Journal of Pediatric Urology (2018) 14, 277.e1e277.
e6
a
Department of Pediatric
Surgery, Montreal Children’s
Hospital, McGill University,
Montreal, Quebec, Canada
b
Department of Urology,
Faculty of Medicine, Menoufia
University, Al Minufya, Egypt
c
Pediatric Radiology Division,
Montreal Children’s Hospital,
McGill University, Montreal,
Quebec, Canada
Correspondence to: A. Hodhod,
Department of Pediatric
Surgery, McGill University, The
Montreal Children’s Hospital,
Room B04.2916.1 GLEN, 1001
Boulevard Décarie, Montréal,
Quebec H4A 3J1, Canada, Tel.:
þ1 4514 412 4384
amr.hodhod@mail.mcgill.ca
(A. Hodhod)
Keywords
Hydronephrosis; Pelvi-ureteric
junction obstruction;
Ultrasonography
Received 17 July 2017
Accepted 15 January 2018
Available online 20 March 2018
https://doi.org/10.1016/j.jpurol.2018.01.025
1477-5131/ª 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Is the renal pyramidal thickness a good
predictor for pyeloplasty in postnatal
hydronephrosis?
Amr Hodhod a,b, John-Paul Capolicchio a, Roman Jednak a,
Hadeel Eid c, Abd El-Alim El-Doray b, Mohamed El-Sherbiny a
Summary
Objectives
We evaluated the feasibility and value of renal py-
ramidal thickness (PT) as a predictor of pyeloplasty
in high-grade postnatal hydronephrosis.
Patients and methods
We retrospectively reviewed the charts of patients
who presented with postnatal hydronephrosis from
2008 to 2013. Included cases had grade 3 or 4
hydronephrosis. We included only units diagnosed as
ureteropelvic junction obstruction. Gender, later-
ality, hydronephrosis side, renogram data, and
follow-up data were recorded. Two investigators
reviewed all patients’ ultrasounds images. We
measured PT and pelvic anteroposterior diameter
(APD) in the last ultrasound before surgery. For
those managed conservatively, measurements were
obtained from the ultrasound with worst hydro-
nephrosis. PT was measured in supine position in the
middle third of the sagittal plane (Figure). We
assessed the reliability of PT measurement using the
intraclass correlation coefficient (ICC). Univariate
and multivariate analyses were used to correlate the
collected parameters to pyeloplasty incidence.
Receiver operating characteristic curve was used to
evaluate the cutoff value of PT that predicts
pyeloplasty.
Figure Measurement of the renal pyramidal thickness.
Results
The total included cases were 155 patients (165
units). One hundred and fourteen units had grade 3
hydronephrosis and 51 units had grade 4 hydro-
nephrosis. Fifty-two cases (55 units) underwent
pyeloplasty. The median follow-up period was 37.6
months. PT measurement was reliable (ICC Z 0.94).
Univariate analysis revealed that SFU grading, APD,
PT, T1/2, and MAG-3 curves were associated with
surgery. Multivariate analysis showed that PT was a
single independent predictor for pyeloplasty.
PT  3 mm had 98.1% sensitivity and 89.7% speci-
ficity in predicting pyeloplasty.
Discussion
PT is the first portion of renal parenchyma that is
affected in high-grade hydronephrosis. Moreover, it
changes little over the first 9 years of life. PT mea-
surement in hydronephrosis was not previously
evaluated. We found that PT was easily measured in
most kidneys with high negative predictive value.
The PT value as an indicator for pyeloplasty should
undergo extensive assessment by other institutions
with different protocols.
Conclusion
Being a slowly growing part of the parenchyma, PT
can be a good measurable parameter to predict
pyeloplasty. Measurement of PT in hydronephrosis is
reliable. PT  3 mm can predict pyeloplasty with
98.1% sensitivity and 89.7% specificity.
277.e2
Introduction
Many studies have evaluated the prediction value of ultra-
sound parameters regarding the surgical intervention and
renal function [1e3]. Renal parenchymal thinning was
considered as a subjective parameter to define the severity
of hydronephrosis [4e6].
However, in addition to its subjectivity, the parenchymal
thickness essentially changes with age that makes its clin-
ical application difficult especially in bilateral hydro-
nephrosis [7]. The pyramidal thickness (PT) changes little
over the first nine years of life, which makes it superior to
the parenchymal thickness [7].
Multiple classification systems were used to define
various grades of antenatal hydronephrosis (ANH)
[4e6,8,9]. PT is the first portion of renal parenchyma that is
affected in high-grade hydronephrosis [7]. Using PT to
define the hydronephrosis severity, regarding ureteropelvic
junction obstruction (UPJO) has not been reported before.
We tried to prove the feasibility and reliability of PT
measurement in hydronephrosis. The renal pyramid grows
slowly during the first years of life. Owing to its proximity to
the calyx, it is the first part of the renal parenchyma to be
affected by the increase of intracalyceal pressure. So, we
hypothesized that PT measurement can be utilized to
assess the need for pyeloplasty. We evaluated PT as a
predictor for pyeloplasty compared with other possible
predictors such as anteroposterior diameter (APD), Society
for Fetal Urology (SFU) grading, and renogram findings.
Parenchymal thinning in SFU grade 4 is not objectively
well defined. In the current study, we provided a feasible
alternative measurement that would help in defining sur-
gically important parenchymal thinning.
Patients and methods
Local ethics approval was obtained (#14-256-ped.).
We retrospectively reviewed patients’ charts who pre-
sented with antenatal hydronephrosis (ANH) from January
2008 till December 2013. All included patients presented
with ANH in the first year of life and had SFU grade 3 or 4
initially diagnosed as isolated hydronephrosis. We excluded
cases associated with posterior urethral valve (PUV),
vesico-ureteric reflux (VUR), ureterocele, vesicoureteric
junction obstruction (VUJO), and neurogenic bladder.
Moreover, we excluded patients with UPJO of non-
functioning kidneys.
We recorded the patients’ personal data regarding the age
and gender. Laterality and side of hydronephrosis were also
collected. Two investigators (A.H.) and (H.E.) reviewed all
patients’ ultrasound images. This review was blinded to sur-
gical need and outcome. The last ultrasound before surgery
was reviewed. Otherwise, for units managed conservatively,
the ultrasound with worst hydronephrosis was reviewed.
Postnatal hydronephrosis was graded using the SFU system.
We collected only renal units with SFU grade 3 or 4. SFU grade
3 was defined as dilated renal pelvis and all renal calyces with
normal parenchyma while SFU grade 4 was considered as
grade 3 but with parenchymal thinning [5].
Thereafter, PT was measured. The method and in-
terpretations of PT measurement were applied as described
A. Hodhod et al.
by Kadioglu [7]. PT was measured in the middle third of the
sagittal renal ultrasonic images that were captured in su-
pine position, as the distance between the cup of calyx and
the base of pyramid. To get the most accurate measure-
ment, we selected the sagittal images that showed mostly
all pyramids. Further, we chose the one with maximal
diameter of the mid-renal pyramid. We considered PT in a
non-visualized pyramid, in all renal sagittal images, with
very thin parenchyma as 0 mm. Moreover, we measured PT
of the contralateral kidneys if not included in the diseased
group.
Moreover, APD was measured at the mid-renal trans-
verse plane of the renal pelvis in the supine position.
Mercaptoacetyltriglycine 3 (MAG-3) was indicated for all
patients with SFU grade 4. Patients with SFU grade 3 had
MAG-3 when hydronephrosis was bilateral high grade, in a
single kidney or worsening in subsequent ultrasounds. We
recorded MAG-3 data regarding the differential renal func-
tion (DRF), post-Furosemide radioisotope T1/2 washout and
curve type. When the T1/2 was <10 min, non-obstructive
renogram was considered. In cases of T1/2 > 10 min, we
reviewed the renal washout percentage to exclude
obstruction. Renogram curve types were obstructive or not
obstructive. Obstructive curve was considered when
continuously rising or slow down sloping without adequate
washout (<50%) in response to furosemide, otherwise the
curve was considered to be non-obstructive [10].
We reviewed the hydronephrosis outcome regarding the
surgical intervention throughout the follow-up period.
Pyeloplasty was indicated when DRF < 40% with impaired
drainage (T1/2 > 20 min) or deterioration of the renal
function > 10% on follow up renogram study. Moreover,
surgery was indicated in cases of high-grade worsening
hydronephrosis on follow-up ultrasound or symptomatic
hydronephrosis. These indications are similar to that of the
SFU recommendations [11]. Otherwise, conservative man-
agement was considered. Patients who underwent conser-
vative management were followed up every 3e6 months.
When worsening hydronephrosis was detected, MAG-3 was
performed. Patients with improving hydronephrosis were
followed at longer intervals.
According to our institutional post-pyeloplasty protocol,
patients had their first ultrasound study within the first 3
months postoperatively then after 3e4 months. The fre-
quency of further follow-up was decided by the surgeon. PT
was remeasured post pyeloplasty by reviewing post-
operative ultrasound images during short-term follow up.
For renal units with preoperative PT > 0 mm, the per-
centage of PT change (DPT%) was calculated using the
following formula:
½postoperative PT  preopertive PT  100
:
preopative PT
When the preoperative PT Z 0, we calculated the PT
change (DPT) according to the following formula: post-
operative PT e preoperative PT.
Postoperative hydronephrosis status was assessed by
comparing hydronephrosis grade pre- and postoperatively
according to the SFU system [5]. Thereafter, downgraded
was defined was “improved hydronephrosis” and the term
Pyramidal thickness as a predictor for pyeloplasty 277.e3

“non-improved hydronephrosis” was considered for units

Table 1 Patient demographics.
with the same or upgraded hydronephrosis.
Our primary outcome was to study the feasibility of PT Number Percentage
measurement in hydronephrosis. Moreover, our secondary Gender
outcome was to assess the usefulness of PT in prediction of Male 124 80
pyeloplasty. Female 31 20
SPSS 20 was used for recording patients’ data and sta- Laterality
tistical analysis. The intraclass correlation coefficient (ICC) Unilateral 77 49.7
was used to test the inter-rater reliability (0.7 indicates Bilateral 78 50.3
good reliability). Internal consistency was tested using Side
Cronbach’s alpha (0.7 indicates robust consistency Right 40 24.2
without redundancy). For better evaluation of PT, average Left 125 75.8
PT was used [(PT measured by investigator 1 þ PT measured SFU grade
by investigator 2)/2]. Univariate and multivariate analyses Grade 3 114 69.1
were done using Cox regression. Univariate analysis was Grade 4 51 30.9
used to correlate patients’ gender, laterality, the SFU
grading system, average PT, APD, and MAG-3 findings
regarding pyeloplasty. Gender, laterality, SFU grading, and
type of MAG-3 curve were considered categorical variables. We were not able to measure PT in six out of 165 renal units
PT, APD, T1/2, and DRF were considered continuous vari- (3.6%) because of inadequate ultrasonic images. The median
ables. PT for units that underwent pyeloplasties (preoper- PT was 3.5 mm (range 0e7 mm). Average PT was considered
ative PT) and those managed conservatively was compared 0 mm in 17 renal units with sever parenchymal thinning. The
with the contralateral side. ICC was 0.94 for diseased group, and for the control group the
Furthermore, multivariate analysis was done for pa- ICC was 0.89. Cronbach’s alpha was 0.97 for the diseased
rameters with p < 0.1. Multicollinearity was evaluated for group and 0.94 for the control group (Table 2).
parameters found to be significant in the univariate analysis Ninety-eight out of 155 patients (63.2%) with 106 units
using linear regression model. Value of variance inflation had MAG-3 renograms. Thirty-nine out of 98 patients (40%)
factor (VIF) > 5 indicated a multicollinearity problem.
Receiver operating characteristic (ROC) curve was used
to evaluate the cut-off value of average PT that predicts
pyeloplasty. Moreover, Spearman’s rank correlation test Table 2 PT measurement reliability by both investigators.
was used to determine the correlation between the T1/2 Parameter Observer 1 Observer 2
and PT. The KruskaleWallis test was used to evaluate DPT% Diseased group
in relation to the postoperative status of hydronephrosis. A Units measured (%) 161/165 159/165
p-value  0.05 was defined as significant. (97.6) (96.4)a
Median PT (range)
All units (range) 3.6 (0e7) 3.5 (0e7)
Results Pyeloplasty units 1.6 (0e3.2) 1.8 (0e3.4)
Conservatively 4.4 (1e7) 4.3 (2e7)
Of 626 cases with ANH, 256 cases were considered as SFU managed units
grade 3 or grade 4. We excluded three cases with PUV, 28 Units with PT equals 0 18 17
cases with VUR, 30 cases with non-obstructing megaureter, Intraclass correlation coefficient
seven cases with vesicoureteric junction obstruction, and All units 0.95
six cases with neurogenic bladder. Moreover, we excluded Pyeloplasty units 0.92
21 cases with missed follow-up during conservative man- Conservatively 0.91
agement and six patients considered non-functioning by managed units
renogram. Cronbach’s alpha
Total eligible cases were 155 patients (165 units). Pa- All units 0.97
tients’ demographics are presented in Table 1. Of 78 cases Pyeloplasty units 0.96
with bilateral hydronephrosis only 10 patients (12.8%) had Conservatively 0.94
bilateral grade 3 or 4 while the others (87.2%) had one unit managed units
with grade 3 or grade 4 and hydronephrosis of lower grade Control group
on the contralateral side. Units measured (%) 141/145 140/145
The median age at presentation is 0.5 months (97.3) (96.5)a
(0.03e11.6). Median PT (range) 6.2 (5e7) 6.3 (5e7)
Included ultrasound measurements were obtained at a Intraclass correlation 0.89
median age of 3.3 months (0.1e48.3). The median age of coefficient
measurements for patients who underwent pyeloplasties Cronbach’s alpha 0.94
was 4.9 months (0.1e48.3) and 2.5 months (0.2e14.1) for
PT Z pyramidal thickness.
those who were managed conservatively (p Z 0.001). a
All units that investigator 1 was not able to measure were
The median APD for all renal units was 13 mm (range
included in the units that investigator 2 could not measure.
3.5e47 mm).
277.e4
had more than one renogram. The median age at renogram
was 3.2 months (0.9e50 months). Fifty-one out of 106 units
(48.2%) had a non-obstructive curve, and 55 units (51.8%)
had obstructive ones. The median DRF was 48% (17e68%)
while the median T1/2 was 8.8 (1.8e650) minutes.
The median follow-up period for all cases was 37.6
(12.5e102) months.
Fifty-two patients with 55 out of total included renal
units (33.3%) underwent pyeloplasty. Thirty-three percent
(18/55 units) were SFU grade 3 while 67% were grade 4 (37/
55 units). On the other hand, 110 units (66.7%) were
managed conservatively. Of the conservatively managed
units, 50% (55/110 units) were resolved while the others
were either improved or had the same hydronephrosis.
The median average PT for units that underwent pye-
loplasty was 1.8 (0e3.2) mm while for resolved renal units
on conservative management was 4.35 (2e7) mm. We
measured the PT in 141 contralateral kidneys. We were not
able to measure the contralateral PT in five units. The
median contralateral PT was 6.2 (5.8e7) mm. Twenty-seven
patients had contralateral SFU grade 2, grade 1 was diag-
nosed in 41, and the remaining patients had non-
hydronephrotic contralateral kidneys. The median contra-
lateral PT was 6.2 mm for those who had pyeloplasties or
were treated conservatively (p < 0.001 in both groups). The
median APD for units undergoing pyeloplasty was 25
(13e47) mm. While for units with conservative manage-
ment, the median APD was 9.4 (3.5e20) mL.
Univariate analysis revealed that SFU grade 4, APD,
average PT, T1/2, and a MAG-3 obstructive curve had sig-
nificant relationships with pyeloplasty (Table 3).
Multivariate analysis (Table 3) showed that PT was a
single independent predictor for pyeloplasty. The multi-
collinearity statistics yielded a VIF value of 2.1 and 2.3 for
APD and PT respectively. This revealed non-problematic
multicollinearity.
The ROC curve was used to estimate the cut-off value of
average PT regarding the pyeloplasty incidence. The area
under the curve (AUC) was 0.965 (Fig. 1). A cut-off value of
3 mm had 98.1% sensitivity and 89.7% specificity regarding
the need for surgery (positive predictive value
(PPV) Z 0.82.8 and negative predictive value (NPV) Z 0.99).
Moreover, there was a moderate correlation between T1/2
and average PT (r Z 0.58, p < 0.001).
Table 3 Univariate and multivariate Cox regression analyses regarding pyeloplasty.
Parameters Univariate analysis
Hazard ratio (confidence interval)
Gender 0.846 (0.445e1.609)
Laterality 0.599 (0.33e1.086)
SFU Grade 3 0.207 (0.115e0.371)
Grade 4 1 1
PT 0.485 (0.4e0.584)
APD 1.067 (1.031e1.104)
MAG-3 T1/2 1.003 (1.003e1.005)
DRF 0.992 (0.975e1.009)
Curve Obstructive 1 <0.001
Non-obstructive 0.14 (0.06e0.328)
APD Z pelvic anteroposterior diameter; DRF Z differential renal function; PT Z pyramidal thickness.
A. Hodhod et al.
The median postoperative follow up period was 29
(6.3e98.4) months. Postoperative PT was measured in 41
out of 55 units (74.5%) at median postoperative time in-
terval 7.6 months (6.1e9.4). We could not measure PT in 14
units because the renal pyramids were not clearly defined
within the parenchyma. The median DPT% was 69.6% (100
to 358.3). Renal units with non-visualized PT (PT Z 0 mm;
12/17 units, 70.6%) were improved with median
DPT Z 2.30 mm, one unit showed no improvement, and we
were not be able to define the renal pyramid within the
remaining units. Hydronephrosis improvement was noted in
38 out of 41 (92.7%) units and three units were not
improved. One unit with non-improved hydronephrosis un-
derwent redo pyeloplasty and two units showed improve-
ment on subsequent ultrasounds. The renal unit that had
redo pyeloplasty had a preoperative PT Z 1.5 mm and
postoperative PT Z 0. The status of hydronephrosis showed
excellent association with DPT% (p Z 0.004). For the non-
defined pyramids, preoperative PT was 0 mm in 11 out of
14 units (78.6%) because of significant thin parenchyma.
Discussion
The renal pyramid is the first renal component that is
affected by hydronephrosis [7]. So, it can be a good
parameter to evaluate the hydronephrosis severity. We
included only SFU grade 3 and 4 because pyeloplasty deci-
sion is made for considering these grades.
Kadioglu [7] measured PT in healthy children. According
to his results, during the first year of life the mean PT is
6 mm while at the age of nine it is 7 mm; so, it was slightly
changed within the first years of life. In comparison to the
whole parenchymal thickness, which was significantly
changed with age (9 mm at 1 year to 13.3 mm at 9 years)
[7]. So, we used PT to evaluate hydronephrosis severity
because it is easier to interpret than the whole paren-
chymal thickness.
PT measurement in hydronephrosis was not previously
evaluated. We found that PT was easily measured in most
kidneys. However, the feasibility of postoperative mea-
surement was lesser as some renal pyramids were not easy
identified. Moreover, we measured the contralateral PT as
an internal control for those who underwent pyeloplasties
Multivariate analysis
p Hazard ratio (confidence interval) p
0.61 e
0.11 e
<0.001 0.976 (0.456e2.09) 0.6
<0.001 0.639 (0.481e0.849) 0.002
<0.001 1.03 (0.993e1.068) 0.12
0.01 0.998 (0993e1.003) 0.42
0.339 e
1 0.07
0.484 (0.225e1.041)
Pyramidal thickness as a predictor for pyeloplasty
Figure 1 Evaluation of the cutoff value of PT for prediction of pyeloplasty using the receiver operating characteristic curve with
the coordinates of the curve. Area under the curve interpretations: 0.90e1 Z excellent; 0.80e0.89 Z good; 0.70e0.79 Z fair;
0.60e0.69 Z poor; 0.50e0.59 Z fail.
or managed conservatively. There were significant differ-
ences in both groups; this indicated the early affection of
PT in high-grade hydronephrosis.
Many pyeloplasty predictors were previously evaluated.
APD is the best predictor for surgical intervention in UPJO
[1,2]. Mudrik-Zohar and colleagues [2] reported that the
parenchymal thickness is a good predictor of postnatal
pyeloplasty especially if used as APD/parenchymal thick-
ness ratio. Moreover in a recent prospective study, the APD
and DRF were considered the most independent predictors
for pyeloplasty [12]. In our study, only PT showed to be
associated significantly with pyeloplasty.
All available grading systems classify ANH according to
the probability of complication or surgery [4e6,9]. SFU
grade 4 is just different from grade 3 by the presence of
thin parenchyma [5]. However, SFU grade 4 is not a good
predictor of pyeloplasty [12]. The inter-rater reliability of
grade 3 hydronephrosis is low [13]. This may be because the
parenchymal thinning is not clearly defined to differentiate
between grade 3 and grade 4 [14].
According to our results, PT is a good predictor for
pyeloplasty in high-grade hydronephrosis and DPT% is
associated with postoperative hydronephrosis status.
Moreover, it is correlated with post-furosemide T1/2. The
important factor to classify the hydronephrosis is to predict
the probability of surgical intervention. High-grade hydro-
nephrosis was defined as hydronephrosis associated with
parenchymal thickness <50% regarding the measurement of
a normal contralateral kidney [3,4]. However, it cannot be
applied for patients with bilateral hydronephrosis. To
clearly define the parenchymal thinning, it necessitates
using a parameter that not changes significantly with the
first years of life.
277.e5
We did not exclude renal units with PT Z 0, as evalua-
tion of PT as a reliable and valid parameter was to be
assessed by at least two investigators for all patients with
SFU grade 3 and 4. Otherwise, the agreement of non-
visualized PT (PT Z 0 mm) would not be assessed.
Post pyeloplasty, the renal parenchymal growth is more
evident than APD reduction [15]. We found that DPT%
post pyeloplasty is associated with hydronephrosis
improvement.
The preoperative non-assessed PT could be due to py-
ramidal atrophy [16]. We supposed that PT could not be
assessed postoperatively due to absence of cortico-
medullary differentiation secondary to previous atrophy or
fibrosis. Despite the significant association between DPT%
and postoperative hydronephrosis status, the percentage of
non-defined PT (25.5%) may hinder its use as a good pre-
dictor for improvement especially for units with thin pa-
renchyma (grade 4).
Measurement of PT just before surgery or the worst
hydronephrosis for non-operative group reflects the time at
which the PT is maximally affected in both groups. Thus, it
makes the comparison of PT regarding the surgical or con-
servative managements more justified. The trend of PT in
both groups could be a further step in evaluating the PT
value in high-grade hydronephrosis management.
Further studies are needed to evaluate agreement of PT
measurement and its ability to predict surgical intervention
for other causes of hydronephrosis according to the natural
history. Furthermore, assess of PT utility in the term of
definition of parenchymal thinning.
The determination of the “need” for pyeloplasty re-
mains subjective. We presented our indications of pyelo-
plasty that not all other practitioners would follow. The PT
277.e6
value as an indicator for pyeloplasty should undergo
extensive assessment by other institutions with different
protocols.
Our study had some limitations. It is a retrospective
study. However, we tried to overcome this point through
blind revision of all images and exclusion of cases with
incomplete ultrasound profile. Despite being a slowly
growing part of the renal parenchyma during the first years
of life, its feasibility as a predictor for pyeloplasty should
be studied at older ages. However, our median age at
pyeloplasty was 4.9 months which is similar to others [17].
Multiple surgeons were implicated in this study regarding
the decision of pyeloplasty. However it is the usual in pe-
diatric urology practice. Moreover, the follow-up period
was relatively short; therefore, another study with long-
term follow up is warranted.
Conclusion
PT measurement is feasible in hydronephrosis with an
excellent reliability. Being the first part of the renal pa-
renchyma to be affected by high-grade hydronephrosis and
being a slowly growing part of the parenchyma, it can be a
good measurable parameter to predict pyeloplasty.
PT  3 mm is a good predictor for pyeloplasty in high-grade
hydronephrosis with 98.1% sensitivity and 89.7% specificity.
Moreover, the post pyeloplasty increase in PT is associated
with hydronephrosis improvement.
Conflict of interest
None.
Funding resources
Internal departmental fund.
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