Renal Pelvis and Ureteral Cancer
Renal pelvic and ureteral cancer are unique type of cancer is a transitional cell cancer, or urothelial carcinoma. The urothelium is the cell layer lining the renal pelvis, ureter, and bladder. Bladder cancer is the more common location for urothelial cancers. Less than 10% of tumors starting in the renal pelvis or ureter.
Several factors may increase the risk of developing renal pelvis cancer, including tobacco use, prolonged exposure to certain chemicals (aniline dyes and aromatic amines), chronic irritation, and a known history of bladder cancer, and Lynch Syndrome.
How do we diagnose a renal pelvis or ureter transitional cell cancer?
Most patients are diagnosed with this kind of cancer when they are evaluated for blood in the urine. Patients with blood in the urine will typically had an imaging study of the kidney (most often a CT scan with and without contrast), a cystoscopy (scope of the bladder), and urine testing to evaluate for cancer called a urine cytology.
If a CT, ultrasound, or MRI suggest a tumor in the ureter or renal pelvis then a procedure called ureteroscopy is performed under general anesthesia to get a tissue diagnosis.
How do we treat renal pelvis or ureter transitional cell cancer?
Treatment options for renal pelvis cancer vary based on the stage of the disease and the overall health of the patient. Surgery is the most common treatment for localized renal pelvis cancer. The surgery most often involves removing the affected kidney (nephrectomy), the renal pelvis, the entire ureter, and a small section of bladder. Although this sounds like a major operation it is the only way to remove ALL of the urothelium that may be at risk of being affected by the cancer. Resection or ablation of the tumor, radiation, chemotherapy, and immunotherapy also may be employed when needed.
Is this kind of cancer treatable?
The prognosis for renal pelvis cancer depends on the cancer stage at diagnosis. Early-stage cancers have a better outlook, those cases where the tumor has spread beyond the kidney have a poorer prognosis.
Can you comment on Stage and Grade of Renal Pelvic Cancer?
The GRADE of a cancer is how aggressive the individual cells appear under the microscope. High grade cancers grow faster and are more aggressive. Low grade cancers grow more slowly.
The STAGE of a cancer is how far advanced the tumor is at diagnosis. Stage A is a tumor on the surface. Stage 1 is initial invasion to the lamina propria. Stage 2 invades the muscle of the renal pelvis and ureter. Stage 3 invades tissue (fat) around the renal pelvis or ureter. Stage 4 is a cancer that has spread to lymph nodes, organs (including the kidney itself), and bone.
What happens after treatment?
Regular follow-up and monitoring are essential. Routine testing is used such as CT scans, PET scans and cystoscopy (of the bladder), and urine testing are important to make sure we are not seeing a recurrence of cancer.
Nephroureterectomy Surgery
Nephroureterectomy
A nephroureterectomy is a surgical procedure that involves the removal of the kidney (nephrectomy) along with the ureter and a small section of the bladder.
The surgery can be performed via an open approach or with the daVinci robot laparoscopically, depending on the size of the tumor.
The procedure is done under general anesthesia and requires a stay in the hospital of 1-3 days. In an open nephroureterectomy, a larger incision is made in the flank or abdomen. Fortunately in most cases we perform a robotic laparoscopic surgery, where several small incisions are used to place the instruments and cameras into the abdomen for the initial dissection. A small incision is made once the kidney has been fully dissected to remove the specimen.
Postoperative care includes monitoring for complications such as bleeding, infection, or urinary leakage. Pain management is usually effectively done with a combination of minimal narcotic use and over the counter medication such as Tylenol or ibuprofen. Patients are encouraged to resume walking and activity beginning on the day of the surgery.
Recovery time can vary, typically lasting from a couple weeks to several months, depending on the surgical method and individual health prior to surgery.
Risks and Complications
As with any major surgery, nephroureterectomy carries potential risks, including: infection, bleeding, blood clots in the veins of the lower extremity, damage to surrounding organs or nearby tissue, urine leakage from the surgery in the bladder, need for prolonged bladder catheter to encourage healing, and more severe complications such as heart attach or stroke from the anesthesia.
Long term risks of the procedure are due primarily to the loss of one kidney, with a natural reduction in the overall kidney functional reserve. For most patients this will not impact their long term health, but for patients with high blood pressure, diabetes, or other kidney concerns careful attention to kidney function after surgery is critical.