The management of bilateral ureteric obstruction and renal failure in advanced prostate cancer

To investigate the effect of upper tract decompression on the prognosis of uraemia secondary to bilateral ureteric obstruction in prostate cancer, with particular reference to the hormone dependency of the tumour.

Prospectively collected data, over the period 1978-1993, were selected from the departmental database and from hospital case code data. Inclusion criteria were: blood urea > or = 15 mM, radiological evidence of bilateral ureteric obstruction, a histological diagnosis of prostate cancer, and the exclusion of out-flow tract obstruction. Of the 820 patients recorded in the departmental database, 27 (3.3%) fulfilled the criteria. Thirty-six patients were identified in total. Statistical analysis was by the Mann-Whitney non-parametric test.

Of the 36 patients with bilateral ureteric obstruction and renal failure, in those in whom androgen depletion had been undertaken after ureteric obstruction (i.e. androgen depletion was a treatment option), the mean survival was 646 days (n = 12, SD = 786). Among these patients upper tract decompression improved survival and reduced the amount of time patients spent in hospital. In those in whom androgen depletion had been carried out before obstruction (i.e. the tumour had escaped from hormonal control), survival was significantly worse (80 days, n = 24, SD = 86.8, P < 0.01). In this group the use of decompression improved survival little. Percutaneous nephrostomy was the commonest means of decompression (nephrostomy, 9; stent, 5; ureteroneocystostomy, 2).

In patients for whom hormonal therapy remains an option, upper tract decompression offers a worthwhile improvement in terms of increased survival and reduced in-patient time. However, if ureteric obstruction is diagnosed after hormone manipulation has been used, upper tract decompression has little effect on survival and should only be used in exceptional circumstances.