Malignant ureteral obstruction: study

Malignant ureteral obstruction: Whether decompression really improves patient outcomes and quality of life?

Wong L et al., [1] in a recent retrospective study of 102 (45 men, 57 women) patients who presented with malignant ureteric obstruction (MUO), analyzed outcome data including survival, complication rates and time spent in hospital following attempted decompression of urinary tract. They also identified the prognostic factors which predict an unfavorable outcome despite technical success of the procedure.

Median patient age at MUO diagnosis was 62 years. The source of primary malignancy was gastrointestinal in 21, gynecological in 32, urological in 30 and other sources (lymphoma, carcinoma breast etc) in 19 patients. At presentation 68% of patients had bilateral obstruction, 59% of patients had known metastases and 69% had symptoms of obstruction. Percutanoues nephrostomy(PCN) was the more common initial procedure (75%). There were 16 patients (16%) who had MUO at the first presentation of cancer whereas MUO developed in 86 patients (84%) with previously diagnosed cancer. The median follow-up of patients was 46 months (95% CI 32-108). Median overall survival (OS) was estimated at 6.8 months (95% CI 4.8- 9.3) and the OS rate at six and 12 months was estimated at 56% (95% CI 46%-65%) and 29% (95% CI 21%- 9%), respectively.

By univariate analysis, inferior OS was associated with presence of metastases (P = 0.041), prior therapy (P = 0.024), diagnosis of MUO in previously established malignancy (P = 0.043) and creatinine greater than 40 mmol/l (P = 0.088). Multivariate analysis revealed independent prognostic factors for inferior OS were presence of metastases (P = 0.020) and diagnosis of MUO in previously established malignancy (P = 0.039) Patients were divided into four risk groups according to the number of baseline unfavorable univariate OS prognostic factors. The OS differed significantly among the four risk groups (P = 0.011) with the 12-month OS rate ranging from 63% (95% CI 38-82%) for the cohort of patients having one or zero unfavorable factors to 12% (95% CI 3%- 8%) for the cohort of patients having all four.

A total of 54 patients (53%) had at least one complication associated with the initial or subsequent procedure. Significant complications occurred in two patients (2%) consisting of arterial hemorrhage and wound dehiscence. Infection and blockage were the most common complications. Of the 54 patients experiencing a complication, 16 (33%) had two or more than two complications. The complication rate was significantly higher for patients who had postoperative therapy for cancer (61% vs. 37% for no therapy, P = 0.03). There was no significant difference in complication rates between primary PCN (53%, 40 of 76) and retrograde stenting (RS) cases (56%, 14 of 25) (P = 0.82).

The overall median remaining lifetime spent in hospital was 17.4% (range 0.2-100%). Six patients spent all of their remaining life as hospital inpatients. Prolonged hospital stay was associated with patients who presented with symptoms (P = 0.012), who had no postoperative therapy for their cancer (P = 0.01) and had a PCN as the initial procedure (P = 0.043).