Ureter and renal pelvis cancer

Cancers in the ureter or renal pelvis are uncommon.

In the middle of each kidney is an area called the renal pelvis. Urine (pee) collects here. It then drains from the kidney through a long muscular tube called a ureter. There are two ureters – one from each kidney. They go into the bladder.

Most cancers of the ureter and renal pelvis are a type called urothelial cancer. It is sometimes called transitional cell carcinoma (TCC).

Treatment depends on the position, type, stage and grade of the cancer, as well as your general health. Surgery is the main treatment used. After surgery, you may have chemotherapy or radiotherapy. Some people may have laser or heat treatment.

You may be asked to take part in clinical trial looking at new ways of treating ureter and renal pelvis cancer. Your cancer doctor or specialist nurse can talk to you about this.

After your treatment, you will have regular check-ups. These will usually continue for several years.

The ureters and renal pelvis

The ureters and renal pelvis are part of the urinary system. The kidneys filter the blood to remove waste products, which are made into urine (pee).

The urine collects in an area in the middle of each kidney. This area is called the renal pelvis. Urine then drains from each kidney through a long, muscular tube called a ureter. There are two ureters – one from each kidney. The ureters connect to the bladder, where urine is stored before being passed out of the body.

Close-up of the kidney in the body
Close-up of the kidney in the body

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The ureters and renal pelvis are made up of layers of tissue. The inner lining is called the mucosa. This is covered by a layer of connective tissue, then a layer of muscle and finally a layer of fat.


What is ureter and renal pelvis cancer?

Cancers that start in the ureter or renal pelvis are uncommon. 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.

About 9 in 10 cancers of the ureter and renal pelvis (90%) start in cells called transitional cells. The cancer is called urothelial carcinoma or transitional cell carcinoma (TCC). Transitional cells line the renal pelvis, ureters, bladder and urethra.

There is a more common type of kidney cancer called renal cell cancer (RCC). The tests, diagnosis 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:

  • squamous cell carcinoma
  • adenocarcinoma
  • some types of lymphoma (a cancer that starts from the cells of the lymphatic system)
  • sarcoma (a cancer that develops from the supporting tissues of the body, such as muscle or cartilage).

The treatment for these types of cancer is also different to that for urothelial cancer of the ureter and pelvis cancer.

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 which part of the body the cancer started from.


Causes and risk factors of ureter and renal pelvis cancer

The causes of cancer of the ureter and renal pelvis are unknown, but research is going on to try to find out more. There are certain things that can affect the chances of developing these cancers. These are called risk factors. Having a risk factor does not necessarily mean you will get cancer of the ureter or renal pelvis, and people without risk factors can also develop cancer.

Gender

Cancers of the ureter and renal pelvis are more common in men than women.

Age

The risk of cancer of the ureter and renal pelvis increases with age. They are rare under the age of 65.

Smoking

Smoking cigarettes is one of the main risk factors for this type of cancer.

Exposure to certain chemicals at work

An increased risk of cancer of the ureter and renal pelvis has been linked to working with certain chemicals. These include industrial dyes, plastics, coal, tar and asphalt.

Painkillers and other drugs

People who have kidney damage from long-term use of certain painkillers may have a higher risk of developing cancer in the renal pelvis. This risk is highest in people who were overexposed to painkillers containing phenacetin. These painkillers are no longer sold. But phenacetin may be added to some illegal recreational drugs such as cocaine, so regular users could still be at risk.

Other risk factors

Some people in Balkan countries can be affected by a form of kidney damage called Balkan nephropathy. This increases the risk of renal pelvis cancer.

A rare condition called Lynch syndrome also increases the risk of developing cancer of the renal pelvis and ureter. Lynch syndrome is also known as hereditary non-polyposis colorectal cancer (HNPCC). 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.

Cancer is not contagious and you cannot pass it on to other people.


Signs and symptoms of ureter and renal pelvis cancer

If you have symptoms, you usually start by seeing your GP. They will examine you and arrange for you to have some tests. They may test your urine (pee). They may also do blood tests to check:

  • your general health
  • the number of cells in your blood (blood count)
  • how well your kidneys and liver are working.

If your GP is not sure what the problem is or they think your symptoms could be caused by cancer, they will usually refer you to the hospital to see a specialist doctor. This doctor is called a urologist. They specialise in treating urinary, bladder and kidney problems.

If you have blood in your urine, you may be referred to a specialist clinic. This is called a haematuria clinic. Often these clinics can do tests on the same day.


How ureter and renal pelvis cancer is diagnosed

If you have symptoms, you usually start by seeing your GP. They will examine you and arrange for you to have some tests. They may test your urine (pee). They may also do blood tests to check:

  • your general health
  • the number of cells in your blood (blood count)
  • how well your kidneys and liver are working.

If your GP is not sure what the problem is or they think your symptoms could be caused by cancer, they will usually refer you to the hospital to see a specialist doctor. This doctor is called a urologist. They specialise in treating urinary, bladder and kidney problems.

If you have blood in your urine, you may be referred to a specialist clinic. This is called a haematuria clinic. Often these clinics can do tests on the same day.


At the hospital

The urologist or a specialist nurse will ask you about your symptoms and your general health. They will also examine you and arrange some of the following tests.

Blood tests

You will have blood samples taken. These help your doctors to check how well your kidneys and liver are working. 

They also show the number of blood cells in your blood. This is called a blood count.

Urinary cytology

A sample of your urine (pee) will be checked for cancer cells.

CT urogram

A CT urogram 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 60 minutes (1 hour). 

CT scans use a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with.

Your will be given instructions on how to prepare for the test. Before the test, you can usually eat and drink normally. Just before the test, you may be asked to empty your bladder.

You will be given an injection of a dye. This helps the doctor see your bladder, ureters and kidneys more clearly. 

The dye may make you feel hot all over for a few minutes. Some people have a stronger reaction to the dye. 

Tell your doctor if you have asthma or an iodine allergy, because you could have a stronger reaction to the injection. 

You should also tell your doctor if you have kidney problems or diabetes, particularly if you take metformin. You will need a blood test before the scan to check how well your kidneys are working.

The dye travels through the bloodstream to the kidneys. The doctor looks at a screen to see the dye passing through the kidneys and ureters.

You should be able to go home as soon as the scan is over.

Cystoscopy and ureteroscopy

These tests let the doctor look inside the bladder, ureter and renal pelvis. The doctor can take samples of cells (biopsies) from any areas that look abnormal. They send the biopsies to a laboratory to be examined for signs of cancer. The doctor may also take a sample of urine (pee) from the renal pelvis to be tested for cancer cells.

A doctor passes a thin, flexible tube with a tiny camera on the end into the opening of the urethra. In men, this is at the tip of the penis. In women, it is just above the vagina. For a cystoscopy, the tube is passed into the bladder. For a ureteroscopy, it is then also passed into the ureter and renal pelvis. Both tests are usually done under a general anaesthetic. In most cases, you can go home later the same day.

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 1 or 2 days. If these side effects do not 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 better show the ureter and renal pelvis on x-rays.

Intravenous urogram (IVU/IVP)

This test is also called an intravenous pyelogram. It is done in the hospital x-ray department and takes about 60 minutes (1 hour).

A dye is injected into a vein, usually in the arm. It flows through your bloodstream to the kidneys. The doctor can watch the flow of the dye on an x-ray screen and see any abnormalities in the kidneys, bladder and the rest of the urinary system.

The dye may make you feel hot and flushed for a few minutes, but this feeling will go away. You may feel some discomfort in the tummy (abdomen), but this will only be for a short time. You should be able to go home as soon as the test is over.

MRI scan

An MRI scan uses 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 is 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 have 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 is likely that you will not be able to have an MRI scan. In this situation, another type of scan can be used. Before the scan, you will be asked to remove any metal belongings including jewellery.

Some people are given an injection of dye into a vein in the arm, which does not 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 will 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. It is also noisy, but you will be given earplugs or headphones. You can hear, and speak to, the person operating the scanner.


Staging ureter and renal pelvis cancer

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 parts of the body. Staging information comes from the tests you have had.

Your cancer doctor and specialist nurse will talk to you about this. They will explain how it helps you and your doctor decide on your treatment plan.

Stages may be described as a number from 0 to 4.

Stage 0

This stage is also called carcinoma in situ. The cancer is only growing on the inside of the lining (mucosa) of the renal pelvis or ureter, but not through it.

Stage 1

The cancer has spread through the inner lining (mucosa) of the renal pelvis or ureter, into the connective tissue.

Stage 2

The cancer has grown into the muscle layer of the renal pelvis or ureter.

Stage 3

  • For cancer of the renal pelvis – the cancer has grown through the muscle to the tissue or fat inside the kidney.
  • For cancer of the ureter – the cancer has grown through the muscle into the fat that surrounds the ureter.

Stage 4

The cancer has spread to one or more of the following areas:

  • the layer of fat surrounding the kidney
  • nearby organ(s)
  • one or more lymph nodes
  • distant parts of the body, such as the lung, liver, or bone.

Other terms used

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 has not spread outside the kidney or ureter.
  • Regional – the cancer has spread to the tissue around the kidney or to nearby lymph nodes.
  • Metastatic (secondary) – the cancer has spread to other parts of the body.


Grading ureter and pelvis cancer

A doctor decides the grade of the cancer by looking at the cancer cells under a microscope. The grade gives an idea of how the cancer might grow or spread.

Cancers of the ureter and renal pelvis are given a grade from 1 to 4. The lower the number, the lower the grade.

  • Low-grade means the cancer cells are more like normal cells. Grade 1 and 2 cancer cells are slow-growing and less likely to spread.
  • High-grade means the cancer cells are less like normal cells. Grade 3 and 4 cancer cells grow more quickly and are more likely to spread.


Treatment overview for ureter and renal pelvis cancer

Treatment depends on a number of factors, including the cancer’s:

  • position
  • type
  • stage
  • grade.

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 control the cancer. This can improve symptoms and quality of life.


Surgery

Surgery is usually the main treatment for cancer that has not spread to distant parts of the body.

Surgery may be open or keyhole (laparoscopic). Open surgery means the surgeon makes one large cut (incision).

In keyhole surgery, the surgeon makes 2 to 3 small cuts. They pass a laparoscope through one of the cuts. A laparoscope is a thin tube containing a light and camera. It sends video images to a monitor. Then the surgeon passes specially designed surgical tools through the other cuts to remove the cancer.

Laparoscopy
Laparoscopy

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The surgeon may use a specialised machine to help with keyhole surgery. There are instruments attached to the machine, which the surgeon controls. This is called robot-assisted surgery. It makes it possible for the surgeon to do very precise surgery.

Recovery from keyhole surgery is usually quicker than recovery from open surgery, because the wound is smaller.

Some surgical techniques are very specialised and may only be available at some bigger cancer centres. Your surgeon will talk to you about which type of surgery is appropriate for you.

Removing the whole kidney and ureter (nephroureterectomy)

This is the most commonly used operation to treat cancer of the ureter or renal pelvis. The surgeon removes:

  • the kidney
  • a layer of fat around the kidney
  • the ureter
  • an area of tissue where the ureter enters the bladder (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 is not suitable for everyone. Your doctors may need to do tests to check you are fit enough to cope with the surgery. You can live a normal life with just one kidney. It will be able to do the work of both kidneys.

Removing part of the ureter (segmental resection)

This is usually only done if the cancer is in the lower third of the ureter. The surgeon removes the part of the ureter where the tumour is. They also remove a healthy area (margin) of ureter above the tumour and all the ureter below the tumour. Then they reattach the remaining ureter to the bladder.

Endoscopic surgery

It is sometimes possible to remove a low-grade, early-stage tumour in the renal pelvis using endoscopy. The surgeon passes a flexible tube called an endoscope up through the urethra, bladder and ureter to the renal pelvis. This is called a ureteroscopy. The surgeon then removes the tumour using tools passed through the endoscope.

Sometimes the surgeon will reach the kidney by making a small cut in your back (percutaneous renoscopy). They then pass the endoscope into the kidney to reach the renal pelvis.

Endoscopic surgery may sometimes be done for higher-grade cancers if you only have one kidney. Or it may be done if your kidneys do not 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 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 afterwards. This is because there is a risk the cancer could grow back. If this happens, it is important the cancer is found as soon as possible.


Chemotherapy

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 2 or more chemotherapy drugs into a vein (intravenously). The most commonly used treatments are:

  • GemCis (gemcitabine and cisplatin)
  • GemCarbo (gemcitabine and carboplatin)
  • MVAC (methotrexate, vinblastine, doxorubicin and cisplatin).

Rarely, chemotherapy is given directly into the ureter. This may be done after laser treatment or after some types of surgery.

Side effects of chemotherapy

Chemotherapy can cause side effects, but they can often be well controlled with medicines. Your cancer doctor or specialist nurse will explain what to expect. Let them know about any side effects you have. There are different ways to manage or treat side effects. Most side effects will go away once your treatment has finished.

We have more information about coping with the side effects of chemotherapy and about different chemotherapy drugs.


Immunotherapy

Immunotherapy drugs encourage the body’s immune system to fight cancer cells.

BCG

The immunotherapy drug BCG is sometimes given directly into the ureter after laser treatment or some types of surgery. It is only suitable for non-invasive cancers.

Checkpoint inhibitors

Immunotherapy drugs called checkpoint inhibitors are sometimes used to treat ureter and renal pelvis cancers that have spread (locally advanced or metastatic cancer). They are used if the cancer continues to grow or if it comes back after chemotherapy containing a platinum-based drug, such as cisplatin. It may also be used if cisplatin is not suitable.

The most commonly used checkpoint inhibitors are:

Both pembrolizumab and atezolizumab are given by drip (infusion) into a vein once every 3 weeks.

The side effects are usually mild and include:

Your cancer doctor or specialist nurse will give you more information about these drugs.

Your cancer doctor can tell you if pembrolizumab or atezolizumab are appropriate for you. If a drug is not routinely available on the NHS, your doctor can give you advice on whether there are any other ways to get it.

We have more information about what to do if a treatment is not available on the NHS. You can also call our cancer support specialists free on 0808 808 00 00, Monday to Friday, 9am to 8pm.


Radiotherapy

Radiotherapy uses high-energy rays to destroy cancer cells and shrink the tumour. It aims to do as little harm as possible to normal cells. It is not commonly used to treat this type of cancer. It may occasionally be given after surgery to treat any cancer cells that could not be removed, or if surgery is not possible.


Clinical trials

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials. These may be carried out to:

  • test new treatments, such as new chemotherapy drugs or targeted therapies
  • look at new combinations of existing treatments, or change the way they are given to make them more effective or reduce side effects
  • compare the effectiveness of drugs used to control symptoms
  • find out how cancer treatments work
  • find out which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different type of surgery, chemotherapy, radiotherapy, or other treatment is better than what is already available.


Follow-up after treatment for ureter and renal pelvis cancer

After your treatment has finished, you will have regular check-ups with your cancer doctor to monitor how you are recovering after treatment. These will usually include a physical examination. It may also involve taking some urine (pee) or blood samples.

You may have regular checks with a CT urogram or ureteroscopies. You will also have cystoscopies to detect any changes in the bladder. This is because people with cancer of the ureter or renal pelvis have an increased risk of developing a bladder cancer after a few years.

You can talk to your cancer doctor or specialist nurse about any problems or worries you have at these check-ups. If you have any problems or notice any new symptoms between your appointments, let your doctor know as soon as possible.

Many people find that they get anxious before their appointments. You may worry about the cancer coming back. This is natural. It can help to get support from family, friends or your specialist nurse. Or you can speak to our cancer support specialists on 0808 808 00 00.


Your feelings

During your diagnosis and treatment, you are likely to experience a number of different emotions. These can include shock, disbelief, guilt, fear, anxiety and anger. It is common to feel overwhelmed by different emotions. These feelings are natural. Partners, family and friends may also have some of the same feelings.

You might have different reactions to the ones we have mentioned. There is no right or wrong way to feel. Everyone has their own way of coping with difficult situations, and help is available if you need it. Some people find it helpful to talk to family or friends, while others prefer to ask for help from people outside their situation. Our cancer support specialists on 0808 808 00 00 can give you more information about where to get help and support.

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