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362 Appendix I

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3 What is the long-term risk of hypertension

arising from a renal injury in childhood?

a) Less than 5% b) 5% to 10%

c) 10% to 15%

d) 15% to 20%

e) 20% to 25%

4 Which of the following statements is most

applicable to renal injuries in children?

a) Contact sports are the commonest cause b) Haematuria is a reliable indicator of the

severity of injury in this age group

c) Grade I injuries account for 45% of case

d) Urinary extravasation always requires

either extrarenal and/or intrarenal drainage

e) e outcomes of penetrating injuries are

worse than those of blunt injuries

5 A 2½-year-old girl is brought by her mother

to the accident and emergency department following an accident which occurred whilst being looked aer overnight by a neighbour. No one saw the accident occur. Examination reveals bruising of the perineum and labia, contusion of the introitus and a supercial laceration of the vaginal mucosa. What measures should be taken next?

a) Admit to hospital, proceed to urgent

cystoscopy

b) Admit to hospital. Contact the duty pedia-

trician to investigate the circumstances of the injury

c) Prescribe antibiotic cream and regular

baths. Arrange further review in the outpatient clinic in 2 days

d) Prescribe oral antibiotics and regular

baths. Arrange further review in 2 days

e) Reassure, no antibiotics prescribed but

advise regular baths. No arrangement for follow up

CHAPTER 23: LAPAROSCOPIC PAEDIATRIC UROLOGY

1 Which of the following statements best

describes the use of robotic laparoscopic sur-

gery in children?

a) Excellent tactile feedback is one of the

advantages of the Da Vinci Robot

b) It is unsuitable for use in neonates

c) Comparative studies have found that

success rates for Robotic-Assisted Laparoscopic Pyeloplasty are 20% lower than for open and conventional laparoscopic pyeloplasty

d) e system has two major components:

the robot and the cart containing image processing equipment and light source

e) e ports should be placed no more than

8 cm apart

2 Which of the following is not regarded as an

absolute contraindication to laparoscopic

adrenalectomy in children?

a) Phaeochromocytoma b) Cardiac failure due to severe congenital

heart disease

c) Respiratory insuciency due to cystic

brosis

d) Uncorrectable coagulopathy

e) Systemic sepsis

3 Which of the following statements are most

applicable to the technical aspects of laparo-

scopic urological surgery in children?

a) Anaesthesia does not routinely require

endotracheal intubation

b) Cooling mats are used routinely because

of the increased risk of hyperthermia

c) A 5mm cannula is required when using an

Endopouch retrieval device for specimen extraction

d) Children absorb relatively less CO2 than

adults

e) e Hasson technique is preferable for

establishing a pneumoperitonem

Self-Assessment Section: Questions 363

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4 Which of the following is not currently a

well-recognised indication for Minimally Invasive Surgery in Paediatric Urology laparoscopic?

a) Nephrectomy for dysplastic kidney b) Nephrectomy for Stage IV Wilms tumour

c) Adrenalectomy

d) Gonadal biopsy

e) Excision of ureteric stump

5 What was the rst laparoscopic procedure

to gain widespread acceptance in Paediatric Urology?

a) Laparoscopic nephrectomy b) Diagnostic laparoscopy for impalpable

testes

c) Laparoscopic pyeloplasty

d) Laparoscopic excision of Müllerian

remnants

e) Laparoscopic hemi nephrectomy

CHAPTER 24: ADOLESCENT UROLOGY

1 What is the commonest cause of death in

adult spina bida patients?

a) Renal failure b) Uncontrolled hydrocephalus

c) Bladder cancer

d) Cardiovascular and respiratory disease

e) Suicide

3 Which of the following is not a well recog-

nised feature of Prune-Belly syndrome?

a) Renovascular malformations b) Bilateral undescended testes

c) Absent abdominal wall musculature

d) Kyphoscoliosis

e) Dilatation of the upper urinary tract

4 Which of the following statements best

describes the prognosis for sexual and repro-

ductive function in female bladder exstrophy

patients?

a) Substitution vaginoplasty is usually

required to permit normal intercourse

b) Uterine prolapse occurs in up to 50% of

women

c) Fewer than 15% of women with a history of

bladder exstrophy can achieve pregnancy

d) Genital sensation is severely impaired as a

result of clitoral agenesis

e) Infertility is inevitable because of the asso-

ciation between bladder exstrophy and uterine agenesis

5 Which of the following is well-documented

prognostic indicators of long-term renal

impairment in patients with posterior ure-

thral valves?

a) GFR 70 mls/min/1.73 m2 at 11 years of age b) Daytime incontinence aer 5 years of age

c) Diagnosis aer 5 years of age

d) Non-reuxing upper tracts

e) High urine osmolality

2 What is the approximate risk of bladder can-

cer associated with enterocystoplasty aer a latency period of 20 to 25 years?

a) 2% to 5% b) 5% to 7%

c) 7% to 10%

d) 10% to 12%

e) 12% to 15%

364 Appendix I

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CHAPTER 25: PEDIATRIC AND ADOLESCENT GYNECOLOGY

1 Which of the following statements is most

applicable to labial adhesions?

a) ey present most commonly between 5

and 7 years of age

b) Separation of the adhesions with a

blunt surgical instrument is required in 30%– 40% of cases.

c) Labial adhesions can be treated with appli-

cation of a topical steroid ointment

d) e adhesions usually persist into

adolescence

e) Labial adhesions are usually congenital

rather than acquired in etiology

2 Which of the following statements do not

apply to Mayer Rokitansky Kuster Hauser (MRKH) Syndrome?

a) MRKH syndrome has an incidence of

approximately 1: 4500

b) MRKH results from failure of normal

embryological development of the urogenital sinus

c) e condition usually presents with pain-

less amenorrhea

d) Vaginal dilatation is the rst line of treat-

ment for patients wishing to become sexually active

e) e external appearances of the genitalia

are usually normal

3 A 14-year-old girl has undergone a non

urgent ultrasound scan to investigate upper

abdominal pain occurring over several

months. e scan demonstrates the presence

of a complex mass 10 mm in diameter in the

le ovary. e appearances are not those of

a typical mature teratoma. Which of the fol-

lowing would be most appropriate?

a) Rescan with ultrasound in 1 month b) Arrange for laparoscopy within the next

week

c) Urgent CT scan

d) Pregnancy test

e) Send blood for tumour markers

4 Which of the following statements are most

applicable to Lichen Sclerosus?

a) e incidence is approximately 1 in 200 b) It occurs more commonly in children than

adults

c) Biopsy is required to conrm the diagnosis

d) A single 2–3 month course of topical ste-

roids will prevent recurrence in > 90% of cases

e) e appearances can be mistaken for geni-

tal trauma

5 Which of the following may present with

obstructed menstruation?

a) Lichen sclerosis b) Labial adhesions

c) Imperforate hymen

d) Longitudinal vaginal septum

e) Labial hypertrophy

Appendix II

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Self-Assessment Section: Answers

CHAPTER 1 – EMBRYOLOGY

Question 1 - e Question 2 - b Question 3 - d Question 4 - a Question 5 - d

Question 4 Comment. Although conditions such as vesico ureteric reux, hypospadias and ureteric duplication have a well documented familial basis, attempts to implicate individual gene mutations have been unfruitful and it is generally believed that they result from the interaction of multiple genes. By contrast, specic mutations have been identied in autosomal dominant polycystic kidney disease – see Chapte r 10, ‘Cystic Renal Disease’.

CHAPTER 2 – RENAL DEVELOPMENT AND DYSFUNCTION

Question 1 - d Question 2 - e Question 3 - b Question 4 - d Question 5 - d

sick and premature newborn infants. Monitoring of sodium and uid balance in such infants is particularly important in the early weeks of life.

CHAPTER 3 – IMAGING

Question 1 - c Question 2 - d Question 3 - a Question 4 - e Question 5 - b

Question 2 Comment. A renal pelvic AP diameter of greater than 10 mm is regarded as abnormal but is not necessarily indicative of clinically signicant pathology.

CHAPTER 4 – PRENATAL DIAGNOSIS

Question 1 - d Question 2 - c Question 3 - d Question 4 - a Question 5 - d

Question 1 Comment. Hyponatremia (plasma sodium less than 130 mmol/L), due to water retention and sodium depletion is a common feature of

365

366 Appendix II

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CHAPTER 5 – URINARY TRACT INFECTION

Question 1 - b Question 2 - c Question 3 - e Question 4 - e Question 5 - b

Question 1 Comment. A child of this age should be able to cooperate in the correction of a ‘clean catch’ midstream sample – the least invasive, reliable method of collecting an uncontaminated specimen.

Question 3 Comment. Leucocyte esterase negative, nitrite positive. is nding represents presumptive evidence of UTI. Antibiotic treatment should be commenced and a urine sample sent for culture.

CHAPTER 6 – VESICO-URETERAL REFLUX

Question 1 - a Question 2 - b Question 3 - d Question 4 - b Question 5 - e

CHAPTER 8 – DUPLICATION ANOMALIES, URETEROCELES AND ECTOPIC URETERS

Question 1 - c Question 2 - a Question 3 - c Question 4 - b Question 5 - a

CHAPTER 9 – POSTERIOR URETHRAL VALVES AND OTHER URETHRAL ABNORMALITIES

Question 1 - c Question 2 - b Question 3 - e Question 4 - b Question 5 - d

Question 4 Comment. ere are no long-term data from comparative studies which demonstrate that vesico amniotic shunting improves the prognosis for renal function.

CHAPTER 10 – CYSTIC RENAL DISEASE

CHAPTER 7 – UPPER TRACT OBSTRUCTION

Question 1 - e Question 2 - b Question 3 - b Question 4 - e Question 5 - b

Question 1 Comment. e imaging points to a diagnosis of obstructed megaureter with good preservation of function. In most cases the natural history is one of gradual spontaneous resolution. In this case, conservative management would be more appropriate than any form of surgical intervention at this stage.

Question 1 - d Question 2 - d Question 3 - b Question 4 - a Question 5 - a

CHAPTER 11 – URINARY TRACT CALCULI

Question 1 - e Question 2 - e Question 3 - a Question 4 - c Question 5 - e

Self-Assessment Section: Answers 367

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Question 3 Comment. By the time the diagnosis of xanthogranulomatous pyelonephritis comes to light the kidney is usually non-functioning or contributing only a very small percentage of dierential function.

CHAPTER 12 – URINARY INCONTINENCE

Question 1 - b Question 2 - b Question 3 - e Question 4 - b Question 5 - d

Question 3 Comment. is boy has monosymptomatic nocturnal enuresis. In the absence of daytime wetting or any other unusual features the yield from investigation is minimal and the parents can be reassured that he will be come dry. Neverthele ss some active treatment such as an alarm or Desmopressin may be considered if he does not improve spontaneously.

Question 4 Comment. Giggle incontinence is a rare but distinctive disorder. Treatment with anticholinergics is usually unhelpful, but Methylphenidate (Ritalin) can sometimes be dramatically eective.

CHAPTER 13 – NEUROGENIC BLADDER

CHAPTER 14 – UROLOGIC ANOMALIES IN ANORECTAL MALFORMATIONS AND RENAL ECTOPIA

Question 1 - d Question 2 - c Question 3 - d Question 4 - e Question 5 - d

Question 4 Comment. A pelvic kidney can be missed on ultrasound. A DMSA scan is indicated to identify any ectopic function in renal tissue – principally to look for a pelvic kidney.

CHAPTER 15 – BLADDER EXSTROPHY AND EPISPADIAS

Question 1 - c Question 2 - e Question 3 - b Question 4 - c Question 5 - b

Question 3 Comment. Practice varies between different specialist centres with regard to the timing of primary closure. e authors’ preference is to defer primary closure until 2–3 weeks of age, to allow time for the establishment of breast feeding and maternal bonding.

Question 1 - d Question 2 - a Question 3 - c Question 4 - d Question 5 - b

Question 1 Comment. Far from denoting a ‘safe’ pattern of neurogenic bladder dysfunction, the nding of detrusor/sphincter dyssynergia indicates an ‘unsafe’ or ‘hostile’ neurogenic bladder which should be actively managed to protect renal function.

CHAPTER 16 – HYPOSPADIAS

Question 1 - b Question 2 - a Question 3 - e Question 4 - b Question 5 - d

Question 1 Comment. Minor to moderate degrees of chordee can usually be corrected during a

368 Appendix II

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single-stage closure. However, severe degrees of chordee are usually associated with proximal hypospadias – for which better long-term results are achieved with a two stage procedure. Despite apparently successful correction in childhood, residual or recurrent chordee may sometimes become apparent again aer puberty.

CHAPTER 17 – THE PREPUCE

Question 1 - e Question 2 - d Question 3 - b Question 4 - c Question 5 - a

Question 5 Comment. No form of intervention is usually required is such cases (apart, perhaps from a short course of topical steroid ointment combined with gentle retraction of the foreskin). Division of preputial adhesions under general anaesthesia is of largely historic interest and is rarely performed by Paediatric Urologists.

CHAPTER 19 – THE ACUTE SCROTUM

Question 1 - c Question 2 - e Question 3 - e Question 4 - b Question 5 - a

Question 2 Comment. e diagnosis is idiopathic scrotal oedema – for which no specic treatment is required.

Question 3 Comment. ere is a high probability of torsion in this 13 year old. e history is relatively short and there is a reasonable prospect of conserving a viable testis with urgent surgical exploration. Performing an ultrasound scan will lead to inevitable delay which is likely to compromise potential viability of the testis.

CHAPTER 20 – DISORDERS OF SEX DEVELOPMENT

CHAPTER 18 – TESTIS, HYDROCOELE AND VARICOCOELE

Question 1 - d Question 2 - e Question 3 - a Question 4 - d Question 5 - a

Question 3 Comment. Conservative management of ascending testes has been described but there are concerns regarding temperature – related histological damage during the period the testis remains outside the scrotum. e safest option is to proceed to orchidopexy in any boy with either a congenital or acquired undescended testis.

Question 1 - c Question 2 - c Question 3 - e Question 4 - b Question 5 - e

CHAPTER 21 – GENITOURINARY MALIGNANCIES

Question 1 - b Question 2 - b Question 3 - d Question 4 - e Question 5 - a

Question 4 Comment. Wilms tumours classically have triphasic histology with stromal, blastemal, and epithelial components.

Self-Assessment Section: Answers 369

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CHAPTER 22 – PEDIATRIC GENITOURINARY TRAUMA

Question 1 - d Question 2 - c Question 3 - a Question 4 - e Question 5 - b

CHAPTER 23 – LAPAROSCOPIC PAEDIATRIC UROLOGY

Question 1 - b Question 2 - a Question 3 - e Question 4 - b Question 5 - b

Question 3 Comment. Contrary to answer b, the main risk is of intraoperative hypothermia. For this reason a warming blanket is commonly used during longer procedures.

CHAPTER 24 – ADOLESCENT UROLOGY

Question 1 - d Question 2 - a Question 3 - a Question 4 - b Question 5 - b

Question 1 Comment. Renal failure was historically the commonest cause of death in young adults with spina bida. However, the long-term outlook for renal function has been transformed in recent decades by advances in management of the neuropathic bladder

CHAPTER 25 – PEDIATRIC AND ADOLESCENT GYNECOLOGY

Question 1 - c Question 2 - b Question 3 - e Question 4 - e Question 5 - c

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Index

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Abdominal mass, urinary calculi,

142

Abdominal X-ray (AXR), 39

urinary calculi, 14 3

Absorbent urine collection pads,

Acid-base homeostasis, in fetus

and neonate, 15 Acute balanoposthitis, 230 Acute hydrocoele, 264 Acute kidney injury (AKI), 15–16

KDIGO 2012 classication, 15

pRIFLE classication, 15–16 Acute obstruction, 84 Acute rejection, transplantation,

Acute renal failure (ARF), 15 Acute scrotum, 255–265

clinical features, 255, 258 diagnosis, 255 epidemiology, 256

testicular torsion, 256–262 Adhesive collection bags, 57 Adjunctive genetic testing, 277 Adolescence, renal impairment in,

15–18

Adolescent urology

bladder exstrophy, 323–324

enterocystoplasty, 329

fertility and pregnancy in adult

patients, 330 hypospadias, 325–326 posterior urethral valves

(PUV), 326–327 prune-belly syndrome, 327–328

spina bida (social and sexual

development), 329–330

vesicoureteric reux, 322–323

AMH, see Anti-Müllerian

hormone

AMH/MIS deciency, 273 Amnioinfusion, 52–53 Anaemia, in CKD, 18 Anderson-Hynes dismembered

pyeloplasty, 94–95 Androgen activity, defect in, 273 Androgen biosynthesis defects,

272

Ano rectal anomalies, 183–191

adult outcomes, 190–191 associated congenital

anomalies, 185, 188

classication, 184 initial management and

workup, 187–188

lower urinary tract

dysfunction, 186–187

surgical management,

188–189

upper urinary tract anomalies,

185

Antegrade pyelography, 40 Anterior urethral valves, 125 Antibiotics

hypospadias, 221 prophylactic, 48–49

Anti-Müllerian hormone (AMH),

7, 8–9, 10

Appendix testis, torsion of, 262 Aromatase deciency, 271 Arteriography, 39 Ascending testis, 246–247

Ascent and fusion abnormalities

kidney, 5–6, 191–193

Asymptomatic bacteriuria (ABU),

Atrial natriuretic peptide (ANP),

Augmentation cystoplasty,

125

Automated peritoneal dialysis

(APD), 19

Autosomal dominant polycystic

kidney disease (ADPKD), 2, 131–132

Autosomal recessive polycystic

kidney disease (ARPKD), 2, 129–131

AXR, see Abdominal X-ray

Balanitis, 61 Balanitis xerotica obliterans, 225,

229–230

Bilateral impalpable testis in DSD,

244

Bilateral renal agenesis, 50 Bilateral single ectopic ureters,

113–114

Biopsy, tumour, 41, 288 Bladder and bowel dysfunction

(BBD), 71

posterior urethral valves,

124–125

VUR treatment, 76

Bladder augmentation

(enterocystoplasty),

177–179

371

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