Clinical management of carcinoma of prostate, associated with bilateral ureteral obstruction

Ureteral involvement by metastatic malignant disease

Ureteral metastases from other primary cancers are very rare. Treatment of these metastases is difficult and outcomes are poor. A thorough literature review was done with the aim of finding characteristics that may influence survival rates of patients with ureteral metastases. Systematic literature searches of PubMed and Web of Science were performed in Jan 2019. A total of 79 papers that included 265 patients with cancer metastases to their ureters were finally considered for evidence synthesis. Prostate, bladder, breast, gut cancer and lymphoma were the predominant primary tumors. The median interval time from primary tumor diagnosis to ureter metastasis was 28.5 months. The median survival time after diagnosis of ureter metastasis was 18 months. Risk factors of survival were analyzed. Age, sex, hydronephrosis, ureter side, and segment were not associated with survival. Interval time and treatment were associated with overall survival. Further analysis indicated that patients who underwent surgery had better outcomes.

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents

BACKGROUND AND PURPOSE

Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique.

PATIENTS AND METHODS

Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkin's lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements.

RESULTS

Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested.

CONCLUSION

Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.

[Recanalization of pelvic ureter in prostatic neoplastic obstruction: endoscopic and radiologic approach]

Obstruction of the lower ureter by pelvic cancer requires a palliative treatment. Percutaneous derivation is often performed as an emergency. If obstruction is limited to the peri-meatic area (a few mm or a cm) resection of the ureteral orifice can be enough to catheterize the obstructed ureter. Stenting of the ureter can be done even if the obstruction is longer, using the extra vesical repermeabilization.

METHODS

A guide wire is passed via the nephrostomy, and ureteral stent is passed over the guide wire. Dye additionned with methylene blue is injected tovisualize the lower extremity of the ureter. A regular resectoscope is placed transuretraly, and resection is conducted using X ray localisation with a C arm and several incidences. The tissue resected first is usually extravesical, in the adipous perivesical tissue. Dissection of this area can be performed bluntly with the tip of the resectoscope until the ureter is reached. At this time, the resectoscope is used to open the lower extremity of the ureter, localized with the C arm. It is important to open widely the ureter, so as to be sure to catheterize easily this opening with a ureteral catheter. A double J can then be passed easily. Tunnel of several cm can be performed using this technique.

RESULTS

Seven patients with pelvic cancer with obstruction of the last cm of the pelvic ureter were included in this series. They were recurrent prostate cancer already treated with hormone therapy, stage T3, T4. All procedures were performed under rachianesthesia or general anesthesia according to general status. After this procedure normal miction were obtain in all patients and nephrostomies were removed. This technique is possible for extended pelvic obstruction. Blunt dissection with the endoscope is usualy blood less. This palliative procedure can be done in patients with poor general condition and allows for a better quality of life than nephrostomy or urinary diversions.

Use of dexamethasone for ureteric obstruction in advanced prostate cancer: percutaneous nephrostomies can be avoided

OBJECTIVE

To evaluate the effectiveness of dexamethasone in relieving bilateral lower ureteric obstruction in the acute phase of renal failure secondary to locally advanced prostate cancer.

PATIENTS AND METHODS

This study comprised 11 patients (median age 72 years, range 52-84) presenting with advanced prostate cancer, bilateral ureteric obstruction and gross renal failure. Their response to immediate administration of intravenous followed by oral dexamethasone for 4 weeks, in conjunction with definitive treatment and final outcome, was evaluated.

RESULTS

Renal function improved in 10 patients within 72 h. avoiding the need for insertion of percutaneous nephrostomies. However, four of 10 patients whose renal failure initially improved, failed to respond to definitive therapy, and died 3 to 4 weeks after cessation of the steroids.

CONCLUSION

When administered in the acute phase of renal failure from prostate cancer, dexamethasone may obviate the need for urinary diversion in patients with bilateral ureteric obstruction, particularly in men who will not respond favourably to available forms of therapy for advanced and aggressive disease.

Laparoscopic bilateral cutaneous ureterostomy for palliation of ureteral obstruction caused by advanced pelvic cancer

In cases of advanced urologic malignancies with impairment of renal function secondary to tumor infiltration in high-risk patients, the possibility of performing a laparoscopic instead of an open cutaneous ureterostomy should be considered. We performed laparoscopic cutaneous ureterostomy in three male patients, two with prostate cancer and one with bladder cancer, and in one female patient with uterine cancer. Five operative ports were used. The ureters were identified, dissected, severed, and passed through two 10-mm ports; and cutaneous ureterostomies were performed in the usual manner. The mean operative time was 96 minutes. Patients were discharged after 5 to 7 (mean 6) days. The two patients with prostate cancer are now in treatment with GnRH analogues with a follow-up of 3 and 7 months. The patient with bladder cancer underwent palliative radiotherapy and is well after 6 months. The patient with uterine cancer has stable disease after 3 months. Laparoscopic urinary diversion causes less discomfort and has a low complication rate and may be the first-choice diversion in patients with advanced cancer who have a life expectancy longer than 6 months.

Hormonal treatment of obstructed kidneys in patients with prostatic cancer

A review of 1288 patients with previously untreated prostatic cancer revealed 209 patients (16%) with ureteric obstruction; the obstruction was bilateral in 36%. The effect of hormonal treatment was assessed in 88 patients with 120 obstructed kidneys: 77 patients had androgen deprivation or hormonal medication alone and 11 patients needed percutaneous nephrostomy or ureteric catheters in addition. Drainage improved in 58% of the kidneys. The diverting catheter was withdrawn in 9 of the 11 patients after a median of 4 weeks. In all, 95% of patients were discharged. The patients with hormonal therapy alone survived for a median of 26 months (range 1-111), while the patients who also needed diversion survived for a median of 13 months (range 1-28). The median time spent at home was 24 months (0-102) and 10 months (0-23) respectively, presumably reflecting the worse general condition of the patients who required diversion.

Outcome and prognostic factors in patients with advanced prostate cancer and obstructive uropathy

In a series of 51 patients with prostate cancer and obstructive uropathy, unilateral or bilateral obstruction was identified in 22 (43%) and 29 (57%) respectively. This included a non-functioning kidney in 12 patients. In 86% of patients the T category was advanced. Bone metastases were present in 36 cases (71%); 19 patients (37%) had chronic retention. All patients with metastatic disease underwent hormonal manipulation and 43 underwent transurethral resection of the prostate. External beam radiotherapy, percutaneous nephrostomy and ureteric reimplantation were performed in 4, 5 and 1 patient respectively. Actuarial survival of all 51 patients was 57 and 25% at 2 and 5 years. Presentation with bilateral or non-function did not predict a worse prognosis in comparison with patients with unilateral hydroureteronephrosis. Raised alkaline phosphatase and prostatic acid phosphatase were of no prognostic value, while creatinine reached marginal significance. A positive bone scan and raised urea were strongly predictive of a poor outlook. It was concluded that prostate cancer and obstructive uropathy should not uniformly imply a terminal event, and interventional therapy is justified with a 25% 5-year survival rate.

Palliative percutaneous and endoscopic urinary diversion for malignant ureteral obstruction

We performed a retrospective analysis of 22 patients with malignant ureteral obstruction who underwent palliative urinary diversion by retrograde ureteral stenting or nephrostomy tube placement. The average duration of survival after diversion was 526 days and was unrelated to tumor type, patient's age or sex, renal function, or indications for diversion. As a group, patients without previous hormonal or chemotherapy survived longer. Morbidity related to the urinary diversion was low. The majority of patients (77%) were discharged from the hospital, and this group spent 86 percent of their survival time at home. We conclude that modern palliative urinary diversion can be performed with low morbidity and can result in long-term survival and improved quality of life. Predictions or assumptions concerning survival of individual patients should be made with caution.

Ureteral obstruction associated with prostate cancer: the outcome after percutaneous nephrostomy

We retrospectively reviewed the outcome of 37 prostate cancer patients with ureteral obstruction treated by percutaneous nephrostomy. The over-all survival was 57% at 1 year and 29% at 2 years (median survival time 21 months). The 1 and 2-year survival rates of 15 patients with no prior hormonal therapy were 73 and 47%, respectively, while those of patients who had previously received hormonal therapy were 48 and 19%, respectively. Median survival times of these groups were 24 months and 12 months, respectively. Of 12 patients who had severe renal failure before percutaneous nephrostomy (serum creatinine greater than or equal to 6.9 mg. per dl.) 9 had an adequate return of renal function (serum creatinine less than 3 mg. per dl.) after drainage and 58% survived more than 1 year (median survival time 22 months). Percutaneous nephrostomy is safe and effective in relieving ureteral obstruction and reasonable survival can be achieved even in patients with renal failure. Percutaneous nephrostomy should be considered strongly in these patients.

Percutaneous nephrostomy in the management of malignant ureteric obstruction

A study was made of 16 patients who developed renal failure secondary to ureteric obstruction by tumour. All were managed by percutaneous nephrostomy inserted under local anaesthesia. The results in terms of recovery of renal function, subsequent management and long-term outcome are described.

Nonoperative urinary diversion for malignant ureteral obstruction

The management of malignant ureteral obstruction (MUO) has undergone major changes due to the availability of percutaneous drainage techniques and new ureteral stents for endoscopic insertion. These procedures are less morbid than conventional surgical techniques so that the indications for urinary diversion due to untreated or relapsing malignancy have to be reconsidered. During the period of technological change from 1978 to 1984, 135 patients with unilateral (37) or bilateral (98) MUO were managed. Open nephrostomy is now almost never necessary. Initial retrograde ureteral stenting (RS) was successful under local anaesthesia in 41% of patients. Forty-seven had percutaneous nephrostomy (PN), nine of whom underwent antegrade ureteral stenting (AS) and elimination of external appliances. Twenty-nine patients underwent miscellaneous open procedures mostly in the earlier years, with a 57% morbidity rate compared to the minimal morbidity associated with the newer techniques. The overall mean survival post diversion was 9.9 months, which is significantly longer than that reported using open procedures. MUO can now be successfully relieved with little morbidity and frequently without the use of external urine collection devices. The relative ease of diversion can complicate decision making in patients with progressive renal failure due to bilateral MUO.

Percutaneous nephrostomy for palliation of metastatic ureteral obstruction

Urinary diversion for palliation of metastatic ureteral obstruction has been associated with high rates of morbidity and mortality, especially with open surgical nephrostomies. An evaluation of percutaneous nephrostomy drainage for the palliation of metastatic ureteral obstruction in 27 patients revealed an increase in survival with decreased morbidity, and a follow-up ranging from three to twenty-five months. The mean survival of all patients was 6.63 months (N = 19), with 8 patients still alive. The histology was the main determinant of length of survival, with prostate, rectal, and cervical cancer patients surviving the longest. The perioperative mortality was 11.1 per cent (3/27), and the postoperative complications consisted of hemorrhage requiring transfusion 29.6 per cent (8/27), gastrointestinal bleeding 3.7 per cent (1/27), and dislodged nephrostomy tubes 44.4 per cent (12/27). Percutaneous nephrostomy drainage is a less morbid procedure than open surgical procedures, and the main determinant of length of survival is the histology of the primary tumor in patients with metastatic ureteral obstruction.

Palliative nephrostomy for relief of ureteral obstruction secondary to malignancy

A mean survival of 7.6 months in 20 patients undergoing nephrostomy for relief of ureteral obstruction from advanced pelvic malignancy was not as dismal as previous reports have indicated. Patients with bilateral ureteral obstruction from direct extension of pelvic malignancy survived considerably longer and appear to be the best candidates for nephrostomy. The physician must be cautious in advising the procedure to patients with bilateral ureteral obstruction from disseminated disease originating outside the pelvis since mean survival in this group (3 patients) was less than one month. Nephrostomies were associated with a significant incidence of perinephric abscess (15 per cent) emphasizing the technical aspect of accurate placement to avoid leakage of potentially infected urine.

Palliative urinary diversion

With the development of nonsurgical methods of urinary diversion and the availability of new and more effective methods for treating cancer, an increasing number of patients will be candidates for palliative urinary diversion. Urinary diversion is clearly indicated to provide the time necessary to establish the correct diagnosis, to treat pain or sepsis, and to provide time for other treatments to control the underlying disease. When diversion is being considered solely for the purpose of treating uremia and the tumor has proved to be refractory to all known effective forms of treatment, the decision about whether to perform a diversion must be based on the individual circumstances of the patient including the age, type of tumor, and social and economic considerations. Methods of internal diversion such as ureteral stents are preferred when feasible. Percutaneous nephrectomy may be useful when internal diversion cannot be accomplished or when it can be anticipated that the diversion will be only temporary. When permanent diversion is required, loop cutaneous ureterostomy using the better kidney or bilateral cutaneous ureterostomy is effective only when the ureters are dilated. Diversion into an ileal segment is necessary when the ureters are of normal caliber.

Intermittent hemodialysis therapy in the cancer patient

The occurrence of renal failure in the cancer patient presents a series of medical, technical, philosophical, and logistic problems that are rarely found in other patient population groups. In a review of 70 cancer patients requiring intermittent hemodialysis therapy at Roswell Park Memorial Institute over the last 6 years for acute renal failure, 46 (65.7%) of the patients were salvaged from renal failure to allow the use of further therapeutic modalities for their neoplastic disease. Patient survival after successful intermittent hemodialysis therapy was comparable to that expected in the nonazotemic cancer patients submitted to similar anticancer therapy. Hemodialysis should, therefore, be considered and offered in selected cancer patients in acute renal failure.

Reimplantation of the ureter in prostatic carcinoma associated with bilateral ureteric obstruction

Bilateral ureteric obstruction from prostatic carcinoma is not uncommon. A number of techniques for urinary diversion have been used in selected patients when uraemia develops. Reimplantation of the ureter(s) as an alternative to urinary diversion has been carried out in 21 patients over a 7-year period. In 6 of these patients bilateral reimplantation was done. In another 6 patients reimplantation of the ureter was not possible and cutaneous ureterostomy was carried out. The overall survival time was 10.6 months. In 13 patients living more than 6 months post-operatively, survival time was 1.8 years. Most patients had severe uraemia and advanced (clinical stage III or IV) prostatic carcinoma. The immediate management of these patients is outlined and the importance should be considered is stress. It is concluded that, whenever possible, ureteric reimplantation should be considered for relieving ureteric obstruction in patients selected for active treatment.

Nephrostomy in cancer patients: to do or not to do?

One hundred patients who have had nephrostomies performed for obstructive uropathy in the presence of extensive carcinoma have been retrospectively analysed. Patients with prostatic and cervical carcinoma had a moderately good long-term survival and quality of life, but those with bladder carcinoma or other primary sites had poor results. Significant factors in the selection of patients for nephrostomy drainage in the presence of pelvic cancer are discussed.

The use of percutaneous nephrostomy in 42 patients

Percutaneous nephrostomy has been used for the diagnosis and treatment of 42 patients with obstructive uropathy. Bilateral puncture was done in 6 cases and this was the sole means of establishing permanent urinary diversion in 8.

Palliative urinary diversion for malignant ureteral obstruction

An analysis of 62 palliative urinary diversions for malignant ureteral obstruction is presented. The average postoperative survival was 187 days. Cell type, duration of known disease, tumor grade and stage, renal function and previous therapy did not strongly influence survival. Renal function returned to normal in 64 per cent of the azotemic patients. Morbidity and mortality rates were high, largely because of underlying disease and adjuvant therapy . Nearly two-thirds of the patients left the hospital and this group subsequently spent 84 per cent of their remaining survival time at home. A criterion is presented for patient selection and suggestions are made for the selection of an operative procedure.

Ureteroneocystostomy for bilateral ureteral obstruction in carcinoma of prostate

"Fish-mouth" ureteroneocystostomy was successful in a patient with bilateral ureteral obstruction secondary to locally invasive adenocarcinoma of the prostate. The complications of permanent intubation are avoided and renal function is restored.

Ureteral obstruction from prostatic carcinoma: response to endocrine and radiation therapy

Ureteral obstruction occurred in 10% of the patients treated for prostatic carcinoma and most often was associated with poorly differentiated tumors. The response of ureteral obstruction to different forms of therapy was evaluated. Obstruction diminished in 22 of 25 orchiectomized patients (88%) but in only 1 of 6 patients receiving estrogen or antiandrogen therapy alone (17%). Patients who responded favorably to therapy had a significantly better survival than did non-responders. Patients treated early in the course of ureteral obstruction responded better than those treated late, while neither tumor stage nor grade correlated with response to therapy. Radiation therapy for endocrine-resistant ureteral obstruction was effective in only 2 of 8 cases (25%). The literature on ureteral obstruction from prostatic carcinoma and its treatment is reviewed.

Hemodialysis in patients with carcinoma

All patients who underwent hemodialysis as part of their treatment for cancer at Roswell Park Memorial Institute from 1965 to 1974 were retrospectively studied to determine the value of hemodialysis in cancer patients. Approximately 25% (8 cases) lived 5 weeks or longer in spite of advanced renal failure and carcinoma with no severe complications. The longest survivor is still alive after ten years.