Urological Pathology Flashcards
Urinary tract structure
Urinary tract is lined by urothelium which rests on a basement membrane.
the urothelium is a specialised epithelium which is several cell layers thick, allowing it to stretch and distend as needed.
What are the layers of the wall of the renal pelvis, ureter, bladder and urethra?
- urothelium/transitional epithelium
- lamina propria
- muscularis propria (detrusor muscle in the bladder)
- adventitia (perivisceral fat in the bladder)
What is the structure of the prostate?
slightly larger than a walnut
surrounds the urethra just below the urinary bladder and it is palpable on rectal examination
has three zones: transition, central and peripheral zones
What is the function of the prostate?
produces an alkaline secretion which neutralises the acidic environment of the vaginal.
What are common causes of macroscopic/frank haematuria?
kidney cancer (Renal Cell Carcinoma) stone in kidney or ureter trauma bladder cancer BPH infection (bacterial cystitis)
Investigations of macroscopic haematuria?
MDU for MC+S
urine cytology
flexible cystoscopy ± biopsy
what do LUTS suggest?
a problem in the bladder or prostate
What are causes of LUTS?
BMP UTI UT stones bladder cancer prostate cancer (late feature)
What is the most common malignant tumour of the kidney?
RCC
clear cell is the most common type of RCC
What are risk factors for RCC?
male gender (4:1) increasing age (>50) smoking obesity familial syndromes eg von Hippel Lindau syndrome
What is the grading system for RCC?
Fuhrman grading system
assesses how closely the tumour cell nuclei resemble renal tubule cell nuclei
grade 1: closely resemble normal (less aggressive, better prognosis)
grade 4: largerand pleomorphic (more aggressive, worse prognosis)
Staging of RCC
TNM
Clinical presentation of RCC
Triad: loin pain, loin mass, haematuria
uncommon in clinical practice!
don’t forget B symptoms!
incidental finding on scan for another reason
S+S of metastatic disease
paraneoplastic sindrome
What is the most common type of bladder cancer?
transitional cell carcinoma urothelial carcinoma
What are risk factors for bladder cancer?
Cigarette smoking the most important risk factor
industrial exposure to certain industrial dyes and solvents (particularly aryl amines)
What sit he grading of bladder cancer?
3 tier system - 1, 2, 3
low grade: grade 1 and most of grade 2
high grade: grade 3 and minority of grade 2
Staging of bladder cancer
TNM
superficial tumours are Ta or T1
muscle invasive tumours are T2, T3 or T4
CIs is Tis
What are the three main groups of classification bladder cancer?
low risk bladder cancer: superficial tumours (Ta or T1) and low grade
high risk bladder cancer: muscle invasive tumours (T2 or worse) and high grade
carcinoma in situ (CIS): pre cancer
Low risk bladder cancers
confined to the mucosa or into the lamina propria
they do NOT invade into the muscularis propria
fond like papillary growths
What are possible consequences following removal of a low risk bladder cancer?
a high chance of the tumour recurring as another superficial bladder cancer
a low chance that the tumour will transform into a high risk (muscle invasive) tumour
require regular check cystoscopies for this reason
High risk (muscle invasive) bladder cancer
invade into the detrusor muscle or beyond
tend to be solid rather than papillary
much worse prognosis than low risk tumours as more likely to spread to regional nodes and metastasise to distant sites
radical treatment required for cure, often cystectomy with or without other organs such as the uterus
urothelial carcinoma in situ (CIS)
flat lesion in which the urothelium contains cells that display the nuclear features associated with malignancy But there is no invasion through the basement membrane
about 40% will progress to muscle invasive cancer if let untreated - more ominous diagnosis than superficial carcinoma!
cytological investigations
blue light cystoscopy
urine cytology
What mutations are low risk (superficial) bladder cancers associated with?
HRAS and FGFR3
What mutations are CIS and high risk (muscle invasive) bladder cancers associated with?
TP53 and RB1
What is BPH
benign prostatic hyperplasia results from the overgrowth o prostatic tissue in the TRANSITION ZONE of the gland
the overgrowth results in the formation of large nodules which form due to hyperplasia of all the cellular elements in the prostate.
what are the complications of BPH?
gradual compression of the prostatic urethra causing urinary tract obstruction
the detrusor muscle undergoes compensatory hypertrophy to compensate for this but will eventually decompensated and relax, resulting in chronic urinary retention. this can lead to hydrometer and hydronephrosis
hydronephrosis
water inside th kidney. refers to dissension and dilatation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine from the kidney.
untreated it leads to progressive atrophy of the renal parenchyma.
as a consequence there is progressive loss of renal function in both kidneys and the development of chronic kidney injury
How might BPH present
LUTS
acute urinary retention
urinary tract infection
renal dysfunction
clinical presentation of prostate cancer
latent prostate cancer - no symptoms at diagnosis. may just be a man in his 50-60s asking for a PSA test which comes back positive resulting in biopsy and diagnosis.
symptomatic prostate cancer - may be due to primary tumour effects of those of metastases (e.g. bone - back pain)
which cancers commonly metastasise to bone?
BLT Plus Ketchup
Breast
Lung Thyroid
Prostate
Kidney
bone metastases are usually OSTEOLYTIC with the exception of those from prostate cancer which are typically SCLEROTIC
what is the most common type of prostate cancer?
almost all are adenocarcinomas arising from the epithelial cells lining the acini or ducts of the prostate gland
wha t is the premalignant prostate condition?
prostatic intraepithelial neoplasia (PIN)
how is prostate cancer graded?
Gleason scoring system
given 2 scores 1-5 and added together gives a score of 2-10
in practice only 3-5 are given
the gleason grade is very important in helping determine the most appropriate treatment and prognosis for prostate cancer patients
how is prostate cancer stand?
TNM
How is prostate cancer managed?
staged
MDT meeting
latent: quite often active surveillance as not causing any problems for the patient
radical prostatectomy (SE: urinary incontinence, erectile dysfunction, bladder neck obstruction and death)
radial radiotherapy (external beam radiation or brachytherapy)
active surveillance
where do urinary tract stones most commonly arise?
renal calyces and pelvis
what i the lifetime risk of urinary tract stone formation?
up to 10% of the population
What are the most common types of renal calculi
calcium oxalate or a mixture of calcium oxalate and calcium phosphate
what are causes of hypercalciuria?
absorptive hypercalciuria - over absorption from the gut
renal hypercalciuria- defect int he renal tubules which impairs tubular absorption of calcium in the proximal tubule
hypercalcaemia - usually due to primary hyperparathyroidism
what is the clinical presentation of urinary tract stones?
can be silent, especially larger stone sea stag horn calculus which are often found when investigating haematuria or recurrent UTIs
smaller stones can pass into the ureter and cause ureteric colic. if it becomes impact then the pain gets even worse.
can cause obstruction
what are the three most common places of urinary tract stone obstruction?
VESICOURETERIC JUNCTION (most common)
pelviureteric junction
pelvic brim
complications of urinary tract stone impaction
IMMEDIATE:
UTI
pyelonephirits
sepsis
MEDIUM AND LONG TERM:
hydrometer and hydronephrosis
loss of function- unilateral obstructive uropathy
hypertension
Treatment of urinary tract stone obstruction
emergency nephrostomy to bypass the stone
stone may be removed by stereoscopy and/or laser lithotripsy which breaks the stone up into small pieces which can then be removed
causes/risk factors for UTI
increased bacterial inoculation:sexual activity, incontinence, constipation
increased binding of uropathogenic bacteria: spermicide use, decreased oestrogen, menopause
decreased urine flow: dehydration, obstructed urinary tract
increased bacterial growth: DM, immunosuppression, obstruction, stones, catheter, renal tract malformation, pregnancy
UTI treatment in non-pregnancy women
3 day course of trimethoprim or nitrofurantoin
upper UTI broad spectrum e.g. co-amoxiclav. consider hospitalisation and avoid nitro
UTI treatment in pregnant women
1st trimester AVOID ciprofloxacin and trimethoprim
3rd trimester AVOID nitrofurantoin
UTI treatment in men
7 day course of trimethoprim or nitrofurantoin
if prostatitis consider longer term (4w) with a fluoroquinolone e.g. ciprofloxacin
UTI treatment in catheterised patients
change long term catheter before starting antibiotics and refer to local guidelines
what makes a UTI complicated?
structural or functional abnormality of GU tract
risk factors for pyelonephritis
previous UTI stress incontinence frequent sexual intercourse DM foreign body in urinary tract anatomical/functional abnormality immunosuppression pregnancy
risk factors for renal stones
family or personal history
dehydration
certain diets e.g. high protein, salt and sugar
obesity
digestive diseases and surgery
other medical conditions e.g. renal tubular acidosis
prevention of renal stones
drink plenty, normal calcium intake thiazide diuretics oxalate decreased intake (pyridoxine) struvite - treat infection urate - allopurinol, urine alkalisation cysteine - vigorous hydration
medical management of BPH
alpha blockers: tamsulosin, alfuzosin, doxazosin, terazosin
5alpha-reductase inhibitors: finasteride
surgical management of BPH
TURP
TUIP
prostatectomy
TULIP
what is urge incontinence?
leakage and urgency
RFs: cystitis bladder stone bladder obstruction idiopathic detrusor overactivity neuropathic detrusor overactivity
what is stress incontinence
leakage on effort or exertion
RFs:
age, repvious childbirth, hysterectomy, obesity, trauma, previous prostate surgery
causes of bladder obstruction
enlarged prostate previous surgery bladder stones urethral stricture constipation
treatment of urge incontinence
resolve underlying pathology lifestyle changes anticholinergics BOTOX sacral nerve stimulation surgery (clam cystoscopy)
treatment of stress incontinence
pelvic floor exercises weight loss stop smoking avoid constipation surgery
CKD signs and symptoms
oedema pruritus arthralgia enlarged prostate gland retinopathy fatigue nausea and vomiting anorexia foamy urine coca-cola coloured urine rashes dyspnoea orthopnoea seizures
