minarcik robbins 2013_ch21-lower_ut

LOWER

URINARY

TRACT

LOWER URINARY TRACT=

TRANSITIONALEPITHELIUM

= “URO”THELIUM

MINOR CALYCES

MAJOR CALYCES

RENAL PELVIS

URETERS

BLADDER

URETHRA

MUSCULARIS PROPRIAMUSCULARIS PROPRIA

EPITHELIUM

PRONEPHROSMESONEPHROSMETANEPHROS

CLOACA

MÜLLERIAN ♀WOLFFIAN ♂

EMBRYOLOGY

LOWERUrinary Tract

•Ureters(Anomalies, Infl., Neopl.)

•Bladder(Anomalies, Infl., Neopl.)

•Urethra(Anomalies, Infl., Neopl.)

URETERS• Anomalies (congenital)

• Inflammation/Obstruction (i.e., ureteritis)– Acute, Chronic

• Neoplasms– Benign vs. Malignant– Epithelial vs. “stromal” (i.e., mesoderm

derived)

CONGENITAL Ureter Anomalies

• DOUBLE Ureters

• UPJ (Uretero-Pelvic Junction) Obstruction

• Diverticula

• Hydroureter

INFLAMMATION• The USUAL reasons

• The USUAL patterns, i.e. ?

• Linked to OBSTRUCTION

• GLANDULARIS/CYSTICA

• FOLLICULARIS

OBSTRUCTIONFACTORS

• INTRINSIC:– CALCULI – STRICTURES– TCC, TUMORS– CLOTS– NEUROGENIC

• EXTRINSIC:

• PREGNANCY• INFLAMMATION• ENDOMETRIOSIS• TUMORS• SURGERY

Sclerosing Retroperitoneal Fibrosis

•70% Idiopathic• 30% Drugs (ergot derivatives,

beta blockers) or known retroperitoneal inflammatory conditions, e.g., Vasculitis, Diverticulitis, Crohn’s Disease

TUMORS• Benign

–Fibroepithelial Polyp–Leiomyoma

• Malignant–Transitional Cell Carcinoma, aka,

TCC–Also called UROTHELIAL Carcinoma

Which Ureter?

Which Part?

LOWERUrinary Tract

•Ureters(Anomalies, Infl., Neopl.)

•Bladder(Anomalies, Infl., Neopl.)

•Urethra(Anomalies, Infl., Neopl.)

ANOMALIES• Diverticul-a (plural of –um)• Exstrophy• Vesico-Ureteral Reflux• Persistent Urachus• Fistulas: Vagina, Rectum,

Uterus

EXSTROPHYDevelopmental Anomaly

Very Good Surgical Correction Rate

Vesico-Ureteral Reflux

• Most Common Anomaly

• Very serious in its role in chronic pyelonephritis and hydronephrosis

ADJECTIVES for CYSTITIS

• Acute• Chronic• Hemorrhagic• Suppurative• Follicular• Eosinophilic• Interstitial

CAUSES for CYSTITIS• E. coli • Proteus, Klebsiella, Enterobacter

• Shistosomes (Egypt)

• Chlamydia

• Mycoplasma

• Viruses, e.g., adenoviruses

• ChemoRX

• RadiationRX

SYMPTOMS for CYSTITIS

• Frequency• Urgency

• Hematuria

• Abdominal Pain

• Dysuria

• Systemic Sepsis, i.e., fever, leukocytosis (urosepsis?)

Special Types ofCYSTITIS

•“Interstitial” cystitis, aka, Hunner Ulcer

•Malacoplakia

“Interstitial” Cystitis• Women>> Men

• Bladder Wall Fibrosis

• Aka, “Hunner” ulcer

Malacoplakia• YELLOW Mucosal “Plaques”

• Why Yellow?• Chronic bacterial infection• Michaelis-Gutmann bodies contain Fe

and Ca in macrophages

METAPLASIA•Glandular(is) (Cystica), from Von Brunn nests

•Squamous metaplasia

TUMORS• 95% Epithelial (urothelial), 5%

mesenchymal, i.e., mesodermally derived (mostly smooth muscle)

• Benign or Malignant

• Primarily urothelial or transitional, but a few squamous, from antecedent squamous metaplasia, and a few adenocarcinomas, from antecedent glandular metaplasia

TCC TUMORS• MULTIPLE, MULTIPLE, MULTIPLE, i.e., “soil”

theory

• Papillomas vs. Carcinomas

• Grading, I, II, III, or wellpoor

• Staging, TNM, based on biologic behavior, really based on normal anatomy

TCC TUMORS• Causes/Risk Factors

– Arylamines (aniline dyes)

–Cigarettes–Shistosomiasis– Longstanding analgesics, same as

analgesic nephropathy drugs, most common NSAIDS

– ChemoRX, esp. cyclophosphamides– Radiation RX

Papillomas vs. Carcinomas• Very few pathologists will have enough

guts to diagnose a transitional papilloma. Why?

• PUNLMP, Papillary Urothelial

Neoplasm of Low Malignant Potential– LOW grade PUC (TCC)– HIGH grade PUC (TCC)

LOW Grade

HIGH Grade

BIOLOGIC BEHAVIORNORMAL MUCOSADYSPLASIA, SEVERE DYSPLASIA, CARCINOMA IN SITU, INFILTRATION BASEMENT MEMBRANELAMINA PROPRIAMUSCULARIS

MUCOSAMUSCULARIS PROPRIA (i.e., WALL)SEROSA or ADVENTITIALYMPH NODESDISTANT METASTASES

TNM

TNM example:• Ta----noninvasive, papillary• Tis---Carcinoma in situ, flat• T1----Lamina Propria

• T2----Muscularis propria• T3a---Microscopic beyond the wall• T3b---Grossly beyond the bladder wall• T4----Invades adjacent structures

Bladder Neck OBSTRUCTION

• Cystocele, MOST common cause in women

• Prostate, MOST common cause in MEN

• Congenital• Inflammation• Tumors• Foreign Bodies, Calculi• Neurogenic

LOWERUrinary Tract

•Ureters(Anomalies, Infl., Neopl.)

•Bladder(Anomalies, Infl., Neopl.)

•Urethra(Anomalies, Infl., Neopl.)

URETHRA• Inflammations:

– Gonococcus– Chlamydia– Mycoplasma– Reiter’s Syndrome (men)– “Caruncle” (women)

• Neoplasms:

– Transitional– Squamous– Glandular

Chapter 21

Male

Genital Tract

Diseases

Male Genital Tract(long version)

• Seminiferous tubules • Straight Tubules • Rete Testis (mediast.) • Efferent Ductules • Epididymis • Vas deferens • Seminal Vesicles • Ejaculatory Ducts • Urethra: ProstaticSpongy

Efferent Ductules and Epididymis

LITTRÉ

Male Genital Tract(short version)

• Penis: Congenital, Inflammation, Tumors

• Testis/Epididymis: Congenital, Regressive, Inflammation, Vascular diseases, Tumors

• Prostate: Inflammation, Benign Enlargement, Malignancy

Penis: Congenital•Hypospadias

•Epispadias

•Phimosis

Penis: Inflammation“Balanoposthitis”

• Candida

• Anerobes

• Gardnerella

• Pyogenic

• Role of “smegma”

Penis: Neoplasia

•Benign : Condyloma Acuminata (caused by HPV), aka venereal or genital “warts”

•Malignant: Squamous cell carcinoma

Koilocytosis

Penis: Malignancy

•In-situ = Bowen’s Disease

•Invasive = Infiltrating or

invasive SQUAMOUS Cell Carcinoma

BOWEN’s Disease = SQUAMOUS cell carcinoma-in-situ of the skin of the penis

Male Genital Tract(short version)

• Penis: Congenital, Inflammation, Tumors

• Testis/Epididymis: Congenital, Regressive, Inflammation, Vascular diseases, Tumors

• Prostate: Inflammation, Benign Enlargement, Malignancy

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital

–Regressive (Atrophy)

–Inflammation

–Vascular diseases

–Tumors

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital: Cryptorchidism 1%–Regressive: Atrophy–Inflammation: Mumps, GC,

Chlamydia, E. Coli, Pseudomonas, TB

–Vascular diseases: Torsion–Tumors: Benign/Malig, Germ

Cell/non-Germ Cell

Cryptorchidism• 1% of all births• 25% bilateral• Associated with significantly increased

incidence of germ cell tumors

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital: Cryptorchidism 1%–Regressive: Atrophy–Inflammation: Mumps, GC,

Chlamydia, E. Coli, Pseudomonas, TB

–Vascular diseases: Torsion–Tumors: Benign/Malig, Germ

Cell/non-Germ Cell

Testicular Atrophy• atherosclerotic narrowing of the blood supply in old age

• the end stage of an inflammatory orchitis, whatever the etiologic agent

• Cryptorchidism (undescended testes are sterile)

• hypopituitarism• generalized malnutrition or cachexia• irradiation• prolonged administration of female sex hormones, as in

treatment of patients with carcinoma of the prostate; and cirrhosis

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital: Cryptorchidism 1%–Regressive: Atrophy–Inflammation: Mumps, GC,

Chlamydia, E. Coli, Pseudomonas, TB

–Vascular diseases: Torsion–Tumors: Benign/Malig, Germ

Cell/non-Germ Cell

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital: Cryptorchidism 1%–Regressive: Atrophy–Inflammation: Mumps, TB, GC,

Chlamydia, E. Coli, Pseudomonas–Vascular diseases: Torsion–Tumors: Benign/Malig, Germ

Cell/non-Germ Cell

Male Genital Tract(short version)

•Testis/Epididymis: –Congenital: Cryptorchidism 1%–Regressive: Atrophy–Inflammation: Mumps, GC,

Chlamydia, E. Coli, Pseudomonas, TB

–Vascular diseases: Torsion–Tumors: Benign/Malig, Germ

Cell/non-Germ Cell

Testicular TUMORS• GERM CELL (malig.)

– SEMINOMA– EMBRYONAL– CHORIOCARCINOMA– YOLK SAC– TERATOMA

–MIXED!!!!!, 60%

• NON-GERM (benign)• CELL, i.e., “sex cord”

– LEYDIG– SERTOLI

Seminoma

(look for germ cells and

lymphs)

Embryonal Carcinoma,

Formerly called “adeno”carcinoma, so look for “glands” and AFP!!!)

CHORIOCARCINOMAlook for “trophoblast”, and HCG!!

YOLK SAC TUMOR, aka “endodermal sinus tumor”

Schiller-Duvall Body

TERATOMAMALIGNANT TERATOMA

TERATOCARCINOMAclusters of squamous epithelium, hair, skin glands

neural tissue

retina

muscle bundles

islands of cartilage

structures reminiscent of thyroid gland

bronchial or bronchiolar epithelium

bits of intestinal wall or brain substance

SEX Cord Tumors

•Leydig,

tumor cells look like Leydig cells

•Sertoli ,

tumor cells look like sertoli cells

STAGING• Stage I: Tumor confined to the testis,

epididymis, or spermatic cord

• Stage II: Distant spread confined to retroperitoneal nodes below the diaphragm

• Stage III: Metastases outside the retroperitoneal nodes or above the diaphragm

PROSTATE• INFLAMMATIONS

• BENIGN ENLARGEMENT

• MALIGNANT TUMORS

CZ = CENTRAL

TZ = TRANSITIONAL

PZ = PERIPHAL

PROSTATE• INFLAMMATIONS

• BENIGN ENLARGEMENT

• MALIGNANT TUMORS

PROSTATITIS• ACUTE, usually same as

Urinary Tract Pathogens

• CHRONIC, usually A-bacterial, but also often recurrent or persistent from acute

• GRANULOMATOUS, TB or non-TB, that is the question!

“BENIGN” Enlargement• BPH (H= Hypertrophy)• BPH (H= Hyperplasia)• Glandular and Stromal Hyperplasia• “Nodular” Hyperplasia• Associated with old age• Associated with urinary obstruction,

frequency, bladder hypertrophy and bladder trabeculations

• By itself, it is NOT premalignant, however….

P.I.N.

NUCLEOLI, NUCLEOLI, NUCLEOLINUCLEOLI, NUCLEOLI, NUCLEOLI

PERINEURAL INVASION

BIOLOGIC BEHAVIOR• NORMAL PROSTATE • HYPERPLASIA • P.I.N. (Prostatic Intraepithelial Neoplasia),

is like “dysplasia leading to adenocarcinoma-in situ

• INFILTRATION of “stroma” • CAPSULE • LYMPH NODES • DISTANT, especially BONE

GRADING• GLEASON SCORE = Predominant

pattern (1-5) + Secondary pattern

(1-5)

• Best Score = 2, Worst Score = 10

STAGING

TNM

T1 CLINICALLY INAPPARENT LESION (BY PALPATION/IMAGING STUDIES)T1a Involvement of ≤5% of resected tissueT1b Involvement of >5% of resected tissueT1c Carcinoma present on needle biopsy (following elevated PSA)T2 PALPABLE OR VISIBLE CANCER CONFINED TO PROSTATET2a Involvement of ≤5% of one lobeT2b Involvement of >5% of one lobe, but unilateralT2c Involvement of both lobesT3 LOCAL EXTRAPROSTATIC EXTENSIONT3a Extracapsular extensionT3b Seminal vesical invasionT4 INVASION OF CONTIGUOUS ORGANS AND/OR SUPPORTING STRUCTURES INCLUDING BLADDER NECK, RECTUM, EXTERNAL SPHINCTER, LEVATOR MUSCLES, OR PELVIC FLOOR

N0 NO REGIONAL NODAL METASTASESN1 METASTASIS IN REGIONAL LYMPH NODES

M0 NO DISTANT METASTASESM1 DISTANT METASTASES PRESENTM1a Metastases to distant lymph nodesM1b Bone metastasesM1c Other distant sites

TID-BITS• Prostate is #1 most common malignancy in

men but NOT #1 killer. WHY?

• 80% over 80

• Every elderly male presenting with widespread bone metastases is carcinoma of the prostate until proven otherwise

• PSA (Prostate Specific Antigen) has been controversial as a screening test but is GREAT for follow up of a known prostate cancer