Management of Ureteropelvic Junction Filling Defects

Diagnostic Approach

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, as recommended by The Journal of Urology 1
Urothelial malignancy must be ruled out, especially in elderly patients with filling defects, according to The Journal of Urology 1
Urinary calculi can present as filling defects and cause obstruction, as noted by The Journal of Urology 1
Multi-phasic CT urography is the first-line imaging for further characterization of the filling defect, providing detailed anatomical information about the UPJ and surrounding structures, as recommended by The Journal of Urology 2
MR urography (MRU) is an alternative if the patient has contraindications to CT, providing good visualization of renal parenchyma, and may be combined with retrograde pyelograms for better collecting system detail, according to The Journal of Urology 2

Safety guidewire placement should be used during endoscopic procedures to maintain access to the collecting system, as recommended by The Journal of Urology 1
Antimicrobial prophylaxis should be administered prior to intervention based on prior urine culture results and local antibiogram, according to The Journal of Urology 1
Obtain tissue for pathologic diagnosis in cases of malignant lesions, as recommended by The Journal of Urology 1
Stone material should be sent for analysis if calculi are present, according to The Journal of Urology 1
Endopyelotomy is an option for mild to moderate obstruction without complex anatomy, as noted by The Journal of Urology 1

If purulent urine is encountered during endoscopy, the procedure should be aborted, and drainage should be established with a ureteral stent or nephrostomy tube, as recommended by The Journal of Urology and World Journal of Emergency Surgery 3, 4
Continue antibiotic therapy and obtain urine culture in such cases, according to The Journal of Urology 1

Post-intervention imaging should be based on findings and treatment performed, as recommended by World Journal of Emergency Surgery 4
For malignant conditions, more intensive surveillance is required based on pathology and stage, according to The Journal of Urology 1

Avoid immediate urethroplasty or complex reconstruction without proper diagnostic evaluation, as recommended by The Journal of Urology 3
Do not dismiss filling defects in elderly patients as they may represent malignancy requiring prompt intervention, according to The Journal of Urology 1
Be prepared to abort the procedure and establish drainage if infection is encountered, as recommended by The Journal of Urology 1