Pediatric urology Management Of Antenatal Hydroureteronephrosis

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Professors:
 Prof. Dr.G.Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr.J. Sivabalan, M.S., M.Ch.,
 Dr.R. Bhargavi, M.S., M.Ch.,
 Dr.S. Raju, M.S., M.Ch.,
 Dr.K. Muthurathinam,M.S., M.Ch.,
 Dr.D.Tamilselvan, M.S., M.Ch.,
 Dr.K. Senthilkumar,M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

 Hydronephrosis :-dilatation of the renal pelvis with or without
dilation of the renal calyces
 Currently the term urinary tract dilatiation (UTD) is proposed
3
Dept of Urology, GRH and KMC, Chennai.

 Kidneys first detectable………….13 wks
 Fetal bladder ……………………….10wks
 Filling/emptying cycles……………..15 wks
 Ureters normally not visualized
 Hydronephrosis…………………….16 wks
 Internal renal structure distinct
 Kidney surrounded by fat…………..20 wks
4

Transient/physiological 50-70%
UPJ obstruction 10-30%
VUR 10-40%
UVJ pattern dilatation 5-15%
Ureterocele 5-7%
MCDK 2—5%
Duplex system/ureterocele/ecotpic 5-7%
PUV/PBS etc 0.1-0.5%
5

UNILATERAL BILATERAL
 UPJ obstruction (39-64%)
 UVJ obstruction (9-14%)
 Vesicoureteralreflux
 MCDK (4-25%)
 Ureterocele/ ectopic ureter
 Duplex system
 PCKD
 Physiologic
 Extra-renal pelvis
 Posterior urethral valves
 Vesicoureteral reflux
 Urethral aplasia
 Prune belly syndrome
 Megacystis-megaureter
 PCKD
6

Causes of pediatric HN
Obstructive cause
 UPJ obstruction, 1:1000 , M>F
 UVJ obstruction
 PUV, AUV
 Ectopic ureter - 1:1900,f>m, asso renal hypoplasia ,
 Ureterocele 1:10000,f>m, 80% duplex system 10% bilateral
 Congenital urethral stricture
7

Non-obstructive causes
VUR : 1 – 2 % f>m
Non-obst. mega ureter
Fetal fold
Neurogenic bladder
Mega calycosis
8

ConditionsMimicking HN
Extra renal pelvis
MCDK
Peripelvic cyst
Neonatal kidneys
Radio lucent renal stones
9

AN screening protocol
 Initial screening maternal ultrasound scan : around 20weeks of gestation.
Low risk pregnancies – average of 2 scans(20-32 wks)
High risk pregnancies-averageof 4scans(4-6 wks apart)
 Measurement of the APD of pelvis & AFI has been used widely
 severity of prenataldilation correlatewith obstructive lesions BUT
inconsistentrelationship with VUR(FP 25% )
Normal AFI is 8 to 18, oligohydramniosis less than 5 or 6, and
polyhydramniosis 20 to 24.
10

LINE DIAGRAM TO MEASURE FETAL RENAL PELVIC APD
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.
11

12

APD CAN BE AFFECTED BY
 Gestational age
 Hydration status of the mother
 Bladder hypertonicity
 Degree of bladder distention
13

LIMITATION OF AP DIAMETER
 failure to describe pelvic configuration
 calyceal dilation
 laterality of findings
14

ANTENATAL HYDRONEPHROSIS
Society for Fetal Urology Grading System
Grade 0:No splitting
Grade 1:Mild pelvic dilatation,no calyceal
Dilatation
Grade 2: Moderate pelvic dilatation,
calyceal dilatation(major calyces)
Grade 3: Large pelvis, dilated calyces (minor &
major calyces),normal parenchyma
Grade 4: Large pelvis, dilated calyces, thinned out
parenchyma
15

Urinary Tract Dilation Grading System
 standardized reporting template
 Include whole Urinary tract
16

17

- Majority of sfu g1-2 resolve by 18months
- If increasing hydronephrosis occurs , it does so early in
life and often during the first year.
18

RISK STRATIFICATION AND MANAGEMENT FOR PRENATAL
URINARY TRACT DILATATION
19

20

RUANO’S CLASSIFICATION SYSTEM FOR PRENATAL LOWER URINARY
TRACT OBSTRUCTION
21

EVALUATION OF UTD 2-3
 Evaluation of the sonographic appearance of the fetal kidneys
 Volume of amniotic fluid
 Measurements of fetal urine electrolytes and proteins
22

 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 interventionor a
major anomaly is suspected,
23

 Not a very useful prognostic indicator except at the extreme of
oligohydramnios or anhydramnios
 Fetus producing isotonic urine: poor renal function
 urine electrolyte features of adequate renal function in a fetus
with sonographic evidence of obstructive uropathy include
 urinary sodium of less than 100 mg/dl,
 a calcium of less than 8 mg/dl,
 an osmolality of less than 210 mOsm/L,
 a urine output of more than 2 mL per hour
24

OTHER INDICATORS
 U.sodium strong predictor of renal function
 Fetal urinary calcium
 Total protein
 B2 macroglobulin
 U.osmolaity
25

TIMING OF
INTERVENTION
<20 WKS :-council for
abortion/
Amniotic fluid restoration
20-32 wks,
shunting, or
surgery
32 wks:- early
labour
26

FETAL INTERVENTION
 Goal :
 prevent the sequelae of the
obstructive process
 renal maldevelopmentas seen
in renal dysplasia
 pulmonary hypoplasia
 Limitation
 Improve perinatal survival but
complication rate to the
mother and fetus ≥ 40%
 Need for renal replacement in
future
27

28

 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 interventionis not
recommendedregardless of the detected abnormality.
29

 Technique
 Vesicostomy or pyelostomy
 Pigtail shunt
30

 Complications:(50%)
 Shunt blockage or migration,
 preterm labor,(12%)
 urinary ascitis,
 Chorioamnionitis
 Iatrogenic gastroschisis,
 intrauterine death
 Outcome:
 Perinatal survival 47%
 Post renal insufficiency 87.5%
31

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 ultimatelyon dialysis
 33% had a transplant
32
Society for Fetal Urology 35th Biannual Meeting 2005

 US guided
 1.3mm fetoscope
 Cannula through maternal then fetal abdomen then fetal bladder
 Nd:YAG LASER to ablate the valve in an antegrade manner
33

IMPROVE DRAINAGE AND TO
RESTORE NORMAL CYCLING OF THE BLADDER
Quintero et al. 34

RUANO R, SANANESN, SANGI-HAGHPEYKARH, ET AL: FETAL INTERVENTIONFOR
SEVERELOWER URINARYTRACT OBSTRUCTION: A MULTICENTERCASE-CONTROL
STUDY COMPARINGFETAL CYSTOSCOPYWITH VESICOAMNIOTICSHUNTING,
ULTRASOUNDOBSTETGYNECOL 45(4):452–458, 2015.
 CONCLUSION:
 Both VAS placement and FCA demonstrated a clear survival advantage
 FCA demonstrated an improvementin both 6-month survival (ARR
4.10; 95% CI, 1.75 to 9.62; P < 0.01) and renal function in PUV
35

36

37

INVESTIGATIONS
 Ultrasound
 VCUG
 Isotope renogram
 MR Urogram
38

Ultrasonography should be done
after 48 hr of birth
o In neonates with suspected
 posterior urethral valves,
 oligohydramnios
 severe bilateral hydronephrosis,
 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
39

VOIDING CYSTOURETHROGRAPHY
 Follow ALARA principal
 ONLY if risk for UTI/LUTO
1.Females
2.Uncircumcised males
3.Patients with high-grade kidney/ ureteral dilation
4. Suspected BOO: thick-walled bladder (≥0.5 cm), distended urinary
bladder, and bilateral hydroureteronephrosis
use of a nonballoon catheter and cycling of the study
increases reliability of the study
40

ISOTOPE RENOGRAM
 Assess renal perfusion
 Glomerularfunction of each kidney
 Structural anomalies
 Drainage of the collecting system
 surgical intervention may include decreased differential
function (<40%),T1/2 greater than 20 minutes, and significant
retention on delayed upright imaging
41

MAGNETIC RESONANCE UROGRAM
 Not clearly defined
 Require when there is need for anatomical detail and/or renal
function to aid in operative planning
42

MANAGEMENT ALGORITHM
43

44

45

Severe Bilateral
Urinary Tract
Dilation
PROPHYLATIC
ANIOBIOTIC
DECOMPRESSION EVALUATION
strongly suggestive
of BOO
46

 SFU 1-2
 90-95% resolve within 24-48 months followup
47

VU reflux
 up to 31% of patientsscreened with prenatalUTD
 M:F = 5:1
 Grade of prenatalUTD correlatespoorly with the severity of VUR
 An. Diag – potential for spontaneous resolving than presenting clinically
48

VUR
Bottom up
approach
Top down
approach
usg
49

 Elder etal study
 78% - Grade 1 – 3
 36% - Grade 4 – 5, resolve spontaneously
 When breakthrough urinary infection needs early interventionauthor
prefers cutaneous vesicostomy & proceed with ureteral reimplantation
50

 VUR is common in patients with a history of prenatal UTD
 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
 SCREENING for risk of UTI to decrease progression
 females with high grade UTD or males with intact foreskin, BBD are at
high risk for UTI.
51

MEGAURETER/URETEROVESICAL
JUNCTION OBSTRUCTION
 British Association of Pediatric Urologists Consensus Statement:
 1. Evaluation: postnatal renal ultrasonography, initiation of PA, VCUG in
all patients and renal scintigraphy to assess function and obstruction at
the level of the ureterovesicaljunction (UVJ).
 2. Surgical Intervention: for decreased renal function (<40%), fUTI, or
pain. Ideally, the procedure should be deferred until 1 year of age
 3. Follow-up: follow-up into adulthood because of the risk for late
asymptomatic deterioration
52

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
53

 postnatal ultrasound scan in P2 or P3 UTD
 Prophylactic antibiotics for (P3/SFU 4)
 VCUG to exclude VUR and assure normalcy of the posterior urethra in
males
 Use of renal scintigraphy is left on physician and should be used for
persistent P3 UTD (at 1 month for severe disease as base line)
 A prompt VCUG and diuretic renogram should be done
 severe hydronephrosis with marked parenchymal thinning
 bilateral hydronephrosis
54

55

 SFU Grade 3 and 4 or APRPD ≥15 mm 14.6% vs. 28.9%
 Recommended in
 APD >10mm
 SFU >3,4
 VUR
 Amoxiclillin50 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.
56

RECOMMENDATIONS FOR SURGERY
 Include increased APD and urinary tract dilation on serial
ultrasonography
 Decreased differential function (<40%) and/or a delayed drainage
curve
 Increased retention of radiotracer on delayed upright imaging on MAG3
renal scan
 ideal age for surgery is above 2 yr but can be performed above 6
month
57

LOWER URINARY TRACT OBSTRUCTION
(POSTERIOR URETHRAL VALVE, PRUNE BELLY
SYNDROME, URETHRAL STENOSIS/ATRESIA)
 abdominal mass (48%),
 failure to thrive (10%),
 urosepsis (8%),
 urinary ascites (7%)
 Perirenal urinoma
58

MANAGEMENT
Bladder
decompreesion
serum creatinine
nadir.
evaluation Definitive mgt.
Post
decompression
Postobstructive
diuresis
concentrating defect
inherent
oliguria or even
anuria
Anticholinergic
medication
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60

 Most diagnoses made based on a finding of prenatalhydronephrosis can be
handled conservatively.
 The role of prophylactic antibioticsinitiatedat birth is controversial.
 The need to further investigatemild postnatalhydronephrosis (SFU 0–2) with a
VCUG is controversial,and depends on the physician’s attitude toward
diagnosing asymptomaticVUR.
 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.
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62

Pediatric urology Management Of Antenatal Hydroureteronephrosis

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