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12/21/2014

Pathology of Urinary tract


obstruction
ID# 3347
DEPARTMENT OF PATHOLOGY
Phase II Curriculum -4th year (2011 intake)
Renal, Reproductive and Breast system module

Weekly learning objectives


To explain the pathological findings in obstructive uropathy and correlate
with the clinical, radiological findings and effect on renal
function.
Objectives
Illustrate the pathological changes affecting the kidney and ureter seen in
urinary tract obstruction.
Describe the pathological features of the most important causes of
obstruction to urinary tract including: renal stones, ureteric structure, and
prostatic disease.

Practical 4

23-12-2014
1.00-2.50

Case No. 1
A 45 year old Egyptian woman was admitted
to hospital with an attack of severe left flank
pain. She was diagnosed in Egypt
earlier with renal calculi.

Her initial hospital evaluation showed the following:


BP
160 / 100 mmHg
Pulse rate
80 / min
Temperature
37.0 o C
24 hour urine output
Urine microscopy
Hb
ESR
Glucose
BUN
Creatinine

900 ml
normal

100 g/L
23 mm /1 hr
5.5 mmol/L
6.2 mmol/L
110 mmol/L

(140-160g/L)
(1-20 mm/hr)
(3.9-6.1)
(2.5-6.6)
(60-120)

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IVU
Abdominal X ray

Normal

IVU

See photograph

A left nephrectomy was performed on


the patient. The right kidney looked
normal during surgery.

Left nephrectomy specimen

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A tissue section from the


kidney showed the following

Chronic inflammatory cells (High power view)

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Thyroidization, due to dilation of tubules which


contain eosin-staining proteinaceous material
(colloid).

Microscopic Findings in left kidney:

Thinning (atrophy) of renal parenchyma


Chronic interstitial inflammation
Interstitial fibrosis
Arterial sclerosis
Glomerular sclerosis

Self study
Diagnosis:
Left kidney hydronephrosis with Hydrourteter
complicated by chronic pyelonephritis

1. Name 4 different conditions which may give rise to


unilateral hydronephrosis.
2. Name 3 different conditions which may give rise to
bilateral hydronephrosis
3. What does the fact that this patient has unilateral
hydronephrosis with hydroureter suggest to you?
4. Did this patient have renal failure? Explain.

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Investigations

Case No. 2
A 40 year old man was investigated for repeated
colicky pains on the left side of abdomen for the
last 5 years.
Examination showed the following:
BP
Pulse rate
Temperature

180 / 100 mmHg


90 / min
37.0 o C

Hb
90 g/L
ESR
30 mm /1 hr
Glucose
5.0 mmol/L
BUN
6.0 mmol/L
Creatinine
100 mmol/L
Ca
3.3 mmol/L
24 hour urine output 1100 ml

(140-160g/L)
(1-20 mm/hr)
(3.9-6.1)
(2.5-6.6)
(60-120)
(2.2-2.6)

A left nephrectomy was carried out

Left Nephrectomy
Gross Findings

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Self study

Diagnosis:
Left kidney hydronephrosis secondary to
ureteric obstruction by stone.

1. Name 5 conditions that predispose to renal stone


formation. Which one do you think is present in this
patient?
2. What type of renal stones can be seen on routine
abdominal X-ray?
3. What is the significance of serum Calcium value in this
patient
4. Can you recall three common causes of elevated serum
calcium level
5. List at least 2 findings in urine that may be seen as a
complication of renal stones.

Case No.3
A 79 year old man who was recently diagnosed
with chronic kidney disease was found dead
at home .
Postmortem examination was performed.
His urinary bladder specimen shows the following

Macroscopic Findings

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Macroscopic Findings

A tissue section from his enlarged


prostate showed the following

Hyperplasia ( high power )

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Diagnosis
Microscopic Findings of prostate
Nodular architecture of prostatic tissue
Hyperplasia of prostatic glands
Hyperplasia of prostatic stromal tissue

Self study
1. Give two explanation for the development of
chronic renal disease in this patient, based on
the autopsy specimen provided.
2. If you were performing the postmortem
examination how would both kidneys grossly look?

Nodular hyperplasia of prostate

Case No. 4
A 74 year old hypertensive and heavy tobacco smoker
was admitted to the emergency room in a state
of coma and died within 1 hour of admission. His
medical record showed that he passed red urine on
several occasions
A postmortem examination was carried out.

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He was hospitalized 3 month back and his clinical


notes on previous admission showed the following :
BP
Pulse rate
Temperature

170 / 110 mmHg


100 / min
37.5 o C

24 hour urine output


Urine microscopy

1400 ml
370 RBC/HPF

Hb
ESR
Glucose
BUN
Creatinine

(140-160g/L)
(1-20 mm/hr)
(3.9-6.1)
(2.5-6.6)
(60-120)

Right

160 g/L
40 mm /1 hr
8.0 mmol/L
4.5 mmol/L
110 mmol/L

His kidney and bladder specimens are shown

Left

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Histology of normal urothelium

Total architectural disorganization and significant cytologic atypia of urothelium


There is loss of nuclear polarity; considerable variation in nuclear
size, shape, and chromatin content; mitoses are frequent

Histopathological report on the urinary


bladder lesion:
High grade transitional cell carcinoma

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Final diagnosis
Hydronephrosis with hydroureter secondary to
obstruction by a transitional cell carcinoma of
urinary bladder

Self study
1.Name 5 different causes that may give rise to red
colored urine. What is the cause of red urine in this
patient?
2. Can you explain the serum creatinine value in this
patient?

Case No.5

Macroscopic Findings

A 5 year old boy was investigated for recurrent


abdominal pain. All laboratory tests were normal.
An ultrasound showed distension of the pelvis of
left kidney. The other kidney was normal.
Following thorough investigations a left
nephrectomy was carried out.

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Macroscopic Findings

Diagnosis

Ureteropelvic Junction Obstruction

Self study
1. How common is this condition and at what age group is
it most prevalent?
2. What do you know about the etiology of this condition?
3. What would be the effect on the patient if the condition
was bilateral?

Case No.6
A 55 year old diabetic woman with a history of
recurrent attacks of upper urinary tract infection
(Acute pyelonephritis) that usually settles down with
intravenous antibiotic presented with dysuria and
frequency that became worse in the last two weeks.

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Acute pyelonephritis

Section from kidney with acute pyelonephritis


from another patient showed the following

Neutrophils are seen in the tubules and interstitium.


The neutrophils can coalesce in the distal tubules and collecting ducts
and passed in urine as WBC casts.

Ultrasound examination revealed the presence of a


large right sided stone with branching structure
within the pelvis that is starting to impinge on the
calyceal structure.
The stone was removed and the patient was
discharged.

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Large stone with branching structures

Radiological and gross findings of another patient with similar presentation

open kidney and staghorn calculi


Two year later more attacks of pyelonephritis occurred. Radiology
examination this time showed hydronephrotic changes and new
branching stone formation. Nephrectomy was done. Nephrectomy
specimen is shown

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Diagnosis

Self study
Chronic pyelonephritis with
formation of staghorn calculi

1. What is the chemical composition of staghorn calculi?


2. What type of organism is responsible for the
formation of this type of calculi?

1. What is the chemical composition of


this stone removed from kidney ?

Quiz
(To be answered during class)

a. Calcium oxalate
b. Magnesium ammonium
phosphate
a. Cystine
b. Uric acid

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2.What is the likely cause of


Right sided hydronephrosis
withhydroureter?

a.
b.
c.
d.

Carcinoma of bladder
Benign prostate hyperplasia
Ureteric stone
Ureteric stricture

3. Name the diagnosis on this kidney

a. Hydronephrosis
b. Acute pyelonephritis
c. Renal stone
d. Hydroureter

4. Section of kidney from a

patient with recurrent urinary


tract infection.
Identify two important features present in this
photomicrograph
a. Interstitial chronic inflammatory cell infiltrate
b. Arteriolosclerosis
c. Thyroidization of tubules
d. Crescent formation

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