Chapter 21. Male GU Flashcards
(98 cards)
1
Q
Where can field effect GU cancers occur due to urothelial carcinoma of the renal pelvis?
A
Ureters, bladder and urethra.
2
Q
Most common cause of hydronephrosis in children/infants?
A
Ureteropelvic junction (UPJ) obstruction
3
Q
If Ureteropelvic junction (UPJ) Obstruction occurs in children which sex is preferentially affected?
Bilateral or unilateral?
In adults?
A
Children —> males; sometimes bilateral
- Adults —> woman; most often unilateral
4
Q
About 1/3 of children w/ recurrent UTI’s are found to have what?
A
Vesicoureteral reflux; most commonly dx in infancy/childhood
5
Q
Why is damage to the ureters during surgery so dangerous?
A
They are located near a shit ton of BV and organs
6
Q
How can we ID abnormalaties of the ureter early?
A
Aberrant ureteral anatomy
7
Q
Where do the ureters lie in the body?
A
Retroperitoneal postiion
8
Q
What can happen if we have a retroperitoneal tumor/fibrosis?
A
It can entrap the ureters or obstruct them.
9
Q
As the ureter enter the pelvis, what arteries do they pass in front of?
What arteries do they lie near when they are in the female pelvis?
A
- Common iliac or external iliac.
- Uterine arteries; so be careful when there is surgery to female GU tract.
10
Q
What are the proposed 3 points of narrowing where kidney stones can lodge?
A
- Uteropelvic junction*
- Where they cross the iliac arteries
- As the enter the bladder. *
*new research shows only these 2 exist.
11
Q
Although rare, what is the most common primary malignant tumor of the Ureters?
Most often occurs when and causes what?
A
- Urothelial carcinomas
- 60s-70s causing obstruction
12
Q
What is the most common malignant mesenchymal tumor of the bladder seen in infants/children?
Often have what type of growth pattern?
A
- Embryonal rhabdomyosarcoma
- Polypoid mass of grapes = Sarcoma botryoides
13
Q
What is the most common malignant mesenchymal tumor seen in the bladder of adults?
A
Leiomyosarcoma
14
Q
Why is ureteral obstruction clinically significant?
A
Compromise renal function by causing hydronephrosis or pyelonephritis
15
Q
In children, what is the most common obstructive lesion in the kidney?
A
Congenital UPJ obstruction
16
Q
In adults, uretal obstructions can be acute or chronic.
Give an example of a cause for each?
A
- Acute: kidney stone
- Chronic: intrinsic/extrinsic tunors or sclerosing retroperitoneal fibrosis
17
Q
What are Congenital Abnormalities of the ureter?
A
-
Double or bifed ureters
- unilateral and not clinically important
- UPJ Obstruction
-
Diverticula: saccular outpouchings of the ureteral wall that can be acquired or congenital
- Asx unless traps urine, causing recurrent infections
18
Q
Uteritis is associated with ________.
Clinically significant?
A
- Inflammation, not infection of the ureters.
- No
19
Q
Unilateral ureteral obstruction is typically due to: _______ causes,
Bilateral obstruction is typically due to: ________ causes
A
- Unilateral: proximal causes
- Bilateral: distal causes
20
Q
Obstructions to the uterus can cause what 3 things?
A
- 1. Hydroureter (dilation of ureter)
- 2. Hydronephrosis
- 3. Pyelonephritis
21
Q
Sclerosing Retroperitoneal Fibrosis most often occurs in which age group and sex?
What is it?
A
- Middle - late age Men
- Fibrotic proliferative inflammatory process of retroperitoneal structures causing hydronephrosis => narrow and obstruct the ureter
22
Q
A subset of Sclerosing Retroperitoneal Fibrosis is associated with what immunological related disease?
A
IgG4-related disease
an immunologic related disease
23
Q
Most cases of Sclerosing Retroperitoneal Fibrosis arise how and are known as?
A
- No obvious cause = considered primary or idiopathic
- Ormond disease
24
Q
What are some of the common secondary causes of retroperitoneal fibrosis, which may lead to ureteral obstruction?
A
- Drugs (ergot derivatives, β-blockers)
- Adjacent inflammatory conditions –> vasculitis, diverticulits, Chron’s
- Malignant disease –> lymphomas, urinary tract carcinomas
25
**Initial** treatment and **long term** treatment of **Sclerosing Retroperitoneal Fibrosis?**
- **Corticosteroids**
- Eventually require ureteral **stents** or **surgical extrication** of ureters from surrounding fibrous tissue (**ureterolysis**)
26
What are the 4 major **extrinisic** causes of **obstruction of ureters?**
1. **Pregnancy** --\> relaxation of smooth m. or pressure on ureters
2. **Periureteral inflammation** --\> salpingitis, diverticulitis, peritonitis
3. **Endometriosis**
4. **Tumors**
27
what layer of the urinary wall do **bladder cancers** arise from?
**Urothelium (mucosal surfaces)**
28
**Diverticulae** is pouchlike evagination of the bladder wall.
Are they more commonly inherited or acquired?
**Acquired.**
29
**Acquired diverticulae** of the **bladder** are most often seen in association with?
Clinical significance?
**Prostate hypertrophy** that **obstructs urethral outflow**, causing a _increase in intravesicle pressure_ and _thickening_ of the bladder wall.
30
**Congenital diverticulae** of the **bladder** are usually due to what?
* **Muscles do not develop properly**
* **UT obstruction in fetal development**
31
**Bladder diverticulae** are clinically significant because they can predispose to what?
1. - **Urinary stasis** --\> **infection** and forming **bladder calculi**
2. - If they impinge on the ureter, can cause **vesicoureteral reflux**
3. - Rarely, **carcinoma** may arise; tend to be in more advanced stage
32
What is **exstrophy**?
Exposed bladder bc abdominal wall doesnt fuse, which can lead to **colonic glandular metaplasia** and **infection** that can spread to **upper GU tract.**
33
Patients with **exstrophy** of the bladder have an increased risk of what cancer?
**Adenocarcinoma** arising in bladder remnant
34
What is the prognosis if a baby is born with **exstrophy** of the bladder?
If done early, l**ong-term survival is HIGH.**
35
When does **vesicoureteral reflux** occur?
Ureter NTRs the bladder at an unusual angle or when the length of the ureter through the bladder wall is too short, causing **valve malfunction** and reflux.
36
When does **VUR** become a problem?
When **urinary stasis** causes **infection** in the ureter and kidney
37
**Abdominal pain** and **fever** in a **4 yo** w/ a CT showing a heterogenous mass in the midline anterior to the bladder is consistent with what?
**Infected urachal remnant/ _urachal cyst_**
38
**Urachal Cyst c**an lead to what cancer?
**Bladder adenocarcinoma**
39
**Cystitis** is very common and occurs more often in F due a shorter urethra. It often precedes bacterial pyelonephritis.
## Footnote
**Triad of symptoms?**
1. **Increase frequency and urgency**
2. **Dysuria**: pain when peeing
3. **Lower abdominal pain**
40
**Fevers of unkown origin** can be due to what?
**Cystitis**
41
How can we differentiate between patients with **acute cystitis** or those complicated with **UTI**?
People with **UTI**
* 1. Have an **anatomic abnormality**
* 2. Vulnerable **disease state** that leaves their UT more prone to UTIs
* 3. UTIs caused by resistant pathogens.
42
What are the most common causes of **cystitis**?
* 1. **E.coli**
* 2. Proteus
* 3. Klebsiella
* 4. Enterobacter
* Other: Staph saprophyticus
43
What can cause a **Cystitis** in immunocompromised?
* Mycobacteria
* Fungi
* Viruses
* Protozoa
44
What are **pre-disposing** factors to cystitis?
* 1. Bladder calculi
* 2. Urinary obstruction or structural abnormalities
* **3. DM**
* **4. Instrumentation**
* **5. Immune deficiency**
45
Which **gram negative**, **obligate intracellular** _bacteria_ may cause cystitis?
Which 2 organisms can cause cystitis in immunocompromised pts or those receiving long-term Abx?
**-Chlamydia**
**-Candida albicans\*\*\* or cryptococcal agents**
46
What is the morphology of a patient with **acute cystitis?**
* **Inflammation**: **Hyperemia** of mucosa, **neutrophils** (pyruria; inc WBC) and sometime an **exudate**
47
What leads to **chronic cystitis?**
How is it different from **acute?**
**-Persistance of bacterial infection.**
-Has **mononuclear** inflammatory cells and **THICKND BLADDER WALL.**
48
What 2 things can lead to **hemorrhagic cystitis?**
* 1. **Adenovirus**
* 2. Patients taking **cytoxic anti-tumor drugs** (cyclophosphamide)
49
**Chronic, persistent, painful form of cystitis** characterized by:
* intermittent, often severe suprapubic pain,
* urinary frequency, urgency,
* hematuria and dysuria
* **without evidence of bacterial infection is known as?**
**Interstitial Cystisis** (Chronic Pelvic Pain Syndrome/ Hunner Ulcer)
50
What will **cystoscopy** show in someome with **Interstital Cystitis?**
Fissures/punctate **hemorrhages** in **bladder mucosa** (**glomerulations/Hunners ulcers)**
51
How does one get **Interstitial Cystitis?**
Who is more common in?
What do we see on **LM**?
* **Idiopathic**, but can be autoimmune
* **Women 30-40**
* **Inflammation** and **fibrosis** of the **bladder wall** and fissures and **mast cells,** lymphocytes.
52
What is **Malakoplakia** and what is it caused by?
* **Chronic inflammatory reaction** that forms **granulomas** and **mucosal plaques** in the bladder.
* Due to **defects in the function of phagocytes** & chronic infection by **E.coli** and sometimes **Proteus**.
53
**Malakoplakia** occurs with increased frequency in which patients?
* **Middle-aged F**
* **Immunosupressed**
54
**Malacoplakia** produces what on the bladder?
Yellow, slighly-raised **mucosal plaques** that can involve the bladder and other organs
-**Granulomas** filled with _foamy MO,_ _giant cells_ and _lymphocytes_
55
Major characteristics histological finding is assx w/ **Malakoplakia**?
* **-Michaelis-Gutmann bodies: r**ound mineralized concentrations of Ca2+ in lysosomes of **MO**
* -MO also have alot of **granular cytoplasm**
56
**Polypoid Cystitis** is most commonly due to what?
What is the characteristic morphology of the urothelium?
* Inflammatory condition due to **irradiation** of the **bladder mucosa**, most often i**ndwelling cathers**
* **Submucosal edema** causes _broad bulbous polypoid_ projections
57
**Polypoid Cystitis** may be confused with what malignancy both clinically and histologically?
**Papillary urothelial carcinoma**
58
What are **Cystitis glandularis** and **cystitis cystica?**
**Chronic inflammatory metaplastic lesions** of the bladder where nests of urothelium (von Brunn nests) grow down into lamina propria and epithelial cells in the center undero metaplasia.
that occur in the setting of chronic irradiation due to irrtants such as infection, stones, obstruction, tumor that undero **metaplasia.**
59
What causes CC/CG?
Chronic inflammation d/t irrtants such as infection, stones, obstruction, tumor that occur in the setting of chronic irradiation .
60
**von Brunn nests then** differentiate into what?
1. Cystic deposits w flat urothelium (**CC)**
2. Intestinal columnar goblet cells (secrete mucus), resulting in **CG**
61
* In **CC and CG**, what do we see on LM?
* When do they occur and in who?
* Sx?
* -**Features of both**, not just one bc they both tend to co-exist
* - **Any age,** slightly more in M
* -**Chronic irration;** frequenxcy, dysruria, urgency and heamturia
62
1. Bladder infection manifested by submucosal eosinophils d/t subacute inflammation
2. Bladder infection d/t chronic inflammation characteristized by lymphocytes in lymphoid follicles in mucosa and wall.
**Eosinophilic cystitis**
**Follicular cystitis**
63
**Acute** and **chronic bacterial cystitis** is extremely common, particularly in \_\_\_\_\_\_\_\_, and results from what?
**Women**
**Retrograde spread of colonic bacteria**
64
Some inflammatory or metaplastic bladder lesions are significant in that they can **mimic bladder.** Which ones are these
* **1. Malakoplakia**
* **2. Polypoid cystitis**
* **3. CC/CG**
* **4. Nephrogenic adenoma**
65
Epithelial cells undergoing metaplasia in the center of Brunn nests taking on a **cuboidal** or **columnar** appearance is known as?
**Cystitis glandularis**
66
are **NON-epithelial tumor**s of the bladder common?
* **NO! 95% of bladder cancers are from epithelial cells.**
* **The rest are mesenchymal origin.**
But the most common is a **leiomyoma**.
67
What are other **benign neoplasm**s that can occur in the bladder?
* **1. Lipoma**
* **2. Fibroma**
* **3. Neurofibroma**
* **4. Other (inflammatory pseudotumor)**
68
What are other **malignant neoplasms** that can occur in the bladder?
1. **Rhabdomyosarcoma (childhood)**
2. **Leiomyosarcoma (adults)**
3. **Lymphoma**
4. **Other**
69
What is the most common malignant **mesenchymal tumor** of the bladder seen in infants/children?
Often seen manifesting with what type of growth pattern?
- Embryonal rhabdomyosarcoma
- Manifest as a **polypoid grapelike mass** (Sarcoma botryoides)
70
What is the most common malignant **mesenchymal** tumor seen in the bladder of **adults**?
* **Leiomyosarcoma**
71
About 95% of bladder tumors are of **\_\_\_\_\_\_\_** origin, the remainder are ________ tumors. most epithelial tumors are ______ cell type.
At presentation, many urothelial tumors are \_\_\_\_\_\_\_. Through most common in the bladder, all of the urothelial tumors can be seen at \_\_\_\_\_\_\_\_\_\_\_
About 95% of bladder tumors are of **epithelial** origin, the remainder are **mesenchymal** tumors. most epithelial tumors are **urothelial** cell type.
At presentation, many urothelial tumors are **multifocal**. Through most common in the bladder, all of the urothelial tumors can be seen **at any site where there is urothelium, from the renal pelvis =\> distal urethra.**
72
What are the **2 distinct precursor lesions** of _invasive urothelial carcinoma of the bladde_r and which is most common?
Type of grade for each?
1. **Noninvasive** **papillary urothelial carcinoma** (low- or high-grade) = _most common_
2. **Noninvasive** **Flat urothelial carcinoma in situ** (uniformly high grade)
73
* **CIS** is used to descrbe what?
* About half of the time, why is a **precursor lesion NOT detected** in a invasive bladder cancer?
* CIS epithelial lesions that have cytologic features of malignancy, but are confined to the epithelium, showing no sign of BM invasion
* Bc the tumor has **already invaded** the bladder wall.
74
* The incidence of carcinoma of thre bladder is higher in **_M/W/Equal?_**
* **Age?**
* **Race?**
* **Heriditary/familial or sporadic?**
* Men
* 50-80
* white
* NOT familial
75
What are 6 risk factors associated with **urothelial carcinoma of the bladder?**
**1. Cigarette smoking --\> 3-7x ↑ risk**
2. Industrial exposure to aryl amines
3. Schistosoma hematobium (SCC-70%)
4. Long-term use of analgesics
5. Long-term exposure to cyclophosphamide
6. Radiation
76
* Loss of genetic material on which chromosome are particularly common in urothelial carcinoma?
* Which genetic mutation associated with urothelial carcinoma is a poor prognostic indicator?
- **Chromosome 9**
* **- Monosomy or deletions of 9p and 9q**
- **p53**
77
* Non-invasive **high-grade urothelial carcinom**a is associated with what genetic mutations allowing for progression to invasion?
* Non-invasive l**ow-grade papillary urothelial carcinoma** is associated with what genetic mutations?
* **Loss of TP53 or RB** ---\> frequently progesses to muscle invasive dz
* Gain of function **FGFR3** and **HRAS** mutations
78
The appearance of urothelial tumors ranges from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Overall, the majority of papillary tumors are low grade.
**purely papillary =\> flat.**
79
When do **embryonal rhadomyosarcomas** occur and in when gender?
## Footnote
**Leiomyosarcoma?**
* **Children** (4 YO);
* **=** in M and W
* **60** YO
* **Men**
80
**Dominant** and **sometimes only clinical finding** associated with urothelial carcinoma of the bladder **is** \_\_\_\_\_\_\_\_\_\_\_\_
* **Painless Hematuria**
* Discomfort is more likely in flat, hematuria in papillary.
81
What is the critical prognostic factor for **bladder cancer**?
Why is grading not as important to establish.
- **Extent of spread/depth (staging),** not grading (bc almost all invasive bladder cancers are high-grade
* - **Muscle invasion** i.e., depth of muscle invasion is **major prognostic issue to be established**
*
82
Major decrease in survival rates associated with bladder cancer is due to?
* **Invasion** of the **muscularis propria (detrusor m.)**
83
Although rare, what type of lymphoma may involve the bladder as a either a **primary lesion** but is much more common as a part of a systemic disease?
**Non-Hodgkin lymphoma (diffuse large B-cell and MALT)**
84
What are the features of **sarcomas** (mesenchymal tumors) which are distinct from other tumors of the bladder?
- Produce **large masses**
- **Protrude** **into** the vesicle **lumen**
85
What is the most common cause of bladder obstruction in a female?
**Cystocele** of the bladder
86
Implantation of shed renal tubular cells at sites of injured urothelium (nephrogenic adenoma), the overlying urothelium may be focally replaced by what?
Assuming what type of growth pattern?
- Replaced by **cuboidal epithelium**
- Assume a **papillary growth pattern**
87
In two-pathway model, low-grade superficial papillary tumors are characterized by what genetic mutations first and then second?
1) **FGFR3** and **RAS** mutations + chromosome 9 deletions
2) May then lose TP53 or RB ---\> invasion
88
What is the major pathologic finding of **Papillary Urothelial Neoplasia of Low Malignant Potential (PUNLMP)** that distinguishes it from papilloma?
* - **THICKENED** **urothelium** covering papillary projections
* - Also tend to be **larger** & **little atypia**
89
**High-grade papillary urothelial cancers** contain what morphologically distinct cells and other findings?
- **Dyscohesive cells** w/ large **hyperchromatic nuclei**
- Some cells are highly **anaplastic**
- **Loss** of **polarity**
90
The lack of cohesiveness in **high-grade papillary urothelial carcinoma** and **flat urothelial CIS,** results in what common finding?
**Shedding** of malignant cells into the urine
91
What are 2 treatment options utilized in the majority of patients with **non-invasive** urothelial carcinoma of the bladder?
1. T**ransurethral resection** (TUR) and surveillance
2. **Intravesical therapy** - chemotherapy or instillation of an attenuated strain of Mycobacterium bovis called bacillus Calmette-Guerin (BCG)
92
What are 2 treatment options utilized in the majority of patients with **invasive** urothelial carcinoma of the bladder?
1. Segmental cystectomy
2. Radical cystectomy w urinary division
3. Immunotherapy and photodynamic therapy
93
With high recurrence and the possibility of progression, how can we follow urothelial neoplasms?
What is not a good to use?
* Urine cytology is **NOT** a good idea: low specificity.
* **Stone, inflammation or instrument artifact** can mimick low grade.
94
**Painless hematuria** is the most common presenting symptom of bladder cancer and requires __________ to rule or urethelial neoplasma
* **cytoscopy**
* **urine cytology**
95
**Urethritis** (inflammation of the urethra) can be divided into what 3 causes?
* 1. **Gonoccocal** urethritis
* 2. **Non-gonoccoccal** urethritis
* 3. **TRULY** non-infectious
96
Gonococcal urethritis is the earliest manifestation of infection by which organism?
What is the gram stain and morhphology of this organism?
- **Neisseria** gonorrhea
- **Gram (-); diplococcus**
97
Which organisms may be responsible for **Non-Gonococcal Urethritis?**
* \*\***Chlamydia trachomatis** (D-K serotypes) = gram (-), ovoid, non-motile
* **Mycoplasma** (Ureaplasma urealyticum)
98
**Urethritis** is most often accompanied by what in men and what in women?
- **Men** = prostatitis
- **Women** = cystitis
