DIAGNOSTIC ACCURACY, MANAGEMENT IMPACT, AND COST-UTILITY OF ULTRASOUND VERSUS MR UROGRAPHY IN THE EVALUATION OF PUJ OBSTRUCTION IN A RESOURCE-LIMITED SETTING
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Keywords
Pelviureteric junction obstruction; MR urography; Ultrasound; Diagnostic accuracy; Cost-utility analysis
Abstract
Accurate evaluation of pelviureteric junction (PUJ) obstruction is essential for appropriate management, yet reliance on ultrasound alone may be insufficient, particularly in resource-limited settings. Evidence comparing diagnostic accuracy, clinical impact, and cost-utility of ultrasound versus MR urography (MRU) remains limited in low- and middle-income countries (LMICs).
Objective: To compare the diagnostic accuracy, impact on clinical decision-making, and cost-utility of ultrasound versus MR urography in the evaluation of PUJ obstruction in a resource-limited setting.
Methods: This prospective study included 100 patients (112 kidneys) with suspected PUJ obstruction. All patients underwent ultrasound and MR urography. Diagnostic performance of both modalities was assessed against multidisciplinary clinical consensus. Sensitivity, specificity, predictive values, and area under the receiver operating characteristic curve (AUC) were calculated. Cost-utility analysis was performed using institutional tariffs and quality-adjusted life years (QALYs) from the payer perspective.
Results: MR urography demonstrated higher diagnostic accuracy than ultrasound, with sensitivity of 92.7% versus 76.7% and specificity of 84.2% versus 71.2%, respectively. The AUC was significantly greater for MRU (0.89) compared with ultrasound (0.74). MRU influenced clinical management by refining surgical indications and identifying crossing vessels and functional impairment not detected on ultrasound. Although MRU incurred higher upfront costs, it was cost-effective under local willingness-to-pay thresholds due to improved QALYs.
Conclusion: MR urography outperforms ultrasound in diagnosing PUJ obstruction, meaningfully impacts clinical decision-making, and is cost-effective even in a resource-limited setting. An ultrasound-first strategy with selective MRU for equivocal or high-risk cases represents a rational and sustainable imaging pathway for LMICs.
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Muhammad Waleed Khan
Consultant Radiologist, Institute of Kidney Diseases / Hayatabad Medical Complex (IKD-HMC), Peshawar, Pakistan
Nazish Javed
Consultant Radiologist, Institute of Kidney Diseases / Hayatabad Medical Complex (IKD-HMC), Peshawar, Pakistan
Jawad Ali
Postgraduate Resident, Department of Radiology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan
Faryal Bashir
Specialist Registrar, Department of Radiology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan
Kiran Zafar
Postgraduate Resident, Department of Radiology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan
Ammara Haroon Durrani
Assistant Professor, Department of Radiology, Institute of Kidney Diseases / Hayatabad Medical Complex (IKD-HMC), Peshawar, Pakistan
