What is the best management for a patient with stage 4 prostate cancer, bilateral orchiectomy, left hydronephrosis, impaired renal function, and elevated PSA?

From the Guidelines

The best management for this 78-year-old man with stage 4 prostate adenocarcinoma, bilateral orchiectomy history, marked left hydronephrosis, elevated PSA (31 ng/dl), and mildly elevated creatinine (1.4 ng/dl) is placement of a left nephrostomy tube or ureteral stent to relieve the obstruction and prevent further renal deterioration. This intervention is necessary to address the immediate cause of hydronephrosis, which is likely due to local tumor extension or metastatic disease, as suggested by the elevated PSA level indicating disease progression despite prior surgical castration, suggesting castration-resistant prostate cancer 1. The patient's asymptomatic status does not preclude the need for intervention, as preserving renal function and preventing further deterioration are crucial for maintaining quality of life and overall prognosis. Following urinary tract decompression, the patient should be evaluated for second-line hormonal therapy, such as abiraterone or enzalutamide, to address the underlying progressive cancer, as recommended for patients with castration-resistant prostate cancer 1. Key considerations in managing this patient include:

• Relieving the urinary obstruction to prevent renal failure and preserve quality of life
• Addressing the underlying castration-resistant prostate cancer with second-line hormonal therapy
• Monitoring the patient's condition closely to adjust treatment as needed and prevent complications. The goal of treatment is to improve quality of life, prevent complications, and potentially prolong survival, while also considering the patient's age, comorbidities, and overall health status 1.

From the FDA Drug Label

XTANDI® is indicated for the treatment of patients with: • castration-resistant prostate cancer (CRPC) • metastatic castration-sensitive prostate cancer (mCSPC) • non‑metastatic castration‑sensitive prostate cancer (nmCSPC) with biochemical recurrence at high risk for metastasis (high-risk BCR)

The patient has stage 4 adenocarcinoma of the prostate and has undergone bilateral orchiectomy 3 years ago, which suggests he has castration-resistant prostate cancer (CRPC). Given his PSA is 31ng/dl, the best management would be to consider treatment with enzalutamide (XTANDI), as it is indicated for CRPC. However, it is crucial to address the marked left hydronephrosis before initiating treatment, as it may require urological intervention to prevent further complications. The patient's serum creatinine is 1.4ng/dl, which should be monitored closely while on treatment. Key considerations:

• Treat the underlying cause of hydronephrosis
• Monitor renal function
• Consider enzalutamide (XTANDI) for CRPC 2

From the Research

Management of Hydronephrosis

• The patient has stage 4 adenocarcinoma of the prostate and has undergone bilateral orchiectomy 3 years ago, presenting with marked left hydronephrosis and a normal right kidney 3.
• The serum creatinine is 1.4ng/dl and PSA is 31ng/dl, indicating the need for management of the hydronephrosis to prevent further kidney damage.

Treatment Options

• Percutaneous nephrostomy or internal urinary diversion by a double-J ureteral stent can be used to relieve hydronephrosis in patients with prostate cancer 3.
• The choice between percutaneous nephrostomy and ureteral stenting depends on the patient's health status, with nephrostomies preferred in patients who are in bad health or infected, and double-J stents offered to healthier or stronger patients 3.
• A study comparing percutaneous nephrostomy and ureteral stenting for diversion of hydronephrosis caused by stones found that percutaneous nephrostomy was superior, especially in patients with high temperature, males, and younger patients 4.

Considerations

• The presence of unilateral or bilateral hydronephrosis can be a prognostic indicator in patients with bladder cancer, with bilateral obstruction being an ominous sign 5.
• The management of ureteral obstruction, including hydronephrosis, requires a multidisciplinary approach, with options including retrograde ureteral stent insertion or antegrade nephrostomy placement 6.
• The patient's asymptomatic status and relatively normal serum creatinine level should be taken into account when deciding on the best management strategy 7.