Society For Fetal Urology Research Articles

Review of 'Diary of a first time mum: an uncensored account of all the stuff that really happens' by N Hall, Finch publishing, Sydney, 2009

To explore the potential value of an objective assessment, renal parenchyma to hydronephrosis area ratio (PHAR), as an early predictor of surgery.Initial sagittal renal ultrasound (US) images of patients prospectively entered into a prenatal hydronephrosis database from January 2008 to January 2016 with baseline Society for Fetal Urology (SFU) grades III and IV prenatal hydronephrosis, without vesicoureteral reflux, were evaluated using the National Institutes of Health-sponsored image processing software. PHAR, anteroposterior diameter, SFU grade, and urinary tract dilation risk categories were contrasted with nuclear scan data (differential renal function and drainage time [t1/2]) and analyzed for predictive value in determining the decision to proceed with surgery by drawing receiver operating characteristic curves.Out of 196 infants (162 male; 138 left sided hydronephrosis), 58 (30%) underwent surgery to address obstruction. Surgical patients compared with those managed conservatively had longer t1/2 (60 vs 18 min; P < .01) and lower differential renal function (46 vs 50%; P = .01). Of the initial US parameters, PHAR (area under the curve = 0.816; P < .001) had a better predictive performance than anteroposterior diameter, SFU grade, or urinary tract dilation classification. PHAR values correlated with subsequent parameters obtained on nuclear scan.PHAR is a promising parameter that can be estimated on presentation US to help predict future need for surgery in newborns with high-grade hydronephrosis.

Long-term follow-up and management of prenatally detected, isolated hydronephrosis

Purpose The aim of the study was to determine the outcome and management of infants with isolated hydronephrosis, detected prenatally and confirmed postnatally. Materials and Methods Between January 1988 and January 2008, the files of 629 children (492 males and 137 females), who were diagnosed prenatally with isolated, unilateral hydronephrosis, and the diagnosis was confirmed postnatally, were retrospectively reviewed. The median follow-up time was 142 months. Serial ultrasonography and isotope diuretic renography nuclear imaging were performed. Hydronephrosis was assessed and classified according to the Society of Fetal Urology (SFU) grading system. Results Initially, all of the children were treated conservatively. Stabilization occurred in all children with grade 1 hydronephrosis, in 87% of children (144) with grade 2 hydronephrosis, and in 30% of children (37) with grade 3 hydronephrosis. However, 13% of children (21) with grade 2 hydronephrosis, 70% of children (85) with grade 3 hydronephrosis, and 100% of children with grade 4 hydronephrosis received surgical intervention according to our predetermined criteria. Ninety-five patients (late pyeloplasty group) were treated for a reduction for a differential renal function (DRF) to less than 40%, and 80 children (early pyeloplasty group) underwent surgery for a DRF more than 40%, but hydronephrosis progressed to higher grades or failed to improve and had poor radiotracer clearance. Significant improvements after pyeloplasty were noted in both groups with respect to the DRF and the ratio of the depth of the calyces to the thickness of the parenchyma (C/P ratio; P < .0001). The improvement in DRF was greater in the late pyeloplasty group than the early pyeloplasty group ( P = .044), whereas the improvement in the C/P ratio was greater in the early pyeloplasty group than the late pyeloplasty group ( P = .001). The ipsilateral DRF was preserved in the early pyeloplasty group, whereas the ipsilateral DRF was still less than 40% in the late pyeloplasty group. The improvement in DRF was significant during the first year postoperatively and became stable thereafter. The C/P ratio was inversely correlated with the DRF in the patients before and after pyeloplasty ( r = −0.257; P = .01; and r = −0.616; P = .001, respectively). Conclusions All infants with SFU-1 and most infants with SFU-2 hydronephrosis have relatively benign conditions and do not need an invasive procedure. Although greater improvement occurred in patients with an initial DRF less than 40%, the reduced DRF did not recover to the predeterioration level postoperatively. Earlier surgical intervention after a short period of strict clinical surveillance is beneficial for preserving renal function for patients with persistent SFU-3 or SFU-4 hydronephrosis.

Candidate Urinary Biomarker Discovery in Ureteropelvic Junction Obstruction: A Proteomic Approach

Ureteropelvic junction obstruction may either worsen and require surgery, improve or remain stable. It may take upward of 3 years for the natural history to unfold. Urinary proteome analysis using capillary electrophoresis mass spectrometry has been shown to differentiate between normal infants and those with ureteropelvic junction obstruction. We sought to confirm these findings using liquid chromatography/nano-spray mass spectrometry to examine the urinary proteome in patients with unilateral grade IV ureteropelvic junction obstruction compared to age matched healthy infants. Urine specimens were obtained from 21 healthy infants with normal maternal/fetal ultrasound and 25 infants with grade IV unilateral ureteropelvic junction obstruction. Specimens were prepared using standard methods and subjected to liquid chromatography/tandem mass spectrometry analysis. Normalized data were annotated using the IPA(R) knowledge platform. There were 31 proteins significantly different in their level of abundance at 1 to 6 months, and 18 at 7 to 12 months compared to age matched controls. These proteins clustered into major functional networks. All of the biomarkers previously reported in clinical studies of ureteropelvic junction obstruction were observed with the notable exception of transforming growth factor-beta1. These results confirm the presence of significant differences in the urinary proteome in unilateral ureteropelvic junction obstruction compared to age matched normal individuals. This study adds new information about levels of abundance of specific proteins and peptides in ureteropelvic junction obstruction, which may allow for better classification of disease subgroups and help to establish improved indications for the early selection of surgical candidates based on urinary protein biomarkers.

Editorial Comment

Ideally, any measure of hydronephrosis severity will be reproducible by different observers, predictive for renal damage, and useful for assessing worsening urinary obstruction or improvement of vesicoureteral reflux. The authors of the present study attempted to improve the widely used Society for Fetal Urology (SFU) classification system for ultrasound hydronephrosis with their proposed metric, the hydronephrosis index (HI). The HI is put forward by the authors as a better method of quantifying hydronephrosis and is designed to supplant other metrics such as the SFU system.

Long-term follow up of antenatally diagnosed megaureters

Aim We have retrospectively evaluated our 17 years of experience with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter, and tried to determine criteria for surgery. Patients and methods Seventy-nine children (64 boys and 15 girls) with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter were followed conservatively over a period of 18 years (1988–2006). Right ureterohydronephrosis was seen in 23 children, left in 30 and 26 had bilateral ureterohydronephrosis comprising a total of 105 renal units (RU). According to SFU (Society for Fetal Urology) classification, 8 RU were grade 1, 57 grade 2, 29 grade 3 and 11 grade 4 postnatal hydronephrosis. Mean ureteral diameter was 1.2 cm. Relative renal function was in 82 RU more than 40%, in 18 RU 30–40% and in 5 RU less than 30%. Functional deterioration of the hydronephrotic kidney of more than 5%, worsening of hydronephrosis (SFU upgrade) and a persistent obstructive curve on radionuclide scans were the main indications for surgery. Results Twenty-five (31%) children required surgical correction. Mean age at surgery was 14.3 months (range 3–60). Univariate analysis revealed that gender and side of obstruction are not significant predictive factors for surgery SFU grade 3–4 of postnatal hydronephrosis, Relative renal function less than 30% and ureteral diameter more than 1.33 cm were significant independent risk factors leading to reimplantation. Conclusions Only 30% of children with antenatal diagnosis of megaureter required surgical correction. Renal function less than 30%, grades 3 and 4 hydronephrosis, and ureteric diameter more than 1.33 cm are statistically significant and independent predictive factors for surgery.

Appropriate Follow-up Ultrasonography Interval after Pyeloplasty in Children with Ureteropelvic Junction Obstruction

Purpose: Serial ultrasonography (US) is routinely performed after pyeloplasty in the setting of pediatric ureteropelvic junction obstruction (UPJO). We evaluated the adequacy of the follow-up US interval we are currently using, which calls for US at 1, 3, 6, 9, and 12 months following surgery. Materials and Methods: Between January 2002 and August 2005, 102 patients underwent dismembered pyeloplasty for unilateral UPJO. Within this group, we selected 95 patients with high grade hydronephrosis to participate in this study. The degree of hydronephrosis was graded according to the classification issued by the Society for Fetal Urology (SFU). Improvement was defined as at least one grade of reduction. Serial sonograms were performed at 1, 3, 6, 9, and 12 months postoperatively. Results: On follow-up US, 33.7%, 69.5%, 77.9%, 80.0%, and 83.2% of the patients showed improvement in their hydronephrosis at 1, 3, 6, 9, and 12 months, respectively. One patient presented with aggravation at 1 month. However, at 3 months, this patient had returned to the preoperative grade. There was no significant difference between the mean hydronephrosis grades at 6 and 12 months. No patient showed hydronephrosis aggravation at the 12-month follow-up examination. Conclusions: US at 1, 3, and 6 months revealed significant improvements in hydronephrosis. However, no significant change in hydronephrosis occurred beyond 6 months. Therefore, US performed between 6 and 12 months after pyeloplasty may be inefficient, and we propose follow-up US at the following time points: 1 month, 3 to 6 months, 12 months, and then annually. (Korean J Urol 2008;49:1018-1023) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Clinical Course of Prenatally-detected Hydronephrosis: Focus on Ureteropelvic Junction Obstruction

Purpose: The diagnosis and treatment of prenatally-diagnosed hydronephrosis remain controversial. We have conducted a retrospective study to examine the clinical characteristics and course of prenatally-diagnosed hydronephrosis, especially when in the presence of ureteropelvic junction obstruction (UPJO). Materials and Methods: Among all pediatric patients diagnosed with hydronephrosis by prenatal ultrasonography between September 2002 and June 2008, the study was performed on 103 patients (126 renal units), and the mean follow-up period was 19.2 months (range, 6-24 months). Ultrasonography was performed 2-3 days after birth, and after 1, 3, 6, and 12 months, and annually thereafter. Hydronephrosis was graded according to the Society for Fetal Urology (SFU) classification guidelines. Results: On ultrasonography performed 2-3 days after birth hydronephrosis was graded as follows: grade 1, 45 (35.7%); grade 2, 49 (38.9%); grade 3, 23 (18.3%); and grade 4, 9 (7.1%) renal units. In cases with UPJO complete improvement of hydronephrosis was detected in 16 renal units (40%); the renal units and rate of complete improvement in grades 1, 2, 3, and 4 were 12 (75%), 3 (17.6%), 1 (16.7%), and 0 (0%), respectively. The anticipated times of complete improvement of hydronephrosis in UPJO grades 1, 2, and 3 were 22.0, 31.3, and 50.4 months, respectively. Conclusions: In UPJO, the possibility of improvement of hydronephrosis lower than grade 2 was high, and thus follow-up for approximately 30 months may be needed. In patients with hydronephrosis >grade 3, the rate of improvement was low, thus compulsive follow-up is required. (Korean J Urol 2008;49:1125-1130) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Nomogram of Fetal Renal Growth Expressed in Length and Parenchymal Area Derived From Ultrasound Images

We constructed nomograms of fetal renal length and parenchymal area derived from ultrasound images to develop a standard for normal fetal renal growth. Longitudinal and transverse ultrasound renal images from 216 normal fetuses (16 to 41 weeks of gestation) were evaluated to construct growth charts. We measured the parenchymal area as well as the longitudinal and transverse lengths of each kidney using computer software for image analysis. Data were separately plotted as a mean +/- 2 SD determined by polynomial regression analysis. Nomograms for a renal growth chart were constructed independently for the right and left fetal kidneys. No statistically significant difference was noted between the right and left renal measurements. The polynomial regression equations for the left renal longitudinal length and parenchymal area, respectively, were y = -0.0002x(3) + 0.0139x(2) - 0.2162 x 2.3929 (r(2) = 0.9842), and y = -0.0009x(3) + 0.0724x(2) - 1.5643 x 11.68 (r(2) = 0.9779). The longitudinal and transverse fetal renal growth curves displayed significant growth associated with gestational age (p <0.001). Our data on left longitudinal renal length exhibited an intermediate level compared to 2 published Western growth charts. However, statistical comparisons revealed the differences were partially, but not universally, significant. We present our nomogram of fetal renal growth expressed in length and parenchymal area. To our knowledge this is the first report of a fetal renal growth chart in Asia that includes the parenchymal area. This nomogram may serve as a valuable tool for evaluation of fetal renal growth.

An alternative grading system to refine the criteria for severity of hydronephrosis and optimal treatment guidelines in neonates with primary UPJ-type hydronephrosis

Objective We present our alternative hydronephrosis grading system (AGS) in an attempt to establish optimal treatment guidelines, and clarify and refine the criteria for severity of hydronephrosis in neonates. Patients and methods A total of 162 newborns (228 affected kidneys) with antenatally diagnosed primary ureteropelvic junction-type hydronephrosis were prospectively followed and treated by the same surgeon for a mean of 46 (6–65) months. Ultrasonography and diuretic renogram were used for diagnosis and follow up. Society for Fetal Urology (SFU) grading system, anteroposterior diameter of renal pelvis (APDRP) and our AGS were used to determine the degree of hydronephrosis. AGS: 0, no hydronephrosis; 1, dilatation of renal pelvis alone; 2, plus caliceal dilatation; 3, plus <1/2 (mild-to-moderate) renal parenchymal loss; 4, plus >1/2 (severe) renal parenchymal loss (cyst-like kidney with no visually significant renal parenchyma). Results On the first postnatal ultrasound, the severity of hydronephrosis was SFU ≤ 2 in 152 kidneys (surgery, 0%), SFU-3 in 41 kidneys (surgery, 19.5%) and SFU-4 in 35 kidneys (surgery, 68.6%). The follow up, treatment and outcome of SFU-1 and SFU-2 patients were similar; all resolved spontaneously without renal deterioration (renal function >40%). Renal function ranged between 7% and 39% in SFU-4 patients. Intrarenal pelvis was found in one patient with an APDRP of <15 mm, seven patients of 16–30 mm, and five patients of >30 mm. Overall, 201 hydronephrotic kidneys (88.2%) resolved spontaneously while 27 (11.8%) required pyeloplasty. Conclusion Neither an SFU grading system nor measurement of APDRP is the gold standard in determining the severity of hydronephrosis. Both methods may fail, particularly in children with intrarenal pelvis configuration or SFU-4 hydronephrosis. Our AGS promises easier follow up and more timely treatment.

Does Surgical Release of Secondary Spinal Cord Tethering Improve the Prognosis of Neurogenic Bladder in Children With Myelomeningocele?

The diagnostic criteria for secondary tethering of the spinal cord in children with prior closure of an open spinal defect are not well defined. Urological, neurological or orthopedic deterioration during followup remains the only strong indicator for the diagnosis of this condition. However, the outcome of untethering surgery cannot always be predicted. The aim of this study was to determine neurourological outcome after secondary untethering surgery in children with myelomeningocele. Of 401 children with myelomeningocele followed at our multidisciplinary spina bifida clinic between 1996 and 2005, 56 (14%) were diagnosed with secondary tethering of the spinal cord (median age at diagnosis 4.1 years). The diagnosis was based on urological and neuro-orthopedic deterioration in 58% and 42% of children, respectively. Preoperative urological findings were compared with 6-month postoperative findings. Febrile urinary tract infection, upper tract dilatation and vesicoureteral reflux were preoperatively documented in 48.2%, 19% and 30% of the 56 children, respectively. At 6 months postoperatively urine cultures were sterile in 34% of patients and upper tract dilatation completely resolved in 45%. For all grades of vesicoureteral reflux complete resolution occurred in 47% of patients. Urodynamic parameters in terms of cystometric bladder capacity and detrusor leak point pressure substantially improved 6 months after untethering surgery (125 vs 170 ml and 69.1 vs 47.5 cm H2O, respectively, p < 0.05). Assessment of urodynamic findings in 19 children at 1 year failed to demonstrate a significant change in these parameters. A subgroup analysis according to patient age at untethering surgery revealed urodynamic improvement was more significant in children who were diagnosed and treated before age 7 years. Secondary tethering of the spinal cord is a major risk factor for urological and neurological deterioration in children with myelomeningocele. Close urological surveillance remains the most valuable tool in the early diagnosis. Our study shows that secondary untethering surgery may significantly improve urological outcome.

Magnetic Resonance Urographic Parameters for Predicting the Need for Pyeloplasty in Infants With Prenatally Diagnosed Severe Hydronephrosis

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. 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. 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. 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.

Conservative Treatment of Ureteropelvic Junction Obstruction in Children with Antenatal Diagnosis of Hydronephrosis: Lessons Learned after 16 Years of Follow-Up

ObjectivesWe attempted to define predictive factors for surgery in children with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of ureteropelvic junction (UPJ) obstruction. MethodsWe retrospectively evaluated our 16-yr experience (1988–2003) with 343 children (260 male and 83 female) with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of UPJ obstruction and who were followed conservatively. Right-sided hydronephrosis was present in 110 and left-sided in 233 children. According to the Society for Fetal Urology (SFU) classification none had grade 0 of postnatal hydronephrosis, 20 had grade 1, 118 grade 2, 147 grade 3, and the remaining 58 children grade 4 postnatal hydronephrosis. Relative renal function (RRF) on radionuclide scans revealed 235 children with RRF>40%, 68 with RRF between 30% and 40%, and 40 patients with RRF<30%. Renal function deterioration >5% was the main indication for surgery. Commercially available software GraphPad Prism 4.0 (GraphPad prism, Prism 4 for Windows, version 4) using the Fisher exact test was used for statistical evaluation. ResultsSurgical correction was needed in 179 children (52.2%) during the course of conservative management. The average age at surgery was 10.6 mo (range, 1 mo to 7 yr). Of those, 50% underwent surgery during the first 2 yr of life and the majority of the remaining patients underwent surgery between the 2 and 4 yr of age; only two patients required surgery later on. Univariate analysis revealed that child sex, side of hydronephrosis, and SFU grade of prenatal hydronephrosis were not significant predictive factors for surgery. However, SFU grade 3–4 of postnatal hydronephrosis (p<0.0001; odds ratio, 0.06281) and RRF<40% (p<0.0001; odds ratio, 0.1022) were significant independent risk factors for surgery. ConclusionIn contrast with previous publications by others and by us these data show that >50% of children with antenatal diagnosis of UPJ obstruction in this series required surgical correction while on conservative protocol. SFU grade 3–4 of postnatal hydronephrosis and RRF<40% are significant independent predictive factors for surgery.

1 year follow-up results of prenatally diagnosed unilateral hydronephrosis according to renal sonographic findings at 1 month of age

Purpose:The natural courses of prenatally diagnosed hydronephrosis(HN) are diverse. Our purpose was to determine if the findings of renal ultrasonography(USG) in patients with prenatal HN at 1 month of age can predict the 1 year follow-up results and determine the guideline of follow-up study. Methods:Among 462 hydronephrotic patients registered between 1996 and 2004, 153 unilateral hydronephrotic renal units were enrolled in this study, bilateral HN, vesicoureteral reflux and other associated anomaly were excluded. These were classified into four groups respectively, according to anterior posterior pelvic diameter(APPD) or Society for Fetal Urology(SFU) grading by USG findings at 1 month after birth. Renal USG and Tc99m-mercaptoacetyl triglycerine(MAG3) scan were done according to a set protocol. Results:Most cases improved or remained stationary. No one underwent an operation SFU grade 1,2 groups and only one case of SFU grade 3 group was operated. Thirty two cases(64 percent) were operated on among the 50 cases of SFU grade 4 group. 0/2(0 percent), 5/11(45.5 percent), 11/ 17(64.7 percent) and 16/20(80 percent) were operated on in each group with APPD 30 mm, and the operation risk is higher as the APPD is increased. Conclusion:In group with SFU grade below 3 and APPD below 10 mm, we can delay the follow- up study beyond existing set protocol. Operations are recommended immediately if diuretic renogram show the obstructive pattern or decreased renal function in SFU grade 4 group with APPD over 10 mm.

Outcome of isolated antenatal hydronephrosis: a systematic review and meta-analysis

Idiopathic antenatal hydronephrosis (IAHN), defined as antenatal hydronephrosis not associated with other morphologic renal tract abnormalities, is the most common abnormality detected by antenatal ultrasound. We performed a systematic review and meta-analysis to determine the outcome of IAHN. We screened three databases and bibliographies to identify English-language original peer-reviewed papers that reported serial postnatal renal ultrasonography in children with IAHN. Patients who stabilized and/or improved were extracted and pooled according to the individual grading systems used by each study. A systematic analysis of data extracted from 25 articles revealed overall resolution of pelviectasis in milder cases of IAHN (Society of Fetal Urology [SFU] grade 1-2; anterior posterior pelvic diameter [APPD]<12 mm). In contrast, IAHN of higher severity (grades 3-4; APPD>12 mm) resolved with a lower frequency. Meta-analysis of data extracted from seven papers showed stabilization of pelviectasis in 98% of patients with grades 1-2 (95% confidence interval [CI] 0.93-1.0; p =0.0008) and in 51% of patients with grades 3-4 (95% CI 0.34-0.68; p <0.00001). Grades 1-2 pelviectasis was five times more likely to stabilize than grades 3-4 pelviectasis (odds ratio [OR] 4.69; 95% CI 1.73-12.76; p =0.002). We conclude that in patients with IAHN and lesser degrees of pelvic dilatation, pelvic diameter decreases to the normal range or does not worsen with the vast majority of patients. Further studies are needed to define outcomes, particularly in more severe forms of IAHN.

Long-term followup of prenatally detected severe bilateral newborn hydronephrosis initially managed nonoperatively.

We determine the outcome of severe bilateral primary ureteropelvic junction type hydronephrosis detected prenatally and managed postnatally with an initially nonoperative protocol. A total of 19 newborns (38 kidneys) with prenatally diagnosed primary grade 3 to 4 bilateral hydronephrosis were followed nonoperatively for a mean of 54 months (range 14 to 187). If urinary obstruction with evidence of renal deterioration (decreased differential function and/or progressive hydronephrosis) occurred pyeloplasty was performed. Pyeloplasty was required in 13 kidneys (35%) in 9 patients (bilateral 4, unilateral 5). Age at pyeloplasty ranged from 2 to 22 months (mean 6.5) in 12 patients and 64 months in 1. The remaining 25 kidneys were followed nonoperatively (bilateral 20, unilateral 5). At last followup the Society for Fetal Urology grade of hydronephrosis in kidneys followed nonoperatively was 0 to 2 in 21 and 3 in 4, compared to 0 to 2 in 9 and Society for Fetal Urology 3 in 4 kidneys treated with pyeloplasty. Mean followup required for the most severely hydronephrotic kidney to achieve maximum ultrasound improvement was 10 months (range 3 to 34) for kidneys followed nonoperatively and 14 months (4-31) for kidneys after pyeloplasty. Differential renal function was measured in each kidney pair and compared using the difference in percent function between the 2 kidneys. In the nonoperative group mean initial difference in percent function was 8% (range 6% to 20%) and mean final difference was 5% (2% to 8%). In the pyeloplasty group mean initial difference in percent function was 16% (range 8% to 30%) and mean final difference was 7% (2% to 16%). With close followup and prompt pyeloplasty renal function improved to greater than pre-deterioration levels in all kidneys. These data represent the natural history of severe bilateral newborn hydronephrosis. Renal dilatation and function improve with time in most kidneys. Close followup is required in the first 2 years of life to identify the subgroup (35%) of children with obstruction that requires prompt surgery. Such an approach prevented permanent loss of renal function. Nonoperative management with close followup during the first 2 years appears to be a safe and recommended approach for neonates with primary bilateral ureteropelvic junction type hydronephrosis.

Mass screening for early detection of congenital kidney and urinary tract abnormalities in infancy.

Recent widespread use of ultrasound has led to new efforts at screening for congenital kidney and urinary tract abnormalities. However, a standard screening methodology, criteria defining abnormalities, and follow-up procedures remain to be established. In order to establish screening criteria for these abnormalities, we performed a preliminary study in 800 1-month-old infants using provisional methods and criteria. Based on the results of preliminary study, we screened 2700 1-month-old infants in a prospective study using the criteria of renal size (longitudinal diameter <or=35 mm or >or=60 mm, or a difference between sides of >or=10 mm), and of pelvic dilatation (Society for Fetal Urology [SFU] grade 2 or higher) as positive at the first ultrasound screening. We used the SFU grading system instead of anteroposterior pelvic diameter measurements for pelvic dilatation. One hundred and twelve (4.1%) of the 2700 infants had abnormalities at the first ultrasound screening, while 18 (0.67%) had congenital kidney and urinary tract abnormalities on further examination. Use of the SFU grading system enabled us to reduce the false-positive rate at first screening, while maintaining a high diagnostic rate. The abnormalities consisted of ureteropelvic junction obstruction in seven infants, megaureter in two, hypoplastic kidney in four, vesicoureteral reflux in six (three were accompanied by hypoplastic kidneys or multicystic dysplastic kidney), multicystic dysplastic kidney in one, and horseshoe kidney in one. These results indicate that our screening methods and criteria are useful variables for detecting congenital kidney and urinary tract abnormalities.

Assessment and Management of Fetal Hydronephrosis

After completing this article, the reader should be able to: 1. Differentiate genitourinary abnormalities associated with hydronephrosis detected on fetal ultrasonography. 2. Describe the type of fetal hydronephrosis that requires a complete uroradiologic evaluation. 3. Characterize the complete postnatal uroradiologic evaluation of significant fetal hydronephrosis. 4. Delineate the factor that sets the timetable for postnatal uroradiologic evaluation. 5. Describe the neonates for whom diuretic renography is reserved. Ultrasonographic detection of antenatal anomalies in the fetus has increased steadily since its initial widespread use in the 1970s. During these early years, antenatal ultrasonography detected structural abnormalities in approximately 1% to 3% of all pregnancies. (1) Currently, it is estimated that genitourinary anomalies comprise 20% of all antenatally detected fetal anomalies. (2) In a recent British population-based study, fetal genitourinary anomalies were identified in 2.3% of women undergoing routine obstetric ultrasonography between 18 and 23 weeks of gestation. (3) Hydronephrosis clearly has become the most commonly detected antenatal anomaly on fetal ultrasonography. Detection of antenatal dilation of the urinary tract does not always indicate postnatal urinary tract obstruction or even a significant genitourinary anomaly. (4) Among infants diagnosed as having prenatal hydronephrosis or other genitourinary anomalies, the question often is raised about the need for and extent of the postnatal evaluation to assess the magnitude of this commonly detected antenatal anomaly. The purpose of this review is to provide a framework for assessment and management of antenatally detected hydronephrosis. Fetal hydronephrosis is a nonspecific finding that can be associated with multiple congenital anomalies of the genitourinary tract. A thorough understanding of disorders that can result in hydronephrosis postnatally allows the physician to assess the need for postnatal diagnostic tests and guide treatment recommendations. The congenital anomalies that may result in hydronephrosis can be categorized as disorders of urinary reflux and disorders of urinary obstruction. It can be …

Role of Urinary Transforming Growth Factor-β1 Concentration in the Diagnosis of Upper Urinary Tract Obstruction in Children

No AccessJournal of UrologyBasic Science1 Oct 2002Role of Urinary Transforming Growth Factor-β1 Concentration in the Diagnosis of Upper Urinary Tract Obstruction in Children M.T. El-Sherbiny, O.M. Mousa, A.A. Shokeir, and M.A. Ghoneim M.T. El-SherbinyM.T. El-Sherbiny More articles by this author , O.M. MousaO.M. Mousa More articles by this author , A.A. ShokeirA.A. Shokeir More articles by this author , and M.A. GhoneimM.A. Ghoneim More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64416-3AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluate the role of transforming growth factor-β1 (TGF-β1) in the diagnosis and followup of children with pelviureteral junction obstruction. Materials and Methods: TGF-β1 concentration was measured in renal pelvic and bladder urine samples obtained from 15 children who underwent surgery for symptomatic unilateral pelviureteral junction obstruction. Bladder urine TGF-β1 was also measured in 11 age matched patients with dilated nonobstructed kidneys as documented by nonobstructed washout curve and half-time drainage less than 10 minutes on diuretic renography. In the obstructed group bladder urine TGF-β1 was measured 3 months after surgery. Results: In the obstructed group mean TGF-β1 plus or minus SD in the renal pelvic urine was 285 ± 191 pg./mg. creatinine, or 4-fold that of bladder urine (p >0.001). Mean bladder urine TGF-β1 was 3-fold higher in patients with upper tract obstruction than in controls (68 ± 59 versus 22 ± 18 pg./mg. creatinine, p <0.003). Mean bladder TGF-β1 3 months after surgery showed a trend towards a decrease, albeit still insignificant (68 ± 59 versus 39 ± 31 pg./mg. creatinine for preoperatively versus postoperatively, p <0.08). Using a bladder urine concentration of 29 pg./mg. creatinine as a cutoff between obstruction and no obstruction, TGF-β1 was 80% sensitive, 82% specific and 81% accurate for the diagnosis of obstruction. Conclusions: Bladder urine TGF-β1 is a useful noninvasive tool for diagnosis of upper urinary tract obstruction. At 3 months following corrective surgery there is a trend towards decrease in bladder TGF-β1 concentration in comparison to the preoperative value. References 1 : Outcome analysis of pediatric pyeloplasty as a function of patient age, presentation and differential renal function. J Urol1995; 154: 1889. Link, Google Scholar 2 : Comparison of pediatric renogram and the pressure perfusion study in children. J Urol1985; 134: 92. Link, Google Scholar 3 : Renal Doppler ultrasound in children with normal upper urinary tracts: effect of fasting, hydration with normal saline, and furosemide administration. Urology1996; 47: 740. Google Scholar 4 : Urine levels of transforming growth factor-beta 1 in children with ureteropelvic junction obstruction. Urology1997; 50: 5. Google Scholar 5 Furness P.D. Maizels M. Han S.W. Elevated bladder urine concentration of transforming growth factor-b1 correlates with upper urinary tract obstruction in children. J Urol 162:, 1033, 1999 Google Scholar 6 : Ultrasound grading of hydronephrosis: introduction of the system used by the Society for Fetal Urology. Pediatr Radiol1993; 23: 478. Google Scholar 7 : TGF-beta mRNA expression in the renal pelvis after experimental and clinical ureteropelvic junction obstruction. J Urol1996; 156: 261. Link, Google Scholar 8 : Sustained expression of TGF-beta 1 underlies development of progressive kidney fibrosis. Kidney Int1994; 45: 916. Google Scholar 9 : Arrested development of the neonatal kidney following chronic ureteral obstruction. J Urol1996; 155: 1139. Google Scholar 10 : Impaired nephrogenesis in rats with congenital obstructive uropathy. J Urol2001; 165: 2289. Link, Google Scholar 11 : Transforming growth factor-beta 1 antisense oligodeoxynucleotides block interstitial fibrosis in unilateral ureteral obstruction. Kidney Int2000; 58: 1885. Google Scholar 12 : Recoverability of renal function after relief of chronic partial upper urinary tract obstruction. BJU Int1999; 83: 11. Google Scholar From The Urology and Nephrology Center, Mansoura University, Mansoura, Egypt© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byAlmodhen F, Loutochin O, Capolicchio J, Jednak R and El-Sherbiny M (2018) The Role of Bladder Urine Transforming Growth Factor-β1 Concentrations in Diagnosis and Management of Unilateral Prenatal HydronephrosisJournal of Urology, VOL. 182, NO. 1, (292-298), Online publication date: 1-Jul-2009. Volume 168Issue 4 Part 2October 2002Page: 1798-1800 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordshydronephrosis, kidney, ureteral obstructionbladder, transforming growth factor betaMetricsAuthor Information M.T. El-Sherbiny More articles by this author O.M. Mousa More articles by this author A.A. Shokeir More articles by this author M.A. Ghoneim More articles by this author Expand All Advertisement PDF downloadLoading ...

Vesicoureteral Reflux and Clinical Outcomes in Infants With Prenatally Detected Hydronephrosis

No AccessJournal of UrologyReflux1 Oct 2002Vesicoureteral Reflux and Clinical Outcomes in Infants With Prenatally Detected Hydronephrosis M. Michele Brophy, Paul F. Austin, Yan Yan, and Douglas E. Coplen M. Michele BrophyM. Michele Brophy More articles by this author , Paul F. AustinPaul F. Austin More articles by this author , Yan YanYan Yan More articles by this author , and Douglas E. CoplenDouglas E. Coplen More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64396-0AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluate the incidence of vesicoureteral reflux and urinary tract infections in infants with prenatally detected hydronephrosis. Materials and Methods: We retrospectively reviewed the charts of children referred to our hospital for evaluation of prenatally detected hydronephrosis between 1992 and 1998. Measured variables included ultrasound and voiding cystourethrogram findings, and infectious and clinical reflux outcomes. Results: Vesicoureteral reflux was identified in 40 of 234 infants (21%), including 24% of males and 13% of females. A significant correlation was found between the degree of hydronephrosis and incidence of reflux. Urinary tract infections were uncommon and identified in 7.5% of children on prevention for reflux and 4% with normal voiding cystourethrogram. In the majority (58%) of cases reflux resolved with medical management. Conclusions: The incidence of reflux increases with greater degrees of sonographic dilatation but a normal ultrasound does not exclude reflux and, therefore, voiding cystourethrogram is recommended in all children with prenatally detected hydronephrosis. Since urinary tract infections are uncommon with prevention, antibiotics should be continued until reflux resolves and/or hydronephrosis significantly improves. References 1 : Can careful ultrasound examination of the urinary tract exclude vesicoureteric reflux in the neonate?. Br J Radiol1997; 70: 977. Google Scholar 2 : Pyelectasis and hydronephrosis in the newborn and infant. Acta Paediatr2000; 89: 900. Google Scholar 3 : The role of micturating cystourethrography in antenatally detected mild hydronephrosis. Pediatr Radiol1998; 28: 152. Google Scholar 4 Jaswon M.S. Dibble L. Puri S. Prospective study of outcome in antenatally diagnosed renal pelvis dilatation. Arch Dis Child Fetal Neonatal Ed, 80: F135, 1999 Google Scholar 5 : Outcome of primary vesicoureteric reflux detected following fetal renal pelvic dilatation. J Paediatr Child Health2000; 36: 569. Google Scholar 6 : Perception of fear, distress and pain by parents of children undergoing a micturating cystourethrogram: a prospective study. J Paediatr Child Health2001; 37: 271. Google Scholar 7 : Vesicoureteral reflux in infants with prenatal hydronephrosis confirmed at birth: racial differences. J Urol1999; 161: 248. Link, Google Scholar 8 : Does every patient with prenatal hydronephrosis need voiding cystourethrography?. J Urol1999; 162: 1218. Link, Google Scholar 9 : Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol1993; 23: 478. Google Scholar 10 : Sibling reflux: a dual center retrospective study. J Urol1996; 156: 677. Link, Google Scholar 11 : The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis. J Urol2000; 164: 1057. Link, Google Scholar 12 : A multicenter outcomes analysis of patients with neonatal reflux presenting with prenatal hydronephrosis. J Urol1999; 162: 1203. Link, Google Scholar 13 : Complications of voiding cystourethrography in the evaluation of infants with prenatally detected hydronephrosis. J Urol1999; 162: 1221. Link, Google Scholar 14 : Re: Vesicoureteral reflux in infants with prenatal hydronephrosis confirmed at birth: racial differences. J Urol1999; 162: 1705. Link, Google Scholar 15 : A high multiethnic incidence of reflux in the screening of antenatal hydronephrosis. J Urol, suppl.2000; 163: 67. abstract 293. Google Scholar From the Division of Pediatric Urology, St. Louis Children’s Hospital and Washington University School of Medicine, St. Louis, Missouri© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 168Issue 4 Part 2October 2002Page: 1716-1719 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsurinary tract infectionshydronephrosis, vesico-ureteral refluxprenatal diagnosisMetricsAuthor Information M. Michele Brophy More articles by this author Paul F. Austin More articles by this author Yan Yan More articles by this author Douglas E. Coplen More articles by this author Expand All Advertisement PDF DownloadLoading ...

REDUCED NUMBER OF GLOMERULI IN KIDNEYS WITH NEONATALLY INDUCED PARTIAL URETEROPELVIC OBSTRUCTION IN PIGS

We quantify the structural components of the nephron in adult pig kidneys with neonatally induced unilateral hydronephrosis in comparison with nonobstructed kidneys. The study included 11 pigs with unilateral partial ureteropelvic obstruction induced 2 days after birth and 8 sham operated control pigs. Obstructed kidney glomerular filtration rate was significantly reduced at age 4 weeks but did not differ from control kidneys after 24 weeks. At age 24 weeks the kidneys were perfusion fixed, and the number and volume of glomeruli and tubular lengths were measured using stereological methods. Mean obstructed kidney volume did not differ from that of control kidneys. Mean number plus or minus standard deviation of glomeruli in the obstructed kidneys was reduced by 28% compared to that of control kidneys (502 +/- 163 x 103 versus 697 +/- 161 x 103, p = 0.02), whereas no difference in mean glomerular volume was observed. Mean length of the proximal or distal tubules did not differ between obstructed and control kidneys. Mean number or volume of glomeruli in nonobstructed kidneys contralateral to obstructed kidneys did not differ from that of control kidneys. The individual number of glomeruli in the obstructed kidneys was not associated with function of these kidneys. Neonatally induced unilateral partial ureteropelvic obstruction causes impaired nephrogenesis with a significant reduction in the number of nephrons, which is not reflected in measurements of kidney function in this model. The reduction in the number of glomeruli suggests that congenital unilateral obstruction impairs nephrogenesis.