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LOWER URINARY TRACT
This document discusses various congenital anomalies, inflammations, and tumors of the lower urinary tract. It begins by describing common congenital anomalies like vesicoureteric reflux and double ureters. It then covers inflammations of the ureter, bladder, and urethra. The majority of the document discusses tumors of the bladder, including classification of urothelial/transitional cell tumors and their histological features. Non-epithelial bladder tumors and tumors of the renal pelvis and ureters are also briefly covered.
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LOWER URINARY TRACT
- 1. LOWER URINARY TRACT -1 DR. ROOPAM JAIN PROFESSOR & HEAD, PATHOLOGY
- 2. CONGENITAL ANOMALIE • Vesicouretericrefl ux is the most common anomaly
- 3. CONGENITAL ANOMALIE DOUBLE URETER •This is a condition in which the entire ureter or only the upper part is duplicated. Double ureter is invariably associated with a double renal pelvis, one in the upper part and the other in the lower part of the kidney
- 4. CONGENITAL ANOMALIE URETEROCELE • Ureteroceleis cystic dilatation of the terminal part of the ureter which lies within the bladder wall. • The cystic dilatation lies beneath the bladder mucosa and can be visualised by cystoscopy
- 5. CONGENITAL ANOMALIE ECTOPIA VESICAE(EXSTROPHY) • rare condition • congenital developmental deficiency of anterior wall of the bladder and is associated with splitting of the overlying anterior abdominal wall. • This results in exposed interior of the bladder. • The condition in males is often associated with epispadias in which the urethra opens on the dorsal aspect of penis. • If the defect is not properly repaired, the exposed bladder mucosa gets infected repeatedly and may undergo squamous metaplasia with subsequent increased tendency to develop carcinoma of the bladder
- 6. INFLAMMATIONS • Inflammation ofthe tissues of lower urinary tract • ureteritis • cystitis • urethritis
- 7. URETERITIS • Infection ofthe ureter is almost always secondary to pyelitis above, or cystitis below. • Ureteritis is usually mild but repeated and longstanding infection may give rise to chronic ureteritis.
- 8. CYSTITIS • Inflammation ofthe urinary bladder is called cystitis. • Cystitis may occur by spread of infection from upper urinary tract as seen following renal tuberculosis, or may spread from the urethra such as in instrumentation. • The most common pathogenic organism in UTI is E. coli, Enterobacter, Klebsiella, Pseudomonas and Proteus. • Infection with Candida albicans may occur in the bladder in immuno suppressed patients. • Besides bacterial and fungal organisms, parasitic infestations such as with Schisto soma haematobium is common in the Middle-East countries, particularly in Egypt.
- 9. CYSTITIS • Chlamydia andMyco plasma may occasionally cause cystitis. • In addition, radiation, direct exposure to chemical irritant, foreign bodies and local trauma may all initiate cystitis. • Cystitis, like UTI, is more common in females than in males. • In males, prostatic obstruction is a frequent cause of cystitis. • clinically characterised by a triad of symptoms—frequency (repeated urination), dysuria (pain ful or burning micturition) & low abdominal pain. • There may, however, be systemic manifestations of bacteraemia such as fever, chills and malaise
- 10. URETHRITIS • Urethritis maybe gonococcal or non-gonococcal. • Gonococcal (gonorrhoeal) urethritis is an acute suppurative condition caused by gonococci (Neisseria gonorrhoeae). Th e mucosa and submucosa are eventually converted into granulation tissue which becomes fi brosed and scarred resulting in urethral stricture. • Non-gonococcal urethritis is more common and is most frequently caused by E. coli. Th e infection of urethra often accompanies cystitis in females and prostatitis in males. Urethritis is one of the components in the triad of Reiter’s syndrome which comprises arthritis, conjunc tivitis and urethritis. Th e pathologic changes are similar to infl ammation of the lower urinary tract elsewhere but strictures are less common than following gonococcal infection of the urethra
- 11. TUMOURS • Majority oflower urinary tract tumours are epithelial. • Both benign & malignant tumours occur; the latter being more common. • About 90% of malignant tumours of the lower urinary tract occur in the urinary bladder, 8% in the renal pelvis and remaining 2% are seen in the urethra or ureters.
- 12. TUMOURS OF THEBLADDER • The tumours of urinary bladder are divided into epithelial & non- epithelial (uncommon). • Thus, epithelial tumours are the main tumours, vast majority of which are of transitional cell type (urothelial) tumours
- 13. WHO classification ofurinary bladder tumours
- 14. Urothelial (Transitional Cell) BladderTumours • More than 90% of bladder tumours arise from transitional epithelial (urothelium) lining of the bladder. • Bladder cancer comprises about 3% of all cancers. • Most of the cases appear beyond 5th decade of life • 3-times higher preponderance in males than females
- 15. Urothelial (Transitional Cell)Bladder Tumours ETIOPATHOGENESIS • 1. Smoking • 2. Industrial occupations • 3. Schistosomiasis • 4. Dietary factors • 5. Local lesions • 6. Drugs • 7. Prior irraditation
- 16. Urothelial (Transitional Cell)Bladder Tumours ETIOPATHOGENESIS • Several cytogenetic abnormalities have been seen in bladder cancer. These include several mutations: • fibroblast growth factor receptor 3, • p53, • RB gene • p21 gene. • These mutations are associated with higher rate of recurrences and metastasis.
- 17. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES - Grossly • Urothelial tumours may be single or multiple. • About 90% of the tumours are papillary (non-invasive or invasive), whereas the remaining 10% are flat indurated (non-invasive or invasive) (Fig). • Most common location in the bladder is lateral walls, followed by posterior wall and region of trigone. • The papillary tumours have free floating fern-like arrangement with a broad or narrow pedicle. • The non-papillary tumours are bulkier with ulcerated surface (Fig). More common locations for either of the two types are the trigone, the region of ureteral orifices and on the lateral walls
- 18. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES • Th e WHO and ISUP (International Society of Urologic Pathology), in 1998 have proposed histologic criteria to categorise urothelial tumours into • Papillomas (exophytic, inverted), • Carcinoma in situ (CIS), • Papillary urothelial neoplasms of low malignant potential (PUNLMP) • Urothelial carcinoma (low grade and high grade).
- 19. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES Gross patterns of epithelial bladder tumours
- 20. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES Gross patterns of epithelial bladder tumours
- 21. Carcinoma urinary bladder Themucosal surface shows papillary tumour floating in the lumen (arrow)
- 22. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES - Histologically Histologic criteria for classifying urothelial tumours as per WHO/ISUP
- 23. Urothelial (Transitional Cell)Bladder Tumours MORPHOLOGIC FEATURES - Histologically Histologic criteria for classifying urothelial tumours as per WHO/ISUP
- 24. Urothelial (Transitional cell)carcinoma, low grade. There is increase in the number of layers of epithelium in an orderly manner and slight loss of polarity. The cells show slight nuclear enlargement and mild variation in nuclear size and shape and infrequent mitosis.
- 25. OTHER VARIANTS • Squamouscell carcinoma comprises about 5% of the bladder carcinomas. • Adenocarcinoma of the bladder is rare. • Small cell carcinoma has morphologic resemblance with small cell carcinoma of the lung or other neuroendocrine carcinomas and has a worse outcome.
- 26. STAGING OF BLADDERCANCER • The clinical behaviour and prognosis of bladder cancer can be assessed by the following simple staging system: • Stage 0: Carcinoma confined to the mucosa. • Stage A: Carcinoma invades the lamina propria but not the muscularis. • Stage B1: Carcinoma invades the superficial muscle layer. • Stage B2: Carcinoma invades the deep muscle layer. • Stage C: Carcinoma invades the perivesical tissues. • Stage D1: Carcinoma shows regional metastases. • Stage D2: Carcinoma shows distant metastases.
- 27. Non-epithelial Bladder Tumours •Mesenchymal tumours of the bladder are less common and may be • Benign • Malignant.
- 28. Non-epithelial Bladder Tumours BENIGN •Benign mesenchymal tumour of the bladder is uncommon • but most common is leiomyoma. • Other less common examples are neurofibroma, haemangioma & granular cell myoblastoma.
- 29. Non-epithelial Bladder Tumours MALIGNANT •Rhabdomyosarcoma is the most frequent malignant mesenchymal tumour. It exists in 2 forms: • Adult form • occurring in adults over 40 years of age • resembles the rhabdomyosarcoma of skeletal muscle. • Childhood form • occurring in infancy and childhood • appears as large polypoid, soft, fleshy, grapelike mass and is also called sarcoma botryoides or embryonal rhabdo myosarcoma. • It is morphologically characterised by masses of embryonic mesenchyme consisting of masses of highly pleomorphic stellate cells
- 30. TUMOURS OF RENALPELVIS AND URETERS • Almost all the tumours of the renal pelvis and ureters are of epithelial origin. • They are of the same types as are seen in the urinary bladder. However, tumours in the ureters are quite rare.