Obstructive uropathies in palliative care

Ureteric obstruction, either due to intrinsic lesions or extrinsic compression, may complicate pelvic, abdominal or retroperitoneal cancers and retroperitoneal inflammatory conditions. Presenting clinical features of ureteric obstruction may include abdominal pain (especially loin pain), abnormalities on renal ultrasound (including ureteric dilation and hydronephrosis) and, if bilateral, anuria and abnormal kidney function.

Management of ureteric obstruction depends on the cause. Consider the potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care.

If the patient’s prognosis and goals of care allow, a ureteric stent or percutaneous nephrostomy may be appropriate to relieve ureteric obstruction and associated symptoms. These invasive interventional procedures do not treat the underlying disease, but they may be appropriate if the patient is receiving concurrent specific treatment (such as palliative chemotherapy or radiotherapy), or the intervention is likely to significantly prolong life or ameliorate distressing symptoms.

Interventional procedures can be painful and unpleasant; the outcomes can be burdensome (eg increased risk of pyelonephritis) and may significantly impact on quality of life (eg living with a nephrostomy). In addition, the intervention may change the natural history of disease progression, resulting in a more prolonged and symptomatic death. Therefore, a frank discussion and clear explanation of the benefits, burdens and likely long-term outcomes (with and without specific treatment) is essential.