Newborn society of fetal urology grade 3 hydronephrosis is equivalent to preserved percentage differential function

Appropriate timing of performing abdominal ultrasonography and termination of follow-up observation for antenatal grade 1 or 2 hydronephrosis

Background

Most cases of antenatal the Society of Fetal Urology (SFU) grade 1or 2 hydronephrosis (HN) improve or resolve spontaneously with conservative treatment. However, there is no consensus on the duration of follow-up for cases of grade 1or 2 HN. The aim of this study was to determine the need for continuous follow-up period and new management of children with antenatal grade 1or 2 HN.

Methods

Subjects underwent ultrasonographic assessment for HN according to the SFU classification. We retrospectively evaluated 112 patients with postnatal grade 1 HN and 69 with grade 2 HN using abdominal ultrasonography between January 2010 and December 2017. We examined the change in HN grade on repeat ultrasonography. Kaplan–Meier method was used to show the effect of HN grade on the rate of HN changes.

Results

The mean follow-up duration was 44.9 ± 36.4 months (range 12–274). Initial SFU grade 1 HN disappeared in 47.0% of cases at 12 months, 66.4% at 24 months and 73.2% at 48 months. Initial SFU grade 2 HN showed improvement in grade in 74.7% of cases at 12 months, 88.3% at 24 months and 89.5% at 48 months. However, 14.6% of SFU grade 1 and 2.8% of SFU grade 2 cases increased in grade and of the 17 cases, 16 cases worsened within the first 6 months. No cases with increased grade required pyeloplasty. Initial disappearance and later reappearance of HN occurred in 40.5% of SFU grade 1 and 2 cases. The mean duration of later reappearance of HN was 39.1 ± 36.2 months (range 12–137). No cases showed reappearance of HN after more than 1 year.

Conclusions

Ultrasonography within the first 6 months was necessary for management of children with antenatal grade 1or 2 HN, because some patients showed worsening. After that, it is considered safe to spread the follow-up interval for stable cases. Most cases of grade 1or 2 HN resolved spontaneously, however a few cases reappeared within 1 year. Therefore, ultrasonography after 1 year was necessary in children with HN that spontaneously disappeared. The appropriate time to end the follow-up was considered to have been after 1 year or more has passed since the disappearance was confirmed.

Prenatal Urinary Tract Dilatation

Urinary tract dilatation (UTD) is the most common congenital anomaly detected on prenatal ultrasonography (US), affecting 1% to 3% of all pregnancies. This article focuses on the prenatal detection of UTD and the postnatal evaluation and management based on the UTD grading system risk assessment. Prophylactic antibiotics and postnatal imaging are discussed. The recent management trend is for a more conservative approach to minimize unnecessary testing and exposures to the fetus and neonate while detecting those who may have clinically significant disorder. The renal bladder US remains a critical part of the evaluation and helps guide further investigations.

Diagnostic accuracy of Onen's Alternative Grading System combined with Doppler evaluation of ureteral jets as an alternative in the diagnosis of obstructive hydronephrosis in children

Introduction

Ureteropelvic junction obstruction (UPJO) is a common congenital anomaly leading to varying degrees of hydronephrosis (HN), ranging from no apparent effect on the renal function to atrophy. Evaluation of these children is based on Diuretic Renal Scintigraphy (DRS) and Ultrasonography (US). Recent studies have suggested that new parameters of conventional and color Doppler ultrasonography (CDUS) may be useful in discriminating which kidneys are obstructed. The present study aims to assess the diagnostic accuracy of such parameters in the diagnosis of obstruction in children with UPJO.

Methods

We evaluated 44 patients (33 boys) with a mean age of 6.53 ± 4.39 years diagnosed with unilateral high-grade hydronephrosis (SFU grades 3 and 4). All underwent DRS and index tests (conventional US and CDUS to evaluate ureteral jets frequency) within a maximum interval of two weeks. Hydronephrotic units were reclassified according to the alternative grading system (AGS) proposed by Onen et al. Obstruction in the DRS was defined as a differential renal function <40% on the affected side and/or features indicating poor drainage function like T1/2 >20 minutes after the administration of furosemide, and a plateau or ascending pattern of the excretion curve.

Results

Nineteen hydronephrotic units (43.1%) were obstructed. Some degree of cortical atrophy—grades 3 (segmental) or 4 (diffuse)—was present in those obstructed units. AGS grades had 100% sensitivity, 76% of specificity and 86.4% of accuracy. The absence of ureteral jets had a sensitivity of 73.68%, a specificity of 100% with an accuracy of 88.6%. When we analyzed the two aspects together and considered obstructed the renal units classified as AGS grade 3 or 4 with no jets, sensitivity increased to 78.9%, accuracy to 92%, remaining with a maximum specificity of 100%. These features combined would allow us to avoid performing DRS in 61% of our patients, leaving more invasive tests to inconclusive cases.

Conclusions

Although DRS remains the mainstay to distinguishing obstructive from non-obstructive kidneys, grade of hydronephrosis and frequency of ureteral jets, independently or in combination may be a reliable alternative in the mostly cases.This alternative approach has high accuracy, it is less invasive, easily reproducible and may play a role in the diagnosis of obstruction in pediatric population.

A practice pattern assessment of members of the Society of Pediatric Urology for evaluation and treatment of urinary tract dilation

INTRODUCTION

Over the last decade the literature, including a multidisciplinary consensus statement, has supported a paradigm shift in management of urinary tract dilation, yet the impact on practice patterns has not been well documented.

OBJECTIVE

This study aims to elucidate specific practice patterns for treatment of prenatal unilateral urinary tract dilation and to assess surgical intervention patterns for ureteropelvic junction obstruction.

STUDY DESIGN

An online survey was distributed to 234 pediatric urologists through the Society of Pediatric Urology. The survey was composed of five clinical case scenarios addressing evaluation and management of unilateral urinary tract dilation.

RESULTS

The response rate was 71% (n = 168). Circumcision status, gender, and grade were significant factors in recommending prophylactic antibiotics for newborn urinary tract dilation. Prophylactic antibiotic use in the uncircumcised male and female was twice that of a circumcised male for grade 3 (Table). This difference was minimized for grade 4. Use of VCUG was high for circumcised males with grade 3 or 4 (Table). The choice of minimally invasive surgery for ureteropelvic junction repair increased with age from 19% for a 5-month-old, 49% for a 2-year-old, and 85% for a 10-year-old. Notably, 44% of respondents would observe a 10-year-old with intermittent obstruction. Retrograde pyelography was recommended in conjunction with repair in 65% of respondents. Antegrade stent placement was the most common choice (38-47%) for urinary diversion after pyeloplasty. Regarding postoperative imaging, only 5% opted for routine renal scan whereas most would perform renal ultrasound alone.

DISCUSSION

Practice patterns seen for use of prophylactic antibiotics are in agreement with the literature, which promotes selective use in those at highest risk for urinary tract infections. Interestingly, use of aggressive screening was not concordant with this literature. Several studies have indicated an increased usage of robotic pyeloplasty; however, results indicate that minimally invasive surgery is not preferred in those younger than 6 months. Study limitations include use of clinical case scenarios as opposed to actual clinical practice.

CONCLUSION

Practice patterns for prophylactic antibiotic use for neonatal urinary tract dilation are dependent on gender, circumcision status, and grade. The use of minimally invasive surgery for ureteropelvic junction repair increased with patient age, with 50% preferring this modality at 2 years.

Teaching of the Society for Fetal Urology grading system for pediatric hydronephrosis is improved by e-Learning using Computer Enhanced Visual Learning (CEVL): A multi-institutional trial

INTRODUCTION

It is unclear how clinicians learn to grade pediatric hydronephrosis (HN) and how effective their training has been. We sought to: 1. Assess how clinicians learn to grade HN and their confidence in their training and abilities and 2. To assess Computer Enhanced Visual Learning (CEVL) e-Learning to learn the Society for Fetal Urology (SFU) grading system for pediatric HN.

METHODS AND MATERIALS

A multi-institutional online survey was distributed to pediatric urologists, nephrologists, and radiologists. Respondents used a 6-point Likert scale (0 = not confident to 5 = very confident) to assess their confidence in knowledge of the criteria, indications, and ability to grade HN, and how they learned to grade. Participants assigned SFU grades to 15 neonatal ultrasounds (US). A CEVL module on the SFU grading system was accessed and a post-CEVL survey completed. Changes in confidence and accuracy of grading were compared before and after CEVL e-Learning.

RESULTS

The most common method of learning was "casually during training" (44.5%). Significant increases in confidence in knowledge of criteria, indications, and ability to grade, as well as the accuracy of grading were seen following CEVL e-Learning (Figure A and B).

DISCUSSION

Although the SFU grading system is considered the predominant grading system for HN, its application in clinical practice has been inconsistent. While this may be due to the grading system itself, it is possible that deficient training and confidence are the root causes. Our data supports this by demonstrating that most clinicians receive only casual training and accordingly, report low confidence in their knowledge and ability to grade HN. Therefore, we conclude that there exists a strong need to improve the teaching of the SFU grading system. e-Learning has been shown to be effective in teaching difficult topics and skills. We demonstrate that e-Learning with CEVL is effective in increasing both the confidence and accuracy of SFU grading of pediatric HN. Limitations of our study include a small sample size, low response rate, and discrepant participation. Furthermore, we did not assess the extent to which the CEVL module was used or include a control group learning through traditional means. Therefore, we were unable to evaluate the efficiency of learning or be certain that the improvements seen were derived exclusively from CEVL.

CONCLUSION

Current training in SFU grading of HN is mostly unstructured and inaccurate grading is common. Learners who use CEVL show improvements in their confidence and ability to SFU grade HN.

Hydronephrosis: prenatal and postnatal evaluation and management

Antenatal hydronephrosis (ANH) is one of the most frequently detected abnormalities found on routine prenatal ultrasounds, affecting 1% to 4.5% of all pregnancies. Despite its prevalence, there continues to be uncertainty regarding the clinical impact after birth. Prognosis depends on the severity of the dilation. Expectant prenatal management is the rule with fetal intervention rarely needed in a few select cases. Ureteropelvic junction obstruction and vesicoureteral reflux are the most common postnatal diagnoses. A renal and bladder ultrasound is essential in the follow-up of patients with ANH and helps dictate further investigation with voiding cystourethrography and/or diuretic renography.

Mild to moderate postnatal hydronephrosis--grading systems and management

No universal guidelines exist for the management of patients with mild to moderate antenatal hydronephrosis (ANH). Unsurprisingly, practice patterns vary considerably with respect to recommendations for postnatal evaluation and follow-up imaging schedule. Although some clinical tools are available to specifically grade ANH and postnatal hydronephrosis, these are commonly used interchangeably with varying degrees of success. A universal classification system and nomenclature are needed to best identify patients at risk of renal deterioration, UTI and need for surgical intervention. We present our own approach to postnatal risk stratification and management, including recommendations regarding serial ultrasonography schedule, prophylactic antibiotics, voiding cystourethrogram and renal scintigraphy.

Prediction of the outcome of antenatally diagnosed hydronephrosis: a multivariable analysis

PURPOSE

The majority of cases of antenatal hydronephrosis (ANH) resolve postnatally. The purpose of this study was to determine independent predictors for resolution of ANH using a multivariable analysis model.

METHODS

A retrospective study was performed on 100 children (80 males and 20 females, 118 renal units) referred to a single pediatric urology clinic with the diagnosis of ANH. Patients with ultimately resolved ANH were compared to unresolved cases in a univariate analysis in terms of sex, laterality, severity of ANH using Society for Fetal Urology (SFU) grading, antero-posterior pelvic diameter (APD), parenchymal thickness, renographic differential function and development of clinical complications, followed by a Cox proportional hazard model for multivariable analysis.

RESULTS

Median follow up was 34 months (range 3-204). Hydronephrosis in 62 units resolved spontaneously and pyeloplasty was done in 29. The remaining 27 units had persistent uncomplicated hydronephrosis at last follow up. Multivariate analysis showed larger APD (hazard ratio 0.54; 95%CI 0.36-0.80) and SFU grade 4 (HR 0.34; 95%CI 0.13-0.90) to be associated with a significantly lower likelihood of resolution. The mean initial APD in resolved cases was 9.4mm as opposed to 29.0mm in cases requiring surgery.

CONCLUSION

Large initial APD has predictive value for surgical intervention. This model is helpful in counseling families about the potential outcomes of ANH.

When is it necessary to perform nuclear renogram in patients with a unilateral neonatal hydronephrosis?

PURPOSE

To examine whether anteroposterior(AP) pelvic diameter on postnatal renal ultrasound scan (US) can predict both initial differential renal function (DRF) and deterioration in DRF in patients with prenatally diagnosed hydronephrosis.

METHODS

One hundred and thirty-three patients diagnosed with a unilateral prenatal hydronephrosis, confirmed postnatally, were evaluated. We tried to find the cutoff values for initial AP diameter and change in AP diameter based on initial DRF and renal outcome. Reduction of 5% or more was considered as deterioration in function. All patients had an initial US scan at a mean age of 1.62 weeks (1-4) and nuclear renogram at 13.24 weeks (7-21). All patients had a second US at a mean age of 10.58 weeks (6-19). 119 patients had a second renogram.

RESULTS

Initial mean pelvic diameter was 20.86 (11-49) mm. When AP pelvic diameter was less than 20 mm, 98.6% of all renal units had a function of ≥40%. The cutoff point for AP pelvic diameter was 19.05 when DRF was ≥45% (P < 0.001). When the reduction in hydronephrosis in pelvic diameter was analyzed to predict the initial renal function, a cutoff point of 1.3 mm decrease was found when initial renal function was ≥40% (P < 0.001). The reduction in AP pelvic diameter was 2.1 mm when initial DRF was ≥45% (P = 0.009). For all patients except 3 individuals, if there was a reduction in AP diameter or the AP diameter was stable, then no reduction in function was observed.

CONCLUSION

When the AP pelvic diameter is less than 20 mm at presentation, DRF is normal. If the AP diameter is stable or decreases, there is unlikely to be a significant deterioration in renal function. Consequently, in selected patients, congenital unilateral hydronephrosis can be followed with serial ultrasounds.

Effectiveness of the computer enhanced visual learning method in teaching the society for fetal urology hydronephrosis grading system for urology trainees

OBJECTIVE

A novel educational tool, Computer Enhanced Visual Learning (CEVL), has been used to improve resident performance of routine orchiopexy. Our objective was to assess the effect of a CEVL teaching module on the diagnostic accuracy of medical trainees in grading neonatal hydronephrosis on ultrasound using the Society for Fetal Urology (SFU) grading system.

METHODS

The authors designed an online-based computerized tutorial to teach the grading of hydronephrosis using multimedia, practice cases and a grading checklist. In a crossover design trial, 29 residents and medical students were asked to grade 16 standard neonatal renal ultrasounds using the SFU grading system before and after viewing the web-based e-learning module. Primary outcome was percent improvement in grading accuracy.

RESULTS

The mean percentages of ultrasounds that were graded correctly before and after CEVL intervention were 51% and 72% respectively (mean improvement 21%, 95% CI 3-13%, P < 0.001). Residents graded correctly 56% of ultrasounds before and 74% after CEVL (mean 18%, 7-28%, P = 0.002). Medical students graded correctly 37% before and 69% after CEVL (mean improvement 32%, 95% CI 16-48%, P = 0.002).

CONCLUSION

Exposure to a computer-based learning module based on the CEVL platform improved urology residents' and medical students' correct assignment of SFU hydronephrosis grading to newborn renal ultrasounds.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.