Malignant extrinsic ureteral obstruction (MEUO) is a challenging clinical problem. Many factors weigh into the decision to proceed with retrograde ureteral stent (RUS), nephrostomy tube (NT), or observation; however, there is no consensus for the optimal approach. The objective of this study was two-fold: First, to determine practice patterns by correlating patient, hospital and disease characteristics to management of MEUO; second, to describe treatment trends of MEUO over time.
Using the National Inpatient Sample 2010 - 2015, we abstracted all adults with diagnoses of hydronephrosis and concurrent metastasis or lymphoma, excluding any record with a diagnosis of urinary tract stone. Multinomial regression assessed predictors of undergoing no decompression, stenting, or nephrostomy. Quarterly trends and annual % change of MEUO prevalence and %decompressed with stent vs nephrostomy were calculated.
There were an estimated 238,500 cases of MEUO from 2010 to 2015, of whom 18.0% underwent decompression with RUS and 11.4% NT. On multinomial regression, prostate (OR 1.5), bladder (1.6), cervical (1.6) cancer academic hospitals (1.4) and acute kidney injury were among factors that most significantly increased odds of undergoing NT. Factors that significantly increased odds of undergoing RUS included colon (OR 1.4), rectal/anal (1.3) ovarian (1.2) cancer, Midwest (vs northeast) hospitals (1.4) and female gender (1.4), whereas decreased odds of RUS was associated with bladder cancer (0.7), non-white race (0.8), and weekend admission (0.8). While MEUO prevalence has been increasing on average 2.9%/year, decompression rates have been decreasing, driven solely by a decrease in RUS of 3.8%/year on average.
There is substantial variation in approach for MEUO among patient, hospital, and disease types with an overall decline in stenting compared to steady nephrostomy use. Further investigation into best approaches for certain patient characteristics and disease types is needed to standardize care and reduce disparities.
Journal of endourology. 2020 Apr 28 [Epub ahead of print]
Christopher Haas, Ojas Shah, Elias S Hyams
Columbia University Irving Medical Center, 21611, Urology, New York, New York, United States; ., Columbia University Irving Medical Center, 21611, Urology, New York, New York, United States; ., Columbia University Irving Medical Center, 21611, Urology, New York, New York, United States; .