At Providence Saint John’s Health Center, our urology specialists provide personalized care for upper tract urothelial carcinoma (UTUC), including cancers of the renal pelvis and ureter. Treatment is guided by the location, grade and extent of the cancer, with an emphasis on preserving kidney function whenever clinically appropriate while providing effective treatment for more aggressive disease.
What Is Upper Tract Urothelial Cancer?
Upper tract urothelial carcinoma (UTUC) is cancer that develops in the urothelial lining of the renal pelvis—the part of the kidney that collects urine—or the ureter, the tube that carries urine from the kidney to the bladder. UTUC is uncommon compared with urothelial cancer of the bladder, but the two cancers are closely related because they arise from the same type of cells lining the urinary tract.
UTUC may develop in one or more areas of the upper urinary tract. Because the same urothelial lining continues into the bladder, patients with UTUC can also develop bladder cancer and require ongoing surveillance of the entire urinary tract.
How Is UTUC Different From Kidney Cancer?
Although UTUC can develop within the kidney’s renal pelvis, it is biologically different from the cancers that arise from kidney tissue and are commonly referred to as kidney cancer. Most kidney cancers are renal cell carcinomas, while UTUC develops from the urothelial lining and is more closely related to bladder cancer.
Ureteral Cancer
Ureteral cancer is UTUC that develops specifically within the lining of a ureter. A tumor can interfere with the flow of urine from the kidney to the bladder and may cause obstruction, pain or changes in kidney function. Treatment depends on the location, size, grade and extent of the tumor as well as the function of the affected and opposite kidney.
What Are the Symptoms of Upper Tract Urothelial Cancer?
Blood in the urine is the most common sign of UTUC and may be visible or detected only during a urine test. Some tumors cause few or no symptoms initially and are discovered during imaging performed for another reason.
- Blood in the urine, or hematuria
- Persistent pain in the side, flank or back
- Pain or difficulty with urination
- Urinary symptoms associated with obstruction
- Unexplained fatigue or weight loss in some patients with more advanced disease
These symptoms can also be caused by kidney stones, infection and other noncancerous urinary conditions. Persistent blood in the urine or unexplained urinary symptoms should be evaluated to determine their cause.
What Increases the Risk of UTUC?
There is not always an identifiable reason why UTUC develops. Several factors, however, are associated with increased risk because they can contribute to changes in the cells lining the urinary tract.
Smoking
Tobacco use is an important preventable risk factor for urothelial cancer. Cancer-causing chemicals from tobacco smoke can enter the bloodstream, be filtered by the kidneys and become concentrated in urine, exposing the lining of the urinary tract.
Previous Urothelial Cancer
Patients who have previously been treated for bladder cancer or another urothelial cancer may have an increased risk of developing UTUC. Similarly, patients treated for UTUC require continued bladder surveillance because urothelial tumors can subsequently develop in the bladder.
Occupational and Chemical Exposure
Long-term exposure to certain industrial chemicals has been associated with an increased risk of urothelial cancer. Historical occupational exposures involving some aromatic amines and chemicals used in dye, rubber, textile and related manufacturing industries are among the recognized risk factors.
Lynch Syndrome and Inherited Risk
Lynch syndrome is an inherited cancer syndrome associated with an increased risk of several cancers, including UTUC. Patients diagnosed at a younger age or whose personal or family history suggests an inherited cancer predisposition may benefit from genetic evaluation and counseling.
How Is Upper Tract Urothelial Cancer Diagnosed?
Diagnosing UTUC typically combines imaging of the urinary tract with urine testing and, when needed, direct examination of the ureter and renal pelvis. These tests help determine where a tumor is located and provide information about its grade and likelihood of invading or spreading beyond the upper urinary tract.
CT Urography and Other Imaging
CT urography provides detailed images of the kidneys, ureters and bladder and can reveal a tumor, narrowing, obstruction or other abnormality within the urinary tract. MRI or MR urography may be used when CT imaging or its contrast material is not appropriate for an individual patient.
Ureteroscopy and Biopsy
Ureteroscopy allows the urologist to pass a small flexible instrument through the urinary tract to directly examine the ureter and renal pelvis. Suspicious areas can be evaluated and, when appropriate, tissue can be collected for pathology. These findings help determine the characteristics of the tumor and whether a kidney-sparing treatment may be appropriate.
Urine Cytology
Urine cytology examines cells shed into the urine for abnormalities that may indicate urothelial cancer. Cytology can provide additional information about the likelihood of higher-grade disease and is interpreted together with imaging, ureteroscopy, biopsy and other clinical findings.
Retrograde Pyelography
Retrograde pyelography is a specialized imaging procedure in which contrast material is introduced into the ureter so the upper urinary tract can be seen on X-ray imaging. It may be used selectively to evaluate an area of narrowing or obstruction or when additional anatomical detail is needed.
Is the Cancer Low-Risk or High-Risk?
One of the most important decisions after diagnosing UTUC is determining how likely the cancer is to invade, recur or spread. Physicians consider information from imaging, ureteroscopy, biopsy, urine cytology and other findings to classify the disease and select an appropriate treatment strategy.
Low-Risk UTUC
Selected tumors with favorable characteristics may be appropriate for kidney-sparing treatment. The goal is to control or remove the cancer while preserving as much kidney and ureter function as possible. Because urothelial cancer can recur, kidney-sparing treatment requires careful and ongoing surveillance.
High-Risk UTUC
High-grade tumors and cancers with features suggesting deeper invasion or spread generally require more aggressive treatment. Depending on the location and extent of disease, treatment may include radical surgery, systemic therapy or a combination of approaches.
Stages of Upper Tract Urothelial Cancer
Stage describes how deeply the cancer has grown and whether it has spread beyond its original location. Stage is considered together with tumor grade, imaging, pathology and other clinical characteristics when developing a treatment plan.
Stage 0
Stage 0 disease is noninvasive and remains within the urothelial lining. This includes papillary tumors confined to the surface and carcinoma in situ, a flat form of high-grade urothelial cancer.
Stage I
Stage I cancer has grown beneath the urothelial lining into the connective tissue of the renal pelvis or ureter but has not invaded the muscular layer.
Stage II
Stage II cancer has invaded the muscular layer of the renal pelvis or ureter.
Stage III
Stage III cancer has grown beyond the muscular wall. Depending on where the tumor began, it may extend into surrounding tissue or into kidney tissue.
Stage IV
Stage IV UTUC has spread more extensively, which may include nearby organs, lymph nodes or distant parts of the body. Treatment is individualized according to the location and extent of disease, previous treatment, kidney function and other clinical factors.
Tumor Grade
Grade describes how abnormal the cancer cells appear and provides information about how aggressively the tumor is likely to behave. Low-grade tumors tend to grow and spread less aggressively, while high-grade tumors have a greater likelihood of invasion and progression. Grade and stage provide different information, and both are important when selecting treatment.
How Is Upper Tract Urothelial Cancer Treated?
Treatment for UTUC is individualized according to the location, size, grade and stage of the cancer, whether the disease is considered low-risk or high-risk, and the patient’s kidney function and overall health. When cancer control can be achieved safely, kidney-sparing approaches may preserve renal function. More aggressive disease may require removal of the kidney and ureter combined with systemic treatment when appropriate.
Kidney-Sparing Treatment
Kidney-sparing treatment may be appropriate for selected patients with favorable UTUC and is designed to control the cancer while preserving the affected kidney. The specific approach depends on tumor location, accessibility and other clinical characteristics, and patients require careful follow-up because tumors can recur within the urinary tract.
Endoscopic Tumor Ablation
For selected tumors, a ureteroscope can be passed through the urinary tract to reach the ureter or renal pelvis without an external incision. The urologist can directly visualize the tumor and use specialized instruments or energy to remove or destroy cancerous tissue while preserving the kidney.
Upper-Tract Chemotherapy
Selected low-grade tumors may be treated with medication delivered directly into the upper urinary tract. One approach uses mitomycin formulated as a gel that remains in contact with the tumor longer than a conventional liquid medication, allowing localized chemotherapy to treat appropriately selected disease.
Upper-tract treatment requires careful patient selection and follow-up because treatment can cause side effects, including narrowing or obstruction of the ureter. Patients treated with kidney-sparing approaches also require surveillance to detect persistent or recurrent disease.
Segmental Ureterectomy
When a tumor is confined to a suitable portion of the ureter, selected patients may be candidates for removal of the affected segment rather than the entire kidney and ureter. The remaining urinary tract is then reconstructed when feasible, allowing the kidney to be preserved while surgically removing the cancer.
Treatment for High-Risk or Invasive UTUC
High-grade, invasive or otherwise high-risk cancers generally require treatment designed to provide more extensive cancer control. Surgery remains central for many patients, while chemotherapy, immunotherapy and other systemic treatments may be incorporated according to the stage and characteristics of the disease.
Radical Nephroureterectomy
Radical nephroureterectomy removes the affected kidney and the entire ureter, typically including a small cuff of bladder tissue where the ureter enters the bladder. Lymph nodes may also be removed when appropriate based on the location and risk of the cancer.
For selected patients, the operation can be performed using minimally invasive or robotic techniques. The surgical approach is individualized according to tumor location and extent, previous procedures, anatomy and other clinical considerations.
Chemotherapy
Platinum-based combination chemotherapy may be recommended for selected patients with high-risk, locally advanced or metastatic UTUC. In some patients with high-risk disease, chemotherapy may be given before radical nephroureterectomy while both kidneys are still functioning, because removal of a kidney can reduce renal function and affect the ability to receive certain chemotherapy afterward.
Systemic treatment may also be recommended after surgery or for cancer that has spread beyond the upper urinary tract, depending on pathology findings, kidney function, previous treatment and the extent of disease.
Immunotherapy and Other Systemic Treatments
Immunotherapy can help the immune system recognize and attack cancer cells and may be appropriate for selected patients with advanced or high-risk urothelial cancer. Additional treatments may be considered according to the cancer’s genetic and molecular changes, previous therapies and other individual characteristics. Clinical trials can also provide access to evolving treatment strategies.
Protecting Kidney Function
Kidney function is an important consideration throughout UTUC treatment. When kidney-sparing treatment can provide appropriate cancer control, preserving the affected kidney may help maintain long-term renal function. When removal of a kidney is necessary, physicians consider the health of the remaining kidney before and after treatment and may recommend ongoing monitoring or additional medical care when needed.
Most people can live well with one healthy kidney. Long-term care focuses on protecting remaining kidney function through appropriate medical follow-up and management of conditions that can affect kidney health.
Surveillance After UTUC Treatment
Continued surveillance is especially important because urothelial cancer can recur within the treated upper urinary tract or develop elsewhere in the urinary system, including the bladder. Follow-up is individualized according to the original tumor’s grade, stage, treatment and risk of recurrence.
Surveillance may include cystoscopy to examine the bladder, urine testing, imaging and, after kidney-sparing treatment, repeat evaluation of the upper urinary tract. Following the recommended surveillance schedule allows recurrent or new urothelial tumors to be identified as early as possible.
Personalized UTUC Care at Saint John’s
At Providence Saint John’s Health Center and Saint John’s Cancer Institute, treatment for upper tract urothelial cancer balances effective cancer control with preservation of kidney function whenever clinically appropriate. Our urology specialists evaluate the location and biological characteristics of each tumor to determine whether kidney-sparing treatment, surgery or systemic therapy offers the most appropriate approach.
If you have been diagnosed with ureteral cancer or upper tract urothelial carcinoma, or are seeking another opinion about treatment, our specialists can help you understand your diagnosis and determine the appropriate next steps.
If you have questions regarding Ureteral Cancer treatment, please call today. Click here to request an appointment.
