Ten Years of Tubes: Characterizing Delays in Definitive Management of Benign Ureteral Obstruction

Background: Ureteral obstruction (UO) may be managed initially with nephrostomy tubes (NT). Risks of long-term NT include pain, dislodgement, urolithiasis, and infection. For stone and malignancy-related UO, definitive management can lead to NT removal. However, access to and eligibility for ureteral reconstruction (UR) for benign ureteral stricture (BUS) (i.e., those caused by inflammation, radiation, or trauma) is not well defined. We evaluated the incidence and predictors of delays in referral for UR among patients with chronic NT at our tertiary referral center. Methods: We reviewed billing data from 1/2013 to 1/2023 at our institution for patients with at least two encounters for NT placement or exchange over a 2-year period. We excluded cases where NT was placed for urolithiasis, malignancy, or unrelated to UO. Demographics, medical history, and etiology of BUS, as well as time to urologic evaluation and UR, were recorded. Multivariable Cox regression of predictors for total time with NT was performed. Results: During the study period, 1381 patients underwent de novo NT placement, 756 had NT exchange, of whom 108 had BUS. Median time with NT was 9.7 month (3.2–40.5); 67 patients (63%) experienced unplanned encounters because of NT complications, and 31 patients (29%) underwent >10 NT exchanges. Thirty-eight patients (35%) underwent urologic evaluation >6 month after initial NT placement or were not referred. UR was ultimately performed for 49 patients (45%). On multivariable analysis, distance to facility, encounters for NT complications, and time to urologic evaluation remained significantly associated with total time with NT. Conclusions: Up to one-third of patients with BUS and NT at a tertiary referral center experience delays in referral for management, potentially mediated by geographic location. Future analyses of factors leading to prolonged NT duration, the impact of delays on eventual UR success, and costs to health systems and patients are warranted.