Outcome analysis of percutaneous nephrostomy insertion to relieve urinary obstruction in advanced malignancy

Abstract

Objective:

The aim is to evaluate the benefits of percutaneous nephrostomy (PCN) for urinary drainage in patients with malignancy-associated urinary obstruction (MUO). This study examines the impact of PCN on immediate renal recovery, procedural morbidity, short-term outcomes, and patient survival.

Methods:

A total of 477 patients with ureteric obstruction underwent PCN placement, of whom one-third had MUO. Demographic and clinical parameters were reviewed to assess renal outcomes, complication rates, hospital stay, and overall survival.

Results:

Nearly two-thirds of the patients with MUO had a primary urological malignancy (bladder cancer 30% and prostate cancer 25%). The mean hospital stay was <7 weeks, with patients with gynecological malignancies experiencing the shortest admissions. During the study period, 59 (37%) patients died. The overall median survival was 107 weeks, with the shortest survival observed in patients with primary colorectal cancer (median 34 weeks). Patients with primary bladder and prostate malignancies demonstrated higher median survival compared to other malignancies.

Conclusion:

MUO often represents advanced disease in colorectal and gynecological cancers. PCN can be beneficial for selected patients who are candidates for further oncological treatment. However, it should be considered only after careful discussion regarding the potential need for long-term nephrostomy, procedural morbidity, and quality-of-life impact. Although PCN achieved high rates of renal function recovery and had low complication rates (12%–17%), the underlying malignancy and associated social factors contributed to prolonged hospital stays, sometimes accounting for up to one-third of a patient’s remaining life.

INTRODUCTION

Urinary tract obstruction in advanced pelvic/retro-peritoneal malignancy occurs either due to direct tumor invasion or from extrinsic compression of the ureter(s) by the tumor mass or enlarged lymph nodes. This is associated with a poor prognosis[1,2,3,4] and heralds the onset of end-stage disease, with palliative care becoming the mainstay of treatment. However, not all causes of urinary obstruction requiring percutaneous nephrostomy drainage (PCN) are malignant diseases. Lukes et al.[5] report a benign cause (calculi, infections, anatomic anomalies) for urinary tract obstruction in almost 40% of their patients. Malignant urinary obstruction (MUO) can be caused by various primary malignancies, either pelvic non-urological malignancies such as colorectal, gynecological (uterine, ovarian), urological malignancies (prostate, urinary bladder); or soft tissue and other retroperitoneal tumors.

In this group of patients, PCN is a well-established technique for rapid relief of renal obstruction to recover renal function and avoid the consequences of uremia. A high technical success rate of 98% has been reported,[6] with a low morbidity and mortality.[7,8] However, the management of renal failure resulting from MUO is controversial, with no existing guidelines to help predict the group of patients who would benefit from PCN both in terms of survival and quality of life. In addition, PCN has significant morbidity in this group of patients. The UK Nephrostomy audit reported a complication rate of only 6.3%.[9] PCN to relieve malignancy-related renal obstruction has been associated with higher complication rates from 27%[10] to 53%.[11] This is due to the inherent morbidity of the underlying malignant disease. Reported complications include sepsis, significant hematuria, catheter displacement or malposition, renal pelvis perforation, paralytic ileus, pneumonia/atelectasis, and pleural effusion. Furthermore, a significant proportion of these patients have progressive or advanced malignancy with poor prognosis and debatable benefits.

Survival in these patients has also been reported to be poor, with studies reporting survival rates of <8 months.[5,12,13] Wong et al.[11] reported a 12-month survival of only 29%. Patients undergoing PCN for MUO are affected by higher complication rates, longer inpatient stay, ongoing care, and the need for community support. Given the significant morbidity, uncertain survival benefit, and lack of clear predictive guidelines, it is crucial to better define the role of PCN in patients with malignancy-associated urinary obstruction. This study aims to evaluate clinical outcomes, survival, and the true impact of PCN in this challenging patient population.

METHODS

Study design and patient selection

Over a 3-year period (2008–2011), 477 PCN procedures were performed across two tertiary referral centers. Eligible patients included those with either a previously diagnosed pelvic malignancy or a newly diagnosed primary malignancy causing urinary obstruction and renal failure. The exclusion criteria were a benign disease, if the PCN insertion was unsuccessful, the nephrostomy tube was being changed (rather than newly inserted), or a simultaneous ureteric stent was also placed.

Procedure technique

Patients were counseled and consented following confirmation of hydronephrosis and renal failure on ultrasound and/or computed tomography imaging. Preprocedure workup included haemoglobin levels, clotting profile, septic screen, and renal function tests. PCN placement was performed under ultrasound guidance with the patient in the prone position, using local anesthesia and varying degrees of sedation. A standard Seldinger technique was utilized to introduce an 8Fr pigtail nephrostomy catheter into the pelvicalyceal system. Experienced Interventional uro-radiologists performed the PCN procedures.

Following PCN insertion, patients were stabilized with correction of sepsis (if present) and optimization of renal function. Definitive investigations and further management plans were pursued as clinically appropriate. Only two patients subsequently underwent retrograde ureteric stenting, with the majority managed through antegrade stenting if required.

Data collection and outcomes

Patient records were retrospectively reviewed to evaluate their presenting symptoms, nature and cause of urinary obstruction, blood parameters, procedural details, PCN-related complications, adjunctive procedures (e.g., stenting), length of hospital stay, recovery of renal function, and patient survival outcomes. Patients were categorized based on the type of primary malignancy.

Statistical analysis

Statistical analyses were conducted using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA). Overall survival was defined as the time from PCN insertion to death from any cause. Comparisons were considered statistically significant if P < 0.05.

RESULTS

Demographics and clinical presentation

Over a 3-year period, 362 PCN procedures that met the study’s inclusion criteria were analyzed. Of these, 211 procedures (53%) were performed in 159 patients with underlying malignant disease. 52 patients had bilateral PCN [Figure 1]. The average age of the cohort was 69 years (range 20–93 years), with a male predominance (101 male patients). Clinical presentation was identifiable in 88% of patients, with 43% remaining asymptomatic despite biochemical evidence of acute renal failure. Approximately three-quarters of patients presented acutely with pain, sepsis, haematuria, hydronephrosis, acute urinary retention, or a general decline in well-being. In contrast, 12% underwent elective PCN following the incidental detection of hydronephrosis and renal dysfunction during routine surveillance for their primary malignancy.

Figure 1.

Flow chart of the patients included in the study

Primary malignancies

The most common primary cancer type was urinary bladder carcinoma (30%), followed by advanced prostate cancer (25%). Colorectal, ovarian, and hematological malignancies collectively accounted for a further 20% of cases

Inpatient stay and complications

The mean hospital stay was 41 days (range 1–776 days). Subgroup analysis revealed the shortest mean inpatient stay in patients with gynecological malignancies, while those with bladder cancer had the longest mean hospital stay, averaging almost 2 months. PCN-associated complications occurred in 17% of patients, of which only 12% were deemed directly related to the procedure itself. There was no significant variation in complication rates according to the primary malignancy. Following nephrostomy placement, 55% of patients underwent successful antegrade ureteric stent insertion. This success rate was notably higher in prostate cancer patients (78%) and exceeded 50% in patients with colorectal and gynecological malignancies.

Renal function recovery

Renal function improved significantly post-PCN, with almost all patients returning to near-baseline creatinine levels. 55% of the patients had subsequent antegrade stent insertion. 78% of the prostate cancer patients and >50% of both colorectal and gynecological patients had successful antegrade stenting.

Survival outcomes

The mean follow-up duration was 8.3 months (range 0.1-37.6 months). During the follow-up period, 59 patients (37%) died. Mortality was highest among patients with gynecological (48%) and colorectal (40%) cancers. Overall mean and median survival were 104.8 and 107 weeks, respectively. Patients with colorectal (mean survival 70.4 weeks) and gynecological cancers (mean survival 71.2 weeks) had the poorest prognoses, whereas those with bladder cancer exhibited the most favorable survival outcomes (mean survival 111.2 weeks) [Table 1].

Table 1.

Mean and median survival times (weeks)

Primary malignancy	Mean survival*	95% CI	Median survival*	95% CI
Colorectal	70.4	39.1–101.6	30.4	26.0–42.0
Gynaecological	71.2	41.0–101.5	45.0	3.6–86.4
Urinary bladder	111.2	84.0–138.4	152.0	6.5–297.6
Prostate	88.9	61.8–116.0	83.0	58.8–107.2
Other tumours	118.8	88.7–148.8	-	-
Overall survival	104.8	89.4–120.2	107.0	57.0–157.0

*In weeks. CI: Confidence interval

DISCUSSION

MUO primarily affects older patients with advanced-stage cancer and significant comorbidities. PCN is widely used in these patients to relieve ureteric obstruction, but its role remains controversial due to the potential for high morbidity and questionable survival benefits.

Our analysis of 159 patients with MUO, the largest cohort reported in the English literature, suggests that PCN offers significant benefits in certain subsets of patients. Table 2 shows the comparison of our study with other similar studies in the English literature.[4,10,11] Almost two-thirds of the patients in this study had primary urological malignancies, in contrast to higher rates of gynecological malignancies reported in Far East studies. This discrepancy may be due to demographic differences, as well as variations in cancer management practices. For instance, in Western countries, gynecological malignancies may be more aggressively managed, often preventing the need for nephrostomy.

Table 2.

Comparative patient demographics by primary malignancy (%)

Primary malignancy	Ishioka et al.[4]	Abraham et al.[10]	Wong et al.[11]	Lau et al.[16]	This study
Patients	140	96	102	77	159
Urinary bladder (%)	9	16	29	38	30
Prostate (%)		13		5	25
Gynecological (%)	25	46	31	55	12
Colorectal (%)	24	15	21	-	11
Hematology (%)	-	3	-	5	5

Patients in this study had a median age of 69 years, which is consistent with the findings of other large cohort studies. The gender distribution was slightly skewed toward males, with a male-to-female ratio of 1:2. This is comparable to data from other studies, although some have reported more female patients.[12]

Morbidity and quality-of-life considerations

Although PCN is generally effective in relieving renal obstruction and restoring renal function, its use in patients with advanced malignancies comes with significant risks. The morbidity versus benefit of decompressing obstructed kidneys in this group of patients has been analyzed over the years but continues to be a clinical conundrum. Complications occurred in 17% of the patients in our study, a rate much lower than previously reported (up to 53% in some series).[3] This discrepancy is likely due to the expertise of the interventional radiology team at our tertiary centers, where PCN procedures are routinely performed. In this cohort of patients, 56% of the patients had their PCN converted to internal stents, rates similar to other reported studies (58%[13]). These results appear to justify antegrade stenting as the standard for renal decompression in MUO. Retrograde stenting was only undertaken in two patients.

The overall low complication rate in our series suggests that PCN is a relatively safe procedure when performed by experienced operators. However, the impact on quality of life (QoL) must be considered, especially in patients with limited life expectancy. Previous studies have shown that patients with MUO who undergo PCN often spend a significant proportion of their remaining life in the hospital, raising questions about the overall benefit of the procedure in terms of QoL. Ishioka et al.[4] highlights key risk factors for poor survival outcomes, including low serum albumin levels, mild hydronephrosis, and a higher incidence of metastasis-related events. Wong et al.[11] also identified several negative prognostic factors, including the presence of metastases, previous treatments for malignancy, recurrent disease, and elevated creatinine levels >40 mmol/L. In such cases, it is vital to carefully select patients with an extremely poor prognosis to avoid unnecessary PCN procedures. This approach aims to minimize complications related to the intervention and prioritize maintaining the patient’s QoL.

Survival and prognosis

The origin of primary malignancy has also been suggested to be a factor in predicting overall survival. Our study found that patients with bladder and prostate cancer had the longest survival times, while patients with colorectal and gynecological cancers had the poorest outcomes. These findings are consistent with previous studies, which have shown that patients with urological cancers, especially bladder cancer, tend to fare better after PCN compared to those with colorectal or gynecological malignancies. This may be due to the biology of these tumors, which are often less aggressive and more responsive to treatment.

Despite the significant survival differences between malignancy types, PCN was associated with a mean survival of over 2 years in patients with bladder and prostate cancers, suggesting that selected patients with MUO may derive substantial benefit from the procedure. In contrast, patients with colorectal and gynecological cancers had much shorter survival, indicating that PCN may be less beneficial in these groups. De Lorenzis et al. reported in their series of 51 patients that MUO caused by upper-GI tumors was related to shorter overall survival, and treatment decisions should be weighted accurately by both specialists and the patient.[14]

Watkinson et al.[15] proposed categorizing patients into four distinct groups based on the cause of urinary obstruction: (1) obstruction resulting from non-malignant complications of prior treatment, (2) obstruction due to untreated primary malignancy, (3) obstruction from relapsed disease with viable treatment options, and (4) obstruction caused by relapsed disease requiring only palliative care. Their analysis revealed that patients in the last group, with relapsed disease for palliation, had extremely poor survival outcomes and derived minimal benefit from PCN.

Similarly, Lau et al.[16] followed a comparable approach by categorizing patients according to the nature of the obstructive lesion. Their findings indicated that patients with disseminated disease had the poorest prognosis, with a mean survival of just over 7 weeks, and none surviving beyond a year. Notably, those with cervical cancer experienced even worse survival rates. Based on these outcomes, they recommended a more palliative approach for such patients.

When counseling patients about PCN, it is critical to consider the stage of their disease, including the extent of prior treatments, the origin and spread of the primary malignancy, as well as other factors such as comorbidities and renal function. PCN in this group of patients is associated with high morbidity and prolonged hospital stays, with mean inpatient durations ranging from 26 to 58 days. This suggests a slow recovery process, compounded by significant comorbidities and the need for comprehensive social recovery support.[13,17]

Considering these factors, along with the inherent risks of PCN, it may be prudent to avoid performing PCN in patients with a short predicted survival.[18] In cases of terminal illness, QoL becomes the most critical factor in determining the success of palliative care or treatment. A prominent study by Shekarriz et al. examined the outcomes of 103 patients with advanced malignancies who underwent palliative urinary diversion. The study focused on evaluating changes in performance status, using the Karnofsky Performance Scale (KPS), and assessing survival following the urinary diversion. The authors reported that the median postprocedural KPS score was 2 (range, 0–4), indicating limited improvement in patient function after urinary decompression. Notably, 15% of patients died during their postoperative hospital stay. In addition, 51% of the patients required further percutaneous procedures, and a substantial 68.4% experienced complications.[1] Artiles et al. presented a series of 188 patients with MUO, in which 25% underwent urinary diversion. Of these, 48.9% received double-J stenting, and 21 (44.7%) patients underwent PCN. The study reported a median survival of 8.67 months (interquartile range, 2.99–17.28 months) in this cohort, highlighting that patients with MUO generally have a poor prognosis. Consequently, the risk–benefit ratio of urinary diversion must be carefully weighed.[19]

These findings suggest that, for some patients, the absence of PCN may have resulted in better overall care, focusing more on comfort and QOL rather than prolonging life with significant inhospital time.

The primary limitations of our study include its retrospective design, the heterogeneity of tumor types included, and the presence of missing data points in our dataset. Nevertheless, we mitigated some of these concerns by conducting a subgroup analysis based on cancer type. Another notable limitation is the absence of information regarding the QoL following urinary diversion. This is an important aspect, and we plan to address it in future research through a prospective study. Despite these limitations, a key strength of our study is the large overall sample size, which adds robustness to our findings.

CONCLUSION

PCN is an effective intervention for relieving ureteric obstruction and improving renal function in patients with MUO. However, its impact on survival and QoL is highly dependent on the underlying malignancy. While patients with bladder and prostate cancers appear to benefit most from the procedure, those with colorectal and gynecological malignancies have poorer outcomes and may derive less benefit.

Careful patient selection is critical to ensure that the potential benefits of PCN outweigh the risks, particularly in those with limited life expectancy or poor prognosis. In patients with advanced malignancies and multiple comorbidities, a multidisciplinary approach should be taken to assess the appropriateness of PCN, with particular attention to the patient’s overall condition and goals of care.

Author's contribution statement

JP, BS, and KS discussed the initial clinical problem. All authors contributed to the drafting and review of the manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.