Long-term follow-up results and complications in cancer patients with persistent nephrostomy due to malignant ureteral obstruction

Malignant upper urinary tract obstruction in cancer patients: A systematic review

Objective

To systematically summarise the current clinical evidence for de novo malignant upper urinary tract obstruction treatment with a focus on standards of reporting, patient outcomes and future research needs.

Methods

This review protocol was published via PROSPERO (CRD42022341588). OVID MEDLINE (R), EMBASE, Cochrane Central Register of Controlled Trials-CENTRAL were searched up to June 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Prospective and retrospective studies were included.

Results

Of 941 articles identified, 82 with 8796 patients were eligible for inclusion.Most studies in the published literature are retrospective and investigate heterogenous malignancies. Percutaneous nephrostomy and ureteric stenting are the most studied interventions. Few studies describe the outcomes from no intervention or investigate patient perspectives. Overall reported median survival after intervention was around 11.7 months. A lack of standardised reporting of outcomes was evident.

Conclusions

Malignant upper urinary tract obstruction is an important clinical condition affecting patients globally. Overall survival after intervention appears poor however the current evidence base has significant limitations due to studies of low methodological quality and the lack of a standardised framework for reporting outcomes.We have provided a pragmatic framework for future studies based on the review to ensure a uniform methodology is utilised moving forward.

Assessing the Impact of Percutaneous Nephrostomy Presence on Neoadjuvant Treatment Quality in Patients With Muscle Invasive Bladder Cancer

INTRODUCTION

Symptomatic hydronephrosis associated with muscle invasive bladder cancer (MIBC) necessitates percutaneous nephrostomy (PCN) insertion before neoadjuvant chemotherapy (NAC). This study assesses the impact of PCN presence on standard intended NAC quality, its related complications and outcome after radical cystectomy (RC).

MATERIALS AND METHODS

The study comprises a retrospective, multicenter cohort of 193 consecutive RCs performed between 2016 and 2019. Eighty (42%) of these patients received NAC and were divided in 2 comparison groups by presence (n = 26; 33%) or absence (n = 54; 67%) of PCN. Endpoints included completion of adequate NAC treatment (cisplatin-based chemotherapy for at least 4 courses), complications during NAC, post-RC complications and hospital stay.

RESULTS

Overall, patients with PCN (45/193; 23%) featured a higher referral rate to NAC (58% vs. 36%, P = .01), worse glomerular filtration rates (P < .001) and more adverse events (P = .04), in comparison to non-PCN patients. In the NAC cohort, PCN patients had less adequate treatment rates (54% vs. 85%, P = .005), and more infections (35% vs, 7%; P = .008) and hospitalizations (58% vs. 13%; P < .001) during chemotherapy. Post-RC outcome was similar for both comparison groups. PCN was an independent risk factor for inadequate NAC (OR = 3.9, P = .04), and infections (OR = 11.3, P = .01) and hospitalizations (OR = 7.5, P = .004) during NAC.

CONCLUSIONS

PCN in MIBC patients is a significant risk factor for inadequate NAC and adverse events during treatment. This finding may quire the rationale of NAC, potentially leading to consideration of NAC avoidance and upfront RC in PCN patients. Further survival studies with long follow-up are needed for elucidating this issue.

Formation and composition of crust in the nephrostomy tube of patients undergoing percutaneous nephrostomy

To investigate the formation and composition of crust in the nephrostomy tube (NT) of patients undergoing percutaneous nephrostomy (PCN). Consecutive patients undergoing PCN for the treatment of obstructive nephropathy who then underwent NT exchange between January 2020 and May 2022 were included in the study. The composition of crust in NTs was analyzed using infrared spectrum automatic analysis system. A total of 46 NTs were collected from 46 consecutive patients (19 men, 27 women; mean age, 68.5 ± 13.4 years) who underwent PCN. The median indwelling time of NTs was 96 days (Q1, 90 days; Q3, 140 days). Among the 46 NTs, 20 (43.5%) were positive for the presence of crust. The mean indwelling time was significantly longer in NTs positive for crust than in those negative for crust (169.7 ± 55.7 days vs 86.5 ± 15.0 days; P < .01). In the NTs positive for crust, the crust was composed of mixed components (apatite carbonate and magnesium ammonium phosphate hexahydrate, n = 7; apatite carbonate and calcium oxalate monohydrate, n = 4) in 11 NTs and a single component (apatite carbonate, n = 5; anhydrous uric acid, n = 2; calcium oxalate monohydrate, n = 2) in 9 NTs. When the NT indwelling time was longer than 3 months, the incidence of crust formation in the NT was significantly increased. Crust was most commonly composed of mixed components. In light of these findings, we suggest that NTs should be exchanged every 3 to 4 months to prevent the formation of crust and thus prevent obstruction of the NT.

Quality of life with tandem ureteral stents compared to percutaneous nephrostomy for malignant ureteral obstruction

PURPOSE

Malignant ureteral obstruction (MUO) is treated with kidney decompression by a percutaneous nephrostomy (PCN) or internal ureteral stents. The objective of this study was to compare quality of life (QoL) with a PCN compared to tandem ureteral stents (TUS) in cases of MUO.

METHODS

We reviewed the medical records of patients with MUO who were treated by PCN/TUS in our institution between June 2019 and May 2020. Patients were asked to fill out a QoL questionnaire, a tube-symptoms questionnaire, report a general health scale, and asked for a drain preference if they had experience with both drains. Scores of both groups were compared and predictors of all QoL and tube-symptoms measures were searched using multivariate analysis.

RESULTS

Seventy-four patients with a PCN and 30 with TUS were included in the study. No statistically significant difference was found in all QoL and tube-symptoms measurements between the two drains. Type of drain was not found to be a predictor of QoL or tube-related symptoms. Eighty-four percent of patients (11/13) who have experience with both types of drains preferred TUS.

CONCLUSION

TUS and PCN for relief of MUO have a negative and similar effect on various areas of QoL and urinary symptoms. Most patients who had experience with both types of drains preferred TUS over PCN. In this patient population with a grim prognosis, this negative effect must be communicated to patients, and calculated against the potential benefits of drainage.