URINARY BLADDER PATHOLOGY

Benign Proliferative and Metaplastic Urothelial Lesions

Benign Proliferative and Metaplastic Urothelial Lesions

Occurs mostly in the urinary bladder (although may be found in the entire length of urinary tract) a/w chronic inflammation (caused by UTI), calculi, neurogenic bladder. Greater risk urothelial bladder carcinoma

Pathological types
Cystitis cystica (CC). CC lined by Transitional epithelium. Metaplasia of transitional -> cuboidal or columnar cystitis glandularis (with increased risk of ADENOCARCINOMA) Squamous metaplasia -> due to chronic injury or inflammation (particularly when it is associated with calculi) Nephrogenic metaplasia (due to inplants detached renal tubular cells) Brunn Buds and nest. Just like keratin pearl.

Tumors of the Urinary Bladder

INTRODUCTION

Important facts
Most commonest site of Urinary tract tumors. Occur in older patient: median age 65 (rare under 50 yo) Commonest type -> urothelial malignant neoplasm Rare: SCC, adenocarcinoma, sarcomas If local treatment is applied -> risk for recurrence Site: posterior and lateral aspect of the bladder Malignant tumor: papillary or flat. Invasive or non-invasive.

Risk factors
Cigarette smoking polycyclic hydrocarbon Occupational health hazards -> dye industry (aniline), rubber, leather, paint. Parasitic infections schistosoma Drugs cyclophosphamide, analgesics Radiation therapy- cervical, prostate or rectal cancer.

Urothelial Tumor

 Represents about 90% of bladder tumor. Commonly reported is Urothelial Malignant neoplasm Tumor that arises from the urothelium (transitional epithelium). Can occur anywhere along the urinary tract, but the commonest site is urinary bladder. Location; posterior and lateral aspect of the bladder

Precursor lesions and Prognosis

Two distinct precursor lesions to invasive urothelial carcinoma; non-invasive papillary tumor and flat non-invasive urothelial tumor. Prognosis: how far invasion had happened. Invasion of the lamina propria worsens prognosis Invasion of the muscular propria: there is 30% 5-year mortality rate.

Grading of Urothelial Tumor

WHO/ISUP Grades (1998) WHO Grades (2004) Urothelial papiloma Urothelial neoplasm of low malignant potential Papillary urothelial carcinoma, low grade Papillary urothelial carcinoma, high grade

TNM Staging
T Primary Tumor:
T0: no grossly visible tumor Ta: urothelial papilloma Tis: CIS, flat non-invasive urothelial tumor T1: invasion of the lamina propria T2: Invasion of the muscularis propria. 2a-inner half, 2b-outer half T3: Invasion of the perivesical tissue (serosa). 3amicroinvasion, 3b-macroinvasion T4: invasion of extravesical tissue. 4a-prostate, seminal vesicle, uterus, vagina. 4b-pelvic wall and abdominal wall

 N Regional lymph nodes

N0 no lymph node involvement N1 single lymph nodes involvement N2, N3 more lymph nodes involvement

M distant metastases
M0 no distant metastases M1 positive distant metastases (liver, lung, bone marrow)

Clinical features
Painless hematuria:
Painless intermittent hematuria (+groos bleeding) Classic sign for malignancy causing bleeding. If the malignancy occur at upper urinary tract (kidney till vesicoureteric junction) ureteric colic and long stringy clots. Ureteric obstruction if bleeding is gross. Lower tract blood clot in urine and acute urine retention (clot retention).

Recurrent urinary infections Incontinence when invading the neck (or tumor at the neck) dribbling incontinence, urge incontinence Dysuria, frequency, urgency. Depending on the location and severity: may have voiding symptoms (poor stream, post micturition dribbling, hesitancy,

Tumors of the Urinary Bladder