Hydronephrosis: prenatal and postnatal evaluation and management

The potential causal relationship between BMI, T1D, urolithiasis, and hydronephrosis in European ancestry: A Mendelian randomization analysis

Body mass index (BMI), type 1 diabetes (T1D), urolithiasis, and hydronephrosis are interrelated. Our aim was to analyze their causal relationships at the genetic level. Mendelian randomization is an instrumental variable analysis method that follows Mendel genetic law of random allocation of parental alleles to offspring. In observational studies, genetic variants are used as instrumental variables to infer causal relationships between exposure factors and study outcomes. All the genome-wide association study data in our study were publicly available and from published genome-wide association studies, UK Biobank, and FinnGen. Random-effects inverse variance weighted was the primary analysis method, with R Egger, weighted median, and weighted mode as supplementary methods. We examined heterogeneity, horizontal pleiotropy, and the influence of individual single nucleotide polymorphisms on the analysis. We further explored the causal relationships between BMI, T1D, urolithiasis, and hydronephrosis, as well as the robustness of the analysis results. Inverse variance weighted results showed genetic causal relationships between BMI (P = .034, odds ratio [OR] 95% confidence interval [CI] = 1.273 [1.019-1.589]), T1D (P = .028, OR 95% CI = 0.921 [0.855-0.991]), urolithiasis (P < .001, OR 95% CI = 1.361 [1.175-1.576]), and hydronephrosis. Sensitivity analyses confirmed the accuracy and robustness of these findings. Our results support significant causal roles of BMI, T1D, and urolithiasis in hydronephrosis, potentially offering new intervention strategies for preventing its development.

Application of different CO2 pneumoperitoneum pressure in laparoscopic pyeloplasty for infants with ureteropelvic junction obstruction

Background

Laparoscopic pyeloplasty is a minimally invasive approach for the therapy of infant ureteropelvic junction obstruction (UPJO), reliant on CO2 pneumoperitoneum insufflation. While the impact of CO2 insufflation on adult and older pediatric populations has been studied, its effects on infants remain less explored.

Methods

This prospective randomized controlled trial included infants with UPJO undergoing laparoscopic pyeloplasty. Patients were allocated to low pneumoperitoneum pressure (LPP, 5 mmHg) or high pneumoperitoneum pressure (HPP, 8 mmHg) groups. Surgical parameters, postoperative complications, acid-base balance, stress markers, inflammatory cytokines, and oxidative stress markers were evaluated and compared.

Results

A total of 116 infants were analyzed. Preoperative characteristics were comparable between LPP and HPP groups. No significant differences in blood loss, operation time, or hospitalization time were observed. Postoperative complications were similar between groups. Acid-base balance analysis revealed a decrease in pH after pneumoperitoneum in both groups, with greater reductions in actual base excess and standard base excess in the HPP group. Stress markers, cytokines, and oxidative stress markers increased postoperatively in both groups, with higher levels in the HPP group.

Conclusion

HPP leads to more pronounced physiological responses, including acid-base alterations, stress reactions, and inflammatory cytokine elevations.

Long Term Follow-Up Of Patients With Nonrefluxing Hydronephrosis

BACKGOUND

The aim of this study is to examine the long-term prognosis of children with ureteropelvic junction obstruction-like hydronephrosis (UPJO-like HN).

PATIENTS AND METHODS

The files of children with hydronephrosis (HN) were analyzed retrospectively. Patients with vesicoureteral reflux (VUR) and other genitourinary anomalies were excluded. The final status of the HN, the need for surgery, and urinary tract infection (UTI) frequency were evaluated.

RESULTS

The study included 219 patients with 302 renal units (RU) with HN. Surgery rate was higher in RUs with larger kidney size and parenchymal thinning (p:<0.001 for both). Hydronephrosis resolved in 113 (40.2%) RUs, improved in 66 (23.3%), unchanged in 100 (35.5%) and worsened in 4 (1.4%). The frequency of recovery and improvement was found to be less in RUs with severe HN, large kidney size, and thin parenchyma. The UTI frequency was higher in severe HN group (12.2% vs 30.6% p:<0.001).

CONCLUSIONS

Children with mild HN had an excellent prognosis. Although the majority of the patients with high-grade HN had also a good prognosis, it seems important to closely follow up patients with severe HN, increased kidney size, and accompanying parenchymal thinning. Clinicians should be aware of the increased frequency of UTIs in children with severe HN.

Motion-compensated image reconstruction for improved kidney function assessment using dynamic contrast-enhanced MRI

Accurately measuring renal function is crucial for pediatric patients with kidney conditions. Traditional methods have limitations, but dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) provides a safe and efficient approach for detailed anatomical evaluation and renal function assessment. However, motion artifacts during DCE-MRI can degrade image quality and introduce misalignments, leading to unreliable results. This study introduces a motion-compensated reconstruction technique for DCE-MRI data acquired using golden-angle radial sampling. Our proposed method achieves three key objectives: (1) identifying and removing corrupted data (outliers) using a Gaussian process model fitting with a k -space center navigator, (2) efficiently clustering the data into motion phases and performing interphase registration, and (3) utilizing a novel formulation of motion-compensated radial reconstruction. We applied the proposed motion correction (MoCo) method to DCE-MRI data affected by varying degrees of motion, including both respiratory and bulk motion. We compared the outcomes with those obtained from the conventional radial reconstruction. Our evaluation encompassed assessing the quality of images, concentration curves, and tracer kinetic model fitting, and estimating renal function. The proposed MoCo reconstruction improved the temporal signal-to-noise ratio for all subjects, with a 21.8% increase on average, while total variation values of the aorta, right, and left kidney concentration were improved for each subject, with 32.5%, 41.3%, and 42.9% increases on average, respectively. Furthermore, evaluation of tracer kinetic model fitting indicated that the median standard deviation of the estimated filtration rate (σ F T ), mean normalized root-mean-squared error (nRMSE), and chi-square goodness-of-fit of tracer kinetic model fit were decreased from 0.10 to 0.04, 0.27 to 0.24, and, 0.43 to 0.27, respectively. The proposed MoCo technique enabled more reliable renal function assessment and improved image quality for detailed anatomical evaluation in the case of bulk and respiratory motion during the acquisition of DCE-MRI.

Ultrasound and magnetic resonance imaging features of fetal urogenital anomalies: A pictorial essay

This pictorial essay focuses on ultrasound (US) and magnetic resonance imaging (MRI) features of fetal urogenital anomalies. Fetal urogenital malformations account for 30%-50% of all anomalies discovered during pregnancy or at birth. They are usually detected by fetal ultrasound exams. However, when ultrasound data on their characteristics is insufficient, MRI is the best option for detecting other associated anomalies. The prognosis highly depends on their type and whether they are associated with other fetal abnormalities.

Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis

Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.

Giant Bilateral Hydronephrosis in A Newborn-A Case Report

BACKGROUND

Prenatal hydronephrosis is common and may vary in size. Although mostly unproblematic, it may be a sign of urinary tract obstruction of differing severity.

CASE DIAGNOSIS/TREATMENT

We present a boy with prenatally detected bilateral giant hydronephrosis. A prenatal ultrasound showed the whole abdominal cavity of the fetus filled with urine. Kidney parenchyma could not be seen. The boy was born at 34 + 1 weeks' gestation. After delivery, he showed a severely distended abdomen. Insertion of a nasogastric tube was not possible, and he had to be intubated due to respiratory distress. A bilateral percutaneous nephrostomy was performed immediately. After a few hours, he could be stabilized and extubated. An ultrasound on the following day showed two kidney units with normal kidney parenchyma of normal size. The initially slightly elevated serum creatinine level normalized within one week. An antegrade pyelography via the nephrostomy tubes showed bilateral ureteropelvic junction obstruction.

CONCLUSION

Severe bilateral hydronephrosis may be associated with good outcome and well-preserved kidney function. Prenatal counseling should be done carefully, with discussion of different treatment possibilities and without definitive prediction of outcome.

Timing of delivery in antenatal fetal hydronephrosis: a snap shot social media survery of obstetric and fetal medicine practice

OBJECTIVES

To identify when obstetricians would deliver a fetus with antenatal hydronephrosis and normal liquor. Designed as snap-shot survey. Setting: Survey Monkey link. Population/sample were obstetrics and fetal medicine consultants who received the survey link via closed professional forums on the North West Coast Maternity Clinical Network, Facebook, and publicly on Twitter.

METHODS

Survey link publicised as above, obstetric consultants were asked at what gestation would they deliver a fetus with antenatal hydronephrosis and normal liquor; and what criteria would they use to make that decision. Main outcome measures were number of years in practice, gestation at delivery, anteroposterior diameter (APD) of renal pelvis.

RESULTS

A total of 44/102 respondents (43%) would deliver prior to 40 weeks (median no. of years as consultant 10 years [IQR 5-17]) vs. those who would not (median years as consultant 5.5 [IQR 3-12]). Re APD threshold of delivery: 17 indicated delivery if the APD were 20 mm, 10 if it were 21-30 mm and 16 if it were >30 mm. Re gestation at which they would deliver: 13 indicated 37-38 weeks, 13 indicated 38-39 weeks and 17 indicated 39-40 weeks. Reasons selected for delivery before term were obstetric anxiety n=2, maternal request n=2, maternal anxiety n=2 and concern about fatal renal damage/renal damage n=34.

CONCLUSIONS

A surprising number of respondents would consider early delivery of a fetus with hydronephrosis and normal liquor despite the lack of evidence of benefit. The evidence supporting term delivery means that early term delivery is only indicated for obstetric reasons in this scenario.

Frequency and prediction of persistent urinary tract dilation in third trimester and postnatal urinary tract dilation in infants following diagnosis in second trimester

OBJECTIVE

To determine the frequency, associated characteristics and prognostic value of the current risk stratification system for prenatal urinary tract dilation (UTD) for predicting persistent UTD in the third trimester and subsequent postnatal UTD in the infant, following diagnosis in the second trimester.

METHODS

This was a single-institution retrospective cohort study of singleton pregnancies diagnosed with unilateral or bilateral UTD in the second trimester (before 28 weeks' gestation) with follow-up in the third trimester (at or after 28 weeks) between January 2017 and May 2019. In all cases, the prenatal diagnosis and stratification to low-risk (Grade A1) or increased-risk (Grade A2-3) UTD was made using the 2014 UTD consensus classification system. The primary outcomes included persistent prenatal UTD in the third trimester and postnatal UTD up to 6 months of age. We performed multivariable analysis to assess whether patient and second- and third-trimester sonographic characteristics (such as UTD laterality, other renal abnormality (calyceal dilation, abnormal parenchymal appearance, abnormal ureter or bladder) and anteroposterior renal pelvic diameter (AP-RPD)) were associated with the study outcomes. We assessed the predictive value of the current risk stratification system (Grade A1 vs Grade A2-3) in the second and third trimesters for persistent prenatal UTD and postnatal UTD using the area under the receiver-operating-characteristics curve (AUC).

RESULTS

Of 26 620 second-trimester ultrasound assessments in the study period, 347 patients were diagnosed with UTD in the second trimester and had third-trimester follow-up, of whom 150/347 (43% (95% CI, 38-49%)) had persistent UTD in the third trimester. Among the 282/347 (81%) patients with postnatal follow-up available, the frequency of postnatal UTD was 49/282 (17% (95% CI, 13-22%)), and among the subset with persistent UTD in the third trimester, the frequency of postnatal UTD was 46/102 (45% (95% CI, 35-55%)). The most frequent postnatal diagnosis was transient UTD (76%), followed by duplicated collecting system (10%). Of infants originally diagnosed with UTD in the second trimester, 2% (7/347) required surgery; stated differently, of the 49 infants with postnatal UTD, 14% (7/49) required surgery. At second-trimester diagnosis, sonographic predictors of both persistent prenatal UTD and postnatal UTD included the presence of other renal abnormality and UTD Grade A2-3. At third-trimester follow-up, predictors of postnatal UTD were larger mean AP-RPD and UTD Grade A2-3, while all cases had other renal abnormality. Second-trimester diagnosis of UTD Grade A2-3 had satisfactory discrimination for predicting persistent prenatal UTD (AUC, 0.64 (95% CI, 0.58-0.70)) and postnatal UTD (AUC, 0.72 (95% CI, 0.63-0.81)), as did third-trimester UTD Grade A2-3 for predicting postnatal UTD (AUC, 0.66 (95% CI, 0.56-0.76)).

CONCLUSIONS

The majority of cases of prenatal UTD did not result in postnatal UTD, and of those that did, very few required surgery. Follow-up third-trimester assessment after a second-trimester diagnosis of UTD is warranted. The current risk stratification system by UTD grade, based on the 2014 UTD consensus classification, can be used to predict postnatal UTD with fair accuracy. Further research is needed to determine whether the predictive performance of this system can be improved by incorporating additional risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Urinary Tract Dilation in the Fetus and Neonate

Urinary tract dilation (UTD), previously known as hydronephrosis, is the most common congenital condition identified on prenatal ultrasonography. UTD can be physiologic and resolve spontaneously or can be caused by various congenital anomalies of the urinary tract, which can lead to renal failure if not treated properly. In 2014, a multidisciplinary consensus group established UTD definitions, a classification system, and a standardized scheme for perinatal evaluation. Various imaging modalities are available to help diagnose the cause of UTD in fetuses and neonates and to help identify those patients who may benefit from fetal or early postnatal intervention. In this article, we will review the diagnosis and quantification of antenatal and postnatal UTD based on the UTD classification system, outline the imaging studies available to both evaluateUTD and determine its cause, briefly review the most common causes of UTD in the fetus and neonate, outline management strategies for UTD including the role for fetal intervention and prophylactic antibiotics, and report on the outcome and prognosis in patients with UTD.

Pediatric Nephro-Urology: Overview and Updates in Diuretic Renal Scans and Renal Cortical Scintigraphy

Nuclear medicine offers several diagnostic scans for the evaluation of congenital and acquired conditions of the kidneys and urinary track in children. Tc-99m-MAG 3 diuretic renal scans are most commonly used in the evaluation and follow up of urinary track dilatations. They provide functional information on the differential renal function and on drainage quality which is allows distinction between obstructed and non-obstructed kidneys and the need for surgical correction vs conservative management in kidneys with impaired drainage. Standardized imaging and processing protocols are essential for correct interpretation and for meaningful comparisons between follow up scans. Different approaches and conceptions led to some contradicting recommendations between SNMMI and EANM guidelines on diuretic renography in children which caused confusion and to the emergence of self-made institutional protocols. In Late 2018 the two societies published joint procedural guidelines on diuretic renography in infants and children which hopefully will end the confusion. Tc-99m DMSA scans provide important information about the function of the renal cortex allowing detection of acute pyelonephritis, renal scars dysplasia and ectopy as well as accurate determination of the differential renal function. They are commonly used in the evaluation of children with urinary tract infections and affect clinical management. A standardized imaging and processing protocol improves the diagnostic accuracy of these studies. SPECT or pinhole images should be a routine part of the imaging protocol. This is one of the recommendations in the new EANM and SNMMI procedural guidelines for renal cortical scintigraphy in children available online on the SNMMI website and is under publication. This article provides an overview on the clinical role of diuretic renography and cortical scintigraphy in children and describes the imaging protocols focusing on the new recommendations in the procedural guidelines.

Outcome analysis of early surgery and conservative treatment in neonates and infants with severe hydronephrosis

Objective

The treatment strategy and timing of ureteropelvic junction obstruction (UPJO) in infants remain controversial. This study aimed to compare the effect of early surgical treatment (EST) and conservative treatment (CT) on neonates and infants with UPJO and their recovery of renal function and morphology.

Methods

Eighty neonates and infants with severe hydronephrosis were enrolled in this study. They received early pyeloureteroplasty or CT. Diethylenetriamine pentaacetate was used to assess renal function.

Results

There were no significant differences in renal function or renal indices at baseline between the two groups. At 3 and 6 months of follow-up, the anteroposterior diameter of the renal pelvis and the Society of Fetal Urology grade in the EST surgery group were significantly lower compared with those at baseline. The thickness of the renal cortex was greater in the EST group than in the CT group at 3 and 6 months of follow-up. After follow-up for 6 months, renal function in the EST group was significantly better than that in the CT group.

Conclusion

EST accelerates the recovery of renal morphological and functional indices in neonates and infants with severe hydronephrosis.

Long-term follow-up of congenital anomalies of the kidney and urinary tract diagnosed in utero: a longitudinal study

BACKGROUND

Congenital-anomalies of the kidney-and-urinary-tract (CAKUT) are diagnosed in 3-6 per 1000 live-births. The objective of the current study was to examine the short and long-term outcomes of children diagnosed prenatally with CAKUT.

METHODS

A retrospective study was performed in 2018 on all pregnancies diagnosed with CAKUT between 2004 and 2008 at our hospital. Pregnancy outcomes and long-term morbidity were evaluated. Comparison was made between mild and severe forms of CAKUT and between unilateral and bilateral anomalies.

RESULTS

Ninety-eight children were included in the study. Most of them were born with an adequate weight for gestational-age, and were born at term by vaginal-deliveries. Children with major renal anomalies suffered significantly more frequently from recurrent UTIs (33.3% vs. 8.4%), needed more preventive antibiotics (50% vs. 20.5%), and had more renal surgeries (75% vs. 28%) than those with milder forms of CAKUT. Significantly more children with polycystic/multicystic kidney disease had recurrent UTIs (50% compared to 25% of the children with renal agenesis, and 5.6% of the children with hydronephrosis/hydroureter). There were no significant differences in the need for neurodevelopmental follow-up between the different groups of severity. Unilateral CAKUT patients required longer periods of nephrologist follow-up and repeated sonographic exams compared to bilateral CAKUT patients. Children with bilateral CAKUT more often needed special educational support than peers with unilateral disease (29.4% vs. 11.1%, P = 0.03).

CONCLUSIONS

Pregnancies whose children are diagnosed with CAKUT in utero usually deliver at term, with adequate-weight for gestational-age. The most common long-term comorbidities in children were recurrent UTIs and the use of preventive antibiotics was often needed. Expecting couples can be reassured of a generally good outcome of their children, at least during the first decade of life.

Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center

Background

Hydronephrosis (HN) is the most common abnormality detected on prenatal ultrasound. This study sought to stratify outcomes of patients by severity of prenatal HN with postnatal outcomes.

Methods

This was a retrospective review of patients referred to a tertiary care fetal-maternal clinic with diagnosis of prenatal HN from 2004 to 2019. HN severity was categorized as mild, moderate, or severe. Data were analyzed to determine the association between HN severity and surgical intervention. Decision for surgery was based on factors including history of multiple urinary tract infections, evidence of renal scarring, and/or reduced renal function. Surgery-free survival time was represented by the Kaplan–Meier method, and hazard ratios were calculated using the log-rank test.

Results

131 kidneys among 101 infants were prenatally diagnosed with hydronephrosis; 35.9% had mild HN, 29.0% had moderate HN, and 35.1% had severe HN. 8.5% of patients with mild HN, 26.3% of patients with moderate HN, and 65.2% of patients with severe HN required surgery. Patients with severe HN were 12.2 (95% CI 6.1–24.4; p < 0.001) times more likely to undergo surgery for HN than patients with mild HN and 2.9 (95% CI 1.5–5.3; p = 0.003) times more likely to undergo surgery than patients with moderate HN. Patients with moderate HN were 4.3 times more likely to require surgery than patients with mild HN (95% CI 1.5–12.9; p = 0.01). Median age at surgery was 11.8 months among patients with mild HN (IQR 11.7–14.1 months), 6.6 months among patients with moderate HN (IQR 4.2–16.4 months), and 5.4 months among patients with severe HN (3.7–12.4 months).

Conclusion

Among this cohort of referrals from a fetal-maternal clinic, severity of HN correlated with increased likelihood of surgical intervention. Continued assessment of patients with prenatal HN should be evaluated to best determine the role of the pediatric urologist in cases of prenatal HN.

Management of antenatal hydronephrosis

Antenatal hydronephrosis (AHN) is the most frequently detected abnormality by prenatal ultrasonography. Differential diagnosis of AHN includes a wide variety of congenital abnormalities of the kidney and urinary tract ranging from mild abnormalities such as transient or isolated AHN to more important ones as high-grade congenital vesicoureteral reflux or ureteropelvic junction obstruction. It is well known that the outcome depends on the underlying etiology. Various grading systems have been proposed for the classification of AHN on prenatal and postnatal ultrasonography. Mild isolated AHN represents up to 80% of cases, is considered to be benign, and majority of them resolve, stabilize, or improve during follow-up. Controversies exist regarding the diagnosis and management of some important and severe causes of AHN such as high-grade vesicoureteral reflux and ureteropelvic junction obstruction. Current approach is becoming increasingly conservative during diagnosis and follow-up of these patients with less imaging and close follow-up. However, there is still no consensus regarding the clinical significance, postnatal evaluation, and management of infants with AHN. The aim of this review is to discuss the controversies and provide an overview on the management of AHN.

Antenatally detected urinary tract dilatation: a 12-15-year follow-up

BACKGROUND

Antenatally diagnosed urinary tract dilatation (UTD) still burdens healthcare providers and parents. This study was conducted to establish long-term outcome in an unselected group of children with antenatally detected UTD.

METHODS

Seventy-one out of 103 children born in 2003-2005 and diagnosed with antenatal UTD agreed to participate in a 12-15-year follow-up including blood and urine samples, a kidney ultrasound exam, and kidney scintigraphy. The records were searched for previous urinary tract infections.

RESULTS

Among children with an anteroposterior diameter (APD) ≤ 7 mm and no calyceal, kidney, ureteral, or bladder pathology in the early postnatal period, no one tested had reduced estimated glomerular filtration rate (eGFR), albuminuria, or UTD at the follow-up at a mean age of 13.6 years. One child had kidney damage not affecting kidney function. Among children with postnatal APD > 7 mm and/or kidney, calyceal, ureteral, or bladder pathology, 15% had persistent UTD and 32-39% (depending on the method used) had kidney damage. Major postnatal urinary tract ultrasound abnormalities and a congenital anomalies of the kidney and urinary tract (CAKUT) diagnosis were factors associated with an increased risk for permanent kidney damage (odds ratios 8.9, p = 0.016; and 14.0, p = 0.002, respectively). No one had reduced eGFR. One child (1/71, 1%) had a febrile urinary tract infection after the age of 2.

CONCLUSIONS

We conclude that in children with postnatal APD ≤ 7 mm, no calyceal dilatation, normal bladder, ureters, and kidney parenchyma, the outcome is excellent. There is no need for long-term follow-up in these patients.

Current perspective and scope of fetal therapy: part 1

Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.

How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis

BACKGROUND

Routine third-trimester ultrasound is frequently offered to pregnant women to identify fetuses with abnormal growth. Infrequently, a congenital anomaly is incidentally detected.

OBJECTIVE

To establish the prevalence and type of fetal anomalies detected during routine third-trimester scans using a systematic review and meta-analysis.

SEARCH STRATEGY

Electronic databases (MEDLINE, Embase and the Cochrane library) from inception until August 2019.

SELECTION CRITERIA

Population-based studies (randomised control trials, prospective and retrospective cohorts) reporting abnormalities detected at the routine third-trimester ultrasound performed in unselected populations with prior screening. Case reports, case series, case-control studies and reviews without original data were excluded.

DATA COLLECTION AND ANALYSIS

Prevalence and type of anomalies detected in the third trimester. We calculated pooled prevalence as the number of anomalies per 1000 scans with 95% confidence intervals. Publication bias was assessed.

MAIN RESULTS

The literature search identified 9594 citations: 13 studies were eligible representing 141 717 women; 643 were diagnosed with an unexpected abnormality. The pooled prevalence of a new abnormality diagnosed was 3.68 per 1000 women scanned (95% CI 2.72-4.78). The largest groups of abnormalities were urogenital (55%), central nervous system abnormalities (18%) and cardiac abnormalities (14%).

CONCLUSION

Combining data from 13 studies and over 140 000 women, we show that during routine third-trimester ultrasound, an incidental fetal anomaly will be found in about 1 in 300 scanned women. This information should be taken into account when taking consent from women for third-trimester ultrasound and when designing and assessing cost of third-trimester ultrasound screening programmes.

TWEETABLE ABSTRACT

One in 300 women attending a third-trimester scan will have a finding of a fetal abnormality.

Role of Urinary Transforming Growth Factor Beta-B1 and Monocyte Chemotactic Protein-1 as Prognostic Biomarkers in Posterior Urethral Valve

Background:

Posterior Urethral Valves (PUV) are the most common cause of congenital LUT obstruction in males. Biomarkers of glomerular or tubular injury may be of particular value in predicting the need for surgical intervention or in tracing progression of chronic kidney disease. Measurement of biomarker in urine is relatively easy.

Aim:

To evaluate the changes in values of urinary Transforming Growth Factor Beta 1(TGF-B1) and Monocyte Chemotactic Protein (MCP-1) before and after valve ablation and its prognostic value in Posterior urethral valve.

Material and Method:

This prospective study was conducted from September 2016 to August 2018. The study group included 20 consecutive male babies with the diagnosis of PUV treated and followed up versus equal numbers of age matched control without any renal or urinary tract disease. Pre-operative urine samples were collected in Operative room. Cystoscopy and valve ablation was done. Follow up was done clinically by urinary stream and radiologically with VCUG. Follow-up was planned at 1 month, 3 months and 6 months following cystoscopic valve ablation. All collected urine samples were centrifuged at 10,000 rpm for 20 minutes. Supernatant was collected and two divided aliquots were stored at -200c to be thawed on the day of assay. Optical density of each well was recorded at 450 nm and 540 nm A p-value of <0.05 was considered to be statistically significant.

Result and Discussion:

Out of 20 cases of PUV, 14 (70%) cases were 1st born males of their family. The median age at the time of valve ablation in PUV cases was 2.5 (1.20-3.87) years.. Most common symptoms are fever and UTI. The preoperative median serum creatinine level was 1.65 mg/dl(1.22-2.42) pre-ablation, and fall significantly after ablation. Median eGFR level (calculated) was 25.635 (16.38-35.40) and after 6 months was 71.490 (45.44-96.93). Preoperative median MCP1 in PUV cases was 147.2 (82.8-512.5) and significant difference was also found in 1st, 3rd and 6th months after surgery (p<0.001, p=0.004 and p=0.002).Preoperative median TGF-B1 level was 197.8 pg/ml (79.9-386.4). There was no statistically significant change in TGF-B1 level at preoperative to 1 month and preop to 3 months after surgery but at 6 months after surgery the median TGF-B1 level significantly decreased as compared with preoperative TGF-B1 level.

Conclusion:

TGF β1 and MCP1 can be considered as prognostic urinary biomarkers in patients of PUV and can be used to specify and counsel patient's attendant regarding possibility of ESRD and need for further intervention.

Prenatal Diagnosis and Findings in Ureteropelvic Junction Type Hydronephrosis

The widespread use of obstetric ultrasonography has increased the detection rate of antenatal hydronephrosis. Although most cases of antenatal hydronephrosis are transient, one third persists and becomes clinically important. Ultrasound has made differential diagnosis possible to some extent. Ureteropelvic junction type hydronephrosis (UPJHN) is one of the most common cause of persistent fetal hydronephrosis and occurs three times more in male fetuses. It is usually sporadic and unilateral. However, when bilateral kidneys are involved and presents with severe hydronephrosis, the prognosis may be poor. Typical ultrasound findings of UPJHN is hydronephrosis without hydroureter. The size and appearance of the fetal bladder is usually normal without thickening of the bladder wall. Several grading systems are developed and increasingly being used to define the severity of prenatal hydronephrosis and provides much more information about prediction of postnatal renal prognosis. If fetal urinary tract dilation is detected; laterality, severity of hydronephrosis, echogenicity of the kidneys, presence of ureter dilation should be assessed. Bladder volume and emptying, sex of the fetus, amniotic fluid volume, and presence of associated malformations should be evaluated. Particularly the ultrasonographic signs of renal dysplasia, such as increased renal parenchymal echogenicity, thinning of the renal cortex, the presence of cortical cysts, and co-existing oligohydramnios should be noticed. Unfortunately, there is no reliable predictor of renal function in UPJHN cases. Unilateral hydronephrosis cases suggesting UPJHN are mostly followed up conservatively. However, the cases with bilateral involvement are still difficult to manage. Timing of delivery is also controversial.

Role of Antibiotic Prophylaxis in the Management of Antenatal Hydronephrosis, Vesicoureteral Reflux, and Ureterocele in Infants

Widespread prenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. Antenatal hydronephrosis (AHN) and vesicoureteral reflux (VUR) are among the most common congenital anomalies diagnosed in utero or after birth. Pediatric urologists frequently rely on continuous antibiotic prophylaxis (CAP) for managing AHN, VUR, and ureterocele, unless definitive treatment is performed. The main aim of antibiotic prophylaxis (ABP) is to prevent urinary tract infection and long-term complications. Nevertheless, the efficacy of ABP has been a source of considerable debate, and pediatricians have varied opinions on who would benefit from ABP. In this review article, we searched the currently available literature, for evidence of the role of ABP in the setting of AHN, VUR, and ureterocele. Most of our studies showed a limited benefit of ABP for HN and VUR. The data on the use of CAP in the management of ureterocele is scarce. However, due to the involvement of independent risk factors and other variables, a conclusion cannot be drawn from these studies alone. Pediatric urologists are urged to conduct randomized controlled trials to compare patients followed up with and without ABP. Given the lack of guidelines, an individualized approach should be used for the use of ABP, until precise guidelines and recommendations are developed.

Percutaneous Nephrostomy in the Neonatal Period: Indications, Complications, and Outcome-A Single Centre Experience

PURPOSE

The purpose of this study was to evaluate the indications, technique for percutaneous nephrostomy (PCN) insertion, the complications related to PCN, duration of PCN, and outcome following PCN removal regarding the kidney function.

MATERIAL AND METHODS

Medical charts of 31 neonates (22 boys and 9 girls, mean age 13.9 days) treated with 43 PCN were reviewed. Collected data included indications for PCN, PCN complications, duration of PCN, and outcome of these patients by analysing the kidney function.

RESULTS

The indications for PCN insertion were obstructive urinary tract dilation in 24 neonates (four with associated infection), and non-obstructive urinary tract dilation with urosepsis or pyonephrosis in seven cases. Primary technical success of PCN placement using Seldinger technique was 97.7%. The following complications were reported: self-limited post-procedural bleeding into the pelvicalyceal system in two, chronic microscopic haematuria in five, and clinically manifested urinary tract infection in five children. Four PCN were dislocated. Cellulitis was present at the skin entry of 5 PCN, urinary leak in 5 PCN, and mechanical damage of 5 PCN. Eight PCN had to be replaced. Mean duration of PCN was 5 months. Kidney insufficiency was detected in 5/29 children with the mean follow-up of 3.9 years.

CONCLUSIONS

PCN is a safe, effective transient solution in neonates with pyonephrosis or when surgery of obstructed urinary system has to be postponed. The rate of minor complications increased with PCN duration. If kidney insufficiency is present after PCN removal, it is related to the complexity of kidney anomalies.

Gynecologic and reproductive health in patients with pathogenic germline variants in DICER1

OBJECTIVE

Germline pathogenic variation in DICER1 underlies a tumor-predisposition disorder with increased risk for cervical embryonal rhabdomyosarcoma and ovarian sex-cord stromal tumors, particularly Sertoli-Leydig cell tumors. The gynecologic and reproductive health of these females has not yet been described.

METHODS

All female subjects recruited from November 2011 to July 2018 participating in an epidemiologic study of families with pathogenic DICER1 germline variation were included in this cross-sectional analysis. Participant evaluation included obstetric-gynecologic history, physical examination, hormone testing, pelvic ultrasound and record review.

RESULTS

Of 64 females aged 2-72 years, fifteen underwent treatment for pleuropulmonary blastoma as children and three were treated for cervical embryonal rhabdomyosarcoma. Of nine patients reporting a history of ovarian tumors, all presented with virilization or amenorrhea; eight occurred in adolescence. Post-pubertal females with no history of ovarian tumors experienced normal pubertal development, reported regular menstrual cycles, were fertile and underwent natural menopause at median age of 52 years. Thirty-two of 33 women who tried to conceive successfully delivered liveborn children. Of these 32, 10 experienced pregnancy-related thyroid enlargement resulting in thyroidectomy within one year of pregnancy; nine others had undergone pre-pregnancy thyroidectomy.

CONCLUSION

In these DICER1-carrier females, DICER1-related gynecological tumors occurred during childhood or adolescence in some after which women generally experienced healthy reproductive lives. Individual education and screening for these tumors is warranted. The high rate of DICER1-related multinodular goiter resulting in pre- and post-pregnancy thyroidectomy underscores the importance of thyroid monitoring during pregnancy to ensure maternal and fetal wellbeing.

Does the presence of non-refluxing hydroureter impact the management and outcome of high-grade hydronephrosis?

INTRODUCTION

We aimed to evaluate the impact of non-refluxing hydroureter on the initial management of high-grade hydronephrosis (HGH) management. Moreover, we evaluated the occurrence of febrile urinary tract infection (fUTI) and surgical intervention for conservatively managed units.

METHODS

Patients' charts with postnatal hydronephrosis from 2008-2014 were retrospectively reviewed. We included patients who presented in the first year of life. All included patients had HGH (Society of Fetal Ultrasound [SFU] grades 3 and 4) and all were non-refluxing using voiding cystourethrogram (VCUG). We categorized renal units into two groups: with hydroureteronephrosis (HUN) and without hydroureter (isolated hydronephrosis [IH]). We recorded the initial management. We evaluated the impact of non-refluxing hydroureter on hydronephrosis fate, fUTI, and change to surgery for those managed conservatively.

RESULTS

We included 169 patients (180 units). IH was diagnosed in 146 units (137 patients), whereas 34 units (32 patients) had HUN. Median followup was 42.9 months. A total of 25.3% (37/146) of IH units had initial surgical management in comparison to 5.1% (2/34) of HUN units (p=0.01). During conservative management, nine HUN patients (30%) and 11 IH patients (10.7%) experienced fUTI (p=0.009). Surgical intervention after failed conservative management was indicated for 12 IH units (11%) and six HUN units (18.8%) (p=0.25). Anteroposterior diameter (APD) worsening was significantly associated with the change to surgery in IH group (p=0.003). More than half (52.3%) of IH units resolved during conservative management in comparison to 18.7% of HUN (p<0.001). HUN had longer time to resolution (log rank=0.004).

CONCLUSIONS

IH units had more initial surgical interventions. The fUTI rate was much higher in association with dilated ureter even under antibiotic coverage. HUN was associated with less and slower resolution rate.

A clinical predictive model of renal injury in children with isolated antenatal hydronephrosis

Background

Antenatal hydronephrosis (ANH) affects ∼1-5% of pregnancies. The aim of this study was to develop a clinical prediction model of renal injury in a large cohort of infants with isolated ANH.

Methods

This is a longitudinal cohort study of 447 infants with ANH admitted since birth between 1989 and 2015 at a tertiary care center. The primary endpoint was time until the occurrence of a composite event of renal injury, which includes proteinuria, hypertension and chronic kidney disease (CKD). A predictive model was developed using a Cox proportional hazards model and evaluated by C-statistics.

Results

Renal pelvic dilatation (RPD) was classified into two groups [Grades 1-2 (n = 255) versus Grades 3-4 (n = 192)]. The median follow-up time was 6.4 years (interquartile range 2.8-12.5). Thirteen patients (2.9%) developed proteinuria, 6 (1.3%) hypertension and 14 (3.1%) CKD Stage 2. All events occurred in patients with RPD Grades 3-4. After adjustment, three covariables remained as predictors of the composite event: creatinine {hazard ratio [HR] 1.27, [95% confidence interval (CI) 1.05-1.56]}, renal parenchyma thickness at birth [HR 0.78(95% CI 0.625-0.991)] and recurrent urinary tract infections [HR 4.52 (95% CI 1.49-13.6)]. The probability of renal injury at 15 years of age was estimated as 0, 15 and 24% for patients assigned to the low-risk, medium-risk and high-risk groups, respectively (P < 0.001).

Conclusion

Our findings indicate an uneventful clinical course for patients with Society for Fetal Urology (SFU) Grades 1-2 ANH. Conversely, for infants with SFU Grades 3-4 ANH, our prediction model enabled the identification of a subgroup of patients with increased risk of renal injury over time.

Ultrasound evaluation for prediction of outcomes and surgical decision in fetal hydronephrosis

Fetal hydronephrosis (HY) is a frequent congenital condition, which may be detected by prenatal ultrasound. Society for Fetal Urology (SFU) and anterior-posterior diameter (APD) grading are two major grading systems based on ultrasonography. The present study aimed to assess the predictive value of the SFU and APD grades in patients with fetal HY. A total of 162 patients with 234 kidneys affected by HY were included in the present study. The SFU and APD grades were determined from the ultrasound images at 38 gestational weeks, and a 12-month follow-up was performed after birth. The associations of the SFU and APD grades with the outcome of fetal HY, including HY regression, and post-partum surgery were examined. In the present study, 16 patients with 17 kidneys were diagnosed with pathological HY, and stenosis at the ureteropelvic junction was demonstrated to be a leading cause of pathological HY. Among the 234 kidneys affected by HY, 161 kidneys were scored as SFU grade I, 57 as SFU grade II, 7 as SFU grade III and 9 kidneys as SFU grade IV. According to the APD grading system, 112 kidneys were determined as having low, 104 as having moderate and 18 as having severe HY. The SFU and APD grades were demonstrated to be independently associated with the occurrence of pathological HY by logistic regression analysis with a high diagnostic accuracy to distinguish pathological and physiological HY cases as evidenced by the results of ROC analysis. In addition, univariate and multivariate logistic regression analysis indicated that patients with spontaneous HY regression usually had low SFU and APD grades. Furthermore, the rate of surgery was increased in the group of patients with high SFU or APD grades, and these two systems were identified as independent predictors for the requirement of surgery by Kaplan-Meier analysis. Patients with pathological HY had high SFU and APD grades, and these two grading systems may be used as reliable predictors for the outcome of fetal HY, including HY regression, and post-partum surgery.

Time to resolution of isolated antenatal hydronephrosis with anteroposterior diameter ≤ 20 mm

Data regarding spontaneous resolution of mild hydronephrosis consist of different etiologies, and hence, it is heterogeneous. The aim of this study is to evaluate spontaneous resolution rates and the time to complete resolution of antenatally detected isolated hydronephrosis in patients with renal pelvis antero-posterior diameter (RPAPD) ≤ 20 mm. Retrospective chart review of patients who were admitted to our pediatric nephrology clinic for the evaluation of antenatal hydronephrosis between 2011 and 2017 was conducted. Patients that had hydronephrosis with RPAPD ≤ 20 mm, < SFU (Society for Fetal Urology) grade IV on initial postnatal evaluation, and ≥ 3 months of follow-up with at least two renal ultrasounds (US) were included. Complete resolution of hydronephrosis was regarded as SFU grade 0 with a RPAPD of < 7 mm. Patients with ureteric and lower urinary tract abnormalities were excluded. There were a total of 276 patients who met the inclusion criteria. Median follow-up was 16 months (range 3-96 months). Hydronephrosis completely resolved in 198 patients (71.7%). Surgery was not required in any of the patients; however, nine patients (3.3%) showed progression to higher grades of hydronephrosis or increase in AP diameter. Median time to complete resolution of hydronephrosis was 6 months (range 2-35 months) in our study. Those with AP diameter < 10 mm became normal in median of 5 months, while it took median 11 months for patients with AP diameter 10-20 mm to become normalized (p < 0.001).Conclusion: Isolated antenatal hydronephrosis with RPAPD ≤ 20 mm would spontaneously resolve in 71.7% of the cases. Resolution may be expected to happen in 3 years, while the majority will take place in the first year of life. What is Known: • Antenatal hydronephrosis comprises an important amount of clinical visits. • Spontaneous resolution rates differ for various etiologies. What is New: • Isolated antenatal hydronephrosis with RPAPD ≤ 20 mm completely resolves within 3 years in approximately 72% of the cases. • Resolution can be observed within the first year of life in most of the cases.

Posterior urethral valves: comparison of clinical outcomes between postnatal and antenatal cohorts

BACKGROUND

Posterior urethral valves (PUVs) constitute the most common infravesical urinary obstruction in boys and are often accompanied by severe consequences to the lower and upper urinary tract. Currently, about two-thirds of diagnosis of PUVs has been suspected by prenatal ultrasonography findings. The aim of this study was to compare long-term clinical outcomes in two groups of patients with PUVs, with antenatal vs. postnatal diagnosis.

STUDY DESIGN

This was a retrospective cohort study of 173 patients with PUVs systematically followed up in a tertiary center. Median follow-up time was 66.5 months (interquartile range [IQ], 11.4-147.9 months) for those patients who survived neonatal period. Seventy-nine (45.6%) patients were followed up for more than 5 years and 55 (32%) for more than 10 years. For analysis, the cohort was stratified into two groups according to the clinical presentation (prenatal vs. postnatal). The events of interest were urinary tract infection (UTI), surgical interventions, proteinuria, hypertension, chronic kidney disease (CKD), and death. Survival analyses were performed to evaluate time until occurrence of the events.

RESULTS

Sixty-two patients (35.8%) were diagnosed by fetal sonography. Patients of postnatal group presented a higher incidence rate of UTI episodes (6.5, 95% confidence interval [CI], 4.9-8.3) than antenatal group (1.2, 95% CI, 0.4-2.7) (P < 0.001). Thirty-six patients (21%) presented hypertension, and 77 (44.5%) had persistent mild proteinuria. There was no significant difference in the estimated incidence of hypertension (P = 0.28) and proteinuria (P = 0.78) between antenatal and postnatal groups. The cumulative incidence of CKD stage ≥3 was estimated to be about 37% at 10 years of age, and 56% at 18 years of age. By survival analysis, there was no significant difference in the estimated incidence of CKD stage ≥3 (log-rank = 0.32, P = 0.57) and CKD stage 5 (log-rank = 1.08, P = 0.28, Figure) between antenatal and postnatal groups. Of 173 patients included in the analysis, 13 (7.5%) died during follow-up with a median age of 2.6 months (IQ, 15 days-62 months). Survival analyses have not shown any significant difference in the estimated incidence of death between antenatal and postnatal groups (log-rank = 1.38, P = 0.24).

CONCLUSION

The study findings did not corroborate the initial hypothesis that the rates of renal function declining in patients with PUVs would be attenuated by an early diagnosis and intervention after antenatal diagnosis.

Inpatient interventions that may preclude outpatient open pyeloplasty in infants

Objective:

In the majority of published series, children undergoing open pyeloplasty are admitted for at least one night. We hypothesized that it would be possible in the majority of infants to perform open pyeloplasty as an outpatient procedure.

Materials and Methods:

All patients who underwent open pyeloplasty by a single surgeon between 2008 and 2016 were retrospectively reviewed. Demographic data (age at surgery, gender, pre- and postoperative imaging studies, laterality, type of local anesthesia), operative time, duration of hospital stay, need for narcotic analgesics, complications, readmission within 1-month after surgery and need for additional procedures were abstracted.

Results:

A total of 18 infants underwent open pyeloplasty by single surgeon. Mean age at time of surgery was 19 months (range 3-23 months). There were 8 girls and 10 boys. In addition to general anesthesia, all of the patients received regional anesthesia (caudal block 8, epidural block 8, subcutaneous nerve block 2). Median operative time was 135 minutes (range 81-166). Median hospital stay was 1 day (range 1 to 2). Two patients required iv narcotics for pain management. None of the patients required parenteral administration of other medications during the short hospitalization. No patients required any additional procedures or hospital readmissions within 1 month from surgery.

Conclusions:

In appropriately selected patients, outpatient pyeloplasty appears to be feasible with an oral postoperative analgesia plan to be administered at home.

A Predictive Model of Postnatal Surgical Intervention in Children With Prenatally Detected Congenital Anomalies of the Kidney and Urinary Tract

The aim of this study was to identify predictive factors and develop a model to assess individualized risk of postnatal surgical intervention in patients with antenatal hydronephrosis. This is a retrospective cohort study of 694 infants with prenatally detected congenital anomalies of kidney and urinary tract with a median follow-up time of 37 months. The main event of interest was postnatal surgical intervention. A predictive model was developed using Cox model with internal validation by bootstrap technique. Of 694 patients, 164 (24%) infants underwent surgical intervention in a median age of 7.8 months. Predictors of the surgical intervention in the model were: baseline glomerular filtration rate, associated hydronephrosis, presence of renal damage and the severity of renal pelvic dilatation. The optimism corrected c statistic for the model was 0.84 (95%CI, 0.82-0.87). The predictive model may contribute to identify infants at high risk for surgical intervention. Further studies are necessary to validate the model in patients from other settings.

A long-term follow-up in conservative management of unilateral ureteropelvic junction obstruction with poor drainage and good renal function

The aim of the study was to retrospectively review the outcome of neonatal ureteropelvic junction obstruction with a good renal function and a poor drainage at a first diuretic renal scan, in cases where surgery was recommended on the basis of a loss of renal function, worsening of hydronephrosis or occurrence of clinical symptoms. Hydronephrosis was graded from 1 to 4 or as ureteral tract dilatation (UTD) P1 to UTD P3. During follow-up, 15 out of 38 patients (34.2%) required surgery while 25 out of 38 (65.8%) could have been managed conservatively. In patients with grade 2, 3, and 4 hydronephrosis, the ureteropelvic junction obstruction resolved or improved spontaneously in 100%, 63%, and 33% of cases (in 100% of UTD P1, 67% of UTD P2, and 50% of UTD P3), respectively. The median of follow-up was 14 years. Chi-square test showed a significant relationship between initial grade of hydronephrosis or UTD and the possibility of an efficient conservative management (p = 0.0088 and p = 0.0460).Conclusion: Conservative management can be safely achieved in ureteropelvic junction obstruction with poor drainage. Scheduled controls are needed for early discovery of functional renal deterioration. High-grade hydronephrosis is unlikely to resolve spontaneously and is often accompanied by a loss of renal function during the first years of life. What is Known: • There is controversy about which management should be adopted in infants with unilateral ureteropelvic junction obstruction with poor drainage but good differential renal function. What is New: • Long-term follow-up suggests that conservative management can be safely achieved also in unilateral ureteropelvic junction obstruction with poor drainage in more than 60% of cases, even if high-grade hydronephrosis is unlikely to resolve spontaneously and it is often accompanied by a loss of renal function during the first years of life. In our experience, surgical intervention was required in more than 50% of cases before 1 year of life and in all cases before 3 years of life.

Perinatal Care of Infants with Congenital Birth Defects

Prenatal diagnosis has changed perinatal medicine dramatically, allowing for additional fetal monitoring, referral and counseling, delivery planning, the option of fetal intervention, and targeted postnatal management. Teams participating in the delivery room care of infants with known anomalies should be knowledgeable about specific needs and expectations but also ready for unexpected complications. A small number of neonates will need rapid access to postnatal interventions, such as surgery, but most can be stabilized with appropriate neonatal care. These targeted perinatal interventions have been shown to improve outcome in selected diagnoses.

Feasibility and Quality Determinants of 3D Sonography in Children With Hydronephrosis

The objective was to determine the image quality of 3D diagnostic medical sonography (DMS) in children with hydronephrosis. 3D DMS was assessed based on 24 pediatric patients. Image quality was evaluated by two radiologists and a sonographer in terms of rib shadowing, cut-off parenchymal edges, motion artifact, and overall quality. The interreader reliability and relation between image quality and other variables were calculated. The results were based on images of 32 hydronephrotic kidneys. The average quality scoring of the images was quite high. Rib shadowing, cut-off edges, and motion artifact were present in the majority of the cases. The interreader reliability for overall quality, rib shadowing, cut-off, and motion was quite high. There was a correlation between the Society for Fetal and Neonatal Urology’s hydronephrosis grade and higher cut-off edges. Larger kidneys were more likely to show cut-off, motion, and lower quality scores. In this cohort of infants and toddlers with hydronephrotic kidneys, 3D DMS demonstrated good image quality; however, artifacts were attributed to kidney size and severity of hydronephrosis.

Ureteropelvic Junction Obstruction and Parathyroid Adenoma: Coincidence or Link?

Congenital ureteropelvic junction obstruction (UPJO) is the most common cause of upper urinary tract obstruction in children. It is generally diagnosed in the routine work-up during antenatal period and is characterized by spontaneous recovery. It can be associated with urolithiasis; hence further investigation should be carried out. We report the case of a 15-year-old boy, who is known to have right UPJO, presented with right renal colic and discovered to have bilateral kidney stones. Further studies showed primary hyperparathyroidism and genetic analysis revealed a CDC73 mutation (initially HRPT2). We believe that association of UPJO and PHPT is a rare coincidence that can be linked. Careful work-up of children with UPJO and urolithiasis is recommended to exclude an underlying metabolic disease. Surgical correction can be evitable as treatment of the primary cause can lead to complete dissolution of kidney stones and improvement of the medical condition.

Perinatal and follow-up outcome study of fetal anomalies with multidisciplinary consultation

Synopsis

The establishment of a multidisciplinary consultation system is necessary for the diagnosis of complicated fetal anomalies.

Purpose

We aimed to investigate the incidences of different types of fetal anomalies and the influence of multidisciplinary consultation on fetal prognosis.

Patients and methods

Multidisciplinary specialists include obstetricians, pediatricians, pediatric surgeons, and experts of ultrasound department and genetic counseling. Consultation was done if the fetal ultrasound examinations showed abnormality. Follow-up, assistance, and guidance for the fetus were achieved by phone calls.

Results

Ultrasound screening showed that the incidences of central nervous system anomaly and genitourinary anomaly were 25.80% (275/1,066) and 22.05% (235/1,066), respectively. The detection rates of fetal anomalies were 5.07% (54/1,066), 36.12% (385/1,066), and 58.82% (627/1,066) in pregnant women with gestational age of <20, 20–28, and >28 weeks, respectively. In addition, the fetal cerebral ventriculomegaly accounted for 40.73% of central nervous system malformation, while 71.43% cases with fetal cerebral ventriculomegaly were alleviated during the follow-up period. The proportion of hydronephrosis in genitourinary anomalies was 50.64%, and the remission rate of hydronephrosis was 67.23% during the follow-up period.

Conclusion

The establishment of a multidisciplinary consultation system is necessary for the diagnosis of complicated fetal anomalies. The central nervous system anomaly and genitourinary anomaly are the most common fetal anomalies. In addition, the remission rates of cerebral ventriculomegaly and fetal hydronephrosis are high during the follow-up period.

Renal development in the fetus and premature infant

Congenital abnormalities of the kidney and urinary tract (CAKUT) are one of the leading congenital defects to be identified on prenatal ultrasound. CAKUT represent a broad spectrum of abnormalities, from transient hydronephrosis to severe bilateral renal agenesis. CAKUT are a major contributor to chronic and end stage kidney disease (CKD/ESKD) in children. Prenatal imaging is useful to identify CAKUT, but will not detect all defects. Both genetic abnormalities and the fetal environment contribute to CAKUT. Monogenic gene mutations identified in human CAKUT have advanced our understanding of molecular mechanisms of renal development. Low nephron number and solitary kidneys are associated with increased risk of adult onset CKD and ESKD. Premature and low birth weight infants represent a high risk population for low nephron number. Additional research is needed to identify biomarkers and appropriate follow-up of premature and low birth weight infants into adulthood.

Prognostic factors and biomarkers of congenital obstructive nephropathy

Congenital obstructive nephropathy (CON) is the leading cause of chronic kidney disease (CKD) in children. Anomalies of the urinary tract are often associated with abnormal nephrogenesis, which is compounded by obstructive injury and by maternal risk factors associated with low birth weight. Currently available fetal and postnatal imaging and analytes of amniotic fluid, urine, or blood lack predictive value. For ureteropelvic junction obstruction, biomarkers are needed for optimal timing of pyeloplasty; for posterior urethral valves, biomarkers of long-term prognosis and CKD are needed. The initial nephron number may be a major determinant of progression of CKD, and most patients with CON who progress to renal failure reach this point in adulthood, presumably compounded by episodes of acute kidney injury. Biomarkers of tubular injury may be of particular value in predicting the need for surgical intervention or in tracking progression of CKD, and must be adjusted for patient age. Discovery of new biomarkers may depend on "unbiased" proteomics, whereby patterns of urinary peptide fragments from patients with CON are analyzed in comparison to controls. Most promising are the analysis of urinary exosomes (restricting biomarkers to relevant tubular cells) and quantitative magnetic resonance imaging techniques allowing precise determination of nephron number and tubular mass. The greatest need is for large prospective multicenter studies with centralized biomarker sample repositories to follow patients with CON from fetal life through adulthood.

Evaluation and management of hydronephrosis in the neonate

PURPOSE OF REVIEW

The prenatal detection of congenital anomalies of the kidney and urinary tract (CAKUT) has permitted the early management of these conditions. The aim of this review is to provide an overview of the management of neonates with antenatal hydronephrosis (ANH).

RECENT FINDINGS

In spite of the continuous advances in the understanding of the genetic basis, clinical course, and outcomes of CAKUT, there are still many controversies regarding the clinical significance, postnatal evaluation, and management of neonates with ANH. Mild ANH will often resolve spontaneously, whereas moderate to severe ANH is frequently associated with CAKUT.

SUMMARY

ANH is a surrogate marker of potential congenital renal anomalies, but usually cannot identify a specific disease. A multidisciplinary team approach is required to diagnose and treat these complex disorders. Currently nonsurgical management of CAKUT should be considered whenever possible for infants with ANH.

Postnatal Evaluation and Outcome of Prenatal Hydronephrosis

BACKGROUND

Prenatal hydronephrosis (PNH) is dilation in urinary collecting system and is the most frequent neonatal urinary tract abnormality with an incidence of 1% to 5% of all pregnancies. PNH is defined as anteroposterior diameter (APD) of renal pelvis ≥ 4 mm at gestational age (GA) of < 33 weeks and APD ≥ 7 mm at GA of ≥ 33 weeks to 2 months after birth. All patients need to be evaluated after birth by postnatal renal ultrasonography (US). In the vast majority of cases, watchful waiting is the only thing to do; others need medical or surgical therapy.

OBJECTIVES

There is a direct relationship between APD of renal pelvis and outcome of PNH. Therefore we were to find the best cutoff point APD of renal pelvis which leads to surgical outcome.

PATIENTS AND METHODS

In this retrospective cohort study we followed 200 patients 1 to 60 days old with diagnosis of PNH based on before or after birth ultrasonography; as a prenatal or postnatal detected, respectively. These patients were referred to the nephrology clinic in Zahedan Iran during 2011 to 2013. The first step of investigation was a postnatal renal US, by the same expert radiologist and classifying the patients into 3 groups; normal, mild/moderate and severe. The second step was to perform voiding cystourethrogram (VCUG) for mild/moderate to severe cases at 4 - 6 weeks of life. Tc-diethylene triamine-pentaacetic acid (DTPA) was the last step and for those with normal VCUG who did not show improvement in follow-up examination, US to evaluate obstruction and renal function. Finally all patients with mild/moderate to severe PNH received conservative therapy and surgery was preserved only for progressive cases, obstruction or renal function ≤35%. All patients' data and radiologic information was recorded in separate data forms, and then analyzed by SPSS (version 22).

RESULTS

200 screened PNH patients with male to female ratio 3.5:1 underwent first postnatal control US, of whom 65% had normal, 18% mild/moderate and 17% severe hydronephrosis. 167 patients had VCUG of whom 20.82% with VUR. 112 patients performed DTPA with following results: 50 patients had obstruction and 62 patients showed no obstructive finding. Finally 54% of 200 patients recovered by conservative therapy, 12.5% by surgery and remaining improved without any surgical intervention.

CONCLUSIONS

The best cutoff point of anteroposterior renal pelvis diameter that led to surgery was 15 mm, with sensitivity 88% and specificity 74%.

Occult Congenital Ureteropelvic Junction Obstruction in Two Adults Presenting with Collecting System Rupture After Blunt Renal Trauma: A Case Report Series

We report two adult cases of congenital ureteropelvic junction obstruction detected incidentally in the setting of blunt abdominal trauma. CT images are provided to describe the presentation, while review of the literature and management of renal trauma are discussed.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

CEVL e-learning teaches GUMS method to "score" hypospadias preoperatively and predict postoperative outcomes

INTRODUCTION

Pediatric urological surgeons recognize the importance of formalizing the assessment of outcomes after hypospadias repair. To this end, surgical outcomes may be predicted by correlation with a summative score of objective assessments (Likert 1-4) of each: glans size, urethra plate appearance, meatus position, and extent of shaft chordee (GUMS). The best surgical outcome will be found in cases with the lowest score (GUMS = 4) and the worst surgical outcome in cases with the highest score (GUMS = 16).

OBJECTIVE

We aimed to determine if e-learning is suitable for training of the GUMS method. We did this by re-formatting the GUMS method of assessment of the hypospadias penis into an e-learning platform. Re-formatting was done using the CEVL (Computer Enhanced Visual Learning) context.

METHODS

A total of 49 cases provided content for the following content groups: learn basics (4 cases), scoring samples (16 cases), learn by examples (4 cases), practice scoring (15 cases), and self-test (10 cases). The content was formatted, edited (Adobe), and imported for interactive use (Articulate Storyline). Various frequently asked questions on how to score are also presented.

RESULTS

The survey respondents were pediatric urology attendings or fellows (60%) or urology residents (40%). E-learning GUMS scoring was done under 40 min before completion of the survey. Over 80% of respondents agreed/strongly agreed with the utility of the CEVL platform for learning the method. Respondents assigned GUMS scores to the survey cases and, on average, agreed on exactly the same scores for each component 63% of the time. The respondents chose the consensus score, or the next most common consensus score, 90% of the time.

CONCLUSION

We show that CEVL e-learning is an effective tool, which requires a minimal time investment, for teaching GUMS scoring. We believe that e-learning is a good platform to promote uniform clinical practices in outcomes research and for resident training.

Hydronephrosis alters cardiac ACE2 and Mas receptor expression in mice

INTRODUCTION

Hydronephrosis is characterized by substantial loss of tubules and affects renin secretion in the kidney. However, whether alterations of angiotensin-converting enzyme (ACE), ACE2 and Mas receptor in the heart are observed in hydronephrosis is unknown. Thus, we assessed these components in hydronephrotic mice treated with AT1 receptor blockade and ACE inhibitor.

MATERIALS AND METHODS

Hydronephrosis was induced by left ureteral ligation in Balb/C mice except sham-operated animals. The levels of cardiac ACE, ACE2 and Mas receptor were measured after treatment of losartan or enalapril.

RESULTS

Hydronephrosis led to an increase of ACE level and a decrease of ACE2 and Mas receptor in the heart. Losartan decreased cardiac ACE level, but ACE2 and Mas receptor levels significantly increased in hydronephrotic mice (p < 0.01). Enalapril increased ACE2 levels (p < 0.01), but did not affect Mas receptor in the heart. Plasma renin activity (PRA) and Ang II decreased in hydronephrotic mice, but significantly increased after treatment with losartan or enalapril.

CONCLUSIONS

Hydronephrosis increased cardiac ACE and suppressed ACE2 and Mas receptor levels. AT1 blockade caused sustained activation of cardiac ACE2 and Mas receptor, but ACE inhibitor had the limitation of such activation of Mas receptor in hydronephrotic animals.