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bladder pathology
R-GU
51
Medical
Graduate
09/29/2010

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Term
what characterizes most congenital anomalies involving the bladder?
Definition
most have little clinical significance, though some can contribute to obstruction of urine flow or cause clinical disease
Term
what characterizes the congenital anomaly of double and bifid ureters?
Definition
double and bifid ureters may be associated with distinct double renal pelves or anomalous development of a large kidney w/partially bifid ureters terminating in separate ureters. these double ureters may pursue separate courses into the bladder wall and then drain into a single ureteral orifice. *most double ureters are unilateral* and are of *no clinical significance*.
Term
what characterizes the congenital anomaly of ureteropelvic junction obstruction?
Definition
ureteropelvic junction obstruction results in *hydronephrosis and is due to the *abnormal organization of smooth muscle bundles which create abnormal stromal collagen deposition*. the kidney becomes large and swollen, but ureteropelvic junction obstruction generally doesn't come to clinical signifigance for a while b/c it is unilateral and the other kidney can pick up the slack. there may also be *congenital compression of the polar renal vessels* associated with this.
Term
who is more affected by ureteropelvic junction obstruction?
Definition
ureteropelvic junction obstruction is more common in infant boys, but in adult cases - women are more commonly affected
Term
what characterizes the effect of diverticuli on the ureters?
Definition
diverticuli, or outpouchings of mucosa are usually asymptomatic - though multiples *can cause stasis and lead to secondary infections*. the ureters may become dilated, tortuous and elongated as a result.
Term
what are two kinds of inflammation seen in the ureters?
Definition
ureteritis follicularis: an accumulation of *lymphocytes which form follicles w/germinal centers* and elevate the mucosa w/a varying degree of *granularity and ureteritis cystic: the mucosa is *lined by very small cyst structures lined themselves by flattened urothelium*.
Term
what characterizes the incidence of tumors in the ureters?
Definition
ureteral tumors are rare relatively rare. *fibroepithelial polyps are benign tumors w/loose vascularized connective tissue presenting as a mass projecting into the lumen. *transitional cell carcinomas are malignant tumors which closely resemble those seen in the renal pelvis, calyces, and bladder and are usually seen in men >60 yrs old. both can cause obstruction.
Term
what are the intrinsic obstructive lesions? how commonly are they the cause of ureteral problems?
Definition
intrinsic obstructive lesions such as diverticuli, fibroepithelial polyps, malignancies, strictures, caliculi, blood clots (if hypercoagulable state) and neurogenic problems (w/peristalsis) are more commonly the cause of ureteral problems than extrinsic.
Term
what are the extrinsic obstructive lesions?
Definition
extrinsic obstructive lesions consist of anything surrounding and compressing the ureter such as pregnancy, periureteral inflammation (general pelvic inflammation), endometriosis (deposits of endometrial tissue outside the uterus), and tumors (ovarian/pelvic - hydronephrosis: common cause of morbidity)
Term
what are the results of ureteral obstruction?
Definition
hydroureter (ureter itself expands and becomes enlarged/dilated), hydronephrosis (kidney expands, usually unilateral - but if bilateral, more symptomatic), and pyelonephritis (infection due to stasis of urine flow, tends to be ascending)
Term
what is sclerosing retroperitoneal fibrosis?
Definition
*fibrous proliferation of inflammatory processes encasing the retroperitoneal structures* (including ureters) leading to hydronephrosis that occurs in late to middle age and is often due to drugs and associated with other inflammatory conditions: *vasculitis, diverticulitis, and crohn disease*. it is uncommon, but distinct.
Term
what are two congenital anomalies which can affect the bladder?
Definition
diverticula and exstrophy
Term
what characterizes the incidence diverticula in the bladder?
Definition
congenitally: bladder diverticula emerge due to *failure of normal musculature development and increased intraluminal pressure leading to outpouchings of mucosa. acquired: obstruction of urinary flow leads to increased intraluminal pressure and thickening of the bladder wall - the musculature is normal, but pressure exceeds its limits and produces outpouching. diverticula are often multiple, particularly w/congenital forms, and can lead to infections and reflux from the bladder into the ureter. *most of the time diverticula are asymptomatic - but can predispose pts to calculi formation*. CA rarely arises from diverticuli.
Term
what is exstrophy of the bladder?
Definition
when the bladder communicates with a *congenital defect in the abdominal wall. this is surgically correctable, though the bladder may undergo *glandular or squamous metaplasia due to abnormal function. once fixed, pts usually fare well - however it raises the red flag for other anomalies.
Term
what is the most commonly seen bladder pathology?
Definition
cystitis: acute and/or chronic inflammation of the bladder
Term
what are the common infectious agents responsible for acute/chronic cystitis?
Definition
*e. coli, which is the most common due to the close proximity of rectum/ureters, followed by *proteus, klebsiella, and enterobacter*. candida may infect bladders of immunocompromised, *schistosomiasis may be seen more in the middle east (association w/SCC), and less commonly viruses/chlamydia/mycoplasma may infect the bladder.
Term
what is a major cause of cystitis in men?
Definition
catheterization
Term
how does acute hemorrhagic cystitis appear grossly? histologically?
Definition
grossly: the mucosal wall is hyperemic w/focal areas of hemorrhage. histologically: transitional epithelium may be fragmented/denuded off w/hemorrhage below the epithelial surface.
Term
what characterizes chronic cystitis histologically?
Definition
more inflammatory infiltration, epithelial cell changes, often fragmentation of epithelial lining - seen often in congenital problems or pts w/long indwelling catheterization.
Term
what is radiation cystitis?
Definition
after decades of radiation exposure, *reactive hyperplastic epithelial cells invade the lamina propria* and may form bizarre squamous cell-like nests exhibiting nuclear polymorphism. fibrin deposits and hemorrhage are usually seen. if these changes are seen w/o hx of radiation - may indicate SCC or transitional cell CA
Term
what are some predisposing factors for cystitis?
Definition
bladder calculi (can be the result/cause of inflammation), urinary obstruction (BPH in men), DM (neuropathy), instrumentation, immunodeficiency, *cytotoxic antitumor drugs (hemorrhagic cystitis), and radiation cystitis
Term
what is the morphology of cystitis?
Definition
hemorrhagic cystitis features edema/hyperemia and focal areas of hemorrhage. nonspecific acute and chronic inflammation are generally concurrent. if the inflammation becomes severe, suppurative/ulcerative cystitis may occur.
Term
what characterizes the histological presentation of chronic cystitis?
Definition
thickening of the bladder wall (over years), infiltration of lymphocytes, granularity, *infiltration of fibroblasts (further decrease in elasticity = increase in cystitis), and then there are also specific follicular/eosinophilic types of chronic inflammation.
Term
what are the clinical features of cystitis?
Definition
frequency (constant urge to urinate), dysuria (burning feeling), lower abdominal pain, and possible fever
Term
what is interstitial cystitis/hunner ulcer?
Definition
this describes *inflammation and fibrosis of all layers in the bladder as well as fissures w/hemorrhage that heal poorly (hunner ulcers)*. it is seen mostly in women (possible autoimmune etiology), and is a cause of high morbidity and lower abdominal pain. on bx, abnormal cells due to chronic inflammation may be visible.
Term
what is the morphology associated with interstitial cystitis/hunner ulcers?
Definition
bladder walls are thickened, fissures are scattered throughout and pts present with abdominal pain, dysuria, and frequency
Term
what is malakoplakia? what is an important histologic structure associated with this?
Definition
infiltration of large foamy macrophages, chronic inflammatory cells, giant cells, and lymphocytes which appear as *raised yellow mucosal plaques and are due to *chronic bacterial infection - as often seen in immunosuppressed transplant pts. *michaelis-gutmann bodies* are important structures associated with malakoplakia consisting of *laminated mineralized concretions* engulfed by macrophages and between cells*.
Term
what is polypoid cystitis?
Definition
inflammation which results in polyp formation of the bladder mucosa - usually in response to some kind of chronic infiltration (catheter) as a reparative measure and is associated with submucosal edema. polypoid cystitis can mimic papillary CA.
Term
what is cystitis glandularis/cystitis cystica?
Definition
metaplastic changes where *nests of transitional epithelium transform into cuboidal or columnar epithelium*. these may undergo further cystic change, but are *relatively common findings in normal urinary bladders.
Term
how does cystitis glandularis/cystitis cystica appear histologically?
Definition
normal transitional epithelium at the top layer, but nests of cuboidal/columnar change in the lamina propria
Term
when is squamous cell metaplasia usually seen in the bladder? how does it usually appear histologically?
Definition
in response to injury - histologically, it is associated with increased keratin production
Term
what is nephrogenic metaplasia?
Definition
focal replacement of transitional cells with cuboidal epithelium in papillary structures that can mimic CA. this may occur in response to injury.
Term
what characterizes the over all incidence of bladder tumors?
Definition
bladder CA rates are increasing. most are transitional cell CA, but SCC or mesenchymal tumors may also be seen.
Term
what are the 2 basic morphologies of bladder CA? how do they usually present?
Definition
papillary and flat - either of which can be invasive and usually both will present w/some kind of hematuria as well as flaking of abnormal cells (detectable w/urinary cytology)
Term
what is transitional cell hyperplasia?
Definition
in transitional cell hyperplasia, transitional cells are simply increasing in number.
Term
what characterizes transitional cell tumors in the bladder?
Definition
transitional cell tumors can range from benign to malignant and many are multifocal. there are 2 precursor lesions leading to CA: *noninvasive papillary tumors and *CA in situ - however, invasive CA is often not associated with precursor lesions (rises denove). grossly, transitional cell tumors can range from purely papillary (red excrescences) to flat (hyperemic).
Term
what characterizes papillomas as seen in the bladder?
Definition
papillomas are composed of fibrovascular tissue covered w/benign epithelium and are seen in younger pts. *inverted papillomas* are also possible, which consist of benign epithelium extending into the lamina propria (dimpling in).
Term
what is a PUNLMP?
Definition
a papillary urothelial neoplasm of low malignant potential, these are similar to papillomas - but tend to be larger. they have a thicker urothelium or nuclear enlargement and may recur - though they rarely progress to higher grade lesions.
Term
what is a low grade papillary urothelial CA?
Definition
low grade papillary urothelial CA is a kind of transitional cell CA characterized by orderly structures, nuclear atypia, mild pleomorphism, and rare invasion but common recurrence.
Term
what is high grade papillary urothelial CA?
Definition
high grade papillary urothelial CA is a kind of transitional cell CA characterized by large hyperchromatic nuclei, frank anaplasia (lack of differentiation), loss of polarity, increased mitosis, higher invasion risk and greater metastatic potential
Term
what characterizes CA in situ?
Definition
w/transitional cell CA in situ, malignant cells are in flat urothelium and may shed into urine due to lack of cohesiveness. the mucosa is reddened and thick, there are no intraluminal masses, and they are often multifocal. if left untreated, CA in situ can lead to invasive CA.
Term
what characterizes transitional CA in situ histologically?
Definition
malignant cells are observed with high n/c ratios, much disorganization, stratification of nuclei, fragmentation, and *non-invasion of the basement membrane*.
Term
what determines prognosis for invasive transitional cell CA?
Definition
the extent of invasion determines the prognosis, for example invasion of the muscularis propria is more ominious than if the lamina propria is invaded.
Term
what characterizes the incidence of SCC in the bladder?
Definition
SCC is less common than transitional cell CA in the bladder and has a *strong association with schistosomiasis (egypt/sudan). SCC is more invasive and fungating and will cover large areas of the bladder. SCC has a poor 5 yr survival rate.
Term
how common are adenocarcinomas in the bladder? what characterizes their appearance?
Definition
rare. if seen they are histologically identical to those seen in the GI tract, but with some serologic differences. these will secrete a significant amount of mucin, which enables invasion. most adenocarcinomas develop from *chronic irritation of the surface urothelium.
Term
what are some of the risk factors for bladder CA?
Definition
bladder CA affects mostly males 50-80 yrs old, whose risk increases with *smoking, arylamine exposure, schistosomasis, long term analgesis use, cyclophosphamide (tumor drug) use, and radiation exposure.
Term
what is the clinical course of bladder CA?
Definition
painless hematuria, occasional frequency/urgency/dysuria, possible pyelonephritis, and a higher recurrence rate (f/u cytology w/various urine markers)
Term
what characterizes the incidence of mesenchymal tumors in the bladder?
Definition
mesenchymal tumors are relatively rare, the *most common of which in adults being leiomyoma and embryonal rhabdomyosarcoma in infants*. sarcomas tend to appear as large, soft, fleshy masses and *sarcoma botroides appear as polypoid grape-like masses in children and infants*.
Term
what are the more common metastatic tumors to the bladder?
Definition
breast, melanoma, lung, kidney, stomach, pancreas, and ovary
Term
what are the important components of a bladder CA path report?
Definition
grade, configuration (sessile/papillary), depth of penetration, lymphatic/blood vessel penetration, and changes in the adjacent mucosa
Term
what are things which can result in bladder obstruction?
Definition
prostatic hyperplasia/CA, narrowing of the urethra, invasion by perivesicular lesions, cystitis, bladder tumors, foreign bodies/calculi, and injury to bladder innervation (neurogenic bladder associated with DM and trauma)
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