Antenatal Hydronephrosis(ANH):

Surgical Aspects

Dr Prashant Jain
Sr. Consultant
Pediatric Surgery & Pediatric Urology
Dr BLK Superspeciality Hospital, New Delhi
 Antenatal Hydronephrosis

 Renal anomalies accounts for 17% of all the

congenital anomalies

 Hydronephrosis is commonest
(1-5% of all pregnancies)

 Management dilemma
 ANTENATAL HYDRONEPHROSIS
DILATATION OF FETAL RENAL COLLECTING SYSTEM

Transient dilatation
Vesico-ureteric reflux
(41 to 88%)
(10 -20%)

True Obstruction
(20 -50%)
What is True Obstruction???

• Anatomical or Functional impairment in urinary

drainage from kidney which ultimately is going to
affect the renal function

Impairment in Urinary drainage

Dilatation

Impairment of renal functions

True obstruction

Pelvi Ureteric Junction

Uretero-vesical Junction

Bladder outlet
Posterior Urethral Valve
Why diagnostic Dilemma?

 Transient impairment of urinary flow

 Permanent impairment of urinary flow

IMPORTANT TO DIFFERENTIATE
 Evaluation Of ANH
- Ultrasound

- Micturiting Cystourethrogram

- Nuclear renal scan

* DRCG
* DMSA
* DTPA

- Magnetic Resonance Urography (MRU)

 Antero-Posterior Diameter of
Renal Pelvis (Transverse plane)
Definition of ANH by AP(Antero-Posterior) Diameter
of Renal Pelvis

Second trimester Third trimester

Mild 4 to <7 mm 7 to <9 mm

Moderate 7 to 10 mm 9 to 15 mm
Severe >10 mm >15 mm
 Case: Antenatal hydronephrosis

 Antenatal scan- 32 wks

 Lt hydronephrosis with dilated pelvicalyceal system; No
hydroureter
 Antero-posterior(AP) diameter of Lt renal pelvis: 13 mm
 AFI: 9

 What Next??

13mm
 Counseling is Challenge…..

 Is it a transient dilatation or pathological

dilatation?
 What is accurate diagnostic tool?
 How to prognosticate?
 How long to follow?
 When to operate?
 Risk Of Postnatal Pathology

 Mild: 11.8%

 Moderate:44.1%

 Severe: 88.3%
 Moderate hydronephrosis (Resolution: 40-
50%)
 CAN NOT BE IGNORED
 Re-assessment after delivery
 Will require regular follow up with USG and
renal scans
 Continue pregnancy till term
 Post natal

 Newborn passing urine

 Bladder not palpable

What Next?

 USG KUB after 48-72hrs

AP Diam: 14mm

What Next?
 Chemoprophylaxis
 USG & DTPA Scan after 1 month of age
 ANTENATAL HYDRONEPHROSIS
Post Natal USG at 48 -72 hrs

No hydronephrosis Hydronephrosis present Hydro-ureteronephrosis present

Mild Moderate/severe Chemoprophylaxis

Early MCU
Repeat USG at 3 months USG at 3, 6, 12 mths

No hydronephrosis Chemoprophylaxis
No further evaluation ??MCU
DTPA Scan

B/L HN, BLADDER OUTLET OBSTRUCTION, AND SINGLE KIDNEY NEEDS EARLY
EVALUATION
 Consider Surgery

 Split function is < 40%

 Progressive increase in AP diameter

 Symptomatic
 RK AP DIAMETER LK AP DIAMETER

ANTENATAL - 14 MM

DAY3 - 14 MM

1MTH - 18 MM
DTPA scan
3MTH - 18 MM

6MTH 19

12MTH 19

Advised DTPA scan

At 2 months of age
At 1 year of age
Pyeloplasty
Case: Antenatal Hydronephrosis
Rt AP of Pelvis diameter of 6
20 wks scan mm

Rt AP diameter of pelvis 8 mm
28 wks scan

36 wks scan Rt AP diameter of pelvis 7mm

Before discharge Rt AP of Pelvis diameter of 8 mm

USG at 1mth Rt AP of Pelvis diameter of 8 mm

USG at 3mth & 1 year No dilatation

 Antenatal Scan 32 wks

 Bilateral hydronephrosis and hydroureter

 Bilateral AP diameter 7mm
 Bilateral echogenic kidneys
 Bladder full; Key hole sign

 AFI 8
• POSSIBILITIES????
 Antenatal Scan:
Hydrouretronephrosis

 Vesico-ureteric reflux
 Vesico-ureteric junction obstruction
 Posterior Urethral Valve
 Counseling

 Obstruction at vesico-urethral junction

 Need for surgery(Endoscopic
Fulgaration)
 Need for long term follow up

 Risk of ESRD
 Case…

37 wks, LSCS, 1.6 kg

USG: B/L HN & HU
Thinned out renal parenchyma
Thickened and distended bladder

Catheterised
Serum Na: 132
Serum K: 5.3
S. Creatinine:1.6
VBG: Normal
Urine C/S: sterile
MCU
Endoscopic Fulgaration of Valves
 Post Operataive

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

 Intermittent dribbling present

 Urinary Stream good
 DMSA: left scarred kidney
 S.Creatinine : 0.6
 Dilatation on USG is less, PVR5 ml
 Now 2yrs
 No chemoprophylaxis

 Needs long term follow up

 MCU on follow up
Fulgaration with resectocope
 Case

 Ante natal USG s/o left moderate hydronephrosis

 Repeat USG, dilatation of upper kidney with hydroureter s/o
duplex system and ureterocele
VCUG and MRU
Ureterocoel Incision
Repeat USG after 2 wks
 CASE

 Antenatal scan 32 wks

 Left hydronephrosis AP diam of renal pelvis
11mm
 Left ureteric dilatation present

 Right Kidney normal

 Bladder normal
 Post natal
 Term male newborn;3kg
 Newborn passing urine
 Bladder not palpable
WHAT NEXT

 Antibiotic prophylaxis
 USG KUB after 48-72hrs
AP Diam: 11mm;Ureter dilated
WHAT NEXT
 MCU under antibiotic cover
 MCU

• Rt Grade III VUR

 DMSA Scan

• Scarred left kidney

 Follow up Advice

 Chemoprophylaxis
 Early toilet training
 Avoid constipation
 Perineal Hygine

 Growth/BP monitoring
 Regular Urine
examination/ultrasounds/DMSA scan
 When to intervene?

 Recurrent breakthrough UTI

 Progressive scars in DMSA SCAN
 Parents choice

 Endoscopic injection Vs Ureteric

Reimplantation
 STING technique
(Subureteric transurethral injection)

43
 Follow Up

 Chemoprophylaxis stopped
 Follow up with nephrologist
 CARRY HOME MESSAGE

 Do not ignore ANH even if it is transient

 Remember AP diameter of pelvis 4/7/10 mm

 Most ANH just need surveillance

 Hydronephrosis is not synonymous with

obstruction

 Be positive, supportive, ANH usually have good

prognosis.