Viva · Specialty
Genitourinary Viva Questions
Oral-exam style questions and answers on genitourinary for MD, DNB and super-specialty practical examinations. Each answer links back to the playbook or Library entry it was written from.
- What does PI-RADS v2.1 actually assess?
- It assesses the likelihood that a lesion on multiparametric prostate MRI represents clinically significant prostate cancer, on a per-lesion five-point scale, in treatment-naive patients. It is not a histological grade and not a staging system.
- Which sequence is dominant in each zone?
- Diffusion-weighted imaging with the ADC map is dominant in the peripheral zone, and T2-weighted imaging is dominant in the transition zone.
- What role does dynamic contrast enhancement play in v2.1?
- It is binary. A positive DCE study upgrades a peripheral-zone DWI score of 3 to an overall category 4. It does not upgrade transition-zone lesions and never independently produces a category 5.
- How is a transition-zone T2 score of 3 handled?
- A transition-zone lesion scored T2W 3 is upgraded to overall category 4 when the DWI score is 5; otherwise it remains category 3.
- What separates category 4 from category 5?
- Size of 1.5 cm or more in greatest dimension, or definite extraprostatic extension or invasive behaviour, moves an otherwise category 4 lesion to category 5.
- How should a suspicious lesion be measured?
- Measure the greatest dimension on the axial image of the sequence that determined the score, that is the ADC map for peripheral-zone lesions and T2-weighted images for transition-zone lesions. If the largest dimension is on a sagittal or coronal image, report that value and state the plane.
- Name the key technical requirements introduced or tightened in v2.1.
- High b-value imaging of at least 1400 s/mm2, acquired or calculated from lower b-values, DWI slice thickness of 3 mm or less with no gap, and dynamic contrast-enhanced temporal resolution of 15 seconds or less.
- What is the commonest interpretive pitfall with PI-RADS?
- Scoring the wrong dominant sequence for the zone, or using positive DCE to justify a category 4 or 5 transition-zone lesion. A further pitfall is quoting a PI-RADS category as if it were a Gleason grade or a stage.
- Which RCC is classically T2-dark and hypovascular?
- Papillary RCC; lipid-poor angiomyolipoma and haemorrhagic cysts remain important mimics.
- How do you prove enhancement in a T1-bright renal mass?
- Use well-registered pre/postcontrast subtraction MRI, checking for motion misregistration.
- Does a central scar diagnose oncocytoma?
- No. Chromophobe RCC and other tumours may also have a scar-like centre.
- Does microscopic lipid establish angiomyolipoma?
- No. Clear-cell RCC may contain intracellular lipid and lose signal on opposed-phase imaging.
- Is papillary RCC still formally split into types 1 and 2 in WHO 2022?
- No. The subdivision was removed because the former groups included overlapping and molecularly distinct entities.
- Which staging details matter regardless of likely RCC subtype?
- Renal sinus and perinephric invasion, renal-vein/IVC extension, regional nodes and distant disease.
- What does the acronym RENAL stand for in the nephrometry score?
- Radius (maximal tumour diameter), Exophytic/endophytic properties, Nearness of the deepest tumour portion to the collecting system or sinus, Anterior/posterior descriptor, and Location relative to the polar lines.
- Which components of the score actually carry points, and what is the possible range?
- Only R, E, N and L are scored, each from 1 to 3 points, so the total ranges from 4 to 12. A is recorded as a suffix a, p or x, and h is added for a hilar tumour touching the main renal artery or vein.
- How is the radius component scored?
- Maximal tumour diameter of 4 cm or less scores 1 point, greater than 4 cm but less than 7 cm scores 2 points, and 7 cm or greater scores 3 points.
- How is nearness to the collecting system measured and scored?
- It is the distance from the deepest portion of the tumour to the collecting system or renal sinus. Seven millimetres or more scores 1 point, greater than 4 but less than 7 millimetres scores 2, and 4 millimetres or less scores 3.
- What earns 3 points in the location component?
- More than 50% of the mass lying across a polar line, or the mass crossing the axial renal midline, or the mass lying entirely between the polar lines.
- What are the complexity bands and why do they matter?
- Four to six is low complexity, seven to nine moderate, and ten to twelve high. Higher complexity predicts greater technical difficulty and perioperative morbidity, informing the choice between partial and radical nephrectomy or ablation and the approach used.
- What is the commonest interpretive pitfall with this score?
- Treating it as a marker of malignancy or as a staging system. It is a purely anatomical complexity score for procedural planning and does not replace TNM staging or predict histology.
- Which component has the poorest interobserver reliability?
- The exophytic/endophytic component, because judging whether at least 50% of the mass projects beyond the renal contour is subjective; radius and nearness show the best agreement.