UPJ ObstructionUPJ Obstruction

Zarine BalsaraZarine Balsara

HMS IVHMS IV

September 17, 2007September 17, 2007

CC: Left flank pain

HPI: 32 yoM

who presented to the BIDMC Emergency Department with acute, colicky left flank pain

with nausea and vomiting. Pain has

actually been long-standing and is exacerbated with large fluid intake.

PMH/PSH: none

Meds: none

ALL: none

Patient presentation

Patient presentation (cont.)

FH: non-contributory

SH: Bar owner; 2-4 alcoholic drinks/day

PE: AVSS in NADsignificant for left-sided palpable abdominal mass

Labs:BUN 15, Cr 1.0U/A: Neg

for LE and nitrite; occ

bacteria

5 RBC/hpf, 2 WBC/hpf

UrolithiasisUrolithiasis

HydronephrosisHydronephrosis

Benign tumor/cyst vs malignant tumor Benign tumor/cyst vs malignant tumor

PyelonephritisPyelonephritis/Renal abscess/Renal abscess

Renal infarctionRenal infarction

HematomaHematoma

Clinical differential diagnosis

UrolithiasisUrolithiasis

HydronephrosisHydronephrosis

Benign tumor/cyst vs malignant tumor Benign tumor/cyst vs malignant tumor

PyelonephritisPyelonephritis/Renal abscess/Renal abscess

Renal infarctionRenal infarction

HematomaHematoma

Clinical differential diagnosis

Our patient AG: axial non-contrast abdominal CT

Patient AGPACS, BIDMC

Axial CT of abdomen/pelvis without contrast at the level of the kidneys suggests hydronephrosis

of left kidney

prone

Hydronephrosis

of left kidney

Hydronephrosis

of left kidney

Our patient AG: axial non-contrast abdominal CT

Patient AGPACS, BIDMC prone

Axial CT of abdomen/pelvis without contrast at the level of the kidneys suggests hydronephrosis

of left kidney

8.05 cm7.70 cm

HU ~ 23

Hydronephrosis

of left kidney

Our patient AG: axial non-contrast abdominal CT

Patient AGPACS, BIDMC prone

Axial CT of abdomen/pelvis without contrast at the level of the kidneys suggests hydronephrosis

of left kidney

Non-obstructing 2mm calculus at UVJ

Our patient AG: axial non-contrast abdominal CT

Patient AGPACS, BIDMC prone

Axial CT of abdomen/pelvis without contrast at the level of the bladder reveals a small ureteral

calculus that is unlikely to be responsible for AG’s symptoms

Axial CT of abdomen/pelvis with contrast (pyelogram

phase) demonstrates delayed excretion of contrast from the left kidney

Perinephric

fat stranding

Dilated extrarenal

pelvis

Patient AGPACS, BIDMC prone

Our patient AG: axial contrast-enhanced abdominal CT

Contrast-filledextrarenal

pelvis

Our patient AG: axial contrast-enhanced abdominal CT

Patient AGPACS, BIDMC prone

Axial CT of abdomen/pelvis with contrast (pyelogram

phase) demonstrates delayed excretion of contrast from the left kidney

Patient AGPACS, BIDMC

Reformatted coronal CT of abdomen/pelvis with contrast (pyelogram

phase) illustrates severe hydronephrosis

of left kidney with clubbed calyces

Dilated extrarenal

pelvis

Our patient AG: coronal contrast- enhanced abdominal CT

“Clubbed” calyx

Hospital course

Admitted to hospital for pain control and IV hydration

Cystoscopy

and retrograde pyelogram

performedLeft uretero-pelvic junction (UPJ) obstruction

confirmedDouble J left ureteral

stent

placed to relieve

obstruction and reduce hydronephrosis

Successful stent placement confirmed on KUB

Our patient AG: left ureteral

stent on abdominal plain film

Double J ureteral

stent

Renal pelvis

bladder

Abdominal plain film confirms appropriate placement of stent within left ureter

supinePatient AG

PACS, BIDMC

Hospital course

Admitted to hospital for pain control and IV hydration

Cystoscopy

and retrograde pyelogram

performedLeft uretero-pelvic junction (UPJ) obstruction confirmedDouble J left ureteral

stent placed to relieve

obstruction and reduce hydronephrosis

Successful stent placement confirmed on KUB

MAG3 scan performed to evaluate differential renal function

Radionuclide MAG3 scan

Tc-99m

MAG3 IV bolusAcquire images Q1-2s for 1 min

Blood Flow Curves

KidneyAssess Renal Perfusion

t1/2

< 10 min No obstruction

t1/2

> 20 min Obstruction present

Acquire images Q30-60s for 30 min

Dynamic Curves

Assess Tubular Absorption

Assign ROI

Acquire images Q30-60s for 20 min

Lasix

Curves

Assess Excretion

Administer 20-40mg Lasix

** Radionuclide MAG3 scan allows evaluation of renal function and the presence of obstruction

Our patient AG: radionuclide MAG3 scan, flow curves

L RL R

MAG3 scan (Flow phase)

L R

** Flow curves demonstrate comparable renal arterial blood flow to both kidneys

Patient AGImages courtesy of

Dr. Kevin Donohoe

MAG3 scan (Dynamic phase)

L R Left: 59% function

Concentration phase

Right: 41% function

L R

Our patient AG: radionuclide MAG3 scan, dynamic curves

** Dynamic curves demonstrate similar tubular function of both kidneys

Patient AGImages courtesy of

Dr. Kevin Donohoe

MAG3 scan (post-lasix)

L R

L R

Excretion of tracer by left kidney is significantly slowed

Our patient AG: radionuclide MAG3 lasix scan

** Lasix

scan reveals partial UPJ obstruction of left kidney

Patient AGImages courtesy of

Dr. Kevin Donohoe

Our patient AG: Radionuclide MAG3 scan, real time movie

MAG3 dynamic flow curves MAG3 flow curvespost-lasix

Patient AGImages courtesy of

Dr. Kevin Donohoe** Flow through renal collecting system is shown in real time and illustrates partial

UPJ obstruction of left kidney

Patient follow-up

Patient continued to have left flank pain despite ureteral

stent placement

He underwent elective dismembered pyeloplasty of left kidney 3 weeks later

Patient’s pain was relieved following pyeloplasty

Follow-up IVP 7 months later showed resolution of obstruction despite a persistently dilated left renal pelvis

Repair of UPJ obstruction: dismembered pyeloplasty

Kausik

and Segura. Int

Braz

J Urol. 2003; 29:3-10.

Ureteropelvic

junction (UPJ) obstruction

Texas Pediatric Surgical Associates, http://www.pedisurg.com/PtEduc/Antenatal_Hydronephrosis.htm

** UPJ obstruction is defined as a functional or anatomic obstruction to urine flow from the renal pelvis to the proximal ureter

that leads to symptoms and/or renal damage

Congenital (Primary) Acquired (Secondary)

Causes of UPJ obstruction

Failure of recanalization

of ureter

at UPJ

Abnormal collagen/muscle within ureter aperistalticsegment at UPJ (likely etiology in our patient **)

Aberrant crossing renal vessels

High ureteral

insertion

Vesicoureteral

reflux ureteralscarring and strictures

Atypical mucosal valves, polyps, true ureteral

strictures

Stricture/stenosis

from repeated injury, manipulation, infection, inflammation

Obstructive stones

Obstructing tumor

Retroperitoneal fibrosis

** Histologic

analysis of our patient’s diseased UPJ segment revealed muscular hypertrophy and perifascicular

fibrosis of the muscularis

propria

consistent with this etiology of UPJ obstruction.

**

Radiology has been particularly useful in evaluating whether aberrant crossing vessels are responsible for UPJ obstruction within a patient

Congenital (Primary) Acquired (Secondary)

Causes of UPJ obstruction

Failure of recanalization

of ureter

at UPJ

Abnormal collagen/muscle within ureter aperistaltic segment at UPJ

Aberrant crossing renal vessels **

High ureteral

insertion

Vesicoureteral

reflux ureteralscarring and strictures

Atypical mucosal valves, polyps, true ureteral

strictures

Stricture/stenosis

from repeated injury, manipulation, infection, inflammation

Obstructive stones

Obstructing tumor

Retroperitoneal fibrosis

Lawler, L. P. et al. Radiographics

2005;25:121-134

Aberrant “crossing vessels”

** Aberrant “crossing vessels” can cross either anterior to or posterior to the ureteropelvic

junction and cause obstruction to urine outflow

Crossing vessels on axial contrast- enhanced helical CT with multiplanar

reconstruction

Mitsumori, A. et al. Radiographics

2000;20:1383-1393

hydronephrosis

crossing vessel

oblique sagittal curved anteriorcrossing vessels

ureter

UPJ

Mitsumori, A. et al. Radiographics

2000;20:1383-1393

Crossing vessels on axial contrast- enhanced helical CT with multiplanar

reconstruction

Complications of UPJ obstruction are varied

Progressive functional impairment of kidneysProgressive functional impairment of kidneys

Poor growth in infantsPoor growth in infants

Urinary stasisUrinary stasis

UTIs/pyelonephritisUTIs/pyelonephritis

StonesStones

HypertensionHypertension

Increased susceptibility to renal pelvis rupture with blunt Increased susceptibility to renal pelvis rupture with blunt

traumatrauma

Symptoms of pain, nausea, vomiting, and Symptoms of pain, nausea, vomiting, and hematuriahematuria, ,

especially with large fluid intake especially with large fluid intake DietlDietl’’ss crisiscrisis

Some surgical treatment options for UPJ obstruction

Open dismembered Open dismembered pyeloplastypyeloplasty

Laparoscopic Laparoscopic pyeloplastypyeloplasty

AntegradeAntegrade endopyelotomyendopyelotomy

PercutaneousPercutaneous access to renal calyx with access to renal calyx with antegradeantegrade placement of placement of

nephroscopenephroscope

Endoscopic incision of diseased UPJ segment with cutting Endoscopic incision of diseased UPJ segment with cutting

instrumentinstrument

Retrograde Retrograde endopyelotomyendopyelotomy

UreteroscopeUreteroscope advanced past diseased UPJ segment advanced past diseased UPJ segment

Holmium laser incision of diseased UPJ segmentHolmium laser incision of diseased UPJ segment

Acknowledgments

Dr. Dan AnghelsescuDr. Kevin DonohoeDr. David Graham

Dr. Gillian LiebermanNyca

Bowen

ReferencesGrasso M, Gitlin

JS, and Johnson GB. Ureteropelvic

junction obstruction. eMedicine

from WebMD. Last updated 05-22-06. Retrieved 09-13-07. http://www.emedicine.com/med/topic3074.htm

Kausik

S and Segura JW. Surgical management of ureteropelvic

junction obstruction in adults. Int

Braz

J Urol. 2003; 29:3-10.

Lawler LP, Jarret

TW, Corl

FM, and Fishman EK. Adult ureteropelvic

junction obstruction: insights with three-dimensional multi-detector row CT. Radiographics.

2005; 25:121-134.

Mitsumori

A, Yasui

K, Akaki

S, Togami I, Joja

I, Hashimoto H, Kumon

H, and Hiraki

Y. Radiographics. 2000; 20:1383-1393.

Texas Pediatric Surgical Associates, http://www.pedisurg.com/PtEduc/Antenatal_Hydronephrosis.htm

Weiner J, Yang B, and Gaca

A. Ureteroplevic

Junction Obstruction, Congenital. eMedicine

from WebMD. Last updated 08-03-2007. Retrieved on 09-13-07. http://www.emedicine.com/radio/topic730.htm