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Transitional Cell Carcinoma of the Renal Pelvis and Ureter

(Urothelial carcinoma)

Reviewed by Michael Stifelman, M.D. and Ojas Shah, M.D.

Although relatively rare in the population, transitional cell carcinoma (also known as urothelial carcinoma) is the most common type of malignant tumor of the renal pelvis and ureter. When present, it is likely to be found in more than one area of the urinary tract, including the bladder. Small, low-grade tumors can often be removed via endoscopy, and when part or all of the kidney must be removed, we use a laparoscopic or robotic approach.

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Definition and risk factors

Transitional cell carcinoma is a cancer of the tissues lining the urine-collecting basin of the kidney (the renal pelvis) and/or the ureters, which connect the kidneys to the bladder. This type of tumor is often found in multiple areas (synchronous lesions) of the upper urinary tract.

Transitional cell carcinoma is more common in men than women, and patients who smoke or have certain chemical exposures may also be at higher risk for this type of cancer.

Symptoms, diagnosis and detection

Symptoms of transitional cell carcinoma can include blood in the urine and pain in the flank or abdomen. Sometimes there are no symptoms at all, and the cancer is found incidentally during examination for an unrelated medical issue.

To diagnose or rule out transitional cell carcinoma, your doctor will ask about your medical history and symptoms, perform a physical exam and order blood tests, urine tests and radiologic imaging studies such as a CT scan or MRI. If transitional cell carcinoma is suspected, your doctor may recommend a ureteroscopy in order to determine best way to surgically manage the disease. During a ureteroscopy, a thin, flexible tube is passed through the urethral opening and threaded up through the bladder into the ureters. Fiber optic cable within the tube allows doctors to view any lesions in the ureteral or renal pelvic wall. In this way, doctors can count the lesions and determine their precise location. During ureteroscopy, a biopsy of the lesions may be taken for further examination by a pathologist, who can confirm the grade of the cancer. X-rays, radiologic imaging and urine cytology (examining the size and shape of cells found in the urine) may also be used in diagnosing transitional cell carcinoma.

Treatment of transitional cell carcinoma

Treatment for this cancer depends on the stage and location of the cancer. It will also depend on your overall kidney function, the function of your other kidney, and other medical problems, such as diabetes and high blood pressure (hypertension), which can affect future kidney function.

For low-grade, smaller cancers, we prescribe minimally invasive endoscopic management of the cancer whenever possible. NYU Urology Associates is one of the premier locations in New York City for the endoscopic management of upper tract transitional cell carcinoma. Here, the doctor uses a ureteroscope with a special attachment to locate, heat and destroy the cancerous lesions. Because the ureteroscope is passed through the urethral opening, there is no need for surgical incisions, improving on recovery time.

For larger tumors that require kidney preservation, percutaneous approaches to the kidney may be used. Here, a ‘tunnel’ is created from the back into the kidney, and a thin tube is inserted to remove and destroy cancerous lesions. A nephrostomy tube is typically left at the end of the procedure to allow drainage of urine from the kidney and to allow the kidney to heal. A second-stage procedure is usually performed 1-2 weeks later to ensure that tumor removal is complete.

The key for any minimally invasive procedure to allow for kidney preservation is strict follow-up and surveillance. To ensure that this type of tumor does not return, or, if it does, to ensure that it can again be removed and controlled in a minimally invasive manner, strict follow-up plans are created for each patient.

For moderate- to high-grade cancers, removal of the entire kidney, ureter and a small cuff of bladder where the ureter enters the bladder may be required (nephroureterectomy). In most cases, this can be performed using a laparoscopic or robotic approach. Often a retroperitoneal lymph node dissection will be performed at the same time to aid in prognosis as well possibly improving survival. In a subset of patients who have a tumor only in the distal end of the ureter, the last third of the ureter is removed and the healthy ureter is reconnected to the bladder (distal ureterectomy with reimplant). This, too, can often be performed using a laparoscopic or robotic approach. Depending upon the final pathology, including the grade of the tumor and depth of penetration, chemotherapy may be prescribed after surgery.

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