What are the pros and cons of performing a nephrostomy in a patient with hydronephrosis, bladder cancer, intermittent hematuria, and impaired renal function (declining eGFR) due to end-stage cancer?

Nephrostomy in End-Stage Bladder Cancer with Hydronephrosis and Declining Renal Function

In end-stage bladder cancer with hydronephrosis and declining eGFR, nephrostomy should generally be avoided as hydronephrosis consistently predicts treatment failure and poor prognosis, and urinary diversion in this setting primarily prolongs suffering without meaningful survival benefit or quality of life improvement. 1, 2

Critical Prognostic Context

Hydronephrosis in bladder cancer is an independent predictor of poor outcomes and advanced disease:

• Hydronephrosis indicates a 67.9% vs 37.6% reduction in organ-confined disease rates compared to patients without hydronephrosis 3
• It independently predicts worse recurrence-free survival even after controlling for tumor stage and lymph node status 3
• Patients with hydronephrosis have significantly higher rates of muscle-invasive (≥pT2) and non-organ-confined disease 4
• Hydronephrosis is an absolute contraindication to bladder-sparing curative therapies, as it consistently predicts treatment failure 1, 2

Cons of Nephrostomy (Predominant Considerations)

Quality of Life Deterioration

• Nephrostomy tubes cause significant morbidity including chronic pain, recurrent infections, tube dislodgement requiring repeated procedures, and body image disturbance 5
• Patients experience ongoing hematuria management challenges despite urinary diversion, as bleeding originates from the bladder tumor itself 5
• The procedure does not address the underlying malignancy or prevent disease progression 6

Limited Survival Benefit in End-Stage Disease

• In end-stage cancer with hydronephrosis, the prognosis is determined by tumor biology, not renal function 3
• Temporary renal function improvement does not translate to meaningful survival extension when the cancer is incurable 7
• Hydronephrosis resolution rarely occurs with intervention alone - only 1 patient in 59% who had ureteric orifice involvement showed resolution after resection 6

Complications and Burden

• Nephrostomy placement carries risks of bleeding (particularly problematic with ongoing hematuria), infection, and tube-related complications 5
• Requires ongoing maintenance, tube changes, and healthcare visits that may not align with palliative care goals 5
• In patients with declining performance status, repeated procedures increase suffering 7

Pros of Nephrostomy (Limited Scenarios)

Temporary Renal Function Optimization

• May enable cisplatin-based chemotherapy if the patient is otherwise a candidate for systemic treatment and does not have end-stage disease 8
• Can temporarily improve eGFR to allow chemotherapy dosing in patients with potentially responsive disease 7

Symptom Management in Select Cases

• May relieve flank pain from acute obstruction in patients with reasonable performance status 6
• Can prevent uremic symptoms if life expectancy exceeds several weeks and other quality of life measures are preserved 7

Clinical Decision Algorithm

For patients with end-stage bladder cancer, hydronephrosis, and declining eGFR:

1. Assess disease curability:

   • If metastatic/end-stage with no curative options → Avoid nephrostomy, focus on palliative care 1, 2
   • If potentially responsive to systemic therapy → Consider temporary drainage only if it enables chemotherapy 8

2. Evaluate performance status:

   • Poor performance status (ECOG ≥3) → Nephrostomy not indicated, as it increases burden without benefit 7
   • Good performance status with treatable disease → May consider if part of active treatment plan 7

3. Determine treatment intent:

   • If goal is comfort-focused palliative care → Nephrostomy contradicts this goal 7
   • If attempting disease-modifying therapy → Temporary stenting preferable to nephrostomy when anatomically feasible 6

4. Address hematuria separately:

   • Hematuria management should follow a stepwise approach using intravesical therapies, radiation, or systemic agents rather than assuming nephrostomy will resolve bleeding 5

Critical Pitfalls to Avoid

• Do not place nephrostomy tubes reflexively for rising creatinine in end-stage cancer - this prolongs dying rather than living 7
• Avoid the misconception that "optimizing renal function" improves outcomes when the underlying cancer is incurable and hydronephrosis indicates advanced disease 3
• Do not use carboplatin as a substitute for cisplatin in bladder cancer even with borderline renal function, as efficacy is inferior 1
• Recognize that hydronephrosis resolution with intervention is rare (occurred in only 1 of 59% of patients with ureteric involvement), so expecting functional improvement is unrealistic 6

Alternative Approach

For end-stage disease with symptomatic uremia:

• Engage palliative care early for symptom management without invasive procedures 7
• Consider ureteric stenting over nephrostomy if temporary drainage is absolutely necessary, as it avoids external tubes 6
• Focus on managing hematuria with conservative measures (transfusions, antifibrinolytics, radiation) rather than urinary diversion 5