Treatments for cancer of the renal pelvis or ureter

If you have cancer of the renal pelvis or ureter, your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for cancer of the renal pelvis or ureter, your healthcare team will consider the stage and grade of the cancer.

Surgery is the main treatment for cancer that is only in the renal pelvis or ureter. Depending on where the cancer is located and the stage of the cancer, you may have one of the following types of surgery.

A radical nephroureterectomy is the most common surgery done for cancer of the renal pelvis or ureter. The surgeon removes the entire kidney, all of the ureter and the tissue where the ureter connects to the bladder (called the bladder cuff). The surgeon may also remove some nearby lymph nodes (called a retroperitoneal lymph node dissection, or RPLND) and surrounding tissue.

This surgery is done using a general anesthetic (you will be unconscious). The surgeon most often does laparoscopic surgery. For this type of surgery, the surgeon makes several small cuts (incisions) and then inserts a thin tube with a light and lens on the end (laparoscope) and special tools to remove the organs.

Sometimes open surgery is done instead. This is when the surgeon makes a large cut along your side and abdomen to remove the organs and tissue.

A segmental resection of the ureter is usually only done to remove small tumours in the lower part of the ureter closest to the bladder. The surgeon removes the part of the ureter with the tumour in it along with a margin of healthy tissue above the tumour. Then the ureter is reattached to (reimplanted in) the bladder.

This surgery is done using a general anesthetic. The surgeon may use open surgery or laparoscopic surgery to complete a segmental resection of the ureter.

Endoscopic surgery is when the surgeon removes the tumour using an endoscope and cutting tools passed through the endoscope. It may be done for cancer of the renal pelvis or ureter that is low grade and at an early stage. It may also be done when the kidneys aren’t working well, you only have one kidney or there is cancer in both sides of the urinary tract.

There are 2 ways to do endoscopic surgery for cancer of the renal pelvis or ureter.

• For a ureteroscopy, the surgeon passes the endoscope through the urethra and bladder then up to the ureter and renal pelvis.
• For a percutaneous endoscopy, the surgeon makes a cut in the skin on the side (flank) or back of the body then passes the endoscope into the renal pelvis or ureter.

Surgery for cancer of the renal pelvis or ureter may cause these side effects:

• pain
• bleeding
• an infection
• an intense need to urinate (pee) (urgent urination)
• a need to urinate more often than usual (frequent urination)
• bleeding when you urinate
• narrowing of the ureters (stricture)
• blocked ureters (obstruction)

Chemotherapy uses anticancer (cytotoxic) drugs to destroy cancer cells. It can be used before surgery (neoadjuvant chemotherapy) or after surgery (adjuvant chemotherapy) to treat cancer of the renal pelvis or ureter that has spread to the lymph nodes or other parts of the body. It can also be used to lower the chance of the cancer spreading to other parts of the body.

Chemotherapy for cancer of the renal pelvis or ureter is a systemic therapy. This means that the drugs travel through the blood to reach and destroy cancer cells all over the body, including those that may have broken away from the primary tumour in the renal pelvis or ureter.

A combination of chemotherapy drugs that includes cisplatin is usually used to treat cancer of the renal pelvis and ureter. The most common chemotherapy combinations are:

• cisplatin and gemcitabine (Gemzar)
• MVAC – methotrexate, vinblastine, doxorubicin (Adriamycin) and cisplatin

These drugs are usually given through a needle into a vein (intravenously). How often and how long chemotherapy is given depends on the type of drugs used and the doses. But it is usually given every 3 or 4 weeks for up to 6 cycles.

In a few cases, chemotherapy may be placed directly in the renal pelvis, ureter or bladder (called instillation) after surgery. The chemotherapy drug used is mitomycin (Mutamycin).

Some common side effects of chemotherapy for cancer of the renal pelvis or ureter are:

• nausea and vomiting
• loss of appetite
• fatigue
• an infection
• hair loss
• diarrhea
• sore mouth and throat
• nerve damage ( peripheral neuropathy) that can cause pain, burning or tingling in the hands and feet

Immunotherapy helps to strengthen or restore the immune system’s ability to find and destroy cancer cells. It may be used to treat advanced or metastatic urothelial carcinoma when chemotherapy doesn’t work.

The immune system normally stops itself from attacking normal cells in the body by using specific proteins called checkpoints, which are made by some immune system cells. Cancer cells sometimes use these checkpoints to avoid being attacked by the immune system. Immune checkpoint inhibitors are types of immunotherapy drugs. They block the checkpoint proteins so immune system cells (called T cells) can attack and kill the cancer cells.

An immune checkpoint inhibitor may be offered for advanced or metastatic urothelial carcinoma that:

• is still growing during or after chemotherapy that includes the drug cisplatin
• comes back within 12 months of finishing chemotherapy

The immune checkpoint inhibitors used for cancer of the renal pelvis or ureter target the PD-1 or PD-L1 checkpoint protein. They are:

• pembrolizumab (Keytruda)
• nivolumab (Opdivo)
• durvalumab (Imfinzi)
• avelumab (Bavencio)

The drug is given through a needle into a vein (called intravenous infusion) once every 2 or 3 weeks until the disease progresses or the side effects outweigh the benefits of having the treatment.

In a few cases, immunotherapy may be placed directly in the renal pelvis, ureter or bladder after surgery. The immunotherapy drug used is bacillus Calmette-Guérin (BCG).

Immune checkpoint inhibitors may cause these side effects:

• fatigue
• diarrhea
• skin problems, such as a rash and itching
• nausea and vomiting
• loss of appetite
• low blood cell counts( myelosuppression)
• lung problems, such as a cough and difficulty breathing
• heart problems, such as inflammation of the heart muscle (myocarditis)

Radiation therapy uses high-energy rays or particles to destroy cancer cells. During external radiation therapy, a machine directs radiation through the skin to the area with the cancer and some of the tissue around it. It is not usually used for cancer of the renal pelvis or ureter, but in some cases, it can be given to relieve pain or control other symptoms of advanced cancer (called palliative radiation therapy).

Side effects of radiation therapy will depend mainly on the size of the area being treated, the specific area or organs being treated, the total dose of radiation and the treatment schedule. Some common side effects of radiation therapy for cancer of the renal pelvis or ureter are:

• an irritated or inflamed bladder, which can cause a need to urinate more often than usual or blood in the urine
• fatigue
• skin problems
• diarrhea
• bleeding from the rectum
• loss of bladder control ( urinary incontinence)

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Follow-up after treatment is an important part of cancer care. You will need to have regular follow-up visits, especially in the first 2 to 3 years after treatment has finished. These visits allow your healthcare team to monitor your progress and recovery from treatment.

Follow-up visits for cancer of the renal pelvis or ureter are usually scheduled every 3 to 6 months. There is a higher risk of developing cancer in the bladder after having cancer of the renal pelvis or ureter so a cystoscopy and urine cytology are usually done to check for bladder cancer. CT urography is also commonly done during follow-up to check for cancer in the abdomen and pelvis.

Talk to your doctor about clinical trials open to people with cancer of the renal pelvis or ureter in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

To make the decisions that are right for you, ask your healthcare team questions about treatment.