Ch 21 Flashcards
1
Q
Whats the most common cause of hydronephrosis in infants and kids?
A
ureteropelvic junction (UPL) obstruction
- early cases more likely to be bilateral and happen in males
- in adults, more common in women and bilateral
2
Q
What can urinary stasis lead to if a diverticula is present?
A
recurrent infection
3
Q
tumor-like lesion that presents as a small mass projecting into the lumen
- often in children
- may also occur in the bladder, renal pelvis, and urethra
A
fibroepithelial polyp
- composed of loose, vascularized connective tissue overlaid by urothelium
4
Q
what are the most common primary malignant tumors or the ureters?
A
urothelial carcinomas
5
Q
what type of tissue are renal pelvic carcinoma, bladder malignancy and ureteral carcinoma made up of?
A
urothelial tissue
6
Q
what can an obstruction of the ureteral lumen lead to?
A
hydronephrosis
7
Q
fibrotic proliferative inflammatory process encasing the retroperitoneal structures, causing hydronephrosis
- more common in middle aged men
- associated with IgG4-related diseases
A
Sclerosing Retroperitoneal Fibrosis
8
Q
What are the other causes of sclerosing retroperitonial fibrosis?
A
- drug exposures (ergot derivatives, beta-blockers)
- adjacent inflammatory processes (vasculitis, diverticulitis)
- malignant disease (lymphomas, urinary tract carcinomas
9
Q
What is the treatment for sclerosing retroperitoneal fibrosis?
A
corticosterioids, but will need stents or surgery (uterolysis = exctrication of the ureters from the surrounding fibrous tissue)
10
Q
What can cause a urinary bladder diverticula?
A
often due to increase in intravesical pressure
NOTE: advanced carcinoma is possible, and more advanced as a result of the thin or absent muscle wall of diverticula
11
Q
development failure of the anterior abdominal wall
- exposed bladder mucosa may undergo colonic glandular metaplasia and is subject to infections
A
exstrophy of the bladder
12
Q
what is the treatment for bladder exstrophy?
A
surgery -> long term survival
13
Q
what is a urachal cyst?
A
only the center part is patents and lined by urothelium or metaplastic glandular epithelium
14
Q
E.coli, proteus, klebsiella, enterobacter, chlamydia, mycoplasma, t.cyctisis, candica albicans, and schistoma can all cause what?
A
cystitis
15
Q
bladder calculi, urinary obstruction, DM, instrumentation (catheter), immune defficiency and irradiation of the bladder are all predispositions to what?
A
cystitis
16
Q
hyperemia of the mucose and neutrophillic infiltrate (sometimes with exudate)
A
acute cystitis
NOTE: pt receiving cytotoxic anti-tumor drugs or infected with adenovirus can develop hemorrhagic cyctitis
17
Q
caused by chronic bacterial infection associated with mononuclear cells
A
chronic cystitis
18
Q
presence of lymphoid follicles within the bladder mucosa and underlying wall, not al ways related to infection
A
follicular cystitis
19
Q
infiltration of eosinophils into the submucosa, not always related to infection
A
eosinophilic cystitis
20
Q
what is the clinic triad of cystitis?
A
- frequency (every 15-20 mins)
- lower abdominal pain, localized over bladder/suprapubic region
- dysuria (pain/burning with urination)
21
Q
chronic cystitis, usually female
- pain/dysuria in absence of infection
- early phase: puntatte hemorrhages
- late/classic/ulcerative phase: chronic mucosal ulcer (Hunner ulcers) with inflammation and trandmural fibrosis leading to a contracted bladder
- increased mucosal mast cells
A
interstitial cystitis (Chronic Pelvic Pain Syndrome)
22
Q
chronic bacterial cystitis (E.coli or proteus)
- acquired defect of phagocyte function
- immunocomprimised pt
- 3-4cm soft, yellow mucosal plaques with foamy macrophages
- abundant granular PAS-positive cytoplasm
- Michaelis-gutmann bodies (macrophage with intra-lysosomal laminated calcified concretions -> become giant)
A
Malakoplakia
23
Q
inflammatory lesion from irritation of bladder mucosa
- most commonly due to indwelling catheters, but can be due to any injurious agent
- marked submucosal edema -> broad bulbous polypoid projections
A
polypoid cystitis
24
Q
can be seen in normal bladders or chronic cystitis (two conditions that often occur together)
- nests of transitional epithelium (Bunn nests) grow downward into lamina propria
- nests transform into cuboidal or columnar epithelium (glandularis)
- flattened cells lining fluid filled cysts
A
cystitis glandularis and cistitis cistica
25
response to injury
| - urothelium replaced by nonkeratizing squamous epithelium (more durable)
squamous metaplasia
26
What should squamous metaplasia be distinguished from?
glycosylated squamous epithelium that is normally found in women at the trigone
27
sloughed tubular cells implant and proliferate at sites of injured urothelium
- urothelium turns into cuboidal epithelium that assumes a papillary growth pattern
- possibly extends into superficial detrusor muscle and mimics a malignant process (still benign)
nephrogenic adenoma
28
What tissue type are 95% of bladder cancers from?
epithelial origin
| - remainder are mesenchymal
29
What are bladder neoplasms called?
urothelial or transitional tumors
30
90% of all bladder tumors (may arise anywhere that is urothelium)
- small benign lesions -> aggressive cancers
- often multifocal at presentation
urothelial tumors
31
What are the two precursor lesions of urothelial tumors?
- noninvasive papillary tumors (most common)
| - flat noninvasive urothelial carcinoma (carcinoma in situ)
32
Where do noninvasive papillary tumors arise from?
urothelial hyperplasia
33
high grade epithelial lesions that have cytological features of malignant cells, but are confined to the epithelium and show no evidence of basement membrane invasion
carcinoma in situ
34
typically appear as a large, ulcerated mass
- high grade invasive component destroys the precursor lesion
- invasion into the lamina propria worsens prognosis, but invasion into the muscularis propria (detrusor muscle) is a major factor for survival
invasive bladder cancers
35
what are the risk factors for urothelial carcinoma?
- age (50-80), male
- **smoker** (50-80% of all bladder cancers associated with cigarette use
- industrial exposure
- schistosoma haematobium (Egypt)
- long term use analgesics
- irradiation of other pelvic malignancy
36
FGFR3 rtk
GOF mutation, oncogene
| - noninvasive, low grade papillary carcinomas
37
TP53 and RB
LOF mutation, tumor supressor genes
| - almost always seen in high-grade invasive tumors
38
HRAS
GOF mutation, oncogene
- low-grade non-invasive tumors
NOTE: HRAS and FGFR3 are mutually exclusive in bladder cancer because RAS signal transducers act downstream of rtk's
39
loss of Xsome 9p
specifically loss of CDKN2A tumor supressor gene
| - often only abnormality seen in superficial non-invasive papillary tumors and occasionally in non-invasive flat tumors
40
where do most urothelial tumors arise from?
lateral and posterior walls of the bladder, at the base
| - multiple, discrete tumors often present
41
what are the two characteristics that set papillary urothelial neoplasms of low malignant potential (PUNLMP) apart from papilomas?
1. slightly larger than papillomas
| 2. thicker urothelium
42
orderly cytology and architecture
- minimal atypia
- rarely invade
- rarely fatal
low grade papillary urothelial carcinomas
43
discohesive cells with anaplastic features
- architectural disarray, loss of polarity
- large, hyperchromatic nuclei
- atypical figures
**high risk of invasion into muscular layer, higher risk of progression, and significant metastatic potential
high grade papillary urothelial cancer
44
adjacent structure invasion
- fistulous communications with vagina or rectum
- 40% to regional LN's
- hematogenous spread to liver, lungs, bone marrow
metastases of urothelial tumor of the bladder
45
cytological malignant cells within a flat urothelium
- can range from full thickness atypia to scattered malignant cells in otherwise normal urothelium
- multifocal, no evident intraluminal mass
carcinoma in situ (flat urothelial carcinoma)
46
associated with papillary urothelial cancer, high grade or adjacent CIS
- invasion of muscularis mucosae (detrusor muscle) is prognostically important
invasive urothelial cancer
47
why is biopsy "under-staging" a problem with invasive urothelial cancer?
staging at the initial diagnosis the the **most important** factor in determining the outlook for the patient
NOTE: staging = extent of spread
48
associated with chronic bladder irritation and infection
| - increased incidence in Middle East (unusual in US)
squamous cell carcinoma of the bladder
49
invasive, fungating and/or infiltrating and ulcerating tumors
- more common than purely squamous cell bladder cancers
- can be well differentiated or anaplastic
mixed urothelial carcinomas with areas of squamous carcinoma of the bladder
50
where do adenocarcinomas of the bladder arise from?
some arise from urachal remnants, or in the setting of intestinal metaplasia
51
* *painless hematuria**
- frequency, urgency, dysuria
- pyelonephritis or hydronephrosis may follow if ureteral orifice is involved
- tend to recur after excision at higher grade in different sites
bladder cancer
52
what is the treatment for small, low-grade papillary tumors?
diagnostic transurethral resection, follow with cytoscopy and urine cytology
53
what is the treatment for patients at high risk of recurrence?
intra-vesical instillation of an attenuated strain of mycobacterium bovis (BCG)
- bacteria elicit a local inflammatory reaction the destroys the tumor
54
what are the most common benign mesenchymal tumors or the bladder?
leiomyomas (still rare)
| - they grow as isolated, intramural, encapsulated, oval-to-spherical masses
55
what are the most common sarcomas in kids?
embryonal rhabdomyosarcomas
| - can grow in grape-like mass
56
What are the most common sarcomas in adults?
leiomyosarcoma
57
What is the most common cause of bladder obstruction in males?
prostate enlargement
| - due to nodular hyperplasia
58
what is the most common cause of bladder obstruction in females?
cystocele of the bladder
- bladder wall continues to thicken -> becomes so thick that diverticula forms
- bladder can also become very enlarged and thinned -> reaching the brim of the pelvis or umbilicus
59
Early manifestation of Neisseria gonorrhea infection, often with a more purulent discharge
Gonococcal urethritis
60
most commonly caused by chlamydia trachomatis
| - more serous discharge/no discharge
Non-gonococcal urethritis
61
What do the A-C, D-K, and L1-3 serotypes of non-gonococcal infection cause?
- A-C: leading cause of blindness in the world, cause trachoma
- D-K: GU track one, cause urethritis, pelvic inflammatory disease, ectopic pregnancy neonatal pneumonia, neonatal conjunctivitis
- L1-3: lymphogranuloma venereum (painless lesion)
62
What is urethritis associated with in men and women?
```
women = cystitis
men = prostatitis
```
63
painful, small, red inglammatory lesion of the external urethral meatus in (older) females
- granulation tissue with friable mucosa covering
- bleed easily due to ulceration
- excision is curative
urethral caruncle
64
proximal urethra: slow urothelial differentiation, just like in the bladder
distal urethra; more commonly squamous cell carcinomas
primary carcinoma of the urethra
65
what are uncommon in the urethra, but occur in women if they do appear?
adenocarcinomas of the urethra
66
urethral opening on the ventral aspect of the penis (more common)
hypospadias
67
urethral opening on the dorsal surface of the penis (less common)
epispadias
68
what are both epi and hypospadias associated with?
abnormalities of normal descent of the testes and comorbid with other malformations of the urinary tract
69
prepuce orifice is too small to permit normal retraction
| - developmental causes are less common than secondary to inflammation that cause scarring of the preputial ring
phimosis
70
infection of the glans and prepuce by non-specific organisms (not STD's)
- candida albicans
- anaerobic bacteria
- garnerella
- pyogenic bacteria
** poor hygeine in uncircumcised males -> inflammatory scarring -> phimosis
balanoposthitis
71
benign sexually transmitted wart
- **HPV 6>11**
- single or multiple sessile or pedunculated, red papillary excrescences
- recurrant after incision, rarely becomes malignant
- often at coronal sulcus or inner prepuce
- can present with acanthosis and loilocytosis
Condyloma acuminata (penile tumor)
72
What are the 5 malignant tumors of the penis listed?
1. carcinoma In Situ
2. Bowen Disease
3. Bowen Disease
4. Bowenoid Papulosis
5. Squamous cell carcinoma of the penis
73
What HPV strains are strongly associated with carcinoma in situ?
6, 11, 16 and 18
74
males or female >35 years old***
- solitary** thickened, gray-white plaques over penile shaft (or red shiny lesions) on the glands and prepuce
- epidermis is hyerproliferative, lots of mitoses, some atypia, dysplasia, no orderly maturation
- hyperchromatic nuclei
- intact basement membrane, but 10% can transform into squamous cell carcinoma in approximately 10% of patients over a span of many years
Bowen disease
75
multiple, pigmented papular lesions on external genitalia
- typically younger, sexually active
- multiple** reddish-brown papular lesions
- frequently spontaneously regress
- rarely evolve to invasive carcinoma
Bowenoid Papulosis
76
associated with poor genital hygiene and high risk HPV infection
- 40-70 years old
- higher prevalence in Asia, Africa and south America than US -> d/t lack of circumcision
- smoking increases risk
Squamous cell carcinoma of the penis
77
what is the flat pattern morphology of squamous cell carcinoma of the penis?
epithelial thickening on the glans or inner surface of the prepuce
- progresses to ulcerated papule
78
what is the papillary morphology of squamous cell carcinoma of the penis?
epithelial thickening with graying and fissuring of the mucosal surface
- stimulate condyloma acuminata and may produce a cauliflower-like fungating mass
79
invasive squamous cell carcinoma of the penis
- slow growing and locally-invasive
- often present for a year or more before it is brought to medical attention
- not painful until they secondarily ulcerate and become infected
- metastases to regional (inguinal and iliac) LN's
squamous cell carcinoma of the penis
80
completely asymptomatic, comes to attention when the scrotal sac is discovered to be empty by the pt (or examining physician)
- concominant inguinal hernia accompanies undescended testis in 10-20% of cases
- greater risk of developing testicular cancer with undescended testes
cryptorchidism
81
middle age pt, painless or moderately tender testicular mass of sudden onset sometimes associated with fever
- granulomas are restricted to spermatic tubules
- found diffusely throughout the testes
granulomatous (autoimmune) orchitis
82
retrograde expansion of infection from posterior urethra to prostate, seminal vesicles and epididymis
- ascending infection
- from neglected gonococcal infection
- if left untreated can lead to testis suppurative orchitis
gonorrhea
83
systemic viral infection
- common affects children, though testicular involvement at that age
- 20-30% of post-pubertal men who are infected present with orchitis 1 week after inflammation of parotid glands
mumps
84
congenital or acquired- testes involved first, epididymus is commonly spared
- two morphologic patterns:
1. nodular gummas
2. diffuse interstitial inflammation (histologic hallmark syphilitic infection)
syphilis
