What is the best management for a 78-year-old man with stage 4 adenocarcinoma (cancer) of the prostate, presenting with left hydronephrosis (kidney swelling due to urine flow obstruction) and impaired renal function (elevated serum creatinine), after treatment with bilateral orchiectomy (surgical removal of testes)?

From the Guidelines

The best management for this 78-year-old man with stage 4 prostate adenocarcinoma, left hydronephrosis, and impaired renal function after bilateral orchiectomy is immediate placement of a left ureteral stent or percutaneous nephrostomy tube to relieve the hydronephrosis and prevent further renal deterioration. This approach is based on the high sensitivity of ultrasound in detecting hydronephrosis associated with acute urinary tract obstruction, as noted in the study by 1. The patient's risk factors for urinary obstruction, such as pelvic tumors (prostate cancer), and the presence of hydronephrosis, support the need for prompt intervention to relieve the obstruction.

Key considerations in managing this patient include:

• Relieving the urinary obstruction to prevent further renal deterioration
• Addressing the castration-resistant prostate cancer with second-line hormonal therapy or chemotherapy
• Managing pain and symptoms according to the WHO pain ladder
• Regularly monitoring renal function, PSA levels, and imaging studies to assess treatment response

The use of ultrasound to evaluate renal size, echogenicity, and morphology can help differentiate acute kidney injury (AKI) from chronic kidney disease (CKD) and determine prognosis, as discussed in the study by 1. However, the primary focus should be on relieving the urinary obstruction and addressing the underlying cancer.

In terms of specific interventions, options include:

• Left percutaneous nephrostomy (option A)
• Antegrade placement of double-J stent (option B)
• Retrograde placement of double-J stent (option C)

Of these options, left percutaneous nephrostomy (option A) or antegrade placement of double-J stent (option B) may be the most appropriate initial approach, as they can provide rapid relief of the obstruction and allow for further evaluation and management of the patient's condition.

From the Research

Management of Hydronephrosis

The patient in question has stage 4 adenocarcinoma of the prostate and is presenting with left hydronephrosis and impaired renal function. The best management of his hydronephrosis can be determined by considering the following options:

• Percutaneous nephrostomy: This involves the insertion of a catheter into the kidney to drain urine directly from the kidney [ 2, 3, 4, 5 ].
• Antegrade placement of double-J stent: This involves the insertion of a stent into the ureter to allow urine to flow from the kidney into the bladder [ 2, 3, 5 ].
• Retrograde placement of double-J stent: This is a similar procedure to antegrade placement, but the stent is inserted through the bladder and into the ureter [ 2, 3, 5 ].
• Pelvic radiation therapy: This is a treatment option for the patient's prostate cancer, but it is not directly related to the management of hydronephrosis [ 6 ].
• Observation: This involves monitoring the patient's condition without intervening, which may not be the best option given the patient's impaired renal function [ 6 ].

Comparison of Treatment Options

Studies have compared the efficacy and safety of percutaneous nephrostomy and retrograde ureteral stenting for the treatment of acute obstructive uropathy. The results show that:

• Percutaneous nephrostomy is associated with lower rates of haematuria and dysuria post-operatively, but longer hospitalisation duration [ 3, 4, 5 ].
• Retrograde ureteral stenting is associated with shorter hospitalisation duration, but higher rates of haematuria and dysuria post-operatively [ 3, 4, 5 ].
• There is no significant difference in the improvement of septic parameters, quality of life, failure rates, post-procedural pain, or analgesics use between the two methods [ 3, 4, 5 ].

Best Management Option

Based on the patient's condition and the comparison of treatment options, the best management of his hydronephrosis is:

• Left percutaneous nephrostomy or antegrade placement of double-J stent [ 2, 3, 4, 5 ]. These options can help to relieve the obstruction and improve the patient's renal function. However, the choice between these two options depends on the individual patient's situation and the surgeon's preference.