LOWER

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LOWER URINARY TRACT
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LOWER URINARY TRACT TRANSITIONALEPITHELIUM
UROTHELIUM
MINOR CALYCES MAJOR CALYCES RENAL PELVIS
URETERS BLADDER URETHRA
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EPITHELIUM
MUSCULARIS PROPRIA
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EMBRYOLOGY
PRONEPHROS MESONEPHROS METANEPHROS CLOACA MÜLLER
IAN ? WOLFFIAN ?
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LOWERUrinary Tract

• Ureters(Anomalies, Infl., Neopl.)
• Bladder(Anomalies, Infl., Neopl.)
• Urethra(Anomalies, Infl., Neopl.)

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URETERS

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

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CONGENITAL Ureter Anomalies

• DOUBLE Ureters
• UPJ (Uretero-Pelvic Junction) Obstruction
• Diverticula
• Hydroureter

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INFLAMMATION

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

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OBSTRUCTIONFACTORS

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

• EXTRINSIC
• PREGNANCY
• INFLAMMATION
• ENDOMETRIOSIS
• TUMORS
• SURGERY

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Sclerosing Retroperitoneal Fibrosis

• 70 Idiopathic
• 30 Drugs (ergot derivatives, beta blockers) or
  known retroperitoneal inflammatory conditions,
  e.g., Vasculitis, Diverticulitis, Crohns Disease

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TUMORS

• Benign
• Fibroepithelial Polyp
• Leiomyoma
• Malignant
• Transitional Cell Carcinoma, aka, TCC
• Also aka, UROTHELIAL Carcinoma

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Which Ureter? Which Part?
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LOWERUrinary Tract

• Ureters(Anomalies, Infl., Neopl.)
• Bladder(Anomalies, Infl., Neopl.)
• Urethra(Anomalies, Infl., Neopl.)

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ANOMALIES

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

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EXSTROPHY
Developmental Anomaly Very Good Surgical
Correction Rate
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Vesico-Ureteral Reflux

• Most Common Anomaly
• Very serious in its role in chronic
  pyelonephritis and hydronephrosis

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ADJECTIVES for CYSTITIS

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

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CAUSES for CYSTITIS

• E. coli
• Proteus, Klebsiella, Enterobacter
• Shistosomes (Egypt)
• Chlamydia
• Mycoplasma
• Viruses, e.g., adenoviruses
• ChemoRX
• RadiationRX

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SYMPTOMS for CYSTITIS

• Frequency
• Urgency
• Hematuria
• Abdominal Pain
• Dysuria
• Systemic Sepsis, i.e., fever, leukocytosis

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Special Types ofCYSTITIS

• Interstitial cystitis, aka, Hunner Ulcer
• Malacoplakia

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Interstitial Cystitis

• Womengtgt Men
• Bladder Wall Fibrosis
• Aka, Hunner ulcer

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Malacoplakia

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

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METAPLASIA

• Glandular(is) (Cystica), from Brunn nests
• Squamous metaplasia

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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

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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

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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

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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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LOW Grade
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HIGH Grade
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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
TNM
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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

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Bladder Neck OBSTRUCTION

• Cystocele, MOST common cause in women
• Prostate, MOST common cause in MEN
• Congenital
• Inflammation
• Tumors
• Foreign Bodies, Calculi
• Neurogenic

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LOWERUrinary Tract

• Ureters(Anomalies, Infl., Neopl.)
• Bladder(Anomalies, Infl., Neopl.)
• Urethra(Anomalies, Infl., Neopl.)

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URETHRA

• Inflammations
• Gonococcus
• Chlamydia
• Mycoplasma
• Reiters Syndrome
• Caruncle
• Neoplasms
• Transitional
• Squamous
• Glandular

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Chapter 21 Male Genital Tract Diseases
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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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Efferent Ductules and Epididymis
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LITTRÉ
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Male Genital Tract(short version)

• Penis Congenital, Inflammation, Tumors
• Testis/Epididymis Congenital, Regressive,
  Inflammation, Vascular diseases, Tumors
• Prostate Inflammation, Benign Enlargement,
  Malignancy

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Penis Congenital

• Hypospadias
• Epispadias
• Phimosis

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Penis InflammationBalanoposthitis

• Candida
• Anerobes
• Gardnerella
• Pyogenic
• Role of smegma

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Penis Neoplasia

• Benign Condyloma Acuminata (caused by HPV), aka
  venereal or genital warts
• Malignant Squamous cell carcinoma

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Koilocytosis
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Penis Malignancy

• In-situ Bowens Disease
• Invasive Infiltrating or invasive SQUAMOUS Cell
  Carcinoma

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BOWENs Disease SQUAMOUS cell carcinoma-in-situ
of the skin of the penis
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Male Genital Tract(short version)

• Penis Congenital, Inflammation, Tumors
• Testis/Epididymis Congenital, Regressive,
  Inflammation, Vascular diseases, Tumors
• Prostate Inflammation, Benign Enlargement,
  Malignancy

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Male Genital Tract(short version)

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

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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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Cryptorchidism

• 1 of all births
• 25 bilateral
• Associated with significantly increased incidence
  of germ cell tumors

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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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Testicular Atrophy

• atherosclerotic narrowing of the blood supply in
  old age
• the end stage of an inflammatory orchitis,
  whatever the etiologic agent
• cryptorchidism
• 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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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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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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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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Testicular TUMORS

• GERM CELL (malig.)
• SEMINOMA
• EMBRYONAL
• CHORIOCARCINOMA
• YOLK SAC
• TERATOMA
• MIXED!!!!!, 60

• NON-GERM (benign)
• CELL, i.e., sex cord
• LEYDIG
• SERTOLI

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Seminoma (look for germ cells and lymphs)
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Embryonal Carcinoma, Formerly called
adenocarcinoma, so look for glands and AFP!!!)
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CHORIOCARCINOMAlook for trophoblast, and HCG!!
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YOLK SAC TUMOR, aka endodermal sinus tumor
Schiller-Duvall Body
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TERATOMAMALIGNANT TERATOMATERATOCARCINOMA
neural tissue retina muscle bundles islands of
cartilage clusters of squamous epithelium structur
es reminiscent of thyroid gland bronchial or
bronchiolar epithelium bits of intestinal wall or
brain substance
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SEX Cord Tumors

• Leydig, tumor cells look like Leydig cells
• Sertoli , tumor cells look like sertoli cells

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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

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PROSTATE

• INFLAMMATIONS
• BENIGN ENLARGEMENT
• MALIGNANT TUMORS

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CZ CENTRAL TZ TRANSITIONAL PZ PERIPHAL
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PROSTATE

• INFLAMMATIONS
• BENIGN ENLARGEMENT
• MALIGNANT TUMORS

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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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BENIGN Enlargement

• BPH
• BPH
• 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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P.I.N.
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NUCLEOLI, NUCLEOLI, NUCLEOLI
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PERINEURAL INVASION
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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 ?

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GRADING

• GLEASON SCORE Predominant pattern (1-5)
  Secondary pattern (1-5)
• Best Score 2, Worst Score 10

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STAGING
TNM
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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