Management of extrinsic malignant ureteral obstruction with urinary diversion

Abstract

Objective: The effectiveness of urinary diversion for patients with renal insufficiency due to extrinsic ureteral obstruction was assessed. Methods: Between 1990 and 2003, 30 males and 45 females, ranging 36-90 years of age (average, 62.7) who had secondary ureteral obstruction due to either a retroperitoneal or pelvic invasion of malignant disease, underwent nephrostomy or ureteral stenting using a double-J stent without side holes. Results: Ureteral stenting was attempted as an initial procedure in 51 of the 75 cases. The remaining 24 cases had a nephrostomy at the first step. Of 51, 37 cases were successfully stented , while internal stenting was unsuccessful in the remaining 14 cases. These 14 cases were treated with nephrostomy at the second step following the unsuccessful internal stenting. Eight cases of the 37 successfully stented cases were eventually changed to a nephrostomy because of catheter trouble. As a result, 29 cases could be managed by internal ureteral stenting up until the end of their life. The follow-up period for the 75 cases who underwent urinary diversion ranged from 5 days to 19 months, averaging 5.7 months. The average period from diversion to death was 5.6 months in the internally stented group and 5.9 months in the nephrostomy group. Conclusion:The high patency rate of the internal ureteral stent in our cases might be due to our use of a stent without shaft vent holes.

Predicting the failure of retrograde ureteral stent insertion for managing malignant ureteral obstruction in outpatients

“…In a previous study of 61 advanced malignancies, the stent failed to indwell in 21.3% of patients and 17.9% of UUs (4). In addition, in a study reporting 14 years of experience in the management of extrinsic ureteral obstruction, 27.5% of UUs with MUO had insertion failure (11). By contrast, in one study published in 2008, only 12.2% of UUs with MUO had insertion failure (7).…”

“…The use of ureteral stents to bypass the obstruction is common in clinical practice, and RUS is more advantageous than PCN, particularly in view of the limited life expectancy of patients with advanced malignancies (3,4,7). However, the incidence of insertion failure is markedly higher in cases of MUO, ranging from 15.0 to 27.5% (3)(4)(5)(6)(7)(8)(9)(10)(11)(12). This high failure rate may be associated with extrinsic compression or invasion of the ureter by tumors, which may lead to the bending and deformation of the ureter, which then increases resistance during intubation in the majority of advanced malignancies (15).…”

“…Stent failure was defined as any ureteral unit (UU) in which stent insertion failed or any UU that continued to cause symptoms for the patient after stent placement (3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Stents were inserted by three experienced urological surgeons on an outpatient basis, using local anesthesia.…”

“…The advantages of this procedure are its simplicity and convenience, with no requirement for hospitalization, and a cheaper cost. However, cystoscopic ureteral stent insertion is a challenging procedure even for the most experienced urologists, with a mean failure rate of 15.0-27.5% (3)(4)(5)(6)(7)(8)(9)(10)(11)(12).…”

Endourologic Management of Malignant Ureteral Obstruction: Indications, Results, and Quality-of-Life Issues

“…PCN should also be opted for in cases of significant involvement of the bladder by bladder or prostate tumor where attempts at identification of the ureteral orifice and stent placement of the ureter are usually unsuccessful. 3,[30][31][32][33][34][35] Other contraindications to retrograde stent placement include gross bladder hemorrhage or difficulty in reaching the bladder because of previous surgery or anatomic anomalies.…”