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Cancers
of the renal pelvis and ureters are usually transitional cell carcinomas
and occasionally squamous cell carcinomas. Symptoms include hematuria
and sometimes pain. Diagnosis is by CT, cytology, and sometimes
biopsy. Treatment is surgery.
Transitional cell carcinoma (TCC) of the renal pelvis accounts for about 7 to 15% of all kidney tumors. TCC of the ureters accounts for about 4% of upper tract tumors. Risk factors are the same as those for bladder cancer. Also, inhabitants of the Balkans with endemic familial nephropathy are inexplicably predisposed to develop upper tract TCC.
Symptoms
Most patients present with hematuria; dysuria and frequency may occur if the bladder also is involved. Colicky pain may accompany obstruction (see Obstructive Uropathy). Uncommonly, hydronephrosis results from a renal pelvic tumor.
Diagnosis
In patients with unexplained urinary tract symptoms, typically ultrasonography or CT with contrast is done. If the diagnosis cannot be excluded, cytologic or histologic analysis is done for confirmation. Ureteroscopy is done when biopsy of the upper tract is needed or when urine cytology is positive but no source of the malignant cells is obvious. Abdominal and pelvic CT and chest x-ray are done to determine tumor extent and to check for metastases. The standard TNM staging system is used (see Table 1: Genitourinary Cancer: Genitourinary Cancer Staging  ).
Prognosis
Prognosis depends on depth of penetration into or through the uroepithelial wall, which is difficult to determine. Likelihood of cure is > 90% for patients with a superficial, localized tumor but is 10 to 15% for those with a deeply invasive tumor. If tumors penetrate the wall or distant metastases occur, cure is unlikely.
Treatment
Usual treatment is radical nephroureterectomy, including excision of a cuff of bladder. Partial ureterectomy is indicated in some carefully selected cases (eg, in patients with a distal ureteral tumor, decreased renal function, or a solitary kidney). Laser fulguration for accurately staged and adequately visualized renal pelvic or low-grade ureteral tumors is sometimes possible. Occasionally, a drug, such as mitomycin C or BCG, is instilled. However, efficacy of laser therapy and chemotherapy has not been established.
Periodic cystoscopy is indicated because renal pelvic and ureteral cancers tend to recur in the bladder, and such recurrence, if detected at an early stage, may be treated by fulguration, transurethral resection, or intravesical instillations. Management of metastases is the same as that for metastatic bladder cancer.
Last full review/revision December 2007 by David A. Swanson, MD
Content last modified December 2007
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