Which supportive care intervention is best? Endourology management: Patient needs, expectations and QoL
Conclusion In the field of supportive care in patients with urological malignancies and endourological problems, clinicians should tailor the care to a patient’s needs at the time, expectations and QoL. Although, in this complex clinical scenario, the choice is never black and white, but it should be an informed decision between patients and clinicians, by balancing out the pros and cons of the different approaches. . References 1. H ui D. Definition of supportive care: does the semantic matter? Curr Opin Oncol 2014;26(4):372-9 2. Hui D, De la Cruz M, Mori M et al. Concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and “hospice care” in the published literature, dictionaries, and textbooks. Support Care Cancer 2013; 21: 659-85 3. Hugar LA, Wulff-Burchfield EM, Winzelberg GS et al. Incorporating palliative care principles to improve patient care and quality of life in urologic oncology. Nat Rev Urol. 2021; 18: 623-25 4. Wu JN, Meyers FJ, Evans CP. Palliative care in urology. Surg Clin North Am 2011; 91: 429-444 5. Umbher MH, Wagg A, Hamza M et al. Top ten Palliative care clinicians should know about urological care. J Palliat Med 2022; online ahead of print 6. Hsu L, Li H, Pucheril D et al. Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction. World J Nephrol 2016; 5: 172-81 7. Chung PH, Krabbe LM, Darwish OM et al. Degree of hydronephrosis predicts adverse pathological features and worse oncological outcomes in patients with high grade urothelial carcinoma of the upper urinary tract. Urol Oncol 2014; 32: 981-88 8. Chitale SV, Scott-Barrett S, Ho ET et al. The management of ureteric obstruction secondary to obstruction secondary to malignant pelvic disease. Clin Radiol 2022; 57: 1118-21 9. Docimo SG, Dewolf WC. High failure rate of indwelling ureteral stents in patients with extrinsic obstruction: experience at 2 institutions. J Urol 1989; 142: 277-79 10. Khoo CC, Abboudi H, Cartwright R et al. Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review. Urology 2018; 118:12-20 11. Elsamra SE, Leavitt DA, Motato HA et al. Stenting for malignant ureteral obstruction: Tandem, metal or metal-mesh stents. Int J Urol. 2015; 22:629-36. 12. Huang GL, Luo HL, Chiang PH. Does preoperative percutaneous nephrostomy insertion worsen upper-tract urothelial cancer oncological outcome? A retrospective single centre study. BMC Urol 2019; 19: 50 13. Proietti S, Marchioni M, Eisner B et al. Conservative treatment of upper urinary tract carcinoma in patients with imperative indications. Minerva Urol Nephrol 2021; 73: 245-52 14. USRDS (2010) United States renal data system 2010 annual data report. Atlas of chronic kidney disease and end-stage renal disease in the United States, Bethesda, MA (2010). National institutes of health, national institute of diabetes and digestive and kidney diseases) 15. Go AS, Chertow GM, Fan D et al: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004, 351: 1296-305 16. Pan Y, Xu XD, Guo LL et al: Association of early versus late initiation of dialysis with mortality: systematic review and meta-analysis. Nephron Clin Pract 2012; 120: 121-31 17. Krambeck AE, Thompson RH, Lohse CM et al: Imperative indications for conservative management of upper tract transitional cell carcinoma. J Urol 2007; 178: 792-6 18. Churchill DN, Torrance GW, Taylor DW et al: Measurement of quality of life in end-stage renal disease: The time trade-off approach. Clin Invest Med 1987; 10:14-20 19. Verberne WR, Dijkers J, Kelder JC et al: Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study. BMC Nephrol 2018; 19: 205 20. Chewcharat A and Curhan G. Trends in the prevalence of kidney stones in the United States from 2007 to 2016. Urolithiasis 2021; 49: 27-39. 21. Scales CD Jr, Smith AC, Hanley JM and Saigal CS. Prevalence of kidney stones in the United States. Eur Urol 2012; 62: 160-165.
with a multidisciplinary approach, involving patients, their family and members of their supportive care team. Retrograde placement of ureteral stents sometimes may be technically challenging and associated with a high failure rate due to extrinsic pelvic/ retroperitoneal obstruction or trigone invasion [8,9]. Also, patients with ureteral stents may experience bothersome irritative urinary tract symptoms, pain and mild haematuria. While polymer ureteral stents may be effective in relieving obstructions in the short term, unfortunately, the stents require regular substitution, are prone to obstruction, tumour ingrowth, encrustation, migration and are a source of infections [10]. When a single polymer stent has failed, the use of tandem polymer stents can be considered. However, they still need regular replacement, exposing an already high-comorbid patient group to further multiple hospital admissions and interventions [11]. Metallic ureteric stents may be used more effectively than polymeric stents in maintaining lumen patency, reducing stent related lower urinary tract symptoms and the frequency of replacement (mean indwelling-time 1-3 years) [10]. Nevertheless, available evidence on the exact indication for metallic ureteral stents is small due to low quality and heterogenous data. Randomised controlled studies are needed to evaluate cost- effectiveness. Patients need to be selected according to aetiology, site of obstruction, and prognosis. This will help to improve outcomes and patient satisfaction. An alternative to urinary decompression with retrograde stent insertion is the placement of a nephrostomy tube. However, the associated external urine bag is often seen as a disability by some patients, for which they may initially reject this option [6]. When disease-factors allow, antegrade stenting can be considered in patients who desire to be free of external tubes. Patients with nephrostomies may also have complications related to tube occlusion, leakage and inadvertent displacement requiring multiple hospital admissions. Rare intra-postoperative complications can be from adjacent organ injury or bleeding. Although there are case reports and small retrospective studies on tumour seeding and invasion through the percutaneous nephrostomy tract, percutaneous nephrostomy on upper-tract urothelial cancer can be considered as part of a treatment strategy if renal function preservation is needed [12]. As reported by Hsu et al., patient preference is strongly conditioned by a clinician’s opinion. Yet, as there are no strong clinical guidelines on the use of nephrostomy vs ureteral stenting, clinicians often rely on their personal experience, logistical factors and preference in counselling their patients [6]. The preference on different urinary decompression methods also vary between different clinical specialties (i.e. radiologists vs urologists) and institutions. Lastly, there is also a sort of Hamlet dilemma “to drain or not to drain” still present among urologists for this subset of patients. Endourological management of upper urinary tract carcinoma in ‘imperative’ cases There is a general misperception that surgery is the antithesis of supportive care, but it is not. The argument for conservative measures rather than nephroureterectomy in the setting of a solitary kidney, bilateral UTUC, and pre-existing severe chronic kidney disease are predicated on the morbidity and mortality associated with dialysis. This would be a potential consequence of extirpative surgery in patients with imperative indications for endoscopic management. In our study on 29 patients with UTUC who underwent imperative conservative endourological treatment, we recorded overall survival (OS) rates of 96.4% with a median follow-up of 23 months (IQR 14-35) [13]. Although renal function declined in our series, only one patient (3.4%) showed a clinically significant impairment. When reviewing the 2010 United States Renal Data System (USRDS) Annual Data Report, their results showed that 5-year overall survival for end-stage renal disease was only 39%,
but our data suggests that in carefully-selected patients, endoscopic management of UTUC should be considered. The authors of the USRDS report argued that conservative treatment should be considered for high-grade tumours in imperative conditions due to the significant morbidity and mortality associated with end-stage renal disease [14]. Similarly, Go et al. showed that mortality rates remain above 20 percent per year with the use of dialysis, with more than half of the deaths related to cardiovascular disease [15]. A meta-analysis showed that older aged patients with a medium and high Charlson Comorbidity Index (CCI) at the initiation of dialysis were associated with increased risk of death [16]. In our cohort, most of the patients were of advanced age (median 69 years; IQR 63-79) with a median CCI of 6 (IQR 4-8) and a median estimated 10-year survival of 2% (IQR 0-53%) [13]. Despite their advanced age and associated comorbidities, the patients in our study achieved approximately 95% of OS rates after their UTUC diagnosis. Our rationale for performing endoscopic management in ‘imperative cases’ was corroborated by Krambeck et al. who in their series of patients with UTUC imperative conditions (average age 74 years; 35-month follow-up) reported the cancer-specific and overall survival of 49.3% and 35%; in contrast OS rates on chronic haemodialysis for a 70-year-old patient are 70.6%, 38.8%, and 19.2%, respectively, at 1, 3, and 5 years [17]. Endoscopic management of UTUC has important positive implications on a patient’s QoL. As a matter of facts, QoL evaluations in haemodialysis patients have revealed that patients would give up one-quarter to one-half of their remaining life expectancy in current health if the sacrifice would allow them to have perfect health for a shorter time [18]. Additionally, Verberne et al. reported that patients with chronic renal disease managed conservatively had 352.7 hospital-free days per year, versus 282.7days in patients on dialysis, contributing to worse QoL in the dialysis group [19]. In our study, 61.1% of the patients had at least one recurrence and the 24-month RFS was 31.7% [13]. This is in line with the outcomes reported by Krambeck et al. who found a 5-year local recurrence- free survival of 27.1% [17]. Our results had also corroborated the safety of endoscopic management of UTUC patients, even those with serious comorbidities. Despite high CCI, the complication rate was low with Clavien-Dindo complication grade III and IV in only 3 (2.2%) and 1 (0.7%) cases respectively, in a total of 137 endoscopic procedures performed [13]. At this point, the question arises, why should endoscopic management in ‘imperative’ cases be considered a supportive care? Surely, because the end-point of the decision of performing conservative treatment in patients (otherwise candidate to nephroureterectomy and consequently to dialysis), is based on the concept that the life-expectancy in this subset of patients is associated with a better QoL. Certainly, endourologists should perform accurate preoperative patient counselling explaining all the personalised pros and cons associated with the UTUC conservative treatment. Endourological management of urinary stones in patients with urological malignancies Urinary tract stones are one of the most common urinary tract pathologies. The prevalence of kidneys stones increased from 3.2% in 1980 to 10.1% in 2016 [20], affecting nearly 11% of men and 7% of women [21]. This risk increases with age. Stone disease in patients with urological malignancies could be related to recurrent burden for stone-former patients, extraosseous calcification (i.e. calcium salt precipitation outside of the skeletal system) secondary to paraneoplastic syndromes or side effects of anticancer therapy with bone resorption, tumour lysis after chemotherapy (i.e. risk of uric acid stones) or urinary stasis due to malignant ureteral compression. The decision for treatment of asymptomatic renal stones is arguable in the field of supportive care, whereas an endourological surgery for a symptomatic renal/ureteral stone is justified to prevent complications. This decision has to be based on each patient-specific situation.
Dr. Silvia Proietti Department of Urology, IRCCS San Raffaele Hospital, Milan (IT)
'Supportive care’ is a typically used term in oncology and harbours different definitions for different groups of clinicians and patients. Despite the fact that broad variations of supportive care exist, all definitions involve factors addressing symptom management and quality of life (QoL) improvement, for oncologic patients having treatment, and those with advanced diseases [1]. A clear definition of supportive care is essential for good communication between clinicians, patients and their families. Hui et al. developed a conceptual framework in which ‘supportive care’ lies under its umbrella, ‘palliative care’. This includes the full range of issues for patients throughout the disease trajectory, from survivorship to bereavement [2]. Hence, it is a general misconception that supportive care is related only to end-of-life care. The decision-making process for supportive care includes several diverse factors, such as cancer stage, performance-status, prognosis, comorbidities, patient preferences, and social background. When making a ‘supportive care’ intervention, it is important to identify the specific supportive care needs of the individual, balancing the pros and cons of each treatment choice, taking into consideration the patient’s life expectancy and their QoL. There is ample evidence showing the importance of supportive care in urological malignancies, with consistent improvements in physical and psychological well-being [3,4]. Despite these valuable advantages, there is still no consensus on the indications and timing of intervention for supportive care in urologic oncology [3]. Urologists are part and parcel of the supportive care in urological cancer management, since they usually diagnose the disease, follow-up the patients and advise them over time [5]. The most common situations that require endourological management in the field of supportive care in patients with urological cancers are addressed below. Supportive care: Endourological management of ureteral obstruction Ureteral malignant obstruction represents a common urologic scenario, but often the best method of urinary diversion poses a challenging dilemma for clinicians. The aetiology of obstruction is important for estimating a patient’s prognosis (i.e. primary tumour, lymphadenopathy or metastasis). It is often an extrinsic compression, with non- urological malignancies more commonly implicated than urological cancers. An obstruction may be diagnosed during staging of the disease or during an investigation for impaired renal function or incidental hydronephrosis. On the other hand, some patients may be symptomatic from the obstruction with acute flank pain or chronic lumbar discomfort, or present with renal failure, urinary tract infections and sepsis [6]. The management of ureteral obstruction with decompression strives to relieve pain, to prevent urosepsis and deterioration in renal function, and consequently, to allow systemic anticancer therapies. One of the aims of urinary diversion may also be to prolong life expectancy, but unfortunately the prognosis of patients with malignant ureteral obstruction is generally poor, even if the urinary decompression is performed [7]. There is no consensus on the superiority of ureteral stent vs percutaneous nephrostomy in the management of ureteral obstruction in terms of efficacy, complications and QoL implications. This is due to the lack of homogenous, comparative and prospective data on this issue [6]. Therefore, treatment decisions must be tailored case by case
Friday, 10 March 09:09 - 09:14 Plenary Session: Challenges in supportive care in GU cancers Yellow Area, eURO Auditorium 1
European Urology Today
February/March 2023
35
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