Chapter 21. Male GU Flashcards
Where can field effect GU cancers occur due to urothelial carcinoma of the renal pelvis?
Ureters, bladder and urethra.
Most common cause of hydronephrosis in children/infants?
Ureteropelvic junction (UPJ) obstruction
If Ureteropelvic junction (UPJ) Obstruction occurs in children which sex is preferentially affected?
Bilateral or unilateral?
In adults?
Children —> males; sometimes bilateral
- Adults —> woman; most often unilateral
About 1/3 of children w/ recurrent UTI’s are found to have what?
Vesicoureteral reflux; most commonly dx in infancy/childhood
Why is damage to the ureters during surgery so dangerous?
They are located near a shit ton of BV and organs
How can we ID abnormalaties of the ureter early?
Aberrant ureteral anatomy
Where do the ureters lie in the body?
Retroperitoneal postiion
What can happen if we have a retroperitoneal tumor/fibrosis?
It can entrap the ureters or obstruct them.
As the ureter enter the pelvis, what arteries do they pass in front of?
What arteries do they lie near when they are in the female pelvis?
- Common iliac or external iliac.
- Uterine arteries; so be careful when there is surgery to female GU tract.
What are the proposed 3 points of narrowing where kidney stones can lodge?
- Uteropelvic junction*
- Where they cross the iliac arteries
- As the enter the bladder. *
*new research shows only these 2 exist.
Although rare, what is the most common primary malignant tumor of the Ureters?
Most often occurs when and causes what?
- Urothelial carcinomas
- 60s-70s causing obstruction
What is the most common malignant mesenchymal tumor of the bladder seen in infants/children?
Often have what type of growth pattern?
- Embryonal rhabdomyosarcoma
- Polypoid mass of grapes = Sarcoma botryoides
What is the most common malignant mesenchymal tumor seen in the bladder of adults?
Leiomyosarcoma
Why is ureteral obstruction clinically significant?
Compromise renal function by causing hydronephrosis or pyelonephritis
In children, what is the most common obstructive lesion in the kidney?
Congenital UPJ obstruction
In adults, uretal obstructions can be acute or chronic.
Give an example of a cause for each?
- Acute: kidney stone
- Chronic: intrinsic/extrinsic tunors or sclerosing retroperitoneal fibrosis
What are Congenital Abnormalities of the ureter?
-
Double or bifed ureters
- unilateral and not clinically important
- UPJ Obstruction
-
Diverticula: saccular outpouchings of the ureteral wall that can be acquired or congenital
- Asx unless traps urine, causing recurrent infections
Uteritis is associated with ________.
Clinically significant?
- Inflammation, not infection of the ureters.
- No
Unilateral ureteral obstruction is typically due to: _______ causes,
Bilateral obstruction is typically due to: ________ causes
- Unilateral: proximal causes
- Bilateral: distal causes
Obstructions to the uterus can cause what 3 things?
- 1. Hydroureter (dilation of ureter)
- 2. Hydronephrosis
- 3. Pyelonephritis
Sclerosing Retroperitoneal Fibrosis most often occurs in which age group and sex?
What is it?
- Middle - late age Men
- Fibrotic proliferative inflammatory process of retroperitoneal structures causing hydronephrosis => narrow and obstruct the ureter
A subset of Sclerosing Retroperitoneal Fibrosis is associated with what immunological related disease?
IgG4-related disease
an immunologic related disease
Most cases of Sclerosing Retroperitoneal Fibrosis arise how and are known as?
- No obvious cause = considered primary or idiopathic
- Ormond disease
What are some of the common secondary causes of retroperitoneal fibrosis, which may lead to ureteral obstruction?
- Drugs (ergot derivatives, β-blockers)
- Adjacent inflammatory conditions –> vasculitis, diverticulits, Chron’s
- Malignant disease –> lymphomas, urinary tract carcinomas
Initial treatment and long term treatment of Sclerosing Retroperitoneal Fibrosis?
- Corticosteroids
- Eventually require ureteral stents or surgical extrication of ureters from surrounding fibrous tissue (ureterolysis)
What are the 4 major extrinisic causes of obstruction of ureters?
- Pregnancy –> relaxation of smooth m. or pressure on ureters
- Periureteral inflammation –> salpingitis, diverticulitis, peritonitis
- Endometriosis
- Tumors
what layer of the urinary wall do bladder cancers arise from?
Urothelium (mucosal surfaces)
Diverticulae is pouchlike evagination of the bladder wall.
Are they more commonly inherited or acquired?
Acquired.
Acquired diverticulae of the bladder are most often seen in association with?
Clinical significance?
Prostate hypertrophy that obstructs urethral outflow, causing a increase in intravesicle pressure and thickening of the bladder wall.
Congenital diverticulae of the bladder are usually due to what?
- Muscles do not develop properly
- UT obstruction in fetal development
Bladder diverticulae are clinically significant because they can predispose to what?
- Urinary stasis –> infection and forming bladder calculi
- If they impinge on the ureter, can cause vesicoureteral reflux
- Rarely, carcinoma may arise; tend to be in more advanced stage
What is exstrophy?
Exposed bladder bc abdominal wall doesnt fuse, which can lead to colonic glandular metaplasia and infection that can spread to upper GU tract.
Patients with exstrophy of the bladder have an increased risk of what cancer?
Adenocarcinoma arising in bladder remnant
What is the prognosis if a baby is born with exstrophy of the bladder?
If done early, long-term survival is HIGH.
When does vesicoureteral reflux occur?
Ureter NTRs the bladder at an unusual angle or when the length of the ureter through the bladder wall is too short, causing valve malfunction and reflux.
When does VUR become a problem?
When urinary stasis causes infection in the ureter and kidney
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?
Infected urachal remnant/ urachal cyst
Urachal Cyst can lead to what cancer?
Bladder adenocarcinoma
Cystitis is very common and occurs more often in F due a shorter urethra. It often precedes bacterial pyelonephritis.
Triad of symptoms?
- Increase frequency and urgency
- Dysuria: pain when peeing
- Lower abdominal pain
Fevers of unkown origin can be due to what?
Cystitis
How can we differentiate between patients with acute cystitis or those complicated with UTI?
People with UTI
- Have an anatomic abnormality
- Vulnerable disease state that leaves their UT more prone to UTIs
- UTIs caused by resistant pathogens.
What are the most common causes of cystitis?
- E.coli
- Proteus
- Klebsiella
- Enterobacter
- Other: Staph saprophyticus
What can cause a Cystitis in immunocompromised?
- Mycobacteria
- Fungi
- Viruses
- Protozoa
What are pre-disposing factors to cystitis?
- Bladder calculi
- Urinary obstruction or structural abnormalities
- 3. DM
- 4. Instrumentation
- 5. Immune deficiency
Which gram negative, obligate intracellular bacteria may cause cystitis?
Which 2 organisms can cause cystitis in immunocompromised pts or those receiving long-term Abx?
-Chlamydia
-Candida albicans*** or cryptococcal agents
What is the morphology of a patient with acute cystitis?
- Inflammation: Hyperemia of mucosa, neutrophils (pyruria; inc WBC) and sometime an exudate
What leads to chronic cystitis?
How is it different from acute?
-Persistance of bacterial infection.
-Has mononuclear inflammatory cells and THICKND BLADDER WALL.
What 2 things can lead to hemorrhagic cystitis?
- Adenovirus
- Patients taking cytoxic anti-tumor drugs (cyclophosphamide)
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?
Interstitial Cystisis (Chronic Pelvic Pain Syndrome/ Hunner Ulcer)
What will cystoscopy show in someome with Interstital Cystitis?
Fissures/punctate hemorrhages in bladder mucosa (glomerulations/Hunners ulcers)
How does one get Interstitial Cystitis?
Who is more common in?
What do we see on LM?
- Idiopathic, but can be autoimmune
- Women 30-40
- Inflammation and fibrosis of the bladder wall and fissures and mast cells, lymphocytes.
What is Malakoplakia and what is it caused by?
- Chronic inflammatory reaction that forms granulomas and mucosal plaques in the bladder.
- Due to defects in the function of phagocytes & chronic infection by E.coli and sometimes Proteus.
Malakoplakia occurs with increased frequency in which patients?
- Middle-aged F
- Immunosupressed
Malacoplakia produces what on the bladder?
Yellow, slighly-raised mucosal plaques that can involve the bladder and other organs
-Granulomas filled with foamy MO, giant cells and lymphocytes
Major characteristics histological finding is assx w/ Malakoplakia?
- -Michaelis-Gutmann bodies: round mineralized concentrations of Ca2+ in lysosomes of MO
- -MO also have alot of granular cytoplasm
Polypoid Cystitis is most commonly due to what?
What is the characteristic morphology of the urothelium?
- Inflammatory condition due to irradiation of the bladder mucosa, most often indwelling cathers
- Submucosal edema causes broad bulbous polypoid projections
Polypoid Cystitis may be confused with what malignancy both clinically and histologically?
Papillary urothelial carcinoma
What are Cystitis glandularis and cystitis cystica?
Chronic inflammatory metaplastic lesions of the bladder where nests of urothelium (von Brunn nests) grow down into lamina propria and epithelial cells in the center undero metaplasia.
that occur in the setting of chronic irradiation due to irrtants such as infection, stones, obstruction, tumor that undero metaplasia.
What causes CC/CG?
Chronic inflammation d/t irrtants such as infection, stones, obstruction, tumor that occur in the setting of chronic irradiation .
von Brunn nests then differentiate into what?
- Cystic deposits w flat urothelium (CC)
- Intestinal columnar goblet cells (secrete mucus), resulting in CG
- In CC and CG, what do we see on LM?
- When do they occur and in who?
- Sx?
- -Features of both, not just one bc they both tend to co-exist
- Any age, slightly more in M
- -Chronic irration; frequenxcy, dysruria, urgency and heamturia
- Bladder infection manifested by submucosal eosinophils d/t subacute inflammation
- Bladder infection d/t chronic inflammation characteristized by lymphocytes in lymphoid follicles in mucosa and wall.
Eosinophilic cystitis
Follicular cystitis
Acute and chronic bacterial cystitis is extremely common, particularly in ________, and results from what?
Women
Retrograde spread of colonic bacteria
Some inflammatory or metaplastic bladder lesions are significant in that they can mimic bladder. Which ones are these
- 1. Malakoplakia
- 2. Polypoid cystitis
- 3. CC/CG
- 4. Nephrogenic adenoma
Epithelial cells undergoing metaplasia in the center of Brunn nests taking on a cuboidal or columnar appearance is known as?
Cystitis glandularis
are NON-epithelial tumors of the bladder common?
- NO! 95% of bladder cancers are from epithelial cells.
- The rest are mesenchymal origin.
But the most common is a leiomyoma.
What are other benign neoplasms that can occur in the bladder?
- 1. Lipoma
- 2. Fibroma
- 3. Neurofibroma
- 4. Other (inflammatory pseudotumor)
What are other malignant neoplasms that can occur in the bladder?
- Rhabdomyosarcoma (childhood)
- Leiomyosarcoma (adults)
- Lymphoma
- Other
What is the most common malignant mesenchymal tumor of the bladder seen in infants/children?
Often seen manifesting with what type of growth pattern?
- Embryonal rhabdomyosarcoma
- Manifest as a polypoid grapelike mass (Sarcoma botryoides)
What is the most common malignant mesenchymal tumor seen in the bladder of adults?
- Leiomyosarcoma
About 95% of bladder tumors are of _______ origin, the remainder are ________ tumors. most epithelial tumors are ______ cell type.
At presentation, many urothelial tumors are _______. Through most common in the bladder, all of the urothelial tumors can be seen at ___________
About 95% of bladder tumors are of epithelial origin, the remainder are mesenchymal tumors. most epithelial tumors are urothelial cell type.
At presentation, many urothelial tumors are multifocal. Through most common in the bladder, all of the urothelial tumors can be seen at any site where there is urothelium, from the renal pelvis => distal urethra.
What are the 2 distinct precursor lesions of _invasive urothelial carcinoma of the bladde_r and which is most common?
Type of grade for each?
- Noninvasive papillary urothelial carcinoma (low- or high-grade) = most common
- Noninvasive Flat urothelial carcinoma in situ (uniformly high grade)
- CIS is used to descrbe what?
- About half of the time, why is a precursor lesion NOT detected in a invasive bladder cancer?
- CIS epithelial lesions that have cytologic features of malignancy, but are confined to the epithelium, showing no sign of BM invasion
- Bc the tumor has already invaded the bladder wall.
- The incidence of carcinoma of thre bladder is higher in M/W/Equal?
- Age?
- Race?
- Heriditary/familial or sporadic?
- Men
- 50-80
- white
- NOT familial
What are 6 risk factors associated with urothelial carcinoma of the bladder?
1. Cigarette smoking –> 3-7x ↑ risk
- Industrial exposure to aryl amines
- Schistosoma hematobium (SCC-70%)
- Long-term use of analgesics
- Long-term exposure to cyclophosphamide
- Radiation
- Loss of genetic material on which chromosome are particularly common in urothelial carcinoma?
- Which genetic mutation associated with urothelial carcinoma is a poor prognostic indicator?
- Chromosome 9
- - Monosomy or deletions of 9p and 9q
- p53
- Non-invasive high-grade urothelial carcinoma is associated with what genetic mutations allowing for progression to invasion?
- Non-invasive low-grade papillary urothelial carcinoma is associated with what genetic mutations?
- Loss of TP53 or RB —> frequently progesses to muscle invasive dz
- Gain of function FGFR3 and HRAS mutations
The appearance of urothelial tumors ranges from _______________
Overall, the majority of papillary tumors are low grade.
purely papillary => flat.
When do embryonal rhadomyosarcomas occur and in when gender?
Leiomyosarcoma?
-
Children (4 YO);
- = in M and W
-
60 YO
- Men
Dominant and sometimes only clinical finding associated with urothelial carcinoma of the bladder is ____________
-
Painless Hematuria
- Discomfort is more likely in flat, hematuria in papillary.
What is the critical prognostic factor for bladder cancer?
Why is grading not as important to establish.
- Extent of spread/depth (staging), not grading (bc almost all invasive bladder cancers are high-grade
-
Muscle invasion i.e., depth of muscle invasion is major prognostic issue to be established
*
-
Muscle invasion i.e., depth of muscle invasion is major prognostic issue to be established
Major decrease in survival rates associated with bladder cancer is due to?
- Invasion of the muscularis propria (detrusor m.)
Although rare, what type of lymphoma may involve the bladder as a either a primary lesion but is much more common as a part of a systemic disease?
Non-Hodgkin lymphoma (diffuse large B-cell and MALT)
What are the features of sarcomas (mesenchymal tumors) which are distinct from other tumors of the bladder?
- Produce large masses
- Protrude into the vesicle lumen
What is the most common cause of bladder obstruction in a female?
Cystocele of the bladder
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?
- Replaced by cuboidal epithelium
- Assume a papillary growth pattern
In two-pathway model, low-grade superficial papillary tumors are characterized by what genetic mutations first and then second?
1) FGFR3 and RAS mutations + chromosome 9 deletions
2) May then lose TP53 or RB —> invasion
What is the major pathologic finding of Papillary Urothelial Neoplasia of Low Malignant Potential (PUNLMP) that distinguishes it from papilloma?
- THICKENED urothelium covering papillary projections
- Also tend to be larger & little atypia
High-grade papillary urothelial cancers contain what morphologically distinct cells and other findings?
- Dyscohesive cells w/ large hyperchromatic nuclei
- Some cells are highly anaplastic
- Loss of polarity
The lack of cohesiveness in high-grade papillary urothelial carcinoma and flat urothelial CIS, results in what common finding?
Shedding of malignant cells into the urine
What are 2 treatment options utilized in the majority of patients with non-invasive urothelial carcinoma of the bladder?
- Transurethral resection (TUR) and surveillance
- Intravesical therapy - chemotherapy or instillation of an attenuated strain of Mycobacterium bovis called bacillus Calmette-Guerin (BCG)
What are 2 treatment options utilized in the majority of patients with invasive urothelial carcinoma of the bladder?
- Segmental cystectomy
- Radical cystectomy w urinary division
- Immunotherapy and photodynamic therapy
With high recurrence and the possibility of progression, how can we follow urothelial neoplasms?
What is not a good to use?
- Urine cytology is NOT a good idea: low specificity.
- Stone, inflammation or instrument artifact can mimick low grade.
Painless hematuria is the most common presenting symptom of bladder cancer and requires __________ to rule or urethelial neoplasma
- cytoscopy
- urine cytology
Urethritis (inflammation of the urethra) can be divided into what 3 causes?
- Gonoccocal urethritis
- Non-gonoccoccal urethritis
- TRULY non-infectious
Gonococcal urethritis is the earliest manifestation of infection by which organism?
What is the gram stain and morhphology of this organism?
- Neisseria gonorrhea
- Gram (-); diplococcus
Which organisms may be responsible for Non-Gonococcal Urethritis?
- **Chlamydia trachomatis (D-K serotypes) = gram (-), ovoid, non-motile
- Mycoplasma (Ureaplasma urealyticum)
Urethritis is most often accompanied by what in men and what in women?
- Men = prostatitis
- Women = cystitis
