ANTENATALLY

DETECTED
HYDRONEPHROSIS
FETAL
HYDRONEPHROSI
S

Dilatation of fetal renal collecting system on prenatal ultrasonography

UPJ obstruction is the most common cause of moderate to severe, congenital hydronephrosis

It is more common in boys and maybe associated with other congenital anomalies or syndromes

Diagnosis confirmed, by an obstructive pattern observed on diuretic, enhanced, radionuclide scan.

Antibiotic prophylaxis to prevent UTI
Effective in preventing infection in patients with
high grade hydronephrosis

Definitive treatment often involves surgical

repair
Ureterovesical Junction obstruction

● Hydronephrosis associated with Ureteral dialataion

● Associated with deficient development of distal ureter or the presence of a ureterocele
● Diagnosis- radionuclide scan and VCUG.
● Temporary or permanent surgical interventions may be required based on clinical situation
• Posterior urethral valves (PUV) represent
the most common cause of lower urinary tract
obstruction, with an incidence of 1 in 5000-
8000 live male births.

• A posterior urethral valve is composed of a

congenital membrane that obstructs
or partially obstructs the posterior urethra and is
formed when the mesonephric duct fails to
adequately regress.
• Findings on prenatal ultrasound may include
hydronephrosis
1. dilated ureters
2. a thickened, trabeculated bladder
3. dilated proximal urethra
4. oligohydramnios.

The antenatal presentation may include a palpable,

distended bladder, poor urinary stream, and signs and
symptoms of renal and pulmonary insufficiency.
• The VCUG is diagnostic for PUV and reveals
associated VUR in 30% of patients
Multicystic Dysplastic kidney

most severe form of renal dysplasia characterized

by a nonfunctioning kidney

devoid of normal renal architecture - composed of

multiple large cysts that resemble a cluster of
grapes

• About 20% of children with unilateral MCDK

will have vesicoureteral reflux into the
contralateral kidney, which is grades I-Ill in 96%.
Grading

•Renal pelvic diameter (RPD)

• Society of Fetal Urology (SFU) criteria

• Urinary tract dilation (UTD) classification

system
Renal pelvic diameter (RPD)

• The most generally accepted method to define and

grade fetal hydronephrosis - maximum APPD
(also referred to as RPD, in the transverse)

● Fetal hydronephrosis is graded according to the

RPD during 2nd &3rd trimester

•RPD is a measure of collecting system dilation ;does

not reflect the extent of hydronephrosis and
parenchymal changes.
Society of Fetal Urology (SFU)
Based upon the

• degree and site of pelvic dilation

• number of calyces seen, and
the presence and severity of parenchymal
atrophy.

• The SFU grading system focuses on the degree

of hydronephrosis in the kidney
Without directly assessing ureter and bladder
Urinary tract dilation (UTD) classification
system
• The UTD classification system is based on six
ultrasound findings

• Anterior and posterior RPD

• Calyceal dilation
• Renal parenchymal thickness
• Renal parenchymal appearance
•Bladder abnormalities
• Ureteral abnormalities
UTD A1: APPD;

● 16 to 27 weeks: 4 mm to <7 mm

● ≥ 28 weeks: 7 mm to <10 mm

With or without central calyceal dilatation

UTD A2-3: APPD

● 16 to 27 weeks: >7 mm
● >28 weeks: >10 mm

Peripheral calyceal dilatation

Abnormal parenchyma thickness or appearance

Abnormal ureter or bladder

Unexplained oligohydramnios
PHYSICAL EXAMINATION
•The neonatal physical examination can identify
abnormalities that are indicative of congenital
anomalies of the kidney and urinary tract (CAKUT),
which are associated with fetal hydronephrosis.
These include the following:
• Abdominal mass - enlarged kidney due to
obstructive uropathy or multicystic dysplastic kidney

• A palpable bladder in a male infant- posterior

urethral valves (PUV).
● a male infant with deficient abdominal wall
musculature and undescended testes-prune-belly
syndrome
● outer ear abnormalities - associated with an
increased risk of CAKUT.
● A single umbilical artery - increased risk of
CAKUT, particularly vesicoureteral reflux
(VUR.
● Spinal and/or lower extremity abnormalities
suggesting a neurogenic bladder, which may
result in hydronephrosis and dilated ureters
Imaging studies

• USG
• Voiding cystourethrogram
• Diuretic renography
• Magnetic resonance urography
Voiding cystourethrogram
• VCUG is performed in the majority of neonates with persistent postnatal hydronephrosis (RPD >10 mm)
to identify patients with bladder outlet obstruction, most commonly PUV,VUR.

• MCU be performed in patients with unilateral or bilateral hydronehrosis with renal pelvic APD > 10 mm,
SFU grade 3-4 or ureteric dilatation.

• MCU be performed early, within 24-72 h of life, in patients with suspected lower urinary tract
obstruction. In other cases, the procedure should be done at 4-6 weeks of age.

•MCU done for infants with antenatally detected hydronephrosis who develop a urinary tract infection
DIURETIC RENOGRAPHY
To diagnose urinary tract obstruction in infants
with persistent grade 4 and possibly grade 3
hydronephrosis after a VCUG has demonstrated no
VUR.

• measures the drainage time from the renal pelvis

• The test requires insertion of a bladder catheter to

relieve any pressure that can be transmited to the
ureters and kidneys
• intravenous access is needed for hydration and the
administration of the radioisotope and diuretic.

The preferred radioisotope istechnetium-99m-

mercaptoacetyltriglycine (Te99mMAG3)

taken up by the renal cortex, filtered across the

glomerular basement
membrane to the renal tubules,and excreted into the
renal pelvis and urinary tract.
• moderate to severe unilateral or bilateral
hydronephrosis (SFU grade
3-4, APD >10 mm) who do not show VUR
-should undergo diuretic renography.

• Infants with hydronephrosis and dilated ureters) and

no evidence of VUR undergo diuretic renography.
Magnetic resonance urography
• Magnetic resonance urography (MRU) in children is becoming more commonly used in the

diagnosis and management of congenital uropathies, such as ureteropelvic junction obstruction

(UPJO) .

• MRU is especially useful in the management of obstructed kidneys that have rotation or ascent

anomalies, or are single

•MRU can more clearly define the anatomy and delineate the proper surgical approach (ie,

retroperitoneal versus transperitoneal).

• often requires general anesthesia or heavy conscious sedation in children.

•However, for patients in the newborn period, many centers are now performing

"swaddle MRI" after the infant falls asleep after feeding, thus avoiding general

anesthesia and conscious sedation.

• Another disadvantage is the use of the contrast agent gadolinium, which can only be used if the renal
function is normal
NON EMERGENCY POSTNATAL
MANAGEMENT
• Since infants are relatively dehydrated at birth,
the initial postnatal ultrasonography should be
performed after 48 h of birth.

● Also breast fed neonates may not be

adequately hydrated until a steady milk flow
is established.
•Hence the first postnatal ultrasound is
preferably done between 3-7 d after birth.
Ultrasonography at 5-7 d would show one of the
following scenarios:
• No hydronephrosis-Normal pelvicalyceal system
• Unilateral hydronephrosis;
•Bilateral hydronephrosis;
• Unilateral Hydronephrosis with hydroureter; and
• Bilateral hydronephrosis with bilateral hydroureter
• Continuous prophylaxis cephalexin 10 mg/
kg/d HS,

● Trimethoprim 1-2 mg/kg/d HS

● Nitrofurantoin 1-2 mg/kg/d HS

*Counsel parents regarding increased risk of

urinary tract infections due to VUR
*perform urine culture for any fever without
focus.
Indications for surgery

• obstructive pattern on diuretic renography and differential function exceeding

40%.

• infants with lower urinary tract obstruction

• obstructed hydronehrosis, and either reduced differential renal function or its worsening on repeat evaluation

• bilateral hydronephrosis or hydronephrosis in solitary kidney showing worsening dilatation and deterioration
of function.
Other indications for surgery include

• presence of pain,

• palpable renal lump or

• recurrent febrile UTI.

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