Malignant Obstructive Uropathy Research Articles

Patterns of Utilization and Outcomes of Perioperative Chemotherapy in Patients With Locally Advanced-urothelial Bladder Cancer (LABC)-Real World Data From an Indian Tertiary Care Cancer Center.

Optimal utilization of perioperative systemic therapy in locally advanced bladder cancer (LABC) holds the key in improving the survival outcomes. We aim to analyze the oncological outcomes of clinically locally advanced urothelial bladder cancer patients treated with neoadjuvant (NACT) or adjuvant chemotherapy or without any systemic therapy in the perioperative period of radical cystectomy. We retrospectively analyzed the medical records of patients with cancer of the urinary bladder diagnosed between 2012 and 2020. The demographic profile, and the treatment received, was recorded for all patients. Oncological outcomes of the patients based on these variables were analyzed. Two hundred and twenty nine (229) locally advanced bladder cancer patients were included in the study. Eighty eight (38%) of them underwent upfront radical cystectomy and 141 (62%) received neoadjuvant chemotherapy (NACT). With a median follow-up of 27 months, the 2-year DFS in either of the groups was 65.4% and 67.1% respectively (P - 0.373). In the multivariate analysis, the pathological lymph nodal status and lymph vascular invasion (LVI) status influenced the DFS. The initial modality of management chosen did not affect the outcome. (HR - 0.688; 95% CI: 0.38-1.21). The commonest reason for not receiving NACT was Cisplatin ineligibility due to malignant obstructive uropathy and a subgroup analysis of this set of patients also did not show any significant difference in 2 year DFS compared to those who received NACT. A significant proportion of patients with LABC are unable to receive the recommended neoadjuvant chemotherapy and obstructive uropathy is the commonest reason for this in our centre. In our single centre series upfront radical cystectomy followed by adjuvant platinum based therapy had an outcome similar to neoadjuvant chemotherapy in LABC patients, in patients who were unable to receive the same due to various reasons.

Role of percutaneous nephrostomy in cancer patients

Ureteric obstruction is common in cancer patients, representing an unfavorable prognostic factor in this population. Percutaneous nephrostomy (PCN) is often performed in these patients to prevent renal dysfunction and potentially increase survival. However, this procedure may negatively affect patients’ quality of life, and its survival benefit is not established. The objective is to characterize the population of cancer patients undergoing PCN, assess complications related to PCN, and identify potential prognostic factors in this population. Ninety-two patients were included; the median age was 70 years (range: 26–85), and 55 (60%) were males. Most patients had metastatic disease (n = 51; 55%). Bladder (n = 24; 26%), prostate (n = 15; 16%), and rectum (n = 10; 11%) were the most frequent primary tumor topographies. Twenty-seven patients (29%) had NPC-related complications, 16 (17%) had more than one complication, and 20 (22%) required hospitalization. The most frequent complications were infection (n = 23; 25%) and obstruction (n = 14; 15%). In the multivariate analysis, malignant obstructive uropathy was the only independent prognostic factor post-PCN. After three years of follow-up, 70 patients (76%) had died, mainly from cancer progression, and 2 (2%) due to PCN-related complications. Given the potential benefits and burdens, patients and, in some cases, family members should be involved in the decision. The problem is not the efficacy of PCN but the adequacy of the decision in the face of a limited life expectancy.

Does percutaneous drainage of malignant obstructive uropathy improve renal function? A retrospective records review

Does percutaneous drainage of malignant obstructive uropathy improve renal function? A retrospective records review

The implications when offering percutaneous nephrostomy for the management of malignant obstructive uropathy secondary to urological malignancy: can we be more selective?

Percutaneous nephrostomy (PN) for malignant ureteric obstruction (MUO) is increasingly accessible with high success rates. However, it is not without associated risks and morbidity, impacting quality of life, while not improving overall survival. In two UK hospitals, we investigated the outcomes of undergoing PN for MUO, to inform future patient counselling and selection for this intervention. A retrospective audit of electronic records identified patients that received PN for bladder, and prostate cancer (PCa) between January 2015 and December 2018. Hospital 1 had a 24-h nephrostomy service, while Hospital 2 had a limited service; Group A: recurrent or treatment-resistant PCa, Group B: primary PCa, Group C: Bladder cancer. A total of 261 patients (Hospital 1 = 186, Hospital 2 = 75), had PN insertion. Seventy-eight had prostate or bladder cancer. Group A n = 30, Group B n = 12, Group C n = 36. Median age = 79 [interquartile range (IQR) = 72-86]. Following PN insertion, 12-month mortality was significantly greater in Hospital 1 at 82%, versus 52% in Hospital 2 (p = 0.015). Median survival: Group A: 177 days (IQR = 80-266), Group B: 209 days (IQR = 77-352), Group C: 145 days (IQR = 97-362). There was no significant difference in same-admission mortality, although group A had the greatest same-admission mortality at 17%. A total of 69% of all patients received bilateral nephrostomies. Patients with bilateral versus unilateral PN had no difference in mortality or nadir creatinine. Most patients with malignant obstruction secondary to prostate or bladder cancer lived less than 12 months after PN insertion. When offering PN, careful consideration of disease prognosis should be made, and frank discussion of the implications of a life-long nephrostomy with patients and relatives.

EP032 - Antegrade double J stent placement for the treatment of malignant obstructive uropathy: A systematic review

EP032 - Antegrade double J stent placement for the treatment of malignant obstructive uropathy: A systematic review

Antegrade double-J stent placement for the treatment of malignant obstructive uropathy: A retrospective cohort study

BackgroundUreteral double- J stent is usually inserted by retrograde approach to treating obstructed upper urinary tract. The antegrade approach, can be suitable alternative in certain situations without general or spinal anesthesia. The present study demonstrates the indications, success rate, and complications of this approach in treatmenting malignant obstructive uropathy. MethodsData of consecutive patients with malignant obstructive uropathy who underwent antegrade ureteral stenting in the Department of Interventional Radiology at Sahloul hospital from January 2013 to February 2020 was retrieved and retrospectively analyzed. ResultA total of 188 attempts of antegrade ureteral stent insertion was performed during the study period (left side = 78, right side = 82, bilateral = 14). The mean age was 54 years (range: 9–91 years). The indication of the antegrade stenting was the failure of retrograde approach in 63 patients.The single-stage approach was performed 103 times. A percutaneous nephrostomy was placed for the average duration of 22.4 days (range: 2–60 days) for subsequent attempts. Only four patients required general anesthesia. Ureteral obstruction was caused by bladder cancer (n = 92), uterine cancer (n = 31), prostate cancer (n = 28), colorectal cancer (n = 15) and retroperitoneal tumor (n = 8). A protective nephrostomy was left in situ in 44 cases for 48 h. Clinical success was achieved in 96% of the cases. Two and three patients required hospitalization for perirenal abscess and hematuria, respectively. ConclusionThis retrospective study shows that antegrade ureteral stent insertion has a high success rate with minimal complications. Trial registrationClinicalTrials.gov Identifier: NCT04649970. Registered december 2, 2020- Retrospectively registered,https://clinicaltrials.gov/ct2/show/NCT04649970;

Outcomes of locally advanced cervical cancer presenting with obstructive uropathy: An institutional audit.

There is paucity of outcome data of patients with cervical cancer presenting with malignant obstructive uropathy. The present retrospective study describes outcomes of patients with cervical cancer who presented with obstructive uropathy at the time of diagnosis and underwent urinary diversion with percutaneous nephrostomy (PCN) before/during treatment. Patients who underwent PCN from January 2010 to June 2015 were included. Intent of treatment (radical or palliative) was decided within multidisciplinary team depending on disease stage, Karnofsky performance status (KPS), and degree of renal derangement. Treatment and outcome details were retrieved from electronic records. Time to normalization of creatinine, feasibility of delivering planned treatment, and overall survival (OS) were determined. Impact of various prognostic factors on outcomes was determined using univariate or multivariate analysis. After PCN and double-J stenting, 50% were eligible for (chemo) radiation. All radically treated patients (26/52) received brachytherapy. The median EQD2 to point A was 78 Gy (72-84 Gy). The median OS was 10 (0.5-60) months. Patients who completed chemoradiation had median OS of 31 months. Those receiving radical radiation and palliative radiation had median OS of 11 and 6 months, respectively. On univariate analysis, smaller tumor size (p = 0.03), high KPS (P = 0.04), and radical intent of treatment (P = 0.05) predicted for OS. Patients presenting with obstructive uropathy have median OS less than a year despite urinary diversion. Select cohort with good performance status, small tumor size, and serum creatinine of ≤3 mg/dL may be selected for diversion procedures and potential radical treatment.

Percutaneous nephrostomy versus antegrade double-J stent placement in the treatment of malignant obstructive uropathy: a cost-effectiveness analysis from the perspective of the Brazilian public health care system.

ObjectiveTo compare two percutaneous techniques used in the treatment of malignant obstructive uropathy-antegrade double-J stent placement (JJ stenting) and percutaneous nephrostomy-in terms of their cost-effectiveness, from the perspective of the Brazilian public health care system.Materials and MethodsIn this cost-effectiveness analysis, we employed decision-analytic modeling. We calculated material costs from 2017 factory prices listed by the Brazilian Pharmaceutical Market Regulatory Board (for medications) and published in the journal Revista Simpro (for medical devices). Procedure-related costs were evaluated, as were the rates of technical and clinical success. Those measures were then used as inputs for a cost-effectiveness analysis comparing the two procedures.ResultsThe sample comprised 41 patients, of whom 16 underwent antegrade JJ stenting (26 procedures) and 10 underwent percutaneous nephrostomy (15 procedures). Patient records, radiology reports, and expense reports of the interventional radiology department of the public hospital where the study was conducted were analyzed retrospectively. There were no significant complications: one patient had low back pain, and one had a transient retroperitoneal hematoma. The mean procedure time was 24 min, and clinical success (improvement in serum creatinine and resolution of hydronephrosis) was achieved in 97.5% of the cases. The average cost of JJ stenting was significantly lower than was that of percutaneous nephrostomy (US$164.10 vs. US$552.20).ConclusionIn the absence of any clinical contraindications, antegrade JJ stenting is a suitable alternative to both percutaneous nephrostomy and retrograde stenting in patients with dilated renal collecting systems secondary to malignant ureteral obstruction, providing significant cost savings and high success rates.

Localized prostate cancer presenting as a renal pseudo-tumour.

Malignant obstructive uropathy can be a result of common genitourinary malignancies (i.e., ureter, prostate, bladder, or kidney) or extrinsic processes, such as colon and ovarian tumours. We present a case of uropathy caused by prostatic obstruction, which initially presented as a renal psuedo-tumour. We also review the relevant literature.

Role of ultrasound-guided percutaneous antegrade pyelography in malignant obstructive uropathy: A Nigerian experience.

Ultrasound-guided percutaneous nephrostomy of the renal pelvis is a technique that is widely acceptable especially when contrast media is introduced in the procedure of antegrade pyelography. It is a relatively safe procedure that effectively improves renal function in obstructed kidneys. It can be performed in most cases as an alternative to retrograde pyelography. We present our experience and its role in obstructive uropathy due to malignancy.

A prognostic model for survival after urinary diversion for malignant ureteral obstruction: A prospective study of 208 patients.

102 Background: To determine prognostic factors and create a model for risk stratification in patients with malignant obstructive uropathy. Methods: We prospectively collected clinical and laboratory variables of 208 patients who underwent palliative urinary diversion by ureteral stenting or percutaneous nephrostomy between January 2009 and November 2011 in two tertiary care university hospitals, with minimum 6 months follow-up. Inclusion criteria were age>18yr and malignant urinary obstruction confirmed by computed tomography, ultrasound or magnetic resonance imaging. Results: Median survival after urinary diversion was 144 days. At the end of the study 164 patients died, 44 (21.2%) during the urinary diversion hospitalization. There was no difference in overall survival between the 2 types of diversion (p=0.216). The number of events related to malignant dissemination (≥4) and ECOG index≥2 were associated with shorter survival in multivariable analysis. Using these 2 risk factors (RF), patients were divided into 3 groups: favorable(no RF), intermediate(1RF) and unfavorable(2RF). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favorable group, 78.0%, 36.3%, and 15.5% in the intermediate, and 46.4%, 14.3%, and 7.1% in the unfavorable. There were differences in survival profiles of the 3 groups (p<0.001). Conclusions: Our stratification model may be useful tool to determine whether urinary diversion procedures are indicated in patients with malignant urinary obstruction.

Mitomycin C guidelines: An improvement in department adherence through the process of audit, led by junior doctors

s / International Journal of Surgery 12 (2014) S13eS117 S104 0328: MITOMYCIN C GUIDELINES: AN IMPROVEMENT IN DEPARTMENT ADHERENCE THROUGH THE PROCESS OF AUDIT, LED BY JUNIOR DOCTORS Gerard Walls , David Curry, Hugh O'Kane. Regional Urology Unit, Belfast City Hospital, Northern Ireland, UK. Introduction: The authors intended to establish adherence to guidelines regarding time to administration of intravesical chemotherapy postTURBT, in the Regional Urology Unit. EORTC recommends Mitomycin C (MMC) instillation within 6 hours in eligible patients this reduces recurrence rates by 39%. Methods: Prospective audit of time to administration in all eligible patients during a 3 month period. Results were discussed at departmental level with a three tiered approach to improvement. Primarily, initiation of in-theatre instillation (Mostafid et al). Second, a training programme for ward staff in handling cytotoxic agents. Finally, awareness of the problem was raised to trainee urologists at the Regional Audit Meeting. A repeat three month audit series was performed six months later. The latter two processes had been implemented with plans for in-theatre administration on-going. Results: Initially, in 19 patients (40 eligible) the mean time to MMC administration was 18.3hrs (2.3-28.2hrs). 15.7% patients received MMC 3mm, first time. Unanimous, unequivocal histopathological diagnoses were achieved. Conclusions: Few biopsy devices provide satisfactory, representative and consistent samples for diagnosis. We experienced an unpredictable outcome with a 25% re-biopsy rate with various devices, however with BIGopsy forceps accurate histopathological diagnoses were achieved with a significant impact on the timely treatment for urothelial malignancies. 0401: HOW CLINICAL AUDIT HAS LED TO REDUCED RATES OF POST TRUS BIOPSY SEPSIS IN OUR TRUST Nicholas Gill , Michael Onyema, Anne Dyas, Vincent Koo, Paul Rajjayabun. Alexandra Hospital, Redditch, UK. Introduction: We recently reported the findings of a regional audit which identified rates of sepsis increasing to 1.8% following transrectal ultrasound guided prostate biopsies (TRUS). Following this audit I.V. Gentamicin 160mg was introduced as additional prophylaxis for patients undergoing TRUS biopsy. Our aim was to assess the impact of adding Gentamicin to the TRUS antibiotic prophylaxis bundle since implementation in August 2013. Methods: Analysis of all patients who underwent TRUS biopsy across our Trust between August-December 2013 with minimum 1-month follow up. Our findings were compared against our previous audit data and published literature. Results: Therewere 246 TRUS biopsy procedures carried out across the Trust following the introduction of our new antibiotic prophylaxis regime. Median age of the population examined was 67 years (range 42-84). Only 1 patient was admitted to Secondary care with significant sepsis (0.4%), 3 patients had positive urine cultures performed inPrimarycare but didnot require hospital admission (1.2%). There were no ITU admissions or mortalities. Conclusion: We conclude that the addition of I.V. Gentamicin has dramatically reduced the incidence of significant sepsis post-TRUS biopsy. This is an example of howwe have utilised audit tomodify clinical practice for the benefit of our patients. 0403: PROGNOSIS FOLLOWING PERCUTANEOUS NEPHROSTOMY INSERTION FOR MALIGNANT OBSTRUCTIVE UROPATHY: ONE CENTRE'S EXPERIENCE Nicholas Gill , Kevin Williams, Phil Holland, Chris Phillips, Fabio Conti, K. Wong, L. Delaney, L. Moore, Paul Rajjayabun. Alexandra Hospital,

Prognosis following percutaneous nephrostomy insertion for malignant obstructive uropathy: One centre's experience

Prognosis following percutaneous nephrostomy insertion for malignant obstructive uropathy: One centre's experience

Evaluation of 18F-FDG Excretion Patterns in Malignant Obstructive Uropathy

This study aims to evaluate whether (18)F-FDG excretion patterns reflect renal function in malignant obstructive uropathy and to evaluate if these patterns predict internal ureteral stent success. One hundred twelve patients who underwent PET/CT for abdominal tumors and displayed hydronephrosis on CT and 59 patients who underwent PET/CT for cancer screening were included in a retrospective study. Hydronephrosis was graded by initial CT and correlated with visual analysis of (18)F-FDG renal parenchymal uptake and excretion patterns. Stent insertion was performed for 84 patients after PET. Follow-up CT was reviewed for hydronephrosis improvement. There were 4 PET patterns in obstructive hydronephrosis which correlated linearly with hydronephrosis severity and serum creatinine levels. Patients with no parenchymal retention and renal excretion (PET pattern 1) showed 97% (28/29) hydronephrosis improvement after stent insertion, and patients with no parenchymal retention and no renal excretion showed 0% (0/9) hydronephrosis improvement after stent insertion. Multivariate analysis showed creatinine levels and PET pattern predicted stent success, but CT hydronephrosis did not. There are 4 PET patterns of obstructive hydronephrosis which correlated with hydronephrosis grade and creatinine levels. Some of these PET patterns can be useful in the prediction of hydronephrosis improvement after stent insertion. Recognition of these patterns in obstructive hydronephrosis may be helpful in improving patient prognosis and quality of life.

Spontaneous renal forniceal rupture due to advanced cervical carcinoma with obstructive uropathy

To report and describe the clinical presentation and outcome of a woman presenting with gross perinephric urinary extravasation (due to spontaneous renal forniceal rupture), secondary to malignant obstructive uropathy caused by advanced cervical carcinoma. To review the etiopathogenesis, approach to diagnosis and management of 'spontaneous renal forniceal rupture. The published English literature (PubMed) was searched for similar cases of 'spontaneous renal forniceal rupture' using the keywords: carcinoma cervix, metastatic carcinoma cervix, renal pelvis rupture, renal fornix rupture, spontaneous renal fornix rupture and urinoma. The diagnosis of renal forniceal rupture with gross urinoma formation secondary to advanced cervical carcinoma was suspected on ultrasound and was subsequently confirmed by a computed tomographic scan of the abdomen. Percutaneous nephrostomy with a pigtail catheter resolved the urinoma. Search results for similar cases yielded several causes of spontaneous renal forniceal rupture, however, only one such case report due to advanced cervical carcinoma was found. To the best of our knowledge, this is the second case of spontaneous renal forniceal rupture secondary to ureteral obstruction caused by advanced cervical carcinoma to be reported in the published English literature. A high clinical index of suspicion is warranted in any patient of advanced cervical carcinoma that presents with sudden uremia or oliguria with flank pain and swelling in order to arrive at an early diagnosis. A decompressive nephrostomy may provide the much needed comfort and succor towards prolonging the life of such unfortunate patients.

Palliation of obstructive nephropathy due to malignancy.

To conduct a prospective study of patients with malignant obstructive uropathy treated actively by percutaneous nephrostomy and J-J ureteric stents. Forty-two patients (27 men, 15 women, median age 62 years, range 29-83) with obstructive nephropathy secondary to malignancy underwent urinary diversion followed, where appropriate, by active treatment of the underlying cancer. The median survival of all patients was 133 (range 7-712) days. Seventeen patients (40%) survived for > 6 months and five (12%) for < 1 month. Patients who had received no prior therapy and for whom further therapeutic options were available were more likely to benefit from urinary diversion. In nine patients (21%) nephrostomy insertion failed to relieve renal failure. In 20 patients (48%) obstructive nephropathy recurred. The procedure was complicated by urinary tract or nephrostomy site infection in 16 patients, by septicaemia in six patients, by percutaneous urine leak in 13 patients and by pelvi-calyceal perforation in two patients, but not by haemorrhage or death. The median percentage of the patients' remaining life which was spent in hospital was 23.6% (range 2.2-100). Patients likely to benefit from nephrostomy were those for whom there were therapeutic options available for the treatment of their malignancy. Prolonged survival is possible in obstructive nephropathy secondary to malignancy, which should no longer be cited as an absolute contra-indication to urinary diversion. Patients unlikely to benefit from urinary diversion can also be identified and they should not routinely undergo this intervention.