Bladder Pathology Flashcards
What are the risk factors to developing bladder TCC?
SMOKING, aromatic amines (rubber), B-naphthylamine, benzidine, chronic cystitis, schistosomiasis (squamous type), pelvic irradiation, drugs (phenacetin, cyclophosphamide)
Non-papillary type bladder TCC is p53…
dependent (mutation)
Papillary type bladder TCC is p53…
independent
What is the pathophysiology of papillary type bladder TCC?
grow outwards from urothelium = can become malignant
What is the pathophysiology of non-papillary type bladder TCC?
grows horizontally and downwards = always malignant
what is the spread of bladder TCC?
local – to pelvic structures
lymphatic – to iliac and para-aortic nodes
haematogenous – to liver and lungs
what are the clinical features of bladder TCC?
- Painless haematuria
- Frequency
- Urgency
- Dysuria
- Urinary tract obstruction
- Pain from local nerve involvement or TCC of the kidney and ureter
what is the gold standard investigation for bladder TCC?
Cystoscopy with biopsy
what are the investigations for bladder TCC?
- Cystoscopy with biopsy
- Urine: microscopy/cytology for malignant cells
- Ct Urogram
- Bimanual EUA
- MRI or lymphangiography
what is the criteria for T0 bladder TCC?
No evidence of tumour
what is the criteria for Ta bladder TCC?
Non invasive papillary carcinoma
what is the criteria for T1 bladder TCC?
Tumour invades sub epithelial connective tissue
what is the criteria for T2a bladder TCC?
Tumor invades superficial muscularis propria (inner half)
what is the criteria for T2b bladder TCC?
Tumor invades deep muscularis propria (outer half)
what is the criteria for T3 bladder TCC?
Tumour extends to perivesical fat
what is the criteria for T4 bladder TCC?
Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
what is the criteria for T4a bladder TCC?
Invasion of uterus, prostate or bowel
what is the criteria for T bl4badder TCC?
Invasion of pelvic sidewall or abdominal wall
what is the criteria for N0 bladder TCC?
No nodal disease
what is the criteria for N1 bladder TCC?
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
what is the criteria for N2 bladder TCC?
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
what is the criteria for N3 bladder TCC?
Lymph node metastasis to the common iliac lymph nodes
what is the criteria for M0 bladder TCC?
No distant metastasis
what is the criteria for M1 bladder TCC?
Distant metastasis
what is the management of pTa stage bladder TCC?
transurethral resection. and cystoscopy monitoring
what is the management of pT1 stage bladder TCC?
o Intravesical BCG –as a form of immunotherapy.
Given after the main tumour has been removed by surgery.
The vaccine is left in place in the bladder for 2 hours.
what is the management of pT2 stage and above bladder TCC?
o <70 = radical cystectomy “gold standard” + Post-Op Chemo – M-VAC or neoadjuvant chemo - CMV
o >70, treatment is with radiotherapy
what is frank haematuria?
presence of blood on macroscopic investigation (i.e. looking at the blood)
what is microscopic haematuria?
where you can only see RBC’s on microscopic investigation
what is Haemoglobinurea?
presence of free haemoglobin in the urine
what is initial haematuria?
presence of blood in the urine when you first start micturating – this implies urethral damage
what is terminal haematuria?
presence of blood in the urine at the end of the stream, and this suggests a problem with the prostate or bladder base.
what do ribbon clots suggest?
suggest a ureteric cause
what are kidney bleeds?
can mimic renal colic as the clot passes down the ureter.
what are the kidney causes of haematuria?
Trauma Tumours RCC Calculus Glomerulonephritis Pyelonephritis Renal TB Polycystic disease Renal infarction TCC
what is the ureter cause of haematuria?
Calculus
what are the bladder causes of haematuria?
Calculus
TCC
Acute cystitis
Interstitial Cystitis
what are the prostate causes of haematuria?
BPH
Carcinoma
what are the urethra causes of haematuria?
Trauma
Calculus
Urethritis
what is a bladder prolapse/cystocele?
womens bladder bulges into her vagina
what are the causes of cystocele?
age, heavy lifting, pregnancy, childbirth, chronic lung disease/smoking, FH, ethnicity, pelvic floor trauma, CTD, hysterectomy, cancer of pelvic organs
what is the underlying mechanism of a cystocele?
• Occurs when the muscles, fascia, tendons and connective tissues between a woman’s bladder and vagina weaken, or detach.
what are the different types of bladder prolapse?
midline defect, paravaginal defect, transverse defect, apical cystocele, medial cystocele, lateral cystocele
what is a midline defect bladder prolapse?
cystocele caused by the overstretching of the vaginal wall
what is a paravaginal defect bladder prolapse?
separation of the vaginal connective tissue at the arcus tendineus fascia pelvis
what is a transverse defect bladder prolapse?
when the pubocervical fascia becomes detached from the top (apex) of the vagina.
what is a apical cystocele?
located upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.
what is a medial cystocele?
forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia.
what is a lateral cystocele?
when both the pelviperineal muscle and its ligamentous–fascial develop a defect.
what are the clinical of a cystocele?
a vaginal bulge, pelvic heaviness or fullness, hesitancy, incomplete urination, frequency, urgency, faecal incontinence, frequent UTI, back and pelvic pain, fatigue, painful intercourse, bleeding
what investigations are used in diagnosis of cystocele?
- pelvic exam
- US
- Voiding cystourethrogram
- Urine culture
- Grading – POP-Q
what is the preventative management of cystoceles?
smoking cessation, losing weight, pelvic floor strengthening, treatment of chronic cough, maintaining heathy bowel habits – high fibre food, avoid constipation
what is the non-surgical management of cystocele?
pessary, pelvic floor muscle therapy, dietary changes, oestrogen
what is the surgical management of cystocele?
wall repair
what are the causes of interstitial cystitis?
- An antiproliferative factor
- PAND
- Associated with: IBS, Fibromyalgia, Chronic fatigue, Allergies, Sjogren
what is the pathophysiology of interstitial cystitis?
Unknown
Several theories: autoimmune theory, nerve theory, mast cell theory, leaky lining theory, infection theory, and a theory of production of a toxic substance in the urine, neurologic, allergic, genetic, and stress-psychological
what are the clinical features of interstitial cystitis?
Suprapubic pain, frequency, Painful intercourse, dysuria, Hesitancy, Pelvic pain worsen with filling of bladder, and improve with urination, Hunners Ulcers
how is interstitial cystitis diagnosed?
Exclusion tests plus hydrodistention during cystoscopy with biopsy.
what is the 1st line management of interstitial cystitis?
education, self care (diet modification), stress management
what is the 2nd line management of interstitial cystitis?
physical therapy, oral medications (amitriptyline, cimetidine or hydroxyzine, pentosan polysulfate), bladder instillations (DMSO, heparin, or lidocaine)
what is the 3rd line management of interstitial cystitis?
treatment of Hunner’s ulcers (laser, fulguration or triamcinolone injection), hydrodistention (low pressure, short duration)
what is the 4th line management of interstitial cystitis?
neuromodulation (sacral or pudendal nerve)
what is the 5th line management of interstitial cystitis?
cyclosporine A, botulinum toxin (BTX-A)
what is the 6th line management of interstitial cystitis?
surgical intervention (urinary diversion, augmentation, cystectomy)
