Pelvic tumors can produce urinary symptoms, obstruction, and renal failure. Urinary obstruction often requires palliation or urinary diversion before systemic therapy can be delivered. An algorithm for management of these complications based on factors such as sensitivity to chemotherapy, and expected survival can be used to develop a reasoned approach to the management of pelvic disease. Before intervening in urinary obstruction, the first question that should always be asked is, “To what end?” Relief of urinary obstruction does not relieve pelvic symptoms attributed to infiltration of tumor. Thus, the relief of urinary obstruction should principally be used in those subsets of patients in whom cancer control can be expected.

Methods for relief of urethral obstruction are principally retrograde or antegrade. Rarely, in the era of interventional radiology, is open surgical diversion considered as a treatment option. Retrograde placement of urethral stents by cystoscopy is frequently used. The advantage of this approach is the avoidance of external catheters and urinary diversion. However, the success of such an approach frequently is difficult to assess. In some subsets of patients, ureteral stents cannot be placed because of acute angulation and lack of control of the primary tumor. The approach that is frequently used by many physicians is a percutaneous nephrostomy. Percutaneous nephrostomies are safe and reliable procedures when performed by experienced radiologists in properly selected patients. Bilateral percutaneous nephrostomies are best placed in renal failure when a delay in response to therapy is expected or nephrotoxic cytotoxic agents are used. Coagulopathy and patient preference are the two major contraindications to percutaneous nephrostomies. The risk of such procedures is exceedingly low and complications as a consequence of malplacement occasionally occur, such as bleeding into the pelvocaliceal system producing an obstructive uropathy. Both the percutaneous nephrostomy and retrograde ureteral stents often result in urinary tract infection.

On occasion, even obstructive uropathy from urethral obstruction expectant management could be considered, as in situations where highly responsive tumors are expected to respond quickly and result in relief of urinary obstruction. Examples include lymphomas and germ cell tumors where the placement of nephrostomy can be delayed in hopes of an excellent response resulting in relief of the tumor. Tumors of intermediate response rate that can produce obstructive uropathy and where a nephrostomy is often considered are ovarian, urothelial tumors, and, rarely, breast cancers. If bilateral obstructive uropathy is present, relief with percutaneous nephrostomy is generally recommended.

For patients with urethral obstruction, the symptoms are often more difficult to relieve. While percutaneous nephrostomies can divert urinary drainage, they do not result in relief of the pelvic symptoms related to urgency, hematuria, dysuria, and frequency. In such instances, transurethral resection of the prostate can be considered, as can a simple placement of a percutaneous nephrostomy or suprapubic tube. Although relieving the urinary obstruction, such management often fails to relieve the severe pelvic symptoms related to progressive disease at this site. This management of these severe symptoms is a therapeutic challenge for clinicians.