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Adult Ureteropelvic Junction Obstruction: Insights with Three-dimensional Multi–Detector Row CT¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science (L.P.L., F.M.C., E.K.F.) and the James Buchanan Urological Institute (T.W.J.), the Johns Hopkins Medical Institutions, 601 N Caroline St, Rm 3254, Baltimore, MD 21287-0801. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received February 23, 2004; revision requested April 14 and received June 23; accepted July 28. All authors have no financial relationships to disclose. Address correspondence to L.P.L. (e-mail: llawler@jhmi.edu).

View larger version (166K): [in a new window]   Figure 1a.  (a) Coronal volume-rendered multi-detector row CT angiogram shows the renal arteries. Note the two right renal arteries (arrowheads), with the lower-pole segmental artery (a common variant) arising directly from the inferior aorta. Long arrow = left renal artery, short arrow = left renal vein. (b) Coronal volume-rendered image shows the renal arteries (arrowheads), left renal vein (short arrow), and left gonadal vein (long arrow). (c) Coronal volume-rendered multi-detector row CT angiogram, obtained with slab editing to remove foreground and background tissues, shows an early-branching left renal vein (arrow) anterior to the renal artery (arrowhead).

View larger version (188K): [in a new window]   Figure 1b.  (a) Coronal volume-rendered multi-detector row CT angiogram shows the renal arteries. Note the two right renal arteries (arrowheads), with the lower-pole segmental artery (a common variant) arising directly from the inferior aorta. Long arrow = left renal artery, short arrow = left renal vein. (b) Coronal volume-rendered image shows the renal arteries (arrowheads), left renal vein (short arrow), and left gonadal vein (long arrow). (c) Coronal volume-rendered multi-detector row CT angiogram, obtained with slab editing to remove foreground and background tissues, shows an early-branching left renal vein (arrow) anterior to the renal artery (arrowhead).

View larger version (174K): [in a new window]   Figure 1c.  (a) Coronal volume-rendered multi-detector row CT angiogram shows the renal arteries. Note the two right renal arteries (arrowheads), with the lower-pole segmental artery (a common variant) arising directly from the inferior aorta. Long arrow = left renal artery, short arrow = left renal vein. (b) Coronal volume-rendered image shows the renal arteries (arrowheads), left renal vein (short arrow), and left gonadal vein (long arrow). (c) Coronal volume-rendered multi-detector row CT angiogram, obtained with slab editing to remove foreground and background tissues, shows an early-branching left renal vein (arrow) anterior to the renal artery (arrowhead).

View larger version (141K): [in a new window]   Figure 2.  Left UPJO and hydronephrosis in a 49-year-old woman. Coronal MPR image of the kidneys shows moderate hydronephrosis (L). Note how the image displays the mild asymmetric cortical thinning of the left kidney.

View larger version (132K): [in a new window]   Figure 3.  Coronal MIP image of a normal left kidney shows the left renal artery (long arrow) and intrarenal branch vessels, the left renal vein (short arrow), and the left gonadal vein (arrowhead). Note how the image depicts the small intrarenal vasculature.

View larger version (190K): [in a new window]   Figure 4.  Coronal volume-rendered multi-detector row CT angiogram of a normal kidney shows the depth and 3D relationships of the renal artery (long arrow) and renal vein (short arrow), both proximally and at the hilum.

View larger version (141K): [in a new window]   Figure 5.  Coronal volume-rendered multi-detector row CT angiogram shows a horseshoe kidney with four right renal arteries (white arrowheads) and three left renal arteries (black arrowheads, black arrow). Note the lateral rotation of the upper poles relative to the medial lower poles.

View larger version (152K): [in a new window]   Figure 6.  Hilar clock-face view. Oblique sagittal image obtained at the right renal hilum shows the radial distribution of the renal arteries and veins (arrows) as they enter the hilum around the exiting enhanced ureter.

View larger version (91K): [in a new window]   Figure 7.  Drawings show the vascular anatomy of the renal hilum and the anterior and posterior segmental divisions of renal perfusion. The common arterial variation implicated in UPJO—an inferior segmental artery arising directly from the aorta—is also shown.

View larger version (81K): [in a new window]   Figure 8.  Drawing shows the anatomy of the renal hilum and the ureterovascular relationships. This perspective is useful in assessment of UPJO and may be reproduced by means of an oblique sagittal clock-face MPR image. Note also the segmental renal perfusion and the common site of insertion of the lower-pole segmental artery variant. A = anterior, P = posterior.

View larger version (77K): [in a new window]   Figure 9a.  Drawings show left UPJO with hydronephrosis in which the dilated extrarenal pelvis and proximal ureter bow anteriorly (a) or posteriorly (b) over the lower-pole segmental artery. Note that, when there is significant hydronephrosis, the UPJO site is frequently more cephalad behind the overgrown pelvis. UPJ = ureteropelvic junction.

View larger version (84K): [in a new window]   Figure 9b.  Drawings show left UPJO with hydronephrosis in which the dilated extrarenal pelvis and proximal ureter bow anteriorly (a) or posteriorly (b) over the lower-pole segmental artery. Note that, when there is significant hydronephrosis, the UPJO site is frequently more cephalad behind the overgrown pelvis. UPJ = ureteropelvic junction.

View larger version (136K): [in a new window]   Figure 10a.  UPJO in a 24-year-old man. (a) Coronal MPR image shows the inverted teardrop shape of right UPJO with a dilated extrarenal pelvis (arrowhead) and a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal MIP image shows two right renal arteries (arrowheads) with the dilated extrarenal pelvis in between (arrow). (c) Oblique sagittal hilar clock-face view shows the relationship of the renal vein and main renal artery (arrowhead), the dilated extrarenal pelvis (short arrow), and the variant lower-pole artery (long arrow). Note that the crossing vessel is above the point of caliber transition.

View larger version (126K): [in a new window]   Figure 10b.  UPJO in a 24-year-old man. (a) Coronal MPR image shows the inverted teardrop shape of right UPJO with a dilated extrarenal pelvis (arrowhead) and a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal MIP image shows two right renal arteries (arrowheads) with the dilated extrarenal pelvis in between (arrow). (c) Oblique sagittal hilar clock-face view shows the relationship of the renal vein and main renal artery (arrowhead), the dilated extrarenal pelvis (short arrow), and the variant lower-pole artery (long arrow). Note that the crossing vessel is above the point of caliber transition.

View larger version (120K): [in a new window]   Figure 10c.  UPJO in a 24-year-old man. (a) Coronal MPR image shows the inverted teardrop shape of right UPJO with a dilated extrarenal pelvis (arrowhead) and a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal MIP image shows two right renal arteries (arrowheads) with the dilated extrarenal pelvis in between (arrow). (c) Oblique sagittal hilar clock-face view shows the relationship of the renal vein and main renal artery (arrowhead), the dilated extrarenal pelvis (short arrow), and the variant lower-pole artery (long arrow). Note that the crossing vessel is above the point of caliber transition.

View larger version (134K): [in a new window]   Figure 11a.  Incidentally discovered UPJO in a 36-year-old man without crossing vessels at CT. (a) Axial planar image shows left hydronephrosis and a dilated extrarenal pelvis (arrow). (b) Coronal volume-rendered image shows the inverted teardrop shape of left UPJO, which tapers inferiorly (long arrow). The left renal artery and vein are noted (short arrows).

View larger version (146K): [in a new window]   Figure 11b.  Incidentally discovered UPJO in a 36-year-old man without crossing vessels at CT. (a) Axial planar image shows left hydronephrosis and a dilated extrarenal pelvis (arrow). (b) Coronal volume-rendered image shows the inverted teardrop shape of left UPJO, which tapers inferiorly (long arrow). The left renal artery and vein are noted (short arrows).

View larger version (137K): [in a new window]   Figure 12a.  UPJO in a 71-year-old woman. (a) Coronal volume-rendered CT image shows the main renal artery (long black arrow) and a variant lower segmental renal artery (short black arrow). The lower segmental artery crosses posteriorly to the UPJO. An early-branching retroaortic left renal vein is noted, with the lower-pole branch crossing anteriorly to the dilated pelvis in the region of the UPJO (white arrow). (b) Oblique sagittal hilar clock-face view shows a renal vein branch and the main renal artery above the dilated renal pelvis (short arrow). The early-branch lower-pole renal vein is noted below the dilated renal pelvis (long arrow). The distal normal ureter is seen (white arrowhead). Note how the dilated extrarenal pelvis balloons anteriorly (black arrowhead) in the potential space created between the vasculature above and below.

View larger version (119K): [in a new window]   Figure 12b.  UPJO in a 71-year-old woman. (a) Coronal volume-rendered CT image shows the main renal artery (long black arrow) and a variant lower segmental renal artery (short black arrow). The lower segmental artery crosses posteriorly to the UPJO. An early-branching retroaortic left renal vein is noted, with the lower-pole branch crossing anteriorly to the dilated pelvis in the region of the UPJO (white arrow). (b) Oblique sagittal hilar clock-face view shows a renal vein branch and the main renal artery above the dilated renal pelvis (short arrow). The early-branch lower-pole renal vein is noted below the dilated renal pelvis (long arrow). The distal normal ureter is seen (white arrowhead). Note how the dilated extrarenal pelvis balloons anteriorly (black arrowhead) in the potential space created between the vasculature above and below.

View larger version (146K): [in a new window]   Figure 13a.  UPJO in a 54-year-old man. (a) Coronal MPR image shows mild right hydronephrosis with a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal volume-rendered view shows right UPJO. The dilated renal pelvis is noted to balloon anteriorly (black arrow) over a second lower-pole segmental vein draining directly to the inferior vena cava (white arrowhead). Black arrowhead = main renal vein, white arrow = distal ureter beyond the UPJO. (c) Coronal MIP image shows the right UPJO. The main renal artery (short arrow) and a variant lower-pole segmental artery (long arrow) are noted. (d) Oblique sagittal MPR image shows that the enlarged extrarenal pelvis balloons posteriorly over the lower-pole artery and vein (short arrow). Note that the vessels are above the transition zone of the UPJO (long arrow).

View larger version (182K): [in a new window]   Figure 13b.  UPJO in a 54-year-old man. (a) Coronal MPR image shows mild right hydronephrosis with a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal volume-rendered view shows right UPJO. The dilated renal pelvis is noted to balloon anteriorly (black arrow) over a second lower-pole segmental vein draining directly to the inferior vena cava (white arrowhead). Black arrowhead = main renal vein, white arrow = distal ureter beyond the UPJO. (c) Coronal MIP image shows the right UPJO. The main renal artery (short arrow) and a variant lower-pole segmental artery (long arrow) are noted. (d) Oblique sagittal MPR image shows that the enlarged extrarenal pelvis balloons posteriorly over the lower-pole artery and vein (short arrow). Note that the vessels are above the transition zone of the UPJO (long arrow).

View larger version (176K): [in a new window]   Figure 13c.  UPJO in a 54-year-old man. (a) Coronal MPR image shows mild right hydronephrosis with a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal volume-rendered view shows right UPJO. The dilated renal pelvis is noted to balloon anteriorly (black arrow) over a second lower-pole segmental vein draining directly to the inferior vena cava (white arrowhead). Black arrowhead = main renal vein, white arrow = distal ureter beyond the UPJO. (c) Coronal MIP image shows the right UPJO. The main renal artery (short arrow) and a variant lower-pole segmental artery (long arrow) are noted. (d) Oblique sagittal MPR image shows that the enlarged extrarenal pelvis balloons posteriorly over the lower-pole artery and vein (short arrow). Note that the vessels are above the transition zone of the UPJO (long arrow).

View larger version (154K): [in a new window]   Figure 13d.  UPJO in a 54-year-old man. (a) Coronal MPR image shows mild right hydronephrosis with a transition point in the region of the ureteropelvic junction (arrow). (b) Coronal volume-rendered view shows right UPJO. The dilated renal pelvis is noted to balloon anteriorly (black arrow) over a second lower-pole segmental vein draining directly to the inferior vena cava (white arrowhead). Black arrowhead = main renal vein, white arrow = distal ureter beyond the UPJO. (c) Coronal MIP image shows the right UPJO. The main renal artery (short arrow) and a variant lower-pole segmental artery (long arrow) are noted. (d) Oblique sagittal MPR image shows that the enlarged extrarenal pelvis balloons posteriorly over the lower-pole artery and vein (short arrow). Note that the vessels are above the transition zone of the UPJO (long arrow).

View larger version (149K): [in a new window]   Figure 14a.  UPJO in a 49-year-old patient. The presence of a soft tissue mass in the renal pelvis was suggested at retrograde pyelography. (a) Coronal volume-rendered view shows three right renal arteries (arrows). (b) Coronal MPR image shows a curved UPJO (long arrow) above the level of the variant lower-pole renal artery (short arrow). Arrowhead = soft tissue mass in the superior renal pelvis. (c) Oblique coronal hilar clock-face view shows a dilated extrarenal pelvis (black arrowhead) ballooning anteriorly over lower-pole variant vessels (short arrow). Note that the transition zone of the UPJO is above the level of the variant vasculature (long arrow). White arrowhead = soft tissue mass in the superior renal pelvis. Right nephrectomy revealed a low-grade papillary carcinoma.

View larger version (126K): [in a new window]   Figure 14b.  UPJO in a 49-year-old patient. The presence of a soft tissue mass in the renal pelvis was suggested at retrograde pyelography. (a) Coronal volume-rendered view shows three right renal arteries (arrows). (b) Coronal MPR image shows a curved UPJO (long arrow) above the level of the variant lower-pole renal artery (short arrow). Arrowhead = soft tissue mass in the superior renal pelvis. (c) Oblique coronal hilar clock-face view shows a dilated extrarenal pelvis (black arrowhead) ballooning anteriorly over lower-pole variant vessels (short arrow). Note that the transition zone of the UPJO is above the level of the variant vasculature (long arrow). White arrowhead = soft tissue mass in the superior renal pelvis. Right nephrectomy revealed a low-grade papillary carcinoma.

View larger version (148K): [in a new window]   Figure 14c.  UPJO in a 49-year-old patient. The presence of a soft tissue mass in the renal pelvis was suggested at retrograde pyelography. (a) Coronal volume-rendered view shows three right renal arteries (arrows). (b) Coronal MPR image shows a curved UPJO (long arrow) above the level of the variant lower-pole renal artery (short arrow). Arrowhead = soft tissue mass in the superior renal pelvis. (c) Oblique coronal hilar clock-face view shows a dilated extrarenal pelvis (black arrowhead) ballooning anteriorly over lower-pole variant vessels (short arrow). Note that the transition zone of the UPJO is above the level of the variant vasculature (long arrow). White arrowhead = soft tissue mass in the superior renal pelvis. Right nephrectomy revealed a low-grade papillary carcinoma.

View larger version (152K): [in a new window]   Figure 15.  UPJO after pyeloplasty. Coronal MPR image obtained after pyeloplasty shows residual hydronephrosis (P). Note the segmental perfusion defect of the right inferior renal cortex (arrow) and the variant lower-pole artery (arrowhead).