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

Chapter 21: Lower Urinary Tract - Ureters, Bladder, Urethra COPY 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
46
Q

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

A

Papillary urothelial carcinoma

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

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

49
Q

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

A

Nephrogenic adenoma

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
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

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

CPR EXAM 2 (52 decks)

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