A 60-year-old woman with known advanced ovarian cancer presents to the emergency department with abdominal swelling associated with nausea and constipation. The patient had previously undergone extensive surgery and multiple lines of chemotherapy. A blood test on admission revealed impaired renal function with a serum creatinine of 280 µmol/l. Abdominal ultrasound revealed bilateral hydronephrosis.
What is the differential diagnosis?
How would you investigate the patient?
How would you manage this patient?
Malignant obstructive uropathy occurs when obstruction of the urine flow due to malignant infiltration, or external compression of the urinary tract in the retroperitoneum or pelvis, results in increased collecting system pressure, urinary stasis and renal failure. The obstruction can be partial or complete, unilateral or bilateral, and it can occur at any level below or above the bladder.
Obstruction of the urinary tract may result from a range of primary malignancies (Table 36.1) or occasionally represent a late complication of external beam radiotherapy to the abdomen and pelvis.1 Extrinsic obstruction may be due to direct compression or encasement of the urinary tract by retroperitoneal tumour or malignant lymphadenopathy, or invasion of the ureter, bladder neck or urethra by the primary or metastatic cancer.2-4 Gynaecological and urological cancers are the most common causes, followed by gastrointestinal and other sites, including metastatic breast cancer or lymphoma. Prostate cancer is the most common cause in males, whereas uterine cervix cancer is the most common cause in females.
Table 36.1Most common causes of malignant obstructive uropathy |Favorite Table|Download (.pdf) Table 36.1 Most common causes of malignant obstructive uropathy
|Uterine cervix and endometrial cancer |
|Bladder cancer |
|Prostate cancer |
|Colorectal cancer |
|Ovarian cancer |
Intrinsic obstruction is caused by transitional cell carcinoma of the bladder, renal pelvis or ureter.
Symptoms may vary depending on the site of obstruction (upper or lower), the degree, the speed of onset and whether it is unilateral or bilateral. Malignant obstruction typically develops over a long period of time causing minimal or no symptoms, and is frequently discovered on routine imaging performed for staging purposes or triggered by abnormal renal function on routine blood test.
Both partial and complete obstruction increase the tendency for urinary tract infections, which may present with acute clinical deterioration and systemic sepsis.
Rectal or pelvic examination can reveal rectal, prostate or uterine cervix tumours as possible causes of urinary obstruction. General examination may detect increased abdominal girth due to the underlying cancer, enlarged kidney, bladder or palpable abdominopelvic mass. Further clinical signs include, volume overload, weight gain and bilateral leg oedema.
The patient presents with advanced intra-abdominal malignancy following multiple lines of potentially nephrotoxic drugs. Possible diagnoses include: intrinsic renal ...