Andr#{233}eGrignon,

#{149} Pierre Robitaille,

MD

#{149}

MD

Robert Filion, MD #{149} Yves Homsy, MD

Filiatrault, Boutin, #{149} Richard Leblond,

#{149} Helene

#{149} Denis

MD MD MD

Urinary Classification

Tract Dilatation in Utero: and Clinical Applications

A morphologic classification of in utero urinary tract dilatation is presented. Ninety-two hydronephrotic fetal kidneys diagnosed with ultrasound were graded according to the proposed classification. The findings suggest that grade I dilatation

W
tions

generalized use of obstetnical ultrasonography (US), fetal hydronephrosis can now be detected systematically. Recent pubhicahave older indicated than that 24 weeks minimal de-

ITH the

Grade

#{149}
Physiological Normal calyces
,

Ca1ycea

dilation

Size of pev1s

Ca

Grade

II

1 - 1.5 co

grees
fetuses

of pyehectasis (1) and that hanger than

hydnonephnosis follow-up of uniform

are common

in
Grade III Sllqht Olation > 1.5 cm

menstru-

(anteropostenior diameter of the renal pelvis less than 10 mm) should be considered normal. Grades II and III constitute an intermediate hydronephrosis, requiring postnatal urologic surgery in nearly half the cases. Grade IV (moderate dilatation of the calyces, with easily identified residual renal cortex) and grade V (severe dilatation of the calyces with atrophic cortex) are clearly pathologic and require neonatal conrective surgery. It is hoped that use of this simple and practical classification will facilitate communication and comparison of results in the literature.
Index
tus,

a! age pelvis
icant close sence

those with a renal 10 mm have signifabtenmin-

Grade

IV

Moderate

dilation

) 1.5 cm

warranting (2). However, and specific

Grade V

Severe dflation + atrophic cortex

> 1.5 cm

ology that describes fetal hydronephnosis

transfer of valuable

and quantitates complicates

information be-

Figure
tract

1.
dilatation

Prenatal
after

grading
20th week

of fetal

urinary

of gestation.

tween

ultrasonologists.

Furthermore,

hack of knowledge of the range of normality in fetal urinary tract dihatation is often responsible for unnecessary and costly transfer of infants or

oveninvestigation and may warranted source of parental We propose a morphologic cation of fetal hydronephrosis define the degree of urinary
tasia that physiologic may be considered limits.

be an unanxiety. chassifiand tract ecwithin

terms:
US studies,

Fetus,

genitouninary

system

#{149} Fe-

856.1298 #{149} Genitourinary system, abnormalities #{149} Genitouninary system, US studies, 88.1298

Radiology

1986; 160:645-647

MATERIALS

AND

METHODS
Figure 2. Abdominal transverse sonogram

Between January 1981 and July 1984, 34,592 fetal US examinations were performed at our institution. All sonograms were obtained with either a 3.5- or 5.0MHz
The tween
nancy. thus

probe.
first

the
All detected

sonogram 20th and

cases were

was obtained be39th week of preghydronephrosis according to graded

of fetus at 32 weeks gestation. The hydronephrosis is grade I because the renal pelvis is less than 1 cm in anteropostenior diameter. Arrows indicate dilatation of the pelvis. S spine, RK = right kidney, LK left kidney.

of fetal

From the Departments of Radiology (AG., R.F., D.F.), Nephrology (P.R.), Urology (Y.H., H.B.), and Nuclear Medicine (R.L.), H#{244}pital

Sainte-Justine,

University

of Montreal,

3175

Chemin C#{244}te Ste-Catherine, Montreal, Quebec, Canada H3T iC5. Received July 23, 1985; accepted and revision requested October 18; final
revision received July print requests to AG.
0

19, 1986.

Address

re-

the proposed classification described in Figure 1 . This classification consists of five grades according to the severity of the hydronephrosis. Before the 20th week of gestation, kidneys are too small to permit precise grading. Grading was always determined from sonograms obtained when the fetal bladder was empty. Norma! ureters cannot be visualized on sonograms. Any increase up to 1 cm in the anteroposterior diameter of the renal pelvis on a transverse sonogram was considered grade I (Fig. 2). A grade II hydronephrosis is reached when the anteropostenior

tasia

has

yet

occurred

(Fig.

3).

A slight

di-

latation of the calyces independent of the pelvic size is considered grade III (Fig. 4). Grade IV includes a moderate dilatation of the calyces independent of the pelvic size, with a well-visualized cortex (greater than 2 mm thick) (Fig. 5). Grade V is reached when severe dilatation of the calyces associated with cortical atrophy (cortex less than 2 mm thick) is seen (Fig. 6).
All neonates known to have had fetal

RSNA,

1986

diameter

exceeds

1 cm but

no calyceal

ec-

hydronephrosis underwent renal US 3-7 days after birth. We performed renal isotope scanning (RIS) with technetium-99m

645

Figure 3. Abdominal transverse sonogram of fetus at 22 weeks gestation. The hydronephrosis is grade II. Arrows indicate dilata-

Figure 4. Abdominal transverse sonogram of fetus at 34 weeks gestation. The hydronephrosis is grade III. Arrows indicate slight

tion of the ney.

pelvis.

spine,

RK

right

kid-

dilatation of the calyces. centa, LK = left kidney.

spine,

pla-

Figure 5. Abdominal of fetus at 28 weeks

phrosis is grade

transverse

sonogram

gestation.

The
indicate

hydronemoder-

IV. Arrows

diethylenetriaminepentaacetic

acid

in 29 kidneys

(Fig.

7). Twenty-eight

ate dilatation left kidney, Eight suggesting of them stenosis

of the calyces. S = spine, LX P = pelvis, C = renal cortex.

(DTPA)

during

furosemide-induced

di-

uresis (1 mg/kg) and excretory urography in 60 patients and 57 patients, respectively, during the 1st month of life. Since renal isotope scans and excretory urograms remained normal on follow-up study in the first 1 1 patients with normal sonograms obtained in the immediate postnatal period, further follow-up examinations were not done in later cases when early postnatal studies were all normal. Voiding cystourethrography (VCU) was performed during the 1st month of life in 59 patients (84%).

of these considered

kidneys (97%) were finally normal since the dihata-

tion either completely resolved on a subsequent fetal sonognam on the postnatal investigation proved to be entirely normal. The only patient with persistent grade I hydnonephrosis had a mild UPJ stenosis, which has now been followed up for 3 years

kidneys were hyperechoic, renal dysplasia (3, 4). Two (grades IV and V) had UPJ and a favorable outcome af-

ten pyehophasty. The kidneys (grades IV and V) in one infant with bilateral ureterah stenoses and acute renal failune were also hyperechoic. A hyper-

without Grade
tified

any signs of deterioration. II hydnonephrosis was

in 31 kidneys. Fifteen (48%)

echoic idenbe-

kidney
with from

(grade

IV) was

found

in a baby who died

tnisomy 13 syndrome an unrelated comphi-

came normal after are being followed

12 (39%) required

birth, four (13%) up medically, and

urohogic surgery.

cation, detected

and another in a child

(grade IV) was with a posterior

a di-

RESULTS
Ninety-two kidneys ed to be hydronephrotic obstetrical sonograms Postnatal investigation hydronephrosis was were suspecton routine of 70 fetuses. revealed that secondary to

Grade

III hydronephrosis

was

diaga

urethral valve. In two additional cases cortical cysts were present,

nosed in 16 kidneys. Two (13%) had normal appearance at the first postnatal assessment, four (25%) are being followed up medically, and ten (62%) required surgery.

rect

sign

of renal

dysphasia

(3, 4). The

obstruction prune-belly

was associated with syndrome in one (grade

II) and other.

UPJ

stenosis

(grade

V) in the

ureteropelvic
in 29 kidneys, in six, posterior

junction
unetenovesical urethral

(UPJ)

stenosis

The

14 kidneys

with

grade

IV hyDISCUSSION
The struction hong-term on renal consequences function congenital who were of obhave obfol-

stenosis valve in

four, vesicoureteral abdominal muscle

belly) syndrome

reflux in three, deficiency (prunein three, and distal

dnonephrosis and the two with grade V hydronephrosis all needed surgical correction. None of the 22 grade II and III kidneys that required postnatal surgery

been
patients structive

studied

by Mayor

et al. (5) in 24

unetenah

stenosis

in two,

for a total

of
kid-

showed

regression

of the

hydroneTwo (17%) that

47 abnormal neys suspected

kidneys. Forty-five of being hydrone-

phrosis during cases of grade

pregnancy. II hydronephnosis

with severe uropathy

lowed

up for

1-10

years

after

surgical

phrotic during the fetal stage normal after birth. Grades based on initial and
sonograrns ity of cases did (72

were final

required
throughout progressed

surgery

remained
III, five two

stable
(42%) (17%) to

pregnancy, to grade

not vary in the majorof 92 cases [78%]). Of

the 20 cases in which changes were observed, 16 showed progression. One grade I progressed to grade II; ten grade II cases progressed to five grade III, two grade IV, and three grade V; three grade III cases progressed to grade IV; and two grade IV progressed to grade V. Four cases showed regression (from grade II to normal). Grade I hydnonephnosis was seen
646

grade IV, and three (25%) to grade V. Of the kidneys graded III that required surgery, seven (70%) remained unchanged and three (30%)
progressed nancy. None subjected to grade of the pregnant to invasive IV during women intrauterine pregwere

treatment. Rena! function improved or normalized only in patients who had undergone surgery during the first year of life. When surgery was performed on patients older than 2 years, progressive deterioration of re-

nal

function Prenatal

occurred. diagnosis,
intervention facilitates

which

allows
when managein-

early surgical dicated, greatly

ment a

and

should

improve

the

progI

procedures.
fetus with

One
bilateral

woman
ureteral

carrying
stenosis

required induction weeks of pregnancy

appearance

of labor because

at 34 of the

nosis of urinary tract dilatation. Our findings strongly suggest that grade dilatation is physiologic. The reasons

for persistence
nary tract

or regression
dilatation remain

of ununclear.

of ohigohydnamnios.

Radiology

September

1986

(97%) Grade I 29 kidneys

(3%)

[
(45%)

28

(13%)

(35%)

Grade

31 kldeeys

[
(13%)

15

(25%)

(62%) _IO_

Grade

I!

16 kdeeys

[2

[.. 4

) 100%)
Grade IV 14 kIdneys 14

(100%) Grade V 2 kIdneys 2

The grading of upper urinary tract dilatation provides a practical rnethod of gauging the severity of fetal hydnonephrosis. It is also valuable in predicting postnatal outcome and is helpful in determining which patients require surgery. If adopted, this classification would allow precise terminology to be used and thus facilitate comparison of results and

exchange
Acknowledgment:

of information.
The authors
assistance Collins

N
thank Sylvie

Figure
kidneys grams

7.

Outcome

of 70 cases

were to have

suspected on hydronephrosis.

in which 92 antenatal sonoNonshaded

areas
normal.

represent
Striped

kidneys
areas

determined
represent kidneys

to be ar-

Tass#{233} secretarial for Veillette and Denyse trations.

and Richard for medical illus-

treated with eas represent

medical kidneys

follow-up. Shaded treated surgically.

References
1. Hoddick WK, Filly RA, Mahony BS, Callen PW. Minimal fetal renal pyelectasis. J UItrasound Med 1985; 4:85-89. Arger PH, Coleman BC, Mintz MC, et al. Routine fetal genitouninary tract screening. Radiology 1985; 156:485-489. Glazer GM, Filly RA, Callen PW. The varied sonographic appearance of the urinary tract in the fetus and newborn with urethral obstruction. Radiology 1982; 144:563568. Mahony BS, Filly RA, Callen PW, Hricak H, Golbus MS. Harrison MR. Fetal renal dysplasia: sonographic evaluation. Radiology 1984; 152:143-146. Mayor C, Genton N, Torado A, Guignard Jp. Renal function in obstructive nephropathy: long term effect of reconstructive surgery. Pediatrics 1975; 56:740-743. McCrory WW. Developmental nephrology. Cambridge, Mass.: Harvard University Press, 1972; 51-79. Laing FC, Burke VD, Wing VW, Jeffrey RB Jr., Hashimoto B. Postpartum evaluation of fetal hydronephrosis: optimal timing for follow-up sonography. Radiology 1984; 152:423-424.

2.

served Figure 6. Abdominal transverse sonogram of fetus at 38 weeks gestation. The hydronephrosis dilatation phy. S vis. is grade V. Arrows indicate severe of the calyces with cortical atro= spine, RK = right kidney, P pel-

transient

hydronephrosis.

Since

grade

I fetal

hydnonephnosis
3.

Regression suggests that the dilatation may have been due to transient vesicouneterah refhux, mild resolving obstruction, on a nonobstructive mechanism (6). A full bladder may also be responsible for slight dilatation of the urinary tract. In the fetal lamb, urine production is first detected at the beginning of the second tnrnester (6); its production peaks early in the third trimester and decreases just before birth. Should tern of urine production mans, it might account such a patoccur in hufor the ob-

disappears after birth in as many as 97% of cases, we believe that no postnatal investigation is necessary. Kidneys with either grades II on III hydronephnosis must be followed closely after birth and require further investigation, since as many as 47% needed postnatal surgery in our study. Kidneys with grades IV and V are cleanly pathologic, as all required postnatal surgical correction.

4.

5.

6.

Cane

should

be taken

when

inter7.

preting neonatal sonognams obtained in the first 24 hours of life, since mild and moderate hydnonephrosis may transiently be absent (7). This is probably due to a relative state of dehydration and decreased ghornerulan filtration rate during the first 24 hours of life. Therefore, we usually obtain the initial sonograir 3 days aften delivery in cases diagnosed as intrautenine hydronephnosis of grades

I-Ill.

Volume

160

Number

Radiology

#{149} 647