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The Management of Ureteric Obstruction Secondary to Malignant Pelvic Disease
Clinical Radiology (2002) 57: 1118±1121 doi:10.1053/crad.2002.1114, available online at http://www.idealibrary.com on
The Management of Ureteric Obstruction Secondary to Malignant Pelvic Disease S. V. C H I TA L E , S . SCOT T - B A R R E T T, E . T. S . HO , N . A . B U R G E S S *Departments of Urology and {Radiology, Norfolk & Norwich University Hospital NHS Trust, Brunswick Road, Norwich, Norfolk, U.K. Received: 16 May 2002
Revised: 1 August 2002 Accepted: 14 August 2002
AIM: Management of upper-tract obstruction secondary to a malignant pelvic process is a dicult problem and is best dealt with by a multi-disciplinary team. In the present audit, we address the question: is staged antegrade stenting better than retrograde ureteric stenting? MATERIALS AND METHODS: We reviewed our present management of upper-tract obstruction secondary to malignant pelvic disease in 65 patients treated over a period of 2 years. Fifty-eight patients had urological cancer and seven patients had non-urological cancers; 70% of all cases had renal impairment. Twenty-four of 65 patients had an attempt at endoscopic retrograde ureteric stenting as a primary method of decompression while percutaneous nephrostomy followed by antegrade ureteric stenting was performed in 41/65 patients. RESULTS: Endoscopic retrograde stenting had a success rate of 21% whereas two-stage antegrade stenting was successful in 98% of patients. The antegrade approach had minimal morbidity. CONCLUSION: Obstruction of the pelvic ureter secondary to any pelvic malignancy is best managed by two-stage antegrade ureteric stenting. This approach has a high success rate with minimal morbidity, and should be preferred to an endoscopic approach. This highlights the important role of an interventional uroradiologist in the management of these patients. Chitale, S. V. et al. (2002). Clinical Radiology 57, 1118±1121. # 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved Key words: pelvic ureter, ureteric stenting, nephrostomy, renal failure, hydronephrosis, uroradiologist.
INTRODUCTION
Management of lower ureteric obstruction secondary to pelvic malignancy is a therapeutic challenge. A multidisciplinary team approach is necessary to determine if active decompression of the upper tract is indeed the right thing to do. Having decided to proceed on the grounds of improving the patient's quality of life and possibly longevity, the next decision to be made is how best to achieve this objective. The urological literature is full of papers describing a number of decompression/bypass techniques. However, the ®nal decision will depend upon the availability of resources, local clinical expertise and the urologist's natural inclination as an endoscopist. We performed a retrospective review of our practice over a 2-year period to answer a speci®c question: what was the relative success rate of the methods used to decompress the obstructed upper tract and bypass the pelvic malignancy Author for correspondence and guarantor of study: Mr S. V. Chitale, Department of Urology, Norfolk & Norwich University Hospital NHS Trust, Colney Lane, Norwich NR4 7UY, U.K. Tel: 01603 286776; Fax: 01603 287741; E-mail: [email protected] 0009-9260/02/$35
with least morbidity? Was staged antegrade ureteric stenting superior to retrograde ureteric stenting?
MATERIAL AND METHODS
Three hundred patients over 2 years (July 1998 to July 2000) who had undergone either one-stage retrograde stenting or nephrostomy with subsequent antegrade ureteric stenting were studied. Of these, 65 patients had ureteric stenting for upper tract obstruction secondary to malignant pelvic disease. Case histories of these 65 patients were reviewed. There were 52 men and 13 women with an age range of 53±84 years. The majority (38/65, 58%) were in the age range 71±80 years (Table 1). The primary pelvic pathology predominantly involved the prostate (28/65, 43%) and urinary bladder (30/65, 46%) (Table 2). Fortysix out of 65 patients presented with renal impairment of varying severity and only 19 had normal renal function. Hydronephrosis was found bilaterally in 47 cases (87 functional renal units and 7 non-functioning renal units). The remaining 18 patients had unilateral hydronephrosis,
# 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved
THE MANAGEMENT OF URETERIC OBESTUCTION SECONDARY TO MALIGNANT PELVIC DISEASE
Table 1 ± Age distribution of patients 5 60 years
61±70 years 71±80 years 4 80 years
Total
02
11
65
38
14
Table 2 ± Primary pelvic disease Ca Prostate T3/4
Bladder TCC
Ca Cervix
Ca Rectum
Total
28
30
4
3
65
the contralateral kidney being either absent (4 patients) or non-obstructed (14 patients). In total, 105 renal units needed decompression. RESULTS
Endoscopic retrograde stenting (5 F/6 F) was attempted in 24 out of 65 (37%) patients as the primary method of decompression of the upper tracts but was successful in only ®ve of these patients (21%) (Table 3). Percutaneous nephrostomy was oered to 41 out of 65 (63%) patients and was successful in 100% of cases (Table 4). Nineteen out of 24 (79%) patients in whom retrograde stenting failed were then oered percutaneous nephrostomy as a secondary treatment and this was successful in all cases (100%). These patients with a nephrostomy inserted either as a primary or secondary treatment procedure went on to have an antegrade stent (8 F) inserted at a later stage, i.e. within a week of the nephrostomy insertion. A second puncture was made when necessary. If the initial nephrostomy was placed Table 3 ± Success rate of RG stenting PCN-AG stenting in malignant pelvic disease Primary treatment
Attempted
Successful
Failed
Retrograde stenting Percutaneous nephrostomy Ante grade stenting First attempt Second attempt
24 41 60 ± ±
5 41 59 57 2
19 0 1 ± ±
Table 4 ± Success rate of retrograde stenting percutaneous nephrostomy antegrade stenting in urological cancers
Retrograde stenting Percutaneous nephrostomy Antegrade stenting
Ca Pr (n 28)
Ca Bladder (n 30)
S: 1 F: 6 S : 21 F: 0 S : 20 F: 1
2 8 20 0 20 0
1119
in the lower calyx, a mid-calyceal puncture was performed to facilitate antegrade insertion of stent. Antegrade stenting was successful at the ®rst attempt in 57 out of 60 cases (95%), at the second attempt in two (3.3%) (Table 3) but failed in one case (1.7%) leaving that patient with a permanent nephrostomy (Table 4). In total, 59 out of 60 patients (98.3%) had an antegrade stent inserted successfully to overcome the lower ureteric obstruction and decompress the upper tracts. Failure of antegrade stenting in the only case of the series was attributed to a dense impassable stricture of the lower ureter secondary to prostatic carcinoma. Endoscopic retrograde stenting failed in 19 out of 24 patients (79%). The reasons for this high rate of failure were: inability to cannulate the ureteric ori®ces due to trigonal distortion or failure to negotiate the lower segment ureter in 17 out of 19 patients (89%) and non-visualization of the ureteric ori®ce due to post-operative scarring in the remainder. Follow-up of these 65 patients ranged from 10 months to 3 years. Forty-nine patients had their stents changed regularly via an endoscopic approach with no further diculty. One patient had a total cystectomy and urinary diversion as de®nitive treatment for muscle-invasive transitional cell carcinoma of the bladder. Another patient underwent a nephro-ureterectomy. Fourteen patients including the one with a permanent nephrostomy died of their primary pathology over a period of 6 to 18 months (mean 12 months). DISCUSSION
Obstructive uropathy secondary to involvement of the lower ( pelvic) ureter by a urological, gynaecological or colorectal malignancy can be a presenting clinical feature, or may develop in the later stages of the disease. The ureter is involved either by an extrinsic compression or mural in®ltration or both. In addition, radiotherapy to a primary pelvic tumour can lead to lower ureteric stricturing and upper tract obstruction as a result of ischaemic ®brosis of the ureter. Such patients often present with either renal failure at primary presentation or indeed have a degree of renal insuciency and unilateral/bilateral hydronephrosis detected on ultrasound examination during the course of their routine follow-up. A therapeutic dilemma remains as to whether to be aggressive in decompressing the upper tracts or simply oer palliative non-surgical treatment. A decision is usually made through a multi-disciplinary approach and the patient with his/her family should be involved in the decision-making. Only those who can bene®t with an improved quality of life and survival should be oered decompression of their upper tract [1]. Patients with hormone-sensitive prostate cancer, who have advanced local disease (T3/T4) or indeed metastatic disease, have a better survival than those with hormone-insensitive or ``hormone-escaped'' tumours [2]. This observation makes a strong case for oering decompression to those who are still hormone responsive, those who have not as yet been started on hormone therapy, or to those for whom eective treatment is still available and in those without a de®nite diagnosis. However, if a patient with hormone-escaped
1120
CLINICAL RADIOLOGY
disease requests active intervention despite being aware of the long-term prognosis, it is reasonable to oer surgical palliation. A number of surgical techniques have been described in the literature for upper-tract decompression in these patients. Each has advantages and disadvantages. In a retrospective view of 218 patients, Holden et al. [3] found that open nephrostomies for advanced pelvic tumours had a high incidence of post-operative morbidity and mortality. They suggested it should be oered to only those who could return to a ``useful life'' for at least 2 months [3]. Percutaneous nephrostomy has become a much less morbid procedure. Staging the nephrostomy placement and antegrade ureteric stent insertion further reduces the morbidity and complication rate to a minimum. Sharer et al. [4] in their analysis of palliative urinary diversion for malignant ureteric obstruction identi®ed selection criteria for diversion and the variety of procedures used for diversion. Age was not a major factor aecting survival until the ninth decade. Two thirds of their patients spent 84% of their remaining lives at home. They found ureters obstructed by vesical/prostatic/cervical cancers dicult or impossible to catheterize endoscopically. Our ®ndings concur with these reports. With lower ureteric obstruction it is dicult to obtain access into the lower ureter. Moreover, even when the access to the ureter is obtained, because of distal ( pelvic) ureteric narrowing and tortuosity, there is little ``purchase'' into the lower ureter for the guide wire to advance successfully and negotiate the site of rigid lower ureteric obstruction. There is a lack of mechanical advantage from the lower end and this is overcome when dealing with the same obstruction in an antegrade fashion due to the ``funnel'' eect of the dilated proximal ureter. There are several reports of success rates with antegrade stents on failing to insert a retrograde stent in this category of patient [5±8]. Various authors have reported a success rate of 90 to 92% with nephrostomy followed by subsequent antegrade stenting where retrograde stenting proved impossible. The antegrade approach has been found to be safe, cost-eective, relatively easy and minimally invasive. Stents were either not replaced at all or left up to 20 months without replacement. In our experience the pigtails needed regular change every 6 to 12 months because even though they were not overtly encrusted on the plain radiograph, the lumen was found to be blocked at the time they were due for routine replacement or even earlier. Regular checks on renal function at times brought forward the stent change as transient renal impairment with evidence of hydronephrosis on the USS was regarded as being due to a blocked stent. This is often immediately reversed following stent replacement. In terminally ill or, medically un®t patients, the option of withholding stent change was available and used when appropriate due to a high risk:bene®t ratio, even though the dwell time had been longer than 6 months. Endoscopic stenting happens to be the natural choice of a urologist when faced with a case of ureteric obstruction secondary to pelvic malignancy. In our hands, the chances of success with this approach have been low (5 20%) in
contrast to antegrade stent insertion (98%). Hepperlen et al. [9] suggested that an attempt at endoscopic stenting be made when the hydronephrosis was unilateral and there was no uraemia. In our series, out of 18 patients with unilateral hydronephrosis an endoscopic stent was attempted in seven patients but was successful in only two (28%). We believe that pelvic obstruction of the ureter is most eectively dealt with by an antegrade approach. Sharma et al. have reported a similar experience in the management of ureteric obstruction due to diverse aetiology with an overall success rate of 83% [10]. Their series included cases of upper ureteric obstruction in addition to the lower ureteric obstruction secondary to benign as well as malignant pathology. Antegrade insertion of metallic stents has also been reported in the literature [11,12] and found to be a safe eective technique with a long-term patency rate. For those patients managed with a permanent nephrostomy due to a failed attempt at ureteric stenting, subcutaneous diversion with a nephro-vesical stent by a percutaneous access to both kidney and the bladder is also an option but long-term follow-up is needed [13]. From our present series we believe percutaneous nephrostomy followed by antegrade stent insertion by an interventional radiologist as a two-stage primary approach has signi®cant advantages over attempts at endoscopic stenting. It requires only sedation and local anaesthetic. Patients with compromised renal function and other comorbidities tolerate this procedure very well with few complications. Since the nephrostomy and stenting are staged, patients are physiologically much improved by the time they are oered an antegrade stent and are discharged from the hospital within 48±72 h following stent insertion. Intraoperative ®nding of lower ureteric obstruction secondary to a pelvic pathology noted during an emergency or even an elective laparotomy for a surgical or gynaecological indication should be dealt with by postoperative nephrostomy and subsequent stenting. In the hands of an experienced interventional radiologist the success rate approaches 100%. The two-stage approach is relatively easy, minimally invasive and less expensive. It can also be performed in a semi-elective fashion. It helps avoid the increased risk of sepsis in an obstructed system following a failed attempt at endoscopic stenting and the unavoidable delay that follows before a nephrostomy can be inserted. All but one patient in our series were managed with indwelling ureteric stents without any associated sepsis, contrary to this reported [14]. Subsequent endoscopic change of a stent does not pose any technical diculty. The old stent is replaced with a new one over a guide wire placed either through or beside the old stent by an endoscopic approach. In the rare event of inability to replace the old stent with a new one endoscopically, nephrostomy insertion at a subsequent stage (within 24 h) followed by an antegrade insertion of a ureteric stent is still a feasible option. We believe that obstruction of the pelvic ureter is best managed by a two-staged antegrade approach and subsequent stent change by an endoscopic retrograde approach. It requires the ready availability of an experienced
THE MANAGEMENT OF URETERIC OBESTUCTION SECONDARY TO MALIGNANT PELVIC DISEASE
interventional radiologist. This approach has minimal morbidity and high success rate. In our experience, primary endoscopic retrograde ureteric stenting has an unacceptably high failure rate in this group of patients. REFERENCES 1 Brin EN, Schi M Jr, Weiss RM. Palliative urinary diversion for pelvic malignancy. J Urol 1975;113:619±622. 2 Paul AB, Love C, Chisholm GD. The management of bilateral ureteric obstruction and renal failure in advanced prostate cancer. Br J Urol 1994;74:642±645. 3 Holden S, McPhee M, Grabstald H. The rationale of urinary diversion in cancer patients. J Urol 1979;121:19±21. 4 Sharer W, Grayhack JT, Graham J. Palliative urinary diversion for malignant ureteral obstruction. J Urol 1978;120:162±164. 5 Singh B, Kim H, Wax SH. Stent versus nephrostomy: is there a choice?. J Urol 1979;121:268±270. 6 Smith A. Antegrade path prepares way for ureteral stent placement. Clin Trends Urol 1977;6.
1121
7 Harding JR. Percutaneous antegrade ureteric stent insertion in malignant disease. J R Soc Med 1993;86:511±513. 8 Jenkins CNJ. The value of antegrade stenting for lower ureteric obstruction. J R Soc Med 1995;88:446±449. 9 Hepperlen TW, Mardis HK, Kammandel H. The pigtail ureteral stent in the cancer patient. J Urol 1979;121:17±18. 10 Sharma SD, Persad RA, Haq A, et al. A review of ante grade stenting in the management of the obstructed kidney. Br J Urol 1996;78:511±515. 11 Lopez-Martinez RA, Singireddy S, Lang EK. The use of metallic stents to bypass ureteral strictures secondary to metastatic prostate cancer: experience with eight patients. J Urol 1997;158:50±53. 12 Pandian SS, Hussey JK, McClinton S. Metallic ureteric stents: early experience. Br J Urol 1998;82:791±797. 13 Nakada SY, Gerber AJ, Wolf JS Jr, Hicks ME, Picus D, Clayman RV. Subcutaneous urinary diversion utilising a nephrovesical stent: a superior alternative to long-term external drainage?. Urology 1995;45:538±541. 14 Hyppolite JC, Daniels ID, Friedman EA. Obstructive uropathy in gynaecologic malignancy: detrimental eect of intraureteral stent placement and value of percutaneous nephrostomy. ASAIO J 1995;41:318±323.
The Management of Ureteric Obstruction Secondary to Malignant Pelvic Disease S. V. C H I TA L E , S . SCOT T - B A R R E T T, E . T. S . HO , N . A . B U R G E S S *Departments of Urology and {Radiology, Norfolk & Norwich University Hospital NHS Trust, Brunswick Road, Norwich, Norfolk, U.K. Received: 16 May 2002
Revised: 1 August 2002 Accepted: 14 August 2002
AIM: Management of upper-tract obstruction secondary to a malignant pelvic process is a dicult problem and is best dealt with by a multi-disciplinary team. In the present audit, we address the question: is staged antegrade stenting better than retrograde ureteric stenting? MATERIALS AND METHODS: We reviewed our present management of upper-tract obstruction secondary to malignant pelvic disease in 65 patients treated over a period of 2 years. Fifty-eight patients had urological cancer and seven patients had non-urological cancers; 70% of all cases had renal impairment. Twenty-four of 65 patients had an attempt at endoscopic retrograde ureteric stenting as a primary method of decompression while percutaneous nephrostomy followed by antegrade ureteric stenting was performed in 41/65 patients. RESULTS: Endoscopic retrograde stenting had a success rate of 21% whereas two-stage antegrade stenting was successful in 98% of patients. The antegrade approach had minimal morbidity. CONCLUSION: Obstruction of the pelvic ureter secondary to any pelvic malignancy is best managed by two-stage antegrade ureteric stenting. This approach has a high success rate with minimal morbidity, and should be preferred to an endoscopic approach. This highlights the important role of an interventional uroradiologist in the management of these patients. Chitale, S. V. et al. (2002). Clinical Radiology 57, 1118±1121. # 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved Key words: pelvic ureter, ureteric stenting, nephrostomy, renal failure, hydronephrosis, uroradiologist.
INTRODUCTION
Management of lower ureteric obstruction secondary to pelvic malignancy is a therapeutic challenge. A multidisciplinary team approach is necessary to determine if active decompression of the upper tract is indeed the right thing to do. Having decided to proceed on the grounds of improving the patient's quality of life and possibly longevity, the next decision to be made is how best to achieve this objective. The urological literature is full of papers describing a number of decompression/bypass techniques. However, the ®nal decision will depend upon the availability of resources, local clinical expertise and the urologist's natural inclination as an endoscopist. We performed a retrospective review of our practice over a 2-year period to answer a speci®c question: what was the relative success rate of the methods used to decompress the obstructed upper tract and bypass the pelvic malignancy Author for correspondence and guarantor of study: Mr S. V. Chitale, Department of Urology, Norfolk & Norwich University Hospital NHS Trust, Colney Lane, Norwich NR4 7UY, U.K. Tel: 01603 286776; Fax: 01603 287741; E-mail: [email protected] 0009-9260/02/$35
with least morbidity? Was staged antegrade ureteric stenting superior to retrograde ureteric stenting?
MATERIAL AND METHODS
Three hundred patients over 2 years (July 1998 to July 2000) who had undergone either one-stage retrograde stenting or nephrostomy with subsequent antegrade ureteric stenting were studied. Of these, 65 patients had ureteric stenting for upper tract obstruction secondary to malignant pelvic disease. Case histories of these 65 patients were reviewed. There were 52 men and 13 women with an age range of 53±84 years. The majority (38/65, 58%) were in the age range 71±80 years (Table 1). The primary pelvic pathology predominantly involved the prostate (28/65, 43%) and urinary bladder (30/65, 46%) (Table 2). Fortysix out of 65 patients presented with renal impairment of varying severity and only 19 had normal renal function. Hydronephrosis was found bilaterally in 47 cases (87 functional renal units and 7 non-functioning renal units). The remaining 18 patients had unilateral hydronephrosis,
# 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved
THE MANAGEMENT OF URETERIC OBESTUCTION SECONDARY TO MALIGNANT PELVIC DISEASE
Table 1 ± Age distribution of patients 5 60 years
61±70 years 71±80 years 4 80 years
Total
02
11
65
38
14
Table 2 ± Primary pelvic disease Ca Prostate T3/4
Bladder TCC
Ca Cervix
Ca Rectum
Total
28
30
4
3
65
the contralateral kidney being either absent (4 patients) or non-obstructed (14 patients). In total, 105 renal units needed decompression. RESULTS
Endoscopic retrograde stenting (5 F/6 F) was attempted in 24 out of 65 (37%) patients as the primary method of decompression of the upper tracts but was successful in only ®ve of these patients (21%) (Table 3). Percutaneous nephrostomy was oered to 41 out of 65 (63%) patients and was successful in 100% of cases (Table 4). Nineteen out of 24 (79%) patients in whom retrograde stenting failed were then oered percutaneous nephrostomy as a secondary treatment and this was successful in all cases (100%). These patients with a nephrostomy inserted either as a primary or secondary treatment procedure went on to have an antegrade stent (8 F) inserted at a later stage, i.e. within a week of the nephrostomy insertion. A second puncture was made when necessary. If the initial nephrostomy was placed Table 3 ± Success rate of RG stenting PCN-AG stenting in malignant pelvic disease Primary treatment
Attempted
Successful
Failed
Retrograde stenting Percutaneous nephrostomy Ante grade stenting First attempt Second attempt
24 41 60 ± ±
5 41 59 57 2
19 0 1 ± ±
Table 4 ± Success rate of retrograde stenting percutaneous nephrostomy antegrade stenting in urological cancers
Retrograde stenting Percutaneous nephrostomy Antegrade stenting
Ca Pr (n 28)
Ca Bladder (n 30)
S: 1 F: 6 S : 21 F: 0 S : 20 F: 1
2 8 20 0 20 0
1119
in the lower calyx, a mid-calyceal puncture was performed to facilitate antegrade insertion of stent. Antegrade stenting was successful at the ®rst attempt in 57 out of 60 cases (95%), at the second attempt in two (3.3%) (Table 3) but failed in one case (1.7%) leaving that patient with a permanent nephrostomy (Table 4). In total, 59 out of 60 patients (98.3%) had an antegrade stent inserted successfully to overcome the lower ureteric obstruction and decompress the upper tracts. Failure of antegrade stenting in the only case of the series was attributed to a dense impassable stricture of the lower ureter secondary to prostatic carcinoma. Endoscopic retrograde stenting failed in 19 out of 24 patients (79%). The reasons for this high rate of failure were: inability to cannulate the ureteric ori®ces due to trigonal distortion or failure to negotiate the lower segment ureter in 17 out of 19 patients (89%) and non-visualization of the ureteric ori®ce due to post-operative scarring in the remainder. Follow-up of these 65 patients ranged from 10 months to 3 years. Forty-nine patients had their stents changed regularly via an endoscopic approach with no further diculty. One patient had a total cystectomy and urinary diversion as de®nitive treatment for muscle-invasive transitional cell carcinoma of the bladder. Another patient underwent a nephro-ureterectomy. Fourteen patients including the one with a permanent nephrostomy died of their primary pathology over a period of 6 to 18 months (mean 12 months). DISCUSSION
Obstructive uropathy secondary to involvement of the lower ( pelvic) ureter by a urological, gynaecological or colorectal malignancy can be a presenting clinical feature, or may develop in the later stages of the disease. The ureter is involved either by an extrinsic compression or mural in®ltration or both. In addition, radiotherapy to a primary pelvic tumour can lead to lower ureteric stricturing and upper tract obstruction as a result of ischaemic ®brosis of the ureter. Such patients often present with either renal failure at primary presentation or indeed have a degree of renal insuciency and unilateral/bilateral hydronephrosis detected on ultrasound examination during the course of their routine follow-up. A therapeutic dilemma remains as to whether to be aggressive in decompressing the upper tracts or simply oer palliative non-surgical treatment. A decision is usually made through a multi-disciplinary approach and the patient with his/her family should be involved in the decision-making. Only those who can bene®t with an improved quality of life and survival should be oered decompression of their upper tract [1]. Patients with hormone-sensitive prostate cancer, who have advanced local disease (T3/T4) or indeed metastatic disease, have a better survival than those with hormone-insensitive or ``hormone-escaped'' tumours [2]. This observation makes a strong case for oering decompression to those who are still hormone responsive, those who have not as yet been started on hormone therapy, or to those for whom eective treatment is still available and in those without a de®nite diagnosis. However, if a patient with hormone-escaped
1120
CLINICAL RADIOLOGY
disease requests active intervention despite being aware of the long-term prognosis, it is reasonable to oer surgical palliation. A number of surgical techniques have been described in the literature for upper-tract decompression in these patients. Each has advantages and disadvantages. In a retrospective view of 218 patients, Holden et al. [3] found that open nephrostomies for advanced pelvic tumours had a high incidence of post-operative morbidity and mortality. They suggested it should be oered to only those who could return to a ``useful life'' for at least 2 months [3]. Percutaneous nephrostomy has become a much less morbid procedure. Staging the nephrostomy placement and antegrade ureteric stent insertion further reduces the morbidity and complication rate to a minimum. Sharer et al. [4] in their analysis of palliative urinary diversion for malignant ureteric obstruction identi®ed selection criteria for diversion and the variety of procedures used for diversion. Age was not a major factor aecting survival until the ninth decade. Two thirds of their patients spent 84% of their remaining lives at home. They found ureters obstructed by vesical/prostatic/cervical cancers dicult or impossible to catheterize endoscopically. Our ®ndings concur with these reports. With lower ureteric obstruction it is dicult to obtain access into the lower ureter. Moreover, even when the access to the ureter is obtained, because of distal ( pelvic) ureteric narrowing and tortuosity, there is little ``purchase'' into the lower ureter for the guide wire to advance successfully and negotiate the site of rigid lower ureteric obstruction. There is a lack of mechanical advantage from the lower end and this is overcome when dealing with the same obstruction in an antegrade fashion due to the ``funnel'' eect of the dilated proximal ureter. There are several reports of success rates with antegrade stents on failing to insert a retrograde stent in this category of patient [5±8]. Various authors have reported a success rate of 90 to 92% with nephrostomy followed by subsequent antegrade stenting where retrograde stenting proved impossible. The antegrade approach has been found to be safe, cost-eective, relatively easy and minimally invasive. Stents were either not replaced at all or left up to 20 months without replacement. In our experience the pigtails needed regular change every 6 to 12 months because even though they were not overtly encrusted on the plain radiograph, the lumen was found to be blocked at the time they were due for routine replacement or even earlier. Regular checks on renal function at times brought forward the stent change as transient renal impairment with evidence of hydronephrosis on the USS was regarded as being due to a blocked stent. This is often immediately reversed following stent replacement. In terminally ill or, medically un®t patients, the option of withholding stent change was available and used when appropriate due to a high risk:bene®t ratio, even though the dwell time had been longer than 6 months. Endoscopic stenting happens to be the natural choice of a urologist when faced with a case of ureteric obstruction secondary to pelvic malignancy. In our hands, the chances of success with this approach have been low (5 20%) in
contrast to antegrade stent insertion (98%). Hepperlen et al. [9] suggested that an attempt at endoscopic stenting be made when the hydronephrosis was unilateral and there was no uraemia. In our series, out of 18 patients with unilateral hydronephrosis an endoscopic stent was attempted in seven patients but was successful in only two (28%). We believe that pelvic obstruction of the ureter is most eectively dealt with by an antegrade approach. Sharma et al. have reported a similar experience in the management of ureteric obstruction due to diverse aetiology with an overall success rate of 83% [10]. Their series included cases of upper ureteric obstruction in addition to the lower ureteric obstruction secondary to benign as well as malignant pathology. Antegrade insertion of metallic stents has also been reported in the literature [11,12] and found to be a safe eective technique with a long-term patency rate. For those patients managed with a permanent nephrostomy due to a failed attempt at ureteric stenting, subcutaneous diversion with a nephro-vesical stent by a percutaneous access to both kidney and the bladder is also an option but long-term follow-up is needed [13]. From our present series we believe percutaneous nephrostomy followed by antegrade stent insertion by an interventional radiologist as a two-stage primary approach has signi®cant advantages over attempts at endoscopic stenting. It requires only sedation and local anaesthetic. Patients with compromised renal function and other comorbidities tolerate this procedure very well with few complications. Since the nephrostomy and stenting are staged, patients are physiologically much improved by the time they are oered an antegrade stent and are discharged from the hospital within 48±72 h following stent insertion. Intraoperative ®nding of lower ureteric obstruction secondary to a pelvic pathology noted during an emergency or even an elective laparotomy for a surgical or gynaecological indication should be dealt with by postoperative nephrostomy and subsequent stenting. In the hands of an experienced interventional radiologist the success rate approaches 100%. The two-stage approach is relatively easy, minimally invasive and less expensive. It can also be performed in a semi-elective fashion. It helps avoid the increased risk of sepsis in an obstructed system following a failed attempt at endoscopic stenting and the unavoidable delay that follows before a nephrostomy can be inserted. All but one patient in our series were managed with indwelling ureteric stents without any associated sepsis, contrary to this reported [14]. Subsequent endoscopic change of a stent does not pose any technical diculty. The old stent is replaced with a new one over a guide wire placed either through or beside the old stent by an endoscopic approach. In the rare event of inability to replace the old stent with a new one endoscopically, nephrostomy insertion at a subsequent stage (within 24 h) followed by an antegrade insertion of a ureteric stent is still a feasible option. We believe that obstruction of the pelvic ureter is best managed by a two-staged antegrade approach and subsequent stent change by an endoscopic retrograde approach. It requires the ready availability of an experienced
THE MANAGEMENT OF URETERIC OBESTUCTION SECONDARY TO MALIGNANT PELVIC DISEASE
interventional radiologist. This approach has minimal morbidity and high success rate. In our experience, primary endoscopic retrograde ureteric stenting has an unacceptably high failure rate in this group of patients. REFERENCES 1 Brin EN, Schi M Jr, Weiss RM. Palliative urinary diversion for pelvic malignancy. J Urol 1975;113:619±622. 2 Paul AB, Love C, Chisholm GD. The management of bilateral ureteric obstruction and renal failure in advanced prostate cancer. Br J Urol 1994;74:642±645. 3 Holden S, McPhee M, Grabstald H. The rationale of urinary diversion in cancer patients. J Urol 1979;121:19±21. 4 Sharer W, Grayhack JT, Graham J. Palliative urinary diversion for malignant ureteral obstruction. J Urol 1978;120:162±164. 5 Singh B, Kim H, Wax SH. Stent versus nephrostomy: is there a choice?. J Urol 1979;121:268±270. 6 Smith A. Antegrade path prepares way for ureteral stent placement. Clin Trends Urol 1977;6.
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