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Antenatal Hydronephrosis(ANH):
Surgical Aspects
Dr Prashant Jain Sr. Consultant
Pediatric Surgery & Pediatric Urology
Dr BLK Superspeciality Hospital, New Delhi
Antenatal Hydronephrosis
Renal anomalies accounts for 17% of all the
congenital anomalies
Hydronephrosis is commonest
(1-5% of all pregnancies)
Management dilemma
ANTENATAL HYDRONEPHROSIS DILATATION OF FETAL RENAL COLLECTING SYSTEM
Transient dilatation
(41 to 88%)
Vesico-ureteric reflux
(10 -20%)
True Obstruction
(20 -50%)
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
True obstruction
Pelvi Ureteric Junction
Uretero-vesical Junction
Bladder outlet Posterior Urethral Valve
Why diagnostic Dilemma?
Transient impairment of urinary flow
Permanent impairment of urinary flow
IMPORTANT TO DIFFERENTIATE
Evaluation Of ANH
- Ultrasound
- Micturiting Cystourethrogram
- Nuclear renal scan
* DRCG
* DMSA
* DTPA
- Magnetic Resonance Urography (MRU)
Antero-Posterior Diameter of
Renal Pelvis (Transverse plane)
Definition of ANH by AP(Antero-Posterior) Diameter
of Renal Pelvis
Mild 4 to <7 mm 7 to <9 mm
Moderate 7 to 10 mm 9 to 15 mm
Severe >10 mm >15 mm
Second trimester Third trimester
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
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?
Risk Of Postnatal Pathology
Mild: 11.8%
Moderate:44.1%
Severe: 88.3%
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
Post natal
Newborn passing urine
Bladder not palpable
USG KUB after 48-72hrs
AP Diam: 14mm
What Next?
Chemoprophylaxis
USG & DTPA Scan after 1 month of age
What Next?
ANTENATAL HYDRONEPHROSIS
Post Natal USG at 48 -72 hrs
No hydronephrosis
Repeat USG at 3 months
No hydronephrosis No further evaluation
Hydronephrosis present Hydro-ureteronephrosis present
Chemoprophylaxis Early MCU
Mild Moderate/severe
Chemoprophylaxis ??MCU DTPA Scan
USG at 3, 6, 12 mths
B/L HN, BLADDER OUTLET OBSTRUCTION, AND SINGLE KIDNEY NEEDS EARLY EVALUATION
Consider Surgery
Split function is < 40%
Progressive increase in AP diameter
Symptomatic
RK AP DIAMETER LK AP DIAMETER
ANTENATAL - 14 MM
DAY3 - 14 MM
1MTH - 18 MM
3MTH - 18 MM
6MTH 19
12MTH 19
DTPA scan
Advised DTPA scan
At 2 months of age
At 1 year of age
Pyeloplasty
Case: Antenatal Hydronephrosis
20 wks scan
28 wks scan
36 wks scan
Before discharge
Rt AP of Pelvis diameter of 6
mm
Rt AP diameter of pelvis 8 mm
Rt AP of Pelvis diameter of 8 mm
Rt AP diameter of pelvis 7mm
USG at 1mth Rt AP of Pelvis diameter of 8 mm
USG at 3mth & 1 year No dilatation
Antenatal Scan 32 wks
Bilateral hydronephrosis and hydroureter
Bilateral AP diameter 7mm
Bilateral echogenic kidneys
Bladder full; Key hole sign
AFI 8
• POSSIBILITIES????
Antenatal Scan:
Hydrouretronephrosis
Vesico-ureteric reflux
Vesico-ureteric junction obstruction
Posterior Urethral Valve
Counseling
Obstruction at vesico-urethral junction
Need for surgery(Endoscopic
Fulgaration)
Need for long term follow up
Risk of ESRD
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. Creatinine:1.6
VBG: Normal
Urine C/S: sterile
MCU
Endoscopic Fulgaration of Valves
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)
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
Fulgaration with resectocope
Case
Ante natal USG s/o left moderate hydronephrosis
Repeat USG, dilatation of upper kidney with hydroureter s/o
duplex system and ureterocele
VCUG and MRU
Ureterocoel Incision
Repeat USG after 2 wks
CASE
Antenatal scan 32 wks
Left hydronephrosis AP diam of renal pelvis
11mm
Left ureteric dilatation present
Right Kidney normal
Bladder normal
Post natal
Term male newborn;3kg
Newborn passing urine
Bladder not palpable
Antibiotic prophylaxis
USG KUB after 48-72hrs
AP Diam: 11mm;Ureter dilated
MCU under antibiotic cover
WHAT NEXT
WHAT NEXT
MCU
• Rt Grade III VUR
DMSA Scan
• Scarred left kidney
Follow up Advice
Chemoprophylaxis
Early toilet training
Avoid constipation
Perineal Hygine
Growth/BP monitoring
Regular Urine
examination/ultrasounds/DMSA scan
When to intervene?
Recurrent breakthrough UTI
Progressive scars in DMSA SCAN
Parents choice
Endoscopic injection Vs Ureteric
Reimplantation
STING technique (Subureteric transurethral injection)
43
Follow Up
Chemoprophylaxis stopped
Follow up with nephrologist
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.