Percutaneous Urinary Drainage and Ureteric Stenting in Malignant Disease

Prediction of Stent Failure for Malignant Ureteral Obstruction in Non-Urological Cancer

PURPOSE

To analyze prognostic factors associated with ureteral stent failure and to develop a prediction model for malignant ureteral obstruction (MUO) in patients with non-urological cancers.

MATERIALS AND METHODS

We retrospectively reviewed patients with non-urological cancers who underwent ureteral stenting or percutaneous nephrostomy (PCN) for MUO between 2006 and 2014. Variables predicting stent failure were identified using Cox regression analysis.

RESULTS

Of the 743 patients, 468 (63.0%) underwent ureteral stenting only, and 275 (37.0%) underwent PCN owing to technical (n=215) or functional (n=60) stent failure. The median overall survival was 4 [interquartile range (IQR) 1-11] months, and the median interval duration to stent failure was 2 (IQR 0-7) months. In univariate analysis, lower gastrointestinal cancer, previous radiotherapy to the pelvis, bladder invasion, lower ureteral obstruction, and low previous estimated glomerular filtration rate (eGFR) (<30 mL/min/1.73 m²) were significantly associated with a decreased survival rate. In multivariate analysis, bladder invasion and previous eGFR were significant predictors. With these two predictors, we divided patients into three groups based on their presence: low-risk (neither factor; n=516), intermediate-risk (one factor; n=206), and high-risk (both factors; n=21). The median stent failure-free survival rates of patients in the low-, intermediate-, and high-risk groups were 26 (8-unreached), 1 (0-18), and 0 (0-0) months, respectively (p<0.001).

CONCLUSION

In cases of ureteral obstruction caused by non-urological cancers, patients with bladder invasion and a low eGFR showed poor stent failure-free survival. Therefore, PCN should be considered the primary procedure for these patients.

Long-term Indwelling Tandem Polymeric Ureteral Stents for Benign Ureteral Obstruction

Objective: To assess the outcome of tandem polymeric internal stents (TIS) for benign ureteral obstruction (BUO). Material and Methods: We conducted a retrospective study that included all consecutive patients treated for BUO by means of TIS in a single tertiary center. Stents were replaced routinely every 12 months or earlier, when indicated. The primary outcome was permanent stent failure, and the secondary outcomes included temporary failure, adverse events, and renal function status. Kaplan-Meier and regression analyses were used to estimate outcomes, and logistic regression was used to assess the association between clinical variables and outcomes. Results: Between July 2007 and July 2021, 26 patients (34 renal units) underwent a total of 141 stent replacements, with median follow-up of 2.6 years (interquartile range [IQR] 0.75-5). Retroperitoneal fibrosis was the leading cause of TIS placement (46%). Permanent failures occurred in 10 (29%) renal units, and the median time to permanent failure was 728 days (IQR 242-1532). There was no association between preoperative clinical variables and permanent failure. Temporary failure occurred in four renal units (12%), which were treated by nephrostomy and eventually returned to TIS. Urinary infection and kidney injury rates were one event for every four and eight replacements, respectively. There was no significant alteration in serum creatinine levels throughout the study (p = 0.18). Conclusion: TIS provides long-term relief for patients with BUO and offers a safe and effective solution for urinary diversion, while avoiding the need for external tubes.

Emergency Decompression of Obstructive Uropathy Using Percutaneous Nephrostomy: Disease Pattern and Treatment Outcome at Two Urology Centers in Ethiopia

Purpose

Obstructive uropathy (OU) is a potentially life-threatening urologic emergency that requires urgent decompression. Percutaneous nephrostomy (PCN) is a commonly performed procedure to decompress OU. The objective of this study is to assess disease patterns and treatment outcome at two urologic centers in Ethiopia.

Methods

A cross-sectional study was conducted on 110 patients who underwent emergency PCN from October 1, 2019 to September 30, 2020. Data were collected by a retrospective chart review. SPSS 25 was used for analysis. Descriptive statistics and logistic regression were utilized to assess disease pattern and significant predictors. A p-value of <0.05 on multivariate logistic regression was considered statistically significant.

Results

Females accounted for 70% of cases and mean age at presentation was 48 ± 12.9 years. Bilateral OU was diagnosed in 60% of patients and 77.3% of obstructions occurred at the level of the ureter. Malignancies were diagnosed in >80% of patients among which cervical cancer was the commonest (37.3%) followed by bladder cancer (17.3%). Acute kidney injury (AKI) accounted for 70% of the presenting indications for PCN. Success rate after emergency PCN was 75.5% and 41.8% of the cases developed post-procedure complications. Factors that predicted successful outcome include male gender [AOR = 5.72 (1.13–28.92), 95% CI; p = 0.035], severe hydronephrosis pre-operatively [AOR = 7.12 (1.32–38.45), 95% CI; p = 0.022], and use of combined imaging (ultrasound and fluoroscope) to guide PCN [AOR = 12.91 (1.13–46.54), 95% CI; p = 0.039]. On the other hand, postoperative complication is a negative predictor [AOR = 0.26 (0.08–0.86), 95% CI; p = 0.027].

Conclusion

In this study, overall success of emergency PCN is low. Presence of severe hydronephrosis predicts technical ease and better outcome of PCN. Procedures performed under ultrasound and fluoroscope guidance also improve outcome. Postoperative complication rate is high in this study and mandates strict preventive measures as it predicts unfavorable outcome.

Treatment of Acute Kidney Injury in Cancer Patients

Acute kidney injury (AKI), either of pre-renal, renal or post-renal origin, is an important complication in cancer patients, resulting in worse prognosis, withdrawal from effective oncological treatments, longer hospitalizations and increased costs. The aim of this article is to provide a literature review of general and cause-specific treatment strategies for AKI, providing a helpful guide for clinical practice. We propose to classify AKI as patient-related, cancer-related and treatment-related in order to optimize therapeutic interventions. In the setting of patient-related causes, proper assessment of hydration status and avoidance of concomitant nephrotoxic medications is key. Cancer-related causes mainly encompass urinary compression/obstruction, direct tumoural kidney involvement and cancer-induced hypercalcaemia. Rapid recognition and specific treatment can potentially restore renal function. Finally, a pre-treatment comprehensive evaluation of risks and benefits of each treatment should always be performed to identify patients at high risk of treatment-related renal damage and allow the implementation of preventive measures without losing the potentialities of the oncological treatment. Considering the complexity of this field, a multidisciplinary approach is necessary with the goal of reducing the incidence of AKI in cancer patients and improving patient outcomes. The overriding research goal in this area is to gather higher quality data from international collaborative studies.

Defining cisplatin eligibility in patients with muscle-invasive bladder cancer

The current treatment paradigm for muscle-invasive bladder cancer (MIBC) consists of cisplatin-based neoadjuvant chemotherapy followed by local definitive therapy, or local definitive therapy alone for cisplatin-ineligible patients. Given that MIBC has a high propensity for distant relapse and is a chemotherapy-sensitive disease, under-utilization of chemotherapy is associated with suboptimal cure rates. Cisplatin eligibility criteria are defined for patients with metastatic bladder cancer by the Galsky criteria, which include creatinine clearance ≥60 ml/min. However, consensus is still lacking regarding cisplatin eligibility criteria in the neoadjuvant, curative MIBC setting, which continues to represent a substantial barrier to the standardization of patient care and clinical trial design. Jiang and colleagues accordingly suggest an algorithm for assessing cisplatin eligibility in patients with MIBC. Instead of relying on an absolute renal function threshold, their algorithm emphasizes a multidisciplinary and patient-centred approach. They also propose mitigation strategies to minimize the risk of cisplatin-induced nephrotoxicity in selected patients with impaired renal function. This new framework is aimed at reducing the inappropriate exclusion of some patients from cisplatin-based neoadjuvant chemotherapy (which leads to under-treatment) and harmonizing clinical trial design, which could lead to improved overall outcomes in patients with MIBC.

Clinical Outcomes After Urinary Diversion for Malignant Ureteral Obstruction Secondary to Non-urologic Cancer: An Analysis of 778 Cases

BACKGROUND

This study investigated patient outcomes after urinary diversion in order to manage malignant ureteral obstruction caused by non-urologic cancers and to evaluate predictive factors for overall survival.

METHODS

The study retrospectively reviewed patients with non-urologic malignancies who underwent ureteral stenting or percutaneous nephrostomy for ureteral obstruction between 2006 and 2014. The variables for predicting overall survival were identified by Cox regression analysis.

RESULTS

The study enrolled 778 patients, including 522 patients who underwent ureteral stenting and 256 patients who underwent percutaneous nephrostomy. Renal function was assessed immediately and then 2 weeks after urinary diversion. The median survival period was 5 months (interquartile range [IQR] 2-12 months). A total of 708 patients died. The patients who received chemotherapy after urinary diversion had a survival gain of 7 months compared with the patients who did not receive subsequent chemotherapy (p < 0.001). The survival rate did not differ between the various types of urinary diversion (p = 0.451). In the multivariate analysis, lower survival rates were significantly associated with male sex; previous chemotherapy without radiotherapy; an increasing number of events related to malignant dissemination; low preoperative hemoglobin (< 10 mg/dL), albumin (< 3 g/dL), and estimated glomerular filtration (< 60 mL/min/1.73 m²) rates; and no subsequent chemotherapy or radiotherapy.

CONCLUSIONS

In cases of ureteral obstruction caused by non-urologic malignancies, the overall survival was poor. However, the patients who received chemotherapy after urinary diversion had a survival gain of 7 months. Therefore, urinary diversion could be considered to preserve renal function for subsequent chemotherapy, whereas patients with the poor prognostic factors should be presented with the option of no intervention.

Preventive strategies for acute kidney injury in cancer patients

Acute kidney injury (AKI) is a common complication of cancer that occurs in up to 50% of neoplastic patients during the natural history of their disease; furthermore, it has a huge impact on key outcomes such as overall prognosis, length of hospitalization and costs. AKI in cancer patients has different causes, either patient-, tumour- or treatment-related. Patient-related risk factors for AKI are the same as in the general population, whereas tumour-related risk factors are represented by compression, obstruction, direct kidney infiltration from the tumour as well by precipitation, aggregation, crystallization or misfolding of paraprotein (as in the case of multiple myeloma). Finally, treatment-related risk factors are the most common observed in clinical practice and may present also with the feature of tumour lysis syndrome or thrombotic microangiopathies. In the absence of validated biomarkers, a multidisciplinary clinical approach that incorporates adequate assessment, use of appropriate preventive measures and early intervention is essential to reduce the incidence of this life-threatening condition in cancer patients.

The Fate of Ureteral Memokath Stent(s) in a High-Volume Referral Center: An Independent Long-Term Outcomes Review

Purpose: To independently assess upper urinary tract Memokath (MMK-051) stent outcomes in a national tertiary referral center. Materials and Methods: Two researchers, completely independent to the treating team, reviewed electronic MMK-051 stent(s) patient management records. Outcomes included time to first complication, complication(s)-severity, MMK-051 stent lifespan and change incidence, salvage therapy, further surgical intervention, and mortality. Results and Limitations: One hundred patients received 162 MMK-051 stent(s) (59% with malignant and 63% with distal ureteral obstruction [UO]) with only three lost to follow-up (FU). At 5-year mean FU, only 25 patients had complication-free original MMK-051 stents (14 alive, 11 dead). Of the remaining 75 patients, 22 had other stents, 12 had major surgery (e.g., nephrectomy), 3 became dialysis dependent, and 14 stabilized without ureteral stenting after original MMK-051 removal. Malignant obstruction patients had greater original MMK-051 stent longevity (p < 0.02), but also 20 of the 21 deaths (95%). The 72% mean 5-year stent complication rate included migration (46%), blockage (34%), nonfunctioning kidney (8%), urosepsis needing intravenous antibiotics (8%), and others (6%), including one postoperative death, one ureteral injury, and two with intractable pain. Median time to first complication was 12.5 months. Conclusions: MMK-051 stents had optimal utility in managing malignant UO and in those unfit for corrective surgery. Longer independently assessed mean 5-year outcomes review revealed much higher complication rates (72%) than previously reported. Future international metallic ureteral stent guidelines should encourage clinicians to adopt patient-centered multidisciplinary assessment and selection, with counseling plus goal-setting, and harmonized long-term protocol-based reporting, for optimized future patient safety and outcomes.

Long-Term Follow-Up of Yearly Replaced Double Internal Stents for Extrinsic Malignant Ureteral Obstruction

Introduction: To assess long-term outcomes of double internal stents (DIS) for the relief of external malignant ureteral obstruction (MUO). Materials and Methods: DIS (7F each; 12-month indwelling time) were inserted under general anesthesia in 62 consecutive patients (75 renal units) with MUO during 2007-2018. Surveillance was performed every 3 months, and stents were exchanged routinely every year. The need for permanent stent retrieval was considered stent failure. Maintenance of stent patency and disease-specific survival (DSS) were estimated (Kaplan-Meier). Risk factors were also assessed (univariate and multivariable Cox regression analyses). Results: The median follow-up was 27 months (interquartile range [IQR] 20-27). The most frequent tumors causing obstruction were colorectal and ovarian cancers. Six patients (10%) had stent failure caused by sepsis, creatinine elevation, or hematuria. The average time to failure was 15 months (range 1-27). A history of radiation and an estimated glomerular filtration rate (eGFR) ≤45 mL/(min/1.73 m²) were associated with stent failure (p = 0.038 and p = 0.001, respectively). Thirty-nine patients died with a median DSS of 21 months (IQR 8.6-not reached). Multivariate analysis identified eGFR ≤60 mL/(min/1.73 m²) (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.1-4.2, p = 0.02) and need for balloon dilation (HR 2.1, 95% CI 1.1-4.1, p = 0.02) as independent predictors for disease-related mortality. Twenty-six patients (42%) had stent-related complications, for example, irritative symptoms, hematuria, and infections, of whom only two failed. Conclusions: One-year indwelling DIS provide effective long-term relief of MUO and represent a simple and effective alternative to other methods of urinary diversion. They avoid the need for external tubes and contribute to improved patient satisfaction.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management and treatment options when facing malignant ureteral obstruction

Malignant ureteral obstruction is an unfortunate finding that can be caused by a wide-ranging number of malignancies with a prognosis of limited survival. Given its presentation and progression, it can be refractory to treatment by traditional single polymeric ureteral stents. With a higher failure rate than causes of benign ureteral obstruction, a number of other options are available for initial management, as well as in cases of first-line therapy failure, including tandem stents, metallic stents, percutaneous nephrostomies and extra-anatomic stents. We reviewed the literature and carried out a PubMed search including the following keywords and phrases: "malignant ureteral obstruction," "tandem ureteral stents," "metallic ureteral stents," "resonance stent," "metal mesh ureteral stents" and "extra-anatomic stents." The vast majority of studies were small and retrospective, with a large number of studies related to metallic stents. Given the heterogenous patient population and diversity of practice, it is difficult to truly assess the efficacy of each method. As there are no guidelines or major head-to-head prospective trials involving these techniques, it makes practicing up to the specific provider. However, this article attempts to provide a framework with which the urologist who is presented with malignant ureteral obstruction can plan in order to provide the individualized care on a case-by-case basis. What is clear is that prospective, randomized clinical trials are necessary to help bring evidence-based medicine and guidelines for patients with malignant ureteral obstruction.

Clinical outcomes and prognostic factors associated with internal ureteral stent placement for malignant extrinsic ureteral obstruction

PURPOSE

The optimal management of malignant extrinsic ureteral obstruction (MUO) remains unclear. It is necessary to assess the patient prognosis in deciding the adaptation of drainage of renal pelvis. In this study, we investigated the clinical outcomes after ureteral stenting for MUO and the predictive factors for overall survival in order to create a risk-stratification model.

METHODS

We retrospectively analyzed the clinical and laboratory data of 93 patients with radiologically significant hydronephrosis associated with MUO who underwent successful stent placement between May 2005 and May 2018.

RESULTS

The median survival duration after the initial stent insertion was 266 days. Of the 93 patients, 70 died, and the median interval from the first stent insertion to death was 160 days. Multivariate analysis showed that gastric cancer as the primary disease, poor performance status before stenting, and treatment after stent insertion were significant predictors of survival. According to these three factors, we stratified patients into the following four prognostic groups: no-factor (43 patients), one-factor (23 patients), two-factor (23 patients), and three-factor (4 patients) groups. This classification was effective for predicting survival, and the median survival durations in these groups were 807, 269, 44, and 12 days, respectively (p < 0.001).

CONCLUSIONS

Our stratification model of patients with a poor prognosis after ureteral stent placement for MUO may allow urologists and clinicians to identify patients who will benefit from ureteral stenting.

Retrospective Analysis of the Role of Antibiotic Prophylaxis in the Placement and Replacement of Percutaneous Nephrostomy Catheters in Patients with Malignant Ureteral Obstruction

Background: Antibiotic prophylaxis is usually adopted to prevent urinary tract infection (UTI) after nephrostomy catheter placement and replacement. This prophylaxis has been little studied in cancer patients, and its efficacy is uncertain. Objective: To determine the rate of UTI associated with percutaneous nephrostomy catheters placement and replacement and associated risk factors. Methods: This retrospective study collected data from the available medical records. Catheter-related UTI was defined as any diagnosis of UTI based on clinical symptoms recorded in antibiotic prescription charts, and on the results of urine culture collected up to 7 days after percutaneous nephrostomy catheter. The associations between categorical variables were analyzed using Fisher's exact test. The risk factors for UTI were assessed using logistic regression. Results: In the univariate analyses, there was no significant difference in the rate of urinary infection between patients receiving and not receiving antibiotic prophylaxis before percutaneous nephrostomy and after replacement. Conclusion: The results of the present study suggest that the use of antibiotic prophylaxis for managing urinary tract obstruction by percutaneous nephrostomy is not recommended in cancer patients. In contrast, for catheter replacement, antibiotic prophylaxis appears to have a protective effect for UTI.

[Optimizing the management of bladder cancer in older patients]

AIM

To define and present potential improvements for the management of bladder cancer in older patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly.

RESULTS

The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management.

CONCLUSION

The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.

CT Imaging of Emergent Renal Conditions

The kidneys are paired intra-abdominal organs which provide essential functions and maintain homeostasis throughout the human body. Numerous disease processes affect the kidneys and cause acute renal dysfunction or other potentially catastrophic complications. These conditions can be broadly categorized into obstructive, infectious, hemorrhagic, traumatic, and vascular diseases. Imaging plays a vital role in the work-up and diagnosis of acute and emergent renal conditions. Evaluation of emergent renal conditions with a focus on CT imaging is discussed.

Change of Renal Parenchymal Width in Patients with Unilateral Ureteral Stent: A Bicenter Retrospective Study

PURPOSE

To determine whether kidney sizes were changed after ureteral stents were instilled, and if so, what parameters were significant.

METHODS

Parenchymal width (PW) of 98 patients with unilateral ureteral stents was measured from the coronal view of CT scans for both stented and unstented contralateral kidney. The mean PW and % change of mean PW were calculated before stenting and at the time of last stent change. Estimated glomerular filtrate rate (eGFR) was recorded as well.

RESULTS

The mean duration of ureteral stent indwelled was 15.6 ± 10.2 (mean ± SD) months. The change of mean PW of stented kidneys and unstented contralateral kidneys was -16.9 ± 16.4 (mean ± SD)% and 3.6 ± 10.7%, respectively. eGFR before and at the time of the last stent change did not show significant difference (p = 0.294). Duration of ureteral stent indwelled was found to be inversely related to the % change of mean PW (Spearman's correlation coefficient = -0.291, p < 0.001).

CONCLUSIONS

For unilateral ureteral obstruction, kidney size was decreased over time in spite of indwelling ureteral stent. This finding can be overlooked by clinicians due to compensatory growth of contralateral kidney and resultant normal eGFR.

Stents for malignant ureteral obstruction

Malignant ureteral obstruction can result in renal dysfunction or urosepsis and can limit the physician's ability to treat the underlying cancer. There are multiple methods to deal with ureteral obstruction including regular polymeric double J stents (DJS), tandem DJS, nephrostomy tubes, and then more specialized products such as solid metal stents (e.g., Resonance Stent, Cook Medical) and polyurethane stents reinforced with nickel-titanium (e.g., UVENTA stents, TaeWoong Medical). In patients who require long-term stenting, a nephrostomy tube could be transformed subcutaneously into an extra-anatomic stent that is then inserted into the bladder subcutaneously. We outline the most recent developments published since 2012 and report on identifiable risk factors that predict for failure of urinary drainage. These failures are typically a sign of cancer progression and the natural history of the disease rather than the individual type of drainage device. Factors that were identified to predict drainage failure included low serum albumin, bilateral hydronephrosis, elevated C-reactive protein, and the presence of pleural effusion. Head-to-head studies show that metal stents are superior to polymeric DJS in terms of maintaining patency. Discussions with the patient should take into consideration the frequency that exchanges will be needed, the need for externalized hardware (with nephrostomy tubes), or severe urinary symptoms in the case of internal DJS. This review will highlight the current state of diversions in the setting of malignant ureteral obstruction.

The profile of patients with obstructive uropathy in Cameroon: case of the Douala General Hospital

Introduction

Obstructive uropathy can lead to irreversible kidney damage. The etiology largely determined by the patient's age can be benign or malignant. This study aimed at determining the profile and outcome of patients with obstructive uropathy in Cameroon.

Methods

A cross sectional study carried out in the urology unit of the Douala General Hospital, including patients with a diagnosis of obstructive uropathy seen from January 2004 to December 2013. Clinical profile, treatment and outcome data were obtained from patients records.

Results

Of the 229 patients included 69% were men, mean age 50 ±18 years. Associated comorbidities were hypertension, diabetes, and HIV. Mean haemoglobin 8,40±2,4g/dl, mean GFR 10,3 ±10ml/min, 94 (41%) patients needed emergency dialysis. Symptoms at presentation: asthenia (57%), anorexia (55%), loin pain (37%), vomiting (28%), oedema (20%), and anuria (15%). Urinary tract infection was present in 33 patients. Main aetiologies of obstruction: urolithiasis (35%), begnin prostatic hypertrophy (27%), prostatic cancer (12%), cervical cancer (16%), and congenital malformations (5%). Drainage was effective in 102 (45%) patients, 63 (28%) recovered completely, 91 (41%) were loss to follow up, 49 (22%) died and more women (p = 0.02). Mortality was associated with prostatic cancer (p = 0.000), cervical cancer (p = 0.004) and radiotherapy (p = 0.03).

Conclusion

Patients with obstructive uropathy presented with significant impaired renal function. Main causes were urinary stones, prostatic hypertrophy, prostatic and cervical cancers. Renal recovery was poor, loss to follow up and mortality high. Specific strategies to target improvement in renal recovery and patient's survival are needed in this patient's group.

Metallic stents in the management of ureteric strictures

Management of ureteric strictures is a challenging task. Subtle presentation, silent progression and complex aetiology may delay diagnosis. A wide range of available treatment options combined with the lack of adequate randomised trials has led to the introduction of personal bias in the management of this difficult group of patients. Metallic ureteric stents offer an alternative to the conventional treatment modalities. A review of the currently available metallic stents and their role in the long-term management of ureteric strictures is presented. Materials used in the manufacture of indwelling urological devices are evolving all the time. Improved endo-urological techniques combined with new devices made from better compounds will continue to improve patient experience.

Robotic technology for pelvic exenteration in cases of cervical cancer

BACKGROUND

Cervical cancer represents one of the most common types of neoplasia among women; the use of minimally invasive techniques in the treatment of cervical cancer is a challenge.

OBJECTIVES

To present evidence regarding robotic technology in the performance of pelvic exenteration in cases of cervical cancer.

SEARCH STRATEGY

PubMed and Scopus databases were searched.

SELECTION CRITERIA

Articles examining the use of robotic technology for pelvic exenteration in cases of cervical cancer were included.

DATA COLLECTION AND ANALYSIS

Four studies were included.

MAIN RESULTS

Most cancers treated with robotic-assisted pelvic exenteration were squamous cell carcinomas of the cervix. The stage of primary cancer ranged from IB2 to IVA. In 7 of the 8 patients, anterior pelvic exenteration was performed; the other patient underwent total pelvic exenteration. Procedure duration ranged from 375 to 600 minutes; blood loss was 200-550 mL. Postoperative complications occurred in 2 of the 8 patients and included perineal abscess, Miami pouch fistula, and ureteral stenosis. Postoperative hospital stay ranged from 3 to 53 days, and postoperative follow-up ranged from 2 to 31 months.

CONCLUSIONS

The gold standard for pelvic exenteration remains the open surgical approach; however, the application of robotic technology could be an alternate choice associated with excellent results.

Long-term results of metallic stents for malignant ureteral obstruction in advanced cervical carcinoma

PURPOSE

We present our experience with the use of metallic stents (Wallstents®) in the management of malignant ureteral obstruction to maintain renal function, thereby permitting the use of chemotherapeutic agents to treat the underlying malignancy.

PATIENTS AND METHODS

We retrospectively reviewed the records of 24 patients with ureteral obstruction secondary to advanced cervical carcinoma, stage T3b (n=10) and T4 (n=14), that was relieved by Wallstents. Nineteen patients needed bilateral and 5 needed unilateral Wallstents to relieve the obstruction. Fifty-six additional endourologic interventions were necessary to assure continued patency. Holmium laser ablation was used 14 times to manage tumor proliferation and ingrowth at the distal end of the stent. Thirty-two endostents, 4 extension, and 6 replacement stents were used to maintain patency of the ureter.

RESULTS

Nineteen of our 24 patients received between one and five chemotherapeutic cycles over 18 to 140 months. In five patients, placement of Wallstents did not achieve adequate decrease of the creatinine levels to allow treatment with chemotherapy. Thirteen of 24 Wallstents remained patent over 18 months, yielding a primary patency rate of 54%. Technical success rate of Wallstent placement was 100%. The overall mean primary and secondary patency rates of the stent were 16.5 and 52 months, respectively. For T3b and T4 patients, the mean primary patency rates were 20.6 and 13.6 months, respectively. Secondary patency for T3b patients was 73.9 months vs 36.4 months for T4 patients. There were no serious complications associated with Wallstent placement.

CONCLUSION

Wallstents offer a salutary solution to the problem of maintaining prolonged patency of ureters compromised by encasing neoplasms.

Acute reversible kidney injury secondary to bilateral ureteric obstruction

BACKGROUND

Acute reversible kidney injury (ARKI) secondary to bilateral ureteric obstruction (BUO) is a common urological problem. Our goals were to describe the etiology, management and outcomes of such patients identified between 2006 and 2009 and to compare them with a similar historical study published in 1982.

METHODS

Chart review was performed on 49 patients with AKRI secondary to BUO. ARKI was defined as ≥33% decrease in serum creatinine after intervention. Those with malignant and benign causes of obstruction were identified and management and outcome data were collected.

RESULTS

Of these 49 patients, 83% had BUO secondary to malignancy, 28% of these presenting for the first time. Prevalence of bladder cancer was increased (p = 0.04) and cervix trended lower (p = 0.07) compared with the earlier study; prostate cancer was unchanged (p = 0.51). The average survival was 239 days; 90% of patients died within a year after presenting with BUO from a malignant etiology. Compared with the 1982 group, there were trends towards a decrease in the frequency of retroperitoneal fibrosis (p = 0.08) and an increase in bilateral ureteric calculi (p = 0.16) in the benign group.

CONCLUSIONS

Patients with ARKI secondary to BUO most likely have an underlying malignancy, with almost a third of them being diagnosed for the first time. Prevalence of bladder cancer increased while cervical cancer trended lower. The cause for the former is unclear; the latter may be due to aggressive screening. Prostate cancer remained unchanged despite the widespread implementation of prostate-specific antigen testing. Patients with an underlying malignancy do poorly and those with a newly diagnosed malignancy do worst. Those with ARKI secondary to benign causes did well.

Outcomes of metallic stents for malignant ureteral obstruction

PURPOSE

Malignant ureteral obstruction often necessitates chronic urinary diversion and is associated with high rates of failure with traditional ureteral stents. We evaluated the outcomes of a metallic stent placed for malignant ureteral obstruction and determined the impact of risk factors previously associated with increased failure rates of traditional stents.

MATERIALS AND METHODS

Patients undergoing placement of the metallic Resonance® stent for malignant ureteral obstruction at an academic referral center were identified retrospectively. Stent failure was defined as unplanned stent exchange or nephrostomy tube placement for signs or symptoms of recurrent ureteral obstruction (recurrent hydroureteronephrosis or increasing creatinine). Predictors of time to stent failure were assessed using Cox regression.

RESULTS

A total of 37 stents were placed in 25 patients with malignant ureteral obstruction. Of these stents 12 (35%) were identified to fail. Progressive hydroureteronephrosis and increasing creatinine were the most common signs of stent failure. Three failed stents had migrated distally and no stents required removal for recurrent infection. Patients with evidence of prostate cancer invading the bladder at stent placement were found to have a significantly increased risk of failure (HR 6.50, 95% CI 1.45-29.20, p = 0.015). Notably symptomatic subcapsular hematomas were identified in 3 patients after metallic stent placement.

CONCLUSIONS

Failure rates with a metallic stent are similar to those historically observed with traditional polyurethane based stents in malignant ureteral obstruction. The invasion of prostate cancer in the bladder significantly increases the risk of failure. Patients should be counseled and observed for subcapsular hematoma formation with this device.