ARAB BOARD EXAM

Clinical Skills Assessment (CSA)

LONG CASE

BLADDER TUMOR
NMIBC

Type of station: Longcase

Station Title:Bladder mass
Reference:European Association of urologyguidelines
Duration:35 minutes

Aim/Focus of the station:

This station tests the candidate’s ability to diagnose, investigate and manage a case of urinary
bladder mass.

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UROLOGYLONG CASEMARKING SHEET
Examiner’s Name: Candidate’s Name:
Examiner’s Code: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H 20 10 8 5
Past H& Family H

Examination General status

Vital Signs 20 10 8 5
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation 10 7 5 2.5
Local Percussion & Auscult.
(Abdomino- Special tests
pelvic) DRE
External Genitalia
Identifying Main signs in this case:
Physical Signs Pallor and weight loss 10 7 5 2.5

Communication Introduction to patient

Skills Attitude 10 7 5 2.5
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case: 10 7 5 2.5

Main management
lines for this case: 20 15 8 5

Global Judgment

Serious Concern

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 ARAB BOARD EXAM

What does the author feel the candidate has to do to

pass the station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on findings.
H. Propose appropriate plan for management.

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Station setup
Clothing
• Hospital gown.
Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.
• KY gel for DRE.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Liver function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis with oral and IV contrast
• Chest X-ray.

OtherInvestigations:(given when requested by the candidate)

• Biopsy report

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Instructions to the patient(sheet to be completed based on real patient

data):

Make sure you give the same information to all candidates in the same way.
If for any reason you made a mistake in the scenario given, repeat the mistake with the rest of the
candidates.
Name:
Age:
Gender:
Background information about the patient: "I work as a………..".
Specific instructions to the patient:
• You should be relaxed, accommodating specially for the DRE
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have blood in my urine ".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• 3 year history of haematuria , weak stream, hesitancy, incomplete emptying, mild urgency,
nocturia twice
• I underwent a cystoscopy and biopsy.
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language:
• You are anxious and irritable.

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Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination. You will then
present your findings and discuss the case with the examiners

Duration of the station: 50 minutes

Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes

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Instructions to the assessors:

Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
DRE/Bimanual exam: palpable bladder mass (site, mobility)

This station tests the candidate’s ability to:to diagnose, investigate and manage a case of
bladder cancer

Duration of the station: 50 minutes:

Supervised history taking and examination 20 minutes
Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed history
and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.
Timing for interaction:
When the candidate asks for laboratory or radiological investigation the examiner provides
the results to the candidate.
Discussion:
Assessors will discuss the case with the candidate for 25 minutes.
Bell:
The bell rings at the end of the discussion time.The candidate has to leave the station once
the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the marking
sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing the reason
for failure. These comments will be used for providing the examinee with feedback.
Serious concern: This section will only be filled if the performance of the candidate is
unacceptable with poor professional conduct and serious roughness in handling the patient
or there is serious ethical concern. Serious concern will be investigated and may lead to
legal action against the candidate including reporting to the Egyptian Medical syndicate.

Station grading: average

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Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

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Questions to be asked to the candidate:

1) What is your provisional diagnosis?

2) What investigations would you like to request to reach a diagnosis?

3) What are the risk factors for bladder cancer?

• Tobacco smoking
• Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons and
chlorinated hydrocarbons ( in industrial branches processing paint, dye, metal and
petroleum products).
• Chlorination of drinking water and subsequent levels of trihalomethanes is potentially
carcinogenic, and exposure to arsenic in drinking water increases BC risk .
• The exposure to ionizing radiation is connected with increased risk of BC. It is suggested
that cyclophosphamide and pioglitazone are weakly associated with BC risk .
• Schistosomiasis.

4) Define non-muscle-invasive bladder cancer/ Discuss the TNM staging of bladder cancer.
2009 TNM classification of urinary bladder cancer

T - Primary tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Ta Non-invasive papillarycarcinoma
TisCarcinoma in situ: ‘flat tumour’
T1 Tumourinvadessubepithelial connective tissue
T2 Tumourinvades muscle
T2a Tumourinvadessuperficial muscle (innerhalf)
T2b Tumourinvadesdeep muscle (outerhalf)
T3 Tumourinvadesperivesical tissue:
T3a Microscopically
T3b Macroscopically (extravesical mass)
T4 Tumour invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall
T4a Tumour invades prostate, uterus or vagina
T4b Tumour invades pelvic wall or abdominal wall
N - Lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac, or
presacral).
N2 Metastasis in multiple lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or
presacral).
N3 Metastasis in common iliac lymph node(s).

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M - Distant metastasis
MX Distant metastasis cannot be assessed.
M0 No distant metastasis.
M1 Distant metastasis.

5) You receive a path report G3 pT1, what do you do next?

Is there muscle in the specimen?

If not – book an early re-resection – may be upstaged to pT2 and therefore require radical
treatment
If there is muscle, decision between
BCG x6 and GA cystoscopy / re-resection / random biopsies after
Early radical cystectomy

6) What do you understand by the term CIS of bladder?

CIS is a histological diagnosis: poorly differentiated TCC NOT crossing the basement
Membrane It may appear as a velvety patch of erythematous mucosa (usually invisible)
May be more visible with blue light cystoscopy after bladder pre-treated with 5 ALA.
Clinically
may be asymptomatic or have severe LUTS – esp. filling / storage symptoms
Cytology -80-90% positive if CIS present
Association: G3pT1 CIS present in more than 25%
Progression 40-83%
G3 T2+ TCC has CIS present 20-75%

7) How do you manage CIS of the bladder?

Lamm maintenance BCG regime

6 weekly installations; followed by GA check cystoscopy.
Maintenance doses 3 weekly installations at 3,6,12,18,24,30,36 months.

8) What are the indications, contraindications and possible side effects of intravesical BCG? How
to manage BCG sepsis?
Indications for BCG
In patients with high-risk tumours, for whom radical cystectomy is not carried out, 1-3 years full
dose maintenance BCG is indicated. The additional beneficial effect of the second and third years of
maintenance on recurrence in high-risk patients should be weighed against its added costs and
inconveniences.

• In intermediate-risk patients, full-dose BCG with 1 year maintenance is more effective than
Chemotherapy for prevention of recurrence; however, it has more side effects than chemotherapy.
Forthis reason both BCG with maintenance and intravesical chemotherapy remain an option.

BCG should not be administered (absolute contraindications):

• During the first 2 weeks after TUR;
• In patients with macroscopic haematuria;
• After traumatic catheterisation;
• In patients with symptomatic urinary tract infection.

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• History of BCG sepsis.

BCG should be used with caution (relative contraindication):

• in immunocompromised patients
• immunosuppressed patients,
• human immunodeficiency virus (HIV) infection

Possible side effects:

• Symptoms of cystitis
• Haematuria.
• Symptomatic granulomatous prostatitis
• Epididymo-orchitis
• General malaise, fever .
• Arthralgia and/or arthritis
• Persistent high-grade fever (> 38.5°C for > 48 h)

BCG sepsis: Prevention: initiate BCG at least 2 weeks post TURBT (if no signs andsymptoms of
haematuria).Cessation of BCGForsevere infection: High-dose quinolones or isoniazid, rifampicin and
ethambutol 1.2 gdaily for 6 months.- Early, high-dose corticosteroids as long as symptoms
persist.Consider an empirical non-specific antibiotic to cover Gram-negativebacteria and/or
Enterococcus.
• Allergic reactions

9) Additional question (at the discretion of the examiners)

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Evaluation criteria
Criteria of good performance Criteria of poor performance
• Communicate effectively with the patient. • Does not communicate effectively with the
• Clarifies reason for visit. patient.
• Correct, Thorough, Systematic and • Does not clarify reason for visit.
professional history taking and physical • Incorrect techniques.
examination. • Omits significant or important tests.
• Identifies correct physical signs. • Unsystematic.
• Does not find signs that are not present. • Hesitant and lacking in confidence.
• Construct a sensible differential diagnosis • Misses important physical signs.
including the correct one. • Finds signs that are not present.
• Order 3 relevant investigations. • Does not order the relevant investigations.
• Selects a sensible and appropriate • Poor differential diagnosis.
management plan. • Fails to consider the correct diagnosis.
• Treats patient respectfully and sensitively • Unfamiliar with correct management plan.
ensures comfort, safety and dignity. • Selects inappropriate management.
• Follow infection control procedures. • Causes patient physical or emotional
discomfort.
• Jeopardizes patient safety.

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 ‫‪ARAB BOARD EXAM‬‬

‫‪APPENDIX 1: Arabic Translation‬‬

‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺒﺄﻧﺘﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاءﻓﺤﺼﻜﺎﻣﻠﻠﻠﺒﻄﻦ واﻟﻤﺜﺎﻧﮫ‪.‬‬

‫اﻹﺳﻢ‪:‬‬
‫اﻟﻌﻤﺮ‪:‬‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪:‬‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي ‪".............................‬‬

‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬

‫"ﻋﻨﺪي ﺻﻌﻮﺑﺔ ﻓﻲ اﻟﺒﻮل و ﺗﺒﻮل دﻣﻮي ﻣﻦ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• ﻗﻤﺖ ﺑﺎﺟﺮاء ﻣﻨﻈﺎر ﻣﺜﺎﻧﮫ وﺗﻢ اﺧﺬ ﻋﯿﻨﺎت ﺑﯿﻨﺖ وﺟﻮد ورم‪.‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬

‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬

‫أﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬

‫• ﺗﺒﺪو ﻗﻠﻖ و ﻣﺘﻮﺗﺮ‬

‫‪Page 13 of 13‬‬
 ARAB Board of Urology

Clinical Skills Assessment (CSA)

Type of station: Long Case

Station Title: LUTS / BPH

Author’s name: Date: Dec. 2013

Revised by: Urology accreditation team Date: Dec. 2013
Reference:
Duration: 50 minutes

Contents
Aim/Focus of the station: .......................................................................................................................... 2
Intended Learning Outcomes: ................................................................................................................... 2
What does the author feel the candidate has to do to pass the station? ................................................ 4
Station setup ............................................................................................................................................. 5
Instructions to the role player / patient:................................................................................................... 6
Instructions to the candidate: ................................................................................................................... 7
Instructions to the assessors: .................................................................................................................... 8
Calibration sheet: .................................................................................................................................... 10
Questions to be asked to the candidate: ................................................................................................ 11
Evaluation criteria ................................................................................................................................... 13
Marking Sheet: ............................................................................................ Error! Bookmark not defined.
APPENDIX 1: Arabic Translation .............................................................................................................. 15
APPENDIX 2: Investigations Supplied ...................................................................................................... 16

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 ARAB BOARD OF UROLOGY

Aim/Focus of the station:

This station tests the ability of the candidate to diagnose, investigate and manage a case LUTS due
to bladder outlet obstruction and benign enlargement of prostate.

Intended Learning Outcomes (Trainees should be able to):

K.1.1.1 Recognize the importance of different elements of history
Recognize the different possibilities (differential diagnosis) of the different clinical
K.1.1.4
symptoms
Find clues in the urologic history to allow for provisional diagnosis, differential
ICS.1.1.1
diagnosis and plan the management
A.B. 1.1.1 Demonstrate respect, compassion and empathy for the patients and their caregivers
Recognize and interpret the use of non-verbal communication from patients and
A.B. 1.1.3
caregivers
ICS.1.2.1 Carry out general examination relevant to urologic disorders.
Carry out a thorough abdomino-pelvic examination and elicit physical signs that are
ICS.1.2.2
relevant to the presentation and that is valid, targeted and time efficient
ICS.1.2.3 Elicit important clinical findings
ICS.1.2.4 Perform relevant adjunctive examinations
Demonstrate respect, compassion and empathy for the patients and their caregivers
A.B. 1.1.1
Recognize and overcome barriers to effective communication
A.B. 1.1.2

A.B.1.2.1 Trainees should be able to respect patients’ dignity and confidentiality

ICS.1.3.1 Prioritize, select and use appropriate investigations
ICS.1.3.2 Interpret the findings
Interpret clinical features, their reliability and correlation to clinical scenarios
ICS.1.4.3
including recognition of the variability of presentation.
Formulate an evaluation plan for appropriate medical, laboratory, and radiological
ICS.1.4.4
examinations
CS.1.4.5 Prioritize the investigations needed to reach final diagnosis
ICS.1.5.1 Establish a rapport with the patient and any relevant others (e.g. care givers)
To assess and manage a patient presenting with lower urinary tract symptoms due
K.3.3
to obstruction and /or LUT dysfunction.
K3.3.3 Describe the epidemiology of BPH

K3.3.4 Outline the natural history and complications of BPH

K3.3.5 Discuss the underlying mechanism for lower urinary tract symptoms
K3.3.6 List non-urological causes of LUTS
K3.3.7 Outline the utility of PSA in the evaluation of prostate diseases
K3.3.8 Detail the non-surgical management therapy of BPH

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K3.3.9 Detail the surgical management therapy of BPH
ICS3.3.1 Assess and appropriately investigate patients presenting with LUTS

ICS3.3.1.1 Interpret fluid charts

ICS3.3.1.2 Interpret biochemistry results (e.g. PSA)

ICS3.3.1.3 Interpret urodynamic investigations (e.g. flow rate, residual urine)

ICS3.3.2 Formulate an appropriate differential diagnosis

Formulate an appropriate plan of management for patients presenting with
ICS3.3.3
LUTS/BPH
ICS3.3.4 Select appropriate medical therapy of patients with BPH/ LUTS

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 ARAB BOARD OF UROLOGY

What does the author feel the candidate has to do to pass the
station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination & other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on findings.
H. Propose appropriate plan for management.

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Station setup
Clothing & props
• Hospital gown

Set pieces:
• 3 chairs and a desk
• Blue pen and white paper sheets
• Examination bed & white sheet
• Examination gloves
• Disinfectant
• Examination lubricant
• Paravan / partition for examination in privacy
• Stethoscope and sphygmomanometer

Laboratory Investigations: (given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function test
• CBC
• Bleeding Profile
• PSA (Free and Total)

Radiological Investigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography

Urological Investigations: (given when requested by the candidate)

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 ARAB BOARD OF UROLOGY

Instructions to the candidate:

In this station you are a Urologist working in a Hospital

You will take a complete history and perform a full examination. You will then
present your findings and discuss the case with the examiners

Duration of the station: 50 minutes

Supervised history taking and examination 30 minutes

Free time to prepare notes 5 minutes
Sheet presentation & Discussion 25 minutes

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 ARAB BOARD OF UROLOGY
Instructions to the assessors:
Patient data (to be completed based on real patient data):
History:

General examination:

Local examination:

This station tests the candidate’s ability to: diagnose, investigate and manage a case of
LUTS due BPH as well as communicate the management plan with the patient based upon the
history and clinical findings in the case as well as the investigations requested and provided to the
patient.

Duration of the station: 60 minutes

Supervised history taking and examination 20 minutes
Free time to prepare notes 5 minutes
Sheet presentation & Discussion 25 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed history
and performing general and local examination.

Interaction:
The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the examiner provides
the results to the candidate.

Discussion:
Assessors will discuss the case with the candidate for 25 minutes.

Bell:
The bell rings at the end of the discussion time. The candidate has to leave the station once
the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the marking
sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing the reason
for failure. These comments will be used for providing the examinee with feedback.

Station grading: average

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 ARAB BOARD OF UROLOGY

Calibration sheet:

What do the examiners feel the candidate has to do to pass the station?
A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

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 ARAB BOARD OF UROLOGY
Questions to be asked to the candidate:
1) What's meant by LUTS and IPSS…?

2) What would you look for on examination?

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 ARAB BOARD OF UROLOGY
3) What are the recommended tests ?

4) What is your differential diagnosis in this case?

5) List the types of pharmacological and endoscopic treatments for BPH …?

6) What are the absolute & relative indications of surgery?

1-Although this previously was the presence of voiding symptoms without formal subjective or
objective quantification, we now recognize that the indication is more likely to be moderate-to-
severe voiding symptoms attributed to BPH that are refractory to medical therapy.
2-Recurrent and robust gross hematuria
3-The findings of bladder calculi, bladder diverticula
4-Bilateral hydronephrosis with renal functional impairment.

7) What is the most appropriate period of stopping anticoagulation prior to proceeding with
endoscopic management of BPH? And does the period differ with the type of
anticoagulation…?

8) How do you decide whether to give a single versus combined medical treatment (alpha-
blocker & 5-alpha-reductase inhibitor)?

Combination therapy with both an α-blocker and a 5α-reductase inhibitor has been
demonstrated to be the most effective means of preventing disease progression and
Seems likely to become the standard of care in appropriate cases. . Antimuscarinic agents and
PDEIs are useful adjuncts for men with storage symptoms or ED. The true importance of
These agents will become clearer with time.

9) What are the main components of watchful waiting treatment?

Main Components of Self-Management Program for Men

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 ARAB BOARD OF UROLOGY
With Uncomplicated Lower Urinary Tract Symptoms

Education and Reassurance

• Discuss the causes of LUTS, including normal prostate and bladder function.
• Discuss the natural history of BPH and LUTS, including the expected future symptoms.
• Reassure that no evidence of a detectable prostate cancer has been found.
Fluid Management
• Advise a daily fluid intake of 1500 to 2000 mL (minor adjustments made for climate and activity).
• Avoid inadequate or excessive intake on the basis of a frequencyvolume chart.
• Advise fluid restriction when symptoms are most inconvenient (e.g., during long journeys or when out in public).
• Advise evening fluid restriction for nocturia (no fluid for 2 hours before retiring).
Caffeine and Alcohol
• Avoid caffeine by replacing with alternatives (e.g., decaffeinated or caffeine-free drinks).
• Avoid alcohol in the evening if nocturia is bothersome.
• Replace large-volume alcoholic drinks (e.g., pint of beer) with small-volume alcoholic drinks (e.g., wine or spirits).
Concurrent Medication
• Adjust the time when medication with an effect on the urinary system is taken, to improve LUTS at times of greatest inconvenience
(e.g., during long journeys and when out in public).
• Replace antihypertensive diuretics with suitable alternatives with fewer urinary effects (via the patient’s general practitioner).

Types of Toileting and Bladder Retraining

• Advise men to double-void.
• Advise urethral milking for men with postmicturition dribble.
• Advise bladder retraining. Using distraction techniques (predetermined mind exercise, perineal pressure or pelvic floor exercises),
aim to increase the minimum time between voids to 3 hours (daytime) and/or the minimum voided volume to between 200 and 400 mL (daytime). The urge to void should be
suppressed for 1 minute, then 5 minutes, then 10 minutes, and so
on, increasing on a weekly basis. Use frequency-volume charts to monitor progress.

Miscellaneous
• Avoid constipation in men with LUTS.

10) What are the complications of TURP:

•• Early
•• Anaesthesia related, ischaemic event, deep vein thrombosis
•• Blood transfusion in 1%–2% (on average 10 mL blood loss per gram of tissue resected)
•• Urinary sepsis in up to 3%
•• Systemic sepsis in up to 1.5%
TUR syndrome
Risk 0.8% if <45 g tissue resected and 1.5% if >45 g tissue resected
Risk 0.8% if resection time <90 minutes and 2% if resection time
>90 minutes (No risk of TUR syndrome in HoLEP)
•• There is a risk of mortality of approximately 0.3% (within 30 days of operation)
•• Late
•• Urinary incontinence in <1%
•• Retrograde ejaculation in 80%–100%
•• Erectile dysfunction is reported in approximately 10%
•• Bladder neck stenosis/urethral stricture in 3%–5%

How do you manage a man with confusion 6hrs after a TURP?

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 ARAB BOARD OF UROLOGY
Possible causes:
Blocked catheter with urinary retention
Hypotension
Hypovolaemia from haemorrhage
Septicaemia (was there a long-term catheter before?)
Hyponatraemia (TUR syndrome)
Rapid assessment:
Assess for palpable bladder – if so Bladder washout
Look at colour of draining urine
Take Pulse and BP (may be hypertensive / bradycardic if TUR syndrome)
Temperature / vasodilated (sepsis) or vasoconstricted (haemorrhage)
Management
O2
Send FBC, U and E’s, ABG
Treat the underlying cause
If due to bleeding: transfuse and make arrangements to take the patient back to theatre.
How would you manage a post TURP haemorrhage?
In recovery / On the ward
Warn the anaesthetist and theatre that the patient may need to come back to theatre
Get more blood cross-matched
Check clotting for coagulopathy
Ensure good iv access and resuscitate with colloid until more blood available
100% O2
Broad-spectrum antibiotics
Inflate the balloon (upto 50 mL / traction (for 30 minutes then release for 5 minutes)– does it
control the bleeding?
If not – back to theatre. Roller ball diathermy
If doesn’t control  open and pack
If doesn’t control  ligate internal iliac arteries
Tie off AFTER the posterior branch to avoid buttock ischaemia
This question is a lead in to the “draw the branches of the internal iliac artery” so think about
it when you start talking about tying it off!
The patient may need HDU/ ITU post op

Page 12 of 16
 ARAB BOARD OF UROLOGY

Evaluation criteria:
Criteria of good performance Criteria of poor performance
• Communicate effectively with the patient. • Does not communicate effectively with the
• Clarifies reason for visit. patient.
• Correct, thorough, systematic and • Does not clarify reason for visit.
professional history taking and physical • Incorrect techniques.
examination. • Omits significant or important tests.
• Identifies correct physical signs. • Unsystematic.
• Does not find signs that are not present. • Hesitant and lacking in confidence.
• Constructs a sensible differential diagnosis • Misses important physical signs.
including the correct one. • Finds signs that are not present.
• Orders relevant investigations. • Does not order the relevant investigations.
• Selects a sensible and appropriate • Poor differential diagnosis.
management plan. • Fails to consider the correct diagnosis.
• Treats the patient respectfully and • Unfamiliar with correct management plan.
sensitively ensuring comfort, safety and • Selects inappropriate management.
dignity. • Causes patient physical or emotional
• Follows infection control procedures. discomfort.
• Jeopardizes patient safety.

Page 13 of 16
 ARAB BOARD OF UROLOGY

UROLOGY LONG CASE MARKING SHEET

Examiner’s Name: Examiner’s Code:
Candidate’s Name: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H
Past H & Family H

Examination General status

Vital Signs
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation
Local Percussion & Auscult.
(Abdomino- Special tests
pelvic) DRE / PV / Bimanual
External Genitalia
Identifying Main signs in this case:
Physical Signs

Communication Introduction to patient

Skills Attitude
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case:

Main management
lines for this case:

Global Judgment

Serious Concern

Page 14 of 16
 ‫‪ARAB BOARD OF UROLOGY‬‬
‫‪APPENDIX 1: Arabic Translation‬‬
‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺐ أن ﺗﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاء ﻓﺤﺺ ﻛﺎﻣﻞ‬
‫اﻹﺳﻢ‪... :‬‬
‫اﻟﻌﻤﺮ‪ ... :‬ﻋﺎﻣﺎ‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪ :‬ﻣﺘﺰوج و ﺗﻌﻤﻞ ‪...‬‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي ‪"...‬‬
‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬
‫"ﻋﻨﺪي ‪ ...‬ﻣﻦ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• ‪...‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬
‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬
‫ھﻞ اﻟﻌﻼج ﻣﻜﻠﻒ؟‬ ‫•‬
‫ھﻮ أﻧﺎ ھﺎﻋﻤﻞ ﻋﻤﻠﯿﺔ وﻟﻼ ﻣﻨﻈﺎر؟‬ ‫•‬
‫ھﺎﻗﻌﺪ ﻗﺪ إﯾﮫ ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ؟‬ ‫•‬
‫…‬ ‫•‬
‫اﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬
‫• ﺗﺒﺪو ﻗﻠﻖ و ﻣﺘﻮﺗﺮ‬

‫‪Page 15 of 16‬‬
ARAB BOARD OF UROLOGY

Page 16 of 16
 Arab Exam
Clinical Skills Assessment (CSA)

Type of station: Long Case

Station Title: Prostate Cancer (localized prostate cancer)
Author’s name: Ashraf Mosharafa `
Duration: 50 minutes

Contents
Aim/Focus of the station: .......................................................................................................................... 2
Intended Learning Outcomes: ................................................................................................................... 2
What does the author feel the candidate has to do to pass the station? ................................................ 3
Station setup ............................................................................................................................................. 4
Instructions to the role player / patient:................................................................................................... 5
Instructions to the candidate: ................................................................................................................... 6
Instructions to the assessors: .................................................................................................................... 7
Calibration sheet: ...................................................................................................................................... 9
Questions to be asked to the candidate: ................................................................................................ 10
Evaluation criteria ................................................................................................................................... 14
Marking Sheet: ............................................................................................ Error! Bookmark not defined.
APPENDIX 1: Arabic Translation .............................................................................................................. 16
APPENDIX 2: Investigations Supplied ...................................................................................................... 17

Page 1 of 21
 Arab exam.
Aim/Focus of the station:
This station tests the ability of the candidate to diagnose, investigate and manage a case of
localized Prostate Cancer

Intended Learning Outcomes (Trainees should be able to):

K.1.1.1 Recognize the importance of different elements of history
Recognize the different possibilities (differential diagnosis) of the different clinical
K.1.1.4
symptoms
Find clues in the urologic history to allow for provisional diagnosis, differential
ICS.1.1.1
diagnosis and plan the management
A.B. 1.1.1 Demonstrate respect, compassion and empathy for the patients and their caregivers
Recognize and interpret the use of non-verbal communication from patients and
A.B. 1.1.3
caregivers
ICS.1.2.1 Carry out general examination relevant to urologic disorders.
Carry out a thorough abdomino-pelvic examination and elicit physical signs that are
ICS.1.2.2
relevant to the presentation and that is valid, targeted and time efficient
ICS.1.2.3 Elicit important clinical findings
A.B.1.2.1 Respect patients’ dignity and confidentiality
ICS.1.3.1 Prioritize, select and use appropriate investigations
ICS.1.3.2 Interpret the findings
Interpret clinical features, their reliability and correlation to clinical scenarios
ICS.1.4.3
including recognition of the variability of presentation.
Formulate an evaluation plan for appropriate medical, laboratory, and radiological
ICS.1.4.4
examinations
CS.1.4.5 Prioritize the investigations needed to reach final diagnosis
ICS.1.5.1 Establish a rapport with the patient and any relevant others (e.g. care givers)
Describe the rationale for, indications, complications of different therapies for
K6.2.2.1 localized and locally advanced prostate cancer (Radical surgery, Radiotherapy,
Brachytherapy, Adjuvant hormones, and active surveillance)
Outline the rationale for, indications, complications of different therapies for
K6.2.3
metastatic and hormone refractory disease
ICS6.1.2 Appropriately assess patients with possible malignancy
ICS6.1.4 Interpret tests correctly
Select relevant radiological and pathological investigations for Prostate Cancer
ICS6.2.1
patients
ICS6.2.2 Formulate a best fit management policy for Prostate Cancer patients
ICS6.2.5 Formulate a relevant follow up plan for Prostate Cancer patients

Page 2 of 21
 Arab exam.

What does the author feel the candidate has to do to pass the
station?
A. Take history in an appropriate way.
B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination including a DRE, external genitalia examination and bimanual
examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on findings.
H. Propose appropriate plan for management.

Page 3 of 21
 Arab exam.

Station setup
Clothing & props
• Hospital gown

Set pieces:
• 3 chairs and a desk
• Blue pen and white paper sheets
• Examination bed & white sheet
• Examination gloves
• Disinfectant
• KY gel
• Stethoscope and sphygmomanometer

Laboratory Investigations: (given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function test
• PSA
• Pathology report (for Prostate Biopsy)

Radiological Investigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography
• TRUS
• CT abdomen & pelvis
• Bone scan

Page 4 of 21
 Arab exam.

Instructions to the patient (sheet to be completed based on real patient

data):
Make sure you give the same information to all candidates in the same way.
If for any reason you made a mistake in the scenario given, repeat the mistake with the rest of the
candidates.
Name:
Age: … years old
Gender: male
Background information about the patient: "I am retired"
Specific instructions to the patient:
Opening statement: "I have a weak interrupted urinary stream"
Information to be given freely without asking:
• I’ve been having difficulties passing urine for … months
• …

Don’t reveal the following unless you are asked:

• 3 year history of weak stream, hesitancy, incomplete emptying, mild urgency, nocturia
twice, no hematuria & no dysuria.
• I have an elevated blood level in one of my investigations & I do not know what does this
mean.
• I had a Transrectal Ultrasound and biopsies were taken from the prostate
• …
Past History:
• …
Family History:
• …

Questions to be asked:
• Will I need surgery?

Behavior/Body language:
• You are calm and comfortable

Page 5 of 21
 Arab exam.

Instructions to the candidate:

In this station you are a Urologist working in a Hospital

You will take a complete history and perform a full examination. You will then
present your findings and discuss the case with the examiners

Duration of the station: 60 minutes

Supervised history taking and examination 25 minutes

Free time to prepare notes 5 minutes
Sheet presentation & Discussion 20 minutes

Page 6 of 21
 Arab exam.

Instructions to the assessors:

Patient data (to be completed based on real patient data):
History:

General examination:

Local examination:
DRE: induration in the right lobe of the prostate

This station tests the candidate’s ability to: diagnose, investigate and manage a case of
localized prostate cancer

Duration of the station: 60 minutes

Supervised history taking and examination 25 minutes
Free time to prepare notes 5 minutes
Sheet presentation & Discussion 20 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed history
and performing general and local examination.

Interaction:
The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the examiner provides
the results to the candidate.

Discussion:
Assessors will discuss the case with the candidate for 30 minutes.

Bell:
The bell rings at the end of the discussion time. The candidate has to leave the station once
the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the marking
sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing the reason
for failure. These comments will be used for providing the examinee with feedback.
Serious concern: This section will only be filled if the performance of the candidate is
unacceptable with poor professional conduct and serious roughness in handling the patient

Page 7 of 21
 Arab exam.
or there is serious ethical concern. Serious concern will be investigated and may lead to
legal action against the candidate including reporting to the Egyptian Medical syndicate.

Station grading: average

Page 8 of 21
 Arab exam.

Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?
A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management

Page 9 of 21
 Arab exam.

Questions to be asked to the candidate:

1) What is your provisional diagnosis?

2) What are the features in the clinical history you be interested with?

3) Describe the TNM staging of P.Ca.?

4) What are the clinical features on DRE that suggest the possibility of prostate cancer?
Nodularity, hardness, asymmetry, fixation of overlying rectal mucosa

5) What is the differential diagnosis of a prostate nodule?

Prostate cancer, BPH, granulomatous prostatitis

6) What's meant by Gleason grade?

Page 10 of 21
 Arab exam.

7) Define risk categories of prostate cancer?

Page 11 of 21
 Arab exam.

8) How do you prepare a patient scheduled for TRUS with biopsies?

Patients should be informed of the risks and benefits of the procedure and provide informed
consent. Main risks are post-biopsy infection (2% of patients will go on to develop a febrile
urinary tract infection, bacteremia, or acute prostatitis), bleeding (hematuria in 23% to 63%,
rectal bleeding in 2.1% to 21.7% of patients, and hematospemia that may persist for 4 to 6
weeks).

All anticoagulant therapy (warfarin, clopidogrel, aspirin/nonsteroidal anti-inflammatory

drugs [NSAIDs], herbal supplements) should be stopped 7 to 10 days before prostate biopsy.
The international normalized ratio should be corrected below 1.5.

The American Urological Association Best Practice Policy Statement on Urologic Surgery
Antimicrobial Prophylaxis advocates antibiotic prophylaxis prior to transrectal prostate biopsy
(e.g. a 3-day course of fluoroquinolone to be started before the Bx)

The enema’s effect on reducing infections is debatable, but it seems logical that a
cleansing enema and empty rectal vault may reduce bacterial seeding of the prostate.
infiltration anesthesia around the nerve bundles with local anesthetic may provide excellent
pain control.

9) How can you use PSA & PSA formulas in diagnosis of early prostate cancer?
PSAD, F/T PSA, age-specific PSA, velocity, PSA doubling time

10) How do you manage this patient?

Page 12 of 21
 Arab exam.

11) What is the difference between WW and active surveillance?

12) 12) What are the complications of radical prostatectomy?

Page 13 of 21
 Arab exam.
Evaluation criteria
Criteria of good performance Criteria of poor performance
• Communicate effectively with the patient. • Does not communicate effectively with the
• Clarifies reason for visit. patient.
• Correct, thorough, systematic and • Does not clarify reason for visit.
professional history taking and physical • Incorrect techniques.
examination. • Omits significant or important tests.
• Identifies correct physical signs. • Unsystematic.
• Does not find signs that are not present. • Hesitant and lacking in confidence.
• Constructs a sensible differential diagnosis • Misses important physical signs.
including the correct one. • Finds signs that are not present.
• Orders relevant investigations. • Does not order the relevant investigations.
• Selects a sensible and appropriate • Poor differential diagnosis.
management plan. • Fails to consider the correct diagnosis.
• Treats the patient respectfully and • Unfamiliar with correct management plan.
sensitively ensuring comfort, safety and • Selects inappropriate management.
dignity. • Causes patient physical or emotional
• Follows infection control procedures. discomfort.
• Jeopardizes patient safety.

Page 14 of 21
 Arab exam.

UROLOGY LONG CASE MARKING SHEET

Examiner’s Name: Examiner’s Code:
Candidate’s Name: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H
Past H & Family H

Examination General status

Vital Signs
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation
Local Percussion & Auscult.
(Abdomino- Special tests
pelvic) DRE
External Genitalia
Identifying Main signs in this case:
Physical Signs

Communication Introduction to patient

Skills Attitude
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case:

Main management
lines for this case:

Global Judgment

Serious Concern

Page 15 of 21
 ‫‪Arab exam.‬‬
‫‪APPENDIX 1: Arabic Translation‬‬
‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺐ أن ﺗﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاء ﻓﺤﺺ ﻛﺎﻣﻞ‬

‫اﻹﺳﻢ‪... :‬‬
‫اﻟﻌﻤﺮ‪ ... :‬ﻋﺎﻣﺎ‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪ :‬ﻣﺘﺰوج وﻋﻠﻰ اﻟﻤﻌﺎش‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي اﻟﺒﻮل ﺿﻌﯿﻒ وﻣﺘﻘﻄﻊ"‬
‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬
‫"ﻋﻨﺪي ﺻﻌﻮﺑﺔ ﻓﻲ اﻟﺒﻮل ﻣﻦ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• أﻧﺎ اﺗﻌﻤﻞ ﻟﻲ ﻣﻮﺟﺎت ﺻﻮﺗﯿﺔ ﻋﻠﻰ اﻟﺒﺮوﺳﺘﺎﺗﺎ وﺗﻢ أﺧﺬ ﻋﯿﻨﺎت ﻣﻦ اﻟﺒﺮوﺳﺘﺎﺗﺎ‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬
‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬
‫• ھﻞ ﺳﺄﺣﺘﺎج ﻟﻌﻤﻠﯿﺔ ﺟﺮاﺣﯿﺔ؟‬
‫• ‪...‬‬
‫اﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬
‫• ﺗﺒﺪو ﻣﺮﺗﺎح وھﺎدئ‬

‫‪Page 16 of 21‬‬
 Arab exam.

APPENDIX 2: Investigations Supplied

URINE ANALYSIS
PH: 5.2
COLOUR: Yellow
SAMPLE: Random
Specific Gravity: 1020
Protein: nil
RBCs: 3-5 /hpf
Pus Cells: 2-3 /hpf
Casts: none

Urine culture & sensitivity: No growth

Page 17 of 21
 Arab exam.

LAB REPORT
Serum Creatinine: 1.1 mg/dl
Blood Urea: 32 mg/dl
Potassium: 4.5 mg/dl
Sodium: 134 mg/dl
Uric Acid: 6.4 mg/dl

Page 18 of 21
 Arab exam.

LAB REPORT
PSA

Total PSA: 7.8 ng/ml

Free/total PSA: 18%

Page 19 of 21
 Arab exam.

Pathology Report
Patient Name: …

Medical Record #: 01020304

Date of Birth: 04/01/… (Age: …) Sex: Male

Procedure performed by: Dr. M. Mohammed

Specimen #: S00-9999

Procedure date: 07/15/2013

Report date: 07/16/2013

Gross description by: Dr. M. Abdalla

DIAGNOSIS:

Prostate needle biopsies: 10

A) Rt Apex: Fibromuscular tissue only; no prostatic epithelium seen.

B) Rt Middle: Atypical glandular focus suspicious for adenocarcinoma.

C) Rt Base: No malignancy identified.

D) Rt Middle lateral: No malignancy identified.

E) Rt Base lateral: No malignancy identified; focal chronic inflammation.

F) Lt Apex: Fibromuscular tissue and colonic mucosa; no prostatic epithelium seen.

G) Lt Middle: Adenocarcinoma, Gleason score 7 (3 + 4), involving 50% of core.

H) Lt Base: Adenocarcinoma, Gleason score 8 (4 + 4), involving 70% of core.

I) Lt Middle Lateral: No malignancy identified.

J) Lt Base Lateral: Adenocarcinoma, Gleason score 7 (4 + 3), involving 40% of core.

Note: Perineural invasion is seen. Focally, a tertiary Gleason 5 pattern is noted.

Clinical Data: None given.

Gross Description: Received in 10 formalin containers labeled with the patient’s name, “John
Doe,” the medical record number, and additionally labeled (As above) are multiple prostate cores
measuring up to 1.5 cm, entirely submitted in cassettes A–J respectively.

Page 20 of 21
 Arab exam.
Notes:

The pathology report should be revised and adjusted according to the

patient’s clinical data (e.g. site of nodule)

Abdominal and pelvic US, TRUS and +/- MRI are to be prepared with
the actual case

Page 21 of 21
 ARAB BOARD EXAM

Clinical Skills Assessment (CSA)

LONG CASE

RENAL STONES
PCNL

Type of station: Longcase

Station Title:Renal stone PCNL
Reference:European Association of urologyguidelines
Duration:35 minutes

Page 1 of 11
What does the author feel the candidate has to do to pass the
station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on findings.
H. Propose appropriate plan for management.

Page 2 of 11
Station setup
Clothing
• Hospital gown.

Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis
• KUB

OtherInvestigations:(given when requested by the candidate)

Page 3 of 11
 Instructions to the patient
(sheet to be completed based on real patient data):

Make sure you give the same information to all candidates in the same way.
If for any reason you made a mistake in the scenario given, repeat the mistake with the rest of the
candidates.
Name:
Age:
Gender:
Background information about the patient: "I work as a………..".
Specific instructions to the patient:
• You should be relaxed.
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have…".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• The professional diagnosis.
• Results of investigations.
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language:Normal

Page 4 of 11
 Instructions to the candidate:

In this station you are a Urologist working in a Hospital

You will take a complete history and perform a full examination. You will then
present your findings and discuss the case with the examiners

Duration of the station: 35 minutes

Supervised history taking and examination 20minutes

Sheet presentation & Discussion 15 minutes

Page 5 of 11
 Instructions to the assessors:
Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
Bimanual exam
This station tests the candidate’s ability to:to diagnose, investigate and manage a case of
bladder cancer

Duration of the station: 35 minutes:

Supervised history taking and examination 20 minutes
Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed history
and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.
Timing for interaction:
When the candidate asks for laboratory or radiological investigation the examiner provides
the results to the candidate.
Discussion:
Assessors will discuss the case with the candidate for 25 minutes.
Bell:
The bell rings at the end of the discussion time.The candidate has to leave the station once
the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the marking
sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing the reason
for failure. These comments will be used for providing the examinee with feedback.
Serious concern: This section will only be filled if the performance of the candidate is
unacceptable with poor professional conduct and serious roughness in handling the patient
or there is serious ethical concern. Serious concern will be investigated and may lead to
legal action against the candidate including reporting to the Egyptian Medical syndicate.

Station grading: average

Page 6 of 11
 Calibration sheet:

What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

Page 7 of 11
 Questions to be asked to the candidate:

1) What is your provisional diagnosis?

2) What investigations would you like to request to reach a diagnosis?

3) Which images modalities would you use and why?

4) Should the left staghorn renal calculus be treated or be left alone? Justify your answer.

The authors concluded that there is no such clinical entity as a ‘silent staghorn’ based on the post-mortem study.
Furthermore, they stated that long-term survival is better in those treated surgically (mortality 7%) than in those
managed conservatively (mortality 28%).

5) The patient opts for percutaneous nephrolithotomy (PCNL). What are the indications and
contraindications for this procedure?

Indications
1. Stone size
a. Stones >3 cm diameter.
b. Renal pelvis stones >2 cm.
c. Lower pole stones >1 cm.
d. Staghorn stones.
2. Obstruction
a. An anatomic abnormality is present that will prevent stone fragments from passing spontaneously, especially where
extracorporeal shock wave lithotripsy (ESWL) is usually contraindicated.
3. Anatomical considerations
a. Abnormal renal anatomy such as horseshoe kidney or calyceal diverticular stones.
b. Abnormal patient anatomy such as kyphoscoliosis or obesity preventing ESWL.
4. Failed ESWL/ureteroscopy (URS)
5. Stones associated with a foreign body
6. Patient choice/desire for one treatment only
Contraindications
1. Absolute
a. Uncorrected bleeding disorder
b. Pregnancy
c. Sepsis
d. Poor kidney function (e.g. <15%), where nephrectomy would be indicated
e. Need for coincidental open procedure
2. Relative
a. Medical problems – Patient high risk for anaesthesia
b. Anterior calyceal diverticulum

Page 8 of 11
6-Describe how you would take informed consent for this procedure.
Informed consent must include a discussion of available alternative treatment options, as described above, the
intended benefit of the proposed procedure, and the potential complications, which are listed as follows with
approximate percentages in parentheses:

Complications related to access

Bleeding Requiring transfusion (2%–3%)
Requiring embolisation (1%)
Requiring nephrectomy (rare)
Perforation of adjacent organs (bowel <1%, pneumothorax 0%–5%)
Access failure (up to 5%)
•Complications related to stone removal Infection (bacteriuria 77%; sepsis 0.25%–1.5%)
Transurethral resection (TUR) syndrome
Irrigant extravasation (30%)
Renal pelvis injury
Residual stones (>10%), dependent upon stone complexity
•Others Pleural effusion (10%)
Hypertension and fibrosis (late)
Mortality (0.3%)

7- Are there any advantages of supine versus prone PCNL?

Patient positioning during supine PCNL is less time consuming and the potential risks of musculoskeletal injuries (e.g. cervical spine,
brachial plexus), cardiovascular (increased cardiac output, venous stasis and thromboembolic events) and visual complications are
decreased. The supine position also allows easy access to the urethral meatus for simultaneous retrograde procedures during
PCNL, is more ergonomic for the surgeon during the procedure, may reduce radiation exposure, promotes spontaneous drainage
of stone fragments due to the relatively downward direction of the tract and provides lower irrigating pressures.
Prone PCNL provides more options and a wider surface area for puncture (upper pole/multiple punctures), may reduce the risk of
damage to visceral organs (retro-renal colon and lateral rotation of spleen/liver away from puncture site), allows greater
manipulation with the nephroscope and may reduce perirenal injury (excessive anterio-medial movement with supine increases
risk of injury during dilation) [3].
Three meta-analyses have been carried out to date comparing outcomes of prone versus supine PCNL and have reported
conflicting results [4–6]. Two of these reported similar stone-free rates (SFRs) (prone 81.6%–83.4% versus supine 83.5%–
84.5%), length of stay and complication rates but shorter operative times with supine [4,5]. In contrast, Zhang et al. [6] found
better SFRs with the prone position compared to supine (77.3% versus 72.9%).

8- In this case what is this stone likely to consist of?

This is most likely to be a struvite stone, named after the nineteenth-century Russian diplomat Baron von Struve. They
are also referred to as triple-phosphate stones (calcium, ammonium and magnesium, phosphate), infection stones or
urease stones. The following conditions must coexist for crystallisation of struvite:
Alkaline urine pH > 7.2
Ammonia in urine
The driving force is UTI with urease-producing bacteria. Urease-producing bacteria hydrolyse urea to ammonia
molecules and carbon dioxide (Figure 10.2).

High urine pH with high ammonia concentration, abundant phosphate and magnesium lead to crystallisation of
magnesium ammonium phosphate and the subsequent formation of large branched staghorn stones.

9- Q. Which bacteria produce urease?

A. Gram −ve
Proteus (mirabilis)
Providencia
Klebsiella
Pseudomonas
Gram +ve
Staphylococcus
Mycoplasma
Ureaplasma urealyticum

Page 9 of 11
 UROLOGYLONG CASEMARKING SHEET
Examiner’s Name: Candidate’s Name:
Examiner’s Code: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H 20 10 8 5
Past H& Family H

Examination General status

Vital Signs 20 10 8 5
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation 10 7 5 2.5
Local Percussion & Auscult.
(Abdomino- Special tests
pelvic) DRE
External Genitalia
Identifying Main signs in this case:
Physical Signs Scar from previous 10 7 5 2.5
PCNL

Communication Introduction to patient

Skills Attitude 10 7 5 2.5
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case: 10 7 5 2.5

Main management
lines for this case: 20 15 8 5

Global Judgment

Serious Concern

Page 10 of 11
 ‫‪APPENDIX 1: Arabic Translation‬‬
‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺒﺄﻧﺘﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاءﻓﺤﺼﻜﺎﻣﻠﻠﻠﺒﻄﻦ واﻟﻤﺜﺎﻧﮫ‪.‬‬

‫اﻹﺳﻢ‪:‬‬
‫اﻟﻌﻤﺮ‪:‬‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪:‬‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي ‪".............................‬‬

‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬

‫"ﻋﻨﺪي اﻟﻢ ﻓﻲ اﻟﻜﻠﯿﺔ ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• اﻟﻤﻔﺮاس اﻟﺤﻠﺰوﻧﻲ واﻟﺴﻮﻧﺎر‬
‫• ﻧﻮع اﻟﺘﺪاﺧﻞ اﻟﺠﺮاﺣﻲ‪.‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬

‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬

‫أﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬

‫ﻋﺎدي‬

‫‪Page 11 of 11‬‬
 ARAB BOARD EXAM

LONG CASE

RENAL TUMOR (AML )

Type of station: Longcase
Station Title:M RCCA
Reference: Modified from Egyptian BU, Champbell urology

Duration: 35 minutes

Contents
Aim/Focus of the station: ............................................................................ Error! Bookmark not defined.
Intended Learning Outcomes:..................................................................... Error! Bookmark not defined.
What does the author feel the candidate has to do to pass the station? ................................................. 3
Station setup .............................................................................................................................................. 4
Instructions to the real patient: ................................................................................................................. 5
Instructions to the candidate: .................................................................................................................... 6
Instructions to the assessors: ..................................................................................................................... 7
Calibration sheet: ....................................................................................................................................... 7
Questions to be asked to the candidate: .................................................... Error! Bookmark not defined.
Evaluation criteria ....................................................................................... Error! Bookmark not defined.
Marking Sheet: ............................................................................................ Error! Bookmark not defined.
APPENDIX 1: Arabic Translation .................................................................. Error! Bookmark not defined.
APPENDIX 2: Investigations Supplied .......................................................... Error! Bookmark not defined.
 ARAB BOARD EXAM

What does the author feel the candidate has to do to pass the
station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the
examiner.
G. Prioritize & order investigations needed to reach proper diagnosis
based on findings.
H. Propose appropriate plan for management.
 ARAB BOARD EXAM

Station setup
Clothing
• Hospital gown.

Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.
• KY gel for DRE.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Liver function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis with oral and IV contrast
• Chest X-ray.

OtherInvestigations:(given when requested by the candidate)

• Biopsy report
 ARAB BOARD EXAM

Instructions to the patient

(sheet to be completed based on real patient data):

Make sure you give the same information to all candidates in the same way.

If for any reason you made a mistake in the scenario given, repeat the mistake with the
rest of the candidates.

Name:
Age:
Gender:
Background information about the patient: "HOUSE WIFE ".
Specific instructions to the patient:
• You should be relaxed
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have right loin pain and haematuria ".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language:
• You are anxious and irritable.
 ARAB BOARD EXAM

Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination.

You will then present your findings and discuss the case with the
examiners

Duration of the station: 35 minute

Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes
 ARAB BOARD EXAM

Instructions to the assessors

Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
General exam: pallor

This station tests the candidate’s ability to:to diagnose, investigate and manage
a case of renal cancer.
Duration of the station: 35 minutes:
Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed
history and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the examiner
provides the results to the candidate.

Discussion: Assessors will discuss the case with the candidate for 25 minutes.

Bell:
The bell rings at the end of the discussion time.The candidate has to leave the
station once the bell rings.
The Marking Sheet
It is recommended to fill the “History Taking” and “Examination” sections of the
marking sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing
the reason for failure. These comments will be used for providing the examinee
with feedback.
Serious concern: This section will only be filled if the performance of the
candidate is unacceptable with poor professional conduct and serious roughness
in handling the patient or there is serious ethical concern. Serious concern will be
investigated and may lead to legal action against the candidate including
reporting to the Egyptian Medical syndicate.

Station grading: average

 ARAB BOARD EXAM

Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade

descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

 ARAB BOARD EXAM

Suggested questions
What are the indications for nephron-sparing surgery?
A. Absolute indications are bilateral synchronous RCC, and an anatomical or functionally
solitary kidney.
Relative indications are unilateral RCC with a reduced or poorly functioning contralateral
kidney, unilateral RCC in patients with comorbidity associated with potential renal
impairment (diabetes, renovascular disease), and patients with an increased risk of a
second renal malignancy (hereditary RCC such as von Hippel–Lindau [VHL] disease).
Elective indications include localised unilateral RCC with a normal contralateral
kidney.

Q. How would you consent a patient for laparoscopic partial nephrectomy?

A. I would explain that the aim of the procedure is to remove cancer while at the same
time preserving kidney function. I would use the British Association of Urological
Surgeons (BAUS) procedure specific consent form which explains the procedure, the
risks, the benefits and the alternatives. The procedure-specific complications include
the need to convert to open, conversion to a radical nephrectomy, need for a second
procedure or vascular intervention in the post-op period to control bleeding and chance
of a urine leak needing further intervention (ureteric stent insertion).
I would explain that the risk of local recurrence is about 8% and complications
(including bleeding and urinary leakage) are greater than with radical nephrectomy
(this is particularly so with larger tumours).

Q) What is Wunderlich syndrome?

A. Wunderlich syndrome (WS) is a rare condition characterised by a non-traumatic
spontaneous acute renal haemorrhage into the subcapsular and perirenal space. It is
characterised by Lenk’s triad: acute abdominal pain, mainly in the flank, palpable
mass and hypovoleamic shock. Renal angiomyolipoma (AML) is the most prevalent
cause, however malignant renal neoplasm, vascular disorders (vasculitis,
arteriosclerosis, rupture of a renal artery aneurysm), kidney infection, anticoagulant
therapy and undiagnosed blood dyscrasia must be ruled out. Treatment depends on
the clinical state of the patient, the degree of rupture of the kidney and the size of
the retroperitoneal bleeding. If the patient is responsive to resuscitation and the
haemorrhage is self-contained, a conservative approach may be adapted
with/without arteriography and embolisation, otherwise the patient may require an
emergency nephrectomy – if clinically indicated

Q) CT reveals a fatty lesion of less than 10 Hounsfield units in the upper pole of the
right kidney. What is the diagnosis and is this lesion associated with any inherited
conditions?
A. The diagnosis is an angiomyolipoma (AML). 80% of AML are sporadic with 4:1
female predominance. These typically present in middle age, 80% are right sided with
a recognised growth rate of 5% per year. The remainder are associated with tuberous
sclerosis (TS) which has a 2:1 female predominance. These tumours tend to be
smaller, bilateral and multicentric with a mean age of presentation at 30 years and a
 ARAB BOARD EXAM

growth rate of 20% per year. TS is an autosomal dominant disorder characterised by

mental retardation, epilepsy and adenoma sebaceum. There is incomplete penetrance
and half of patients with TS develop AMLs.
Q. The pain settles and the patient has a normal contralateral kidney and no
significant co-morbidity. What would your management plan be?
A. Four centimeters is usually recognised as a cut-off at which point an AML is more
likely to become symptomatic (though this is currently being debated with some
centres using 3 cm as a cut-off).
For most AMLs, active surveillance is considered as the first option. If the AML is more
than 4 cm and/or the patient is symptomatic at diagnosis then delaying intervention
increases the risk of spontaneous bleeding.

Q. What is your managemant in case of bleeding?

Women of child-bearing age, lipid-poor AMLs with significant vascularity or solid
components are also at increased risk of spontaneous haemorrhage. Selective
embolisation is usually considered as the first line of intervention especially in the
acute setting. This woman’s treatment options are selective arterial embolisation
(given the non-incidental presentation) or close radiological surveillance.
Significant increase in size or further haemorrhage would indicate the need for
intervention during follow-up. The volume of AML can be reduced by the mTOR
inhibitor everolimus,
 ARAB BOARD EXAM

UROLOGYLONG CASEMARKING SHEET

Examiner’s Name: Candidate’s Name:
Examiner’s Code: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail

History Taking Personal H

C/O & Present H 20 10 8 5

Past H& Family H

Examination General status

Vital Signs 20 10 8 5

General Regional exam

Systems review

Examination Exposure & position

Inspection & palpation 10 7 5 2.5

Local Percussion & Auscult.

(Abdomino-
pelvic) Special tests

DRE

External Genitalia

Identifying Main signs in this case:

Physical Signs
Pallor 10 7 5 2.5

Communication Introduction to patient

Skills
Attitude 10 7 5 2.5

Language
 ARAB BOARD EXAM

Interpretation & Summary of findings &

Management Diff. Dx for this case:
10 7 5 2.5

Main management
lines for this case:
20 15 8 5

Global Judgment

Serious Concern
 ARAB BOARD EXAM

LONG CASE

RENAL TUMOR (m RCCA)

Type of station: Longcase
Station Title:M RCCA
Reference: Modified from Egyptian BU, Champbell urology

Duration: 35 minutes

Contents
Aim/Focus of the station: ............................................................................ Error! Bookmark not defined.
Intended Learning Outcomes:..................................................................... Error! Bookmark not defined.
What does the author feel the candidate has to do to pass the station? ................................................. 3
Station setup .............................................................................................................................................. 4
Instructions to the real patient: ................................................................................................................. 5
Instructions to the candidate: .................................................................................................................... 6
Instructions to the assessors: ..................................................................................................................... 7
Calibration sheet: ....................................................................................................................................... 7
Questions to be asked to the candidate: .................................................... Error! Bookmark not defined.
Evaluation criteria ....................................................................................... Error! Bookmark not defined.
Marking Sheet: ............................................................................................ Error! Bookmark not defined.
APPENDIX 1: Arabic Translation .................................................................. Error! Bookmark not defined.
APPENDIX 2: Investigations Supplied .......................................................... Error! Bookmark not defined.
 ARAB BOARD EXAM

What does the author feel the candidate has to do to pass the
station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the
examiner.
G. Prioritize & order investigations needed to reach proper diagnosis
based on findings.
H. Propose appropriate plan for management.
 ARAB BOARD EXAM

Station setup
Clothing
• Hospital gown.

Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.
• KY gel for DRE.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Liver function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis with oral and IV contrast
• Chest X-ray.

OtherInvestigations:(given when requested by the candidate)

• Biopsy report
 ARAB BOARD EXAM

Instructions to the patient

(sheet to be completed based on real patient data):

Make sure you give the same information to all candidates in the same way.

If for any reason you made a mistake in the scenario given, repeat the mistake with the
rest of the candidates.

Name:
Age:
Gender:
Background information about the patient: "I work as a free worker ".
Specific instructions to the patient:
• You should be relaxed
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have right loin pain and haematuria ".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language:
• You are anxious and irritable.
 ARAB BOARD EXAM

Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination.

You will then present your findings and discuss the case with the
examiners

Duration of the station: 35 minute

Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes
 ARAB BOARD EXAM

Instructions to the assessors

Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
DRE/Bimanual exam: palpable renal mass (site, mobility),supra clavicular LAP
,Hepatomegally

This station tests the candidate’s ability to:to diagnose, investigate and manage
a case of renal cancer.
Duration of the station: 35 minutes:
Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed
history and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the examiner
provides the results to the candidate.

Discussion: Assessors will discuss the case with the candidate for 25 minutes.

Bell:
The bell rings at the end of the discussion time.The candidate has to leave the
station once the bell rings.
The Marking Sheet
It is recommended to fill the “History Taking” and “Examination” sections of the
marking sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing
the reason for failure. These comments will be used for providing the examinee
with feedback.
Serious concern: This section will only be filled if the performance of the
candidate is unacceptable with poor professional conduct and serious roughness
in handling the patient or there is serious ethical concern. Serious concern will be
investigated and may lead to legal action against the candidate including
reporting to the Egyptian Medical syndicate.

Station grading: average

 ARAB BOARD EXAM

Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade

descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

 ARAB BOARD EXAM

Suggested Questions

How commonly are paraneoplastic syndromes associated with RCC?

Paraneoplastic syndromes are seen concurrently with or develop in 30% of patients with RCC and
are more
common in patients with advanced disease.
❍ Describe Stauffer syndrome.
Reversible hepatic dysfunction in the absence of metastatic disease. Patients have abnormal liver
function tests,
fever, and hepatic necrosis, which typically resolve after nephrectomy. Persistence or recurrence
of disease is a poor
prognostic sign.

What is the role, if any, of cytoreductive nephrectomy for patients with metastatic RCC?
Cytoreductive nephrectomy can be completed prior to the systemic therapy, for palliation, in
conjunction with
resection of select solitary metastasis and prior to the initiation of systemic therapy. In fact,
randomized series have
demonstrated a signifi cant increase in survival in patients undergoing cytoreductive nephrectomy
prior to cytokine
therapy compared to patients not undergoing nephrectomy.
❍ What is the role of cytoreductive nephrectomy for patients who are to be treated with
tyrosine kinase inhibitors?
The role of cytoreductive nephrectomy prior to the use of tyrosine kinase inhibitors for metastatic
renal cancer
is unknown. The routine use of cytoreductive nephrectomy in this population is based on the data
evaluating
cytokine therapy and that the majority of patients enrolled in trials evaluating the effi cacy of
tyrosine kinase
inhibitors having undergone nephrectomy prior to treatment.
❍ Should solitary metastases in RCC be surgically resected if possible?
Yes. Metastasectomy has been associated with increased long-term survival. Nephrectomy in
conjunction with
resection of a solitary pulmonary metastasis has yielded 5-year survival rates of 30% to 35%.
Patients with CNS
metastasis represent a special case in which they are treated preferentially prior to cytoreductive
nephrectomy.
❍ List the various forms of systemic therapy for metastatic RCC.
Immunotherapy and targeted therapy. Since the introduction of targeted therapy, the use of
immunotherapy has
decreased signifi cantly. However, immunotherapy is the only form of therapy for metastatic RCC
that has been
associated with the potential for a complete treatment response.
❍ List the various forms of immunotherapy for metastatic RCC.
• Active specifi c immunotherapy: stimulation of T cell by immunization of patient with inactivated
autologous
tumor cells, limited proven benefi t.
• Adoptive immunotherapy: typically involves either in vitro or in vivo interleukin stimulation
(usually IL-2) of
peripheral lymphocytes (lymphocyte-activated killer cells or LAK cells), reported response rates up
to 20%.
 ARAB BOARD EXAM

• Cytokines: typically _-interferon or IL-2 therapy with direct or indirect cytotoxic effects on the
tumor, response
rates of 5% to 25%.
• Vaccines and stem cell transplantation techniques are being developedList the various forms
of targeted therapy for metastatic RCC.
Tyrosine kinase inhibitors, mTOR inhibitors, and vascular endothelial growth factor (VEGF)
monoclonal
antibodies.
❍ List the benefi ts of targeted therapy compared to immunotherapy.
Decreased toxicity, oral administration (tyrosine kinase and mTOR inhibitors), increased partial
response rate, and
disease stabilization compared to cytokine therapy.
❍ Which receptors are targeted by the tyrosine inhibitors approved for metastatic renal
cancer?
Multiple receptors are targeted by each agent; however, all inhibit the tyrosine kinase domains of
VEGF and
platelet-derived growth factor (PDGF) receptors.
❍ What is the proposed mechanism of action of tyrosine kinase inhibitors for treating
metastatic renal cancer?
Inhibition of angiogenesis and cellular proliferation of endothelial cells.
❍ What is the mechanism of action of bevacizumab?
Monoclonal antibody which binds to circulating VEGF.
❍ True/False: Bevacizumab is approved as monotherapy for metastatic RCC.
False. Bevacizumab is approved in combination with interferon-alpha for the treatment of
metastatic RCC.
❍ What is the proposed mechanism of action of mTOR inhibitors?
Decreased transcription of hypoxia-inducible factor, VEGF, and PDGF ligands.
❍ What are common side effects of mTOR inhibitors?
Anemia, fatigue, stomatitis, hyperglycemia, dyspnea, pain, infection, rash, edema, and
hyperlipidemia.
❍ What are common side effects of the oral tyrosine kinase inhibitors?
Hand-and-foot syndrome, rash, mucositis/stomatitis, hypertension, neutropenia,
hypophosphatemia, anemia,
fatigue, hypothyroidism, and diarrhea.
❍ True/False: Tyrosine kinase inhibitors have been associated with hypothyroidism during
the treatment of
metastatic renal cancer.
True. Hypothyroidism has been noted in 21% to 84% of patients treated with tyrosine kinase
inhibitors. It should
be treated with replacement therapy when noted.

What is the etiology of hypercalcemia in patients with RCC?

Hypercalcemia has been noted in approximately 15% of patients with RCC. Osteolytic bone
metastasis or
paraneoplastic syndrome frequently cause hypercalcemia. Stromal cells of RCC are thought to
produce a
parathyroid hormone-like peptide responsible for the paraneoplastic syndrome.
❍ List the levels of tumor thrombus associated with RCC.
• Level 0: limited to the renal vein.
• Level 1: extending into the inferior vena cava (IVC), _2 cm above the renal vein.
• Level 2: extending _2 cm above renal vein, but below the hepatic veins.
• Level 3: extending to the hepatic veins, but below the diaphragm.
• Level 4: extending above the diaphragm.
 ARAB BOARD EXAM

❍ What is the incidence of venous involvement by a tumor thrombus in RCC?

Renal vein only, up to 25%; inferior vena cava, 5% to 10%; atrial, 1%.
❍ What clinical fi ndings are suggestive of an increased risk for venous involvement by
RCC?
The presence of a varicocele, leg edema, deep vein thrombosis, recurrent pulmonary emboli, and
caput medusae
are reported manifestations but are found infrequently. A high index of suspicion for patients with
larger, centrally
located tumors is an important fi nding.

UROLOGYLONG CASEMARKING SHEET

Examiner’s Name: Candidate’s Name:
Examiner’s Code: Candidate’s Number:
 ARAB BOARD EXAM

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail

History Taking Personal H

C/O & Present H 20 10 8 5

Past H& Family H

Examination General status

Vital Signs 20 10 8 5

General Regional exam

Systems review

Examination Exposure & position

Inspection & palpation 10 7 5 2.5

Local Percussion & Auscult.

(Abdomino-
pelvic) Special tests

DRE

External Genitalia

Identifying Main signs in this case:

Physical Signs
Pallor ,weight 10 7 5 2.5
loss,supra clavicular
LAP

Communication Introduction to patient

Skills
Attitude 10 7 5 2.5

Language

Interpretation & Summary of findings &

 ARAB BOARD EXAM

Management Diff. Dx for this case: 10 7 5 2.5

Main management
lines for this case:
20 15 8 5

Global Judgment

Serious Concern
 ARAB BOARD EXAM

Clinical Skills Assessment (CSA)

LONG CASE

Ureteric Stone
Ureteroscopic Laser lithotripsy

Type of station: Longcase

Station Title:Ureteric stone
Reference:European Association of urologyguidelines
Duration:35 minutes

Aim/Focus of the station:

This station tests the candidate’s ability to diagnose, investigate and manage a case of urinary
bladder mass.

Page 1 of 15
 ARAB BOARD EXAM
UROLOGYLONG CASEMARKING SHEET
Examiner’s Name: Candidate’s Name:
Examiner’s Code: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H 20 10 8 5
Past H& Family H

Examination General status

Vital Signs 20 10 8 5
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation 10 7 5 2.5
Local Percussion & Auscult.
(Abdomino- Special tests
pelvic) DRE
External Genitalia
Identifying Main signs in this case:
Physical Signs Costo vertabral angle 10 7 5 2.5
tenderness

Communication Introduction to patient

Skills Attitude 10 7 5 2.5
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case: 10 7 5 2.5

Main management
lines for this case: 20 15 8 5

Global Judgment

Serious Concern

Page 2 of 15
 ARAB BOARD EXAM

What does the author feel the candidate has to do to pass the
station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on findings.
H. Propose appropriate plan for management.

Page 3 of 15
 ARAB BOARD EXAM

Station setup
Clothing
• Hospital gown.

Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Liver function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis with oral and IV contrast

OtherInvestigations:(given when requested by the candidate)

Page 4 of 15
 ARAB BOARD EXAM

Instructions to the patient

(Sheet to be completed based on real patient data):

Make sure you give the same information to all candidates in the same way.
If for any reason you made a mistake in the scenario given, repeat the mistake with the rest of the
candidates.
Name:
Age:
Gender:
Background information about the patient: "I work as a………..".
Specific instructions to the patient:
• You should be relaxed.
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have…".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• The professional diagnosis.
• Results of investigations.
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language: Normal

Page 5 of 15
 ARAB BOARD EXAM

Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination. You will then
present your findings and discuss the case with the examiners

Duration of the station: 35 minutes

Supervised history taking and examination 20 minutes

Sheet presentation & Discussion 15 minutes

Page 6 of 15
 ARAB BOARD EXAM

Instructions to the assessors:

Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
Bimanual exam
This station tests the candidate’s ability to:to diagnose, investigate and manage a case of
bladder cancer

Duration of the station: 35 minutes:

Supervised history taking and examination 20 minutes
Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed history
and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.
Timing for interaction:
When the candidate asks for laboratory or radiological investigation the examiner provides
the results to the candidate.
Discussion:
Assessors will discuss the case with the candidate for 25 minutes.
Bell:
The bell rings at the end of the discussion time.The candidate has to leave the station once
the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the marking
sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing the reason
for failure. These comments will be used for providing the examinee with feedback.
Serious concern: This section will only be filled if the performance of the candidate is
unacceptable with poor professional conduct and serious roughness in handling the patient
or there is serious ethical concern. Serious concern will be investigated and may lead to
legal action against the candidate including reporting to the Egyptian Medical syndicate.

Station grading: average

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 ARAB BOARD EXAM

Calibration sheet:

What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

Page 8 of 15
 ARAB BOARD EXAM

Questions to be asked to the candidate:

1) What is your provisional diagnosis?

2) How would you manage the patient with ureteric colic?

This man should be given parental NSAIDs to relieve his pain unless contraindicated (history of gastric ulcer, severe
asthma or renal impairment). A Cochrane review of the management of pain in acute renal colic was published in 2005
[27]. RCTs comparing any opioid with any NSAID, regardless of dose or route of administration were included. Twenty
trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically
significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled
although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were
significantly less likely to require rescue medication. The majority of trials showed a higher incidence of adverse events,
particularly vomiting, in patients treated with opioids (especially pethidine) [27]. NSAIDs are thought to work by
prostaglandin-induced afferent arteriole vasoconstriction of the glomerulus therefore reducing diuresis, oedema and
ureteric smooth muscle stimulation [28]. A further Cochrane review in 2015 was unable to determine which NSAID was
the most effective [29].

3) What investigations would you like to request to reach a diagnosis?

4) What is the imaging test of choice and why?

CT-KUB (non-contrast CT of kidneys, ureters and bladder) has now replaced IVU as the gold standard for investigating
acute flank pain. CT-KUB (sensitivity 94%–100% and specificity 92%–100%) is significantly more accurate at detecting
stones compared to IVU (sensitivity 51%–87% and specificity 92%–100%) with the added benefit of being able to
measure their diameter, skin to stone distance and Hounsfield unit (HU) density [30]. CT-KUB is also much quicker to
perform, does not require the delivery of intravenous contrast and if a stone is not detected it has the added benefit of
being able to diagnose other causes of abdominal pain. Radiation risk can be reduced to similar levels as IVU by low-
dose CT (3 mSv) with a recent meta-analysis of prospective studies a pooled sensitivity of 96.6% and specificity of
94.9% [31].

5) Which stones are not visible on CT-KUB and what is the benefit of performing the scan with
the patient in the prone position?

Ninety-nine per cent of stones in the urinary tract are visible on CT-KUB. Indinavir stones (HIV drug with poor
solubility and excessive excretion in urine leading to crystallisation) and pure matrix stones (consist of protein and
cellular debris) are the only two stones which are radiolucent on CT-KUB.
One of the most common sites for stones to become obstructed is at the vesicoureteric junction (VUJ). Scanning the
patients prone allows for clinicians to establish if the stone is still contained within the VUJ or if it has already
passed into the bladder. If it has passed into the bladder, then the stone will fall away from the VUJ on the prone CT.

6) What are the signs of obstruction on CT-KUB?

A. Hydronephrosis, increased renal size (nephromegaly), unilateral perinephric stranding, periureteric stranding and
ureteric wall oedema/soft tissue cuff/ring around stone (Rim sign).

Page 9 of 15
 ARAB BOARD EXAM

7)What is a Hounsfield unit? How can this property be utilised in the management of stone
Disease?

CT attenuation values (HU) have shown some promise in predicting stone composition which plays an important role in
helping clinicians determine the most effective treatment for an individual patient. Uric acid stones have a low
density (200–450 HUs) and can sometimes be successfully treated non-surgically with urine alkalinisation. Calcium
base stones, however, have a higher density (1000 + HUs) making them more resistant to ESWL and therefore more
likely to require surgical management. CT attenuation values priorto ESWL have been shown to help predict
treatment success (threshold of ≤815 HUs has significantly better stone clearance than ≥815 HUs) [34].

The HUs of common pure stones can be predicted by CT HUs during in vitro studies to an accuracy between 64% and
81% and usually fall within certain ranges (Table 1) [35]. The accuracy of HUs in clinical practice is much more
complicated and less reliable as factors such as stone size, accurate placement of area of interest (average HU) and mixed
stones (35%–65% of all stones) reduce its effectiveness. Dual-energy CT is a new technique which measures stone
attenuation much more accurately and has been shown in a recent meta-analysis to have a pooled sensitivity of 96% and
specificity of 99% at predicting uric acid stones [36].

Table 1 : The attenuation values of common stones during in

vitro studies
Houns_eld units Stone composition
200–450 Uric acid
600–900 Struvite
600–1100 Cystine
1200–1600 Calcium phosphate
1700–2800 Calcium monohydrate and
brushite
Adapted from Bellin MF et al. EurRadiol2004; 14(11): 2134–2140.

8)What is the recommendation for conservative treatment in ureteric stone?

A period of observation is therefore recommended by the 2017 EAU guidelines panel in patients with small
stones (<6 mm) who are fully informed and have no evidence of complications such as infection,
deteriorating renal failure or uncontrolled pain [8].
The EAU 2017 guideline panel have concluded that MET seems to be efficacious in patients with ureteric
stones with the greatest benefit in larger and more distal stones [8]. If considering offering MET, patients
should be informed that the evidence is controversial, its use is ‘off label’ and be made aware of the
potential side effects (low blood pressure, retrograde ejaculation and stuffy nose).
Finally, with regards to intervention, the stone-free (clearance) rates of ureteric stones when treated with
ESWL or with URS, the guidelines addressed proximal, mid and distal stones separately. The overall
stone-free figures, according to location and size.

9) What are the options for upper ureteric stones?

Briefly, for proximal ureteric stones, it appears that ESWL may be superior for stones <10 mm, but that URS
is better for stones >10 mm. In patients with distal ureteric stones, URS is considered superior irrespective
of size. Finally, for mid-ureteric stones the treatments are generally considered equivalent. Importantly, it
should be understood that the data from the guidelines have been based on the ‘index patient’, designed to
reflect the typical individual with a ureteric stone. The definition of an index patient is a non-pregnant
adult with a unilateral non-cystine/non-uric acid radiopaque ureteral stone without renal calculi requiring
therapy whose contralateral kidney functions normally and whose medical condition, body habitus, and
anatomy allow any one of the treatment options to be undertaken.

Page 10 of 15
 ARAB BOARD EXAM
10) While under observation, this patient develops a temperature of 39° Celsius. What is your further
management?
A. An infected obstructed system is a urological emergency and must be drained expeditiously after initial
resuscitation of the patient and administration of intravenous antibiotics according to local microbiology
department guidelines.
The question of whether to use nephrostomy tube drainage or pass a retrograde JJ stent under
anaesthesiacystoscopically has been addressed in two studies. Pearle et al. [45] compared the efficacy of
percutaneous nephrostomy with retrograde ureteral catheterisation for renal drainage in cases of
obstruction and infection associated with ureteral calculi. Forty-two patients presenting with obstructing
ureteral calculi and clinical signs of infection were randomised to nephrostomy or stenting. There was no
significant difference in the time to treatment between the two groups. Procedural and fluoroscopy times
were significantly shorter in the retrograde ureteral catheterisation group.
One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with
retrograde ureteral catheterisation. Time to normal temperature was 2.3 days in the percutaneous
nephrostomy and 2.6 in the retrograde ureteral catheterisation group. The authors concluded that stenting
and percutaneous nephrostomy both effectively relieved obstruction and infection due to ureteral calculi.
Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. The
decision of which mode of drainage to use may be based on logistical factors, surgeon preference and
stone characteristics.
In a similar study, Mokhmalji and co-workers [46] observed that those randomised to nephrostomy
tube drainage required antibiotics for a shorter time after drainage, and that this mode of drainage
appeared to be superior to stent insertion, especially in those with a high temperature, males and
juveniles. In addition, stent insertion was unsuccessful in 20% of cases, compared to 100% success
with percutaneous nephrostomy.

11) Describe how you would take informed consent for ureteroscopy.
A. Informed consent must include a discussion of available alternative treatment options, as described previously, the
intended benefit of the proposed procedure, and the potential complications, which are listed as follows with
approximate percentages in brackets, based on complications of 3000 semi-rigid ureteroscopies performed by
Geavlete et al. [47]:

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 ARAB BOARD EXAM

12) What are the indications for DJ placement following URS?

The EAU 2017 guidelines recommend JJ stent insertion in the following circumstances:
• Ureteric trauma during the procedure
• Residual stone fragments greater than 2 mm remaining in ureter
• Bleeding (potential for clot colic)
• Pregnancy
• If treating an impacted stone (usually ureter very oedematous at site of impaction)
• Prolonged manipulation within ureter, particularly upper third
• After flexible ureteroscopy and use of an access sheath
• All doubtful cases, to avoid stressful emergencies

Page 12 of 15
 ARAB BOARD EXAM

Evaluation criteria
Criteria of good performance Criteria of poor performance
• Communicate effectively with the patient. • Does not communicate effectively with the
• Clarifies reason for visit. patient.
• Correct, Thorough, Systematic and • Does not clarify reason for visit.
professional history taking and physical • Incorrect techniques.
examination. • Omits significant or important tests.
• Identifies correct physical signs. • Unsystematic.
• Does not find signs that are not present. • Hesitant and lacking in confidence.
• Construct a sensible differential diagnosis • Misses important physical signs.
including the correct one. • Finds signs that are not present.
• Order 3 relevant investigations. • Does not order the relevant investigations.
• Selects a sensible and appropriate • Poor differential diagnosis.
management plan. • Fails to consider the correct diagnosis.
• Treats patient respectfully and sensitively • Unfamiliar with correct management plan.
ensures comfort, safety and dignity. • Selects inappropriate management.
• Follow infection control procedures. • Causes patient physical or emotional
discomfort.
• Jeopardizes patient safety.

Page 13 of 15
 ‫‪ARAB BOARD EXAM‬‬

‫‪APPENDIX 1: Arabic Translation‬‬

‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺒﺄﻧﺘﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاءﻓﺤﺼﻜﺎﻣﻠﻠﻠﺒﻄﻦ واﻟﻤﺜﺎﻧﮫ‪.‬‬

‫اﻹﺳﻢ‪:‬‬
‫اﻟﻌﻤﺮ‪:‬‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪:‬‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي ‪".............................‬‬

‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬

‫"ﻋﻨﺪي اﻟﻢ ﻓﻲ اﻟﻜﻠﯿﺔ ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• اﻟﻤﻔﺮاس اﻟﺤﻠﺰوﻧﻲ واﻟﺴﻮﻧﺎر‬
‫• ﻧﻮع اﻟﺘﺪاﺧﻞ اﻟﺠﺮاﺣﻲ‪.‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬

‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬

‫أﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬

‫• ﻋﺎدي‬

‫‪Page 14 of 15‬‬
 ARAB BOARD EXAM

References:
8. European Association of Urology Guidelines on urolithiasis. 2017. http://uroweb.org/ guideline/urolithiasis/
27. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic.
Cochrane Database Syst Rev 2005; Apr 18(2): CD004137.
28. Teichman JMH. Acute renal colic from ureteral calculus.N Engl J Med 2004; 350(7): 684–693.
29. Afshar K, Jafari S, Marks AJ, Eftekhari A, MacNeily AE. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-
opioids for acute renal colic. Cochrane Database Syst Rev 2015; Jun 29(6): CD006027.
30. Worster A, Preyra I, Weaver B, Haines T. The accuracy of noncontrast helical computed tomography versus
intravenous pyelography in the diagnosis of suspected acute urolithiasis: A meta-analysis. Ann Emerg Med 2002;
40(3): 280–286.
31. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of urolithiasis: A
meta-analysis. AJR Am J Roentgenol2008; 191(2): 396–401.
32. Smith-Bindman R et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med
2014; 371(12): 1100–1110.
33. Heidenreich A, Desgrandschamps F, Terrier F. Modern approach of diagnosis and management of acute flank pain:
Review of all imaging modalities. EurUrol2002; 41(4): 351–362.
34. Nakasato T, Morita J, Ogawa Y. Evaluation of Hounsfield units as a predictive factor for the outcome of
extracorporeal shock wave lithotripsy and stone composition. Urolithiasis2015; 43(1): 69–75.
35. Bellin MF et al. Helical CT evaluation of the chemical composition of urinary tract calculi with a discriminant
analysis of CT-attenuation values and density.EurRadiol2004; 14(11): 2134–2140.
36. Zheng X, Liu Y, Li M, Wang Q, Song B. Dual-energy computed tomography for characterizing urinary calcified
calculi and uric acid calculi: A meta-analysis. Eur J Radiol2016; 85(10): 1843–1848.
37. Preminger GM et al. 2007 Guideline for the management of ureteral calculi. EurUrol2007; 52(6): 1610–1631.
38. Preminger GM et al. 2007 Guideline for the management of ureteral calculi. J Urol2007; 178(6): 2418–2434.
39. Skolarikos A, Laguna MP, Alivizatos G, Kural AR, de la Rosette JJ. The role for active monitoring in urinary stones:
A systematic review. J Endourol2010; 24(6): 923–930.
40. Furyk JS et al. Distal ureteric stones and tamsulosin: A double-blind, placebo-controlled, randomized, multicenter
trial. Ann Emerg Med 2016; 67(1): 86–95.e82.
41. Pickard R et al. Medical expulsive therapy in adults with ureteric colic: A multicentre, randomised, placebo-
controlled trial. Lancet (London, England) 2015; 386(9991): 341–349.
42. Dauw CA, Hollingsworth JM. Medical expulsive therapy: PRO position. Int J Surg2016; 36: 655–656.
43. Sur RL et al. Silodosin to facilitate passage of ureteral stones: A multi-institutional, randomized, double-blinded,
placebo-controlled trial. EurUrol2015; 67(5): 959–964.
44. Hollingsworth JM et al. Alpha blockers for treatment of ureteric stones: Systematic review and meta-analysis. The
BMJ 2016; 355: i6112.
45. Pearle MS et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due
to ureteral calculi. J Urol1998; 160(4): 1260–1264.
46. Mokhmalji H, Braun PM, Martinez Portillo FJ, Siegsmund M, Alken P, Kohrmann KU. Percutaneous nephrostomy
versus ureteral stents for diversion of hydronephrosis caused by stones: A prospective, randomized clinical trial. J
Urol2001; 165(4): 1088–1092.
47. Geavlete P, Georgescu D, Nita G, Mirciulescu V, Cauni V. Complications of 2735 retrograde
semirigidureteroscopy procedures: A single-center experience. J Endourol2006; 20(3): 179–185.

Page 15 of 15
 ARAB BOARD EXAM

LONG CASE

BLADDER TUMOR
&
Bladder sustitution
 ARAB BOARD EXAM

Type of station: Longcase

Station Title:Bladder Tumors
Reference: Modified from Egyptian BU

Duration:50 minutes

Contents
Aim/Focus of the station: ............................................................................ Error! Bookmark not defined.
Intended Learning Outcomes:..................................................................... Error! Bookmark not defined.
What does the author feel the candidate has to do to pass the station? ................................................. 3
Station setup .............................................................................................................................................. 4
Instructions to the real patient: ................................................................................................................. 5
Instructions to the candidate: .................................................................................................................... 6
Instructions to the assessors: ..................................................................................................................... 7
Calibration sheet: ....................................................................................................................................... 9
Questions to be asked to the candidate: .................................................... Error! Bookmark not defined.
Evaluation criteria ....................................................................................... Error! Bookmark not defined.
Marking Sheet: ............................................................................................ Error! Bookmark not defined.
APPENDIX 1: Arabic Translation .................................................................. Error! Bookmark not defined.
APPENDIX 2: Investigations Supplied .......................................................... Error! Bookmark not defined.
 ARAB BOARD EXAM

Questions: What does the author feel the candidate has to do to pass
the station?

A. Take history in appropriate way.

B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination& other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on
findings.
H. Propose appropriate plan for management.
 ARAB BOARD EXAM

Station setup
Clothing
• Hospital gown.

Set pieces:
• 3 chairs and a desk.
• Blue pen and white paper sheets
• Examination bed & white sheet.
• Stethoscope&Sphygmomanometer.
• Examination gloves.
• Disinfectant.
• KY gel for DRE.

LaboratoryInvestigations:(given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function tests
• Liver function tests
• Complete blood picture
• Coagulation profile

RadiologicalInvestigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography.
• CT abdomen and pelvis with oral and IV contrast
• Chest X-ray.

OtherInvestigations:(given when requested by the candidate)

• Biopsy report
 ARAB BOARD EXAM

Instructions to the patient(sheet to be completed based on real patient

data):

Make sure you give the same information to all candidates in the same way.

If for any reason you made a mistake in the scenario given, repeat the mistake with the
rest of the candidates.

Name:
Age:
Gender:
Background information about the patient: "I work as a………..".
Specific instructions to the patient:
• You should be relaxed, accommodating specially for the DRE
• Candidate should be able to perform a full clinical examination.
Opening statement:"I have…".
Information to be given freely without asking:
• You have ………….since ……. weeks.
Don’t reveal the following unless you are asked:
• 3 year history of weak stream, hesitancy, incomplete emptying, mild urgency,
nocturia twice, no hematuria & no dysuria.
• I underwent a cystoscopy and biopsy.
• …
Past History:
• …
Family History:
• …

Questions to ask to the doctor if appropriate& timing of those questions:

Behavior/Body language:
• You are anxious and irritable.
 ARAB BOARD EXAM

Instructions to the candidate:

In this station you are aUrologist working in a Hospital

You will take a complete history and perform a full examination. You will
then present your findings and discuss the case with the examiners

Duration of the station: 50 minutes

Supervised history taking and examination 25 minutes

Free time to prepare notes 5 minutes

Sheet presentation & Discussion 20 minutes

 ARAB BOARD EXAM

Instructions to the assessors:

Patient data:name, age with bladder mass
Patient data (to be completed based on real patient data):
History:
General examination:
Local examination:
DRE/Bimanual exam: palpable bladder mass (site, mobility)

This station tests the candidate’s ability to:to diagnose, investigate and manage
a case of bladder cancer

Duration of the station: 50 minutes:

Supervised history taking and examination 20 minutes

Free time to prepare notes 5 minutes

Sheet presentation & Discussion 20 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a detailed
history and performing general and local examination.
Interaction:
The examiners are not expected to interfere during history taking / examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation the examiner
provides the results to the candidate.

Discussion:
Assessors will discuss the case with the candidate for 25 minutes.

Bell:
The bell rings at the end of the discussion time.The candidate has to leave the
station once the bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination” sections of the
marking sheet as the task is being performed by the candidate
You must provide comments in case the examinee is awarded a “fail” describing
the reason for failure. These comments will be used for providing the examinee
with feedback.
 ARAB BOARD EXAM

Serious concern: This section will only be filled if the performance of the
candidate is unacceptable with poor professional conduct and serious roughness
in handling the patient or there is serious ethical concern. Serious concern will be
investigated and may lead to legal action against the candidate including
reporting to the Egyptian Medical syndicate.

Station grading: average

 ARAB BOARD EXAM

Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?

A. Communicate effectively with the patient (based on the associated grade

descriptors)

B. Comment on the history of the patient

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

H. Give a plan for suggested management system

 ARAB BOARD EXAM

1- How you prepare this patient for radical cystectomy ?

History
Physical examination
Laboratory investigations….
Imaging and staging…..
MDT discussion

2- How you perform bowel preparation, what is the clinical evidence of

its usage?

There are two aspects to bowel preparation: mechanical and antibiotic.

Both methods attempt to reduce the complication rate from intestinal
surgery. Mechanical preparation reduces the amount of feces, whereas
antibiotic preparation reduces the bacterial count. The bacterial flora in the
bowel consists of aerobic organisms, the most common of which are
Escherichia coli and Enterococcus faecalis, and anaerobic organisms, the
most common of which are Bacteroides species and Clostridium species.
researchers found that there was no support for the conclusion that
mechanical bowel preparation reduces anastomotic leak rates and other
complications in elective open colon surgery.

3- What is the Enhanced recovery after surgery (ERAS) protocols:

Enhanced recovery programs (ERPs) or “fast-track” programs have become an important
focus of perioperative management after colorectal surgery, vascular surgery, thoracic
surgery and more recently radical cystectomy. These programs attempt to modify the
physiological and psychological responses to major surgery, and have been shown to lead
to a reduction in complications and hospital stay, improvements in cardiopulmonary
function, earlier return of bowel function and earlier resumption of normal activities. The
key principles of the ERAS protocol include pre-operative counseling, preoperative
nutrition, avoidance of perioperative fasting and carbohydrate loading up to 2 hours
preoperatively, standardized anesthetic and analgesic regimens (epidural and non-opiod
analgesia) and early mobilization.
 ARAB BOARD EXAM

4- What is the critical issue that can determine the success of orthotopic
bladder urinary diversion?
Appropriate patient selection is critical to the success of orthotopic diversions. It
should not compromise the cancer control of a potentially curative surgery, and it
is contraindicated if the urethra is non-functional or involved with tumour. Like
continent cutaneous diversions, orthotopicneobladders require active patient
participation to ensure proper maintenance of the reservoir. If medical or psychosocial
issues preclude this level of cooperation the patient may be better served by an
incontinent ileal loop diversion.
Patient selections:

1-Age: age alone is not a contraindication for continent diversion and options should be
considered for each patient on the basis of other factors.

2-Renal Function As a general rule, a serum creatinine level of less than 1.7 to 2.2
mg/dL(150 to 200 µmol/L) or an estimated creatinine clearance of greater than 35 to 40
mL/min is recommended.

3-Body Habitus: In fact, obese patients may be better served with orthotopic diversion
because of the difficulty constructing functional conduit stomas on their abdomens.

4-Manual Dexterity and Willingness to Do Self-Catheterization

5-Prior Pelvic Radiation.

6-Prior Prostate Surgeryor Bowel Resection.

5- What are the basic principles of this type of diversion?What are the types
of bladder substitutes?
Three Basic Principles of Orthotopic Neobladder Construction:

1-Patient must have adequate external sphincter function to maintain continence.

2-Bowel segment should be detubularized and reconstructed into a spherical shape.
3-Ultimate storage volume should be at least 400 to 500 mL at low pressure.

Types:

1-Ileal Reservoirs:

A. Camey II: The ileal loop is folded three times (Z shaped): the ureters are
implanted using a Le Duc antireflux technique.
 ARAB BOARD EXAM

B. IlealNeobladder (Hautmann Pouch): M or W configuration. Le Duc technique

or direct implantation, are stented.

C.OrthotopicKockIleal Reservoir (“Hemi-Kock):

D. StuderIleal Bladder

E.Serous-Lined Extramural Tunne - Ghoneim

F. T Pouch IlealNeobladder

2- Colon and Iliocolonic Pouches

A.Orthotopic Mainz Pouch (Mainz III)

B.Ileocolonic (Le Bag) Pouch

C.Right Colon Pouch

D. Sigmoid Pouch

5- What the advantage and dis advantage of using stomach for orthotopic bladder?

The primary advantage of gastric segments is that the gastric mucosa excretes chloride and hydrogen
ions, effectively reversing the acidosis of renal insufficiency. The latter is worsened with a pouch
made of small or large bowel. The excreted acid from a stomach segment can also reduce the risk of
bacterial colonization, and there is less mucous production. However, the disadvantage of using
stomach is that some patients will suffer from dysuria or hematuria from the excreted acid.

6- A- List three types of uretero- intestinal anastomosis?

A.Combined Technique of Leadbetter and Clarke:

B.Transcolonic technique of Goodwin.

C.Bricker ureterointestinal anastomosis.

D.Wallace ureterointestinal anastomosis.

B-Describe the surgical principels of Wallace type?

Wallace type:Both ureters are spatulated and laid adjacent to each other. The apex of one
ureter is sutured to the apex of the other ureter with 5-0 polydioxanone sutures (PDS). The
posterior medial walls of both ureters are then sutured together with interrupted or running
 ARAB BOARD EXAM

5-0 PDS, the knots tied to the outside. The lateral ureteral walls are then sutured to the
intestine.

7- Discuss in brief the; POST OPERATIVE CARE OF BLADDER SUBSTITUTE?

1- The suprapubic and transurethral catheters need to be flushed and aspirated with saline 0.9%
every 6 h to prevent any catheter blockages which may lead to rupture of the bladder
substitute.
2- Total parenteral nutrition is commenced on the first day and stopped as soon as oral intake is
established. To prevent abdominal bloating and assist bowel function, parasympathomimetic
medications (e.g. neostigmine methylsulphate 3–6& 0.5 mg subcutaneously) is started 3 days
after surgery.

3-The exteriorized ureteric catheters can also be manually irrigated if there is suspected blockage
and ureteric obstruction. The ureteric catheters are removed sequentially at 5–8 days after
surgery.

4- Patients will complain of lethargy, fatigue, nausea, vomiting and anorexia associated with
epigastric burning. The acidosis is monitored using the base excess estimated by venous blood
gas analysis, initially every 2–3 days and later at greater intervals, depending on the blood gas
values. The base excess needs to be corrected if it is negative. Virtually all patients will
require sodium bicarbonate treatment (2–6 g/day) which can be stopped 2–6 weeks later. A
salt–losing syndrome by the bladder substitute can cause hypovolaemia, dehydration and a loss
of body weight.

5- Patients should therefore consume 2–3 L of fluids per day, which is supplemented with
increased salt intake in their diet; body weight should also be monitored daily. Voiding occurs
initially while seated, every 2 h during the day and 3-h with the help of an alarm clock at night.
Voiding occurs by relaxing the pelvic floor, followed by slight abdominal straining. Any UTI
or bacteriuria is treated. The voiding interval is increased stepwise from 2 to 4 h, in hourly
steps, provided the findings from blood gas analysis are compensated. The patient has to
prolong the interval to passively increase bladder capacity to a desired volume of 500 mL even
if incontinent. With an increase in reservoir capacity it is easier for the patient to achieve
continence. Laplace's law (pressure = tension/radius) states that the intravesical pressure will
decrease with an increase in reservoir radius, resulting in a low-pressure system.

8- What about the Management of post-operative bladder dysfunction?The time to

recovering continence depends on surgical technique, with nerve preservation to the urethra
and pelvic floor, good counselling with daily vigilant sphincter training, and the age of the
patient. Effective sphincter training is taught by using a digital rectal examination and helping
the patient to contract only the anal sphincter. The patient receives direct feedback from the
examiner about the adequacy of the contraction and is subsequently ensured of satisfactorily
training the sphincter in the future. This comprises contraction 10 times/h, maintaining the
contraction for 6 s and continued daily once continence is achieved.

8- What are the most common complications of this type of diversion?

 ARAB BOARD EXAM

1- Un drained leak:an attempt at percutaneous drainage and/or bilateral nephrostomy

tube placement is preferable to open surgical repair.
2- Cardiovascular problems: common to patients in this age group.

3- The primary late complications: of orthotopic diversion that may be related to the
diversion itself include urinary tract infection, ureteroileal or afferent limb obstruction,
urethral stricture, upper tract and pouch stones, and incontinence. Most of these
complications can be managed by endoscopic procedures and rarely require open surgical
revision

Pouch perforation: is rare in continent diversion in general, especially in orthotopic

diversion because outlet resistance is usually low. The risk may be increased in patients
who have had previous radiation therapy. It is a potentially life-threatening complication
when it.

Obstruction from an anti- reflux valve: has been seen in both hemi-Kock pouches and
in the extraserosal tunneled afferent limb of the T pouch). These may be clinically silent
until the patient presents with bilateral hydronephrosis or even renal failure. Diagnosis
may be suspected on CT or ultrasound and can be confirmed on retrograde pyelography.
In both types of diversion these may be managed by endoscopic incision of the valve
mechanism.

Pouch-vaginal fistula: is a unique complication of orthotopicneobladder in women that

can be quite difficult to resolve. Repair may be attempted transvaginally, though reported
success varies.

Repair may ultimately require transabdominal exploration or even conversion to a

cutanous form of diversion.
ARAB BOARD EXAM
 ARAB EXAM
Type of station: Long Case
Station Title: Urinary incontinence
Reference:Campbell urology
Duration:35 minutes

Contents
Aim/Focus of the station: .................................................. Error! Bookmark not defined.
Intended Learning Outcomes (please refer to the curriculum ILOs): ..... Error! Bookmark
not defined.
What does the author feel the candidate has to do to pass the station? .......................2
Station setup ..................................................................... Error! Bookmark not defined.
Instructions to the role player/patient: ............................ Error! Bookmark not defined.
Instructions to the candidate: .......................................................................................... 5
Instructions to the assessors: ........................................................................................... 5
Calibration sheet: ............................................................................................................. 7
Questions to be asked to the candidate: ......................................................................... 7
Evaluation criteria ............................................................. Error! Bookmark not defined.
APPENDIX 2: Investigations Supplied ................................ Error! Bookmark not defined.
 ARAB EXAM

Aim/Focus of the station:

This station tests the ability of the candidate to diagnose, investigate and manage a
case of female mixed urinary incontinence.

Candidate has to do to pass the station?

A. Take history in appropriate way.
B. Communicate effectively with the patient.
C. Conduct general examination.
D. Conduct local examination & other relevant examination.
E. Summarize findings to the examiner.
F. Provide a provisional diagnosis and differential diagnoses to the examiner.
G. Prioritize & order investigations needed to reach proper diagnosis based on
findings.
H. Propose appropriate plan for management.
 ARAB EXAM

Station setup
Clothing & props
• Hospital gown
• Wheel chair

Set pieces:
• 3 chairs and a desk
• Blue pen
• Examination bed & white sheet
• Examination gloves
• Lubricating gel
• Disinfectant
• Neurologic examination tools including: Hammer, Pins.

Laboratory Investigations: (given when requested by the candidate)

• Urine analysis, urine culture & sensitivity
• Kidney function test

Radiological Investigations: (given when requested by the candidate)

• Pelvi-abdominal ultrasonography
• Urodynamic test
 ARAB EXAM

Instruction to the role player /Patient

Make sure you give the same information to all candidates in the same way.
If for any reason you made a mistake in the scenario given, repeat the mistake with
the rest of the candidates.

Name:
Age:
Gender:
Background information about the patient:
Specific instructions to the patient:
Opening statement: "I cannot withhold my urine"
Information to be given freely without asking:

Don’t reveal the following unless you are asked:

Past History:
Family History:

Questions to ask to the doctor if appropriate & timing of those

questions:

Behavior/Body language:
 ARAB EXAM

Instructions to the candidate:

In this station you are an Urologist working in a Urology clinic

Duration of the station: 35 minutes

Supervised history taking and examination 20 minutes
Sheet presentation & Discussion 15 minutes

Instructions to the assessors:

Patient data:
History:

General examination:

Local examination:

This station tests the candidate’s ability to: diagnose, investigate and
manage a case of neuropathic bladder.

Duration of the station: 35 minutes

Supervised history taking and examination 20 minutes
Sheet presentation & Discussion 15 minutes

Conduct of the assessors:

Observation:
The examiners are expected to observe the candidate while he’s taking a
detailed history and performing general and local examination.

Interaction:
The examiners are not expected to interfere during history taking /
examination.

Timing for interaction:

When the candidate asks for laboratory or radiological investigation
the examiner provides the results to the candidate.

Discussion:
 ARAB EXAM
Assessors will discuss the case with the candidate for 25 minutes &
inform the candidate that he has 10 questions to answer in 25
min.

Bell:
The bell rings at the end of the examination time (30 min) and at the
end of discussion time. The candidate has to leave the station once
the 2nd bell rings.

The Marking Sheet

It is recommended to fill the “History Taking” and “Examination”
sections of the marking sheet as the task is being performed by the
candidate
You must provide comments in case the examinee is awarded a “fail”
describing the reason for failure. These comments will be used for
providing the examinee with feedback.

Station grading: average

 ARAB EXAM

Calibration sheet:
What do the examiners feel the candidate has to do to pass the station?
A. Communicate effectively with the patient (based on the associated grade
descriptors)

B. Comment on the history of the patient

History of present illness and all previous medications and interventions

Number of padsHistory of other body systems that have been affected

C. Comment on general examination on the patient

D. Comment on local examination and other relevant examination

E. Summarizing findings to the examiner

F. Provide a provisional diagnosis & Make appropriate differential diagnosis.

G. Ask for the appropriate investigations according to the priority

VCUG ,Urodynamics

H. Give a plan for suggested management

Questions to be asked to the candidate:

1) What's your provisional diagnosis?
(Please provide a guide to the answer and relevant references)
 ARAB EXAM

2) What are the types of urine incontinence ?

• Stress
• Urge
• Mixed
• Nocturnal Enuresis
• Overflow incontinence
• Total incontinence

3) How can you differentiate between the types of incontinence by investigations

…?
a. Ultrasound for residual urine
b. VCUG
c. Urodynamics

4) What is the treatment options?

5) What are the types & side-effects of anti-cholinergics?
6) What is the difference between ALPP & DLPP?
7) What is the significance of DLPP?
8) What is the technique of Sling operation ?
9) What are the types of bladder augmentation?
10) What are the causes of acute transient urinary retention?
 ARAB EXAM
UROLOGY LONG CASE MARKING SHEET
Examiner’s Name: Examiner’s Code:
Candidate’s Name: Candidate’s Number:

Performance Items Clear Marginal Marginal Clear Fail Comment

Area Pass Pass Fail
History Taking Personal H
C/O & Present H 25 15 10 5
Past H & Family H

Examination General status

Vital Signs 20 10 8 5
General Regional exam
Systems review
Examination Exposure & position
Inspection & palpation 10 7 5 2.5
Local Percussion &Auscult.
(Abdomino- Special tests
pelvic) DRE / PV / Bimanual
External Genitalia
Identifying Main signs in this case:
Physical Signs Q tip test 10 7 5 2.5
Cough test

Overall Clinical Examination

Communication Introduction to patient

Skills Attitude 10 7 5 2.5
Language

Interpretation & Summary of findings &

Management Diff. Dx for this case: 10 7 5 2.5

Main management
lines for this case: 20 10 8 5

Overall Interpretation & Management

Global Judgment

Serious Concern
 ‫‪ARAB EXAM‬‬
‫‪APPENDIX 1: Arabic Translation‬‬
‫ﺗﻌﻠﯿﻤﺎت ﻟﻠﻤﺮﯾﺾ‪:‬‬
‫ﺗﺄﻛﺪ ﻣﻦ إﻋﻄﺎء ﻧﻔﺲ اﻟﻤﻌﻠﻮﻣﺎت ﻟﺠﻤﯿﻊ اﻟﻤﺮﺷﺤﯿﻦ ﻓﻲ ﻧﻔﺲ اﻟﻄﺮﯾﻖ‪.‬‬
‫إذا ﺣﺪث ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب أﻧﻚ ارﺗﻜﺐ ﺧﻄﺄ ﻓﻲ ﺳﯿﻨﺎرﯾﻮ ﻣﻌﯿﻦ ﻓﻜﺮر ھﺬا اﻟﺨﻄﺄ ﻣﻊ ﺑﻘﯿﺔ اﻟﻄﻠﺒﺔ‪.‬‬
‫ﯾﺠﺒﺄﻧﺘﻤﻜﻦ اﻟﻄﺎﻟﺐ ﻣﻦ إﺟﺮاءﻓﺤﺼﻜﺎﻣﻞ‬
‫اﻹﺳﻢ‪... :‬‬
‫اﻟﻌﻤﺮ‪ ...:‬ﻋﺎﻣﺎ‬
‫اﻟﺨﻠﻔﯿﺔ اﻹﺟﺘﻤﺎﻋﯿﺔ‪:‬‬
‫اﻟﻌﺒﺎرة اﻹﻓﺘﺘﺎﺣﯿﺔ‪:‬‬
‫"ﻋﻨﺪي ‪"...‬‬
‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮب إﻋﻄﺎءھﺎ ﻟﻠﻄﺒﯿﺐ ﺑﺪون اﻟﺤﺎﺟﺔ ﻟﻠﺴﺆال‪:‬‬
‫"ﻋﻨﺪي ‪ ...‬ﻣﻦ‪"...‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﻌﻄﻰ ﻟﻠﻄﺒﯿﺐ ﻋﻨﺪ اﻟﺴﺆال ﻋﻨﮭﺎ ﻓﻘﻂ‪:‬‬

‫• ‪...‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ اﻟﺴﺎﺑﻖ‪:‬‬
‫• ‪...‬‬
‫اﻟﺘﺎرﯾﺦ اﻟﻤﺮﺿﻲ ﻟﻠﻌﺎﺋﻠﺔ‪:‬‬
‫• ‪...‬‬
‫أﺳﺌﻠﺔ ﻣﻄﻠﻮب ﺳﺆاﻟﮭﺎ ﻟﻠﻄﺒﯿﺐ إذا ﺳﻤﺢ اﻟﺤﻮار ﺑﺬﻟﻚ‪:‬‬
‫• ھﻞ اﻟﻌﻼج ﻣﻜﻠﻒ؟‬
‫• ‪...‬‬
‫اﺳﻠﻮب اﻟﺤﻮار و ﻟﻐﺔ اﻟﺠﺴﺪ‪:‬‬
‫• ﺗﺒﺪو ﻗﻠﻖ و ﻣﺘﻮﺗﺮ‬