Ureteral obstruction secondary to neoplastic pathology

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1 Rev Mex Urol 2013;73(1):17-21 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA Original article Ureteral obstruction secondary to neoplastic pathology Castellanos-Hernández Hibert, a Solares-Sánchez Mario Emanuel, b Ramírez-Santos JG, c Sánchez-Turati José Gustavo, a Martínez-Cervera Pedro Fernando, b Jiménez-Ríos Miguel Ángel. a,b,* a Advanced Specialization Course in Oncologic Urology, Instituto Nacional de Cancerología. Mexico City, Mexico. b Department of Oncologic Urology, Instituto Nacional de Cancerología. Mexico City, Mexico. c Urology Specialty, Programa Multicéntrico Secretaría de Salud, Nuevo León-Tec. de Monterrey. Monterrey, N.L., Mexico. KEYWORDS Obstruction, ureteral, pathology, neoplastic, Mexico. Abstract Background: Malignant ureteral obstruction is a fatal event associated with advanced disease that is often incurable. The causes include extrinsic tumor compression, retroperitoneal lymphadenopathy, or direct tumor invasion. The process is slow and symptoms are vague and nonspecific. Decompression is palliative and is achieved through percutaneous nephrostomy, ureteral catheter, or both, and is a recognized method for improving renal function with low morbidity that has a positive impact on patient quality of life. Objective: To describe the frequency of ureteral obstruction secondary to neoplastic pathology observed at the Department of Urology of the Instituto Nacional de Cancerología. Methods: A descriptive, observational, retrolective cross-sectional study was carried out through a review of the case records of patients that had undergone double-j catheter placement or replacement or nephrostomy catheter replacement for urinary diversion due to ureteral obstruction secondary to neoplastic pathology. The variables of age, sex, type of neoplasia, serum creatinine values prior to catheter placement, and survival were analyzed. Results: The case records of 100 patients were reviewed. Eighty-one percent were women and 19% were men, with a mean age of 48 years ± 13. The most frequent neoplasia causing obstruction was cervical cancer in 68% of the cases. Forty percent of the tumors were in clinical stage III. The mean creatinine value was 4.1 ± 3.7 mg/dl prior to diversion, and 1.56 ± 1.41 mg/ dl after. Only 2% of the patients presented with procedure-related complications. Fifty-six patients are alive at present, whereas 44 died, with a mean survival period of 30.3 months. Discussion: In our study the mean survival period was 30.3 months, underlining the importance of palliative measures as the final support in the quality of life of these patients. In addition, the main cause of ureteral obstruction was found to be cervical cancer. * Corresponding author: Av. San Fernando N 22, Colonia Sección XVI, Delegación Tlalpan, C.P , México D.F., México. Telephone: (52) Fax: address: drmajr@prodigy.net.mx see front matter Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados.

2 18 H. Castellanos-Hernández et al Palabras clave Obstrucción, ureteral, patología, neoplásica, México. Obstrucción ureteral secundaria a patología neoplásica Resumen Introducción: La obstrucción ureteral maligna es un evento funesto, asociado con enfermedad avanzada y a menudo incurable. Las causas incluyen compresión extrínseca del tumor, linfadenopatía retroperitoneal o invasión directa del tumor. Es un proceso lento, con síntomas vagos e inespecíficos, la descompresión paliativa por nefrostomía percutánea, catéter ureteral o ambas, es un método reconocido para mejorar la función renal con baja morbilidad, que impacta de manera positiva en la calidad de vida del paciente. Objetivo: Describir la frecuencia de obstrucción ureteral secundaria a patología neoplásica, observada en el Departamento de Urología del Instituto Nacional de Cancerología. Material y métodos: Se realizó un estudio observacional, retrolectivo, transversal y descriptivo, revisando el expediente de pacientes a quien se realizó cambio o colocación de catéter ureteral JJ o cambio de sonda de nefrostomía para derivación urinaria, por obstrucción ureteral secundaria a patología neoplásica. Se analizaron variables como edad, género, tipo de neoplasia, cifras de creatinina sérica, previo a la colocación de catéteres, así como supervivencia Resultados: Se revisaron los expediente de 100 pacientes, 81% eran mujeres y 19% hombres; la media de edad fue de 48 ± 13 años. El tipo de neoplasia más frecuente que generó obstrucción fue el cáncer cervicouterino en el 68% de los casos. El 40% de los tumores se encontraban en etapa clínica III. La media de la cifra de creatinina previo a la derivación fue de 4.1 ± 3.7 mg/ dl, y posterior fue de 1.56 ± 1.41 mg/dl. Sólo el 2% presentó complicaciones debidas al procedimiento. El número de pacientes vivos a la fecha es de 56, mientras que 44 fallecieron, con una media de 30.3 meses. Discusión: En nuestro estudio, la media de supervivencia fue de 30.3 meses. Esto resalta la importancia que tienen las medidas paliativas, como el sostén final en la calidad de vida de estos pacientes. También se encontró que, el cáncer cervicouterino en estadios avanzados es la principal causa de obstrucción ureteral. Introduction Malignant ureteral obstruction is a fatal event that is usually associated with advanced disease and is often incurable. The obstruction can clinically present as urosepsis, kidney failure, or localized pain, or it can be diagnosed during the staging of a tumor or during kidney failure evaluation. The causes include extrinsic tumor compression, retroperitoneal lymphadenopathy, or direct tumor invasion. 1 Generally the patients presenting with malignant ureteral compression have comorbidities and a mean survival period of 3 to 7 months. Therefore, outcome, quality of life, and complications are important factors to be taken into account. 2 Symptom presentation is quite varied and mainly depends on the acuteness of the underlying problem. In many instances, ureteral obstruction is a slow process, with vague and nonspecific symptoms such as flank discomfort and lethargy. Acute obstruction can present with intense pain, nausea, and vomiting. 3 Palliative decompression of the urinary system obstruction, whether by percutaneous nephrostomy, ureteral catheter, or both, is a recognized method for improving renal function with low morbidity that has a positive impact on patient quality of life. Nevertheless, the draining of such obstructed systems leads to an ethical dilemma: will draining facilitate chemotherapy or radiotherapy treatment or will it perpetuate and allow the development of other problems? 4 The answer to this difficult question could be that palliative urinary diversion indications should always be individualized in each particular case. 5 Even though ureteral obstruction can be one of the most painful conditions treated by physicians, the incidence of this pathology in patients with advanced malignant disease is not known. The present study was carried out precisely due to the lack of reported figures on the frequency of ureteral obstruction secondary to neoplastic pathology, the types of tumors that can cause it, the stage in which they are found, and the most feasible type of urinary diversion in our environment. Methods A descriptive, observational, retrolective, cross-sectional study was conducted in which 122 case records were reviewed of patients that had been seen at the cystoscopy service of the Department of Urology of the Instituto Nacional de Cancerología, for double-j placement or replacement or for the replacement of a nephrostomy catheter due to ureteral obstruction secondary to neoplastic pathology. The medical records reviewed belonged to the period of March 2008 to June Patients were excluded if they required a ureteral catheter for ureteral lesions, upper urinary diversion due to urinary fistulas, and if they presented with lithiasis or ureterointestinal anastomosis stricture in the ileal conduit.

3 Ureteral obstruction secondary to neoplastic pathology 19 Table 1 Description of the study population Variable n=100 Sex Men 19 (19%) Women 81(81%) Age (years) 48±13 Type of neoplasia Cervical 68% Testis with retroperitoneal activity 8% Lymphoma 6% Rectum 6% Ovary 4% Retroperitoneal sarcomas 2% Colon 2% Bladder 1% Pancreas 1% Stomach 1% Primary disease unknown 1% Side of obstruction Right 28% Left 19% Bilateral 53% Type of diversion Double-J catheter 51% Percutaneous nephrostomy 42% Both procedures 7% The variables of age, sex, type of neoplasia, serum creatinine values before and after urinary diversion, hemoglobin and albumin values prior to catheter placement, urinary decompression modality, the presence or absence of metastasis before diversion, functional status, hydronephrosis grade, side of the obstruction, disease stage at the time of diversion, and the presence or absence of ascitis or pleural hemorrhage before the urinary diversion. The patient survival period and the length of time from obstruction diagnosis to urinary diversion were also analyzed. The demographic data were analyzed through descriptive statistics with the SPSS version 17 statistical program and the Student s t test was used to analyze the qualitative data. Results A total of 122 patients with medical records from the unit were analyzed. Twenty-two patients were excluded: nine of them for having undergone urinary diversion due to urinary fistulas, six with diversion due to intraoperative ureteral Table 2 Frequency and percentage of the clinical stage of the tumor Stage N=100 I 12 (12%) II 20 (20%) III 40 (40%) IV 13 (13%) Not able to be staged 5 (5%) Information not available 10 (10%) injury, three due to lithiasis, and four that presented with ureterointestinal anastomosis stricture in the ileal conduit. This left 100 patients in the study, 81% of whom were women and 19% men with a mean age of 48 years ± 13. (Table 1). The most frequent type of neoplasia that caused obstruction was cervical cancer in 68% of the cases, followed by testicular cancer with retroperitoneal activity in 8%, lymphoma 6%, rectal cancer 6%, ovarian cancer 4%, retroperitoneal sarcomas 2%, colon cancer 2%, bladder cancer 1%, cancer of the pancreas 1%, gastric cancer 1%, and unknown primary tumor 1%. Fifty-three percent of the obstructions were bilateral, 28% were situated on the right side, and 19% on the left side. Fifty-one percent of the patients had double-j catheter diversion, 42% required percutaneous nephrostomy, and 7% required both diversion methods. Twelve percent of the tumors were stage I, 20% stage II, 40% stage III, and 13% stage IV. Staging was not possible in 5% of the cases and this information was lacking in 10% of the patients (Table 2). The mean creatinine value was 4.1 ± 3.7 mg/dl before urinary diversion and 1.56 ± 1.41 mg/dl after the procedure. The paired Student s t test was used as a summary measure and there was a statistically significant descent with p < The mean hemoglobin value before diversion was 11±2.4 g and the mean albumin value was 3.1±0.7 mg (Table 3). Twenty-four patients (24%) presented with metastatic disease prior to diversion placement. Sixteen patients (16%) developed metastasis after diversion placement, nine (9%) patients presented with ascitis, and seven (7%) had pleural hemorrhage before the diversion. Only two patients (2%) had the procedure-related complications of ureteral perforation during double-j catheter placement. In regard to hydronephrosis grade: four patients (4%) presented with grade 1 hydronephrosis, 30 patients (30%) grade 2, 35 patients (35%) grade 3, and 31 patients (31%) with grade 4. In relation to functional status, 22 patients (22%) had an Eastern Cooperative Oncology Group (ECOG) performance score of 0, 48 patients (48%) had an ECOG of 1, 27 patients (27%) had an ECOG of 2, and 3 patients (3%) had an ECOG of 3 (Table 4).

4 20 H. Castellanos-Hernández et al Table 3 Mean creatinine before and after urinary diversion Forty-two patients (42%) presented with recurrence, after diversion placement. Eighteen patients (18%) experienced dysfunction of the diversion system employed, and 79 patients still have the diversion in place or had it up until their deaths. The number of patients presently alive is 56, whereas 44 died, with a survival interval of months and a mean of 30.3 months. The time interval between obstruction diagnosis and diversion was from one to 83 days with a mean of 10.2 days. Discussion Variable N=100 Serum creatinine before the diversion (mg/dl) Serum creatinine after the diversion (mg/dl) *paired t (p=<0.0001). 4.1 ± 3.7 *1.58 ± 1.41 Patients with advanced disease are often poor candidates for surgery and their procedures are not exempt from potential morbidity. In our study, the mean period of survival was 30.3 months, underlining the importance of palliative measures as the final support in the quality of life of these patients. We found gynecologic tumors to be the main cause of ureteral obstruction secondary to neoplastic processes, and the most frequent of them was cervical cancer that generally presented in advanced stage. Therefore, the expected outcome and quality of life are important factors to consider in these patients, since both types of diversion have similar complication rates. 2 Quality of life can diminish after the placement of a percutaneous nephrostomy or ureteral catheter, the former presenting with application problems such as leakage or tube movement or exit, and the latter may not completely resolve the problem or relieve the obstruction, leading to subsequent procedures and an increase in morbidity. 3 But in general, there is no significant difference in quality of life and associated morbidities between the two procedures. 6,7 It must simply be taken into account that the patients with nephrostomies require greater attention in catheter and drainage bag care, whereas the patients with ureteral catheter experience more irritative symptoms and local discomfort. Malignant obstruction of an organ can be a serious event that threatens the life of patients in the final stages of neoplasia. As with any palliative intervention, the comfort and quality of life of the patient should be considered before performing any urologic procedure, because unfortunately many of them will not extend the life expectancy of these patients. Therefore it is important to Table 4 Complication frequency and percentage, hydronephrosis grade, and functional status of the study population Variable N=100 Complications 2 (2%) Hydronephrosis grade Grade 1 4 (4%) Grade 2 30 (30%) Grade 3 35 (35%) Grade 4 31 (31%) ECOG 0 22 (22%) 1 48 (48%) 2 27 (27%) 3 3 (3%) ECOG: Eastern Cooperative Oncology group consider how these procedures affect the general wellbeing of the patient. 8 Expressly, the management of malignant extrinsic ureteral obstruction is a difficult situation in which the urologist must put in the balance patient quality of life, preservation of renal function, and the complication risk, with the likelihood of a poor outcome. And even though there are many options, there is no consensus on the optimum management for this pathology. 2 Conclusions Presently, ureteral obstruction secondary to neoplastic processes is a subject that is mistakenly given very little attention, ignoring the fact that this entity can reduce the survival and quality of life of the patients presenting with some type of oncologic pathology that causes obstruction. And if such obstruction is susceptible to decompression, it should not be forgotten that indications for palliative urinary diversion should always be made on an individual basis for each patient. Conflict of Interest The authors declare that there is no conflict of interest. Financial disclosure No financial support was received in relation to this article. References 1. Wong LM, Cleeve LK, Milner AD, et al. Malignant Ureteral Obstruction: Outcomes After Intervention. Have Things Changed? J Urol 2007;178(1):

5 Ureteral obstruction secondary to neoplastic pathology Ganatra AM, Loughlin KR. The Management Of Malignant Ureteral ObstructionTreated With Ureteral Stents. J Urol 2005;174(6): Kouba E, Wallen EM, Pruthi RS. Management of Ureteral Obstruction Due to Advanced Malignancy: Optimizing Therapeutic and Palliative Outcomes. J Pharmacol Exp Ther 1972;180(1): Wilson JR, Urwin GH, Stower MJ. The Role of Percutaneous Nephrostomy in Malignant Ureteric Obstruction. Ann R Coll Surg Engl 2005;87(1): Ishioka J, Kageyama Y, Inoue M, et al. Prognostic Model for Predicting Survival After Palliative Urinary Diversion for Ureteral Obstruction: Analysis of 140 Cases. J Urol 2008;180(2): Joshi HB, Adams S, Obadeyi OO, et al. Nephrostomy tube or JJ ureteric stent in ureteric obstruction: assessment of patient perspectives using quality-of-life survey and utility analysis. Eur Urol 2001;39(6): Ku JH, Lee SW, Jeon HG, et al. Percutaneous nephrostomy versus indwelling ureteral stents in the management of extrinsic ureteral obstruction in advanced malignancies: are there differences? Urology 2004;64(5): Sato KT, Takehana C. Palliative Nonvascular Interventions. Semin Intervent Radiol 2007;24(4):

Current Outcome of Patients With Ureteral Stents for the Management of Malignant Ureteral Obstruction

Current Outcome of Patients With Ureteral Stents for the Management of Malignant Ureteral Obstruction Kouji Izumi,* Atsushi Mizokami, Yuji Maeda, Eitetsu Koh and Mikio Namiki From the Department of Integrative