Obstructive Uropathy from Locally Advanced and ...

Reviews in Endourology

JOURNAL OF ENDOUROLOGY Volume 26, Number 2, February 2012 ª Mary Ann Liebert, Inc. Pp. 102–109 DOI: 10.1089/end.2011.0227

Obstructive Uropathy from Locally Advanced and Metastatic Prostate Cancer: An Old Problem with New Therapies Justin I. Friedlander, M.D., Brian D. Duty, M.D., Zeph Okeke, M.D., and Arthur D. Smith, M.D.

Abstract

Despite stage migration to more organ-confined disease in the era of prostate-specific antigen, the complications of advanced prostate cancer are still relatively common. Urinary tract obstruction in advanced and metastatic prostate cancer can have a varied presentation, because it may occur in multiple anatomic locations at any point in the natural history of the disease. In all cases, management depends on the current stage of disease, technical feasibility of potential therapeutic interventions, and overall prognosis of the patient. This review highlights a practical approach to the evaluation, diagnosis, and management of obstructive uropathy from prostate cancer.

Obstructive Uropathy

Introduction

O

bstructive uropathy was once a common presentation for patients with prostate cancer. Fortunately, the introduction of prostate-specific antigen screening in the late 1980s has nearly doubled the number of men with organ-confined disease at the time of diagnosis.1 Nonetheless, up to 3% of patients still present with locally advanced disease and 1% with metastatic disease.2 Because prostate cancer remains the most common solid-organ malignancy in men,3 obstructive uropathy continues to be a problem in prostate cancer management. Given its decreasing incidence, few articles have been published recently on obstructive uropathy from prostate cancer. Many articles have been published on the topic, however; most have included outdated, morbid treatment modalities, such as open nephrostomy tube placement and ileal conduit urinary diversion. As a result, the authors have performed a comprehensive literature review on obstructive uropathy from prostate cancer with a focus on contemporary endourologic management techniques. A practical approach to the evaluation, diagnosis, and management of obstructive uropathy from prostate cancer will be emphasized. Materials and Methods PubMed was used to identify English language articles related to the evaluation, diagnosis, and management of the following conditions: Locally advanced and metastatic prostate cancer, obstructive uropathy, and malignant ureteral obstruction. No limitation was set on the period reviewed. References from these available articles were evaluated to obtain additional information necessary for the review.

Pathophysiology The long-term effects of urinary obstruction depend on the severity of blockage, its acuity, laterality, and the patient’s underlying renal function. Obstructive nephropathy from prostate cancer most commonly results from bilateral ureteral blockage or unilateral ureteral obstruction in the setting of a solitary renal unit. Bilateral obstruction results in a number of well-described changes in renal function.4 Renal blood flow initially increases to both kidneys, but within 90 minutes, a dramatic decrease in perfusion and glomerular filtration rate (GFR) ensues. This phenomenon largely results from the accumulation of vasoactive substances, such as angiotensin II, thromboxane A2, and atrial natriuretic peptide. A deleterious impact on tubular function also occurs. Urinary concentrating ability is diminished from loss of the hypertonic medullary interstitial gradient and dysregulation of aquaporin water channels. If uncorrected, obstruction results in the release of cytokines and growth factors (tumor growth factor b, angiotensin II, nuclear factor jB, and tumor necrosis factor a) that cause interstitial inflammation and, ultimately, fibrosis. Not surprisingly, it has been shown in a dog model that recovery of renal function from unilateral ureteral obstruction is inversely proportional to the length of obstruction. Relief of obstruction lasting 2 and 4 weeks induced a 70% and 30% recovery of GFR, respectively. Essentially, no return of function was found if the blockage lasted longer than 6 weeks. This suggests that relief of long-standing obstruction may not yield much functional benefit, a factor that must be taken into account when making treatment decisions.

The Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York.

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MANAGING OBSTRUCTIVE UROPATHY IN PROSTATE CANCER Polyuria may ensue after relief of urinary obstruction, with urine output potentially exceeding 200 mL/hr. Known as postobstructive diuresis, this phenomenon occurs mainly in patients with bilateral upper tract obstruction, but can also be seen after resolution of lower urinary tract obstruction. In most cases, the diuresis is a normal physiologic response to volume expansion and the accumulation of solutes. Polyuria may continue despite hypervolemia resolution and solute excretion. This pathologic postobstructive diuresis results from a renal concentrating defect that develops during the obstructed state. Clinically significant postobstructive diuresis is uncommon; however, patients with signs of fluid overload, such as peripheral edema, congestive heart failure, or hypertension, are more susceptible. All patients should have a basic metabolic panel and magnesium level checked at least daily. Urine osmolarity and serum electrolytes should be assessed more frequently in patients with signs of fluid overload, azotemia, poor cognitive function, and/or hypovolemia. Clinically stable patients with normal cognitive function can be managed with oral fluid replacement. Patients at risk of aspiration should receive intravenous fluid replacement below their maintenance level to prevent prolonging the physiologic diuresis. Clinical presentation Signs and symptoms of urinary tract obstruction depend largely on the degree, time course, and anatomic level of obstruction. Lower urinary tract obstruction may occur at the bladder outlet or from locally invasive growth of the cancer in the bladder trigone. This can result in urinary urgency, frequency, decreased force of stream, or incomplete bladder emptying.5 Acute upper tract obstruction has a similar presentation to renal colic. Symptoms may include severe flank pain, nausea, and vomiting.6 Patients may present with anuria if they have complete obstruction of the urethra, both ureters, or have unilateral obstruction of a solitary kidney.7 Extrinsic compression of the urinary system is more commonly a chronic process with a slow progression to renal insufficiency. Consequently, patients often present with vague symptoms, such as back pain, anorexia, lethargy, and/or mental status changes.8,9 While no specific prevalence is known, in advanced prostate cancer, urinary tract obstruction is often insidious and silent. These patients can be relatively asymptomatic, with hydronephrosis being discovered as an incidental finding during a workup for renal insufficiency.5 In some cases, a urinary tract infection may be the heralding symptom.6 Diagnosis In many instances the point of obstruction can be determined by the history and physical examination alone. Worsening obstructive voiding symptoms, leading to acute urinary retention, with a palpable bladder and firm prostate on digital rectal examination, indicate posterior urethral occlusion. Measuring the bladder volume with an ultrasoundbased bladder scanner can be readily performed at the bedside to confirm urethral obstruction. Gradually declining urinary output without a perceived need to void and a nonpalpable bladder are more consistent

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with upper tract obstruction. Available modalities to image the upper urinary tract include renal and bladder ultrasonography, intravenous urography, CT, or MRI. The choice of imaging study depends on available resources, physician preference, and the presence or absence of renal insufficiency. Patients with preexisting renal insufficiency should not undergo contrast imaging because contrast-induced nephropathy may further impair renal function. In these instances, renal and bladder ultrasonography or noncontrast CT are the imaging modalities of choice. Ultrasonography has the advantage of being readily available, inexpensive, and lacking in ionizing radiation. CT, however, provides superior anatomic detail, allowing for more accurate determination of the site of obstruction. If anatomic abnormalities are present but the diagnosis of obstruction is equivocal, diuretic nuclear renography should be considered. Management General considerations. First and foremost, patients should be assessed for symptomatic fluid overload (congestive heart failure, pulmonary edema), severe electrolyte abnormalities, such as hyperkalemia, signs of uremia (pericarditis, neuropathy, unexplained decline in mental status), and/or metabolic acidosis. The nephrology staff should be consulted immediately if any are present for possible emergent hemodialysis. In the absence of such findings, management should be directed at relieving the obstruction and addressing its underlying cause. Bladder Outlet Obstruction (BOO) Management of BOO should be initially accomplished via either urethral Foley catheterization or placement of a suprapubic cystostomy tube. These interventions allow for immediate symptom relief and can usually be performed easily at the bedside. Once the systemic sequelae of urinary obstruction have resolved, further management will depend on prostate cancer stage and the patient’s wishes. For patients who desire to be catheter-free but are not candidates for definitive therapy (radical prostatectomy or radiation), options include endocrine therapy or transurethral resection of the prostate (TURP). Endocrine therapy for bladder outlet obstruction Patients without castration-resistant prostate cancer are candidates for endocrine management of BOO, which includes antiandrogen drug therapy and orchiectomy. Both treatments necessitate Foley catheterization until response is noted. In a study by Varenhorst and Alund10 that looked at patients with prostate cancer presenting with urinary retention, 65.5% (80 of 122) of patients were rendered Foley catheter free by 6 months after treatment. Patients who underwent orchiectomy responded on average 1 month sooner than patients who were placed on estrogen treatment (2.7 mos vs 3.4 mos, respectively). Fleischmann and Catalona11 validated these results. They reported a 68.6% success rate by orchiectomy alone. In this later study, neither tumor stage nor grade correlated significantly with the response to orchiectomy.

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FRIEDLANDER ET AL. Table 1. Outcomes for Palliative Transurethral Resection of the Prostate

Study Mazur 199113 Crain 200415 Marszalek 200716

No. of procedures

Reoperation rate (%)

Prolonged/permanent catheterization (%)

Incontinence rate (%)

41 24 89

22 29 25

NR 21 11

5/5a 0 10

a 5% with total urinary incontinence, 5% with stress urinary incontinence. NR = not recorded.

The medical literature is devoid of studies that evaluate the efficacy of contemporary hormonal agents, such as luteinizing hormone-releasing hormone (LHRH) agonists or antagonists, antiandrogens, or androgen biosynthesis inhibitors, in the management of BOO from locally advanced prostate cancer. These medications are unlikely to be any more effective than estrogen therapy or surgical castration. LHRH agonists, however, are advantageous because they have a convenient delivery method, improved safety profile compared with estrogens, and unlike surgical therapy, are reversible. TURP for BOO While much is known about the outcomes of TURP for benign prostatic hyperplasia (BPH),12 until the early 1990s, there were few studies on patients with outlet obstruction from prostate cancer. A review by Mazur and Thompson13 looked at outcomes for obstructive symptoms from advanced prostate cancer. The authors found a 22% reoperation rate, a 5% rate of total urinary incontinence, and a 5% incidence of stress incontinence. Shortly thereafter, a randomized study was performed in England that compared channel TURP plus bilateral orchiectomy to orchiectomy alone for patients who presented with acute urinary retention secondary to locally advanced prostate cancer.14 Four of the 10 patients initially undergoing TURP needed prolonged catheterization, while 10 of the 12 patients who received orchiectomy alone were able to void successfully 1 month after the procedure. A more recent study performed by Crain and colleagues15 reexamined the role of palliative TURP for BOO in patients with prostate cancer. Using the International Prostate Symptom Score, they found greater symptomatic improvement in the group undergoing TURP for benign disease compared with the palliative TURP group (73% vs 48%, respectively). In addition, they showed that 42% of patients undergoing palliative TURP had a failed initial voiding trial, 29% needed repeated procedures for bleeding or obstruction, and 21% needed prolonged bladder catheterization via either suprapubic tube or Foley catheterization. These rates were much higher than those seen for TURP performed for benign disease, with only 2.5% needing a repeat procedure and 1.4% needing chronic bladder drainage. A third study looked at functional outcomes and impact on survival for 89 patents undergoing palliative TURP after initial primary oncologic therapy.16 The 1-, 2- and 5-year survival rates were 83%, 70% and 61%, respectively. Patients found to have residual prostate cancer in the TURP specimen had a shorter 3-year survival (52%) than those with negative histology (89%). Seventy-nine percent of men voided spontaneously and were continent at their final follow-up visit. A repeated palliative TURP was necessary in 25% of patients,

11% needed permanent catheterization, and 10% were incontinent. Table 1 summarizes the results of the three main studies on palliative TURP. Prostatic/urethral stent insertion for BOO Urethral or prostatic stent insertion is commonly used in the management of BOO in countries such as Israel and Norway; however, much of the literature on this topic focuses on patients with BPH or iatrogenic posterior urethral strictures secondary to previous prostate cancer therapy. These stents have been shown to be a safe and reasonable treatment option for the above stated conditions17,18 in carefully selected patients with urologists who have extensive experience with the use and management of these stents.17 Longer-term follow up studies have reported significant complications,19,20 such as stent migration, encrustation, infection, pain, and repeated stenosis, as well as nontrivial rates of repeated intervention. At this point, their use for patients with untreated, advanced prostate cancer with BOO has not been thoroughly investigated. Summary and recommendations for BOO management All patients with BOO should have a Foley catheter or suprapubic tube placed as the initial intervention. Patients who are not candidates for definitive therapy (radical prostatectomy or radiation) but desire to be catheter free should be treated with either endocrine therapy or a palliative TURP. Endocrine therapy may be in the form of surgical castration or hormonal ablation. Patients undertaking endocrine therapy should understand that this approach requires months of catheter diversion until the potential benefit is seen. Indications for transurethral prostatectomy include patients in whom endocrine therapy has failed, are not candidates for hormonal treatment, or do not want prolonged catheter drainage.21 Patients should be counseled that there is roughly a 25% chance of needing an additional procedure and there is a small, but definite, risk of urinary incontinence. Upper Urinary Tract Obstruction If the initial evaluation is consistent with obstruction of the upper urinary tract, the patient will typically need a surgical or procedural intervention to relieve the obstruction. Retrograde single internal polymeric ureteral stent (IUS) insertion and percutaneous nephrostomy (PCN) tube insertion are currently the most common interventions for the relief of malignant urinary obstruction (MUO) from external compression. Other options include the use of dual ipsilateral polymeric stents, metallic ureteral stents, and endoscopic stented ureterocystostomy.

MANAGING OBSTRUCTIVE UROPATHY IN PROSTATE CANCER

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Table 2. Outcomes for Stent Insertion for Malignant Ureteral Obstruction

Study Chung 200441 Ganatra 200540 Rosevear 200742 a

Overall no. of stents attempted

No. immediate PCN placed (%)

No. of stents for prostate cancer

No. of stent failures in prostate cancer

Overall stent failure rate (%)

Avg. time to stent failure (mos)

Avg. no. of stent exchanges (interval in days)

Overall mean survival time (mos)

138 157 87

18 (13%) 24 (15.3%) NRb

5 14 5

3 5 1

44.4a 35.7 19a

11 6 5.9

NR 2.8 (95) 5.5 (108)

NR 11.1 16

Included only stents placed for malignant etiologies. Patients who were unable to have stent placement were excluded from the analysis.

b

The reported incidence of ureteral obstruction from the local spread of prostate cancer has been shown to be in the range of 3.3% to 16%.22–27 Eighty percent of cases of upper urinary tract obstruction involve invasion of the bladder trigone and the ureteral orifices, whereas 20% of cases involve obstruction of the lower one-third of the ureter, either by local spread or impaired drainage from retroperitoneal lymph node metastasis.28–30 Endocrine and radiation therapy for upper tract obstruction Michigan and Catalona22 did early work looking at the response of ureteral obstruction to endocrine and radiation therapy. Their results demonstrated that if the patient is naı¨ve to endocrine therapy, a response could be expected in more than 85% of patients, with most of these responders having undergone orchiectomy. A similar success rate was not noted with radiation therapy. Another study, however, suggests more than a 70% success rate when high doses of radiation are administered over a 4- to 5-week period.31 In general, the response to radiation therapy is slower than that of endocrine therapy.21 Single polymeric ureteral stent insertion for upper tract obstruction Polymeric ureteral stent insertion is a procedure usually associated with low morbidity that can be performed easily under fluoroscopic guidance.32 Unfortunately, cystoscopic insertion of polymeric ureteral stents has a well-documented stent failure rate of 44% to 58%.33–35 While not entirely known, according to Markowitz and coworkers36 (1989), stent failure is thought to be related to impairment of ureteral smooth muscle by extrinsic compression, resulting in dysfunctional ureteral peristalsis. Another component thought to play a role is stent encrustation. Factors predictive of polymeric ureteral stent failure are ureteral invasion seen at the time of cystoscopy, as well as obstruction of the distal ureter at the pelvic brim (compared with obstruction at the level of the proximal ureter or renal pelvis).37,38 In addition, 16% to 28% of patients with MUO have been found to need PCN at the time of initial urinary decompression,35,39 commonly because of the inability to pass the stent through an identified orifice because of ureteral obstruction. Trigonal distortion, however, can also be a source of difficulty by preventing the identification or localization of the ureteral orifice. In this situation, some of the following steps can be taken to identify the ureteral orifice: One, identify the con-

tralateral ureteral orifice and look across the intertrigonal ridge; two, fill or empty the bladder as needed to obtain optimal distention; three, switch from a flexible to a rigid cystoscope or vice versa; four, colored dyes such as indigo carmine will be filtered by the kidneys and can be given intravenously—one can assess the bladder for site of dye efflux. If the ureteral orifice cannot be identified, the patient will need a percutaneous procedure. Table 2 lists the results of studies using single polymeric ureteral stents for MUO, with success rates ranging from 58% to 81%.40–42 Dual ipsilateral polymeric ureteral stent insertion for upper tract obstruction First introduced by Liu and Hrebinko43 and then by Hamm and Rathert,44 the use of two parallel Double-J polymeric ureteral stents has been shown to be an effective alternative to PCN when a single polymeric IUS has failed. Rotariu and associates45 reported a case series of seven patients in whom management with a single polymeric IUS failed and who were subsequently treated successfully with two ipsilateral polymeric stents. They demonstrated that placement of either two 7F stents or a combination of 8F/6F Double-J ureteral stents was a safe and effective technique, with reduced flank pain, relief of hydronephrosis, improved renal function, and no increase in irritative symptoms compared with the use of a single stent. The mechanism for this success was subsequently demonstrated in an ex vivo porcine kidney model of extrinsic ureteral obstruction.46 The authors of this study demonstrated better flow down the ureter with dual stents than one stent. This was true for both flow through and around the stents. Metallic ureteral stent insertion for upper tract obstruction In patients who wish to avoid PCN tubes but in whom polymeric ureteral stents have failed, an alternative is the use of a metallic ureteral stent, either a vascular self-expandable or a full-metal double pigtail. One potential benefit of metallic stents is that they provide drainage for up to 12 months. In patients with limited life expectancy, this could avoid the potential morbidity and inconvenience of multiple stent changes that are needed with traditional stents.47 Use of metallic stents, however, has been limited by complications, which include hyperplastic mucosal reaction and/or tumor in-growth through the stent struts, encrustation, stent migration, and infection.48 Liatsikos and coworkers49 reported long-term results with vascular self-expandable metallic stents. The 10-year data, in

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FRIEDLANDER ET AL. Table 3. Outcomes for PCN Insertion for Malignant Ureteral Obstruction

Study Chiou 199062 Wilson 200538 Nariculam 200965

Mean survival Mean survival Avg. survival No. of 1 year Mean time time post-PCN time post-PCN time (mos) PCN inserted No. of after PCN for with known prostate for untreated prostate survival to creatinine for prostate PCN cancer (mos) (%) nadir (d) cancer (mos) prostate cancer cancer insertions 37 52 25

37 NR 25

NR 2.9 7.5

12a NR 4.5

24a NR 16

57 NR NR

NR 16.8 10

a

Median survival time. PCN = percutaneous nephrostomy.

which all stents were inserted in an antegrade fashion via a nephrostomy tract, showed primary and secondary patency rates of 51.2% and 62.1%, respectively. A total of 45 of 119 (37.8%) of these stents had postprocedural hyperplastic reaction or tumor in-growth necessitating repeated balloon dilation and eventual need for standard double-pigtail or external-internal stents. They also had a 10.9% stent migration rate. With regard to the full-metal double-pigtail metallic stent, the Resonance (Cook Medical, Bloomington, IN) metallic alloy stent has been shown to have superior compression resistance over polymeric ureteral stents in cases of external compression.50 Borin and colleagues51 described their initial experience with full-length metal stents to relieve MUO in a patient with retroperitoneal fibrosis secondary to metastatic breast cancer. At 4 months, the patient continued to be unobstructed. Two additional studies have shown the effectiveness of these stents. Wah and associates52 demonstrated only 3 stent failures among 17 stents inserted via an antegrade approach for MUO, while Liatsikos and coworkers48 showed 100% patency of 25 stents at a mean follow-up of 11 months. Thermoexpandable shape memory stents for upper tract obstruction First described by Kulkarni and Bellamy53 in 1999, the Memokath 051 (PNN Medical, Kvistgaard, Denmark) thermoexpandable shape-memory nickel-titanium alloy stent is another option for the management of ureteral obstruction. The stent has a unique thermal memory for shape, softening below 10C and regaining its shape when reheated to above 55C. The stent has a 22F fluted proximal end with a 10.5F shaft diameter and comes in variable lengths. The insertion technique has been well described,53,54 with early follow-up showing no patient rehospitalizations for stent-related sepsis, pain, or hematuria.54 The 11-year follow-up data55 showed an overall stent migration rate of 18% (13/74), two encrustations, three fungal infections, and 19% reinsertion rate at a mean time of 7.1 months, of which only 3 were for stricture progression. Of the 28 patients with a malignant obstructive etiology, 89% (25/28) has postprocedural imaging showing normal or improved functional drainage. One major prohibitive factor is cost, because the Memokath stent is roughly 19 times the cost of a conventional single polymeric ureteral stent.53 At present, this technique appears to be best suited for patients in whom convention endoscopic techniques fail, have significant comorbidites that limit repetitive stent changes, need primary stent placement for malignancy, or palliation.

Percutaneous nephrostomy tube placement for upper tract obstruction The other common endoscopic treatment option is PCN, which is favored by some authors because malignancy has been shown to be a predictor of polymeric stent failure.41 The procedure is typically performed under either ultrasonography or fluoroscopic guidance and allows for subsequent polymeric ureteral stent placement in an antegrade manner if anatomically feasible or preferred by the patient.21 Complications of PCN tubes include malposition, dislodgement, or occlusion of the tube, and have been noted to occur in 4% to 26% of procedures.27,36,56 Other problems related to PCN tubes include urinary leakage and skin excoriation at the nephrostomy tube site,57 yet the main source of discomfort to patients was found to be the external urine collection device.58 Table 3 shows outcomes from the larger studies on PCN tube insertion. Comparison of endoscopic options for upper tract obstruction Direct comparison of studies that examine single polymeric IUS and PCN tubes for prostate cancer are complicated by small sample sizes and prostate cancer results being combined with other malignancies. Furthermore, baseline characteristics between the single polymeric IUS and PCN groups, as well as other contributing factors, such as overall survival, often differ between studies.59 Management of MUO by either single polymeric IUS or PCN drainage results in similar complication rates. Ku and colleagues60 demonstrated no significant difference in the incidence of overall complications between the two groups (11% for the stent group vs 8.8% for the PCN group). This analysis included both febrile events and diagnosis of acute pyelonephritis. A separate prospective comparison of these same groups showed no statistical difference with regard to quality of life, but did point out that patients with single polymeric IUS had more lower urinary tract symptoms.58 New directions with endoscopic therapy for upper tract obstruction For patients with ureterovesical junction or distal ureteral obstruction, in whom retrograde polymeric ureteral stent insertion has failed and who wish to avoid PCN tube drainage because of its restrictions and negative impact on quality of life, a new option may have emerged. Slongo and coworkers61 have proposed a novel technique of endoscopic stented ureterocystostomy, where under both cystoscopic and fluoroscopic guidance, a path is created above the obstructing neoplastic

MANAGING OBSTRUCTIVE UROPATHY IN PROSTATE CANCER process between the bladder wall and ureter. The ureterocystostomy is developed using a needle puncture of the ureter after contrast has been instilled from an antegrade renal puncture, all performed under fluoroscopic control. After a guidewire is introduced, the tract is dilated to 10F and a Double-J polymeric ureteral stent is inserted. Success was demonstrated in six patients— however, only for right ureteral involvement and in no patients with prostate cancer. Depending on the neoplastic treatment and patient response, the catheter could be maintained, changed, or removed. Certainly additional studies are warranted to validate the initially promising results. Special considerations: Do both obstructed units need to be drained? Clinicians often encounter the dilemma of whether to intervene on both sides of a bilaterally obstructed system or only divert the better functioning renal unit. 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 associates65 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. Summary and recommendations for UUT management Because of the high failure rate of single ureteral stents, we recommend that physicians attempt to place dual ipsilateral polymeric ureteral stents at the time of initial intervention. Dual stent insertion is safe, effective, and easy to perform, while providing better defense against extrinsic compression than single ipsilateral polymeric stents. They also have been shown to preserve quality of life. We favor the use of dual polymeric stents over metallic pigtail stents, because polymeric stents have more consistent results, have been studied more extensively, and do not carry the risk of tumor ingrowth causing difficulty with stent exchange. For patients with a more limited life expectancy who do not wish to have an external collection device, insertion of a metallic stent should be considered. If stent placement is not possible, then percutaneous nephrostomy tubes should be inserted. We view this as a second-line option because of its many complications and negative impact on patient quality of life. Quality of Life Considerations Given that the median survival for patients who are treated for malignant ureteral obstruction is 3 to 7 months,39,41,66,67 the clinician must carefully consider whether ureteral decompression is going to facilitate treatment with systemic therapy, palliate symptoms, or address a finding on imaging that may not improve the patient’s overall condition.68 One study showed a trend toward better survival and performance status with palliative diversion for patients with prostate cancer compared with other tumors.32 Another study demonstrated that patients with localized prostate cancer did, in fact, have an improvement in quality of life after PCN

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insertion.69 With significant complication rates and postdiversion survival time spent in the hospital approaching 40%,23,32 however, a discussion should take place between patients, families, and healthcare providers regarding outcomes for palliative procedures and goals of care.6,21 Conclusion The management of obstructive uropathy in prostate cancer has evolved from a time when standard therapy was open nephrostomy tube insertion. Due to advances in endoscopic technology, urologists and patients have multiple options for relieving urinary tract obstruction. Clearly delineated guidelines of care do not exist, and sadly the evidence to support recommendations is often of low quality. Despite these shortcomings, the current literature does provide some direction. Going forward, it would be wise for the urologic community to embark on new studies to identify optimal treatment strategies for the treatment of obstructive uropathy from locally advanced and metastatic prostate cancer, as a non-negligible number of patients will eventually present with this condition. These studies would also benefit clinicians who often seek the guidance of urologists for other entities causing ureteral obstruction. Disclosure Statement No competing financial interests exist. References 1. Catalona WJ, Smith DS, Ratliff TL, Basler JW. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA 1993;270: 948–954. 2. Ung JO, Richie JP, Chen MH, et al. Evolution of the presentation and pathologic and biochemical outcomes after radical prostatectomy for patients with clinically localized prostate cancer diagnosed during the PSA era. Urology 2002; 60:458–463. 3. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010;60:277–300. 4. Pais VM, Strandhoy JW, Assimos DG. Pathophysiology of urinary tract obstruction. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology, vol. 2. 9th ed. Philadelphia: Saunders Elsevier, 2007, pp 1195–1226. 5. Tseng TY, Stoller ML. Obstructive uropathy. Clin Geriatr Med 2009;25:437–443. 6. Kouba E, Wallen EM, Pruthi RS. Management of ureteral obstruction due to advanced malignancy: Optimizing therapeutic and palliative outcomes. J Urol 2008;180:444–450. 7. Klahr S. Obstructive nephropathy. Intern Med 2000;39: 355–361. 8. Batlle DC, Arruda JA, Kurtzman NA. Hyperkalemic distal renal tubular acidosis associated with obstructive uropathy. N Engl J Med 1981;304:373–380. 9. Faubert PF, Porush JG. Renal Disease in the Elderly. 2nd ed. New York: Marcel Dekker, 1998, p 441. 10. Varenhorst E, Alund G. Urethral obstruction secondary to carcinoma of the prostate: Response to endocrine treatment. Urology 1985;25:354–356. 11. Fleischmann JD, Catalona WJ. Endocrine therapy for bladder outlet obstruction from carcinoma of the prostate. J Urol 1985;134:498–500.

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Address correspondence to: Justin I. Friedlander, M.D. The Arthur Smith Institute for Urology North Shore-Long Island Jewish Health System 450 Lakeville Rd, Suite M-41 New Hyde Park, NY 11042 E-mail: [email protected]

Abbreviations Used BOO ¼ bladder outlet obstruction BPH ¼ benign prostatic hyperplasia CT ¼ computed tomography GFR ¼ glomerular filtration rate IUS ¼ internal ureteral stent LHRH ¼ luteinizing hormone-releasing hormone MRI ¼ magnetic resonance imaging MUO ¼ malignant ureteral obstruction PCN ¼ percutaneous nephrostomy TURP ¼ transurethral resection of the prostate

This article has been cited by: 1. Michael Froehner, Manfred P. Wirth. 2013. Locally Advanced Prostate Cancer: Optimal Therapy in Older Patients. Drugs & Aging . [CrossRef]