Tuesday, July 29, 2014

Historical Contribution: 1940, Jewett, UPJ Obstruction


H. J. Jewett.  Stenosis of the ureteropelvic juncture - Congenital and acquired.  Journal of Urology, 1940  44: 247-258.

Ureteropelvic junction (UPJ) obstruction is a partial or total blockage at the place where the kidney and the ureter are joined. UPJ obstruction is more common in children than in adults and often resulting from a congenital abnormality and is the most common cause of hydronephrosis (swelling of the renal pelvis, where urine collects from the kidney) detected on prenatal ultrasound or in newborns.  UPJ obstruction impedes the flow of urine, causing it to build up and resulting in hydronephrosis and has the potential complications of recurrent infection and kidney damage.

In this manuscript from 1940, Dr. Jewett reviews the cases of 71 patients with hydronephrosis and a UPJ obstruction.  Dr. Jewett found that 4 patients had stricture, 24 had a crossing vessel causing obstruction and the remaining 43 patients had an obstruction of unclear etiology.  In classifying these patients, in whom the etiology of the obstruction was unclear, Jewett found that a crossing vessel was the culprit in 10.

Drawing of a case of congenital stenosis of the ureteropelvic juncture associated with accessory renal vessel.
In the patients with a crossing vessel, Dr. Jewett made the following observations (that still hold true today):
  • UPJ obstruction without a crossing vessel is 3x more common than with a crossing vessel
  • The average age of onset in this cohort is younger (13 versus 24 years-old)
  • A crossing vessel is not always associated with UPJ obstruction (24 cases)
  • UPJ obstruction with a crossing vessel is characterized by a delicate and thin proximal ureter, as opposed to obstruction cases by trauma or inflammation.
In the remaining 33 patients, the UPJ obstruction was caused by a combination of inflammation and infection (16).  Under the microscope, these patients had a thickened, fibrous stricture at the UPJ.

Importantly, Jewett also identified 17 patients in which there was no crossing vessel or inflammatory reaction. Through careful pathologic and histologic analysis, Jewett concluded these patients had a congenital UPJ obstruction.  

Drawing of a case of congenital stenosis of the ureteropelvic juncture without associated vessels.
Therefore, Dr. Jewett embarked on an autopsy analysis of 11 embryos, 50 stillborn children and 200 consecutive urograms.  He was able to determine the relative frequencies of UPJ obstruction and its etiologies:
  • Normal UPJ (85%)
  • UPJ Obstruction (15%)
    • Bands and kinks (5.6%)
    • Crossing renal vessel (33.8%)
    • Congenital Stenosis (60.5%)
In addition, from these studies he concluded: 
It is possible, therefore, that a ureteropelvic juncture represents a minimal narrowing which, when present in marked degree, becomes a congenital stenosis.     
In the group of cases comprising inflammatory strictures, it is impossible to determine with any degree of certainty whether the inflammatory reaction was primary or whether it was superimposed upon a simple congenital stenosis.
Finally, he theorized a model by which hydronephrosis would develop from stenosis and was accelerated by crossing vessels, infection, high ureteral insertion and, possibly, rapid growth during puberty.  This model, developed 70 years ago, has changed very little in our most contemporary understanding of the UPJ obstruction.

To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 


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