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 Alan J. Wein • Thomas F. Kolon
Partin • Dmochowski • Kavoussi • Peters
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Campbell-Walsh-Wein
UROLOGY
TWELFTH EDITION REVIEW
 third edition

Campbell-Walsh-Wein
UROLOGY
TWELFTH EDITION REVIEW
Alan J. Wein, MD, PhD (Hon), FACS Thomas F. Kolon, MD, FAAP
Founders Professor and Emeritus Chief of Urology Howard M. Snyder III MD Chair
Division of Urology in Pediatric Urology
Director, Residency Program in Urology Pediatric Urology Fellowship
Perelman School of Medicine at the University Program Director
of Pennsylvania Children’s Hospital of Philadelphia
Penn Medicine Professor of Urology in Surgery
Philadelphia, Pennsylvania Perelman School of Medicine
at the University of Pennsylvania
Philadelphia, Pennsylvania

Editors
Alan W. Partin, Roger R. Dmochowski, Louis R. Kavoussi, Craig A. Peters,
MD, PhD MD, MMHC, FACS MD, MBA MD
The Jakurski Family Director Professor, Urologic Surgery, Professor and Chair Chief, Pediatric Urology
Urologist-in-Chief Surgery, and Gynecology Department of Urology Children’s Health System Texas
Chairman, Department Program Director, Female Zucker School of Medicine Professor of Urology
of Urology Pelvic Medicine and at Hofstra/Northwell University of Texas
Professor, Departments Reconstructive Surgery Hempstead, New York Southwestern Medical Center
of Urology, Oncology, Vice Chair for Faculty Affairs Chairman of Urology Dallas, Texas
and Pathology and Professionalism The Arthur Smith Institute
Johns Hopkins Medical Section of Surgical Sciences for Urology
Institutions Associate Surgeon-in-Chief Lake Success, New York
Baltimore, Maryland Vanderbilt University Medical
Center
Nashville, Tennessee
Elsevier
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THIRD EDITION ISBN: 978-0-323-63969-9
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CONTRIBUTORS
Robert Abouassaly, MD Sero Andonian, MD, MSc, FRCS(C), FACS Laurence S. Baskin, MD
Department of Urology Associate Professor Frank Hinman Jr., MD, Distinguished
Glickman Urological and Kidney Institute Department of Urology Professorship in Pediatric Urology
Associate Professor of Surgery (Urology) McGill University Chief of Pediatric Urology
Cleveland Clinic Lerner College of Montreal, Québec, Canada University of California–San Francisco
Medicine Benioff Children’s Hospital
Cleveland Clinic Emmanuel S. Antonarakis, MD Department of Urology
Cleveland, Ohio Professor of Oncology and Urology Mission Hall Pediatric Urology
Johns Hopkins Sidney Kimmel San Francisco, California
Ömer Acar, MD Comprehensive Cancer Center
Department of Urology Baltimore, Maryland Stuart B. Bauer, MD
College of Medicine Professor of Surgery (Urology)
University of Illinois at Chicago Jodi A. Antonelli, MD Department of Urology
Chicago, Illinois Assistant Professor Harvard Medical School
Department of Urology Senior Associate in Urology
Mark C. Adams, MD, FAAP University of Texas Southwestern Medical Department of Urology
Professor of Urologic Surgery Center Boston Children’s Hospital
Division of Pediatric Urology Dallas, Texas Boston, Massachusetts
Department of Urology
Monroe Carell Jr. Children’s Hospital at Joshua J. Augustine, MD Mitchell C. Benson, MD
Vanderbilt Associate Professor of Medicine Herbert and Florence Irving
Vanderbilt University Medical Center Cleveland Clinic Lerner College of Medicine Professor and Chairman Emeritus
Nashville, Tennessee Staff Physician Department of Urology
Glickman Urological and Kidney Institute Columbia University
Riyad Tasher Al Mousa, MD, SSCU, Department of Nephrology and Attending Physician
FEBU, MSHA Hypertension Department of Urology
Consultant Urologist/Neuro-urologist Cleveland, Ohio New York Presbyterian Hospital–
Urology Department Columbia
King Fahad Specialist Hospital–Dammam Paul F. Austin, MD New York, New York
Dammam, Saudi Arabia Professor
Department of Urology Sara L. Best, MD
Mohamad E. Allaf, MD Texas Children’s Hospital Associate Professor
Vice Chairman and Professor of Urology, Baylor College of Medicine Department of Urology
Oncology, and Biomedical Engineering Houston, Texas University of Wisconsin School of
Director of Minimally Invasive and Medicine and Public Health
Robotic Surgery Timothy D. Averch, MD, FACS Madison, Wisconsin
Brady Urological Institute Clinical Professor and Vice Chair for Quality
Department of Urology Department of Surgery Lori A. Birder, PhD
Johns Hopkins University School of Palmetto Health USC Medical Group Professor of Medicine and Pharmacology
Medicine Columbia, South Carolina and Cell Biology
Baltimore, Maryland Renal-Electrolyte Division of Medicine
Gina M. Badalato, MD University of Pittsburgh School of
Christopher L. Amling, MD, FACS Assistant Professor of Urology Medicine
John Barry Professor and Chair Columbia University Vagelos College of Pittsburgh, Pennsylvania
Department of Urology Physicians and Surgeons
Oregon Health and Science University Assistant Attending Jay T. Bishoff, MD
Portland, Oregon New York–Presbyterian Hospital Director, Intermountain Urological
New York, New York Institute
Christopher B. Anderson, MD, MPH Intermountain Health Care
Assistant Professor Daniel A. Barocas, MD, MPH, FACS Salt Lake City, Utah
Department of Urology Associate Professor
Columbia University Irving Medical Center Department of Urology Trinity J. Bivalacqua, MD, PhD
New York, New York Vanderbilt University Medical Center R. Christian Evenson Professor of Urology
Nashville, Tennessee Department of Urology
Karl-Erik Andersson, MD, PhD Johns Hopkins Medicine
Professor Julia Spencer Barthold, MD Baltimore, Maryland
Aarhus Institute for Advanced Studies Principal Research Scientist
Aarhus University Nemours Biomedical Research/Division of Marc A. Bjurlin, DO, MSc
Aarhus, Jutland, Denmark Urology Associate Professor
Professor Alfred I. duPont Hospital for Children Department of Urology
Wake Forest Institute for Regenerative Wilmington, Delaware Lineberger Comprehensive Cancer Center
Medicine Professor of Urology and Pediatrics University of North Carolina at Chapel
Wake Forest University School of Medicine Thomas Jefferson University Hill
Winston-Salem, North Carolina Philadelphia, Pennsylvania Chapel Hill, North Carolina
v
vi CONTRIBUTORS

Brian G. Blackburn, MD, FIDSA Elizabeth Timbrook Brown, MD, MPH, Michael A. Carducci, MD
Clinical Associate Professor of Internal FACS AEGON Professor in Prostate Cancer
Medicine/Infectious Diseases and Assistant Professor of Urology Research
Geographic Medicine Department of Urology Sidney Kimmel Comprehensive Cancer
Stanford University School of Medicine MedStar Georgetown University Center at Johns Hopkins
Stanford, California Hospital Johns Hopkins University School of
Washington, District of Columbia Medicine
Bertil Blok, MD, PhD Baltimore, Maryland
Urologist Benjamin M. Brucker, MD
Department of Urology Associate Professor Maude Carmel, MD
Erasmus Medical Center Director of Female Pelvic Medicine and Assistant Professor of Urology
Rotterdam, the Netherlands Reconstructive Surgery University of Texas Southwestern Medical
Departments of Urology and Obstetrics Center
Michael L. Blute, MD and Gynecology Dallas, Texas
Chief New York University Langone Health
Department of Urology New York, New York Peter R. Carroll, MD, MPH
Walter S. Kerr Jr., Professor of Urology Professor
Massachusetts General Hospital/Harvard Kathryn L. Burgio, PhD Ken and Donna Derr-Chevron
Medical School Professor of Medicine Distinguished Professor
Boston, Massachusetts Division of Gerontology, Geriatrics, and Taube Family Distinguished Professor
Palliative Care Department of Urology
Timothy B. Boone, MD, PhD University of Alabama at Birmingham University of California–San Francisco
Chair, Department of Urology Associate Director for Research San Francisco, California
Houston Methodist Hospital Birmingham/Atlanta Geriatric Research,
Professor and Associate Dean Education, and Clinical Center Clint Cary, MD, MPH
Weill Cornell Medical College and Texas (GRECC) Associate Professor
A&M College of Medicine Birmingham Veterans Affairs Medical Department of Urology
Houston, Texas Center Indiana University
Birmingham, Alabama Indianapolis, Indiana
Stephen A. Boorjian, MD
Carl Rosen Professor of Urology Arthur L. Burnett II, MD, MBA Erik P. Castle, MD
Department of Urology Patrick C. Walsh Distinguished Professor Professor of Urology
Mayo Clinic of Urology Department of Urology
Rochester, Minnesota Department of Urology Mayo Clinic Arizona
Johns Hopkins School of Medicine Phoenix, Arizona
Kristy Borawski, MD Baltimore, Maryland
Clinical Assistant Professor of Urology Toby C. Chai, MD
Department of Urology Jeffrey A. Cadeddu, MD Chair of Department of Urology
University of North Carolina at Chapel Hill Professor of Urology and Radiology Boston University School of Medicine
Chapel Hill, North Carolina Department of Urology Chief of Urology
University of Texas Southwestern Medical Boston Medical Center
Michael S. Borofsky, MD Center Boston, Massachusetts
Assistant Professor Dallas, Texas
Department of Urology Charbel Chalouhy, MD
University of Minnesota Anne P. Cameron, MD, FRCSC, FPMRS Faculty of Medicine
Minneapolis, Minnesota Professor of Urology St. Joseph University
University of Michigan Beirut, Lebanon
Steven Brandes, MD Ann Arbor, Michigan
Given Foundation Professor of Urology Alicia H. Chang, MD, MS
Department of Urology Steven C. Campbell, MD, PhD Medical Director
Columbia University Medical Center Professor of Surgery Department of Public Health,
New York, New York Department of Urology Tuberculosis Control Program
Cleveland Clinic County of Los Angeles
Michael C. Braun, MD Cleveland, Ohio Los Angeles, California
Chief of Renal Service
Texas Children’s Hospital Douglas A. Canning, MD Christopher R. Chapple, MD, BSc,
Professor, Renal Section Chief Professor of Surgery (Urology) FRCS (Urol)
Department of Pediatrics Perelman School of Medicine Professor and Consultant Urologist
Program Director University of Pennsylvania Department of Urology
Pediatric Nephrology Fellowship Program Chief, Division of Urology The Royal Hallamshire Hospital
Baylor College of Medicine Children’s Hospital of Philadelphia Sheffield Teaching Hospitals
Houston, Texas Philadelphia, Pennsylvania Sheffield, United Kingdom

Gregory A. Broderick, MD Paolo Capogrosso, MD Thomas Chi, MD

Professor of Urology IRCCS San Raffaele Hospital Associate Professor
Mayo Clinic Alix School of Medicine Department of Urology Associate Chair for Clinical Affairs
Department of Urology Vita-Salute San Raffaele University Department of Urology
Program Director Milan, Italy University of California–San Francisco
Urology Residency Program San Francisco, California
Mayo Clinic
Jacksonville, Florida
 CONTRIBUTORS vii

John Christodouleas, MD Hillary L. Copp, MD, MS Shubha K. De, MD, FRCSC

Professor of Radiation Oncology Associate Professor, Pediatric Urology Alberta Urology Institute
Urologic Cancer Program Department of Urology Northern Alberta Urology Centre
Penn Medicine University of California–San Francisco Edmonton, Alberta, Canada
Philadelphia, Pennsylvania San Francisco, California
Jean J.M.C.H. de la Rosette, MD, PhD
Peter E. Clark, MD Nicholas G. Cost, MD Professor
Professor and Chairman Associate Professor Department of Urology
Department of Urology Department of Surgery Istanbul Medipol University
Atrium Health Division of Urology Istanbul, Turkey
Chair, Urologic Oncology University of Colorado School of
Levine Cancer Institute Medicine Dirk J.M.K. De Ridder, MD, PhD
Charlotte, North Carolina Aurora, Colorado Professor
Department of Urology
Douglass B. Clayton, MD, FAAP Anthony Costello, MD, AM, FRACS University Hospitals KU Leuven
Associate Professor of Urologic Surgery Professor Leuven, Belgium
Division of Pediatric Urology Department of Urology
Department of Urology Royal Melbourne Hospital Guarionex Joel DeCastro, MD, MPH
Monroe Carell Jr. Children’s Hospital at Parkville, Victoria, Australia Associate Professor, Urology
Vanderbilt Columbia University Medical Center
Vanderbilt University Medical Center Lindsey Cox, MD Department of Urology
Nashville, Tennessee Associate Professor of Urology New York Presbyterian Hospital/Columbia
Department of Urology University
Joshua A. Cohn, MD Medical University of South Carolina New York, New York
Assistant Professor of Urology Charleston, South Carolina
Department of Urology Francisco T. Dénes, MD, PhD
Einstein Healthcare Network Paul L. Crispen, MD Associate Professor
Assistant Professor of Urology Associate Professor Chief, Pediatric Urology Unit
Department of Surgery Department of Urology Division of Urology
Division of Urologic Oncology University of Florida Hospital das Clínicas
Fox Chase Cancer Center Gainesville, Florida Faculdade de Medicina
Philadelphia, Pennsylvania Universidade de São Paulo
Juanita M. Crook, MD, FRCPC São Paulo, Brazil
Michael J. Conlin, MD, MCR Professor
Professor Department of Radiation Oncology Mahesh R. Desai, MS, FRCS,
Department of Urology University of British Columbia FRCS
Portland Veterans Affairs Medical Center Radiation Oncologist Chief Urologist and Managing
Professor Center for the Southern Interior Trustee
Department of Urology British Columbia Cancer Agency Department of Urology
Oregon Health and Sciences University Kelowna, British Columbia, Canada Muljibhai Patel Urological Hospital
Portland, Oregon Nadiad, India
Gerald Cunha, PhD
Christopher S. Cooper, MD, FAAP, FACS Emeritus Professor, Anatomy and David A. Diamond, MD
Professor Urology Urologist-in-Chief
Department of Urology University of California–San Francisco Department of Urology
University of Iowa San Francisco, California Boston Children’s Hospital
Senior Associate Dean of Medical Professor of Surgery (Urology)
Education Douglas M. Dahl, MD, FACS Department of Surgery
University of Iowa Carver College of Associate Professor of Surgery Harvard Medical School
Medicine Harvard Medical School Boston, Massachusetts
Iowa City, Iowa Chief, Division of Urologic Oncology
Department of Urology Heather N. Di Carlo, MD
Kimberly L. Cooper, MD Massachusetts General Hospital Director, Pediatric Urology Research
Associate Professor of Urology Boston, Massachusetts Assistant Professor of Urology
Columbia University Vagelos College of The James Buchanan Brady Urological
Physicians and Surgeons Siamak Daneshmand, MD Institute
Associate Attending Associate Professor of Urology Johns Hopkins Medical Institutions
New York–Presbyterian Hospital Director of Clinical Research Baltimore, Maryland
New York, New York Keck University of Southern California
School of Medicine Colin P.N. Dinney, MD
Lawrence A. Copelovitch, MD Los Angeles, California Chairman and Professor
Assistant Professor of Pediatrics Department of Urology
University of Pennsylvania Perelman Casey A. Dauw, MD University of Texas MD Anderson Cancer
School of Medicine Assistant Professor Center
Attending Physician Department of Urology Houston, Texas
Division of Nephrology University of Michigan
The Children’s Hospital of Philadelphia Ann Arbor, Michigan
Philadelphia, Pennsylvania
viii CONTRIBUTORS

Roger R. Dmochowski, MD, MMHC, FACS Jairam Eswara, MD Reza Ghavamian, MD

Professor, Urologic Surgery, Surgery, and Attending Surgeon Eastern Regional Director of Urology
Gynecology St. Elizabeth’s Medical Center Department of Urology
Program Director, Female Pelvic Medicine Clinical Associate Professor Northwell Health
and Reconstructive Surgery Tufts University School of Medicine Greenlawn, New York
Vice Chair for Faculty Affairs and Boston, Massachusetts Professor of Urology
Professionalism Department of Urology
Section of Surgical Sciences Fernando A. Ferrer, MD, FACS, FAAP Zucker School of Medicine at Hofstra/
Associate Surgeon-in-Chief Surgeon in Chief Northwell
Vanderbilt University Medical Center Department of Pediatric Urology New Hyde Park, New York
Nashville, Tennessee Children’s Hospital Omaha
Professor, Surgery (Urology) Bruce R. Gilbert, MD, PhD
Charles G. Drake, MD, PhD University of Nebraska Professor of Urology
Professor, Medical Oncology and Urology Omaha, Nebraska The Smith Institute for Urology
Department of Medicine Zucker School of Medicine of Hofstra/
Columbia University Neil Fleshner, MD, MPH, FRCSC Northwell
New York, New York Professor of Surgery and Martin Barkin New Hyde Park, New York
Chair Clinical Professor of Urology (Adjunct)
Brian Duty, MD, MBA Department of Urology Department of Urology
Associate Professor University of Toronto Weill Cornell Medical College
Department of Urology Surgeon, Uro-Oncology New York, New York
Oregon Health and Science University University Health Network
Portland, Oregon Toronto, Ontario, Canada Timothy D. Gilligan, MD
Associate Professor of Medicine
James A. Eastham, MD Bryan R. Foster, MD Solid Tumor Oncology
Chief, Urology Service Associate Professor Cleveland Clinic Lerner College of
Department of Surgery Department of Radiology Medicine
Memorial Sloan-Kettering Cancer Center Oregon Health and Science University Program Director, Hematology/Oncology
New York, New York Portland, Oregon Fellowship
Scott Eggener, MD Taussig Cancer Institute
Professor of Surgery and Radiology Richard S. Foster, MD Cleveland Clinic
University of Chicago Professor Cleveland, Ohio
Chicago, Illinois Department of Urology
Indiana University David A. Goldfarb, MD
Mohamed A. Elkoushy, MD, PhD, MSc Indianapolis, Indiana Professor of Surgery
Professor, Urology Cleveland Clinic Lerner College of
Faculty of Medicine Pat F. Fulgham, MD Medicine
Suez Canal University Surgical Director of Oncology Glickman Urological and Kidney
Ismailia, Egypt Services Institute
Chairman, Department of Urology Cleveland Clinic
Jonathan Ellison, MD Texas Health Presbyterian Dallas Cleveland, Ohio
Assistant Professor of Urology Dallas, Texas
Medical College of Wisconsin Marc Goldstein, MD, DSc (hon), FACS
Children’s Wisconsin Arvind P. Ganpule, MS, DNB Matthew P. Hardy Distinguished Professor
Milwaukee, Wisconsin Vice-Chairman of Urology and Male Reproductive
Department of Urology Medicine
Sammy E. Elsamra, MD, FACS Chief, Division of Robotic Surgery Department of Urology and Institute for
Assistant Professor of Surgery (Urology) Muljibhai Patel Urological Hospital Reproductive Medicine
Rutgers Robert Wood Johnson Medical Nadiad, India Weill Cornell Medical College of Cornell
School University
Director of Robotic Surgical Services Kris E. Gaston, MD Surgeon-In-Chief, Male Reproductive
Robert Wood Johnson University Hospital Urologic Oncology Medicine, and Surgery
RWJBarnabas Health Levine Cancer Institute Department of Urology and Institute for
New Brunswick, New Jersey Charlotte, North Carolina Reproductive Medicine
New York Presbyterian Hospital–Weill
Jonathan I. Epstein, MD
John P. Gearhart, MD, FAAP, FACS, Cornell Medicine
Professor of Pathology, Urology, and
FRCS Adjunct Senior Scientist
Oncology
Chief of Pediatric Urology Population Council
The Reinhard Professor of Urological
Professor of Urology Center for Biomedical Research at
Pathology
The James Buchanan Brady Urological Rockefeller University
Director of Surgical Pathology
Institute New York, New York
The Johns Hopkins Medical Institutions
Johns Hopkins Medical Institutions
Baltimore, Maryland
Baltimore, Maryland Leonard G. Gomella, MD, FACS
Carlos R. Estrada, MD, MBA The Bernard W. Godwin Professor of
Associate Professor Matthew T. Gettman, MD Prostate Cancer
Department of Surgery Professor and Vice-Chair Chairman, Department of Urology
Harvard Medical School Department of Urology Sidney Kimmel Cancer Center
Associate in Urology Mayo Clinic Sidney Kimmel Medical College at
Department of Urology Rochester, Minnesota Thomas Jefferson University
Boston Children’s Hospital Philadelphia, Pennsylvania
Boston, Massachusetts
 CONTRIBUTORS ix

Alex Gomelsky, MD, FACS Ethan J. Halpern, MD Sevann Helo, MD

B.E. Trichel Professor and Chairman Professor of Radiology and Urology Minneapolis Veterans Affairs Medical
Department of Urology Sidney Kimmel Cancer Center Center
Louisiana State University Health Sidney Kimmel Medical College at Minneapolis, Minnesota
Shreveport, Louisiana Thomas Jefferson University
Philadelphia, Pennsylvania Amin S. Herati, MD
Mark L. Gonzalgo, MD, PhD Assistant Professor of Urology
Professor and Vice Chairman Misop Han, MD The James Buchanan Brady Urological
Department of Urology David Hall McConnell Professor of Institute and Department of Urology
University of Miami Miller School of Urology and Oncology Assistant Professor
Medicine Department of Urology Department of Gynecology and Obstetrics
Miami, Florida Johns Hopkins Medicine Johns Hopkins University School of
Baltimore, Maryland Medicine
Michael A. Gorin, MD Baltimore, Maryland
Assistant Professor Philip Hanno, MD, MPH
Department of Urology Clinical Professor C.D. Anthony Herndon, MD, FAAP, FACS
Johns Hopkins University School of Department of Urology Professor of Surgery
Medicine Stanford University School of Medicine Director of Pediatric Urology
Baltimore, Maryland Palo Alto, California Surgeon in Chief, Children’s Hospital of
Emeritus Professor Richmond
Tamsin Greenwell, MD, PhD Department of Urology Division of Urology
Consultant Urological Surgeon University of Pennsylvania Virginia Commonwealth University
University College London Hospitals Philadelphia, Pennsylvania Richmond, Virginia
London, United Kingdom
Siobhan M. Hartigan, MD Piet Hoebeke, MD, PhD
Tomas L. Griebling, MD, MPH Female Pelvic Medicine and Reconstructive Professor of Urology
John P. Wolf 33-Degree Masonic Surgery Fellow Dean, Faculty of Medicine and Health
Distinguished Professor of Urology Department of Urology Sciences
Department of Urology and The Landon Vanderbilt University Medical Center Ghent University
Center on Aging Nashville, Tennessee Ghent, Belgium
The University of Kansas
Kansas City, Kansas Christopher J. Hartman, MD David M. Hoenig, MD
Chief of Urology, Forest Hills Hospital Professor and Chief
Khurshid A. Guru, MD Northwell Health North Shore University Hospital
Chair of Urology Department Associate Program Director, Urology Smith Institute for Urology
Director of Robotic Surgery Residency Program North Shore–Long Island Jewish–Hofstra
Robert P. Huben Endowed Professor of Smith Institute for Urology University
Urologic Oncology Assistant Professor of Urology Lake Success, New York
Roswell Park Comprehensive Cancer Center Zucker School of Medicine at Hofstra/
Buffalo, New York Northwell Michael Hsieh, MD, PhD
Hempstead, New York Associate Professor of Urology and
Thomas J. Guzzo, MD, MPH Pediatrics and Microbiology,
Associate Professor of Urology Hashim Hashim, MD, MBBS, MRCS Immunology, and Tropical Medicine
The Hospital of the University of (Eng), FEBU, FRCS (Urol) The George Washington University
Pennsylvania Consultant Urological Surgeon Director, Clinic for Adolescent and
University of Pennsylvania Honorary Professor of Urology and Adult PedIatric OnseT UroLogy
Philadelphia, Pennsylvania Director of the Urodynamics Unit (CAPITUL)
Bristol Urological Institute Children’s National Hospital and the
Jennifer A. Hagerty, DO Southmead Hospital George Washington University
Attending Physician Bristol, United Kingdom Washington, District of Columbia
Department of Surgery/Division of Urology
Nemours/AI duPont Hospital for Children Dorota J. Hawksworth, MD Valerio Iacovelli, MD
Wilmington, Delaware Walter Reed National Military Medical Urology Unit
Assistant Professor Center University of Rome Tor Vergata
Department of Urology and Pediatrics Bethesda, Maryland San Carlo di Nancy General Hospital
Thomas Jefferson University GVM Care and Research
Philadelphia, Pennsylvania Sarah Hazell, MD Rome, Italy
Resident Physician
Simon J. Hall, MD Radiation Oncology and Molecular Stephen V. Jackman, MD
Zucker Professor of Urologic Oncology Radiation Sciences Professor
Smith Institute for Urology Johns Hopkins University School of Department of Urology
Hofstra/Northwell School of Medicine Medicine University of Pittsburgh
Lake Success, New York Baltimore, Maryland Pittsburgh, Pennsylvania

Barry Hallner, MD John P.F.A. Heesakkers, MD, PhD Joseph M. Jacob, MD, MCR
Associate Program Director, Female Pelvic Urologist Assistant Professor
Medicine and Reconstructive Surgery Department of Urology Department of Urology
Assistant Professor Radboud University Medical Centre Upstate Medical University
Departments of OB/GYN and Urology Nijmegen, The Netherlands Syracuse, New York
Louisiana State University Health
New Orleans School of Medicine
New Orleans, Louisiana
x CONTRIBUTORS

Micah A. Jacobs, MD, MPH Parviz K. Kavoussi, MD, FACS Ervin Kocjancic, MD
Associate Professor Reproductive Urologist Lawrence S. Ross Professor of Urology
Department of Urology Department of Urology Vice Chairman
University of Texas Southwestern Austin Fertility and Reproductive Medicine Department of Urology College of
Dallas, Texas Adjunct Assistant Professor Medicine
Department of Psychology University of Illinois at Chicago
Thomas W. Jarrett, MD Division of Neuroendocrinology and Chicago, Illinois
Professor and Chairman Motivation
Department of Urology University of Texas at Austin Chester J. Koh, MD
George Washington University Austin, Texas Professor of Urology, Pediatrics, and
Washington, District of Columbia Adjunct Assistant Professor Obstetrics/Gynecology
Department of Urology Baylor College of Medicine
Gerald H. Jordan, MD, FACS, University of Texas Health Sciences Center Division of Pediatric Urology
FAAP (Hon), FRCS (Hon) at San Antonio Department of Surgery
Associate Professor, Urology San Antonio, Texas Texas Children’s Hospital
Eastern Virginia Medical School Houston, Texas
Norfolk, Virginia Miran Kenk, PhD
Scientific Associate Badrinath Konety, MD, MBA
Martin Kaefer, MD Department of Surgical Oncology Chief Executive Officer
Professor of Urology Princess Margaret Cancer Centre University of Minnesota Physicians
Indiana University School of Medicine University Health Network Vice Dean for Clinical Affairs
Indianapolis, Indiana Toronto, Ontario, Canada University of Minnesota Medical School
Professor
Kamaljot S. Kaler, MD, FRCSC Mohit Khera, MD, MBA, MPH Department of Urology
Clinical Assistant Professor Professor of Urology University of Minnesota
University of Calgary Scott Department of Urology Minneapolis, Minnesota
Southern Alberta Institute of Urology Baylor College of Medicine
Calgary, Alberta, Canada Houston, Texas Casey Kowalik, MD
Assistant Professor
Panagiotis Kallidonis, MD, MSc, PhD, Antoine E. Khoury, MD, FRCSC, FAAP Department of Urology
FEBU Walter R. Schmid, Professor of Pediatric University of Kansas Health System
Assistant Professor Urological Urology Kansas City, Kansas
Surgeon Department of Urology
Department of Urology University of California–Irvine Martin A. Koyle, MD, FAAP, FACS,
University of Patras Head of Pediatric Urology FRCSC, FRCS (Eng)
Patras, Greece Children’s Hospital of Orange County Division Head, Division of Pediatric Urology
Orange, California Women’s Auxiliary Chair in Urology and
Steven Kaplan, MD Regenerative Medicine
Professor and Director, The Men’s Health Eric A. Klein, MD Hospital for Sick Children
Program Andrew C. Novick, Distinguished Professor of Surgery
Department of Urology Professor and Chair University of Toronto
Icahn School of Medicine at Mount Sinai Glickman Urological and Kidney Institute Toronto, Ontario, Canada
New York, New York and Cleveland Clinic Lerner College of
Medicine Amy E. Krambeck, MD
Max Kates, MD Cleveland Clinic Michael O. Koch Professor of Urology
Assistant Professor Cleveland, Ohio Department of Urology
Department of Urology Indiana University
Johns Hopkins Medical Institutions Laurence Klotz, MD, FRCSC, CM Indianapolis, Indiana
Baltimore, Maryland Professor of Surgery
University of Toronto Jessica E. Kreshover, MD
Melissa R. Kaufman, MD, PhD, FACS Urologist, Sunnybrook Health Sciences Associate Professor of Urology
Associate Professor Centre The Arthur Smith Institute for Urology
Department of Urology Toronto, Ontario, Canada Zucker School of Medicine at Hofstra/
Vanderbilt University Northwell
Nashville, Tennessee Bodo E. Knudsen, MD, FRCSC New Hyde Park, New York
Associate Professor
Vice Chair Clinical Operations Venkatesh Krishnamurthi, MD
Louis R. Kavoussi, MD, MBA Department of Urology Director, Kidney/Pancreas Transplant
Professor and Chair Wexner Medical Center Program
Department of Urology The Ohio State University Glickman Urological and Kidney Institute
Zucker School of Medicine at Hofstra/ Columbus, Ohio Transplant Center
Northwell Cleveland Clinic Foundation
Hempstead, New York Kathleen C. Kobashi, MD Cleveland, Ohio
Chairman of Urology Chief, Section of Urology
The Arthur Smith Institute for Urology Urology and Renal Transplantation
Lake Success, New York Virginia Mason Medical Center
Seattle, Washington
 CONTRIBUTORS xi

Ryan M. Krlin, MD, FPMRS Sey Kiat Lim, MBBS, MRCS Yair Lotan, MD
Associate Professor of Urology and ­(Edinburgh), MMed (Surgery), Professor
Gynecology FAMS (Urology) Department of Urology
Department of Urology Senior Consultant and Chief University of Texas Southwestern Medical
Louisiana State University Health New Department of Urology Center
Orleans Changi General Hospital Dallas, Texas
New Orleans, Louisiana Adjunct Associate Professor
Duke–National University of Singapore Alvaro Lucioni, MD
Alexander Kutikov, MD Medical School Program Director, Female Pelvic Medicine
Professor and Chief, Urologic Oncology Singapore Reconstructive Surgery Fellowship
Fox Chase Cancer Center Urology and Renal Transplantation
Philadelphia, Pennsylvania W. Marston Linehan, MD Virginia Mason Medical Center
Chief, Urologic Oncology Branch Seattle, Washington
Jaime Landman, MD National Cancer Institute
Professor of Urology and Radiology National Institutes of Health Tom F. Lue, MD, ScD (Hon), FACS
Chairman, Department of Urology Bethesda, Maryland Professor of Urology
University of California, Irvine Department of Urology
Orange, California Richard Edward Link, MD, PhD University of California–San Francisco
Carlton-Smith Chair in Urologic San Francisco, California
Brian R. Lane, MD, PhD Education
Chief, Urology Associate Professor of Urology Nicolas Lumen, MD, PhD
Spectrum Health Director, Division of Endourology and Professor of Urology
Associate Professor Minimally Invasive Surgery Ghent University Hospital
Michigan State University College of Scott Department of Urology Ghent, Belgium
Human Medicine Baylor College of Medicine
Grand Rapids, Michigan Houston, Texas Marcos Tobias Machado, MD, PhD
Professor of Urology
David A. Leavitt, MD Jen-Jane Liu, MD Department of Urology
Assistant Professor Assistant Professor Faculdade de Medicina do ABC
Department of Urology Director of Urologic Oncology Santo Andre, Brazil
Vattikuti Urology Institute Department of Urology
Henry Ford Health System Oregon Health and Science University Stephen D. Marshall, MD
Detroit, Michigan Portland Oregon Attending Physician
Laconia Clinic Department of Urology
Eugene K. Lee, MD Stacy Loeb, MD Lakes Region General Hospital
Associate Professor Professor of Urology and Population Laconia, New Hampshire
Department of Urology Health
University of Kansas Medical Center New York University and Manhattan Aaron D. Martin, MD, MPH
Kansas City, Kansas Veterans Affairs Associate Professor
New York, New York Department of Urology
Gary E. Lemack, MD Louisiana State University Health
Professor of Urology and Neurology Christopher J. Long, MD Sciences Center
Department of Urology Assistant Professor of Urology (Surgery) Department of Pediatric Urology
University of Texas Southwestern Medical Perelman School of Medicine Children’s Hospital New Orleans
Center University of Pennsylvania New Orleans, Louisiana
Dallas, Texas Division of Urology
Children’s Hospital of Philadelphia Laura M. Martinez, MD
Thomas Sean Lendvay, MD, FACS Philadelphia, Pennsylvania Instructor in Clinical Urology
Professor of Urology Department of Urology
University of Washington Roberto Iglesias. Lopes, MD, PhD Houston Methodist Hospital
Professor of Pediatric Urology Assistant Professor Houston, Texas
Seattle Children’s Hospital Pediatric Urology Unit
Seattle, Washington Division of Urology Timothy A. Masterson, MD
Hospital das Clínicas Associate Professor
Herbert Lepor, MD Faculdade de Medicina Department of Urology
Professor and Martin Spatz Chair Universidade de São Paulo Indiana University Medical Center
Department of Urology São Paulo, Brazil Indianapolis, Indiana
New York University School of Medicine
Chief, Urology Armando J. Lorenzo, MD, MSc, FRCSC, Surena F. Matin, MD
New York University Langone Health FAAP, FACS Professor
New York, New York Staff Paediatric Urologist Department of Urology
Department of Surgery Medical Director
Evangelos Liatsikos, MD, PhD Division of Urology Minimally Invasive New Technology in
Professor and Chairman Hospital for Sick Children Oncologic Surgery (MINTOS)
Department of Urology Associate Professor University of Texas MD Anderson Cancer
University of Patras Department of Surgery Center
Patras, Greece Division of Urology Houston, Texas
University of Toronto
Toronto, Ontario, Canada
xii CONTRIBUTORS

Brian R. Matlaga, MD Alireza Moinzadeh, MD, MHL Neema Navai, MD

Professor Chair, Department of Urology Associate Professor
James Buchanan Brady Urological Lahey Hospital and Medical Center Department of Urology
Institute Burlington, Massachusetts University of Texas MD Anderson Cancer
Johns Hopkins Medical Institutions Assistant Professor of Urology Center
Baltimore, Maryland Tufts University School of Medicine Houston, Texas
Boston, Massachusetts
Kurt A. McCammon, MD Diane K. Newman, DNP, ANP-BC, FAAN,
Devine Chair in Genitourinary Robert M. Moldwin, MD BCB-PMD
Reconstructive Surgery Professor of Urology Adjunct Professor of Urology in Surgery
Chairman and Program Director The Arthur Smith Institute for Urology Division of Urology
Professor Zucker School of Medicine at Hofstra/ Research Investigator Senior
Department of Urology Northwell Perelman School of Medicine
Eastern Virginia Medical School Lake Success, New York University of Pennsylvania
Norfolk, Virginia Co-Director, Penn Center for Continence
Manoj Monga, MD, FACS
Devine-Jordan Center for Reconstructive and Pelvic Health
Director, Stevan Streem Center for
Surgery and Pelvic Health Division of Urology
Endourology and Stone Disease
Urology of Virginia PLLC Penn Medicine
Department of Urology
Virginia Beach, Virginia Philadelphia, Pennsylvania
Cleveland Clinic
Cleveland, Ohio
James M. McKiernan, MD Craig S. Niederberger, MD, FACS
Chairman and Professor Clarence C. Saelhof Professor and Head
Francesco Montorsi, MD, FRCS (Hon)
Department of Urology Department of Urology
Professor and Chairman
Columbia University Irving Medical Center University of Illinois at Chicago College of
Department of Urology
New York, New York Medicine
IRCCS San Raffaele University
Professor
Milan, Italy
Chris G. McMahon, MBBS, FAChSHP Department of Bioengineering
Director Daniel M. Moreira, MD, MHS University of Illinois at Chicago College of
Australian Centre for Sexual Health Assistant Professor Engineering
Sydney, New South Wales, Australia Department of Urology Chicago, Illinois
University of Illinois at Chicago
Kevin T. McVary, MD Chicago, Illinois Victor W. Nitti, MD
Center for Male Health Professor of Urology and Obstetrics and
Loyola University Medical Center Allen F. Morey, MD, FACS Gynecology
Maywood, Illinois Professor Shlomo Raz Chair in Urology
Department of Urology Chief, Division of Female Pelvic Medicine
Luis G. Medina, MD University of Texas Southwestern and Reconstructive Surgery
Research Fellow Dallas, Texas David Geffen School of Medicine at
Department of Urology University of California–Los Angeles
University of Southern California Todd M. Morgan, MD Los Angeles, California
Los Angeles, California Chief of Urologic Oncology
Department of Urology Samuel J. Ohlander, MD
Kirstan K. Meldrum, MD University of Michigan Assistant Professor
Professor Ann Arbor, Michigan Department of Urology
Department of Surgery University of Illinois at Chicago
Central Michigan University John J. Mulcahy, MD, PhD, FACS Chicago, Illinois
Saginaw, Michigan Clinical Professor
Department of Urology L. Henning Olsen, MD
Matthew J. Mellon, MD, FACS University of Alabama Professor
Associate Professor Birmingham, Alabama Department of Urology
Department of Urology Section of Pediatric Urology
Indiana University Ravi Munver, MD, FACS Aarhus University Hospital
Indianapolis, Indiana Vice Chairman Institute of Clinical Medicine
Chief of Minimally Invasive and Robotic Aarhus University
Maxwell V. Meng, MD, FACS Urologic Surgery Aarhus, Denmark
Professor and Chief, Urologic Oncology Hackensack University Medical Center
Department of Urology Hackensack, New Jersey Aria F. Olumi, MD
University of California–San Francisco Professor of Urology Professor of Surgery/Urology
San Francisco, California Hackensack Meridian School of Medicine Department of Urologic Surgery
at Seton Hall University Beth Israel Deaconess Medical Center/
David Mikhail, MD, BSc, FRCSC Nutley, New Jersey Harvard Medical School
Endourology Fellow Boston, Massachusetts
Smith Institute for Urology Stephen Y. Nakada, MD, FACS
Northwell Health Professor and Chairman, The David T. Nadir I. Osman, MBChB (Hons), PhD,
New Hyde Park, New York Uehling Chair of Urology FRCS (Urol)
Department of Urology Consultant Urologist
Nicole L. Miller, MD University of Wisconsin School of Royal Hallmashire Hospital
Associate Professor Medicine and Public Health Sheffield Teaching Hospitals
Department of Urology Professor and Chairman Sheffield, South Yorkshire
Vanderbilt University Medical Center Department of Urology
Nashville, Tennessee University of Wisconsin Hospital and Clinics
Madison, Wisconsin
 CONTRIBUTORS xiii

Brandon J. Otto, MD Alan W. Partin, MD, PhD Thomas J. Polascik, MD

Assistant Professor of Urology The Jakurski Family Director Professor of Surgery
University of Florida College of Medicine Urologist-in-Chief Division of Urology
Gainesville, Florida Chairman, Department of Urology Duke Cancer Institute
Professor, Departments of Urology, Durham, North Carolina
Priya Padmanabhan, MD, MPH, FACS Oncology, and Pathology
Professor of Urology Johns Hopkins Medical Institutions Michel Pontari, MD
Pelvic Reconstruction and Voiding Baltimore, Maryland Professor and Vice-Chair
Dysfunction Department of Urology
William Beaumont Medical Center Roshan M. Patel, MD Lewis Katz School of Medicine at Temple
Royal Oak, Michigan Assistant Clinical Professor University
Department of Urology Philadelphia, Pennsylvania
Rodrigo L. Pagani, MD University of California, Irvine
Assistant Professor Orange, California John C. Pope IV, MD
Department of Urology Professor
University of Illinois at Chicago Margaret S. Pearle, MD, PhD Departments of Urology and
Chicago, Illinois Professor Pediatrics
Department of Urology and Internal Monroe Carell Jr. Children’s Hospital at
Lance C. Pagliaro, MD Medicine Vanderbilt
Professor of Oncology University of Texas Southwestern Medical Vanderbilt University Medical Center
Mayo Clinic College of Medicine Center Nashville, Tennessee
Consultant Dallas, Texas
Division of Medical Oncology Jay D. Raman, MD, FACS
Department of Oncology David F. Penson, MD, MPH Professor and Chief
Mayo Clinic Hamilton and Howd Chair in Urologic Division of Urology
Rochester, Minnesota Oncology Penn State Health Milton S. Hershey
Professor and Chair, Department of Urology Medical Center
Ganesh S. Palapattu, MD Vanderbilt University Medical Center Hershey, Pennsylvania
The George F. Valassis and Sandy G. Nashville Tennessee
Valassis Professor and Chair Ranjith Ramasamy, MD
Department of Urology Craig A. Peters, MD Director of Reproductive Urology
University of Michigan Chief, Pediatric Urology Department of Urology
Ann Arbor, Michigan Children’s Health System Texas University of Miami
Professor of Urology Miami, Florida
Drew A. Palmer, MD University of Texas Southwestern
Endourology Fellow Medical Center Ardeshir R. Rastinehad, DO, FACOS
Department of Urology Dallas, Texas Director, Focal Therapy and Interventional
University of North Carolina at Chapel Hill Urology
Chapel Hill, North Carolina Curtis A. Pettaway, MD Associate Professor of Radiology and
Professor Urology
Jeffrey S. Palmer, MD, FACS, FSPU Department of Urology Departments of Urology and Radiology
Director, Genital Reconstruction University of Texas MD Anderson Cancer Icahn School of Medicine at Mount
Cohen Children’s Medical Center of New Center Sinai
York Houston, Texas New York, New York
Associate Professor of Urology and
Pediatrics Janey R. Phelps, MD Yazan F. Rawashdeh, MD
Zucker School of Medicine at Hofstra/ Department of Anesthesia Consultant Pediatric Urologist
Northwell The University of North Carolina at Department of Urology
Long Island, New York Chapel Hill Section of Pediatric Urology
Chapel Hill, North Carolina Aarhus University Hospital
Lane S. Palmer, MD, FACS, FSPU
Chief, Division of Pediatric Urology Aarhus, Denmark
Ryan Phillips, MD, PhD
Cohen Children’s Medical Center of New Resident Physician
York Pramod P. Reddy, MD
Radiation Oncology and Molecular Professor
Professor of Urology and Pediatrics Radiation Sciences
Zucker School of Medicine at Hofstra/ Division Director, Division of Pediatric
Johns Hopkins University School of Urology
Northwell Medicine
Long Island, New York Cincinnati Children’s Hospital
Baltimore, Maryland Cincinnati, Ohio
Meyeon Park, MD, MAS
Phillip M. Pierorazio, MD
Associate Professor W. Stuart Reynolds, MD, MPH
Associate Professor of Urology and Oncology
Medical Director Associate Professor
Brady Urological Institute and
UCSF PKD Center of Excellence Department of Urology
Department of Urology
Department of Medicine Vanderbilt University Medical Center
Johns Hopkins School of Medicine
Division of Nephrology Nashville, Tennessee
Baltimore, Maryland
University of California–San Francisco
San Francisco, California Hans G. Pohl, MD, FAAP Koon Ho Rha, MD, PhD, FACS
Associate Professor Professor
William P. Parker, MD Department of Urology
Assistant Professor Department of Pediatrics
Division of Urology Urological Science Institute
Department of Urology Yonsei University College of Medicine
University of Kansas Health System Children’s National Medical Center
Washington, District of Columbia Seoul, Republic of Korea
Kansas City, Kansas
xiv CONTRIBUTORS

Lee Richstone, MD Eric S. Rovner, MD Rachel Selekman, MD, MS

Chairman of Urology Professor Assistant Professor, Pediatric Urology
Director of Laparoscopic and Robotic Department of Urology Children’s National Medical Center
Surgery Medical University of South Carolina Washington, District of Columbia
Professor of Urology Charleston, South Carolina
Lenox Hill Hospital Abhishek Seth, MD
New York, New York Steven P. Rowe, MD, PhD Assistant Professor, Urology
Assistant Professor of Radiology and Baylor College of Medicine
Stephen Riggs, MD Radiological Science Houston, Texas
Urologic Oncology Johns Hopkins University School of Karen Sandell Sfanos, PhD
Levine Cancer Institute Medicine Associate Professor
Charlotte, North Carolina Baltimore Maryland Department of Pathology
Johns Hopkins University School of
Richard C. Rink, MD, FAAP, FACS Matthew P. Rutman, MD Medicine
Emeritus Professor, Pediatric Urology Associate Professor of Urology Baltimore, Maryland
Riley Hospital for Children Indiana Columbia University Vagelos College of
University School of Medicine Physicians and Surgeons Paras H. Shah, MD
Faculty, Pediatric Urology Associate Attending Assistant Professor of Urology
Peyton Manning Children’s Hospital at New York–Presbyterian Hospital Albany Medical Center
Ascension St. Vincent New York, New York Albany, New York
Indianapolis, Indiana
Simpa S. Salami, MD, MPH Mohammed Shahait, MBBS
Michael L. Ritchey, MD Assistant Professor Consultant of Urology
Professor Department of Urology Department of Surgery
Department of Urology University of Michigan King Hussein Cancer Center
Mayo Clinic College of Medicine Ann Arbor, Michigan Amman, Jordan
Chief Medical Officer Leonard Davis Institute of Health
Phoenix Children’s Hospital Andrea Salonia, MD, PhD Economics
Phoenix, Arizona IRCCS San Raffaele Hospital University of Pennsylvania
Director, Urological Research Institute Philadelphia, Pennsylvania
Claus G. Roehrborn, MD Vita-Salute San Raffaele University
Professor and Chairman Milan, Italy Robert C. Shamberger, MD
Department of Urology Chief, Emeritus
University of Texas Southwestern Medical Edward M. Schaeffer, MD, PhD Department of Surgery
Center Professor and Chair Boston Children’s Hospital
Dallas, Texas Department of Urology Robert E. Gross Professor of Surgery
Northwestern University Feinberg School Harvard Medical School
Ashley E. Ross, MD, PhD of Medicine Boston, Massachusetts
Adjunct Associate Professor Chicago, Illinois
Department of Urology Alan W. Shindel, MD, MAS
Johns Hopkins Brady Urological Institute Bruce J. Schlomer, MD Associate Professor
Baltimore, Maryland Associate Professor Department of Urology
Department of Urology University of California–San Francisco
Sherry S. Ross, MD University of Texas Southwestern San Francisco, California
Department of Urology Dallas, Texas
The University of North Carolina at Aseem R. Shukla, MD
Chapel Hill Michael J. Schwartz, MD, FACS Endowed Chair in Minimally Invasive
Chapel Hill, North Carolina Associate Professor of Urology Surgery
The Arthur Smith Institute for Urology Division of Pediatric Urology
Christopher C. Roth, MD Zucker School of Medicine at Hofstra/ Children’s Hospital of Philadelphia
Associate Professor Northwell Associate Professor of Surgery (Urology)
Department of Urology New Hyde Park, New York Perelman School of Medicine
Louisiana State University Health Sciences University of Pennsylvania
Center Allen D. Seftel, MD Philadelphia, Pennsylvania
Department of Pediatric Urology Professor of Urology
Children’s Hospital New Orleans Department of Surgery Jay Simhan, MD, FACS
New Orleans, Louisiana Cooper Medical School of Rowan Vice Chairman
University Department of Urology
Kyle O. Rove, MD Chief Einstein Healthcare Network
Assistant Professor Division of Urology Associate Professor of Urology
Department of Pediatric Urology Cooper University Health Care Department of Urology
Children’s Hospital Colorado Camden, New Jersey Fox Chase Cancer Center
Assistant Professor Adjunct Professor Philadelphia, Pennsylvania
Department of Surgery Department of Surgery
Division of Urology MD Anderson Cancer Center Brian W. Simons, DVM, PhD
University of Colorado Houston, Texas Assistant Professor
Aurora, Colorado Department of Urology
Johns Hopkins University School of Medicine
Baltimore, Maryland
 CONTRIBUTORS xv

Eila C. Skinner, MD Julie N. Stewart, MD Kae Jack Tay, MBBS, MRCS (Ed), MMed
Professor and Chair Assistant Professor (Surgery), MCI, FAMS (Urology)
Thomas A. Stamey Research Professor of Department of Urology Consultant
Urology Houston Methodist Hospital Department of Urology
Department of Urology Houston, Texas Singapore General Hospital
Stanford University School of Medicine SingHealth Duke–National University of
Stanford, California John Stites, MD Singapore Academic Medical Center
Minimally Invasive and Robotic Urologic Singapore
Armine K. Smith, MD Surgery
Assistant Professor Hackensack University Medical Center John C. Thomas, MD, FAAP, FACS
Brady Urological Institute Hackensack, New Jersey Professor of Urologic Surgery
Johns Hopkins University Division of Pediatric Urology
Assistant Professor Douglas W. Storm, MD Department of Urology
Department of Urology Assistant Professor Monroe Carell Jr. Children’s Hospital at
George Washington University Department of Urology Vanderbilt
Washington, District of Columbia University of Iowa Hospitals and Clinics Vanderbilt University Medical Center
Iowa City, Iowa Nashville, Tennessee
Daniel Y. Song, MD
Professor Douglas W. Strand, PhD J. Brantley Thrasher, MD, FACS
Radiation Oncology and Molecular Assistant Professor Professor Emeritus of Urology
Radiation Sciences Department of Urology University of Kansas Medical Center
Johns Hopkins University School of University of Texas Southwestern Medical Kansas City, Kansas
Medicine Center Executive Director
Baltimore, Maryland Dallas, Texas American Board of Urology
Rene Sotelo, MD Charlottesville, Virginia
Professor of Clinical Urology Li-Ming Su, MD
Department of Urology David A. Cofrin Professor of Urologic Edouard J. Trabulsi, MD, FACS
University of Southern California Oncology Professor and Vice Chair
Los Angeles, California Chairman, Department of Urology Department of Urology
University of Florida College of Sidney Kimmel Cancer Center
Michael W. Sourial, MD, FRCSC Medicine Sidney Kimmel Medical College at
Assistant Professor Gainesville, Florida Thomas Jefferson University
Department of Urology Philadelphia, Pennsylvania
The Ohio State University Chandru P. Sundaram, MD, FACS, FRCS
Columbus, Ohio Eng Chad R. Tracy, MD
Dr. Norbert and Louise Welch Professor of Professor of Urology and Radiology
Anne-Françoise Spinoit, MD, PhD Urology Department of Urology
Pediatric and Reconstructive Urologist Vice Chair (QI) University of Iowa
Department of Urology Director, Minimally Invasive Surgery and Iowa City, Iowa
Ghent University Hospital Residency Program
Ghent, Belgium Department of Urology Paul J. Turek, MD
Indiana University School of Medicine Director
Arun K. Srinivasan, MD Indianapolis, Indiana The Turek Clinic
Division of Pediatric Urology San Francisco, California
Children’s Hospital of Philadelphia Samir S. Taneja, MD
Assistant Professor of Surgery (Urology) The James M. Neissa and Janet Riha Neissa Mark D. Tyson, MD, MPH
Perelman School of Medicine Professor of Urologic Oncology Urologic Oncologist
University of Pennsylvania Professor of Urology and Radiology Department of Urology
Philadelphia, Pennsylvania Director, Division of Urologic Mayo Clinic Arizona
Oncology Phoenix, Arizona
Ramaprasad Srinivasan, MD, PhD Department of Urology
Head, Molecular Cancer Section New York University Langone Health Robert G. Uzzo, MD, MBA, FACS
Urologic Oncology Branch New York, New York Professor and Chairman
Center for Cancer Research Department of Surgery
National Cancer Institute Nikki Tang, MD G. Willing “Wing” Pepper Chair in Cancer
National Institutes of Health Assistant Professor Research
Bethesda, Maryland Department of Dermatology Adjunct Professor of Bioengineering
Johns Hopkins University Temple University College of Engineering
Irina Stanasel, MD Baltimore, Maryland Fox Chase Cancer Center–Temple
Assistant Professor University Health System
Department of Urology Gregory E. Tasian, MD Lewis Katz School of Medicine
University of Texas Southwestern/ Assistant Professor of Urology and Temple University
Children’s Health Epidemiology Philadelphia, Pennsylvania
Dallas, Texas University of Pennsylvania Perelman
School of Medicine Brian A. VanderBrink, MD
Andrew J. Stephenson, MD, MBA, FACS, Attending Physician Associate Professor
FRCS (C) Division of Urology Division of Urology
Professor The Children’s Hospital of Philadelphia Cincinnati Children’s Hospital
Section Chief and Director, Urologic Philadelphia, Pennsylvania Cincinnati, Ohio
Oncology
Rush Medical College
Chicago, Illinois
xvi CONTRIBUTORS

Alex J. Vanni, MD Dana A. Weiss, MD Christopher E. Wolter, MD

Associate Professor Assistant Professor of Urology Assistant Professor
Department of Urology in Surgery Department of Urology
Lahey Hospital and Medical Center University of Pennsylvania Mayo Clinic Arizona
Burlington, Massachusetts Attending Physician Phoenix, Arizona
Children’s Hospital of Philadelphia
David J. Vaughn, MD Philadelphia, Pennsylvania Dan Wood, PhD, MB BS, FRCS (Urol)
Professor of Medicine Consultant in Adolescent and
Division of Hematology/Oncology Jeffrey P. Weiss, MD Reconstructive Urology
Department of Medicine Professor and Chair University College London Hospitals
Abramsom Cancer Center at the Department of Urology London, United Kingdom
University of Pennsylvania State University of New York Downstate
Philadelphia, Pennsylvania Health Sciences University Michael E. Woods, MD
Attending Surgeon Professor of Urology
Vijaya M. Vemulakonda, MD, JD Veterans Affairs New York Harbor Department of Urology
Associate Professor and Director of Research Healthcare System Loyola University Medical Center
Division of Urology Brooklyn, New York Maywood, Illinois
Department of Surgery
University of Colorado School of Robert M. Weiss, MD Hailiu Yang, MD
Medicine Donald Guthrie Professor of Surgery/ Resident Physician
Attending Pediatric Urologist Urology Department of Urology
Children’s Hospital Colorado Department of Urology Cooper University Hospital
Aurora, Colorado Yale University School of Medicine Camden, New Jersey
New Haven, Connecticut
Manish A. Vira, MD Richard Nithiphaisal Yu, MD, PhD
System Chief of Urologic Oncology R. Charles Welliver, Jr., MD Department of Urology
Northwell Health Cancer Institute Department of Urology Assistant Professor of Surgery (Urology)
Smith Institute for Urology Albany Medical Center Boston Children’s Hospital and Harvard
Lake Success, New York Albany, New York Medical School
Associate Professor of Urology Boston, Massachusetts
Zucker School of Medicine at Hofstra/ Hunter Wessells, MD, FACS
Northwell Professor and Nelson Chair Joseph Zabell, MD
Hempstead, New York Department of Urology Assistant Professor
Affiliate Member Department of Urology
Ramón Virasoro, MD Harborview Injury Prevention and University of Minnesota
Associate Professor Research Center Minneapolis, Minnesota
Department of Urology University of Washington School of
Eastern Virginia Medical School Medicine Mark R. Zaontz, MD
Norfolk, Virginia Seattle, Washington Professor of Urology (Surgery)
Fellowship Co-Director Perelman School of Medicine
Department of Urology Duncan T. Wilcox, MD, MBBS University of Pennsylvania
Universidad Autonoma de Santo Domingo Surgeon in Chief, Ponzio Family Chair of Division of Urology
Santo Domingo, Dominican Republic Pediatric Urology Children’s Hospital of Philadelphia
Department of Pediatric Urology Philadelphia, Pennsylvania
Alvin C. Wee, MD Children’s Hospital Colorado
Assistant Professor of Surgery Aurora, Colorado Rebecca S. Zee, MD, PhD
Cleveland Clinic Lerner College of Assistant Professor
Medicine J. Christian Winters, MD, FACS Division of Urology
Director, Kidney Transplant Program H. Eustis Reily Professor and Chairman Children’s Hospital of Richmond
Glickman Urological and Kidney Institute Department of Urology Virginia Commonwealth University
Cleveland Clinic Louisiana State University Health New Richmond, Virginia
Cleveland, Ohio Orleans
New Orleans, Louisiana
Elias Wehbi, MD, MSc, FRCSC
Assistant Professor Anton Wintner, MD
Department of Urology Instructor of Surgery
University of California–Irvine Harvard Medical School
Children’s Hospital of Orange County Associate Residency Program Director
Orange, California Department of Urology
Massachusetts General Hospital
Alan J. Wein, MD, PhD (Hon), FACS Boston, Massachusetts
Founders Professor and Emeritus Chief of
Urology J. Stuart Wolf, Jr., MD
Division of Urology Professor and Associate Chair for Clinical
Director, Residency Program in Urology Integration and Operations
Perelman School of Medicine at the Surgery and Perioperative Care
University of Pennsylvania Dell Medical School of the University of
Penn Medicine Texas at Austin
Philadelphia, Pennsylvania Austin, Texas
HOW TO USE THIS STUDY GUIDE
This study guide is designed to provide the reader with a com- the author to make several points. Both formats serve to broaden
prehensive review of urology based on the text Campbell-Walsh- the reader’s knowledge.
Wein Urology, twelfth edition. Each chapter includes a series of We hope that this study guide will be helpful to both the resi-
questions and possible answers, explanations for each answer, dent or fellow in training and the practicing clinician in refreshing
and a collection of chapter review points. Within the answer knowledge as well as in preparing for a urology examination.
explanations, text of particular importance has been indicated
in blue. If the reader knows the blue text and the chapter review Alan J. Wein, MD, PhD (Hon), FACS
points, he or she will know the majority of important points for Founders Professor and Emeritus Chief of Urology
that particular chapter. Moreover, if the questions are understood Division of Urology
and the emphasized points are remembered, then the reader will Director, Residency Program in Urology
have a thorough understanding of the important aspects of each Perelman School of Medicine at the University of Pennsylvania
chapter. Penn Medicine
It is important to note that some of the questions are not of the Philadelphia, Pennsylvania
format used in standardized tests such as the Qualifying Examina-
tion of the American Board of Urology. The proper format for exam- Thomas F. Kolon, MD, FAAP
ination questions is a question that asks for the one best possible Howard M. Snyder III MD Chair in Pediatric Urology
answer out of five. While many questions in this review guide are Pediatric Urology Fellowship Program Director
in this format, some additional formats are used for teaching pur- Children’s Hospital of Philadelphia
poses. For example, “all of the following are true except” allows the Professor of Urology in Surgery
author to provide the reader with four true statements regarding the Perelman School of Medicine at the University of Pennsylvania
question, and “more than one answer may be correct” also allows Philadelphia, Pennsylvania

xvii
CONTENTS
PART I Clinical Decision Making 17 Complications of Urologic Surgery, 50
Reza Ghavamian and Charbel Chalouhy
1  valuation of the Urologic Patient: History and
E
Physical Examination, 1 18 Urologic Considerations in Pregnancy, 52
Sammy E. Elsamra Melissa R. Kaufman

2  valuation of the Urologic Patient: Testing and

E 19 Intraoperative Consultation, 55
­Imaging, 5 Michael J. Schwartz and Jessica E. Kreshover
Erik P. Castle, Christopher E. Wolter, and Michael Woods

3  rinary Tract Imaging: Basic Principles of CT, MRI,

U PART III Pediatric Urology
and Plain Film Imaging, 7
Jay T. Bishoff and Ardeshir R. Rastinehad
SECTION A Development and Prenatal Urology
4  rinary Tract Imaging: Basic Principles of Urologic
U 20 Embryology of the Human Genitourinary Tract, 57
Ultrasonography, 11
Laurence S. Baskin and Gerald Cunha
Bruce R. Gilbert and Pat F. Fulgham
21 Urologic Aspects of Pediatric Nephrology, 60
5  rinary Tract Imaging: Basic Principles of Nuclear
U
Michael C. Braun and Chester J. Koh
Medicine, 15
Michael A. Gorin and Steven P. Rowe 22 Perinatal Urology, 64
C.D. Anthony Herndon and Rebecca S. Zee
6 Assessment of Urologic and Surgical Outcomes, 17
David F. Penson and Mark D. Tyson

7 Ethics and Informed Consent, 19

SECTION B Basic Principles
Vijaya M. Vemulakonda 23 Urologic Evaluation of the Child, 67
Rachel Selekman and Hillary L. Copp

PART II Basics of Urologic Surgery 24 Pediatric Urogenital Imaging, 70

Hans G. Pohl
8  rinciples of Urologic Surgery: Perioperative
P
Care, 21 25 I nfection and Inflammation of the Pediatric
Simpa S. Salami Genitourinary Tract, 72
Christopher S. Cooper and Douglas W. Storm
9  rinciples of Urologic Surgery: Incisions and
P
Access, 23 26  ore Principles of Perioperative Management in
C
David Mikhail and Simon J. Hall Children, 77
Sherry S. Ross and Janey R. Phelps
10  rinciples of Urologic Surgery: Intraoperative
P
­Technical Decisions, 26 27  rinciples of Laparoscopic and Robotic Surgery in
P
Manish A. Vira and Christopher J. Hartman Children, 80
Thomas Sean Lendvay and Jonathan Ellison
11 Lower Urinary Tract Catheterization, 28
Joseph M. Jacob and Chandru P. Sundaram
SECTION C Lower Urinary Tract Conditions
12 Fundamentals of Upper Urinary Tract Drainage, 30
Casey A. Dauw and J. Stuart Wolf, Jr. 28  linical and Urodynamic Evaluation of Lower
C
Urinary Tract Dysfunction in Children, 83
13 Principles of Urologic Endoscopy, 36 Duncan T. Wilcox and Kyle O. Rove
Brian Duty and Michael J. Conlin
29 Management Strategies for Vesicoureteral Reflux, 86
14  undamentals of Laparoscopic and Robotic ­Urologic
F Antoine E. Khoury and Elias Wehbi
Surgery, 38
Roshan M. Patel, Kamaljot S. Kaler, and Jaime Landman 30 Bladder Anomalies in Children, 93
Aaron D. Martin and Christopher C. Roth
15 Basic Energy Modalities in Urologic Surgery, 44
Michael W. Sourial, Shubha K. De, Manoj Monga, and Bodo E. 31 Exstrophy-Epispadias Complex, 96
Knudsen John P. Gearhart and Heather N. Di Carlo

16 Evaluation and Management of Hematuria, 46 32 Prune-Belly Syndrome, 103

Stephen A. Boorjian, Jay D. Raman, and Daniel A. Barocas Francisco T. Dénes and Roberto Iglesias Lopes

xviii
 CONTENTS xix

33 Posterior Urethral Valves, 106 50 Adolescent and Transitional Urology, 172

Aseem R. Shukla and Arun K. Srinivasan Dan Wood

34  euromuscular Dysfunction of the Lower Urinary

N 51  rologic Considerations in Pediatric Renal
U
Tract in Children, 110 ­Transplantation, 174
Carlos R. Estrada and Stuart B. Bauer Craig A. Peters and Armando J. Lorenzo

35  unctional Disorders of the Lower Urinary Tract in

F 52 Pediatric Genitourinary Trauma, 177
Children, 114 Bruce J. Schlomer and Micah A. Jacobs
Paul F. Austin and Abhishek Seth

36 Management of Defecation Disorders, 117 SECTION G Oncology

Martin A. Koyle and Armando J. Lorenzo
53 Pediatric Urologic Oncology: Renal and Adrenal, 180
37 Lower Urinary Tract Reconstruction in Children, 122 Michael L. Ritchey, Nicholas G. Cost, and Robert C. Shamberger
John C. Thomas, Douglass B. Clayton, and Mark C. Adams
54 Pediatric Urologic Oncology: Bladder and Testis, 184
Fernando A. Ferrer
SECTION D Upper Urinary Tract Conditions
38 Anomalies of the Upper Urinary Tract, 129
Brian A. VanderBrink and Pramod P. Reddy PART IV Infections and Inflammation
39  enal Dysgenesis and Cystic Disease of the
R 55 Infections of the Urinary Tract, 187
Kidney, 132 Kimberly L. Cooper, Gina M. Badalato, and Matthew P. Rutman
John C. Pope IV 56 I nflammatory and Pain Conditions of the Male
40 Pathophysiology of Urinary Tract Obstruction, 138 Genitourinary Tract: Prostatitis and Related Pain
Craig A. Peters and Kirstan K. Meldrum Conditions, Orchitis, and Epididymitis, 196
Michel Pontari
41  ctopic Ureter, Ureterocele, and Ureteral Anomalies,
E
140 57 I nterstitial Cystitis/Bladder Pain Syndrome and
Irina Stanasel and Craig A. Peters Related Disorders, 200
Robert M. Moldwin and Philip M. Hanno
42  urgery of the Ureter in Children: Ureteropelvic
S
Junction, Megaureter, and Vesicoureteral Reflux, 144 58 Sexually Transmitted Diseases, 206
L. Henning Olsen and Yazan F.H. Rawashdeh Kristy McKiernan Borawski

43 Management of Pediatric Kidney Stone Disease, 147 59 Cutaneous Diseases of the External Genitalia, 211
Gregory E. Tasian and Lawrence Copelovitch Richard Edward Link and Nikki Tang

60  uberculosis and Parasitic Infections of the

T
SECTION E Genitalia ­Genitourinary Tract, 218
Alicia H. Chang, Brian G. Blackburn, and Michael Hsieh
44  anagement of Abnormalities of the External
M
­Genitalia in Boys, 149
Lane S. Palmer and Jeffrey S. Palmer
PART V Molecular and Cellular Biology
45 Hypospadias, 154
61  asic Principles of Immunology and
B
Christopher J. Long, Mark R. Zaontz, and Douglas A. Canning
­Immunotherapy in Urologic Oncology, 224
46  tiology, Diagnosis, and Management of
E Charles G. Drake
­Undescended Testis, 160
62 Molecular Genetics and Cancer Biology, 227
Julia Spencer Barthold and Jennifer A. Hagerty
Karen Sandell Sfanos and Mark L. Gonzalgo
47  anagement of Abnormalities of the Genitalia in
M
Girls, 164
Martin Kaefer
PART VI Reproductive and Sexual Function
48  isorders of Sexual Development: Etiology,
D 63  urgical, Radiographic, and Endoscopic Anatomy of
S
­Evaluation, and Medical Management, 166 the Male Reproductive System, 233
Richard Nithiphaisal Yu and David A. Diamond
Parviz K. Kavoussi

64 Male Reproductive Physiology, 236

SECTION F Reconstruction and Trauma Paul J. Turek
49  urgical Management of Differences of Sexual
S 65 I ntegrated Men’s Health: Androgen Deficiency,
Differentiation and Cloacal and Anorectal ­Cardiovascular Risk, and Metabolic Syndrome, 239
Malformations, 170
Neil Fleshner, Miran Kenk, and Steven Kaplan
Richard C. Rink
xx CONTENTS

66 Male Infertility, 242 85  hysiology and Pharmacology of the Renal Pelvis

P
Craig S. Niederberger, Samuel J. Ohlander, and Rodrigo L. Pagani and Ureter, 327
Dana A. Weiss and Robert M. Weiss
67 Surgical Management of Male Infertility, 247
Marc Goldstein 86  enal Physiology and Pathophysiology Including
R
Renovascular Hypertension, 331
68  hysiology of Penile Erection and Pathophysiology
P Thomas Chi and Meyeon Park
of Erectile Dysfunction, 253
Alan W. Shindel and Tom F. Lue 87 Renal Insufficiency and Ischemic Nephropathy, 334
Joshua J. Augustine, Alvin C. Wee, Venkatesh Krishnamurthi, and David
69  valuation and Management of Erectile
E A. Goldfarb
­Dysfunction, 256
Arthur L. Burnett II and Ranjith Ramasamy 88  rological Complications of Renal
U
Transplantation, 338
70 Priapism, 259 Mohammed Shahait, Stephen V. Jackman, and Timothy D. Averch
Gregory A. Broderick

71 Disorders of Male Orgasm and Ejaculation, 264

Chris G. McMahon Upper Urinary Tract Obstruction and
PART IX 
72 Surgery for Erectile Dysfunction, 269 Trauma
Matthew J. Mellon and John J. Mulcahy 89  anagement of Upper Urinary Tract
M
Obstruction, 340
73  iagnosis and Management of Peyronie’s
D
Stephen Y. Nakada and Sara L. Best
Disease, 271
Allen D. Seftel and Hailiu Yang 90 Upper Urinary Tract Trauma, 344
Steven Brandes and Jairam Eswara
74 Sexual Function and Dysfunction in the Female, 275
Ervin Kocjancic, Valerio Iacovelli, and Ömer Acar

PART X Urinary Lithiasis and Endourology

PART VII Male Genitalia 91  rinary Lithiasis: Etiology, Epidemiology, and
U
Pathogenesis, 347
75  urgical, Radiographic, and Endoscopic Anatomy of
S
Margaret S. Pearle, Jodi A. Antonelli, and Yair Lotan
the Retroperitoneum, 279
Drew A. Palmer and Alireza Moinzadeh 92  valuation and Medical Management of Urinary
E
Lithiasis, 352
76 Neoplasms of the Testis, 284
Nicole L. Miller and Michael S. Borofsky
Andrew J. Stephenson and Timothy D. Gilligan
93  trategies for Nonmedical Management of Upper
S
77 Surgery of Testicular Tumors, 293 Urinary Tract Calculi, 358
Stephen Riggs, Kris E. Gaston, and Peter E. Clark
David A. Leavitt, Jean J.M.C.H. de la Rosette, and David M. Hoenig
78  aparoscopic and Robotic-Assisted Retroperitoneal
L 94  urgical Management for Upper Urinary Tract
S
Lymphadenectomy for Testicular Tumors, 299 ­Calculi, 361
Mohamad E. Allaf and Louis R. Kavoussi
Brian R. Matlaga and Amy E. Krambeck
79 Tumors of the Penis, 301 95 Lower Urinary Tract Calculi, 365
Curtis A. Pettaway, Juanita M. Crook, and Lance C. Pagliaro
Arvind P. Ganpule and Mahesh R. Desai
80 Tumors of the Urethra, 306
Christopher B. Anderson and James M. McKiernan

81 Inguinal Node Dissection, 309 PART XI Neoplasms of the Upper Urinary Tract
Rene Sotelo, Luis G. Medina, and Marcos Tobias-Machado 96 Benign Renal Tumors, 369
82  urgery for Benign Disorders of the Penis and
S William P. Parker and Matthew T. Gettman
­Urethra, 312 97 Malignant Renal Tumors, 372
Ramón Virasoro, Gerald H. Jordan, and Kurt A. McCammon Steven C. Campbell, Brian R. Lane, and Philip M. Pierorazio
83 Surgery of the Scrotum and Seminal Vesicles, 320 98  rothelial Tumors of the Upper Urinary Tract and
U
Dorota J. Hawksworth, Mohit Khera, and Amin S. Herati Ureter, 384
Panagiotis Kallidonis and Evangelos Liatsikos

99  urgical Management of Upper Urinary Tract

S
PART VIII Renal Physiology and Pathophysiology Urothelial Tumors, 387
Thomas W. Jarrett, Surena F. Matin, and Armine K. Smith
84  urgical, Radiologic, and Endoscopic Anatomy of
S
the Kidney and Ureter, 324 100 Retroperitoneal Tumors, 389
Mohamed A. Elkoushy and Sero Andonian Timothy A. Masterson, Clint Cary, and Richard S. Foster
 CONTENTS xxi

101 Open Surgery of the Kidney, 391 118 The Underactive Detrusor, 451
Aria F. Olumi and Michael L. Blute Christopher R. Chapple and Nadir I. Osman

102 L
 aparoscopic and Robotic Surgery of the 119 Nocturia, 453
Kidney, 395 Stephen D. Marshall and Jeffrey P. Weiss
Daniel M. Moreira and Louis R. Kavoussi
120 P
 harmacologic Management of Lower Urinary Tract
103 Nonsurgical Focal Therapy for Renal Tumors, 399 Storage and Emptying Failure, 455
Chad R. Tracy and Jeffrey A. Cadeddu Karl-Erik Andersson and Alan J. Wein

104 Treatment of Advanced Renal Cell Carcinoma, 401 121 C

 onservative Management of Urinary Incontinence:
Ramaprasad Srinivasan and W. Marston Linehan Behavioral and Pelvic Floor Therapy, Urethral and
Pelvic Devices, 463
Diane K. Newman and Kathryn L. Burgio

PART XII The Adrenals 122 E

 lectrical Stimulation and Neuromodulation in
Storage and Emptying Failure, 465
105 S
 urgical and Radiographic Anatomy of the
John P.F.A. Heesakkers and Bertil Blok
Adrenals, 404
Ravi Munver and John Stites 123 R
 etropubic Suspension Surgery for Incontinence in
Women, 469
106 P
 athophysiology, Evaluation, and Medical
Siobhan M. Hartigan, Christopher R. Chapple, and Roger R. Dmochowski
­Management of Adrenal Disorders, 406
Alexander Kutikov, Paul L. Crispen, and Robert G. Uzzo 124 V
 aginal and Abdominal Reconstructive Surgery for
Pelvic Organ Prolapse, 475
107 Surgery of the Adrenal Glands, 413
J. Christian Winters, Ryan M. Krlin, and Barry Hallner
Sey Kiat Lim and Koon Ho Rha
125 S
 lings: Autologous, Biologic, Synthetic, and
­Midurethral, 479
Urine Transport, Storage, and Emptying
PART XIII  Alex Gomelsky and Roger R. Dmochowski

108 S
 urgical, Radiographic, and Endoscopic Anatomy of 126 C
 omplications Related to the Use of Mesh and Their
the Female Pelvis, 416 Repair, 487
Priya Padmanabhan Anne P. Cameron

109 S
 urgical, Radiographic, and Endoscopic Anatomy of 127 A
 dditional Therapies for Storage and Emptying
the Male Pelvis, 419 ­Failure, 489
Jen-Jane Liu, Bryan R. Foster, and Christopher L. Amling Timothy B. Boone, Julie N. Stewart, and Laura M. Martinez

110 P
 hysiology and Pharmacology of the Bladder and 128 Aging and Geriatric Urology, 492
Urethra, 422 Tomas L. Griebling
Toby C. Chai and Lori A. Birder 129 Urinary Tract Fistulae, 496
111  athophysiology and Classification of Lower
P Dirk J.M.K. De Ridder and Tamsin Greenwell
Urinary Tract Dysfunction: Overview, 427 130 Bladder and Female Urethral Diverticula, 502
Elizabeth Timbrook Brown, Alan J. Wein, and Roger R. Dmochowski
Lindsey Cox and Eric S. Rovner
112 E
 valuation and Management of Women With 131 S
 urgical Procedures for Sphincteric Incontinence in
­Urinary Incontinence and Pelvic Prolapse, 431 the Male, 507
Alvaro Lucioni and Kathleen C. Kobashi Hunter Wessells and Alex J. Vanni
113 E
 valuation and Management of Men With Urinary
Incontinence, 436
Riyad Tasher Al Mousa and Hashim Hashim
Benign and Malignant Bladder
PART XIV 
114 U
 rodynamic and Video-Urodynamic Evaluation of Disorders
the Lower Urinary Tract, 439
Benjamin M. Brucker and Victor W. Nitti 132 Bladder Surgery for Benign Disease, 510
Paras H. Shah and Lee Richstone
115 U
 rinary Incontinence and Pelvic Prolapse:
­Epidemiology and Pathophysiology, 442 133 Genital and Lower Urinary Tract Trauma, 513
Gary E. Lemack and Maude Carmel Allen F. Morey and Jay Simhan

116 N
 euromuscular Dysfunction of the Lower Urinary 134 S
 pecial Urologic Considerations in Transgender
Tract, 444 Individuals, 516
Casey Kowalik, Alan J. Wein, and Roger R. Dmochowski Nicolas Lumen, Anne-Françoise Spinoit, and Piet Hoebeke

117 Overactive Bladder, 449 135 Tumors of the Bladder, 518

W. Stuart Reynolds and Joshua A. Cohn Max Kates and Trinity J. Bivalacqua
xxii CONTENTS

136 M
 anagement Strategies for Non–Muscle-Invasive 148 E
 pidemiology, Etiology, and Prevention of Prostate
Bladder Cancer (Ta, T1, and CIS), 526 Cancer, 571
Joseph Zabell and Badrinath Konety Andrew J. Stephenson, Robert Abouassaly, and Eric A. Klein

137 M
 anagement of Muscle-Invasive and Metastatic 149 Prostate Cancer Biomarkers, 574
Bladder Cancer, 530 Todd M. Morgan, Ganesh S. Palapattu, and Simpa S. Salami
Thomas J. Guzzo, John Christodouleas, and David J. Vaughn
150 Prostate Biopsy: Techniques and Imaging, 577
138 S
 urgical Management of Bladder Cancer: Edouard J. Trabulsi, Ethan J. Halpern, and Leonard G. Gomella
­Transurethral, Open, and Robotic, 533
151 Pathology of Prostatic Neoplasia, 581
Neema Navai and Colin P.N. Dinney
Jonathan I. Epstein
139 U
 se of Intestinal Segments in Urinary Diversion,
536 152 Diagnosis and Staging of Prostate Cancer, 583
Stacy Loeb and James A. Eastham
Anton Wintner and Douglas M. Dahl

140 Cutaneous Continent Urinary Diversion, 540 153 A

 ctive Management Strategies for Localized Prostate
Cancer, 586
Guarionex Joel DeCastro, James M. McKiernan, and Mitchell C. Benson
Samir S. Taneja and Marc A. Bjurlin
141 Orthotopic Urinary Diversion, 546
154 Active Surveillance of Prostate Cancer, 590
Eila C. Skinner and Siamak Daneshmand
Laurence Klotz
142 Minimally Invasive Urinary Diversion, 551
155 Open Radical Prostatectomy, 592
Khurshid A. Guru
Edward M. Schaeffer, Alan W. Partin, and Herbert Lepor

156 L
 aparoscopic and Robotic-Assisted Radical
PART XV The Prostate ­Prostatectomy and Pelvic Lymphadenectomy, 597
143 D
 evelopment, Molecular Biology, and Physiology of Li-Ming Su, Brandon J. Otto, and Anthony Costello
the Prostate, 554 157 Radiation Therapy for Prostate Cancer, 600
Brian W. Simons and Ashley E. Ross Ryan Phillips, Sarah Hazell, and Daniel Y. Song
144 B
 enign Prostatic Hyperplasia: Etiology, 158 Focal Therapy for Prostate Cancer, 603
­Pathophysiology, Epidemiology, and Natural Kae Jack Tay and Thomas J. Polascik
­History, 557
Claus G. Roehrborn and Douglas W. Strand 159 Treatment of Locally Advanced Prostate Cancer, 606
Maxwell V. Meng and Peter R. Carroll
145 E
 valuation and Nonsurgical Management of Benign
Prostatic Hyperplasia, 561 160 M
 anagement Strategies for Biochemical Recurrence
Paolo Capogrosso, Andrea Salonia, and Francesco Montorsi of Prostate Cancer, 609
Eugene K. Lee and J. Brantley Thrasher
146 M
 inimally Invasive and Endoscopic Management of
Benign Prostatic Hyperplasia, 566 161 Hormonal Therapy for Prostate Cancer, 611
Sevann Helo, R. Charles Welliver, Jr., and Kevin T. McVary Scott Eggener

147 S
 imple Prostatectomy: Open and Robot-Assisted 162 T
 reatment of Castration-Resistant Prostate
Laparoscopic Approaches, 569 Cancer, 615
Misop Han and Alan W. Partin Emmanuel S. Antonarakis and Michael A. Carducci
 PART
I Clinical Decision Making

1 Evaluation of the Urologic Patient: History and Physical

Examination
Sammy E. Elsamra

QUESTIONS 7. What percentage of patients with multiple sclerosis will pre-

sent with urinary symptoms as the first manifestation of the
1. Pain associated with a stone in the ureter is the result of: disease?
a. obstruction of urine flow with distention of the renal capsule. a. 1%
b. irritation of the ureteral mucosa by the stone. b. 5%
c. excessive ureteral peristalsis in response to the obstructing c. 10%
stone. d. 15%
d. irritation of the intramural ureter. e. 20%
e. urinary extravasation from a ruptured calyceal fornix.
8. What important information is gained from pelvic biman-
2. The most common cause of gross hematuria in a patient older ual examination that cannot be obtained from radiologic
than 50 years is: ­evaluation?
a. renal calculi. a. Presence of bladder mass
b. infection. b. Invasion of bladder cancer into perivesical fat
c. bladder cancer. c. Presence of bladder calculi
d. benign prostatic hyperplasia. d. Presence of associated pathologic lesion in female adnexal
e. trauma. structures
e. Mobility/fixation of pelvic organs
3. The most common cause of pain associated with gross hema-
turia is: 9. With which of the following diseases is priapism most com-
a. simultaneous passage of a kidney stone. monly associated?
b. ureteral obstruction due to blood clots. a. Peyronie disease
c. urinary tract malignancy. b. Sickle cell anemia
d. prostatic inflammation. c. Parkinson disease
e. prostatic enlargement. d. Organic depression
e. Leukemia
4. All of the following are typical lower urinary tract symptoms
associated with benign prostatic hyperplasia EXCEPT: 10. What is the most common cause of cloudy urine?
a. urgency. a. Bacterial cystitis
b. frequency. b. Urine overgrowth with yeast
c. nocturia. c. Phosphaturia
d. dysuria. d. Alkaline urine
e. weak urinary stream. e. Significant proteinuria
5. The most likely cause of continuous incontinence (loss of 11. Conditions that decrease urine specific gravity include all of
urine at all times and in all positions) is: the following EXCEPT:
a. enterovesical fistula. a. increased fluid intake.
b. noncompliant bladder. b. use of diuretics.
c. detrusor hyperreflexia. c. decreased renal concentrating ability.
d. vesicovaginal fistula. d. dehydration.
e. sphincteric incompetence. e. diabetes insipidus.
6. All of the following are potential causes of anejaculation EX- 12. Urine osmolality usually varies between:
CEPT: a. 10 and 200 mOsm/L.
a. sympathetic denervation. b. 50 and 500 mOsm/L.
b. pharmacologic agents. c. 50 and 1200 mOsm/L.
c. bladder neck and prostatic surgery. d. 100 and 1000 mOsm/L.
d. androgen deficiency. e. 100 and 1500 mOsm/L.
e. cerebrovascular accidents.
1
2 PART I Clinical Decision Making

13. Elevated ascorbic acid levels in the urine may lead to false- 21. All of the following are microscopic features of squamous
negative results on a urine dipstick test for: epithelial cells EXCEPT:
a. glucose. a. large size.
b. hemoglobin. b. small central nucleus.
c. myoglobin. c. irregular cytoplasm.
d. red blood cells. d. presence in clumps.
e. leukocytes. e. fine granularity in the cytoplasm.
14. Hematuria is distinguished from hemoglobinuria or myoglo- 22. The number of bacteria per high-power microscopic field that
binuria by: corresponds to colony counts of 100,000/mL is:
a. dipstick testing. a. 1.
b. the simultaneous presence of significant leukocytes. b. 3.
c. microscopic presence of erythrocytes. c. 5.
d. examination of serum. d. 10.
e. evaluation of hematocrit. e. 20.
15. The presence of one positive dipstick reading for hematuria 23. Pain in the flaccid penis is usually due to:
is associated with significant urologic pathologic findings on a. Peyronie disease.
subsequent testing in what percentage of patients?
b. bladder or urethral inflammation.
a. 2%
c. priapism.
b. 10%
d. calculi impacted in the distal ureter.
c. 25%
e. hydrocele.
d. 50%
e. 75% 24. Chronic scrotal pain is most often due to:
a. testicular torsion.
16. The most common cause of glomerular hematuria is:
b. trauma.
a. transitional cell carcinoma.
c. cryptorchidism.
b. nephritic syndrome.
d. hydrocele.
c. Berger disease (immunoglobulin A nephropathy).
e. orchitis.
d. poststreptococcal glomerulonephritis.
e. Goodpasture syndrome. 25. Terminal hematuria (at the end of the urinary stream) is usu-
ally due to:
17. The most common cause of proteinuria is: a. bladder neck or prostatic inflammation.
a. Fanconi syndrome. b. bladder cancer.
b. excessive glomerular permeability due to primary glomeru- c. kidney stones.
lar disease.
d. bladder calculi.
c. failure of adequate tubular reabsorption.
e. urethral stricture disease.
d. overflow proteinuria due to increased plasma concentration
of immunoglobulins. 26. Enuresis is present in what percentage of children at age 5 years?
e. diabetes. a. 5%
18. Transient proteinuria may be due to all of the following EXCEPT: b. 15%
a. exercise. c. 25%
b. fever. d. 50%
c. emotional stress. e. 75%
d. congestive heart failure (CHF). 27. All of the following in the medical history suggest that erectile
e. ureteroscopy. dysfunction is more likely due to organic rather than psycho-
genic causes EXCEPT:
19. Glucose will be detected in the urine when the serum level is a. sudden onset.
above:
b. peripheral vascular disease.
a. 75 mg/dL.
c. absence of nocturnal erections.
b. 100 mg/dL.
d. diabetes mellitus.
c. 150 mg/dL.
e. inability to achieve adequate erections in a variety of cir-
d. 180 mg/dL. cumstances.
e. 225 mg/dL.
28. All of the following should be routinely performed in men
20. The specificity of dipstick nitrite testing for bacteriuria is: with hematospermia EXCEPT:
a. 20%. a. cystoscopy.
b. 40%. b. digital rectal examination.
c. 60%. c. serum prostate-specific antigen (PSA) level.
d. 80%. d. genital examination.
e. >90%. e. urinalysis.
 CHAPTER 1 Evaluation of the Urologic Patient: History and Physical Examination 3

29. Pneumaturia may be due to all of the following EXCEPT: 15. c. 25%. Investigators at the University of Wisconsin found that
a. diverticulitis. 26% of adults who had at least one positive dipstick reading
for hematuria were subsequently found to have significant
b. colon cancer. urologic pathologic findings.
c. recent urinary tract instrumentation. 16. c. Berger disease (immunoglobulin A nephropathy). IgA
d. inflammatory bowel disease. nephropathy, or Berger disease, is the most common cause of
glomerular hematuria, accounting for about 30% of cases.
e. ectopic ureter.
17. b. Excessive glomerular permeability due to primary glo-
30. Which of the following disorders may commonly lead to irrita- merular disease. Glomerular proteinuria is the most common
tive voiding symptoms? type of proteinuria and results from increased glomerular cap-
a. Parkinson disease illary permeability to protein, especially albumin. Glomerular
proteinuria occurs in any of the primary glomerular diseases
b. Renal cell carcinoma such as IgA nephropathy or in glomerulopathy associated with
c. Bladder diverticula systemic illness such as diabetes mellitus.
d. Prostate cancer 18. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
cially in the pediatric population, and usually resolves sponta-
e. Testicular torsion neously within a few days. It may result from fever, exercise, or
emotional stress. In older patients, transient proteinuria may
be due to CHF.
ANSWERS 19. d. 180 mg/dL. This so-called renal threshold corresponds to
a serum glucose level of about 180 mg/dL; above this level,
1. a. Obstruction of urine flow with distention of the renal glucose will be detected in the urine.
capsule. Pain is usually caused by acute distention of the renal 20. e. >90%. The specificity of the nitrite dipstick test for detecting
capsule, usually from inflammation or obstruction. bacteriuria is greater than 90%.
2. c. Bladder cancer. The most common cause of gross hematuria 21. d. Presence in clumps. Squamous epithelial cells are large,
in a patient older than age 50 is bladder cancer. have a central small nucleus about the size of an erythrocyte,
3. b. Ureteral obstruction due to blood clots. Pain in associa- and have an irregular cytoplasm with fine granularity.
tion with hematuria usually results from upper urinary tract 22. c. 5. Therefore five bacteria per high-power field in a spun
hematuria with obstruction of the ureters with clots. specimen reflect colony counts of about 100,000/mL.
4. d. Dysuria. Dysuria is painful urination that is usually caused 23. b. Bladder or urethral inflammation. Pain in the flaccid penis
by inflammation. is usually secondary to inflammation in the bladder or urethra,
5. d. Vesicovaginal fistula. Continuous incontinence is most with referred pain that is experienced maximally at the urethral
commonly due to a urinary tract fistula that bypasses the ure- meatus.
thral sphincter or an ectopic ureter. 24. d. Hydrocele. Chronic scrotal pain is usually related to nonin-
6. e. Cerebrovascular accidents. Anejaculation may result from flammatory conditions such as a hydrocele or varicocele, and
several causes: (1) androgen deficiency, (2) sympathetic den- the pain is usually characterized as a dull, heavy sensation that
ervation, (3) pharmacologic agents, and (4) bladder neck and does not radiate.
prostatic surgery. 25. a. Bladder neck or prostatic inflammation. Terminal hema-
7. b. 5%. In fact, 5% of patients with previously undiagnosed turia occurs at the end of micturition and is usually secondary
multiple sclerosis present with urinary symptoms as the first to inflammation in the area of the bladder neck or prostatic
manifestation of the disease. urethra.
8. e. Mobility/fixation of pelvic organs. In addition to defin- 26. b. 15%. Enuresis refers to urinary incontinence that occurs
ing areas of induration, the bimanual examination allows the during sleep. It occurs normally in children as old as 3 years
examiner to assess the mobility of the bladder; such informa- but persists in about 15% of children at age 5 and about 1% of
tion cannot be obtained by radiologic techniques such as children at age 15.
computed tomography (CT) and magnetic resonance imaging 27. a. Sudden onset. A careful history will often determine
(MRI), which convey static images. whether the problem is primarily psychogenic or organic. In
9. b. Sickle cell anemia. Priapism occurs most commonly in pa- men with psychogenic impotence, the condition frequently
tients with sickle cell disease but can also occur in those with develops rather quickly, secondary to a precipitating event such
advanced malignancy, coagulation disorders, and pulmonary as marital stress or change or loss of a sexual partner.
disease, as well as in many patients without an obvious cause. 28. a. Cystoscopy. A genital and rectal examination should be
10. c. Phosphaturia. Cloudy urine is most commonly caused by done to exclude the presence of tuberculosis, a PSA assessment
phosphates in the urine. and digital rectal examination should be done to exclude pro-
11. d. Dehydration. Conditions that decrease specific gravity static carcinoma, and a urinary cytologic assessment should be
include (1) increased fluid intake, (2) diuretics, (3) decreased done to exclude the possibility of transitional cell carcinoma
renal concentrating ability, and (4) diabetes insipidus. of the prostate.
12. c. 50 and 1200 mOsm/L. Osmolality is a measure of the 29. e. Ectopic ureter. Pneumaturia is the passage of gas in the
amount of solutes dissolved in the urine and usually varies urine. In patients who have not recently had urinary tract
between 50 and 1200 mOsm/L. instrumentation or a urethral catheter placed, this is almost al-
13. a. Glucose. False-negative results for glucose and bilirubin may ways due to a fistula between the intestine and bladder. Com-
be seen in the presence of elevated ascorbic acid concentra- mon causes include diverticulitis, carcinoma of the sigmoid
tions in the urine. colon, and regional enteritis (Crohn disease).
14. c. Microscopic presence of erythrocytes. Hematuria can be 30. a. Parkinson disease. The second important example of non-
distinguished from hemoglobinuria and myoglobinuria by specific lower urinary tract symptoms that may occur second-
microscopic examination of the centrifuged urine; the presence ary to a variety of neurologic conditions is irritative symptoms
of a large number of erythrocytes establishes the diagnosis of resulting from neurologic disease such as cerebrovascular
hematuria. accident, diabetes mellitus, or Parkinson disease.
4 PART I Clinical Decision Making

CHAPTER REVIEW
1. IPSS score: 0 to 7 mild symptoms, 8 to 19 moderate symp- 18. The bulbocavernosus reflex tests the integrity of this spinal
toms, 20 to 35 severe symptoms. cord reflex involving S2 to S4.
2. Renal pain radiates from the flank anteriorly to the respec- 19. A positive dipstick for blood in the urine indicates hema-
tive lower quadrant and may be referred to the testis, turia, hemoglobinuria, or myoglobinuria. Hematuria is
labium, or medial aspect of the thigh. The pain is colicky distinguished from hemoglobinuria and myoglobinuria
(fluctuates). It may be associated with gastrointestinal by microscopic examination of the centrifuged urine and
symptoms due to reflex stimulation of the celiac ganglion. identification of red blood cells (more than three red blood
3. Patients with slowly progressive urinary obstruction with cells per high-power field is abnormal).
bladder distention often have no pain, despite residual 20. Hematuria of nephrologic origin is frequently associated
volumes in excess of a liter. with proteinuria and dysmorphic erythrocytes.
4. Pain of prostatic origin is poorly localized. 21. Anticoagulation at normal therapeutic levels does not pre-
5. Scrotal pain may be primary or referred. Pain referred to the dispose patients to hematuria.
testicle originates in the retroperitoneum, ureter, or kidney. 22. The most accurate method to diagnose urinary tract infection
6. Hematuria, particularly in adults, should be regarded as a is by microscopic examination of the urine and identifying
symptom of malignancy until proven otherwise. pyuria and bacteria. This is confirmed by urine culture.
7. Adults normally arise no more than twice a night to void. 23. The chief complaint is the focus of the visit and is the
Urine production increases at night (recumbent position) reason the patient seeks consultation. It should be the lead
in older patients and those with cardiac disease, particularly sentence in the history and physical (H&P).
CHF. 24. A family history should always include questions about
8. Postvoid dribbling: Urine escapes into the bulbar urethra renal and prostate cancer, renal cysts, and stone disease.
and then leaks at the end of micturition. This may be allevi- 25. Priapism occurs most commonly in patients with sickle cell
ated by perineal pressure following voiding. disease but can also occur in those with advanced malig-
9. Those who present with microscopic hematuria and ir- nancy, coagulation disorders, or pulmonary disease, as well
ritative voiding symptoms should be suspected of having as in many patients without an obvious cause.
carcinoma in situ of the bladder until proven otherwise. 26. On urine dipstick, false-negative results for glucose and
10. Continuous incontinence is most commonly due to ectopic bilirubin may be seen in the presence of elevated ascorbic
ureter, urinary tract fistula, or totally incompetent sphincter. acid concentrations in the urine.
11. Hematospermia almost always resolves spontaneously and 27. Glomerular proteinuria is the most common type of
is rarely associated with any significant urologic pathology. proteinuria and results from increased glomerular capillary
12. When urinary obstruction is associated with fever and permeability to protein, especially albumin. Glomeru-
chills, it should be regarded as a urologic emergency. lar proteinuria occurs in any of the primary glomerular
13. It is always worthwhile to obtain the previous operative diseases such as IgA nephropathy or in glomerulopathy
report in patients who are to be operated on. associated with systemic illness such as diabetes mellitus.
14. If the patient is uncircumcised, the foreskin must be re- 28. Five bacteria per high-power field in a spun specimen
tracted for inspection of the glans. reflect colony counts of about 100,000/mL.
15. The testes are normally 6 cm in length and 4 cm in width. 29. An important example of nonspecific lower urinary tract
16. If one obtains a stool guaiac test (hemoccult) as a screen symptoms that may occur secondary to a variety of neuro-
for colon cancer, two subsequent stool specimens must be logic conditions is irritative symptoms resulting from neu-
obtained for an adequate test. If the hemoccult is positive, rologic disease such as cerebrovascular accident, diabetes
the patient should be on a red meat–free diet for 3 days mellitus, and Parkinson disease.
before collection of three specimens. 30. The renal threshold for glucose corresponds to a serum
17. A male urologist should always perform a female pelvic glucose level of about 180 mg/dL; above this level, glucose
examination with a female nurse in attendance. will be detected in the urine.
2 Evaluation of the Urologic Patient: Testing and Imaging
Erik P. Castle, Christopher E. Wolter, and Michael Woods

QUESTIONS c. Berger disease (immunoglobulin A nephropathy).

1. What is the most common cause of cloudy urine? d. poststreptococcal glomerulonephritis.
a. Bacterial cystitis e. Goodpasture syndrome.
b. Urine overgrowth with yeast 8. The most common cause of proteinuria is:
c. Phosphaturia a. Fanconi syndrome.
d. Alkaline urine b. excessive glomerular permeability due to primary glomeru-
e. Significant proteinuria lar disease.
2. Conditions that decrease urine specific gravity include all of c. failure of adequate tubular reabsorption.
the following EXCEPT: d. overflow proteinuria due to increased plasma concentration
a. increased fluid intake. of immunoglobulins.
b. use of diuretics. e. diabetes.
c. decreased renal concentrating ability. 9. Transient proteinuria may be due to all of the following
d. dehydration. ­EXCEPT:
e. diabetes insipidus. a. exercise.
b. fever.
3. Urine osmolality usually varies between:
c. emotional stress.
a. 10 and 200 mOsm/L.
d. congestive heart failure.
b. 50 and 500 mOsm/L.
e. ureteroscopy.
c. 50 and 1200 mOsm/L.
d. 100 and 1000 mOsm/L. 10. Glucose will be detected in the urine when the serum level is
above:
e. 100 and 1500 mOsm/L.
a. 75 mg/dL.
4. Elevated ascorbic acid levels in the urine may lead to false- b. 100 mg/dL.
negative results on a urine dipstick test for:
c. 150 mg/dL.
a. glucose.
d. 180 mg/dL.
b. hemoglobin.
e. 225 mg/dL.
c. myoglobin.
d. red blood cells. 11. The specificity of dipstick nitrite testing for bacteriuria is:
e. leukocytes. a. 20%.
b. 40%.
5. Hematuria is distinguished from hemoglobinuria or myoglo-
binuria by: c. 60%.
a. dipstick testing. d. 80%.
b. the simultaneous presence of significant leukocytes. e. >90%.
c. microscopic presence of erythrocytes. 12. All of the following are microscopic features of squamous
d. examination of serum. epithelial cells EXCEPT:
e. evaluation of hematocrit. a. large size.
b. small central nucleus.
6. The presence of one positive dipstick reading for hematuria
is associated with significant urologic pathologic findings on c. irregular cytoplasm.
subsequent testing in what percentage of patients? d. presence in clumps.
a. 2% e. fine granularity in the cytoplasm.
b. 10% 13. The number of bacteria per high-power microscopic field that
c. 25% corresponds to colony counts of 100,000/mL is:
d. 50% a. 1.
e. 75% b. 3.
7. The most common cause of glomerular hematuria is: c. 5.
a. transitional cell carcinoma. d. 10.
b. nephritic syndrome. e. 20.

5
6 PART I Clinical Decision Making

14. All of following is true of uroflowmetry EXCEPT: microscopic examination of the centrifuged urine; the presence
a. Qmax >20 mL/s is not consistent with obstruction. of a large number of erythrocytes establishes the diagnosis of
hematuria.
b. Qmax, mean flow rate, and voided volume are parameters 6. c. 25%. Investigators at the University of Wisconsin found that
obtained from this study. 26% of adults who had at least one positive dipstick reading
c. 80 mL voided volume is adequate for uroflowmetry. for hematuria were subsequently found to have significant
d. the study can be performed in sitting and standing positions. urologic pathologic findings.
7. c. Berger disease (immunoglobulin A nephropathy). IgA
e. uroflowmetry cannot diagnose the location of obstruction.
nephropathy, or Berger disease, is the most common cause of
15. The following should be given to uncomplicated patients glomerular hematuria, accounting for about 30% of cases.
undergoing simple flexible diagnostic cystourethroscopy: 8. b. Excessive glomerular permeability due to primary glo-
a. single-dose oral antibiotic following procedure merular disease. Glomerular proteinuria is the most common
type of proteinuria and results from increased glomerular cap-
b. 3 days of oral antibiotics following procedure illary permeability to protein, especially albumin. Glomerular
c. 3 days of oral antibiotics starting the day prior to procedure proteinuria occurs in any of the primary glomerular diseases
d. nothing such as IgA nephropathy or in glomerulopathy associated with
systemic illness such as diabetes mellitus.
e. single intramuscular injection of ceftriaxone following 9. e. Ureteroscopy. Transient proteinuria occurs commonly, espe-
procedure cially in the pediatric population, and usually resolves sponta-
16. What is the most appropriate initial workup for asymptomatic neously within a few days. It may result from fever, exercise, or
microscopic hematuria (AMH)? emotional stress. In older patients, transient proteinuria may
be due to congestive heart failure.
a. Flexible cystoscopy, urinary cytology, CT urogram, and
10. d. 180 mg/dL. This so-called renal threshold corresponds to
UroVysion FISH
a serum glucose level of about 180 mg/dL; above this level,
b. Flexible cystoscopy and CT urogram glucose will be detected in the urine.
c. CT urogram and NMP22 11. e. >90%. The specificity of the nitrite dipstick test for detecting
d. Flexible cystoscopy, urinary cytology, and CT urogram bacteriuria is greater than 90%.
12. d. Presence in clumps. Squamous epithelial cells are large,
e. Flexible cystoscopy, renal ultrasound, and urinary cytology have a central small nucleus about the size of an erythrocyte,
and have an irregular cytoplasm with fine granularity.
13. c. 5. Therefore 5 bacteria per high-power field in a spun
ANSWERS specimen reflect colony counts of about 100,000/mL.
14. c. 80 mL voided volume is adequate for uroflowmetry. The
1. c. Phosphaturia. Cloudy urine is most commonly caused by
minimum voided volume that is accepted as a requirement for
phosphates in the urine.
considering an adequate assessment is at least 100 mL.
2. d. Dehydration. Conditions that decrease specific gravity
15. d. Nothing. For patients undergoing simple diagnostic flexible
include (1) increased fluid intake, (2) diuretics, (3) decreased
cystoscopy no antibiotic prophylaxis is recommended un-
renal concentrating ability, and (4) diabetes insipidus.
less there are extenuating risk factors for infection or recent
3. c. 50 and 1200 mOsm/L. Osmolality is a measure of the
orthopedic implantation of artificial joints. Refer to American
amount of solutes dissolved in the urine and usually varies
Urological Association (AUA) recommendations on antibiotic
between 50 and 1200 mOsm/L.
prophylaxis for urological procedures.
4. a. Glucose. False-negative results for glucose and bilirubin may
16. b. Flexible cystoscopy and CT urogram. For the initial work-
be seen in the presence of elevated ascorbic acid concentra-
up of AMH, routine urine cytology is not necessary. Cytology
tions in the urine.
is generally utilized in patients with a history of bladder cancer
5. c. Microscopic presence of erythrocytes. Hematuria can be
undergoing surveillance or the index of suspicion of a high-
distinguished from hemoglobinuria and myoglobinuria by
grade lesion is present.

CHAPTER REVIEW
1. A catheterized urine specimen should be obtained in the evaluation and screening for asymptomatic microscopic
female patient with a history of recurrent urinary tract hematuria.
infections or suspected contaminated specimen. 9. Urine cytology is very specific for high-grade urothelial
2. Hematuria should be stratified into glomerular, nonglo- carcinoma.
merular, medical, and surgical causes. 10. Uroflowmetry and assessment of postvoid residual should
3. A dipstick alone is inadequate for the diagnosis of micro- be ordered when lower urinary tract obstruction is suspect-
scopic hematuria. ed.
4. Asymptomatic microscopic hematuria is defined as three or 11. Urodynamic studies provide information on disorders of
greater RBC/HPF on a properly collected urinary specimen storage and voiding.
in the absence of an obvious benign cause. 12. Routine use of antimicrobial prophylaxis is not recom-
5. Urine dipstick positive for only leukocyte esterase or nitrites mended for office cystourethroscopy, urodynamics, or
but not both should be confirmed with microscopic analy- cystography in the patient without risk factors.
sis and urine culture. 13. Renal ultrasonography can provide basic screening infor-
6. Serum creatinine and glomerular filtration rate should be mation on the presence of hydronephrosis and medical
ordered when renal obstruction of nephrologic disease is renal disease but is not an adequate stand-alone study for
suspected. the workup of hematuria.
7. Prostate-specific antigen is a very sensitive test for prostate 14. CT without contrast of the abdomen and pelvis is the gold
conditions such as BPH and prostatitis and correlates most standard for detecting urinary stones.
often with prostate volume. 15. A KUB is a useful and easy test for the follow-up of existing
8. Urine cytology is not recommended during the initial non-emergent radio opaque urinary stones.
3 Urinary Tract Imaging: Basic Principles of CT, MRI,
and Plain Film Imaging
Jay T. Bishoff and Ardeshir R. Rastinehad

QUESTIONS b. Severe allergic reactions are not dose dependent.

c. Hyperosmolar contrast media are more likely to cause
1. The measure of the potential adverse health effects of ionizing contrast reactions than are iso-osmolar agents.
radiation in sieverts (Sv) is known as:
d. The mechanism of action associated with severe idiosyncratic
a. radiation exposure. anaphylactoid (IA) reactions is an immunoglobulin E (IgE)
b. absorbed dose. antibody reaction to the contrast media.
c. equivalent dose. e. Severe cardiac disease is a risk factor for an adverse reaction
d. effective dose. to contrast media.
e. relative radiation levels. 7. After rapidly assessing airway, breathing, and circulation,
the medical treatment of choice for a severe, life-threatening
2. The relative radiation level associated with abdominal
adverse drug reaction following exposure to contrast
computed tomography (CT) without and with contrast is:
media is:
a. none.
a. subcutaneous injection of epinephrine 0.5 mg of 1:10,000
b. minimal, less than 0.1 mSv. epinephrine.
c. low, 0.1 to 1.0 mSv. b. intravenous injection of 100 mg of methylprednisone.
d. moderate, 1 to 10 mSv. c. 0.01 mg/kg of epinephrine (1:10,000 concentration), given
e. high, 10 to 100 mSv. intramuscularly in the lateral thigh.
3. Bladder filling may precipitate autonomic dysreflexia in d. intravenous diphenhydramine, 50 mg.
patients with a spinal cord injury above: e. 0.01 mg/kg of epinephrine (1:1000 concentration), given
a. S2. intramuscularly in the lateral thigh.
b. L4. 8. Which of the following is NOT a risk factor for developing
c. T10. contrast-induced nephropathy (CIN)?
d. T12. a. Type 2 diabetes mellitus
e. T6. b. Dehydration
c. Hypertension
4. Radiation exposure diminishes as the square of the distance
from the radiation source. An exposure of 9 mSv at 1 foot d. Ventricular ejection fraction less than 50%
from the source would be how much at 3 feet from the e. Chronic kidney disease (CKD) (glomerular filtration rate
source? [GFR] < 60 mL/min)
a. 0.09 mSv 9. Nephrogenic systemic fibrosis (NSF) is:
b. 1 mSv a. a rare genetic condition exacerbated by the use of
c. 3 mSv gadolinium-based contrast medium (GBCM).
d. 9 mSv b. immediately evident after exposure to gadolinium in 10%
e. 27 mSv of exposed patients.
c. fibrosis of the skin, subcutaneous tissue, and skeletal
5. Type 2 diabetics on oral metformin biguanide hyperglycemic muscle seen in patients with chronic hypertension exposed
therapy are at risk for biguanide lactic acidosis after exposure to gadolinium contrast medium.
to intravascular radiologic contrast media if they:
d. not seen in patients with GFR greater than 60 mL/min/
a. discontinue metformin 48 hours before the study. 1.73 m2.
b. have severe renal insufficiency and take metformin the day e. mainly seen in dialysis patients exposed to gadolinium
of the study. contrast medium.
c. are given a saline injection while taking metformin.
10. During a diuretic renal scintigraphy:
d. have normal kidney function and fail to stop metformin 48
hours before the study. a. the diuretic is administered approximately 2 minutes after
peak activity is seen in the collecting system.
e. decrease metformin dose and increase other
antihyperglycemic agents on the day of the study. b. a T½ of greater than 14 minutes is consistent with
obstruction.
6. All of the following are true EXCEPT: c. 99mTc-DMSA is the most sensitive for obstruction and
a. Patients with a history of asthma are at greater risk of determination of GFR.
having an adverse reaction to contrast media.

7
8 PART I Clinical Decision Making

d. intestinal or gallbladder activity should never be seen with 17. Which renal mass exhibits signal drop on opposed phase
99mTc-MAG3. imaging?
e. a T½ of less than 10 minutes is consistent with a a. Papillary renal cell
nonobstructed system. b. Chromophobe carcinoma
11. Positron emission tomography (PET): c. Angiomyolipoma
a. has a higher diagnostic accuracy than CT for seminoma and d. Clear cell carcinoma
nonseminoma testis cancer following chemotherapy. e. Transitional cell carcinoma
b. is sensitive and specific for detection of postchemotherapy
teratoma. 18. What signal characteristics do kidney stones exhibit on MR
urography?
c. can be used with high positive predictive value within
2 weeks of completion of chemotherapy for bulky lymph a. High signal on T2-weighted images
adenopathy. b. Low signal on T2-weighted images
d. has greater predictive value of primary disease in metastatic c. Signal void
urothelial carcinoma than magnetic resonance imaging (MRI). d. High signal on T1-weighted images
e. is able to detect local or systemic recurrence of prostate e. Low signal on T1-weighted images
cancer in 74% of patients with prostate-specific antigen
recurrence. 19. Multiparametric imaging of the prostate consists of anatomic
and functional sequences. Match the correct pair.
12. What is the minimum estimated GFR for use of gadolinium-
a. Anatomic: Diffusion-weighted imaging
based contrast agents?
b. Functional: T1- and T2-weighted images
a. Less than 30 mL/min/1.73 m2
c. Anatomic: Dynamic contrast enhanced sequences
b. Greater than 50 mL/min/1.73 m2
d. Functional: Apparent diffusion coefficient maps
c. Greater than 35 mL/min/1.73 m2
e. All of the above
d. Greater than 30 mL/min/1.73 m2
e. There are no restrictions for patients with renal
insufficiency.
ANSWERS
13. In magnetic resonance (MR) images using T2-weighted
sequences, fluid appears as: 1. d. Effective dose. The distribution of energy absorption in the
human body will be different based on the body part being
a. dark. imaged and a variety of other factors. The most important
b. bright. risk of radiation exposure from diagnostic imaging is the
c. low signal. development of cancer. The effective dose is a quantity used
to denote the radiation risk (expressed in sieverts) to a
d. signal void. population of patients from an imaging study.
e. indeterminate.
2. e . High, 10 to 100 mSv. The average person living in the
14. What lesions may have a high signal (bright) on T2-weighted United States is exposed to 6.2 mSv of radiation per year from
MRI of the adrenal gland? ambient sources, such as radon, cosmic rays, and medical
a. Pheochromocytoma procedures, which account for 36% of the annual radiation
exposure (NCRP, 2012). The recommended occupational
b. Metastasis
exposure limit to medical personnel is 50 mSv per year
c. Adrenal cortical carcinoma (ACC) (NCRP, 2012). The effective dose from a three-phase CT of the
d. None of the above abdomen and pelvis without and with contrast may be as high
e. All of the above as 25 to 40 mSv.

15. MR chemical shift imaging (CSI) for adrenal adenoma takes 3. e. T6. Autonomic dysreflexia, also known as hyperreflexia,
advantage of which of the following phenomena to aid in the means an overactivity of the autonomic nervous system
diagnosis? that can result in an abrupt onset of excessively high blood
pressure. Persons at risk for this problem generally have spinal
a. Water and fat within the same voxel signals are canceled cord injury level above T6. Autonomic dysreflexia can develop
out in opposed-phase imaging. suddenly, is potentially life threatening, and is considered a
b. Opposed-phase imaging will exhibit a high signal (bright). medical emergency. If not treated promptly and correctly, it
c. Intracellular lipid content within an adenoma is low. may lead to seizures, stroke, and even death.
d. Intravenous contrast is required. 4. b. 1 mSv. Maintaining the maximum practical distance from
e. All of the above. an active radiation source significantly decreases exposure to
medical personnel.
16. Oncocytoma typically has been characterized by a central scar.
Which other renal lesion may also exhibit a central scar on T2- 5. b. Have severe renal insufficiency and take metformin
weighted images? the day of the study. Patients with type 2 diabetes mellitus
on metformin may have an accumulation of the drug after
a. Clear cell carcinoma administering intravascular radiologic contrast medium
b. Angiomyolipoma (IRCM), resulting in biguanide lactic acidosis presenting with
c. Chromophobe carcinoma vomiting, diarrhea, and somnolence. This condition is fatal in
approximately 50% of cases (Wiholm, 1993).a
d. Transitional cell carcinoma
e. No other renal masses exhibit a central scar.
a Sourcesreferenced can be found in Campbell-Walsh-Wein Urology, 12th Edition,
on the Expert Consult website.
 CHAPTER 3 Urinary Tract Imaging: Basic Principles of CT, MRI, and Plain Film Imaging 9

Biguanide lactic acidosis is rare in patients with normal administration can be helpful for the treating urologist to
renal function. Consequently in patients with normal renal consider when planning surgery in the patient with middle
function and no known comorbidities, there is no need to to moderate obstruction. A T½ of greater than 20 minutes is
discontinue metformin before IRCM use, nor is there a need consistent with a high-grade obstruction.
to check creatinine following the imaging study.
11. a . Has a higher diagnostic accuracy than CT for seminoma
6. d
 . The mechanism of action associated with severe and nonseminoma testis cancer following chemotherapy.
idiosyncratic anaphylactoid (IA) reactions is an There are data on the use of PET/CT in testis cancer, where
immunoglobulin E (IgE) antibody reaction to the contrast PET/CT was found to have a higher diagnostic accuracy
media. The IA reactions are most concerning because they than CT for staging and restaging in the assessment of a
are potentially fatal and can occur without any predictable CT-visualized residual mass following chemotherapy for
or predisposing factors. Approximately 85% of IA reactions seminoma and nonseminomatous germ cell tumors (Hain
occur during or immediately after injection of IRCM and are et al., 2000; Albers et al., 1999).
more common in patients with a prior adverse drug reaction
to contrast media; patients with asthma, diabetes, impaired 12. d. Greater than 30 mL/min/1.73 m2. NSF occurs in patients
renal function, or diminished cardiac function; and patients with acute or chronic renal insufficiency with a GFR less
on beta-adrenergic blockers (Spring et al., 1997). than 30 mL/min/1.73 m2.

7. e. 0.01 mg/kg of epinephrine (1:1000 concentration), given 13. b. Bright. High signal on T2-weighted images. Fluid exhibits a
intramuscularly in the lateral thigh. Rapid administration low signal on T1-weighted images.
of epinephrine is the treatment of choice for severe contrast 14. e . All of the above. Traditional teaching reported the lightbulb
reactions. Epinephrine can be administered intravenously (IV) sign to be consistent with pheochromocytoma. However,
0.01 mg/kg body weight of 1: 10,000 dilution or 0.1 mL/kg metastasis and ACC also have a high signal on T2-weighted
slowly into a running IV infusion of saline and can be repeated images. Furthermore, Varghese and colleagues reported that
every 5 to 15 minutes as needed. If no IV access is available, 35% of pheochromocytomas demonstrated low T2 signal,
the recommended intramuscular dose of epinephrine is 0.01 contrary to conventional teaching. Therefore the conventional
mg/kg of 1:1000 dilution (or 0.01 mL/kg to a maximum of teaching of the “lightbulb sign” is incorrect.
0.15 mg of 1:1000 if body weight is <30 kg; 0.3 mg if weight is
>30 kg) injected intramuscularly in the lateral thigh. 15. a. Water and fat within the same voxel signals are canceled
out in opposed-phase imaging. MR CSI is performed on T1-
8. d. Ventricular ejection fraction less than 50%. The most weighted images. Opposed-phase imaging will demonstrate
common patient-related risk factors for CIN are CKD a low signal (dark) if fat and water occupy the same voxel.
(creatinine clearance <60 mL/min), diabetes mellitus, Adrenal adenomas have high intracytoplasmic fat. CSI is
dehydration, diuretic use, advanced age, congestive heart performed without the use of intravenous contrast.
failure, age, hypertension, low hematocrit, and ventricular
ejection fraction less than 40%. The patients at highest 16. c . Chromophobe carcinoma. Chromophobe carcinoma
risk for developing CIN are those with both diabetes and exhibits a high signal on T2-weighted images.
preexisting renal insufficiency. 17. d
 . Clear cell carcinoma. Microscopic intracytoplasmic lipids
9. d. Not seen in patients with GFR greater than 60 mL/ have been found in 59% of clear cell carcinomas, which allows
min/1.73 m2. Patients with CKD but GRF greater than 30 mL/ it to be differentiated from other renal cell carcinoma cell types.
min/1.73 m2 are considered to be at extremely low or no risk 18. c . Signal void. Nephrolithiasis/calcification on MR imaging has
for developing NSF if a dose of GBCM of 0.1 mmol/kg or less no signal characteristics; therefore it appears as a void on imaging.
is used. Patients with GFR greater than 60 mL/min/1.73 m2 do
not appear to be at increased risk of developing NSF, and the 19. d. Functional: Apparent diffusion coefficient maps.
current consensus is that all GBCM can be administered safely Multiparametric MRI refers to the use of anatomic sequences
to these patients. (T1-weighted images, T2 triplanar [axial, sagittal, and
coronal] images) and functional sequences (diffusion-
10. e. a T½ of less than 10 minutes is consistent with a weighted imaging/apparent diffusion coefficient maps,
nonobstructed system. Transit time throughout the collecting dynamic contrast-enhanced MRI, spectroscopy). The
system in less than 10 minutes is consistent with a normal, combined approach has reported negative and positive
nonobstructed collecting system. A T½ of 10 to 20 minutes predictive values to be greater than 90% in detecting
shows mild to moderate delay and may be a mechanical prostate cancer.
obstruction. The patient’s perception of pain after diuretic

CHAPTER REVIEW
1. Absorbed dose for therapy is measured in units called gray 4. IA reactions are potentially fatal, are not dose dependent,
(Gy); 1 rad = 0.01 Gy, or 1 centigray (cGy) = 1 rad. and are more common in patients with a history of adverse
2. The amount of energy absorbed by a tissue for diagnos- reactions to contrast media, those with asthma or diabetes,
tic purposes is referred to as the equivalent dose and is those with impaired renal and cardiac function, and those
measured in sieverts (Sv). Exposure of the eyes and gonads on β-adrenergic blockers.
to radiation has a more significant biologic impact than 5. It is common to have nausea, flushing, pruritus, urticaria,
exposure of other parts of the body. The occupational safety headache, and occasionally emesis after administration of
limit is 50 mSv. Exposure time during fluoroscopy should contrast media.
be minimized by the use of short bursts of fluoroscopy; 6. Patients at high risk for adverse allergic reactions should be
positioning the image intensifier as close to the patient as medicated with steroids, given 12 to 24 hours before the
feasible substantially reduces scatter radiation. injection of contrast media, as well as antihistamines.
3. There are four basic types of iodinated contrast media: (1) 7. For retrograde pyelography, it is useful to dilute contrast
ionic monomer, (2) nonionic monomer, (3) ionic dimer, media by half with sterile saline, which facilitates identify-
(4) nonionic dimer. ing filling defects in the collecting system. There is a low
10 PART I Clinical Decision Making

CHAPTER REVIEW—cont’d
risk of contrast reactions in patients in whom a retrograde 17. The Hounsfield units scale assigns a value of −1000 Houns-
or loopogram is performed. field units for air. Dense bone is assigned a value of +1000
8. Metformin does not need to be held before contrast admin- Hounsfield units, and water is assigned 0 Hounsfield units.
istration in a patient with normal renal function and no 18. With the exception of some indinavir stones, all renal and
comorbidities. ureteral calculi may be detected by helical CT.
9. The risk of developing contrast-induced nephropathy is 19. The advantage of MRI is high-contrast resolution of soft tis-
increased in patients with decreased renal function (GFR < sue on T1-weighted images. Fluid has a low signal and ap-
60 mL/min), diabetes mellitus, dehydration, advanced age, pears dark on T1-weighted images; on T2-weighted images,
congestive heart failure, liver disease, and cardiac ejection fluid has a high signal and appears bright. Gadolinium
fraction less than 40%. increases the brightness of T1-weighted images. Hemor-
10. TcDTPA is primarily filtered by the glomerulus. It is a good rhage within a cyst results in a high signal on T1-weighted
agent to assess renal function. images. MRI is the imaging modality of choice for patients
11. Because TcDMSA is both filtered by the glomerulus and with iodine contrast allergies.
secreted by the proximal tubule, it localizes in the renal 20. The risk of developing NSF after gadolinium administration
cortex and is a good agent for assessing cortical scarring and is increased in patients with GFRs less than 30 mL/min.
ectopic renal tissue. 21. Adrenal adenomas have high lipid content and may be
12. TcMAG3 is cleared mainly by tubular secretion; it has a differentiated from adrenal cancers or metastatic disease by
limited ability to access renal function. specialized CT or MRI scans.
13. A T½ less than 10 minutes suggests an unobstructed system. 22. Thirty-five percent of pheochromocytomas do not enhance
A T½ greater than 20 minutes is consistent with renal ob- on T2-weighted images.
struction. 23. MRI and CT are excellent imaging studies to determine
14. A positive bone scan is not specific for cancer. Moreover, the presence and extent of renal vein and vena cava tumor
the volume of cancer cannot be quantitated on bone scan. thrombus. Uptake of gadolinium by the thrombus on MRI
Patients with widely metastatic disease may have diffuse differentiates tumor from bland (blood clot) thrombus.
uptake (hyper scan) and no discrete lesions. 24. Prostate MRI coupled with an assessment of dynamic con-
15. Glucose, choline, and amino acids have been used as imag- trast uptake and washout increases the diagnostic accuracy
ing agents for PET scans. for detecting cancer.
16. 18F-fluorodeoxyglucose (FDG) is used as an imaging agent 25. MR spectroscopy for prostate cancer is based on decreased
in PET scanning and takes advantage of the fact that tumors citrate levels and increased creatine and choline levels.
have increased glycolysis and decreased dephosphorylation. 26. Bladder filling in patients with spinal cord injuries higher
This scan is useful in testicular germ cell tumors, particu- than T6 may precipitate autonomic dysreflexia.
larly seminomas, in determining residual viable tumor 27. Radiation exposure diminishes as the square of the distance
following chemotherapy. from the radiation source.
4 Urinary Tract Imaging: Basic Principles of Urologic
Ultrasonography
Bruce R. Gilbert and Pat F. Fulgham

QUESTIONS d. frequency.
e. number of foci.
1. The maximum excursion of a wave above and below the
baseline is known as its: 8. Increasing frequency results in a loss of:
a. wavelength. a. absorption.
b. frequency. b. axial resolution.
c. period. c. lateral resolution.
d. cycle. d. depth of penetration.
e. amplitude. e. mechanical index.
2. The artifact that occurs when an ultrasound wave strikes an inter- 9. When sound waves encounter the interface between two
face at a critical angle and is refracted with limited reflection is: tissues with large differences in impedance, the waves are:
a. reverberation artifact. a. increased in frequency.
b. increased through-transmission artifact. b. decreased in frequency.
c. edging artifact. c. reflected.
d. comet-tail artifact. d. refracted.
e. aliasing artifact. e. reverberated.
3. Which ultrasound mode allows for detection and 10. When a tissue appears darker than the surrounding tissue on
characterization of the velocity and direction of motion? ultrasound it is said to be relatively:
a. Harmonic scanning a. hypoechoic.
b. Color Doppler b. hyperechoic.
c. Power Doppler c. hypodense.
d. Spatial compounding d. isoechoic
e. Gray-scale ultrasonography e. anechoic.
4. If the kidney is less echogenic than the liver, the kidney is
described as: 11. The focal zone represents the area of best:
a. hyperechoic. a. lateral resolution.
b. hypoechoic. b. axial resolution.
c. isoechoic. c. echogenicity.
d. anechoic. d. blood flow.
e. echogenic. e. tissue penetration.
5. The sonographic hallmark of testicular torsion is: 12. Increasing the gain has the effect of:
a. the “blue dot” sign. a. increasing amplitude of the sound waves.
b. epididymal edema. b. increasing acoustic power.
c. paratesticular fluid. c. increasing thermal index.
d. increased epididymal blood flow. d. increasing mechanical index.
e. absence of intratesticular blood flow. e. increasing transducer sensitivity.
6. Ultrasound waves are examples of: 13. One way to improve the visualization of deep structures is to:
a. radio waves. a. increase the frequency.
b. mechanical waves. b. decrease the frequency.
c. electromagnetic waves. c. increase the wave velocity.
d. ionizing radiation. d. decrease the gain.
e. light waves. e. employ Doppler flow.
7. The most important determinant of axial resolution is: 14. The best frequency for performing external renal ultrasound in
a. impedance. most adults is:
b. speed of propagation. a. 3.5 to 5 MHz.
c. acoustic power. b. 6 to 7 MHz.
11
12 PART I Clinical Decision Making

c. 7.5 to 8.4 MHz. 22. Characteristics of prostate cancer as demonstrated on

d. 8.5 to 9.9 MHz. transrectal ultrasound of the prostate may include:
e. None of the above. a. hypoechogenicity.
b. hyperechogenicity.
15. A simple cyst of the kidney would not display which of the
following characteristics? c. prostate asymmetry.
a. Bright back wall d. increased vascularity.
b. Increased through transmission e. all of the above.
c. Anechoic interior 23. The single most important determinant of patient safety in
d. Edging artifact ultrasound utilization is:
e. Hyperechoic internal nodule a. multifrequency probes.
b. good documentation.
16. Which of the following is correct?
c. an informed operator.
a. Measuring bladder volume requires three-dimensional
scanning. d. periodic equipment inspection.
b. A nearly empty bladder is desirable for bladder scanning. e. Doppler capability.
c. A curved array transducer is preferred for bladder ultra- 24. The disinfection level protocol required for transrectal
sound in most patients. ultrasound probes following needle biopsy is:
d. Ureteroceles are usually poorly visualized because the a. low.
membrane is thin. b. moderate.
e. Bladder ultrasound is a sensitive screening exam for sus- c. high.
pected bladder tumors.
d. critical.
17. Which of the following are evaluable by transabdominal e. none of the above.
bladder ultrasound?
a. Urine volume 25. For patient safety it is preferable to maximize and limit:
b. Bladder wall characteristics a. acoustic power, exam duration.
c. Stones or diverticulum b. acoustic power, gain.
d. Dilated ureters c. gain, acoustic power.
e. All of the above d. gain, use of cine function.
e. images, description.
18. Scrotal ultrasound for the evaluation of possible testicular
torsion may include all of the following but must include:
a. B-mode ultrasound. ANSWERS
b. multiple scrotal views.
1. e. Amplitude. In ultrasound physics it is crucial to understand
c. Doppler flow studies. the concept of amplitude. The amplitude of an ultrasound wave
d. simultaneous bilateral views. represents its relative energy state, and it is the amplitude of the
e. harmonic scanning. returning sound wave that determines the pixel brightness to be
displayed on a monitor during real-time gray-scale imaging.
19. The most important limitation of ultrasound in attempting to 2. c. Edging artifact. Echo reflection is the primary mechanism
characterize complex renal cysts as benign or malignant is: whereby sound waves are returned to a transducer. It is
a. refraction. important to understand how the angle of insonation affects
b. inability to evaluate enhancement. the reflection and refraction of sound waves. There is a critical
angle at which waves will travel along an interface rather than
c. lack of axial resolution. being returned to the probe. When this angle is encountered,
d. increased through-transmission with artifact. it provides a dark or hypoechoic “shadow” called an “edging
e. reverberation artifact. artifact.” A reverberation artifact is one caused by multiple
transits of a sound wave between the transducer and the
20. A complete transrectal ultrasound of the prostate should reflecting object. Increased through-transmission artifact is
include an evaluation of: caused by decreased attenuation of sound waves as they travel
a. rectal wall. through a fluid-filled structure. Comet-tail artifact is seen as
the result of the interaction between sound waves and fluid
b. seminal vesicles and ejaculatory ducts.
and gas filled structures such as the bowel. Aliasing artifact is
c. bladder. seen with Doppler ultrasonography.
d. prostate. 3. b. Color Doppler. Doppler ultrasonography is important for
e. all of the above. evaluating motion and flow. The critical difference between
color Doppler and power Doppler is that color Doppler
21. Which of the following would not typically be visible in a is able to evaluate both flow velocity and direction. Power
sagittal midline prostate ultrasound? Doppler evaluates integrated amplitude of the returning sound
a. Middle lobe of the prostate waves. Although gray-scale ultrasonography does permit the
evaluation of motion, it does not permit the characterization
b. Central zone of velocity or direction. Harmonic scanning and spatial
c. Ejaculatory duct compounding are modes that allow the selective evaluation
d. Tip of right seminal vesicle or combination of reflected frequencies in ways that improve
image quality.
e. Apex of the prostate
 CHAPTER 4 Urinary Tract Imaging: Basic Principles of Urologic Ultrasonography 13

4. b. Hypoechoic. In describing ultrasound images, it is deeper structures (e.g., right kidney, bladder) require lower
important to use correct terminology. Descriptive terms frequencies of 3.5 to 5 MHz to penetrate. Such images will
involving echogenicity are relative terms. A hyperechoic have poorer axial resolution.
or hypoechoic structure is being described in relation to 14. a. 3.5 to 5 MHz: Deeper structures (e.g., right kidney, bladder)
the echogenicity of a reference standard. In most cases the require lower frequencies of 3.5 to 5 MHz to penetrate.
reference standard is the liver. In the adult the normal kidney 15. e. Hyperechoic internal nodule: A simple cyst is an example
is hypoechoic relative to the normal liver in approximately of a structure that is well circumscribed, with an anechoic
75% of patients. interior and through transmission.
5. e. Absence of intratesticular blood flow. The absence of 16. c. A curved array transducer is preferred for bladder
intratesticular blood flow is the classic sonographic finding in ultrasound in most patients: A curved array transducer is
testicular torsion. However, there are many documented cases of lower frequency (3.5–6 MHz) and provides greater depth
of some preserved intratesticular blood flow even in cases of penetration but with less axial resolution. It is most often
with significant torsion. Therefore testicular torsion remains a the transducer of choice for imaging the kidney and urinary
clinical diagnosis. Epididymal edema, paratesticular fluid, and bladder.
increased epididymal blood flow may be seen with testicular 17. e. All of the above: Urine volume, bladder wall characteristics,
torsion but may also be seen with other clinical conditions. the presence of calculi or diverticulum, and the presence of
The blue dot sign is a classic physical finding in torsion of the dilated ureters just outside the bladder are all evaluable by
appendix testis. transabdominal bladder ultrasound.
6. b. Mechanical waves: Mechanical waves are represented 18. c. Doppler flow studies: Caution should be used when
graphically as a sine wave alternating between a positive and interpreting Doppler flow studies in the evaluation of
negative direction from the baseline. Sound waves as they suspected testicular torsion. The hallmark of testicular torsion
propagate through human tissue produce areas of returning is the absence of intratesticular blood flow. Paratesticular flow
compression and rarefaction. in epididymal collaterals may appear within hours of torsion.
7. d. Frequency: Axial resolution is directly dependent on Comparison with the contralateral testis should be performed
the frequency of sound waves. The higher the sound wave’s to ensure that the technical attributes of the study are adequate
frequency is, the better the axial resolution. to demonstrate intratesticular blood flow.
8. d. Depth of penetration: The optimal ultrasound image 19. b. Inability to evaluate enhancement: Unlike computed
requires tradeoffs between resolution and depth of tomography (CT), currently ultrasound cannot evaluate
penetration. High-frequency transducers of 6 to 10 MHz may enhancement. Once it is approved by the US Food and Drug
be used to image structures near the surface of the body (e.g., Administration (FDA) for this purpose, contrast-enhanced
testis, pediatric kidney) with excellent resolution. However, ultrasound will allow the detection of enhancement of renal
deeper structures (e.g., right kidney, bladder) require lower masses by ultrasound.
frequencies of 3.5 to 5 MHz to penetrate. Such images will 20. e. All of the above: When evaluating the prostate, surrounding
have poorer axial resolution. structures need to be assessed. Rectal lesions (including
9. c. Reflected: The shape and size of the object and the angle cancer), dilated seminal vesicles, and/or ejaculatory ducts
at which the advancing wave strikes the object are critical as well as bladder pathology should all be evaluated for a
determinants of the amount of energy reflected. The amount complete examination.
of energy reflected from an interface is also influenced by the 21. d. Tip of right seminal vesicle: In a midline sagittal view the
impedance of the two tissues at the interface. Impedance is tips of the seminal vesicles are not normally visualized on
a property that is influenced by tissue stiffness and density. It ultrasound. An axial projection needs to be obtained to be
is the difference in impedance that allows an appreciation of able to measure the length of each seminal vesicle.
interfaces between different types of tissue. 22. e. All of the above: Although excellent resolution and tissue
10. a. Hypoechoic: The liver is usually used as a benchmark for characteristics is possible with transrectal ultrasound a
echogenicity. A hypoechoic area is described as “darker” on diagnosis of prostate cancer is not often able to be made with
B-mode ultrasound. ultrasound alone.
11. a. Lateral resolution: Lateral resolution refers to the ability 23. c. An informed operator: The ALARA (as low as reasonably
to identify separately objects that are equidistant from the achievable) principle is intended to limit the total energy
transducer. Lateral resolution is a function of the focused imparted to the patient during an examination. This can be
width of the ultrasound beam and is a characteristic of the accomplished by (1) keeping power outputs low, (2) using
transducer. The location of the narrowest beam width can be appropriate scanning modes, (3) limiting examination times,
adjusted by the user. The more focused the beam is, the better (4) adjusting focus and frequency, and (5) using the cine
the lateral resolution at that location. Thus image quality can function during documentation. All of these are dependent
be enhanced by locating the narrowest beam width (focus or upon an informed sonographer.
focal zone) at the depth of the object or tissue of interest 24. d. Critical: Any time body fluids or tissues come in contact
12. e. Increasing transducer sensitivity: The gain control on the with an ultrasound transducer, critical or high-level
console of the ultrasound machine permits the user to increase disinfection protocols must be strictly adhered to.
or decrease the sensitivity of the transducer to reflected sound 25. c. Gain, acoustic power: Unlike gain, which refers to
waves. amplification of the acoustic signal returning to the transducer,
13. b. Decrease the frequency: The optimal ultrasound acoustic power is the amount of acoustic energy applied to the
image requires trade-offs between resolution and depth of tissue. The biologic effects of ultrasound in terms of power are
penetration. High-frequency transducers of 6 to 10 MHz may in the milliwatt range. High levels generate heat and cavitation,
be used to image structures near the surface of the body (e.g., which might result in tissue damage.
testis, pediatric kidney), with excellent resolution. However,
14 PART I Clinical Decision Making

CHAPTER REVIEW
1. One cycle per second is known as 1 hertz (Hz). High- 4. Ultrasonography may produce injury due to mechanical ef-
frequency ultrasonic transducers of 6 to 10 MHz are used to fects caused by cavitation or by heat generation.
image structures near the surface. Deeper structures require 5. With the exception of some indinavir stones, all renal and
lower frequencies of 3.5 to 5 MHz. Axial resolution improves ureteral calculi may be detected by helical CT.
with increasing frequency, and depth of penetration decreases 6. The advantage of magnetic resonance imaging (MRI) is
with increasing frequency. high-contrast resolution of soft tissue on T1-weighted im-
2. Resistive index is the peak velocity minus the end-diastolic ages. Fluid has a low signal and appears dark on T1-weighted
velocity over the peek systolic velocity. This is measured using images; on T2-weighted images, fluid has a high signal and
the color flow Doppler with spectral display and is used to appears bright. Gadolinium increases the brightness of T1-
characterize renal artery stenosis, ureteral obstruction, and weighted images. Hemorrhage within a cyst results in a high
penile arterial insufficiency. signal on T1-weighted images.
3. By convention, the liver is used as a benchmark for echo-
genicity. By convention, the cephalad aspect of the structure
is to the left of the image.
5 Urinary Tract Imaging: Basic Principles of
Nuclear Medicine
Michael A. Gorin and Steven P. Rowe

QUESTIONS 7. Which urologic malignancy is poorly imaged with 18F-FDG

positron emission tomography (PET)?
1. 99mTc-diethylenetriaminepentaacetic acid (99mTc-DTPA) a. Bladder cancer
undergoes renal clearance by which mechanism?
b. Penile cancer
a. Glomerular filtration
c. Prostate cancer
b. Active tubular secretion
d. Renal cell carcinoma
c. Anion exchange
e. Seminomatous germ cell tumor
d. Both A and B
e. All of the above 8. What is the half-life of the radionuclide 18F?
a. 20.3 minutes
2. 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) undergoes renal
clearance by which mechanism? b. 109.8 minutes
a. Glomerular filtration c. 68.0 minutes
b. Active tubular secretion d. 4.17 days
c. Anion exchange e. 78.4 hours
d. Both A and B 9. Which of the following PET radiotracers for prostate cancer
e. All of the above imaging is an amino acid analog?
18F-DCFPyL
a. 
3. 99mTc–dimercaptosuccinic acid (99mTc-DMSA) undergoes renal
68Ga-PSMA-11
b. 
clearance and is endocytosed by cells of which part of the
nephron? 11C-choline
c. 
a. Glomerulus d. 68Ga-RM2
b. Proximal tubule 18F-FACBC
e. 
c. Distal tubule 10. Which protein is highly expressed by clear cell renal cell carci-
d. Ascending loop of Henle noma (RCC) but not other renal tumor types and serves as a
e. Collecting duct target for molecular imaging of this malignancy?
a. GLUT1
4. When performing 99mTc-MAG3 renography, the relative function
of each kidney is determined by measuring the area under the b. PSMA
time activity curve between what two time points post injection? c. GRPR
a. 1 to 3 minutes d. CAIX
b. 3 to 5 minutes e. ASCT2
c. 5 to 10 minutes 11. Which radiotracer has the highest specificity for imaging pros-
d. 10 to 15 minutes tate cancer?
e. 15 to 20 minutes a. 18F-DCFPyL

b. 67Ga-citrate
5. Which radiotracer is ideally suited for imaging renal scaring?
99mTc-DTPA c. 11C-choline
a. 
99mTc-MAG3
b.  d. 18F-FDG
99mTc-DMSA e. 18F-FACBC
c. 
d. 67Ga-citrate 12. 18F-FDG PET is recommended for which application in men
99mTc–sulfur colloid
e.  with testicular cancer?
a. Initial cancer staging of patients with elevated postorchiec-
6. 2-Deoxy-2-[18F]fluoro-D-glucose (18F-FDG) is phosphorylated tomy tumor markers
by which glycolytic enzyme, trapping it inside metabolically
active cells? b. Initial cancer staging of patients with negative postorchiec-
tomy tumor markers
a. Hexokinase
c. Postchemotherapy imaging of a residual retroperitoneal
b. Glucokinase mass in men with a seminomatous germ cell tumor
c. Phosphofructokinase d. Postchemotherapy imaging of a residual retroperitoneal
d. Pyruvate kinase mass in men with a nonseminomatous germ cell tumors
e. Phosphoglucose isomerase e. Post-treatment surveillance in patients with negative markers
15
16 PART I Clinical Decision Making

ANSWERS group, cannot undergo further glycolytic metabolism and remain

   intact allowing for their detection with PET imaging.
a. Goluerular filtration. 99mTc-DPTA is a single-photon
1.  c. Prostate cancer. 18F- FDG is taken up by malignant cells,
7. 
radiotracer that is excreted in the urine and can be used to which commonly shunt energy production toward anaerobic
determine renal split function and to assess for functional metabolism, a phenomenon referred to as the Warburg effect.
obstruction. 99mTc-DTPA is extracted by the kidneys through A number of genitourinary malignancies, including urothelial
glomerular filtration. The drug then quickly moves through carcinoma, renal cell carcinoma, squamous cell carcinoma of
the renal tubules and is excreted in the urine without being the penis, and testicular germ cell tumors, can be successfully
reabsorbed. imaged with 18F-FDG PET. Prostate cancer is unique in that it
b. Active tubular secretion. 99mTc-MAG3 is a single-photon
2.  does not show increased levels of glycolysis and therefore is
radiotracer that is excreted in the urine and can be used to poorly visualized with 18F-FDG PET.
determine renal split function and to assess for functional b. 109.8 minutes. The half-lives of other commonly used
8. 
obstruction. 99mTc-MAG3 is protein bound in circulation and radionuclides for PET imaging can be found in Table 5.2.
undergoes clearance exclusively through tubular secretion. a. 18F-FACBC. This radiotracer functions as a substrate for
9. 
99mTc-MAG3 imaging is therefore not impacted by impaired
the amino acid transporters LAT1 and ASCT2, which are
glomerular filtration. overexpressed by multiple malignancies including prostate
b. Proximal tubule. 99mTc-DMSA is cleared from the plasma
3.  cancer.
primarily by glomerular filtration. Once within the lumina d. CAIX. This cell surface protein is near universally expressed
10. 
of the renal tubules, 99mTc-DMSA undergoes receptor-medi- by clear cell RCC but not other renal tumor histologies. CAIX
ated endocytosis by the proximal tubular cells. The receptors is upregulated following loss of the von Hippel-Lindau (VHL)
responsible for the endocytosis of 99mTc-DMSA are megalin gene, which is a defining event in the pathogenesis of clear cell
and cubilin. RCC.
a. 1 to 3 minutes. Dynamic renal imaging is performed in
4.  a. 18F-DCFPyL. PET radiotracers targeting prostate-specific
11. 
two phases. In the first phase, known as the perfusion phase, membrane antigen (PSMA) have the highest specificity for
renal plasma flow to each individual renal unit is measured prostate cancer imaging. Of the radiotracers listed, 18F-DCF-
and compared with flow within the aorta. Activity should be PyL is the only PSMA-targeted radiotracer. A summary of other
detected in the regions of interest overlying the kidneys within radiotracer used for prostate cancer imaging can be found in
several seconds of detection in the aorta. The relative function Table 5.3.
of each kidney is determined by measuring the area under the
time activity curves between 1 and 3 minutes post injection of c. Postchemotherapy imaging of a residual retroperito-
12. 
the radiotracer. neal mass in men with a seminomatous germ cell tumor.
Guidelines from the European Association of Urology en-
c. 99mTc-DMSA. Because this radiotracer undergoes endocyto-
5.  dorse the use of 18F-FDG PET for men with a residual mass
sis by the proximal tubular cells, it is ideally suited for imag- following treatment of a seminoma with chemotherapy.
ing cortical processes such as acute pyelonephritis and renal Using 18F-FDG PET in this manner helps to differentiate
scaring. fibrosis from residual active tumor. For patients with non-
a. Hexokinase. 18F-FDG is a glucose analog that is taken up by
6.  seminomatous germ cell tumors, 18F-FDG PET imaging
metabolically active cells via GLUT transporters. Once within is not indicated because there appears to be no clinical
the cell, 18F-FDG is phosphorylated by the glycolytic enzyme benefit for PET in the detection of viable tumor over the
hexokinase, preventing diffusion back across the cell membrane. combination of computed tomography (CT) and serum
The trapped 18F-FDG molecules, which are missing a 2-hydroxyl markers.

CHAPTER REVIEW
1. The most commonly used radiopharmaceutical agents for using the positron emission tomography (PET) radiotracer
nuclear imaging of the kidneys are technetium 99mTc-diethyl- 2-deoxy-2-(18F)fluoro-D-glucose (18F-FDG)
enetriaminepentaacetic acid (99mTc-DTPA), 99mTc- mercaptoa- 8. A number of genitourinary malignancies can be success-
cetyltriglycine (MAG3), and 99mTc–dimercaptosuccinic acid fully imaged with 18F-FDG PET, albeit with varying degrees
(DMSA). of clinical utility beyond conventional anatomical imaging
2. 99mTc-DTPA and 99mTc-MAG3 are used to measure renal techniques.
blood flow, determine differential renal function, and to 9. Because 18F-FDG is excreted in the urine, imaging with this
evaluate for the presence and degree of renal obstruction. radiotracer is typically performed to detect distant sites of
3. 99mTc-DTPA is cleared by glomerular filtration, whereas disease.
99mTc-MAG3 is cleared by tubular secretion. 10. 18F-FDG has little role in imaging prostate cancer and a
4. 99mTc-MAG3 is the preferred at most centers over 99mTc- number of other radiotracers have been developed for this
DTPA because it has a higher extraction efficiency and is purpose.
less impacted by changes in renal function 11. Radiotracers targeting PSMA are the most promising class
5. 99mTc-DMSA is retained by cells of the proximal renal tu- of agents for prostate cancer imaging and in many parts of
bules and is used to evaluate for infection and the presence the world have become the new standard of care for imag-
renal scarring. ing this malignancy.
6. 99mTc-DTPA and 99mTc-MAG3 can also be used to evaluate 12. One of the most well-established indications for 18F-FDG
renovascular hypertension, transplant graft function, and PET imaging is in the detection of residual seminomatous
vesicoureteral reflux. germ cell tumors following chemotherapy.
7. Molecular imaging of cancer is most commonly performed
6 Assessment of Urologic and Surgical Outcomes
David F. Penson and Mark D. Tyson

QUESTIONS 6. If a urologist were designing an instrument to measure cancer-

1. When assessing disease-specific mortality, researchers need to specific quality of life following prostatectomy, how would she
be aware that this outcome is subject to: design an experiment to assess test-retest reliability?
a. detection bias. a. She could administer the questionnaire before and after the
operation.
b. attribution bias.
b. She could administer the questionnaire to her patients and
c. problems with loss to follow-up. a group of age-matched healthy controls.
d. all of the above. c. She could use a differently worded questionnaire to obtain
e. b and c. the same information.
2. Which of the following is NOT one of the four require- d. She could administer the questionnaire to the same patient
ments for a valid surrogate endpoint as described by twice in the same week and compare the results.
­P rentice? e. She could administer the questionnaire to the same patient
a. Treatment is associated with the true endpoint. twice at an interval of one year and compare the results.
b. The surrogate endpoint is associated with the true end- 7. Of the following types of validity, which one often takes
point. many years of instrument use by numerous investigators to
c. The full effect of treatment on the true endpoint is ex- ­adequately assess?
plained by the surrogate endpoint. a. Face validity
d. The surrogate endpoint can reliably be measured using b. Content validity
highly objective methods. c. Concurrent validity
e. Treatment is also associated with the surrogate endpoint. d. Predictive validity
3. With regard to patient-centered outcomes: e. Construct validity
a. clinicians can reliably assess these outcomes from the 8. The use of uroflow results in validating a new survey instru-
doctor–patient interaction. ment that measures disease-specific HRQOL in benign pros-
b. there are very few validated and reliable questionnaires tatic hyperplasia (BPH) patients is an example of:
available for use in urology. a. concurrent validity.
c. health-related quality of life is an important outcome to b. content validity.
measure, but only function need be assessed to get a full
portrait of this outcome. c. construct validity.
d. patient-centered questionnaires are developed using the d. predictive validity.
principles of psychometric test theory. e. face validity.
e. none of the above. 9. A patient undergoes a radical cystectomy. On post-operative day
4. Which of the following methods has not been suggested as a #2, he aspirates and requires emergent intubation and transfer to
technique to assess patient experience of pain? the ICU. He is started on intravenous antibiotics and is extubated
on post-operative day #4. The remainder of his hospital course in
a. Collect verbal or written descriptions of the pain unremarkable and he is discharged on post-operative day #8. The
b. Query patient’s caregiver regarding patient’s pain level. complication he experienced is a Clavien-Dindo grade:
c. Have subject rate pain via its effect on observable a. II.
­b ehavior. b. IIIa.
d. Use analogue techniques in which the patient compares c. IIIb.
his/her pain with an experimentally induced stimulus of a
known intensity in a laboratory setting. d. IVa.
e. All of the above can be used to assess pain levels. e. IVb.

5. When a scale has a coefficient α of 0.90, one can be assured 10. A patient with kidney cancer has a single target lesion, a 5-cm
that the scale has high degree of: bony metastases. She is treated with a tyrosine kinase inhibitor
(TKI). The lesion is reduced in size and is now 4 cm on imag-
a. alternate form reliability. ing. According to the RECIST criteria, this is considered a:
b. test-retest reliability. a. complete response.
c. internal consistency reliability. b. partial response.
d. intraobserver reliability. c. stable disease.
e. interobserver reliability. d. non-CR/non-PD.
e. progressive disease.

17
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 Kuusen lehviltä kevään lämmin
sulaa talven lunta.
Todenkin uudesti kirkkahana
löytävi ihmiskunta.

Niinkuin kummulla uusia lehviä kukkivi aarnikuusi, niin tosi,

vaikka on ainovanha, alati siltä on uusi.

Valhe ja totuus.

Valhe se loistoa, kiiltoa etsii, yllensä verhovi välkkyvät

vaipat, jotta se tenhoisi ihmisten silmät, etteivät huomaisi sen
sisäpuolta kuinka se tyhjä ja ontto on.

Totuus kuortansa kelsiä koittaa, yltänsä riisuvi mutkaisat

muodot, niin että silmämme selvemmin nähdä voisivat
puhtaalta sen sisäpuolta suuret ja kirkkaat helmyet.

Turhia kysymyksiä.

Miksikä alati maailmassa vaihtuvi yö ja päivä? Miksikä

verhona totuudenkin väihkyvi valheen häivä?

Miksikä hyvänkin ympärillä

on niin paljo pahaa?
Miksikä särkynyt sekasorto
sydänten sointua sahaa? —
 Vaiti! Turhaan tuhat kertaa teen nämä kysymykset. Ei pysty
juuriin olemuksen älyni yllätykset.

Oikeus.

Oikeus ylevä, suuri on kuni jykevä tammi, joka voi valossa

vasta, valossa ja lämpimässä suoravarreksi selitä,
iaajalehväksi levitä.

Onnemme asunto.

Ei asu elämän onni taivahissa, tuulosissa, ei vesissä, ei

kukissa eikä muissa muotoloissa.

Tuolla onnemme asuvi sydämessämme syvällä,

tuntehettaren tuvassa, hengettären huonehessa.

Karkaiseva kärsimys.

Ei terästy raisu rauta, teräs kirkastu, teroitu, jos ei ensin se

puristu vetten, liekkien välissä.

Lapsi ei tule uroksi, yrkä mieheks ylene, jos ei taistossa

terästy, kärsimyksissä karaistu.
KANSALLISIA LAULUJA.

Pohjolan huhtikuu.

Sinivalkonen taivas,
lumivalkonen maa
helopäivästä taivon
suloloistehen saa!
Niin läikkyvä leuto on viileä sää,
jää päivässä välkkyen kimmeltää,
ja kaukana äärellä vainion
lumenhohtavat huiput vuoriston
yläilmahan yllättää!

Sinivalkonen taivas,
lumivalkonen maa
helopäivästä taivon
suloloistehen saa!
Koko maa ihan huikean kirkas on,
valo väräjävi lehvillä kuusiston,
valo väräjävi, palajavi leivonen
ja livertävi, lurittavi riemuiten
yläilmahan kiemurtain!

Jos mulla olisi —

 Jos mulla olisi leivosen siivet, en minä olisi täällä: livertäen
lentäisin luokse Herran ylhäällä pilvien päällä.

"Herrani", livertäisin hänelle siellä,

"tunnetko Wäinölän kansan?
Miksikä sille sä heittää annoit
vierahan viekkaan ansan?"

Oi, miten palavasti rukoileisin

sydämestä hartahasta:
"Suo säde kansalle kärsivälle
valostasi kirkkahasta!"

Herrani kuulisi, jos minä pyytää

oikein hellästi voisin.
Herrani armoa henkivän viestin
maahani sitte mä toisin. —

Kansani, katsele taivahalle sinisillä silmilläsi! Nouskosi itse

sä luokse Herran veisaten virsiäsi!

Mihin suuntaan?

Orot niityllä hirnuvat korskuen, palo mielemme viehtävi

sinne. Me lentäen riennämme ratsaillen ja kiidämme kilvaten,
riemuiten — mut minnekä, minnekä, minne?

Oi, vielähän taistelutantereet

Ovat taatoilta tallella meille!
Ja vielähän viettävät mantereet
ja vielähän viehtävät välkeveet
sydänsyitämme uusille teille!

Koko kansan me tahdomme kohottaa

hyvän, oikean kukkuloille!
Sen mieli ja kieli kun vapaaks' saa,
Se suurena kuorona kohahtaa
sopusointujen soitelmoille!

Koko kansan me nostamme oikeuteen,

joka miehen naisen ja lapsen!
Me kutsumme hellään veljeyteen
ja vapauteen tasa-arvoiseen
joka nuoren ja harmaahapsen!

Tätä työtä me tyynenä toimimme,

joka tointamme harkiten tarkoin.
Mut muutakin vaativi sentään se:
sydän-intoa, tarmoa tahdolle,
kiven rouhua vahvoin harkoin.

Työ itse se tarmoa kasvattaa ja kansassa kasvun voimaa.

Mut kerta kun työmme valmiiks saa, ei ole ken väärästä
vaikertaa ja sorrosta veljeä soimaa.

Tulkaa ja katselkaa!

Oi, tulkaa käykää ja katselkaa mun maatani, vanhat ja

nuoret! Kas, rannoilta järvien välkkyväin ylös kaartuvat uljaat
vuoret!

Mäen rinteillä runsaina rehottaa

kotilehdot ja kuusikot taajat
ja taustalla lehtojen, vuorien
kovat korvet ja hongikot laajat.

Salon korvessa koppelo kotkottaa,

jänö, karhu ja hirvikin hyppii.
Joka paikassa juoksevat, siivekkäät
elinvoimia luonnosta nyppii.

Kotikansani vakaa ja järkkymätön,

syvämielinen, miettiväinen,
se tarmolla maatansa viljelee,
maa vaikkapa onkin jäinen.

Kevätkaskissa liekkejä leimuaa,

kotirannoilla laihoja loistaa,
hakalehdoissa karjojen kellot soi,
kodit piirtonsa lahdessa toistaa.

Kohukoskissa jyskyen tehtaat käy,

salot pyssyjen kaikuja paukkaa,
venot, laivatkin aaltoja vellovat,
tuliorhit kangasta laukkaa.

Ja hermoina sähköjohdot käy

maan aivoista jäntereihin,
ja tieteemme taivasta tahdittaa,
luo taiteemme kukkia teihin.
 Mäkihaavikon keinuilla kisaillaan,
viriaalloilla nuoriso laulaa.
Sitä ei voi äänettä kuunnella,
sitä itsekin täytyvi laulaa!

Kotikantelo kaunonen kasvattaa

helokirkasta sointujen viljaa.
Surusointuista on se ja vienoa —
sitä täytyvi kuunnella hiljaa.

Oi, kansani, henkesi siiville

kotikantelo kallis nosta,
tuo pöydälle pirtin se helkkymään,
sen kärsimät kohlut kosta!

Ylös nosta se kaunosti kaikumaan, niin henkesi nostaa se

myötään! Ja silloin mielesi puhtainnaan voi tehdä kauneinta
työtään.

Kansanrakkaus.

Kuin aurinko aamulla taivahalle, niin nouskosi

kansanrakkaus, ja tavalla auringon kaikkialle sä levitä lämpösi
runsaus!

Kuin koitar aamulla kuusikoitten

yli yöhyen häivään sajastaa
ja sitten ruskona lehtoloitten
ja kuusten latvahan kajastaa —
 Ja ruskosta taivahan rantamalta
terä kirkas punasena pilkahtaa,
käy kaartansa, usvia kaikkialta,
joka laaksonkin pohjasta hajottaa —

Ja hallan hyytämät niityt, pellot

taas lietsovi vireänä vihertämään
ja herättävi heimojen siskot, vellot
ylös työhön: kyntöön ja kylväntään.

Ja hellästi hivuttavi kaiken kansan

sulolämpöönsä, loistoonsa sulkeumaan,
siten johtaen silmistä surman ansan
sen riemuhun, onneen ja kunniaan —

Niin, niinkuin aurinko taivahalle, niin nouskosi

kansanrakkaus, ja tavalla auringon kaikkialle sä levitä lämpösi
runsaus.

Kristalli.

Oi kansani kalliin henki kuin kristalli kirkas on! Kuin kristalli!

Mutta se vielä niin kovin on muodoton.

Hyvä luoja jos mestarin loisi, joka särmiön siitä sais,

tuhatvälkkehin ympäri maata se päivyttä heijastais.
 Viljelysoppia.

I.

Kovin paljo se tarhuri harhaa. joka laatii kukkatarhaa kedon

kumpuhun karheaan, jota tunne ei laisinkaan.

Kovin paljo te hairahdatte, kun kansaa valistatte, sydän

vaikka on teillä sen kuin suljettu kirjanen.

II.

Mitä voipi se tarhuri voittaa, joka kasveja kastella koittaa, mut

unhotti perkata maan, johon istutti kasviksiaan.

Mihin joudumme valistustyössä, valo vaikkakin liehuu

yössä, jos rinnasta kansamme ei leimua liekki se.

III.

Älä, tarhuri, vieraasta maasta tuliruusuja tarhaasi raasta! Ei

etelän ruusunen kuki hallassa pohjoisen.

Älä, kansani, vieraasta maasta ihanteita ja aatteita raasta!

Hymy, nauru ei vierasten sovi kyynelen suihkeeseen.

IV.

Miten, tarhuri, kukkasen tehnet, jos ensin et varren ja lehdet

ylös kummusta kasvata — nehän versovat kukkia?
 Miten kukkivi kansani henki, jos vartta ja lehtiä ensin ei
hellästi hoidella, ylös mullasta nosteta?

V.

Puutarhuri, tunne maasi, sitä viljele, kasvikkaasi sen rinnassa

kasvata, kunis versoo se kukkia!

Kotikansani, itsesi tunne, sydänsyistäsi tutki kunne sun

täytyvi suunnata tie, joka matkasi määrään vie!

Herrasluontoa.

Olipa puisto pienokainen vierellä herraskartanon ja polku

jäykkä, kaavamainen välissä penkkilöitten on.

Puut vahtii tietä rivissänsä

kuin haarniskoidut sotilaat,
ja saksittuina yrmillänsä,
on pensasaidat pullokkaat.

Ja nurmen, joka vehmahasti

yrittää nousta kukkimaan,
puutarhuri sen nokkelasti
koneella niittää oraassaan.

Ja hovin herra mahtavasti

kuin laiva kulkee polkua.
On sillä rouva rinnallansa
kuin aika auma pellolla.

Kas, siinä sitä on sivistystä, on varakkuutta, arvoa! He

etsivät nyt virkistystä — nähkääpäs! — luonnon helmasta…

Kansanmielinen.

Henttuni hieno on herraslapsi, vaikkei se siltä näytä, vaikkei

se veitikka itseänsä yhtään ylväästi käytä.

Kyllä se taitaisi ruotsinkieltäkin, vaikka se ei sitä solkkaa;

taitaa se valssitkin, vaikka se hippaa vekkulipietun polkkaa.

Pennin saimme

Pennin saimme me perinnöksi sekä vähä rantaluhtaa. Itse

me korpehen peltoja teimme itse ohjaten juhtaa.

Pennin saimme me perinnöksi vanhoilta taatoiltamme —

sittenkin varkaat vahtailevat meidän rikkauttamme.
 *** END OF THE PROJECT GUTENBERG EBOOK KANSA JA
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