AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

The French urologist Albarran first described retroperitoneal fibrosis (RPF) in 1905,¹ but with Ormond's publication in 1948,² the disease became an established clinical entity.

In most patients (approximately 68%), no etiologic factor is found. Therefore, the term idiopathic RFP is used. Evidence suggests that RPF is an autoimmune response to an insoluble lipid called ceroid that has leaked through a thinned arterial wall from atheromatous plaques.^{3, 4} Other implicated causes include drugs, abdominal aortic aneurysm, ureteric renal injury, infection, retroperitoneal malignancy, postirradiation therapy, chemotherapy and hemilaminectomy, hypothyroidism and carcinoid tumor. No genetic predominance is seen in malignant retroperitoneal fibrosis.^{5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15}

RPF can be diagnosed on the basis of the history and the radiologic observations. At times, the diagnosis is not established firmly until surgical exploration. The use of steroids in RPF remains controversial; however, some authors believe that steroids can be used as an adjuvant to surgical ureterolysis. Immunosuppressive drugs, such as azathioprine, cyclophosphamide, and tamoxifen, have been used to treat RPF.^{16, 17, 18, 19, 20, 21, 22}

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Pathophysiology

Grossly, RPF appears as an exuberant mass of white, woody, fibrous tissue covering the retroperitoneal structures such as the aorta, vena cava, ureters, and psoas muscle. It may extend from the renal pedicle to below the pelvic brim. The center of the plaque is usually located at the level of the fourth or fifth lumbar vertebra, overlying the aortic bifurcation. Not uncommonly, the fibrous tissue bifurcates and follows the common iliac arteries. Rarely, the fibrous process extends into the root of the mesentery or passes through the crura of the diaphragm to continue as fibrous mediastinitis.

Histologically, the predominant finding is a fibrous tissue consisting of collagen fibrils and fibroblasts. A subacute nonspecific inflammatory reaction is often present, or completely hyalinized fibrosis may be the only finding. The cellular infiltrate includes polymorphonuclear cells, lymphocytes, eosinophils, or plasma cells. In the chronic phase, the only finding may be an acellular fibrosis.

The coexistence of RPF with primary biliary cirrhosis, fibrosing mediastinitis, panhypopituitarism, glomerulonephritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), polyarteritis nodosa, ankylosing spondylitis, and Riedel²³ or Hashimoto thyroiditis support the hypothesis of an immune-mediated mechanism.

The association of RPF with the prolonged use of certain drugs and with the improvement of clinical symptoms (in most instances after cessation of the drug therapy) indicates that the fibrotic process is the end stage of vasculitis resulting from a hypersensitivity reaction to various antigens such as drugs and diseases. Drugs implicated in causing RPF include methysergide, beta-adrenergic blockers, lysergic acid diethylamide, methyldopa, amphetamines, phenacetin, pergolide (withdrawn from US market March 29, 2007), and cocaine.

Frequency

United States

The overall incidence in the United States appears to be the same as that found internationally.

International

RPF is relatively uncommon, with an incidence of 1 case per 200,000 population.

Mortality/Morbidity

Although fatalities do occur, a satisfactory outcome can be expected if renal impairment is not too severe.

• Unlike idiopathic (nonmalignant) RPF, a distinctly poor prognosis is associated with malignant RPF, which occurs in response to metastatic tumor cells in the retroperitoneum.
• Most patients live only 3-6 months after receiving a diagnosis of malignant RPF, although prolonged survival has been reported. Close follow-up care is critically important to ensure the absence of progressive or recurrent disease.

Race

No racial preponderance has been recorded.

Sex

The disease is 3 times more common in males than in females; however, methysergide-related RPF has a female-to-male ratio of 2:1. No sex predominance is noted in malignant RPF.

Age

• The age range of patients is 7-85 years, with predominance in patients aged 40-60 years.
• RPF in children has been reported in the literature.
• One case has been reported in a stillborn fetus.

Anatomy

The retroperitoneum is a large space bounded anteriorly by the posterior parietal peritoneum, posteriorly by the transversalis fascia, and superiorly by the diaphragm. Inferiorly, it extends to the level of the pelvic brim.

On either side, the retroperitoneum is divided into 3 compartments by coronally oriented anterior and posterior renal fascia, which lie anterior and posterior to the kidneys, respectively. The anterior renal fascia is a thin layer of connective tissue, which is difficult to identify on images. The anterior and posterior renal fasciae fuse laterally to form the lateroconal fascia. The lateroconal fascia extends posterolaterally to the ascending and descending colon and fuses with the parietal peritoneum. Superiorly, both layers of renal fasciae blend with the diaphragmatic fascia, and inferiorly, this fuses with the iliac fascia and periureteric connective tissue at the level of the iliac crest. Medially, the anterior renal fascia blends with the connective tissue and fat that surround the great vessels, and the posterior renal fascia blends with the fascia of the psoas and quadratus lumborum muscles.

Each perirenal space, which is situated between the anterior and posterior renal fasciae, contains a kidney, adrenal gland, pelvocalyceal system, proximal ureter, and neurovascular and lymphatic structures. No potential communication exists between the 2 perirenal spaces.

The anterior pararenal space is limited anteriorly by the posterior parietal peritoneum and posteriorly by the anterior renal fascia. The contents are the first, second, and third parts of the duodenum; the pancreas; the ascending colon; the descending colon; and the splenic, hepatic, and proximal superior mesenteric arteries. The anterior pararenal space communicates across the midline.

The posterior pararenal space is bounded anteriorly by the posterior renal fascia and posteriorly by the transversalis fascia. The medial extent of this space is limited by the fusion of posterior renal fascia with the fasciae of the psoas and quadratus lumborum muscles; however, communication with the retrocrural space and, therefore, the mediastinum is possible. Laterally, the fat of the posterior pararenal space continues as the properitoneal fat stripe. The posterior pararenal space contains no organs. The anterior and posterior pararenal spaces communicate along their inferior margin.

Clinical Details

Most patients present with nonspecific symptoms of less than 12 months' duration. Children may present with hip or gluteal pain.^{24, 25, 26}

In the early stage, signs and symptoms originate from the disease process; in the advanced stage, clinical features represent the effects of obstructive uropathy and renal failure. The most common presentation is pain (92%) occurring in the flank (42%), the back (32%), the scrotum (8%), or the lower abdomen (28%). Other presentations include fever, weight loss (38%), nausea and vomiting (32%), malaise (18%), polyuria (18%), polydipsia (18%), anorexia (15%), nocturia (13%), oliguria (10%), urinary frequency (8%), and hematuria (2%).^{9, 27, 28, 29, 30, 31, 32, 33}

Hypertension is a common clinical feature. The disease has been reported to manifest as constipation and large-bowel and duodenal obstruction. Fibrotic processes can also cause compression of the great vessels, resulting in thrombophlebitis and arterial insufficiency. RPF has been documented to present as jaundice resulting from involvement of the common bile duct and exophthalmos resulting from retro-orbital disease.

RPF can appear at a later stage as a complication of fibrosis. The patient may present with renal failure resulting from ureteric involvement. Venous and lymphatic obstruction may present as lower-limb edema. Claudication may result secondary to arterial insufficiency. Invasion of the duodenum and colon and the common bile duct has been documented as causing bowel obstruction and jaundice, respectively. Neurologic presentation secondary to spinal epidural extension has been reported.^{34, 35}

Idiopathic RPF may rarely involve the thoracic aorta and the origin of its major branches, with a pattern similar to that of other forms of large-vessel vasculitides.³⁶

There is an association between RPF and autoimmune pancreatitis. 

Laboratory findings include anemia, azotemia, and an increased erythrocyte sedimentation rate (ESR). Elevated white cell counts and pyuria can occur. The diagnosis of RPF often is delayed because of its nonspecific presentation.

Preferred Examination

Plain radiographic findings in RPF are nonspecific, and most findings are related to the late complications of fibrosis, such as bowel obstruction and pulmonary edema secondary to renal failure. Contrast-enhanced studies, such as barium follow-through and barium enema examinations, can show the level of bowel obstruction. The diagnosis of RPF has often been suggested on the basis of the excretory urographic findings due to extensive changes in the urinary tract. Retrograde pyelography is used in patients with severely impaired renal function.^{37, 38, 39, 40}

Aortography, venography, and lymphangiography help in assessing the level and extent of occlusion; however, findings from these examinations can be normal in advanced disease.

Ultrasonography can be used as a noninvasive technique. Sonograms may or may not help in identifying the retroperitoneal mass, but they can readily demonstrate the degree of obstruction to the ureters and kidneys. Attempts have been made to differentiate benign RPF from malignant RPF by using color Doppler imaging.

Computed tomography (CT) and magnetic resonance imaging (MRI) provide superior delineation of the extent of the masses of RPF.^{37, 41, 42, 43}

Isotope renography is useful in the serial assessment of renal function. Gallium scintigraphy may demonstrate increased uptake, depending on the activity of inflammation. The use of fluorodeoxyglucose positron emission tomography (FDG-PET) in differentiating benign from malignant RPF is promising.^{44, 45}

Limitations of Techniques

Findings on plain radiography and contrast-enhanced studies are nonspecific, demonstrating the late effects of fibrosis. Excretory urography helps in establishing a diagnosis in the early stage of the disease.

Characteristically, medial deviation of the ureter is present, usually at the middle third, beginning at the level of the third or fourth lumbar vertebra. The medial deviation of the ureter is not a constant finding in patients with RPF, and approximately 20% of patients with normal urographic findings have medial deviation of ureters without demonstrable evidence of pathologic change in the urinary tract. Most retroperitoneal neoplasms displace the ureters in a lateral direction, but medial deviation can occur. Other causes for medial displacement of the ureters include aneurysm, metastatic tumors, and bladder diverticulum. Medial displacement may be seen after abdominoperineal resection and removal of pelvic malignancy.

Retrograde pyelography is an invasive technique with no additional value compared with excretory urography.

On sonograms, RPF may appear as a relatively echo-free mass centered on the sacral promontory. Imaging the retroperitoneum may not be possible, particularly in obese patients or in those with excessive bowel gas.

With CT and MRI, the fibrosis can be shown in more detail. The symmetric distribution and geometric shape are highly suggestive of RPF. CT scans may not be helpful in differentiating benign RPF from malignant RPF. MRI may help in differentiating the two, but the diagnosis cannot be certain by using MRI.

DIFFERENTIALS

Section 3 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

RPF must be differentiated from other conditions that can cause ureteric obstruction and renal failure, such as retroperitoneal abscess, infections, inflammation, pelvic surgery, and radiation therapy. Unusual causes that can cause ureteric obstruction include barium granuloma after colon perforation, use of sclerosing agents for treatment of inguinal hernia and hemorrhoids, and methyl methacrylate cement used for joint replacement.

Imaging appearances similar to those of RPF can be demonstrated by abdominal aortic aneurysm; tumors inducing desmoplastic response, such as lymphomas, sarcomas, and pancreatic carcinomas; and metastatic malignancies from the breast, lung, stomach, colon, kidney, bladder, prostate, carcinoid and cervix. Other conditions that may simulate RPF include periaortic hematoma and amyloidosis.

RADIOGRAPH

Section 4 of 12  

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• Radiograph
• CT SCAN
• MRI
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Findings

Plain radiography

On plain abdominal radiographs, the psoas shadows may not be visible. The renal outline may be enlarged if hydronephrosis has occurred. Features related to the complications of RPF may be visualized; these include bowel dilatation due to obstruction and splenomegaly secondary to portal hypertension. Findings related to associated bone conditions may be seen. Such findings include metastasis, ankylosing spondylitis, and tuberculosis of the spine.

On chest radiographs, signs of noncardiogenic pulmonary edema may be seen secondary to fluid overload. Pulmonary fibrosis can occur if associated with SLE and ankylosing spondylitis. Mediastinal widening may occur due to a soft-tissue mass associated with mediastinal fibrosis.

Excretory urography

Characteristically, medial deviation of the ureters occurs, usually at the middle third, beginning at the level of third and fourth lumbar vertebrae. Varying degrees of ureteric obstruction with resultant hydronephrosis, hydroureter, and tapering of the ureter at the level of L4-L5 vertebrae may be evident.⁴⁶

Retrograde pyeloureterography

Small ureteral catheters can be passed easily beyond the obstruction, despite the appearance of complete occlusion on excretory urograms, because of restricted peristalsis rather than intraluminal constriction.

Degree of Confidence

Plain radiographic findings are nonspecific and occur in a variety of other conditions that are more common than RPF. Moreover, the findings are related to late effects or complications of the disease process rather than to the disease itself.

A diagnosis of RPF often is suggested on the basis of excretory urographic findings. Although excretory urography may be useful in showing the degree and level of obstruction in the ureters, it may not be particularly helpful in identifying the cause. Moreover, ureteric involvement and obstruction may not be seen in the early stage of the disease.

Retrograde studies are used to demonstrate the pelvocalyceal system and ureter when they are inadequate because of poor renal function and to assess the extent of the disease process.

False Positives/Negatives

Medial deviation of the ureter is not a constant finding in RPF, and approximately 20% of patients without RPF can have medial deviation. A minority of retroperitoneal neoplasms can also cause medial deviation of the ureter. Other conditions causing medial deviation of the ureters include aneurysm, metastatic tumor, and bladder diverticulum. Medial deviation can occur after abdominoperineal and pelvic malignancy resection. Findings from one study suggest no correlation between the degree of obstruction and clinical renal disease.

On retrograde studies, the characteristic features of RPF are not a constant finding.

CT SCAN

Section 5 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

• On CT scans, RPF may appear as a rind of soft tissue around the aorta and inferior vena cava extending between the renal hilum and sacral promontory.
• Laterally, RPF spreads to involve the ureters, causing varying degrees of obstruction.
• The fat plane between the mass and the psoas muscle may be obliterated.
• The mass tends not to displace the aorta anteriorly.
• The attenuation value of the mass is similar to that of muscle and shows variable degrees of enhancement depending on the stage of the disease.
• Certain CT features can help in differentiating benign masses from malignant masses. The mass in RPF may be bulky but not as massive as neoplastic lesions; however, some exceptions exist. The presence of enlarged mesenteric nodes and displacement of the aorta from the spine by the periaortic mass favors malignancy, although some displacement can occur in RPF. Unlike RPF, most retroperitoneal neoplasms displace the ureters laterally.
• RPF does not produce local bone destruction.
• The CT value and contrast enhancement have no role in distinguishing benign masses from malignant masses.

Degree of Confidence

CT is the imaging modality used to diagnose RPF and to perform follow-up studies. CT scans help in assessing the extent of disease and in studying the effects on other organs. Differentiating benign RPF from malignant RPF may not be possible.^{37, 42}

False Positives/Negatives

On CT scans, RPF can be seen in detail. The exact etiology cannot be identified, but it can be suggested by excluding other identifiable causes. Similar CT features may be seen in metastatic malignancy, lymphoma, periaortic hematoma, and amyloidosis.

MRI

Section 6 of 12  

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• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Findings

RPF appears as a mass with low signal intensity on T1-weighted images and variable signal on T2-weighted images, depending on the activity of the disease. On T2-weighted images, RPF may appear hyperintense when active inflammation is present and hypointense in end-stage fibrosis. Inhomogeneous signal intensity on T2-weighted MRIs suggests malignancy.^{41, 43}

Degree of Confidence

The signal intensity of RPF is distinct from that of the adjacent fat and psoas muscle, thereby enabling adequate visualization of the lesion. MRI may help in assessing the response to treatment. After steroid therapy in the early stage of the disease, tissue edema is reduced and appears hypointense on T2-weighted sequences. Since the MR imaging features of most retroperitoneal soft-tissue masses are nonspecific, prediction of a specific histologic diagnosis remains a radiologic challenge. Nevertheless, there are some specific MRI appearances that are useful. Dynamic enhancement patterns can reflect the vascularity of masses, differentiating benign from malignant soft-tissue masses.

False Positives/Negatives

Most malignancies demonstrate high signal intensity on T2-weighted images; therefore, differentiating the early stage of RPF from malignancy may not be possible. Although the inhomogeneity of signal on T2-weighted sequences suggests malignancy, the diagnosis cannot be certain on the basis of MRI appearances alone.

ULTRASOUND

Section 7 of 12  

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• MRI
• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Findings

On sonograms, RPF may appear as a well-defined, smooth-marginated, hypoechoic, retroperitoneal soft-tissue mass encasing the aorta and inferior vena cava. Distal extension beyond the sacral promontory and the absence of lobulation suggest a benign etiology. Ultrasonography may demonstrate dilatation of the pelvocalyceal system and the ureters. Sonograms may show features of coexisting primary biliary cirrhosis, bile duct dilatation due to common bile duct stricture, portal hypertension due to portal vein compression, focal or diffuse pancreatic mass due to sclerosing pancreatitis, and dilated bowel loops due to obstruction.

Some have attempted to use Doppler ultrasonography to differentiate benign RPF from malignant RPF. However, recent findings suggest that color Doppler ultrasonography has no role in differentiating benign masses from malignant retroperitoneal masses.

Degree of Confidence

Ultrasonography is a noninvasive technique that can be used to diagnose RPF and to perform follow-up studies. The detection of RPF with ultrasonography depends on the size of the periaortic soft tissue. Detecting RPF in the early stage may not be possible, and assessing the retroperitoneum may be difficult, particularly in obese patients or in those with a large amount of bowel gas.

Ultrasonography is not a sensitive examination, as compared with CT and MRI. Color Doppler imaging is not helpful in differentiating benign masses from malignant masses because they have no distinguishing features.

False Positives/Negatives

Ultrasonography is not the imaging modality used to assess RPF. Assessing the para-aortic region may be difficult, particularly in obese individuals, because of excessive retroperitoneal fat. Although features such as caudal extension beyond the sacral promontory and the absence of lobulation suggest a benign cause, malignancy cannot be excluded with confidence. Color Doppler imaging has no role in differentiating benign masses from malignant retroperitoneal masses.

NUCLEAR MEDICINE

Section 8 of 12  

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• Nuclear Medicine
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Findings

In the early inflammatory stage of the disease, gallium-67 scintigraphy may show increased uptake. Little or no uptake may occur in the later stages of the disease. Therefore, gallium imaging may be helpful in predicting the therapeutic response to steroids and to monitor the response to treatment. The absence of gallium uptake in the mature stage of the disease makes the lesion less likely to be of malignant origin. Both benign inflammation and malignancy can show increased uptake.⁴⁴

On FDG-PET scanning, benign RPF masses exhibit low uptake, whereas malignant masses exhibit increased uptake.⁴⁵

Degree of Confidence

The role of nuclear medicine studies is yet to be defined. Such studies may be useful in assessing the activity of the disease and in monitoring the response to treatment. The use of FDG-PET scanning is still in the preliminary stages.⁴⁵

ANGIOGRAPHY

Section 9 of 12  

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Findings

Angiography and venography help in assessing the level and degree of obstruction. Abdominal aortic aneurysm can be demonstrated on angiograms.

Lymphangiographic findings in RPF include a delay in the passage of contrast material through the aortic and para-aortic lymphatics. Lymphatic flow may be obstructed at the L3-L4 vertebral level, resulting in nonvisualization of the lymphatics above the fourth lumbar vertebra, filling of collateral lymphatic channels, and small irregular filling defects in the mesenteric and para-aortic lymph nodes. The absence of lymph node metastasis helps in excluding malignancy.

Degree of Confidence

Lymphangiography can be a complementary study to excretory urography. The retroperitoneal lymphatics are delicate structures; therefore, obstruction of the lymphatics occurs before compression of the ureters or major vessels. Angiography often causes underestimation of the size of the aorta; therefore, aneurysms cannot be excluded.

False Positives/Negatives

Lymphangiographic findings can be negative in patients with severe RPF.

Angiography and venography are not helpful in the diagnosis of RPF. Angiography often leads to underestimation of the size of aortic aneurysm due to the presence of a mural thrombus.

INTERVENTION

Section 10 of 12  

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• Intervention
• Multimedia
• References

Biopsy can be performed under CT guidance to differentiate benign masses from malignant retroperitoneal masses. Drainage of the upper urinary tract can be performed as a temporary measure. Percutaneous nephrostomy and the insertion of a double-J stent helps restore renal function and allows time to improve fluid, electrolyte, and acid-base balance prior to surgery.^{21, 47}

The use of steroids in RPF remains controversial; however, some authors believe that steroids can be used as an adjuvant to surgical ureterolysis. Immunosuppressive drugs, such as azathioprine, cyclophosphamide, and tamoxifen, have been used to treat RPF.^{16, 17, 18, 19, 20, 21, 22}

In drug-related RPF, cessation of the drug therapy can result in restitution of the urinary tract and disappearance of the symptoms.

Special Concerns

• As a result of the nonspecific nature of the symptoms, the diagnosis often is delayed.
• Significant morbidity may result because of renal failure.
• In younger patients, the diagnosis is often overlooked.

MULTIMEDIA

Section 11 of 12  

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• CT SCAN
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• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Media file 1:  Plain abdominal radiograph of a patient with biopsy-proven retroperitoneal fibrosis shows a calcified mass in the retroperitoneum (to the right of the mid lumbar spine).
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Media file 2:  Excretory 5-minute urographic image demonstrates medial deviation of the right ureter at the L3-L4 vertebral level, which is suggestive of retroperitoneal fibrosis. Note the delayed excretion of the hydronephrotic left kidney (see also Image 3).
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Media file 3:  Excretory 15-minute urographic image (same patient as in Image 2 and obtained 1 year later) shows progression in the severity of hydronephrosis. Smooth tapering of the medially deviated ureters is noted.
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Media file 4:  Excretory urogram in a 54-year-old man shows characteristic medial deviation of the ureter at the L4-L5 vertebral level. Note the lack of contrast material excretion on the left.
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Media file 5:  Analog (top) and digital (bottom) images of a radionuclide renogram show bilateral hydronephrosis with reduced function in the left kidney.
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Media type:  Image

Media file 6:  Nephrostogram obtained after percutaneous nephrostomy shows smooth tapering of the ureter at the L4-L5 vertebral level.
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Media file 7:  CT scan in a 62-year-old man shows a soft-tissue attenuating mass encircling the abdominal aorta (see also Image 8). Note the extension of the soft-tissue mass around the left kidney. A right-sided nephrostomy and a left ureteric stent are seen.
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Media type:  CT

Media file 8:  CT scan in a 62-year-old man (same patient as in Image 7) shows a soft-tissue attenuating mass encircling the common iliac arteries.
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Media type:  CT

Media file 9:  Nonenhanced transaxial CT scan of the abdomen in a 55-year-old man shows a well-defined, soft-tissue attenuating mass around the atheromatous abdominal aorta of normal caliber (see also Image 10).
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Media type:  CT

Media file 10:  Contrast-enhanced transaxial CT scan in a 55-year-old man (same patient as in Image 9) shows mild enhancement of a soft-tissue mass encircling the lower abdominal aorta.
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Media type:  CT

Media file 11:  Transaxial enhanced abdominal CT scan in a 72-year-old man shows bilateral hydronephrosis that is more pronounced on the left than on the right (see also Image 12).
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Media type:  CT

Media file 12:  Transaxial contrast-enhanced CT scan through the lower abdomen in a 72-year-old man (same patient as in Image 11) shows a soft-tissue mass encasing the iliac vessel and ureters at the L5 vertebral level.
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Media file 13:  Bilateral ureteric double-J stent in a patient with ureteric obstruction. Note the characteristic medial course of the right ureteric stent at the L4-L5 vertebral level.
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Media file 14:  Aortic and common iliac arterial graft in a patient with severe arterial insufficiency secondary to retroperitoneal fibrosis. Note a nephrostomy catheter in the right renal collecting system and the fragmented left ureteric stent.
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Media type:  X-RAY

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

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19. McDougal WS, MacDonell RC Jr. Treatment of idiopathic retroperitoneal fibrosis by immunosuppression. J Urol. Jan 1991;145(1):112-4. [Medline].
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Article Last Updated: Feb 29, 2008