Cancer of the ureter and renal pelvis

This information is about primary cancer of the ureter or renal pelvis. This means cancer that has started in the ureter or renal pelvis.



The ureters and the renal pelvis
Cancer of the ureter and renal pelvis
Causes
Signs and symptoms
How it is diagnosed
Further tests
Staging and grading
Treatment
Follow up
Your feelings
References
The ureters and the renal pelvis
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.




Structure of the kidneys


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Cancer of the ureter and renal pelvis
Cancers affecting the ureter and renal pelvis are rare. Approximately 400 people are diagnosed with this type of cancer in the UK each year. Cancer of the ureter and renal pelvis tends to affect more men than women, and is rare under the age of 65.

The main type of cancer affecting the ureter and renal pelvis is called transitional cell carcinoma (TCC). This type of cancer develops in cells, known as transitional cells, which form the lining of the bladder, ureters and renal pelvis. 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. This information is only about TCC. 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 is known as secondary or metastatic cancer in the ureter or renal pelvis.



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Causes
The exact causes of cancer of the ureter and renal pelvis is unknown. It is 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.

There may also be an increased risk in people who have papillary necrosis, a condition where parts of the kidney are damaged or have died off. Papillary necrosis can occur because of overexposure to certain painkillers, and sometimes in people who have conditions affecting the kidney, such as diabetes or repeated infections.

Cancer of the ureter and renal pelvis, like other cancers, is not infectious and so cannot be passed on to other people. It is not caused by an inherited faulty gene, so other members of your family are not likely to develop it.



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Signs and symptoms
The symptoms of cancer of the ureter and renal pelvis may include any of the following:

blood in the urine (haematuria)
passing blood clots in the urine
unexplained weight loss
having to pass urine frequently
pain when passing urine
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. If this happens, the above symptoms may develop more quickly and may be more severe, often accompanied by a high temperature. This is known as a ureteric obstruction.

The above symptoms may be caused by a number of conditions other than cancer of the ureter or renal pelvis. Symptoms which are severe, get worse, or that last for a few weeks, should always be checked by your doctor.



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How it is diagnosed
Your GP will examine you and organise a series of urine and blood tests. The urine sample will 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 see 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.

Cystoscopy and biopsy A small, flexible, fibre-optic telescope (cystoscope) is passed up the urethra to enable the doctor to look at the bladder. The doctor can also extend the tip of the cystoscope up into the ureter: this procedure, known as ureteroscopy, can be done under a local or a general anaesthetic. In most cases it is done under a local anaesthetic because this is the quickest and simplest way.

If any abnormality that could be a cancer is seen, it has to be examined while you are under a general anaesthetic. The doctor will then take a sample of abnormal cells, and these are examined in a laboratory under a microscope by a pathologist (biopsy).

Intravenous urogram or pyelogram (IVU or IVP) This test shows up abnormalities in the urinary system. It is done in the hospital x-ray department and takes about an hour. A dye is injected into a vein, usually in the arm, that travels through the bloodstream to the kidneys. The doctor can watch the passage of dye on an x-ray screen and pick up any abnormalities.

The dye will probably make you feel hot and flushed for a few minutes, but this feeling gradually disappears. You may feel some discomfort in your abdomen, but this will only be temporary. You should be able to go home as soon as the test is over.

Ultrasound scan Sound waves are used 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 scanning 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 are 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.

Retrograde pyelography This is a special x-ray which involves inserting a catheter into the ureter at the time of ureteroscopy. Dye is then passed up the catheter to highlight the ureter and renal pelvis.



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Further tests
If a cancer is found, you may be referred for other tests to find 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 and puts these together to give a 3-D picture of the inside of your body. The scan is painless and takes between 10 and 30 minutes.

You may be asked not to eat or drink anything for several hours before your appointment. Most people who have a CT scan are given a drink or injection of dye before the scan. This helps the doctor to see particular areas more clearly. People who are allergic to iodine or have asthma may be at higher risk of reacting to the dye. If you are allergic to iodine or have asthma, tell the doctor and the person doing the test before you have the injection or drink. After having the injection, most people feel hot and flushed, but this only lasts for a few minutes. You will probably be able to go home as soon as the scan is over.

MRI (magnetic resonance imaging) scan This test is similar to a CT scan, but uses magnetism instead of x-rays to build up cross-sectional pictures of your body. During the test, you will be asked to lie very still on a couch inside a long tube for about 30 minutes. It can be slightly uncomfortable and some people feel claustrophobic during the scan. It is also very noisy, but you will be given earplugs or headphones to wear.

The combination of tests will help the specialist to find out the stage and grade of the cancer. This will help the doctors to decide on the most appropriate treatment for you.



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Staging and grading
Staging
Staging refers to the size of the cancer and whether or not it has spread beyond the ureter or renal pelvis.

The following stages are used for transitional cell cancer of the renal pelvis and ureter:

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. Lymph nodes are bean-shaped structures that are found throughout the body. They produce cells that fight infection.
Metastatic The cancer has spread to other parts of the body.
Grading
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) or faster-growing (high-grade).



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Treatment
Treatment will depend on a number of factors, including your age, general health and the position, type, stage and grade of the cancer.

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 will be recommended, such as radiotherapy or chemotherapy. 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 is not 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.

Surgery
Nephro-ureterectomy means the removal of the kidney, ureter and top part of the bladder. Sometimes the surrounding lymph glands, fat and tissue may also be removed.

Segmental ureterectomy resection is the removal of the affected part of the ureter. The remaining parts are then rejoined. This procedure is usually only possible if the tumour is small, low-grade and contained within the ureter.

Ureteroneocystomy (or reimplantation) is the removal of the lower part of the ureter, and sometimes 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 either by laser treatment or electrosurgery. These two surgical treatments are in the early stages of development.

Laser therapy A 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.
Electrosurgery An electric current is used to remove the cancer. The tumour and surrounding area can be burned away.
Radiotherapy
Radiotherapy treats cancer by using high-energy rays, which destroy the cancer cells and shrink the tumour while doing as little harm as possible to normal cells.

Chemotherapy
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).



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Follow up
After treatment, you will have regular follow-up appointments with your specialist to monitor how you are recovering after treatment. Follow-up 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. If you have any problems, or notice any new symptoms between these times, let your doctor know as soon as possible.



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Your feelings
During your diagnosis and treatment of cancer, you are 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. It is quite natural, and important, to be able to express them. Each individual has their own way of coping with difficult situations; some people find it helpful to talk to friends or family, 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.



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