0022-534 7/78/1202-0162$02. 00/0 Vol. 120, August
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1978 by The Williams & Wilkins Co.
PALLIATIVE URINARY DIVERSION FOR MALIGNANT URETERAL OBSTRUCTION WILLIAM SHARER, JOHN T. GRAYHACK
AND
JOHN GRAHAM
From the Department of Urology, Northwestern University, McGaw Medical Center, Chicago, Illinois
ABSTRACT
An analysis of 62 palliative urinary dJversions for malignant ureteral obstruction is presented. The average postoperative survival was 187 days. Cell type, duration of known disease, tumor grade and stage, renal function and previous therapy did not strongly influence survival. Renal function returned to normal in 64 per cent of the azotemic patients. Morbidity and mortality rates were high, largely because of underlying disease and adjuvant therapy. Nearly two-thirds of the patients left the hospital and this group subsequently spent 84 per cent of their remaining survival time at home. A criterion is presented for patient selection and suggestions are made for the selection of an operative procedure. listed in table 7. There were 22 patients who never left the hospital (35 per cent) but only 31 per cent of the post-diversion surviving time for the group as a whole was spent in the hospital. Furthermore, once discharged from the hospital survivors spent 84 per cent of the remaining time at home. Patient age had minimal effect on survival, patients less than 65 years old surviving 206 days compared to 152 days for those between 65 and 82 years old. All 4 patients more than 80 years old did poorly, with a mean survival of only 27 days. Duration of disease greater than 1 year correlated with a survival of 210 days, while patients with more recent disease lived 147 days. The effects of renal failure and previous therapy are outlined in table 8. Postoperative adjuvant therapy increased survival from 101 days in the untreated group to 253 days in the group receiving radiation or chemotherapy. This differential is abnormally large because many patients in the untreated group did not survive long enough to receive adjuvant therapy. Therefore, if the postoperative deaths are excluded from each group survival for untreated patients is 203 days compared to 305 days for patients treated.
Ureteral obstruction is associated with a variety of neoplasms. Tumors arising from the pelvic viscera obstruct the lower ureter by invasion or compression. Primary or metastatic lesions in the retroperitoneum compress the middle or upper ureter and invasion is less common. Advances in diagnostic techniques, tumor therapy and dialysis have increased gradually the number of candidates for palliative urinary diversion. Although several series have been reported the cumulative experience is not sufficient to establish criteria to guide clinical judgment with respect to these patients. 1- 3 CASE MATERIAL
The records of all patients who underwent diversion for malignant ureteral obstruction from 1967 to 1976 were examined. Of these 62 patients 50 are known to be dead, 7 have been lost to followup and 5 are still living. The 7 patients lost to followup are included in the analysis of presenting characteristics, operative techniques and postoperative morbidity but are excluded from the survival data. The study included 28 men and 34 women with a mean age of 59 years (range 27 to 82 years). The interval between the diagnosis of malignancy and diversion averaged 38 months but the median interval was only 19 months (table 1). Bladder neoplasms predominated followed by tumors of the cervix, prostate and gastrointestinal tract (table 2). In 13 cases the tumors were locally extensive, while in 49 they were metastatic. The majority of the patients had received treatment for the malignancies before diversion, including attempted but incomplete surgical resection in 14, radiation therapy in 30, chemotherapy in 11 and endocrine manipulation in 7. At the time of diversion 36 patients (58 per cent) had markedly impaired renal function, defined as a blood urea nitrogen (BUN) of more than 30 mg. per cent and a creatinine value of more than 2 mg. per cent. Individual renal units were categorized by an excretory urogram (IVP) as normal in 9 cases, hydronephrotic in 61, non-functioning in 51 and surgically absent in 3. Presenting symptomatology, indications for diversion and the methods of diversion were noted (tables 3 to 6).
TYPES OF DIVERSION
Tables 5 and 6 summarize the methods of diversion, the response of renal function to diversion, the necessity for revision of the initial procedure and the number of diversions successfully reversed. Renal function returned to normal in 23 of 36 azotemic patients (64 per cent). The decreases in BUN and creatinine value were at least 20 mg. per cent and 2.0 mg. per cent, respectively, for 20 of the 23 patients whose renal function returned to normal. There were 13 patients who remained azotemic after diversion but 4 of these patients had enough improvement in renal function that dialysis was not necessary. The remaining 9 patients were markedly azotemic and remained so after diversion. Initially, normal renal function was preserved in 22 patients and deteriorated in 4 others. The azotemia became severe in 1 patient with hemorrhage from a gastric carcinoma and was probably caused by multiple organ system failure rather than malfunction of the ureteral catheters. Mild azotemia was caused by stomal stenosis in 2 patients with cutaneous ureterostomies. Azotemia in the fourth patient was related to an episode of sepsis. Complications and malfunctions related to the diversion were common. Six drainage tubes were displaced, 3 cutaneous ureterostomy stomas stenosed, 2 transureteroureterostomies leaked and 2 obstructed at the site of anastomoses, 2 catheters drained poorly, 1 ureter was perforated by a ureteral catheter, 1 nephrostomy required reoperation for bleeding and in 1
RESULTS AND SURVIVAL
The average survival of 55 patients with complete followup was 187 days, with a range of 2 to 758 days. The mortality rate 1 month postoperatively was 22 per cent. By 6 months 53 per cent of the patients had died and at 1 year the mortality rate reached 82 per cent. A breakdown of survival by tumor type is Accepted for publication December 2, 1977.
162
163
PALLIATIVE URINARY DIVERSION FOR MALIGNANT URETERAL OBSTRUCTION TABLE
1. Duration of disease before diversion Pts.
Mos.
TABLE
No.(%)
N ephrostomy Cutaneous ureterostomy Transureteroureterostomy and cutaneous ureterostomy Ilea! conduit Intubated ureterostomy Ureteral catheter Gibbons' stent Lysis of adhesions
16 (25) 10 (16) 16 (26) 6 (10) 14 (23)
0-6 7-12 13-36 37-60 61-276
Mean duration 38 months and median duration 19 months. TABLE
2. Cell type of primary malignancy SloanPts. Kettering* No.(%) % 20 (32) 9 (15) 7 (11) 7 (11) 5 ( 8) 5 ( 8) 3 ( 5) 2 ( 3) 2 ( 3) 1 ( 2) 1 ( 2)
Bladder Cervix Prostate Gastrointestinal Breast Lymph Ovary Endometrial Choriocarcinoma Pancreas Undifferentiated
TABLE
1 0 2
2 0 0
8 6 19 1 1
1 5 4 0 1
0 3 4: 0 1
0 0 7* 1 0
15 19 6
10
Days Survival
% Spent in Hospital
Bladder Cervix Gastrointestinal Prostate Lymphatic Breast Ovary Uterus Choriocarcinoma Pancreas
18 9 7 5 5 3 3 2 2 1
237 128 254 189
27 27 30 25 58 16 16 20 Unknown 100
TABLE
3. Presenting symptoms 32 17 17 16
Renal Failure Yes Yes No No
9
9 6 6 5
3
7. Postoperative survival time No. Pts.
11
No. Pts.
TABLE
2 2 4
Cell Type
36
20 35 5 14 6
Uremia Gross hematuria Flank pain Voiding symptoms Vaginal symptoms Fever Edema Non-specific Gastrointestinal Bone pain
21 10 8
* 1 ureteral catheter had to be reinserted. Yalet %
* 170 patients. t 47 patients. TABLE
6. Complications of diversion and removal rate No. Postop. Requiring Removed Pts. Sepsis Revision
71
2/2/128 5/217/758 15/363 13/242 21
8. Effects of previous tumor therapy and renal function on survival Previous Therapy
Days Survival
% Complication
% Operative Related Mortality
Yes No Yes No
142 232 167 224
75 75 47 44
38 25 30 11
technique. In our hands intubated ureterotomy and transureteroureterostomy were prone to complications, including obstruction, extravasation and sepsis.
4. Indication for diversion No. Pts.
MORBIDITY AND MORTALITY
62 36
Hydronephrosis Renal failure Bleeding Flank pain Sepsis Fistula Voiding symptoms
9
15 9* 6 6
* 6 of 9 urine cultures positive at operation. TABLE
5. H,esponse of renal failure to diversion Preop. BUN Elevated Preop. BUN Normal
Nephrostomy Cutaneous ureterostomy Transureteroureterostomy Ilea! conduit Intubated ureterotomy Ureteral catheter Gibbons' stent Lysis
Postop. BUN Decreased
Postop. BUN Stable
Postop. BUN Stable
Postop. BUN Increased
4 2 3
6 2 0
11 5 4
0 1 1
1 4 9 0 0
0 1 4 0 0
6 1 5 1 1
1 0 1 0 0
patient a colo-ureterocutaneous fistula developed after an intubated ureterotomy. A total of 14 diversions required revision: 3 temporizing ureteral catheters were replaced electively by a permanent diversion, 2 catheters were repositioned, 2 cutaneous ureterostomies were revised and 7 diversions were considered failures and replaced by a new form of diversion. Urinary sepsis was not uncommon for any operative
An accurate assessment of operative morbidity and mortality rates is severely limited by the complex nature of the underlying disease. It frequently is impossible to separate operative complications from the natural history of the disease. No patient died during the procedure or the first 24 hours thereafter. Subsequently, 5 patients (8 per cent) died primarily of operative complications. The surgical procedure contributed to the death of an additional 13 patients, for an over-all operation-associated mortality rate of 29 per cent. Only 19 patients (31 per cent) had an uneventful postoperative course. Roughly, half of the patients had a significant febrile episode but the etiology usually was hard to define. As previously stated obstruction and displacement of drainage tubes were common. Convalescence was complicated in 13 cases by gastrointestinal problems, including bleeding, perforation and prolonged ileus. The majority of these complications were caused by the malignancy or adjuvant therapy. A variety of pulmonary, cardiac, central nervous system and hematologic irregularities required treatment, this being successful in the majority of cases. One or more additional operative procedures were necessary in 30 patients (49 per cent). Revision of the diversion (14), endoscopic procedures (8) and colostomy (6) were the most frequent. Only 1 operation, a hip-pinning procedure for a non-pathologic fracture, was totally unrelated to the neoplasm. DISCUSSION
Ureteral obstruction is a common occurrence in patients with an abdominal malignancy. In the future more aggressive
164
SHARER, GRAYHACK AND GRAHAM
evaluation and treatment of cancer will probably increase the number of patients with symptomatic obstruction. It is apparent from this study and other reviews that a few guide lines can be established for the management of malignant obstruction. We do not divert silent obstruction if the BUN and creatinine values are normal. Aggressive radiation and chemotherapy can decrease the obstruction in a relatively short period, obviating the need for diversion in many patients. 2• 4-7 In addition, many patients will die of other organ involvement or unrelated diseases before the obstruction produces symptoms of azotemia. Finally, this approach provides an opportunity to evaluate the response to radiation or chemotherapy. In our opinion early progression despite maximal therapy strongly mitigates against future diversion. In our experience patients with ureteral obstruction from gastrointestinal and bladder neoplasms fared the best. However, the results for these groups of patients in the experience reported by Brin and associates were much less favorable. 3 On the other hand, the reported good survival rate of patients with prostatic neoplasms in their series was not matched in our review. In a series of 7 patients with prostatic carcinoma requiring urinary diversion Khan and Utz reported on 2 patients with long-term survivals of 2 and 4 years but the remaining 5 patients died within 5 months. 2 Our data confirm that reported by Grabstald and McPhee, in that stage and duration of disease did not strongly influence survival. 1 Although patients less than 65 years old lived longer than those more than 65 years old age did not seem to be a major factor in survival until the ninth decade. All 4 of our patients more than 80 years old died within 6 weeks of the operation. Previously untreated patients without azotemia tend to survive longer, have fewer complications and less operative mortality than previously treated or azotemic patients but the differences were not of sufficient magnitude nor invariable enough to warrant the use of either parameter as a prime factor in patient selection. One exception might be the patient who has received all treatment modalities and presents with a rapidly progressive course. Grabstald and McPhee argue against diversion in these people1 and we would generally agree. Most investigators stress the importance of the quality of life after diversion. Intractable pain, senility or severe unrelated medical disease argue against extraordinary procedures to prolong life. Grabstald and McPhee found that 40 per cent of their patients returned to useful life, defined as 2 months at home with minimal pain, normal mentation and few complications. We were not able to make this type of analysis but we did find that 65 per cent of our patients did leave the hospital. Once discharged they spent 85 per cent of their surviving time at home. Hospitalization consumed 31 per cent of survival time for all patients, including the initial hospital stay. Various operative procedures were used. Ureteral catheters were passed whenever possible if the cause of the obstruction was believed to be reversible. In these cases adjuvant therapy could be instituted and the response could be evaluated before the decision was made relative to the desirability of a permanent diversion. In our experience ureteral catheters were used most frequently to bypass upper or mid ureteral obstruction. Ureters obstructed by vesical, prostatic and cervical neoplasms are notoriously hard to catheterize. We were successful in passing catheters in 3 such patients. Both patients with prostatic carcinoma were extubated after orchiectomy and recovery of normal renal function. They died subsequently without having undergone a definitive diversion. In all, 7 of the 20 patients who underwent diversion by ureteral catheters or a Gibbons' stent were extubated successfully. One addi.tional patient was extubated but required recatheterization. Since 2 nephrostomies were removed a total of 9 patients (15
per cent) were undiverted. Therefore, an attempt to pass a ureteral catheter should be made in any patient with potentially reversible obstruction, so that permanent diversion can be avoided in a significant number of patients. Recent reports oflong-term urinary diversion by indwelling ureteral stents have been encouraging. Gibbons and associates reported an impressive series of 17 cancer patients who underwent diversion with silicone ureteral stents for up to 44 months. 8 Catheter-related problems were reported to be few and easily managed. Since the stent may function as either a temporary or permanent diversion and does not seem to have the disadvantages associated with nephrostomy it may prove to be a valuable ~ddition to the armamentarium of diverting procedures. Classical nephrostomy, U-tube nephrostomy, percutaneous nephrostomy, cutaneous ureterostomy and ileal conduit all performed satisfactorily in our experience and may be used when ureteral catheterization cannot be performed or is not indicated. The various advantages and disadvantages of each procedure are well known. Intubated ureterotomy and transureteroureterostomy were plagued by a high rate of complications, particularly urinary extravasation and sepsis. No obvious explanation for the poor performance of the transureteroureterostomy with cutaneous ureterostomy can be found. Since this procedure can be an attractive method for diversion in patients with bilateral obstruction we continue to use it in selected cases. We propose the following criteria to select patients for diversion, none of which should be construed as absolute: 1) neoplasm stable or potentially treatable, 2) obstruction complicated by azotemia, sepsis, fistula and so forth, 3) patients less than 80 years old, 4) patients with potential for independent existence and 5) quality of life acceptable to the patient. In arriving at a decision to divert or bypass an obstruction the cell type, grade and stage, duration of disease and the type of response to previous therapy warrant consideration but should not be of primary importance. In selecting a method of diversion it would seem prudent to use a simple temporary diversion, such as a ureteral stent for tumors of unknown cell type or tumors that are likely to respond to adjuvant therapy. N ephrostomy, classical or percutaneous, is a good alternative if ureteral catheters cannot be passed. If reversal of the diversion seems unlikely then a permanent form of urinary diversion, such as ileal conduit or cutaneous ureterostomy, warrants consideration. Intubated ureterotomy and transureteroureterostomy should be used with caution because of a high complication rate. REFERENCES
1. Grabstald, H. and McPhee, M.: Nephrostomy and the cancer patient. South. Med. J., 66: 217, 1973. 2. Khan, A. U. and Utz, D. C.: Clinical management of carcinoma of prostate associated with bilateral ureteral obstruction. J. Urol., 113: 816, 1975. 3. Brin, E. N., Schiff, M., Jr. and Weiss, R. M.: Palliative urinary diversion for pelvic malignancy. J. Urol., 113: 619, 1975. 4. Kraus, P. A., Lytton, B., Weiss, R. M. and Prosnitz, L. R.: Radiation therapy for local palliative treatment of prostatic cancer. J. Urol., 108: 612, 1972. 5. Carlton, C. E., Jr., DaWoud, F., Hudgins, P. and Scott, R., Jr.: Irradiation treatment of carcinoma of the prostate: a preliminary report based on 8 years of experience. J. Urol., 108: 924, 1972. 6. Loening, S., Carson, C. C., III, Faxon, D. P. and Morin, L. J.: Ureteral obstruction from Hodgkin's disease. J. Urol., 111: 345, 1974. 7. Megalli, M. R., Gursel, E. 0., Demirag, H., Veenema, R. J. and Guttman, R.: External radiotherapy in ureteral obstruction secondary to locally invasive prostatic cancer. Urology, 3: 562, 1974. 8. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Experience with indwelling ureteral stent catheters. J. Urol., 115: 22, 1976.
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1978 by The Williams & Wilkins Co.
PALLIATIVE URINARY DIVERSION FOR MALIGNANT URETERAL OBSTRUCTION WILLIAM SHARER, JOHN T. GRAYHACK
AND
JOHN GRAHAM
From the Department of Urology, Northwestern University, McGaw Medical Center, Chicago, Illinois
ABSTRACT
An analysis of 62 palliative urinary dJversions for malignant ureteral obstruction is presented. The average postoperative survival was 187 days. Cell type, duration of known disease, tumor grade and stage, renal function and previous therapy did not strongly influence survival. Renal function returned to normal in 64 per cent of the azotemic patients. Morbidity and mortality rates were high, largely because of underlying disease and adjuvant therapy. Nearly two-thirds of the patients left the hospital and this group subsequently spent 84 per cent of their remaining survival time at home. A criterion is presented for patient selection and suggestions are made for the selection of an operative procedure. listed in table 7. There were 22 patients who never left the hospital (35 per cent) but only 31 per cent of the post-diversion surviving time for the group as a whole was spent in the hospital. Furthermore, once discharged from the hospital survivors spent 84 per cent of the remaining time at home. Patient age had minimal effect on survival, patients less than 65 years old surviving 206 days compared to 152 days for those between 65 and 82 years old. All 4 patients more than 80 years old did poorly, with a mean survival of only 27 days. Duration of disease greater than 1 year correlated with a survival of 210 days, while patients with more recent disease lived 147 days. The effects of renal failure and previous therapy are outlined in table 8. Postoperative adjuvant therapy increased survival from 101 days in the untreated group to 253 days in the group receiving radiation or chemotherapy. This differential is abnormally large because many patients in the untreated group did not survive long enough to receive adjuvant therapy. Therefore, if the postoperative deaths are excluded from each group survival for untreated patients is 203 days compared to 305 days for patients treated.
Ureteral obstruction is associated with a variety of neoplasms. Tumors arising from the pelvic viscera obstruct the lower ureter by invasion or compression. Primary or metastatic lesions in the retroperitoneum compress the middle or upper ureter and invasion is less common. Advances in diagnostic techniques, tumor therapy and dialysis have increased gradually the number of candidates for palliative urinary diversion. Although several series have been reported the cumulative experience is not sufficient to establish criteria to guide clinical judgment with respect to these patients. 1- 3 CASE MATERIAL
The records of all patients who underwent diversion for malignant ureteral obstruction from 1967 to 1976 were examined. Of these 62 patients 50 are known to be dead, 7 have been lost to followup and 5 are still living. The 7 patients lost to followup are included in the analysis of presenting characteristics, operative techniques and postoperative morbidity but are excluded from the survival data. The study included 28 men and 34 women with a mean age of 59 years (range 27 to 82 years). The interval between the diagnosis of malignancy and diversion averaged 38 months but the median interval was only 19 months (table 1). Bladder neoplasms predominated followed by tumors of the cervix, prostate and gastrointestinal tract (table 2). In 13 cases the tumors were locally extensive, while in 49 they were metastatic. The majority of the patients had received treatment for the malignancies before diversion, including attempted but incomplete surgical resection in 14, radiation therapy in 30, chemotherapy in 11 and endocrine manipulation in 7. At the time of diversion 36 patients (58 per cent) had markedly impaired renal function, defined as a blood urea nitrogen (BUN) of more than 30 mg. per cent and a creatinine value of more than 2 mg. per cent. Individual renal units were categorized by an excretory urogram (IVP) as normal in 9 cases, hydronephrotic in 61, non-functioning in 51 and surgically absent in 3. Presenting symptomatology, indications for diversion and the methods of diversion were noted (tables 3 to 6).
TYPES OF DIVERSION
Tables 5 and 6 summarize the methods of diversion, the response of renal function to diversion, the necessity for revision of the initial procedure and the number of diversions successfully reversed. Renal function returned to normal in 23 of 36 azotemic patients (64 per cent). The decreases in BUN and creatinine value were at least 20 mg. per cent and 2.0 mg. per cent, respectively, for 20 of the 23 patients whose renal function returned to normal. There were 13 patients who remained azotemic after diversion but 4 of these patients had enough improvement in renal function that dialysis was not necessary. The remaining 9 patients were markedly azotemic and remained so after diversion. Initially, normal renal function was preserved in 22 patients and deteriorated in 4 others. The azotemia became severe in 1 patient with hemorrhage from a gastric carcinoma and was probably caused by multiple organ system failure rather than malfunction of the ureteral catheters. Mild azotemia was caused by stomal stenosis in 2 patients with cutaneous ureterostomies. Azotemia in the fourth patient was related to an episode of sepsis. Complications and malfunctions related to the diversion were common. Six drainage tubes were displaced, 3 cutaneous ureterostomy stomas stenosed, 2 transureteroureterostomies leaked and 2 obstructed at the site of anastomoses, 2 catheters drained poorly, 1 ureter was perforated by a ureteral catheter, 1 nephrostomy required reoperation for bleeding and in 1
RESULTS AND SURVIVAL
The average survival of 55 patients with complete followup was 187 days, with a range of 2 to 758 days. The mortality rate 1 month postoperatively was 22 per cent. By 6 months 53 per cent of the patients had died and at 1 year the mortality rate reached 82 per cent. A breakdown of survival by tumor type is Accepted for publication December 2, 1977.
162
163
PALLIATIVE URINARY DIVERSION FOR MALIGNANT URETERAL OBSTRUCTION TABLE
1. Duration of disease before diversion Pts.
Mos.
TABLE
No.(%)
N ephrostomy Cutaneous ureterostomy Transureteroureterostomy and cutaneous ureterostomy Ilea! conduit Intubated ureterostomy Ureteral catheter Gibbons' stent Lysis of adhesions
16 (25) 10 (16) 16 (26) 6 (10) 14 (23)
0-6 7-12 13-36 37-60 61-276
Mean duration 38 months and median duration 19 months. TABLE
2. Cell type of primary malignancy SloanPts. Kettering* No.(%) % 20 (32) 9 (15) 7 (11) 7 (11) 5 ( 8) 5 ( 8) 3 ( 5) 2 ( 3) 2 ( 3) 1 ( 2) 1 ( 2)
Bladder Cervix Prostate Gastrointestinal Breast Lymph Ovary Endometrial Choriocarcinoma Pancreas Undifferentiated
TABLE
1 0 2
2 0 0
8 6 19 1 1
1 5 4 0 1
0 3 4: 0 1
0 0 7* 1 0
15 19 6
10
Days Survival
% Spent in Hospital
Bladder Cervix Gastrointestinal Prostate Lymphatic Breast Ovary Uterus Choriocarcinoma Pancreas
18 9 7 5 5 3 3 2 2 1
237 128 254 189
27 27 30 25 58 16 16 20 Unknown 100
TABLE
3. Presenting symptoms 32 17 17 16
Renal Failure Yes Yes No No
9
9 6 6 5
3
7. Postoperative survival time No. Pts.
11
No. Pts.
TABLE
2 2 4
Cell Type
36
20 35 5 14 6
Uremia Gross hematuria Flank pain Voiding symptoms Vaginal symptoms Fever Edema Non-specific Gastrointestinal Bone pain
21 10 8
* 1 ureteral catheter had to be reinserted. Yalet %
* 170 patients. t 47 patients. TABLE
6. Complications of diversion and removal rate No. Postop. Requiring Removed Pts. Sepsis Revision
71
2/2/128 5/217/758 15/363 13/242 21
8. Effects of previous tumor therapy and renal function on survival Previous Therapy
Days Survival
% Complication
% Operative Related Mortality
Yes No Yes No
142 232 167 224
75 75 47 44
38 25 30 11
technique. In our hands intubated ureterotomy and transureteroureterostomy were prone to complications, including obstruction, extravasation and sepsis.
4. Indication for diversion No. Pts.
MORBIDITY AND MORTALITY
62 36
Hydronephrosis Renal failure Bleeding Flank pain Sepsis Fistula Voiding symptoms
9
15 9* 6 6
* 6 of 9 urine cultures positive at operation. TABLE
5. H,esponse of renal failure to diversion Preop. BUN Elevated Preop. BUN Normal
Nephrostomy Cutaneous ureterostomy Transureteroureterostomy Ilea! conduit Intubated ureterotomy Ureteral catheter Gibbons' stent Lysis
Postop. BUN Decreased
Postop. BUN Stable
Postop. BUN Stable
Postop. BUN Increased
4 2 3
6 2 0
11 5 4
0 1 1
1 4 9 0 0
0 1 4 0 0
6 1 5 1 1
1 0 1 0 0
patient a colo-ureterocutaneous fistula developed after an intubated ureterotomy. A total of 14 diversions required revision: 3 temporizing ureteral catheters were replaced electively by a permanent diversion, 2 catheters were repositioned, 2 cutaneous ureterostomies were revised and 7 diversions were considered failures and replaced by a new form of diversion. Urinary sepsis was not uncommon for any operative
An accurate assessment of operative morbidity and mortality rates is severely limited by the complex nature of the underlying disease. It frequently is impossible to separate operative complications from the natural history of the disease. No patient died during the procedure or the first 24 hours thereafter. Subsequently, 5 patients (8 per cent) died primarily of operative complications. The surgical procedure contributed to the death of an additional 13 patients, for an over-all operation-associated mortality rate of 29 per cent. Only 19 patients (31 per cent) had an uneventful postoperative course. Roughly, half of the patients had a significant febrile episode but the etiology usually was hard to define. As previously stated obstruction and displacement of drainage tubes were common. Convalescence was complicated in 13 cases by gastrointestinal problems, including bleeding, perforation and prolonged ileus. The majority of these complications were caused by the malignancy or adjuvant therapy. A variety of pulmonary, cardiac, central nervous system and hematologic irregularities required treatment, this being successful in the majority of cases. One or more additional operative procedures were necessary in 30 patients (49 per cent). Revision of the diversion (14), endoscopic procedures (8) and colostomy (6) were the most frequent. Only 1 operation, a hip-pinning procedure for a non-pathologic fracture, was totally unrelated to the neoplasm. DISCUSSION
Ureteral obstruction is a common occurrence in patients with an abdominal malignancy. In the future more aggressive
164
SHARER, GRAYHACK AND GRAHAM
evaluation and treatment of cancer will probably increase the number of patients with symptomatic obstruction. It is apparent from this study and other reviews that a few guide lines can be established for the management of malignant obstruction. We do not divert silent obstruction if the BUN and creatinine values are normal. Aggressive radiation and chemotherapy can decrease the obstruction in a relatively short period, obviating the need for diversion in many patients. 2• 4-7 In addition, many patients will die of other organ involvement or unrelated diseases before the obstruction produces symptoms of azotemia. Finally, this approach provides an opportunity to evaluate the response to radiation or chemotherapy. In our opinion early progression despite maximal therapy strongly mitigates against future diversion. In our experience patients with ureteral obstruction from gastrointestinal and bladder neoplasms fared the best. However, the results for these groups of patients in the experience reported by Brin and associates were much less favorable. 3 On the other hand, the reported good survival rate of patients with prostatic neoplasms in their series was not matched in our review. In a series of 7 patients with prostatic carcinoma requiring urinary diversion Khan and Utz reported on 2 patients with long-term survivals of 2 and 4 years but the remaining 5 patients died within 5 months. 2 Our data confirm that reported by Grabstald and McPhee, in that stage and duration of disease did not strongly influence survival. 1 Although patients less than 65 years old lived longer than those more than 65 years old age did not seem to be a major factor in survival until the ninth decade. All 4 of our patients more than 80 years old died within 6 weeks of the operation. Previously untreated patients without azotemia tend to survive longer, have fewer complications and less operative mortality than previously treated or azotemic patients but the differences were not of sufficient magnitude nor invariable enough to warrant the use of either parameter as a prime factor in patient selection. One exception might be the patient who has received all treatment modalities and presents with a rapidly progressive course. Grabstald and McPhee argue against diversion in these people1 and we would generally agree. Most investigators stress the importance of the quality of life after diversion. Intractable pain, senility or severe unrelated medical disease argue against extraordinary procedures to prolong life. Grabstald and McPhee found that 40 per cent of their patients returned to useful life, defined as 2 months at home with minimal pain, normal mentation and few complications. We were not able to make this type of analysis but we did find that 65 per cent of our patients did leave the hospital. Once discharged they spent 85 per cent of their surviving time at home. Hospitalization consumed 31 per cent of survival time for all patients, including the initial hospital stay. Various operative procedures were used. Ureteral catheters were passed whenever possible if the cause of the obstruction was believed to be reversible. In these cases adjuvant therapy could be instituted and the response could be evaluated before the decision was made relative to the desirability of a permanent diversion. In our experience ureteral catheters were used most frequently to bypass upper or mid ureteral obstruction. Ureters obstructed by vesical, prostatic and cervical neoplasms are notoriously hard to catheterize. We were successful in passing catheters in 3 such patients. Both patients with prostatic carcinoma were extubated after orchiectomy and recovery of normal renal function. They died subsequently without having undergone a definitive diversion. In all, 7 of the 20 patients who underwent diversion by ureteral catheters or a Gibbons' stent were extubated successfully. One addi.tional patient was extubated but required recatheterization. Since 2 nephrostomies were removed a total of 9 patients (15
per cent) were undiverted. Therefore, an attempt to pass a ureteral catheter should be made in any patient with potentially reversible obstruction, so that permanent diversion can be avoided in a significant number of patients. Recent reports oflong-term urinary diversion by indwelling ureteral stents have been encouraging. Gibbons and associates reported an impressive series of 17 cancer patients who underwent diversion with silicone ureteral stents for up to 44 months. 8 Catheter-related problems were reported to be few and easily managed. Since the stent may function as either a temporary or permanent diversion and does not seem to have the disadvantages associated with nephrostomy it may prove to be a valuable ~ddition to the armamentarium of diverting procedures. Classical nephrostomy, U-tube nephrostomy, percutaneous nephrostomy, cutaneous ureterostomy and ileal conduit all performed satisfactorily in our experience and may be used when ureteral catheterization cannot be performed or is not indicated. The various advantages and disadvantages of each procedure are well known. Intubated ureterotomy and transureteroureterostomy were plagued by a high rate of complications, particularly urinary extravasation and sepsis. No obvious explanation for the poor performance of the transureteroureterostomy with cutaneous ureterostomy can be found. Since this procedure can be an attractive method for diversion in patients with bilateral obstruction we continue to use it in selected cases. We propose the following criteria to select patients for diversion, none of which should be construed as absolute: 1) neoplasm stable or potentially treatable, 2) obstruction complicated by azotemia, sepsis, fistula and so forth, 3) patients less than 80 years old, 4) patients with potential for independent existence and 5) quality of life acceptable to the patient. In arriving at a decision to divert or bypass an obstruction the cell type, grade and stage, duration of disease and the type of response to previous therapy warrant consideration but should not be of primary importance. In selecting a method of diversion it would seem prudent to use a simple temporary diversion, such as a ureteral stent for tumors of unknown cell type or tumors that are likely to respond to adjuvant therapy. N ephrostomy, classical or percutaneous, is a good alternative if ureteral catheters cannot be passed. If reversal of the diversion seems unlikely then a permanent form of urinary diversion, such as ileal conduit or cutaneous ureterostomy, warrants consideration. Intubated ureterotomy and transureteroureterostomy should be used with caution because of a high complication rate. REFERENCES
1. Grabstald, H. and McPhee, M.: Nephrostomy and the cancer patient. South. Med. J., 66: 217, 1973. 2. Khan, A. U. and Utz, D. C.: Clinical management of carcinoma of prostate associated with bilateral ureteral obstruction. J. Urol., 113: 816, 1975. 3. Brin, E. N., Schiff, M., Jr. and Weiss, R. M.: Palliative urinary diversion for pelvic malignancy. J. Urol., 113: 619, 1975. 4. Kraus, P. A., Lytton, B., Weiss, R. M. and Prosnitz, L. R.: Radiation therapy for local palliative treatment of prostatic cancer. J. Urol., 108: 612, 1972. 5. Carlton, C. E., Jr., DaWoud, F., Hudgins, P. and Scott, R., Jr.: Irradiation treatment of carcinoma of the prostate: a preliminary report based on 8 years of experience. J. Urol., 108: 924, 1972. 6. Loening, S., Carson, C. C., III, Faxon, D. P. and Morin, L. J.: Ureteral obstruction from Hodgkin's disease. J. Urol., 111: 345, 1974. 7. Megalli, M. R., Gursel, E. 0., Demirag, H., Veenema, R. J. and Guttman, R.: External radiotherapy in ureteral obstruction secondary to locally invasive prostatic cancer. Urology, 3: 562, 1974. 8. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Experience with indwelling ureteral stent catheters. J. Urol., 115: 22, 1976.
