Matthias W. Wichmann and Guy Maddern (eds.)Palliative Surgery201410.1007/978-3-642-53709-7_23
© Springer-Verlag Berlin Heidelberg 2014
23. Urology
(1)
Department of Urology, The Queen Elizabeth Hospital, Woodville Road, Woodville, 5011, SA, Australia
23.1 Kidney
23.2 Bladder
23.3 Ureteric Obstruction
23.4 Prostate
23.5 Testicular Cancer
23.7 Adrenal
Abstract
Primary and secondary malignancies can affect the urological system. The intention of palliative surgery is to improve the patient’s quality of life. However, urological intervention may also increase life expectancy. The most commonly performed palliative urological procedures are ureteric stenting and fulguration of bleeding bladder and prostate tumours. Ureteric stents or nephrostomy tubes may reverse obstructive renal failure. The improved renal function may increase life expectancy and allow for palliative chemotherapy to be considered. However, ureteric stents may not be able to overcome the compressive forces of malignancy. Therefore, nephrostomy tubes may be required to alleviate the obstruction. One must bear in mind the quality of life implications of nephrostomy tubes. Nephrostomy tubes require regular changes and have an increased risk of infection and the potential for dislodgement. There is also a role for palliative resection of the primary tumour in some metastatic solid organ malignancies. This may be to reduce bleeding and pain such as in metastatic bladder cancer. Additionally resection of the primary lesion has been shown to improve survival, despite metastases, in renal cell carcinoma.
23.1 Kidney
The triad of symptoms that renal cell carcinoma (RCC) historically presented with were mass, hematuria and pain. Due to the increased use of CT scanning, many renal masses are now incidentally discovered. Importantly this has led to an increased proportion of organ-confined masses being detected [1]. Regardless up to one-third of cases will present with synchronous metastatic disease [2].
Cytoreductive nephrectomy has potential quality of life benefits as it may reduce bleeding, pain from clot colic as well as paraneoplastic symptoms [3]. Approximately 1–2 % of patients also demonstrate regression of metastases [4]. Furthermore patients who underwent cytoreductive nephrectomy followed by systemic interferon alpha treatment enjoyed a 30–50 % survival advantage over patients who were treated with systemic interferon alpha alone [5]. Nevertheless, mean survival amongst this group remains poor with median survival improving from 7.8 months to 13.6 months [5].
Since 2005 tyrosine kinase inhibitors (TKIs) have become the first-line systemic therapy for metastatic RCC. The available data suggest that cytoreductive nephrectomy remains an integral part of treatment of these patients [6]. This recommendation is only valid for patients with good performance status [7]. Several factors have been identified on multivariate analysis to determine a patient’s appropriateness for cytoreductive nephrectomy. Patients with four or more of the risk factors listed next did not benefit from cytoreductive nephrectomy compared to patients treated with medical therapy alone [6]. Poor prognostic factors are:
1.
Serum albumin below normal
2.
Lactate dehydrogenase above normal
3.
Tumour stage T3 or T4
4.
Symptomatic metastatic disease
5.
Liver metastases
6.
Retroperitoneal or supradiaphragmatic lymphadenopathy
Moreover, the percentage of tumour burden removed at the time of cytoreductive nephrectomy predicts progression-free survival on univariate and multivariate analysis [6]. Timing of cytoreductive nephrectomy is controversial. Presurgical therapy followed by nephrectomy has the potential advantages of down staging irresectable disease, reducing time to systemic therapy and assessing the tumours’ response to targeted therapy. However, there are no randomised controlled trials comparing pre- to postsurgical-targeted therapy [6].
Cytoreductive nephrectomy is a challenging operation due to loss of tissue planes, local invasion and tumour neovascularisation. Therefore, these operations should be undertaken in a centre of excellence and may require a multidisciplinary approach with vascular surgery input. Due to the potential impact on wound healing, haemorrhage and intraoperative adhesions, it is recommended that the TKIs be ceased for at least 2 weeks prior to surgery [8].
The gold standard treatment for organ-confined ureteric or renal pelvis transitional cell carcinoma (TCC) is nephroureterectomy [9]. Patients with synchronous or asynchronous metastatic disease have a universally poor outcome [9]. Chemotherapy regimens are based on the chemosensitive properties of bladder TCC and are therefore extrapolated for upper tract TCC [9].
Patients presenting with advanced upper tract TCC that are symptomatic from bleeding or pain from clot colic may benefit from palliative nephroureterectomy. These advantages must be balanced against the negative impact that nephrectomy has on renal function as this may preclude palliative chemotherapy or result in dose reduction [10]. There is no evidence that removal of the primary tumour improves chemotherapy response [10]. Moreover, by avoiding dose modification chemotherapeutic response may be improved [10]. A ureteric stent may resolve the renal colic by disobstructing the ureter and therefore improve renal function sufficiently for the patient to be able to tolerate chemotherapy.
Palliative nephroureterectomy for advanced upper tract TCC may be technically difficult. Laparoscopic surgery may be possible depending on the site of the lesion and which surrounding structures are involved. In the event of a non-resectable symptomatic upper tract TCC, radiotherapy may improve local control [11]. Radiotherapy combined with cisplatin-gemcitabine chemotherapy may provide increased disease-free survival and an overall survival advantage [12].
23.2 Bladder
Cystectomy has traditionally been reserved for patients without evidence of metastatic disease [13]. However, patients with metastatic bladder cancer may require treatment to control local disease and the distant metastases. For metastatic bladder TCC the current standard of care involves a transvesical debulking of the bladder tumour (TURBT) with adjuvant chemotherapy and radiotherapy [14]. Current chemotherapeutic regimes include cisplatin and gemcitabine, and this may provide a survival advantage [15].
However, palliative cystoprostatectomy (men) or anterior pelvic exenteration (women) remains an option for patients with significant local symptoms such as refractory haemorrhage. Muscle-invasive bladder tumours may also result in ureteric obstruction. Ureteric stenting may be insufficient to disobstruct the ureters. Ureteric obstruction occurs secondary to direct blockage of the ureter by tumour and invasion of the ureteric wall interrupting peristalsis [13]. Furthermore, non-urothelial carcinomas of the bladder respond poorly to chemo- and radiotherapy, and therefore palliative cystectomy may be required to control local symptoms.
As cystectomy carries greater morbidity than radiotherapy, it should be considered only if there are no other options [13]. Moreover, perioperative morbidity and mortality is greater in those over 75 years of age [16]. Palliative cystectomy may be a technically challenging operation, especially in T4b tumours [13]. Therefore, palliative diversion with nephrostomy tubes or via an ileal conduit may provide adequate symptom relief.
23.3 Ureteric Obstruction
Malignancy may cause ureteric obstruction and renal failure. The obstruction may be due to direct invasion or external compression from lymph node masses. Disobstructing the ureters may resolve renal failure and thus increase the life expectancy of the patient. Additionally, this may improve the renal function sufficiently for the patient to be able to tolerate chemotherapy. However, ureteric stents may not be able to overcome the compressive forces, and nephrostomy tubes may be a palliative option.
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