Urologic Cancer Center
Urologic Cancer Center
WHAT IS THE URINARY COLLECTING SYSTEM?
WHAT ARE RISK FACTORS FOR CANCER OF THE URETER/RENAL PELVIS?
WHAT ARE SYMPTOMS OF CANCER ODF THE URETER/RENAL PELVIS?
HOW IS CANCER OF THE URETER/RENAL PELVIS DIAGNOSED?
HOW IS CANCER OF THE URETER/RENAL PELVIS TREATED?
The urinary system starts with the kidneys. The kidneys filter the blood to extract excess fluid and waste products to make the urine. Once urine is made in the kidneys, it travels through the first part of the urinary drainage system called the renal pelvis, and then into the ureter which is the tube that drains fluid from the kidney to the bladder. Then the bladder holds urine until full then empties to the outside through the urethra.
The lining of the urinary system is made up of specialized cells called transitional cells. These cells are designed to allow the urine to pass to the outside without any of the urine being reabsorbed back into the body. Cancerous changes can occur in these cells anywhere along the urinary collecting system (in the renal pelvis, the ureter, the bladder, or the urethra) forming a type of cancer known as transitional cell carcinoma (also called uroepithelial cancer).
By far the most common risk factors for transitional cell carcinoma is smoking or other tobacco exposure. Men are more likely to develop the disease than women. Other less common risk factors include certain types of occupational exposures (aniline dyes, coal and tar), chronic irritation from infection or stones, prior exposure to the chemotherapy agent cyclophosphamide, and the long standing use of pain medicines (acetaminophen, ibuprofen). There are also some rare medical syndromes (Lynch Syndrome II, Balkan nephropathy) that may predispose to formation of transitional cell cancer.
The most common symptom is hematuria, which is a word that means blood in the urine. Hematuria can be “gross” (meaning it can be seen with the naked eye), or it may be microscopic (meaning it is detected on a urinalysis lab test).
Some patients may have back or flank pain, or they may present with episode of repeated urinary infections.
Evaluation for hematuria usually begins with a study of the upper part of the urinary system. An x-ray, known as an imaging study, is carried out to gather information about the kidneys, the ureters, and the bladder. The imaging study used most often is the CT urogram. The CT urogram uses x-ray type pictures to give detailed information about the kidneys, the renal pelvis, and the ureters. During the CT urogram, contrast (dye) is injected through one of the veins in the arm or the hand. The dye can then be filtered through the kidneys and the ureter which allows them to show up on an x-ray. CT images are typically taken before and after contrast injection. Both renal ultrasound and CT urogram give limited information about the bladder as well.
Urinary cytology may help determine if there are any cancerous or pre-cancerous cells that are being shed into the urinary system. Cytology is carried out by doing a “Pap smear” on the voided urine.
The lower part of the urinary tract, the bladder and urethra, is usually studied by cystoscopy. Cystoscopy refers to the visual inspection of the bladder and urethra. This is carried out by inserting a small fiberoptic catheter into the urethra and the bladder which allows direct visualization of these structures. This is typically carried out under a local anesthetic in an examination room in the office.
The upper part of the urinary collecting system, that is the ureter and renal pelvis, can be inspected with ureteroscopy. A fiber optic catheter can be used to inspect the entire length of the upper urinary collecting system. This is typically done in the OR under general anesthesia.
X-ray showing ureteroscope going
through the ureter up to the renal pelvis.
If transitional cell carcinoma is diagnosed in the collecting system, surgery is often indicated. This may involve removal of the affected kidney, ureter and portion of the bladder. If the affected area is in the lower portion of the ureter, and the cancer is not too aggressive, then just that part of the ureter may be removed.
For transitional cell cancer that occurs anywhere in the urinary system, ongoing life long follow up is needed with the recognition that new disease may form elsewhere in the urinary system.
Written by: Jennifer L. Young MD, The Urology Group. Copyright 2011.
References: 1. Jamal JE and Jarrett TW: Techniques and Management of Upper Tract Urolthelial Cancer. AUA Update Series 2011, Lesson 22, Volume 30. © 2011 American Urological Association, Education and Research Inc., Linthicum, MD. 2. EM Messing. Chapter 76. Urothelial tumors of the urinary tract. Campbell’s Urology 8th ed. Ed PC Walsh. New York: Saunders 2002. Pg 2732.