Abbreviations & Acronyms LUTS = lower urinary tract symptoms MMS = metal-mesh stents MUO = malignant ureteral obstruction PCN = percutaneous nephrostomy TUS = tandem ureteral stents UTI = urinary tract infection Abstract: Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

BACKGROUND: Men with locally (LAPCa) or regionally advanced (RAPCa) prostate cancer are at high risk of death from their disease. Clinical guidelines support multi-modal approaches, which include radical prostatectomy (RP) followed by radiotherapy (XRT) or radiotherapy plus androgen deprivation therapy (ADT). However, limited data exists comparing these substantially different treatment approaches. Using SEER-Medicare data, we compare survival outcomes and adverse effects associated with RP+XRT vs XRT+ADT in these men. METHODS: SEER-Medicare data was queried for men with cT3-T4, N0, M0 (LAPCa) or cT3-T4, N1, M0 (RAPCa) prostate cancer. Propensity score methods were used to balance cohort characteristics between treatment arms. Survival analyses were analyzed using the Kaplan-Meier method and Cox proportional hazards models. RESULTS: From 1992 to 2009, 13,856 men (≥65 years) were diagnosed with LAPCa or RAPCa, of which 6.1% received RP+XRT vs 23.6% who received XRT+ADT. At a median follow-up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Irrespective of tumor stage and Gleason score, adjusted 10-year prostate cancer-specific survival and 10-year overall survival favored men who underwent RP+XRT when compared to XRT+ADT. However, RP+XRT vs. XRT+ADT was associated with higher rates of erectile dysfunction (28% vs. 20%, p=0.0212, respectively) and urinary incontinence (49% vs. 19%, p<0.001, respectively). CONCLUSIONS: Men with LAPCa or RAPCa treated initially with RP+XRT had a lower risk of prostate cancer-specific death and improved overall survival when compared to those men treated with XRT+ADT, but experienced higher rates of erectile dysfunction and urinary incontinence.

Ureteral stent pain is common and multiple modalities have been studied and are in clinical use for its treatment. Care should be taken to avoid placement of stents if possible, with continual reassessment of indications to maintain stents in patients. Relative heterogeneity among studies and small sample sizes make creating specific evidence-based pain management recommendations challenging. Alpha-blockers, antimuscarinics, and NSAIDs are all generally well tolerated and effectively reduce symptoms, but patient-specific factors must be the paramount consideration when choosing monotherapy or combination therapy. Future studies are needed to better define ideal material characteristics and pharmacologic treatments.