Ureteropelvic Junction Obstruction Workup

  • Author: Michael Grasso III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Aug 23, 2011
 

Laboratory Studies

  • All patients with possible ureteropelvic junction (UPJ) obstruction should be evaluated with a CBC count, coagulation profile, electrolyte level, and assessment of overall renal function with BUN and creatinine and urine culture.
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Imaging Studies

  • Renal ultrasonography and VCUG are performed in children with suspected UPJ obstruction.Intraluminal sonogram of ureteropelvic junction obIntraluminal sonogram of ureteropelvic junction obstruction demonstrating multiple crossing vessels.
  • Historically, IVP was used to evaluate patients with possible UPJ obstruction. However, in the evaluation of a child with a hydronephrotic kidney, diuretic renography has taken the place of IVP. The benefits of diuretic renography are that iodine-based intravenous contrast is not used, radiation exposure is minimal, and renal function can be better quantified. The disadvantage of the nuclear medicine scan is that insight into renal anatomy is not obtained.
  • In 1992, the Society for Fetal Urology and the Pediatric Nuclear Medicine Council published guidelines for the "Well-Tempered Diuresis Renogram." Standardized protocols for hydration, radiopharmaceuticals, bladder catheterization, diuretic dose, timing of diuretic, and determination of clearance half-time (T 1/2) have been established.
  • Functionally significant obstruction is often diagnosed with diuretic renal scanning. The conventional renographic criteria include a flat or rising washout curve after diuretic with T 1/2 of greater than 20 minutes and differential function of less than 40. The differential function is important in determining the need for intervention, especially in asymptomatic patients, and in selecting the appropriate treatment (pyeloplasty vs nephrectomy). Poorly functioning kidneys (< 10%) are often best treated with nephrectomy. Nuclear medicine scanning is also used to assess outcomes after surgical intervention.
  • The evaluation of ureteral anatomy is difficult with nuclear medicine renal scanning. In adult patients, IVP is more commonly used to outline this anatomy and can often replace nuclear medicine scanning altogether. Multidetector CT scanning with 3-dimensional reconstruction may be used to help establish the anatomy of UPJ obstruction and associated vessels. In children, retrograde ureteropyelography is sometimes performed to define the entire ureter just prior to surgical repair. Intravenous pyelogram demonstrating ureteropelvic Intravenous pyelogram demonstrating ureteropelvic junction obstruction with dilatation of the collecting system and lack of excretion of contrast. Retrograde pyelogram demonstrating ureteropelvic jRetrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to annular stricture. Retrograde pyelogram demonstrating ureteropelvic jRetrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to crossing vessels.
  • Contrast-enhanced color Doppler imaging is recommended by some as a useful imaging modality for the detection of crossing vessels in patients with UPJ obstruction.
  • Dynamic contrast-enhanced magnetic resonance urography (MRU) is the latest imaging modality used in assessing UPJ obstruction. In children, this study offers the advantages of no radiation exposure and excellent anatomical and functional details with a single study. The study also provides details of renal vasculature, renal pelvis anatomy, location of crossing vessels, renal cortical scarring, and ureteral fetal folds in the proximal ureter. Recent criteria for diagnosis of UPJ obstruction on MRU include fluid levels on delayed contrast-enhanced scans and the presence of swirling contrast material on the dynamic images. MRU using a time-resolved, data-sharing 3-dimensional contrast-enhanced technique can demonstrate ureteral peristalsis and permits quantification of ureteral peristaltic frequency.[5]
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Diagnostic Procedures

  • When the workup results are equivocal, a Whitaker antegrade pressure-flow study may be performed to further evaluate for UPJ obstruction.
    • This test begins with the placement of a small-diameter nephrostomy tube through the back and directly into the kidney.
    • Dilute contrast medium is instilled, and the intrarenal collecting system is pressure-monitored. Under fluoroscopy, the UPJ is assessed and drainage through this segment is defined.
    • While function cannot be assessed, relative resistance and pressure within the renal pelvis can be measured. High intrarenal pressures define obstruction, while low pressures in the presence of hydronephrosis are consistent with normal variance. This is particularly useful in large dilated systems in which the renal pelvis must be completely full prior to drainage assessment. In this setting, nuclear medicine scanning can yield false-positive results.
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Contributor Information and Disclosures
Author

Michael Grasso III, MD  Director of Endourology, Lenox Hill Hospital; Professor and Vice Chairman, Department of Urology, New York Medical College

Michael Grasso III, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, Medical Society of the State of New York, National Kidney Foundation, Société Internationale d'Urologie (International Society of Urology), and Society of Laparoendoscopic Surgeons

Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Coauthor(s)

Jacob H Cohen, MD, MPH  Fellow in Endourology, Lenox Hill Hospital

Disclosure: Nothing to disclose.

Srinivas Rajamahanty, MD, MCh  Staff Physician, Department of Urology, Westchester Medical Center, Valhalla, New York

Disclosure: Nothing to disclose.

Jordan S Gitlin, MD  Assistant Professor, Department of Urology, Albert Einstein College of Medicine-Yeshiva University; Consulting Staff, Pediatric Urology Associates PC

Jordan S Gitlin, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association

Disclosure: Nothing to disclose.

G Blake Johnson, MD  Consulting Staff, Middleton Urology Associates

G Blake Johnson, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Allen Donald Seftel  MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel is a member of the following medical societies: American Urological Association

Disclosure: lilly Consulting fee Consulting; sanofi-aventis Consulting fee Consulting; auxilium Consulting fee Consulting; solvay Consulting fee Consulting; plethora Grant/research funds clinical trial; endo Consulting fee Consulting; nature publishing journal editor

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shlomo Raz, MD  Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

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Intravenous pyelogram demonstrating ureteropelvic junction obstruction with dilatation of the collecting system and lack of excretion of contrast.
Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to annular stricture.
Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to crossing vessels.
Intraluminal sonogram of ureteropelvic junction obstruction demonstrating multiple crossing vessels.
CT scan without contrast demonstrating severe left-sided hydronephrosis secondary to ureteropelvic junction obstruction.
CT scan with intravenous contrast demonstrating pooling of contrast and delayed excretion of contrast from a left-sided ureteropelvic junction obstruction.
Intraluminal sonogram demonstrating the renal vein surrounding the ureteropelvic junction and causing extrinsic compression and obstruction.
 
 
 
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