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Ureteropelvic Junction Obstruction Workup

  • Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Jan 30, 2015
 

Laboratory Studies

All patients with possible ureteropelvic junction (UPJ) obstruction should be evaluated with the following laboratory studies:

  • Complete blood cell count (CBC)
  • Coagulation profile
  • Electrolyte levels
  • Renal function assessment - Blood urea nitrogen (BUN) and serum creatinine levels
  • Urine culture
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Imaging Studies

Neonates who present with hydronephrosis should be fully evaluated with voiding cystourethrography (VCUG; to rule out vesicoureteral reflux) and renal ultrasonography (see image below) soon after birth. These patients should also be placed on prophylactic antibiotics (amoxicillin 15 mg/kg) to prevent urinary tract infections (UTIs), especially while diagnostic imaging is being performed.

Intraluminal sonogram of ureteropelvic junction ob Intraluminal sonogram of ureteropelvic junction obstruction demonstrating multiple crossing vessels.

If renal ultrasonography demonstrates hydronephrosis without reflux on VCUG, a diuretic renal scan (mercaptotriglycylglycine [MAG-3], diethylenetriamine [DTPA], or dimercaptosuccinic acid [DMSA]) should be performed to quantify relative renal function and to define the extent of obstruction. Renal ultrasonography and VCUG are performed in children with suspected UPJ obstruction.

Historically, intravenous pyelography (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."[3] 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. See the images below.

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 j Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to annular stricture.
Retrograde pyelogram demonstrating ureteropelvic j Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to crossing vessels.

Multidetector computed tomography (CT) scanning with three-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. 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 three-dimensional contrast-enhanced technique can demonstrate ureteral peristalsis and permits quantification of ureteral peristaltic frequency.[4]

Contrast-enhanced magnetic resonance angiography (MRA) had a sensitivity of 85%, a specificity of 80%, and a positive predictive value of 0.8 for the diagnosis of aberrant and obstructing renal arteries in a retrospective study of 19 pediatric patients with UPJ obstruction.[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 Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital

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

Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.

Coauthor(s)

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, 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, American Urological Association

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

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

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, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

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, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

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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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