High early mortality following percutaneous nephrostomy in metastatic cancer: a national analysis of outcomes

Objectives: To assess the outcomes of percutaneous nephrostomy in England for renal decompression, in the context of metastatic cancer.

Methods: Retrospective observational study of all patients undergoing nephrostomy with a diagnosis of metastatic cancer from 2010 to 2019 in England, identified and followed up within Hospital Episode Statistics.

The primary outcome measure was mortality (14-day and 30-day postprocedure). Secondary outcomes included subsequent chemotherapy or surgery and direct complications of nephrostomy.

Results: 10 932 patients were identified: 58.0% were male, 51.0% were >70 years old and 57.7% had no relevant comorbidities (according to Charlson’s criteria, other than cancer).

1 in 15 patients died within 14 days of nephrostomy and 1 in 6 died within 30 days. Factors associated with higher 30-day mortality were the presence of comorbidities (Charlson score 1–4 (OR 1.27, 95% CI 1.08 to 1.50, p=0.003), score 5+ (OR 1.29, 95% CI 1.14 to 1.45), p < 0.001)); inpatient nephrostomy (OR 3.76, 95% CI 2.75 to 5.14, p < 0.001) and admitted under the care of specialities of internal medicine (OR 2.10, 95% CI 1.84 to 2.40, p < 0.001), oncology (OR 1.80, 95% CI 1.51 to 2.15, p < 0.001), gynaecology/gynaeoncology (OR 1.66, 95% CI 1.21 to 2.28, p=0.002) or general surgery (OR 1.62, 95% CI 1.32 to 1.98, p < 0.001)), compared with urology.

25.4% received subsequent chemotherapy. Receiving chemotherapy was associated with younger patients (eg, age 18–29 (OR 4.04, 95% CI 2.66 to 6.12, p < 0.001) and age 30–39 (OR 3.07, 95% CI 2.37 to 3.97, p < 0.001)) and under the care of oncology (OR 1.60, 95% CI 1.40 to 1.83, p < 0.001) or gynaecology/gynaeoncology (OR 1.64, 95%CI 1.28 to 2.10, p < 0.001) compared with urology.

43.8% had subsequent abdominopelvic surgery. Not receiving surgery was associated with inpatient nephrostomy (OR 0.82, 95%CI 0.72 to 0.95,p=0.007): non-genitourinary cancers (eg, gynaecology/gynaeoncology cancer (OR 0.86, 95% CI 0.74 to 0.99, p=0.037)); and under the care of a non-surgical specialty (medicine (OR 0.69, 95% CI 0.63 to 0.77, p < 0.001), oncology (OR 0.58, 95% CI 0.51 to 0.66, p < 0.001)).

24.5% of patients had at least one direct complication of nephrostomy: 12.5% required early exchange of nephrostomy, 8.1% had bleeding and 6.7% had pyelonephritis.

Conclusions: The decision to undertake nephrostomy in patients with poor prognosis cancer is complex and should be undertaken in a multidisciplinary team setting. Complication rates are high and minimal survival benefit is derived in many patients, especially in the context of emergency inpatient care.