Épidémiologie
Comparativement aux cancers de la vessie, ces cancers sont rares et ne dépassent pas 1500 cas par an en France.
Symptomatologie
Ces cancers ressemblent dans leurs symptômes aux cancers du rein qui se signalent par des douleurs lombaires et dans leur diagnostic, aux tumeurs de vessie puisqu’ils provoquent des saignements dans les urines (hématurie).
Diagnostic
La découverte d’un cancer de la voie excrétrice urinaire du haut appareil est rarement fortuite. Les patients se plaignent parfois de douleurs lombaires, mais on les recherche surtout chez les porteurs de tumeurs de vessie : 5 à 6 % ont également une tumeur du haut appareil.
Le diagnostic repose sur l’imagerie (scanner, urographie, IRM) et sur l’endoscopie (urétéroscopie) souple ou rigide. Selon la localisation de la tumeur, l’examen endoscopique permettra de la voir, de la biopsier et de chercher d’autres tumeurs passées inaperçues. Pour pratiquer cet examen, on fait remonter l’endoscope dans les uretères et dans les reins sous anesthésie générale en y associant une exploration radiologique. Il n’est pas rare que le temps du diagnostic soit séparé de celui du traitement pour des raisons liées à la tumeur, sa localisation, son extension et l’information nécessaire pré-opératoire.
Traitement
Il repose d’abord et essentiellement sur la chirurgie avec l’exérèse (ablation) complète du rein et de l’uretère.
Les tumeurs de petite taille et de bas grade peuvent se contenter d’un traitement conservateur par endoscopie.
Surveillance
Elle est réalisée par l’imagerie et la surveillance cytologique urinaire.
Le pronostic
Le pronostic est le même que pour les cancers de la vessie.
Il est excellent pour les tumeurs superficielles pour lesquelles on obtient 90 % de guérison.
En revanche, comme dans le cancer de vessie, les formes infiltrantes, de découverte tardive, sont de mauvais pronostic (60 % de survie à 5 ans) car la faible épaisseur de la paroi de l’uretère ne protège pas des atteintes ganglionnaires
La chimiothérapie est prescrite dans les formes récidivantes ganglionnaires en complément du traitement initial.
Le pronostic dépendant du grade de la tumeur et est également fonction de sa localisation.
Les tumeurs situées dans le bas uretère bénéficient d’une meilleure survie que les tumeurs situées dans l’uretère proximal.
Stades
La stadification est la même que pour le cancer de vessie qui reconnaît 4 stades différents avec une graduation qui distingue les formes superficielles des formes infiltrantes : Tx à T4b
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