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Flashcards in Pathology of the Bladder Deck (39)

What is important to know about double and bifid ureters?

- may be associated with distinct double renal pelvises.
- may be associated with anomalous development of a large kidney having a partially bifid pelvis terminating in separate ureters.
- double ureters may purse separate courses in the bladder wall and drain through a single ureteral orifice.
*not usually a problem


What does a ureteropelvic junction obstruction cause?

- HYDRONEPHROSIS usually in infants and children (usually boys).
- will see abnormal organization of smooth muscle bundles with excess collagen.


Can diverticula of the ureters occur?

- YES and may cause stasis and secondary infections.


What is ureteritis FOLLICULARIS?

- accumulation of LYMPHOCYTES forming germinal centers, causing elevation of mucosa resulting in a fine granularity.


What is ureteritis CYSTICA?

- mucosa of ureters sprinkled with fine CYSTS lined by flattened urothelium (transitional cells).


Are tumors of the ureters common?

NO, they are very rare.
*fibroepithelial polyp is the one that would form, if it does.


What could obstruct the lumen of the ureter (INTRINSIC)?

- calculi
- strictures
- tumors
- blood clots
- neurogenic causes


What could cause obstruction of the ureter from the outside (EXTRINSIC)?

- pregnancy
- periureteral inflammation
- endometriosis
- tumors


What can result from ureter obstruction?

- hydroureter
- hydronephrosis
- pyelonephritis


*** What is sclerosing retroperitoneal fibrosis?

- fibrous proliferative inflammtory process encasing retroperitoneal structures, causing hydronephrosis.


What inflammatory conditions can contribute to sclerosing retroperitoneal fibrosis?

- vasculitis
- diverticulitis
- Crohn's disease


*** What congenital anomalies can occur in the bladder?

- diverticula= pouch-like projections of the bladder wall. Can be acquired also.
- exstrophy= bladder communicates through a defect in the abdominal wall (aka bladder is outside the abdomen). Surgically correctable, but increased risk of developing ADENOCARCINOMA.


*** What is cystitis?

- infection of the bladder that presents as dysuria, urinary frequency, urgency, and suprapubic pain.
- may have hemorrhage and hyperemia of bladder.
*systemic signs (fever) are usually absent.


What are the lab findings for cystitis?

- uninalysis= cloudy urine with greater than 10 WBCs/hpf.
- dipstick= positive leukocyte esterase (due to pyuria) and nitrities (bacteria convert nitrATES to nitrITES).
- culture= greater than 100k colony forming units.


What are the etiologies of cystitis?

- E. coli (80%)
- Staph saprophyticus (young sexually active women)
- Klebsiella pneumoniae
- Proteus mirabilis (ALKALINE urine with ammonia scent)
- Enterococcus faecalis


What does sterile pyuria (pyuria with negative urine culture) suggest?

- URETHRITIS due to Chlamydia trachomatis or Neisseria gonorrhoeae.


What is interstitial cystitis (Hunner ulcer)?

- inflammation and fibrosis of all layers of the bladder.
- characterized by fissures, hemmorrhages, and ulcers.
- usually in women
- sometimes associated with SLE


Can radiation cause cystitis?

- YES, may mimic squamous cell carcinoma, so make sure you tell the pathologist they had radiation.
*can develop decades after radiation exposure.


What is polypoid cystitis?

- irritation of the bladder mucosa causing polypoid lesions.
- often due to indwelling catheters.


What is cystitis glandularis/cystitis cystica?

- nests of transitional epithelium that eventually transforms to cuboidal or columnar epithelium.


*** What is Malakoplakia?

- soft yellow raised mucosal plaques with large foamy macrophages, multinucleated giant cells, and lymphocytes due to chronic bacterial infection.
- Michaelis-Gutmann bodies= laminated mineralized concretions in macrophages and between cells.
- may be seen in immunosuppressed transplant patients.


What metaplasia can occur in the bladder?

- squamous metaplasia= converts in response to injury.
- nephrogenic metaplasia= resembles cuboidal epithelium of renal cancers.


What are the types of bladder tumors?

- urothelial (transitional cell)= MOST
- squamous cell
- adenocarcinoma


** What are the 2 precursor lesions leading to bladder cancer?

1. noninvasive papillary tumors
2. carcinoma in situ (not invasive)
* often invasive cancer is NOT associated with a precursor lesion.


What are papillomas of the bladder?

- fibrovascular tissue covered with benign epithelium.
- seen in younger age group


What are PUNLMPs?

- Papillary Urothelial Neoplasms of Low Malignant Potential= similar to papillomas but have increased cellular proliferation.
*rarely metastasize, but should remove these anyway.


What is LOW grade papillary urothelial carcinoma?

- one step up from PUNLMPs.
- nuclear atypia and mild pleomorphism (variation in size and shape).


What is HIGH grade papillary urothelial carcinoma?

- large hyperchromatic nuclei
- frank anaplasia (lack of growth; aka growing backwards).
- loss of polarity
- higher risk of invasion
- greater metastatic potential


What is carcinoma in situ of the bladder?

- malignant cells in a FLAT urothelium.
- NO invasion into the lamina propria.
- no intraluminal mass.


*** What is UROTHELIAL (transitional cell) carcinoma?

- malignant tumor arising from the urothelial lining of the renal pelvis, ureter, bladder, or urethra.
*MOST COMMON type of lower urinary tract cancer (usually arises in bladder).


What are some major risk factors for UROTHELIAL (transitional cell) carcinoma?

- cigarette smoke
- naphthylamine (found in cigarettes)
- azo dyes (used for coloring in hair dressers)
- long-term cyclophosphamide or phenacetin use


What is the classic presentation of UROTHELIAL (transitional cell) carcinoma?

- painless hematuria in older adults.


What are the 2 pathways by which UROTHELIAL carcinoma can arise?

1. FLAT= develops as a HIGH-grade flat tumor and then invades (associated with p53 mutations).
- PAPILLARY= develops as a LOW-grade papillary tumor that progresses to a high-grade papillary tumor and then invades.
*tumors are often MULTIFOCAL and RECUR ("field defect").


*** What is SQUAMOUS CELL carcinoma of the bladder?

- malignant proliferation of squamous cells that arise in a background of squamous metaplasia (duh bc there isn't normally squamous epithelium in the bladder).


What are the risk factors for SQUAMOUS CELL carcinoma of the bladder?

- chronic cystitis
- long-standing nephrolithiasis


*** What is ADENOCARCINOMA of the bladder?

- malignant proliferation of GLANDS arising from urachal remnant (urachus was the duct that connected the fetal bladder to the yolk sac), cystitis glandularis (columnar metaplasia from chronic inflammation), or EXSTROPHY.


*** Where would you find ADENOCARCINOMA due to urachal remnant? (HIGH-YIELD)

- at the DOME of the bladder


*** What will you see with Schistosoma haematobium causing SQUAMOUS CELL carcinoma of the bladder?

- terminal spine of parasite (spread by the snail host through water).


What are mesenchymal tumors of the bladder?

- rare, but most common is leiomyoma.
*most common in infancy and childhood is embryonal rhadomyosarcoma.