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
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
- 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
-
Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
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-
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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.