Surgical Pathology & X-rays

for medical students

2007
UROLOGY
 Index
Urinary stones
Investigations for stones
Plain UT & IVU
Congenital anomalies
Renal US
Trauma
CT scan
Polycystic kidney
Urethra stones
Renal TB
Bladder stones
Testis & epididymis
Urethral stones
Hydrocele
Hydronephrosis
Torsion testis
Urinary Bilharziasis
Seminoma
Bladder tumours
BPH
Renal neoplasms
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 Urinary Stones

3 © UROLOGY
Index
 Multiple renal stone
Stag horn stone Index

1-Calcium stones : 75% of kidney stones contain calcium, mostly calcium oxalate and calcium phosphate
2-Infection stones : urea-splitting bacteria such as proteus, produce a more alkaline urine that favors
precipitation of magnesium ammonium phosphate and calcium phosphate These stones vary from hard to
soft and friable, they can eventually fill calyces and the renal pelvis to form stag horn calculi. Infection
stones are frequently responsible for complications such as bleeding, pain, and urinary tract infection and
sepsis
3-Uric acid stones : occur in patients with and without gout, can develop in patients with diseases where
there
4 is a high rate of cell turnover such as leukemias, pure uric acid stones are radiolucent (not ©visualized
UROLOGY on
x-rays). Calcium containing stones are radiopaque.
 Investigations for urinary stones

Plain X-ray of the urinary tract (Plain UT)

UT
Intravenous urography (IVU)
IVU
Renal ultrasonography (US)
US
Computed tomography (CT)
CT

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Index
 Plain UT:
Lt. stag horn stone

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Index
 Normal IVP (30 minutes)

•Normal calyces
•Renal pelvis
•Ureter
•Bladder

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Index
8 © UROLOGY
Index
 IVU showing:
Rt. stag horn stone
with non visulization
of the Rt. ureter
Lt. hydronephrosis

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Index
Early film: Late film:

Normal Rt. Kidney function The Rt. Kidney is not seen anymore
10 © UROLOGY
Index Delayed excretion with Lt. hydronephrosis
Lt. renal stoned with no dye excretion yet
 Bilateral multiple renal stones
Note delayed renal excretion

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Index
Bilateral multiple renal stones
Note delayed renal excretion
The dye is excreted only in late films

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Index
 Stag horn stone

Plain X-ray

Remember the different types of renal

stones.
What are the complications of renal
stones?
Lt. renal pelvis stag horn stone
13
Index & Lt. ureter stone
© UROLOGY
 IVU:
Staghorn stone in the left
renal collecting system
(arrows)

Stone in the lower left ureter

(arrowheads)

Hydronephrosis in the right

kidney
The urogram was taken 3
hours after administration of
the contrast medium. No
excretion of contrast medium
3 h. is seen on the left side
14 © UROLOGY
Index
 IVU: Normal Lt kidney – no
function yet in Lt. kidney

Stag horn stone

complicated by
Plain UT: Multiple stones, hydronephrosis
Rt. kidney & pyelonephritis
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Index
 Renal ultrasonography

Lower polar renal stone

appears as echogenic area with
acoustic shadow

Normal renal U.S.

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Index
 Lt. Renal stone
Lt.

Renal ultrasound showing

hydronephrosis (dilated calyces)
calyces
from a large stone (indicated by Plain UT showing
shadow effect). Lt renal pelvic
stone
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17
Index
CT scan

LT renal pelvic stone with

hydornephrosis
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Index
 Ureteric Stones

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Index
 Ureteric Stones

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Index
 Effects of stone Lt. ureter

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Early film Index Late film
Dornier basket
Extraction of ureteric stone

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Index
 Urinary Bladder Stones

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Index
Plain U.T.
Multiple stones – urinary bladder

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Index
Plain U.T.
Stones urinary bladder

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Index
Plain UT:
UT
Stone bladder

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Index
Plain UT:
UT
Stone bladder &
Rt. lower end
ureter

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Index
 Stone urethra

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Index
 Ureterocele

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Index
IVU:Lt.
IVU ureterocele (copra head) Note: ballooning of the intramural
part of the Lt. ureter with mild back
pressure on the ureter (the whole
course of the Lt. ureter is seen)

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Index
Ureteroceles:
Ureteroceles Mild dilatation of both distal ureters

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Index
Ureterocele
IVU showing cystic
dilatation of the
intramural part of
the ureter with cobra
head appearance.
Note the radiolucent
stone in the
ureterocele.

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Index
 Hydronephrosis

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Index
Hydronephrosis due to pelvi-ureteric junction obstruction

Normal kidney

Remember the causes of

unilateral & bilateral
Indexhydronephrosis.
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Dilated pelvis & calyces, renal atrophy
Dilated Lt. renal pelvis
35 (cut surface) Index
© UROLOGY
 Hydroureter - hydronephrosis
The cut surface shows a very thin rim of
cortex, The area of the pelvis and calyx
are distended, and large cystic spaces
occupy the pyramids.
The ureter is dilated.

© UROLOGY
IVU36Lt. Hydroureter - hydronephrosis
Index
Double ‘J’ ureteric catheter

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Index
 Urinary Bilharziasis

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Index
 Stricture in the lower
end Lt. ureter
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Index
Bilharzial ureteral
strictures

PUT showing multiple radio- IVU showing bilateral ureteral dilatation with
opaque shadows in the pelvis bilateral multiple lower ureteral stones
secondary to bilharzial bilateral ureteral
© UROLOGY
40
strictures.
Index
Urinary tract
Bilharziasis
Calcification of ureters,
bladder & seminal
vesicles

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Index
 Pain X-ray:
Calcified
urinary bladder

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Index
 Bladder Tumors

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Index
IVU
Bladder carcinoma
Note the irregular outline
of the filling defect

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Index
 IVU:
CA bladder with
back pressure
on the Rt. ureter
& kidney
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Index
 IVU:
CA bladder with
Rt. hydroureter
&
hydronephrosis

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Index
 CA bladder

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Index
Bladder Carcinoma

A large "filling defect"

(yellow arrows) within
the left side of the
bladder. The bladder
wall around the defect
is irregular.

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Index
IVU:
Bladder tumor (filling defect)

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Index
 Bladder Cancer
IVU:
IVU Right lateral
wall bladder mass
appearing as filling
defect in the
cystogram.

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Index
Bladder Cancer - CT
Pelvic CT with IV
contrast:
contrast Anterior
wall bladder mass
infiltrating the
anterior
abdominal wall

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Index
Bladder Cancer - CT
Pelvic CT
without
contrast:
Bladder mass
arising from
posterior and RT
lateral bladder
wall.

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Index
 Benign Prostatic Hypertrophy
(BPH)

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Index
 Trans Abdominal U/S of BPH

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Index
 IVU

Benign senile
prostatic enlargement
Note the smooth outline of the
prostatic shadow

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Index
 Benign prostatic hypertrophy

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Index
 For comparison

IVU: normal
This is a female
Notice the smooth
impression of the
uterus

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Index
IVU of BPH

Smooth basal filling

defect in the cystogram
by the enlarged
intravesical bulge of the
prostate

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Index
 Urinary bladder stone

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Plain UT Index
 Ureter Vas

Bladder

Prostate

Benign enlargement of the middle lobe of the prostate resulted in back pressure on the
ureter and renal pelvis on both sides (hydroureter & hydronephrosis)
hydronephrosis
Prostatic enlargement resulted in elevation of the bladder base as well. The ureters are hooked
60
by the vas crossing their terminal ends giving this characteristic sign (fish hook sign) © UROLOGY
Index
IVU of BPH
Fish hook sign of the
lower ureters:
ureters

Elevation of bladder
base by the enlarged
prostate push the lower
end of ureter upwards
against the crossing vas
deferens.

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Index
IVU of BPH

Middle lobe
causing filling
defect in the
cystogram

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Index
IVU of BPH
Chronic retention
of urine, bladder
with dilute
contrast reaching
above umbilicus

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Index
IVU of BPH
Bladder diverticulum

Secondary to BPH and increased intravesical pressure during voiding

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Index
 Bladder diverticulum

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Index
BPH removed by open surgery

Prostate adenoma
removed by surgery
BPH complicated by
multiple bladder
stones
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Index
 Renal
Neoplasms

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Index
 Nephroblastoma (Wilm’s tumour)

Mixed tumour arising from the emberionic nephrogenic tissue. Usually discovered during the first 4 years of life. Occur in
one or other pole of the kidney. The cut surface is grayish or pinkish white. Rapidly growing tumors may be soft in
.consistency
68 © UROLOGY
Microscopically, Index
it is a mixed tumour composed of epithelial & connective tissue cells. It may occasionally contain islands
of bone, cartilage or muscle fibers. Some elements may be less sensitive to radiotherapy than others
 Nephroblastoma
(Wilm’s tumour)

Wilm’s tumor common

presents as rapidly growing
abdominal tumor with
deterioration of the child's
. general condition
Pyrexia is common
Haematuria is a bad
prognostic sign. It reflects
tumor extension into the
renal pelvis
Blood born metastasis
69
Index occurs early to the lung
© UROLOGY
 Renal cell carcinoma
(Hypernephroma)

This adenocarcinoma arises from the

renal tubules. It is the most common
. tumor of the kidney
Moderate sized tumors are spherical in
. shape
They occupy a SINGLE pole of the
kidney (usually the upper pole, but
may still arise from the lower pole)
Tumors in the hilum are less common
The cut surface is usually yellowish or
dull white, semi-transparent, with
areas of hemorrhage
The tumor is often divided into lobules
70
by fibrous septa © UROLOGY
Index
 Renal cell carcinoma
(Hypernephroma)
:Spread
The tumor is prone to grow into the
renal vein. Secondaries reach the lung
and grow to form cannonball
metastasis. Secondary deposits in the
long bones may pulsate if they are
highly vascular
Lymphatic spread to the LNs in the
kidney hilum then para-aortic nodes
occurs when the tumor extends beyond
. the renal capsule
It is important to do a chest X-ray & an
isotope bone scan

You should know that the usual clinical

.presentation is Haematuria
What are the other rare or atypical
71 © UROLOGY
Index ?presentations
 Renal cell carcinoma
(Hypernephroma)

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Index
 Renal cell carcinoma
(Hypernephroma)

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Index
Renal cell carcinoma (Hypernephroma)

Notice the
yellow (lipid/fat),
the focal
hemorrhage,
and areas of
necrosis

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Index
Renal malignancy
PUT:
PUT
Note the soft tissue
shadow of an enlarged
left kidney

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Index
Renal malignancy

IVU:
IVU Space occupying
lesion in the left kidney.
Note the stretching,
splaying, and amputation
of calyces.

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Index
Lt. Renal cell carcinoma

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Index
Renal malignancy
Abdominal CT
with IV contrast:
contrast

Note the normal

RT kidney and
the huge LT renal
mass (Arrow)

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Index
 Cannon ball metastasis
79
Index in the lungs © UROLOGY
 Congenital
anomalies

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Index
 Bilateral double ureter

If the condition is
asymptomatic and
discovered accidentally, no
treatment is required.

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Index
 Rt. Lt.

Double Double
pelvis pelvis &
double
ureter

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Index
 IVU:
Lt. pelvic kidney

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Index
IVU

Horseshoe kidney

C.T.

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Index
 IVU

Horseshoe kidney

Autopsy showing fusion

of the lower poles
Note the mal-directed
pelvis & calyces
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Index
 IVU:
Horseshoe kidney

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Index
 IVU:
IVU
The "left" kidney is
located below the
right kidney

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Index
Congenital pelvi-ureteric
junction obstruction
Normal right kidney
Left kidney revealed moderate
dilatation of the intra-renal
collecting system up to the
level of the UPJ

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Index
Bladder extrophy

Note the everted

posterior wall of
the bladder
The anterior wall of
the bladder together
with the anterior
abdominal wall in this
region is absent
Note that the pubic rami are widely separated
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Index
 Hypospadias

Remember the types of hypospadias.

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Index
 Trauma

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Index
Renal Trauma
Motor car accident. Chest X-Ray showed multiple right sided rib fractures and pneumohaemothorax.

Right intercostal chest drain inserted

On follow-up, he showed distended abdomen, with pain and tenderness in the right flank.
Urethral catheterisation showed macroscopic haematuria

On laparotomy

IVU showed extravasation of contrast from the Large laceration of the lower pole of the right
right kidney, and a functioning left kidney kidney

What are the types of closed renal injuries & how are they managed. What are the
92
possibleIndex
complications? © UROLOGY
Extraperitoneal bladder rupture
Cystography shows bladder rupture secondary to a pelvic fracture

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Index
 Polycystic kidney

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Index
 Autosomal dominant (adult)
polycystic kidney disease

Patients usually remain

asymptomatic until middle
age when hematuria,
hypertension, flank pain, and
in ~50% of patients chronic
renal failure develops

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Index
 polycystic kidney The kidneys are
enormously
enlarged, each with
a length of 30 cm
(normal < 12.5 cm),
and appear to be
completely replaced
by cystic spaces,
some of which
contain blood.
There is no
recognisable
normal kidney
tissue

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Index
 polycystic kidney

Close-up view of cut

surface

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Index
 polycystic kidney

Both kidneys are enlarged with

irregular contours.
 The pyelocalyceal systems are
splayed and deformed.
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Index
 Renal TB

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Index
 TB of the
Kidney
TB of the urinary tract
occurs secondary to
haematogenous infection.

This specimen shows a

caseous kidney divided by
fibrous septa.

What are the other

types of tuberculous
lesions that can affect
the kidney?
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Index
 Tuberculous
perinephric cold
abscess

What are the other

causes of perinephric
abscess (How would
infection reach the
perinephric space)?

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Index
 Compare & contrast

TB of the Kidney Polycystic Kidney Hydronephrosis

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Index
 Testis &
Epididymis

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Index
Normal anatomy of testis,
epididymis & spermatic cord

Testicular
artery

Cremasteric
muscle

Pampiniform
venous plexus Head

Tunica
vaginalis

Testis

104 © UROLOGY
Index
 Hydrocele
Trans-illumination

Remember the types

& complications of
hydrocele
105 © UROLOGY
Index
Torsion
of the
testis

Remember the
predisposing
causes for
testicular torsion
What are the clinical
features of torsion of © UROLOGY
106
testis? Index
 Seminoma

Closed Opened
Lymphatic
107
spread of testicular tumors will follow the spermatic cord to the
© UROLOGY
para-aortic LNs near the Index
origin of the gonadal vessels