1991, The British Journal of Radiology, 64, 318-320
Use of percutaneous nephrostomy in malignant ureteric obstruction By M. E. Chapman, MRCP, DMRD and J. H. Reid, DMRD, FRCR Department of Diagnostic Radiology, Edinburgh Royal Infirmary, Edinburgh, UK {Received June 1990 and in revised form September 1990) Keywords: Percutaneous nephrostomy, Renal failure, Ureteric obstruction Abstract. Seventeen patients with malignant disease underwent percutaneous nephrostomy to relieve renal failure secondary to ureteric obstruction. Renal function improved in 88%. The median survival time was 18 weeks and 58% left the primary hospital to return home or to a terminal care hospice. Minor complications occurred in 58%. The use of bilateral nephrostomy tubes conferred no greater benefit than a unilateral tube. Intervention in malignant ureteric obstruction may confer some benefit and should not necessarily be viewed with pessimism.
Percutaneous nephrostomy is a well established, relatively safe procedure which effectively improves renal function in obstructed kidneys (Keidan et al, 1988). Its use in malignant ureteric obstruction is a contentious issue because of the poor prognosis in this group of patients (Hepperle et al, 1979; Holden et al, 1979; Keidan et al, 1988). There are few studies on the use of percutaneous nephrostomy in this situation, the most recent by Keidan et al (1988). The lack of data contributes to the continued speculation as to whether this procedure is worthwhile or merely prolongs suffering. In this study, the effect on renal function of unilateral or bilateral drainage, the complications, survival and quality of life of patients with malignant disease who underwent percutaneous nephrostomy for ureteric obstruction are assessed. Methods
Seventeen patients who underwent percutaneous nephrostomy in a 5 year period between 1984 and 1989 at the Edinburgh Royal Infirmary were analysed retrospectively. All the patients presented with renal failure and bilateral ureteric obstruction. Each patient had either a single or bilateral nephrostomy tube with either an 8 or 10 FG pigtail catheter. The diagnosis, effect on renal function, complications and survival time were noted. Where a patient was either at home or in a hospice with a tube in situ, a questionnaire was sent to the General Practitioner or attendant physician to obtain further information on the quality of the patient's life. The nephrostomy tubes were all inserted in the Radiology Department under local anaesthesia usually by combined ultrasonic and fluoroscopic guidance. Results
There were 12 female and five male patients (see Table I). The sites of primary malignancy were three Address correspondence to Dr M. E. Chapman. Current address: Edinburgh Royal Infirmary, Lauriston Place, Edinburgh, UK. 318
bladder, six cervical, two colon, one ovary, one bronchus, one oesophageal, one prostate and two breast. Twelve patients had a primary pelvic malignancy and in five patients distant retroperitoneal metastatic disease was responsible for the ureteric obstruction. Five patients presented without a history suggesting malignancy. In five the renal failure and malignancy were diagnosed concurrently. In a further five a distant primary was known, but the cause of ureteric obstruction, subsequently shown to be metastatic ureteric involvement, was not known at the time of nephrostomy. Two patients with previous pelvic malignancy, cervical in each, re-presented with acute renal failure, one with recurrent local disease and the other with probable radiation fibrosis. Improved renal function occurred in 15 (88%) with a return to normal blood urea levels within 10 days. There was no significant difference in the time to achieve this between patients with single or bilateral nephrostomy tubes (as assessed by the Wilcoxon rank sum test). Ureteric stents were subsequently inserted in four patients. Ten patients (58%) experienced minor complications which included minor sepsis, leaking, local inflammation and uncomplicated pelvic rupture. Two patients (12%) had major complications, one with serious local superficial infection and a second with pyonephrosis. The tube was changed in seven patients, usually owing to the tube being inadvertently dislodged. Survival data were analysed for 15 patients (survival data are not known for two patients). Three patients are still alive. These patients (two cervical and one prostate carcinoma) no longer have nephrostomy tubes in situ. Two have ureteric stents and well controlled disease. In the remainder, survival ranged from 4 weeks to 32 weeks with a median survival of 18 weeks. In the five patients with primary disease outside the pelvis, the median survival time, 16 weeks, was less. Four patients died at home and five in a local hospice, all with nephrostomy tubes in situ. Three patients died in hospital. In those patients managed by nephrostomy outside the primary hospital, there was one major complication, The British Journal of Radiology, April 1991
Percutaneous nephrostomy in malignant ureteric obstruction Table I. Summary of results Number
Sex
Primary site
Number of nephrostomy tubes
Improved function
Survival time (weeks)
Place of death
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
M M F F F F M F F F F M F F M
Bladder Bladder Cervical Colon Cervical Ovary Bronchus Colon Cervical Cervical Oesophagus Prostate Cervical Breast Bladder Cervical Breast
1 2 1 1 2 2 2 2 1 2 2 1 1 1 2 1 2
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes
4 28 16 32 Alive 32 28 NK 20 NK 8 Alive Alive 16 20 12 16
Hospital Home Hospice Hospice — Home Home — Hospital —a Hospital — — Home Hospice Hospice Hospice
F F
NK, not known. "Lost to follow-up.
local sepsis. One patient complained of poor sleep because of the need for frequent bag emptying and another was afraid to leave the house in case the tube fell out. The remainder had no reported problems. Discussion
Urinary diversion in malignant disease presents a therapeutic dilemma. Before the advent of percutaneous nephrostomy, the high complication rates of surgical urinary diversion weighed against intervention (Hepperle et al, 1979). However, percutaneous nephrostomy is relatively safe in the relief of ureteric obstruction, including malignancy (Grabstald & McPhee, 1973; Mann et al, 1980, 1983; Soper et al, 1988). Our study supports its effectiveness and low rate of serious complications. The use of bilateral nephrostomy tubes conferred no greater benefit on renal function than the use of a unilateral tube. Thus the low complication rates are further diminished. Local symptoms, for example the presence of pyonephrosis, may dictate the need for bilateral tubes. Indications for tube insertion are less problematic where there is a possibility of effective therapy for the tumour or a diagnosis has not been reached. This was the case in ten patients (58%). However, for these patients and others where the prognosis is more certain, it is important to assess survival time and quality of life. Grabstald and McPhee's (1973) definition of a useful life of minimal pain, few complications, full mental faculties and ability to return home for at least two months to participate in family life is a reasonable definition, although these may not be the only Vol. 64, No. 760
considerations for the individual. Our results have shown that 58% of people were able to return home or be cared for in a specialized hospice. The median overall survival of 18 weeks, and 16 weeks for those with a distant primary, is reasonable by the above definition. Our results are slightly more favourable than the recent study of Keidan et al (1988) whose overall median survival was 13 weeks with only 35% of patients leaving the hospital. Although assessment of the quality of life is subjective, the responses from our questionnaires indicated that in nearly all cases the nephrostomy tubes were well tolerated by patients. At home or in the hospice, very few problems were encountered. Ureteric stents were subsequently inserted into four patients, selected by the referring oncologist. Since antegrade and retrograde stenting requires either general anaesthesia or further intervention, this was reserved for patients in whom a reasonable life expectancy was envisaged. Where appropriate and technically feasible, this may be the optimal method for long term relief of obstruction (Hepperle et al, 1979). In conclusion, we have confirmed that percutaneous nephrostomy is effective in improving renal function in malignant ureteric obstruction. The use of bilateral tubes confers no greater benefit to improved renal function than the use of unilateral tubes. Our median survival times and quality of life were acceptable. Intervention in malignant ureteric obstruction should not necessarily be viewed with as much pessimism as in the past. Ultimately, however, the decision to place a nephrostomy tube lies with the physician, family and above all the patient. 319
M. E. Chapman and J. H. Reid References GRABSTALD, H. & MCPHEE, M., 1973. Nephrostomy and the
cancer patient. Southern Medical Journal, 66,217. HEPPERLE, T. W., MARDIS, H. K. & KAMMANDEL, H., 1979. The
MANN, W. J., HATCH, K. D., TAYLOR, P. T., PARTRIDGE, E. M., ORR, J. W. & SHINGLETON, H. M., 1983. The role of
percutaneous
nephrostomy
in gynaecologic
oncology.
Gynecologic Oncology, 16, 393-399.
pigtail ureteral stent in the cancer patient. The Journal of Urology, 121, 17-18. HOLDEN, S., MCPHEE, M. & GRABSTALD, H., 1979. The rationale of urinary diversion in cancer patients. The Journal
MANN, W. J., JANDER, P., ORR, J., TAYLOR, P. T., HATCH, K. D. & SHINGLETON, H. M., 1980. The use of percutaneous nephrostomy in gynaecologic oncology. Gynecologic Oncology, 10, 343-349.
of Radiology, 121, 19-21. KEIDAN, R. D., GREENBERG, R. E., HOFFMAN, J. P. & WEESE,
SOPER, J. T., BLASZCYZK, T. M., OKE, E., CLARKE-PEARSON, D. & CREASMAN, W. T., 1988. Percutaneous nephrostomy in
J. L., 1988. Is percutaneous nephrostomy for hydronephrosis appropriate in patients with advanced cancer? American Journal of Surgery, 156, 206-208.
320
gynaecologic oncology patients. American Obstetrics and Gynecology, 158, 1126-1130.
Journal of
The British Journal of Radiology, April 1991
Use of percutaneous nephrostomy in malignant ureteric obstruction By M. E. Chapman, MRCP, DMRD and J. H. Reid, DMRD, FRCR Department of Diagnostic Radiology, Edinburgh Royal Infirmary, Edinburgh, UK {Received June 1990 and in revised form September 1990) Keywords: Percutaneous nephrostomy, Renal failure, Ureteric obstruction Abstract. Seventeen patients with malignant disease underwent percutaneous nephrostomy to relieve renal failure secondary to ureteric obstruction. Renal function improved in 88%. The median survival time was 18 weeks and 58% left the primary hospital to return home or to a terminal care hospice. Minor complications occurred in 58%. The use of bilateral nephrostomy tubes conferred no greater benefit than a unilateral tube. Intervention in malignant ureteric obstruction may confer some benefit and should not necessarily be viewed with pessimism.
Percutaneous nephrostomy is a well established, relatively safe procedure which effectively improves renal function in obstructed kidneys (Keidan et al, 1988). Its use in malignant ureteric obstruction is a contentious issue because of the poor prognosis in this group of patients (Hepperle et al, 1979; Holden et al, 1979; Keidan et al, 1988). There are few studies on the use of percutaneous nephrostomy in this situation, the most recent by Keidan et al (1988). The lack of data contributes to the continued speculation as to whether this procedure is worthwhile or merely prolongs suffering. In this study, the effect on renal function of unilateral or bilateral drainage, the complications, survival and quality of life of patients with malignant disease who underwent percutaneous nephrostomy for ureteric obstruction are assessed. Methods
Seventeen patients who underwent percutaneous nephrostomy in a 5 year period between 1984 and 1989 at the Edinburgh Royal Infirmary were analysed retrospectively. All the patients presented with renal failure and bilateral ureteric obstruction. Each patient had either a single or bilateral nephrostomy tube with either an 8 or 10 FG pigtail catheter. The diagnosis, effect on renal function, complications and survival time were noted. Where a patient was either at home or in a hospice with a tube in situ, a questionnaire was sent to the General Practitioner or attendant physician to obtain further information on the quality of the patient's life. The nephrostomy tubes were all inserted in the Radiology Department under local anaesthesia usually by combined ultrasonic and fluoroscopic guidance. Results
There were 12 female and five male patients (see Table I). The sites of primary malignancy were three Address correspondence to Dr M. E. Chapman. Current address: Edinburgh Royal Infirmary, Lauriston Place, Edinburgh, UK. 318
bladder, six cervical, two colon, one ovary, one bronchus, one oesophageal, one prostate and two breast. Twelve patients had a primary pelvic malignancy and in five patients distant retroperitoneal metastatic disease was responsible for the ureteric obstruction. Five patients presented without a history suggesting malignancy. In five the renal failure and malignancy were diagnosed concurrently. In a further five a distant primary was known, but the cause of ureteric obstruction, subsequently shown to be metastatic ureteric involvement, was not known at the time of nephrostomy. Two patients with previous pelvic malignancy, cervical in each, re-presented with acute renal failure, one with recurrent local disease and the other with probable radiation fibrosis. Improved renal function occurred in 15 (88%) with a return to normal blood urea levels within 10 days. There was no significant difference in the time to achieve this between patients with single or bilateral nephrostomy tubes (as assessed by the Wilcoxon rank sum test). Ureteric stents were subsequently inserted in four patients. Ten patients (58%) experienced minor complications which included minor sepsis, leaking, local inflammation and uncomplicated pelvic rupture. Two patients (12%) had major complications, one with serious local superficial infection and a second with pyonephrosis. The tube was changed in seven patients, usually owing to the tube being inadvertently dislodged. Survival data were analysed for 15 patients (survival data are not known for two patients). Three patients are still alive. These patients (two cervical and one prostate carcinoma) no longer have nephrostomy tubes in situ. Two have ureteric stents and well controlled disease. In the remainder, survival ranged from 4 weeks to 32 weeks with a median survival of 18 weeks. In the five patients with primary disease outside the pelvis, the median survival time, 16 weeks, was less. Four patients died at home and five in a local hospice, all with nephrostomy tubes in situ. Three patients died in hospital. In those patients managed by nephrostomy outside the primary hospital, there was one major complication, The British Journal of Radiology, April 1991
Percutaneous nephrostomy in malignant ureteric obstruction Table I. Summary of results Number
Sex
Primary site
Number of nephrostomy tubes
Improved function
Survival time (weeks)
Place of death
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
M M F F F F M F F F F M F F M
Bladder Bladder Cervical Colon Cervical Ovary Bronchus Colon Cervical Cervical Oesophagus Prostate Cervical Breast Bladder Cervical Breast
1 2 1 1 2 2 2 2 1 2 2 1 1 1 2 1 2
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes
4 28 16 32 Alive 32 28 NK 20 NK 8 Alive Alive 16 20 12 16
Hospital Home Hospice Hospice — Home Home — Hospital —a Hospital — — Home Hospice Hospice Hospice
F F
NK, not known. "Lost to follow-up.
local sepsis. One patient complained of poor sleep because of the need for frequent bag emptying and another was afraid to leave the house in case the tube fell out. The remainder had no reported problems. Discussion
Urinary diversion in malignant disease presents a therapeutic dilemma. Before the advent of percutaneous nephrostomy, the high complication rates of surgical urinary diversion weighed against intervention (Hepperle et al, 1979). However, percutaneous nephrostomy is relatively safe in the relief of ureteric obstruction, including malignancy (Grabstald & McPhee, 1973; Mann et al, 1980, 1983; Soper et al, 1988). Our study supports its effectiveness and low rate of serious complications. The use of bilateral nephrostomy tubes conferred no greater benefit on renal function than the use of a unilateral tube. Thus the low complication rates are further diminished. Local symptoms, for example the presence of pyonephrosis, may dictate the need for bilateral tubes. Indications for tube insertion are less problematic where there is a possibility of effective therapy for the tumour or a diagnosis has not been reached. This was the case in ten patients (58%). However, for these patients and others where the prognosis is more certain, it is important to assess survival time and quality of life. Grabstald and McPhee's (1973) definition of a useful life of minimal pain, few complications, full mental faculties and ability to return home for at least two months to participate in family life is a reasonable definition, although these may not be the only Vol. 64, No. 760
considerations for the individual. Our results have shown that 58% of people were able to return home or be cared for in a specialized hospice. The median overall survival of 18 weeks, and 16 weeks for those with a distant primary, is reasonable by the above definition. Our results are slightly more favourable than the recent study of Keidan et al (1988) whose overall median survival was 13 weeks with only 35% of patients leaving the hospital. Although assessment of the quality of life is subjective, the responses from our questionnaires indicated that in nearly all cases the nephrostomy tubes were well tolerated by patients. At home or in the hospice, very few problems were encountered. Ureteric stents were subsequently inserted into four patients, selected by the referring oncologist. Since antegrade and retrograde stenting requires either general anaesthesia or further intervention, this was reserved for patients in whom a reasonable life expectancy was envisaged. Where appropriate and technically feasible, this may be the optimal method for long term relief of obstruction (Hepperle et al, 1979). In conclusion, we have confirmed that percutaneous nephrostomy is effective in improving renal function in malignant ureteric obstruction. The use of bilateral tubes confers no greater benefit to improved renal function than the use of unilateral tubes. Our median survival times and quality of life were acceptable. Intervention in malignant ureteric obstruction should not necessarily be viewed with as much pessimism as in the past. Ultimately, however, the decision to place a nephrostomy tube lies with the physician, family and above all the patient. 319
M. E. Chapman and J. H. Reid References GRABSTALD, H. & MCPHEE, M., 1973. Nephrostomy and the
cancer patient. Southern Medical Journal, 66,217. HEPPERLE, T. W., MARDIS, H. K. & KAMMANDEL, H., 1979. The
MANN, W. J., HATCH, K. D., TAYLOR, P. T., PARTRIDGE, E. M., ORR, J. W. & SHINGLETON, H. M., 1983. The role of
percutaneous
nephrostomy
in gynaecologic
oncology.
Gynecologic Oncology, 16, 393-399.
pigtail ureteral stent in the cancer patient. The Journal of Urology, 121, 17-18. HOLDEN, S., MCPHEE, M. & GRABSTALD, H., 1979. The rationale of urinary diversion in cancer patients. The Journal
MANN, W. J., JANDER, P., ORR, J., TAYLOR, P. T., HATCH, K. D. & SHINGLETON, H. M., 1980. The use of percutaneous nephrostomy in gynaecologic oncology. Gynecologic Oncology, 10, 343-349.
of Radiology, 121, 19-21. KEIDAN, R. D., GREENBERG, R. E., HOFFMAN, J. P. & WEESE,
SOPER, J. T., BLASZCYZK, T. M., OKE, E., CLARKE-PEARSON, D. & CREASMAN, W. T., 1988. Percutaneous nephrostomy in
J. L., 1988. Is percutaneous nephrostomy for hydronephrosis appropriate in patients with advanced cancer? American Journal of Surgery, 156, 206-208.
320
gynaecologic oncology patients. American Obstetrics and Gynecology, 158, 1126-1130.
Journal of
The British Journal of Radiology, April 1991
