Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 64-67

Palliative management of bilateral malignant ureteric obstruction


1 Urology Division, Department of Surgery, Jos University Teaching Hospital; Department of Surgery, College of Medical Sciences, University of Jos, Jos, Nigeria
2 Urology Division, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria

Date of Submission17-May-2020
Date of Decision12-Jun-2020
Date of Acceptance22-Jul-2020
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Samaila I Shuaibu
Department of Surgery , Jos University Teaching Hospital, Jos,
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_26_20

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  Abstract 

Background Malignant ureteric obstruction is often associated with end-stage cancer arising from the cervix, bladder, prostate and other pelvic organs. We reviewed palliative therapeutic options and outcome of patients with bilateral malignant ureteric obstruction at the Jos University Teaching Hospital (JUTH). Methods This was a retrospective cross-sectional study. Data from patients managed by the Urology division of JUTH for patients with bilateral ureteric obstruction of malignant cause over a period of 10 years were reviewed. Patients’ age, cause of malignant ureteric obstruction and types of interventions carried out were extracted. In addition, mean serum creatinine level at presentation and one-month post intervention were analysed. The overall patient survival over a 6-month period was evaluated. Data were analysed using SPSS version 23. Result 24 patients managed within the period of the study had complete data for analysis. The age range was 43-73years with a median of 49 years. Majority (79.2%) of patients were female. 54.2% of the patients had open nephrostomy. Retrograde ureteric stent insertion (16.6%) and permanent haemodialysis (29.2%) were the other palliative management options. Open nephrostomy offered the most significant improvement in biochemical outcome at one-month post intervention (P = 0.039). 41.6% of patients were alive at 6 months post intervention. None of the treatment options conferred survival advantage over the others. Conclusion Open nephrostomy is the most common palliative management option for patients with bilateral malignant ureteric obstruction at JUTH and achieves the most significant biochemical improvement. No palliative management option conferred superior survival outcome among the patients.

Keywords: Malignant ureteric obstruction, open nephrostomy, retrograde ureteric stenting


How to cite this article:
Shuaibu SI, Umana IP, Osunaiye OI, Jila BJ, Akpayak IC, Ofoha CG. Palliative management of bilateral malignant ureteric obstruction. J Med Trop 2021;23:64-7

How to cite this URL:
Shuaibu SI, Umana IP, Osunaiye OI, Jila BJ, Akpayak IC, Ofoha CG. Palliative management of bilateral malignant ureteric obstruction. J Med Trop [serial online] 2021 [cited 2021 Dec 8];23:64-7. Available from: https://www.jmedtropics.org/text.asp?2021/23/1/64/314848




  Introduction Top


Palliative care plays an important role in the management of patients with advanced malignancies. At such stage, cancer is often considered incurable and patients do not wish to go ahead with surgical interventions that have high probability of morbidity.[1],[2],[3] Thus, in patients with advanced malignancies the main aim of palliative interventions is to attain the highest level of quality of life by providing relief from disease-related or symptom-related conditions and prolong quality life survival.[3]

Malignant ureteric obstruction (MUO) is a feature of advanced malignancies arising from the cervix, prostate, bladder, colon, rectum, and other pelvic malignancies. It may be unilateral or bilateral, intrinsic, or extrinsic.[1] it is often a precursor of terminal events in patients with these malignancies. Currently, there are no uniformly acceptable management guidelines for MUO.[2] This study aimed at reviewing the palliative therapeutic measures deployed in managing patients with bilateral MUO at Jos University Teaching Hospital (JUTH), a tertiary hospital in north central Nigeria. The study also assessed the changes in serum creatinine level at 1-month post intervention and the overall survival for patients at 6 months post intervention.


  Patients and methods Top


This study was a retrospective cross-sectional study carried out in the Urology Division of Jos University Teaching Hospital from January 2010 to September 2019. Records of patients with histological diagnosis of malignancies causing bilateral ureteric obstruction were reviewed and data extracted. Patients with unilateral malignant ureteric obstruction were excluded. Patients with prior renal impairment e.g. Diabetic or Hypertensive Nephropathy were also excluded.

Data retrieved and analysed included patients’ bio-demographics, diagnosis, type of malignancy and type of palliative intervention. Serum creatinine before intervention and one month after the palliative intervention were analysed. Survival outcome was measured by the percentage of patients who were alive at six months following each intervention option. Analysis was done using SPSS version 23. Results were presented using tables and gtables and graphs. Chi-square was used to determine difference between groups and P-value of <0.05 was considered significant. The Human Research Ethics Committee of the hospital approved the publication of the data in this retrospective study.


  Results Top


Twenty-four patients had complete data for analysis. Age ranged from 24 to 73 years with a median of 49 years. Nineteen (79.2%) of the patients analysed were females [Table 1]. Of the four identified aetiologies for malignant ureteric obstruction, advanced cervical cancer accounted for an overwhelming proportion, 62.5% [Table 1]. The remaining causes, namely advanced bladder cancer, advanced prostate cancer and advanced colorectal cancer all accounted for equal percentages (12.5%).
Table 1: Characteristics of 24 patients with bilateral malignant ureteric obstruction

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Open nephrostomy was the most frequent intervention, accounting for 54.2% of the treatment offered. Haemodialysis accounted for 25% of interventions. Haemodialysis was offered for patients adjudged to be unfit for anaesthesia or who rejected any form of palliative surgical intervention. Retrograde ureteric stent insertion for at least one renal unit was done in 20.8% of patients [Table 1].

There was a significant difference in the mean reduction of creatinine among the various treatment options at one-month post intervention (P = 0.039) [Table 2]. Open nephrostomy offered the most improvement in biochemical outcome, accounting for the largest mean difference between the pre- and post-intervention creatinine level at one month [Table 2].
Table 2: Change in serum creatine levels at 1-month post-intervention

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At 6 months post intervention only 41.6% of patients were alive. No treatment option conferred survival advantage over the other options at six-months post intervention (P = 0.598) as seen in [Table 3].
Table 3: Palliative Tteatment option vs survival outcome at 6 months post intervention among 24 patients with MUO

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  Discussion Top


Malignant ureteric obstruction is an ominous sign, generally occurring in patients with advanced pelvic malignancies.[3] Cancer of the cervix accounted for majority of bilateral MUO in this study. This is consistent with various studies which show that malignant ureteric obstruction (MUO) is a feature of advanced cancers of the pelvic organs.[2],[3],[4]

This study aimed at reviewing the palliative therapeutic options in patients with MUO at JUTH. It was found that open nephrostomy was by far the commonest type of intervention (54.2%). The lack of options in minimal access surgery at our centre is partly responsible for the widespread use of open nephrostomy as the procedure of choice for managing MUO. It has been highlighted that nephrostomy is not the drainage procedure of choice by oncologists, urologists, or patients.[4] However, in the event of failed retrograde access, percutaneous nephrostomy is the most common intervention as it has been touted to improve the quality of life of these patients and can be conducted as an outpatient procedure.[4] In contrast to open nephrostomy, percutaneous nephrostomy has less pain for the patient with associated reduced hospital stay.[4]

The relatively small percentage of patients who had retrograde stenting is an indication of the challenges of retrograde stenting insertion in patients with advanced pelvic tumours. Retrograde stenting has been associated with success rates of 20-35% of patients depending on the stage and the type of tumour.[5] Antegrade ureteric stenting has been advocated in situations where retrograde access is not achieved.[5] However, our centre lacks the ancillary equipment needed for such intervention.

Permanent haemodialysis was employed in 25% of patients and these were patients considered to be unfit for anaesthesia or those who declined any form of surgical intervention. Where there is no absolute indication for drainage of the renal units such as severe pain or infection, our practice is to allow patients and/or the relations to have the final decision on any form of palliative surgical intervention. Other workers have advocated non-intervention in these patients who are terminally ill.[6],[7] The debate on intervention versus non- intervention in patients with MUO is ongoing.

This study showed that palliative intervention to divert urine resulted in appreciable biochemical improvement (P = 0.039). Similarly, Shekarriz et al.[8] found that biochemically significant improvement occurred following intervention for malignant ureteric obstruction with a decrease in serum creatinine from 6mg/dl to 3mg/dl (P < 0.0001). However, the study did not assess the performance status of the patients so it cannot be objectively determined if the decrease in serum creatine translated to an improvement in general wellbeing of the patients.

Patient survival post-intervention has been used as a measure of assessing the benefit or otherwise of palliative therapies in patients with MUO. This study found no overall survival benefit with regards to modality (P = 0.598). Likewise, Cordeiro et al.[9] determined that none of the methods of palliative urinary diversion, namely ureteric stenting, and percutaneous nephrostomy (PCN), conferred survival advantage over the other. Despite the lack of benefit of all the treatment options in overall survival, at six months post intervention 41.6% of patients were alive. The study by Cordeiro et al.[9] showed a lower percentage survival of 21.1% at six months. This difference may be accounted for by difference in type and stage of tumour between the two studies. A relatively small sample size in this study may also account for the difference in findings. Whichever type of intervention is offered, the prognosis in patients with bilateral malignant ureteric obstruction is poor with median survival duration even after intervention reported by Lienet et al.[6] and Wong et al.[7] as 6 months and 6.8 months respectively.

This study has certain limitations. The study population was retrospectively enrolled from a single centre. The retrospective nature of the study restricted the analysable variables to only the ones available in the original records. Nevertheless, the study gives an insight to the palliative management of patients with bilateral MUO in our institution.

In conclusion, open nephrostomy was the most common palliative treatment option offered to patients with bilateral MUO at the Jos University Teaching Hospital and achieved the most significant improvement in biochemical outcome over 1 month. There was a significant reduction in mean creatinine level following all the intervention modalities. However, no palliative treatment modality conferred superior survival advantage over the others at 6 −month post intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meldrum KK. Pathophysiology of urinary tract obstruction. In: Alan JW, Louis RK, Alan WP, Craig AP, editors. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016;1089–1102  Back to cited text no. 1
    
2.
Prentice J, Amer T, Tasleem A, Aboumarzouk O. Malignant ureteric obstruction decompression: how much gain for how much pain? A narrative review. J R Soc Med 2018;111:125–35.  Back to cited text no. 2
    
3.
Wang J, Zhang H, Zhu Y, Qin X, Dai B et al. Predicting the failure of retrograde ureteral stent insertion for managing malignant ureteral obstruction in outpatients. Oncol Lett 2016;11:879–83.  Back to cited text no. 3
    
4.
Hyams E, Shah O. Malignant extrinsic ureteral obstruction: a survey of urologists and medical oncologists regarding treatment patterns and preferences. Urology 2008;72:51–6  Back to cited text no. 4
    
5.
Zadra JA, Jewett MA, Keresteci AG, Rankin JT, Louis ES et al. Non-operative urinary diversion for malignant ureteral obstruction. Cancer 1987;60:1353–7.  Back to cited text no. 5
    
6.
Lienert A, Ing A, Mark S. Prognostic factors in malignant ureteric obstruction. BJU Int 2009;104:938–41.  Back to cited text no. 6
    
7.
Wong LM, Cleeve LK, Milner AD, Pitman AG. Malignant ureteral obstruction: outcomes after intervention. Have things changed? J Urol 2007;178:178–83.  Back to cited text no. 7
    
8.
Shekarriz B, Shekarriz H, Upadhyay J, Banerjee M, Becker H et al. Outcome of palliative urinary diversion in the treatment of advanced malignancies. Cancer 1999;85:998–1003.  Back to cited text no. 8
    
9.
Cordeiro MD, Coelho RF, Chade DC, Pessoa RR, Chaib MS et al. A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: a prospective study of 208 patients. BJU Int 2016;117:266–71.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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