Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

Table 1 Percutaneous nephrostomy vs retrograde stent in malignant ureteral obstruction

Ref.	Study design	Cohort	Diagnosis	Stent	Complications	Nephrostomy	Complications	Mortality	Conclusions
Feng et al[1], 1999	Retrospective, 1984-1996	n = 37 (20 female) patients with ureteral obstruction due to pelvic malignancy	Diuretic renogram or abdominal CT scan	22/31 underwent successful stent placement, 13/31 (42%) remained successfully diverted with stents	Migration (1), encrustation requiring cystolitholapaxy (1), intractable pain requiring repositioning (2)	6 had primary PCN placement, 9/31 had PCN placed due to unsuccessful placement of stent, 6/22 had PCN placed due to failed internal stent, 3 failed stent but did not have PCN placement	Dislodgement requiring reinsertion (3)	NR	33% of patients with disease confined to primary organ or locally advanced disease were managed successfully by stents vs 36% of patients with distant metastases, 92% of cervical cancer patients required PCN (89% failed initial internal stents), 50% of prostate cancer patients required PCN but 100% of patients who initially had successful stent placement did not require PCN at average follow-up of 15 mo, 100% colon cancer patients required PCN due to failure of internal stents
Hyppolite et al[32], 1995	Retrospective, 1989-1994	n = 34 females with gynecologic malignancy	US and serum cr > 1.5 mg/dL	8 (3 had PCN as well)	6/7 (86%) developed urosepsis	17 (unilateral/bilateral)	7/17 (41%) (1 urosepsis, 3 bleeding, 3 urine leak)	2/34 died within 2 wk and declined intervention, 3/7 who underwent stent placement died from urosepsis from procedure	Stenting predisposes to urosepsis and should be avoided. Bilateral nephrostomy allows significant improvement of renal function
Kanou et al[48], 2007	Retrospective, 1990-2003	n = 75 (45 female) patients with pelvic malignancy, patients with normal excretion from 1 kidney excluded	NR, need for primary PCN reported to be based on CT, MRI, or cystoscopic evaluation	37/51 underwent successful stent placement, 29/37 (78%) remained successful	Earlier replacement (5), discomfort requiring no intervention (2)	24 had primary PCN placement, 14/51 had PCN due to inability to place stent, 8/37 had PCN placed after failed stent	Dislodgement (9), obstruction requiring exchange (4), difficulty in exchange (2), pain/dermatitis (3), minor hemorrhage (2)	66/75 with mean survival of 5.9 (PCN) and 5.6 mo (stent)	Higher percentage (78%) of success may be related to utilizing stents without shaft side holes
Ku et al[27], 2004	Retrospective, 2000-2002	n = 148 (80 female) patients with advanced malignancy causing ureteral obstruction	US, CT, or MRI with high grade obstruction, impaired renal function, clinical symptoms, or febrile UTI	68 (5 had antegrade stent placement), 60/68 (89%) remained successful	8 (11.8%)	80 (5 secondary PCN after failed stent placement), 1/80 failed PCN	7 (8.8%)	NR	Stenting and PCN placement have similar outcomes in terms of decreases in serum creatinine, complications, and incidence of pyelonephritis but significant differences in failure (11% stent vs 1.3% PCN) suggesting that patients with retrograde stenting may have ongoing obstruction requiring eventual PCN placement
Monsky et al[19], 2013	Prospective survey	n = 30 (16 female) patients with malignancy-related ureteral obstruction	Initially evaluated by symptoms of urinary obstruction such as pain, deterioration of renal function, or infection and confirmed by CT	15 patients (22 stents)	Dislodgement (1), Pain (1), Infection (1), Fistula (1)	15 patients (24 PCN)	Dislodgement (7), Pain (4), Infection (3) Obstruction (4), Leak (1)	2/30	Patients with PCN or stents have similar QOL. Patient with stents have more irritative symptoms while PCN may experience more minor complications requiring more frequent changes
Song et al[26], 2012	Retrospective, 2006-2010	n = 75 females with gynecologic malignancy	US, CT, or MRI with hydronephrosis, elevated cystanin(sic) c, or clinical symptoms	61/75 underwent stent placement, 50/61 (82%) were managed with stents successfully	16/25	14/75 underwent PCN after unsuccessful stenting, 11/61 required PCN after failure with stent management	24/50	61/75 with mean survival of 9 mo for stent and PCN cohort	Progression to PCN was noted in patients with bladder invasion and severe hydronephrosis. Multivariate analysis revealed that obstruction > 3 cm and elevated cystatin(sic) > 2.5 mg/L predicted stent failure. Stenting was less expensive and required less procedural time as compared to PCN

CT: Computed tomography; PCN: Percutaneous nephrostomy; MRI: Magnetic resonance imaging; NR: Not reported/studied; US: Ultrasonography.