Management of Ureteral Obstruction Due to Advanced Malignancy: Optimizing Therapeutic and Palliative Outcomes

Purpose

Treatment of ureteral obstruction due to advanced abdominal or pelvic malignancy is a clinical challenge. We discuss improvements and modern day outcomes in the palliative treatment of patients with ureteral obstruction by antegrade or retrograde ureteral decompression. Also, potential areas of clinical investigation involving ureteral stent improvement and pharmacological management of relief of symptoms resulting from ureteral obstruction are discussed.

Materials and Methods

A literature search was performed using the Entrez-PubMed® database. All relevant literature on ureteral obstruction, advanced malignancy and nephrostomy, ureteral stent and associated topics concerning palliative care and quality of life were reviewed and analyzed.

Results

Presenting symptoms are varied and depend on the acuity of the underlying problem. Mechanisms underlying the pain and symptoms of extrinsic ureteral compression have not fully been explored but they may include prostaglandin and renin-angiotensin pathways with medical interventions potentially directed at such therapeutic targets. Progressive obstructive uropathy may likely lead to clinical manifestations, such as uremia, electrolyte imbalances and persistent urinary tract infections, if obstruction is not bypassed. New approaches to antegrade and retrograde stenting, and the evaluation of new stent materials may help minimize the complications and side effects of such procedures. Unfortunately the finding of ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of 3 to 7 months. This prognosis highlights the importance of maintaining quality of life in these patients.

Conclusions

Patients presenting with symptoms of ureteral obstruction due to advanced malignancy should be informed of the therapeutic options in the context of the poor prognosis. In the meantime research is needed to find methods of urinary diversion and pharmacological intervention for symptomatic relief without compromising quality of life in patients at the end of life.

Key Words: ureter, ureteral obstruction, neoplasms, quality of life, stents

Abbreviations and Acronyms: COX, cyclooxygenase, NMDA, N-methyl-D-aspartate receptor, NSAID, nonsteroidal anti-inflammatory drug, PCN, percutaneous nephrostomy, QOL, quality of life