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Malignancies of the renal pelvis and ureter

Jerome P Richie, MD, FACS
Philip W Kantoff, MD
Section Editor
Seth P Lerner, MD
Deputy Editor
Michael E Ross, MD


The mucosal surfaces of the renal collecting tubules, calyces, and pelvis, as well as the ureter, bladder, and urethra, all have the same embryologic origin, and the term "urothelium" is used to delineate the lining surface epithelium [1]. This common embryologic origin has important implications for the management of patients with these tumors.

The clinical manifestations, diagnosis, and treatment of malignancies arising in the urothelium of the renal pelvis or ureter are reviewed here. Urothelial tumors originating in the bladder and urethra are discussed separately. (See "Overview of the initial approach and management of urothelial bladder cancer" and "Urethral cancer".)


Primary tumors — Urothelial (also called transitional cell) carcinomas of the upper urinary tract, bladder, and urethra tend to be multifocal. This phenomenon is termed "field cancerization" and is thought to be caused by exposure of the urothelium to potential carcinogens that are either excreted in the urine or activated by hydrolyzing enzymes in the urine. (See "Pathology of bladder neoplasms" and "Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder", section on 'Risk factors'.)

Primary tumors arising in the renal pelvis include urothelial carcinomas, squamous cell carcinomas, and adenocarcinomas.

Over 90 percent of tumors of the renal pelvis and ureter are of urothelial origin and are histologically identical to those originating in the bladder.

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Literature review current through: Dec 2017. | This topic last updated: Sep 13, 2017.
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  1. Melicow MM. Tumors of urinary drainage tract: urothelial tumors. J Urol 1945; 54:186.
  2. Holmäng S, Lele SM, Johansson SL. Squamous cell carcinoma of the renal pelvis and ureter: incidence, symptoms, treatment and outcome. J Urol 2007; 178:51.
  3. Paonessa J, Beck H, Cook S. Squamous cell carcinoma of the renal pelvis associated with kidney stones: a case report. Med Oncol 2011; 28 Suppl 1:S392.
  4. Hafner C, Knuechel R, Zanardo L, et al. Evidence for oligoclonality and tumor spread by intraluminal seeding in multifocal urothelial carcinomas of the upper and lower urinary tract. Oncogene 2001; 20:4910.
  5. PRESMAN D, EHRLICH L. Metastatic tumors of the ureter. J Urol 1948; 59:312.
  6. Abeloff MD, Lenhard RE Jr. Clinical management of ureteral obstruction secondary to malignant lymphoma. Johns Hopkins Med J 1974; 134:34.
  7. Cohen WM, Freed SZ, Hasson J. Metastatic cancer to the ureter: a review of the literature and case presentations. J Urol 1974; 112:188.
  8. Raman JD, Messer J, Sielatycki JA, Hollenbeak CS. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973-2005. BJU Int 2011; 107:1059.
  9. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67:7.
  10. Cosentino M, Palou J, Gaya JM, et al. Upper urinary tract urothelial cell carcinoma: location as a predictive factor for concomitant bladder carcinoma. World J Urol 2013; 31:141.
  11. Rouprêt M, Babjuk M, Compérat E, et al. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update. Eur Urol 2017.
  12. Herr HW, Cookson MS, Soloway SM. Upper tract tumors in patients with primary bladder cancer followed for 15 years. J Urol 1996; 156:1286.
  13. Lynch HT, Ens JA, Lynch JF. The Lynch syndrome II and urological malignancies. J Urol 1990; 143:24.
  14. Watson P, Vasen HF, Mecklin JP, et al. The risk of extra-colonic, extra-endometrial cancer in the Lynch syndrome. Int J Cancer 2008; 123:444.
  15. Gylling AH, Nieminen TT, Abdel-Rahman WM, et al. Differential cancer predisposition in Lynch syndrome: insights from molecular analysis of brain and urinary tract tumors. Carcinogenesis 2008; 29:1351.
  16. Yang MH, Chen KK, Yen CC, et al. Unusually high incidence of upper urinary tract urothelial carcinoma in Taiwan. Urology 2002; 59:681.
  17. Lee YL, Shih MC, Wu WJ, et al. Clinical and urographic presentation of transitional cell carcinoma of the ureter in a blackfoot disease endemic area in southern Taiwan. Kaohsiung J Med Sci 2002; 18:443.
  18. Colin P, Koenig P, Ouzzane A, et al. Environmental factors involved in carcinogenesis of urothelial cell carcinomas of the upper urinary tract. BJU Int 2009; 104:1436.
  19. Holmäng S, Johansson SL. Synchronous bilateral ureteral and renal pelvic carcinomas: incidence, etiology, treatment and outcome. Cancer 2004; 101:741.
  20. Pommer W, Bronder E, Klimpel A, et al. Urothelial cancer at different tumour sites: role of smoking and habitual intake of analgesics and laxatives. Results of the Berlin Urothelial Cancer Study. Nephrol Dial Transplant 1999; 14:2892.
  21. Gago-Dominguez M, Yuan JM, Castelao JE, et al. Regular use of analgesics is a risk factor for renal cell carcinoma. Br J Cancer 1999; 81:542.
  22. Linet MS, Chow WH, McLaughlin JK, et al. Analgesics and cancers of the renal pelvis and ureter. Int J Cancer 1995; 62:15.
  23. Nortier JL, Martinez MC, Schmeiser HH, et al. Urothelial carcinoma associated with the use of a Chinese herb (Aristolochia fangchi). N Engl J Med 2000; 342:1686.
  24. Wu MJ, Lian JD, Yang CR, et al. High cumulative incidence of urinary tract transitional cell carcinoma after kidney transplantation in Taiwan. Am J Kidney Dis 2004; 43:1091.
  25. Williams CB, Mitchell JP. Carcinoma of the ureter--a review of 54 cases. Br J Urol 1973; 45:377.
  26. Batata MA, Whitmore WF, Hilaris BS, et al. Primary carcinoma of the ureter: a prognostic study. Cancer 1975; 35:1626.
  27. Wang LJ, Wong YC, Huang CC, et al. Multidetector computerized tomography urography is more accurate than excretory urography for diagnosing transitional cell carcinoma of the upper urinary tract in adults with hematuria. J Urol 2010; 183:48.
  28. Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: part 2, upper urinary tract. AJR Am J Roentgenol 2009; 192:1488.
  29. Blute ML, Segura JW, Patterson DE, et al. Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol 1989; 141:1298.
  30. Bagley DH, Rivas D. Upper urinary tract filling defects: flexible ureteroscopic diagnosis. J Urol 1990; 143:1196.
  31. Chitale S, Mbakada R, Irving S, Burgess N. Nephroureterectomy for transitional cell carcinoma - the value of pre-operative histology. Ann R Coll Surg Engl 2008; 90:45.
  32. Gill WB, Lu CT, Thomsen S. Retrograde brushing: a new technique for obtaining histologic and cytologic material from ureteral, renal pelvic and renal caliceal lesions. J Urol 1973; 109:573.
  33. Blute RD Jr, Gittes RR, Gittes RF. Renal brush biopsy: survey of indications, techniques and results. J Urol 1981; 126:146.
  34. Williams SK, Denton KJ, Minervini A, et al. Correlation of upper-tract cytology, retrograde pyelography, ureteroscopic appearance, and ureteroscopic biopsy with histologic examination of upper-tract transitional cell carcinoma. J Endourol 2008; 22:71.
  35. McKiernan JM, Hansel DE, Bochner BH, et al. Renal Pelvis and Ureter. In: AJCC Cancer Staging Manual, 8th, Amin MB (Ed), Springer, New York 2017. p.749.
  36. Roscigno M, Cozzarini C, Bertini R, et al. Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract. Eur Urol 2008; 53:794.
  37. Lughezzani G, Sun M, Perrotte P, et al. Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study. Eur Urol 2010; 57:956.
  38. Box GN, Lehman DS, Landman J, Clayman RV. Minimally invasive management of upper tract malignancies: renal cell and transitional cell carcinoma. Urol Clin North Am 2008; 35:365.
  39. Lucas SM, Svatek RS, Olgin G, et al. Conservative management in selected patients with upper tract urothelial carcinoma compares favourably with early radical surgery. BJU Int 2008; 102:172.
  40. Thompson RH, Krambeck AE, Lohse CM, et al. Endoscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. Urology 2008; 71:713.
  41. Strong DW, Pearse HD. Recurrent urothelial tumors following surgery for transitional cell carcinoma of the upper urinary tract. Cancer 1976; 38:2173.
  42. Ni S, Tao W, Chen Q, et al. Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma: a systematic review and cumulative analysis of comparative studies. Eur Urol 2012; 61:1142.
  43. Muntener M, Schaeffer EM, Romero FR, et al. Incidence of local recurrence and port site metastasis after laparoscopic radical nephroureterectomy. Urology 2007; 70:864.
  44. Roscigno M, Shariat SF, Margulis V, et al. Impact of lymph node dissection on cancer specific survival in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. J Urol 2009; 181:2482.
  45. Lughezzani G, Jeldres C, Isbarn H, et al. A critical appraisal of the value of lymph node dissection at nephroureterectomy for upper tract urothelial carcinoma. Urology 2010; 75:118.
  46. Goel MC, Matin SF, Derweesh I, et al. Partial nephrectomy for renal urothelial tumors: clinical update. Urology 2006; 67:490.
  47. Smith AK, Stephenson AJ, Lane BR, et al. Inadequacy of biopsy for diagnosis of upper tract urothelial carcinoma: implications for conservative management. Urology 2011; 78:82.
  48. Giannarini G, Kessler TM, Birkhäuser FD, et al. Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit? Eur Urol 2011; 60:955.
  49. Krambeck AE, Thompson RH, Lohse CM, et al. Imperative indications for conservative management of upper tract transitional cell carcinoma. J Urol 2007; 178:792.
  50. Krambeck AE, Thompson RH, Lohse CM, et al. Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma. J Urol 2007; 177:1721.
  51. Daneshmand S, Quek ML, Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long-term experience. Cancer 2003; 98:55.
  52. Goel MC, Mahendra V, Roberts JG. Percutaneous management of renal pelvic urothelial tumors: long-term followup. J Urol 2003; 169:925.
  53. Palou J, Piovesan LF, Huguet J, et al. Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup. J Urol 2004; 172:66.
  54. Tsivian A, Sidi AA. Port site metastases in urological laparoscopic surgery. J Urol 2003; 169:1213.
  55. Jeldres C, Lughezzani G, Sun M, et al. Segmental ureterectomy can safely be performed in patients with transitional cell carcinoma of the ureter. J Urol 2010; 183:1324.
  56. Thalmann GN, Markwalder R, Walter B, Studer UE. Long-term experience with bacillus Calmette-Guerin therapy of upper urinary tract transitional cell carcinoma in patients not eligible for surgery. J Urol 2002; 168:1381.
  57. O'Brien T, Ray E, Singh R, et al. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicentre, randomised clinical trial of a single postoperative intravesical dose of mitomycin C (the ODMIT-C Trial). Eur Urol 2011; 60:703.
  58. Ito A, Shintaku I, Satoh M, et al. Prospective randomized phase II trial of a single early intravesical instillation of pirarubicin (THP) in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma: the THP Monotherapy Study Group Trial. J Clin Oncol 2013; 31:1422.
  59. Seisen T, Krasnow RE, Bellmunt J, et al. Effectiveness of Adjuvant Chemotherapy After Radical Nephroureterectomy for Locally Advanced and/or Positive Regional Lymph Node Upper Tract Urothelial Carcinoma. J Clin Oncol 2017; 35:852.
  60. Leow JJ, Martin-Doyle W, Fay AP, et al. A systematic review and meta-analysis of adjuvant and neoadjuvant chemotherapy for upper tract urothelial carcinoma. Eur Urol 2014; 66:529.
  61. Porten S, Siefker-Radtke AO, Xiao L, et al. Neoadjuvant chemotherapy improves survival of patients with upper tract urothelial carcinoma. Cancer 2014; 120:1794.
  62. Raman JD, Sosa RE, Vaughan ED Jr, Scherr DS. Pathologic features of bladder tumors after nephroureterectomy or segmental ureterectomy for upper urinary tract transitional cell carcinoma. Urology 2007; 69:251.
  63. Kang CH, Yu TJ, Hsieh HH, et al. The development of bladder tumors and contralateral upper urinary tract tumors after primary transitional cell carcinoma of the upper urinary tract. Cancer 2003; 98:1620.
  64. Matsui Y, Utsunomiya N, Ichioka K, et al. Risk factors for subsequent development of bladder cancer after primary transitional cell carcinoma of the upper urinary tract. Urology 2005; 65:279.
  65. Wu WJ, Ke HL, Yang YH, et al. Should patients with primary upper urinary tract cancer receive prophylactic intravesical chemotherapy after nephroureterectomy? J Urol 2010; 183:56.
  66. Lang EK. The arteriographic diagnosis of primary and secondary tumors of the ureter or ureter and renal pelvis. Radiology 1969; 93:799.
  67. Ku JH, Choi WS, Kwak C, Kim HH. Bladder cancer after nephroureterectomy in patients with urothelial carcinoma of the upper urinary tract. Urol Oncol 2011; 29:383.
  68. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  69. Lane BR, Smith AK, Larson BT, et al. Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy. Cancer 2010; 116:2967.
  70. Margulis V, Shariat SF, Matin SF, et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 2009; 115:1224.
  71. Lughezzani G, Jeldres C, Isbarn H, et al. Nephroureterectomy and segmental ureterectomy in the treatment of invasive upper tract urothelial carcinoma: a population-based study of 2299 patients. Eur J Cancer 2009; 45:3291.
  72. Jeldres C, Sun M, Lughezzani G, et al. Highly predictive survival nomogram after upper urinary tract urothelial carcinoma. Cancer 2010; 116:3774.
  73. Cornu JN, Rouprêt M, Carpentier X, et al. Oncologic control obtained after exclusive flexible ureteroscopic management of upper urinary tract urothelial cell carcinoma. World J Urol 2010; 28:151.
  74. Raman JD, Ng CK, Scherr DS, et al. Impact of tumor location on prognosis for patients with upper tract urothelial carcinoma managed by radical nephroureterectomy. Eur Urol 2010; 57:1072.