Cancer of the ureter and renal pelvis
Primary cancer of the ureter and/or renal pelvis means cancer that has started in the lining of the ureter or renal pelvis. This type of cancer is also known as transitional cell cancer (TCC) of the ureter or kidney.
The ureters and the renal pelvis
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The ureters are hollow, muscular tubes that carry urine from the kidneys to the bladder. The renal pelvis is the lower part of each kidney that connects to each ureter.
Cancer of the ureter and renal pelvis
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Cancers affecting the ureter and renal pelvis are rare. Of all kidney cancers, around 7 out of 100 are of the renal pelvis, and 5 out of 100 are of the ureter. Cancers of the ureter and renal pelvis tend to affect more men than women, and are rare under the age of 65. Usually only one ureter or renal pelvis is affected.
Another more common type of cancer that can affect the kidney is known as renal cell cancer (RCC). The tests, investigations and treatment of RCC are very different. Our general information on kidney cancer covers the treatment of renal cell cancer.
Very rarely, other types of cancer can start in the ureter or renal pelvis. These include some types of lymphoma (a cancer that starts from the cells of the lymphatic system) and sarcoma (a cancer that develops from the supporting tissues of the body, such as muscle or cartilage).
Cancer that starts in the ureter or renal pelvis is known as primary cancer. When cancer spreads from another part of the body to the ureter, it’s known as secondary or metastatic cancer in the ureter or renal pelvis.
Causes of ureter and renal pelvis cancer
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The exact causes of cancer of the ureter and renal pelvis are unknown. It's thought that smoking may increase the risk of developing these types of cancer. People who have been exposed to certain chemicals used in dye factories and chemical industries are also at a slightly increased risk.
People who have kidney damage from long-term use of certain painkillers may also have a higher risk of developing cancer in the renal pelvis. This risk is highest in people who were overexposed to painkillers containing phenacetin. Although these painkillers have now been discontinued, phenacetin may be added to some illegal recreational drugs, such as cocaine, so regular users could still be at risk.
People living in the Balkan countries may be affected with a specific form of kidney damage called Balkan Nephropathy. This condition increases the risk of renal pelvis cancer.
People with a rare condition called Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC), have an increased risk of developing TCC of the renal pelvis and ureter.
Ureter and renal pelvis cancer, like other cancers, is not infectious and can't be passed on to other people. It isn't caused by an inherited faulty gene, so other members of your family aren't likely to develop it.
Symptoms may include any of the following:
blood in the urine (haematuria)
passing blood clots in the urine
unexplained weight loss
mid-back pain or cramps
fatigue (tiredness and lack of energy)
anaemia (if you have been passing blood in the urine for some time), but this is rare.
Sometimes the ureter may become blocked, either by cancer cells or by a blood clot. This causes urine to be held up in the kidney and ureter and is called hydronephrosis. If this happens, the symptoms above may develop more quickly, and may be more severe. They are often accompanied by a high temperature.
These symptoms may be caused by a number of conditions other than cancer of the ureter or renal pelvis. Symptoms that are severe, get worse, or that last for a few weeks, should always be checked by your doctor.
How ureter and renal pelvis cancer is diagnosed
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Your GP will examine you and organise a series of urine and blood tests. The urine sample may be sent to a laboratory to be checked under a microscope for any cancer cells. Samples of blood will also be taken to check your general health, the number of cells in your blood (blood count), and to check how well your kidneys and liver are working.
Your GP will refer you to a urologist (a doctor who specialises in diseases of the urinary system) if further tests are needed. These tests will help to make the diagnosis and, if cancer is found, to check how far, if at all, the disease has spread. Further tests may include:
Cystoscopy and biopsy
A small, flexible, fibre-optic telescope (cystoscope) is passed up the urethra to enable the doctor to look at the bladder. In most cases this is done under a local anaesthetic. Before having a cystoscopy, you may be asked to give a urine sample so it can be tested for infection.
The doctor may also pass a smaller telescope (ureteroscope) through the bladder into the ureter. This procedure is known as ureteroscopy and is usually done under a general anaesthetic.
If the doctor sees any abnormality that could be a cancer, they will take a sample of the abnormal cells (biopsy).These are then examined in a laboratory under a microscope by a pathologist. There may be some bleeding after the biopsy. Some people may feel some discomfort when passing urine (going to the toilet) afterwards. You should be able to go home after the cystoscopy.
Intravenous urogram (IVU), intravenous pyelogram (IVP) or CT urogram
This test helps find anything unusual in the kidneys or urinary system. It’s done in the hospital radiology (x-ray) department and takes about an hour. A dye is injected into a vein in your arm and it travels through the bloodstream to the kidneys. The doctor watches how the dye passes through the kidneys on a screen and can pick up any problems. The dye will probably make you feel hot and flushed for a few minutes, but this feeling goes away after a short time.
This procedure is often combined with a CT scan (see below) and is known as a CT urogram.
This test uses sound waves to build up a picture of the inside of your body. You may have scans of your bladder and pelvis. The scan will be done in the hospital radiology (x-ray) department. Before your test, you will be asked to drink plenty of fluid so that your bladder is full and a clear picture can be seen. Once you’re lying comfortably on your back, a special gel is spread over your abdomen. A small device like a microphone is rubbed over the area. The echoes are converted into a picture by a computer. This is a completely painless procedure and takes about 15–20 minutes. Once the scan is over, you will be allowed to empty your bladder.
This is a special x-ray that involves inserting a catheter into the ureter at the time of the ureteroscopy. Dye is then passed up the catheter to highlight the ureter and renal pelvis.
Further tests for ureter and renal pelvis cancer
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If a cancer is found, you may be referred for other tests to find out the size of the cancer and whether or not it has spread beyond the ureter or renal pelvis. These may include either of the following:
CT (computerised tomography) scan
A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10–30 minutes. CT scans use a small amount of radiation, which is very unlikely to harm you and won't harm anyone you come into contact with.
You'll be asked not to eat or drink for at least four hours before the scan.
You may be given a drink or injection of a dye that allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you're allergic to iodine or have asthma, you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.
MRI (magnetic resonance imaging) scan
This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. Before the scan you may be asked to complete and sign a checklist. This is to make sure that it’s safe for you to have an MRI scan.
Before having the scan, you’ll be asked to remove any metal belongings, including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test, you will be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones.
The combination of tests will help the doctor to find out the stage and grade of the cancer. This will help the doctors to decide on the most appropriate treatment for you.
Staging and grading for ureter and renal pelvis cancer
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Staging refers to the size of the cancer and whether or not it has spread beyond the ureter or renal pelvis. It helps doctors to plan treatment.
The following stages are used for TCC of the renal pelvis and ureter:
The cancer is only in the area where it started and hasn't spread outside the kidney or ureter.
The cancer has spread to the tissue around the kidney or to nearby lymph nodes. Lymph nodes are bean-shaped structures that are found throughout the body. They are connected to each other by small tubes (ducts) called lymphatics and they produce cells to fight infection.
The cancer has spread to other parts of the body.
Grading refers to how abnormal the cancer cells look under the microscope, and can give an idea of whether or not the cancer cells are slow-growing (low-grade), faster-growing (high-grade), or in-between these two.
Treatment for ureter and renal pelvis cancer
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Treatment will depend on a number of factors, including your general health and the position, type, stage and grade of the cancer. Your doctor will also take into account the health of your other kidney and how well your kidneys work overall.
Surgery is the most common treatment for cancer of the ureter and renal pelvis. The extent of surgery will depend on many factors, such as the stage and the grade of the cancer.
After surgery, sometimes further treatment with chemotherapy or occasionally radiotherapy may be recommended. This is known as adjuvant treatment. The aim of adjuvant treatment is to get rid of any remaining cancer cells and to reduce the chance of the cancer coming back. The effectiveness of adjuvant treatment for cancer of the ureter and renal pelvis is unknown.
If surgery isn't possible, other treatments may be more appropriate. These may include chemotherapy or radiotherapy. The aim of these treatments is to reduce the size of the tumour and help control symptoms.
Removal of the kidney and ureter (radical nephro-ureterectomy)
This operation includes removal of the kidney, ureter and top part of the bladder. Sometimes the surrounding lymph nodes, fat and tissue may also be removed.
Segmental ureterectomy (resection)
In this operation the affected part of the ureter is removed. The remaining parts (ends) are then rejoined. This procedure is usually only possible if the tumour is small, low-grade and contained within the ureter.
Ureteroneocystomy (or reimplantation)
This is the removal of the lower part of the ureter and a small part of the bladder. The remaining part of the ureter is then connected to the bladder. This is usually done if the tumour is only in the lower part of the ureter.
Occasionally, a tumour may affect just the surface of the ureter. The cancer may be removed by laser treatment. A thin tube(ureteroscope) is passed through the bladder and into the ureter. A narrow beam of intense laser is then passed through the tube to destroy the tumour. Sometimes a tube (stent) may be left in the ureter temporarily to keep it open.
Radiotherapy treats cancer by using high-energy rays that destroy the cancer cells and shrink the tumour, while doing as little harm as possible to normal cells.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. They work by disrupting the growth and division of cancer cells. The chemotherapy may be given directly into the vein (intravenously).
Follow-up for ureter and renal pelvis cancer
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After treatment, you will have regular follow-up appointments with your doctor to monitor how you are recovering after treatment. These will usually include a physical examination. It may also involve taking some urine or blood samples. You will also have regular cystoscopies to detect any changes in the ureter or bladder. About 3 out of 10 people (30%) with cancer of the ureter or renal pelvis will develop a bladder cancer after a few years.
If you have any problems or notice any new symptoms between your follow-up appointments, let your doctor know as soon as possible.
During your diagnosis and treatment of cancer, you’re likely to experience a number of different emotions, from shock and disbelief to fear and anger. At times, these emotions can be overwhelming and hard to control. These feelings are natural and it's important to be able to express them.
Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it. Our cancer support specialists can give you more information about where to get counselling.
This information has been compiled using information from a number of reliable sources, including:
Hamdy, et al. Management of Urologic Malignancies. 2002. Churchill Livingstone.
Improving Outcomes in Urological Cancers. September 2002. National Institute for Health and Clinical Excellence (NICE).
Raghaven, et al. Textbook of Uncommon Cancers.3rd edition. 2006. Wiley.
UpToDate. Neoplasms of the renal pelvis and ureter (accessed September 2012).
With thanks to: Mr Vinod Nargund, Consultant Urological Surgeon; and the people affected by cancer who reviewed this edition.
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