteral stone, well-controlled pain, and no signs of infection. He asks about medical expulsive therapy. Which agent is most appropriate?

  1. Allopurinol
  2. Potassium citrate
  3. Tamsulosin Correct answer.
  4. Furosemide

Explanation

An alpha-1 adrenergic blocker such as tamsulosin relaxes the distal ureteral smooth muscle and has the best supporting evidence for medical expulsive therapy in distal ureteral stones, particularly those larger than 5 mm. It is used only when analgesia is adequate and there is no infection or obstruction requiring intervention.

Question 45Stone disease and endourology

A 55-year-old woman has a 3.5 cm staghorn calculus with mild hydronephrosis and normal renal function. Which treatment is most appropriate?

  1. Extracorporeal shock wave lithotripsy alone
  2. Flexible ureteroscopy alone
  3. Observation with annual imaging
  4. Percutaneous nephrolithotomy Correct answer.

Explanation

Percutaneous nephrolithotomy is the first-line treatment for a large staghorn calculus because it achieves high stone-free rates in a single procedure. Shock wave lithotripsy and ureteroscopy alone are inadequate for this stone burden, and observation risks infection, pain, and renal deterioration.

Question 46Stone disease and endourology

A 40-year-old man with recurrent calcium oxalate stones has hypercalciuria. Which dietary advice is most appropriate?

  1. Increase animal protein intake
  2. Maintain normal dietary calcium and reduce sodium intake Correct answer.
  3. Increase vitamin C supplementation
  4. Restrict dietary calcium to less than 400 mg per day

Explanation

A normal dietary calcium intake binds oxalate in the gut and reduces oxalate absorption, so severe calcium restriction can increase stone risk. Reducing sodium lowers urinary calcium excretion, and this combination is preferred in hypercalciuric calcium oxalate stone formers.

Question 47Stone disease and endourology

A 58-year-old man has a 1.2 cm radiolucent renal stone and a urine pH of 5.2. Which medical regimen is most appropriate for attempted dissolution?

  1. Allopurinol alone
  2. Sodium bicarbonate targeting pH above 8.5
  3. Ascorbic acid supplementation
  4. Potassium citrate targeting pH 7.0-7.2 Correct answer.

Explanation

Uric acid solubility increases sharply as urine pH rises, and oral potassium citrate is used to target a urine pH of approximately 7.0 to 7.2. Over-alkalinization should be avoided because it can promote calcium phosphate stones, and allopurinol is an adjunct rather than a dissolution agent by itself.

Question 48Stone disease and endourology

A 28-year-old man with recurrent cystine stones undergoes urinalysis. Which finding is most characteristic of cystinuria?

  1. Triple phosphate crystals from urease-producing infection
  2. Coffin-lid crystals typical of struvite
  3. Hexagonal crystals with a positive nitroprusside test Correct answer.
  4. Envelope-shaped crystals typical of calcium oxalate

Explanation

Cystine crystals are hexagonal and the sodium nitroprusside test is a classic screening test for cystinuria. Envelope-shaped crystals suggest calcium oxalate, coffin-lid crystals suggest struvite, and triple phosphate crystals are also associated with struvite infection stones.

Question 49Stone disease and endourology

During flexible ureteroscopy for a 1.5 cm renal stone, a ureteral access sheath is used. What is the main advantage of this device?

  1. It allows stone fragmentation without any irrigation
  2. It prevents all ureteral strictures after ureteroscopy
  3. It facilitates scope passage and lowers intrarenal pressure Correct answer.
  4. It eliminates the need for laser lithotripsy

Explanation

A ureteral access sheath provides a stable conduit for repeated passage of a flexible ureteroscope and improves irrigation outflow, which helps maintain visibility and reduce intrarenal pressure. It does not fragment stones or eliminate the risk of ureteral injury, and stricture risk is reduced by careful technique rather than abolished.

Question 50Stone disease and endourology

A 30-year-old woman presents with sudden severe flank pain and microscopic hematuria; acute ureteral colic is suspected. Which imaging study is first-line in a non-pregnant adult?

  1. Abdominal MRI
  2. Non-contrast CT KUB Correct answer.
  3. Intravenous urography
  4. Renal ultrasound alone

Explanation

Non-contrast CT has high sensitivity and specificity for urinary stones and also identifies obstruction and alternative diagnoses. Ultrasound is preferred in pregnancy or when CT is unavailable, while intravenous urography and routine MRI are not first-line for acute stone disease.