Acute kidney injury due to bilateral malignant ureteral obstruction: Is there an optimal mode of drainage?

Table 1 Summary of studies of reporting drainage of bilaterally obstructed kidneys due to malignant ureteral obstruction during the period of 2000-2022

Study		Patients			Underlying pathology		Drainage		Outcomes
Ref.	Type	Number	Age mean ± SD or median (range) in yr	Male/female	Nature of obstruction	Primary site (IC and EC); Type of malignancy	Tool/Approach	Unilateral/bilateral	Technical success rate	Overall patient survival time and survival rate	Preference/conclusion/recommendation
Pappas et al[9], 2000	Retrospective, comparative	159	65.1 (18.0-94.0)	102/57	BUO (30), MUO (125), and unknown (4)	IC: bladder and prostatic (NA)	PCN vs JJ	149/10	99% for PCN	227 d	PCN is safe and effective
									81% for JJ		Mean SCr improved from 6.9 mg/dL to 2.2 mg/dL
						EC: GIT and Gyn (NA)
Ekici et al[10], 2001	Retrospective series	23	55 (25–76)	21/2	MUO	IC: bladder only (23)	PCN	NA	100%	4.9 mo	PCN is safe to avoid uremia
Chitale et al[11], 2002	Retrospective cohort	65	NA (53–84)	52/13	MUO	IC: bladder (30) and prostatic (28)	Retrograde (24) vs PCN/antegrade JJ (41)	NA	PCN: 100%	1-yr survival rate was 54.8%	Two-stage antegrade JJ was preferred
									JJ: 21%/98.3%
						EC: cervical (4) and rectal (3)
Chung et al[12], 2004	Retrospective cohort	101	61.4 (33.0–90.0)	44/57	BUO (11) and MUO (90)	IC: renal (2), bladder (2) and prostatic (5)	JJ	65/36	95%	NA	40.6% JJ failure at 11 mo; in 50% was due to compression
						EC: GIT (35), uterine (8), ovarian (5), pancreatic (2), lymphoma (12), breast (13) and other (6)
Ku et al[13], 2004	Retrospective, comparative	148	57.3 (20.0-84.0)	68/80	MUO	EC: NA	PCN (80)/JJ (68)	108/40	98.7%/89.0%	NA	PCN is superior to achieve decompression
Danilovic et al[14], 2005	Retrospective cohort	43	50.8 (25.0-84.0)	16/27	MUO (25) and BUO	IC (7): ureteral (1), bladder (1) and prostatic (4)	JJ initially; if failed, PCN was placed	39/4	9% (for IC)/53% (for EC)	NA	PCN might be better for patients with EC
						EC (36): uterine (9), ovarian (2), colorectal (4), and other (3)
Ganatra et al[15], 2005	Retrospective cohort	157	54.7 (23.0-83.0)	NA	MUO	IC: bladder (2)	PCN (24)/JJ (133)	NA	64.3%	11-mo survival rate was 75.8%	Bladder invasion predicts failure of JJ placement
						EC: ovarian (26), cervical (16), GIT (32), breast (8), testicular (6) and others (68)
Romero et al[16], 2005	Retrospective cohort	43	52 (22-88)	14/29	MUO	IC: bladder (10) and prostate (5)	PCN	NA	100%	Mean 12-mo survival rate was 24.2%	PCN drainage is better for those <52 yr
						EC: cervical (23), ovary (7), and vulva (2)
Rosenberg et al[17], 2005	Retrospective, comparative	28	51 (21-78)	1/27	MUO	IC: none	Retrograde JJ; PCN alternative	NA	92%	15.3 mo; 14 patients died from malignancy during study	JJ is recommended to avoid dialysis
						EC: uterine (14), ovarian (4), GIT (9) and breast (1)
											Mean SCr improved from 2.9 mg/dL to 1.2 mg/dL
Uthappa et al[18], 2005	Retrospective cohort	30	61.4 (29.0-90.0)	19/11	MUO	IC: renal (2), ureteral (1), bladder (5), and prostatic (5)	Retrograde JJ; antegrade JJ was alternative	10/20	50%	NA	Retrograde JJ initial method
						EC: ovarian (4), uterine (5), rectal (3), testicular (1), GIT (2), and breast (2)
Wilson et al[19], 2005	Retrospective cohort	32	68.1 (24.0-84.0)	16/16	MUO	IC: bladder (8) and prostatic (9)	PCN; JJ was a second step in 32 patients	12/20	100%	87 d	PCN is best initially and recommended when there is a definitive plan for treatment
						EC: Gynecological (7), colorectal (7), and breast (1)
Radecka et al[20], 2006	Retrospective cohort	151	73.1 (51.0-97.0)	112/39	MUO	IC: renal (4), ureteral (7), bladder (43), and prostatic (55)	PCN	45/106	NA	255 d; 80% died with PCN	PCN for safety and cost
						EC: Gyn (11), colorectal (16), and others (15)
Kano et al[21], 2007	Retrospective, comparative	75	62.7 (36.0-90.0)	30/45	MUO	IC: bladder (4) and prostate (11)	PCN (24)/JJ (51)	NA	100/72.5; only 78.4% of those started with JJ completed	5.9 mo and 5.6 mo for PCN and JJ, respectively	Initial trial of JJ without side holes, PCN is alternative
						EC: uterine (25), GIT (28), ovarian (4), retroperitoneal (2), and lymphoma (1)
1Rosevear et al[22], 2007	Retrospective cohort	54	61 (32-82)	27/27	BUO and MUO	IC: prostatic (5)	Retrograde JJ	21/33	81	Mean 16 mo	Retrograde JJ considered first line for MUO due to EC
						EC: GIT (18), lymphoma (15), ovarian (50), uterine (6), and others (4)
Wong et al[23], 2007	Retrospective cohort	102	62 (31-86)	45/57	MUO	IC (30): bladder and prostatic	PCN/Retrograde JJ	77/25	94%; 99% and 84% for PCN and JJ, respectively	6.8 mo; 12 mo rate was 29%	Prognostic factors; PCN, metastases, and MUO diagnosis in established malignancy
						EC: Gyn (32), GIT (21), lymphoma (5), and other (14)
Ishioka et al[24], 2008	Retrospective cohort	140	57 (31-85)	60/80	MUO	IC: urothelial (13)	PCN	138/2	100%	96 d; 12-mo rate was 12%	Risk stratification of patients relative to 1-3 risk factors
						EC: gastric (29), colorectal (34), ovarian (6), cervical (30) and other (23)
										Mean SCr improved from 4.33 mg/dL to 1.39 mg/dL
McCullough et al[25], 2008	Retrospective comparative	57	69.5 (40.0-91.0)	31/26	MUO	IC: bladder (12) and prostatic (20)	Retrograde JJ; PCN alternative	NA	54%	SCr improved by 50% immediately after drainage	SCr level at presentation can predict success of retrograde JJ
						EC: Gyn (8), colorectal (7), lymphoma (2), and others (8)
Lienert et al[26], 2009	Retrospective cohort	49	71 (36-91)	27/22	MUO	IC: bladder (18) and prostatic (15)	PCN	38/11	100%	174 d; 53% (prostatic) and 82% (non-prostatic) patients died during study	Risk stratification of patients; relative risk factors to validate the prognostic model of Ishioka et al[24]
						EC: colorectal (6), Gyn (5), sarcoma (2), pancreatic (2), and breast (1)
Mishra et al[27], 2009	Retrospective, comparative	15	44.5 (30.0-65.0)	0/15	MUO	EC: cervical (15)	PCN; JJ alternative	1/14	100%	NA	Bilateral temporary PCN helps receive definitive or specific therapy and avoid dialysis
											Mean SCr improved from 7.5 mg/dL to 0.9 mg/dL within 1-3 wk
Nariculam et al[28], 2009	Retrospective, comparative	25	71 (51-85)	25/0	MUO	IC: prostatic only	PCN	7/18	100%	7.5-mo	Unilateral and bilateral PCN drainage were similar
											Mean SCr improved from 612 µmoL to 187 µmoL within 14 d
Jalbani et al[29], 2010	Prospective cohort	40	NA (21-70)	20/20	MUO	IC: bladder (10) and prostatic (5)	PCN	20/20	100%	350 d for IC and 25 d for EC	PCN excellent initial intervention
						EC: cervical (15), ovarian (2), rectal (3), gall bladder (1), breast (1), and lymphoma (3)					Mean SCr normalized in 62.5%
Kamiyama et al[30], 2011	Retrospective cohort	53	61 (32-92)	22/31	MUO	IC: prostatic (3)	JJ as initial tool	20/33	95.3%	Drainage success 66%	Proposed algorithm of drainage based on primary site, performance status, and degree of hydronephrosis
						EC: GIT (31), Gyn (13), breast (3), and lymphoma (3)
Migita et al[31], 2011	Retrospective series	25	61 (29-76)	13/12	MUO	EC: gastric (25)	Retrograde JJ (15); PCN alternative (5)	4/21	80%/100%	5.8 mo; 1-yr survival rate was 32%	Initial trial should be with JJ
											Prognosis is usually poor; urinary diversion should be tailored per patient
Song et al[32], 2012	Retrospective, comparative	75	57.1 (20.0-85.0)	0/75	MUO	EC: uterine (26), cervical (26), ovarian (20), and other (3)	Retrograde JJ; PCN alternative	66/9	81.3%; for PCN 100%	9.1 mo	Retrograde JJ first-line option; with serum cystatin C > 2.5 and obstruction length > 3 cm, PCN is alternative
Misra et al[33], 2013	Retrospective, case series	22	75.1 (54-87)	20/2	MUO	IC: bladder (6) and prostate (12)	PCN; Antegrade JJ second step in 10 patients	11/11	100%/77%	78 d	PCN is effective but with significant morbidity and not prolonging life; decision of drainage made after full discussion
						EC: Gyn (2) and rectal (2)
Cordeiro et al[34], 2016	Prospective cohort	208	61 (19-89)	101/107	MUO	IC: bladder (47) and prostatic (25)	Initial retrograde JJ (58); PCN as alternative (150)	107/101	27.9%/100%	144 d; 1-yr survival rate was 44.9% and 7.1% for favorable and unfavorable groups, respectively	Risk stratification model with three groups to determine usefulness of urinary diversion; favorable, intermediate, and unfavorable
						EC: cervical/uterine (51), ovarian (10), colorectal (45), and other (30)
Efesoy et al[35], 2018	Retrospective series	362	43.2	203/159	BUO and MUO (151)	IC: bladder (31) and prostatic (43)	Ultrasound-guided PCN; Seldinger or direct puncture techniques	293/61	96.1%	NA	Ultrasound-guided PCN is recommended procedure
						EC: cervical (57), uterine (6), ovarian (5), and rectal (9)
Tan et al[36], 2019	Retrospective, comparative	89	50.3 (25.0-78.0)	0/89	MUO	EC: cervical (89)	Retrograde JJ; PCN alternative	67/22	77.5%/100%	100%	No differences between JJ and PCN outcomes
											Drainage using JJ is preferred generally, but PCN is better in patients with severe hydronephrosis and long-segment ureteral obstruction (> 3 cm)
Tibana et al[37], 2019	Retrospective, comparative	41	65.6 ± 9.5	23/18	MUO	IC: bladder (12) and prostatic (9)	PCN; Antegrade JJ	10/16	NA	NA	Antegrade JJ is alternative to PCN and retrograde JJ; clinical improvement in 97.5%
						EC: uterine (11), ovarian (1), colorectal (7), and retroperitoneal (1)
2Haas et al[8], 2020	Retrospective database study	238528	65.5 ± 14.6	47.6%/52.4%	MUO	IC: bladder (9.8%), prostatic (17.9%), and other (4.2%)	Retrograde JJ (18%)/PCN (11.4%)	NA	NA	Death in hospital rate was 7.3%	There was a substantial variation in approaching MUO with temporal decline in use of JJ but steady use of PCN with higher use in metastatic cases
						EC: GIT (24.3%), Gyn (20.8%), lymphoma (10.3%), and other (15%)
											Patients with urologic malignancies were older
De Lorenzis et al[38], 2020	Retrospective, comparative	51	70 (58-76)	20/31	MUO	EC only: colonic (28), rectal (14), gastric (5), pancreatic (3), and appendicular (1)	Retrograde JJ; PCN	30/21	80.4%/ 100%	10.5 mo; survival rate was 15.7%	GIT cancers causing MUO were associated with poor prognosis
Folkard et al[39], 2020	Retrospective multicenter series	105	68.8 (30.0-93.0)	55/50	MUO	IC (54): bladder and prostatic	PCN; Antegrade JJ second step in 62%	46%/54%	100%	139 d; 4-yr survival rate was 24.8%. Only 30.5% underwent further oncological treatment	Mean SCr improved from 348 µmmol/L to 170 µmmol/L
						EC (51): Gyn, colorectal, and other
Izumi et al[40], 2021	Prospective multicenter comparative	300	68 (25-96)	126/174	MUO	IC: bladder (19), ureter (13), prostatic (12), and other (6)	PCN (44)/JJ (217)	161/139	NA	Median survival times (1-yr survival rate) of the good, intermediate, and poor risk groups were 406 (54.4%), 221 (32.7%), and 77 (8%) d, respectively	Risk stratification proposed based on primary site of malignancy, laterality of MUO, SCr level, and treatment for primary site (PLaCT); Good, intermediate and poor risk groups
						EC: Gyn (66), GIT (121), lymphoma (26), and other (37)
Gadelkareem et al[5], 2022	Prospective, non-randomized	107	56.6	68/39	BUO (53) and MUO (54)	IC: bladder (30) and prostatic (5)	PCN (79) and JJ (28)	57/50	98.3%/96.6%	NA	PCN is more suitable to MUO
						EC: colorectal (11), cervical (6), and lymphoma (2)					Mean SCr improved from 6.1 mg/dL to 1.2 mg/dL
Kbirou et al[41], 2022	Retrospective cohort	102	60 (36-84)	0/102	MUO	EC: cervical (95), uterine (5), and ovarian (2)	PCN (94)/JJ (8)	NA	100%	NA; 88% of patients had normalized kidney function	PCN is the main tool of drainage
											Early diagnosis may enable prevention of MUO
Pickersgill et al[42], 2022	Retrospective cohort	78	NA	NA	MUO	EC	JJ; PCN alternative	NA	Median (range) of JJ exchange was 2 (0–17)	19.9 mo	JJ failure was high, warranting early use of PCN in management of MUO

¹Underlying malignancies were classified according to the primary site or origin as malignancy from the urological system, which was named intrinsic cancer and malignancy from other or distant systems or organs which was named extrinsic cancer.

²The values of the subtypes of malignancy were provided as a percentage due to the large number of cases.

BUO: Benign ureteral obstruction, EC: Extrinsic cancer, IC: Intrinsic cancer; GIT: Gastrointestinal tract, Gyn: Gynecological, JJ: Double-J stent, MUO: Malignant ureteral obstruction, PCN: Percutaneous nephrostomy, NA: Not available; SCr; Serum creatinine, SD: Standard deviation.

Table 2 Comparison between the drainage of kidneys with malignant ureteral obstruction by percutaneous nephrostomy vs double-J stent approach

1Variables	Drainage by PCN	Drainage by JJ
Design of catheter
Manufacturing characteristics	One-end coil kidney tube, with a need for fixation to the skin or change by a Foley catheter after tract establishment	Two-coil self-retaining internal ureteral catheter
		Material: different, including polymeric and metallic types
	Material: polymeric materials
Route of drainage	Drain the kidney to outside the body	Drain the kidney to urinary bladder
Length	Suitable to the skin-to-pelvicalyceal distance	Suitable to the ureteral length
Mechanism of drainage	Catheter lumen only	Ureteral lumen plus catheter lumen
Procedure/Technique
Armamentarium required	Needs radiological or ultrasonographic localization of the target calyx	Needs endoscopic armamentarium; C-arm and cystoscope
Approach	External and artificial	Internal and natural/artificial (antegrade)
Anesthesia	Mostly local	Local, epidural, or spinal
Feasibility	Independent on ureteral patency	Dependent on ureteral patency
	Equally feasible to external and internal MUO	More feasible to external (compressive) MUO
Procedural time	Longer	Shorter
Preference and indications	The advanced stages	The early stages
Success rate	High; up to 96%–100%	Relatively low, up to 85%
Drainage and complications
Complications	They are dependent on the non-natural route (more invasive), with a greater incidence of injury of adjacent organs, hemorrhage, discomfort, obstruction, and accidental tube displacement	They are dependent on the internal route, with higher possibilities of LUTS, UTI, hematuria, and potential obstruction by underlying malignancy
Mechanism of failure of drainage	Mainly due to lumen obstruction by thick urinary contents and tube slippage	Mainly due to compression of the ureteral and stent lumens by the underlying malignancy
Effects on the outcomes
Kidney drainage and decompression	No statistical differences, but it is better with PCN, especially with infections	Lower efficacy
Normalization of functions	No difference
Patient survival	No difference
Hospital stay	Longer	Shorter
Periodical change of catheter	No difference
Overall rate of complications	No difference
Potential effect on quality of life	Higher due to external nature of urine drainage	Lower due to internal nature of drainage

¹The variables, classifications, and information provided in this table are drawn from the current literature, specifically within the last two decades[9,12-14,17,21,33,43,44].

MUO: Malignant ureteral obstruction; JJ: Double-J stent; LUTS: Lower urinary tract symptoms; PCN: Percutaneous nephrostomy; UTI: Urinary tract infection.