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 ♂

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

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

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

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

28. Which Ureter?
Which Part?

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

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

41. ADJECTIVES for CYSTITIS
• Acute
• Chronic
• Hemorrhagic
• Suppurative
• Follicular
• Eosinophilic
• Interstitial

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

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

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

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)

63. LOW Grade

65. HIGH Grade

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
TNM

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
– “Caruncle”
• Neoplasms:
– Transitional
–Squamous
– Glandular

75. Male Genital Tract Diseases

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

82. Efferent Ductules and Epididymis

88. LITTRÉ

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

90. Penis: Congenital
•Hypospadias
•Epispadias
•Phimosis

94. Penis: Inflammation
“Balanoposthitis”
• Candida
• Anerobes
• Gardnerella
• Pyogenic
• Role of
“smegma”

95. Penis: Neoplasia
•Benign : Condyloma Acuminata
(caused by HPV), aka venereal or
genital “warts”
•Malignant: Squamous cell
carcinoma

98. Koilocytosis

99. Penis: Malignancy
•In-situ = Bowen’s Disease
•Invasive = Infiltrating or
invasive SQUAMOUS Cell
Carcinoma

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

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

105. Male Genital Tract
(short version)
•Testis/Epididymis:
–Congenital
–Regressive
–Inflammation
–Vascular diseases
–Tumors

106. 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

107. Cryptorchidism
• 1% of all births
• 25% bilateral
• Associated with significantly increased
incidence of germ cell 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. 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

111. 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

113. 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

115. 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

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

117. Seminoma
(look for germ
cells and
lymphs)

118. Embryonal Carcinoma,
Formerly called “adeno”carcinoma,
so look for “glands” and AFP!!!)

119. CHORIOCARCINOMA
look for “trophoblast”, and HCG!!

120. YOLK SAC TUMOR,
aka “endodermal sinus tumor”
Schiller-Duvall Body

121. TERATOMA
MALIGNANT TERATOMA
TERATOCARCINOMA
neural tissue
retina
muscle bundles
islands of cartilage
clusters of squamous epithelium
structures reminiscent of thyroid gland
bronchial or bronchiolar epithelium
bits of intestinal wall or brain substance

122. SEX Cord Tumors
•Leydig,
tumor cells look
like Leydig cells
•Sertoli ,
tumor cells look
like sertoli cells

123. 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

124. PROSTATE
•INFLAMMATIONS
•BENIGN ENLARGEMENT
•MALIGNANT TUMORS

125. CZ = CENTRAL
TZ =
TRANSITIONAL
PZ = PERIPHAL

126. PROSTATE
•INFLAMMATIONS
•BENIGN ENLARGEMENT
•MALIGNANT TUMORS

127. 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

131. “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….

133. P.I.N.

134. NUCLEOLI, NUCLEOLI, NUCLEOLI

135. PERINEURAL INVASION

137. 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 

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

139. STAGING
TNM

140. 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