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INTRODUCTION

The term ‘obstructive uropathy’ encompasses patients with bladder outflow obstruction and those with hydronephrosis, and can be caused by local extension and/or lymphatic spread of prostate cancer. Obstructive uropathy is a relatively common occurrence in patients with advanced, metastatic prostate cancer; reported incidence rates vary between 3.3% and 16% [1–6]. The first step in management is to accurately establish the diagnosis. Treatment strategies depend on whether the underlying cause is from hormone-naive prostate cancer or whether it is hormone resistant prostate cancer; the prognosis for the latter is significantly worse. Close liaison between urologist, oncologist and radiologist is essential to manage optimally patients with these conditions.

LOWER URINARY TRACT SYMPTOMS AND OBSTRUCTIVE UROPATHY

Lower urinary tract symptoms (LUTS) are common among men suffering from locally advanced prostate cancer [7]. Classical symptoms are similar to non-malignant obstruction and commonly include poor flow and frequency, as well as the sensation of incomplete bladder emptying. Other problems may include haematuria, anorexia and weight loss, which may indicate incipient renal failure. The presence of a palpable bladder indicates urinary retention, this occurs in approximately 13% of men with locally advanced prostate cancer [8].

PRESENTATION/DIAGNOSIS

It is essential to determine whether one is dealing with malignant or non-malignant uropathy. A digital rectal examination (DRE) is essential, and any prostate asymmetry, a palpable nodule or an irregular hardening, requires further investigation. On examination of a non-malignant prostate gland, the median sulcus is usually identifiable and the seminal vesicles are impalpable; loss of the sulcus or irregularity in the seminal vesicles indicates malignant involvement. If there is any suspicion of malignancy in a patient who does not have a diagnosis of prostate cancer, it is necessary to perform a transrectal ultrasound and biopsy. The first-line assessment of the urinary tract should be with ultrasound, which should include a measurement of residual urine volume, imaging of the kidneys and, in addition, a flow rate is often useful. A computed tomography (CT) or magnetic resonance imaging (MRI) scan may be indicated if more detail is needed, specifically to determine the extent and location of any metastases.

MANAGEMENT AND TREATMENT OPTIONS

There are a number of treatment options available for men with LUTS and bladder outflow obstruction (BOO). These include long-term bladder catheterization, medical or surgical therapy and systemic treatment for the underlying cancer including hormone therapy. Obviously, the most appropriate treatment for this condition will depend on whether previous definitive primary treatment has been undertaken as well as past systemic therapies for prostate cancer.

In an attempt to predict the likelihood of outflow obstruction after different treatment modalities for prostate cancer, Oefelein studied a population of 260 patients with advanced metastatic prostate cancer over a median of 12 years [9]. Results showed that disease progression causing BOO after radical ...

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