DFT-SURGERY2D2-16-10-2025-MAXEMO

The "bell-clapper deformity" is the most common anatomical risk factor for intravaginal testicular torsion. This deformity, which allows the testis to rotate freely on the spermatic cord, is a direct result of which embryological anomaly?

• An abnormally high attachment of the tunica vaginalis onto the spermatic cord, allowing it to completely encircle the testis.

• Failure of the gubernaculum to descend and properly anchor the inferior pole of the testis to the scrotal floor.

• A widely patent processus vaginalis, which leads to a communicating hydrocele and excessive testicular mobility.

• Complete agenesis of the epididymis, leading to a disconnect between the testis and its scrotal attachments.

Answer explanation

This is the precise definition of the bell-clapper deformity. The tunica vaginalis invests the testis and epididymis completely, attaching high on the cord, which permits the testis to swing and rotate on its vascular pedicle.

A 17-year-old, sexually active male presents with a 5-hour history of severe right scrotal pain, vomiting, and lower abdominal discomfort. On examination, the right testis is exquisitely tender, high-riding with a transverse lie, and the cremasteric reflex is absent. A urine dipstick reveals trace leukoesterase and 5-10 WBC/hpf. Despite the urinalysis finding, which of the following is the most critical and appropriate next step?

• Immediate surgical exploration of the scrotum

• Empiric treatment with ceftriaxone and doxycycline for presumed epididymitis

• Urgent color Doppler ultrasound to confirm the diagnosis before any intervention

• Abdominal and pelvic CT scan to rule out a retroperitoneal cause for the pain

Answer explanation

The physical examination findings are pathognomonic for testicular torsion. The presence of minimal pyuria ("sterile pyuria") can occur due to reactive inflammation and should not dissuade the clinician from the diagnosis. Time is critical, and immediate surgery is the standard of care.

A 35-year-old male presents to his urologist after noticing a painless, firm swelling in his right testicle. He denies any history of trauma. His medical history is significant for cryptorchidism (an undescended testis) as a child, which was surgically corrected. An ultrasound reveals a solid, homogenous, hypoechoic mass. Based on the patient's age and the high prevalence of this tumor type, what is the most likely diagnosis?

• Seminoma

• Yolk Sac Tumor

• Choriocarcinoma

• Leydig Cell Tumor

Answer explanation

Seminoma is the most common type of germ cell tumor, accounting for approximately 50% of all testicular GCTs. It has a peak incidence in men in their 30s and 40s. The clinical presentation of a painless mass in a patient with a history of cryptorchidism (a major risk factor) is classic for seminoma.

A pathologist examines a testicular tumor specimen. On gross examination, the cut surface reveals a solid, homogenous, tan-white, fleshy mass that bulges and appears to compress the surrounding normal testicular tissue. Based on the provided image and this description, which diagnosis is most likely?

• Teratoma

• Seminoma

• Choriocarcinoma

• Yolk Sac Tumor

Answer explanation

The description of a solid, homogenous, tan-white, fleshy, or "creamy" mass that bulges from the cut surface is the classic gross appearance of a seminoma, as depicted on the right side of the image. It is typically well-demarcated from the surrounding parenchyma.

A 24-year-old male presents for a fertility workup. An incidental, firm, 1.5-cm nodule is palpated in his right testis. Scrotal ultrasound confirms a solid, hypoechoic, intratesticular lesion. His serum AFP and β-hCG levels are within the normal range. The surgeon proceeds with an inguinal exploration. After delivering the testis and applying a non-crushing clamp to the spermatic cord, what is the most appropriate next step in management?

• Perform an excisional biopsy of the lesion for intraoperative frozen section analysis

• Proceed directly with a high inguinal radical orchiectomy

• Close the incision and await results from serum tumor markers drawn post-operatively

• Perform a trans-scrotal wedge resection for better cosmetic results

Answer explanation

In a small, marker-negative testicular mass, there is a significant possibility of a benign lesion. The Chevassu maneuver—excisional biopsy with frozen section—is performed to confirm malignancy intraoperatively, allowing for testis preservation if the lesion is benign.

A 28-year-old male was diagnosed with a non-seminomatous germ cell tumor (NSGCT) with para-aortic lymph node metastases (Stage II). He completed three cycles of BEP chemotherapy, after which his serum tumor markers normalized. A follow-up CT scan reveals a single residual 2.5-cm retroperitoneal lymph node. What is the mandatory next step in management?

• Proceed with a retroperitoneal lymph node dissection (RPLND)

• A PET/CT scan to assess the viability of the residual mass

• Observation with serial imaging and tumor markers

• Radiation therapy to the residual para-aortic mass

Answer explanation

•  For NSGCT, a residual retroperitoneal mass >1 cm after chemotherapy must be surgically resected. This is because it may harbor chemo-resistant teratoma (40-50% of cases) or viable cancer (10-15%), which RPLND can cure.

A 19-year-old male complains of a dragging discomfort in his left scrotum. Examination reveals a palpable "bag of worms" superior to the left testis, consistent with a varicocele. As noted in the provided diagram, which physical examination finding is essential to confirm a primary, uncomplicated varicocele?

• The mass decompresses and disappears when the patient is in the supine position.

• The cremasteric reflex is absent on the affected side.

• The mass is exquisitely tender to palpation.

• The testis on the affected side is significantly enlarged.

Answer explanation

• A key clinical feature of a primary varicocele is that the dilated veins decompress due to gravity when the patient lies down. A varicocele that remains palpable in the supine position suggests a fixed obstruction.

A 45-year-old man is diagnosed with invasive ductal carcinoma of the breast. His family history is notable for a sister diagnosed with breast cancer at age 39 and a mother who died from ovarian cancer. This patient's clinical presentation and family history are most strongly suggestive of a mutation in which of the following genes?

• BRCA2

• BRCA1

• CHEK2

• TP53

Answer explanation

• The presence of male breast cancer is a classic hallmark strongly associated with the BRCA2 mutation. While both BRCA1 and BRCA2 increase female breast and ovarian cancer risk, the link to male breast cancer is specific to BRCA2.

A 62-year-old woman presents for her annual screening mammogram. She is asymptomatic. The radiologist identifies a new 1.5 cm spiculated mass with associated microcalcifications in the upper outer quadrant of her right breast. The final report assigns this finding a BI-RADS 5 category. What is the most appropriate next step in management?

• Core needle biopsy of the mass

• Proceed directly to lumpectomy and sentinel lymph node biopsy

• Short-term follow-up mammogram in 6 months

• Reassure the patient and recommend routine screening in one year

Answer explanation

• According to the "Triple Assessment" principle and BI-RADS guidelines, a BI-RADS 5 lesion is highly suggestive of malignancy (>95% risk) and requires tissue diagnosis for definitive pathological confirmation before planning treatment. Core needle biopsy is the standard procedure.

A 38-year-old male is diagnosed with primary hyperparathyroidism after presenting with recurrent kidney stones and being found to have elevated serum calcium and parathyroid hormone (PTH) levels. His family history is significant for his father having had a pituitary tumor and his sister having a pancreatic tumor. A surgeon is planning a neck exploration. Which of the following is the most likely underlying pathology?

• Solitary parathyroid adenoma

• Multi-gland parathyroid hyperplasia

• Parathyroid carcinoma

• Ectopic PTH-secreting tumor

Answer explanation

The patient's presentation with primary hyperparathyroidism, combined with a family history suggestive of pituitary and pancreatic tumors, is classic for Multiple Endocrine Neoplasia type 1 (MEN 1). In patients with MEN 1, primary hyperparathyroidism is the most common manifestation and is characteristically caused by the hyperplasia and enlargement of multiple (usually all four) parathyroid glands, not a single adenoma.