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998
Outcome of Palliative Urinary Diversion in the
Treatment of Advanced Malignancies
Bijan Shekarriz, M.D.1
Hodjat Shekarriz, M.D.2
Jyoti Upadhyay, M.D.1
Mousumi Banerjee, Ph.D.1
Herman Becker, M.D.3
J. Edson Pontes, M.D.1
David P. Wood, Jr., M.D.1
1
Department of Urology, Wayne State University,
Karmanos Cancer Institute, Detroit, Michigan.
2
Klinik für Chirurgie, Medizinische Universität zu
Lübeck, Lübeck, Germany.
3
Department of Urology, Marienkrankenhaus,
Hamburg, Germany.
BACKGROUND. It is unclear whether palliative endourologic or percutaneous urinary
diversion in the treatment of advanced cancer provides significant improvement in
quality or duration of life. The purpose of this study was to evaluate survival and
performance status after endourologic palliative urinary diversion in patients with
advanced malignancy and to compare the results for different malignancies.
METHODS. One hundred three patients with advanced malignancies underwent
palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninetytwo patients and 11 patients had bilateral and unilateral obstruction, respectively.
Indications, complications, performance status after diversion, and survival for
patients with different malignancies were identified and compared. A modified
Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0 – 4 was used: 0) hospitalized until death; 1) bedridden at home,
severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal.
RESULTS. The mean age of patients was 68 years. The mean pre- and postoperative
creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P , 0.0001). The
median survival and days of hospitalization were 112 and 45, respectively. The
median postdiversion KPS score was 2 (range, 0 – 4), and 15% of patients never left
the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4%
had complications (minor, 63%; major, 5.4%).
CONCLUSIONS. Most patients with advanced cancers had poor performance status
and survival after diversion. Eighty six percent had cancer-related symptoms
despite the diversion. The average survival was 5 months, 50% of which was spent
in the hospital. Primary endourologic procedures had a high failure rate, and
additional procedures were required. Cancer 1999;85:998 –1003.
© 1999 American Cancer Society.
KEYWORDS: palliative urinary diversion, malignancy, ureteral stent, percutaneous
nephrostomy, malignant ureteral obstruction.
E
Presented at the 93rd annual meeting of the American Urological Association, San Diego, California,
May, 1998.
Address for reprints: David P. Wood, Jr., M.D.,
Department of Urology, Wayne State University,
4160 John R. 1017, Detroit, MI 48201.
Received June 1, 1998; revision received August
24, 1998; accepted August 24, 1998.
© 1999 American Cancer Society
xtrinsic ureteral obstruction secondary to malignancy is commonly a late manifestation of metastatic disease. Pelvic malignancies are the most common cause; however, metastatic processes
secondary to nonpelvic malignancies, such as breast carcinoma and
upper gastrointestinal tract malignancies, can also cause ureteral
obstruction.1– 6 Most patients present with an advanced stage of the
disease, with other sites of metastasis being commonly documented
at the time of presentation. The optimal management of the malignant ureteral obstruction remains unclear. It has been reported that
self-retaining ureteral stents have a high failure rate in extrinsic obstruction.7 Furthermore, the endoscopic insertion of ureteral stents
may be technically difficult or even impossible in the presence of
advanced pelvic involvement by a malignant process.4 Percutaneous
Palliative Urinary Diversion in Advanced Malignancies/Shekarriz et al.
nephrostomy catheters are a commonly used alternative as either a primary procedure or in the case of
failure of transurethral procedures.8
Clinicians occasionally are confronted with the
dilemma of performing palliative urinary diversion in
terminally ill patients. Previous studies have addressed the technical aspects of urinary diversion and
the associated complications. However, the palliative
nature of these procedures makes the assessment of
the performance status after diversion by means such
as the Karnofsky performance scale (KPS) an important objective factor to determine the success of urinary diversion in this scenario. The aim of this study
was to investigate the survival and performance status
by KPS after palliative urinary diversion in patients
with advanced malignancies and to compare these
results between different malignancies.
MATERIALS AND METHODS
Data were obtained from all patients who underwent
urinary diversion for ureteral obstruction secondary to
advanced malignant disease at two institutions between 1986 and 1997. A total of 103 patients with
advanced malignancies resulting in ureteral obstruction underwent palliative urinary diversion. The diagnosis of urinary obstruction was made by renal ultrasound or computerized tomography (CT). Ninety-two
patients had bilateral obstruction, and 11 patients had
unilateral involvement. Endoscopic ureteral stent
placement or percutaneous nephrostomies were performed according to standard techniques. Indications,
complications, performance status after diversion,
and survival were identified retrospectively and compared between different types of malignancies. The
performance status prior to diversion was not available. For this comparison, patients with bilateral obstruction were divided into four groups based on the
primary diagnosis: 1, bladder carcinoma (n 5 25); 2,
gastrointestinal carcinoma (n 5 19); 3,Gynecological
carcinoma (n 5 20); and 4, prostate carcinoma (n 5
28).The group of gynecological tumors included cervical, ovarian, and breast carcinomas. The primary
tumor types are listed in Table 1.
A modified KPS was used as an objective assessment of physical performance after diversion using a
validated questionnaire. Informed consent was obtained, and the questionnaires were coded to maintain confidentiality. Since its introduction in 1948,9
KPS, which was designed initially for evaluating performance status in patients after chemotherapy treatment, has undergone modifications by other authors
for application in different patient populations.10 –12
For the evaluation of patients after palliative urinary
diversion, the degree of cancer-related pain is an im-
999
TABLE 1
Primary Malignancy in 92 Patients
Type of malignancy
No. of patients (%)
Prostate
Bladder
Colorectal
Gastric
Breast
Cervix
Ovary
Endometrium
Fallopian tubes
Total
28 (30.4)
25 (27.1)
17 (18.4)
2 (2.1)
5 (5.4)
8 (8.7)
5 (5.4)
1 (1.1)
1 (1.1)
92 (100)
portant factor. Because pain is not specifically included in the original scoring system of Karnofsky, this
scale was modified to address both performance and
level of pain in our patients. We used the modified KPS
by Köster et al.10 This scale includes nine categories.
Because of the retrospective nature of our study in a
small cohort of patients, we combined the nine categories into five categories for statistical analysis. A
scale of 0 – 4 was used as follows: 0) hospitalized until
death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite
analgesia; 3) mild disability, pain free with medication; and 4) normal. Primary physicians and family
members were contacted for this evaluation. The degree of social integration, level of pain by need for pain
medication, patient’s functional independence, and
overall performance status were addressed specifically
with a detailed questionnaire. Generally, a performance status of 3 or 4 was considered good because of
minimal limitation of daily activity and achievement
of a pain free status.
Statistical Analysis
Analyses of variance and Kruskal–Wallis tests were
used for all comparisons between the groups. For
changes in pre- and postoperative creatinine level,
analyses of variance on the difference were used. The
t test was performed for comparison of survival and
KPS between patients with and without disseminated
metastasis. Pearson correlation coefficients were used
to determine the correlation of preoperative creatinine levels and time from diagnosis to survival and
KPS.
RESULTS
Bilateral Ureteral Obstruction
Ninety-two patients had bilateral hydronephrosis (n 5
91) or unilateral hydronephrosis in a solitary kidney
(n 5 1). In these patients, the main presentation was
1000
CANCER February 15, 1999 / Volume 85 / Number 4
TABLE 2
Comparison of Age and Pre- and Postoperative Creatinine
Group
All
Bladder
Gastrointestinal
Gynecologic
Prostate
Age
(yrs)
68 6 12
71 6 10
60 6 11
60 6 11
77 6 6
Preoperative
creatinine
6.8 6 5.4
5.6 6 4.6
4.6 6 4.2
7.1 6 6.0
8.8 6 5.8
Postoperative
creatinine
3.34 6 2.7
3.47 6 3.9
2.8 6 2.5
3.2 6 2.3
3.5 6 2.1
TABLE 3
Modified Karnofsky Performance Scale and Survival after Urinary
Diversion
P value
0.0001
0.0017
0.0045
0.0084
0.0002
Group
Median KPS score (range)a
Median survival in days
(range)
Bladder
Gastrointestinal
Gynecologic
Prostate
Total
1 (0–4)
2 (0–3)
1 (0–4)
2 (0–4)
2 (0–4)
122 (3–391)
90 (13–432)
65 (1–502)
173 (5–600)
112 (1–600)
a
low urine output with uremia. In addition, other
symptoms, such as flank pain, hematuria, and urinary
tract infection, were encountered. The mean age in all
groups was 68 years 6 12.5 years (Table 2). Patients
with prostate and bladder carcinomas were significantly older (P 5 0.0001).
Preoperative and postoperative creatinine levels
The pre- and postoperative creatinine levels in different groups are shown in Table 2. Overall, the mean
preoperative creatinine level was 6. 8 6 5.4. The preoperative creatinine level was significantly higher in
patients with gynecological and prostate carcinomas
compared with other groups (P 5 0.02). The mean
postoperative creatinine level was 3.3 6 2. 8; the creatinine level after urinary diversion decreased significantly in all groups (P , 0.0001; Table 2). The correlation of preoperative creatinine levels to survival
approached statistical significance (P 5 0.06).
Clinical stage and survival
Overall, 70% of the patients had known disseminated
metastasis at the time of diversion. The median survival was 112 days (range, 1– 600 days) in all patients;
comparison of survival data between different types of
cancer did not show any significant differences (P 5
0.1; Table 3). Patients with prostate carcinoma had the
longest median survival of 173 days (range, 5– 600
days). For comparison of survival based on disease
stage, patients with pelvic malignancies were divided
into those with known disseminated disease at the
time of diversion and those with locally advanced
disease or regional nodal metastasis. Of the patients
with pelvic tumors, 33% had locally advanced or regional metastases only. The median survival in these
patients was 126 days (range, 2–510 days) compared
with 100 days (range, 1– 600 days) in patients with
pelvic tumors and disseminated metastasis (P 5 0.94).
Prior treatment for primary carcinoma
Most patients had undergone prior surgical or medical
treatment for their disease. These surgical procedures
A modified Karnofsky symptom score (KPS) was used: 0) hospitalized until death; 1) bedridden at
home, pain under analgesia; 2) moderate disability, moderate pain under analgesia; 3) mild disability,
pain free with medication; and 4) normal.
included transurethral resection, simple prostatectomy, orchiectomy, total abdominal hysterectomy,
mastectomy, and various intestinal procedures. Medical treatment included hormonal therapy and chemoradiation therapy. Overall, 62 patients (67.4%) had
multimodal therapy, and 16 patients (17.4%) had at
least one mode of therapy for their primary disease
prior to urinary diversion. Only, 14 patients (15.2%)
had no prior therapy at the time of diversion. Of these
14 patients, 7 were deemed incurable, and no treatment was rendered. The primary diagnosis was unknown at the time of diversion in 4 patients, and 3
patients refused treatment. Therefore, only 3 of the
previously untreated patients had treatment after diversion. Comparison of survival between those patients with prior multimodal therapy and those who
did not have any treatment or had at least one treatment did not show any significant differences (P 5
0.91). The time from diagnosis of the primary tumor to
urinary diversion did not correlate with survival after
urinary diversion (p 5 0.9).
Karnofsky performance scale score and hospitalization
after diversion
The median KPS score in all patients was 2 (range,
0 – 4; Table 3). Patients with prostate carcinoma had a
better KPS score; however, the differences did not
reach statistical significance (P 5 0.56). Only 13 patients (14%) were free of pain with normal functional
status after the procedure. The median KPS score in
patients with known disseminated metastasis was 1
(range, 0 – 4) compared with 2.5 (range, 0 – 4) in those
with locally advanced or local metastatic disease (P 5
0.03). Fourteen patients (15%) never left the hospital
after urinary diversion. The mean time of hospitalization after procedures until death was 45 days 6 32
days, which constituted 52% of total survival (Table 4).
There were no significant differences in survival between malignancy types (P 5 0.73).
Palliative Urinary Diversion in Advanced Malignancies/Shekarriz et al.
TABLE 4
Postdiversion Days in Hospital until Death and the Percentage of
Survival Spent in Hospital
Type of cancer
Days hospitalized
Survival time (%)
Bladder
Gastrointestinal
Gynecologic
Prostate
Total
46 6 31
44 6 29
51 6 43
39 6 25
45 6 32
52
52
59
46
52
1001
TABLE 5
Complications of Urinary Diversion
Patient group
Minor (%)a
Major (%)b
Total (%)
Bladder
Prostate
Gastrointestinal
Gynecologic
Total
25
15.2
10.8
12
63
3.2
0
1.1
1.1
5.4
28.2
15.2
11.9
13.1
68.4
a
b
Minor complications: hematuria, catheter blockage or dislodgement, or urinary tract infection.
Major complications: significant bleeding, bladder tamponade (requiring surgical intervention).
Technical failure and complications
The success rate of primary endoscopic stent placement was evaluated. Fifty-one percent of patients required percutaneous procedures for adequate diversion secondary to unsuccessful stent placement.
Overall, 68.4% had procedural related complications
in the postoperative course (Table 5). Sixty-three percent had minor (hematuria, catheter blockage requiring manipulation and irrigation, and nephrostomy
dislodgment), and 5.4% had major complications (significant bleeding, bladder tamponade, or complications that required reoperation). In 30% of patients,
dislodgment of the percutaneous nephrostomy occurred, which required replacement.
Unilateral Urinary Obstruction
Eleven patients had unilateral ureteral obstruction.
Their primary diagnoses were carcinoma of the prostate (n 5 3), bladder (n 5 3), colon (n 5 3), and breast
(n 5 2). Six patients (54.5%) had known metastatic
disease at the time of presentation. Four patients were
asymptomatic at the time of diagnosis, six presented
with flank pain, and one had hematuria. Flank pain
resolved in these patients after urinary diversion. The
mean pre- and postoperative creatinine levels were
1.43 and 1.48, respectively. The mean survival was 293
days. Average hospitalization was 33.7 days, which
constituted 11.2% of the overall survival.
DISCUSSION
Open surgical placement of nephrostomy tubes for
the management of malignant ureteral obstruction
was common practice until the 1970s. This procedure
was associated with a high complication rate, a significant perioperative mortality rate, and an average
length of survival of 6 months.5 The introduction of
percutaneous techniques associated with the evolution of the field of endourology, the use of ultrasound
and CT guidance, and the routine use of perioperative
antibiotics have dramatically reduced the morbidity of
ureteral stent placement. Furthermore, the availability
of new stenting biomaterial for endoscopic insertion
has contributed to safe urinary diversion. This is reflected in our data, in which the morbidity associated
with the procedures was mostly minor; however, 63%
of patients had complications. Significant major complications occurred in 5.4% of patients with no procedural mortality.
A difficult ethical question arises in patients with
incurable malignancies who are diagnosed with malignant ureteral obstructions. Decompression of the
obstruction may merely prolong the patient’s suffering. Patients who present with bilateral obstruction
and uremia have a short life expectancy if their disease
remains untreated.1 These patients appear to present
in a more advanced stage of the disease. The functional status of these patients is generally poor at the
time of presentation secondary to preexisting conditions related to their malignancy. In a few studies on
palliative urinary diversion in patients with advanced
malignancies, the impact on quality of life after diversion has been addressed.5,13,14 Most of these studies
were conducted prior to the routine use of endoscopic
diversion. The assessment of quality of life is difficult,
and different arbitrary definitions have been used.5,15
The KPS is the most widely used method of quantifying cancer patients’ ability to function.15 The KPS
measures the patient’s ability to carry on the normal
activity of everyday life or degree of dependence on
others to perform these activities. Furthermore, the
KPS has contributed to rehabilitating patients with
cancer and can serve as a helpful tool both in the
initial assessment as well as the ongoing assessment of
prognosis. Although studies have suggested that, in a
palliative setting, assessment of the quality of life using the KPS is more appropriate than survival per se,16
we used this scale as a way to quantify objectively the
functional status of cancer patients after diversion
rather than to assess their “quality of life,” which is
more difficult.
Our data suggest that the majority of patients with
bilateral ureteral obstruction secondary to malignancy
1002
CANCER February 15, 1999 / Volume 85 / Number 4
had a poor performance status for the remainder of
their life after diversion. Overall, 86% were symptomatic mainly from cancer-related pain after urinary diversion, and 15% never left the hospital. Survival of
patients after palliative urinary diversion in earlier
studies has been generally poor.1,4,5,17 The prognostic
values of prior treatment, the stage of disease, and the
period from diagnosis to diversion all have been debated. The site of the initial tumor has been thought to
be the most important prognostic factor for survival,
with prostate and cervical carcinomas having the
longest reported survivals.10,17 It has been reported
that nonurologic malignancies, especially gastric and
pancreatic carcinomas, are worse offenders than urologic malignancies.6 In our series, the average survival
of patients with bilateral obstruction after urinary diversion was between 4 months and 7 months. Although we found a trend toward better survival and
quality of life in patients with prostate carcinoma, the
differences were not significant. This may reflect the
natural history of the disease and the fact that urinary
obstruction may occur earlier during the course of this
disease.4
Intuitively, patients with locally advanced tumors
causing ureteral obstruction should do better than
those with metastatic disease. One study reported a
7.6-month mean survival time in 20 patients who underwent percutaneous nephrostomy placement. However, their disease stages were not stated.18 Conversely, patients with cervical carcinoma who had
disseminated metastasis did poorly.14 The majority of
our patients had disseminated disease at the time of
diversion. In patients with pelvic tumors, the performance status was significantly better in those with
locally advanced (including lymph node metastasis)
disease compared with those with disseminated disease (P 5 0.03); however, no statistically significant
survival benefit was noted.
The prognostic value of prior or subsequent treatment has been controversial. Watkinson et al.8 found
that only patients who had treatment options after
urinary diversion benefited from percutaneous nephrostomy. In their patients with relapsed disease and
no conventional treatment options available, only
5.5% benefited from the procedure. The average survival was 38 days in this group, and 61% never left the
hospital. In our series, 67% of patients had maximized
multimodal treatment prior to diversion with no
noted survival difference compared with patients who
received no treatment or only a single modality of
treatment prior to diversion. The majority of patients
with prostate carcinoma (78%) had prior hormonal
therapy, making a comparison with those who received no treatment difficult. Overall, only three pa-
tients with no prior therapy underwent treatment after
diversion. This may explain the fact that no difference
was found in survival between those with multimodal
and those with some or no prior treatment. It also
highlights the observation that few patients (3.2%)
receive systemic treatment after urinary diversion. In
accordance with previous published data, no correlation existed between the period of time from diagnosis
of malignancy to diversion with survival. Overall, no
factor could be identified as a predictor of improved
survival or performance status after diversion in our
patient cohort.
Zadra et al.4 reported symptomatic relief of pain
in patients with unilateral ureteral obstruction. They
did not recommend urinary diversion in asymptomatic patients with unilateral obstruction and stable
contralateral renal function who failed endoscopic
stenting. In another study, unilateral or bilateral obstruction did not appear to be an important factor in
quality of survival.13 In our series, although the number of patients with unilateral obstruction was small,
decompression resulted in resolution of symptoms in
those patients with isolated flank pain. In asymptomatic patients, urinary diversion may be of little benefit.
The type of urinary diversion in many instances is
related to clinician biases, availability, and urgency of
the diversion. A success rate of 37– 47% using primary
endoscopic ureteral stents has been reported.4,13,19
Prostatic and bladder tumors were more difficult to
divert endoscopically, because the ureteral orifices
were difficult to see or were invaded by the tumor.
Therefore, primary percutaneous nephrostomy in patients with prostate or bladder carcinomas has been
advocated.4 In our patients, primary endoscopic stent
placement had a high failure rate of 51%, necessitating
percutaneous procedures. The failure rate in patients
with prostate and bladder carcinomas was 55%. This is
in agreement with the previously reported studies.
Furthermore, Docimo and Dewolf7 reported a high
postoperative failure rate (defined as occlusion within
30 days) of ureteral stents in 46% of patients with
extrinsic ureteral obstruction. In patients with advanced malignancies, ureteral obstruction is commonly the result of external compression by metastatic process, which may explain the lower success
rate of stenting.
Although the percutaneous approach under ultrasound guidance has a high technical success rate, long
term management of nephrostomy catheters is cumbersome and is associated with an inferior quality of
life compared with internal stents.13 Perinephric abscess rates as high as 15% have been reported.18 Complications, such as bleeding, may be significant, and
revisions may become necessary secondary to malpo-
Palliative Urinary Diversion in Advanced Malignancies/Shekarriz et al.
sition or blockage.17,18 Dislocation of the tube may
occur in up to 40% of patients. With the advent of new
percutaneous techniques, conversion of a percutaneous nephrostomy to an internal double-J stent using
flexible guide wires is possible.20 This will eliminate
the need for external collection devices and will improve patient independence.
In conclusion, the indications for palliative urinary diversion should be individualized. Patients
with prostate carcinoma showed a trend toward better survival and performance status compared with
patients with other tumor sites. No other factors
(tumor stage, metastasis, time from diagnosis to
diversion) seemed to play a significant prognostic
role in deciding which patient benefited from diversion. In an era of advances in the field of endourology with unquestionable improvement in mortality
and morbidity, the quality of life and survival of
patients with malignant ureteral obstruction remains poor. Patients and family members should be
informed of the poor outcomes after palliative procedures to guide them toward appropriate decision
making.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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