T4-L1: Urological Pathology

Question 1

Give the epidemiology of renal cell carcinoma.

Answer 1

RCC is a cancer of the renal tubules. The most common type is clear cell (85%) followed by papillary (10%).

It is:

• Generally a disease of older men (over 60s)
• Most common in a PMH of obesity, smoking, NSAID use, end-stage renal failure and in a family history (e.g. Von Hippel-Liondau)

Question 2

Why might patients with renal cell carcinoma develop polycythaemia?

Answer 2

The tumour produces erythropoietin.

Question 3

What is the aetiology of Wilm’s tumour?

Answer 3

Nephroblastoma - acquired or inherited mutations usually affecting WT1 gene. There is also some environmental factors. It is seen usually in children under 5 with 5-10% associated with genetic syndromes such as Beck-Wiedemann syndrome, WAGR syndrome etc. Results in an abdominal mass.

Question 4

What are complications of urolithiasis?

Answer 4

Renal stonees - can form anywhere. 70% are made of calcium, 15% struvite stones, 5% Urate, and 1% cystine. It is usually due to a too high concentration of a solute in the urine.

Complications include:

• Obstruction
• back pressure can lead to hydronephrosis +/- hydroureter, this can lead to renal failure
• Urinary stasis leading to the risk of infection
• Local trauma and so a SCC risk as transitional epithelium is converted to squamous epithelium in metaplasia

Question 5

Give the aetiology go a struvite stone.

Answer 5

UTI with urease producing bacteria such as proteus is established. The Urease converts urea to ammonia; this raises the pH. As a result we get precipitation of magnesium ammonium phosphate stones.

Question 6

What is the pathogenesis of vesicoureteral reflux?

Answer 6

This is then urine flows backwards from the bladder to the ureter. This affects 10% of the population and shows a genetic cause.

There is an anatomical abnormality in vesicoureteric junction. The ureters enter the bladder at an abnormal angle in which there is less intramural ureter. When voiding, muscle in the bladder wall contracts but there is not enough pressure in contact with the ureter to compress it and so the utter remains patient and so urine flows the wrong way.

Question 7

For urothelial carcinoma, give the:

(a) Epidemiology
(b) Clinical Features

Answer 7

Cancer of the urothelium. Occurs most commonly in the bladder and so account for 90% of bladder carcinoma. It can also occur in the ureter and urethra. Due to acquired mutations.

(a)
- Older Men
- Smokers
- exposure to certain industrial chemicals such as dyes, rubbers chemicals etc.
- Family history
- Treatment for other cancers

(b) Local affects - haematuria, frequency, urgency and dysuria. Obstruction can occur if the tumour is large.

Metastatic affects: Symptoms associated with the lungs such as SOB, liver such as jaundice and bone such as joint pain.

Paraneopastic syndromes are rare.

Question 8

What is the difference been spastic and flaccid bladder dysfunction?

Answer 8

Neurological obstruction is the inability to properly empty the bladder due to neurological damage. It can vibe classified into 2 types:

- Spastic - if the damage to the brain or spinal cord - upper motor neurone - tends to be too much tone 
- Flaccid - if damage to the peripheral nerves (lower motor neurone) - tends to be not enough tone

Question 9

Give causes of neurological obstruction of the bladder.

Answer 9

Upper motor neurone causes - stroke, MS and spinal injury

Lower motor neurone - pregnancy, diabetes and alcohol (B12 deficiency)

Question 10

What are symptoms of neurological obstruction of the bladder?

Answer 10

Symptoms:

- Related to Urinary retention +/- abdominal distention, incontinence, urge, frequency
- Complications can be stasis leading to UTIs and also associated with urinary stones 
- Can also get hydroureter and hydronephrosis leading to real impairment due to inability to empty the bladder

Question 11

What is BPH? What is its epidemiology?

Answer 11

Benign prostatic hyperplasia - increased stroll and glandular cells in the prostate. People have problems getting urine out of the bladder. Complications can therefore be urinary stasis, acute urinary retention (this is very painful and requires a catheter) and back pressure.

it is more common in older men, in obesity, diabetes and those with a family history.

Question 12

How does BPH causes changes in the bladder?

Answer 12

Detrusor muscle hypertrophy. The bladder has to work extra hard to force urine through a narrow gap.

Question 13

For prostatic adenocarcinoma, give the following:

(a) Epidemiology
(b) Clinical appearance

Answer 13

Epidemiology 
	- Older men 
	- Black men 
	- Family history (inc. BRCA1/2)
	- Pesticide exposure)
Especially those with lower grade cancers, patients tend die with the cancer rather than of the cancer.

Clinical features

- Local primary tumour effects - like those of BPH - lower urinary tract symptoms
- Effects of distant metastases - tends to go to the bone leading to bone pair 
- Paraneoplastic - syndromes PNS are RAE