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Lectures > Pathology of the lower urinary tract > Flashcards

Pathology of the lower urinary tract Flashcards

1
Q

Structural/congenital defects of the lower urinary tract

A

Bladder

  • diverticuli
  • exstrophy
  • vesicouretral reflux

Ureter

  • double/bifid ureter
  • uteropelvic junction anomalies
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2
Q

Diverticuli

A

Outpouching of bladder wall, 1 - 10 cm in diameter

Congenital –> Focal failure of development of normal musculature
- Urinary tract obstruction during fetal development

Acquired –> Secondary to Obstruction - marked muscle thickening of the bladder wall

  • Most often secondary to prostatic enlargement
  • Multiple with narrow necks located between hypertrophied muscle bundles.

Complications

  • urinary stasis – leads to infections
  • infections
  • calculi
  • vesicoureteric reflux
  • malignancy
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3
Q

Exstrophy

A

Developmental failure of the anterior wall of the abdomen –> bladder communicates to the exterior

Complications

  • infection
  • ulceration
  • increased risk of adenocarcinoma

Treatment
- after surgical correction, long term survival

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4
Q

Vesicoureteral reflux

A

Most common and most serious = incompentence of the vesicoureteral valve

  • congenital –> absence or shortening of the intravesicle portion of the ureter - prevents compression of ureter during micturation
  • acquired –> can result from bladder atony in adults, due to spinal cord injury
  • bladder infection can accentuate vesicoureteral reflux

Complications

  • pyelonephritis
  • renal scarring
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5
Q

Congenital/structural defects of the ureter

A

Double/bifid ureter –> usually no clinical significance

Ureteropelvic junction obstruction

  • congenital
  • M>F
  • most common cause of hydronephrosis in children
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6
Q

Causes of obstruction

A
  • urinary calculi (stones) –> deposition of minerals (calcium phosphate, uric acid, calcium oxalate)
  • –> can be extremely painful and cause obstruction
  • –> various treatments
  • blood clots
  • strictures
  • neoplasms
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7
Q

Inflammation/infections

A
  • UTI/infectious cystitis
  • interstitial cystitis
  • malakoplakia
  • polypoid cystitis
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8
Q

Cystitis

  • causes
  • symptoms
A

Causes

  • bacterial –> vast majority = enterobacteriaciea, esp. e coli
  • fungal (candida, crypto, etc), can occur in immunosuppressed patients
  • parasitic –> shistosomiasis (middle east/egypt) is associated with increased risk of squamous cell carcinoma
  • anticancer tx –> cytotoxic drugs (cyclophosphamide) and radiation

Symptoms

  • urinary frequency
  • pain localized to bladder - suprapubic
  • dysuria - pain or burning on urination
  • systemic symptoms may be present = fever, chills, malaise
  • untreated UTIs may lead to pyelonephritis

Most are sporadic –> if underlying cause exists, needs to be corrected

  • prostatic enlargement
  • cystocele of the bladder
  • calculi
  • tumors
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9
Q

Cystitis - morphology

A

Grossly = RED

  • hyperemia
  • exudates
  • hemorrhage
  • ulcerations

Microscopic

  • inflammatory cells
  • edema
  • reactive epithelial changes
  • acute –> neutrophils
  • chronic –> lymphocytes + plasma cells
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10
Q

Interstitial cystitis

A

Form of chronic cystitis - etiology unknown

  • Urine is sterile. Many patients have autoimmune diseases. (not infectious)
  • Trauma, structural defects, infections, immunologic derangements may play a role
  • Affects women&raquo_space; men.
  • Usually highly incapacitating and difficult to treat.

Symptoms:

  • frequency, nocturia, urgency, suprapubic pressure
  • pelvic pain on bladder filling, relieved by voiding***

Pathology –> Non-specific

  • chronic Inflammation
  • edema
  • ulceration
  • fibrosis.
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11
Q

Malacoplakia

A

Mass lesion, typically in bladder or kidney, but can be seen elsewhere

  • chronic bacterial infection, mostly by E. coli or occasionally proteus
  • more common in immunosuppressed transplant patients –> can’t clear infection

Gross –> yellow, raised mucosal plaques

Histology

  • foamy macrophages
  • giant cells
  • lymphocytes
  • rounded mineralized inclusions (calcium phosphate) = Michaelis Gutmann bodies
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12
Q

Polypoid cystits

A

Polypoid inflammatory lesion of the bladder –> results from irritation (most commonly from indwelling catheter)

Microscopically

  • broad, bulbous polypoid projections
  • marked submucosal edema and inflammatory cells

Confused with papillary urothelial carcinoma - both clinically and histologically

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13
Q

Neoplasms

A

Malignant

  • urothelial carcinoma = 90% –> all others are rare
  • squamous cell carcinoma
  • adenocarcinoma
  • small cell carcinoma
  • sarcomas

Benign - all are rare

  • papilloma
  • benign spindle cell tumors

Uncertain
- PUNLMP

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14
Q

Urothelial carcinoma - epidemiology + risk factors

A
  • male >female
  • most patients are between 50 and 80 years of age at diagnosis
  • bladder carcinomas account for 3% of cancer deaths in the USA

Risk factors

  • smoking
  • exposure to aniline dyes (textile, printing, plastic and rubber industries)
  • chronic irritation (calculi, diverticula, parasites, chronic cystitis)
  • analgesic abuse nephropathy

Tumors tend to recur multiple times - usually at different location
- over time, may become less differentiated and more aggressive

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15
Q

Urothelial carcinoma

- flat lesions

A

Flat lesions

  • hyperplasia - thickening
  • atypia - reactive
  • dysplasia - low grade
  • carcinoma in situ - high grade lesion of urothelium that is flat = most important lesion
  • –> flat by definition
  • –> high grade cytology = very ugly cells, lots of mitoses
  • –> confined to mucosa
  • –> precursors to invasive carcinoma
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16
Q

Urotherlial carcinoma - papillary lesions

  • papilloma
  • papillary neoplasm of low malignant potential - PUNLMP
A

Papillary lesions = finger like projections above the surface of the epithelium + fibrovascular cores

Papilloma –> rare, benign, typically younger patients, does not recur
- normal looking urothelium arranged on delicate fibrovascular stalks

Papillary neoplasm of low malignant potential (PUNLMP)

  • thickened epithelium
  • no atypia, at most nuclear enlargement
  • at most rare mitoses at base
  • no invasion
  • potential for recurrence
17
Q

Urothelial carcinoma - papillary lesions

  • papillary carcinoma, low grade
  • papillary carcinoma, high grade
A

Papillary carcinoma, low grade

  • branching papillae, lined by cells in orderly arrangement
  • nuclei uniformly enlarged with mild variation in size, shape and chromatin pattern
  • scattered mitoses at all levels
  • recurrence common
  • invasion is rare - no mets

Papillary carcinoma, high grade

  • overtly malignant - marked atypia analogous to CIS
  • numerous mitotic figures including atypical ones at all levels
  • overall disorderly arrangement with irregularly clustered cells + fused papillae
  • dyscohesive single cells
  • recurrence common –> invasion of stroma common - mets possible
18
Q

Invasive urothelial carcinoma

A

Cells penetrate basement membrane into lamina propria

  • may occur in association with CIS (flat) or high grade papillary urothelial carcinoma
  • no clear prognostic difference between the two
19
Q

Urothelial carcinoma staging

A

Based on the depth of invasion and the presence of mets

Tis:  Flat CIS
Ta: non-invasive papillary
T1: Invision of lamina propria
T2: Invasion of muscularis propria
T3: Invasion into perivesicle fat
T4: Direct spread to adjacent organs
20
Q

Urothelial carcinoma

- symptoms

A

Symptoms - painless hematuria
- an elderly patient, especially male, with even one episode of hematuria should have a malignancy work up because of the high incidence of malignancy in the > 65 male age group

21
Q

Urothelial carcinoma

  • diagnosis
  • treatment
A

Diagnosis

  • urine cytology –> pretty good sensitivity for high grade tumors, but misses low grade
  • cystoscopy –> good for papillary lesions, less sensitive for CIS
  • combining both gives good sensitivity for low/high grade lesions

TX
Resection
- Transurethral (TURBT) –> Non-invasive, or lamina propria invasion
- Cystectomy (partion or radical) –> Muscularis propria invasion

Topical therapy

  • Bacille Calmette-Guerin (BCG)
  • Intravesicle chemotherapy

Systemic chemotherapy
- High-stage tumors

22
Q

Squamous cell carcinoma

Rhabdomyosarcoma

A

Squamous cell carcinoma - Rare in US - strongly associated with schistosoma hematobium infections

Rhabdomyosarcoma - most common bladder tumor in kids

Lectures (46 decks)

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