A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: a prospective study of 208 patients.

OBJECTIVE: To identify factors associated with survival after palliative urinary diversion (UD) for patients with malignant ureteric obstruction (MUO) and create a risk-stratification model for treatment decisions. PATIENTS AND METHODS: We prospectively collected clinical and laboratory data for patients who underwent palliative UD by ureteric stenting or percutaneous nephrostomy (PCN) between 1 January 2009 and 1 November 2011 in two tertiary care university hospitals, with a minimum 6-month follow-up. Inclusion criteria were age >18 years and MUO confirmed by computed tomography, ultrasonography or magnetic resonance imaging. Factors related to poor prognosis were identified by Cox univariable and multivariable regression analyses, and a risk stratification model was created by Kaplan-Meier survival estimates at 1, 6 and 12 months, and log-rank tests. RESULTS: The median (range) survival was 144 (0-1084) days for the 208 patients included after UD (58 ureteric stenting, 150 PCN); 164 patients died, 44 (21.2%) during hospitalisation. Overall survival did not differ by UD type (P = 0.216). The number of events related to malignancy (≥4) and Eastern Cooperative Oncology Group (ECOG) index (≥2) were associated with short survival on multivariable analysis. These two risk factors were used to divide patients into three groups by survival type: favourable (no factors), intermediate (one factor) and unfavourable (two factors). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favourable group; 78.0%, 36.3%, and 15.5% in the intermediate group; and 46.4%, 14.3%, and 7.1% in the unfavourable group (P < 0.001). CONCLUSIONS: Our stratification model may be useful to determine whether UD is indicated for patients with MUO.

Risk Factors for Postoperative Complications of Percutaneous Nephrolithotomy at a Tertiary Referral Center.

PURPOSE: We sought to describe and evaluate the complications related to percutaneous nephrolithotomy and identify risk factors of morbidity according to the modified Clavien scoring system. We also sought to specify which perioperative factors are associated with minor and major complications. MATERIALS AND METHODS: We retrospectively analyzed data on patients who underwent percutaneous nephrolithotomy from 1990 to 2013. Descriptive statistics were used to analyze patient characteristics, medical comorbidities and perioperative features. Complications were categorized according to the Clavien score for percutaneous nephrolithotomy. The Mann-Whitney and Fisher exact tests were used as appropriate. Logistic regression analysis was performed to look for prognostic factors associated with major complications. RESULTS: A total of 2,318 surgeries were evaluated. Mean age of the population was 53.7 years. The stone-free rate at hospital discharge was 81.6%. The overall complication rate was 18.3%. Two deaths occurred. Patients with any postoperative complications were older, had more comorbidities, were more likely to have staghorn calculi and had longer operative time and hospital stay on univariate analysis (p<0.05). Age 55 years or older and upper pole access were independent predictors of major complications on multivariate analysis. Other factors such as a history of urinary tract infections, body mass index, stone composition, previous percutaneous nephrolithotomy and multiple tracts were not associated with a major complication. CONCLUSIONS: At our center percutaneous nephrolithotomy is an excellent option for complex kidney stone management with a low overall complication rate. Older patient age and upper pole access are significantly associated with an increased risk of a major complication.

Trends in percutaneous nephrolithotomy use and outcomes in the United States.

PURPOSE: We investigated recent trends in the use and perioperative outcomes of percutaneous nephrolithotomy in the United States in a population based cohort. MATERIALS AND METHODS: We obtained the records of patients treated with percutaneous nephrolithotomy between 1999 and 2009 from the Nationwide Inpatient Sample (NIS). A weighted sample was used to estimate national utilization rates. Trends in age, comorbidity, perioperative complications and in-hospital mortality were analyzed. Temporal trends were quantified by the estimated annual percent change. We evaluated the association between patient and hospital characteristics, including complications, prolonged length of stay and in-hospital mortality, using logistic regression models adjusted for clustering. RESULTS: During 1999 to 2009, percutaneous nephrolithotomy use increased in men and women from 3.0/100,000 and 2.99/100,000 to 3.63/100,000 and 4.07/100,000, respectively. Women showed the largest increases in percutaneous nephrolithotomy use with an estimated annual percent change of 4.49% (95% CI 2.7-6.3, p <0.001) vs 2.90% (95% CI 1.5-4.3, p = 0.003) in men. Baseline comorbidity in patients undergoing percutaneous nephrolithotomy increased with time. Overall complications increased from 12.2% to 15.6% (p <0.001), while mortality remained stable at 0.0% to 0.4%. The transfusion rate was 4.0%. Sepsis increased from 1.2% to 2.4% of cases (p <0.001). Patients were at risk for complications if they were older, more ill and treated in more recent years. Age was significantly associated with increased odds of mortality. CONCLUSIONS: Percutaneous nephrolithotomy use in the United States has increased and females are now the majority gender. Although mortality remains low, rates of sepsis and overall complications have increased. Broad use of percutaneous nephrolithotomy, especially in older and more ill patients, may account for these changes.

Outcomes of locally advanced cervical cancer presenting with obstructive uropathy: An institutional audit.

BACKGROUND: There is paucity of outcome data of patients with cervical cancer presenting with malignant obstructive uropathy. The present retrospective study describes outcomes of patients with cervical cancer who presented with obstructive uropathy at the time of diagnosis and underwent urinary diversion with percutaneous nephrostomy (PCN) before/during treatment. METHODS: Patients who underwent PCN from January 2010 to June 2015 were included. Intent of treatment (radical or palliative) was decided within multidisciplinary team depending on disease stage, Karnofsky performance status (KPS), and degree of renal derangement. Treatment and outcome details were retrieved from electronic records. Time to normalization of creatinine, feasibility of delivering planned treatment, and overall survival (OS) were determined. Impact of various prognostic factors on outcomes was determined using univariate or multivariate analysis. RESULTS: After PCN and double-J stenting, 50% were eligible for (chemo) radiation. All radically treated patients (26/52) received brachytherapy. The median EQD2 to point A was 78 Gy (72-84 Gy). The median OS was 10 (0.5-60) months. Patients who completed chemoradiation had median OS of 31 months. Those receiving radical radiation and palliative radiation had median OS of 11 and 6 months, respectively. On univariate analysis, smaller tumor size (p = 0.03), high KPS (P = 0.04), and radical intent of treatment (P = 0.05) predicted for OS. CONCLUSION: Patients presenting with obstructive uropathy have median OS less than a year despite urinary diversion. Select cohort with good performance status, small tumor size, and serum creatinine of ≤3 mg/dL may be selected for diversion procedures and potential radical treatment.

Prognostic factors in malignant ureteric obstruction.

OBJECTIVE: To validate a model to stratify patients with obstructive nephropathy due to malignant ureteric obstruction, associated with a poor prognosis, into different prognostic groups, as a recent report identified low serum albumin, degree of hydronephrosis and number of events related to metastatic disease as prognostic indicators before palliative decompression. PATIENTS AND METHODS: We retrospectively review the charts to identify all patients who had a nephrostomy tube inserted for malignant ureteric obstruction. Laboratory and clinical factors that might influence prognosis were reviewed to attempt to externally validate the previously identified factors and model for risk stratification. RESULTS: The median (range) age of the 49 patients identified was 71 (36-91) years, and the median survival was 174 (14-602) days. Tumours were of urological origin in 66% of patients. Patients with prostate cancer had nephrostomy tubes indwelling for a mean of 279 days, vs 190 days (P = 0.07) for patients with tumours not of prostatic origin. A serum albumin level of >30 g/L (P ≤ 0.001), serum sodium <135 mmol/L (P = 0.019) and three or more events related to dissemination of cancer (P = 0.04) were factors associated with a significantly shorter mean survival. Complications related to the nephrostomy tube were experienced by 39% of patients. The model proved useful in stratifying these patients into different risk groups (P = 0.002). CONCLUSION: Consistent with a previous report we showed that a low serum albumin level and events related to metastatic disease were indicative of a poor prognosis. We also found that a low serum sodium level might be associated with a worse prognosis. We externally validated a model for stratifying patients into different prognostic groups. Palliative decompression is associated with significant morbidity.

Cervical cancer: Renal complications and survival after percutaneous nephrostomy.

INTRODUCTION: Obstructive nephropathy is a frequent complication in the course of advanced cervical cancer (CC), and ultrasonography-guided percutaneous nephrostomy (PCN) is a well established technique for fast ureteral desobstruction. OBJECTIVE: To identify possible factors related to the survival and quality of life of patients with advanced CC presenting acute urinary obstructive complications that after desobstruction by PCN recovered urinary flux and renal function. METHOD: This is an analytical, descriptive, cross-sectional study that included 45 patients with CC who underwent PCN and were divided into 2 groups: "death" (DG) and "survival" (SG), in a public hospital that is reference for oncologic diseases in Northern Brazil. RESULTS: The mean serum creatinine of the patients preceding PCN was >10 mg/dL, and after PCN <2 mg/dL. The cutoffs of 8.7 g/dL for Hb (p=0.0241) and 27% for Ht (p=0.0065) indicated the values that better discriminate the outcomes of the groups. The presence of low blood pressure was statistically correlated (p=0.0037) to the outcome "death". Changes in glomerular filtration rate (already reduced in all cases) were not associated to the levels of Hb/Ht or to the outcome "death" during the nephrological follow-up. CONCLUSION: PCN was responsible for the recovery of renal function in 61.7% of the patients, leading to interruption of renal replacement therapy (RRT) in all of those patients. Hb levels >8.7g/dL and Ht >27% were associated to longer survival, and the presence of low blood pressure during follow-up was associated with progression to death.

The role of percutaneous nephrostomy in malignant ureteric obstruction.

OBJECTIVES: Uraemia as a result of malignant ureteric obstruction is a recognised event in those with advanced malignancy, usually of pelvic origin, which, if left untreated, is quickly a terminal event. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The aims of the study were to assess whether PCN placement in malignant ureteric obstruction provided any additional survival benefit or patient morbidity. PATIENTS AND METHODS: The case notes of 32 patients with a mean age of 68.1 years (16 male, 16 female) who underwent PCN drainage for malignant ureteric obstruction were retrospectively analysed. Data on the site of primary malignancy, mode of presentation, improvement in renal function, median survival, conversion to internal ureteric stents and intervention-related complications were collected for analysis. RESULTS: The median survival following PCN insertion was 87 days and was unrelated to the patient's age and renal function. Those patients with primary underlying gynaecological malignancies appeared to survive almost 4 times as long as those with underlying primary bladder cancer. Renal function took a mean of 16.8 days to reach a nadir. Almost 79% of patients were able to be discharged from hospital--each patient, however, being re-admitted back to hospital on average 1.6 times prior to their death through PCN or internal ureteric stent related events. Retrospective "useful quality of life" was seen in less than half of the patient cohort. CONCLUSIONS: In the presence of malignant ureteric obstruction, palliative percutaneous urinary diversion may be performed and is effective in improving renal function. However, long-term survival is limited and should, therefore, be performed only when the views and wishes of the patient and carers are taken into account and if there is a definitive treatment plan available for the patient as quality of life can be suboptimal.

Percutaneous nephrostomy for palliation of metastatic ureteral obstruction.

Urinary diversion for palliation of metastatic ureteral obstruction has been associated with high rates of morbidity and mortality, especially with open surgical nephrostomies. An evaluation of percutaneous nephrostomy drainage for the palliation of metastatic ureteral obstruction in 27 patients revealed an increase in survival with decreased morbidity, and a follow-up ranging from three to twenty-five months. The mean survival of all patients was 6.63 months (N = 19), with 8 patients still alive. The histology was the main determinant of length of survival, with prostate, rectal, and cervical cancer patients surviving the longest. The perioperative mortality was 11.1 per cent (3/27), and the postoperative complications consisted of hemorrhage requiring transfusion 29.6 per cent (8/27), gastrointestinal bleeding 3.7 per cent (1/27), and dislodged nephrostomy tubes 44.4 per cent (12/27). Percutaneous nephrostomy drainage is a less morbid procedure than open surgical procedures, and the main determinant of length of survival is the histology of the primary tumor in patients with metastatic ureteral obstruction.

Is percutaneous nephrostomy for hydronephrosis appropriate in patients with advanced cancer?

Twenty patients with advanced pelvic malignancy and secondary hydronephrosis underwent percutaneous nephrostomy between July 1982 and October 1986. Improvement in renal function occurred in 17 patients (85 percent), and survival ranged from 4 days to 2 years. Median survival was 13 weeks, and 55 percent of the patients required multiple hospitalizations for urosepsis. In addition, 55 percent required multiple tube changes. Thirty-five percent of the patients never left the hospital and an additional 35 percent spent less than 6 weeks at home before they died. Median survival for eight patients with primary cancers most frequently associated with carcinomatosis was 7 weeks, and 63 percent of these patients died during hospitalization. The factors of limited survival, significant morbidity, in-hospital mortality, and poor quality of life should be considered before recommending percutaneous nephrostomy in patients with advanced cancer.

Prognostic factors of morbidity in patients undergoing percutaneous nephrolithotomy.

OBJECTIVE: To determine the preoperative and perioperative predictive factors of morbidity/mortality in patients undergoing percutaneous nephrolithotomy (PCNL), using the Clavien's classification. MATERIALS AND METHODS: We performed a retrospective chart review of patients who underwent PCNL between January 2005 and January 2012. Preoperative and postoperative factors, such as age, obesity, surgical risk, Charlson comorbidity index, stone complexity, access calix, type of dilator used, and surgery time, were evaluated as predictors of complications. RESULTS: A total of 354 patients were included in the study. Of these, 56% were women, with the average age of 47±12.5 years. Stone-free rate for noncomplex calculi was 85% and for complex calculi it was 68%. A total of 103 complications were recorded (29.3%). According to the modified Clavien classification system, 32 (9%) were grade 1, 39 (11%) were grade 2, 16 (4.5%) were grade 3A, 8 (2.3%) were grade 3B, 3 (0.8%) were grade 4A, 1 (0.3%) was grade 4B, and 4 (1.1%) were grade 5. In multivariate analysis female gender (odds ratio [OR] 3.1, confidence interval [CI] 1.1-8.0), Charlson score of ≥3 (OR 23.2, CI 3.5-151.1), complex stone (OR 4, CI 1.6-9.6), and duration of surgery of ≥120 minutes (OR 2.9, CI 1.2-6.9) were associated with major complications. CONCLUSIONS: PCNL is a safe procedure with acceptable efficacy for the resolution of renal calculi. The safety of the procedure should improve, especially to reduce the presence of severe complications (Clavien ≥3). We identified factors that are associated with severe complications: female gender, high Charlson, complex calculi, and surgical length ≥120 minutes.

Contemporary volume-outcome relationships for percutaneous nephrolithotomy: results from the Nationwide Inpatient Sample.

INTRODUCTION/OBJECTIVE: We sought to examine the contemporary relationship between case volume and outcome for percutaneous nephrolithotomy (PCNL) using a publically available administrative database. METHODS: A weighted sample of 7785 patients was obtained from the 2010 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). ICD-9-CM diagnostic codes were used to identify patients with urolithiasis (592.0, 592.1, and 592.9) who underwent percutaneous nephrostomy with fragmentation (5504). Charlson Comorbidity Indices (CCI) were calculated based on diagnostic codes for all patients. Hospital case volume was quartile classified and we then compared key outcomes (the complication rate, transfusion rate, length of stay [LOS], and in-hospital mortality rate) by volume quartile. We then performed multivariate analysis to examine the effect of CCI, annual volume, and age on key outcomes. RESULTS: The overall complication rate was 17% in the weighted sample. In univariate analysis, statistically significant variation in the complication rate, CCI, transfusion rate, and in-hospital mortality was noted with regard to the hospital volume. The complication rate and transfusion rates varied by case volume, but in a nonlinear fashion, wherein rates were highest at the lowest and highest volume centers. CCI was strongly predictive (p<0.001) of complications and LOS in the multivariate analysis. Case volume was only predictive (p=0.042) of LOS in the multivariate analysis. CONCLUSION: Annual case volume of the treating center was associated with shorter LOS after PCNL, but case volume was not independently predictive of complication or transfusion in multivariate analysis. CCI was a strong independent predictor of complication and LOS.

Temporal trends, practice patterns, and treatment outcomes for infected upper urinary tract stones in the United States.

BACKGROUND: The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal. OBJECTIVE: To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS: A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999-2009. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches. RESULTS AND LIMITATIONS: Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3-15.6) to 27.6 (27.4-27.8)/100 000); men increased from 7.8 (7.7-7.9) to 12.1 (12.0-12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% (p=0.013), and severe sepsis increased from 1.7% to 3.2% (p<0.001); mortality rates remained stable at 0.25-0.20% (p=0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p=0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52-1.74), severe sepsis (OR: 2.28; 95% CI, 2.06-2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01-3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57-2.85), and mortality (OR: 3.14; 95%CI, 13-4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity. CONCLUSIONS: Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.

Cervical cancer: Renal complications and survival after percutaneous nephrostomy / Câncer de colo uterino: complicações renais e sobrevida após nefrostomia percutânea

SUMMARY Introduction: Obstructive nephropathy is a frequent complication in the course of advanced cervical cancer (CC), and ultrasonography-guided percutaneous nephrostomy (PCN) is a well established technique for fast ureteral desobstruction. Objective: To identify possible factors related to the survival and quality of life of patients with advanced CC presenting acute urinary obstructive complications that after desobstruction by PCN recovered urinary flux and renal function. Method: This is an analytical, descriptive, cross-sectional study that included 45 patients with CC who underwent PCN and were divided into 2 groups: “death” (DG) and “survival” (SG), in a public hospital that is reference for oncologic diseases in Northern Brazil. Results: The mean serum creatinine of the patients preceding PCN was >10 mg/dL, and after PCN <2 mg/dL. The cutoffs of 8.7 g/dL for Hb (p=0.0241) and 27% for Ht (p=0.0065) indicated the values that better discriminate the outcomes of the groups. The presence of low blood pressure was statistically correlated (p=0.0037) to the outcome “death”. Changes in glomerular filtration rate (already reduced in all cases) were not associated to the levels of Hb/Ht or to the outcome “death” during the nephrological follow-up. Conclusion: PCN was responsible for the recovery of renal function in 61.7% of the patients, leading to interruption of renal replacement therapy (RRT) in all of those patients. Hb levels >8.7g/dL and Ht >27% were associated to longer survival, and the presence of low blood pressure during follow-up was associated with progression to death.

RESUMO Introdução: a nefropatia obstrutiva é complicação frequente na evolução do câncer do colo uterino (CCU) avançado e a nefrostomia percutânea guiada por ultrassonografia (NFT) é uma técnica bem estabelecida para a rápida desobstrução ureteral. Objetivo: esclarecer os fatores relacionados à evolução ou não para óbito e qualidade de vida das pacientes com CCU avançado com complicações obstrutivas urinárias agudas e que, após desobstrução pela NFT, recuperaram fluxo urinário e função renal. Método: foi realizado estudo transversal analítico descritivo, que avaliou dois grupos de pacientes com CCU submetidas à NFT [óbito (GO) e sobrevida (GS)], em um hospital público, referência para doenças oncológicas da região Norte do país. Resultados: a creatinina sérica média inicial era >10 mg/dL pré-NFT e tornou-se <2 mg/dL após. Quanto à sobrevida, os pontos de corte de 8,7 g/dL de Hb e 27% de Ht melhor discriminaram a evolução dos grupos GO e GS (p=0,0241 e p=0,0065). Hipotensão se associou significantemente (p=0,0037) com a evolução para óbito. Variações na taxa de filtração glomerular, que já era reduzida em todos os casos, não se associaram aos níveis de Hb/Ht ou à evolução para óbito durante seguimento nefrológico. Conclusão: a NFT permitiu a recuperação da função renal em 61,7% das pacientes com CCU, dispensando terapia de substituição renal. Níveis de Hb >8,7 g/dL e Ht >27% estiveram associados a maior sobrevida, e a hipotensão durante o seguimento associou-se com evolução para óbito.

Percutaneous nephrostomy--a retrospective study focused on palliative indications.

We present an overview of the fast development of less invasive techniques in intrarenal surgery all based on percutaneous nephrostomy. Life-long urinary diversion with nephrostomy is often necessary in patients with malignant disease and such patients have more postnephrostomy complications than patients with kidney stones and their survival is short. In a follow-up of 246 patients with 275 nephrostomies performed consecutively over two years, mean survival after urinary diversion was only 7.9 months in 38 prostate cancer patients with ureteral obstruction and only 5.3 months in 20 patients with advanced bladder cancer. We emphasize the necessity of informing the patient and his/her family of the expected outcome of the procedure and the importance of using carefully chosen and realistic indications.