Department of Urology, Columbia University Irving Medical Center, New York, New York, USA.
J Endourol. 2020 Aug;34(8):828-835. doi: 10.1089/end.2020.0053. Epub 2020 Jun 12.
Malignant extrinsic ureteral obstruction (MEUO) is a challenging clinical problem. Many factors weigh into the decision to proceed with retrograde ureteral stent (RUS), nephrostomy tube (NT), or observation; however, there is no consensus for the optimal approach. The objective of this study was twofold. First, to determine practice patterns by correlating patient, hospital, and disease characteristics to manage MEUO; second, to describe treatment trends of MEUO over time. Using the National Inpatient Sample 2010-2015, we abstracted all adults with diagnoses of hydronephrosis and concurrent metastasis or lymphoma, excluding any record with a diagnosis of urinary tract stone. Multinomial regression assessed predictors of undergoing no decompression, stenting, or nephrostomy. Quarterly trends and annual percentage change of MEUO prevalence and percentage decompressed with stent nephrostomy were calculated. There were an estimated 238,500 cases of MEUO from 2010 to 2015, of which 18.0% underwent decompression with RUS and 11.4% NT. On multinomial regression, prostate (odds ratio [OR] 1.5), bladder (1.6), cervical (1.6) cancer, academic hospitals (1.4), and acute kidney injury were among factors that most significantly increased odds of undergoing NT. Factors that significantly increased odds of undergoing RUS included colon (OR 1.4), rectal/anal (1.3), ovarian (1.2) cancer, Midwest ( northeast) hospitals (1.4), and female gender (1.4), whereas decreased odds of RUS were associated with bladder cancer (0.7), nonwhite race (0.8), and weekend admission (0.8). While MEUO prevalence has been increasing on an average of 2.9%/year, decompression rates have been decreasing, driven solely by a decrease in RUS of 3.8%/year on average. There is substantial variation in approach for MEUO among patient, hospital, and disease types, with an overall decline in stenting compared with steady nephrostomy use. Further investigation into best approaches for certain patient characteristics and disease types is needed to standardize care and reduce disparities.
恶性外生输尿管梗阻 (MEUO) 是一个具有挑战性的临床问题。许多因素都影响到进行逆行输尿管支架 (RUS)、肾造瘘管 (NT) 或观察的决策；然而，对于最佳方法尚无共识。本研究的目的有两个。首先，通过将患者、医院和疾病特征与 MEUO 管理相关联，确定实践模式；其次，描述 MEUO 随时间的治疗趋势。使用 2010-2015 年国家住院患者样本，我们提取了所有诊断为肾积水并伴有转移或淋巴瘤的成年人的记录，排除了任何尿路结石诊断的记录。多项回归评估了不进行减压、支架或肾造瘘的预测因素。计算了 MEUO 患病率和支架/肾造瘘减压百分比的季度趋势和年百分比变化。2010 年至 2015 年期间，估计有 238500 例 MEUO，其中 18.0% 接受 RUS 减压，11.4% 接受 NT。在多项回归中，前列腺 (比值比 [OR] 1.5)、膀胱 (1.6)、宫颈 (1.6) 癌、学术医院 (1.4) 和急性肾损伤是增加 NT 概率的最重要因素。显著增加 RUS 概率的因素包括结肠 (OR 1.4)、直肠/肛门 (1.3)、卵巢 (1.2) 癌、中西部 (东北) 医院 (1.4) 和女性性别 (1.4)，而 RUS 概率降低与膀胱癌 (0.7)、非白种人 (0.8) 和周末入院 (0.8) 有关。尽管 MEUO 的患病率平均每年增加 2.9%，但减压率一直在下降，这主要是由于 RUS 每年平均减少 3.8%。在患者、医院和疾病类型方面，MEUO 的治疗方法存在很大差异，与稳定的肾造瘘术使用相比，支架的使用总体减少。需要进一步研究某些患者特征和疾病类型的最佳方法，以实现标准化护理并减少差异。
