Urology Flashcards

1
Q

What are urinary calculi?

A

Crystals formed in the renal collecting tracts

o May be deposited anywhere in the urinary tract

o Lifetime incidence is 15% (M>F; 3x)

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2
Q

What can stones be made of?

A

o Calcium oxalate – weddellite – 75%

o Magnesium ammonium phosphate – struvite – 15%

o Uric acid – 5%

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3
Q

What are calcium oxalate crystals?

A

o Related to hypercalciuria

§ Absorptive hypercalciuria – excessive calcium absorption from gut

§ Renal hypercalciuria – impaired absorption of calcium from proximal renal tubule

o Related to ethylene glycol poisoning (metabolises to calcium oxalate)

o Hypercalcemia – primary hyperparathyroidism – rare

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4
Q

What is struvite?

A

Large stones = Staghorn Calculi ^^

o Causes

§ Recurrent UTI -> infection with urease producing organisms – proteus sp.

§ Hyperammonaemia -> ammonia alkalises urine -> precipitation of magnesium phosphate salts

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5
Q

What is uric acid?

A

o Form in patients with hyperuricaemia (i.e. from gout ± rapid cell turnover)

o Most patients do not actually have hyperuricaemia or increased uric acid excretion in urine

o Believed to be due to tendency to produce slightly acidic urine

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6
Q

What are the complications of urinary calculi?

A

o Small stones that stay in kidney – largely asymptomatic

§ Otherwise detected during investigation of haematuria or recurrent UTI

o Small stones that drift out of the kidney may become impacted and cause colic – locations to get struck:

§ Pelvo-ureteric (PUJ) junction, pelvic brim, vesico-ureteric junction (VUJ)

o Large stones tend to stay in the kidney – obstruction, risk of infection, chronic renal failure

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7
Q

What is a papillary adenoma?

A

· Benign epithelial kidney tumour, composed of papules ± tubules

o Well defined – must be 15mm or less (if >15mm = malignant PRCC)

o Well circumscribed

o Trisomy 7, Trisomy 17, loss of Y chromosome

· Frequent incidental finding in nephrectomies and at autopsy

o Especially in chronic kidney disease, acquired cystic renal disease

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8
Q

What is a renal oncocytoma?

A

· Benign epithelial kidney tumour composed of oncocytic cells

o Well circumscribed – see right image – circular

o Usually sporadic

o Can be seen in Birt-Hogg-Dube syndrome

· Usually incidental finding

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9
Q

What is an angiomyolipoma?

A

· Benign mesenchymal kidney tumour composed of thick-walled blood vessels, smooth muscle and fat

o Derived from perivascular epithelioid cells

o Mostly sporadic

o Can be seen in tuberous sclerosis

· Usually incidental

o Larger tumours >4cm may present with flank pain, haemorrhage, shock

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10
Q

What is a renal cell carcinoma?

A

· Accounts for 2% of cancers worldwide

o More common in developed countries, more in men

· RF: smoking, HTN, Obesity, long term dialysis, genetic syndromes (VHL)

· Presentation:

o Painless haematuria (50%) VHL = phaeochromocytoma, neuroendocrine pancreatic

o Incidentally on imaging tumour, clear cell renal cell carcinoma

o Small proportion present with metastatic disease

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11
Q

What is clear cell renal carcinoma?

A

§ Epithelial kidney tumour composed of metastases of clear cells set in a delicate capillary vascular network – associated with VHL

§ Appears grossly, as a golden yellow tumour with haemorrhagic areas

§ Genetically – shows loss of chromosome 3p

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12
Q

What is papillary renal cell carcinoma?

A

§ Epithelial kidney tumour composed or papillae ± tubules

· >15mm in size

· Genetically – trisomy 7, trisomy 17, loss of Y

· Divided into 2 types based on morphology

§ Grossly appears as a fragile, friable brown tumour

· Left = type 1 – single layer of flatter cells

· Right = type 2 – more oncolytic cells – do worse

§ Associated with long-term dialysis

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13
Q

What is chromophobe renal cell carcinoma?

A

§ Epithelial kidney tumours composed of sheets of large cells that display distinct cell borders, reticular cytoplasm and thick-walled vascular network

· Variable genetic aberrations

§ Well circumscribed solid brown tumou

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14
Q

What affects prognosis in RCC?

A

· 5-year survival across all tumour types is 60%

· Staging and grading (most important prognostic factors):

o Clear cell, papillary:

§ ISUP Nuclear Grade (1-4)

o Clear cell, papillary, chromophobe:

§ TNM 8th edition

· Risk of progression index (Leibovich Risk Model – low risk, intermediate risk, high risk):

o Clear cell renal carcinoma

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15
Q

What is a nephroblastoma?

A

· Malignant triphasic kidney tumour of childhood

o Blastema – small round blue cells = a feature of primitive tumours (-blastomas)

o Epithelial

o Stromal

· Typically presents as an abdominal mass in children aged 2-5 (2nd most common childhood malignancy, behind ALL)

· 95% of cases show favourable histological features with excellent prognosis

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16
Q

What is a urothelial carcinoma/ TCC?

A

· Group of malignant epithelial neoplasms arising in urothelial tract

o Bladder (transitional cell carcinoma most common)

o Renal pelvis

o Ureters

· Very common; RFs: smoking, aromatic amines

· More present with frank haematuria

17
Q

What are the 3 main subtypes of TCC?

A

o “Ni PUC”Non-invasive papillary urothelial carcinoma [LEFT image]

§ Frond-like growths

§ Divided into low grade and high grade based on nuclear atypia

· Low grade – low risk of progression to invasive disease <5%

· High grade – higher risk of progression to invasive disease

o Unstable, carry number of genetic aberrations including RbP and p53

o “In UC” Infiltrating urothelial carcinoma [RIGHT 2 images]

§ Urothelial tumour showing invasive behaviour

§ Wide range of subtypes

§ Treatment depends on depth of invasion – lamina propria, muscularis propria

o “FUC IT” Flat urothelial carcinoma in situ

§ May be invisible or appear as a reddish area

§ Flat urothelial lesion with unequivocal high-grade features – high risk of progression

18
Q

What is BPH?

A

· Benign enlargement of prostate because of increase in cell number

· Symptomatic in 25% men by age 80 [very common; histologically present in 90% men by age 80]

· Unclear aetiology

o Increased oestrogen in blood with age -> may induce androgen receptors and stimulate hyperplasia

o Treatment based on alpha blockers and 5 alpha reductase inhibitors as well as transurethral resection

§ Tamsulosin (alpha blocker)

§ Finasteride (5-alpha reductase inhibitor)

· Present with lower urinary tract symptoms

o Frequency, nocturia, urgency

o Hesitancy, poor flow, terminal dribbling

· May also present with UTI, acute urine retention or renal failure

19
Q

What is prostatic adenocarcinoma?

A

· Malignant epithelial prostate tumour

· Most common malignant tumour in men (25% of all male cancers; 1 in 8 men will develop):

o Less prominent cause of cancer related death

o Associations:

§ Red meat

§ FHx (5-10x increased risk of first degree relative affected)

· Arises from prostatic intraepithelial neoplasia

o Mutations in PTEN, AMACR, GST-PI, P27, and more…

· Usually asymptomatic, usually diagnosed on biopsy after raised PSA or DRE

o Some have LUTS

o Signs of metastatic disease

§ I.E. Pathological fracture; RARE

· Prognostic indicator = Gleason score – influences treatment decisions

o X (worst pattern) + Y (most common pattern) = Z

§ Patterns range from 1-5

o Higher scores = more aggressive

§ High volume tumours score 8-10

§ Grade grouping as well

20
Q

What are testicular germ cell tumours?

A

· Tumours of the testes arising from germ cells

o 90% of testicular tumours

o Typically arise in men 20-45

o RF: undescended testes, LBW / SGA

· Malignant tumours arise from germ cell neoplasia in situ

o I.E. begins in foetal stage!

· Present as a painless lump (10% symptoms related to mets – back pain, cough, dyspnoea)

· Five histological subtypes – a single tumour may be just one or a mix of subtype

o Seminoma – most common, lymphocyte infiltrate

o Embryonal carcinoma

o Post-pubertal teratoma

o Yolk sac tumour

o Choriocarcinoma

· Highly sensitive to platinum-based chemo agents

· Great prognosis – 5-year survival 98% in most countries

21
Q

What are testicular non germ cell tumours?

A

· Much less common than germ cell tumours

· Lymphoma

o Older men, 5% of all testicular tumours

o Highly aggressive, poor survival rates

· Leydig cell tumour

o 3% of all testicular tumours

o May present with precocious puberty if pre-pubertal

o Usually benign

· Sertoli cell tumour

o 1% of testicular tumours

o 90% benign

22
Q

What is paratesticular disease?

A

· Epididymal cyst

· Epididymitis – usually related to C. trachomatis, N gonorrhoea in men <35 and E coli in men 35+

· Varicocele – dilated venous plexus

· Hydrocele – fluid between layers of tunica vaginalis

· Adenomatoid tumour – small tubules lined by mesothelial cells

23
Q

What are the penile diseases?

A

o Lichen sclerosis or balanitis xerotica obliterans – inflammatory condition causing phimosis

o Zoon’s balanitis – inflammatory condition causes red areas

o Condylomas – HPV 6 and 11

o Peyronie’s disease – scarring, inflammation, thickening of corpus cavernosa

o Penile carcinoma – rare, elderly men, smoking, HPV, chronic Lichen Sclerosus are RF

24
Q

What are the urethral diseases?

A

o Urethritis – N. gonorrhoea, C trachomatis

o Prostatic urethral polyp – papillary lesion in prostatic urethra

o Urethral caruncle – common lesion at urethral meatus in women

o Urethral carcinoma – rare, more common in women, SCC

o Malignant melanoma – rare

25
Q

What are scrotal diseases?

A

o Epidermoid cyst – common

o Scrotal calcinosis – rare, related to old epidermoid cysts

o Angiokeratomas – benign vascular lesions

o Fournier’s gangrene – necrotising fasciitis – mortality of 15-20%

o Scrotal SCC – very rare, historically chimney sweep