Urology Inservice Exam Jeopardy

JEOPARDY JEOPARDY JEOPARDY JEOPARDY JEOPARDY JEO
COLUMBIA UROLOGY GRAND ROUNDS COLUMBIA UROLOGY GRAND

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YOU’RE IN
TROUBLE
IT’S NOT A
TUMOR!
THIS TOO
SHALL
PASS
LET’S TALK
ABOUT
SEX, BABY
LEAKY
LADIES
GRAB BAG
FINAL JEOPARDY
$100

YOU’RE IN
TROUBLE
(Renal Physiology)

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ANSWER
(question)
What is the
primary stimulant
of aldosterone
secretion?

Angiotensin II

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ANSWER
(question)
In central diabetes
insipidus, the nephron
segment that contains the
most dilute fluid is the…

Collecting duct

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ANSWER
(question)
An 80 y.o. man has urinary retention. He
has bilateral edema, BP 200/120 and
creatinine 4.0 mg/dL. Ultrasound shows
distended bladder and b/l
hydronephrosis. 3 L of urine is drained
from his bladder upon catheterization,
and UOP over the next 2 hrs is 700 mL.
The next step is...

Post obstructive diuresis
1. Spot check urine for Na+ and osmolarity
 determine pathologic vs. physiologic POD
2. Monitor vital signs and urine output
3. Fluid replacement with D5 ½ NS at ½ of previous
hour’s UOP
4. Monitor electrolytes and BUN/Cr every 6-12
hours

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ANSWER
(question)
A 57 y.o. woman has polyuria with daily UOP 4-8
liters. H&P is unremarkable.
UA is normal. Glucose 100 mg/dL, Cr 0.9 mg/dL
Urine Osm 100 mOsm/L, Plasma Osm 270 mOsm/L
After 12 hours of dehydration,
the urine Osm is 700 mOsm/L.
After vasopressin is administered,
urine Osm is 100 mOsm/L.
The most likely diagnosis is…

Psychogenic
Polydipsia

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ANSWER
(question)
A 70 y.o. man with h/o left
radical nephrectomy and right
renal artery stenosis of >75%
develops intractable HTN.
His volume status and
angiotensin levels are best
characterized as…

Hypervolemic
Normal ATII

Renin – Normal/Low
Volume Overload
Tx: Diuretic
Renin – Increased
High ATII Levls
Tx: ACEi

IT’S NOT A
TUMOR!
(Oncology)

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ANSWER
(question)
A 50 y.o. man presents to your
office with an incidentally
detected 3 cm adrenal mass…
What are 3 indications
for surgical intervention?

Surgical Indications
• All tumors >5cm (~25% risk of ACC)
• All functional adrenal tumors
• Suspect adrenocortical carcinoma on imaging
– Heterogeneous, strongly enhancing, calcified
– 5-10% invade the venous system
• Substantial interval growth

Three Tests to Evaluate Incidentaloma:
1. Serum Potassium
 R/O Aldosteronoma (low K)
2. Plasma free metanephrines
 R/O Pheochromocytoma (99% sens.)
Confirm w/ 24-hr urine catecholamine
3. Cortisol Screen (Dex suppresion, 24-hr urinary
free cortisol, or late night saliva)
 R/O steroid-producing adenoma

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ANSWER
(question)
A 58 y.o. man has
asymptomatic,
non-metastatic
castration-resistant
prostate cancer with
rising PSA on leuprolide.
The next step is…

Observation with
continued androgen
deprivation therapy
Option: first generation anti-androgen
(e.g. bicalutamide) or first-generation androgen
synthesis inhibitor (e.g. ketoconazole + steroid)
in patient unwilling to accept observation

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ANSWER
(question)
What are the testicular cancer
tumor markers?
What are their half lives?
What can falsely elevate each?

Marker Half Life False elevation
B-HCG 24-36 hours - Hypergonadotophic hypogonadism
(high LH! Beta subunit homology)
- Marijuana, tobacco
AFP 5-7 days - Liver damage (ETOH, hepatitis)
- Other malignancy; IBD
LDH Variable - non-specific marker of tissue
damage / bulk of disease
Tumor marker notes:
• Seminoma NEVER has elevated AFP
• Choriocarcinoma is ALWAYS B-HCG positive
• Yolk Sac is almost always AFP positive
• Post-orchiectomy marker normalization takes ~5 half lives
• Common to have marker surge 2-3 wks after starting chemo

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ANSWER
(question)
A 21 year old man has a right inguinal
orchiectomy for Stage I mixed germ
cell tumor. He is observed and seven
months later, a 4 cm mass is seen
on abdominal CT scan in the
interaortocaval region.
CXR, B-HCG and AFP are normal
The next step is…

Platinum-based chemo
(Good risk = BEPx3)
• 15-20% of NSGCT Stage 1A relapse within
first 2 years
• Serial exam, markers and imaging x5+ yrs
• Chemo based on risk @ time of relapse
(BEP x3-4, EPx4 or VIP x4)

Post-Chemo RP Mass
SEMINOMA
<3 cm, normal markers
 Surveillance
>3 cm, normal markers
 PET
(if + RPLND v. chemo)
Progressive disease
 Chemo
NONSEMINOMA
>1cm
 RPLND
45% Teratoma
45% Fibrosis
10% Malignant
 +2x chemo
Progressive disease
 Salvage chemo

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ANSWER
(question)
A 60 y.o. man with squamous cell
carcinoma of the penis invading the
right corpus cavernosum undergoes
partial penectomy. After 6 weeks of
cephalexin, a 3.5 cm right inguinal
node has decreased in size to 2 cm.
Pelvic CT is normal.
The next step is…

Bilateral inguinal lymph
node dissection
Stage II penile cancer
T2 = invasion of the corporeal bodies
*High risk  Associated w/ 66% + nodes

Inguinal Lymphadenectomy
Nonpalpable nodes Palpable nodes
Low risk
(Tis, Ta, T1a)
Intermediate
or high risk
Observe B/L mod
ILND
Non Bulky
<4cm
Bulky
>4cm
or pelvic
FNA, Abx
or B/L LND Neoadjuvant
Chemo
(vs. RT for pall)If + deep LND on that side

THIS TOO
SHALL PASS
(Nephrolithiasis)

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ANSWER
(question)
What is the expected
urinary creatinine on a
24-hour urine collection
for an adult

~20 mg/kg/day
Men 20-25 mg/kg/day
Women 15-20 mg/kg/day
*If less, suspect improper collection and repeat study

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ANSWER
(question)
A morbidly obese, 55 y.o.
woman undergoes Roux-
en-Y bypass. In order to
minimize stone risk, the
best treatment is…

Calcium Carbonate
Enteric hyperoxaluria
• Common s/p bariatric surgery (IBD, short gut, celiac)
• Decrease bile salt absorption
 increased bile salt + calcium chelation
 increased absorption of non-calcium bound oxalate
 increased renal filtration of oxalate
• Tx: oral calcium supplementation, low fat / low
oxalate diet, Vit B6 supplementation, increase fluid
intake, potassium citrate

Dietary Hyperoxaluria
• Mild (45-60 mg urinary oxalate per day)
• Increased dietary intake of oxalate rich foods
• Tx: Dietary modification, Vit B6 supplementation

Primary Hyperoxaluria
• Hepatic enzyme deficiencies  increased production
of oxalate that results in increased renal filtration
• Type 1 = AGT deficiency
– Glycolate conversion to oxalate and glycolic aciduria
– Treatment: liver transplant
• Type 2 = GRHPR deficiency
– L-gyceric aciduria
– Very rare
• Type 3 = HOGA1 deficiency
– Extremely rare

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ANSWER
(question)
Thiazides tachyphylaxis
in the treatment of
hypercalciuria is
mediated by…

Calcitonin
Thiazide Diuretics
• Inhibit distal tubule Na+
secretion
• Lose efficacy in up to 25% of pts
• Increased serum Ca++ 
stimulates C-cells in thyroid to
produce calcitonin 
increased urinary Ca++
excretion
• Consider a drug holiday as
effect decreases over time

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ANSWER
(question)
Workup for a 38 y.o. woman with
recurrent nephrolithiasis reveals:
24-hour urine collection 200mg of calcium
Serum calcium 10.8 mg/dl s
Serum PTH 85 pg/ml
After administration of a thiazide,
Serum calcium is 11.8 mg/dl.
What treatment will best reduce
her risk of further stones?

Parathyroidectomy
Resorptive hypercalciuria
• Suspect in patients with serum calcium >10.1
• Elevated PTH (primary hyperparathyroidism)
 Increased bone demineralization leads to
increased renal filtration of calcium
• Dx with “thiazide challenge” to increase proximal
tubular reabsorption of calcium
• Tx: parathyroidectomy (plus K-Cit, increased H2O)

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(question)
A 9 y.o. girl who recently emigrated
from Japan has recurrent right flank
pain and urolithiasis. ESWL has been
unsuccessful in the past.
Urinalysis shows the following:
The most likely cause
of her stones is…

Cysteinuria
• Autosomal recessive
• Defect in renal tubular reabsorption of dibasic amino
acids (“COLA”)… Only cystine is not urine soluble
• Dx: hexagonal crystals, 24-hr urine collection or
sodium cyanide-nitroprusside test of urine
• Tx: high fluid intake, alkalization of urine
• Tiola (alpha-mercaptopropionylglycine)
• Penicillamine

LET’S TALK ABOUT
SEX, BABY
(Sexual Dysfunction)

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ANSWER
(question)
The etiology of
vardenafil-associated
chromatopsia is…

PDE6 cross reactivity
in the retina
• Vardenafil [Levitra ®] is a PDE5 inhibitor
• Chromatopsia is an abnormality of colored vision
causing a bluish visual hue caused by vardenafil and
sildenafil (but not tadalafil) in ~10% of patients
• Other PDE5i side effects include headache (20%),
flushing (20%), dyspepsia (14%), congestion (10%)
• *Contraindicated for those on concomitant nitrates*

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ANSWER
(question)
A 45 y.o. male with low libido and ED,
is found to have morning serum total
testosterone of 200 ng/dL and 190
ng/dL on two tests.
Name two drugs for that will
raise his testosterone while
preserving his fertility…

Clomiphene
(SERM)
Anastrazole
(aromatase inhibitor)
x

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ANSWER
(question)
How would you proceed if you
encountered these scenarios
during infrapubic IPP placement:
A) Left cylinder is placed normally and
right cylinder crosses over to left corpora.
B) During dilation, blood is noted at the
urethral meatus and a tear is identified in
the distal urethra.

A) CROSS OVER:
Place a small dilator on the left
and re-dilate the right.
Continue Procedure.
B) URETHRAL INJURY:
Abort procedure. Place a
catheter for 7-10 days.
(if one side is already inserted,
OK to leave that side in place)

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(question)
One day after his first injection
of intra-lesional collagenase
[Xiaflex ®] for Peyronie’s
disease, a 54 year old man
experiences penile pain, edema
and ecchymosis after sex.
The next step is…

Penile Exploration
• Intralesional clostridial collagenase histolyticum
• AUA Guideline: administer Xiaflex in combination
with modeling for patients with stable Peyronie’s
disease with curvature >30o and <90o and intact
erectile function (32% curvature reduction [-17o])
• Potential adverse effects include ecchymosis (80%),
swelling (55%), pain (45%) and corporal rupture (0.5%)
• Penile fracture  surgical exploration

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ANSWER
(question)
A 39 y.o. man requests vasectomy
reversal 4 years after vasectomy.
At exploration, he has rare non-
motile sperm in the RIGHT vas and
absence of sperm in clear fluid in
the LEFT vas.
How should reconstruction be
performed?

Bilateral Vasovasostomy
• Microsurgical reconstruction is preferable to sperm
retrieval with IVF/ICSI in men with prior vasectomy if
less than 15 years and no female fertility risk factors
• Time since vasectomy is the most important prognostic
indicator: <3 years 97% patency, 3-8 years 90% patency
9-14 years 80% patency, >15 years 70% patency
• Check vasal fluid to decide procedure:
• V .V.  fluid has sperm, is clear, or sperm granuloma
• V.E.  thick fluid without sperm
• May take up to 1 year for return of sperm to ejaculate

LEAKY LADIES
(Female &
Neurourology)

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ANSWER
(question)
An 82 y.o. female with OAB
and urge incontinence
desires medical management
only. Which anticholinergic is
favored for this patient?

Trospium (Sanctura)
• Trospium is a quaternary amine
and does not cross the blood-brain
barrier, and may minimize impact
on cognition in the elderly.
• [Alternatively, consider mirabegron]

AUA OAB Guidelines
SECOND LINE TREATMENTS:
8. Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as 2nd line
tx. [Standard]
9. If an immediate release (IR) and an extended release (ER) formulation are available, then ER
formulations should preferentially be prescribed over IR formulations because of lower rates of
dry mouth. [Standard]
10. Transdermal (TDS) oxybutynin (patch or gel) may be offered. [Recommendation]
11. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events
with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic
medication or a β3-adrenoceptor agonist may be tried. [Clinical Principle]
12. Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless
approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution
in patients with impaired gastric emptying or a history of urinary retention. [Clinical Principle]
13. Clinicians should manage constipation and dry mouth before abandoning effective anti-
muscarinic therapy. Management may include bowel management, fluid management, dose
modification or alternative anti-muscarinics. [Clinical Principle]
14. Clinicians must use caution in prescribing anti-muscarinics in patients who are using other
medications with anti-cholinergic properties. [Expert Opinion]
15. Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor
agonists in the frail OAB patient. [Clinical Principle]

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ANSWER
(question)
Name 2 urinary
pathogens that would
be nitrate negative on
a urinalysis?

Enterococcus
Streptococcus
Acinetobacter
Candida
Adenovirus

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(question)
A 72 y.o. woman with colon
carcinoma s/p LAR, XRT and chemo
develops fecaluria and pneumaturia 3
years later. Cystoscopy shows an
irregular area on the posterior
bladder wall.
The next step is…

Bladder biopsy

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ANSWER
(question)
Match the POP-Q stage to the
definition:
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Most distal <1cm prox. or distal to hymen
No prolapse
Complete eversion
Most distal >1cm above hymen
Most distal >1cm below hymen

Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
No prolapse
Most distal >1cm above hymen (-)
Most distal <1cm prox. or distal to hymen
Most distal >1cm below hymen (+)
Complete eversion

POP-Q
(Pelvic Organ Prolapse – Quantification)
Anterior
Aa, Ba
If +  Cystocele
Posterior
Ap, Bp
If +  Rectocele
Cervix/Pouch of Douglas
C, D
If +  Uterine prolapse

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(question)
A 65 y.o. woman with rectal
carcinoma s/p APR develops
urinary incontinence 2 years
later. Her UA is normal and PVR
is 300. RBUS shows moderate
bilateral hydro.
The most likely urodynamic
findings are…

Detrusor areflexia and
reduced compliance

Patterns of NGB
Lesion above brain stem (supra-pontine)
• DO
• E.g. CVA, NPH, parkinson’s, trauma, dementia
Lesion between brain stem and sacral SC
• DO +/- DSD
• E.g. Spinal stenosis, disc, infection, tumor, SCI
Lesion of sacral SC
• Areflexia, impaired contractility, ?sphincter
• E.g. Pelvic surgery, cauda equina, trauma
Anywhere
• MS 
DO

GRAB BAG

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(question)
What effect will
pneumopertionium of
15mm Hg will have on
MAP, Cardiac output,
and GFR?

MAP increase
Cardiac output decrease
GFR decrease

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ANSWER
(question)
A 55 y.o. woman has
flank pain, fever and
malaise. Her
creatinine is 1.6
mg/dl. A CT of the
abdomen shows:
The most appropriate
treatment is…

Nephrectomy
Xanthogranulomatous pyelonephritis (XGP)
• Infectious process that results in a chronically inflamed
kidney with destruction of renal parenchyma and loss of
function
• Associated with UTI (E.coli or proteus), nephrolithiasis,
diabetes and/or immunocomprimised patients
• Imaging: CT shows enlarged kidney with “bear’s paw”
sign and staghorn calculus
• Tx: nephrectomy with removal of surrounding infected
tissue

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(question)
A 48 y.o. man with GU tuberculosis
has a 4 cm distal ureteral
stricture. He is treated with
ureteral stent placement and
isoniazide + rifampin +
pyrazinamide. After 3 weeks of
treatment, there is no
improvement in the stricture.
The next step is…

Prednisone (x3 weeks)
Distal ureteral stricture from TB:
1. TB medications x3 weeks
2. Steroid course x3 weeks
3. Ureteral dilation or reimplantation
*Consider nephrectomy is
nonfuncational kidney, extensive
disease or coexisting renal cell
carcinoma Masuda, NEJM, 2016

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(question)
A novel medication is being
studied for treatment of urinary
frequency. The best statistical
method to compare the mean
number of voiding episodes per
day in subjects receiving the
medication versus those receiving
placebo is…

T-Test

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(question)
A 40 year old man involved in an
MVC has mild lower abdominal
pain and gross hematuria.
Radiologic evaluation reveals a
normal urethra, pelvic fracture
with large hematoma, and small
extraperitoneal extravasation from
the bladder. A 26 Fr urethral
catheter repeatedly clots off.
The next step is…

Intraperitoneal exploration of the bladder,
repair of laceration and catheter drainage
Contraindications to conservative management of
extraperitoneal rupture:
• Gross hematuria with repetitive clot retention
• Concomitant rectal or vaginal injury
• Bladder neck injury
• Presence of foreign body in the bladder (e.g. bone
or bullet)
• Going to OR anyway for ORIF or repair of
abdominal injury

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ANSWER
(question)
A 21 y.o. patient from the D.R. presents to your
office to discuss gender affirmation surgery.
They report ambiguous genitalia with female
appearance, primary amenorrhea, and lack of
breast development. Exam shows
clitoromegaly, blind ending vaginal pouch, and
palpable gonads in the inguinal canals.
Karyotype reveals 46, XY. LH/FSH are normal.
Serum Testosterone is elevated.
What enzyme is deficient AND
What is the colloquial name of this condition?

5-alpha reductase deficiency
A.K.A.
“Guevedoces”
“Huevos a los doce”
“Testicles at Twelve”

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Urology Inservice Exam Jeopardy

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