Journal Club

Dr. H. Al-Hazmi

Prenatally diagnosed hydronephrosis:the Great Ormond street experince

H.K. DHILLONThe department of paediatric urology,The hospital for sick children, Great Ormond

Street,London,UK

BJU,April,1998

The natural history series

115 children From 1980-1988 Total 148 kidney - 77:Unilateral

- 33:Bilateral - 5 :

Solitary Follow up from 5 to 16 yeats

Protocol:

All hydronephrotic kidneys classified into one of 3 functional group according to DTPA study

poorly : <20% moderately: 20%-39% good: >40%

U/S: in first week Functional imaging (DTPA) with

differential function : 4-6 weeks On initial image:

< 20%: proceeded to surgery 20-30%and >40%: re-imaged at 3mo.

At 3mo. :- still moderate pyeloplasty

- good function conservative

Conservative F/UP:U/S andDTPA: at 6mo.,1 year

then annually till age of 5year then 5,10 and 15 years

Indication for surgery:- If renal function < 40%

-symptoms : UTI or pain

All infant taking trimithoprim

RESULTS POOR FUNCTION:

-10 Kidneys-3 pyeloplasty

-7 nephrectomy

MODERET FUNCTION:-28 kidneys

-5 managed conservatively- 23 underwent

pyeloplasty •12 improved togood function •10 same level

GOOD FUNCTION: -110 Kidneys

-6 early pyeloplasty -104 protocol

•27 pyeloplasty

conclusion

NO INDICATION FOR IMMEDIATE PYELOPLASTY IN INFANTS WITH PRENATALLY DIAGNOSED HYDRONEPHROSIS WHO DEMONESTRATE GOOD FUNCTION POSTNATALLY

RANDOMIZED CLINICAL TRIAL:

April 1988 and continued for 5 years All infant had prenatally diagnosed

hydronephrosis ,unilateral,3-6mo. age > 14mm (a-p) on U/S and > 40% on DTPA

Randomized to either surgery or conservative follow-up

Surgical group followed with U/S and DTPA at 3mo.,1and5 year post op.

Conservative group followed with U/S and DTPA AT 3mo., one year then annually

Surgery indicated if renal function <40% or decrease >10%

RESULTS

75 patient (39 surgical group +36 conservative group)

In surgical group all had good post op. result In conservative group

-12 remain stable-17 hydronephrosis improved

spontaneously -7 required surgery

The out com of differential renal function did not showed any difference between the groups

All pt.who need pyeloplasty had a minimum dilatation of 20mm

U/S the most useful imaging modality for identifying the population at risk for surgery

conclusion The concept of measuring the degree of

renal pelvic dilatation on U/S allow children to divided in 3 groups

1- < 20mm: F/UP with U/S 2- > 50mm: early surgical intervention 3-20-50mm:surgery only with reduced function,symptoms,increasing dilatation,and severe hydronephrosis in solitary kidney