Upper Tract Urothelial Carcinoma (UTUC)

Upper tract urothelial carcinoma (UTUC) is a rare form of cancer that affects the lining of your upper urinary tract. The Urology Care Foundation estimates that 7,000 new cases of UTUC are diagnosed in the United States every year.

A diagnosis of UTUC can be unsettling, and you may wonder how it will affect your quality of life. Below, you’ll find details on the anatomy of your upper urinary tract, the types of symptoms you may have with UTUC, and the tests that are used to diagnose it. We’ll also go over your surgical and non-surgical treatment options and discuss follow-up, as your doctor will want to monitor you closely for recurring disease.

Rest assured that your cancer care team is there to help. If you or your family have any questions, feel free to ask.

Urinary Tract Anatomy

There’s a lot to unpack in the term upper tract urothelial carcinoma, so let’s review some anatomy before we get into specifics.

Your urinary tract is made up of four components:

• Kidneys. These two bean-shaped organs are found below your ribcage, on either side of your spine. The kidneys filter your blood. Much of the fluid the kidneys filter can be reused by your body, but waste products are processed and turned into urine. Most people have two kidneys, but it’s possible to live with one. Urine collects in an area called the renal pelvis. (Doctors often use the word renal when talking about kidneys.)
• Ureters. Your ureters are thin, muscular tubes that connect your kidneys to your bladder. (Each kidney has one ureter attached; both ureters attach to the bladder) Once urine is produced by the kidneys, it travels down the ureters to the bladder.
• Bladder. The bladder is like a storage tank for urine. When it becomes full, your body signals that it’s time to urinate.
• Urethra. The urethra is the tube that urine flows through when you urinate. Urine moves from the bladder, through the urethra, and into the toilet.

What is the upper urinary tract?

The term upper urinary tract refers to your kidneys and ureters only. The bladder and urethra are not included in this description.

What is urothelium?

The urothelium is tissue that lines your entire urinary tract. This lining protects these organs from the acidity of urine as well as germs, keeping you safe from infections.

So, when we talk about upper tract urothelial cancer (UTUC), we mean cancer in the urothelial tissue in the renal pelvis of the kidneys and the ureters. UTUC is not the same as kidney cancer or bladder cancer. It’s also less common than either of those cancers.

UTUC accounts for the vast majority (over 90%) of tumors found in the upper urinary tract. Another 8% are squamous cell carcinomas in the renal pelvis and the rest are primary adenocarcinomas and small cell carcinomas.

Sometimes, there are multiple tumors.

It is rare to find tumors in both kidneys and both ureters.

Types of UTUC

Doctors classify UTUC in one of two ways. High-grade UTUC affects deeper regions of the kidney and might spread beyond it. Low-grade UTUC isn’t as aggressive and tends to stay in a smaller area.

UTUC can also metastasize—spread to other parts of the body. Most often, metastasis occurs through the bloodstream or lymphatic system.

Risk Factors

UTUC is more common in men than in women. In fact, men are two to three times more likely to develop it. Other risk factors include:

• Smoking. Experts estimate that up to 80% of upper urinary tract tumors are linked to smoking.
• Age. UTUC is more common in people age 70 or older.
• History of bladder cancer.
• Chronic urinary tract infections.
• Overuse of pain relievers.
• Lynch syndrome. This is a genetic condition passed from parents to children.
• Balkan ancestry. UTUC is more common in people from the Balkan area in southeastern Europe. Balkan countries include Greece, Romania, Bulgaria, Serbia, and Croatia.
• Exposure to arsenic.
• Use of Chinese herbs that contain aristolochic acid.

What are the symptoms of UTUC?

One of the first noticeable symptoms is blood in the urine (hematuria). Sometimes, you can see the blood yourself when you go to the bathroom. But often, the blood droplets are so small they can’t be seen with the naked eye. A doctor may find them when examining a urine sample under a microscope. This is called microhematuria.
Other symptoms can include flank or pelvic pain, cramps, weight loss, constipation, poor appetite, and night sweats.

Diagnosis

Doctors start with by taking a medical history. They’ll likely ask you about your family health history and whether you’ve been a smoker. You’ll also have a complete medical exam.

Next, you may have one or more of the following tests:

CT scan (computed tomography scan)

A CT scan (sometimes pronounced as “cat scan”) is a type of imaging test. It uses X-rays to create pictures of the inside of your body. Together, these pictures can create 2-dimensional and 3-dimensional images.

Having a CT scan usually isn’t painful, but you do need to lie very still while the images are being taken. You may be given a contrast agent to help doctors get a better view of certain areas.

Ureteroscopy

With this test, the doctor uses a tool called a ureteroscope to see inside your ureters and kidneys. This tool is a thin tube with a light and camera at the end. After you receive general anesthesia, the ureteroscope is inserted into your urethra and threaded through your bladder and into the ureter and kidney.

Cystoscopy

Similar to a ureteroscopy, this procedure uses a thin tube with a camera on the end. It is placed through your urethra and into your bladder to check for cancer cells. (Some people with UTUC also have bladder cancer.)

During a cystoscopy, your provider might also conduct a retrograde pyelography. This is another way to take X-rays of the ureters and kidney. A catheter is placed into your urethra. Then, a dye is injected into your ureters via the catheter. The dye makes certain features easier to spot.

Ultrasound

A ultrasound is another type of imaging test. It uses sound waves to create images of your body.

Urine cytology

A urine sample is examined under a microscope to check for cancer cells.

Biopsy

A biopsy involves removing a small amount of tissue and examining it under a microscope. This may be done during a ureteroscopy. It can also be done with a needle, which the doctor puts through your skin.

Treatment

Your treatment plan will depend on what type of UTUC you have, where it is, and how severe it has become. Your doctor will go over all of your options before you undergo treatment, which may include these procedures:

Your treatment plan will depend on what type of UTUC you have, where it is, and how severe it has become.

Ureteroscopy

Sometimes, cancer cells can be removed during a ureteroscopy, a procedure used during diagnosis. The tumor may be destroyed with a laser or with heat from an electrical current.

Surgery: Nephroureterectomy or Ureterectomy

Nephroureterectomy is surgery to remove your kidney (including the renal pelvis), ureter, and the cuff of the bladder. The goal of this surgery is to remove cancer cells. It is always done under general anesthesia.

A nephroureterectomy can be an open procedure, which means the surgeon makes cuts in your abdomen to remove the tumor(s).

It can also be done as a laparoscopic robot-assisted surgery, which is less invasive. During this type of surgery, a robot holds the surgical instruments. The surgeon controls the robot at a computer console. This approach uses smaller incisions and may shorten your recovery time. Surgeons receive special training to do robotic surgery, and it has become a routine method in many hospitals.

A laparoscopic surgery takes about two to four hours. When complete, the surgeon closes the incisions with stitches.

The recovery time after nephroureterectomy is about six weeks. Depending on the type of work you do, you might be able to return to your usual duties in four weeks.

In some cases, only part of the ureter needs to be removed. The ends that remain are reattached with stitches. This surgery is called a ureterectomy.

Lymph nodes may also be removed during surgery.

If a person has only one kidney, or if the kidneys function poorly, surgery may not be an option.

Chemotherapy

Chemotherapy uses strong drugs to destroy cancer cells or slow down their growth. It may be used before or after surgery. Patients who are unable to have surgery usually have chemotherapy.

Chemotherapy is an intravenous procedure, which means the drugs are given through an IV. The drugs then circulate throughout your body.

Your doctor will let you know how many cycles of chemotherapy you may need. They will also tell you how to cope with side effects, such as nausea, pain, fatigue, diarrhea, and loss of appetite.

BCG Treatment

Bacillus Calmette-Guerin (BCG) might be another option. This treatment, a type of immunotherapy, is more often used to treat bladder cancer, but it can be used for UTUC as well.

BCG contains a weakened form of tuberculosis bacteria infused into your bladder through a catheter. This prompts a response from your immune system, which works with the medicine to destroy the tumor(s).

Mitomycin

Patients with low-grade UTUC might receive mitomycin, which is marketed under the brand name Jelmyto. This medicine is instilled as a cooled liquid into the renal pelvis through a catheter or nephrostomy tube (a surgically placed tube that allows urine to leave the kidney if a ureter is blocked). Once it reaches your body temperature, it forms a gel that comes into contact with the tumors and destroys them.

One mitomycin treatment takes about four to six hours. You may need to have this treatment once a week for six weeks.

What is the prognosis for people with UTUC?

If surgeons can remove all the cancer, and if it hasn’t spread to other parts of the body, then a full recovery is possible. However, if the cancer has spread elsewhere in the body, treatment becomes more challenging and outcomes less certain.

What happens after treatment? Will UTUC recur (come back)?

Follow-up after UTUC treatment is important. UTUC can come back, regardless of whether your cancer is high-grade or low-grade. You may have routine imaging tests and ureteroscopies after treatment to make sure the cancer hasn’t recurred.

Having UTUC also raises your risk for bladder cancer, so your cancer care team will monitor you carefully over time. You may have regular cystoscopies.

You might reduce your risk for recurrence by following healthy habits, like quitting smoking, eating nutritious foods, and exercising regularly. Don’t hesitate to ask your care team for suggestions on meal and fitness plans. Your doctor can also help you quit smoking, if necessary.

Summary: Key Points About UTUC

UTUC stands for upper tract urothelial carcinoma, a rare form of cancer that affects the upper urinary tract (the renal pelvis of the kidney and the ureter).

Men are more likely to develop UTUC than women. Other risk factors include smoking, a history of bladder cancer, older age, and chronic urinary tract infections.

Blood in the urine is one of the most common symptoms of UTUC. A person may also have flank pain, cramps, weight loss, constipation, poor appetite, and night sweats.

Doctors conduct several tests to diagnose UTUC. These may include imaging tests like CT scans, ultrasounds, and retrograde pyelography. Urine cytology, ureteroscopy, and biopsy are also common tests.

Many patients with UTUC undergo surgery to remove the affected kidney and ureter. Lymph nodes may be removed as well. In less severe cases, just the affected portion of the ureter is removed.

Chemotherapy, immunotherapy with BCG, and mitomycin are non-surgical treatment options.

Follow-up after treatment is critical for patients who have had UTUC. The cancer can come back, and it can increase your risk for bladder cancer. Your doctor will monitor your progress regularly. You can lower your risk for recurrence by quitting smoking and following healthy habits, such as good nutrition and proper exercise.

The prognosis for patients with UTUC depends on the severity of the disease.

Resources

American Urological Association

Coleman, J.A., et al.
“Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline”
(2023)
https://www.auanet.org/guidelines-and-quality/guidelines/non-metastatic-upper-tract-urothelial-carcinoma

Bladder Cancer Advocacy Network

“What to Know About BCG Treatment for Bladder Cancer”
(No date)
https://bcan.org/bcg-treatment-for-bladder-cancer/

Cleveland Clinic

“Kidney”
(Last reviewed: May 17, 2022)
https://my.clevelandclinic.org/health/body/21824-kidney

“Nephroureterectomy”
(Last reviewed: July 18, 2022)
https://my.clevelandclinic.org/health/treatments/17264-nephroureterectomy

“Urothelium”
(Last reviewed: October 28, 2024)
https://my.clevelandclinic.org/health/body/22205-urothelium

Jelmyto.com

“How JELMYTO works”
https://www.jelmyto.com/hcp/about/how-jelmyto-works/

“Who JELMYTO is for”
https://www.jelmyto.com/hcp/about/who-jelmyto-is-for/

Mayo Clinic

“Chemotherapy”
(March 13, 2024)
https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033

MedlinePlus.gov

“Cystoscopy”
(Last reviewed: May 17, 2024)
https://medlineplus.gov/ency/article/003903.htm

“Ultrasound”
(Last updated: May 3, 2023)
https://medlineplus.gov/lab-tests/sonogram/

“Ureteroscopy”
(Last reviewed: July 1, 2023)
https://medlineplus.gov/ency/article/007593.htm

Merck Manual – Consumer Version

Chandrasekar, Thenappan, MD
“Renal Pelvis and Ureter Cancers”
(Reviewed/Revised Feb 2025)
https://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/cancers-of-the-kidney-and-genitourinary-tract/renal-pelvis-and-ureter-cancers

National Cancer Institute

“Computed Tomography (CT) Scans and Cancer”
(Reviewed: February 8, 2024)
https://www.cancer.gov/about-cancer/diagnosis-staging/ct-scans-fact-sheet

UCLA Health

“Upper Urinary Tract Tumor”
(No date)
https://www.uclahealth.org/medical-services/urology/conditions-treated/cancer-conditions/upper-tract-tumor

Up to Date

Gupta, Shilpa, MD and Jerome P Richie, MD, FACS
“Malignancies of the renal pelvis and ureter”
(Topic last updated: May 6, 2024)
https://www.uptodate.com/contents/malignancies-of-the-renal-pelvis-and-ureter

Urology Care Foundation

“Upper Tract Urothelial Carcinoma (UTUC)”

“What is Retrograde Pyelography?”
(Updated October 2024)
https://www.urologyhealth.org/urology-a-z/r/retrograde-pyelography