Urology Flashcards
What are urinary calculi?
Crystals formed in the renal collecting tracts
o May be deposited anywhere in the urinary tract
o Lifetime incidence is 15% (M>F; 3x)
What can stones be made of?
o Calcium oxalate – weddellite – 75%
o Magnesium ammonium phosphate – struvite – 15%
o Uric acid – 5%
What are calcium oxalate crystals?
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
What is struvite?
Large stones = Staghorn Calculi ^^
o Causes
§ Recurrent UTI -> infection with urease producing organisms – proteus sp.
§ Hyperammonaemia -> ammonia alkalises urine -> precipitation of magnesium phosphate salts
What is uric acid?
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
What are the complications of urinary calculi?
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
What is a papillary adenoma?
· 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
What is a renal oncocytoma?
· 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
What is an angiomyolipoma?
· 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
What is a renal cell carcinoma?
· 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
What is clear cell renal carcinoma?
§ 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
What is papillary renal cell carcinoma?
§ 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
What is chromophobe renal cell carcinoma?
§ 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
What affects prognosis in RCC?
· 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
What is a nephroblastoma?
· 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
What is a urothelial carcinoma/ TCC?
· 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
What are the 3 main subtypes of TCC?
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
What is BPH?
· 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
What is prostatic adenocarcinoma?
· 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
What are testicular germ cell tumours?
· 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
What are testicular non germ cell tumours?
· 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
What is paratesticular disease?
· 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
What are the penile diseases?
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
What are the urethral diseases?
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
What are scrotal diseases?
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
