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PubMed2005

Postnatal management of infants with antenatally detected hydronephrosis.

With the increasing use of antenatal sonography, fetal hydronephrosis has been reported more frequently. Because of the lack of consensus regarding treatment of these infants, the postnatal approach toward fetal renal pelvis enlargement remains controversial. The aim of this prospective study is to demonstrate the postnatal investigation, treatment, and outcome of infants with prenatally diagnosed hydronephrosis. Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated postnatally using ultrasound (US) and voiding cystourethrography. When indicated, isotope studies and intravenous urograms were also performed. We followed prospectively neonates with antenatally diagnosed hydronephrosis and recommended management guidelines on the basis of our findings. In 156 neonates (193 kidney units) that were found to have hydronephrosis, the average gestational age at which the diagnosis was made was 32.94+/-5.10 weeks. The mean duration of postnatal follow-up was 26.3+/-13.56 months (range 3-60 months). The mean APPD of the fetal renal pelvis was 10.35+/-3.24 mm (5-9 mm in 84 kidneys, 10-14 mm in 96 kidneys and > or =15 mm in 13 kidneys). Of the 193 kidney units, 145 units were found to be pathological. The most common detected underlying abnormalities were ureteropelvic junction obstruction (in 91 kidneys; 62.7%) and vesicoureteral reflux (in 24 kidneys; 16.6%). Postnatally, 23 (45%) of 51 patients whose first US was normal were diagnosed postnatally as having urinary tract abnormality. There was a negative correlation between APPD and the rate of spontaneous resolution and positive correlation between APPD and the rate of surgery (P<0.01). In conclusion, because it is not possible to determine an upper limit of normal for the antenatal renal pelvis, any baby with AH should not be considered clinically insignificant. Infants with antenatal renal pelvis measurements > or =5 mm should be investigated postnatally. A normal postnatal ultrasound scan does not preclude the presence of urinary tract abnormality.

Diagnostic Techniques, Urological↗
PubMed1999

Abnormal urinary acidification in infants with hydronephrosis.

Distal renal tubular abnormalities have been observed in patients with dilated urinary tract disorders. The present study was undertaken to look for patterns in urinary acidification in infants with varying degrees of hydronephrosis due to either reflux or obstruction and occurring as unilateral or bilateral disease. Three groups of infants (mean age 3.7+/-3.8 months) were studied prospectively. Groups IA and IB included patients with hydronephrosis who were acidotic and non-acidotic, respectively. Group II served as controls and consisted of patients with diarrhea and secondary metabolic acidosis with no known renal disease. Serum electrolytes, creatinine, and urine pH were measured in all patients. Urinary titratable acidity, ammonium (NH4), and net acid excretion (NAE) were measured by the titrimetric method. Infants with hydronephrosis demonstrated lower urinary buffering capacity, reflected in low NAE in the face of acidosis. Deficiencies were noted in both titratable acid and NH4 excretion compared with control infants. Acidosis was as common in unilateral as in bilateral disease, regardless of severity score. These data confirm a defect in distal urinary acidification in infants with hydronephrosis, whether unilateral or bilateral. Immaturity and endogenous acid load may play a significant role in the manifestation of metabolic acidosis with unilateral disease.

Female↗
PubMed2002

Antenatal hydronephrosis: evaluation and outcome.

We present a comprehensive and current review of the etiology, evaluation, treatment, and outcome of antenatal hydronephrosis. When a diagnosis of antenatal hydronephrosis is made, many questions regarding pregnancy, prenatal care, intervention, and what may be expected after birth are raised. Debate and controversy exist on the diagnosis and subsequent evaluation and management of the child with antenatal hydronephrosis. A review of the literature and our own experience with antenatal hydronephrosis are presented in order to guide the physician who is caring for mother and child.

Algorithms↗
PubMed1991

Congenital hydronephrosis: correlation of fetal ultrasonographic findings with infant outcome.

Although congenital hydronephrosis is a common fetal disorder, ultrasonographic criteria for prenatal diagnosis remain poorly defined. In this study prenatal ultrasonographic findings were correlated with postnatal outcome in 63 fetuses with suspected hydronephrosis. Prenatal ultrasonographic measurements included length, anteroposterior diameter, and transverse diameter of the kidney and renal pelvis, as well as dorsal renal parenchymal thickness. In 45 of the 63 fetuses, hydronephrosis was confirmed postnatally. These infants were divided into two groups on the basis of renal status: (1) abnormal renal function and/or surgery required (n = 31) and (2) normal renal function with no surgery required (n = 14). The anteroposterior diameter of the renal pelvis was the simplest and most sensitive technique for prenatal diagnosis of congenital hydronephrosis, allowing identification of 100% of cases. Postnatal follow-up studies are warranted if an anteroposterior pelvic diameter is greater than or equal to 4 mm before 33 weeks or greater than or equal to 7 mm after 33 weeks.

False Positive Reactions↗
PubMed1988

Spontaneous hydronephrosis in C57BL/KsJ mice.

Spontaneous hydronephrosis was observed in 15 of 33 necropsied C57BL/KsJ mice. The gross and histological appearances of these lesions are described. Spontaneous hydronephrosis is rare in mice and has not been previously described in this strain. At least four different mutations are reported to cause hydronephrosis in the mouse; each is associated with a high incidence of severe skeletal defects. Because no skeletal malformations were observed in the present study, it is likely that either a multigenic trait which has been present for a long time but is expressed variably, or a mutation other than those previously described may be responsible for hydronephrosis in C57BL/KsJ mice.

Animals↗
PubMed2005

Hydronephrosis as a prognostic factor in pelvic recurrence from rectal and colon carcinomas.

BACKGROUND: After multimodal treatment estimated 5-year survival of locally recurrent rectal cancer is about 25%. Hydronephrosis secondary to pelvic recurrence of colorectal cancer is a condition claimed to represent a contraindication to surgery due to a dismal prognosis. METHODS: Prospective registration of 193 consecutive patients operated for pelvic recurrence in rectal or colon cancer from January 1991 until March 2002 at a tertiary referral hospital, 121 men and 72 women, median age 67 years, all given irradiation preoperatively. Twenty-three of 193 had hydronephrosis prior to preoperative irradiation for recurrent disease. RESULTS: R-0 stage resection was obtained in 22% of patients with hydronephrosis and in 41% without. The median survival times in patients without metastasis were 27 and 32 months, respectively, and 5-year survival rates were 11% and 25%. CONCLUSIONS: An aggressive surgical approach offers patients with pelvic recurrence from rectal and colon cancer the best potential for survival. The presence of hydronephrosis probably indicates a lower chance for complete surgical resection of the recurrence, but local control and improved survival may still be achieved, and about two thirds of patients may benefit from the operation.

Adult↗
PubMed2006

Proximal ureteral ectopia causing hydronephrosis in a kitten.

A 2-month-old, female cat was presented for abdomen dilation. The patient was undernourished, and severe left hydronephrosis was diagnosed after clinical, ultrasonographical and radiographical examination. Although pyelography was performed in order to visualise the ureteral course, surgery was necessary to reach a final aetiological diagnosis and treatment. At gross examination, the left ureter crossed the renal capsula at the level of the caudal renal pole, and the subcapsular ureteral segment was markedly dilated. Distal to the renal capsula, the left ureter was very thin when compared to the right. The parenchyma of the left kidney, as suggested by ultrasonographical evaluation, was extremely reduced in thickness. An ureteronephrectomy was performed. Histopathological evaluation revealed glomerular sclerosis and diffuse parenchymal fibrosis. Severe hydronephrosis derived from an altered renal pelvic anatomy and abnormal ureteral course determining functional stenosis. Diagnosis of congenital anomaly before development of complications such as hydronephrosis could have allowed a surgical renal capsulectomy and obstruction relief. To the author's knowledge, this is the first report of severe hydronephrosis associated to altered renal pelvic anatomy and proximal ureteral ectopia in cat.

Animals↗
PubMed2006

Magnetic resonance urographic parameters for predicting the need for pyeloplasty in infants with prenatally diagnosed severe hydronephrosis.

PURPOSE: Treatment in infants with prenatally diagnosed, severe hydronephrosis remains controversial. We measured anatomical parameters using magnetic resonance urography to create a pelvic index ratio, which we correlated with outcome to assess its value. MATERIALS AND METHODS: We reviewed 35 cases of prenatally diagnosed severe hydronephrosis, including grade III in 19 and grade IV in 16. By 6 weeks after birth all patients had undergone repeat ultrasonography, diuretic renography and magnetic resonance urography. Magnetic resonance urography was used to measure the distance (D) from the bottom of the lowest renal calyx to the ureteropelvic junction and the total longitudinal length (L) of the caliceal system. The pelvic index ratio, defined as D/L, assesses the level at which the ureter inserts into the renal pelvis. RESULTS: All cases were initially managed conservatively. Pyeloplasty was required in 16 kidneys (mean patient age +/- SD 7.5 +/- 3.9 months) because of deterioration in renal function. All patients were well at a mean followup of 3.8 years. The remaining 19 cases continued to be managed conservatively. By a mean of 5.4 years spontaneous resolution of prenatally diagnosed severe hydronephrosis had occurred in 7 of 19 cases, while 12 were downgraded to grades I-II. The mean pelvic index ratio in surgical cases was 0.26 +/- 0.13 and in nonsurgical cases it was 0.12 +/- 0.11, indicating that ureters inserted significantly higher in surgical cases (p = 0.0012). Of 9 kidneys with a pelvic index ratio of greater than 0.3 pyeloplasty was required in 8, while 10 of 12 with a pelvic index ratio of less than 0.1 were managed conservatively. CONCLUSIONS: Pyeloplasty is likely to be required if the pelvic index ratio is greater than 0.3 and conservative management is likely to succeed if the ratio is less than 0.1. The pelvic index ratio can be calculated easily even in the neonatal period. It appears to be prognostic for pyeloplasty in cases of prenatally diagnosed, severe hydronephrosis.

Female↗
PubMed2006

Magnetic resonance urography in the evaluation of prenatally diagnosed hydronephrosis and renal dysgenesis.

PURPOSE: We present our experience with dynamic contrast enhanced magnetic resonance urography for evaluation and treatment in infants born with prenatally recognized hydronephrosis. We determined the characteristics of renal dysgenesis in this population. MATERIALS AND METHODS: We reviewed magnetic resonance urography images done within the first 6 months of life in 67 infants born with prenatally recognized hydronephrosis. High resolution imaging was used to establish a morphological diagnosis. Functional evaluation was used to assess obstruction and individual renal function. Voiding cystourethrography was performed in 62 patients. RESULTS: Our study included 67 infants (87 renal units). There were 54 boys and 13 girls with a mean age of 2.8 months (range 0.9 to 4.6). Of these 87 renal units 30 (35%) had ureteropelvic junction obstruction, 18 (21%) had primary megaureters, 10 (11%) had nondilating vesicoureteral reflux, 10 (11%) had fetal folds, 8 (9%) had posterior urethral valves, 6 (7%) had ectopic ureters, 4 (5%) had multicystic dysplastic kidneys and 1 (1%) had a normal study. Magnetic resonance urography revealed renal dysgenesis in 24 renal units (28%), consisting of loss of corticomedullary differentiation, renal cystic changes distinct from multicystic dysplastic kidneys, solid renal dysplasia, hypoplasia and dysmorphic calyces. CONCLUSIONS: Magnetic resonance urography is an excellent addition to our armamentarium for evaluating neonatal hydronephrosis and renal dysgenesis. Due to its comprehensiveness magnetic resonance urography has the potential to become the study of choice for evaluating infants with significant prenatally recognized hydronephrosis. However, further prospective, comparative studies in larger patient populations are needed to justify the cost and the need for sedation in infants.

Female↗
PubMed2004

Congenital midureteral stricture in children diagnosed with antenatal hydronephrosis.

OBJECTIVES: Antenatal hydronephrosis is the most common genitourinary pathologic finding during gestational ultrasonography. Congenital midureteral strictures are an unusual cause of prenatal hydronephrosis, with 13 total previously reported and only 1 diagnosed as a result of antenatal ultrasonography. METHODS: We present 4 cases of midureteral strictures as the cause of antenatal hydronephrosis and review the published data on congenital midureteral obstruction. RESULTS: All midureteral strictures in our series and in the published reports were treated surgically after varying periods of observation. Retrograde pyelography was diagnostic in all cases. CONCLUSIONS: This atypical cause of antenatal hydronephrosis may provide additional insight into the controversy regarding preoperative retrograde pyelography before surgical intervention for ureteropelvic junction obstruction. Given the typical misdiagnosis of ureteropelvic junction obstruction in the setting of midureteral stricture disease, we believe that the threshold for retrograde pyelography should be very low.

Child, Preschool↗
PubMed1982

Management of the fetus with congenital hydronephrosis.

Twenty-six fetuses with dilated urinary tracts were studied with serial sonograms. Eight fetuses with unilateral hydronephrosis were followed without intervention; all are well after postnatal surgical correction. Three cases of bilateral hydronephrosis resolved spontaneously before birth. Eight fetuses with bilateral hydronephrosis had evidence of poor function: Three were not treated and died shortly after birth with small lungs and dysplastic kidneys; three others had diagnostic intervention that demonstrated irreversible disease and allowed termination of the pregnancy; two had obstruction successfully corrected in utero, but renal damage proved irreversible and precluded survival at birth. Seven fetuses with bilateral hydronephrosis and equivocal function underwent early decompression. Four were delivered early and corrected ex utero; 1 has renal failure and the other 3 are well. Three had obstruction relieved in utero by a catheter shunt placed percutaneously; 1 had multiple anomalies and died; the other 2 are well. Serial sonographic observation improves perinatal management of the fetus with a dilated urinary tract. The need for diagnostic or therapeutic intervention depends on the type and severity of obstruction and the time in gestation when it is discovered. Most fetuses do not require treatment before birth; a few may benefit from early decompression in or ex utero.

Drainage↗
PubMed1999

Complications of voiding cystourethrography in the evaluation of infants with prenatally detected hydronephrosis.

PURPOSE: We determined complications in infants undergoing voiding cystourethrography as part of the evaluation for prenatally detected hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed the records of infants referred to our institution for the evaluation of prenatal hydronephrosis from 1992 to 1997. Infants with a prenatal history of bilateral hydronephrosis, bladder distention and oligohydramnios, oligohydramnios only or a prenatal abnormality involving any other organ system were excluded from study. Of 206 patients 129 male and 49 female infants underwent postnatal voiding cystourethrography at our institution. Chart review and a telephone interview with the parents were done to assess lower urinary tract infection, pyelonephritis, hospital admission for urosepsis, gross hematuria, urinary retention or skin rash. RESULTS: Postnatal voiding cystourethrography was normal in 138 patients but it diagnosed bilateral vesicoureteral reflux in 15, unilateral vesicoureteral reflux in 20, ureterocele in 4 and refluxing megaureter in 1. Of the 129 male infants evaluated 101 had undergone circumcision as a newborn, 14 were uncircumcised and the circumcision status of 14 was unknown. At voiding cystourethrography suppressive antibiotics were administered to 166 infants, 7 were not on suppressive antibiotics and antibiotic status was unknown in 5. No patient had a lower urinary tract infection, pyelonephritis or urosepsis. In addition, there were no episodes of urinary retention, gross hematuria or skin rash. CONCLUSIONS: While the reported rate of new or recurrent infection associated with voiding cystourethrography is as high as 6%, we did not identify any infectious or other complications in infants undergoing voiding cystourethrography for prenatal hydronephrosis. When properly performed, we believe that voiding cystourethrography is safe and presents little risk in these patients.

Female↗
PubMed2002

Prognostic significance of captopril renography for managing congenital unilateral hydronephrosis.

PURPOSE: In this prospective study we evaluated the results of captopril enhanced diuretic renography in patients with congenital unilateral ureteropelvic junction type hydronephrosis. Captopril renography helps to distinguish patients who have renin-angiotensin system activation from those in whom it is not yet activated. Renin-angiotensin system activation heralds the beginning of compensatory vasoactive response in the kidney. Identifying grades of such activation may help in determine the end points of nonoperative management. MATERIALS AND METHODS: We prospectively studied 25 patients with suspected unilateral ureteropelvic junction obstruction treated at our department. A prenatal diagnosis was made in 60% of cases. Patient age was 1 to 144 months (mean 40) and the male-to-female ratio was 4:1. Followup was 6 to 72 months (mean 30). Patient evaluation and analysis included sonography, standard diuretic and captopril renography, glomerular filtration rate, serum creatinine and blood pressure. The indications for surgery were symptoms, differential function below 35%, or a documented decrease of 10% or more during followup. Activation of the renin-angiotensin system was considered positive when split renal function decreased significantly by 5% or more in an obstructed system on a post-captopril study. The results of captopril renography were examined retrospectively in patients who required surgery according to preexisting criteria. RESULTS: Society for Fetal Urology hydronephrosis grade was II to IV in 8, 10 and 7 renal units, respectively. The renin-angiotensin system was activated in 8 of the 25 cases (32%) of unilateral ureteropelvic junction obstruction. In 15 patients there was no change on pre-captopril and post-captopril studies and in 2 split renal function on the obstructed side marginally increased on the post-captopril study. Surgical correction was required in only 6 of the 8 patients with renin-angiotensin system activation. Of those who required surgery hydronephrosis was grades II to IV in 3, 1 and in 2 patients, respectively. CONCLUSIONS: In the current study renin-angiotensin system activation correlated with the need for surgery in 75% of the cases of congenital unilateral ureteropelvic type hydronephrosis. Since captopril serves to identify patients who have renin-angiotensin system activation, it may also be possible to grade this activation. Our preliminary results show that there may be a role for captopril renography for identifying the risk group for surgical intervention.

Captopril↗
PubMed1993

Diuretic renography in the evaluation of neonatal hydronephrosis: is it reliable?

Arguments against the use of diuretic renography in the assessment of newborn hydronephrosis include immature function of neonatal kidneys, previously reported poor diuretic response and nonreproducible drainage patterns. To address these concerns we reviewed the initial and followup renal scans of 17 neonates with hydronephrosis without ureterectasis diagnosed by perinatal ultrasonography. All patients were evaluated with an initial diuretic renal scan up to the age of 28 days, and all had normal cystograms. A total of 19 dilated kidneys was studied of which 13 ultimately required pyeloplasty and 6 were managed nonsurgically. Patient study parameters included age and weight at the time of each renal scan, side of hydronephrosis, differential function of each kidney, pre-diuretic and post-diuretic urine output, and drainage half-time of each kidney. The diuretic renal scans followed a standardized protocol. There was no statistically significant difference between neonatal and followup differential function (p > 0.05), and the correlation coefficient was highly significant (r = 0.968). Comparison of response to diuretic stimulation (ml./kg. per minute) revealed no statistically significant difference as the patients aged with brisk urine output 3 to 5 times greater than previously reported. The distribution and mean drainage half-times for normal nonhydronephrotic kidneys were similar when comparing those performed as neonates and at followup. Hydronephrotic kidneys managed nonsurgically maintained almost identical patterns. Those repaired surgically demonstrated appropriate improvement in drainage but function remained unchanged. These results refute each of the criticisms against the use of diuretic renography to evaluate neonatal hydronephrosis and demonstrate its reliability in neonates.

Furosemide↗
PubMed1989

The fate of infant kidneys with fetal hydronephrosis but initially normal postnatal sonography.

Antenatal hydronephrosis involving 49 renal units in 35 infants seen since 1984 was studied. Postnatal sonography performed in the first few days after birth confirmed upper tract dilatation in 39 kidneys (80 per cent) in 29 neonates and it was normal in 10 kidneys (20 per cent) in 6 neonates. Of the 6 neonates with a normal postnatal sonogram 5 underwent repeat renal sonography at an average of 2 months after birth, all showing moderate hydronephrosis (7 kidneys). Furosemide-enhanced diethylenetriaminepentaacetic acid renography was performed in 4 infants (5 kidneys) with ureteropelvic junction or megaureter obstruction, of whom 2 had persistent unilateral obstruction and underwent successful reconstructive surgery (1 pyeloplasty and 1 megaureter reimplantation). Two infants (3 kidneys) with nonobstructive dilatation are being followed while 1 infant with bilateral vesicoureteral reflux is being managed medically on long-term antimicrobial prophylaxis. Thus, 50 per cent of neonates with antenatal hydronephrosis and a normal postnatal sonogram performed during the first few days of life subsequently were found to have either significant obstruction (2 requiring surgery) or reflux. This study underscores the absolute necessity of followup sonography in all newborns with antenatal hydronephrosis that is not confirmed on the initial postnatal ultrasound.

Female↗
PubMed1986

Implications of hydronephrosis in the newborn with myelodysplasia.

Hydronephrosis has been reported to be present at birth in 6 to 28 per cent of newborns with myelodysplasia. It is unknown whether this hydronephrosis is secondary to abnormal in utero voiding dynamics and is truly present at birth or whether it is acquired postnatally secondary to spinal shock after back closure. We reviewed the perinatal course of 47 myelodysplastic newborns and conclude that the true in utero incidence of hydronephrosis is lower than that suggested in the literature, and that the hydronephrosis seen in many of these newborns is acquired after back closure and is transient in nature.

Female↗
PubMed1985

Incidental hydronephrosis on bone scintigraphy: sonographic verification.

We studied 98 kidneys in 55 patients with bone scintiscans and renal sonography. Among the 29 kidneys in which hydronephrosis was suspected on bone scintiscans only 12 were truly hydronephrotic by renal ultrasound. In the other 17 cases extrarenal pelves, postural stasis, early urinary tract obstruction or renal parenchymal disease may have contributed to the discrepant findings. By ultrasound criteria there were no false negative readings for hydronephrosis on scintiscan. While it is safe to interpret absence of hydronephrosis caution should be used in diagnosing hydronephrosis, since less than half of the cases actually will have the disease when suspected on a bone scintiscan.

Bone and Bones↗
PubMed1981

Electrophysiological investigation of hydronephrosis in children.

The hydrostatics and dynamics of the upper urinary tract were studied in 12 children with congenital hydronephrosis by means of intrapelvic pressure and bipolar electromyography leads from the pelvis and ureter. Studies were performed intraoperatively with the child under general anesthesia. Measurements were obtained during a baseline period of normal diuresis and during diuresis induced by furosemide. The baseline pressure in the hydronephrotic pelvis was within normal limits in most cases but a tendency toward an increased mean baseline pressure was observed in severe hydronephrosis when the cases were grouped according to the excretory urogram. During diuresis the average pressure increase in severe hydronephrosis was parallel to that in moderate hydronephrosis. The peristaltic pattern showed discoordination in pelvis conus transmission but usually preserved anterograde transmission from the conus down the ureter. The results seem to indicate a slight functional obstruction at the pelvioureteral junction. This obstruction leads to the observed alterations in peristalsis and to a slight elevation of the intrapelvic pressure in more severe cases.

Adolescent↗