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Postnatal management of prenatally

diagnosed hydronephrosis

Prof. Dr.Serdar TEKGÜL FEAPU

Division of Pediatric Urology

Department of Urology

Hacettepe University

EAU/ESPU guidelines, 2014

Hydronephrosis Management evidence based

http://www.uroweb.org/guidelines/online-guidelines/

Postnatal Management of UPJ

• Definitions

• Modes of presentation

• How to diagnose and follow-up

• When to do surgery !

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General principles !!

• Hydronephrosis = dilatation

– This what we see

– ≠ obstruction

– May be a sign of obstruction ( at UPJ or UVJ)

– May be a sign of reflux

– May be a sign of LUT dysfunction

– Insignificant

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General principles !!

• Obstruction

– Impairment of flow

• Mechanical ( due to extrinsic or intrinsic

pathology narrowing the lumen of the ureter

)

• Functional ( VUR, LUTD)

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Modes of presentation

• Asymptomatic

– Diagnosed in utero ( 60-80%)

– Diagnosed after birth by USG (10%)

• Symptomatic

– Diagnosed early or late after birth with

clinical symptoms

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What is our responsibility?

• Differential diagnosis

– what causes the dilatation?

• Risk analysis

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Asymptomatic baby

Nonsig. PUV Megureter UPJ Reflux

?

Differential diagnosis

Define prognosis

Prenatal USG

Risk analysis

• Obstruction is the condition that you need to

correct

– if during the follow up there is progression of

dilatation and loss of renal function

• It would be better if you can pick up the

ones which will progress early on before

any imparment in renal function takes place

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• 28 wk male fetus

• Fetal USG

unilateral hydronephrosis

AP pelvis 10 mm

No additional pathological finding

PARENTS IN PANIC

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Clear Definition (prenatal history)

• Hydronephrosis: AP pelvis > 10 mm

– > 4 mm before 28 wk

– > 7 mm after 28 wk

• Serial USG

• AP pelvis diam / Grade / Paranchyma

• Progression !

• 20 wk > 10 mm, 28 wk >20mm, 36 wk >30 mm IMPORTANT!

• Kidney / ureters / bladder / post.urethra

• Amniotic fluid

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postnatal n AP mm

normal 13 6.3 (5-12)

non-obs 137 11.8 (5-50)

Obstructed 59 22.3 (9-65)

reflux 22 14.4 (5-30)

Amer J Obst Gynec 165:384 1994

24-28 wk of gestation

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Prenatal diagnosis

• Serial investigations

• False positive evaluation % 9-22

• False postivity is higher in low AP diam

• Only 20% of cases are clinically important

• Ratio of undergoing risky group less than

5%

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Which cases are under risk !

• Unilateral cases and all all girls are in the good

group

• All bilateral cases are under risk unless bladder

problem is excluded.

• Boys / bil hydro / thick walled and distanded

bladder / dilated post.urethra / oligohydramniosis

• Good: if there is not oligohydroamniosis at 28th wk

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30 wk male

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Should Intervention Be Done in

the risky Group and Poor Renal

Function?

• Bil hydroureteronephrosis / thick walled

distanded bladder/ hiperecogenous kidney

• Diminished amnionic fluid

• Hypertonic urine in the consecutive samples

? vesicoamniotic shunt

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Succes rate at first time : %10

Cause of 7 death only because of intervention

Crombleholme 1990 Freedman 1996

87 fetus

45 fetus

VA shunt

42 fetus

VA no shunt

16 bad prognosis 29 good prognosis

10 death

6 alive

2 good RF

9 death

20 alive

17 good RF

30 bad prognosis 12 good prognosis

30 death

0 alive

7 death

5 alive

4 good RF

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Prenatal Intervention

• High risk for the mother and baby

• Complication rates up to 45%

• With prenatal intervention does the

– Fetal survival ratio

– Kidney function increase?

• Prenatal intervention is an experimental

procedure

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Asymptomatic patients

Diagnostic tests

Normal UPJ Reflux

?

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Healthy newborn baby girl

diagnosed with bilateral

hydronephrosis prenatally

during US screening at 28

weeks of gestation.

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Prophylaxy .. Amoxycilin 50 mg / d

Creatinin evaluation .. useless

( if not bilateral)

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What is the first investigation and when?

• USG

• Renal Scan

• VCU

• ASAP

• After 3 days

• End of 1st month

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Baby born with diagnosis of prenatal hydronephrosis

G 0 G 1 G 2 G 3 G 4

SFU hidronefroz grading

• Serial studies (periodic follow-up)

– Consistent findings

– In relations to other dynamics

NO SINGLE STUDY WILL GIVE YOU

RELIABLE INFO

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Case: Time course of an intrauterine detected

unilateral hydronephrosis

33 weeks, SFU II hydronephrosis, left kidney

First day of life, right kidney, SFU 0

Case: Time course of an intrauterine detected

unilateral hydronephrosis

First day of life, left kidney, SFU 0

Case: Time course of an intrauterine detected

unilateral hydronephrosis

4th week, left kidney, SFU III

Case: Time course of an intrauterine detected

unilateral hydronephrosis

4th month, left kidney, SFU I

Case: Time course of an intrauterine detected

unilateral hydronephrosis

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Within first mo VCU- USG

Reflux + PUV

Valve ablation SFU G3-4 / AP renal pelvis diameter

>50 mm 20 -50 mm < 20mm

Reflux-

conservative

•%100 requires surgery

within 6 mo

•% 60 poor DRF

Scintigraphy at the end

of 1st mo

Prenatal diagnosis hydronephrosis

• 20-29mm %30 opx

• 30-39mm %40 opx

• 39-49mm %90 opx

Surgery

DRF < %10 nephrectomy

> %10 pyeloplasty

• < 5 % opx

Surveillance with USG

SFU G 1-2

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Why do we need VCUG ?

• To exclude VUR

• To exclude PUV

• Bladder diverticula

• Other pathologies

Healthy newborn baby girl

diagnosed with bilateral

hydronephrosis prenatally

during US screening at 28

weeks of gestation.

Incidence of reflux is 18 (10-38) % F>M

• Incidence of reflux : if postnatal US is normal 16 ( 10 - 24 %)

– Normal postnatal US does not exclude VUR

– Postnatal US is more predictive than prenatal US

• Incidence of reflux in high grade hydronephrosis ( 8 – 28 % )

• Incidence of reflux in low grade hydronephrosis ( 10 – 22 % )

– Variable results ( slightly higher VUR in high grade HN )

• Poor definition of ureteric dilatation and other structural abnormalities.

• The incidence of VUR is similar in uni vs bilateral HN

Walsh G 1999 , Aksu 2005, Liedefelt 2008, Merlini 2007, Ismaili K 2005, Dremsek PA 1997, Mami 2009,

Hothi DK 2009 , Skoog 2010

Predictive value of US findings

• Postnatal US does not provide definitive

information about presence of reflux.

3 weeks after birth

8 weeks after birth

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Antenatally diagnosed reflux

• Reflux underlies 15-20% of antenatal

dilatations

• Most are low grade and have high

resolution rate

• Scars are generally congenital

• Absence of hydronephrosis does not rule out the presence of reflux.

• In cases with 2 normal postnatal successive US, VUR is a rare entity and if

present it is low.

• The degree of hydronephrosis is not a good indicator for reflux.

• VCUG is recommended in patients with ultrasound findings of

– bilateral high grade hydronephrosis,

– duplex kidneys,

– ureterocele,

– ureteric dilatation

– abnormal bladders

– presence of cortical abnormalities

• All patients need monitoring for UTI

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J.Urology 162: 1221 1999

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Diuretic renogram

• MAG3

• 2-3 min parenchymal uptake DRF

• 20 min furosemid

• T ½ 10-15min

• Curves

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Diuretic renogram

•Differential renal function

< %20 %20-40 >%40

•Renogram curve

•T1/2 <10 min 10-20 min >20min

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RU 1/12 M

MAG3 renogram curve is obstructive on the left T1/2 66

min

R %48 L %52

left right

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Factors Effecting Washout

• Renal function

• Hydration

• Bladder status

• Severity of hydronephrosis

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DRF >50 50-40 40-30 20-30

< %20 131 26 12 1

% 20 -40 23 24 32 17

> % 40 3 5 18 23

AP pelvis diam Surgery ratio %

<15 2

15-20 7

20-30 29

30-40 61

40-50 67

>50 100

Dhillon 2000

n:914

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Is IVU required?

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DRG MR-U

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Within first mo VCU- USG

Reflux + PUV

Valve ablation SFU G3-4 / AP renal pelvis diameter

>50 mm 20 -50 mm < 20mm

Reflux-

conservative

•%100 requires surgery

within 6 mo

•% 60 poor DRF

Scintigraphy at the end

of 1st mo

Prenatal diagnosis hydronephrosis

• 20-29mm %30 opx

• 30-39mm %40 opx

• 39-49mm %90 opx

Surgery

DRF < %10 nephrectomy

> %10 pyeloplasty

• < 5 % opx

Surveillance with USG

SFU G 1-2

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2nd month USG - Renogram

• increase in hydro

• renal func. less than

%40 and/or renogram

obstructive

•No increase in hydro

•renogram non-obstructive

•renal funct. Above 40 % surgery

Control at 3rd. mo

All other situations

bilateral cases

solitary kidneys

!

Low risk

• AP < 20 mm SFU < G4

– (confirmation in serial USG required)

• Normal function ( equal DRF)

• Follow up by serial USG ( 3 monthly)

• 1 y US ± DTPA/MAG3

Low risk group

• Impairement in function < 40%

• Symptoms

• Increasing hydro

Will require surgery in 10-15 %

Dhillon et al 2008

High risk group

• AP > 20

• G4 hydronehrosis

• DRF values vary

• Majority has obstructed curves

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Indication for operation

• High grade hydronephrosis

• Diminished renal function ( <40% )

• Solitary kidney and bilateral pathologies !

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At 4th.month USG - Renogram

•increase in hydro

• more than 10%

decrease in renal

function • no change in hydro

•No sign change in

renal function

-hydro decreased

-improvement in

renal function

control with

USG after 3-6 mo

surgery

control with

renogram and USG after 3-6 mo

symptomatic

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Operation criteria during

surveillance

• Incerase in hydronephrosis

• Worsening in DRF

• Contralateral compensation

• Symptoms

having an obstructed curve is not an

indication itself

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Operation indications

• DRF less than 40%

• Decreasing DRF

• Increasing hydronephrosis

• Symptoms

• Bilateral hydronephosis ( not resolving-

progressive)

• Solitary kidney (not resolving- progressive)

Pyeloplasty: Anderson Hynes

2.2 cm

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Not all prenatal hydro’s are obstructive and require surgery

Those which will lead to progressive impairement will require surgery.

The challenge is to pick up the cases who will lead to progressive

loss of function if leaft untreated.

High grade hydronephrosis or pregressive hydronephrosis have

higher risk for loss of renal function.

You may be overtreating the patient if you rush for surgery,

Yet you may also be delayed if you do not operate timely.

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OK 8/12 M no prenatal diagnosis. Left flank mass

USG left G4 hydronephrosis AP pelvis diam 65mm

VCU normal

DTPA right compensated %91 – left non-functional % 9

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What to do?

• Nephrectomy

• Pyeloplasty

• Nephrostomy

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OK 9/12 M daily urine output after percutaneous

nephrostomy ~ 200 ml Cr Cl 25 ml/dk

total Cl 110 ml/dk

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OK 1y M functioning left kidney after operation