OBJECTIVE To assess the efficacy of urinary diversion (internal v external) in the management of ureteral obstruction secondary to pelvic malignancies and the patients' quality of life after diversion. METHODS Thirty-seven patients presented with malignant ureteral obstruction secondary to primary neoplasms of the pelvis or metastatic disease of the pelvis and retroperitoneum and underwent urinary diversion. Patients were categorized into two groups according to the success (Group I) or failure (Group II) of internal stent drainage. Successful drainage was defined according to either radiologic study or the serum creatinine concentration in the case of a solitary kidney. "Useful life" was defined as satisfying four criteria: (1) little or no pain; (2) no complications; (3) ability to return home for at least 2 months; and (4) full mental capacity. RESULTS Of the total patient population, 58% ultimately failed internal diversion. Nearly all (92%) of the cervical cancer patients required external drainage. Complications were seen in 10% of the stented patients and 13% of the patients with a percutaneous nephrostomy tube, but no procedure-related deaths occurred. Useful life was achieved by 84% of all patients. CONCLUSIONS Antegrade drainage should be considered initially in patients who are likely to fail internal drainage (i.e., those with cervical cancer). The majority of these patients have a reasonably good quality of life, and intervention is most often warranted.