It then progresses inferiorly and ultimately leads to ureteral obstruction and acute renal failure. Traditional treatment has been temporary stenting followed by formal surgical ureterolysis and omental wrapping. Recently various immunosuppressive agents including prednisone, cyclosporine, methotrexate, azathioprine, mycophenolate mofetil, and tamoxifen have been used successfully in small series and case reports in the non-surgical management of RPF.

A recent prospective observational study was undertaken to examine the efficacy of combination of prednisone and MMF in the treatment of 7 patients with biopsy proven RPF. The study, performed by P. J. Scheel and colleagues from Johns Hopkins, is published in the July 2007 issue of the Journal of Urology.

MMF is an immunosuppressive agent that antagonizes lymphocyte proliferation and function by the inhibition of de novo purine synthesis. It is clear that the immune system plays an important role in the pathology of RPF and there is also evidence to suggest that MMF has efficacy for treating B and T-cell mediated diseases with limited side effects and toxicity.

The seven patients in the study group were treated with 40 mg prednisone daily with a gradual taper over 6 months. MMF was administered at a starting dose of 1000 mg twice daily and continued for 6 months following resolution of systemic symptoms and extubation of affected ureters. Analysis of the results showed that 10 of the 11 obstructed ureters were free of obstruction following ureteral stent removal. The mean time to stent removal was 10.5 months. CT findings revealed a mean 32% regression of the retroperitoneal mass. There were no treatment related side effects reported.

This combination of prednisone and MMF shows promise in this small trial and larger trials should be performed to confirm these results.

Scheel PJ, Piccini J, Rahman MH, Lawler L, Jarrett T

J of Urol. 178(1): 140-44, July 2007
doi:10.1016/j.juro.2007.03.057

UroToday.com Urologic Trauma & Reconstruction Section

Written by Michael J. Metro, MD, a Contributing Editor with UroToday.

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