Nephrostomies in obstructive uropathy; how should hormone resistant prostate cancer patients be managed and can we predict who will benefit?

Abstract

Current opinion advocates the use of nephrostomies in hormone naive patients with obstructive uropathy while hormone resistant patients require an individual approach. Patients undergoing a nephrostomy for uropathy were retrospectively analysed, with particular interest in hormone status and blood levels. Over a 46-month period, 26/112 nephrostomies were performed for prostate cancer induced uropathy. Survival was 226.5 days for hormone naive patients, 114.3 days in the responsive group and 100.2 days if resistant. Bilateral cases survived 72.1 days versus 157.6 days for unilateral patients. All patients should be considered for nephrostomy despite their hormone status.

Management of Obstructive Uropathy Patients with Advanced Prostate Cancer – A Systematic Review

“…In contrast to obstructive uropathy causedbystones,thebiologicalgenesisinprostatecanceris extrinsic, caused by external compression of ureter or bladder,orindirectlybyelevationofthetrigone.Whileastentin patients suffering from urolithiasis simply facilitates passage of the concrements, it needs to resist external compression andinvasioninthecaseofmalignantcompression.Thus,even ifastentisabletobypasstheinternalureteralnarrowing,it willlikelyfailovertime [15].Thismightexplainlowersuccess ratesforstentingofextrinsicobstructionasopposedtointrinsicocclusion [16,17].Thedifferentsortsofreportedstentsdid not allow a systematic assessment of the impact of different stent materials on the outcome in prostate cancer patients. Atpresent,polyurethaneandsiliconearethemostfrequently usedmaterialsinclinicalpractice.Thereisawidevariability inoverallsurvivalofprostatecancerpatientswithobstructive uropathy,dependingondiseasecharacteristicsotherthanobstruction.Thelongestrecordedoverallsurvivalamountedto 26months [6].Thepresenteddatadonotallowacomparison ofoverallsurvivalforthethreeinterventionmodesPCN,retrogradestenting,andAD.Theresultssuggestinferioroverallsurvivalinpatientspre-treatedwithADorknownasAD resistantcomparedtohormone-naivepatients.Theseresults correspond with clinical experience in patients with other There are several problems concerning the validity and generalisabilityoftheseresultsbecausethepublishedstudies showanumberofprofoundmethodologicalflaws.Firstly,the numberofincludedpatientsperstudyissmall.Additionally, some studies report general results on various pelvic malignancieswithoutseparateanalysisofprostatecancerpatients. Asecondmajorissueconcerningthevalidityandcomparabilityofdataistheepidemiologicaldesignofthestudies.Most publisheddataarisefromcaseserieswithpotentiallyconsiderabledifferencesinpatientcharacteristics,whichmayhave a profound impact on differences in recorded outcomes and reduce the comparability of the results.…”

“…Subgroup analyses donebysomeauthorsshoweddifferencesinoverallsurvival dependingoncertainpatientcharacteristics:Accordingtothe results of Bordinazzo et al [11] and Chiou et al [3], overall survivalisnotsignificantlydifferentinpatientswithunilateral andbilateralobstruction(20-21months).Harrisetal. [6]re-portedshorteroverallsurvival,withbilaterallyobstructedand mainly hormone-refractory patients having a much shorter survivaltimethanpatientswithunilateraluretericobstruction (5.3 vs. 2.4 months). The subgroup analyses of five publications [2,3,6,11,13]comparingpatientswithformerADtreatmentandAD-naivepatientsshowatrendforlongersurvival inAD-naivepatients.Thisfindingissupportedbythedataof Michigan and Catalona [14] who treated patients with AD onlyandshowedmarkedlyreducedoverallsurvivalinpatients notrespondingtothistreatment.3studiescomparedoverall survivalofpatientswhohaddecompressionwithpatientswith no performed decompression [1,2,13] in cohorts including bothAD-naiveandhormone-refractorypatients.WhileHonnens de Lichtenberg et al [1] and Paul et al [2] detected a shorteroverallsurvivalinpatientswhoweredecompressedas opposedtopatientswithoutPCNorstent,KhanandUtz [13] report a survival in the treatment arm that is slightly higher thanthatinthecontrolarmwithnodecompression.ThepresentedstudiesdonotallowcomparisonofoverallsurvivalbetweenPCNandretrogradestenting.Althoughthereareoverall survival data on patients receiving PCN, the only study evaluatingretrogradestentingdoesnotreportoverallsurvival [10].The3publicationsthatincludedpatientstreatedeither withPCNorretrogradestentingdidnotperformasubgroup analysis.…”

“…Untreated obstructive uropathy can leadtorenalfailure,upperurinarytractinfection,andsepticaemia.Patientswithureteralobstructionsecondarytoadenocarcinoma of the prostate often present the urologist with a difficultdecisionastowhichformoftreatmentismostappropriate [2].Theurologicalliteratureisfullofpapersdescribing a number of decompression/bypass techniques. Procedures such as open nephrostomy have a significant risk of general anesthesia,andmorbidityandmortalityoftenresultinshort postoperativesurvivalwithpoorqualityoflife [3].Percutaneousnephrostomy(PCN)anduretericstentsmakedecompression much less surgically demanding than when decompressiondependsonopenoperation [2],andhavereplacedopen surgicalapproaches [4].However,theoptimalmanagementof malignantureteralobstructionremainsunderdebate [5]and thereislittlerecentevidencetoassistcliniciansinadvisingpatientswhetherdecompressionwouldbeintheirbestinterests, how this may affect their prognosis, and which mode of decompressionispreferable [6].Themostcommondecompressiontechniqueinclinicalpracticeistheimplantationofaretrogradestent [2].Theaimofthisreviewwastosystematically search,identifyanddisplaythebestavailableevidenceforthe treatment of ureteral obstruction and uropathy in prostate cancer,inordertofacilitateclinicaldecisionmaking.…”

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

“…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 associates 65 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.…”

Managing the local complications of locally advanced prostate cancer

“…While nephrostomy drainage is widely offered for hormone-naïve ureteral obstruction, controversy exists regarding the use of nephrostomy tubes for hormoneresistant ureteral obstruction, which is thought to portend a worse prognosis. Harris and Speakman [16] compared their experience with nephrostomy drainage for patients with hormone-naïve versus hormone-resistant disease. Twenty-six patients were retrospectively identified: two were hormone naïve, three were responding to hormones, and 21 were hormone resistant.…”