39-19: Cancers of the Ureter & Renal Pelvis

Cancers of the ureter and renal pelvis are rare and occur more commonly in patients who have bladder cancer, Balkan nephropathy, or Lynch syndrome, who smoke, or who have a long history of analgesic abuse. The majority are urothelial cell carcinomas. Gross or microscopic hematuria is present in most patients; flank pain secondary to bleeding and obstruction occurs less commonly. As with bladder cancers, urinary cytology is often positive in high-grade cancers. The most common signs identified at the time of CT or intravenous urography include an intraluminal filling defect, unilateral nonvisualization of the collecting system, and hydronephrosis. Ureteral and renal pelvic tumors must be differentiated from calculi, blood clots, papillary necrosis, or inflammatory and infectious lesions. On occasion, upper urinary tract lesions are accessible for biopsy, fulguration, or resection using a ureteroscope. Treatment is based on the site, size, grade, depth of penetration, and number of cancers present. Most are excised with laparoscopic or open nephroureterectomy (renal pelvic and upper ureteral lesions) or segmental excision of the ureter (distal ureteral lesions). Endoscopic resection may be indicated in patients with limited renal function or focal, low-grade, cancers. Similar to urothelial bladder cancers, use of chemotherapy prior to surgery may improve outcomes.