Where is the connection?

Renal failure and Cervical cancer

Clinical ScenarioMrs X 50 YrsPresented with post coital bleeding and vaginal

dischargeFound to have stage 2a cervical carcinoma (invasion

of upper 2/3 of vagina but not parametrium)2 years ago had a radical abdominal hysterectomy

(Wertheim’s hysterectomy) involving pelvic LN clearance, hysterectomy, removal of the parametrium and upper 1/3 of the vagina and oophorectomy.

LN involvement was found hence chemoradiotherapy commenced

Presentation2years after finishing her chemo

radiotherapy Mrs X has now been referred to you, the oncologist, by her GP with the following symptoms:TirednessAnorexia and nauseaOliguriaSome mild rectal bleeding

What will you do?

Course of ActionHistory and examination

History: Full history Details of her treatment for cervical cancer and

status after completing her treatment.Any symptoms of recurrence or metastatic disease –

bowel, lung etc.Examination:

Vaginal examinationPR examinationAbdominal examination

Initial InvestigationsBloods:

FBC, U+E, LFT, TFT, CRPCT abdomen and pelvisCxR

ResultsFBC: Mild normochromic normocytic

anaemiaU+E: Raised creatinine, urea and

potassiumLFT, TFT, CRP normalCT or MRI pelvis: Pelvic mass appearing to

compress both uretersCxR: normal

ImpressionInvestigations suggest post renal acute renal

failure secondary to ureteric obstruction from a likely recurrence of cervical cancer.

Further investigations to consider:Renal ultrasound to look for any other cause of

ARF, determine kidney size and look for hydronephrosis

Urine and plasma sodium, creatinine and osmolarity to rule out pre renal failure

Intravenous urogram (IVU) to confirm obstructionPET scan to look for metastatic disease

ManagementCurative or palliative depending upon stage

and prognosisTumour:

Surgical resectionChemo and/or radiotherapy

Renal failureRelieve obstruction either by treating the

tumour or insert a ureteric stentNephrostomyUrinary diversion (uretroenteric anastamosis)Depending on severity of ARF, manage

hyperkalaemia. Consider dialysis

JJ stent Nephrostomy

New treatmentsDouble J stents often fail in malignant

ureteric obstruction due to lumen obstruction from clots and tumour which enter through the side holes of the stent

A new double lumen stent has been developed which may be superior

Other approaches are being developed such as self expanding stents and drug impregnated stents

PrognosisTumour will be least stage 3 (causing

ureteric obstruction). This is a poor prognostic sign.

5 year survival for stage 3-4 tumours is 10-30%

ReferencesObstetrics and Gynaecology 2nd ed.

Lawrence Impey.Yachia D. Recent advances in ureteral

stents. Curr Opin Urol 2008; 18(2):241-246.