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

Management of Left Hydroureteronephrosis in Advanced Prostate Cancer

Left percutaneous nephrostomy (PCN) is the best management option for this 78-year-old man with stage IV prostate cancer presenting with marked left hydroureteronephrosis, elevated creatinine, and high PSA. 1

Clinical Assessment and Rationale

This patient presents with:

• Stage IV prostate cancer treated with bilateral orchiectomy 3 years ago
• Marked left hydroureteronephrosis discovered incidentally
• Elevated creatinine (1.4 mg/dL) indicating impaired renal function
• Elevated PSA (31 ng/mL) suggesting disease progression
• Currently asymptomatic

Why PCN is the Best Option:

1. Superior Technical Success Rate: PCN has a higher technical success rate (100%) compared to retrograde stenting (80%) in relieving obstruction, particularly in cases of extrinsic compression from malignancy 1

2. Optimal for Malignant Obstruction: PCN is preferred when imaging demonstrates ureteric obstruction due to tumor, especially with obstruction at the ureterovesical junction 1

3. Preservation of Renal Function: PCN decompression has been shown to improve renal function in patients with advanced malignancies 1

4. Specific Benefit in Prostate Cancer: PCN can be valuable in the palliative treatment of patients with advanced prostate carcinoma 1

Alternative Options and Why They're Less Optimal

Antegrade JJ Stent Placement (Option B)

• Usually delayed 1-2 weeks following initial PCN placement
• More complex procedure with increased manipulation risk
• Not recommended as first-line intervention in this scenario 1

Retrograde JJ Stent Placement (Option C)

• Lower technical success rate in malignant obstruction
• More difficult when there is extrinsic compression or obstruction at the ureterovesical junction
• Higher risk of failure in advanced pelvic malignancies 1

Pelvic Radiation Therapy (Option D)

• Not indicated as primary management for acute hydronephrosis
• Would not provide immediate relief of obstruction
• May be considered as part of comprehensive cancer management later

Observation (Option E)

• Inappropriate with impaired renal function (creatinine 1.4)
• Conservative management is usually reserved for palliative purposes/comfort care only
• Does not address the underlying etiology of obstructive uropathy 1

Management Algorithm

1. Immediate Management:

   • Proceed with left PCN placement to decompress the collecting system

2. Post-PCN Assessment:

   • Monitor renal function (creatinine)
   • Assess urine output from PCN
   • Consider urine culture to rule out infection

3. Subsequent Management:

   • After initial decompression (1-2 weeks), consider antegrade ureteral stenting if long-term drainage is needed
   • Reassess PSA and consider oncologic consultation for disease progression

Important Considerations

• Patient Selection: Careful patient selection is critical when determining who may ultimately benefit from PCN 1

• Potential Complications: PCN carries risks including infection, bleeding, and catheter dislodgement; these should be discussed with the patient

• Long-term Planning: Consider the patient's overall prognosis and goals of care when planning for long-term urinary drainage

• Monitoring: Regular follow-up is essential to assess catheter function and renal status

PCN provides the most reliable immediate decompression of the obstructed kidney in this patient with advanced prostate cancer, elevated creatinine, and likely malignant ureteral obstruction. This approach offers the best chance of preserving renal function while allowing time for consideration of additional cancer-directed therapies.