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    Kidney renal pelvis and ureter

    Background

    Nephrectomies and uretectomies may be required to treat malignancies of the urinary collecting system, mostly commonly urothelial cell carcinomas.1,2

    Non-malignant diseases of the pelvic-ureteric junction such as obstruction, reflux uropathy and urinary calculi may also be implicated in these specimens.3

    This protocol includes specimens from tumours of the renal pelvis and/or ureter. See other protocols provided for parenchymal tumour and non-tumour specimens.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-normal fixation (not formalin), describe
    • Yes
      • Special studies required, describe
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen:

    • Renal vein (anterior)
    • Renal artery (middle)
    • Ureter (posterior)
    • Adrenal (if present)
    • Gerota’s fascia

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Feature denoted

    If unable to orientate, call the on-call pathologist or surgeon.

    Although laterality of the kidney is usually indicated in the clinical notes, principal landmarks such as the adrenal gland, ureter, renal vein and artery will confirm whether the specimen is the right or left kidney. The ureter extends inferiorly from the renal sinus along the medial border of the kidney posterior to the renal artery and vein.2 Uretectomy specimens without kidney may require orientation by the clinician to determine proximal and distal margins.

    Photograph the intact specimen if required.

    Describe the following features of the specimen:

    Procedure

    ​Record as stated by the clinician.

    • Total nephrectomy
    • Partial nephrectomy
    • Other, describe

    Anatomical components included and specimen size (mm)

    • Entire specimen
      • Size in three dimensions
      • Weight (g)

    Describe and measure components present.

    • Kidney, in three dimensions
    • Ureter, length, maxiumum diameter and maximum wall thickness
    • Adrenal (if present), in three dimensions
    • Gerota's fascia, in three dimensions
    • Other, describe

    Specimen integrity

    • Intact
    • Disrupted, describe

    Dissection

    Paint the relevant surgical margins (cut-end and circumferential) with ink and record the colours applied.

    Total nephrectomy/ nephro-ureterectomy2,3

    To minimise the risk of contamination, surgical margins should be sampled before the tumour.

    Carefully section longitudinally through the perirenal fat down to the capsule; to exclude or confirm involvement of tumour in capsular/perinephric or periureteric fat.

    Open the kidney coronally along the lateral/convex surface dividing the specimen into equal anterior and posterior halves, leaving the hilum intact.

    Photograph the specimen if required.

    Section tumour perpendicularly to the longitudinal cut surface to ensure adequate tumour/parenchymal assessment.

    Allow to fix overnight.

    Photograph the specimen at this point if required.

    Transversely section the ureter at sequential 10mm intervals from the distal margin towards the renal pelvis and examine for abnormalities such as thickening, induration or tumours.

    Ureterectomy2-4

    Orientate the specimen and section transversely at 3-5mm intervals from proximal to distal ends. Alternatively, transversely section after opening longitudinally to inspect for tumours.


    Internal Inspection

    Describe the internal or cut surface appearance including the following items.1-3

    Tumour

    • Absent
    • Present
      • Number; if more than one tumour, designate and describe each tumour separately

    Tumour size (mm)

    • Maximum dimension
    • Other dimensions

    Tumour location

    • Calyx
      • Upper
      • Mid
      • Lower
    • Renal pelvis
    • Pelviureteric junction
    • Ureter

    Tumour appearance

    • Polypoid
    • Fungating
    • Papillary
    • Ulcerated
    • Solid and indurated
    • Scarring/fibrosis

    Tumour invasion

    List tissues invaded by tumour:

    • Ureter/renal pelvic wall
    • Periureteric/peripelvic tissue
    • Renal parenchyma
    • Renal sinus
    • Perinephric fat
    • Gerota’s fascia
    • Adrenal

    Distance to margins (mm)

    • Distance of tumour to ureter cut margin
    • Distance of tumour to closest periureteric circumferential margin (if applicable)
    • Distance of tumour to perinephric margin (if tumour has penetrated the renal capsule)

    Lymph nodes

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    Processing

    Dissect the specimen further and submit sections for processing according to the diagram provided.

    Nephro-ureterectomy

    Submit representative sections of:2

    • Tumour, at least four sections demonstrating adjoining normal tissue and greatest depth of invasion
    • Interface of tumour with:
      • Renal parenchyma
      • Renal sinus (if applicable)
      • Perinephric fat (if applicable)
      • Ureteric margin
      • Hilar margin
      • Renal vein and margin
    • Macroscopically normal renal parenchyma, one block
    • Adrenal
    • Hilar lymph nodes

    Ureterectomy

    Submit representative sections of: 2

    • Ureteric surgical margins, longitudinal sections if possible. Alternatively submit transverse sections of proximal and distal surgical margins “en face”.
    • Macroscopically normal renal parenchyma, one block
    • Ureter, blocks from each third
    • Tumour,  at least four sections demonstrating adjoining normal tissue and greatest depth of invasion
    • Interface of tumour invading (if present):
      • Perinephric fat
      • Renal parenchyma
      • Periureteric tissues

    If ureter appears normal submit all tissue for processing.

    Submit all lymph nodes


    Record details of each cassette.

    An illustrated block key similar to the one provided may be useful.

    Block allocation keys

    Cassette id Site No. of pieces
    A Ureteric margin  
    B Renal sinus  
    C Vascular margin  
    D-E Tumour close to capsule/capsular penetration with tumour to surgical margin  
    F-G Tumour relationship  to renal sinus fat and adjacent pelvic urothelium  
    H-I Tumour demonstrating interface with renal corticomedullary tissue  
    J Normal renal parenchyma  
    K-M Ureter, proximal, mid and distal (if tumour present see diagram for ureteric tumour)  
    N Adrenal (if present)  
    O+ Hilar lymph nodes  
    Cassette id Site No. of pieces
    A Proximal ureter; proximal margin if ureterectomy  
    B Distal margin  
    C Renal vessel  margins  
    D-E Tumour demonstrating deepest point of invasion  
    F-G Tumour demonstrating interface with adjacent tissue  
    H “Normal” ureter, proximal to tumour  
    I “Normal” ureter, distal to tumour  
    J Renal pelvis and sinus tissue, if applicable  
    K Background renal parenchyma, if applicable  
    L Adrenal, if applicable  
    M+ Hilar lymph nodes, if applicable  
    Cassette id Site No. of pieces
    A Proximal margin  
    B Ureter, sequential serial sections  
    C Distal margin  

     

    Acknowledgements

    A/Prof Hemamali Samaratunga for her contribution in reviewing and editing this protocol.


    References

    1. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    2. Shanks JH, Chandra A, McWilliam L and Varma M. Dataset for tumours of the urinary collecting system (renal pelvis, ureter, bladder and urethra), The Royal College of Pathologists, London, 2013.
    3. O’Rourke D, Turner G and Allen D. Tissue Pathways for Urological Pathology, The Royal College of Pathologists, London, 2010.
    4. Amin MB, Delahunt B, Bochner BH, Epstein JI, Grignon DJ, Humphrey PA, Montironi R, Paner GP, Renshaw AA, Reuter VE, Srigley JR and Zhou M. Protocol for the Examination of Specimens from Patients with Carcinoma of the Urinary Bladder, Cancer Committee, College of American Pathologists, 2012.

    Jump To

      Kidney pelvis tumour 1

      Nephro-ureterectomy for renal pelvis tumour

      Kidney pelvis tumour 2

      Nephro-ureterectomy/ureterectomy for ureteric tumour

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      25-Mar-2019
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