Antenatal hydronephrosis

1. ANTENATAL
HYDRONEPHROSIS

2. • Hydronephrosis :-dilatation of the renal pelvis
with or without dilation of the renal calyces
• Currently the term urinary tract dilatiation
(UTD) is proposed (Congenital Abnormalities
of the Kidney and Urinary Tract or CAKUT)
A single grading system that can be used across the prenatal and postnatal
time period to describe UT dilation

3. Development
• 3 renal systems
– Pronephros :- disappears by 5 wks
– Mesonephros:- contributes to the ureteric bud
– Metanephros :- metanepric blastema which
differentiates to form glomeruli

7. History of antenatal USG
• 1940
– Dr Karl Dussik (austria )
– First paper on U/S brain imaging
• 1958
– First ultasound in preganancy
• 1970
– Fetal GU abnormalities detected

8. • Incidence of fetal anomalies :- 1%
• The incidence of urologic anomalies detected
in utero is approximately 1 in 500
• Hydronephrosis the most commonly detected
congenital condition that is observed by
prenatal ultrasound

9. Causes
Transient/physiological 41-88%
UPJ obstruction 10-30%
VUR 10-20%
Mega ureter 5-10%
Ureterocele 5-7%
MCDK 5-6%
PUV/urethral atresia 1-2%

10. Unilateral
• UPJ obstruction (39-64%)
• UVJ obstruction (9-14%)
• Vesicoureteral reflux (33%)
• MCDK (4-25%)
• Ureterocele/ ectopic ureter
• Duplex system
• PCKD
• Physiologic
• Extra-renal pelvis
Bilateral
• Posterior urethral valves (2-
9%)
• Vesicoureteral reflux
• Urethral aplasia
• Prune belly syndrome
• Megacystis-megaureter
• PCKD

11. Normal fetal ultrasound
• Most anomalies are detected as early as 12-14
wks
• The role of ultrasound in the evaluation of the
fetal urinary tract is two fold:
– (a) to identify the fetuses with any anomalies
involving the urinary tract
– (b) to monitor these lesions and characterize their
effect on the overall health of the fetus

12. PRENATAL GU MILESTONES
• Kidneys first detectable………….13 wks
• Hydronephrosis…………………….16 wks
• Internal renal structure distinct
• Kidney surrounded by fat…………..20 wks
• Fetal bladder
• Filling/emptying cycles……………..15 wks
• Ureters normally not visualized

13. BLADDER
• The bladder is visible at 10 weeks
• Appears as an echolucent area at
the base of the fetal trunk
• The size of the bladder may vary as
it fills and empties in a cyclical
manner

14. • The maximum bladder capacity typically is
– 10 mL at 30 weeks
– 50 mL at term
• The presence of a filled bladder and normal
kidneys gives presumptive evidence of
adequate renal function

15. • Inability to identify the
bladder on repeat
studies should raise the
question of bladder
exstrophy.
• Increased bladder wall
thickness may indicate
outlet obstruction, and
dilation of the posterior
urethra (keyhole sign) is
strongly suggestive of
posterior urethral valves

16. • Appearance
of a fetal
perinephric
urinoma
associated
with
posterior
urethral
valves.

17. Kidneys
• The kidneys can be visualized
by 12 to 13 weeks
• The fetal kidneys are seen in
transverse section just below
the level of the umbilical vein
early in gestation

18. • The ultrasound evaluation of the kidney
should comment
• on number, location, size,
• duplication, renal parenchyma (echogenicity),
pelvic dilation,
• calyceal dilation, urothelial thickening, and
cystic disease.

19. The kidneys may be recognized by their typical shape and by the
presence of a central echo from the intrarenal portion of the
collecting system

20. • The renal collecting system
(calyces and pelvis) should not
be seen.
• The renal pelvis, when visible,
is indicative of hydronephrosis
• Echogenicity should be slightly
less than that of spleen and
liver
• normal fetal kidney length has
been proposed: kidney length
(mm) = 16 + 0.06 × gestational
age in weeks

21. • Normally, the fetal ureter should not be seen.
Fetal ultrasonography showing a dilated,
tortuous ureter (arrow).
These may be associated with
reflux, valves,
ectopic ureters,
ureteroceles,
ureterovesical junction obstruction.
In this case the ureter is associated with a
dilated upper pole indicating an ectopic ureter
or ureterocele

22. External genitilia
• Fetal sex also can be determined early in
gestation
• Birnholz demonstrated the sexual identity of
40% of fetuses less than 24 weeks of gestation
• Gender specific anomalies
– PUV,megalourethrea(prune belly rare in females)
– Females with b/l HUN :-- cloacal anomalies

23. Amniotic fluid
• Oligohydramnios -<500ml
• In the first half of pregnancy, amniotic fluid is derived
from fetal and possibly maternal compartments
• Excretion of urine by the fetus is the major source of
amniotic fluid production in the second half of the
pregnancy
• Measured by AFI

24. What is not normal ?
• Hydronephrosis
– dilation of the upper urinary tract,
– the most common urologic abnormality found by
prenatal ultrasound

25. • The causes of fetal hydronephrosis are many but
can be divided broadly into
– obstructive
– nonobstructive dilation
• obstructive process,
– UPJ obstruction, UVJ obstruction, or bladder outlet
obstruction
• non obstructive
– VUR . physiologic

26. • No consensus on the best and most consistent
method of reporting ANH
• Measurement of the APD has been used
widely
• Antenatal hydronephrosis is present if the
– APD is ≥4 mm in second trimester
– ≥7 mm in the third trimester

27. Line diagram to measure fetal renal pelvic
anteroposterior diameter (APD). The APD is measured in the
transverse axial image of the renal pelvis at level of the renal
hilum
Antenatal ultrasound at 38-
weeks showing right-sided
hydronephrosis in transverse
view (+—+): 11.9 mm.
Anteroposterior diameter of the
kidney (x—x): 28.8 mm.

29. • APD can be affected by
– gestational age,
– hydration status of the mother,
– Bladder hypertonicity,
– degree of bladder distention
Disadvantages of the APD
• failure to describe pelvic configuration,
• calyceal dilation,
• laterality of findings

30. • Obstructive uropathy refers to urologic lesions
that significantly affect the development of renal
function and are caused by a fixed obstruction
within the urinary tract.
• Three most common causes of obstructive
uropathy in the fetus are
– UPJ obstruction,
– ectopic ureterocele,
– PUV

31. Natural history of ANH
• The vast majority of the cases of hydronephrosis
diagnosed during the second trimester have been
noted to resolve during follow-up imaging in the
third trimester.
- Majority of SFU G1-2 resolve by 18months
- If increasing hydronephrosis occurs , it does so
early in life and often during the first year.
- Multivariate analysis showed larger APD and SFU
grade 4 to be associated with a lower likehood of
resolution. Michelle et al J Ped Urol 2011
Surgery
25%
Persistence
23%
Resolution
52%

33. UPJ obstruction
• Most common cause of neonatal
hydronephrosis
• Believed to be an abnormality in the
development of the UPJ or proximal ureters
with disorganization in the smooth muscle
and connective tissue elements resulting in a
narrowed ureteral lumen

34. • Ureteral obstruction early in pregnancy (first or second
trimester) may result in
– pelvocaliectasis
– renal dysplasia,
• Late partial obstruction may only cause
pelvocaliectasis.
• Complete ureteral obstruction occurring before 10
weeks of gestation may be the cause of multicystic
dysplastic kidney and contralateral hydronephrosis in
the newborn

35. • UPJ obstruction usually occurs unilaterally
• 21% bilateral
• Unilateral UPJ obstruction,
– the amniotic fluid and bladder are normal,
– and the ipsilateral ureter is not visualized

36. • The prenatal sonographic diagnosis of UPJ
obstruction is a diagnosis of exclusion
• The diagnosis of UPJ obstruction prenatally
depends on fulfilling the echographic criteria for
significant pelviectasis, in the absence
– of a dilated ureter,
– Distended bladder,
– ectopic ureterocele,
– posterior urethra

37. Ureterocele.
• Hydronephrosis is
common in the upper
pole
• Careful inspection of the
bladder can diagnose
ureterocele
• Ectopic ureterocele
obstructing the bladder
outlet may result in
bilateral hydronephrosis

38. • 80% of affected neonates are female,
• bilateral in 10% to 15% of patients.
• In male patients, 40% have a single system
drained by the ureterocele

39. Megaureter
• Characterized by a dilated kidney and ureter
and usually a normal bladder
• Nonobstructed cases, the megaureter may be
– secondary to VUR,
– physiologic (secondary to high urinary flow in the
fetus)
• Obstruction at the UVJ

40. • Bilateral hydroureteronephrosis is detected, a
distended bladder suggests bladder outlet
obstruction secondary to
– PUV,
– prune-belly syndrome,
– urethral atresia,
– high-grade reflux

41. PUV
• PUV is a common cause of neonatal
hydronephrosis
• Bladder outlet obstruction due to PUV often
has a very deleterious effect on both bladder
and kidney development

42. • Prenatal sonographic findings include
– oligohydramnios,
– a dilated urinary bladder and posterior urethra,
– bilateral hydronephrosis,
– subcortical renal cyst formation indicative of renal
dysplasia
• Popoff
– Massive vur into a nonfunctioning kidney
– Urinary ascitis
– diverticulae

44. • The most important prognostic feature in the
fetus with bladder outlet obstruction is the
presence or absence of sufficient amniotic
fluid
• The primary cause of neonatal mortality is an
inability to ventilate the lungs because of
severe pulmonary hypoplasia

45. Multicystic dysplastic kidney
• Most common cause of an abdominal mass in
the neonate
• The reniform contour of the kidney is lost.
• A grapelike cluster of cysts of varying size
replaces the renal cortex, and these kidneys
do not function

46. • Multicystic kidney occurs bilaterally in 20% of patients
and is fatal.
• Hydronephrosis of the contralateral kidney occurs in
10% of patients and is usually due to UPJ obstruction
Multicystic kidney at 31 weeks
of gestation.
multiple cysts of varying size
without identifiable
parenchyma

47. ARPKD
• Autosomal-recessive disorder that affects the
kidneys and liver
• The kidneys undergo cystic dilation of the
collecting tubules.
• The cysts generally are 1 to 2 mm wide
• The liver demonstrates periportal fibrosis and
bile duct proliferation

48. • Oligohydramnios,
• Non-visualization of the
urinary bladder,
• Bilateral renal
enlargement
• Highly echogenic
appearance secondary to
sound refection off the
wall of the numerous
dilated tubules

49. FETAL INTERVENTION
• The ability to identify congenital lesions in the
fetus has increased our understanding of the
natural history of the lesions prenatally and also
has introduced new therapeutic options
• Goal of management of a fetus with congenital
hydronephrosis is
– prevent the sequelae of the obstructive process
– renal maldevelopment as seen in renal dysplasia
– pulmonary hypoplasia

50. ????
• Questions regarding
– accuracy of diagnosis,
– timing of intervention,
– safety of the procedure for both the fetus and
mother,
– the beneficial effects of interventions with regard
to clinical outcomes

51. • Several methods have been proposed to
assess the functional capacity of the kidneys in
a fetus suspected of having obstructive
uropathy:
– evaluation of the sonographic appearance of the
fetal kidneys,
– volume of amniotic fluid,
– measurements of fetal urine electrolytes and
proteins

52. Renal dysplasia
• The sonographic detection of cortical cysts
implies the presence of severe renal dysplasia
• indicates irreversible renal damage

53. Amniotic fluid
• Amniotic fluid is not a very useful prognostic
indicator except at the extreme of
oligohydramnios or anhydramnios

54. Fetal urine electrolyte sampling
• Fetal kidneys begin making urine at 13 weeks
of gestation, an ultrafiltrate of fetal serum is
produced, which is hypertonic because of
selective tubular reabsorption of sodium and
chloride in excess of free water
• Between 16 and 21 weeks of gestation, the
fetal urine becomes progressively more
hypotonic

55. • Fetus with poor renal function have been shown
to produce isotonic urine
• urine electrolyte features of adequate renal
function in a fetus with sonographic evidence of
obstructive uropathy include
– a urinary sodium of less than 100 mg,
– a chloride of less than 90 mg,
– an osmolality of less than 210 mOsm/L,
– a urine output of more than 2 mL per hour

56. Other indicators
• Fetal urinary calcium ( RAISED)
• B2 microglobulin

57. • Regardless of the degree or severity of the
finding, after any antenatal detection of a
urinary tract anomaly a thorough fetal survey
must be conducted.
• Amniocentesis and karyotype should be
considered if intervention or a major anomaly is
suspected, because the incidence of concurrent
chromosomal anomalies is relatively high in
fetuses with concomitant urologic anomalies

58. • Selective use of fetal MRI
may further delineate
anatomic details and help
with diagnosis and
management.
• Fetal magnetic resonance
image illustrating severe
bladder dilation (black
arrow) and a separate
dilated pelvic structure
behind the bladder (white
arrow) in a female fetus at
22 weeks’ gestation.
• The kidneys were bilaterally
and symmetrically dilated
with ureteral distention.
• This pattern can be seen
with oligohydramnios and
represents a urogenital
sinus malformation with
bladder outlet obstruction
caused by vaginal distention
from urine flowing into the
urogenital sinus.

59. TIMING OF INTERVENTION
• <20 WKS :-council for abortion
• >32 wks:- early labour
• Ideal time 20-32 wks POG

60. 60
Intervention

61. • The simplest and safest method of
intervention for fetal hydronephrosis is
needle aspiration of the fetal bladder or
kidney to assess renal function .

62. 62
Vesicoamniotic Shunting:
– Technique
• Vesicostomy or pyelostomy
• Pigtail shunt
– Complications:(50%)
• Shunt blockage or migration,
• preterm labor, (12%)
• urinary ascitis,
• chorioamnionitis, I
• atrogenic gastroschisis,
• intrauterine death
– Outcome:
• Perinatal survival 47%
• Post renal insufficiency 87.5%

63. 63
Prenatal Evaluation and Treatment for Fetal Lower
Urinary Tract Obstruction"
• The long term outcomes for shunts in fetal bladder
outlet obstruction:
– Etiology:
• Posterior urethral valves 39%
• Urethral atresia 22%
• Prune Belly Syndrome 39%.
– Outcome:
• More than 45% had a GFR of >70ml/min
• 22% had renal insufficiency
• 33% were ultimately on dialysis
• 33% had a transplant
Society for Fetal Urology 35th Biannual Meeting 2005

64. Fetal Cystoscopy
Quintero et al.

65. 65
Fetal Cystoscopy
– US guided
– 1.3mm fetoscope
– Cannula through maternal then fetal abdomen then fetal
bladder
– Laser ablation of valves
– Results
• 9 fetuses:4 success
– 2 viable at birth
» 1 died age 4 months from bronchopneumonia and one died age
3 m from necrotizing enterocolitis

66. • The proposed advantage of fetoscopic
intervention over vesicoamniotic shunting is to
improve drainage and to restore normal cycling of
the bladder.
• There are no studies to determine if this method
of decompression is adequate in the face of
significant prenatal bladder dysfunction.
• Furthermore, fetoscopic intervention also
introduces the additional potential for iatrogenic
injury to the urethra, bladder neck, or external
urethral sphincter.

67. • In a systematic review of the literature, 4
papers totaling 63 patients identified that fetal
cystoscopy as compared with vesicoamniotic
shunts had no significant improvement in
perinatal survival (Morris et al, 2011).
• Overall, experience with fetoscopic or
endoscopic valve ablation is currently at the
case report and experimental levels, and
long-term outcome data are unknown.

68. 68
• Situations that warrant antenatal intervention for a
genitourinary abnormality are exceedingly low and
may include:
– Cases of oligohydramnios
– Suspected favorable renal function
– Absence of life threatening congenital abnormalities.
• In cases with normal amniotic fluid antenatal
intervention is not recommended regardless of the
detected abnormality.

69. • The initial goal was to enroll 150 singleton
pregnancies with ultrasound evidence of lower
urinary tract obstruction to evaluate the safety
and effectiveness of vesicoamniotic shunting as
compared with conservative management.
• The study was stopped early because of poor
enrollment; only 31 patients were enrolled and
randomized (16 vesicoamniotic shunt patients
and 15 controls)

70. • In the vesicoamniotic shunt group, there were 12 live
births and 4 postnatal deaths at 28 days; and in the
control group there were 12 live births and 8 postnatal
deaths.
• All postnatal deaths were from pulmonary hypoplasia.
• Although underpowered, the study demonstrated a
nonsignificant increase in survival in the vesicoamniotic
shunt group.
• Consistent with the results of the systematic review of
existing prenatal intervention data, there was minimal
likelihood of surviving with longterm normal renal
function.

71. • Overall, it appears that select in utero
intervention for the appropriate patient may
reduce the risk of neonatal mortality.
• Improvement in renal function does not
appear to be likely.
• Without doubt, more sensitive and specific
markers to better identify which fetus will
benefit from in utero shunting need to be
defined.

72. RADIOGRAPHIC EVALUATION OF THE
URINARY TRACT IN THE NEWBORN

73. Post natal USG
• Indications
– follow-up of fetuses diagnosed in utero with
hydronephrosis and in the initial
– evaluation of newborns suspected of harboring
congenital anomalies

74. Neonatal USG
• Renal ultrasound examination in babies
usually begins with the bladder because the
cold gel often stimulates a bladder contraction
– determine bladder volume
– thickness
– extravesical or intravesical masses, a
– follow the course of a dilated ureter

75. • The kidneys are studied with longitudinal
scans, with particular attention to the upper
poles
• Neonatal kidneys normally range from
– 4 to 6 cm in length,
– 2 to 3 cm in width,
– 1.5 to 2.5 cm in diameter
• echogenicity of the kidneys should also be
assessed

76. Timing of the neonatal ultrasound
• Antenatal dilated pelvis may appear normal in
the first few days of life despite significant
obstruction
• Oliguria and dehydration during the first 24 to 48
hours of life may cause a distended renal pelvis to
shrink transiently
• Initial postnatal sonogram at 7 to 10 days is
recommended

77. • Ultrasonography should be performed within 24-48
hr of birth -
o In neonates with suspected
– posterior urethral valves,
– oligohydramnios
– severe bilateral hydronephrosis,

78. Severity of hydronephrosis
society for fetal urology (SFU)

80. • In general, only those kidneys with grade 3 or
4 hydronephrosis secondary to suspected
obstruction require surgery

81. 81
Fate of ANH
18766
pregnancies
ANH=100
(0.59%)
Hydro=64
21(21%) GU
Anomaly
43 No
anomaly
Normal=36

82. Voiding Cystourethrography
• Any newborn with a prenatal diagnosis of
hydronephrosis should undergo a VCUG, even
if the postnatal ultrasonogram is normal
• The study is obtained before the baby leaves
the hospital
• If VUR is present, antimicrobial prophylaxis
should be started

83. • Indications for VCUG in the newborn include
the following conditions:
– prenatally diagnosed hydronephrosis,
– unilateral multicystic dysplastic kidney to rule out
contralateral reflux ,
– suspected bladder outlet obstruction (e.g., PUV,
urethral anomalies),
– suspected duplicated upper collecting system with
or without ureterocele

84. Antenatal HUN Post natal USG; initial scan in 1st week
Unilateral Bilateral
MCU
No reflux Reflux
Non-obstructive non
refluxing megaureter
PUV
VUJO
Ureterocele
Physiological
Primary VUR
PUV
Duplication anomalies

85. Alternative?
• Nuclear cystogram confers approximately 1%
to 2% of the radiation exposure of a standard
radiographic study,
• The anatomic detail from the nuclear
cystogram is considerably less
• Grading system for the nuclear cystogram has
not been established

86. Nuclear Medicine Studies
• Radionuclide studies of the kidneys
(renograms) may be used to
– assess renal perfusion,
– glomerular function of each kidney,
– structural anomalies,
– the presence or absence of obstruction

87. • Radiopharmaceuticals are
used for assessing
obstruction (diuretic
renogram):
– technetium (Tc)-99m
MAG3
mercaptoacetyltriglycerine
– Tc-99m
diethylenetriaminepentaac
etic acid (DTPA)
• Reflux and functioning of
a duplicated moiety
– Tc-99m dimercaptosuccinic
acid (DMSA) .
– Tc-99m glucoheptonate
(GHA)

88. Recommended Protocol for Diuretic
Renogram in the Neonate
• Infants should be older than 1 month at
renography to reduce the likelihood that renal
function is immature
• Oral hydration is offered as desired, beginning
2 hours before the study
• The bladder is catheterized to ensure that it is
empty

89. • Before the study, a dilute normal saline solution is
administered at a rate of 10 mL/kg over 15
minutes, before injection of MAG-3 or DTPA, and
is continued for 15 minutes after injection
• The renogram should be recorded in the supine
position
• Furosemide is administered at a dose of 1 mg/ kg
after 20 to 30 minutes

91. Other Imaging Studies of the Upper
Urinary Tract
• Computed tomography (CT) ;-function
• MRI:- requires GA
• Intravenous urography (IVU):-
– The anatomic resolution of the IVU can be excellent
– renal function may be too immature at birth
– 2 to 3 weeks after birth, visualization of the kidneys
and collecting system can be obtained following
administration of 2 to 3 mL/kg of contrast medium
• Retrograde Pyelography :- rarely adds diagnostic
information

95. Ureteropelvic Junction Obstruction
• Incidence 1 in 1,000
• two-thirds are boys,
• 60%, the obstruction is on the left side
• 30% to 50% of children with UPJ obstruction
are diagnosed prenatally
• 15% of neonates with a UPJ obstruction
present with an abdominal mass

97. • If initial ultrasound is normal
• repeat study should be performed in 3 weeks
• Hydronephrosis should be graded according to
the SFU grading scale
• A prompt VCUG and diuretic renogram should
be done
– severe hydronephrosis with marked parenchymal
thinning
– bilateral hydronephrosis

98. • A VCUG is necessary to ascertain
– that the male urethra is normal
– to determine whether there is VUR, ( 15% of
children with a UPJ obstruction)
• Performing a pyeloplasty in a child with reflux
may subject the repair to high pressures and
result in an anastomotic leak.

99. • The most important diagnostic study is the “well-
tempered” MAG-3 diuretic renogram
• Obstruction
– Type 3 slope
– T ½ >20 mins
– Diffn function <35%
• Exceptions to this approach include
– an infant with a solitary kidney,
– bilateral hydronephrosis,
– reduced renal function,
– an abdominal mass,
– constant abdominal pain

101. ?UTI
• Boys with hydronephrosis, circumcision is
recommended to diminish the risk of UTI
• No consensus regarding the use of
prophylactic antibiotics
• 2-31% of infants with PUJO on observation
develop UTI

102. • The risk of UTI with and without antibiotic prophylaxis in children with SFU
Grade 1 and 2 or APRPD < 15 mm was similar (2.2% vs. 2.8%),
• SFU Grade 3 and 4 or APRPD ≥15 mm (14.6% (95% CI: 9.3–22) vs. 28.9%
(95% CI: 24.6–33.66)
• Recommended in
– APD >10mm
– SFU >3,4
– VUR
• Amoxiclillin 50 mg po / cephalexin 50 mg po is usually given
(10mg/kg/day) – first 3 mts
• cotrimoxazole (1-2 mg/kg/d) or nitrofurantoin (1 mg/kg/d) after 3 mts.

103. Indications for surgery
• T ½ greater than 20 minutes
• Differential renal function <35%
• Obstructive pattern of curve
• Exceptions to this approach include
– an infant with a solitary kidney,
– bilateral hydronephrosis,
– reduced renal function,
– an abdominal mass,
– infant with nearly constant abdominal pain

104. Surgical Outcomes
Similar surgical success rates
and complication rates

106. Posterior Urethral Valves
• Type I and type III valves are thought to be
clinically significant
• Type I valves are
– represented by leaflets or sails that extend distally
from either side of the verumontanum to the anterior
urethral wall at the level of the urogenital diaphragm
• A type III valve
– is a diaphragm just distal to the verumontanum that
has a small central perforation

107. Diagnosis
• abdominal mass (48%),
• failure to thrive (10%),
• urosepsis (8%),
• urinary ascites (7%).

108. • 50% are diagnosed by prenatal USG
• When the diagnosis of urethral valves is
suspected, a VCUG should be performed
– A thick trabeculated bladder
– very distended posterior urethra
– Valve leaflets is seen

109. • 50% of these patients have VUR,
• With 25% having bilateral and 25% having
unilateral reflux

110. • Important radiographic study is a renal and
bladder sonogram
– pelvic and calyceal dilation,
– cortical echogenicity,
– presence of dysplasia

111. Management
• The bladder should be drained with a 5- or 8-
Fr pediatric feeding tube
• Initial treatment of the valves depends on the
age at presentation and the size and condition
of the child

112. • 8-Fr cystoscope is used to examine the bladder,
– assessment of the degree of trabeculation,
– the presence of diverticula,
– the position of the ureteral orifices,
– examination of the valves
• WITH the 3-Fr Bugbee electrode The valve
leaflets should be ablated at the 5 and 7 o'clock
positions, and on occasion at the 12 o'clock
position

115. Vesicoureteral Reflux
• Neonates with medium- and high-grade
vesicoureteral reflux are detected by the
finding of hydronephrosis on prenatal
sonography
• Approximately 80% of such patients are boys

116. • Evaluation
– USG
• Prenatal diagnosis
• Initial USG may be normal
– VCUG
• unilateral or unilateral hydronephrosis with renal pelvic APD
>10 mm, SFU grade 3-4 or ureteric dilatation
• Done prior to discharge from hospital
– DMSA scan
• To asses scarring
• After 4-6 wks of age

117. TOP DOWN APPROACH
• Only clinically significant reflux causing renal
scarring and injury is worth uncovering
• If DTPA is normal, no further investigation
• Investigate only if episodes repeat
117

118. International Classification
118

119. Spontaneous resolution
• At birth, likelihood of resolution is inversely
proportional to grade at presentation
• Some people adopt this, especially in girls around
puberty
• Due to remodeling of UVJ
• Upto 80% of grade 1 and 2 will resolve but only 50% of
grade 3 over a 2 year period, but this rises to 92% over
5 years
119

120. European Association of Urology
Guidelines on VUR
• All children diagnosed <1 year should be treated with
CAP irrespective of scars/symptoms and therapy for
breakthrough fever. Those with frequent
breakthrough fevers require correction
• Surgical correction should be considered in those
with high grade IV/V. Open>laparoscopic. Endoscopic
for lower grades
• No advantage of correcting grade I-III with no scars
or fever. Consider endoscopic treatment 120

122. SUMMARY
• Prenatal intervention for hydronephrosis is indicated
only
in very select instances and in specialized centers .
Even when well selected, intervention is highly
controversial.
• Most diagnoses made based on a finding of prenatal
hydronephrosis can be handled conservatively.
• All ANH should be investigated with a post-natal US.
• Antenatal hydronephrosis does not necessary imply
obstruction, nor give any indication of the function of
an affected kidney.

123. SUMMARY
• The role of prophylactic antibiotics initiated at birth is controversial.
• The need to further investigate mild postnatal hydronephrosis (SFU 0–2) with a
VCUG is controversial, and depends on the physician’s attitude toward
diagnosing asymptomatic VUR.
• Persistent moderate or severe hydronephrosis (SFU3–4) should be investigated
with a VCUG, followed by diuretic renography if the hydronephrosis cannot be
explained by VUR.
• Indications for surgical intervention include reduced differential function
(<40%), greater than 5% decrease in baseline differential function,
progressive increase in hydronephrosis, febrile infection or poor parental
compliance.

124. Thank you