Vesicoureteral reflux in infants with isolated antenatal hydronephrosis

Standardized evaluation of all newborns with antenatally recognized hydronephrosis (ANH) at The Hospital for Sick Children (HSC) has included voiding cystourethrography (VCUG). This paper reviews this protocol to determine: (1) the prevalence of vesicoureteral reflux (VUR) in isolated ANH and (2) the value of performing VCUG in cases of mild hydronephrosis, defined as renal pelvis dilatation <10 mm on postnatal ultrasonography (US). A retrospective chart review was performed on infants referred with ANH. The inclusion criterion was isolated ANH. Exclusion criteria were (1) presence of additional genitourinary abnormalities and (2) no VCUG. Pelviectasis was categorized according to the anteroposterior diameter of the renal pelvis. There were 111 infants with isolated ANH. All except 3 underwent VCUG. There were 68 children (63%) with normal postnatal US or mild pelviectasis (<10 mm). VUR was detected in 16 patients, of whom 10 had mild or absent pelvic dilatation. There was no correlation between the degree of pelviectasis on postnatal US and the presence or severity of VUR (P=0.567 and P=0.802). VUR was detected in 15% of children with isolated ANH, many of whom had normal postnatal US or mild postnatal pelviectasis. VCUG is the only reliable test for detecting postnatal VUR.     

Postnatal assessment of growth,nutrition, and urinary tract infections of infants with antenatally detected hydronephrosis

The widespread utilization of prenatal ultrasonography and the detection of antenatal hydronephrosis (AH) have raised the importance of postnatal follow-up of these infants. In this study, we aimed to determine the importance of an early diagnosis for the treatment of urinary tract malformations (UTM) as well as the postnatal evaluation of growth and nutrition status and the frequency of urinary tract infection (UTI) in infants with AH. We evaluated 246 infants (183 boys, 63 girls) whose routine antenatal scans showed an anterior-posterior pelvic diameter (APPD) ≥5 mm. Of the 246 patients, 175 (71.1%) were found to be pathological and 71 were evaluated as normal after the follow-up period. The median follow-up periods of normal and abnormal cases were 45.7 and 43.4 months, respectively. All cases with or without UTM were evaluated in terms of UTI, scars on DMSA, growth [Height Z score (HZ), Weight Z score (WZ)] and nutrition [Weight height index (WHI)] status. The annual UTI frequency was higher in cases with UTM (1.32 ± 1.66 episode/year) than in cases without abnormality (0.27 ± 0.67 episode/year) (P < 0.001). The postnatal evaluation of growth and nutritional status in children with UTM (mean WHI, HZ, and WZ scores: 96.82 ± 10.21, 0.03 ± 0.54 and 0.04 ± 0.61, respectively) was found to be significantly worse than in cases without abnormality (102.25 ± 9.84, 0.14 ± 0.64 and 0.24 ± 0.76, respectively), (P < 0.05). In abnormal patients, the mean WHI, HZ, and WZ were significantly improved to 101.63 ± 9.75, 0.26 ± 1.07, and 0.28 ± 0.98, respectively, and HZ or WZ scores were found to be similar when compared to normals. In conclusion, postnatal early management of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.     

Natural history and long-term follow-up of antenatally detected liver cysts

Background/Purpose

Antenatally detected liver cysts are rare; their diagnostic accuracy is unknown, and their management is controversial. This study assessed the natural history of these lesions.

Methods

We conducted a retrospective review of infants with isolated intrahepatic cysts that were detected antenatally. Data are expressed as median (range).

Results

Fifteen infants presented during the period 1991-2004 with an antenatally detected liver cyst. Their gestational age at detection was 22 (18-34) weeks, and the maximum diameter of their cyst was 23 (10-120) mm. Serial scans, which were performed in 9 fetuses, showed cyst enlargement in 5 cases, diminution in 1 case, and no change in 3 cases. In utero percutaneous aspiration was required in 1 infant. Three infants underwent postnatal surgery. One fetus (postfetal intervention) had a subtotal excision of a large subcapsular cyst filling the abdominal cavity on day 2. Another infant required partial excision and marsupialization (complex cyst arising from segment IV) at 5 months, and a third infant underwent a cyst cholecystostomy at 4 months. Postnatal investigations (including hepatic scintigraphy) suggested that the remaining lesions were either simple parenchymal (n = 10) or isolated intrahepatic choledochal (ie, type V; n = 2) cysts. The median follow-up for these patients was 44 (27-167) months. Serial postnatal ultrasonography showed cyst diminution in 4 cases, an enlargement in 1 case, and no dimensional change in 7 cases.

Conclusions

Most antenatally detected liver cysts appear to be simple and of parenchymal origin and do not require fetal intervention. Their postnatal history is variable, but regression without treatment is seen in most cases.     

Delayed decrease in differential renal function after successful pyeloplasty in children with unilateral antenatally detected hydronephrosis

AIM: The aim of this study was to evaluate functional outcome of congenital hydronephrotic kidney. METHODS: The records of consecutive children who underwent pyeloplasty for unilateral prenatally detected ureteropelvic junction obstruction were reviewed. Renal function was assessed renographically before and after surgery. Mean follow-up period was 100 months. RESULTS: Sufficient pre- and postoperative data were available for 60 children. Differential renal function (DRF) improved in 14 (23%) and decreased in nine (15%) of 60 patients in the early postoperative period. DRF improved in seven (18%) and decreased in 13 (34%) of 38 patients at the end of follow-up. Five of 14 patients with increased DRF at early postoperative scan returned to the preoperative level at the end of follow-up. No patients with decreased DRF at early postoperative scan showed any recovery in DRF and progressive decrease was seen in four of nine children. CONCLUSIONS: The DRF was not stable in some patients after successful pyeloplasty. In some patients impairment of renal function came to be apparent with time. Improvement of DRF may be a transient phenomenon seen in the early postoperative period. To avoid overestimation of functional recovery, long-term follow-up with delayed renographic evaluation is recommended.     

Definitive surgical management of antenatally diagnosed exomphalos

Background/Purpose

The management of exomphalos is controversial with many centers in the United Kingdom and elsewhere advocating a conservative nonsurgical approach for the larger examples. Nevertheless, this approach is not without problems or complication. The aim of the study was to ascertain the outcome of all infants with an antenatally diagnosed exomphalos treated recently at our institution using a policy of aggressive abdominal wall closure.

Methods

This is a retrospective review of all infants with exomphalos treated from January 1995 to September 2002.

Results

There were 35 infants, all of whom underwent surgery. These were separated into 3 groups: group A (all exomphalos minor) underwent primary closure (n = 11), group B (exomphalos major) underwent primary closure (n = 13), and group C (exomphalos major) underwent staged closure involving a silo (n = 11). Infants in group C had a lower birth weight (P = .05) and were less mature (P = .06). They required longer periods of ventilation (P < .001), a longer hospital stay (P = .001), and a longer period to achieve full enteral feeds (P < .001). Overall survival was 34 (97%) of 35 infants. One premature infant who was born with a ruptured exomphalos sac (birth weight, 862 g) died of nonsurgical complications (sepsis and respiratory failure) early after the creation of a silo.

Conclusions

An aggressive surgical approach in infants with exomphalos is a safe option resulting in effective abdominal wall closure. This requires a skilled multidisciplinary approach and possibly greater resources than other options.     

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

PURPOSE: We determine the outcome of severe bilateral primary ureteropelvic junction type hydronephrosis detected prenatally and managed postnatally with an initially nonoperative protocol. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Current management of infants with fetal renal pelvis dilation: a survey by French-speaking pediatric nephrologists and urologists

To analyze the current management recommendations among French-speaking physicians treating infants with antenatal renal pelvis dilatation, we surveyed 83 pediatric nephrologists and 68 pediatric urologists by questionnaire. A total of 45 (54%) pediatric nephrologists and 38 (56%) pediatric urologists responded. The threshold for the diagnosis of abnormal fetal renal pelvis dilatation was significantly higher among pediatric urologists than nephrologists. All responders perform renal ultrasound examinations after birth. Postnatal renal pelvis dilatation was considered abnormal if the anteroposterior diameter was 11±1.9 mm by the pediatric urologists and 9±2.9 mm by the pediatric nephrologists (P=0.003). Pediatric urologists were more likely than nephrologists to recommend routine voiding cystourethrography [41% versus 20% (P=0.04)]. Mercaptoacetyl-triglycine renography was the most routinely used tool to achieve functional evaluation during follow-up among the responders. Pediatric urologists were more likely to recommend surgical treatment in dilated kidneys with initial function <40%. In conclusion, pediatric urologists had significantly higher thresholds for the detection of prenatal and neonatal renal pelvis dilatation. They also more frequently recommended routine voiding cystourethrography and surgical therapy of dilated kidneys with low function than pediatric nephrologists. The variability in attitudes is most probably due to the absence of clear guidelines based on prospective and controlled trials.The following workers contributed to this study. For the French-speaking Society of Pediatric Nephrology (SNP): J. Al Hosri (Hôpital Nord, Amiens, France), J.L. André (Hôpital dEnfants, Nancy, France), A. Bensman (Hôpital Trousseau, Paris, France), E. Berard (LArchet II, Nice, France), J.P. Bertheleme (Centre Hélio Marin, Roscoff, France), F. Bouissou (Hôpital des Enfants, Toulouse, France), G. Bourdat-Michel (CHU, Grenoble, France), G. Champion (CHU, Angers, France), S. Cloarec (Hôpital Clocheville, Tours, France), L. Collard (Hôpital E. Herriot, Lyon, France), J.C. Davin (Emma Childrens Hospital, Amsterdam, Holland), L. de Parscau (Hôpital Augustin Morvan, Brest, France), S. Decramer (Hôpital des Enfants, Toulouse, France), V. Desvignes (CH, Clermont Ferrand, France), R. Donckerwolcke (AZ, Maastricht, Holland), J. Ehrich (MHH, Hannover, Germany), M. Fischbach (Hôpital de Hautepierre, Strasbourg, France), M. Foulard (Hôpital Jeanne de Flandre, Lille, France), M.S. Ghuysen (CHU Sart Tilman, Liège, Belgium), J.B. Gouyon (Hôpital dEnfants, Dijon, France), J.P. Guignard (CHUV, Lausanne, Switzerland), C. Guyot (CHU, Nantes, France), P. Hansen (Hôpital Tivoli, La Louvière, Belgium), J.P. Hehunstre (Hôpital Pellegrin, Bordeaux, France), F. Janssen (Hôpital Universitaire des Enfants, Brussels, Belgium), M.J. Krier (Hôpital dEnfants, Nancy, France), A. Lahoche-Manucci (Hôpital Jeanne de Flandre, Lille, France), H. La Selve (Centre Hélio Marin, Roscoff, France), M.P. Lavocat (Hôpital Nord, Saint Etienne, France), C. Loirat (Hôpital Robert Debré, Paris, France), J. Lombet (CHR La Citadelle, Liège, Belgium), A. May (CH Sud Francilien, Evry, France), D. Morin (Hôpital Arnaud de Villeneuve, Montpellier, France), J.B. Palcoux (Hôtel Dieu, Clermont Ferrand, France), S. Palomera (CTMR, Bordeaux, France), C. Pietrement (American Memorial Hospital, Reims, France), S. Ploos van Amstel (Emma Childrens Hospital, Amsterdam, Holland), W. Proesmans (UZ Gasthuisberg, Leuven, Belgium), N. Ranguelov (CHU, Charleroi, Belgium), B. Roussel (American Memorial Hospital, Reims, France), M.H. Said (Hôpital E. Herriot, Lyon, France), A. Taque (Hôpital de Pontchaillou, Rennes, France), M. Tsimaratos (Hôpital La Timone, Marseille, France). R. Van Damme-Lombaerts (UZ Gasthuisberg, Leuven, Belgium)For the French-speaking Pediatric Urology Study Group (GEUP): T. Aivazoglou (Aglaia Kyriakou Hospital, Athens, Greece), J.L. Alain (CHU Dupuytren, Limoges, France), P. Alessandrini (Hôpital Nord, Marseille, France), G. Audry (Hôpital Trousseau, Paris, France), M. Avérous (Hôpital Lapeyronie, Montpellier, France), R. Besson (Hôpital Jeanne de Flandre, Lille, France), J. Biserte (Hôpital Huriez, Lille, France), B. Boillot (CHU Albert Michallon, Grenoble, France), J.M. Bondonny (Hôpital des Enfants, Bordeaux, France), J.P. Bonnet (Hôpital Simone Veil, Montmorency, France), P. Bugmann (Hôpital des Enfants, Geneva, Switzerland), F. Collier (Hôpital Universitaire des Enfants, Brussels, Belgium), J.F. Colombani (CHU, Fort-de-France, France), H. Dodat (Hôpital E. Herriot, Lyon, France), B. Dore (CHU, Poitiers, France), A. El Ghoneimi (Hôpital R. Debré, Paris, France), C. Esposito (Universitary Hospital, Naples, Italy), B. Fremond (Clinique Chirurgicale infantile, Rennes, France), P. Frey (CHUV, Lausanne, Switzerland), S. Geiss (Centre de la Mère et lEnfant, Colmar, France), I. Germouty (CHU, Brest, France), Y. Heloury (CHU, Nantes, France), A. Lacombe (Hôpital Clocheville, Tours, France), S. Lortat-Jacob (Hôpital Necker-Enfants Malades, Paris, France), T. Merrot (Hôpital Nord, Marseille, France), R. Moog (Hôpital de Hautepierre, Strasbourg, France), G. Morisson-Lacombe (Hôpital Saint Joseph, Marseille, France), J. Moscovici (Hôpital des Enfants, Toulouse, France), P. Mouriquand (Hôpital Debrousse, Lyon, France), E. Sapin (CHU, Dijon, France), A. Savanelli (Universitary Hospital, Catanzaro, Italy), M. Schmitt (Hôpital dEnfants, Nancy, France), H. Steyaert (Fondation Lenval, Nice, France), C. Tölg (CHU, Fort-de-France, France), J.S. Valla (Fondation Lenval, Nice, France), F. Varlet (Hôpital Nord, Saint Etienne, France), P. Wallon (Centre de Chirurgie de lEnfant, Bordeaux, France), D. Weil (Centre Hospitalier, Le Mans, France)     

Renal Doppler ultrasonography in infants with hydronephrosis

The objective was to evaluate the importance of obstruction in unilateral hydronephrosis by using renal Doppler ultrasonography. A total of 19 infants were examined. It was revealed that patients of group withobstruction have in the affected kidney a higher mean resistive index [RI= 0.77 ± 0.04] than in the healthy kidney [RI = 0.69 ± 0.02] [p < 0.001]. In patients of group with nonobstructive dilatation this difference was not observed. In infants it is not possible to evaluate only absolute changes of the resistive index. It is much more useful to compare values of RI of both kidneys using the above indices. The determination of RI, RIR and delta RI can be helpful in distinguishing obstructed from non-obstructed hydronephrosis.     

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.     

The effect of circumcision on the frequency of urinary tract infection,growth and nutrition status in infants with antenatal hydronephrosis

Abstract

The objective of this study was to determine the effect of circumcision on the frequency of urinary tract infection (UTI), growth development, and the nutrition status in infants with antenatal hydronephrosis (AH). The data were collected prospectively between 1998 and 2010. Infants with a fetal pelvis diameter of >5?mm identified with antenatal ultrasound were followed-up. Body height and weight were expressed as HZ scores (observed height???median height/standard deviation) and WZ scores (observed weight???median weight/Standard deviation). The nutritional status was evaluated and the body weight was transformed to a weight-for-height index (WHI?=?weight/median weight for the height age?×?100). The HZ and WZ scores or WHI were calculated for each patient at the first and last visits. The chi-square and Student’s t tests were used for statistical analysis. A p value <0.05 was considered significant. The study included 178 (134 males, 44 females) patients. Of these, 29 were diagnosed by vesicoureteral reflux (VUR), 87 by obstructive uropathy, and 54 by normal. Of 134 males, 111 infants were circumcised. The mean monitoring time was 45±24.9 months and the mean age of circumcision was 14?±?16.06 months. The pre-circumcision UTI frequency (2.97?±?1.14/y) was significantly higher than post-circumcision period (0.25?±?0.67/y) (p?<?0.05). Also, pre-circumcision UTI frequency (2.97?±?1.14/y) was significantly higher than the UTI frequency observed in female cases (0.85?±?0.91/y) and in the overall study group (0.73?±?0.79/y) (p?<?0.05). In all patients, the HZ of the circumcised subjects (0.18?±?1.01) was statistically higher than uncircumcised subjects (?0.26?±?0.92) (p?<?0.05). Although statistically insignificant, the HZ of the circumcised males (0.13?±?1.24) with VUR was higher than the uncircumcised patients (0.03?±?0.55) (p?>?0.05). In obstructive uropathy groups, the HZ of the circumcised males (?0.13?±?0.54) was also found to be higher than uncircumcised males (?0.49?±?0.66) (p?<?0.05). Although nutrition scores were found to be better in circumcised males, no statistically significant effect of circumcision on the nutrition status was detected. In conclusion, postnatal early circumcision of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.     

Antenatally detected urinary tract abnormalities: more detection but less action

We present the findings of a prospective cohort study of babies born with antenatally detected urinary tract abnormalities (AUTAs) between 1999–2003 and compare the outcomes with those of an earlier cohort born between 1989 and 1993. All infants with a fetal anteroposterior renal pelvic diameter (APRPD) ≥7 mm in the third trimester or other urinary tract abnormality underwent a detailed postnatal ultrasound scan and other investigations as indicated. The incidence of AUTAs was significantly greater in the more recent cohort (7.6/1000 vs. 3/1000 live births; p < 0.05). Of the 350 infants on which we had data, 48.6% (170/350) were in the non-specific dilatation (NSD) category, and vesicoureteric reflux (VUR) was detected in 12%. Restricting investigations to those who had an APRPD ≥10 mm at >30 weeks of gestation could have reduced the number with NSD in the more recent cohort (26/115; 25%), but 25% of those with pelviureteric junction hold-up and 50% with VUR would have been missed. Significantly fewer patients in the more recent cohort underwent surgery (7 vs. 21%; p < 0.001). There is a trend towards larger APRPDs on third trimester scans being associated with more significant pathology, but there is a lot of clinical overlap. The study highlights the need for cautious antenatal counselling combined with an assurance to prospective parents that postnatal investigations will be performed in a stepwise manner based on the initial postnatal ultrasound scan and clinical findings.     

Outcome of isolated antenatal hydronephrosis: a prospective cohort study

The purpose of this study was to report the outcome of infants with antenatal hydronephrosis. Between May 1999 and June 2006, all patients diagnosed with isolated fetal renal pelvic dilatation (RPD) were prospectively followed. The events of interest were: presence of uropathy, need for surgical intervention, RPD resolution, urinary tract infection (UTI), and hypertension. RPD was classified as mild (5-9.9 mm), moderate (10-14.9 mm) or severe (>or=15 mm). A total of 192 patients was included in the analysis; 114 were assigned to the group of non-significant findings (59.4%) and 78 to the group of significant uropathy (40.6%). Of 89 patients with mild dilatation, 16 (18%) presented uropathy. Median follow-up time was 24 months. Twenty-seven patients (15%) required surgical intervention. During follow-up, UTI occurred in 27 (14%) children. Of 89 patients with mild dilatation, seven (7.8%) presented UTI during follow-up. Renal function, blood pressure, and somatic growth were within normal range at last visit. The majority of patients with mild fetal RPD have no significant findings during infancy. Nevertheless, our prospective study has shown that 18% of these patients presented uropathy and 7.8% had UTI during a medium-term follow-up time. Our findings suggested that, in contrast to patients with moderate/severe RPD, infants with mild RPD do not require invasive diagnostic procedures but need strict clinical surveillance for UTI and progression of RPD.     

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.     

Outcome of patients with antenatally detected pelviureteric junction obstruction

We investigated the outcome of patients with antenatally detected pelviureteric junction (PUJ) obstruction treated either conservatively or surgically. The series comprised 68 such patients, 54 with unilateral obstruction. Of the unilateral cases, 22 units were treated conservatively, 21 underwent early and 11 late surgery. Of the bilateral cases, 18 units were treated conservatively, 9 underwent early pyeloplasty, whereas 1 underwent later surgery. Among the conservatively treated unilateral cases, none of the patients good renal function deteriorated during follow-up. In the group with early surgery, the primary good function remained unchanged in all. In some patients, moderate function improved after early pyeloplasty, but in patients with poor function no improvement occurred. Of patients who underwent late pyeloplasty, primary good renal function remained unchanged in all except 1, although it had deteriorated to moderate function in some before surgery. In all except 1 patient with bilateral obstruction treated conservatively, both the grade of hydronephrosis and split function remained unchanged. In most patients the outcome of antenatally detected unilateral PUJ obstruction with initially good renal function, whether treated conservatively or surgically, seems favorable. Some patients with moderate function might benefit from pyeloplasty. In kidneys with poor function, recovery may be minimal despite pyeloplasty.     

Current outcome of antenatally diagnosed exomphalos: an 11 year review

Purpose

The aim of this study was to determine the outcome of antenatally diagnosed exomphalos.

Methods

The database of a tertiary referral Fetal Medicine Centre was searched for all cases of antenatally diagnosed exomphalos between January 1991 and December 2002. Patients, general practitioners, and hospitals were contacted for outcome details.

Results

In total, 445 cases of exomphalos were identified. In 250 (56%) cases, the fetal karyotype was abnormal (group A), in 135 (30%) cases, the karyotype was normal (group B), and in 60 (14%) cases, karyotyping was declined (group C). In group A, there were 248 (99%) terminations of pregnancy (TOP) or fetal deaths and 2 live births. In group B, 74 (54%) fetuses had other structural anomalies; 82 (61%) pregnancies resulted in TOP or fetal death, 42 (31%) in live births, and 11 (8%) were lost to follow-up. In group C, 38 (63%) fetuses had other structural anomalies; 41 (69%) pregnancies resulted in TOP or fetal death, 11 (18%) in live births, and 8 (13%) were lost to follow-up. Of the 55 live births, 11 died preoperatively and 44 had surgery. There were no postoperative deaths.

Conclusions

Less than 10% of the antenatal diagnostic workload reached operative repair. In our unit, these babies are a highly selected group, which is a factor in the high postoperative survival.     

Natural history of neonatal reflux associated with prenatal hydronephrosis: long-term results of a prospective study

PURPOSE: We have previously reported on patients with neonatal vesicoureteral reflux followed conservatively. The current study is a long-term followup of our prospective expectant management protocol for the overall cohort. MATERIALS AND METHODS: Between 1993 and 1998, 31 of 260 patients with prenatal hydronephrosis had vesicoureteral reflux and were followed prospectively. Outcome analysis was done on 25 patients, excluding 6 who underwent surgery, with the end point of complete resolution or improvement of reflux using our previously reported Kaplan-Meier survival curve, urinary tract infection, dysfunctional voiding, and changes in renal function or growth, somatic growth and hypertension. RESULTS: Of the 25 cases reflux was grades I to V in 7%, 20%, 34%, 16% and 23%, respectively. Reflux resolved in 13 patients (52%) and improved in 6 (24%). Grades I to V disease resolved in 100%, 77%, 53%, 28% and 40% of refluxing units, respectively. The improvement rate for grades III to V reflux was 13%, 14% and 30%, respectively. Breakthrough urinary tract infection occurred in 4 patients with grades IV and V reflux, and dysfunctional voiding developed in 5. Followup renal scans showed 19% and 17% decreased differential function in 2 units without new scars. There was no difference in renal length in patients with resolved versus persistent reflux or low versus high grade reflux. All patients had normal somatic growth at the 4-year followup and none had hypertension. CONCLUSIONS: Expectant management was effective in the majority of cases and associated with a low urinary tract infection rate. Neonatal vesicoureteral reflux resolved or improved in 76% of our patients by age 4 years without somatic growth retardation or hypertension. High grade reflux resolved or improved in 59% of the units and showed normal renal growth with expectant management.     

Neonatal hydronephrosis—the controversy and the management

Neonatal hydronephrosis is being detected with increasing frequency. The majority of these cases have a tendency to resolve during infancy. Hydronephrosis is an anatomical entity that is not synonymous with obstruction. Review of the pathoembryology, the pathophysiology, the diagnostic techniques currently used and the natural history of hydronephrosis is given. The management and the controversies involved are discussed.