METALLIC STENTING FOR OBSTRUCTUVE UROPATHY IN HORMONE REFRACTORY PROSTATE CANCER

A 70 year old patient came to us with hematuria post TUR channeling for carcinoma prostate.He was a case of hormone refractory carcinoma prostate.He had undergone docetaxel based chemotherapy followed by vinorelbine based chemotherapeutic regimen. He had developed painful bone metastases and bilateral pedal lymphoedma because of inguinal/ retroperitoneal lymphadenopathy.His PSA was 76ng/ml and the bone scan was a superscan.

His CT scan revealed retroperitoneal /iliac lymphadenothay and prostate enlargement with clots in the bladder and bilateral HDUN (L>R).

We took him up for completion laser prostatectomy as the bleeding was ongoing.After the surgery the bleeding subsided.We planned the patient for Extandi(Enzalutamide) but because of the cost factor and also the availability; we couldnot do that.In the interim period we started him on Thalidomide 100 mg twice a day. 

The patient was given samarium radio-isotope therapy for painful bony metastases.His creatinine was rising from 1.1 mg% to 3.3 mg% and was explained the need for DJ stenting.  

We couldnot do DJ stenting from below (as we expected because of subtrigonal infiltration by the tumor) and antegrade stenting with Cook metallic stent was done.On left side the stenting could not be done because of multiple kinks and decision was taken not to go ahead with nephrostomy as it would cripple his quality of life.

DIRECT PELVIC PUNCTURE FOR DELINEATION OF PELVICALYCEAL ANATOMY

METALLIC STENT ASSEMBLY

WITH THE USE OF MICRONEPHROSCOPE INSERTION OF GUIDE WIRE INTO THE BLADDER ANTEGRADELY

GUIDE WIRE PULLED OUT FROM THE BLADDER WITH THE CYSTOSCOPE AND METALLIC STENT BEING PLACED

METALLIC STENT BEING PLACED

His creatinine progressively came down to 1.4 mg% and got stabilised there.He is being planned for Zytiga(Abiraterone acetate) after a gap of 1 week.

Obstructive uropathy secondary to advanced prostate cancer varies between 3.3 and 16%. Historically, the prognosis for patients in the psychological situation is poor.

Obstructive uropathy secondary to prostate cancer is associated with a significant reduction in global survival in comparison with patients with prostate cancer without obstruction. Advanced disease stage is significantly correlated with development of obstructive uropathy. In accordance to this and the bibliographic review, recommendation may be established that every patient should be candidate for nephrostomy disregarding his hormonal status and that nephrostomy tube should be inserted, if indicated, as soon as possible to avoid an increase in mortality secondary to the complications of uremia.

Prior to a possible therapeutic abstention it should be considered if the disease is in terminal phase without possibility of curative treatment, with a high analgesia requirements and bad general status (Karnofsky index).

As this patients karnofsky  performance index was good and his biochemical and hematological parameters were well maintainend ; we decided to go for metallic stenting , samarium therapy for bony metastases and Zytiga for the checking the progression of the disease.