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CPR-2 > Chapter 21: Lower Urinary Tract - Ureters, Bladder, Urethra > Flashcards

Chapter 21: Lower Urinary Tract - Ureters, Bladder, Urethra Flashcards

1
Q

Most common cause of hydronephrosis in children/infants?

A

Ureteropelvic junction (UPJ) obstruction

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2
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
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3
Q

About 1/3 of children w/ recurrent UTI’s are found to have what?

A

Vesicoureteral reflux; most commonly dx in infancy/childhood

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4
Q

Although rare, what is the most common primary malignant tumor of the Ureters?

Most often occurs when and causes what?

A
  • Urothelial carcinomas
  • 6th-7th decade of life causing obstruction
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5
Q

What is the most common malignant mesenchymal tumor of the bladder seen in infants/children?

Often seen manifesting with what type of growth pattern?

A
  • Embryonal rhabdomyosarcoma
  • Manifest as a polypoid grapelike mass = Sarcoma botryoides
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6
Q

What is the most common malignant mesenchymal tumor seen in the bladder of adults?

A

Leiomyosarcoma

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7
Q

What are the 2 distinct precursor lesions of invasive urothelial carcinoma of the bladder and which is most common?

Type of grade for each?

A
  1. Papillary urothelial carcinoma (low- or high-grade) = most common
  2. Flat urothelial carcinoma in situ (uniformly high grade)
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8
Q

Non-invasive high-grade urothelial carcinoma is associated with what genetic mutations allowing for progression to invasion?

A

Loss of TP53 or RB —> frequently progesses to muscle invasive dz

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9
Q

Non-invasive low-grade papillary urothelial carcinoma is associated with what genetic mutations?

A

Gain of function FGFR3 and HRAS mutations

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10
Q

What are 6 risk factors associated with urothelial carcinoma of the bladder?

A
  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
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11
Q

Loss of genetic material on which chromosome are particularly common in urothelial carcinoma?

A
  • Chromosome 9
  • Monosomy or deletions of 9p and 9q
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12
Q

Which genetic mutation associated with urothelial carcinoma is a poor prognostic indicator?

A

p53

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13
Q

What are 2 treatment options utilized in the majority of patients with non-invasive urothelial carcinoma of the bladder?

A
  1. Transurethral resection (TUR) and surveillance
  2. Intravesical therapy - chemotherapy or instillation of an attenuated strain of Mycobacterium bovis called bacillus Calmette-Guerin (BCG)
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14
Q

What is the dominant and sometimes only clinical finding associated with urothelial carcinoma of the bladder?

A

Painless Hematuria

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15
Q

What is the critical prognostic factor for bladder cancer?

A
  • Extent of spread (STAGE) = critical prognostic factor
  • Muscle invasion i.e., depth of muscle invasion is major prognostic issue to be established
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16
Q

Major decrease in survival rates associated with bladder cancer is due to?

A

Invasion of the muscularis propria (detrusor m.)

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17
Q

Unilateral ureteral obstruction typically results from _______ causes, whereas bilateral obstruction arises from ________ causes

A

Unilateral ureteral obstruction typically results from proximal causes, whereas bilateral obstruction arises from distal causes

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18
Q

Sclerosing Retroperitoneal Fibrosis most often occurs in which age group and sex?

Characterized by and leads to what?

A
  • M > F; occurs in middle to late age
  • Fibrotic proliferative inflammatory process of retroperitoneal structures causing hydronephrosis –> urethral narrowing/obstruction
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19
Q

A subset of Sclerosing Retroperitoneal Fibrosis is associated with what immunological related disease?

A

IgG4-related disease

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20
Q

What are the 4 major extrinisic causes of Ureteral Obstruction?

A
  1. Pregnancy –> relaxation of smooth m. or pressure on ureters
  2. Periureteral inflammation –> salpingitis, diverticulitis, peritonitis
  3. Endometriosis
  4. Tumors
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21
Q

Most cases of Sclerosing Retroperitoneal Fibrosis arise how and are known as?

A
  • No obvious cause = considered primary or idiopathic
  • Ormond disease
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22
Q

What are some of the common secondary causes of retroperitoneal fibrosis, which may lead to ureteral obstruction?

A
  • Drug exposures (ergot derivatives, β-blockers)
  • Adjacent inflammatory conditions –> vasculitis, diverticulits, Chron’s
  • Malignant disease –> lymphomas, urinary tract carcinomas
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23
Q

Initial treatment and long term treatment of Sclerosing Retroperitoneal Fibrosis?

A
  • Corticosteroids
  • Eventually require ureteral stents or surgical extrication of ureters from surrounding fibrous tissue (ureterolysis)
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24
Q

Acquired diverticulae of the bladder are most often seen in association with?

Clinical significance?

A
  • Most often w/ prostatic enlargement (hyperplasia or neoplasia)
  • Produce obstruction to urine outflow and marked bladder wall thickening
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25
Q

Bladder diverticulae are clinically significant because they may predispose to what?

A
  • Sites of urinary stasis–>infectionand formingbladder calculi
  • Predispose to vesicoureteral reflux if impinge on ureter
  • Rarely, carcinoma may arise; tend to be in more advanced stage
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26
Q

The exposed bladder mucosa in exstrophy of the bladder may undergo what transformation?

Is subject to what?

A
  • Colonic glandular metaplasia
  • Subject to infections which may spread to upper levels of urinary tract
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27
Q

Patients with exstrophy of the bladder have an increased risk of what malignancy?

A

Adenocarcinoma arising in bladder remnant

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28
Q

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?

A

Infected urachal remnant/cyst

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29
Q

Which malignancy may potentially arise from a Urachal Cyst?

A

Bladder adenocarcinoma

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30
Q

Which gram negative, obligate intracellular parasite may cause cystitis?

A

Chlamydia

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31
Q

Which 2 organisms are a cause of cystitis in immunocompromised pts or those receiving long-term Abx?

A
  1. Candidia albicans = more common
  2. Cryptococcal agents
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32
Q

Which virus may causes cystitis and hemorrhagic cystitis?

A

Adenovirus

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33
Q

Classic triad of cystitis sx’s?

A

1) Frequency –> every 15-20 mins in acute cases
2) Lower abdominal pain - suprapubic region
3) Dysuria - pain or burning on urination

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34
Q

What are 2 patterns of chronic cystitis that are not always related to infection?

A
  1. Follicular cystitis
  2. Eosinophilic cystitis
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35
Q

Patients receiving which drugs may develop hemorrhagic cystitis and are also at an increased risk for carcinoma of the bladder?

A

Cytotoxic antitumor drugs, such as cyclophosphamide

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36
Q

How does chronic cystitis differ from acute in the nature of the inflammatory infiltrate?

A

Chronic associated with mononuclear inflammatory infiltrates

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37
Q

In acute cystitis how does the mucosa appear and what type of inflammatory infiltrate is present?

A
  • Hyperemia of the mucosa
  • Neutrophilic infiltrate, sometimes associated w/ exudate
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38
Q

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?

A

Interstitial Cystitis (Chronic Pelvic Pain Syndrome)

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39
Q

What will cystoscopy show in someome with Interstital Cystitis?

A

Fissures/punctate hemorrhages in bladder mucosa (glomerulations)

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40
Q

Chronic mucosal ulcers (Hunner ulcers) associated with Interstitial Cystitis is characterized by increased numbers of which immune cells?

A

Mucosal mast cells

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41
Q

What is Malakoplakia and what is it caused by?

Related to what infection?

A
  • Chronic inflammatory reaction in the bladder
  • Acquireddefectsinphagocyte functionand related to chronic infection, mainly byE. coliand occasionallyProteus
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42
Q

Malakoplakia occurs with increased frequency in which patients?

A

Immunosuppressed transplant recipients

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43
Q

Major histomorphological characteristics of the mucosal plaques associated w/ Malakoplakia?

A

Soft, yellow, slightly raised and filled w/ large foamy macrophages w/ occasional multinucleate giant cells + lymphocytes

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44
Q

What are the characteristic morphological findings of the macrophages associated w/ Malakoplakia?

A
  • Macrophages w/ adundant granular cytoplasm
  • Laminated mineralized concretions due to deposition of calcium in enlarged lysosomes, known as Michaelis-Gutmann bodies, present in macrophages
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45
Q

Polypoid Cystitis is most commonly due to what?

What is the characteristic morphology of the urothelium?

A
  • Indwelling catheters (most common), but any injurious agent may cause
  • Urothelium thrown into broad bulbous polypoid projections as result of marked submucosal edema
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46
Q

Polypoid Cystitis may be confused with what malignancy both clinically and histologically?

A

Papillary urothelial carcinoma

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47
Q

Cystitis glandularis and cystitis cystica are common lesions of the bladder characterized by what?

A

Nests of urothelium (Brunn nests) grow downward into lamina propria

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48
Q

Epithelial cells undergoing metaplasia in the center of Brunn nests taking on a cuboidal or columnar appearance is known as?

A

Cystitis glandularis

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49
Q

Which lesion is a result of implantation of shed renal tubular epithelial cells at sites of injured urothelium?

A

Nephrogenic adenoma

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50
Q

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?

A
  • Replaced by cuboidal epithelium
  • Assume a papillary growth pattern
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51
Q

In two-pathway model, low-grade superficial papillary tumors are characterized by what genetic mutations first and then second?

A

1) FGFR3 and RAS mutations + chromosome 9 deletions
2) May then lose TP53 or RB —> invasion

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52
Q

What is the major pathologic finding of Papillary Urothelial Neoplasia of Low Malignant Potential (PUNLMP) that distinguishes it from papilloma?

A
  • THICKENED urothelium covering papillary projections
  • Also tend to be larger
53
Q

Papilloma urothelial tumors of the bladder are usually seen in which age group?

A
  • Younger patients
54
Q

Completely benign papillomas consisting of inter-anastomosing cords of cytologically bland urothelium that extends down into the lamina propria are called?

A

Inverted papillomas

55
Q

High-grade papillary urothelial cancers contain what morphologically distinct cells and other findings?

A
  • Dyscohesive cells w/ large hyperchromatic nuclei
  • Some cells are highly anaplastic
  • Loss of polarity
56
Q

CIS or flat urothelial carcinoma may show scattered malignant cells in an otherwise normal urothelium, and this is known as?

A

Pagetoid spread

57
Q

The lack of cohesiveness in high-grade papillary urothelial carcinoma and flat urothelial CIS, results in what common finding?

A

Shedding of malignant cells into the urine

58
Q

Where in the world is SCC of the bladder frequently seen and due to what?

A
  • Middle East (i.e., Ehypt, Sudan)
  • Due to endemic Schistosoma haematobium
59
Q

SCC of the bladder is most commonly seen as what?

A

- Mixed urothelial carcinomas w/ areas of SCC

  • Most are invasive, fungating tumors or are infiltrative and ulcerative
60
Q

How likely is recurrence after resection of urothelial tumor?

If recurrence occurs, at which site does it happen?

A
  • High likelihood of developing new tumors after excision
  • Most of the subsequent tumors arise at different sites from the original lesion
61
Q

What is the prognosis of SCC and adenocarcinoma of the bladder compared to urothelial carcinoma of the same stage?

A

Worse prognosis

62
Q

For bladder tumors detected at early stages, what are the 2 mainstays of diagnosis?

A

1) Cytoscopy
2) Biopsy

63
Q

How can the urine be used as a screening measure of bladder cancer?

Looking for what?

A
  • Cytologic examination of cells in urine to detect chromosomal abnormalities (i.e., aneuploidy of Cr. 3, 7, and 17 and 9p deletions)
  • Using FISH
64
Q

Although rare, what type of lymphoma may involve the bladder as a either a primary lesion as well as component of systemic disease?

A

Non-Hodgkin lymphoma (diffuse large B-cell and MALT)

65
Q

What are the features of sarcomas (mesenchymal tumors) which are distinct from other tumors of the bladder?

A
  • Produce large masses
  • Protrude into the vesicle lumen
66
Q

What is the most common cause of bladder obstruction in a female?

A

Cystocele of the bladder

67
Q

What is an early finding and late finding morphologically with obstruction of the bladder outlet?

A
  • Early = thickening of bladder wall 2’ to muscle hypertrophy
  • Late = muscle bundles enlarge and produce trabeculation of the bladder wall
  • In course of time crypts form and may become diverticula
68
Q

Which organisms may be responsible for Non-Gonococcal Urethritis?

A
  • Chlamydia trachomatis (D-K serotypes) = gram negative, ovoid, non-motile
  • Mycoplasma = Ureaplasma urealyticum
69
Q

Urethritis is most often accompanied by what in men and what in women?

A
  • Men = prostatitis
  • Women = cystitis
70
Q

What is an example of inflammatory urethritis that is truly noninfectious in origin?

A
  • Reactive arthritis
  • Triad = arthritis, conjunctivitis, and urethritis
71
Q

A small, red, painless mass of the external urethral meatus, in an older female, consisting of inflammed granulation tissue covered by intact but extremely friable mucosa

A

Urethral caruncle

72
Q

What is the most common cause of hypertrophy and trabeculation of the bladder wall in a male?

A

Secondary to polpoid hyperplasia of the prostate

73
Q

Gonococcal urethritis is the earliest manifestation of infection by which organism?

What is the gram stain and morhphology of this organism?

A
  • Neisseria gonorrhea
  • Gram negative; diplococcus
74
Q

How does a primary carcinoma of the urethra differ if it is proximally located vs. distally located?

A
  • Proximal = urothelial differentiation
  • Distal = SCC’s
75
Q

What cancer is associated w/ alpha-fetoprotein and alpha1 antitrypsina?

A

yolk sac tumor

(in testes)

76
Q

What cancer is characterized by KIT, OCT4, and PLAP staining?

A

seminoma

(embryonal carcinomas also have this, but seminoma is hallmark)

77
Q

What is the difference in gene markers in seminomas and embryonal carcinomas?

A

both have OCT4 and PLAP

e carcinomas also have cytokeratin and CD30 and are neg for KIT

78
Q

In what cancers can HCG levels be elevated?

A

choriocarcinomas

some syncytiotrophoblast-containing seminomas

79
Q

What are schiller-duval bodies?

A

structures resembling endodermal sinuses

seen in yolk sac tumors

80
Q

What characterizes choriocarcinoma?

A
  • highly malignant testicular tumor
  • often cause no test enlargement
  • cytotrophoblasts (more regular cells)
  • syncytiotrophoblasts (contain HCG)
81
Q

What is distinct about non-germ cell malignancies that can arise within testicular teratomas?

A

chemoresistant - only hope for cure is in resection

retain isochromosome 12p

82
Q

How do testicular tumors spread?

A

seminomas: lymph first, then blood

Non seminomas: use blood more frequently, spread earlier

choriocarcinomas: hematogenous

83
Q

What are the 3 stages of testicular cancer?

A

1: confined to testis, epididymis, or spermatic cord
2. spread confined to retroperitoneal nodes below the diaphragm
3. metastases outside retro nodes or above diaphragm

84
Q

What does the level of lactate dehydrogenase tell you about a testicular tumor?

A

correlates w/ mass of tumor cells

85
Q

How are NSGCTs treated and what is their prognosis?

A

aggressive chemo

90% achieve complete remission

86
Q

Which testicular tumor is radiosensitive?

A

seminoma

good prognosis

87
Q

What are crystalloids or reinke?

A

rod-shaped crystals seen in leydig cell tumors in the cytoplasm

88
Q

What is contained in the cytoplasm of leydig tumor cells?

A

lipid droplets

vacuoles

lipofuscin pigment

89
Q

What type of testicular tumor produces androgens and sometimes estrogens?

A

leydig cell tumors

90
Q

How do adults and children present w/ leydig cell tumors?

A

adults: testicular swelling or gynecomastia
children: precocious puberty

91
Q

What characterize sertoli cell tumors?

A

hormonally silent

distinctive trabeculae that form cordlike structures and tubules

most are benign

92
Q

What is the most common testicular neoplasm in men older than 60?

A

testicular lymphoma (non-hodgkin)

93
Q

What are the most common testicular lymphomas?

A

diffuse large B-cell

Burkitt

EBV-positive extranodal NK/T cell

94
Q

What is a chylocele?

A

lymph in tunica vaginalis

95
Q

What are the 4 zones of the prostate?

A

peripheral

tranzitional (around urethra)

central

96
Q

Where do most hyperplasias and carcinomas arise in the prostate?

A

hyperplasia: transitional zone
carcinoma: peripheral zone

97
Q

What bacteria typically cause prostatitis?

A

e. coli

gram neg rods

enterococci

staphylococci

98
Q

How do acute and chronic bacterial prostatitis differ in presentation?

A

acute: fever, chills, dysuria
chronic: low back pain, dysuria, suprapubic pain; may be asymptomatic

99
Q

What is significant about treatment of bacterial prostatitis?

A

antibx poorly penetrate the prostate

100
Q

How does granulomatous prostatitis most commonly happen?

A

instillation of BCG w/in bladder for tx of cancer –> granulomas form, but no clinical significance or tx

101
Q

What is the most common type of cancer in men?

A

adenocarcinoma of the prostate

102
Q

What ethnic groups is prostate cancer common and uncommon in?

A

asians uncommon

most common in blacks

103
Q

What is the significance of the X-linked AR gene in prostate cancer?

A

short CAG repeats in gene = highest risk, in blacks

medium length in caucasians

asians have the longest = lowest risk

104
Q

What is the significance of the BRCA2 gene in prostate cancer?

A

germline mutations –> 20-fold risk in prostate cancer

105
Q

What is the significance of HOXB13 in cancer?

A

germline mutation –> incr risk in prostate cancer

106
Q

What are the most common genetic changes in prostate cancer?

A

ETS-TMPRss2 chromosomal rearangement

deletions that activate P13K/AKT

hypermethylation in GSTP1 on chrom 11q13

107
Q

What is the significance of basal cell layer in prostatic glands?

A

basal cells present in benign tumors

gone in malignancy

108
Q

What is a reliable IHC marker used to diagnose prostate cancer?

A

AMACR

109
Q

How does the Gleason system work?

A

rate 2 most common patterns 1 to 5 and add them together

2 = most differentiated, best prognosis

10 = worst

110
Q

What are the stages of prostate cancer?

A

T1 = clinically inapparent lesion

T2 = cancer confined to prostate

T3 = local extraprostatic extension

T4 = invasion of contiguous organs/supporting structures

111
Q

What are tumors in the ureters like?

A

primary tumors of ureter are rare

benign tumors sometimes happen and are usually of mesenchymal origin

112
Q

What is a fibroepithelial polyp?

A

in ureters, bladder, ranal pelves and urethra

most commonly in the ureters

tumor-like lesion that presents as a small mass projecting into the lumen

113
Q

What can radiation do to the bladder?

A

cause radiation cystitis

114
Q

What 2 things can cause hemorrhagic cystitis?

A

cytotoxic antitumor drugs

adenovirus

115
Q

What are the 2 types of chronic cystitis w/out infectious origin and what causes them?

A

follicular cystitis: lymphoid follicles w/in bladder mucosa and underlying wall

eosinophilic cystitis: infiltration w/ submucosal eosinophils

116
Q

What is the main goal of biopsy in the treatment of interstitial cystitis?

A

to rule out carcinoma in situ, which can mimic interstitial cystitis

117
Q

What types of bacteria are associated with malakoplakia?

A

E. coli and occasionally proteus

118
Q

What are michaelis-gutmann bodies?

A

deposition of calcium in enlarged lysosomes of macrophages

seen in malakoplakia of the bladder

(look like dark circles in pink macrophages)

119
Q

What is nephrogenic adenoma?

A

unusual lesion where shed renal tubular cells are implanted at sites of injured bladder urothelium –> urothelium is replaced by cuboidal epithelium

120
Q

What is phimosis?

A

orifice of the prepuce of the penis is too small to permit normal retraction

usually the result of repeated infection

121
Q

What is balanoposthitis?

A

infection of the glans and prepuce of the penis

122
Q

What is condyloma acuminatum?

A

benign wart caused by HPV

type 6 and 11 most common

branching, villous papillary CT stroma covered by hyperkeratosed epithelium

123
Q

What are bowen dz and bowenoid papulosis both associated with?

A

infection w/ high risk HPV, most commonly typ 16

124
Q

What is bowen dz?

A

solitary, gray-white lesion on the penis or shiny red, velvety plaques

hyperproliferative epidermis w/ dysplastic characteristics (pre-cancerous lesion)

intact basement membrane

125
Q

What is bowenoid papulosis?

A

multiple reddish brown precancerous lesions on the penis

occurs in younger ppl than bowen dz, but histo is the same

virtually never develops into an invasive carcinoma and usually regresses spontaneously

126
Q

what typically causes epididmytis and orchitis in children, the young, and old?

A

children: congenital abnormality and infection w/ gram neg rods

sexually active men under 35: chlamydia and gonorrhoeae

over 35: UTI stuff - e coli and pseudomonas

127
Q

What are the most common genetic changes in prostate adenocarcenoma?

A

TPRSS2-ETS fusion genes

mutiations or deletions that activate the PI3K/AKT signalling pathway

128
Q

What is the most common epigenetic alteration in prostate cancer?

A

hypermethylation of the GSTP1 gene

on chr 11q13

CPR-2 (28 decks)

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