Ureteric cancers are uncommon. They usually occur together with bladder cancers. An early indication of their presence is blood in the urine.

What is the ureter?

The ureter is the tube that conveys urine from the kidneys to the bladder. There are 2 ureters, one for each kidney.

The ureter is lined with the same transitional cells as the bladder. Cancer of the ureter usually arises from these cells as in the bladder. However, cancer of the ureter is far less common than bladder cancer. When the cancer starts in the ureter, cancer cells will flow with the urine into the bladder. This seeds the bladder with cancer cells and may give rise to cancer forming in the bladder. This phenomenon is common.

How do I know if I have Ureteric Cancer?

The symptoms of cancer of the ureter may include any of the following:

• Blood in the urine (hematuria). Sometimes blood clots are passed.
• weight loss
• passing urine frequently
• pain on passing urine
• back pain or cramps

Sometimes the ureter may be blocked, either by cancer cells or by a blood clot leading to a swelling of the kidney. If this happens, the above symptoms may develop more quickly and may be more severe, often accompanied by a high temperature. This is known as a ureteric obstruction.

The above symptoms may be caused by a number of conditions other than cancer of the ureter or renal pelvis. Symptoms that are severe get worse, or that last for a few weeks, should always be checked by your doctor.

How is Ureteric Cancer diagnosed?

Ultrasound scan
Sound waves are used to look at the kidneys and bladder. In obstruction of the ureter, the kidney may be swollen.

Intravenous urogram or pyelogram (IVU or IVP)
This is a study of the urinary system involving the injection of a contrast or dye into the bloodstream that is later passed out into the urine. It will help show any growth or obstruction in the ureter or kidney.

CT (computerized tomography) scan
A CT scan is able to give a more detailed picture than an IVP and is the preferred imaging for suspected ureteric cancers.

Cystoscopy and biopsy
If there is an abnormality detected in the ureter, the patient is prepared for a cystoscopy. In this procedure, a small telescope (cystoscope) is passed up the urethra to enable the doctor to look at the bladder.

Contrast may be injected directly into the ureter under X-ray imaging to better visualize the problem. This is known as retrograde pyelography.

If a suspicious lesion is seen, the doctor may insert a smaller telescope called a ureteroscope up into the ureter. This procedure, known as ureteroscopy, is done under general anaesthetic. If any abnormality suspicious of a cancer is seen, the doctor will take a sample of tissue called a biopsy that is then examined in a laboratory under a microscope by a pathologist 

How is Ureteric Cancer treated?

Treatment will depend on a number of factors, including your age, general health and the position, type, stage and grade of the cancer.

Surgery
Surgery is the most common and most effective treatment for cancer of the ureter.  The aim of surgery is to remove the cancer.

Nephro-ureterectomy means the removal of the kidney, ureter and top part of the bladder. This is the standard surgery for cancer of the lining of any part of the urinary system from the kidney to the ureter. This ensures the entire stretch of lining that potentially can give rise to cancers in the future is removed. This gives the patient the best chance for cure and free of recurrences.

The surgery is usually performed through an open wound. In selected cases that are suitable and which do not compromise cancer clearance, the procedure may be carried out using instruments inserted through tiny key-hole incisions. This is known as Laparoscopic Nephro-ureterectomy.

Segmental ureterectomy resection is the removal of the segment of the ureter affected by cancer. The remaining ends are then rejoined. This is not the standard treatment and is usually reserved only for patients who are unfit for the standard nephroureterectomy or those with a solitary kidney and only when the tumor is small, low-grade and contained within the ureter. Under the same circumstances when the cancer is at the lower end of the ureter close to the bladder, the segment of ureter with the cancer may be resected and the remnant ureter reimplanted into the bladder. This reimplantation procedure is called Ureteroneocystomy. Sometimes a small part of the bladder is also excised.

If surgery is not possible, other treatments may be more appropriate. These may include chemotherapy or radiotherapy. The aim of these treatments is to reduce the size of the tumor and help control symptoms.

Radiotherapy
Radiotherapy treats cancer by using high-energy rays, which destroy the cancer cells and shrink the tumor while doing as little harm as possible to normal cells. This is used when the cancer cannot be completely removed with surgery.

Chemotherapy
Anti-cancer drugs can be used to destroy the cancer cells when it is not possible to clear the cancer with surgery. They work by disrupting the growth and division of cancer cells. The chemotherapy may be given directly into the vein (intravenously). This is considered when the cancer cannot be removed with surgery or there is a possibility that the cancer may have spread further afield.

Follow up
After treatment, regular follow-up appointments to monitor recovery and progress are important. Follow-up will usually include a physical examination. It may also involve taking some urine or blood samples. Regular cystoscopies are important to detect any cancer in the bladder. If there is a remnant ureter on the affected side, a telescopic examination of the ureter is necessary at intervals to look for new cancers. If you have any problems, or notice any new symptoms between these times, let your doctor know as soon as possible.