Chap 1 Frcs Urology

MCQs for the FRCS(Urol)
and Postgraduate Urology

Examinations
MCQs for the FRCS(Urol)
and Postgraduate Urology
Examinations
Edited by
Manit Arya
MBChB, FRCS, MD(Res), FRCS(Urol)
Taimur T. Shah
MBBS, BSc(Hons), FRCS(Urol)
Jas S. Kalsi
MBBS, BSc(Hons), MD(Res), MRCS(Eng), FRCS(Urol)
Herman S. Fernando
MBBS, MS, DNB, MRCSEd, MD, FRCS(Urol), FEBU
Iqbal S. Shergill
MBBS, BSc(Hons), MRCS, FRCS(Urol), FEBU
Asif Muneer
BSc(Hons), MBChB, MD, FRCSEd, FRCS(Urol)
Hashim U. Ahmed
FRCS(Urol), PhD, BM, BCh, MA
First edition published 2020
by CRC Press
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Library of Congress Cataloging‑in‑Publication Data
Names: Arya, M. (Manit), editor.

Title: MCQs for the FRCS(Urol) and postgraduate urology examinations /
edited by Manit Arya [and six others].
Description: First edition. | Boca Raton : CRC Press, 2020. | Includes
bibliographical references and index. | Summary: “This book provides a
selection of representative MCQs together with a detailed explanation of
each answer covering the topic in depth. Each chapter has been written
by experienced Urological surgeons who have already been successful in
passing the examination. In addition to the FRCS(Urol) examination MCQs
form the basis of equivalent postgraduate Urological examinations
internationally and the scope of this book will be an invaluable
addition to individuals sitting the FEBU and similar exams in the USA,
Australia and Asian countries. Established consultants may also find the
text useful as a ‘refresher’ in areas outside their subspecialist
interest”-- Provided by publisher.
Identifiers: LCCN 2020004716 (print) | LCCN 2020004717 (ebook) | ISBN
9780367076184 (paperback) | ISBN 9780429021633 (ebook)
Subjects: MESH: Urologic Diseases | Urogenital Neoplasms | Examination
Questions
Classification: LCC RC871 (print) | LCC RC871 (ebook) | NLM WJ 18.2 |
DDC 616.60076--dc23
LC record available at https://lccn.loc.gov/2020004716
LC ebook record available at https://lccn.loc.gov/2020004717
ISBN: 9780367076184 (pbk)

ISBN: 9780429021633 (ebk)
Typeset in Rotis
by Lumina Datamatics Limited
Contents
Editorsvii
Contributorsix
Introductionxiii
CHAPTER 1: ANATOMY & EMBRYOLOGY 1

Ali Tasleem and Adam Alleemudder
CHAPTER 2: RENAL PATHOPHYSIOLOGY 19

Herman S. Fernando, Mohamed Yehia Abdallah and Iqbal S. Shergill
CHAPTER 3: BASIC SCIENCE AND MOLECULAR ONCOLOGY 31

Paul Cleaveland, Vijay Sangar and Noel Clarke
CHAPTER 4: STATISTICS, RESEARCH AND GOVERNANCE 41

Hamid Abboudi, Erik Mayer and Justin Vale
CHAPTER 5: IMAGING AND PRINCIPLES OF URO-RADIOLOGY 49

Anuj Goyal, Beth Hickerton and Rebecca Tregunna
CHAPTER 6: PROSTATE CANCER 63

Simon R. J. Bott and Amr Emara
CHAPTER 7: BLADDER CANCER 71

Vineet Agrawal, Lyndon Gommersall and David Mak
CHAPTER 8: RENAL CANCER 87

Nilay Patel (deceased), Vinodh Murali and David Cranston
CHAPTER 9: TESTICULAR CANCER 107

Nkwam Nkwam, Chitranjan J. Shukla, David A. Manson-Bahr, Taimur T. Shah
and Farooq Khan
CHAPTER 10: PENILE CANCER 119

Hussain M. Alnajjar and Asif Muneer
CHAPTER 11: ANDROLOGY 127

Rozh Jalil and Jas S. Kalsi
CHAPTER 12: BENIGN PROSTATIC HYPERPLASIA (BPH) AND LOWER

URINARY TRACT SYMPTOMS (LUTS) 139
Hamid Abboudi, Jas S. Kalsi and Tev Aho
CHAPTER 13: FEMALE AND FUNCTIONAL UROLOGY 147

Angela Cottrell and Hashim Hashim
CHAPTER 14: UROLOGICAL TRAUMA 159

Davendra M. Sharma, Sanjay Agarwal and Shyam Matanhelia
vi Contents
CHAPTER 15: NEUROUROLOGY 163

Tina Rashid and Rizwan Hamid
CHAPTER 16: UROLITHIASIS 169

Thomas Johnston, James Armitage and Oliver Wiseman
CHAPTER 17: URINARY TRACT INFECTIONS (UTI) 195

Nish Bedi, Ali Omar and Jas S. Kalsi
CHAPTER 18: PAEDIATRIC UROLOGY 207

Jemma Hale and Arash K. Taghizadeh
Index221
Editors
Manit Arya is a Consultant Urological Surgeon at Imperial College NHS Trust London
(Charing Cross Hospital) and University College Hospital, London. His research interests include
investigating the molecular basis of prostate cancer – he has been awarded a MD Higher
Research degree from the University of London in this field. He has published extensively in
peer-reviewed journals particularly in the field of prostate cancer and is an editor of 10 text-
books. He is a Principal Investigator of several National Clinical Trials involving focal therapies
(cryotherapy and HIFU) for prostate cancer.
Taimur T. Shah is a final year trainee in London who has a sub-specialist interest in imaging,
focal and radical therapy for prostate cancer and is involved in clinical trials for primary, meta-
static and radio-recurrent prostate cancer. He is a member of the Imperial Prostate (IP) Research
Group at Imperial College London (ICL) and also vice chair of the British Urology Researchers in
Surgical Training (BURST) research collaborative.
Jas S. Kalsi is a Consultant Urological Surgeon and Andrologist at Imperial College in London
and at Frimley Health in Surrey and Berkshire. He runs a regional andrology service based at
Charing Cross Hospital and at Wexham Park. He is currently a clinical lead and clinical gov-
ernance lead at Wexham Park and Heatherwood Hospitals. He is actively involved in education
and is a national trainer for holmium laser enucleation of the prostate (HoLEP) in the UK. He has
been a Foundation Training Programme director and educational supervisor for 5 years for the
Oxford Deanery. He is a member of the urology STC in North Thames. He is on the Trust patient
safety and consent committee and has a commitment to patient safety and governance. His
main clinical interests include andrology (Peyronie’s disease, male factor infertility and severe
ED) and the management of large and complex benign prostates including HoLEP surgery.
Herman S. Fernando is a Consultant Urological Surgeon at University Hospital of North Midlands
NHS Trust and an Honorary Clinical Lecturer at Keele University. He was trained as a Surgeon in
India and subsequently did basic science research on prostate cancer at Cardiff University. He has
published papers in high impact journals and is actively involved in teaching, assessments, stan-
dard setting and examinations for various regional and national institutions. He is the winner of
the BAUS Silver Cystoscope award for the Best Trainer in UK in 2019. His main clinical areas of
interest are Robotic/Laparoscopic Upper Tract Oncology and Stone Diseases.
Iqbal S. Shergill is a Consultant Urological Surgeon in Wrexham Maelor Hospital, Betsi
Cadwaladr University Health Board, Wales; Professor of Urological Innovation at Glyndwr
University, Wrexham and Clinical Director of the North Wales Clinical Research Centre,
Wrexham; Honorary Senior Lecturer at Manchester Medical School, The University of
Manchester; Honorary Senior Lecturer in the Division of Biological Sciences, University of
Chester; Honorary Senior Lecturer in the Division of Medical Sciences, Bangor University; and
Honorary Clinical Teacher at Cardiff University School of Medicine, Wales. He has an active
interest in teaching, education and research. He has been an Assigned Educational Supervisor
for Urology trainees, Lecturer on Core Urology Course, Panellist at National Selection for
Urology Training and is currently Course Director of Rapid Revision Course for FRCS(Urol).
He has been on the Executive Committee for Academic Urology (BAUS) and Clinical Director at
the North Wales and North West Urological Research Centre.
Asif Muneer is a Consultant Urological Surgeon and Andrologist based at University College
London Hospital, UK and Hon Associate Professor at UCL. Having completed his medical degree
(MD) at UCL, he went on to higher surgical training in Oxford. He has published widely on all
aspects of urology with his main interest in andrology and has also edited the Textbook of Penile
viii Editors
Cancer, Atlas of Male Genitourethral Surgery and Prosthetic Surgery in Urology. He has lectured both
nationally and internationally and is the Past President of the British Society for Sexual Medicine and
the Ex Chair of the BAUS Section of Andrology. He is the current Hon Secretary of BAUS.
Hashim U. Ahmed is Chair of Urology at Imperial College London. Hashim is an internationally
renowned expert in prostate cancer diagnosis, imaging and biopsy as well as minimally invasive
therapies for prostate cancer. He has taught dozens of surgeons in these techniques in the UK and
around the world and given numerous invited international lectures in this area as well as Visiting
Professor at a number of institutions. He majors in methodological research in imaging and surgi-
cal methods and has an extensive research portfolio with about £6M in grant income as a principal
applicant and co-applicant to a research programme of approximately £14M. He has published over
150 peer-reviewed papers in areas that have led to key changes in the way we diagnose and treat men
with localised prostate cancer.
Contributors
Hamid Abboudi James Armitage
Charing Cross Hospital Addenbrooke’s Hospital
Imperial College Healthcare NHS Trust Cambridge, United Kingdom
London, United Kingdom
Manit Arya
Mohamed Yehia Abdallah Imperial College Healthcare NHS Trust
Wrexham Maelor Hospital University College Hospital
Betsi Cadwaladr University Health Board London, United Kingdom
North Wales, United Kingdom
Nish Bedi
Specialist Registrar
Sanjay Agarwal
North Thames, United Kingdom
Wrexham Maelor Hospital
Wrexham, United Kingdom Simon R. J. Bott
Frimley Park Hospital
Vineet Agrawal Camberley, United Kingdom
Urology
The Guthrie Clinic Noel Clarke
Sayre, Pennsylvania Christie Hospital
Christie NHS Hospital Foundation Trust
Hashim U. Ahmed Manchester, United Kingdom
Department of Surgery and Cancer
Imperial College Paul Cleaveland
and The Christie NHS Foundation Trust
Imperial Urology Manchester, United Kingdom
Imperial College Healthcare NHS Trust
London, United Kingdom Angela Cottrell
Royal Devon & Exeter Hospital
Exeter, United Kingdom
Tev Aho
Addenbrooke’s Hospital
David Cranston
Cambridge, United Kingdom
Oxford University Hospitals NHS Foundation
Trust
Adam Alleemudder Oxford, United Kingdom
King George Hospital
Barking, Havering and Redbridge University Amr Emara
Hospitals NHS Trust Frimley Park Hospital
Ilford, United Kingdom Camberley, United Kingdom
Hussain M. Alnajjar Herman S. Fernando

University College London Hospital NHS University Hospital of North Midlands NHS
Trust Trust
London, United Kingdom Stoke-on-Trent, United Kingdom
x Contributors
Lyndon Gommersall David A. Manson-Bahr

University Hospital of North Midlands NHS Trust The Royal Marsden NHS Foundation Trust
Stoke on Trent, United Kingdom London, United Kingdom
Anuj Goyal Shyam Matanhelia

Barnet and Chase Farm Hospitals NHS Trust Royal Blackburn Hospital
Enfield, United Kingdom Blackburn, United Kingdom
Jemma Hale Erik Mayer

Kent and Canterbury Hospital Department of Surgery & Cancer
East Kent Hospitals University NHS Foundation Imperial College London
Trust London, United Kingdom
Kent, United Kingdom
Asif Muneer
Rizwan Hamid University College London Hospital NHS Trust
University College Hospital and
London, United Kingdom NIHR Biomedical Research Centre
University College London Hospitals
Hashim Hashim and
Urology Division of Surgery and Interventional Science
Bristol Urological Institute University College London
Bristol, United Kingdom London, United Kingdom
Beth Hickerton Vinodh Murali

Royal Liverpool and Broadgreen University Mujilibhai Patel Urological Hospital
Hospitals NHS Trust Nadiad, India
Liverpool, United Kingdom and
University Hospital of North Midlands NHS
Rozh Jalil Trust
Kings College Hospital NHS Foundation Trust Stoke-on-Trent, United Kingdom
Nkwam Nkwam
Thomas Johnston King’s College Hospital NHS Foundation
Norfolk and Norwich University Hospital Trust
Norwich, United Kingdom London, United Kingdom
Jas S. Kalsi Ali Omar

Frimley Health NHS Foundation Trust Wexham Park Hospital
Frimley, United Kingdom Slough, United Kingdom
Farooq Khan Nilay Patel (deceased)

Luton and Dunstable University Hospital NHS Churchill Hospital
Foundation Trust Oxford, United Kingdom
Luton, United Kingdom
Tina Rashid
David Mak Imperial College Healthcare NHS Trust
Royal Wolverhampton NHS Trust London, United Kingdom
Wolverhampton, United Kingdom
Contributors xi
Vijay Sangar Arash K. Taghizadeh

Christie Hospital Evelina Children’s Hospital
Christie NHS Hospital Foundation Trust London, United Kingdom
Manchester, United Kingdom
Ali Tasleem
Taimur T. Shah Princess Royal University Hospital
London NHS Orpington, United Kingdom
Imperial College London
London, United Kingdom Rebecca Tregunna
University Hospitals of North Midlands NHS
Davendra M. Sharma Trust
St Georges Hospital London, United Kingdom
Justin Vale
Iqbal S. Shergill Department of Surgery & Cancer
Wrexham Maelor Hospital Imperial College London
Betsi Cadwaladr University Health Board London, United Kingdom
North Wales, United Kingdom
Oliver Wiseman
Chitranjan J. Shukla Addenbrooke’s Hospital
Western General Hospital Cambridge, United Kingdom
Edinburgh, United Kingdom
Introduction
This book is unique in that it is the first MCQ revision book to be published specifically for
candidates sitting the FRCS(Urol) examination. Together with the published and companion book
Viva Practice for the FRCS(Urol) and Postgraduate Urology Examinations, it will form the basis
of the well-established course titled ‘Rapid Revision for the FRCS(Urol)’ (this course is run by the
editors of both books).
The FRCS(Urol) examination is set to test the required standard of a recognised Urology
specialist in the UK (i.e., a day one NHS UK/Ireland consultant). The examination is divided into
two parts. The first part is devoted entirely to MCQs that aim to test the entire urology syllabus
in depth.
The second part uses clinical scenarios to form the basis of the viva voce section of the
examination. These vivas test the candidate on the domains of overall professional capability,
knowledge and judgement, logical thought process, safe practice and communication skills.
The aim of this book is to provide a selection of representative MCQs together with a detailed
explanation of each answer covering the topic in depth. Each chapter has been written by
experienced Urological surgeons who have already been successful in passing the examination.
In addition to the FRCS(Urol) examination MCQs form the basis of equivalent postgraduate
Urological examinations internationally and the scope of this book will be an invaluable
addition to individuals sitting the FEBU and similar exams in the USA, Australia and Asian
countries. Established consultants may also find the text useful as a ‘refresher’ in areas outside
their subspecialist interest.
Manit Arya
Taimur T. Shah
Jas S. Kalsi
Herman S. Fernando
Iqbal S. Shergill
Asif Muneer
Hashim U. Ahmed
CHAPTER 1: ANATOMY & EMBRYOLOGY
Ali Tasleem and Adam Alleemudder
MCQs
Q1. Anatomy of the ureter. Which one is Q4. Anatomy of the penis. Which one of the
TRUE? following is TRUE?
A. Along its course, the ureter passes in A. The corpus spongiosum is attached to
front of the gonadal vessels and behind the inferior ischiopubic rami at the root
the bifurcation of the common iliac of the penis.
vessels. B. The cavernosal artery supplies the ure-
B. The wall of the ureter has three thra, glans and spongiosum.
layers. C. Buck’s fascia is continuous with Colles’
C. The ureter originates in front of the fascia in the perineum.
renal artery. D. The cavernosal nerve provides sensory
D. The blood supply to the ureter includes supply to the penile skin.
the middle rectal artery. E. The arcuate subpubic ligament helps to
E. There are two areas of narrowing along maintain the erect penis in an upright
the length of the ureter. position.
Q2. Anatomy of the renal vasculature. Q5. Anatomy of the anterior abdominal wall
Which one is TRUE? and fascial layers. Which one of the fol-
A. The posterior segmental artery is lowing is TRUE?
formed after entering the renal hilum. A. The aponeuroses all pass in front of the
B. Arcuate arteries give rise to interlobar rectus muscle at the level of the umbilicus.
arteries. B. Pyramidalis muscle acts to stabilise the
C. There are four anterior segmental linea alba and keep it taut.
arteries. C. The internal oblique originates from the
D. PUJ obstruction may be caused by an anterior aspect of the lower eight ribs.
anterior segmental artery. D. The deep inguinal ring is medial to the
E. The left renal vein passes in front of inferior epigastric artery.
the superior mesenteric artery to reach E. Camper’s fascia lines the scrotum and
the IVC. perineum.
Q3. Which one of the following is TRUE Q6. Embryology of the gonads. Which one
regarding the adrenal glands? of the following is TRUE?
A. The right gland is round in shape and A. The genital ridges develop during the
lies lower than the left. 12th week.
B. The zona fasciculata produces sex B. In female embryos, Müllerian Inhibiting
hormones. Substance causes regression of the
C. The cortex contains chromaffin cells, paramesonephric duct.
which produce catecholamines. C. Sertoli cells secrete testosterone that
D. The blood supply to the adrenal gland plays a role in embryogenesis.
includes the inferior phrenic artery. D. Hydatid of Morgagni is a remnant of
E. Postganglionic sympathetic fibres the paramesonephric duct.
directly innervate the adrenal glands. E. The testes reach the inguinal region by
the 24th week.
2 Chapter 1: Anatomy & Embryology
Q7. Anatomy of the kidneys. Which one of Q9. Regarding the bladder, which of the fol-
the following is TRUE? lowing is FALSE?
A. The left kidney lies between L1 and L3. A. The urachus is the remnant of the
B. The dromedary hump on the medial allantois.
aspect of the kidney is more common on B. During filling, the bladder neck rises
the right. upwards.
C. The lower pole of the kidney is more C. The ureters are surrounded by the Sheath
medial and posterior than the upper pole. of Waldeyer.
D. Gerota’s fascia surrounds the kidney D. The middle circular and outer longitudi-
except medially where there is a potential nal fibres are deficient around the blad-
open space. der neck in women.
E. The main lymphatic drainage from the E. The urothelium overlying the trigone is
left kidney is into the lateral paraaortic thinnest.
nodes.
Q10. Regarding the urethra, which of the fol-
Q8. Which of the following is TRUE regarding lowing is TRUE?
the prostate? A. Transitional cell epithelium lines the
A. The prostate gland develops from the length of the urethra.
distal nephric ducts. B. The external urethral sphincter is supplied
B. The majority of cancers originate from by the cavernosal nerve.
the central zone. C. Bulbourethral glands open into the mem-
C. Fibromuscular stroma makes up 70% of branous urethra.
the prostate. D. The external sphincter completely sur-
D. The blood supply to the prostate is from rounds the urethra in women.
the pudendal artery. E. Skene glands release mucus into the ves-
E. The glandular elements drain into the tibule in women.
urethra at the verumontanum.
EMQs
Q11. Anatomy of the female organs A. Site of fertilisation of the ovum
1. Infundibulum of uterine tube B. Connects the uterus to the pelvic side
2. Ampulla of uterine tube wall
3. Broad ligament C. Attaches the ovary to the broad
4. Round ligament ligament
5. Mesovarium ligament D. Attaches the ovary to the pelvic wall
6. Suspensory ligament E. Attaches the ovary to the uterus
7. Uterine artery F. Surrounded by fimbriae
8. Ovarian artery G. Branch of the internal iliac artery
9. Vaginal artery H. Runs in the suspensory ligament
10. Cardinal ligament I. Branches also supply the fallopian
For each of the descriptions below, choose tubes
the most appropriate structure from the list J. Connects the cervix with the lateral
above. pelvic wall
Chapter 1: Anatomy & Embryology 3
Q12. Embryology of the urinary system For each of the descriptions below, choose
1. Pronephros the most appropriate structure from the list
2. Mesonephros above.
3. Metanephros A. Provides sensation to the medial aspect of
4. Cloaca the upper thigh and motor innervations
5. Mesonephric duct to the adductors of the leg
6. Seminal vesicles B. Divides the sciatic foramen into lesser
7. Intermediate mesoderm and greater parts
8. Nephrogenic cord C. Root of penis originates from this area
9. Ureteric bud D. Allows the urethra to pass through the
10. Urogenital sinus pelvic floor
11. Paramesonephric duct E. Bounded by the lumbar vertebrae, iliacus
and anterior abdominal wall
For each of the descriptions below, choose
F. Forms the pelvic floor
the most appropriate structure from the list
G. Passes through the lesser sciatic foramen
above.
and attaches to the femur
A. Temporary functional unit that regresses
H. Bounded by pubic symphysis, iliopectin-
by the 8th week of gestation
eal lines and sacral promontory
B. Non-functioning unit that develops in
I. Focal attachment point for the pelvic
the 3rd week of gestation
floor muscles and fascia
C. Becomes the definitive kidney
J. Forms part of levator ani
D. Unsegmented intermediate
mesoderm Q14. Anatomy of the nervous system.
E. Develops adjacent to the nephrogenic 1. Somatic nervous system
cord during the 4th week 2. Autonomic nervous system
F. Common mesodermal ridge that gives 3. Superior hypogastric plexus
rise to the three overlapping kidney 4. Somatic lumbosacral plexus
structures 5. Iliohypogastric nerve
G. Arises from the mesonephric duct to give 6. Obturator nerve
rise to the renal pelvis and calyces 7. Ilioinguinal nerve
H. Drains urine from the intermediate meso- 8. Femoral nerve
derm and mesonephric duct 9. Genitofemoral nerve
I. Forms from the mesonephric duct 10. Lateral cutaneous nerve of the thigh
J. Embryological origin of the bladder and For each of the descriptions below, choose
urethra the most appropriate structure from the list
K. Becomes the uterus, fallopian tubes and above.
upper two-thirds of the vagina A. Superior branch of the anterior rami of L1
B. Disruption causes retrograde ejaculation
Q13. Anatomy of the pelvis and perineum. C. Passes under the inguinal ligament to
1. False pelvis supply quadriceps
2. True pelvis D. Involved in the cremasteric reflex
3. Obturator nerve E. Provides sensation to the anterior
4. Sacrotuberous and sacrospinous scrotum
5. Obturator internus F. Originates from the anterior rami of L2 to L3
6. Levator ani and coccygeus G. Supplies smooth muscle
7. Puborectalis H. Provides sensory innervations to medial
8. Perineal body aspect of thigh
9. Urogenital hiatus I. Supplies skeletal muscle
10. Superficial perineal pouch J. Originate from L1 to S3
Q15. Great vessels A. Branch from the aorta at the level of L2

1. Inferior phrenic artery B. Gives off the deep circumflex iliac and
2. Celiac trunk inferior epigastric arteries
3. Renal artery C. Gives rise to the superior vesical artery
4. Middle sacral D. First branch of the abdominal aorta
5. External iliac artery E. Drains into the renal vein
6. Accessory obturator artery F. Found in 25% of individuals
7. Internal pudendal artery G. Gives rise to the common hepatic artery
8. Umbilical artery H. Final branch of the aorta
9. Left adrenal vein I. Gives off the iliolumbar artery
10. Posterior trunk of internal iliac artery J. Leaves through the greater sciatic fora-
For each of the descriptions below, choose the men and then re-enters through the
most appropriate structure from the list above. lesser sciatic foramen
MCQs – ANSWERS
Q1. Answer D
The ureter is up to 30 cm long. From its origin behind the renal artery, each ureter descends
over the anterior border of the psoas to the pelvis. In doing so, it passes behind the gonadal
vessels but over the bifurcation of the common iliac vessels. In men, the ureter continues along
the lateral wall of the pelvis and then turns forward at the ischial spine to enter the bladder
just after it is crossed by the vas deferens. In women, the ureter turns forwards and medi-
ally at the ischial spine and runs in the base of the broad ligament where it is crossed by the
uterine artery. It continues forward passing the lateral fornix of the vagina to enter the blad-
der. The four layers in the wall of the ureter include the inner transitional cell epithelium,
lamina propria, smooth muscle and outer adventitia. The blood supply is from several sources;
in the abdomen the ureter receives branches from the renal, gonadal, common iliac arteries and
the abdominal aorta. In the pelvis, it is supplied by the internal iliac artery and its branches
including the vesicle, uterine, vaginal and middle rectal arteries. There are three main points
of narrowing along its course: at the pelvi-ureteric and vesico-ureteric junctions and over the
common iliac vessels.
Q2. Answer C
Roughly a quarter of the cardiac output is supplied to the kidneys via the paired renal arteries.
They branch from the aorta at the level of L2 just below the origins of the superior mesenteric
(SMA) and adrenal arteries. The right artery passes behind the inferior vena cava (IVC) first,
in contrast to the left, which passes almost directly to the kidney. Before entering the hilum,
each artery initially gives off a single posterior segmental branch that passes behind the renal
pelvis to supply the posterior aspect of the kidney. It can cause obstruction of the pelvi-ureteric
junction if it passes in front of the ureter. After entering the hilum, the artery commonly
divides into four anterior segmental branches (apical, upper, middle and lower). The divisions
and blood supply of the anterior and posterior segmental arteries give rise to a longitudinal
avascular plane, known as Brodel’s line, 1–2 cm posterior to convex border of the kidney.
Segmental arteries give rise to lobar arteries within the renal sinus, which become interlobar
arteries that lie in between the Columns of Bertin in the parenchyma. These give off arcuate
branches, which become the interlobular arteries that eventually form the afferent arteries
of the glomeruli. The renal vein lies in front of the artery in the renal hilum. The right vein
is 2–4 cm in length in comparison to the left, which may be up to 10 cm. The left renal vein
reaches the IVC by passing behind the SMA and in most cases in front of the aorta.
Q3. Answer D
The pair of adrenal glands are located just above each kidney in the retroperitoneum enclosed
by Gerota’s fascia. In the newborn, the glands weigh much more but the cortex undergoes a
degree of atrophy over the following 12 months to reach the adult weight of 5 g. The right gland
is more triangular in shape and lies higher than the left. Each is made up of an outer cortex and
an inner medulla, which contains catecholamine producing chromaffin cells. The cortex makes
up the majority of the gland weight and consists of three distinct zones producing different
hormones:
• Outer zona glomerulosa – Mineralocorticoids (e.g., aldosterone)
• Middle zona fasciculata – Glucocorticoids (e.g., cortisol)
• Inner zona reticularis – Sex hormones
The blood supplying the glands stems from the aorta, inferior phrenic and ipsilateral renal
arteries. Preganglionic sympathetic fibres directly innervate the medulla to stimulate
c atecholamine release.
Q4. Answer E
The two corpora cavernosa originate as the crus penis from the inferior ischiopubic rami and
perineal membrane in the superficial pouch. Their outer surfaces are covered by the ischicaver-
nosus muscles. They come together below the pubic symphysis, separated by a midline septum
and surrounded by the tunica albuginea. The corpus spongiosum lies underneath in a groove
and contains the urethra. The proximal end is dilated to form the bulb of the penis, which
originates from the centre of the perineal membrane, and is covered by the bulbospongiosus
muscle. Distally, the spongiosum expands and caps the two corpora to form the glans penis,
containing the external urethral meatus at its tip. The three bodies are further surrounded by a
deeper Buck’s fascia, which merges proximally with the tunica albuginea, and a superficial dar-
tos fascia, which merges with Colles’ fascia in the perineum. The suspensory ligament helps to
maintain the erect penis in an upright position for coitus and has three components including,
the superficial fundiform, suspensory ligament proper and the arcuate subpubic ligaments.
The penis and urethra is supplied by the internal pudendal artery, which divides into three
branches:
• Bulbourethral – Supplies the urethra, spongiosum and glans penis.
• Cavernosal – Passes through the middle of each cavernosa to supply the sinuses.
• Dorsal artery of penis – Passes underneath Buck’s fascia towards the glans to supply the
spongiosum and urethra.
The skin and dorsal structures are supplied by the external pudendal artery, which runs in the
dartos fascia and originates from the femoral artery.
The nerves supplying the penis include:
• Dorsal – Passes underneath Buck’s fascia to supply the glans penis.
• Cavernosal – Provides autonomic supply to the corporal bodies.
• Perineal – Supplies the ventral aspect of the penis.
Q5. Answer B
The anterior abdominal wall is made up of several layers including skin, superficial (Camper’s)
and deep (Scarpa’s) fascia, muscle, extraperitoneal fascia and parietal peritoneum. Camper’s
fascia is just beneath the skin and continuous with the superficial fat over the rest of the body.
Scarpa’s fascia blends with the superficial layer superiorly and laterally but inferiorly it contin-
ues as the deep fascia of the thigh 1 cm below the inguinal ligament, and medially, it becomes
Buck’s fascia. Colles’ fascia lines the scrotum (or labia majora) and perineum and inserts
posteriorly to the edges of the urogenital diaphragm and inferior ischiopubic rami. The wall
musculature consists of the outer external oblique, internal oblique and inner transversus
abdominus. They play a role in respiration, movement and increase abdominal pressure during
micturition, defaecation and childbirth. The external oblique originates from the anterior sur-
face of the lower 8th rib and inserts inferiorly to the lateral half of the iliac crest and medially
to the rectus sheath. Its fibres run lateral to medial. The internal oblique originates from the
lumbodorsal fascia and iliac crest. Its fibres run at right angles to the external oblique, from
medial to lateral, and the muscle inserts onto the anterior surface of the lower four ribs and the
rectus sheath medially. Transversus abdominis originates from the lumbodorsal fascia and iliac
crest and inserts medially into the rectus sheath. Its fibres run horizontally. The aponeuroses
of the three muscles form the rectus sheath that surrounds the rectus abdominis muscle and
they meet in the midline to form the avascular linea alba. The composition of the rectus sheath
varies depending on the arbitrary arcuate line, which is a third of the way from the umbilicus
to the pubic symphysis. Below the line, the aponeuroses of all three muscles pass in front of the
rectus abdominis, leaving its posterior surface covered by transversalis fascia. Above the line,
the rectus is covered anteriorly by the aponeuroses of the external and internal oblique, and
posteriorly by the aponeuroses of internal oblique and transversus abdominis. The sheath is
attached to the rectus abdominis anteriorly at segmental tendinous intersections. Pyramidalis,
when present, lies in front of the lower end of rectus abdominis that originates from the pubic
symphysis and inserts into the linea alba. The inguinal canal lies parallel to and just above the
inguinal ligament at the lower end of the anterior abdominal wall that transmits the ilioingui-
nal nerve and the spermatic cord (round ligament in women). It is 4 cm in length and extends
medially and inferiorly from the deep (internal) to the superficial (external) inguinal rings.
The boundaries of the canal include the inguinal ligament in the floor, the external oblique as
the anterior wall (reinforced laterally by the internal oblique), mainly tranversalis fascia as the
back wall and the roof by the conjoint tendon, which is formed from fusion of the lower fibres
of internal oblique and transversus abdominis. The deep ring is an opening in the transversalis
fascia that lies 1 cm above the inguinal ligament midway between the anterior superior iliac
spine and pubic symphysis. The inferior epigastric artery lies medial to the ring. The super-
ficial ring lies medial to and above the pubic tubercle and is an opening within the external
oblique aponeurosis. The upper abdominal wall is supplied by the superior epigastric artery
(branch of the internal thoracic artery) and the lower half by the deep circumflex iliac and
inferior epigastric arteries (branches of the external iliac artery).
Q6. Answer D
The sex of the embryo is determined genetically at the time of fertilisation. However, it
is not until the 7th week that the gonads develop features of male or female morphology.
Primordial germ cells migrate during the 5th week of gestation from the yolk sac along
the hindgut and its dorsal mesentery towards the mesenchyme of the posterior body wall.
The mesonephros and coelomic epithelium proliferate to form a pair of genital ridges. During the
6th week, cells of the genital ridge invade the mesenchyme to form primitive sex cords, consist-
ing of cortical and medullary regions that will eventually invest the germ cells and support their
development. At the same time, paramesonephric ducts develop lateral to the mesonephric ducts
in a cranio-caudal direction. Primordial germ cells carry the XY sex chromosome if the embryo
is genetically male. The SRY gene located on the Y chromosome encodes for testis determin-
ing factor. This acts to stimulate proliferation of cells in the medulla and degeneration of cells
in the cortical regions of the primitive sex cords. During the 7th week, the cells differentiate
into Sertoli cells that become organised into testis cords and eventually to seminiferous tubules
around the time of pubescence. These Sertoli cells secrete Müllerian Inhibiting Substance (MIS)
that cause regression of the paramesonephric ducts between the 8th and 10th weeks, some of
which remain as the Hydatid of Morgagni. Near the hilum, the testis cords break up into a net-
work of thin strands that eventually become the rete testis. Some of these thin walled ducts con-
nect to the mesonephric ducts from the medial aspect of the gonads. With further development,
the testis cords become separated from the surface epithelium by the fibrous tunica albuginea.
By the 10th week, Leydig cells develop from the mesenchymal cells of the genital ridge and
secrete testosterone, initially under the influence of placental chorionic gonadotropin and later
by the pituitary gonadotrophins. By the 12th week, the mesonephric (Wolffian) duct is trans-
formed into the vas deferens under the influence of testosterone. The cranial nephric duct also
degenerates whilst the part adjacent to the presumptive testis becomes the epididymis. During
the 7th week, the testes are located near the kidneys, held in position by the dorsal cranial
suspensory ligament and the ventral ligament, which becomes the gubernaculum. During the
12th week, the testes descend to the inguinal canal and the suspensory ligament regresses. By
the 28th week, there is an outgrowth from the gubernaculum that passes through the external
ring and enters the scrotum. It is hollowed out by a tongue of peritoneum (processus vaginalis),
that allows the testes to descend into the scrotum by 33 weeks. The peritoneal layer covering
the testis becomes the visceral layer of the tunica vaginalis and the remainder of the perito-
neal sac forms the parietal layer. The canal connecting the peritoneal cavity with the vaginal
process becomes obliterated shortly before or after birth. The lack of testis determining factor
in the female embryo causes the primitive sex cords to degenerate and the mesothelium of the
genital ridge forms the secondary cortical sex cords. They invest the primordial germ cells to
form ovarian follicles, which differentiate into oogonia and then primary oocytes that remain in
this phase until puberty. The mesonephric ducts regress but the paramesonephric ducts develop
into fallopian tubes, uterus and upper two-thirds of the vagina. The remainder of the inferior
third of the vagina forms as a result of the caudal ends of the paramesonephric ducts, which
come together and form a common channel (uterovaginal canal). It then fuses with the thickened
tissue on the posterior urogenital sinus known as the sinovaginal bulb. The vaginal plate then
develops at the inferior part of the canal, which then elongates and canalises between 12 and
20 weeks to form the inferior vaginal lumen.
Q7. Answer E
Each kidney measures 10–12 cm in length and weighs between 135 and 150 g. The right
kidney is shorter and wider than the left and lies between the levels of the L1–L3 vertebrae
from displacement by the liver. The left kidney lies up to 2 cm higher between T12 and L3.
The dromedary hump is a bulge on the lateral contour of the kidney, more common on the
left, caused by downward pressure from either the liver or spleen and is of no clinical signifi-
cance. Each kidney is orientated in such a way that the upper poles are more medially and
posteriorly located than the lower poles. Much of the surrounding relationship of each kidney
is similar. The posterior upper third is covered by the diaphragm, the medial lower two-thirds
lie against the psoas and the lateral contours are in contact with quadratus lumborum and
the aponeurosis of transversus abdominis. Additionally, on the right, much of the medial
aspect lies opposite the descending duodenum and the hepatic flexure of the colon cross over
the anterior surface of the lower pole. On the left, the pancreatic tail reaches the upper pole
and above this is the posterior gastric wall. The spleen is found on the outer upper aspect and
is attached to the kidney by the splenorenal ligament. The splenic vessels lie adjacent to the
hilum and the splenic flexure of the colon lies anterior to the lower pole. Gerota’s fascia sur-
rounds the kidney except inferiorly. Each kidney is divided into an outer thinner cortex and
deeper thicker medulla. The medulla typically contains 7–9 renal pyramids whose apex (renal
papillae) point towards the renal pelvis. Each papillae is cupped by a minor calyx and each
drains via an infundibulum into two or three major calyces. These coalesce to form the renal
pelvis that gives rise to the ureter. The cortex extends between the pyramids as columns of
Bertin that contain the branching renal vasculature. Closely associated with these blood ves-
sels are lymphatics that empty into larger trunks in the renal sinus before eventually reaching
the lymph nodes closely associated with the renal veins. On the left, the lymphatic drainage is
mainly to the lateral paraaortic nodes whilst on the right it is to the interaortocaval and paracaval
nodes. The autonomic supply to the kidney is mainly concerned with vasomotor control; the sym-
pathetic fibres originate from spinal nerves T8 to L1 and cause vasoconstriction whilst the vagal
parasympathetic fibres cause vasodilation.
Q8. Answer E
The prostate develops during the 10th–12th week of gestation under influence of testosterone.
The urogenital sinus gives off a prostatic bud comprised of solid epithelial cords, which canalise
into solid prostatic ducts, and the epithelial cells become luminal and basal cells. The prostatic
mesenchyme differentiates into smooth muscle cells to surround the ducts. There is a marked
increase in the size of the prostate at puberty under the influence of testosterone and secretion
of prostate specific antigen occurs. The gland is ovoid in shape, lies at the base of the bladder
and weighs roughly 18 g in the normal adult. A fibrous capsule surrounds the gland composed
of predominant glandular tissue (70%) and fibromuscular stroma (30%). It has an anterior,
posterior and lateral surface with an inferior apex that lies on the urogenital diaphragm and a
superior base. The prostate is further anatomically divided the gland into four zones based on
the glandular elements.
1. Peripheral – Located posterior-laterally and forms the bulk of the gland. The ducts drain
into the prostatic sinus. 75% of cancers arise from this zone.
2. Central – Cone-shaped zone that extends from around ejaculatory ducts to the base of the
bladder.
3. Transitional – Surrounds the urethra and is separated from the other zones by a thin band
of fibromuscular tissue. More commonly gives rise to benign prostatic hyperplasia.
4. Anterior fibromuscular stroma – Non-glandular segment extending from the bladder neck
to the external urethral sphincter.
The rectum is posterior to the gland, separated by Denonvilliers’ fascia and a loose layer of
areolar tissue, the endopelvic fascia anterolaterally and the pubococcygeal muscles of levator
ani laterally. Near the apex, the puboprostatic ligaments are on either side of the midline that
extend from the prostate to the pubic bone. The base is continuous with the bladder neck where
the detrusor muscle fibres merge with the capsule. The prostatic urethra is about 3 cm long
and runs through the prostate from the bladder neck to become the membranous urethra. On
the posterior wall, is a longitudinal ridge (urethral crest) that runs the length of the gland in
between two grooves (prostatic sinus) into which the glandular elements open into the urethra.
The crest widens distally to form the verumontanum. At its apex lies the slit-like prostatic
utricle and represents a Müllerian remnant. The ejaculatory ducts open on either side of this.
The main blood supply to the prostate is from the inferior vesical artery, which becomes the
prostatic artery and divides into two main branches. The urethral arteries enter the prostate
at the junction with the bladder and approach the bladder neck at the 1–11 (Flock) and 5–7
(Badenoch) o’clock positions. From here they run parallel to the urethra to supply the transition
zone and periurethral glands. The capsular arteries supply the capsule and glandular tissues.
The veins of the prostate drain into the dorsal vein complex lying just beneath the pubic sym-
physis; the deep dorsal vein leaves the penis under Buck’s fascia and penetrates the urogenital
diaphragm dividing into three major branches – the superficial branch and the right and left
lateral plexus. The superficial branch pierces the endopelvic fascia and runs over the neck and
anterior bladder surface to drain the anterior prostate, bladder and retropubic fat. The lateral
branches pass down the sides of the prostate to join the vesical plexus, which subsequently
drains into the internal iliac veins.
Q9. Answer B
The bladder has a dual function of storing and voiding urine with a capacity of 500 mL. Its
shape changes with the amount of urine: a pyramidal shape when empty but ovoid when full.
When empty, the apex faces anteriorly and lies just behind the pubic symphysis. It is the point
of attachment for the urachus, a fibrous cord and remnant of the allantois, which suspends
the bladder from the anterior abdominal wall by fusing with one of the obliterated umbilical
arteries near the umbilicus. The base faces posteriorly, is triangular in shape and is in contact
with a pair of seminal vesicles separated by the vas deferens. The inferior angle gives rise to
the u rethra. The bladder neck is 3–4 cm directly behind the pubic symphysis, and its position
remains fixed during bladder distention. The superior surface is covered with peritoneum,
which in women is further reflected over the uterus (vesicouterine pouch) and continues
further back to cover the rectum (rectouterine pouch). On filling, the superior surface rises
into the abdominal cavity, pushing the peritoneum away to come into direct contact with
the posterior surface of the abdominal wall. The layers of bladder wall include an innermost
transitional cell epithelium, made up to 6 cells thick overlying a basement membrane, the
lamina propria and the outermost detrusor (smooth) muscle. The fibres of the detrusor are
arranged into an inner longitudinal, circular and outer longitudinal fashion that forms the
internal (proximal) sphincter. In men, the inner fibres are continuous with those of the urethra.
The middle fibres form a ring around the bladder neck with the anterior fibromuscular stroma
of the prostate. The outer fibres are abundant in the bladder base and they also form a loop
around the bladder neck to provide continence. In females, the arrangement of the inner
layer is similar but less is known about the arrangement of the middle and outer fibres. On
approaching the bladder, the ureters become covered by a fibromuscular Sheath of Waldeyer
before passing obliquely through the wall for about 2 cm and ending at the ureteral orifice.
The intramural portion is narrow from compression by the detrusor muscle. This angle of
entry and the surrounding detrusor muscle acts to prevent retrograde reflux of urine up the
ureter. The two ureteric orifices form a triangular-shaped trigone with the apex at the bladder
neck. The longitudinal muscle fibres of the ureter fan out over trigone and deep to this is the
fibromuscular sheath of Waldeyer that inserts into the bladder neck. The urothelium is thinnest
on the trigone. The fibres between the two orifices are thickened to form the interureteric ridge.
The blood supply to the bladder is the superior and inferior vesical arteries. Venous drainage is
to the vesical plexus, which drains into the internal iliac vein.
Q10. Answer E
The urethra extends from the bladder neck to the external meatus. It is longer in men (up to
20 cm) than in women (4 cm). In men, it is broadly divided into the anterior and posterior
urethra. The latter is further subdivided into prostatic and membranous while anteriorly it is
bulbar and pendulous. There are bends at the junctions between the membranous and bulbar
and the bulbar and pendulous urethra. The membranous urethra is short and narrow as it passes
through the u rogenital diaphragm. It is surrounded by the striated external urethral sphincter
whose inner smooth muscle is continuous with that of the proximal sphincter at the bladder
neck. The outer muscle extends from the bladder neck and anterior prostate. The sphincter has a
horseshoe configuration on cross section due to a broad anterior and a deficient posterior surface.
Some of the fibres also attach to the perineal body causing the urethra to be pulled backwards
when the sphincter contracts. The sphincter is also suspended from the pubic bones through
attachments to the puboprostatic and suspensory ligament of the penis. Neural supply is from the
somatic pudendal nerve and an autonomic branch from the sacral plexus. The anterior urethra is
longer (15 cm), beginning at the level of the perineal membrane and transversing the whole length
of the spongiosum to end at the narrow external meatus. It is dilated at the bulbar urethra and
fossa navicularis in the glans. Mucus is secreted into the urethra by bulbourethral glands in the
base of the external urethral sphincter and the glands of Littre in the submucosa. Proximally,
the anterior urethra is lined by columnar epithelium but distally within the glans penis it is lined
by stratified squamous epithelium. In contrast, the prostatic urethra is lined by transitional cell
epithelium. The female urethra opens into the vestibule at the external meatus. On either side of
the meatus are two ducts that drain mucus from the paraurethral (Skene) glands. It is surrounded
by a striated external urethral sphincter. At the proximal and distal ends, the slow twitch muscle
fibres completely surround the urethra whilst the fibres in the middle do not meet posteriorly
and instead attach to the vagina. The urethra is pulled against the vagina when the sphincter
contracts. The urethra is suspended beneath the pubic bone by the suspensory ligament of cli-
toris and the pubourethral ligament. It is lined proximally by transitional cell epithelium, which
becomes stratified squamous epithelium distally. Somatic nerve innervation is similar to that in
the male.
EMQs – ANSWERS
Q11. Answers
1F, 2A, 3B, 4E, 5C, 6D, 7I, 8J, 9K, 10I
The female reproductive tract is made up of the uterus, a pair of ovaries and fallopian tubes, and
the vagina. The uterus measures roughly 8 × 6 cm and lies in front of the rectum and over the
dome of the bladder. It consists of the upper fundus, middle body and lower cervix. It is anchored
by the round ligament of uterus, which originates at the uterine horns, leaves the pelvis at the
deep inguinal ring, passes through the inguinal canal and continues on to the labia majora where
its fibres attach to the mons pubis. Each fallopian tube extends laterally from the side of the uterus
at the junction between the fundus and body. There are four anatomical parts:
• Infundibulum – ‘Funnel shaped’ lateral end, which opens into the peritoneal cavity.
Fimbriae surround the mouth of the tube to collect ova from the ovary.
• Ampulla – Site of fertilisation.
• Isthmus – Involved with the transport of gametes in both directions.
• Uterine – Within the wall of the uterus.
The fallopian tubes protrude upwards and lift the peritoneum into a fold known as the broad
ligament that connects the sides of the uterus to the pelvic walls and floor. The cardinal
(Mackenrodt’s) ligament is located in the base of the broad ligament and attaches the cervix to
the lateral pelvic wall at the ischial spine and carries the uterine vessels. Each ovary sits in a
fossa on the lateral wall of the pelvis surrounded by the external iliac vessels above, the inter-
nal iliac vessels and ureter behind and the obturator nerve in the floor. Each ovary is secured to
a different structure by several ligaments;
• Mesovarium ligament – To the back of the broad ligament.
• Round ligament of ovary – To the side of the uterus by passing through the broad ligament.
• Suspensory ligament – To the pelvic side wall and carries the ovarian artery.
The vagina measures approximately 8 cm in length and is a muscular tube connecting the
vulva to the uterus. The cervix pierces the upper anterior wall of the vagina, which lies above
the pelvic floor. The space surrounding the cervix is divided into the anterior, posterior, right
and left lateral fornices. The vagina is lined by non-keratinised squamous epithelium and sur-
rounded by smooth muscle. The surrounding anatomical relationships include the lateral levator
ani muscles, and posteriorly the Pouch of Douglas at the upper third, ampulla of the rectum in
the middle third and the anal canal at the lower third. The vagina and rectum are separated by
a septum, deep to which is the rectovaginal space. The bladder base rests on the vaginal wall
immediately in front of the cervix and is held in place by strong muscle fibres.
The blood supply to the female organs mainly originates from branches of the internal iliac
artery; the vaginal artery provides the main supply to the vagina whilst the uterine artery,
which runs in front of the ureter and in the cardinal ligament, supplies the proximal vagina,
uterus and part of the fallopian tubes. The ovarian arteries usually arise from the aorta below
the renal arteries at the level of L1, but in a small number may originate from the renal artery.
It descends over the psoas and in the pelvis runs in the suspensory ligament to anastomose
with the ovarian branch of the uterine artery supplying the ovary.
Q12. Answers
1B, 2A, 3C, 4H, 5E, 6I, 7F, 8D, 9G, 10J, 11K
The embryological development of the urinary system passes through three main stages: the
pronephros, mesonephros and metanephros. The process begins with the intermediate meso-
derm, a ridge-like structure located on either side of the midline notochord and neural tube
along the posterior abdominal cavity. The cervical and upper thoracic portions of this ridge
are segmented but unsegmented in the lower thoracic, lumbar and sacral regions and known
as the nephrogenic cord. Caudally, the nephrogenic cord, and later the mesonephric ducts,
drain into an endoderm lined yolk sac known as the cloaca. This develops from the cloacal
membrane during the 4th week but, by the 6th week, its cavity has divided into the anterior
urogenital sinus, which becomes the bladder and urethra, and the posterior anorectal canal.
The pronephros is a temporary non-functioning unit that develops during week 3 at the cranial
end of the intermediate mesoderm and regresses by the end of the 4th week, that consists of
6–10 pairs of pronephric tubules that mature, starting at the cranial end and then regress as
more caudal tubules develop. The mesonephros then forms from the 4th week in the middle
part of the intermediate mesoderm that acts as the excretory organ for the embryo. Thereafter,
it degenerates leaving behind parts of the duct system to form the male reproductive organs.
Whilst the mesonephros is developing, a pair of mesonephric (Wolffian) duct form on either
side that fuse caudally with the cloaca. Between 40 and 42 pairs of (mesonephric) tubules arise
from the mesonephros that elongate and join laterally with the mesonephric ducts. The medial
end of the tubule is cup-shaped and accepts a sphere of capillaries to form a Bowman’s capsule.
At the start of the 5th week, the tubules begin to degenerate in a cranial to caudal direction,
but some remain to become the efferent ductules of the testes. The epididymis, vas deferens,
seminal vesicles and ejaculatory ducts all develop from persistence of the mesonephric ducts.
At the end of the 5th week, the metanephros begins its development, eventually differentiating
into the kidney. A pair of paramesonephric (Müllerian) ducts develop lateral to the mesoneph-
ric ducts. They extend from the urogenital sinus to the level of the 3rd thoracic segment where
the cranial ends open into the coelomic cavity. In males, these ducts eventually degenerate,
however, in females they become the fallopian tubes, uterus, cervix and upper two-thirds of the
vagina. The ureteric bud becomes the ureter, renal pelvis, calyces and collecting ducts. It arises
from the distal end of the mesonephric duct and penetrates the adjacent metanephric tissue. Its
tip (ampulla) divides dichotomously to give rise to the metanephric tissue that will become the
glomeruli and nephrons. The first division of the ampulla defines the primitive renal pelvis and
the future major calyces. The buds then continue to divide towards the periphery until 12 or
more generations of collecting tubules have been formed. The first five generations of tubules
dilate and develop into the pelvis and calyces. Successive generations elongate to become
the renal pyramids. At the periphery, tubular formation continues until the end of the 5th
month. The metanephric mesenchyme, in contact with the tips of the collecting tubule,
condense and then elongate. One end forms Bowman’s capsule whilst the other forms an
open connection with the collecting tubule. Although urine production starts at week 10,
nephron formation continues throughout the developing kidney until the 32nd to 34th week.
The developing kidneys migrate upwards from the 6th week to reach the lumbar region
below the adrenals by week nine. Arteries arise from the aorta and then regress as they
supply the kidneys, which migrate superiorly to their destination where the definitive renal
arteries will develop.
Q13. Answers
1E, 2H, 3A, 4B, 5G, 6F, 7J, 8I, 9D, 10C
The bony pelvis protects the distal ends of the gastrointestinal and urinary systems, and the
internal reproductive organs. The anterior and lateral walls are made up of two hip bones
that meet anteriorly at the symphysis pubis and posteriorly with the sacrum at the sacroiliac
joints. The sacrum and coccyx form the back wall. The pelvis is often divided into the true and
false pelvis. The former lies below the pelvic brim, and consists of an inlet, outlet and cav-
ity. The inlet is surrounded by the sacral promontory posteriorly, iliopectineal lines laterally
and the pubic symphysis anteriorly. In contrast, the outlet is bounded by the coccyx behind,
ischial tuberosities laterally and the pubic arch anteriorly. The false pelvis lies above the pelvic
brim to form part of the lower abdominal cavity. The boundaries include the lumbar verte-
brae behind, iliac fossa and iliacus laterally, and the abdominal wall anteriorly. The greater
and lesser sciatic notches lie behind the acetabulum and are separated by the ischial spines.
The greater and lesser sciatic foramina are formed by two muscles; sacrotuberous extends from
the sacrum, coccyx and posterior inferior iliac spine to the ischial tuberosity, whilst sacro-
spinous extends from the sacrum and coccyx to the ischial spine. The obturator foramen is
surrounded by the pubic bone above and ischium below and is filled by a fibrous sheet through
which the obturator nerve and vessels pass as they enter the thigh. Attached to this sheet is the
obturator internus muscle that gives rise to a tendon that leaves the pelvis through the lesser
sciatic foramen and attaches to the greater trochanter of the femur. The pelvic floor supports
the pelvic organs and separates them from the perineum. Anteriorly, the floor is incomplete
allowing the urethra to pass through and in females the vagina (urogenital hiatus). It is made
up of two main muscle groups: levator ani made up of several structures and also the smaller
coccygeus muscle. Levator ani originates from the back of the pubic bone, ischial spine and
the thickened fascia of obturator internus and is supplied by the perineal branches of the 4th
sacral and pudendal nerves. The anterior levator prostate, or sphincter vaginae, which attach to
the perineal body either form a sling around and support the prostate, or surround the vagina,
respectively. Puborectalis and pubococcygeus lie behind and form a sling that serves as a
sphincter around the junction of the rectum and anal canal. Posteriorly is iliococcygeus, which
attaches to the anococcygeal body in a similar way to pubococcygeus. Coccygeus is the most
posterior muscle that is supplied by the 4th and 5th sacral nerves and arises from the ischial
spine extending to the sacrum and coccyx. The pelvic fascia is made of collagen, elastic tissue
and smooth muscle. It is continuous above with the fascia of the abdominal wall and below
with the fascia of the perineum. The parietal layer lines the walls of the pelvis and its muscles.
Anteriorly, at the urogenital hiatus, the fascia becomes continuous with that of the perineum.
The visceral layer covers and supports the pelvic organs. In some areas it is thickened to form
ligaments that support organs. The puboprostatic ligament attaches at the junction of the
prostate and external sphincter to the back of the pubic bone. In females, the equivalent is the
pubourethral ligament, which attaches to the proximal third of the urethra. Another ligament
is the arcus tendineus fascia pelvis, which extends from the puboprostatic/pubourethral
ligament to the ischial spine and has the lateral branches of the dorsal vein complex beneath
it. The urogenital diaphragm supports the urethral sphincter above and is a point of attach-
ment for the external genitalia below. It extends from the pubic symphysis to the ischial
tuberosities and covers the urogenital hiatus from below. At its centre lies the triangular-
shaped perineal membrane. Posteriorly, the transverse perineal muscles run along its free
edge. The perineal body lies just behind the diaphragm and serves as a point of attachment
for almost all pelvic muscles and fascia and is therefore important in providing pelvic sup-
port. The perineum is ‘rhomboid shaped’ when viewed from below. The pubic symphysis lies
anteriorly, with the coccyx at the back and the ischial tuberosities laterally to make up its
four corners. The perineum is also divided into an anterior urogenital triangle and a poste-
rior anal triangle by an imaginary line connecting both ischial tuberosities. The boundaries
of the urogenital triangle are the pubic arch anteriorly and the ischial tuberosities laterally.
Camper’s fascia lies below the skin covering the perineum and overlies the deeper Colles’
fascia. The urogenital diaphragm bridges the urogenital triangle. The superficial perineal
pouch is a space between the urogenital diaphragm and Colles’ fascia where the root of
the penis originates. The space can also communicate with another potential space lying
in between the fascia and muscles of the anterior abdominal wall. The blood supply to the
perineum includes the perineal branch of the internal pudendal artery with branches of the
pudendal nerve providing sensory innervation to the area.
Q14. Answers
1I, 2G, 3B, 4J, 5A, 6H, 7D, 8C, 9E, 10F
The autonomic nervous system provides sympathetic and parasympathetic supply to organs,
blood vessels, glands and smooth muscle. The somatic system innervates skin, skeletal
muscles and joints. Parasympathetic fibres arise from cranial and sacral spinal nerves,
whilst sympathetic fibres for the thoracolumbar region originate from spinal nerves T1 to L3.
The two sympathetic chains lie anteriorly on either side of the vertebral column to which the
preganglionic fibres synapse. These fibres then continue via splanchnic nerves to the coeliac
or superior and inferior plexuses associated with the aorta to synapse with postganglionic
fibres that supply the target organ. Preganglionic fibres also directly supply the adrenal
gland. The coeliac plexus is closely associated with the coeliac trunk and is where a signifi-
cant proportion of the autonomic supply to the kidneys, adrenals, renal pelvis and ureters
pass through. The superior hypogastric plexus lies below this near the aortic bifurcation and
connects with the inferior hypogastric plexus below. Any disruption here during retroperi-
toneal lymph node dissection can result in retrograde ejaculation. The somatic lumbosacral
plexus is formed from spinal nerves L1 to S3 and provides innervation to the abdomen and
lower extremities. The major nerves of the plexus are described in the following table.
Nerve Origins Course Function

Iliohypogastric Superior Emerges from the upper Sensory: Skin of the gluteal
branch of the psoas and crosses in front and pubic region.
anterior of quadratus lumborum Motor: Internal oblique and
ramus of L1 to the iliac crest. It pierces transversus abdominis.
transversus abdominis,
and divides into lateral
and anterior cutaneous
branches.
Ilioinguinal Inferior branch Similar route to the Sensory: Male: Skin over the
of the anterior iliohypogastric nerve root of the penis and anterior
ramus of L1 but below it. Pierces the scrotum.
internal oblique muscle Female: Skin covering the
and then accompanies mons pubis and labia majora.
the spermatic cord Motor: Internal oblique and
through the superficial transversus abdominis.
inguinal ring travels
partway through the
inguinal canal.
Genitofemoral Anterior rami Emerges from the Femoral branch: Sensation to
of L1–L2 anterior surface of the skin overlying the femoral
psoas and divides into triangle.
femoral and genital Genital branch: Male: Travels
branches. with the spermatic cord in the
inguinal canal and supplies
the cremaster and dartos
muscles (cremasteric reflex)
and the scrotal skin.
Female: Sensation to the skin
of the mons pubis and labia
majora.
Lateral Anterior rami Emerges from the lateral Sensory: Skin of the anterior
cutaneous of L2–L3 psoas and crosses the and lateral aspect of the
nerve of the iliacus muscle, passing thigh.
thigh under the inguinal
ligament and over the
sartorius muscle into
the thigh.
(Continued)
Nerve Origins Course Function

Obturator Anterior rami Descends through the Sensory: Skin of the medial
of L2–L4 psoas and emerges from aspect of the thigh.
its medial border. Motor: Adductor muscles of
It then passes behind lower extremity.
the common iliac
arteries, runs along the
lateral wall of the pelvis
and passes through the
obturator foramen to
enter the thigh through
the obturator canal to
split into anterior &
posterior branches.
Femoral Anterior rami Descends through the Sensory: Skin of the anterior
of L2–L4 psoas and emerges from thigh and medial leg.
its lateral lower border. Motor: Supplies pectineus,
It then passes over the sartorius and quadriceps
iliacus muscle and under femoris.
the inguinal ligament to
enter the thigh.
Q15. Answers
1D, 2G, 3A, 4H, 5B, 6F, 7J, 8C, 9E, 10I
The abdominal aorta lies in the retroperitoneum on the anterior surface of the vertebral
bodies. It is a continuation of the thoracic aorta, where it passes through the aortic hiatus
between the diaphragmatic crura at the level of T12. It continues down to the level of L4,
where it bifurcates into the paired common iliac arteries. Moving down the aorta in the
caudal direction, inferior phrenic arteries are the first branches of the abdominal aorta and
supply the diaphragm and adrenal glands. The next branch to arise is the coeliac trunk,
which gives rise to the common hepatic, left gastric and splenic arteries. The paired adrenal
arteries are the next to branch. Below this is the superior mesenteric artery that supplies
the small bowel and part of the large bowel. The renal arteries are the next to branch from
the aorta at the level of L2. The paired testicular (or ovarian in women) arteries origi-
nate just below the renal arteries. They cross over the ureter as they run towards the deep
inguinal ring to leave the abdomen. The ovarian artery does not enter the inguinal canal but
passes over the iliac vessels and proceeds to the ovary via the suspensory ligament. Both the
testes and ovaries have a collateral blood supply, which means they can be sacrificed during
surgery. The inferior mesenteric artery supplies the remainder of the large bowel and is
the next branch of the aorta. Due to its collateral circulation, it can be ligated without any
detrimental effects on the bowel. The final branch, just before the aortic bifurcation, is the
middle sacral artery, which supplies the anterior sacrum and rectum. Pairs of lumbar arter-
ies (typically four) are given off along the lateral aspect of the aorta to supply the spinal
cord and posterior body wall. The common iliac arteries run laterally and bifurcate anterior
to the sacroiliac joint into the internal and external iliac arteries. The external iliac arter-
ies run along the medial border of the psoas and become the femoral arteries below the level
of the inguinal ligament just before giving rise to the deep circumflex iliac and inferior
epigastric arteries. The inferior epigastric artery runs upwards, medial to the deep inguinal
ring, to supply the rectus abdominis and skin of the anterior abdominal wall. An accessory
obturator artery is found in a quarter of subjects and arises from the inferior epigastric
artery that runs medially to the femoral vein to reach the obturator canal. The internal iliac
artery divides into an anterior and posterior trunk and their branches are listed in the table
below.
Anterior Trunk
Umbilical The proximal portion gives rise to the superior vesical artery, which
supplies the upper portion of the bladder, seminal vesicles and vas
deferens.
Inferior vesical Supplies the ureter, bladder base, prostate and seminal vesicles (vagina
in females).
Middle rectal Supplies the prostate and seminal vesicles. Joins the superior and
inferior rectal arteries to supply the rectum.
Internal pudendal Leaves the pelvis through the greater sciatic foramen, passes behind
sacrospinous ligament and enters the pelvis again through the lesser
sciatic foramen to reach the perineum. It passes forward in the
pudendal canal with the pudendal nerve to supply the anal canal and
skin/muscles of the perineum.
Inferior gluteal Exits the pelvis through the greater sciatic foramen to supply the
gluteal and thigh muscles.
Uterine Passes superiorly and anteriorly to the ureter and runs up the lateral
wall of the uterus in the broad ligament and then follows the fallopian
tube laterally where it joins the ovarian artery.
Vaginal Supplies the vagina.
Obturator Runs along the lateral wall of the pelvis with the obturator nerve and
leaves the pelvis through the obturator canal to supply the adductors
of the thigh.
Posterior Trunk
Superior gluteal Leaves the pelvis through the greater sciatic foramen to supply the
gluteal muscles.
Iliolumbar Supplies iliacus, psoas, quadratus lumborum and cauda equina
anastomosing with the last lumbar artery.
Lateral sacral Runs down in front of the sacral plexus joining the middle sacral artery
to supply neighbouring structures.
The common iliac veins join at the level of L5 posteriorly and to the right of the aortic bifur-

cation. The first tributary of the inferior vena cava (IVC) is the middle sacral vein then the
gonadal, renal, adrenal and hepatic veins moving cranially. The IVC receives multiple lumbar
veins along its posterior aspect. The right gonadal, adrenal and inferior phrenic veins drain into
the IVC whereas on the left side, these drain into the left renal vein.
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Library of Congress Cataloging‑in‑Publication Data

Names: Arya, M. (Manit), editor.

ISBN: 9780367076184 (pbk)

CHAPTER 1: ANATOMY & EMBRYOLOGY 1

CHAPTER 2: RENAL PATHOPHYSIOLOGY 19

CHAPTER 3: BASIC SCIENCE AND MOLECULAR ONCOLOGY 31

CHAPTER 4: STATISTICS, RESEARCH AND GOVERNANCE 41

CHAPTER 5: IMAGING AND PRINCIPLES OF URO-RADIOLOGY 49

CHAPTER 6: PROSTATE CANCER 63

CHAPTER 7: BLADDER CANCER 71

CHAPTER 8: RENAL CANCER 87

CHAPTER 9: TESTICULAR CANCER 107

CHAPTER 10: PENILE CANCER 119

CHAPTER 11: ANDROLOGY 127

CHAPTER 12: BENIGN PROSTATIC HYPERPLASIA (BPH) AND LOWER

CHAPTER 13: FEMALE AND FUNCTIONAL UROLOGY 147

CHAPTER 14: UROLOGICAL TRAUMA 159

CHAPTER 15: NEUROUROLOGY 163

CHAPTER 16: UROLITHIASIS 169

CHAPTER 17: URINARY TRACT INFECTIONS (UTI) 195

CHAPTER 18: PAEDIATRIC UROLOGY 207

Hussain M. Alnajjar Herman S. Fernando

Lyndon Gommersall David A. Manson-Bahr

Anuj Goyal Shyam Matanhelia

Jemma Hale Erik Mayer

Beth Hickerton Vinodh Murali

Jas S. Kalsi Ali Omar

Farooq Khan Nilay Patel (deceased)

Vijay Sangar Arash K. Taghizadeh

Ali Tasleem and Adam Alleemudder

Q15. Great vessels A. Branch from the aorta at the level of L2

Nerve Origins Course Function

Nerve Origins Course Function

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CHAPTER 1: ANATOMY & EMBRYOLOGY 1

CHAPTER 2: RENAL PATHOPHYSIOLOGY 19

CHAPTER 3: BASIC SCIENCE AND MOLECULAR ONCOLOGY 31

CHAPTER 4: STATISTICS, RESEARCH AND GOVERNANCE 41

CHAPTER 5: IMAGING AND PRINCIPLES OF URO-RADIOLOGY 49

CHAPTER 6: PROSTATE CANCER 63

CHAPTER 7: BLADDER CANCER 71

CHAPTER 8: RENAL CANCER 87

CHAPTER 9: TESTICULAR CANCER 107

CHAPTER 10: PENILE CANCER 119

CHAPTER 11: ANDROLOGY 127

CHAPTER 13: FEMALE AND FUNCTIONAL UROLOGY 147

CHAPTER 14: UROLOGICAL TRAUMA 159

CHAPTER 15: NEUROUROLOGY 163

CHAPTER 16: UROLITHIASIS 169

CHAPTER 17: URINARY TRACT INFECTIONS (UTI) 195

CHAPTER 18: PAEDIATRIC UROLOGY 207