The burden of chronic ureteral stenting in cervical cancer survivors

Radiotherapy induced ureteric stenosis in locally advanced cervical cancer: A review of current evidence

BACKGROUND

Concurrent chemo-radiation followed by high dose rate brachytherapy is the standard of care for locally advanced cervical cancer. The proximity of the ureters to the tumor volume risks ureteric stenosis. Here we outline the current understanding of radiotherapy induced ureteric stenosis in patients treated for cervical cancer, focusing on the incidence, risk factors, clinical consequences, and management.

METHODS

Searches on EMBASE, PubMed, Science Direct, and Google Scholar were performed for publications reporting on radiotherapy, cervix cancer and ureteric stenosis. Multi and single center, prospective/retrospective, cohort, and cross-sectional studies were included.

RESULTS

This narrative review identified key issues relevant to radiation induced ureteric stenosis in cervical cancer in the literature. Thirteen studies were evaluated, identifying crude and actuarial rates of ureteric stenosis of 0.3-13.5% and 1.5-4.4% (at 5 years) respectively. The risk of ureteric stenosis is highest in the first 5 years after radiotherapy but continues to occur at a rate of 0.15% per year. Risk factors including advanced FIGO stage, tumor size >5 cm and baseline hydronephrosis increase the incidence of ureteric stenosis. EQD2 doses of ≥ 77Gy were significantly associated with ≥grade 3 ureteric morbidity. The majority of patients were managed with nephrostomy +/- ureteric stent insertion, with some requiring ureteral reimplantation, urinary diversion or nephrectomy.

CONCLUSIONS

This review has identified multiple considerations, highlighting the need to identify patients highest at risk of ureteric stenosis. There is also a need to recognize ureters as organs at risk, record dose exposure, and apply dose constraints, all of which set the landscape for allowing dose optimization.

Evaluation of Renal Function and Stent Durability Following Resonance Stent Placement for Benign Disease

Introduction: The metal-based Resonance stent (RS) has traditionally been placed in patients with malignant ureteral obstruction; as such, the long-term utility of RS among patients with benign ureteral obstruction (BUO) remains underinvestigated. Methods: We retrospectively reviewed our database for patients with BUO who underwent RS placement between 2010 and 2020. The impact of chronic RS placement on renal function was evaluated by estimated serum creatinine-based glomerular filtration rate (eGFR), furosemide renal scan, and CT-based renal parenchymal volume measurement. The number of and reason for RS stent exchanges during the follow-up period, incidence of encrustation, and the average indwell time were recorded. A cost analysis of placing the RS vs a polymeric stent was performed. Results: Among 43 RS patients with BUO, at a mean follow-up of 26 months, there was no change in eGFR (p = 0.99), parenchymal volume (p = 0.44), or split renal function of the stent-bearing side on renal scan (p = 0.48). The mean RS indwell time was 9.7 months. Eleven patients (26%) underwent premature stent replacement (6 cases) or removal (5 cases). Stents in 9 patients (32%) were encrusted, of which 4 (44%) required laser lithotripsy. Overall, 25 patients (58%) and 12 patients (28%) had a mean stent indwell time of ≥6 months and ≥12 months, respectively. Placing an RS resulted in a 52%, 37%, and 5.6% cost reduction compared with a regular polymeric stent placement, where it was exchanged every 6, 4, or 3 months, respectively. Conclusions: RS deployment in the patient with a BUO results in cost-effective maintenance of renal function and of renal parenchymal volume at a mean follow-up of 2 years; however, only 28% of patients fulfilled the 1-year criterion for RS indwell time.

Survival Outcome of Urinary Diversion in Advanced Cervical Cancer Patients with Hydronephrosis

OBJECTIVE

Urinary diversion is the treatment of choice for cervical cancer patients with urinary tract obstruction. The aim of this study is to determine the survival rate among advanced cervical cancer patients with hydronephrosis who undergo urinary diversion and factors that affect patient survival.

METHODS

Clinical data of cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) Stage-IIIB or advanced cervical cancer were not surgical candidates admitted to Saiful Anwar Hospital, Malang from May 2016 to August 2022 were retrospectively analyzed. The parameters including age, cancer stage, comorbidity, cancer treatment at diagnosis, hydronephrosis treatment, grade, site, and survival, were analyzed using the IBM SPSS Statistics version 21. The significance level was set up to 0.05.

RESULT

One hundred eighteen patients were included in this study. Most patients were under 60 (84.75%) and presented with stage IIIB (79.66%). Diabetes mellitus type 2 (8.47%), hypertension (7.63%), acute kidney injury (16.10%), and chronic kidney disease (36.78%) were comorbidities discovered in patients. More than half of patients received chemotherapy (54.24%). Ureteral stents were inserted in 85.59% of patients. Patients with moderate hydronephrosis were the most common, accounting for 67.80% of all cases. Patients with bilateral hydronephrosis outnumber those with unilateral by 91.53% to 8.47%. The survival rate did not differ significantly between ureteral stents (median survival was 11.00 months) and percutaneous nephrostomies (median survival was 15.00 months), p=0.749. In univariate analysis, age, cancer stage, and hydronephrosis stage were associated with worse 1-year survival. In multivariate analysis, age, DM type 2, cancer staging and hydronephrosis staging were associated with worse 1-year survival.

CONCLUSION

In advanced cervical cancer patients, urinary diversion techniques such as ureteral stents and percutaneous nephrostomy offer similar survival rates. In addition, age, cancer stage, DM type 2, and hydronephrosis site are strong predictors of a worsening survival rate in patients.

It is Possible to Reduce Ureteral Stent Clogging and Stent-Related Symptoms to Soothe the Pain of the Patient: A Case Report

Introduction

Ureteral stent obstruction hinders the management of malignant diseases. Adequate stent insertion through an obstructed ureter does not necessarily guarantee renal decompression and stent-related symptoms adversely affect patient comfort. There are two major problems associated with ureteral stents: obstruction and intolerance to the stents.

Case Presentation

A 45-year-old woman was treated for cervical cancer with metastatic lymph nodes and ureteral obstruction with chemotherapy, radiotherapy, immunotherapy, and bilateral retrograde stenting. After recurrent stent obstruction, stent replacement was attempted more than 18 times over two years. In addition, stent-related symptoms adversely affected patient comfort. The patient was finally fitted with Superglide 8-French reinforced ureteral stents. Their replacement every six months was viewed by the patient as a relief compared to the all too frequent replacement of the previous stents. Moreover, the customized changes in the shape of Superglide stents improved patient comfort.

Discussion

Recent publications tend to indicate that large-lumen ureteral stents are most likely to remain permeable over time. Various modifications of the bladder or endo-ureteral part of double-pigtail stents have been increasingly reported, with the aim of improving their tolerance while maintaining effective drainage.

Conclusion

Adaptation of the internal lumen and shape of stents to the characteristics of the tumor and patient measurements appears to be important for increasing the drainage and tolerance of ureteral stents. The top priority for future ureteral stents suitable for malignant diseases should be to integrate these characteristics based on state-of-the-art data.

Prognostic role of hydronephrosis in the treatment of patients with locally advanced cervical cancer: a retrospective cohort

BACKGROUND

Obstructive uropathy is present in almost 50% of patients with advanced cervical cancer and is associated with worse outcomes.

OBJECTIVE

To estimate the prognostic role of hydronephrosis and the impact of ureteral obstruction resolution in patients with locally advanced cervical cancer undergoing treatment.

METHODS

A retrospective cohort study was conducted of patients with International Federation of Gynecology and Obstetrics 2018 stage IIIB to IVA treated in a tertiary oncologic referral center in Brazil between January 2009 and June 2018. Three different groups were evaluated: (I) without hydronephrosis, (II) with hydronephrosis and urinary diversion, and (III) with hydronephrosis but no urinary diversion. Kaplan-Meier curves and log-rank tests estimated overall survival and progression-free survival based on the presence of hydronephrosis and urinary diversion. Clinicopathological variables were evaluated using univariate and multivariate Cox proportional hazard regression model for overall survival and progression-free survival.

RESULTS

A total of 151 patients were evaluated: group I - 62 (41.1%); II - 44 (29.1%), and III - 45 (29.8%). Stage, histological type or grade, tumor size, parametrial or lymph node involvement were not statistically different between groups. Group I had more favorable overall survival than groups II (p<0.003) and III (p<0.02); however, no difference was noted between groups II and III. Progression-free survival was similar between groups (log-rank test p=0.95). Univariate analysis revealed hydronephrosis (p=0.002) and concurrent chemoradiotherapy (p<0.001) as a prognostic factor for worse overall survival; while tumor size (p=0.023), pelvic lymphadenopathy (p=0.015), and histological type (p=0.03) were associated with worse progression-free survival. On multivariate analysis, hydronephrosis remained as an independently associated factor with worse overall survival (HR=2.06; 95% CI 1.12 to 3.79, p=0.02).

CONCLUSION

Patients with locally advanced cervical cancer with hydronephrosis had lower overall survival even after controlling for potential confounding factors, but no difference in progression-free survival. Urinary diversion showed no impact on overall survival or progression-free survival.

Analysis of Ureteral Tumour Stents for Malignant Ureteral Obstruction: Towards Reshaping an Optimal Stent

Introduction

Ureteral obstruction hinders the management of malignant diseases. Adequate stent placement does not necessarily guarantee renal decompression. The stent stiffness may play a major role to maintain patency. We carried out the present study in order to evaluate drainage efficiency by using stents with distinctive degrees of stiffness and to identify the physical factors that could prevent obstruction of the stent in patients with malignant ureteral obstruction (MUO).

Materials and Methods

We performed an analysis of 150 patients with MUO drainage at a single institution from June 2009 to June 2019. A progressive choice of stents was shaped to overcome each failure by focusing on the criterion of increasingly stiff stents.

Results

During the study period, 556 ureteral stent procedures (USP) were analysed separately. The stent failure with obstruction occurred in 23.0% (128/556) of USP at a mean of 4.4±3.6 months and depended on the type of stent. Stent failure occurred in 34.2% (70/205) of Vortek^® stents, in 42.9% (15/35) of Urosoft stents, in 15.4% (39/254) of Superglide or ureteral catheters and in 6.5% (4/62) of tandem stents. No significant differences were found between Vortek^® and Urosoft stents regarding stent failures, but there were significant differences between Superglide or Tandem stents and Vortek^® or Urosoft stents (p<10⁻⁷). The study demonstrated that ureteral stent obstruction significantly decreased with a larger lumen or a stiffer stent (p<10⁻⁷).

Conclusion

In the present study, Superglide and tandem stents were the best stents against stent failure, and the lumen and the stiffness of the stent have been shown to be critical factors in controlling patency. The results suggest that the lumen seems more important than the stiffness, and the stiffness would be the only means of keeping the lumen intact. Future stents for MUO should integrate the importance of the lumen of the stent.

Longitudinal Outcomes from Conservative Management of Cervical Cancer Associated Ureteral Obstruction

OBJECTIVE

To identify predictors of hydronephrosis (HN) resolution and HN treatment failure. HN is a common comorbid condition with cervical cancer (CCa). Treatments for CCa continue to improve and long-term management strategies of HN are becoming increasingly necessary.

METHODS

A query of a single hospital (2004 - 2019) ICD-9 and CPT codes was made to develop a cohort of CCa patients with HN. A retrospective review was performed. The effects of patient, renal/HN, and cancer covariates on time to HN treatment failure, treatment complications and time to HN resolution were evaluated using logistic regression and competing risk Cox regression models.

RESULTS

Of the 1670 women treated for CCa during the study period, 179 (10.7%) developed HN (n = 72 (40%) bilateral), 78 (44%) at time of CCa diagnosis and 101 (56%) as a result of treatment, of which 145 (81%) underwent initial treatment with a PCN (n = 77, 53%) or US (n = 68, 47%). Complication rates were similar between PCN (56%) and US (61%) when adjusting for treatment time. Initial treatment failure was more likely with US vs PCN (HR 3.2, P <0.01). HN resolution (n = 32, 22%) without reconstruction was predicted by HN concurrent with CCa diagnosis (HR 3.1, P <0.01) and bilateral HN (HR 0.2, P <0.01).

CONCLUSION

CCa associated HN has a resolution rate of only 19% at 12 months. Those presenting with HN after CCa treatment are less likely to resolve without reconstruction. PCN and US have similar complication rates but initial US placement has a nearly three times increased risk of failing than PCN.

10-Year Experience with Reinforced Ureteral Stents for Malignant Ureteral Obstruction

Introduction

Malignant ureteral obstruction (MUO) hinders the management of malignant diseases. Indwelling stent is a common method to release renal obstruction, but stent failure with obstruction is frequent. The studies conclude that stent obstruction divides survival by 2 or even 4. We carried out the present study in order to evaluate drainage efficiency and overall survival by using stents with distinctive degrees of stiffness.

Materials and Methods

We performed an analysis of 156 patients with MUO drainage at a single institution from June 2009 to June 2019.

Results

Of the 156 patients, 128 (82.1%) died with a mean survival time of 15.3 ± 14.4 months after the first ureteral stent procedure (USP). In order to study stent failure and overall survival, the patients were divided into 3 groups. Group 1 with patients died soon after only one USP (n=37). Group 2 with patients had more than one USP and no obstruction (n=41). Patients in Group 3 had more than one USP and at least one stent obstruction (n=62). During the study period, 556 USPs were analysed separately. The stent failure with obstruction occurred in 23.0% (128/556) of USP at a mean of 4.4 ± 3.6 months. In case of stent failure, a progressive choice of stents was shaped to overcome each failure by focusing on the criterion of increasingly stiff stents. Patients in Group 1 died soon at mean of 4.9 ± 4.8 months. The mean survival time of patients in Groups 2 and 3 were, respectively, 19.4 ± 11.2 and 21.5 ± 16.3 months (P = 0.19).

Conclusion

MUO is a serious disease but this study is the first to prevent survival rate from falling by choosing the stent stiffness suitable for the patient. The active detection of stent failure has been shown to be essential for preserving survival.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents

OBJECTIF

Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US).

MATERIAL

We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion.

RESULTS

22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4μmol/l respectively, P=0.67), nor urinary diversion.

CONCLUSION

KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers.

LEVEL OF EVIDENCE

3.

The role of perioperative ureteral stenting for urologic complications in radical surgery of cervical cancer

INTRODUCTION

This study aimed to establish the urologic complications of radical type C2 hysterectomy in cervical cancer patients with or without ureteral stenting.

METHODS

This prospective randomized study included 76 (100%) patients with clinically and pathologically established cervical cancer stages I and II treated with radical type C2 hysterectomy with pelvic lymph node dissection for the last 5 years (2014-2019). Patients were randomized into two groups (2:1 ratio): group II received perioperative ureteral stenting (n = 24, 31.6%) and group I did not (n = 52, 68.4%). Urologic complications observed during follow-up include intraoperative ureter and urinary bladder lesions and postoperative ureterovaginal and vesicovaginal fistulas.

RESULTS

Of the 52 patients in group I who underwent surgery for cervical cancer, urologic complications were observed in 8 (10.5%) patients, 2 (2.6%) of whom underwent preoperative radiation therapy. In group II, urologic complications were observed in 2 (2.6%) patients, of which 1 (1.3%) received preoperative radiation therapy. Intraoperative urologic complications in group I (6.6%) included 3 (3.9%) ureteral lesions cases and 2 (2.6%) cases of urinary bladder lesions, wherein 1 patient received preoperative radiation therapy. One case of (1.3%) urinary bladder lesion was observed in group II. Postoperative complications were observed in 3 patients (3.9%) in group I, including 2 (2.6%) ureterovaginal fistula cases, wherein 1 (1.3%) patient received preoperative radiation therapy, and 1 (1.3%) case of vesicovaginal fistula. In group II, 1 (1.3%) patient who received perioperative radiotherapy developed postoperative vesicovaginal fistula.

DISCUSSION

Urologic complications are extremely common during and after radical surgery (hysterectomy type C2) for cervical cancer. The cervical cancer stage had a significant effect on intra- and postoperative urologic complication rates in this study; however, no such effect was observed for preoperative radiation therapy and ureteral stenting, and significant differences were observed between the two study groups.

Repurposing Individualized Nutritional Intervention as a Therapeutic Component to Prevent the Adverse Effects of Radiotherapy in Patients With Cervical Cancer

Worldwide, cervical cancer was the fourth leading cause of cancer death among women, while in Mexico was the second cause (5.28%). Cancer patients receiving chemotherapy and radiotherapy have a high risk of malnutrition secondary to the disease and treatment, affects the patient's overall, with adverse effects on gastrointestinal symptoms. These use affects the medical therapy. The aim of the present study was to evaluate the benefits on individualized nutritional therapy on decrease weight loss and gastrointestinal adverse effects and to consider these outcomes in pharmacology research, especially in repurposing drugs. We conducted a longitudinal design with two comparation groups with medical diagnosis of cervical cancer and received radiotherapy weekly, 1) the intervention group (nutritional intervention and counseling -INC-) with 20 participants and 2) control group (retrospective cohort -CG-) with 9 participants. Weekly body composition, dietary intake, adverse effects (gastrointestinal symptoms), glucose, hemoglobin, and blood pressure were analyzed during 4 to 5 weeks. Both groups had weight loss weekly (p = 0.013 and p = 0.043 respectively) but the CG vs INC presented loss fat-free mass ≥500g in 67 and of 37% respectively. By the end of the intervention a 25% of the INC group had <10 g/dL of hemoglobin vs 60% for the CG. To compare the dietary intake of vitamins (A and folic acid), fiber (p = 0.006), iron (p = 0.03) and energy (mainly carbohydrates) (p = 0.04) were according to the recommendations in INC group (p>0.05). The number needed to treat was 4 (95% CI, 2 to 13). The nutritional intervention and counseling weekly during radiotherapy in cervical cancer to maintain/improve muscle mass, hemoglobin, and dietary intake above 70% of the recommendations for INC group compared to the evidence. Adequate nutritional status was maintained and decrease the rate of complications, mainly gastrointestinal symptoms, in INC group. The efficacy of drug repurposing can improve through individualized nutritional therapy for preventing adverse effects of radiotherapy in patients with cervical cancer.

Urologic Complications Requiring Intervention Following High-dose Pelvic Radiation for Cervical Cancer

OBJECTIVE

To identify the incidence of radiation-induced urologic complication requiring procedural intervention following high-dose radiotherapy for cervical carcinoma, and to identify predictors of complication occurrence.

MATERIALS AND METHODS

We performed a retrospective chart review of cervical cancer patients undergoing radiotherapy with primary focus on procedural complications (Clavien-Dindo ≥ III). Clinical data were collected including radiation dose, procedure performed, timing of complication, and need for additional procedures. Univariate and multivariate logistic regression modeling was performed to assess predictive value of demographic and clinical variables.

RESULTS

A total of 126 patients with FIGO stage 1A2-4B cervical cancer were included in study analysis, with 18 patients experiencing procedural complication (14.3%). A total of 22 complications were identified, representing an average of 1.2 complications per patient with complication. The most common complications were ureteral stricture and radiation cystitis. The most common nononcologic procedures performed in the treatment of these complications were ureteral stenting, percutaneous nephrostomy tube placement, and cystoscopy. Notably, a total of 259 procedures were performed in the treatment of urologic complications, representing 14.4 procedures per patient and 24.6 procedures per patient with ureteral stricture. Logistic regression demonstrated active smoking at the time of diagnosis to be a predictor of procedural complication.

CONCLUSION

Radiotherapy in the treatment of cervical cancer is associated with a high rate of urologic procedural complication. These complications often require numerous procedures and long-term management given their complexity. These findings suggest a need for awareness and plans for multidisciplinary management of urologic complications in this patient population.

Incidence, management, and sequelae of ureteric obstruction in women with cervical cancer

PURPOSE

Hydronephrosis due to ureteric obstruction (UO) is stage-defining at cervical cancer presentation but may occur after primary staging. We aimed to determine the incidence and review the presentation and management of UO in women with cervical cancer attending our center. Particular attention was paid to the evolving role of interventional radiology (IR) in management.

METHODS

Women with a new diagnosis of cervical cancer between January 2012 and December 2016 formed the cohort that was retrospectively reviewed from the oncology database and patient records.

RESULTS

There were 310 women diagnosed with cervical cancer; 240 were stages I/II and 70 were stages III/IV. Primary treatments were chemoradiotherapy (n = 168; 54.2%), surgery (n = 121; 39.0%), and palliative care alone (n = 21; 6.8%). UO occurred in 74 (23.9%); present at primary staging in 53 (71.6%) and arising after staging in 21 (28.4%). Primary interventions for hydronephrosis were IR (n = 50; 67.6%), cystoscopic stenting (n = 19; 25.7%), bowel urinary conduit construction (n = 2; 2.7%), and none (n = 3; 4.1%). For those who attended IR, the mean number of IR procedures was 2.2, range 1-7. Maximum serum creatinine was 303 μmol/L for women with UO at primary staging compared with 252 μmol/L for UO after staging (P = 0.267). Thirty-eight women experienced substantial morbidity related to UO. Stage-adjusted mortality risk was 2.3 times higher for UO cases compared with those without UO.

CONCLUSIONS

UO is associated with substantial morbidity and survival disadvantage in cervical cancer and may present after primary cancer staging. We recommend renal biochemistry during routine follow-up. A majority of cervical cancer-associated UO cases are managed with IR in our center.

A Population-Based Assessment of Urologic Procedures and Operations After Surgery or Pelvic Radiation for Cervical Cancer

Objective

The treatment of cervical cancer can result in genitourinary morbidity. We measured selected urologic procedures after the treatment of cervical cancer with either surgery or radiation.

Methods

We used administrative data from the province of Ontario Canada to identify adult women who had nonmetastatic cervical cancer and were treated with surgery or radiation between 1994 and 2014. Study outcomes were surgical or procedure codes representing ureteric repair or fistula repair. Stress incontinence surgery, minimally invasive urologic procedures, open bowel/bladder surgeries, and secondary malignancy were measured to compare between treatment modalities. Multivariable Cox proportional hazards models were used.

Results

Our final cohort consisted of 7311 women (median follow-up, 7.0 years [interquartile range, 2.9–13.3 years]), of which 3354 (44.9%) underwent radiation, and 3957 (54.1%) underwent surgery. After treatment of cervical cancer, ureteral repair was less common after surgery (3.4%) compared with radiation (10.3%) (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.19–0.32). Fistula repair was uncommon (0.9%) and occurred significantly more often in the surgery and radiation group compared with the radiation-alone group (HR, 4.02; 95% CI, 1.80–9.00). Overall, stress incontinence surgery was uncommon (2.2%) but was significantly more likely after surgery versus radiation (HR, 3.73; 95% CI, 2.13–6.53). Minimally invasive urologic procedures were less common after surgery compared with radiation (HR, 0.49; 95% CI, 0.44–0.54). Open bowel/bladder surgeries were similar among treatment modalities, and secondary malignancy was less common after treatment with surgery versus radiation (HR, 0.60; 95% CI, 0.39–0.92;P= 0.02).

Conclusions

Women treated for cervical cancer undergo ureteral stricture interventions at 0.8% per year over the 20 years after their treatment; this risk is higher among women who receive radiation treatment. Fistula repair is rare after cervical cancer.