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26. A follow-up computed tomography (CT) scan in a
60-year-old patient with previous nephrolithiasis reveals
a 1.5 cm hypovascular round lesion with clear margins
in the right adrenal gland. The patient is not hypertensive, hyperglycemic, or hypokalemic. Urinary catechol
metabolites are within normal limits, and serum cortisol and adrenocorticotropin hormone (ACTH) levels are
normal. Which course is advisable?
CHAPTER 38
Thyroid, Parathyroid, and Adrenal
A. Repeat CT scan and chemical tests annually
B. Percutaneous fine needle aspiration biopsy
C. Adrenal venous sampling for cortisol, renin, and
angiotensin
D. Laparoscopic adrenalectomy
27. Advantages of laparoscopic adrenalectomy compared
to open adrenalectomy include all of the following
EXCEPT:
A. Decreased blood loss.
B. Faster return to work.
C. Decreased operative time.
D. Decreased narcotic analgesic use.
28. In patients who undergo bilateral adrenalectomy in treatment of Cushing disease after failed attempts at resection
of an adrenocorticotropin hormone (ACTH)-secreting
pituitary adenoma, the subsequent development of Nelson syndrome is associated with which of the following?
A. Hypertension
B. Diminished visual fields
C. Loss of hearing
D. Incontinence
Answer: A
The adrenal “incidentaloma” is an increasingly common
finding with the ubiquitous use of CT scanning, with an incidence of 0.4% to 4.4%. A variety of benign and malignant
lesions can account for these findings, and a distant history
of malignancy elsewhere should raise the possibility of metastatic disease. Primary malignancy of the adrenal gland is
rare, and the functioning tumors are excluded by screening
tests for cortisol and catecholamine excess. In the absence of
symptoms associated with adrenal disease, annual follow-up
of these lesions with imaging and chemical tests seems prudent. (See Schwartz 11th ed., pp. 1696–1697.)
Answer: C
Laparoscopic (videoscopic) approaches to adrenalectomy
have been shown to be advantageous for several outcomes
including wound complications, analgesic use, and length of
hospital stay. These advantages are in balance to adverse considerations including length of operative time and cost. (See
Schwartz 11th ed., p. 1698.)
Answer: B
Nelson syndrome describes symptoms due to the progressive
enlargement of a persistent ACTH-secreting pituitary fossa
tumor. These symptoms include hyperpigmentation, visual
field loss, headaches, and extraocular muscle palsies. Interference with the olfactory nerve, hypertension, and incontinence is not part of the syndrome. (See Schwartz 11th ed.,
p. 1701.)
CHAPTER 39
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Pediatric Surgery
1. Operative management of a newborn with the chest
X-ray shown in Fig. 39-1 should occur:
A. Immediately after birth.
B. Within 24 hours after birth.
C. Within 72 hours after birth.
D. None of the above.
Answer: D
The diagnosis of congenital diaphragmatic hernia (CDH) is
made by chest X-ray with the vast majority of infants developing immediate respiratory distress and pulmonary hypertension. Congenital diaphragmatic hernia care has improved
considerably through effective use of improved methods of
ventilation and timely cannulation for extracorporeal membrane oxygenation. In the past, correction of the hernia was
believed to be a surgical emergency and patients underwent
surgery shortly after birth. It is now accepted that the presence of persistent pulmonary hypertension that results in
right-to-left shunting across the patent foramen ovale or
the ductus arteriosus and the degree of pulmonary hypoplasia are the leading causes of cardiorespiratory insufficiency.
Current management is therefore directed toward managing
the pulmonary hypertension, which is usually seen within 7
to 10 days, but in some infants, may take up to several weeks
to develop. (See Schwartz 11th ed., p. 1712.)
FIG. 39-1.
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2. A 4-year-old boy presents with a midline neck mass. On
physical examination, the mass is nontender and moves
up and down with swallowing. There is no drainage or
erythema and the thyroid gland is palpable in its normal
anatomic location. A thyroglossal duct cyst is suspected.
What is the appropriate treatment?
A. Observation
B. Incision and drainage of the cyst
CHAPTER 39
Pediatric Surgery
C. Resection of the cyst, central portion of the hyoid
bone and tract to the pharynx
D. Excision of the cyst
3. An infant comes to the emergency room with bilious
emesis and irritability. Physical examination is notable
for abdominal tenderness and erythema of the abdominal wall. Abdominal X-ray demonstrates dilated proximal
bowel with air-fluid levels. What is the most appropriate
next step in management, after resuscitation?
A. Upper gastrointestinal series
B. Barium enema
C. Gastrostomy
D. Laparotomy
Answer: C
Resection of the thyroglossal duct cyst in continuity with the
central portion of the hyoid bone and the tract connecting to
the pharynx in addition to ligation at the foramen cecum (the
Sistrunk operation) is curative in >90% of patients. Lesser
operations result in unacceptably high recurrence rates, and
recurrence is more frequent following infection. According
to a recent review, factors predictive of recurrence included
more than two infections prior to surgery, age < 2 years, and
inadequate initial operation. (See Schwartz 11th ed., p. 1710.)
Answer: D
The cardinal symptom of intestinal obstruction in the newborn is bilious emesis. Prompt recognition and treatment of
neonatal intestinal obstruction can truly be life-saving. Bilious
vomiting is usually the first sign of volvulus, and all infants
with bilious vomiting must be evaluated rapidly to ensure
that they do not have intestinal malrotation with volvulus.
The child with irritability and bilious emesis should raise particular suspicions for this diagnosis. If left untreated, vascular
compromise of the midgut initially causes bloody stools, but
eventually results in circulatory collapse. Additional clues to
the presence of advanced ischemia of the intestine include
erythema and edema of the abdominal wall, which progress
to shock and death. It must be reemphasized that the index
of suspicion for this condition must be high, since abdominal
signs are minimal in the early stages. Abdominal films show
a paucity of gas throughout the intestine with a few scattered
air-fluid levels. When these findings are present, the patient
should undergo immediate fluid resuscitation to ensure adequate perfusion and urine output followed by prompt exploratory laparotomy. (See Schwartz 11th ed., p. 1725.)
4. A 4-week-old full-term, otherwise healthy female is admitted with nonbilious projectile emesis. Ultrasound shows a
pyloric channel length of 16 mm and a pyloric thickness of
4 mm. Labs show hypokalemic, hypochloremic metabolic
alkalosis. What is the next best step in management?
A. Fluid resuscitation with 5% dextrose and 0.45% saline
with added potassium until correction of electrolyte
abnormalities
B. Fluid resuscitation with normal saline until achieving
a urine output of >2 mL/kg per hour for 24 hours
C. Immediate laparoscopic pyloromyotomy
D. Emergent open pyloromyotomy
5. The most common form of esophageal atresia (EA) is:
A. Pure EA (no fistula).
B. Pure tracheoesophageal fistula (TEF) (no atresia).
C. EA with distal TEF.
D. EA with proximal TEF.
Answer: A
Given frequent fluid and electrolyte abnormalities at time of
presentation, pyloric stenosis is never a surgical emergency.
Fluid resuscitation with correction of electrolyte abnormalities and metabolic alkalosis is essential prior to induction of
general anesthesia for operation. For most infants, fluid containing 5% dextrose and 0.45% saline with added potassium
of 2 to 4 mEq/kg over 24 hours at a rate of approximately 150
to 175 mL/kg for 24 hours will correct the underlying deficit.
It is important to ensure that the child has an adequate urine
output (>2 mL/kg per hour) as further evidence that rehydration has occurred. (See Schwartz 11th ed., p. 1722.)
Answer: C
The five major varieties of EA and TEF are shown in Fig. 39-2.
The most commonly seen variety is EA with distal TEF
(type C), which occurs in approximately 85% of the cases in
most series. The next most frequent type is pure EA (type A),
occurring in 8% to 10% of patients, followed by TEF without
EA (type E). This occurs in 8% of cases and is also referred to
as an H-type fistula, based on the anatomic similarity to that
letter (Fig. 39-3). EA with fistula between both proximal and
distal ends of the esophagus and trachea (type D) is seen in
approximately 2% of cases, and type B, EA with TEF between
proximal esophagus and trachea, is seen in approximately 1%
of all cases. (See Schwartz 11th ed., p. 1717.)
FIG. 39-2. The five varieties of esophageal atresia and tracheoesophageal fistula. A. Isolated esophageal atresia.
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B. Esophageal atresia with tracheoesophageal fistula between proximal segment of esophagus and trachea.
C. Esophageal atresia with tracheoesophageal fistula between distal esophagus and trachea. D. Esophageal atresia
with fistula between both proximal and distal ends of esophagus and trachea. E. Tracheoesophageal fistula without
esophageal atresia (H-type fistula).
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CHAPTER 39
Pediatric Surgery
6. The predicted 4-year survival rate of a child with a Wilms
tumor that is confined to one kidney and is grossly
excised is:
A. 24%.
B. 38%.
C. 68%.
D. 97%.
FIG. 39-3. Barium esophagram showing H-type
tracheoesophageal fistula (arrow).
Answer: D
Following nephroureterectomy for Wilms tumor, the need for
chemotherapy and/or radiation therapy is determined by the
histology of the tumor and the clinical stage of the patient
(Table 39-1). Essentially, patients who have disease confined
to one kidney that is completely excised surgically receive a
short course of chemotherapy and can expect a 97% 4-year
survival, with tumor relapse rare after that time. Patients with
more advanced disease or with unfavorable histology receive
more intensive chemotherapy and radiation. Even in stage IV,
cure rates of 80% are achieved. The survival rates are worse in
the small percentage of patients considered to have unfavorable histology. (See Schwartz 11th ed., p. 1747.)
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CHAPTER 39
Pediatric Surgery
TABLE 39-1 Staging of Wilms tumor
Stage I: Tumor limited to the kidney and completely excised.
Stage II: Tumor that extends beyond the kidney but is completely excised. This includes penetration of the renal capsule, invasion of the soft tissues of
the renal sinus, or blood vessels within the nephrectomy specimen outside the renal parenchyma containing tumor. No residual tumor is apparent at or
beyond the margins of excision.
Stage III: Residual nonhematogenous tumor confined to the abdomen. Lymph nodes in the abdomen or pelvis contain tumor. Peritoneal contamination
by the tumor, such as by spillage or biopsy of tumor before or during surgery. Tumor growth that has penetrated through the peritoneal surface.
Implants are found on the peritoneal surfaces. Tumor extends beyond the surgical margins either microscopically or grossly. Tumor is not completely
resectable because of local infiltration into vital structures. The tumor was treated with preoperative chemotherapy with or without biopsy. Tumor is
removed in greater than one piece.
Stage IV: Hematogenous metastases or lymph node involvement outside the abdomino-pelvic region.
Stage V: Bilateral renal involvement.
International Neuroblastoma Staging System
Stage 1: Localized tumor with complete gross resection, with or without microscopic residual disease
Stage 2A: Localized tumor with incomplete gross excision; representative ipsilateral nonadherent lymph nodes negative for tumor
Stage 2B: Localized tumor with or without complete gross excision, with ipsilateral nonadherent lymph nodes positive for tumor. Enlarged contralateral
lymph nodes must be negative microscopically
Stage 3: Unresectable unilateral tumor crossing midline, with or without regional lymph node involvement; or localized unilateral tumor with contralateral
regional lymph node involvement; or midline tumor
Stage 4: Any primary tumor with dissemination to distant lymph nodes, bone, bone marrow, liver, skin, and/or other organs
Stage 4S: In infants <1 year of age; localized primary tumor with dissemination limited to skin, liver, and/or bone marrow
International Neuroblastoma Risk Group Staging System
L1 Localized tumor not involving vital structures as defined by the list of IDRFs and confined to one body compartment
L2 Locoregional tumor with the presence of one or more IDRFs
M Distant metastatic disease (except MS)
MS Metastatic disease in children <18 months confined to skin, liver, and bone marrow
a
Rupture or spillage confined to the flank, including biopsy of the tumor, is no longer included in stage II and is now included in stage III.
a
7. A premature infant boy has been started on enteral feeds
shortly after birth, but develops feeding intolerance
2 weeks postnatally. He displays abdominal tenderness,
distention, and bloody stools. An abdominal radiograph
is obtained and is shown in Fig. 39-4. What should be the
next step in management?
A. Nasogastric decompression, parenteral nutrition,
broad spectrum antibiotics
B. Laparotomy, excision of the affected bowel with
ostomy formation
C. Laparotomy, reduction of the volvulus, division of
adhesions, appendectomy
D. Water-soluble contrast enema
Answer: A
The radiograph demonstrates pneumatosis intestinalis and,
in conjunction with the clinical scenario described, exhibits
Bell stage II necrotizing enterocolitis (NEC). In all infants suspected of having NEC, feeds are discontinued, a nasogastric
tube is placed, total parenteral nutrition (TPN) is started and
broad-spectrum parenteral antibiotics are given. The infant
is resuscitated and inotropes are administered to maintain
perfusion as needed. Intubation and mechanical ventilation
may be required to maintain oxygenation. Subsequent treatment may be influenced by the particular stage of NEC that is
present. Patients with Bell stage II disease merit close observation. Serial physical examinations are performed looking
FIG. 39-4. Abdominal radiograph of
infant with necrotizing enterocolitis.
Arrows point to area of pneumatosis
intestinalis.
for the development of diffuse peritonitis, a fixed mass, pro-
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gressive abdominal wall cellulitis, or systemic sepsis. If infants
fail to improve after several days of treatment or if abdominal
radiographs show a fixed intestinal loop, consideration should
be given to exploratory laparotomy. (See Schwartz 11th ed.,
p. 1727.)
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8. An infant girl is found to have persistent jaundice after
birth. A metabolic screen is normal, ultrasound demonstrates an absent gallbladder, and a technetium-99m
iminodiacetic acid scan shows radionuclide that is concentrated in the liver, but not excreted into the intestine.
Which of the following statements is TRUE?
A. This condition is usually managed nonoperatively.
B. Surgery should be performed within 60 days of life.
C. Cystoenterostomy provides adequate biliary
drainage.
D. Most of these patients will not require transplantation.
9. The leading cause of death among children older than 1
year of age is:
A. Malignancy.
B. Infection.
C. Injury.
D. Congenital anomalies.
Answer: B
This patient has biliary atresia, a rare disease characterized by
fibroproliferative obliteration of the biliary tree, which progresses toward hepatic fibrosis, cirrhosis, and end-stage liver
failure. Surgical treatment is the first-line therapy, consisting
of creation of a hepatoportoenterostomy (Kasai procedure).
Numerous studies suggest that the likelihood of surgical
success is inversely related to the age at the time of portoenterostomy. Infants treated prior to 60 days of life are more
likely to achieve successful and long-term biliary drainage
than older infants. Although the outlook is less favorable for
patients after the 12th week, it is reasonable to proceed with
surgery even beyond this time point, as the alternative is certain liver failure. Approximately one-third of patients remain
symptom-free after portoenterostomy; the remainder require
liver transplantation due to progressive liver failure. Independent risk factors that predict failure of the procedure include
bridging liver fibrosis at the time of surgery and postoperative
cholangitic episodes. (See Schwartz 11th ed., p. 1737.)
Answer: C
Injury is the leading cause of death among children older than
1 year. In fact, trauma accounts for almost half of all pediatric
deaths, more than cancer, congenital anomalies, pneumonia,
heart disease, homicide, and meningitis combined. Motor
vehicle collisions are the leading cause of death in people age
1 to 19 years, followed by homicide or suicide (predominantly
with firearms) and drowning. Unintentional injuries account
for 65% of all injury-related deaths in children younger than
19 years. Each year, approximately 20,000 children and teenagers die as a result of injury in the United States. For every
child who dies from an injury, it is calculated that 40 others
are hospitalized and 1120 are treated in emergency departments. An estimated 50,000 children acquire permanent
disabilities each year, most of which are the result of head
injuries. Thus, the problem of pediatric trauma continues to
be one of the major threats to the health and well-being of
children. (See Schwartz 11th ed., p. 1751.)
CHAPTER 39
Pediatric Surgery
10. A “double bubble” on an abdominal radiograph in an
infant is characteristic of:
A. Duodenal atresia.
B. Jejunal atresia.
C. Meconium ileus.
D. Pyloric stenosis.
Answer: A
Whenever the diagnosis of duodenal obstruction is entertained, malrotation and midgut volvulus must be excluded.
Other causes of duodenal obstruction include duodenal atresia, duodenal web, stenosis, annular pancreas, or duodenal
duplication cyst. The classic finding on abdominal radiography is the “double bubble” sign, which represents the dilated
stomach and duodenum (Fig. 39-5). In association with the
appropriate clinical picture, this finding is sufficient to confirm the diagnosis of duodenal obstruction. (See Schwartz
11th ed., p. 1724.)
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CHAPTER 39
Pediatric Surgery
11. How is the diagnosis of Hirschsprung disease definitively
made?
A. Observation of failure to pass meconium within
48 hours after birth
B. Barium enema showing a rectosigmoid ratio < 1
C. Rectal biopsies with no ganglion cells in the myen-
teric plexus
D. Barium enema showing a rectosigmoid ratio > 1
FIG. 39-5. Abdominal X-ray
showing “double bubble” sign in
a newborn infant with duodenal
atresia. The two “bubbles” are
numbered.
Answer: C
The definitive diagnosis of Hirschsprung disease is made by
rectal biopsy. Samples of mucosa and submucosa are obtained
at 1 cm, 2 cm, and 3 cm from the dentate line. This can be performed at the bedside in the neonatal period without anesthesia, as samples are taken in bowel that does not have somatic
innervation and is thus not painful to the child. In older children, the procedure should be performed using IV sedation.
The histopathology of Hirschsprung disease is the absence of
ganglion cells in the myenteric plexuses, increased acetylcholinesterase staining, and the presence of hypertrophied nerve
bundles. It is important to obtain a barium enema in children
in whom the diagnosis of Hirschsprung disease is suspected.
This test may demonstrate the location of the transition zone
between the dilated ganglionic colon and the distal constricted aganglionic rectal segment. Our practice is to obtain
this test before instituting rectal irrigations if possible so that
the difference in size between the proximal and distal bowel is
preserved. Although the barium enema can only suggest, but
not reliably establish, the diagnosis of Hirschsprung disease,
it is very useful in excluding other causes of distal intestinal
obstruction. (See Schwartz 11th ed., p. 1734.)
12. Which of the following statements regarding pediatric
inguinal hernia repair (herniorrhaphy) is FALSE?
A. Herniorrhaphy should be performed following
reduction of an incarcerated hernia either during the
index admission or promptly on an elective basis.
B. An asymptomatic inguinal hernia may be monitored
for spontaneous closure.
C. Inguinal hernias in children result from a congeni-
tally patent processus vaginalis.
D. Spinal anesthesia in preterm infants undergoing her-
niorrhaphy decreases the risk of postoperative apnea
when compared to general anesthesia.
Answer: B
When the diagnosis of inguinal hernia is made in an otherwise normal child, operative repair should be planned.
Spontaneous resolution does not occur, and therefore a nonoperative approach cannot ever be justified. (See Schwartz
11th ed., p. 1743.)
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13. During attempted reduction of bowel in a newborn with
gastroschisis who has a 3 cm abdominal wall defect to
the right of the umbilical cord, the ventilator begins to
alarm with high peak inspiratory pressures (>25 cm
H2O). What is the next best step in management?
A. Place the remaining bowel into a plastic silo and per-
form delayed reduction.
B. Proceed with reduction but avoid primary closure.
C. Decompress the stomach with an orogastric tube and
the rectum with irrigations.
D. Proceed with reduction and primary closure.
14. A 3-year-old patient presents with recurrent lower gastrointestinal bleeding. What imaging modality is used to
diagnose a bleeding Meckel’s diverticulum?
A. Doppler ultrasound
B. Computed tomography
C. Technetium pertechnetate scan
D. Capsule endoscopy
Answer: A
Care must be taken to prevent markedly increased abdominal
pressure during the reduction, which will lead to compression of the inferior vena cava, respiratory embarrassment,
and abdominal compartment syndrome. To avoid this
complication, it is helpful to monitor the bladder or airway
pressures during reduction. In infants whose intestine has
become thickened and edematous, it may be impossible to
reduce the bowel into the peritoneal cavity in the immediate
postnatal period. Under such circumstances, a plastic springloaded silo can be placed onto the bowel and secured beneath
the fascia or a sutured silastic silo constructed. The silo covers the bowel and allows for graduated reduction on a daily
basis as the edema in the bowel wall decreases. (See Schwartz
11th ed., p. 1741.)
Answer: C
A Meckel diverticulum is a remnant of a portion of the embryonic omphalomesenteric (vitelline) duct. It is located on the
antimesenteric border of the ileum, usually within 2 ft of the
ileocecal valve. Ectopic gastric mucosa within a Meckel diverticulum may produce ileal ulcerations that bleed and lead
to the passage of maroon-colored stools. Pancreatic mucosa
may also be present. Diagnosis may be made by technetium
pertechnetate scans when the patient presents with bleeding.
(See Schwartz 11th ed., p. 1733.)
CHAPTER 39
Pediatric Surgery
15. What type of choledochal cyst accounts for 80% to 90%
of all cases and has a fusiform dilatation of the common
bile duct?
A. Type IV
B. Type III
C. Type II
D. Type I
16. A 9-month-old boy presents with two episodes of vomiting as well as episodes of colicky pain. His abdominal
examination is notable for upper abdominal tenderness
and his stools are guaiac positive. Ultrasound demonstrates a target sign. He is taken for an air-contrast
enema. What is the likelihood that he will need operative
intervention?
A. 25%
B. 50%
C. 75%
D. 90%
Answer: D
Type I choledochal cyst is characterized by fusiform dilatation of the bile duct. This is the most common type and
is found in 80% to 90% of cases. Type II choledochal cysts
appear as an isolated diverticulum protruding from the wall
of the common bile duct. The cyst may be joined to the common bile duct by a narrow stalk. Type III choledochal cysts
arise from the intraduodenal portion of the common bile
duct and are also known as choledochoceles. Type IVA cysts
consist of multiple dilatations of the intrahepatic and extrahepatic bile ducts. Type IVB choledochal cysts are multiple
dilatations involving only the extrahepatic bile ducts. Type V
(Caroli disease) consists of multiple dilatations limited to the
intrahepatic bile ducts. (See Schwartz 11th ed., p. 1739.)
Answer: A
Patients with intussusception should be assessed for the presence of peritonitis and for the severity of systemic illness. In the
absence of peritonitis, the child should undergo radiographic
reduction. The air enema is diagnostic and may also be curative, and it is the preferred method of diagnosis and treatment of intussusception. Air is introduced with a manometer,
and the pressure that is administered is carefully monitored.
Under most instances, this should not exceed 120 mm Hg.
Successful reduction is marked by free reflux of air into multiple loops of small bowel and symptomatic improvement as
the infant suddenly becomes pain-free. Unless both of these
signs are observed, it cannot be assumed that the intussusception is reduced. If reduction is unsuccessful and the infant
remains stable, the infant should be brought back to the radiology suite for a repeat attempt at reduction after a few hours.
This strategy has improved the success rate of nonoperative
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reduction in many centers. In addition, hydrostatic reduction
with barium may be useful if pneumatic reduction is unsuccessful. The overall success rate of radiographic reduction
varies based on the experience of the center and is typically
between 60% and 90%. (See Schwartz 11th ed., p. 1731.)
17. A male infant is born with an imperforate anus. Prior to
surgery, a VACTERL workup is performed. Which study
CHAPTER 39
is not part of the typical workup?
A. Echocardiogram
B. Renal ultrasound
C. Spinal radiographs
D. Brain MRI
Pediatric Surgery
18. A newborn female with cystic fibrosis and meconium
ileus without perforation has been managed with
N- acetylcysteine (Mucomyst) infused transanally every
12 hours. She remains obstructed and is taken to the
operating room for intervention. What is the optimal
surgical procedure?
A. Enterectomy with ileostomy creation
B. Simple enterotomy with lavage
C. Ileocecectomy with primary anastomosis
D. Colotomy with retrograde lavage
Answer: D
Approximately 60% of patients with imperforate anus have
an associated malformation. The most common is a urinary
tract defect, which occurs in approximately 50% of patients.
Skeletal defects are also seen, and the sacrum is most commonly involved. Spinal cord anomalies especially tethered
cored are common, particularly in children with high lesions.
Gastrointestinal anomalies occur, most commonly esophageal atresia. Cardiac anomalies may be noted, and occasionally patients present with a constellation of defects as part of
the VACTERL syndrome. (See Schwartz 11th ed., p. 1735.)
Answer: B
If surgical intervention is required because of failure of contrast enemas to relieve obstruction in meconium ileus, operative irrigation with dilute contrast agent, N-acetylcysteine,
or saline through a purse-string suture may be successful.
Alternatively, resection of the distended terminal ileum is
performed, and the meconium pellets are flushed from the
distal small bowel. At this point, an end ileostomy may be created. The distal bowel may be brought up as a mucus fistula or
sewn to the side of the ileum as a classic Bishop-Koop anastomosis. An end-to-end anastomosis may also be considered
in the appropriate setting. (See Schwartz 11th ed., p. 1726.)
19. Standard volume of packed red blood cell transfusion in
the newborn infant is:
A. 10 mL/kg.
B. 5 mL/kg.
C. 20 mL/kg.
D. 7 mL/kg.
20. Undescended testes are usually repaired by what age?
A. 6 months
B. 1 year of age
C. 2 years of age
D. 4 years of age
Answer: A
A useful guideline for estimating blood volume for the newborn infant is approximately 80 mL/kg of body weight. When
packed red blood cells are required, the transfusion requirement is usually administered in 10 mL/kg increments, which
is roughly equivalent to a 500-mL transfusion for a 70-kg
adult. (See Schwartz 11th ed., p. 1707.)
Answer: C
Males with bilateral undescended testicles are often infertile.
When the testicle is not within the scrotum, it is subjected to a
higher temperature, resulting in decreased spermatogenesis.
Mengel and coworkers studied 515 undescended testicles by
histology and demonstrated a decreasing presence of spermatogonia after 2 years of age. Despite orchidopexy, the incidence of infertility is approximately two times higher in men
with unilateral orchidopexy compared to men with normal
testicular descent. Consequently, it is now recommended that
the undescended testicle be surgically repositioned by 1 year
of age. (See Schwartz 11th ed., p. 1744.)
CHAPTER 40
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Urology
1. Which of the following is TRUE about bladder cancer?
A. For patients with bladder, cancer invading into the
bladder muscle (T2 lesion) immediate radiotherapy
followed by surgery offers the best chance of cure.
B. Patients with limited lymph node involvement may
be cured by surgery alone.
C. Continent neobladders have yet to be successfully
utilized in patients undergoing cystectomy.
D. lntravesical chemotherapy prior to surgery is rou-
tinely used for bladder cancers invading into the
bladder muscle (T2 lesion).
2. Which of the following are TRUE concerning testicular
cancer?
A. Most common malignancy in men aged 15–35.
B. Most commonly presents as a painful enlarging mass.
C. Initial work up includes chest, abdominal, and brain
imaging.
D. Most common site of metastases is to the lungs.
Answer: B
For patients who have disease invading into bladder muscle
(T2), immediate (within 3 months of diagnosis) cystectomy
with extended lymph node dissection offers the best chance
of survival. Patients with limited lymph node involvement
may be cured with surgery alone. Patients have multiple
reconstructive options, including continent and noncontinent urinary diversions. The orthotopic neobladder has
emerged as a popular urinary diversion for patients without
urethral involvement. This diversion type involves the detubularization of a segment of bowel, typically distal ileum,
which is then refashioned into a pouch that is anastomosed to
the proximal urethra (neobladder) or to the skin (continent
cutaneous diversion). Patients with nonmuscle-invasive bladder cancer (confined to the bladder mucosa or submucosa)
can be managed with transurethral resection alone and adjuvant intravesical (instilled into the bladder) chemotherapy/
immunotherapy. (See Schwartz 11th ed., pp. 1770–1771.)
Answer: A
Testicular cancer is the most common solid malignancy in
men age 15 to 35 years. Chest and abdominal imaging must
be performed to evaluate for evidence of metastasis. The most
common site of spread is the retroperitoneal lymph nodes
extending from the common iliac vessels to the renal vessels.
(See Schwartz 11th ed., pp. 1771–1772.)
3. Which of the following statements about renal cell carcinoma (RCC) are FALSE?
A. Lesions are usually solid but can be cystic.
B. May be sporadic or hereditary.
C. Surgical debulking can improve survival in patients
who present with metastatic disease.
D. Patients are not curable (and therefore should not be
operated on) if tumor thrombus extends proximally
into the vena cava.
Answer: D
Renal tumors are usually solid, but they also can be cystic.
Most cases of RCC are sporadic, but many hereditary forms
have been described. Up to 20% to 30% of patients may present with metastatic disease, in which case, surgical debulking
can improve survival, as shown in randomized controlled trials. Up to 10% of RCC invades the lumen of the renal vein or
vena cava. The degree of venous extension directly impacts
the surgical approach. Patients with thrombus below the
level of the liver can be managed with cross-clamping above
and below the thrombus and extraction from a cavotomy
at the insertion of the renal veins. (See Schwartz 11th ed.,
pp. 1772–1773.)
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