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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 526-531
Clinical outcome and follow-up of prenatal hydronephrosis


Department of Pediatrics, Guilan University of Medical Sciences, Islamic Republic of Iran

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Date of Web Publication7-May-2012
 

   Abstract 

Hydronephrosis is probably the most common congenital abnormality detected prenatally by ultrasonography This study was performed to determine the cause and outcome of prenatal hydronephrosis in our hospital. A total of 45 infants, with 57 prenatally hydronephrotic renal units, were enrolled into this study. For the purpose of this study, the degree of hydronephrosis was defined as mild, moderate or severe. Postnatal ultrasonography was performed as soon as possible in those with bilateral hyronephrosis and 3-7 days after birth in those with unilateral hydronephrosis. Voiding cystourethrogram was performed in 6-8 weeks time. In the absence of vesicoureteral reflux (VUR), Diethylenetriamene penta acetate scan was performed to exclude obstructive uropathy. There were 29 males and 16 females (male:female ratio 1.8:1), and unilateral and bilateral hydronephrosis were seen in 33 (73%) and 12 (27%) of the cases, res­pectively. Hydronephrosis was caused by ureteropelvic junction obstruction (UPJO) in 20 (44.5%), VUR in 10 (22.2%), ureterovesical junction obstruction in four (8.9 %), posteriorurethral valves in four (8.9 %), UPJO with VUR in two (4.4%) and non-VUR non-obstructive in one (2.2%). During follow-up, 16 patients (35.5%) required operative intervention while seven (15.5%) improved spontaneously. Fetal hydronephrosis needs close follow-up during both ante­natal and postnatal periods. In this study, the most common cause for hydronephrosis were UPJO and VUR. Also seen in this study is the noteworthy point that mild fetal hydronephrosis is relatively benign and does not require surgical intervention in most cases and surgery should be performed only if there is renal function compromise. Prenatal consultation with a pediatric nephrologist and urologist is useful in decreasing parental anxiety and facilitating postnatal management.

How to cite this article:
Asl AS, Maleknejad S. Clinical outcome and follow-up of prenatal hydronephrosis. Saudi J Kidney Dis Transpl 2012;23:526-31

How to cite this URL:
Asl AS, Maleknejad S. Clinical outcome and follow-up of prenatal hydronephrosis. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Oct 17];23:526-31. Available from: http://www.sjkdt.org/text.asp?2012/23/3/526/95792

   Introduction Top


Prenatal ultrasonographic detection of fetal genitourinary abnormalities was first reported in 1970 by Garrett et al. [1] Prenatal hydronephrosis is diagnosed at an incidence of 1:100 to 1:500 by ultrasonographic studies. [2],[3],[4] By renal ultrasound examination, urological anomalies may be demonstrated in 1-2% of fetuses and in about 0.5% of newborns. [5] Shokeir et al as well as Garne et al reported that two to nine neo-nates per 1000 newborns births have uro­genital anomaly, and 50-87% of these at births have urogenital anomaly, with 50-87% of these having hydronephrosis. [6],[7],[8] Data from a large European database for surveillance of conge­nital malformations showed an overall preva­lence of congenital hydronephrosis as 11.5 cases per 10,000 births. [7]

When a fetus is identified with a suspected urinary tract abnormality, the goals of manage­ment should include determining the differen­tial diagnosis, assessment of associated ano­malies and determining the fetal and postnatal risk of the malformations. [2],[3],[4],[5],[6],[7] Prenatal consulta­tion with a pediatric nephrologist and urologist is useful in decreasing parental anxiety and facilitating postnatal management. [9] The detec­tion of fetal hydronephrosis presents a diag­nostic and therapeutic dilemma. For these rea­sons, a retrospective study was performed to determine the cause and outcome of 45 infants with prenatal hydronephrosis in our hospital.


   Patients and Methods Top


We retrospectively analyzed the case records of 45 infants (29 male, 16 female) with 57 prenatally diagnosed hydronephrotic renal units who were referred to our hospital between 2006 and 2009. Prenatal hydronephrosis was defined based on prenatal sonography that was performed after the 20 th week of gestation. Postnatal ultrasound was performed in 3-7 days after the delivery to confirm the presence of hydronephrosis. For the purpose of this study, the degrees of hydronephrosis was classified as mild, moderate or severe hydronephrosis when the anteroposterior pelvic diameter (APPD) was 5-9 mm, 10-14 mm and ≥15 mm, respectively, according to antenatal sonographic measurements. At birth, infants had undergone complete physical examination to exclude any other congenital anomalies. In infants with history of prenatal hydronephrosis, antibiotic prophylaxis was started if a voiding cytourethrogram (VCUG) was requested (moderate and severe cases). VCUG was per-formed after six to eight weeks in infants with unilateral hydronephrosis and as soon as possible in those with bilateral hyronephrosis to rule out poste­rior urethral valves and other abnormalities. In the absence of vesicoureteral reflux (VUR), a DTPA scan was performed to exclude obstruc­tive uropathy. Following this, postnatal follow-up was performed for these infants by serial sonography and radionuclide scan to assess differential function. The statistical analysis for measuring the confidence intervals was carried out using WinPepi software V9.9.


   Results Top


Forty-five infants, 29 males and 16 females (male:female ratio 1.8:1 ) with 57 dilated renal units were included in this study. The left kidney kidney was more commonly involved (left: 21, right: 12). Mild hydronephrosis was present in 13 (23%), moderate hydronephrosis in 28 (49%) and severe hydronephrosis in 16 (28%) of the dilated kidney units. The average age of mothers ranged from 17 to 43 years (mean age 25.6 years). The demographic data are given in [Table 1].
Table 1: Demographic data and anteroposterior pelvic diameter (APPD) of the study group.

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Unilateral and bilateral hydronephrosis were seen in 33 (73%) and 12 (27%) of the cases, respectively. Etiologic classification of postnatally detected urologic abnormalities in hydronephrotic units in unilateral and bilateral hydronephrosis are given in [Table 2] and [Table 3].
Table 2: Etiologic classification of postnatally detected urologic abnormalities in unilateral hydronephrosis.

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Table 3: Etiologic classification of postnatally detected urologic abnormalities in bilateral hydronephrosis.

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Dilatation of the renal pelvis in the 13 renal units with mild hydronephrosis was caused by mild ureteropelvic junction obstruction (UPJO) in nine (69%) and VUR in four (31%). None of the children with mild hydronephrosis were operated, and hydronephrosis resolved sponta­neously in seven renal units during the follow-up period.

In total, surgical intervention was performed in 16 patients due to progressive deterioration of kidney function and increasing severity of hydronephrosis and recurrent urinary tract in­fections in VUR cases. [Table 4] show the de­tails of follow-up of patients. The operative in­tervention consisted of correction of UPJO in seven (43.8%), uretrovesical obstruction (UVJ) in two (12.5%), VUR in three (18.8%) and posterior uretheral valve (PUV) in four patients (25%). The remaining of the patients remained stable on follow-up (49%) by serial sonography and differential function tests.
Table 4: The details of surgical intervention in patients with prenatal hydronephrosis

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VUR was identified in ten infants (bilateral in three cases), giving a total of 13 renal units. De­mographic data of patient with VUR are given in [Table 5]. Three children underwent surgical intervention due to breakthrough infection and high-grade reflux. In this study, dilatation of the renal pelvis was caused by UPJO in 20 (44.5%), VUR in ten (22.2%) ureterovesical junction obstruction (UVJO) in four (8.9%), PUV in four (8.9 %), UPJO with VUR in two (4.4%) and non-VUR non-obstructive in one (2.2%). In four patients (8.9%) with unilateral hydronephrosis, dilatation renal units improved spontaneously. In this study, the most common causes of hydronephrosis were UPJO followed by VUR.
Table 5: Demographic data of patient with VUR.

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   Discussion Top


Prenatal hydronephrosis is diagnosed at an incidence of 1:100 to 1:500 by ultrasonogra­phic studies. [1],[3],[4] Because a normal postnatal ultrasound scan does not preclude the presence of urinary tract abnormality, sonography was repeated at seven to ten days after birth. In most cases, there were persistent postnatal renal abnormalities when the APPD of the fetal renal pelvis measured >5 mm at 20 weeks, >8 mm at 20-30 weeks and >10 mm at >30 weeks of gestation. [1],[3],[8],[10],[11],[12] However, there is a lack of correlation between the degree of prenatal hydronephrosis and etiology, a fact that has been well documented. [13],[14] In this study, the male to female ratio was 1.8:1, which was similar to other studies conducted by Miranda, Aksu, Pourissa, Garne and Cortes et al. [5],[8],[15],[16],[17]

In this study, dilatation of the renal pelvis was caused by UPJO in 18 (40%), VUR in 12 (26.7%), UVJO in four (8.9%), PUV in four (8.9%), UPJO with contralateral VUR in two (4.4%) and non-VUR non-obstructive in one (2.2%). In four patients (8.9%) with unilateral hydronephrosis, dilatation renal units improved spontaneously. Thus, the most common de­tected underlying abnormalities were UPJO (44.5%) and VUR (22.2%). Our study also showed a similar pattern when compared with studies in other centers in Iran as well as in other countries. [8],[15],[17],[18],[19],[20] The low incidence of transitory hydronephrosis is noticeable in our cases. This is possibly due to the fact that this was a tertiary care service center and majority of the neonates referred to our hospital were those with pathological hydronephrosis for further follow-up. Also, in this study, the se­cond common abnormality was VUR (22.2%). Although controversial issues exist about the timing of postnatal cystography and whether postnatal voiding cystourethrography should be performed in infants with a history of pre­natal hydronephrosis, some groups advocate postnatal cystography in any infant with a his­tory of prenatal hydronephrosis. [19],[21],[22],[23],[24],[25] Others have questioned about this approach. A prac­tical point for performing postnatal cystography has been mentioned as the presence of a dilated ureter or hydronephrosis of varying degrees. [1],[2] Because of these controversies, my policy in this study was the later approach, and VCUG was performed in the presence of a dilated ureter or hydronephrosis of varying degrees. The available data suggest that VUR is present in 17-38% of the patients with pre­natal hydronephrosis. [26],[27] However, postnatal calicectasis appears to be an important predic­tor of VUR in children with fetal renal pelvic dilatation. [28] In a study by Lee et al, children with any degree of antenatal hydronephrosis were at a greater risk of postnatal pathology as compared with the normal population. [10] In the present study, during the entire clinical follow-up, 16 patients (35.5%) required operative inter­vention while seven patients with hydronephrosis improved spontaneously (15.7%). Twenty-two patients (48.8%) remained stable, as de­monstrated by serial sonography and diffe­rential renal function tests, and did not need surgical intervention. These results were compa­tible with different studies conducted in Brazil, Turkey, Germany, Israel, Korea and Switzerland. [10],[15],[18],[29],[30],[31],[32] Our results show that the ma­nagement of prenatally detected hydronephrosis has undergone a paradigm shift in the last decade, from early surgery to close observa­tion until there are signs of deterioration of renal function or there is progression of hydronephrosis and operative intervention is not required for any patient with mild hydronephrosis of the kidney units.

When a fetus is identified with prenatal hydronephrosis, the goals of management should include determining the differential diagnosis, assessment of associated anomalies and deter­mining the fetal and postnatal follow-up. In this study, the most common causes of hydronephrosis were UPJO and VUR. Also, mild fetal hydronephrosis is relatively benign and does not require surgical intervention in most cases, and surgery should be performed only if renal compromise occurs. Prenatal consulta­tion with a pediatric nephrologist and urologist is useful in decreasing parental anxiety and facilitating postnatal management.


   Acknowledgment Top


This study is performed with a grant made to Dr. Allaedin Asgari (pediatric urologist). The authors thank the patients and their families for their contribution to the study.

 
   References Top

1.Garrett WJ, Grunwald J, Robinson DE. Pre­natal diagnosis of fetal polycystic kidney by ultrasound. Aust N Z J Obstet Gynaecol 1970;10:7-9.  Back to cited text no. 1
    
2.Diamond DA, Peters CA. Prenatal Urology. In: Barratt TM, Avner ED, Harman WE, Niaudet P, Eds. Pediatric nephrology. 5 th ed, Lippincott Williams and Wilkins 2005. p. 73-82.  Back to cited text no. 2
    
3.Crage EP. Prenatal hydronephrosis. In: Campbell, Walsh. Pediatric Urology. 9th Ed, Philadelphia: Saunders; 2007;3176-97.  Back to cited text no. 3
    
4.Roth JA, Diamond DA. Prenatal hydronephrosis. Curr Opin Pediatr 2001;13:138-42.  Back to cited text no. 4
    
5.Cortes D. Prenatal diagnosed hydronephrosis and other urological anomalies. Ugeskr Laeger 2006;168:2544-50.  Back to cited text no. 5
    
6.Shokeir AA, Nijman RJ. Antenatal hydroneph-rosis. changing concepts in diagnosis and subsequent management. Br J Urol 2000;85: 987-94.  Back to cited text no. 6
    
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9.Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics. 2006;118:586-93.  Back to cited text no. 9
    
10.Cachat F. Antenatally detected hydronephrosis: practical approach for hydronephrosis. Rev Med Suisse 2005;7:509-12.  Back to cited text no. 10
    
11.Narchi H, Amirlak I. Antenatal Hydronephrosis. J Arab Neonatal Forum 2006;3:33-9.  Back to cited text no. 11
    
12.Brophy MM, Austin PF, Coplen DE. Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis. J Urol 2002;168:1716-9.  Back to cited text no. 12
    
13.McIlroy PJ, Abbott GD, Anderson NG, Turner JG, Mogridge N, Wells JE. Outcome of pri­mary vesicoureteric reflux detected following fetal renal pelvic dilatation. J Paediatr Child Health 2000;36:569-74.  Back to cited text no. 13
    
14.Aksu N, Yavascan O, Kangin M, et al. Post­natal management of infants with antenatally detected hydronephrosis. Pediatr Nephrol 2005;20:1253-9.  Back to cited text no. 14
    
15.Pourissa MS, Refahi S, Nazari H. Evaluation of the incidence and outcome of fetal hydronephrosis prenatally diagnosed by ultrasound. Acta Medica Iranica 2005;43:336-8.  Back to cited text no. 15
    
16.Marcio LM, Lourenco S, Antonio A, et al. Prenatal hydronephrosis. Brazilian J Urol 2002; 28:147-53.  Back to cited text no. 16
    
17.Lim DJ, Park JY, Kim JH, Paick SH, Oh SJ, Choi H. Clinical characteristics and outcome of hydronephrosis detected by prenatal ultra-sonography. J Korean Med Sci 2003;18:859-62.  Back to cited text no. 17
    
18.Pena CA, Roman EL, Maseda MA, et al. Neonatal pelvic ectasia: long-term outcome and association with ureterovesical anomalies. Ann Pediatr 2004;61:493-7.  Back to cited text no. 18
    
19.Karnak I, Woo LL, Shah SN, Sirajuddin A, Kay R, Ross JH. Prenatally detected ureteropelvic junction obstruction: clinical features and associated urologic abnormalities. Pediatr Surg Int 2008;24:395-402.  Back to cited text no. 19
    
20.Eisenhardt A, Arntzen D, Conrad S, et al. Occurrence, diagnostics and therapeutic ma­nagement of hydronephrosis in pediatric patients in Germany. Urologe A 2003;42:538-46.  Back to cited text no. 20
    
21.Signorelli M, Cerri V, Taddei F, Groli C, Bianchi UA. Prenatal diagnosis and manage­ment of mild fetal pyelectasis: implications for neonatal outcome and follow-up. Eur J Obstet Gynecol Reprod Biol 2005;118:154-9.  Back to cited text no. 21
    
22.Douglas E, Coplen A, Paul F, et al. Correlation of prenatal and postnatal ultrasound finding with the incidence of vesicoureteral reflux in children with fetal renal pelvic dilatation. J Urol 2008;180:1631-4.  Back to cited text no. 22
    
23.Silva JM, Oliveira EA, Diniz JS, Bouzada MC, Vergara RM, Souza BC. Clinical course of prenatally detected primary vesicoureteral reflux. Pediatr Nephrol 2006;21:86-90.  Back to cited text no. 23
    
24.Estrada CR, Peters CA, Retik AB, Nguyen HT. Should Voiding Cystourethrography be Per­formed in Cases of Postnatally Persistent Grade II Hydronephrosis. J Urol 2009;181: 801-7.  Back to cited text no. 24
    
25.Brophy MM, Austin PF, Yan YC. Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis. J Urol 2002;168:1716-9.  Back to cited text no. 25
    
26.Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology 1993;187:157-62.  Back to cited text no. 26
    
27.Douglas EC, Paul FA, Jeffrey MD. Correlation of prenatal and postnatal ultrasound findings with the incidence of vesicoureteral reflux in children with fetal renal pelvic dilatation. J Urol 2008;180:1631-4.  Back to cited text no. 27
    
28.Chertin B, Pollack A, Koulikov D. Long-term follow up of antenatally diagnosed megaureters. Pediatr Urol 2008;4:188-91.  Back to cited text no. 28
    
29.Onen A, Jayanthi VR, Koff SA. The natural history and therapeutic approach of antenatally diagnosed primary upj-type hydronephrosis. Turkish J Pediatr Surg 2006;20:33-8.  Back to cited text no. 29
    
30.Apocalypse GT, Oliveira EA, Rabelo EA, et al. Outcome of apparent ureteropelvic junction obstruction identified by investigation of fetal hydronephrosis. Int Urol Nephrol 2003;35: 441-8.  Back to cited text no. 30
    
31.Ulman I, Jayanthi VR, Koff SA. The long-term follow-up of newborns with severe unilateral hydronephrosis initially treated nonoperatively. J Urol 2000;164:1101-5.  Back to cited text no. 31
    
32.Koff SA. Postnatal management of antenatal hydronephrosis using an observational approach. Urology 2000;55:809-11.  Back to cited text no. 32
    

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Correspondence Address:
Afshin Safaei Asl
Associate Professor, Department of Pediatrics, Guilan University of Medical Sciences, 17 Shahrivar Hospital, Namjoo Street, Rasht, Guilan
Islamic Republic of Iran
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