Year : 2011 | Volume
: 27 | Issue : 1 | Page : 150--151
Equivocal ureteropelvic junction obstruction: Is there a role of therapuetic double J stent
Sumit Sharma, Ravimohan S Mavuduru, Mohan M Agarwal
Department of Urology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
Ravimohan S Mavuduru
Department of Urology, Postgraduate Institute of Medical Education & Research, Chandigarh
|How to cite this article:|
Sharma S, Mavuduru RS, Agarwal MM. Equivocal ureteropelvic junction obstruction: Is there a role of therapuetic double J stent.Indian J Urol 2011;27:150-151
|How to cite this URL:|
Sharma S, Mavuduru RS, Agarwal MM. Equivocal ureteropelvic junction obstruction: Is there a role of therapuetic double J stent. Indian J Urol [serial online] 2011 [cited 2020 Oct 24 ];27:150-151
Available from: https://www.indianjurol.com/text.asp?2011/27/1/150/78404
The authors conducted a prospective clinical study to evaluate the role of temporary double J ureteric stenting (TDJS) in cases of equivocal ureteropelvic junction obstruction (EqUPJO).  One hundred and nine consecutive adult patients with loin pain and ipsilateral EqUPJO on radioisotope diuretic renogram (RDR) were studied. EqUPJO was defined as T1/2 from 10 to 20 min, and an inconclusive pattern of the clearance curve on F + 20 protocol of DTPA or MAG3 RDR. Exclusion criteria were massively dilated pelvis (>7cm) and split function of the ipsilateral kidney <20%. All patients underwent TJDS for 3 weeks, after which it was removed. Response (relief of pain) to TDJS was assessed by visual analog pain score (VAPS). A patient was considered "responder" if he/she experienced ≥50% improvement in VAPS after DJ insertion and a worsening of VAPS by ≥ 50% after removal of DJ. All patients were counseled and given option of surgical intervention versus no intervention. Based on response to TJDS, patient preference and further management, they were classified into four groups: Group Ia non-responders who elected conservative treatment for their condition, Group Ib non-responders who elected intervention, Group IIa responders who elected conservative treatment and Group IIb responders who elected intervention. Last group patients were randomized to either early [Group IIb(1)] or delayed intervention [3 months later (Group IIb(2)]. Intervention was in the form of pyeloplasty (24 patients) and endopyelotomy (38 patients). All patients were followed up by measuring VAPS and RDR. After at least 6 months from management decision, 97 patients were available for evaluation. The VAPS dropped by 21.25% (P < 0.001), 32% (P = 0.004), 2% (P = 0.6), 54% (P < 0.001) and 65% (P < 0.001) in groups Ia, Ib, IIa, IIb1 and IIb2, respectively. Difference in VAPS and T1/2 was not significant in subgroups IIb1 and IIb2. On the other hand the T (1/2) of RDR dropped significantly only in groups Ib, IIb1 and IIb2 by a mean of 6.5 min (P = 0.005), 8.02 min (P < 0.001) and 7.3 min (P < 0.001), respectively. The authors concluded that TDJS simplified patient counseling in cases of EqUPJO, and suggested surgical intervention only in presence of improvement after DJS.
EqUPJO remains a quandary for treating clinicians as there may be no relief to incomplete relief of pain following surgery. Modalities that have been studied to unequivocally establish significant UPJO includes using different protocols of RDR (such as the F-0 and the F-15 protocols),  invasive techniques as the Whitaker test  or complicated tests as the dynamic MRI.  However, these tests have disadvantages such as low sensitivity, non-standardization, high cost or non-reproducibility. Although TDJS stenting appears logical to assist decision making in such cases, this is the first well-designed prospective study to check its efficacy. Previously Plata et al,  had addressed this method in a report on six patients.
The authors have used F+20 protocol for RDR in all the cases. It is well-established that F-15 or F-0 protocol are more sensitive in unequivocally diagnosing UPJO. In 29 cases of EqUPJO (on F+15 RDR), Upsdell et al,  reported that using F-15 protocol enabled unequivocal categorization of 91% of the patients who had equivocal drainage curve on F+15 RDR. Thus, some of their results might have been confounded by such cases. Usage of F-15 protocol could have better settled the ambiguity regarding significance of obstruction.
The interesting fact to note is that patients who were non-responders whether intervened or not, showed significant improvements in their VAPS scores at 3 and 6 months, although the improvement seemed better in intervention group. Statistical analysis of this fact among the non-responders would have helped us to better understand the process. All patients who were non-responders (group 1a and b) showed significant improvement in VAPS at 3 and 6 months of follow-up. Although, the degree of improvement seems better in the group 1b, which has not been statistically evaluated, comparing improvement in VAPS between subgroups Ia and Ib at follow-up of 3 and 6 months, might have provided some decisive information. Also, the status of renal function and VAPS over long term in these patients (group 1) would be useful in making a rational choice between intervention or conservative measures.
|1||Osman T, Fawaz K, Abdelmaksoud A, Eltahawy I, Safa W, El Zayat T, et al. Insertion of double J stent as a therapeutic test in management of adults presenting with loin pain and equivocal ureteropelvic junction obstruction. World J Urol 2010;28:373-8.|
|2||Roarke MC, Sandler CM. Provocative imaging: Diuretic renography. Urol Clin North Am 1998;25:227-49.|
|3||Whitaker RH. The Whitaker test. Urol Clin North Am 1979;6:529-39.|
|4||Perez-BrayWeld MR, Kirsch AJ, Jones RA, Grattan-Smith JD. A prospective study comparing ultrasound, nuclear scintigraphy and dynamic contrast enhanced magnetic resonance imaging in the evaluation of hydronephrosis. J Urol 2003;170:1330-4.|
|5||Plata AL, Faerber GJ, Wolf JS Jr. Stent placement for the diagnosis of upper tract obstruction. Tech Urol 1999;5:207-9.|
|6||Upsdell SM, Testa HJ, Lawson RS. The F-15 Diuretic renogram in suspected Obstruction of Upper Urinary Tract. Br J Urol 1992;69:126-31.|