Is a ureteral stent a good drainage procedure for ureteral obstruction due to prostate cancer?

Ureteral Stenting for Prostate Cancer-Related Ureteral Obstruction

Ureteral stents are an appropriate and effective drainage option for ureteral obstruction caused by prostate cancer, though patient selection and clinical context are critical to optimize outcomes. 1

Evidence-Based Recommendation

The ACR Appropriateness Criteria specifically identify prostate carcinoma as one of the pelvic malignancies where percutaneous nephrostomy (PCN) decompression has proven valuable in improving renal function and survival 1. However, both retrograde ureteral stenting and PCN are considered appropriate first-line options for malignant ureteral obstruction from pelvic malignancies including prostate cancer 1, 2.

Key Decision Factors

When Ureteral Stenting is Preferred

• Retrograde ureteral stenting should be attempted first when the patient has reasonable treatment options for their underlying malignancy and acceptable performance status 1
• Stenting avoids the external drainage burden and skin complications associated with nephrostomy tubes, improving quality of life 1, 3
• Internal double-J stents are better tolerated than external catheters due to elimination of skin irritation and infection at exit sites 1

When PCN May Be Superior

• PCN has higher technical success rates than retrograde stenting when obstruction involves the ureterovesical junction, when there is extrinsic compression, or when obstruction length exceeds 3 cm 1
• PCN should be considered if imaging demonstrates ureteric orifice occlusion by tumor or tight stricture very close to the ureterovesical junction 1
• If retrograde stenting fails initially, PCN placement followed by antegrade stent placement is the appropriate next step 1

Critical Patient Selection Considerations

Patients Most Likely to Benefit

• Those with reasonable treatment options for their prostate cancer (hormone therapy, chemotherapy, radiation) benefit most from drainage procedures 1
• Patients with preserved performance status and life expectancy measured in months to years 1
• PCN decompression has been shown to improve both renal function and survival in prostate carcinoma patients 1

Patients Less Likely to Benefit

• In advanced disease with only palliative care planned, drainage procedures may offer little benefit as performance status and survival rates are frequently poor 1
• The procedure itself carries significant morbidity including risk of pyelonephritis and symptomatic bacteriuria 1
• Frequent stent exchanges may be necessary, adding to patient burden 1

Stent Failure Considerations

• Ureteral stent failure occurs in approximately 45% of patients with malignant ureteral obstruction, requiring unplanned exchanges, PCN placement, or tandem stents 4
• Median time between stent exchanges is approximately 4 months in patients requiring multiple procedures 4
• Tandem (double) ureteral stents can be used to treat malignant ureteral obstruction and may provide lower renal pelvis pressures, potentially decreasing failure rates 1, 5
• Both standard plastic and metal/reinforced stents have been used with similar results 1
• Metallic stents for prostate cancer-related obstruction show average patency of 19 months with preservation of renal function 6

Practical Algorithm

1. Assess patient prognosis and treatment options: If life expectancy is very limited with no active cancer treatment planned, consider whether drainage will meaningfully improve quality of life 1

2. Attempt retrograde ureteral stenting first if patient has reasonable prognosis and no contraindications 1, 2

3. If retrograde approach fails or anatomic factors predict failure (ureterovesical junction involvement, >3 cm obstruction, orifice occlusion), proceed directly to PCN 1

4. Consider antegrade stent placement 1-2 weeks after initial PCN if external drainage is poorly tolerated 1

5. For recurrent stent failures, consider tandem stents or metal stents to improve patency duration 1, 4, 6, 5

Important Caveats

• Infection risk is substantial: Culture-proven UTI develops in approximately 44% of patients with indwelling stents for malignant obstruction 4
• Preprocedural antibiotics are recommended when infection is suspected, with third-generation cephalosporins showing superiority over fluoroquinolones 2
• Careful attention to patient selection is critical - the decision should weigh potential survival benefit against procedural morbidity and need for repeated interventions 1
• Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early if initial stenting shows signs of failure 4