CANCERS OF THE RENAL PELVIS AND URETERS
Approximately 10% of transitional cell carcinomas occur in the ureters and the renal pelvis. These tumours can arise either de novo or in the setting of prior tumours; the risk for developing an upper tract tumour in patients with multifocal carcinoma in situ of the bladder approaches 25% by 10 years. These tumours are morphologically similar to the tumours in the bladder and behave in a similar manner. Haematuria is the most common manifesting symptom, although patients with large tumours and/or ureteral obstruction can present with flank pain. A CT scan or MRI is used to stage the extent of primary disease and detect regional metastases. Low-grade tumours can be treated endoscopically, but high-grade tumours are most commonly treated with a nephroureterectomy. In contrast to cystectomy, a regional lymphadenectomy is not routinely performed. In renal pelvis tumours, the ureter is removed in addition to a nephrectomy because of the high risk for multifocal tumours along the entire upper tract and the inability to monitor the ureteral stump with accuracy. Systemic chemotherapy is used for unresectable primary tumours, patients with regional adenopathy, or recurrent tumours. Upper tract transitional cell carcinomas are staged according to the TNM system. Treatment for advanced, nonsurgical disease is with chemotherapy; these urothelial tumours have the same sensitivity to chemotherapy as bladder cancer, with similar response rates and 5-year survival rates. Cisplatin-based chemotherapy is used in patients with normal renal function, and carboplatin-based chemotherapy is considered if there is renal insufficiency from obstruction, a prior nephroureterectomy, or medical comorbidity.