Management of Malignant Ureteral Obstruction in Advanced Bladder Cancer: Percutaneous Nephrostomy Versus Double-J Ureteral Stenting—An Evidence-Based Case Report

Abstract

Background: Malignant ureteral obstruction (MUO) is a frequent consequence of locally advanced bladder cancer and can lead to hydronephrosis, obstructive nephropathy, progressive renal dysfunction, and ultimately renal failure. Urinary diversion using double-J (DJ) ureteral stents or percutaneous nephrostomy (PCN) is commonly performed to relieve obstruction; however, the choice of the most appropriate decompression strategy remains a matter of ongoing clinical debate.
Objective: This evidence-based case report aimed to compare the clinical role of DJ ureteral stenting and PCN in the management of MUO caused by advanced bladder cancer.
Case Presentation: An 85-year-old male with advanced bladder carcinoma was admitted with oliguria, generalized fatigue, nausea, and worsening lower urinary tract symptoms. Computed tomography demonstrated disease progression from T3bN0Mx to T4bN2M1, accompanied by bilateral hydronephrosis. Initial laboratory investigations showed severe renal impairment, with a serum creatinine concentration of 10.21 mg/dL. Considering the extensive local tumor burden and the likelihood of trigonal involvement, retrograde DJ stent placement was expected to have a low probability of technical success. Consequently, urinary diversion was achieved through PCN. Following the procedure, renal function improved, as reflected by a decline in serum creatinine to 4.48 mg/dL, indicating effective urinary decompression and partial recovery of kidney function.
Results: Current evidence demonstrates that both DJ stenting and PCN provide effective relief of malignant ureteral obstruction. Gauhar et al. reported that ureteral stenting required significantly less operative time and shorter hospitalization than PCN, whereas renal function recovery, complication rates, and overall survival were comparable between the two approaches. Likewise, De Lorenzis et al. found no significant differences in major clinical outcomes and highlighted PCN as a dependable option for patients with advanced malignant obstruction. In addition, Artiles Medina et al. reported a median overall survival of 6.43 months among patients with MUO and identified advanced-stage malignancy, bilateral hydronephrosis, and delayed urinary diversion as predictors of poor prognosis. Recent studies have also raised concerns regarding a possible association between ureteral stenting and the subsequent development of metachronous upper tract urothelial carcinoma.
Conclusion: PCN represents a reliable and effective method of urinary diversion for patients with advanced bladder cancer complicated by severe MUO, particularly in the presence of suspected trigonal invasion or when retrograde stent placement is unlikely to succeed. In addition to providing satisfactory decompression and facilitating renal function recovery, PCN may reduce potential oncological concerns associated with ureteral stenting. Careful patient selection and timely individualized intervention remain essential to optimize renal preservation and overall clinical outcomes.