SEPTEMBER, 1966

URETEROPELVIC JUNCTION OBSTRUCTION

By CHARLES E. SHOPFNER, M.D.
KANSAS CITY, MISSOURI
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U RETEROPELVIC junction obstruc- pelvic dilatation in relationship to that

tion is an established and often made caused by obstruction. A classification of
diagnosis. Roentgenologic and surgical the dilated renal pelvis and criteria for the
findings have given rise to conflicts con- various types will be presented.
cerning the etiology with no complete
agreement on any one cause. Stenosis, MATERIAL
valve, blood vessel and fibrotic band have
Thirty five patients with dilatation of
been variously given as causes for the ob-
the renal pelvis, typical of ureteropelvic
struction.5 May&7 mentions anomalous
obstruction, have been observed in over
blood vessels as a common cause for this
350 examined by intravenous pyelography
condition, but Hahn1’ states that fibrotic
and cystourethrography for urinary tract
strictures and bands may be mistaken for
infection. Twenty-nine of these had non-
anomalous vessels and reports cases of un-
obstructive dilatation, whereas the remain-
improved hydronephrosis following divi-
ing 6 had organic obstruction. The patients
sion of blood vessels which were thought at
were between the ages of 2 and io years ex-
surgery to have caused the obstruction.
cept for one I 6 year old boy and one i 8
In i 961 , Gross and Sanderson8 stated
month old girl. Four of the 29 with non-
that ureteral and pelvic dilatation is oc-
obstructive dilatation and all 6 with organic
casionally produced by the vesicoureteral
obstruction had surgical exploration.
reflux phenomenon and cautioned of the
high incidence ofreflux in patients showing
PATHOGENESIS
ureteropelvic obstruction on excretory uro-
NONOBSTRUCTIVE DILATATION
grams. In 1962, Hutch et al.’3 made the ob-
servation that some renal pelves, overfilled Renal pelvic dilatation and kinking or
by refluxed urine, were roentgenologically narrowing at the pelviureteric junction are
identical in appearance to “primary” the classic criteria which have been used in
ureteropelvic obstruction. the past for a diagnosis of ureteropelvic
Lack of correlation between the roentgen junction obstruction (Fig. i, A, B and C).
and surgical findings is common and has Such an appearance is not pathognomonic
been emphasized by Emmett.5 Jonathan of organic obstruction as shown in this
and Magri’6 found no obvious abnormality study. Twenty-nine patients without ob-
of the pelviureteric junction in 35 of 55 struction exhibited features of the renal
patients operated on for ureteropelvic junc- pelvis which, ifconsidered alone, were iden-
tion obstruction. It is evident that some tical to those of classic ureteropelvic ob-
patients are diagnosed and operated on for struction (Fig. 2, ii, B and C).
a roentgenologically apparent ureteropelvic Generalized nonobstructive dilatation of
junction obstruction which does not ac- the renal collecting system has been estab-
tually exist. An explanation for this situa- lished as an entity by several investigators.
tion has been provided by a group of pa- Some believe that infection is one factor
tients who exhibited features of the upper causing such dilatation,15’18”9’2’ whereas
urinary tract resembling ureteropelvic junc- others have considered reflux as the only
tion obstruction yet in whom obstruction etiologic agent.6’8”3 Tubular structures,
was obviously absent. such as the ureter, become tortuous and
The purpose of the author is to discuss elongated as their diameter increases. The
the pathogenesis of nonobstructive renal tortuosity occurs in the areas of greatest

148
 ‘sO!.. 98, No, I Ureteropelvic junction Obstruction ‘49
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lic. I. A iO ‘ear old male who has had intermittent abdominal pain since the age of years. Left flank pain
has been present since the age of 14 years at which time the diagnosis of pyelonephritis was first made.
(A) Classic appearance of ureteropelvic obstruction. The exact junction of the ureter with the Pelvis is not
demonstrated. (13 and C) Roentgenograms of the injected surgical specimen showing the ureter apparently
having a high insertion i1 relation to the renal pelvis. The uppermost 3 cm. of the ureter was encased in and
bound to the renal pelvis by a dense mass of calcification and fibrosis which microscopically showed chronic
i nfl 1i11 m a tion.
 i#{231}o Charles E. Shopfner SEPtEMBER, 1966
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 S 01,. 98, No. I Ureteropelvic junction Obstruction ‘4’
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lic. . Intravenous pvelogram

of a tear old male with bilateral pyelonephritis. There was no reflux or
obstruction I)\ cystographv.
demonstrated (A) \ovem her 6, 1962. Each ureter is segnien tally dilated and
tortuous. The left ureter has a pronounced kink at the ureteropelvic junction which is the initial segment
to kink. \linimal kinking is also present at the left ureterovesical area. (B) June ,, 196,1. The segmental
dilatation and tortuositv have improved after 7 months of antibiotic therapy. ‘l’he kink at the left urettro-
vesical area has disappeared and the one at the ureteropelvic junction has decreased.

iflOl)ilitV Ifl(l produceS kinks at the site of study, 23 of the 29 patients with nonol)-
junction of the mobile with tile more fixed structive renal pelvic dilatation simulating
portions. The points of relative fixation in obstruction had reflux.
the ureter are at the ureteropelvic junction, Hanlev’#{176} studied excretory pyelograms of
l)011\’ pelvic inlet and ureterovesical junc- 500 normal individuals and found that 90
tioll -areas at which most ureteral oh- per cent of the renal pelves were of the
structions are described. open type and that 10 per cent were of the
The ureter kinks initially at the uretero- closed type. After forcing fluids orally in
pelvic junction during the early’ stages of patients with both types of pelves, he ob-
dilatation and tortuositv (Fig. 3, i and served that the increased urine flow caused
B). Progressive dilatation, elongation, and dilatation of the closed pelves but not of
tortuositv produce kinks at other sites, the open ones. ihis suggests that the closed
causing the ureter to fold upon itself 1w as type of renal pelvis is susceptible to earlier
much as 4 cm. (FIg. 4). and more severe dilatation and may be the
Infection and reflux; then, are responsi- one which will most often S11OW the ap-
he for the tortuosit and kinking which pearance suggesting obstruction. In our
results in the roentgen appearance of material u reteropelvic 0l)s tru c tion was
ureteropelvic obstruction. The ureter below simulated in both types of pelves with the
the apparent obstruction is dilated, tor- severity being related to tile degree of
tuous and kinked in all instances but not all ureteral dilatation, tortuositv and kinking
will show vesicoureteral reflux. In this rather than to the type of pelvis.
 152 Charles E. Shopfner SEPTEMBER, 1966

Another had a normal right kidney at the

time that severe obstruction was demon-
strated on the left only. Seven years later
the patient developed obstruction in the
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previously normal right kidney (Fig. 6, A

and B). This experience in these patients
indicates that infection and reflux play a
major role in the pathogenesis of uretero-
B pelvicjunction obstruction.
As explained earlier, infection and reflux
cause pelvic and ureteral dilatation with
secondary tortuositv and kinking of the

k ureter
periureteri
phritis
(Fig.

cause
tis
3, A and
which
exudation,
B).
accompany
The

necrosis,
ureteritis
pyelone-
stenosis
and

and adhesions. The adhesions between the

adjacent and parallel segments of the tor-
tuous ureter, if severe enough, may pro-
duce secondary obstruction by compression
or acute kinking. Stenosis due to mucosal
and intramural inflammatory necrosis may
occur at the sites of ureteral kinking,
expecially at the ureteropelvic junction.
The findings in patients who were
operated on for nonobstructive dilatation
which simulated obstruction confirm the
role played by infection and reflux. All
showed fibrotic thickening of the ureter
and periureteral i nflammatorv adhesions,
FIc. 4. Cystogram of a 6 year old female with vesi-
most marked at the sites ofkinking (Fig. 7,
coureteral reflux revealing extreme dilatation,
tortuosity, and kinking ofeach ureter. The wall of
A and B). The fact that the renal artery is
the ureter lies in an adjacent and parallel position sometimes found in relation to the stenosis
and may become adherent. The usual sites of and periureteral adhesions is purely an
kinking are well demonstrated. anatomic coincidence. It is easily encased
within the periureteral inflammatory pro-
onsrRuc’IIvE DILATATION cess because ofits natural proximit’ to the
The etiology of tile pelvic dilatation in 6 ureter (Fig. 8, A and B).
patients with roentgenologically and surgi- The ureter was dilated, tortuous, and
cally proven ureteropelvic obstruction was kinked below the obstruction in all 6 pa-
fibrotic bands in 4 and intrinsic stenosis in tients with adhesions and stenosis, as it WS

. The practice of utilizing intravenous in those with nonobstructive dilatation.

pyelography and cystourethrography in the The 4 patients with adhesive ureteropelvic
diagnostic work-up of children with urinary obstruction had fibrotic thickening of the
tract infection has resulted in a better ureter which was fixed in its bed by periure-
understanding of the pathogenesis of this teral inflammatory tissue, as it was in those
type of obstruction. Four of the 6 patients with nonobstructive dilatation due to in-
had previous examinations which showed fection and reflux.
no ureteropelvic obstruction but did show One of the patients with ureteropelvic
reflux and nonobstructive dilatation of the stenosis had previous intravenous p’elogra-
renal pelvis and ureter (Fig. 5, 1, B and C). phy and cvstographv that showed ureteral
 Vo. 98, No. i Ureteropelvic junction Obstruction 143

i’ ‘‘
I
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stenosls. The ureter was fibrotIc, thIckened,

dilated and fixed in its bed by periureteral inflammatory adhesions.
 154 Charles E. Shopfner SEPTEMBER, 1966
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lIc. 6. A 5 rear old female with a year history of recurrent urinary tract infection. (A) MaY 17, 19#{231}7.
Retrograde pyelogram demonstrating extreme and typical left ureteropelvic junction obstruction. ‘Ihe
ureter is moderately dilated below the obstruction. The intravenous pyelogram at this time showed no
function on the left and a normal kidney on the right. The ureter was bound to the pelvis by dense fibrous
adhesions and was thickened and fibrotic. The adhesions had obstructed the ureteropelvic junction and
microscopically there was chronic inflammation. (B) February i I, Io65. Retrograde pvelogram made 7
years and months after A. There is typical right ureteropelvic junction obstruction due to inflamniatort’
fibrotic adhesions binding the upper ureter to the pelvis. The ureter below the obstruction is dilated and
was thickened by fibrosis.

dilatation and kinking due to infection and with nonobstructive dilatation aild ad-
reflux (Fig. 5, A, B and C). The other had hesive obstruction.
dilatation of the ureter below the stenosis
shown in examinations subsequent to CLASSIFICATION OF RENAL lELVIC
pveloplasty (Fig. 9, A, B and C). Each pa- DI LAI’ATION

tient with stenosis had fibrotic thickening The conventional concept that renal
and periureteral adhesions similar to those
pelvic dilatation and ureteropelvic kinking
TABLE I or narrowing are due to organic obstruction
on a congenital basis is probabi’ not valid.
CLASSIFICATION OF RENAL PELVIC DILATATION Nonobstructive dilatation and the role of
infection and reflux in the pathogenesis of
I. Non-obstructive 1)ilatation
both nonobstructi ye and obstruc tive pelvic
A. Vesicoureteral Reflux
B. No Vesicoureteral Reflux dilatation necessitate a new approach to
II. Obstructive Dilatation this problem. A classification ofthe types of
A. Secondary dilatation of tile renal pelvis which takes
I. Vesicoureteral Reflux into consideration tile above mentioned
2. No Vesicoureteral Reflux
factors is presented in Table i.
B. Primary
The division of the dilated renal pelvis
 ‘sOL. 98, No. i Ureteropelvic junction Obstruction 145
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lic. 7. A tear old female recurrent with urinary known

tract infection for years. (A) Intravenous pyelo-
gram shos Poorly I)ilaterally.
excreting The univ indication
kidneys that there might be nonobstructive
(likltlttU)il and retlux is segmental dilatation of the lower third of the right ureter. (B) ‘I’he refluxing cysto_
gram shows marked dilatation of the entire right ureter and kinking at the ureteropelvic junction. l)rain-
age from the pelvis into the ureter was prompt. librotic thickening of the ureter and periureteral adhesions,
particularly at the site of kinking, were found at surgery.

into Iloflobstr,ictive anil obstructive types demonstrate reflux on one occasion is not
is Illade 1)ecause tile concept that dilatation absolute evidence that it may not occur at
does Ilot alwa’s indicate obstruction is an otiler times. In either instance, however,
unfamiliar one. Delayed renal excretion the treatment should be medical and the
and po()r pelvic drainage are established response of the dilatation is more likely to
criteria ofobstruction, l)ut there has been a be favorable if reflux is absent (Fig. 3, /1
ten(lencv to ignore tileir absence and con- and B). Reflux, if present, may respond to
sider all dilatation to be obstructive. medical treatment, but, ifnot, a reflux cor-
\esicoureteral reflux is aflotiler useful recting operation may be indicated.
11leI?lS of deternlining i f dilatation is oh- That renal pelvic dilatation is caused by a
structive. There are nanv instances in secondar’ obstruction (Type Il-A) is not
which tile presence ofobstructive dilatation an entirely new concept. lilere ilave been
is equivocal in tile excretory pvelogram and scattered reports of cases with inflamma-
copious reflux on cvstographv fills tile renal tory ureteral obstruction.4’ Vesicoure-
pelvis. Prompt drainage of the reflux filled teral reflux in this group has etiologic
pelvis indicates absence of obstruction. significance since its presence is a strong
tile presence of reflux in nonobstructive indication tilat tile reflux and infection are
pelvic dilatation has etiologic, tilerapeu tic the causes of the obstruction.
and prognostic significance. It ilas already Reflux also has important therapeutic
l)eefl stated that reflux is one of tile causes considerations in this group. Surgical at-
of nonobstructive dilatation. Failure to tempts to correct the obstruction at the
 i#{231}6 Charles E. Shopfner SEITEMBIIR, 1966
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Fic. 8. .5 , year old male with a history

tract infection ofurinary
for i year. (A) Intravenous pvelogram shows
a relatively normal renal with no sign of obstruction.
collecting system (B) Right ureteral (lilatation and
ureteropelvic kinking are revealed by the reflux in the cystogram. Pelvic drainage was adequate. Periure-
teral adhesions at the kinked ureteropelvic junction were found at operation. The renal artery as encased
in the adhesions but neither caused obstruction.

ureteropelvic junction probably will fail if be directed toward tile existing infection
reflux is present and uncorrected because and the generalized ureteral dilatation,
the pathogenetic situation remains un- which niay be refluxing, l)efore attention is
changed. If reflux is absent, a dilated, given to the secondart’ ureteropelvic oh-
tortuous ureter below the obstruction struction. It may’ not alwat’s be possible to
signifies tilat infection and reflux have been completely eradicate in fection by medical
previously present and the ureteral dilata- fl’l anagement alone. Several ill ‘sTestiga-
non is an irreversible residual. Surgical re- tors’’2’3’12’2#{176} have designed operations by
lief of tile ureteropelvic obstruction would which to correct reflux and reconstruct tile
again only recreate the pathogenetic situa- dilated ureter, and thus assist in eradicat-
tion, i.e., an open ureteropelvic junction ing refractor’ infection. lilis approacil to
With a dilated and tortuous lower ureter. secondary, obstructive dilatation of the
The results of surgical attempts to cor- renal pelvis will also guard against areas of
rect this type of obstruction have been existing stenosis and kinks in the lower
poor. It is felt that the dilated ureter below ureter and should improve the surgical re-
the obstructive point, with or without suits.
reflux, is the major factor responsible for Primary obstructive renal pelvic dilata-
the disappointing results. Treatment should tion (Type Il-B) has proven to be ex-
 \OL. 98, No. Ureteropelvic junction Obstruction ‘57
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tremely rare when the wilOle problem is tion are that it occurs at a relatively early
considered in view of the concepts and age, is quite severe, and the ureter below
proposed classification presented in this is small from disuse (Fig. io). It is possible
paper. It should be regarded as being con- that this group will fall into the familiar
genital, wiletiler due to stenosis, band or category of the cystic dysplasias of the
vessel. Tile criteria for this type of obstruc- kidney, i.e., cystic hydronephrotic, cystic
 i 8 Charles E. Shopfner SEPTEMBER, 1966

DISCUSSION

Gondos7 has stated that organic ureteral

stenosis and adherent kinks are most corn-
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monly the result of chronic pvelonepilritis

and should be considered an indication of
such unless proven otherwise. He specifi-
cally excludes the ureteropelvic and tire-
terovesical areas. However, he reports 2
cases of stenosis and adherent kink of tile
body of the ureter in which tilere was also
narrowing of the ureteropelvic junction
that was considered congenital.
The relationship of the patilogeflesis of
nonobs tru c ti ye to secondary ohs tm c ti ye
dilatation of the renal pelvis indicates tilat
Gondos’ concept should be extended to in-
dude obstruction at tile ureteropelvic junc-
tion. Ureteral dilatation below the obstruc-
tive point and tile presence of vesicoureter-
al reflux in a given patient are specific signs
that the obstruction is acquired and secon-
dary to infection and its ravages; i.e., re-
flux, dilatation, tortuosity, kinking, pen-
ureteral fibrosis and intrinsic stenosis. It
seems likely that these same principles
apply to the ureterovesi cal obstruction.

SUMMARY

I. Thirty-five patients with renal pelvic

FIc. 10. A i month old male who presented with a
left flank mass. Intravenous pyelogram shows de- dilatation resem bling ureteropelvic ju nc-
laved excretion and crescents (arrows), which are tion obstruction have been studied to de-
usually due to opacified renal parenchyma corn- termine the pathogenesis.
pressed by dilated calyces. Severe stenosis of the 2. Twenty-nine of the patients had non-
ureteropelvic junction and cystic hydronephrosis
obstructive and 6 had obstructive dilata-
were found at operation. The ureteral body was
hypoplastic, indicating disuse. tion.
3. A classification of tile types of renal
hypoplastic and multicystic kidneys. Ure- pelvic dilatation is presented which has
teral stenosis and atresia are commonly but etiologic, therapeu tic and prognostic signi-
not invariably found with these conditions cance.
and the relationship of the two is not clear 4. Tile nonobstructive variety is a nlani-
at the present time. The presence of dys- festation of generalized renal collecting sys-
plastic renal elements, in association with tern dilatation in wilicil the pelvis, if con-
ureteropelvic obstruction, is thought to be sidered alone, exhibits features typical of
evidence in favor of the primary type be- uretenopelvic junction obstruction.
cause it indicates interference with the de- #{231}.
Ureteral dilatation, tortuosity and
velopment of the fetal or neonatal kidney. kinking with extrinsic and intrinsic fibrosis
These cases are not completely understood due to infection and reflux are the patho-
and it is anticipated that additional infor- genetic factors involved.
mation will be forthcoming to provide 6. Roentgen and surgical findings indi-
clarification. cate that the pathogenesis is the same in
 VOL. 98, No. Ureteropelvic Junction Obstruction 159

the nonobstructive and secondary ob- 8. GROSS, K. E., and SANDERSON, S. E. Cineure-
thrography and voiding cinecystography with
structive types ofrenal pelvic dilatation.
special attention to vesico-ureteral reflux.
7. Pri m ary obstru cti ye ureteropelvic Radiology, 1961, 77, 573-585.
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dilatation is rare and it is believed that 9. GUPTA, N. N. Abacterial pyuria producing bi-
renal pelvic dilatation is not always oh- lateral ureteric stenosis. Brit. M. 7., 1943, I,

structive or congenital. 1083-1097.

10. HANLEY, H. G. Pelvi-ureteric junction: cine-
pyelography study. Brit. 7. Urol., 1959, 3!,
Department of Radiology’
377-384.
Children’s Mercy Hospital I I. HAHN, E. V. Congenital hydronephrosis: review
1710 Independence Avenue
of literature with report of two cases. Arch.
Kansas City, Missouri
Surg., 1924, 9, 256-274.
I 2. HUTCH, J. A. Vesico-ureteral reflux in para-
The author expresses his appreciation to R. plegic: cause and correction. 7. Urol., 1952,
Parker Allen, M.D., for reviewing the manu- 68, 457469.
script and making helpful suggestions.
13. HUTCH, J. A., HINMAN, F. JR., and MILLER,
E. R. Reflux as cause of hydronephrosis and
chronic pyelonephritis. 7. Urol., 1962, 88,
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