Hydronephrosis in Child Treatment Delhi: Expert Pediatric Care

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Antenatal Hydronephrosis(ANH) Surgical Aspects
Dr Prashant Jain Sr. Consultant Pediatric Surgery
Pediatric Urology Dr BLK Superspeciality
Hospital, New Delhi
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Antenatal Hydronephrosis

• Renal anomalies accounts for 17 of all the
  congenital anomalies
• Hydronephrosis is commonest (1-5 of all
  pregnancies)
• Management dilemma

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ANTENATAL HYDRONEPHROSIS
DILATATION OF FETAL RENAL COLLECTING SYSTEM
Transient dilatation (41 to 88)
Vesico-ureteric reflux (10 -20)
True Obstruction (20 -50)
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What is True Obstruction???

• Anatomical or Functional impairment in urinary
  drainage from kidney which ultimately is going to
• affect the renal function

Impairment in Urinary drainage
Dilatation
Impairment of renal functions
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True obstruction



e
Pelvi Ureteric Junction
Uretero-vesical Junction
Bladder outlet Posterior Urethral Valv
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Why diagnostic Dilemma?

• Transient impairment of urinary flow
• Permanent impairment of urinary flow

IMPORTANT TO DIFFERENTIATE
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Evaluation Of ANH

• Ultrasound
• Micturiting Cystourethrogram
• Nuclear renal scan
• DRCG
• DMSA
• DTPA
• Magnetic Resonance Urography (MRU)

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Antero-Posterior Diameter of Renal Pelvis
(Transverse plane)
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Definition of ANH by AP(Antero-Posterior)
Diameter of Renal Pelvis
Second trimester Third trimester
Mild 4 to lt7 mm 7 to lt9 mm
Moderate 7 to 10 mm 9 to 15 mm
Severe gt10 mm gt15 mm
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Case Antenatal hydronephrosis

• Antenatal scan- 32 wks
• Lt hydronephrosis with dilated pelvicalyceal
  system No hydroureter
• Antero-posterior(AP) diameter of Lt renal pelvis
  13 mm
• AFI 9
• What Next??

13mm
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Counseling is Challenge..

• Is it a transient dilatation or pathological
  dilatation?
• What is accurate diagnostic tool?
• How to prognosticate?
• How long to follow?
• When to operate?

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Risk Of Postnatal Pathology

• Mild 11.8
• Moderate44.1
• Severe 88.3

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• Moderate hydronephrosis (Resolution 40- 50)
• CAN NOT BE IGNORED
• Re-assessment after delivery
• Will require regular follow up with USG and renal
  scans
• Continue pregnancy till term

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Post natal

• Newborn passing urine
• Bladder not palpable
• What Next?
• USG KUB after 48-72hrs
• AP Diam 14mm

What Next?

• Chemoprophylaxis
• USG DTPA Scan after 1 month of age

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ANTENATAL HYDRONEPHROSIS
Post Natal USG at 48 -72 hrs
Hydro-ureteronephrosis present
No hydronephrosis
Hydronephrosis present
Chemoprophylaxis Early MCU
Mild
Moderate/severe
Repeat USG at 3 months
USG at 3, 6, 12 mths
Chemoprophylaxis ??MCU DTPA Scan
No hydronephrosis No further evaluation
B/L HN, BLADDER OUTLET OBSTRUCTION, AND SINGLE
KIDNEY NEEDS EARLY EVALUATION
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Consider Surgery

• Split function is lt 40
• Progressive increase in AP diameter
• Symptomatic

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RK AP DIAMETER RK AP DIAMETER RK AP DIAMETER RK AP DIAMETER LK AP DIAMETER
ANTENATAL - - - - 14 MM
DAY3 - - - - 14 MM
1MTH - - - - 18 MM
1MTH DTPA scan 18 MM
3MTH - - - - 18 MM
6MTH 19
12MTH 19
12MTH 19
Advised DTPA scan Advised DTPA scan Advised DTPA scan
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At 2 months of age
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At 1 year of age
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Pyeloplasty
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Case Antenatal Hydronephrosis
Rt AP of Pelvis diameter of 6 mm
20 wks scan
Rt AP diameter of pelvis 8 mm
28 wks scan
Rt AP diameter of pelvis 7mm
36 wks scan
Before discharge
Rt AP of Pelvis diameter of 8 mm
Rt AP of Pelvis diameter of 8 mm
USG at 1mth
USG at 3mth 1 year
No dilatation
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Antenatal Scan 32 wks

• Bilateral hydronephrosis and hydroureter
• Bilateral AP diameter 7mm
• Bilateral echogenic kidneys
• Bladder full Key hole sign
• AFI 8

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• POSSIBILITIES????

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Antenatal Scan Hydrouretronephrosis

• Vesico-ureteric reflux
• Vesico-ureteric junction obstruction
• Posterior Urethral Valve

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Counseling

• Obstruction at vesico-urethral junction
• Need for surgery(Endoscopic Fulgaration)
• Need for long term follow up
• Risk of ESRD

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Case
37 wks, LSCS, 1.6 kg USG B/L HN HU Thinned out
renal parenchyma Thickened and distended bladder
Catheterised Serum Na 132 Serum K 5.3 S.
Creatinine1.6 VBG Normal Urine C/S sterile
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MCU
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Endoscopic Fulgaration of Valves
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Post Operataive

• Stable
• Polyuria 5ml/kg/hr(Post operative diuresis)
• Catheter removed after 72 hrs
• Polyuria Settled in 7 days
• Discharged with S.Creatinine of 1meq/l
• Chemoprophylaxis
• Anticholinergics (Tropan)

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Follow up

• Intermittent dribbling present
• Urinary Stream good
• DMSA left scarred kidney
• S.Creatinine 0.6
• Dilatation on USG is less, PVR5 ml
• Now 2yrs
• No chemoprophylaxis
• Needs long term follow up
• MCU on follow up

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Fulgaration with resectocope
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Case

• Ante natal USG s/o left moderate hydronephrosis
• Repeat USG, dilatation of upper kidney with
  hydroureter s/o duplex system and ureterocele

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VCUG and MRU
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Ureterocoel Incision
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Repeat USG after 2 wks
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CASE

• Antenatal scan 32 wks
• Left hydronephrosis AP diam of renal pelvis 11mm
• Left ureteric dilatation present
• Right Kidney normal
• Bladder normal

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Post natal

• Term male newborn3kg
• Newborn passing urine
• Bladder not palpable

WHAT NEXT

• Antibiotic prophylaxis
• USG KUB after 48-72hrs
• AP Diam 11mmUreter dilated

WHAT NEXT

• MCU under antibiotic cover

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MCU

• Rt Grade III VUR

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DMSA Scan

• Scarred left kidney

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Follow up Advice

• Chemoprophylaxis
• Early toilet training
• Avoid constipation
• Perineal Hygine
• Growth/BP monitoring
• Regular Urine examination/ultrasounds/DMSA scan

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When to intervene?

• Recurrent breakthrough UTI
• Progressive scars in DMSA SCAN
• Parents choice
• Endoscopic injection Vs Ureteric Reimplantation

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STING technique (Subureteric transurethral
injection)
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Follow Up

• Chemoprophylaxis stopped
• Follow up with nephrologist

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CARRY HOME MESSAGE

• Do not ignore ANH even if it is transient
• Remember AP diameter of pelvis 4/7/10 mm
• Most ANH just need surveillance
• Hydronephrosis is not synonymous with obstruction
• Be positive, supportive, ANH usually have good
  prognosis.

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