4. Genitourinary p33-37 (Bladder)

Question 1

Normal anatomy (3)

Answer 1

Extraperitoneal structure with 4 layers.
Dome of bladder has peritoneal cover.
Lined with transitional urothelium

Question 2

Prune belly (Eagle Barrett) (5)

Answer 2

Malformation triad occuring in babies.
Classically shown with baby shaped like a pear (big wide belly)
Triad:
- Deficiency of abdmonal musculature
- Hydroureteronephrosis
- Cryptorchidism (bladder distention interfered with descend of testes)

Question 3

Bladder diverticula (5)

Answer 3

More common in males.
Most are due to chronic outlet obstruction (big prostate).
Associated with some syndromes, like Ehlers Danlos.
Bladder diverticula usually arise from lateral walls or near ureteral orifices.
Diverticula at anterior/superior bladder more likely to be urachal diverticula.
Ureters more commonly deviate medially adjacent to diverticula.

Question 4

Hutch diverticulum (2)

Answer 4

Occurs at UVJ and NOT associated with posterior urethral valves.
Associated with ipsilateral reflux (normal slanted insertion of ureter is altered.

Question 5

Bladder ears (4)

Answer 5

Transitory extraperitoneal herniation of the bladder.
Not a diverticulum, but lateral protrusion of bladder into inguinal canal.
Common, associated with inguinal hernia.
Smooth wall and wide neck differentiates it from diverticulum.

Question 6

Cloacal malformation (2)

Answer 6

GU and GI both drain into common opening (like a bird).
Only happens in females.

Question 7

Urachus (4)

Answer 7

Umbilical attachment of the bladder usually atrophies and becomes the umbilical ligament, as bladder descends into the pelvis.
Persistent patent urachus can result in urine flow from bladder to umbilicus.
Spectrum from patent > sinus > diverticulum > cyst.
Can get infected. Seen in midline. Associated with adenocarcinoma.

Question 8

Rhabdomyosarcoma (4)

Answer 8

Most common bladder cancer under 10 years old.
Often infiltrative, hard to tell where they originate.
“paratesticular mass” is often a buzzword.
Can met to lungs, bones, nodes.
Botryoid variant produces a polypoid mass, looks like bunch of grapes.

Question 9

Squamous cell carcinoma (2)

Answer 9

Associated with schistosomiasis.
Heavily calcified bladder and distal ureters.

Question 10

TCC (2)

Answer 10

Most common site of TCC.
Most common subtype is Superficial Papillary.

Question 11

Adenocarcinoma of bladder (2)

Answer 11

Associated with urachus.
90% of urachal cancers are midline at bladder dome.

Question 12

Leiomyoma (3)

Answer 12

Benign tumour, often incidentally discovered.
Most common at trigone.
Most common mesenchymal bladder tumour.

Question 13

Diversion surgery (2)

Answer 13

After cystectomy for bladder cancer, several urinary diversion procedures can be done. Usually split into incontinent and continent.
General idea is a piece of bowel is made into either a conduit or reservoir, then ureters are attached to it.

Question 14

Diversion surgery - early complications (3)

Answer 14

Alteration in bowel function
- Adynamic ileus is commonest early complication, in almost 25%. 3% get SBO, usually from adhesions near enteroenteric anastamosis.
Urinary leakage
- 5% of cases, usually at ureteral-reservoir anastamosis. Urinoma can develop when leaked urine isn’t collected by urinary drains.
Fistula
- Uncommon, seen more after pelvic radiation

Question 15

Diversion surgery - late complications (6)

Answer 15

Urinary infection (can be early or late)

Stones (look at non contrast study)

Parastomal herniation
- 15% with ileal conduits, obesity is a contributing factor. 10% need surgical Rx.

Urinary stricture
- Left side is higher risk than right, due to angulation (brought through or under mesentery)

Tumour recurrence
- more advanced original disease = higher risk of recurrence.
- Incidence between 3-15%, can present as soft tissue mass at ureter, bladder or pelvis lymph node.

Question 16

Emphasematous cystitis

Answer 16

Gas forming organism in wall of bladder. Usually diabetic. Usually E.Coli.
Dirty shadowing on US.
Gas in wall of bladder on CT.

Question 17

TB

Answer 17

Upper GU tract is more commonly affected, with secondary bladder involvement.
Can lead to thick, contracted bladder.
Calcification may be present.

Question 18

Schistosomiasis

Answer 18

Common in third world.
Eggs deposited in bladder wall, leading to chronic inflammation.
Entire bladder is calcified. Can lead to squamous cell Ca.

Question 19

Fistula

Answer 19

3 conditions: Diverticulitis (Colovesicular), Crohns (Ileovesicular), Cancer or trauma (rectovesical).
More common in men. More common in women post hysterectomy (uterus protects bladder)

Question 20

Neurogenic bladder (3)

Answer 20

Either small contracted bladder or atonic large bladder.
“Pine Cone” bladder, due to appearance.
Can lead to urine stasis, predisposing to bladder cancer, stones, infection

Question 21

Acquired bladder diverticula

Answer 21

Acquired mainly via outlet obstruction (big prostate).
Commonest at UVJ.
Can lead to stasis, leading to bladder Ca, stones, infection.

Question 22

Bladder stones

Answer 22

Either kidney stones which make their way distally, or developing in the bladder due to urine stasis.
Can cause chronic irritation.
Known risk factor for TCC and SCC

Question 23

“Pear shaped bladder”

Answer 23

Caused by pelvic lipomatosis or Haematoma

Question 24

Bladder rupture

Answer 24

CT cystography needed to determine clinically important intra vs extraperitoneal.

Question 25

Extraperitoneal bladder rupture

Answer 25

More common (80%), usually associated with pelvic fracture.
Managed medically.
Pelvic fracture confers 10% risk of bladder rupture.
Molar tooth sign: Contrast surrounding bladder in prevesical space of Rezius. Indicates extraperitoneal bladder rupture

Question 26

Intraperitoneal bladder rupture

Answer 26

Less common. Direct trauma to full bladder.
Essentially bursts the top off the bladder (dome is weakest part).
Contrast outlining bowel loops and in paracolic gutters.
Requires surgery.