Nephrostomy insertion for patients with bilateral ureteric obstruction caused by prostate cancer

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1 The British Journal of Radiology, 82 (2009), Nephrostomy insertion for patients with bilateral ureteric obstruction caused by prostate cancer 1 J NARICULAM, MBBS, MRCS, 2 D G MURPHY, MBBS, MD, FRCS, 3 C JENNER, RGN, 3 N SELLARS, MBBS, MRCP, FRCR, 3 S GWYTHER, MBBS, FRCS, FRCR, 4 S G GORDON, FRCS and 3 M J SWINN, BSc, MBBS, FRCS, MSc, MD, FRCS (UROL) 1 St Helier Hospital, Carshalton, Surrey, 2 Guy s Hospital, London, 3 East Surrey Hospital, Redhill and 4 Epsom and St Helier NHS Trust, Epsom, Surrey, UK ABSTRACT. Ureteric obstruction causing renal failure is a serious complication of advanced prostate cancer. Percutaneous nephrostomies (PCNs) are used to decompress the obstructed kidney(s). This study aims to identify whether bilateral PCN insertion confers any advantage over unilateral PCN insertion for patients with bilateral ureteric obstruction. In a cohort of 25 patients, 18 underwent bilateral and 7 underwent unilateral PCN insertion. The mean survival time following PCN was 7.5 months for all patients. The data suggest that the nadir serum creatinine after PCN insertion was similar, independent of whether one or two nephrostomies were inserted. There was also little difference in the serum creatinine levels at the time of death, suggesting that survival after PCN insertion is based on the aggressiveness of the prostate cancer as opposed to the number of nephrostomies inserted. Received 13 March 2008 Revised 3 July 2008 Accepted 22 August 2008 DOI: /bjr/ The British Institute of Radiology Between 3% and 16% of patients treated for locally advanced prostate cancer develop ureteric obstruction as a result of local tumour spread [1 6]. Prostate cancer tissue invades the trigone of the bladder, involving the ureteric orifice (80% of cases) or the lower third of the ureter (20%), and causing obstruction of either or both of the ureters [7, 8]. Ureteric drainage may also be impaired by lymph node metastases [9]. As a result, ureteric pressure increases and hydroureter and hydronephrosis ensue, leading ultimately to renal failure. If immediate intervention is not performed, these patients are likely to die from acute renal failure. Once renal function has improved, nephrostomies are commonly removed after antegrade ureteric stenting has taken place. This form of management had been a source of debate over the years, with some studies concluding that percutaneous nephrostomy (PCN) is of little benefit in patients with advanced disease and should be used only in exceptional circumstances [1, 6, 10]. Others have suggested that PCN decompression for patients with advanced prostate cancer may confer benefit [11 15]. This is confirmed by a review of the management of patients with hormone-refractory prostate cancer, acknowledging that PCN offers effective, if short-term, improvement in renal function [16]. To our knowledge, the issue of bilateral vs unilateral PCN in patients with bilateral ureteric obstruction caused by advanced prostate cancer has not been investigated. Complications of PCN insertion occur in 4 26% of procedures [6, 17, 18] and include malposition, dislodgement or occlusion of the tube. Occlusion may result from Address correspondence to: Joseph Nariculam, Flat 3, Lodden Lodge, 10 Devonshire Avenue, Sutton SM2 5JL, UK. jnariculam@yahoo.co.uk blood clot formation in the pelviureteric junction. Urinary sepsis, in the form of ascending infection, and, rarely, perirenal haematoma may also occur as a consequence of insertion. Other treatments have been performed for patients presenting with ureteric obstruction as a consequence of advanced prostate cancer. If obstruction is caused by nodal masses or bladder infiltration, local treatments such as radiotherapy can be effective in up to 70% of men [19]. This treatment, however, takes an average of 4 5 weeks to be effective. In a study of 11 patients receiving intravenous dexamethasone during the acute phase of renal failure, an improvement in renal function occurred within 72 h in 10 of the patients, obviating the need for PCN [20]. Within 4 weeks of cessation of the steroids, 4 out of the 10 patients had died, having failed to respond to definitive therapy. It is our impression that there is no consistency between different urology departments in the UK when deciding whether to insert PCN unilaterally or bilaterally. This study sought to quantify the duration of response following PCN insertion and to identify whether bilateral PCN insertion confers any advantage over unilateral PCN insertion in patients with bilateral ureteric obstruction. Methods The names of all patients undergoing percutaneous nephrostomy insertion for ureteric obstruction caused by prostate cancer between 1 January 1998 and 31 October 2006 were retrieved. There was a total of 30 patients, but the case notes for five of them were unavailable and these patients were eliminated from the study. The The British Journal of Radiology, July

2 J Nariculam, D G Murphy, C Jenner et al clinical notes of the remaining 25 patients were retrospectively analysed. The following information was retrieved: the date of diagnosis of prostate cancer, the initial diagnostic prostate-specific antigen (PSA) measurement, the diagnostic prostate biopsy Gleason score, the initial staging of the disease and information regarding the initial management of the patient s prostate cancer. Further information obtained included the presenting symptoms, whether patients were hormone refractory/naive, the PSA level at emergency presentation, the pre- and postnephrostomy insertion creatinine level, the pre-nephrostomy ultrasound findings and the urine output of the nephrostomy tubes. The number of patients who had only one nephrostomy tube inserted despite having bilateral hydronephrosis, as well as any complications of the procedure, was recorded. The date of death, where relevant, was noted and the lifespan following PCN insertion calculated. All procedures were performed by a consultant radiologist. An ultrasound scan of the upper renal tract was performed prior to the procedure to confirm bilateral hydronephrosis. Each patient underwent unilateral or bilateral nephrostomy tube insertion with either a size 8 or 10 pigtail catheter. All patients undergoing nephrostomy insertion were given a local anaesthetic and sedation. Results All patients presenting with bilateral ureteric obstruction had acute renal failure. Bilateral obstruction was detected by radiological imaging in all 25 patients (Figure 1). In this cohort, 18 of the patients had known prostate cancer confirmed by histology and, despite androgen deprivation therapy, were hormone refractory at presentation with acute renal failure. In the remaining seven patients, prostate cancer had not been diagnosed, renal failure being the presenting feature of the disease. The mean age and PSA of the patients at diagnosis of prostate cancer was 71 years (range years) and 96.2 ng ml 1 (range ng ml 1 ), respectively, and the mean PSA of the patients on presentation with bilateral obstruction was 116 ng ml 1 (range ng ml 1 ). The mean baseline creatinine levels prior to diagnosis of prostate cancer and on presentation with acute renal failure were 11 mmol ml 1 and 612 mmol ml 1 (range mmol ml 1 ), respectively. The mean potassium level prior to nephrostomy insertion was 5.4 mmol ml 1 (range mmol ml 1 ). 18 patients underwent bilateral PCN insertion and seven patients underwent unilateral PCN insertion for bilateral obstruction. 14 of the 18 patients undergoing bilateral PCN insertion and 4 of the 7 patients undergoing unilateral PCN insertion were hormone refractory at presentation. Figure 1. Flow chart summarising a cohort of 25 patients. PCN, percutaneous nephrostomy. 572 The British Journal of Radiology, July 2009

3 Nephrostomy insertion for patients with advanced prostate cancer Of the 18 patients undergoing bilateral PCN insertion, 12 (66%) had a significantly greater urine output in one PCN than the other. We defined significance as one PCN tube producing more than 75% of the total urine output of both nephrostomies. In the other six patients (34%), there was little difference in the urine output between the nephrostomies. Following nephrostomy insertion, the mean creatinine level of all patients fell to 187 mmol ml 1 (range mmol ml 1 ), taking an average of 10 days to reach this nadir (range 7 14 days). Among patients who underwent either unilateral or bilateral PCN, no major differences in post-pcn creatinine levels were seen (Figure 2, Table 1). In total, 21 out of 25 patients in this study had died by the time retrospective analysis of the data had taken place (Figure 3). The mean time to death following PCN insertion for all 21 patients was 7.5 months (range 10 days to 38 months). Of these 21 patients, 16 patients lived for a mean of 10 months after undergoing bilateral PCN (Table 1). The remaining five patients had undergone unilateral PCN insertion and survived an average of 3 months post PCN insertion (Table 1). The mean survival time for patients post PCN insertion with known prostate cancer treated by hormonal manipulation was 4.5 months (range 10 days to 17 months). The mean survival for patients undiagnosed with prostate cancer and treated with hormones post PCN insertion was 16 months (range 1 38 months). All 21 patients were known to have died from metastatic prostate cancer. Discussion Emergency decompression by PCN insertion can prevent death from renal failure, which also prevents the symptoms of uraemia. In all seven patients who underwent unilateral PCN insertion despite having bilateral hydronephrosis, renal parameters were corrected to the same extent as in those undergoing bilateral PCN insertion. The data revealed no difference in time to resolution of renal parameters depending on whether one or two nephrostomies were inserted. 21 of the patients had died at the time of submission of this paper and the mean survival of these patients post nephrostomy insertion was 235 days. This is different from the results reported by Dowling et al [6], who recorded an average survival of 119 days post PCN insertion in 22 patients, and also those reported by Wilson et al [12], who found an average survival of 87 days in nine patients. In total, 7 out of 21 patients (33%) in our study survived at least 1 year after PCN insertion. These data contrast with those of Chiou et al [21], who reported a 58% survival rate at 1 year. The patients with the shortest lifespan following PCN insertion were those with hormone-refractory disease, but those presenting de novo lived longer [1, 6, 11, 17]. This is presumably explained by the known cytoreductive effect of hormones on the prostate gland [11]. The mean survival post PCN of hormone-relapsed prostate cancer patients in our study was 4.5 months (135 days), with the mean survival of hormone-naive patients being 16 months (496 days). This correlated with the above assumption. Other studies reporting similar results include those by Harris et al [22], who reported a mean time to death of 226 days in the hormone-naive group and 100 days in the hormone-refractory patients, and by Oefelein [4], who reported a mean overall survival of 7 and 24 months for patients with hormone-refractory and hormone-naive disease, respectively. Complications of PCN insertion occurred in 6 of the 25 patients (24%): two patients had malposition of the nephrostomy tube, which led to repositioning, and in one patient the nephrostomy tube fell out and had to be reinserted. In both these patients, urine drained initially from the tubes for up to 24 h, but then ceased. Two patients developed a blood clot in the renal pelvis, which was treated with flushing of the tube, and one patient developed urinary sepsis, which required antibiotic therapy. A significantly greater urine output was found in one nephrostomy tube compared with the other in 12 of the 18 patients (66%) undergoing bilateral PCN. There are various reasons that could explain this finding. One nephrostomy tube may have been blocked by debris or blood clot in the renal pelvis. It must be stressed that an initial decreased urine output in a nephrostomy tube may be physiological due to the time taken for that particular kidney to regenerate function following longstanding obstruction. In the seven patients with bilateral hydronephrosis who received only one nephrostomy tube, it was originally intended to carry out a staged procedure, with a second PCN tube being inserted at a later time. In all seven patients, the solitary nephrostomy tubes drained an average of 1.5 l of urine in 24 h and resulted Table 1. Comparison of mean creatinine nadir values and length of survival following unilateral or bilateral PCN insertion in patients with bilateral ureteric obstruction Unilateral PCN insertion for bilateral obstruction Bilateral PCN insertion One PCN with greater urine output than the other Number of patients Serum creatinine nadir level post-pcn insertion (mmol ml 1 ) Length of survival post-pcn insertion (months) Patients undergoing bilateral PCN were divided into two groups based on urine output of the PCN tubes. PCN, percutaneous nephrostomy. Two PCNs with equal output of both tubes The British Journal of Radiology, July

4 J Nariculam, D G Murphy, C Jenner et al Figure 2. Comparison of mean serum creatinine level before and and after percutaneous nephrostomy (PCN) insertion in patients undergoing unilateral or bilateral PCN insertion for bilateral ureteric obstruction. in a significant drop in serum creatinine. As a result, it was decided not to proceed with PCN insertion on the other side. On retrospective analysis of the radiological imaging data, all patients were demonstrated on ultrasound scanning to have bilateral hydronephrosis. An assessment as to which side had the greater degree of obstruction was made, but this information was not included in all the reports. Furthermore, no comment was made on the thickness of the renal cortex of each kidney in any of the 25 patients. The placement of a PCN tube is safer and more effective the greater the degree of hydronephrosis. However, a more significant hydronephrosis may indicate a longer duration of obstruction with a greater degree of renal impairment. We recommend insertion of one PCN tube in patients with bilateral obstruction and suggest that, if a patient presents with bilateral hydronephrosis, and information regarding renal cortex thickness is reported, a single nephrostomy tube should be placed in the renal pelvis of the kidney with the greater cortical thickness as we assume that this kidney would possess the greater function. If information regarding renal cortex thickness is not available, renal recovery would be best served by draining the least hydronephrotic side. If, following placement of one nephrostomy tube, the urine output after a period of time is reduced or the Figure 3. A comparison of the mean survival (in months) in patients undergoing unilateral or bilateral percutaneous nephrostomy (PCN) insertion for bilateral ureteric obstruction. 574 The British Journal of Radiology, July 2009

5 Nephrostomy insertion for patients with advanced prostate cancer serum creatinine level has not improved significantly, this may suggest that the nephrostomy tube has been placed in a kidney with irrecoverable function. We suggest that in this situation these patients should return to the radiology department for PCN insertion on the contralateral side and that the existing PCN tube should be removed. Insertion of one PCN tube would be beneficial for patients as it reduces morbidity. In situ nephrostomy tubes can be very uncomfortable for patients and can cause complications, as mentioned above. Many of these patients have a reduced lifespan as a consequence of advanced prostate cancer so clinicians should ensure that these patients are kept comfortable as they undergo palliative decompression. The management of patients presenting with acute renal failure as a consequence of ureteric obstruction caused by advanced prostate cancer represents a dilemma for urologists. It has been reported that the development of renal failure in these patients represents an adverse prognostic factor [1, 6, 23]. There have been many papers published describing either the benefits [11, 12 16, 24] or the pitfalls [1, 6, 10] of percutaneous nephrostomy insertion in this group of patients. There is no doubt that patients who are hormone naive at presentation fare better in terms of survival post PCN insertion than similar patients who are hormone refractory [1, 6, 11, 17]. The mean nadir serum creatinine level among the 18 patients undergoing bilateral PCN insertion and the seven patients undergoing unilateral PCN was 182 mmol l 1 and 153 mmol 1, respectively. It was noted that, in the 21 patients who died, the creatinine level was at the time of death similar to the nadir level reached 2 weeks post PCN insertion. This indicates that, although these 21 patients died at different times, with a mean lifespan of 7.5 months, difference in the time to death was more likely to be the result of differences in the aggressiveness of the disease than of the number of nephrostomy tubes inserted. As patients with prostate cancer are known to have a poor prognosis whether or not they undergo PCN insertion, a multidisciplinary team approach should be taken before a decision is made whether or not to insert nephrostomy tubes. If a co-ordinated meeting between the patient, his family, the urologist, the oncologist, the interventional radiologist, the palliative care team and the uro-oncology nurse specialist takes place, then an agreed management plan can be implemented for each individual. Conclusions Our data suggest that, in a patient with bilateral ureteric obstruction and acute renal failure, nadir creatinine levels post PCN do not differ greatly depending on whether one or two nephrostomies are inserted. 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