What is the best management for a 78-year-old man with stage 4 adenocarcinoma (cancer) of the prostate, presenting with marked left hydronephrosis (kidney swelling) and impaired renal function (elevated serum creatinine), despite being asymptomatic?

Management of Hydronephrosis in Advanced Prostate Cancer

Left percutaneous nephrostomy is the best management option for this 78-year-old man with marked left hydroureteronephrosis secondary to advanced prostate cancer. 1, 2

Clinical Assessment

This patient presents with:

• 78-year-old male with stage 4 prostate adenocarcinoma
• History of bilateral orchiectomy 3 years ago
• Marked left hydroureteronephrosis discovered incidentally
• Normal right kidney
• Currently asymptomatic
• Elevated serum creatinine (1.4 mg/dL)
• Significantly elevated PSA (31 ng/mL)

Decision Algorithm

1. Determine cause of obstruction: The patient's history of advanced prostate cancer with elevated PSA (31 ng/mL) strongly suggests malignant ureteral obstruction from disease progression.

2. Assess renal function impact: The elevated creatinine (1.4 mg/dL) indicates renal function compromise despite being asymptomatic.

3. Evaluate urgency: Unilateral hydronephrosis with elevated creatinine requires prompt intervention to preserve renal function.

4. Choose intervention method:

   • Percutaneous nephrostomy (PCN)
   • Retrograde ureteral stent
   • Antegrade ureteral stent
   • Radiation therapy
   • Observation

Evidence-Based Recommendation

Percutaneous nephrostomy (PCN) is the preferred initial management for several reasons:

1. Superior technical success rate: PCN has a 100% technical success rate compared to 80% for retrograde stenting in malignant obstruction 1. In cases of extrinsic compression from malignancy, retrograde stent placement is often technically challenging or impossible.

2. Lower risk of complications: Retrograde ureteral catheters may be associated with a higher risk of urosepsis in patients with extrinsic ureteral obstruction 1. PCN provides more reliable decompression with less manipulation of the obstructed system.

3. Better preservation of renal function: In malignant obstruction, PCN provides more reliable and immediate decompression of the collecting system, which is critical for preserving renal function 2.

4. Appropriate for malignant etiology: The ACR Appropriateness Criteria specifically note that PCN may be the preferred option in patients with extrinsic compression from tumors 1.

Alternative Options and Why They're Inferior

• Retrograde stent placement (option C): Lower technical success rate in malignant obstruction (80% vs 100% for PCN) 1. Higher risk of urosepsis and failure in extrinsic compression from malignancy 1, 3.

• Antegrade stent placement (option B): Requires PCN access first, with additional manipulation that increases infection risk. Should be considered as a second step after initial decompression with PCN 1.

• Radiation therapy (option D): Not an immediate solution for urinary obstruction. While radiation may help reduce tumor burden eventually, it doesn't address the urgent need to decompress the collecting system 1.

• Observation (option E): Inappropriate given the elevated creatinine and marked hydronephrosis. Delay in management could lead to irreversible renal damage 2.

Important Considerations

• Malignant vs. benign obstruction: The approach differs based on etiology. This patient's elevated PSA and history of advanced prostate cancer strongly suggest malignant obstruction.

• Renal function: Despite being asymptomatic, the elevated creatinine indicates renal compromise that requires intervention.

• Long-term management: After initial PCN, conversion to internal ureteral stent can be considered if technically feasible, but PCN provides the most reliable initial decompression 4, 3.

• Follow-up: Regular monitoring of renal function and periodic tube changes (typically every 2-3 months) will be necessary if long-term drainage is required.

Pitfalls to Avoid

1. Delaying intervention: Despite the patient being asymptomatic, the elevated creatinine indicates renal compromise requiring prompt intervention.

2. Attempting retrograde stenting first: In malignant obstruction, especially with marked hydronephrosis, retrograde stenting has a higher failure rate and may delay effective decompression.

3. Focusing only on the obstructed kidney: Comprehensive evaluation of both kidneys is essential, though in this case the right kidney is normal.

4. Overlooking the underlying cause: The elevated PSA indicates disease progression requiring oncologic reassessment and potential systemic therapy adjustment.