Obstructive Uropathy from Locally Advanced and Metastatic Prostate Cancer: An Old Problem with New Therapies

Abstract

Despite stage migration to more organ-confined disease in the era of prostate-specific antigen, the complications of advanced prostate cancer are still relatively common. Urinary tract obstruction in advanced and metastatic prostate cancer can have a varied presentation, because it may occur in multiple anatomic locations at any point in the natural history of the disease. In all cases, management depends on the current stage of disease, technical feasibility of potential therapeutic interventions, and overall prognosis of the patient. This review highlights a practical approach to the evaluation, diagnosis, and management of obstructive uropathy from prostate cancer.

Introduction

O bstructive uropathy was once a common presentation for patients with prostate cancer. Fortunately, the introduction of prostate-specific antigen screening in the late 1980s has nearly doubled the number of men with organ-confined disease at the time of diagnosis.¹ Nonetheless, up to 3% of patients still present with locally advanced disease and 1% with metastatic disease.² Because prostate cancer remains the most common solid-organ malignancy in men,³ obstructive uropathy continues to be a problem in prostate cancer management.

Given its decreasing incidence, few articles have been published recently on obstructive uropathy from prostate cancer. Many articles have been published on the topic, however; most have included outdated, morbid treatment modalities, such as open nephrostomy tube placement and ileal conduit urinary diversion. As a result, the authors have performed a comprehensive literature review on obstructive uropathy from prostate cancer with a focus on contemporary endourologic management techniques. A practical approach to the evaluation, diagnosis, and management of obstructive uropathy from prostate cancer will be emphasized.

Materials and Methods

PubMed was used to identify English language articles related to the evaluation, diagnosis, and management of the following conditions: Locally advanced and metastatic prostate cancer, obstructive uropathy, and malignant ureteral obstruction. No limitation was set on the period reviewed. References from these available articles were evaluated to obtain additional information necessary for the review.

Obstructive Uropathy

Pathophysiology

The long-term effects of urinary obstruction depend on the severity of blockage, its acuity, laterality, and the patient's underlying renal function. Obstructive nephropathy from prostate cancer most commonly results from bilateral ureteral blockage or unilateral ureteral obstruction in the setting of a solitary renal unit.

Bilateral obstruction results in a number of well-described changes in renal function.⁴ Renal blood flow initially increases to both kidneys, but within 90 minutes, a dramatic decrease in perfusion and glomerular filtration rate (GFR) ensues. This phenomenon largely results from the accumulation of vasoactive substances, such as angiotensin II, thromboxane A₂, and atrial natriuretic peptide. A deleterious impact on tubular function also occurs. Urinary concentrating ability is diminished from loss of the hypertonic medullary interstitial gradient and dysregulation of aquaporin water channels.

If uncorrected, obstruction results in the release of cytokines and growth factors (tumor growth factor β, angiotensin II, nuclear factor κB, and tumor necrosis factor α) that cause interstitial inflammation and, ultimately, fibrosis. Not surprisingly, it has been shown in a dog model that recovery of renal function from unilateral ureteral obstruction is inversely proportional to the length of obstruction. Relief of obstruction lasting 2 and 4 weeks induced a 70% and 30% recovery of GFR, respectively. Essentially, no return of function was found if the blockage lasted longer than 6 weeks. This suggests that relief of long-standing obstruction may not yield much functional benefit, a factor that must be taken into account when making treatment decisions.

Polyuria may ensue after relief of urinary obstruction, with urine output potentially exceeding 200 mL/hr. Known as postobstructive diuresis, this phenomenon occurs mainly in patients with bilateral upper tract obstruction, but can also be seen after resolution of lower urinary tract obstruction. In most cases, the diuresis is a normal physiologic response to volume expansion and the accumulation of solutes. Polyuria may continue despite hypervolemia resolution and solute excretion. This pathologic postobstructive diuresis results from a renal concentrating defect that develops during the obstructed state.

Clinically significant postobstructive diuresis is uncommon; however, patients with signs of fluid overload, such as peripheral edema, congestive heart failure, or hypertension, are more susceptible. All patients should have a basic metabolic panel and magnesium level checked at least daily. Urine osmolarity and serum electrolytes should be assessed more frequently in patients with signs of fluid overload, azotemia, poor cognitive function, and/or hypovolemia. Clinically stable patients with normal cognitive function can be managed with oral fluid replacement. Patients at risk of aspiration should receive intravenous fluid replacement below their maintenance level to prevent prolonging the physiologic diuresis.

Clinical presentation

Signs and symptoms of urinary tract obstruction depend largely on the degree, time course, and anatomic level of obstruction. Lower urinary tract obstruction may occur at the bladder outlet or from locally invasive growth of the cancer in the bladder trigone. This can result in urinary urgency, frequency, decreased force of stream, or incomplete bladder emptying.⁵

Acute upper tract obstruction has a similar presentation to renal colic. Symptoms may include severe flank pain, nausea, and vomiting.⁶ Patients may present with anuria if they have complete obstruction of the urethra, both ureters, or have unilateral obstruction of a solitary kidney.⁷

Extrinsic compression of the urinary system is more commonly a chronic process with a slow progression to renal insufficiency. Consequently, patients often present with vague symptoms, such as back pain, anorexia, lethargy, and/or mental status changes.^8,9 While no specific prevalence is known, in advanced prostate cancer, urinary tract obstruction is often insidious and silent. These patients can be relatively asymptomatic, with hydronephrosis being discovered as an incidental finding during a workup for renal insufficiency.⁵ In some cases, a urinary tract infection may be the heralding symptom.⁶

Diagnosis

In many instances the point of obstruction can be determined by the history and physical examination alone. Worsening obstructive voiding symptoms, leading to acute urinary retention, with a palpable bladder and firm prostate on digital rectal examination, indicate posterior urethral occlusion. Measuring the bladder volume with an ultrasound-based bladder scanner can be readily performed at the bedside to confirm urethral obstruction.

Gradually declining urinary output without a perceived need to void and a nonpalpable bladder are more consistent with upper tract obstruction. Available modalities to image the upper urinary tract include renal and bladder ultrasonography, intravenous urography, CT, or MRI. The choice of imaging study depends on available resources, physician preference, and the presence or absence of renal insufficiency. Patients with preexisting renal insufficiency should not undergo contrast imaging because contrast-induced nephropathy may further impair renal function. In these instances, renal and bladder ultrasonography or noncontrast CT are the imaging modalities of choice. Ultrasonography has the advantage of being readily available, inexpensive, and lacking in ionizing radiation. CT, however, provides superior anatomic detail, allowing for more accurate determination of the site of obstruction. If anatomic abnormalities are present but the diagnosis of obstruction is equivocal, diuretic nuclear renography should be considered.

Management

General considerations

First and foremost, patients should be assessed for symptomatic fluid overload (congestive heart failure, pulmonary edema), severe electrolyte abnormalities, such as hyperkalemia, signs of uremia (pericarditis, neuropathy, unexplained decline in mental status), and/or metabolic acidosis. The nephrology staff should be consulted immediately if any are present for possible emergent hemodialysis.

In the absence of such findings, management should be directed at relieving the obstruction and addressing its underlying cause.

Bladder Outlet Obstruction (BOO)

Management of BOO should be initially accomplished via either urethral Foley catheterization or placement of a suprapubic cystostomy tube. These interventions allow for immediate symptom relief and can usually be performed easily at the bedside.

Once the systemic sequelae of urinary obstruction have resolved, further management will depend on prostate cancer stage and the patient's wishes. For patients who desire to be catheter-free but are not candidates for definitive therapy (radical prostatectomy or radiation), options include endocrine therapy or transurethral resection of the prostate (TURP).

Endocrine therapy for bladder outlet obstruction

Patients without castration-resistant prostate cancer are candidates for endocrine management of BOO, which includes antiandrogen drug therapy and orchiectomy. Both treatments necessitate Foley catheterization until response is noted. In a study by Varenhorst and Alund¹⁰ that looked at patients with prostate cancer presenting with urinary retention, 65.5% (80 of 122) of patients were rendered Foley catheter free by 6 months after treatment. Patients who underwent orchiectomy responded on average 1 month sooner than patients who were placed on estrogen treatment (2.7 mos vs 3.4 mos, respectively). Fleischmann and Catalona¹¹ validated these results. They reported a 68.6% success rate by orchiectomy alone. In this later study, neither tumor stage nor grade correlated significantly with the response to orchiectomy.

The medical literature is devoid of studies that evaluate the efficacy of contemporary hormonal agents, such as luteinizing hormone-releasing hormone (LHRH) agonists or antagonists, antiandrogens, or androgen biosynthesis inhibitors, in the management of BOO from locally advanced prostate cancer. These medications are unlikely to be any more effective than estrogen therapy or surgical castration. LHRH agonists, however, are advantageous because they have a convenient delivery method, improved safety profile compared with estrogens, and unlike surgical therapy, are reversible.

TURP for BOO

While much is known about the outcomes of TURP for benign prostatic hyperplasia (BPH),¹² until the early 1990s, there were few studies on patients with outlet obstruction from prostate cancer. A review by Mazur and Thompson¹³ looked at outcomes for obstructive symptoms from advanced prostate cancer. The authors found a 22% reoperation rate, a 5% rate of total urinary incontinence, and a 5% incidence of stress incontinence. Shortly thereafter, a randomized study was performed in England that compared channel TURP plus bilateral orchiectomy to orchiectomy alone for patients who presented with acute urinary retention secondary to locally advanced prostate cancer.¹⁴ Four of the 10 patients initially undergoing TURP needed prolonged catheterization, while 10 of the 12 patients who received orchiectomy alone were able to void successfully 1 month after the procedure.

A more recent study performed by Crain and colleagues¹⁵ reexamined the role of palliative TURP for BOO in patients with prostate cancer. Using the International Prostate Symptom Score, they found greater symptomatic improvement in the group undergoing TURP for benign disease compared with the palliative TURP group (73% vs 48%, respectively). In addition, they showed that 42% of patients undergoing palliative TURP had a failed initial voiding trial, 29% needed repeated procedures for bleeding or obstruction, and 21% needed prolonged bladder catheterization via either suprapubic tube or Foley catheterization. These rates were much higher than those seen for TURP performed for benign disease, with only 2.5% needing a repeat procedure and 1.4% needing chronic bladder drainage.

A third study looked at functional outcomes and impact on survival for 89 patents undergoing palliative TURP after initial primary oncologic therapy.¹⁶ The 1-, 2- and 5-year survival rates were 83%, 70% and 61%, respectively. Patients found to have residual prostate cancer in the TURP specimen had a shorter 3-year survival (52%) than those with negative histology (89%). Seventy-nine percent of men voided spontaneously and were continent at their final follow-up visit. A repeated palliative TURP was necessary in 25% of patients, 11% needed permanent catheterization, and 10% were incontinent. Table 1 summarizes the results of the three main studies on palliative TURP.

Table 1.

Outcomes for Palliative Transurethral Resection of the Prostate

Study	No. of procedures	Reoperation rate (%)	Prolonged/permanent catheterization (%)	Incontinence rate (%)
Mazur 1991¹³	41	22	NR	5/5^a
Crain 2004¹⁵	24	29	21	0
Marszalek 2007¹⁶	89	25	11	10

5% with total urinary incontinence, 5% with stress urinary incontinence.

NR=not recorded.

Prostatic/urethral stent insertion for BOO

Urethral or prostatic stent insertion is commonly used in the management of BOO in countries such as Israel and Norway; however, much of the literature on this topic focuses on patients with BPH or iatrogenic posterior urethral strictures secondary to previous prostate cancer therapy. These stents have been shown to be a safe and reasonable treatment option for the above stated conditions^17,18 in carefully selected patients with urologists who have extensive experience with the use and management of these stents.¹⁷ Longer-term follow up studies have reported significant complications,^19,20 such as stent migration, encrustation, infection, pain, and repeated stenosis, as well as nontrivial rates of repeated intervention. At this point, their use for patients with untreated, advanced prostate cancer with BOO has not been thoroughly investigated.

Summary and recommendations for BOO management

All patients with BOO should have a Foley catheter or suprapubic tube placed as the initial intervention. Patients who are not candidates for definitive therapy (radical prostatectomy or radiation) but desire to be catheter free should be treated with either endocrine therapy or a palliative TURP. Endocrine therapy may be in the form of surgical castration or hormonal ablation. Patients undertaking endocrine therapy should understand that this approach requires months of catheter diversion until the potential benefit is seen. Indications for transurethral prostatectomy include patients in whom endocrine therapy has failed, are not candidates for hormonal treatment, or do not want prolonged catheter drainage.²¹ Patients should be counseled that there is roughly a 25% chance of needing an additional procedure and there is a small, but definite, risk of urinary incontinence.

Upper Urinary Tract Obstruction

If the initial evaluation is consistent with obstruction of the upper urinary tract, the patient will typically need a surgical or procedural intervention to relieve the obstruction. Retrograde single internal polymeric ureteral stent (IUS) insertion and percutaneous nephrostomy (PCN) tube insertion are currently the most common interventions for the relief of malignant urinary obstruction (MUO) from external compression. Other options include the use of dual ipsilateral polymeric stents, metallic ureteral stents, and endoscopic stented ureterocystostomy.

The reported incidence of ureteral obstruction from the local spread of prostate cancer has been shown to be in the range of 3.3% to 16%.^22

–27 Eighty percent of cases of upper urinary tract obstruction involve invasion of the bladder trigone and the ureteral orifices, whereas 20% of cases involve obstruction of the lower one-third of the ureter, either by local spread or impaired drainage from retroperitoneal lymph node metastasis.^28
–30

Endocrine and radiation therapy for upper tract obstruction

Michigan and Catalona²² did early work looking at the response of ureteral obstruction to endocrine and radiation therapy. Their results demonstrated that if the patient is naïve to endocrine therapy, a response could be expected in more than 85% of patients, with most of these responders having undergone orchiectomy. A similar success rate was not noted with radiation therapy. Another study, however, suggests more than a 70% success rate when high doses of radiation are administered over a 4- to 5-week period.³¹ In general, the response to radiation therapy is slower than that of endocrine therapy.²¹

Single polymeric ureteral stent insertion for upper tract obstruction

Polymeric ureteral stent insertion is a procedure usually associated with low morbidity that can be performed easily under fluoroscopic guidance.³² Unfortunately, cystoscopic insertion of polymeric ureteral stents has a well-documented stent failure rate of 44% to 58%.^33
–35 While not entirely known, according to Markowitz and coworkers³⁶ (1989), stent failure is thought to be related to impairment of ureteral smooth muscle by extrinsic compression, resulting in dysfunctional ureteral peristalsis. Another component thought to play a role is stent encrustation. Factors predictive of polymeric ureteral stent failure are ureteral invasion seen at the time of cystoscopy, as well as obstruction of the distal ureter at the pelvic brim (compared with obstruction at the level of the proximal ureter or renal pelvis).^37,38

In addition, 16% to 28% of patients with MUO have been found to need PCN at the time of initial urinary decompression,^35,39 commonly because of the inability to pass the stent through an identified orifice because of ureteral obstruction. Trigonal distortion, however, can also be a source of difficulty by preventing the identification or localization of the ureteral orifice. In this situation, some of the following steps can be taken to identify the ureteral orifice: One, identify the contralateral ureteral orifice and look across the intertrigonal ridge; two, fill or empty the bladder as needed to obtain optimal distention; three, switch from a flexible to a rigid cystoscope or vice versa; four, colored dyes such as indigo carmine will be filtered by the kidneys and can be given intravenously—one can assess the bladder for site of dye efflux. If the ureteral orifice cannot be identified, the patient will need a percutaneous procedure. Table 2 lists the results of studies using single polymeric ureteral stents for MUO, with success rates ranging from 58% to 81%.^40
–42

Table 2.

Outcomes for Stent Insertion for Malignant Ureteral Obstruction

Study	Overall no. of stents attempted	No. immediate PCN placed (%)	No. of stents for prostate cancer	No. of stent failures in prostate cancer	Overall stent failure rate (%)	Avg. time to stent failure (mos)	Avg. no. of stent exchanges (interval in days)	Overall mean survival time (mos)
Chung 2004⁴¹	138	18 (13%)	5	3	44.4^a	11	NR	NR
Ganatra 2005⁴⁰	157	24 (15.3%)	14	5	35.7	6	2.8 (95)	11.1
Rosevear 2007⁴²	87	NR^b	5	1	19^a	5.9	5.5 (108)	16

Included only stents placed for malignant etiologies.

Patients who were unable to have stent placement were excluded from the analysis.

Dual ipsilateral polymeric ureteral stent insertion for upper tract obstruction

First introduced by Liu and Hrebinko⁴³ and then by Hamm and Rathert,⁴⁴ the use of two parallel Double-J polymeric ureteral stents has been shown to be an effective alternative to PCN when a single polymeric IUS has failed. Rotariu and associates⁴⁵ reported a case series of seven patients in whom management with a single polymeric IUS failed and who were subsequently treated successfully with two ipsilateral polymeric stents. They demonstrated that placement of either two 7F stents or a combination of 8F/6F Double-J ureteral stents was a safe and effective technique, with reduced flank pain, relief of hydronephrosis, improved renal function, and no increase in irritative symptoms compared with the use of a single stent. The mechanism for this success was subsequently demonstrated in an ex vivo porcine kidney model of extrinsic ureteral obstruction.⁴⁶ The authors of this study demonstrated better flow down the ureter with dual stents than one stent. This was true for both flow through and around the stents.

Metallic ureteral stent insertion for upper tract obstruction

In patients who wish to avoid PCN tubes but in whom polymeric ureteral stents have failed, an alternative is the use of a metallic ureteral stent, either a vascular self-expandable or a full-metal double pigtail. One potential benefit of metallic stents is that they provide drainage for up to 12 months. In patients with limited life expectancy, this could avoid the potential morbidity and inconvenience of multiple stent changes that are needed with traditional stents.⁴⁷ Use of metallic stents, however, has been limited by complications, which include hyperplastic mucosal reaction and/or tumor in-growth through the stent struts, encrustation, stent migration, and infection.⁴⁸

Liatsikos and coworkers⁴⁹ reported long-term results with vascular self-expandable metallic stents. The 10-year data, in which all stents were inserted in an antegrade fashion via a nephrostomy tract, showed primary and secondary patency rates of 51.2% and 62.1%, respectively. A total of 45 of 119 (37.8%) of these stents had postprocedural hyperplastic reaction or tumor in-growth necessitating repeated balloon dilation and eventual need for standard double-pigtail or external-internal stents. They also had a 10.9% stent migration rate.

With regard to the full-metal double-pigtail metallic stent, the Resonance (Cook Medical, Bloomington, IN) metallic alloy stent has been shown to have superior compression resistance over polymeric ureteral stents in cases of external compression.⁵⁰ Borin and colleagues⁵¹ described their initial experience with full-length metal stents to relieve MUO in a patient with retroperitoneal fibrosis secondary to metastatic breast cancer. At 4 months, the patient continued to be unobstructed. Two additional studies have shown the effectiveness of these stents. Wah and associates⁵² demonstrated only 3 stent failures among 17 stents inserted via an antegrade approach for MUO, while Liatsikos and coworkers⁴⁸ showed 100% patency of 25 stents at a mean follow-up of 11 months.

Thermoexpandable shape memory stents for upper tract obstruction

First described by Kulkarni and Bellamy⁵³ in 1999, the Memokath 051 (PNN Medical, Kvistgaard, Denmark) thermoexpandable shape-memory nickel-titanium alloy stent is another option for the management of ureteral obstruction. The stent has a unique thermal memory for shape, softening below 10°C and regaining its shape when reheated to above 55°C. The stent has a 22F fluted proximal end with a 10.5F shaft diameter and comes in variable lengths. The insertion technique has been well described,^53,54 with early follow-up showing no patient rehospitalizations for stent-related sepsis, pain, or hematuria.⁵⁴ The 11-year follow-up data⁵⁵ showed an overall stent migration rate of 18% (13/74), two encrustations, three fungal infections, and 19% reinsertion rate at a mean time of 7.1 months, of which only 3 were for stricture progression. Of the 28 patients with a malignant obstructive etiology, 89% (25/28) has postprocedural imaging showing normal or improved functional drainage.

One major prohibitive factor is cost, because the Memokath stent is roughly 19 times the cost of a conventional single polymeric ureteral stent.⁵³ At present, this technique appears to be best suited for patients in whom convention endoscopic techniques fail, have significant comorbidites that limit repetitive stent changes, need primary stent placement for malignancy, or palliation.

Percutaneous nephrostomy tube placement for upper tract obstruction

The other common endoscopic treatment option is PCN, which is favored by some authors because malignancy has been shown to be a predictor of polymeric stent failure.⁴¹ The procedure is typically performed under either ultrasonography or fluoroscopic guidance and allows for subsequent polymeric ureteral stent placement in an antegrade manner if anatomically feasible or preferred by the patient.²¹ Complications of PCN tubes include malposition, dislodgement, or occlusion of the tube, and have been noted to occur in 4% to 26% of procedures.^27,36,56 Other problems related to PCN tubes include urinary leakage and skin excoriation at the nephrostomy tube site,⁵⁷ yet the main source of discomfort to patients was found to be the external urine collection device.⁵⁸ Table 3 shows outcomes from the larger studies on PCN tube insertion.

Table 3.

Outcomes for PCN Insertion for Malignant Ureteral Obstruction

Study	No. of PCN insertions	No. of PCN inserted for prostate cancer	Avg. survival time (mos) after PCN for prostate cancer	Mean survival time post-PCN with known prostate cancer (mos)	Mean survival time post-PCN for untreated prostate cancer (mos)	1 year survival (%)	Mean time to creatinine nadir (d)
Chiou 1990⁶²	37	37	NR	12^a	24^a	57	NR
Wilson 2005³⁸	52	NR	2.9	NR	NR	NR	16.8
Nariculam 2009⁶⁵	25	25	7.5	4.5	16	NR	10

Median survival time.

PCN=percutaneous nephrostomy.

Comparison of endoscopic options for upper tract obstruction

Direct comparison of studies that examine single polymeric IUS and PCN tubes for prostate cancer are complicated by small sample sizes and prostate cancer results being combined with other malignancies. Furthermore, baseline characteristics between the single polymeric IUS and PCN groups, as well as other contributing factors, such as overall survival, often differ between studies.⁵⁹

Management of MUO by either single polymeric IUS or PCN drainage results in similar complication rates. Ku and colleagues⁶⁰ demonstrated no significant difference in the incidence of overall complications between the two groups (11% for the stent group vs 8.8% for the PCN group). This analysis included both febrile events and diagnosis of acute pyelonephritis. A separate prospective comparison of these same groups showed no statistical difference with regard to quality of life, but did point out that patients with single polymeric IUS had more lower urinary tract symptoms.⁵⁸

New directions with endoscopic therapy for upper tract obstruction

For patients with ureterovesical junction or distal ureteral obstruction, in whom retrograde polymeric ureteral stent insertion has failed and who wish to avoid PCN tube drainage because of its restrictions and negative impact on quality of life, a new option may have emerged. Slongo and coworkers⁶¹ have proposed a novel technique of endoscopic stented ureterocystostomy, where under both cystoscopic and fluoroscopic guidance, a path is created above the obstructing neoplastic process between the bladder wall and ureter. The ureterocystostomy is developed using a needle puncture of the ureter after contrast has been instilled from an antegrade renal puncture, all performed under fluoroscopic control. After a guidewire is introduced, the tract is dilated to 10F and a Double-J polymeric ureteral stent is inserted. Success was demonstrated in six patients— however, only for right ureteral involvement and in no patients with prostate cancer. Depending on the neoplastic treatment and patient response, the catheter could be maintained, changed, or removed. Certainly additional studies are warranted to validate the initially promising results.

Special considerations: Do both obstructed units need to be drained?

Clinicians often encounter the dilemma of whether to intervene on both sides of a bilaterally obstructed system or only divert the better functioning renal unit. Specifically with regard to PCN tube insertion, two studies did not find a significant difference in overall survival when only unilateral relief of a bilaterally obstructed system was performed,^62,63 and one study found a difference in patients with hormone refractory status.⁶⁴ A more recent study by Nariculam and associates⁶⁵ suggests that the serum creatinine nadir after PCN tube insertion was roughly similar whether unilateral or bilateral tubes were inserted. On the basis of the limited evidence, it appears that if PCN tube placement is to be performed, the clinician need only divert the better functional unit.

Summary and recommendations for UUT management

Because of the high failure rate of single ureteral stents, we recommend that physicians attempt to place dual ipsilateral polymeric ureteral stents at the time of initial intervention. Dual stent insertion is safe, effective, and easy to perform, while providing better defense against extrinsic compression than single ipsilateral polymeric stents. They also have been shown to preserve quality of life. We favor the use of dual polymeric stents over metallic pigtail stents, because polymeric stents have more consistent results, have been studied more extensively, and do not carry the risk of tumor in-growth causing difficulty with stent exchange. For patients with a more limited life expectancy who do not wish to have an external collection device, insertion of a metallic stent should be considered. If stent placement is not possible, then percutaneous nephrostomy tubes should be inserted. We view this as a second-line option because of its many complications and negative impact on patient quality of life.

Quality of Life Considerations

Given that the median survival for patients who are treated for malignant ureteral obstruction is 3 to 7 months,^39,41,66,67 the clinician must carefully consider whether ureteral decompression is going to facilitate treatment with systemic therapy, palliate symptoms, or address a finding on imaging that may not improve the patient's overall condition.⁶⁸ One study showed a trend toward better survival and performance status with palliative diversion for patients with prostate cancer compared with other tumors.³² Another study demonstrated that patients with localized prostate cancer did, in fact, have an improvement in quality of life after PCN insertion.⁶⁹ With significant complication rates and postdiversion survival time spent in the hospital approaching 40%,^23,32 however, a discussion should take place between patients, families, and healthcare providers regarding outcomes for palliative procedures and goals of care.^6,21

Conclusion

The management of obstructive uropathy in prostate cancer has evolved from a time when standard therapy was open nephrostomy tube insertion. Due to advances in endoscopic technology, urologists and patients have multiple options for relieving urinary tract obstruction. Clearly delineated guidelines of care do not exist, and sadly the evidence to support recommendations is often of low quality. Despite these shortcomings, the current literature does provide some direction. Going forward, it would be wise for the urologic community to embark on new studies to identify optimal treatment strategies for the treatment of obstructive uropathy from locally advanced and metastatic prostate cancer, as a non-negligible number of patients will eventually present with this condition. These studies would also benefit clinicians who often seek the guidance of urologists for other entities causing ureteral obstruction.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

Catalona

, Smith

, Ratliff

, Basler

. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA, 1993; 270:948–954.

Ung

, Richie

, Chen

et al. Evolution of the presentation and pathologic and biochemical outcomes after radical prostatectomy for patients with clinically localized prostate cancer diagnosed during the PSA era. Urology, 2002; 60:458–463.

Jemal

, Siegel

, Xu

, Ward

. Cancer statistics, 2010. CA Cancer J Clin, 2010; 60:277–300.

Pais

, Strandhoy

, Assimos

. Pathophysiology of urinary tract obstruction. Wein

, Kavoussi

, Novick

, Partin

, Peters

. Campbell-Walsh Urology, 2 9th. Philadelphia: Saunders Elsevier, 2007; 1195–1226.

Tseng

, Stoller

. Obstructive uropathy. Clin Geriatr Med, 2009; 25:437–443.

Kouba

, Wallen

, Pruthi

. Management of ureteral obstruction due to advanced malignancy: Optimizing therapeutic and palliative outcomes. J Urol, 2008; 180:444–450.

Klahr

. Obstructive nephropathy. Intern Med, 2000; 39:355–361.

Batlle

, Arruda

, Kurtzman

. Hyperkalemic distal renal tubular acidosis associated with obstructive uropathy. N Engl J Med, 1981; 304:373–380.

Faubert

, Porush

. Renal Disease in the Elderly, 2nd. New York: Marcel Dekker, 1998; 441.

10.

Varenhorst

, Alund

. Urethral obstruction secondary to carcinoma of the prostate: Response to endocrine treatment. Urology, 1985; 25:354–356.

11.

Fleischmann

, Catalona

. Endocrine therapy for bladder outlet obstruction from carcinoma of the prostate. J Urol, 1985; 134:498–500.

12.

Mebust

, Holtgrewe

, Cockett

, Peters

. Transurethral prostatectomy: Immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol, 2002; 167:5–9.

13.

Mazur

, Thompson

. Efficacy and morbidity of “channel” TURP. Urology, 1991; 38:526–528.

14.

Thomas

, Balaji

, Coptcoat

, Abercrombie

. Acute urinary retention secondary to carcinoma of the prostate. Is initial channel TURP beneficial? J R Soc Med, 1992; 85:318–319.

15.

Crain

, Amling

, Kane

. Palliative transurethral prostate resection for bladder outlet obstruction in patients with locally advanced prostate cancer. J Urol, 2004; 171:668–671.

16.

Marszalek

, Ponholzer

, Rauchenwald

, Madersbacher

. Palliative transurethral resection of the prostate: Functional outcome and impact on survival. BJU Int, 2007; 99:56–59.

17.

Masood

, Djaladat

, Kouriefs

et al. The 12-year outcome analysis of an endourethral wallstent for treating benign prostatic hyperplasia. BJU Int, 2004; 94:1271–1274.

18.

Eisenberg

, Elliott

, McAninch

. Preservation of lower urinary tract function in posterior urethral stenosis: Selection of appropriate patients for urethral stents. J Urol, 2007; 178:2456–2461.

19.

Hussain

, Greenwell

, Shah

, Mundy

. Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int, 2004; 94:1037–1039.

20.

Shah

, Kapoor

, Badlani

. North American Study Group. Experience with urethral stent explantation. J Urol, 2003; 169:1398–1400.

21.

Smith

Jr , Soloway

, Young

. Complications of advanced prostate cancer. Urology, 1999; 54,suppl 6A:8–14.

22.

Michigan

, Catalona

. Ureteral obstruction from prostatic carcinoma: Response to endocrine and radiation therapy. J Urol, 1977; 118:733–738.

23.

Paul

, Love

, Chisholm

. The management of bilateral ureteric obstruction and renal failure in advanced prostate cancer. Br J Urol, 1994; 74:642–645.

24.

Sandhu

, Mayor

, Sambrook

, George

. Outcome and prognostic factors in patients with advanced prostate cancer and obstructive uropathy. Br J Urol, 1992; 70:412–416.

25.

Honnens de Lichtenberg

, Miskowiak

, Rolff

. Hormonal treatment of obstructed kidneys in patients with prostatic cancer. Br J Urol, 1993; 71:313–316.

26.

Oefelein

. Prognostic significance of obstructive uropathy in advanced prostate cancer. Urology, 2004; 63:1117–1121.

27.

Dowling

, Carrasco

, Babaian

. Percutaneous urinary diversion in patients with hormone-refractory prostate cancer. Urology, 1991; 37:89–91.

28.

Villavicencio

. Quality of life of patients with advanced and metastatic prostatic carcinoma. Eur Urol, 1993; 24:118–121.

29.

O'Reilly

. The effect of prostatic obstruction on the upper urinary tract. Fitzpatrick

, Krane

. The Prostate. Edinburgh: Churchill Livingstone, 1989; 111–118.

30.

Saitoh

, Yoshida

, Uchijima

et al. Two different lymph node metastatic patterns of a prostatic cancer. Cancer, 1990; 65:1843–1846.

31.

Megalli

, Gursel

, Demirag

et al. External radiotherapy in ureteral obstruction secondary to locally invasive prostatic cancer. Urology, 1974; 3:562–564.

32.

Shekarriz

, Shekarriz

, Upadhyay

et al. Outcome of palliative urinary diversion in the treatment of advanced malignancies. Cancer, 1999; 85:998–1003.

33.

Docimo

, Dewolf

. High failure rate of indwelling ureteral stents in patients with extrinsic obstruction: Experience at 2 institutions. J Urol, 1989; 142:277–279.

34.

Yossepowitch

, Lifshitz

, Dekel

et al. Predicting the success of retrograde stenting for managing ureteral obstruction. J Urol, 2001; 166:1746–1749.

35.

Feng

, Bellman

, Shapiro

. Management of ureteral obstruction secondary to pelvic malignancies. J Endourol, 1999; 13:521–524.

36.

Markowitz

, Wong

, Laffey

et al. Maintaining quality of life after palliative diversion for malignant ureteral obstruction. Urol Radiol, 1989; 11:129–132.

37.

Eyre

, Benotti

, Bothe

et al. Management of the urinary tract involved by recurrent cancer. Arch Surg, 1987; 122:493–498.

38.

Wilson

, Urwin

, Stower

. The role of percutaneous nephrostomy in malignant ureteric obstruction. Ann R Coll Surg Engl, 2005; 87:21–24.

39.

Donat

, Russo

. Ureteral decompression in advanced nonurologic malignancies. Ann Surg Oncol, 1996; 3:393–399.

40.

Ganatra

, Loughlin

. The management of malignant ureteral obstruction treated with ureteral stents. J Urol, 2005; 174:2125–2128.

41.

Chung

, Stein

, Landsittel

et al. 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol, 2004; 172:592–595.

42.

Rosevear

, Kim

, Wenzler

et al. Retrograde ureteral stents for extrinsic ureteral obstruction: Nine years' experience at University of Michigan. Urology, 2007; 70:846–850.

43.

Liu

, Hrebinko

. The use of 2 ipsilateral ureteral stents for relief of ureteral obstruction from extrinsic compression. J Urol, 1998; 159:179–181.

44.

Hamm

, Rathert

. [Therapy of extrinsic ureteral obstruction by 2 parallel double-J ureteral stents.] (Ger) Urologe A, 1999; 38:150–155.

45.

Rotariu

, Yohannes

, Alexianu

et al. Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents. J Endourol, 2001; 15:979–583.

46.

Hafron

, Ost

, Tan

et al. Novel dual-lumen ureteral stents provide better ureteral flow than single ureteral stent in ex vivo porcine kidney model of extrinsic ureteral obstruction. Urology, 2006; 68:911–915.

47.

Liatsikos

, Kallidonis

, Kyriazis

et al.

Ureteral obstruction: Is the full metallic double-pigtail stent the way to go?

Eur Urol, 2010; 57:480–486.

48.

Liatsikos

, Karnabatidis

, Kagadis

et al. Metal stents in the urinary tract. EAU-EBU Update Series, 2007; 5:77.

49.

Liatsikos

, Karnabatidis

, Katsanos

et al. Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment. J Urol, 2009; 182:2613–2617.

50.

Christman

, L'Esperance

, Choe

et al. Analysis of ureteral stent compression force and its role in malignant obstruction. J Urol, 2009; 181:392–396.

51.

Borin

, Melamud

, Clayman

. Initial experience with full-length metal stent to relieve malignant ureteral obstruction. J Endourol, 2006; 20:300–304.

52.

Wah

, Irving

, Cartledge

. Initial experience with the resonance metallic stent for antegrade ureteric stenting. Cardiovasc Intervent Radiol, 2007; 30:705–710.

53.

Kulkarni

, Bellamy

. A new thermo-expandable shape-memory nickel-titanium alloy stent for the management of ureteric strictures. BJU Int, 1999; 83:755–759.

54.

Kulkarni

, Bellamy

. Nickel-titanium shape memory alloy Memokath 051 ureteral stent for managing long-term ureteral obstruction: 4-year experience. J Urol, 2001; 166:1750–1754.

55.

Agrawal

, Brown

, Bellamy

, Kulkarni

. The thermo-expandable metallic ureteric stent: An 11-year follow-up. BJU Int, 2009; 103:372–376.

56.

Lau

, Temperley

, Mehta

et al. Urinary tract obstruction and nephrostomy drainage in pelvic malignant disease. Br J Urol, 1995; 76:565–569.

57.

Schmidbauer

, Kratzik

, Klingler

et al. Nephrovesical subcutaneous ureteric bypass: Long-term results in patients with advanced metastatic disease-improvement of renal function and quality of life. Eur Urol, 2006; 50:1073–1078.

58.

Joshi

, Adams

, Obadeyi

, Rao

. Nephrostomy tube or ‘JJ’ ureteric stent in ureteric obstruction: Assessment of patient perspectives using quality-of-life survey and utility analysis. Eur Urol, 2001; 39:695–701.

59.

Rollig

, Wockel

, Weissbach

. Management of obstructive uropathy patients with advanced prostate cancer—a systematic review. Onkologie, 2009; 32:680–684.

60.

, Lee

, Jeon

et al.

Percutaneous nephrostomy versus indwelling ureteral stents in the management of extrinsic ureteral obstruction in advanced malignancies: Are there differences?

Urology, 2004; 64:895–899.

61.

Slongo

, de Fraga

, Mitre

. Endoscopic stented ureterocystostomy. J Endourol, 2010; 24:1817–1820.

62.

Chiou

, Chang

, Horan

. Ureteral obstruction associated with prostate cancer: The outcome after percutaneous nephrostomy. J Urol, 1990; 143:957–959.

63.

Bordinazzo

, Benecchi

, Cazzaniga

et al. Ureteral obstruction associated with prostate cancer: The outcome after ultrasonographic percutaneous nephrostomy. Arch Ital Urol Androl, 1994; 66,suppl 4:101–106.

64.

Harris

, Speakman

. Nephrostomies in obstructive uropathy; how should hormone resistant prostate cancer patients be managed and can we predict who will benefit? Prostate Cancer Prostatic Dis, 2006; 9:42–44.

65.

Nariculam

, Murphy

, Jenner

et al. Nephrostomy insertion for patients with bilateral ureteric obstruction caused by prostate cancer. Br J Radiol, 2009; 82:571–576.

66.

Harrington

, Pandha

, Kelly

et al. Palliation of obstructive nephropathy due to malignancy. Br J Urol, 1995; 76:101–107.

67.

Russo

. Urologic emergencies in the cancer patient. Semin Oncol, 2000; 27:284–298.

68.

Russo

. Ureteral obstruction and stents: Still a difficult problem for patients and urologists alike. J Urol, 2005; 174:2088.

69.

Aravantinos

, Anagnostou

, Karatzas

et al. Percutaneous nephrostomy in patients with tumors of advanced stage: Treatment dilemmas and impact on clinical course and quality of life. J Endourol, 2007; 21:1297–1302.