minarcik robbins 2013_ch21-lower_ut
TRANSCRIPT
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
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