Management of Right Ureteropelvic Junction Filling Defect in an 84-Year-Old Man
For an 84-year-old man with a right ureteropelvic junction (UPJ) filling defect on CT scan, endoscopic evaluation with ureteroscopy should be performed to directly visualize the lesion, obtain tissue diagnosis, and guide appropriate treatment. 1
Differential Diagnosis
- Ureteropelvic junction obstruction (UPJO) - A common cause of filling defects at the UPJ, characterized by impaired urine flow from the renal pelvis to the ureter 2
- Fibroepithelial polyp - Benign mesenchymal tumors that can arise at the UPJ, causing obstruction 3
- Urothelial malignancy - Must be ruled out, especially in elderly patients with filling defects 1
- Urinary calculi - Can present as filling defects and cause obstruction 1
Diagnostic Approach
Imaging Studies
Multi-phasic CT urography - First-line imaging for further characterization of the filling defect 1
- Provides detailed anatomical information about the UPJ and surrounding structures
- Can help identify potential causes of obstruction
MR urography (MRU) - Alternative if patient has contraindications to CT (renal insufficiency, contrast allergy) 1
- Provides good visualization of renal parenchyma
- May be combined with retrograde pyelograms for better collecting system detail
Retrograde pyelography - Useful to identify filling defects and evaluate the extent of obstruction 3
- Should be performed during ureteroscopy
Endoscopic Evaluation
- Ureteroscopy - Essential for direct visualization of the UPJ filling defect 1, 3
- Allows for polyp mapping along the ureter
- Enables evaluation of macroscopic appearance of any lesion
- Facilitates tissue sampling for pathologic diagnosis
Treatment Algorithm
1. Initial Management
- Safety guidewire placement - Should be used during endoscopic procedures to maintain access to the collecting system 1
- Antimicrobial prophylaxis - Administer prior to intervention based on prior urine culture results and local antibiogram 1
2. Treatment Options Based on Endoscopic Findings
For Benign Lesions (e.g., Fibroepithelial Polyps):
For single, pedunculated polyps:
- Holmium laser polypectomy with tissue retrieval for pathologic examination 3
For broad-based, multilobulated polyps:
- Consider surgical intervention with pyeloplasty 3
For Malignant Lesions:
- Obtain tissue for pathologic diagnosis 1
- Stone material should be sent for analysis if calculi are present 1
For UPJ Obstruction:
- Endopyelotomy - For mild to moderate obstruction without complex anatomy 1, 2
- Pyeloplasty - For severe obstruction or complex anatomy 2, 4
- Laparoscopic or robotic approach preferred over open surgery in suitable candidates
- Anderson-Hynes dismembered pyeloplasty has 90-100% success rate 5
Special Considerations for Elderly Patients
- Prioritize minimally invasive approaches when possible to reduce morbidity 2
- Assess renal function prior to intervention to guide management decisions 6
- Consider comorbidities that may affect surgical risk and recovery 2
- If purulent urine is encountered during endoscopy:
- Abort procedure
- Establish drainage with ureteral stent or nephrostomy tube
- Continue antibiotic therapy and obtain urine culture 1
Follow-up
- Post-intervention imaging based on findings and treatment performed 1
- For benign conditions: Follow-up imaging with ultrasound or CT scan to ensure resolution of obstruction 2
- For malignant conditions: More intensive surveillance based on pathology and stage 1
Pitfalls and Caveats
- Avoid immediate urethroplasty or complex reconstruction without proper diagnostic evaluation 1
- Do not dismiss filling defects in elderly patients as they may represent malignancy requiring prompt intervention 1
- Recognize that UPJ obstruction is not a single anatomic entity but can have multiple causes requiring individualized treatment approaches 6
- Be prepared to abort the procedure and establish drainage if infection is encountered 1