DR SHIRIN SURANI

RESIDENT YEAR 1
 Fetal hydronephrosis is the dilation of the
renal pelvis with or without dilation of the
renal calyces

 0.5 to 1 percent of pregnancies

 In most cases, renal pelvic dilation is a

transient physiologic state
 The goal of prenatal management is to:

 Detect those cases of fetal hydronephrosis that may

adversely affect the health of the infant

 Need for antenatal and postnatal evaluation

 Timely referral to a pediatric urologist if required

 Possible intervention to minimize adverse

outcomes

 Limiting testing in those cases that are due to a

benign, transient condition.
WHAT SHOULD WE LOOK FOR ON ULTRASOUND
SCAN??

 Presence and nature of associated renal

and extrarenal anomalies

 Severity of hydronephrosis

 Unilateral versus bilateral involvement

 Amniotic fluid volume

Definition and grading
 Several systems have been developed to diagnose
and grade the severity of fetal hydronephrosis

 The likelihood of having a significant renal anomaly

correlates with the severity of hydronephrosis.

 Scoring systems differ based upon the fetal

ultrasound criteria used and include:
 Renal pelvic diameter (RPD)
 Society of Fetal Urology (SFU) criteria
 Urinary tract dilation (UTD) classification system
 1-Renal pelvic diameter (RPD)
 Most generally accepted method

 Measurement of the maximum anteroposterior diameter of the renal

pelvis (APPD) in the transverse plane, also referred to as RPD

 Fetal hydronephrosis is graded according to the RPD during the

second and/or third trimester of pregnancy.

 RPD is a measure of collecting system dilation and does not reflect the
extent of hydronephrosis and parenchymal changes

 RPD >10 mm in the second trimester is associated with an increased

risk of significant congenital anomalies of the kidney and urinary tract
(CAKUT)

 Fetuses with RPD >15 mm during the third trimester are at the greatest
risk for CAKUT
 2-Society of Fetal Urology (SFU)
 Based upon the degree of pelvic dilation, number of calyces
seen, and the presence and severity of parenchymal
atrophy.

 Grade 0 − Normal examination with no dilation of the renal pelvis

 Grade I − Mild dilation of the renal pelvis only

 Grade II − Moderate dilation of the renal pelvis including a few

calyces

 Grade III − Dilation of the renal pelvis with visualization of all the
calyces, which are uniformly dilated, and normal renal parenchyma

 Grade IV − Similar appearance of the renal pelvis and calyces as

grade III, plus thinning of the renal parenchyma
 3-Urinary tract dilation (UTD) classification
system
 Based on six ultrasound findings:
1. Anterior and posterior RPD
2. Calyceal dilation
3. Renal parenchymal thickness
4. Renal parenchymal appearance
5. Bladder abnormalities
6. urologic abnormalities.

 three antenatal categories:

 Normal
 A1 [mild abnormality]
 A2-3 [more severe finding]

 compared with four postnatal categories

 Normal
 P1 [mild]
 P2 [moderate]
 P3 [severe].
 Urinary tract dilation classification system for
pediatric hydronephrosis
ANTENATAL POSTNATAL
A normal urinary tract is one with no urinary tract abnormalities and anterior posterior renal pelvic diameter (APRPD)
measuring less than 4 mm between 16 and 27 weeks gestation and less than 7 mm ≥28 weeks gestation.

NORMAL NORMAL

A1 describes a normal urinary tract with 4 to <7 mm pelvic dilation at 16 to 27 weeks gestation or 7 to <10 mm ≥28 weeks
gestation with or without central calyceal dilation
P1 describes a normal urinary tract with APRPD 10 to <15 mm and/or central calyceal dilation

A1 P1
A2-3 is for fetuses if there is APRPD ≥7 mm between 16 and P2 describes APRPD ≥15 mm or peripheral calyceal dilation
27 weeks gestation or ≥10 mm ≥28 weeks gestation,
peripheral calyceal dilation, ureteral dilation, renal
parenchymal, or bladder abnormalities

P3 describes additional ureteral dilation, abnormal renal

echogenicity or cysts, or bladder abnormalities regardless of
APRPD measurement
ETIOLOGY
 The finding of mild hydronephrosis
should prompt a detailed assessment of
fetal anatomy to identify other congenital
anomalies
 Urinoma or urinary ascites
 Urinoma is a fluid mass formed by extravasated urine
encapsulated in the perirenal fascia.

 Urinomas are secondary to urinary obstruction such as PUV or

ureteropelvic junction obstruction (UPJO).

 Associated with a nonfunctional dysplastic ipsilateral kidney in 80

percent of cases.

 Urinary ascites can be secondary to spontaneous or iatrogenic

rupture of the bladder and the renal calices due to lower
obstruction and increased pressure, or rarely due to neurogenic
bladder.
Antenatal monitoring
 In fetuses with unilateral hydronephrosis, at least one follow-up
ultrasound be performed in the third trimester is recommended

 Fetuses with bilateral hydronephrosis be monitored frequently

 The frequency of monitoring varies from 4 to 6 weeks, depending on
gestation at which ANH was detected, its severity and presence of
oligohydramnios.

 The risk of in utero worsening is higher for bilateral than for

unilateral disease.
 Fetal intervention
 The predominant cause for lower urinary tract obstruction is posterior
urethral valves in male fetuses.

 Fetal vesicocentesis, done on two or more occasions:

 Decreasing levels of sodium (<100 mEq/l), calcium (<8 mg/dl), osmolarity (<200
mOsm/l), β2 microglobulin (<4 mg/l), and protein (<20 mg/dl) identify fetuses that are
likely to benefit from therapeutic interventions

 Vesicoamniotic shunting or in uteroendoscopic ablation of valves

 Pregnancy in fetuses with unilateral or bilateral ANH should proceed to

term, except if complicated by severe oligohydramnios or major
structural anomalies
Postnatal Evaluation and Management
 TIMING OF INITIAL ULTRASOUND:

 In neonates with suspected posterior urethral valves,

oligohydramnios or severe bilateral hydronephrosis, ultrasonography
should be performed within 24-48 h of birth.

 In all other cases, the ultrasound should be performed preferably

within 3-7 days, or before hospital discharge (before they get lost to
follow up).
 Assessment of severity of postnatal hydronephrosis be based on the
classification proposed by SFU or anteroposterior diameter of the
renal pelvis.

 Ultrasonography should include evaluation for calyceal or ureteric

dilation, cortical cysts and enhanced renal echogenicity, and bladder
wall abnormalities
 POST NATAL MONITORRING:

 A single ultrasound in the first week of life might not detect all
abnormalities of the kidneys or urinary tract, due to low urine flow
secondary to dehydration and low glomerular filtration rate (GFR).

 Repeat study at 4-6 weeks (more sensitive and specific for

obstruction)

 A repeat ultrasound may show late worsening or recurrence of

hydronephrosis in 1-5% patients.

 Progression might occur in the first 2-years of life, and occasionally

until 5-6 years

 Follow-up studies are scheduled at 3-6 months, and then 6-12

monthly until resolution.
 MICTURATING CYSTOURETHROGRAM:

 Patients with unilateral or bilateral hydronephrosis with renal pelvic

APD > 10 mm, SFU grade 3-4 or ureteric dilatation (1B).
 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.
 Infants with antenatally detected hydronephrosis who develop a
urinary tract infection
 DIURETIC RENOGRAPHY:
 Diuretic renography allows differentiation between obstructive and non-
obstructive hydronephrosis and relative renal function

 Indicated in infants with moderate to severe unilateral or bilateral

hydronephrosis (SFU grade 3-4, APD >10 mm) and in infants with
hydronephrosis + dilated ureter

 Radiopharmaceuticals such as99mtechnetium mercaptoacetyltriglycine

(99mTc-MAG3) or ethylenedicysteine (99mTc-EC)

 Values between 45% and 55% are considered normal.

 An initial differential function below 35-40% in the kidney with

obstructed drainage signifies impaired function.

 Features that suggest obstruction include ipsilateral supranormal

differential renal function (≥55%) and prolonged time to clear 50% of
the radionuclide (t1/2 > 20 min).
 INDICATIONS FOR SURGERY:

 Obstructed hydronephrosis, 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

 Presence of pain, palpable renal lump or recurrent febrile UTI.

 The presence of large APD exceeding 20-30 mm predicts the

need for surgery in 50-55% patients.

 Predictors of unsatisfactory outcome include baseline differential

function <30% and renal APD >50 mm with dilated calyces
 ANTIBIOTIC PROPHYLAXIS

 Infants with postnatally confirmed moderate or severe

hydronephrosis (SFU 3-4; renal APD > 10 mm) or dilated ureter
should receive antibiotic prophylaxis while awaiting evaluation.

 All patients detected to have VUR receive antibiotic prophylaxis

through the first year of life.

 Antibiotics that are preferred include cephalexin (10 mg/kg/d) during

the first 3 months of life, and cotrimoxazole (1-2 mg/kg/d) or
nitrofurantoin (1 mg/kg/d) later
 References
 Nelson textbook of pediatrics
 Uptodate.com
 Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M,
Uppal R, Agarwal I. Revised guidelines on management
of antenatal hydronephrosis. Indian pediatrics. 2013 Feb
1;50(2):215-31.
 Kennedy WA. Assessment and management of fetal
hydronephrosis. NeoReviews. 2002 Oct 1;3(10):e214-9.