urological pathology Flashcards
what is renal cell carcinoma?
it is cancer of the kidney that arises from the renal tubular epithelium - cancer of the renal collecting ducts
what types of renal cell carcinoma are there?
there are several types - the two most common are clear cell making up 75% of them and papillary making up 10% of them
what is the epidemiology of renal cell carcinoma?
more males than females and those above 60 years old. It predominantly affects those with a PMHx of obesity, smoking, NSAID use and ESRF and on dialysis. Those with a FHx are also affected
what condition is particularly worrying in FHx?
Von Hippel Lindau - caused by gene mutations and inherited
they can also be caused by acquired mutations
what else can influence mutations?
environmental factors such as smoking
what is the basis of renal cell carcinoma?
the mutations accumulate so the hallmarks of cancer accumulate and result in a malignant cell
what are the effects of a tumour?
local primary tumour effects, effects of distant metastases and the paraneoplastic syndromes effects
what are paraneoplastic syndromes effects?
they are the effects that are not related to the local effects of the primary or metastatic tumours and develop as a result of either the cross reactivity between the normal and tumour tissue or the proteins and hormones secreted by the tumour cells
what connects the kidney to the bladder?
the renal pelvis is the attachment site of the ureter to the kidney which then goes to the bladder
what connects the bladder to the penis?
the urethra travels through the prostate and into the penis
what connects the bladder and seminal vesicle to the testis and epididymis?
the vas deferens
what is the appearance of a clear cell and papillary tumour on histological stain?
the clear cell will have many white cells
the papillary will have papillary finger like architecture
what are the hallmarks of cancer?
enabling replicative immortality, avoiding immune destruction, activating metastasis and invasion, tumour promoting inflammation, sustaining proliferative signalling, resisting cell death and evading growth supressors, deregulating cellular energetics, genomic instability and mutation and inducing angiogenesis
what is the 5YSR of renal cell carcinoma?
around 50%
what are the local primary tumour effects of RCC?
heamaturia and abdo pain
what are the effects of distant metastasis in RCC?
lung - shortness of breath
bone - bone pain
what are the PNSs in RCC?
weight loss cancer cachexia
hypertension from renin
polycythaemia from EPO
they are common in RCC
what is a Wilms tumour?
it is also known as a nephroblastoma and is a cancer of the kidney that arises from the nephroblasts which are the cells that develop into the kidney in embryological development
what is the epidemiology of wilms?
children under 5 and 5-10% have genetic syndromes
what are the genetic syndromes associated with WTs?
Beckwith-Weidemann, WAGR and Denys-Drash syndromes
what is an example of a genetic mutation associated with WT?
WT1
what do environmental factors do in WTs?
cause mutations
what are 10% of WTs?
they are bilateral
what is the 5YSR of WTs?
around 90%
what are the local primary effects of WTs?
high abdominal distention especially if bilateral and haematuria
what are the effects of distant metastasis and PNS in WTs?
they are very rare
what is urolithiasis?
it is urinary tract calculi or stones that form in the lumen of the UT and can be from the renal calyx to the bladder
what types are there of urolithiasis?
the types are based on the composition calcium stones make up 70% of cases urate stones 5% cystine stones 1% struvite stones 15%
what is the epidemiology of stones?
depends on the type and the cause but too high a concentration of a solute in the urine
what is the cause of the individual types of stone?
calcium - hypercalcaemia
urate - gout or malignancy due to high cell turnover
cystine - congenital cystinurira
struvite - UTI
what is struvite?
ammonium, magnesium and phosphate
what is cystinuria?
the inability of the kidneys to reabsorb AAs
what are the symptoms of urolithiasis?
pain in the ureter the bladder or the urethra, haematuria, symptoms of the complications: infection in urinary stasis, hydronephrosis+/-hydroureter in obstruction resulting in renal impairment, local trauma resulting in squamous metaplasia and SCC risk
how is bladder, ureter and urethra pain described?
bladder - lower abdo
urethra - dysuria
ureter - loin to groin such as in renal colic
what is the pathogenesis of calcium, urate and cystine stones?
too high a concentration of soluble material, urine becomes saturated, the soluble material precipitates out and stones form
what is the pathogenesis of struvite stones?
UTI with urease producing bacteria such as proteus
urease converts urea to ammonia
ammonia causes a rise in pH
this causes the precipitation of magnesium, phosphate and ammonium salts causing stones to form
what is VUR?
vesicoureteral reflux - it is when the urine flows backwards from the bladder to the ureter rather than from the ureter to the bladder
what is the epidemiology of VUR?
around 10% of the population have it, usually affects young people under 2, and those with a FHx but people usually grow out of it and is asymptomatic
what causes VUR?
a congenital abnormality of the vesicoureteric junction - the ureter enters the bladder at an abnormal angle resulting in dysfunction of the junction meaning that when voiding the urine flows int he wrong direction
what are the symptoms of VUR?
usually asymptomatic but there are symptoms of complications
stasis results in UTIs
back pressure and ascending infection results in renal damage
what is another pathology of the ureter that also crosses into the bladder?
urothelial carcinoma
what are the stages of the renal damage in VUR?
stages 1-5
get more sever
but stage 5 there is hydronephrosis - fluid in the kidney and hydroureter - fluid in the ureter
what is urothelial carcinoma?
cancer of the urothelial epithelium / transitional epithelium
also known as transitional cell carcinoma
what is the epidemiology of urothelial carcinoma?
elderly men / over 60y/o
accounts for over 90% of bladder cancers
what is the aetiology of urothelial carcinoma?
acquired mutations due to smoking, industrial chemicals and environmental risk factors generally
what is the pathogenesis of urothelial carcinoma?
genetic mutations (inherited) accumulate - malignant cell development
what are the clinical features of primary urothelial carcinoma?
haematuria
frequency, urgency and dysuria
urinary obstruction
what are risk factors for urothelial carcinoma?
FHx
treatment for other cancers such as pelvic radiotherapy and cyclophosphamide
arylamines exposure
what are the effects of distant metastasis in urothelial carcinoma?
lung - shortness of breath
liver - jaundice
bone - bone pain
what are PNSs in urothelial carcinoma?
they are very rare
what is the 5YSR for urothelial cancer?
around 50%
what is neurogenic obstruction?
it is inability to properly empty the bladder due to neurological damage
what are the types of NO?
spastic or flaccid
what are the causes of the types of NO?
spastic - damage to the brain/SC - UMN
flaccid - damage to the peripheral nerves or LMNs
What is the epidemiology?
all ages and genders depending on the cause
what is the cause of UMN damage?
stroke, MS and spinal injury
what is the causes of LMN damage?
pregnancy, alcohol resulting in a B12 deficiency and diabetes
what are the symptoms of NO?
urinary retention, abdo distention, incontinence, urgency, frequency, symptoms related to complications - stasis - UTI - dysuria or stasis - urinary stones - haematuria
bladder distention - hydroureter/hydronephrosis - renal function impairment - oedema
what is another pathology of the bladder?
bladder stones
what is the neural control of the bladder for micturition?
the stretch receptors in the detrusor muscle of the bladder detect increase in bladder pressure and send information via the sensory part of pelvic nerve (parasympathetic fibres) to the pons and cerebral cortex. This then goes back to pons and to motor part of pelvic nerve (para) to the internal sphincter to the urethra to relax, and to a somatic motor fibre of the pudendal nerve to relax the external sphincter to release urine
what are bladder stones?
they are stones in the urinary tract
what is the epidemiology of bladder stones?
depends on the cause
what is the aetiology of bladder stones?
hypercalcaemia, UTI, malignancy
what is benign prostatic hyperplasia?
increased number of both stromal and glandular cells in the prostate - known by patients as an enlarged prostate
what is the epidemiology of BPH?
older men - 70% by age of 60
20% by age of 40
what are risk factors for BPH?
age, obesity, diabetes, FH, maybe hormones such as dihydrotestosterone
what is the pathogenesis of BPH?
compression of the urethra resulting in obstruction of the bladder outlet, this results in acute urinary retention,urinary stasis and back pressure. Back pressure results in renal damage, and stasis in infection and stones
CKD
what are symptoms of BPH?
lower urinary tract symptoms hesistancy or urgency prolonged micturition straining poor or intermittent stream frequency nocturia incontinence incomplete empyting dribbling
what is prostatic adenocarcinoma?
cancer of the glandular epithelium in the prostate that is often seen with BPH but BPH is not a precursor
what is the epidemiology of PAc?
old men
black men
what are the risk factors for PAc?
FHx - including BRCA1/2 so can be inherited genetic mutation or acquired
environmental such as pesticide exposure or obesity
age - hence seen a lot with BPH
what are the local primary, distant metastatic effects and PNSs for PAc?
local - lower urinary tract symptoms
distant - bone - bone pain
PNSs are rare
what is the 5YSR for PAc?
around 90%
what is ?
it is undescended testes - where the testis is not in the scrotum - the types are based on the site of the testis
what are the three main sites of the testes in cryptorchidism?
abdominal - 15%
inguinal canal - 25%
high scrotal - 60%
what is the epidemiology of cryptorchidism?
premature babies - can resolve spontaneously but also present in 3% in full term births
what is the basis of cryptorchidism?
embryological failure of the descent of the testes into the scrotum - empty - 10% are bilateral
what are the complications that could occur if not spontaneously resolved?
infertility
hernias
testicular cancer risk
testicular torsion
what is the cause of cryptorchidism?
multifactorial and often no cause identified
what affects cryptorchidism development?
multiple genes - downs syndrome, klinefelter syndrome and FHx
multiple environmental factors - maternal alcohol, prematurity, maternal smoking, low birth weight
what happens at 7 weeks in development?
the testes begin to form in the abdomen
what happens with the testes at 10-15 weeks?
transabdominal descent
when is the inguinoscrotal descent?
25-35 weeks
what is seminoma?
it is a malignant neoplasm of the testis arising from the germ cells in the seminiferous tubules - most common type of testicular cancer
what are other types of testicular cancer with a good prognosis?
classic, spermatocyte, leydig and sertoli cell
what are other types of testicular cancer with a worse prognosis?
lymphoma, teratoma, choriocarcinoma, yolk sac and embryonal
what are the risk factors for seminoma?
young male - 25-45y/o
FHx
cryptorchidism whether surgically corrected or not
genetic mutations such as KIT - inherited
environmental factors causing mutations
what is the first layer of cells under the basement membrane in the testicle and how does this become spermatid?
spermatogonia - through mitosis and growth becomes a primary spermatocyte which through meiosis I becomes a secondary which through meiosis II becomes a spermatid
what is a sertoli cell?
it is the ‘nurse’ cell of the testicle in the seminiferous tubule that helps with production of sperm (spermatogenesis), is secreted by adenohypophosis through FSH stimulation and has FSH receptors on its membrane
what are the local and distant effects of seminoma?
local will be a testicular lump and swelling or pain, distant will be lung (SOB) and lymph node metastasis resulting in back pain
what is the paraneoplastic syndrome of seminoma?
gynecomastia - beta HCG
what is the 5YSR of seminoma?
95%
what are the divisions of a primary testicular tumour?
first division: can be germ or non germ cell tumour
germ cell tumours can be seminoma (classic or spermatocytic) or non-seminomatous germ cell tumour (teratoma, choriocarcinoma, yolk sac or embryonal)
non germ cell can be lymphoma or sex cord, stromal tumour (leydig or sertoli cells)
what are the symptoms of obstructive lesions of the UT?
symptoms of the causative factor plus anuria and pain if complete obstruction and if partial then can be asymptomatic commonly
what is the result of a blocked urinary tract?
whether physically or functionally damaged may lead to infection, stones or renal damage
what malignancies of the UT have good/bad prognosis?
good - Wilms, seminoma and prostate carcinoma
bad - renal and bladder carcinoma
what occurs due to back pressure in the UTO?
secondary VUR and irreversible renal impairment
what occurs due to urinary stasis in UTO?
calculi formation and infection
what are the causes of UTO in the kidneys, renal pelvis and ureter?
kidneys - large tumours
pelvis - staghorn calculi or tumours
ureter - lumen material (clots, calculi or sloughed papillae), wall abnormalities (stricture, tumour, congenital), external compression (pregnancy, cervical or colon ca, retroperitoneal fibrosis or AAA)s or function such as VUJ reflux
what are the causes of UTO in the bladder and prostate?
bladder = calculi, tumours, neurogenic bladder, anticholinergic drugs and constipation
prostate - BPH, tumours or prostatitis
what are the causes of UTO in the penis and urethra?
penis - tumour or phimososis
urethra - stricture, foreign body, blocked catheter or posterior urethral valves
what are functional not physical obstructions?
neurogenic bladder, anticholinergic drugs VUJ reflux
