1. Where is the connection?
Renal failure and Cervical cancer

2. Clinical Scenario
Mrs X 50 Yrs
Presented with post coital bleeding and vaginal discharge
Found 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

3. Presentation
2years after finishing her chemo radiotherapy Mrs X has now
been referred to you, the oncologist, by her GP with the
following symptoms:
Tiredness
Anorexia and nausea
Oliguria
Some mild rectal bleeding
What will you do?

4. Course of Action
History 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 examination
PR examination
Abdominal examination

5. Initial Investigations
Bloods:
FBC, U+E, LFT, TFT, CRP
CT abdomen and pelvis
CxR

6. Results
FBC: Mild normochromic normocytic anaemia
U+E: Raised creatinine, urea and potassium
LFT, TFT, CRP normal
CT or MRI pelvis: Pelvic mass appearing to compress both
ureters
CxR: normal

7. Impression
Investigations 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 obstruction
PET scan to look for metastatic disease

8. Management
Curative or palliative depending upon stage and prognosis
Tumour:
Surgical resection
Chemo and/or radiotherapy
Renal failure
Relieve obstruction either by treating the tumour or insert a
ureteric stent
Nephrostomy
Urinary diversion (uretroenteric anastamosis)
Depending on severity of ARF, manage hyperkalaemia.
Consider dialysis

9. JJ stent
Nephrostomy

10. New treatments
Double 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

11. Prognosis
Tumour 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%

12. References
Obstetrics and Gynaecology 2nd
ed. Lawrence Impey.
Yachia D. Recent advances in ureteral stents. Curr Opin
Urol 2008; 18(2):241-246.