Ureter Cancer

Ureter cancer is a malignant tumor that develops as a result of the uncontrolled proliferation of cells on the inner surface of the thin tube-shaped channels called the “ureters,” which carry urine produced in the kidneys to the bladder. Also referred to as upper urinary tract urothelial carcinoma, this condition is an aggressive type of urological cancer that directly affects the main transport pathways of the urinary system. Due to its anatomical location and biological structure, it has the potential to progress rapidly; therefore, ureter tumors always require early diagnosis and meticulous medical management. The dynamic nature of the disease distinguishes it from other urinary system problems and necessitates a completely unique, specialist-focused clinical approach.

What Is Ureter Cancer and Where Does It Develop in the Body?

We have two kidneys located on either side of the lower back area of our body, and naturally, we have two ureters that originate from these two kidneys and extend downward toward the bladder. From the outside, these very thin channels may be perceived as simple, motionless water pipes. However, the reality is very different. Thanks to their special muscle layers, the ureters contract and relax on their own, actively pushing urine downward with a milking motion. The inner part of this dynamic structure is covered with a special lining called the “urothelium,” which can withstand the acidic and occasionally irritating chemical nature of urine.

The beverages we consume in our daily lives, additives in the foods we eat, chemicals in the air we breathe, and waste products from the medications we use are filtered through our kidneys and mixed into the urine. Urine is almost a concentrated summary of all these toxic and harmful substances that must be eliminated from the body. As urine leaves the kidney and passes through the ureter, these toxic substances come into direct contact with the lining on the inner surface of the channel. In some cases, this contact lasting for years causes permanent breaks and damage in the DNA structure of the cells forming the lining. A healthy cell has an internal clock that determines when it will divide and when it will die. However, cells with damaged genetics lose this clock, forget to die, and begin to multiply continuously.

This uncontrolled proliferation that begins on the inner surface of the channel initially appears only as a small skin tag-like growth that seems harmless or as a superficial layer. At this early stage, the disease is confined only to the lumen, meaning the cavity of the channel. However, if it is not treated in time, these rebellious cells become even stronger and begin to take root in the muscle layers of the ureter, the surrounding fatty tissue, and ultimately the nearby lymph nodes and other organs. Because the ureter wall has a very thin structure, unfortunately, it does not take very long for the cancer to cross this wall and spread to the surrounding tissues. Once we understand the basic structure of the disease, the reason why it must be treated quickly and decisively becomes self-evident.

What Are the Differences Between Ureter Cancer and Urethral Cancer?

The similarity of medical terms often causes understandable confusion in the minds of patients and their relatives. Although the words “ureter” and “urethra” differ from each other by only a single letter, their functions in the body, their locations, and the characteristics of the diseases they develop are completely independent of each other. Correctly distinguishing these two structures is essential for understanding the course of the disease.

As we have just discussed in detail, the ureter is a structure located between the kidney and the urinary bladder, in the upper and deeper regions of the body. Its diseases progress insidiously and directly threaten kidney function. The urethra, on the other hand, is the final, short, outward-opening channel through which urine accumulated in the urinary bladder is completely expelled from the body. In other words, the urethra is the lower urinary tract. Because it is anatomically open to the outside world, problems in the urethra are generally noticed more quickly.

Ureter cancer is predominantly a disease that grows silently in the inner areas as a result of chemicals carried in the urine irritating the inner surface of the channel over many years. In urethral cancer, however, the situation is quite different. Cancers in this region more commonly arise when cells irritated by chronic infections in that area, certain sexually transmitted viruses such as HPV, major previous surgeries in the region, or chronic strictures undergo transformation. The cell types observed are also different from each other; while transitional cells specific to the urinary tract more commonly become cancerous in the ureter, we see squamous cells with a structure closer to the skin becoming cancerous in the urethra.

Naturally, the complaints these diseases cause in the patient are also not the same. While a tumor in the upper urinary tract causes the kidney to swell and produces lower back pain, a tumor in the lower urinary tract directly blocks the outflow of urine, causing urination drop by drop, bloody discharge, or palpable hard areas in the region. The surgical techniques to be applied, follow-up processes, and the ways in which the diseases spread in the body are also completely different from one another.

What Causes Ureter Cancer and What Are the Main Risk Factors?

Cancer is never a disease that appears overnight. For the cells in our body to become cancerous, our genetic background and environmental factors must engage in a destructive collaboration over many years. There are fundamental factors that poison our cells and damage their genetics in the development of ureter cancer.

The risk factors most commonly blamed during the development process are as follows:

• Smoking and use of tobacco products
• Exposure to industrial chemicals
• Consumption of water with high arsenic levels
• Balkan nephropathy disease
• Uncontrolled and excessive use of painkillers
• Hereditary diseases such as Lynch syndrome

Among these factors, smoking always ranks first as the most prominent and most preventable cause of the disease. When cigarettes are smoked, thousands of carcinogenic substances in the toxic smoke filling the lungs rapidly enter the bloodstream. When the blood reaches the kidneys to be cleansed, these substances are filtered into the urine. These tobacco toxins concentrated in the urine subject the ureter wall to what is almost a chemical wash as they travel toward the bladder. Cells exposed to this toxic wash many times a day for years eventually give up and begin to become cancerous.

Industrial chemicals act through a similar mechanism. Certain chemical substances and aromatic amines used particularly in the plastics, paint, textile, rubber, and leather industries are extremely powerful carcinogens. The incidence of urinary system cancers is quite high among factory workers who inhale these substances or absorb them through the skin for many years. Therefore, occupational exposure is a detail that must always be questioned in a person’s medical history.

Genetic and hereditary predisposition is another important subject that must be emphasized. In the human body, there are special genetic repair mechanisms that correct errors occurring in DNA while cells divide. In individuals with a hereditary condition called “Lynch Syndrome,” these repair genes are defective from birth. Because the DNA cannot be repaired, genetic errors accumulate one after another, and cells may transform into cancer at very young ages. It is vitally important for individuals with a family history of frequent colon, uterine, or urinary tract cancers to be evaluated for this genetic risk. Even when a lifestyle with minimal environmental toxins is adopted, this genetic background alone has the power to trigger tumor formation.

With Which Symptoms Does Ureter Cancer Reveal Itself in the Body?

The greatest factor that makes early diagnosis of cancer difficult is that the body gives no warning at the initial stage. A tumor only a few millimeters in size inside a very thin tube does not interfere with the flow of urine, and the person continues life as though completely healthy. However, as the tumor grows and begins to damage the structure, our body starts sending certain distress signals.

The main clinical symptoms that require attention are as follows:

• Painless bloody urine
• Severe pain in the flank and lower back area
• Frequent urge to urinate
• Burning or stinging while urinating
• Unexplained weight loss
• Complete loss of appetite
• Severe weakness and fatigue

The most critical among these symptoms is painless bloody urine (hematuria), which appears as the first warning sign in the vast majority of patients. Cancer tissue that develops in the urinary tract does not have a strong vascular structure like normal body tissues. As cancer cells grow rapidly, they form extremely fragile, weak, and irregular vessels around themselves. Even the flow of urine over this tumor tissue is enough to rupture these weak vessels. The color of the urine may suddenly turn rusty, tea-colored, pink, or bright red. The dangerous aspect is that this bleeding usually causes no pain or discomfort. Because there is no pain, many people dismiss the condition as a chill or fatigue, and when the bleeding stops on its own, they assume they have recovered. However, painless bleeding is the red alert of the urinary system that requires the most urgent examination.

When the tumor grows slightly larger inside the ureteral channel, it narrows the diameter of the channel and begins to completely or partially obstruct the flow of urine. In this situation, urine accumulates above in the renal pelvis, and the kidney gradually stretches like an inflating balloon. This swelling of the kidney, called “hydronephrosis” in medicine, causes very severe, dull, or stabbing pain in the person’s flank, lower back, or back. Sometimes, when small blood clots in the urine become stuck while trying to move down the channel, excruciating pain similar to passing a kidney stone may also occur. If the tumor is located very close to the bladder, the bladder senses this foreign tissue and is constantly stimulated as though it contains urine; this causes the patient to make continuous trips to the toilet.

Which Tests and Imaging Methods Are Used When Ureter Cancer Is Suspected?

In a patient presenting with the complaints listed above, a highly systematic mapping process is initiated to clarify the situation, locate the problem, and name the disease. During this process, the most advanced imaging and camera-assisted examination methods provided by technology are used.

The main tools used in the diagnostic process are as follows:

• Contrast-enhanced computed tomography
• Magnetic resonance imaging
• PET scan
• Cystoscopy device
• Ureterorenoscopy instrument
• Urine cell examination
• Pathological tissue biopsy

The backbone of the examination stage is Contrast-Enhanced Computed Tomography, medically known as “CT Urography.” A special contrast agent is administered to the patient intravenously. This agent enters the bloodstream, reaches the kidneys, and is filtered, outlining the entire urinary tract from within. Three-dimensional and millimetric tomography sections obtained at this time allow the internal structure of the kidney, the entire ureters, and the bladder to be displayed very clearly on the screen. If a tumor is present, its size, where it obstructs the channel, how much swelling it has caused in the kidney, and whether it has come into contact with surrounding organs are laid out before us like a map. If the patient’s kidney function is weak and the body cannot eliminate this contrast agent, Magnetic Resonance Imaging (MRI) is used as an alternative.

Although imaging methods tell us that a foreign mass is present there, in order to say with certainty that “this is cancer,” we must see the mass directly, obtain a sample from it, and examine it under a microscope. For this purpose, minimally invasive camera systems are used. First, a very thin illuminated instrument called a “Cystoscope” is passed through the urinary tract to examine the inside of the bladder and the openings of the ureters. If everything in the bladder is normal, much thinner, flexible, and steerable camera systems (Ureterorenoscopy) are advanced into the ureteral channel and moved upward along the channel. When the tumor is found, its exact location is identified directly through the camera image, and a biopsy, meaning tiny tissue samples, is taken from it using microscopic instruments. In addition, the urine itself is sent to the laboratory to investigate whether free cancer cells have been shed into it. The final decision is made after the pathologist performs cellular analysis under the microscope.

How Are the Stages of Ureter Cancer Determined and What Do They Mean?

When all tests and biopsy results are completed, a kind of identity card is created for the disease. Knowing only the presence of the cancer cell is not enough to plan treatment; it is also necessary to know how deeply it has progressed, how far it has spread, and how aggressive its behavior is. For this purpose, an internationally accepted staging system is used.

The main criteria determining the stage are as follows:

• How deeply the tumor has invaded the tissue
• Whether it has spread to the surrounding lymph nodes
• Whether it has spread to distant organs such as the liver or lungs
• The microscopic aggressiveness grade of the cancer cells

The depth of the tumor refers to which layers of the ureteral wall it occupies. Tumors remaining on the innermost surface, in the lining layer, are still considered superficial. However, if the tumor has advanced into the muscle layer or has even crossed the outer boundary of the ureter and extended into the surrounding fatty tissue, this means it has become locally advanced and reached a dangerous size.

Lymph nodes are the defense and filtration stations of our body. When cancer cells break away from their original location and enter the lymphatic vessels, they first become trapped in these lymph nodes around the ureter. Detection of tumor in the lymph nodes indicates that the disease has taken a step toward systemic circulation. Distant spread (metastasis), on the other hand, means that cancer cells travel through the blood or lymphatic system to completely different tissues such as the lungs, liver, or bones and establish new tumor colonies there. The “Grade” determined by biopsy indicates the degree of abnormality of the cells under the microscope. Low-grade cells resemble normal cells to some extent and grow slowly, whereas high-grade cells are completely irregular, rule-breaking, and rapidly multiplying aggressive cells. All these staging findings are brought together to create the most appropriate treatment scenario for the patient.

What Surgical Methods Are Used in the Treatment of Ureter Cancer?

The main and most life-saving weapon against this disease is the complete surgical removal of cancerous tissue from the body. When selecting the surgical method, the patient’s age, general health condition, how well the other kidney functions, and the stage of the tumor mentioned above are taken into consideration. Although the aim is always to completely eliminate the cancer, preserving the patient’s own kidney whenever possible is also among the priorities.

The main surgical techniques used are as follows:

• Complete removal of the kidney and ureter
• Removal of a small portion of the bladder
• Cutting out and removing the tumor-containing ureter segment
• Reconnecting the remaining ureter to the bladder
• Burning the tumor with a laser by entering with a camera
• Surgical removal of surrounding lymph nodes

The most classic, oncologically safest, and most commonly performed method is an operation in which the kidney on the affected side, the ureter, and a small amount of tissue surrounding the opening where the ureter connects to the bladder are removed completely as a single unit. The human body is designed with the capacity to continue life perfectly with one healthy kidney. Therefore, if the tumor is aggressive, has invaded the muscle tissue, or is located in a portion of the ureter very close to the kidney, no risk is taken. Even the lowest part of the ureter where it connects to the bladder is not left inside because the risk of the disease recurring there is very high. Today, these extensive operations can be performed laparoscopically, meaning with minimally invasive methods, without making large incisions in the abdomen. This greatly accelerates the patient’s postoperative recovery.

However, there are certain special situations in which sacrificing the patient’s kidney is not possible. The person may have been born with a single kidney, may have chronic kidney failure, or the tumor may be located only at the lowest end of the channel and may be very small and slow growing. In such cases, kidney-preserving operations are used. Only the segment of the tube containing the tumor is cut out, and the remaining healthy ends are sutured back together. If the tumor is as small as a lentil and very superficial, it can be vaporized using laser energy by entering entirely through the urinary tract with closed camera systems, without making any incision in the patient’s abdomen. Although this method preserves the organ perfectly, it carries a risk of the disease reappearing in the same location, so the patient must be monitored very, very closely.

Which Additional Treatments and Follow-Ups Are Applied After Ureter Cancer Surgery?

The successful removal of tumor-containing tissues from the body on the operating table does not mean that the process is over. Cancer is an intelligent disease; if cells have entered the blood or lymphatic system at a microscopic level before surgery, they may reappear in different organs in the following months. Therefore, protective and supportive oncological treatments after surgery are vitally important.

The complementary methods used during the postoperative process are as follows:

• Protective chemotherapy administered intravenously
• Medication administered into the urinary bladder
• Immunotherapies that strengthen the immune system
• Regular tomography scans
• Periodic camera examinations inside the bladder
• Urine cell tests

Especially if the pathology report examined after surgery shows that the cancer has invaded deeply into the ureteral wall or that there is microscopic disease in the surrounding lymph nodes, systemic protective chemotherapy is administered to the patient within the first three months after surgery. The aim here is to find and destroy rogue cells that may be hiding anywhere in the body. In addition, to prevent cells that may have detached and shed from top to bottom during ureter surgery from establishing a new cancer colony on the bladder floor, a single dose of chemotherapy medication is administered into the bladder through a urinary catheter in the days immediately following surgery. This procedure reduces the risk of recurrence in the bladder in the future to an incredible degree. In very advanced cases that do not respond to conventional medications, intelligent immunotherapy agents that stimulate the person’s own immune system cells to fight the cancer are achieving remarkable success today.

The follow-up process that begins after the treatments are completed is a lifelong discipline. This is because ureter cancer has the potential to reappear in the treated area or in the ureter of the other healthy kidney. In the first years, patients are scanned from head to toe very frequently, and in later years at wider intervals, using both minimally invasive camera methods and three-dimensional imaging devices. There is only one reason why these follow-ups are kept so strict: if the disease reappears anywhere in the body, even in a very small form, to detect it very early before it causes any symptoms and immediately eliminate it with small interventions.

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