Cancer of the ureter and renal pelvis
Primary cancer of the ureter or renal pelvis is rare, and starts in the upper urinary tract.
The ureters and the renal pelvis
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The ureters are the tubes that carry urine from the kidneys to the bladder. The renal pelvis is the part of the kidney that connects to the ureters. It funnels urine from the kidney into the ureters. The renal pelvis and ureters are made up of layers of tissue. The inner lining is called the mucosa, then there is a layer of connective tissue, a layer of muscle, and a layer of fat.
Structure of the kidneys
Cancer of the ureter and renal pelvis
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Cancers that start in the ureter or renal pelvis are rare. Of all kidney cancers, only about 7 out of 100 (7%) begin in the renal pelvis, and 5 out of 100 (5%) in the ureter. Usually only one ureter or kidney is affected.
They are more common in men than women. They are rare under the age of 65. There is a more common type of kidney cancer called renal cell cancer (RCC). The tests, investigations and treatment for RCC are very different to those for cancer of the ureter and renal pelvis.
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).
This information is about cancer that starts in the ureter or renal pelvis. Cancer that spreads from another part of the body to the ureter or renal pelvis is called secondary or metastatic cancer. The treatment of a secondary cancer depends on what part of the body the cancer started from.
Risk factors for ureter and renal pelvis cancer
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Things that can increase the chances of developing a cancer are called risk factors. But, having a risk factor for a cancer doesn’t mean a person will definitely get it, and people without risk factors can also develop cancer.
Smoking cigarettes is one of the main risk factors for this type of cancer. The other is working with certain chemicals used in the dye, textile, rubber, petrochemical and coal industries.
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.
A form of kidney damage called Balkan nephropathy, which affects some people in the Balkan countries, increases the risk of renal pelvis cancer.
A rare condition called Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC), increases the risk of developing cancer of the renal pelvis and ureter. People with this condition usually have several relatives on the same side of the family who have developed cancers, such as bowel and womb cancers, at an early age.
Ureter and renal pelvis cancers, like other cancers, are not infectious and can't be passed on to other people.
The most common symptoms of ureter and renal pelvis cancers are:
blood in the urine (haematuria)
pain in one side of your back.
Other symptoms may include loss of appetite, weight loss, tiredness, fever, night sweats, or a cough. Some people don’t have symptoms but are diagnosed by chance when having a test or scan done for another reason.
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, symptoms, especially back pain, may develop more quickly and be more severe.
How ureter and renal pelvis cancer is diagnosed
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Your GP will examine you and arrange for you to have your urine tested. You may also have blood tests to check your general health, the number of cells in your blood (blood count), and how well your kidneys and liver are working.
Your GP will usually refer you to hospital to see a doctor, called a urologist, who specialises in treating urinary, bladder and kidney problems. If you have blood in your urine you may be referred to a haematuria clinic, where tests can often be carried out on the same day.
Before any test, your doctor will explain what is involved and ask you to sign a consent form to say you agree to have it done. Tests that may be done include:
This test checks urine for cancer cells.
This test checks the lining of your bladder. It may be done at the same time as a uretoroscopy or you may have it as a separate test. It can be done under local anaesthetic and takes about 20 minutes. A doctor or nurse gently passes a thin, flexible tube with a camera and light on the end (cystoscope) through the urethra and into the bladder. This allows them to look at the whole lining of the bladder and urethra.
You may have some soreness or mild pain when you pass urine for the first couple of days after the test. There aren’t usually any other effects.
A doctor passes a flexible tube with a tiny camera on the end (ureteroscope) up the urethra into the bladder and on into the ureter and renal pelvis. This is usually done under a general anaesthetic. In most cases, you can go home later the same day.
The test lets the doctor look inside the ureter and renal pelvis and take samples of cells (biopsies) from any areas that look abnormal. The biopsies are sent to a laboratory to be examined for signs of cancer. The doctor may also take a sample of urine from the renal pelvis to be tested for cancer cells.
You may have blood in your urine for a few days after the test. You may also have some soreness or mild pain when you pass urine and in your tummy area or back for one or two days. If these side effects don’t get better or you feel unwell or feverish, contact the hospital for advice, as you may have an infection.
Sometimes x-rays of the kidney and ureter are taken during a ureteroscopy. This is called retrograde pyelography. The doctor places a tube (catheter) into the ureter, then passes dye up the catheter to highlight the ureter and renal pelvis on x-rays.
CT (computerised tomography) urography
CT urography is a type of CT scan. It looks at the kidneys, ureters and bladder.
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 about an hour. 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 a few hours before the test. You are given an injection of a dye. This may make you feel hot all over for a few minutes. 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. The dye travels through your bloodstream to your kidneys. The doctor looks at a screen to see the dye passing through the kidneys and ureters.
MRI (magnetic resonance imaging) scan
MRI scans use magnetism to build up a detailed picture of areas of your body. The scanner is a powerful magnet, so you may be asked to complete and sign a checklist to make sure it's safe for you. The checklist asks about any metal implants you may have, such as a pacemaker, surgical clips or bone pins, etc. You should also tell your doctor if you've ever worked with metal or in the metal industry as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body, it’s likely that you won’t be able to have an MRI scan. In this situation, another type of scan can be used. Before 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, which doesn't usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test, you’ll lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It’s painless but can be slightly uncomfortable, and some people feel a bit claustrophobic. It’s also noisy, but you’ll be given earplugs or headphones. You can hear, and speak to, the person operating the scanner.
Staging and grading for ureter and renal pelvis cancer
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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 refers to how far the cancer has grown into the tissues of the ureter or renal pelvis and whether it has spread to lymph nodes or other organs. Knowing the stage of the cancer helps doctors to plan treatment.
Stages may be described as a number from 0–4.
This stage is also called non-invasive papillary carcinoma or cancer in situ. The cancer is growing on the lining (mucosa) of the renal pelvis or ureter but not through it.
The cancer has spread through the inner lining (mucosa) of the renal pelvis, or ureter, into the connective tissue.
The cancer has grown into the muscle layer of the renal pelvis or ureter.
Renal pelvis: The cancer has grown through muscle to tissue or fat inside the kidney
Ureter: The cancer has grown through muscle into fat that surrounds the ureter.
The cancer has spread to one or more of the following:
The layer of fat surrounding the kidney
One or more lymph nodes
Distant parts of the body, such as the lung, liver, or bone.
Your doctor may use the following terms to describe the stage of the cancer:
Localised: the cancer is only in the area where it started and hasn't spread outside the kidney or ureter.
Regional: the cancer has spread to the tissue around the kidney or to nearby lymph nodes.
Metastatic: 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 depends on a number of factors, including the position, type, stage and grade of the cancer. Your doctors will also take into account how well your kidneys work, your general health and your personal preferences.
Surgery is the most common treatment for cancer of the ureter and renal pelvis. After surgery, you may be offered other treatments to get rid of any remaining cancer cells and reduce the chance of the cancer coming back. This is known as adjuvant treatment.
If the cancer has spread to other organs (metastatic or secondary cancer), chemotherapy is often the main treatment. The aim is to reduce the size of any tumours and help control symptoms.
Surgery is usually the main treatment for cancer that hasn’t spread to distant parts of the body.
Surgery may be open or laparoscopic (keyhole). Open surgery means the surgeon makes one large cut (incision). In laparoscopic surgery, the surgeon makes several small cuts. They pass a laparoscope through one of the cuts. A laparoscope is a thin tube containing a light and camera. Then they pass specially designed surgical tools through the other cuts to remove the cancer. Recovery from laparoscopic surgery is usually quicker than recovery from open surgery.
Your surgeon will talk to you about which type of surgery is appropriate for you.
Removing the kidney and ureter
The most commonly used operation to treat cancer of the ureter or renal pelvis is a radical nephroureterectomy. The surgeon removes the kidney, ureter and an area of bladder around the ureter (bladder cuff).
The surgeon may also remove some lymph nodes close to the kidney to check if they contain cancer cells.
Removing a kidney is a big operation, and it isn’t suitable for everyone. Your doctors may need to do tests to check you are fit enough to cope with the surgery. After a kidney is removed, the other kidney will do the work usually shared by both kidneys.
Operations that don’t remove all of the kidney
These operations are sometimes described as renal- (kidney) sparing surgery. The surgeon removes some of the ureter but doesn’t remove the kidney or only removes a part of the kidney. This type of surgery may be possible if you have a low-grade, early-stage tumour. It may also be done if you only have one kidney or if your kidneys don’t work well enough for you to cope with just one.
Laser or heat (diathermy) treatment
Occasionally, if the cancer is low grade and only growing on the lining of the ureter, it may be removed by laser or heat treatment (diathermy). A ureteroscope is passed up into the bladder and on into the ureter. A beam of laser or heat is then applied to the tumour to destroy it. Sometimes after this, a tube (stent) may be left in the ureter temporarily to keep it open.
If you have laser or heat treatment you will need to be very closely monitored after it. This is because there is a risk the cancer could grow back. If this happens, it’s important the cancer is detected as soon as possible.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. It may be given to reduce risk of cancer coming back after surgery or as the main treatment for cancer that has spread to other parts of the body. You are usually given a combination of two or more chemotherapy drugs into a vein (intravenously). The most commonly used treatments are:
GC (gemcitabine and cisplatin)
Gemcarbo (gemcitabine and carboplatin)
MVAC (methotrexate, vinblastine, doxorubicin and cisplatin).
Rarely, chemotherapy or BCG (an immunotherapy drug, which triggers the immune system to fight infection and disease, to get rid of cancer cells) are given directly into the ureter. This may be done after laser treatment or after some types of renal-sparing surgery.
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. It’s not commonly used to treat this type of cancer. It may occasionally be given after surgery, to treat any cancer cells that couldn’t be removed, or if surgery isn’t possible.
Clinical trials for ureter and renal pelvis cancer
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Research into new ways of treating ureter and renal pelvis cancer is ongoing. Doctors are continually looking for improved ways of treating the disease and they do this by using clinical trials. Many hospitals now take part in these trials. Before any trial is allowed to take place it must have been approved by an ethics committee, which checks that the trial is in the interest of patients.
You may be invited to take part in a clinical trial. Your doctor must discuss the treatment with you so that you have a full understanding of the trial and what it involves. You may decide not to take part, or to withdraw from a trial, at any stage. If this is the case you will still receive the best standard treatment available.
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 have regular checks with CT urography and/or ureteroscopies. You will also have cystoscopies to detect any changes in the 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 page has been compiled using information from a number of reliable sources, including Guidelines on Urothelial Carcinomas of the Upper Urinary Tract, Rouprêt M et al, European Association of Urology 2013. If you’d like further information on the sources we use, please feel free to contact us.
With thanks to Ms Kay Thomas, Consultant Urological Surgeon, and the people affected by cancer who reviewed this edition.
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