MINOR CALYCES MAJOR CALYCES RENAL PELVIS URETERS BLADDER URETHRA

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1 LOWER URINARY TRACT

2 LOWER URINARY TRACT = TRANSITIONAL EPITHELIUM = URO THELIUM MINOR CALYCES MAJOR CALYCES RENAL PELVIS URETERS BLADDER URETHRA

3 EPITHELIUM MUSCULARIS PROPRIA

4 EMBRYOLOGY PRONEPHROS MESONEPHROS METANEPHROS CLOACA MÜLLERIAN WOLFFIAN

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14 LOWER Urinary Tract Ureters(Anomalies, Infl., Neopl.) Bladder(Anomalies, Infl., Neopl.) Urethra(Anomalies, Infl., Neopl.)

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16 URETERS Anomalies (congenital) Inflammation/Obstruction (i.e., ureteritis) Acute, Chronic Neoplasms Benign vs. Malignant Epithelial vs. stromal (i.e., mesoderm derived)

17 CONGENITAL Ureter Anomalies DOUBLE Ureters UPJ (Uretero-Pelvic Junction) Obstruction Diverticula Hydroureter

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22 INFLAMMATION The USUAL reasons The USUAL patterns, i.e.? Linked to OBSTRUCTION GLANDULARIS/CYSTICA FOLLICULARIS

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25 OBSTRUCTION FACTORS INTRINSIC: CALCULI STRICTURES TCC, TUMORS CLOTS NEUROGENIC EXTRINSIC: PREGNANCY INFLAMMATION ENDOMETRIOSIS TUMORS SURGERY

26 Sclerosing Retroperitoneal Fibrosis 70% Idiopathic 30% Drugs (ergot derivatives, beta blockers) or known retroperitoneal inflammatory conditions, e.g., Vasculitis, Diverticulitis, Crohn s Disease

27 Benign TUMORS Fibroepithelial Polyp Leiomyoma Malignant Transitional Cell Carcinoma, aka, TCC Also called UROTHELIAL Carcinoma

28 Which Ureter? Which Part?

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33 LOWER Urinary Tract Ureters(Anomalies, Infl., Neopl.) Bladder(Anomalies, Infl., Neopl.) Urethra(Anomalies, Infl., Neopl.)

34 ANOMALIES Diverticula (plural of um) Exstrophy Vesico-Ureteral Reflux Persistent Urachus Fistulas: Vagina, Rectum, Uterus

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38 EXSTROPHY Developmental Anomaly Very Good Surgical Correction Rate

39 Vesico-Ureteral Reflux Most Common Anomaly Very serious in its role in chronic pyelonephritis and hydronephrosis

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41 ADJECTIVES for CYSTITIS Acute Chronic Hemorrhagic Suppurative Follicular Eosinophilic Interstitial

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46 CAUSES for CYSTITIS E. coli Proteus, Klebsiella, Enterobacter Shistosomes (Egypt) Chlamydia Mycoplasma Viruses, e.g., adenoviruses ChemoRX RadiationRX

47 SYMPTOMS for CYSTITIS Frequency Urgency Hematuria Abdominal Pain Dysuria Systemic Sepsis, i.e., fever, leukocytosis

48 Special Types of CYSTITIS Interstitial cystitis, aka, Hunner Ulcer Malacoplakia

49 Interstitial Cystitis Women>> Men Bladder Wall Fibrosis Aka, Hunner ulcer

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51 Malacoplakia YELLOW Mucosal Plaques Why Yellow? Chronic bacterial infection Michaelis-Gutmann bodies contain Fe and Ca in macrophages

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53 METAPLASIA Glandular(is) (Cystica), from Brunn nests Squamous metaplasia

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58 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

59 TCC TUMORS MULTIPLE, MULTIPLE, MULTIPLE, i.e., soil theory Papillomas vs. Carcinomas Grading, I, II, III, or well poor Staging, TNM, based on biologic behavior, really based on normal anatomy

60 TCC TUMORS Causes/Risk Factors Arylamines (aniline dyes) Cigarettes Shitosomiasis Longstanding analgesics, same as analgesic nephropathy drugs, most common NSAIDS ChemoRX, esp. cyclophosphamides Radiation RX

61 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)

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63 LOW Grade

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65 HIGH Grade

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70 BIOLOGIC BEHAVIOR NORMAL MUCOSA DYSPLASIA, SEVERE DYSPLASIA, CARCINOMA IN SITU, INFILTRATION BASEMENT MEMBRANE LAMINA PROPRIA MUSCULARIS MUCOSA MUSCULARIS PROPRIA (i.e., WALL) SEROSA or ADVENTITIA LYMPH NODES DISTANT METASTASES

71 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

72 Bladder Neck OBSTRUCTION Cystocele, MOST common cause in women Prostate, MOST common cause in MEN Congenital Inflammation Tumors Foreign Bodies, Calculi Neurogenic

73 LOWER Urinary Tract Ureters(Anomalies, Infl., Neopl.) Bladder(Anomalies, Infl., Neopl.) Urethra(Anomalies, Infl., Neopl.)

74 URETHRA Inflammations: Gonococcus Chlamydia Mycoplasma Reiter s Syndrome (men) Caruncle (women) Neoplasms: Transitional Squamous Glandular

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76 Chapter 21 Male Genital Tract Diseases

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78 Male Genital Tract (long version) Seminiferous tubules Straight Tubules Rete Testis (mediast.) Efferent Ductules Epididymis Vas deferens Seminal Vesicles Ejaculatory Ducts Urethra: Prostatic Spongy

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84 Efferent Ductules and Epididymis

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90 LITTRÉ

91 Male Genital Tract (short version) Penis: Congenital, Inflammation, Tumors Testis/Epididymis: Congenital, Regressive, Inflammation, Vascular diseases, Tumors Prostate: Inflammation, Benign Enlargement, Malignancy

92 Penis: Congenital Hypospadias Epispadias Phimosis

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96 Penis: Inflammation Balanoposthitis Candida Anerobes Gardnerella Pyogenic Role of smegma

97 Penis: Neoplasia Benign : Condyloma Acuminata (caused by HPV), aka venereal or genital warts Malignant: Squamous cell carcinoma

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100 Koilocytosis

101 Penis: Malignancy In-situ = Bowen s Disease Invasive = Infiltrating or invasive SQUAMOUS Cell Carcinoma

102 BOWEN s Disease = SQUAMOUS cell carcinomain-situ of the skin of the penis

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106 Male Genital Tract (short version) Penis: Congenital, Inflammation, Tumors Testis/Epididymis: Congenital, Regressive, Inflammation, Vascular diseases, Tumors Prostate: Inflammation, Benign Enlargement, Malignancy

107 Male Genital Tract (short version) Testis/Epididymis: Congenital Regressive Inflammation Vascular diseases Tumors

108 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

109 Cryptorchidism 1% of all births 25% bilateral Associated with significantly increased incidence of germ cell tumors

110 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

111 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

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113 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

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115 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

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117 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

118 Testicular TUMORS GERM CELL (malig.) SEMINOMA EMBRYONAL CHORIOCARCINOMA YOLK SAC TERATOMA NON-GERM (benign) CELL, i.e., sex cord LEYDIG SERTOLI MIXED!!!!!, 60%

119 Seminoma (look for germ cells and lymphs)

120 Embryonal Carcinoma, Formerly called adeno carcinoma, so look for glands and AFP!!!)

121 CHORIOCARCINOMA look for trophoblast, and HCG!!

122 YOLK SAC TUMOR, aka endodermal sinus tumor Schiller-Duvall Body

123 bits of intestinal wall or brain substance TERATOMA MALIGNANT TERATOMA TERATOCARCINOMA clusters of squamous epithelium, hair, skin glands neural tissue retina muscle bundles islands of cartilage structures reminiscent of thyroid gland bronchial or bronchiolar epithelium

124 SEX Cord Tumors Leydig, tumor cells look like Leydig cells Sertoli, tumor cells look like sertoli cells

125 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

126 INFLAMMATIONS BENIGN ENLARGEMENT MALIGNANT TUMORS

127 CZ = CENTRAL TZ = TRANSITIONAL PZ = PERIPHAL

128 INFLAMMATIONS BENIGN ENLARGEMENT MALIGNANT TUMORS

129 PROSTATITIS ACUTE, usually same as Urinary Tract Pathogens CHRONIC, usually A-bacterial, but also often recurrent or persistent from acute GRANULOMATOUS, non-tb or TB

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133 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.

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135 P.I.N.

136 NUCLEOLI, NUCLEOLI, NUCLEOLI

137 PERINEURAL INVASION

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139 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

140 GRADING GLEASON SCORE = Predominant pattern (1-5) + Secondary pattern (1-5) Best Score = 2, Worst Score = 10

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142 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