Management of Neonatal Hydronephrosis. Nader A. Abdelsattar. Assistant Lecturer of Urology. Al-Azhar University

1. Management of
Neonatal Hydronephrosis
Nader A. Abdelsattar
Assistant Lecturer of Urology

2. • Hydronephrosis :-dilatation of the renal pelvis
with or without dilation of the renal calyces

3. Causes Of ANH
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 %

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

5. Diagnostic evaluation

6. PHYSICAL EXAMINATION:
The physical examination of the newborn can
detect abnormalities that suggest genitourinary
abnormalities. These include the following:

7. 1. The presence of an abdominal mass that
could represent an enlarged kidney due to
obstructive uropathy or multicystic
dysplastic kidney (MCDK).

8. 2.Potter appearance
Note the flattening of the nose and
the low-set ears. Pressure deformity from
the oligohydramnios
The facies results from oligohydramnios
causing prolonged intrauterine
compression on the entire face. The nose
is flattened, there are large vertical
creases below the eyes, the ears are low
set and dysplastic, and there is mild
micrognathia.

9. 3. A palpable bladder in a male infant, especially
after voiding, may suggest posterior urethral
valves.

10. palpable bladder in a male infant
with posterior urethral valves

11. Autopsy specimen of the infant with
congenital posterior urethral valves.
Note the urethral valves, enlarged
bladder,bilateral hydroureter, and
bilateral hydronephrosis.
Huge distended ureters and
hydronephrotic kidney

12. 4. supernumerary nipples is associated with an increased
risk of CAKUT, particularly vesicoureteral reflux.

13. 5. The presence of outer ear abnormalities are associated with an
increased risk of congenital anomalies of the kidney and urinary
tract (CAKUT).

14. 6. A male infant with prune belly syndrome will have deficient
abdominal wall musculature and undescended testes. The presence of
associated anomalies should be noted.
Currently it is thought that
the marked distention of
the bladder and ureters
and renal involvement
result in the ablation of
the abdominal muscles,
especially the recti. The
kidneys may be
hypoplastic or severely
hydronephrotic as a result
of the obstruction.

15. 7.Ascites
Marked abdominal
distention in an
infant with urinary
ascites and
bilateral multicystic
kidneys

16. INVESTIGATIONS

17. The most sensitive time for fetal urinary tract
evaluation is the 28th week. If dilatation is
detected, US should focus on:
• Laterality, severity of dilatation, and echogenicity of the
kidneys;
• Hydronephrosis or hydro-ureteronephrosis;
• Bladder volume and bladder emptying;
• Sex of the child;
• Amniotic fluid volume
Antenatal ultrasound

18. • Indications
– Follow-up of fetuses diagnosed in utero
with hydronephrosis
– Evaluation of newborns suspected of harboring
congenital anomalies
Postnatal ultrasound

19. 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

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

21. Severity of hydronephrosis
society for fetal urology (SFU(

22. Society of Fetal Urology grading system for
hydronephrosis.(SFU)
Grade 1: renal pelvis is only visualized.
Grade 2: renal pelvis as well as a few, but not all,
calyces are visualized.
Grade 3: virtually all calyces are visualized.
Grade 4: similar to Grade 3 but, when compared to the
normal centralateral kidney, there is
parenchymal thinning.

23. 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

24. • 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

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

26. 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

27. • 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(

28. 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

29. • 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

30. Other Imaging Studies of the Upper
Urinary Tract
• 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
• MRI:- requires GA
• Retrograde Pyelography :- rarely adds diagnostic
information
• Computed tomography (CT)

31. 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

32. • 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 in:
– severe hydronephrosis with marked parenchymal
thinning
– bilateral hydronephrosis

33. • 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.

34. •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

36. 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

37. • The risk of UTI increased with SFU Grade
3 and 4 or APRPD ≥15 mm.
• Recommended in
–APD > 10mm
–SFU > 3,4
–VUR
• Amoxiclillin is usually given
10mg/kg/day) – first 3 mts).
• cotrimoxazole (1-2 mg/kg/d) or
nitrofurantoin (1 mg/kg/d) after 3 mts.

38. 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

39. Surgical Outcomes
Similar surgical success rates
and complication rates

40. 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

41. • % 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

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

43. • 50 % of these patients have VUR,
• With 25% having bilateral and 25% having
unilateral reflux

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

45. 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 general condition
of the child

46. • 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

47. 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

48. Evaluation
–USG
• Prenatal diagnosis
• Initial USG may be normal
–VCUG
• unilateral or unilateral hydronephrosis with
renal pelvic APD
more than 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

49. International Classification
118

50. 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
• Up to 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

51. European Association of Urology
Guidelines on VUR
• All children diagnosed <1 year should be treated with
prophylactic antibiotics 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.
• No advantage of correcting grade I-III with no scars
or fever. Consider endoscopic treatment 120

52. 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.

53. 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 (SFU 3-4) 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%), progressive increase in hydronephrosis, febrile
infection or poor parental compliance.

57. Thank you