doi:10.1111/j.1447-0756.2010.01486.x J. Obstet. Gynaecol. Res. Vol. 37, No.

8: 1061–1070, August 2011

Impact of palliative urinary diversion by percutaneous

nephrostomy drainage and ureteral stenting among
patients with advanced cervical cancer and obstructive
uropathy: A prospective cohort jog_1486 1061..1070

Marie Carmela M. Lapitan1,2 and Brian S. Buckley1,3

1
Department of Surgery, College of Medicine, Philippine General Hospital, 2National Institutes of Health, University of the
Philippines, Manila, Philippines; and 3Department of General Practice, National University of Ireland, Galway, Ireland

Abstract
Aim: Obstructive uropathy is a recognized complication in advanced cervical cancer. Urinary diversion is
commonly used to bypass the obstruction and improve renal function. The degree of survival benefit that
diversion offers is not well established and its impact on quality of life (QoL) is uncertain. This study
considered these factors in order to inform treatment decisions.
Methods: This study examined a prospective cohort of patients with advanced cervical cancer and obstructive
uropathy in Manila, Philippines. Age, cancer treatment status, comorbidities, serum creatinine level, degree of
obstructive uropathy and QoL were recorded at baseline. Patients with creatinine values >150 mmol/L, or who
were being considered for radiotherapy or nephrotoxic chemotherapy or manifesting uncontrolled or recur-
rent uropathy-related urinary tract infection, were offered diversion. Follow-up data collection was at 3, 6, 9
and 12 months from cohort entry.
Results: Of the 230 patients invited, 205 patients joined the cohort. Complete data were available for 198, of
whom 93 underwent diversion, 56 required diversion but elected not to receive it, and 49 did not require it.
Although survival at 12 months among those who underwent diversion was no greater than among those who
required but elected not to receive the procedure, diversion was associated with significantly improved chance
of survival in the shorter term. There was no significant difference in the QoL between the groups throughout
the study.
Conclusion: With no evidence of an impact on QoL, the decision to offer diversionary surgery might be based
solely on a survival benefit, which is modest but potentially important to patients.
Key words: acute kidney failure, cervical cancer, mortality, quality of life, urinary diversion.

Received: June 9 2010.

Accepted: October 18 2010.
Reprint request to: Professor Marie Carmela M. Lapitan, Department of Surgery, College of Medicine, Philippine General Hospital,
Taft Avenue, Manila 1000, Philippines. Email: melalapitan@gmail.com
Sources of support: The study was funded by the National Institutes of Health (NIH (TRB) 2003-006 and NIH (TRB) 2005-005) and the
Research Implementation and Development Office, College of Medicine, University of the Philippines, Manila, Philippines.
Financial disclosures by authors: Neither of the authors have any conflicts of interest to declare as defined by The Journal of Obstetrics and
Gynaecology Research Disclosure Guideline for Conflict of Interests.
Contributions of the authors: MCML conceived the study and contributed to data interpretation and writing the paper. BSB conducted
the data analysis and contributed to data interpretation and writing the paper.

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M. C. M. Lapitan and B. S. Buckley
Introduction
Cervical cancer is a major cause of death in developing
countries and is a public health concern worldwide.1,2
It is the second most common form of cancer in Fili-
pino women, accounting for 13.3% of prevalent cases in
2005, with 7277 new cases diagnosed. It is the fifth most
common form of cancer in the population when both
sexes are considered together.3
Obstructive uropathy and resultant hydronephrosis
are not uncommon complications in cervical cancer,
although their exact incidence has not been fully estab-
lished in the literature. Obstructive uropathy is com-
monly a late manifestation of advanced disease, a result
of extrinsic ureteral compression secondary to malig-
nancy.4 The presence of ureteral obstruction and conse-
quent renal failure have a significant adverse effect on
survival in cervical carcinoma patients.5 In order to
bypass the ureteric obstruction, urinary diversions have
been employed, but more evidence is needed relating to
the outcomes of such methods. Percutaneous nephros-
tomy drainage has been associated with promising
results in terms of survival, improved renal function and
improvement in pain, uremic symptoms and perfor-
mance status, but most studies are relatively old, have
involved relatively small cohorts and many have been
retrospective.4–10 Although urinary diversion through
endoscopic ureteral stenting and percutaneous neph-
rostomy drainage has offered easily performed proce-
dures that will relieve ureteral obstruction and could
prolong survival, an ethical dilemma persists: it has
been suggested that quality of life in terms of pain and
physical performance after diversion is often poor,
so that the benefit the procedures offer to patients is
uncertain.4
The Philippines is a developing country as defined
by the International Monetary Fund and has a dual
private and public health care system. The Philippine
General Hospital is a tertiary government hospital
linked to the national university that largely serves the
economically disadvantaged. An average of eight cases
of advanced cervical cancer per month are referred
for management of obstructive uropathy. Although
patients in the hospital’s charity wards do not pay pro-
fessional fees to the physicians and surgeons, they and
their families may incur substantial peripheral medical
and other costs associated with their treatment or their
hospital stay. As a result, as in many developing coun-
tries, many must make difficult decisions about
whether they can afford to proceed with treatment or
not, weighing the potential benefits of treatment
1062
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
explained by clinicians with the potential impact on
their families. Cervical cancer patients in the Philip-
pines are more often diagnosed at late stages of the
disease and fewer receive curative surgery than Filipi-
nos or Caucasians in the United States of America.11
This study considered survival among a prospective
cohort of Filipino patients with advanced cervical
cancer and associated obstructive uropathy. In particu-
lar, the study aimed to evaluate the benefits offered by
urinary diversion by comparing survival among those
requiring and undergoing diversion with those requir-
ing but not undergoing and those not requiring the
procedure.
Methods
Recruitment and data collection
A prospective cohort was recruited from May 2004 to
May 2009. Insofar as was possible, all eligible, consecu-
tive patients seen at the Gynecologic Oncology outpa-
tient clinic and those admitted to the malignancy
service of the Department of Obstetrics and Gynecol-
ogy of the Philippine General Hospital, Manila, were
invited to participate. Eligible patients were at least
eighteen years old, diagnosed with cervical cancer
stage IIIB to IVA, with initial clinical evidence of
obstructive uropathy. Any form of supravesical urinary
diversion prior to the initial consult with the investiga-
tors precluded inclusion. On rare occasions, clinical
circumstances, such as a lack of staff time or resources
or distress in the patient, precluded such invitation.
Upon consent for inclusion into the study, each
patient’s age, cancer treatment status, presence of
comorbidities, degree of urinary tract obstruction as
determined by renal ultrasound and serum creatinine
level were recorded. Obstructive uropathy was defined
as any impedance to urine flow causing dilation of the
collecting structures, as documented by KUB ultra-
sound or intravenous pyelography. The degree of
obstruction and consequent hydronephrosis, labeled
as none, minimal, moderate or severe, was based on
the criteria found defined by Malave et al.12 Baseline
quality of life was assessed using the Functional
Assessment of Cancer Therapy Scale (Gynecologic)
(FACT-G) physical, functional and emotional well-
being subscales.
As per standard practice in the Division of Urology
of the Philippine General Hospital, patients with
elevated creatinine values (>150 mmol/L) with radio-
logic evidence of urinary tract obstruction were
offered the option of urinary diversion in the form of
© 2011 The Authors

endoscopic double-J ureteral stent (DJS) insertion or
ultrasound-guided percutaneous nephrostomy drain-
age (PND) insertion. Diversion was also considered in
the presence of normal creatinine levels for patients
with uncontrolled or recurrent urinary tract infection
associated with obstructive uropathy or for those
being considered for radiotherapy or nephrotoxic
chemotherapy, because these patients often experience
subsequent uremia. Known risks and benefits of the
procedure were explained to the patients and their
relatives in a standardized manner. The dates and
types of diversions were recorded. Percutaneous neph-
rostomy drainage was performed by a urologist in an
operating theater under regional anesthesia or local
anesthesia with sedation. Ultrasound was used to visu-
alize the urinary tract. The nephrostomy tracts were
dilated over a guidewire in a standard fashion. Neph-
rostomy tube sizes ranged from 10 to 12 Fr. Endoscopic
double-J stent insertion was done under regional anes-
thesia with the placement of 6 Fr stents confirmed by
radiographic study.
Follow-up data collection took place at consultations
3, 6, 9 and 12 months from the time of inclusion into the
study, with serum creatinine levels and quality of life
score recorded at each time point. Mortality from all
causes was recorded.
Statistical analysis
Data analysis was performed using SPSS 16.0 for Mac.
The Student t-test was used to compare the distribution
of continuous variables between the subgroups and the
c2-test compared the distribution of dichotomous cat-
egorical variables. Kaplan–Meier survival modeling
and log rank tests were used to examine and test the
association between different variables at baseline and
survival to the different outcomes. Cox proportional
hazards modeling was employed to consider the
impact on survival among those who required diver-
sion of baseline covariates, including age, baseline
cancer treatment status, degree of urinary obstruction,
creatinine level, any comorbidity and urinary diver-
sion surgery, controlling for other covariates. The
Charlson Comorbidity Index was considered but not
used because it was not sufficiently sensitive to the type
of comorbidities present in the relatively young cohort.
Survival was measured from the patient’s date of
cohort entry to the date of death. Assumptions of pro-
portional hazards were checked by plotting the log of
the negative log of the survival function against time.
Only patients who were confirmed alive or dead
were included in the survival analysis. Analyses of
© 2011 The Authors
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
Urinary diversion in cervical cancer
FACT-G scores were limited to survivors in the differ-
ent time periods. Comparisons were made according
to groups defined by whether the patients needed or
underwent diversionary procedures: (i) diversion not
needed (patients with obstructive uropathy, but normal
creatinine levels); (ii) diverted (patients with elevated
creatinine levels who underwent diversion surgery);
and (iii) diversion not done (patients with elevated
creatinine levels who did not undergo diversion).
In all analyses, a value of P < 0.01 was selected to
denote significance. This is in line with recent recom-
mendations and practice in observational research, in
which the effect of unmeasured variables is not coun-
tered by the effect of randomization.13
Ethical approval
Ethical approval for the study was granted by the
Ethics Review Board of the National Institutes of
Health, University of the Philippines, Manila.
Informed consent was obtained from all patients prior
to inclusion into the study. Funding was provided by
the National Institutes of Health and the College of
Medicine, University of the Philippines, Manila.
Results
From May 2004 to May 2009, 230 patients who
appeared to meet the inclusion criteria were invited to
participate. All but eight patients gave consent and
were screened for inclusion in the study. Of 222
patients screened, 17 patients did not show any evi-
dence of obstructive uropathy on ultrasound and were
excluded, so that 205 patients were included in the
cohort. Two patients later withdrew from the study for
personal reasons and five (2.4%) were lost to follow up,
leaving 198 patients to complete the study.
Study population
The patients had a mean age of 48.2 years (SD = 9.6,
range = 26–71 years). Despite having cancer stage IIIB
to IVA dictated by the eligibility criteria, more than half
of the patients (56.6%) had had no prior treatment
(primary untreated) for the malignancy when they
were included in the study. Among those who had
previous treatment for their cervical cancer, most had
received chemotherapy with radiotherapy (32.9% of all
patients) upon recruitment. Most of the patients in the
study did not exhibit comorbidities (n = 149; 72.7%); of
those patients who had comorbidities, most were
noted to have hypertension (n = 44; 21.0%); other
comorbidities included asthma (n = 6), diabetes (n = 5)
1063
M. C. M. Lapitan and B. S. Buckley

and anemia (n = 1). Most of the patients (82%) pre-
sented with dilatation of both upper collecting systems.
Nearly half of the study population had moderate bilat-
eral hydronephrosis (44.9%). The median creatinine
value was 286.0 mmol/L (interquartile range = 114.5–
869.0). One third of the study population had normal
creatinine values (<150 mmol/L) (71/205, 34.6%).
Ninety patients (43.9%) had creatinine levels over
400 mmol/L.
For this study comparisons were made according to
groups defined by whether the patients needed or
underwent diversionary procedures: diversion not
needed (patients with obstructive uropathy but with
normal creatinine levels); diverted (patients with
increased creatinine levels who underwent diversion
surgery); and diversion needed but not done (patients
with increased creatinine, but who did not undergo
diversion). Table 1 reports baseline characteristics by
diversion subgroups. The c2-test was used to assess
whether the distributions of characteristics between
subgroups were likely to indicate genuinely significant
differences between groups or to have occurred by
chance. Tests detected no statistically significant differ-
ences in the distribution of cancer treatment status or of
the presence of comorbidities among diversion sub-
groups; however, a significantly greater proportion of
those who underwent diversion had moderate, severe
or bilateral hydronephrosis or more severely elevated
creatinine levels.
Of the 149 patients who presented with elevated
creatinine levels upon study entry or subsequently and
who completed the study, 93 underwent urinary diver-
sion. Five patients underwent double-J stent insertion,
and the rest underwent percutaneous nephrostomy
drainage. The rest of the patient population elected not
to undergo any urinary diversion despite increasing
creatinine levels. The median time to diversion was less
than one week (mean = 1.1, SD = 3.8, range 0–32). A
number of patients whose creatinine rose above
150 mmol/L after cohort entry at baseline were offered
diversion: Eight patients underwent diversion more
than two weeks after entry and are included in the
diversion group. Mean creatinine levels for each group
at different time periods are presented in Table 2.
Survival
For consideration of survival, time was measured from
patient’s date of cohort entry to the date of death. Sen-
sitivity analysis considered the effect on survival of
diversion either within two weeks of entry or more
than two weeks after entry (n8). No significant effect
was detected.
Two patients withdrew from the study and five were
lost to follow up. Of the remainder, 44 patients were
known to be alive at 12 months (22.2%; 44/198).
Among those who did not require a diversion, 20
(40.8%) survived 12 months, whereas 16.1% survived
12 months among those who underwent a diversion
and exactly the same percentage, 16.1%, survived
among those who required diversion but did not
undergo the procedure (n15 and n9, respectively). Sur-
vival at different three-month stages of follow up dif-
fered between these two latter groups, however, as
presented in Table 2.
The overall mean time to mortality among those who
died was 18.7 weeks (SD = 14.0), and the median time

Table 1 Baseline age, cancer treatment status, degree of hydronephrosis, creatinine level and existence of comorbidity by
diversion status subgroup
Diversion not Diverted Diversion needed P-value
needed (n = 51) (n = 94) but not done (n = 60)
n (%) n (%) n (%)
Age (years)† 50.4 (9.6) 46.7 (8.9) 48.8 (10.3)
Cancer treatment status: primary 24 (47.1) 58 (61.7) 34 (56.7) 0.065
untreated
Ongoing RT or chemotherapy 8 (15.7) 5 (5.3) 11 (18.3)
Post-RT, CT or brachytherapy 19 (37.3) 31 (33.0) 15 (25.0)
Comorbidity present 12 (23.5) 26 (27.7) 18 (30.0) 0.744
Moderate/severe hydronephrosis 37 (72.5) 87 (92.6) 48 (80.0) 0.005
Bilateral hydronephrosis 32 (62.7) 89 (94.7) 47 (78.3) <0.001
Creatinine ⱕ150 mmol/L 51 (100.0) 8 (8.5) 12 (20.0) <0.001
Creatinine 150–400 mmol/L 0 (0.0) 19 (20.2) 25 (41.7)
Creatinine >400 mmol/L 0 (0.0) 67 (71.3) 23 (38.3)
†Data are presented as mean (SD). CT, chemotherapy; RT, radiotherapy.

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Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
 Urinary diversion in cervical cancer

Table 2 Survival and creatinine levels amongt Stage IIIb–IV cervical cancer patients with obstructive uropathy, by diversion
status (n = 198, excluding withdrawals and lost to follow up)
Diversion status (n) Survived 3 months (n) Survived 6 months (n) Survived 9 months (n) Survived 12 months
(mean creatinine at (% of diversion (% of diversion (% of diversion (n) (% of diversion
baseline [SD]) subgroup) (mean subgroup) (mean subgroup) (mean subgroup) ([mean
creatinine [SD]) creatinine [SD]) creatinine [SD]) creatinine [SD])
Diversion not needed 38 (77.6) (94.5 [21.6]) 29 (59.2) (100.6 [23.6]) 24 (49.0) (111.7 [29.1]) 20 (40.8) (109.5 [48.1])
(n = 49) (97.4 [28.4])
Diverted (n = 93) 68 (73.1) (257.4 [199.8]) 36 (38.7) (266.6 [176.3]) 25 (26.9) (258.6 [184.9]) 15 (16.1) (206.5 [91.0])
(801.9 [571.6])
Diversion needed but 25 (44.6) (295.1 [197.5]) 16 (28.6) (242.0 [138.7]) 10 (17.9) (237.8 [124.2]) 9 (16.1) (225.6 [75.8])
not done (n = 56)
(457.2 [411.4])

Figure 1 Kaplan–Meier plot

showing survival in weeks
between cohort entry and death
by diversion status. The mean
(SD) follow-up times among all
patients not needing diversion,
undergoing diversion and need-
ing but not undergoing diver-
sion were 34.0 (18.7), 25.8 (16.7)
and 18.4 (18.0) weeks, respec-
tively. Log rank (Mantel–Cox):
P < 0.001. The numbers at risk at
time intervals in each group are
presented in Table 2.

was 21 weeks. Mean (SD; median) survival times
among those in whom diversion was not needed, those
who were diverted, and those who needed but did not
undergo diversion were 21.7 (SD 14.5; median 39), 21.1
(SD 13.7; median 21), and 12.9 (SD 12.6; median 10)
weeks, respectively. A Kaplan-Meier plot graphically
reports survival among the cohort by diversion status.
Whilst those requiring but not undergoing diversion
died more quickly in the months immediately after
entry, survival among those who underwent diversion
more closely follows those not needing diversion
(Fig. 1). However, after 12 months, survival among
those diverted and those requiring but not undergoing
diversion is similar.
Factors affecting survival
Cox proportional hazard models were employed to
determine the influence on survival, among those
requiring diversion, of baseline covariates such as age,
baseline cancer treatment status, degree of urinary
obstruction, creatinine level, comorbidity and urinary
diversion surgery while controlling for other factors.
The degree of urinary obstruction, severely elevated
creatinine levels and urinary diversion surgery signifi-
cantly influenced survival statistically. Moderate-to-
severe hydronephrosis at baseline, whether unilateral
or bilateral, was shown to increase the risk of death
more than threefold compared with those with a

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M. C. M. Lapitan and B. S. Buckley

Table 3 Hazard ratios for death within 12 months of cohort entry among those who required diversion on entry or
subsequently by baseline characteristics and diversion group (n = 149)
n Hazard ratio (95% CI) P
Age (per year increase) 198 0.99 (0.97–1.01) 0.306
Baseline cancer treatment status
Primary untreated 90
Ongoing treatment (compared with primary untreated) 16 0.50 (0.21–1.20) 0.120
Post treatment (compared with primary untreated) 43 0.66 (0.43–1.02) 0.061
Degree of hydronephrosis
Moderate/severe (compared with none/minimal, n = 18) 131 3.26 (1.51–7.01) 0.003
Bilateral (compared with unilateral, n = 16) 133 0.56 (0.23–1.38) 0.210
Baseline creatinine
<150 mmol/L 20
151–400 mmol/L (compared with <150 mmol/L) 41 1.69 (0.83–3.43) 0.151
>400 mmol/L (compared with <150 mmol/L) 88 2.84 (1.42–5.68) 0.003
Diversion performed (compared with diversion needed but not done, n = 56) 93 0.42 (0.28–0.63) 0.000
Comorbidity present (compared with none present) 42 0.84 (0.56–1.26) 0.400

minimal degree of obstruction. Similarly, creatinine
levels >400 mmol/L at baseline conferred a markedly
increased risk. On the other hand, undergoing urinary
diversion surgery significantly improved the chance of
survival (Table 3). When the model was fitted to the
whole cohort, including those not requiring diversion,
the same variables had a statistically significant asso-
ciation with increased or reduced risk of death and the
hazard ratios (HR) and 95% confidence intervals (95%
CI) were very similar: HR 2.44 (95% CI 1.40–4.26), HR
2.53 (95% CI 1.32–4.84) and HR 0.43 (95% CI 0.28–0.65)
for moderate-to-severe hydronephrosis, creatinine
>400 mmol/L and diversion, respectively.
To further consider the effect of diversion on sur-
vival, subgroup analysis was conducted among those
with moderate or severe bilateral hydronephrosis who
underwent diversion (n = 81) to consider the associa-
tion of reduced creatinine levels following diversion
with survival. Creatinine levels <150 mmol/L at
2 weeks and 3 months after diversion were associated
with a statistically significant reduced risk of death
within 12 months, HR 0.53 (95% CI 0.29–0.94) and HR
0.42 (95% CI 0.20–0.89), respectively.
period to the next between those undergoing diversion
and those requiring but not undergoing diversion.
Discussion
Summary of main findings
In this study, patients with advanced cervical cancer
and associated obstructive uropathy had an overall
median survival of 21 weeks and a 12-month survival
rate of 22%. Although urinary diversion did not signifi-
cantly alter the 12-month survival rate, the procedure
was shown to improve survival in the shorter term in
those patients requiring it, with their survival in the
first three months after entry almost approximating
that of those not needing diversion. Among those
requiring diversion, more severely elevated creatinine
levels and moderate-to-severe urinary tract obstruction
adversely impacted upon survival. Reduction of crea-
tinine levels to normal levels following diversion
was associated with a reduced risk of death within
12 months. Quality of life scores did not significantly
differ across the diversion groups over the entire study
period.

Quality of life Strengths and limitations

The FACT-G scores of the different diversion groups
through follow up are presented in Table 4. Scores
were broadly stable over time. T-tests did not show any
significant difference in the scores between the differ-
ent diversion groups, in any domain, at any follow-up
interval. Equally, T-tests did not show any significant
differences in changes in FACT-G scores from one time
This study has considerable strengths. It is among the
largest in the literature and unlike many,4,7,8,14 it is a
prospective incident cohort study which recruited con-
secutive patients from the same population, considered
the most appropriate design for considering progno-
sis.15,16 Recruitment rate was high at 89.1% of those
screened for inclusion and retention was also high,

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© 2011 The Authors
Table 4 Functional Assessment of Cancer Therapy Scale (Gynecologic) (FACT-G) scores (mean, SD) and changes in FACT-G scores by diversion status at each
follow up visit throughout the study (higher scores denote better self-reported quality of life)
Baseline Domain (range n Diversion not n Diverted n Diversion required n All cases
of scores) required but not done
Baseline Physical (0–28) 51 14.7 (6.6) 94 9.6 (6.5) 60 11.8 (6.1) 205 11.5 (6.7)
Emotional (0–24) 51 9.7 (6.0) 94 12.2 (5.5) 60 11.6 (5.1) 205 11.4 (5.6)
Functional (0–28) 51 13.3 (7.4) 94 9.3 (6.4) 60 10.1 (6.9) 205 10.5 (7.0)
Change baseline to 3 months Physical 32 -6.9 (10.4) 68 0.5 (9.9) 25 -3.5 (10.6) 125 -2.2 (10.6)
Emotional 32 -0.5 (3.2) 68 -1.4 (5.0) 25 -2.3 (4.3) 125 -1.4 (4.5)
Functional 32 -0.8 (4.4) 68 -0.2 (6.0) 25 2.0 (4.9) 125 0.1 (5.5)
3 months Physical (2–28) 32 17.9 (6.6) 68 12.3 (6.4) 25 14.8 (7.2) 125 14.5 (6.9)
Emotional (0–24) 32 8.9 (5.9) 68 10.6 (5.2) 25 9.7 (5.3) 125 10.0 (5.4)
Functional (0–28) 32 13.5 (7.4) 68 9.4 (6.6) 25 14.1 (8.9) 125 11.4 (7.6)
Change 3 to 6 months Physical 20 12.1 (10.7) 32 3.8 (11.6) 9 7.6 (13.1) 61 7.0 (11.9)
Emotional 20 -0.6 (3.2) 32 0.2 (3.6) 9 -0.1 (4.0) 61 -0.1 (3.4)
Functional 20 -0.4 (6.0) 32 -1.3 (9.0) 9 -2.4 (4.6) 61 -1.1 (7.6)
6 months Physical (2–28) 20 18.9 (6.5) 32 14.0 (6.6) 9 15.3 (6.4) 61 15.8 (6.8)
Emotional (0–22) 20 7.4 (6.0) 32 10.2 (5.1) 9 10.1 (4.3) 61 9.3 (5.4)
Functional (0–28) 20 14.4 (8.1) 32 10.1 (7.2) 9 13.2 (8.4) 61 12.0 (7.8)
Change 6 to 9 months Physical 15 -0.2 (3.6) 20 -2.8 (5.6) 7 -2.3 (3.9) 42 -1.9 (4.9)
Emotional 15 0.1 (2.5) 20 0.9 (2.7) 7 1.5 (3.9) 42 0.7 (2.7)
Functional 15 1.7 (8.1) 20 -1.0 (7.0) 7 -4.3 (3.3) 42 -0.5 (7.2)
9 months Physical (5–28) 15 20.4 (6.5) 20 13.8 (7.0) 7 14.3 (6.7) 42 16.2 (7.4)
Emotional (2–23) 15 7.7 (4.7) 20 9.2 (5.1) 7 11.3 (4.6) 42 9.0 (4.9)
Functional (1–28) 15 17.2 (6.6) 20 10.2 (6.9) 7 13.6 (7.5) 42 13.3 (7.4)
Change 9 to 12 months Physical 21 0.1 (3.0) 13 1.1 (3.0) 7 0.3 (3.5) 41 0.5 (3.0)
Emotional 21 0.3 (3.2) 13 0.5 (4.5) 7 2.2 (2.3) 41 0.8 (3.5)
Functional 21 -0.2 (2.8) 13 -0.6 (6.5) 7 1.3 (3.5) 41 0.0 (4.4)
12 months Physical (4–28) 21 18.9 (7.1) 13 17.6 (6.5) 7 13.9 (5.4) 41 17.6 (6.7)
Emotional (0–22) 21 8.0 (3.4) 13 8.9 (5.6) 7 12.9 (5.2) 41 9.1 (5.0)
Functional (0–28) 21 14.2 (7.1) 13 9.4 (6.5) 7 14.7 (8.4) 41 12.8 (7.3)

Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
1067
Urinary diversion in cervical cancer
M. C. M. Lapitan and B. S. Buckley
with only 3.4% withdrawing or lost to follow up. The
prospective nature of the study allowed for uniform
and successful data collection that affords the opportu-
nity for consideration of the prognostic effect of indi-
vidual clinical and patient factors. The length of follow
up was longer than in most studies of survival among
patients with cervical cancer and obstructive uropathy.
The study has also adopted the higher level of signifi-
cance that has been recommended to mitigate the pos-
sibility of unknown confounding.13
The study also had weaknesses and these must be
acknowledged. The cancer treatments received during
the study, which could have affected survival rates,
were not recorded. It is unfortunate that we have been
unable to access data on the precise causes of death.
This is indicative of prevailing social and health care
conditions among this population of economically dis-
advantaged patients with advanced cervical cancer. A
substantial proportion of such patients prefer to die in
their homes. In such cases, the deaths were reported to
researchers by their families. Unfortunately, the dimin-
ishing numbers of patients surviving towards the end
of the study period in some subgroups limited the
power of comparative analyses of FACT-G quality of
life scores. The population involved in the study was
largely drawn from economically disadvantaged com-
munities in the Philippines and so its ability to infer
generalizations on other populations must be consid-
ered carefully. Finally, as with all studies where
multiple comparisons are made, some statistically sig-
nificant findings may have occurred by chance.
Discussion of results in the context of
the literature
This study highlights the potentially important role
that urinary diversion has in the treatment of patients
with advanced malignancy and obstructive uropathy.
This may be particularly, but not exclusively, so in
developing countries where radiotherapy or chemo-
therapy may be unavailable or prohibitively expensive
for many patients. Radical, exenterative surgery has
the potential to control both malignancy and urinary
obstruction definitively.17 Where exenterative surgery
is the chosen approach, addressing uremia caused by
obstructive uropathy by diversion can optimize the
condition of the patient in preparation for the perfor-
mance of such surgery.
Although there has long appeared to be a survival
benefit associated with urinary diversion in cases of
advanced cervical cancer with obstructive uropathy,
1068
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
this has not been clearly established in the literature, as
most studies have been retrospective or conducted in
small numbers of patients, or both. This study aimed to
assist patients and clinicians in treatment choices by
assessing survival among patients with advanced cer-
vical cancer with obstructive uropathy from a socioeco-
nomically disadvantaged population, and considering
what factors influence survival and quality of life, with
a particular focus on the impact of urinary diversion.
The 20-week median time to death in those receiving
urinary diversion in this study is slightly greater than
most survival rates reported previously in the litera-
ture. A review of 50 cases of recurrent cervical cancer
patients in Brazil who underwent percutaneous
nephrostomy reported a median overall survival of
8.9 weeks (95% CI 7.4–10.3)7 whilst a 3.1-month
median survival was reported in 24 uremic German
patients with advanced cervical cancer receiving per-
cutaneous diversion after failed ureteric stenting.8 A
retrospective review of 52 women with advanced cer-
vical cancer looking at the impact of ureteral obstruc-
tion and urinary diversion showed a trend toward
improved survival among those who underwent diver-
sion10 and a study of 27 patients with malignant ure-
teral obstruction (not only from cervical cancer)
showed an increase in survival after diversion.6 Other
studies of cases with advanced pelvic malignancy
with ureteral obstruction report median survival of
3–7 months.4,14
Although at 12 months the procedure did not confer a
survival benefit in this study, in the shorter term urinary
diversion prolonged survival markedly. In our cohort,
survival rates among those who were diverted
remained not unlike the rate among those not requiring
diversion for the first three months following entry. The
mean time to death in those who underwent diversion
was significantly higher than in those who needed but
did not undergo the procedure. Median time to death in
those diverted and those not requiring diversion was 20
and 21 weeks, respectively, and 10 in those who
required but did not undergo diversion. After the full
twelve-month follow up, survival rates among those
who underwent diversion had fallen to the rate among
those requiring but not undergoing the procedure.
Although there were no significant differences in
terms of age, existence of comorbidities or cancer treat-
ment status, patients who underwent diversion were
more likely to be affected by moderate or severe or
bilateral hydronephrosis or highly elevated creatinine
levels than those who required but did not undergo
diversion (Tables 1,2). These higher levels of indicators
© 2011 The Authors

of poor clinical prognosis in the diverted group further
underline the value of diversion and may in part
explain why the short term survival benefit conferred
by diversion in this group did not last.
Significant mortality occurred in those patients
included in the study who had obstructive uropathy,
but whose creatinine levels were not so elevated as to
indicate diversion. Whilst in many health care contexts
this would suggest the presence of disseminated
disease in a significant proportion, in this study it
should be borne in mind that the population is fre-
quently malnourished and anemic and therefore prone
to infection and has limited access to transfusion and
medication. In addition, it has been shown that cervical
cancer patients in the Philippines are more often diag-
nosed at later stages of the disease and less often
receive appropriate surgery than in Filipino Americans
or Caucasian Americans, both factors strongly associ-
ated with increased risk of death. Only 24% in the
Philippines are diagnosed at Stage I, compared with
57% of Filipino Americans and 64% of Caucasian
Americans; and 72% do not receive surgery compared
with 36% and 32%, respectively. Adjusting for age,
stage and morphology, the risk of death was more than
double in patients in the Philippines.11
The uniform, planned, prospective data collection in
the present study afforded the opportunity for multi-
variate survival analysis with the aim of determining
the predictive prognostic effect of individual clinical,
surgical and patient characteristics whilst controlling
for other factors. Urinary diversion was shown to be
the most significant factor in increasing short-term sur-
vival among those with obstructive uropathy resulting
in hydronephrosis and elevated creatinine. The degree
of hydronephrosis and elevation of creatinine levels
resulting from the obstructive uropathy were also
shown to have adverse independent significant effects
on survival.
Concerns have been raised previously that urinary
diversion adversely affects quality of life in patients
with advanced cervical carcinoma in terms of pain and
physical performance as measured by a modified Kar-
nofsky performance scale.4 Thus, a dilemma that has
faced surgeons is whether the modest survival benefit
associated with the diversion procedure may be out-
weighed by a reduction in quality of life. However, the
Karnofsky scale measures only physical elements of
quality of life. This study aimed to shed light on this by
using a modified FACT-G questionnaire that includes
an emotional domain as well as physical and func-
tional domains.
© 2011 The Authors
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
Urinary diversion in cervical cancer
No significant differences were identified between
diversion status subgroups at any point in the study or
in any domain, which suggests that the survival benefit
may be the predominant consideration when discuss-
ing treatment options with patients, especially in the
context of advanced carcinoma. Levels of azotemia also
appear relatively constant over time and between those
diverted and those needing but not undergoing diver-
sion, and this may in some way relate to the relatively
similar quality of life data. However, these findings
must be interpreted with caution because of the low
numbers of patients in some subgroups at the later
stages of data collection and because, of course, only
data from survivors are included.
It is of interest that, overall, the FACT-G scores in this
cohort are low compared to other studies involving
gynecological cancer patients in the literature;18,19
however, health status and other characteristics may
not be comparable. The low FACT-G scores may signify
that these patients are quite simply very sick and so
affected by their disease that any treatment or pallia-
tion of the urinary tract obstruction does not signifi-
cantly affect quality of life. The fact that more than half
of these women with cervical cancer stage IIIB to IVA
had received no treatment prior to admission indicates
the limited access to healthcare among this socioeco-
nomically disadvantaged population. Educational
status has been show to be associated with a lower
QOL, and the patients in this study were largely from
an economically disadvantaged population with a
lower educational attainment.19
Conclusions
In patients with advanced cervical cancer with obstruc-
tive uropathy and elevated creatinine levels, urinary
diversion confers a modest survival benefit, and there
is no evidence in this study that it compromises quality
of life in this population. Thus, it might be concluded
that the decision to perform an intervention among
patients with generally poor survival should be driven
solely by the prospect of the clear short-term survival
benefit, if that is desired by the patient. Urinary diver-
sion may be of particular benefit to patients with
advanced cervical cancer, moderate-to-severe hydro-
nephrosis and severely elevated creatinine levels
(>400 mmol/L), and who have not had prior treatment
for the malignancy. Reduction of creatinine levels to
normal levels following diversion was associated with
a reduced risk of death within 12 months.
1069
M. C. M. Lapitan and B. S. Buckley
Acknowledgments
The authors would like to thank Dr Alvin Wee and Dr
Victor Federico Acepcion for helping in the protocol
development and initial patient recruitment, Dr Eliza
Raymundo and Dr Manuel Manalo for further patient
recruitment and data collection, and Ms Rheamel
Lopez for data management and overall research study
administration.
References
1. Flores-Luna L, Salazar-Martinez E, Escudero-De los Rios P,
Gonzalez-Lira G, Zamora-Munoz S, Lazcano-Ponce E. Prog-
nostic factors related to cervical cancer survival in Mexican
women. Int J Gynaecol Obstet 2001; 75: 33–42.
2. Franco EL, Duarte-Franco E, Ferenczy A. Cervical cancer:
Epidemiology, prevention and the role of human papilloma-
virus infection. CMAJ 2001; 164: 1017–1025.
3. Laudico AV, Esteban DB, Redaniel MTM, Mapua CA, Reyes
LM. 2005 Philippine Cancer Facts and Estimates. Manila,
Philippines: Philippine Cancer Society, 2004.
4. Shekarriz B, Shekarriz H, Upadhyay J et al. Outcome of pal-
liative urinary diversion in the treatment of advanced malig-
nancies. Cancer 1999; 85: 998–1003.
5. Hopkins MP, Morley GW. Prognostic factors in advanced
stage squamous cell cancer of the cervix. Cancer 1993; 72:
2389–2393.
6. Culkin DJ, Wheeler JS, Jr, Marsans RE, Nam SI, Canning JR.
Percutaneous nephrostomy for palliation of metastatic ure-
teral obstruction. Urology 1987; 30: 229–231.
7. Dienstmann R, Pinto C, Pereira MT, Small IA, Ferreira CG.
Palliative percutaneous nephrostomy in recurrent cervical
cancer: A retrospective analysis of 50 consecutive cases. J Pain
Symptom Manage 2008; 36: 185–190.
8. Emmert C, Rassler J, Kohler U. Survival and quality of life
after percutaneous nephrostomy for malignant ureteric
obstruction in patients with terminal cervical cancer. Arch
Gynecol Obstet 1997; 259: 147–151.
9. Lau MW, Temperley DE, Mehta S, Johnson RJ, Barnard RJ,
Clarke NW. Urinary tract obstruction and nephrostomy
1070
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
drainage in pelvic malignant disease. Br J Urol 1995; 76: 565–
569.
10. Lee SK, Jones HW, 3rd. Prognostic significance of ureteral
obstruction in primary cervical cancer. Int J Gynaecol Obstet
1994; 44: 59–65.
11. Redaniel MT, Laudico A, Mirasol-Lumague MR et al. Ethnic-
ity and health care in cervical cancer survival: Comparisons
between a Filipino resident population, Filipino-Americans,
and Caucasians. Cancer Epidemiol Biomarkers Prev 2009; 18:
2228–2234.
12. Malave SR, Neiman HL, Spies SM, Cisternino SJ, Adamo G.
Diagnosis of hydronephrosis: Comparison of radionuclide
scanning and sonography. Am J Roentgenol 1980; 135: 1179–
1185.
13. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC,
Vandenbrouke JP. Strengthening the reporting of observa-
tional studies in epidemiology (STROBE) statement: Guide-
lines for reporting of observational studies. BMJ 2007; 335:
806–808.
14. Meyer JE, Yatsuhashi M, Green TH, Jr. Palliative urinary
diversion in patients with advanced pelvic malignancy.
Cancer 1980; 45: 2698–2701.
15. Buckley BSSC, McLernon DJ, Hannaford PC, Murphy AW.
The effect of different methods of cohort identification on
prognostic analysis: Survival in prevalent and incident
cohorts of people with first AMI derived from the same
population. J Clin Epid 2010 doi 10.1016/j.jclinepi.2010.01.017.
16. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology –
The Essentials, 3rd edn. Baltimore, MD: Williams and Wilkins,
1996.
17. Spahn M, Weiss C, Bader P, Frohneberg D, Studer UE,
Burkhard FC. The role of exenterative surgery and urinary
diversion in persistent or locally recurrent gynecological
malignancy – Complications and survival. Urologia interna-
tionalis 2010; 85: 16–22.
18. Kobayashi M, Ohno T, Noguchi W et al. Psychological dis-
tress and quality of life in cervical cancer survivors after
radiotherapy: Do treatment modalities, disease stage, and
self-esteem influence outcomes? Int J Gynecol Cancer 2009; 19:
1264–1268.
19. Miller BE, Pittman B, Case D, McQuellon RP. Quality of life
after treatment for gynecologic malignancies: A pilot study in
an outpatient clinic. Gynecol Oncol 2002; 87: 178–184.
© 2011 The Authors