Author's Accepted Manuscript

Society For Fetal Urology Classification Versus Urinary Tract Dilation Grading
Systems For Prognostication In Prenatal Hydronephrosis: A Time To Resolution
Analysis

Luis H. Braga , Melissa McGrath , Forough Farrokhyar , Kizanee Jegatheeswaran ,

Armando J. Lorenzo

PII: S0022-5347(17)77985-2
DOI: 10.1016/j.juro.2017.11.077
Reference: JURO 15127

To appear in: The Journal of Urology

Accepted Date: 20 November 2017

Please cite this article as: Braga LH, McGrath M, Farrokhyar F, Jegatheeswaran K, Lorenzo AJ, Society
For Fetal Urology Classification Versus Urinary Tract Dilation Grading Systems For Prognostication In
Prenatal Hydronephrosis: A Time To Resolution Analysis, The Journal of Urology® (2017), doi: 10.1016/
j.juro.2017.11.077.

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 ACCEPTED MANUSCRIPT

SOCIETY FOR FETAL UROLOGY CLASSIFICATION VERSUS URINARY TRACT

DILATION GRADING SYSTEMS FOR PROGNOSTICATION IN PRENATAL

HYDRONEPHROSIS: A TIME TO RESOLUTION ANALYSIS

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Luis H. Braga MD PhD1,2,3*†, Melissa McGrath3†, Forough Farrokhyar PhD2,4, Kizanee

Jegatheeswaran B.H. Sc3, Armando J. Lorenzo MD MSc5

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1
Department of Surgery, Division of Urology, McMaster University, Hamilton, Ontario
2
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario

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3
McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton,
Ontario
4
Office of Surgical Research Services, Department of Surgery, McMaster University, Hamilton, Ontario

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5
Division of Urology, The Hospital for Sick Children, and Department of Surgery, University of Toronto, Toronto,
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Ontario

†
Both authors equally contributed to the preparation of this manuscript
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KEY WORDS: Children, hydronephrosis, prenatal, urinary tract dilation, prospective.

DISCLOSURE: This study did not receive external funding. The authors declare no conflict of
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interest to disclose.
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*
Corresponding Author:
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Luis H. Braga MD, MSc, PhD

Associate Professor, Division of Urology, Department of Surgery

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McMaster University
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1280 Main Street West, Hamilton, Ontario, L8S 4K1

Tel: 905-521-2100 ext. 73777 Fax: 905-570-8971

Email: braga@mcmaster.ca

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ABSTRACT

PURPOSE: The Urinary Tract Dilation (UTD) grading system for prenatal hydronephrosis (HN)

was introduced to address potential shortcomings of the SFU classification. HN resolution is an

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important patient outcome and frequently discussed during family counselling. Herein we

compare these two grading systems and their ability to predict time to HN resolution.

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MATERIALS AND METHODS: 855 prospectively screened patients between 2009-2015 with

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prenatal HN due to uretero-pelvic junction-like, primary non-refluxing megaureter or vesico-

ureteral reflux; with 454 being excluded due to surgeries, late referrals, absence of postnatal

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dilation and presence of other anomalies, resulting in 401 eligible patients to be included for
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analyses. HN grades collected at baseline and last follow-up were compared to identify

resolution trends over time. HN resolution was defined as renal pelvis APD≤10mm at last
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follow-up. Time to resolution was analyzed using Cox proportion regression.

RESULTS: Of 401(81% male) patients, 328(82%) resolved over a mean follow-up of 24+18
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(max. 107 months). The cumulative resolution rate at 3 years was 98% for SFU grade I HN
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patients, 87% for SFU grade II, 76% for SFU grade III and 57% for SFU grade IV. Likewise, the
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3-year HN resolution rate was 90% for UTD P1 patients, 81% for UTD P2 and 71% for UTD P3

group.
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CONCLUSIONS: Patients with distinctive baseline HN grades (classified with either the SFU
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or UTD system) had significantly different resolution times for HN (p<0.001). Counselling

families regarding the time to resolution of prenatal HN should remain the same whether using

SFU or UTD grading systems.

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INTRODUCTION

Prenatal hydronephrosis (HN) is relatively common, being reported in 1-5% of

pregnancies.1 The most common aetiologies of prenatal HN are ureteropelvic junction

obstruction-like (UPJO-like) or isolated HN, vesicoureteral reflux (VUR), and primary non-

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refluxing megaureter (PM).2 Prenatal HN is seen in a wide spectrum of disorders, from so-called

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“physiological” dilation of the urinary tract (which resolves spontaneously) to pathological

conditions that may require surgical intervention. Time to resolution varies according to the

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aetiology and the grade of HN, and it is an important parameter to study.

Grading the severity of prenatal HN using renal ultrasound parameters is commonplace,

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and the basis for establishing logical and efficient treatment plans.3 Prenatal HN resolution is a
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critical patient outcome measure, frequently discussed with families during counselling. HN has

been traditionally classified by the Society for Fetal Urology (SFU) into low (I-II) and high
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grade (III-IV).2 More recently, the Urinary Tract Dilation (UTD) classification for HN was
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released to address potential shortcomings of the current SFU grading system; more specifically
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to deal with inconsistencies between prenatally detected HN and postnatal management

strategies within and across specialties.3 The goal of that multidisciplinary consensus was to
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create a single grading system that could be used during both, the pre and postnatal time periods

to describe urinary tract dilation and facilitate communication between different fields.3 The
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UTD classification uses a 3-point system based on six different ultrasound observations [renal
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pelvis anterior-posterior diameter (APD), calyceal dilation, parenchymal thickness/appearance,

ureteral dilation, and bladder abnormalities] to stratify risk based on the most concerning

observations.4

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Herein, we sought to compare these two grading systems and their ability to predict the

spontaneous resolution of prenatal HN in a large, prospective cohort of children that did not

require corrective surgery. We hypothesized that both grading systems will be comparable in

their ability to predict time to resolution according to different HN grades.

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METHODS

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Study Population and Inclusion and Exclusion Criteria

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This study is part of an ongoing larger prospective cohort study that involves all patients

diagnosed with prenatal HN who were referred to our tertiary care paediatric hospital. After

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obtaining ethics board approval, we screened 855 consecutive patients from 2008 to 2015. Of
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these patients, 258 were excluded due to late presentation (>24months) or having resolved HN at

first clinic visit. Patients with ectopic ureters, ureteroceles, posterior urethral valves, multicystic
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dysplastic kidneys, neurogenic bladders and prune belly syndrome were also excluded (n=108).

We further excluded children who underwent surgical procedures (n=83) as their HN resolution
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was arbitrarily impacted by the decision to intervene; leaving a total of 401 consecutive prenatal
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HN patients with the following aetiologies to be included as our study population: isolated HN
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(UPJO-like), hydroureteronephrosis (PM) and vesico-ureteral reflux (VUR).

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Independent Variables, Outcomes of Interest and Follow-up

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Predictors of prenatal HN resolution were decided a priori and included the 4 SFU HN

grades, the 3 UTD risk groups, and APDs measured at the initial ultrasound visit. The severity of

HN was categorized as low (grades I and II) and high (grades III and IV) as per the SFU grading

system using baseline sagittal ultrasound image series.2 SFU grades were prospectively collected

at baseline and last follow-up visits, by our fellowship trained paediatric radiologists -who have

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had extensive training on both SFU and UTD classification systems-, following our institution

protocol (which consists of no pre-test patient hydration to minimize measurement bias). Using

the same sagittal ultrasound image series used to grade HN based on SFU system, the severity of

UTD was categorized as group P1, P2 or P3 as previously described.3 The baseline renal pelvis

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APD variable was coded as >16mm or ≤16mm 5, and as ≤20mm or >20mm 6, according to

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previous studies.

The outcome of interest was resolution of prenatal HN, which was defined as two

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consecutive ultrasounds showing either SFU grade ≤I or a renal pelvis APD ≤10mm for patients

with isolated HN or ureteral dilation <7mm for those with PM at the last follow-up clinic visit.

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These resolution criteria were applicable for patients with SFU II-IV grades or UTD P1 to P3.
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Children born with SFU grade I or APD <10 mm had to demonstrate a reduction (improvement)

to SFU grade 0 to be considered as resolved. Two consecutive ultrasounds indicating resolution

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were required to account for individual fluctuations that could be influenced by patient hydration
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status, bladder urine volume or technical variability. This prospective study was designed to
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follow children for a minimum of 5 years or until the HN resolved, whichever event occurred

first.
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Patients were assessed by US at each clinic visit and given a SFU grade, an UTD group

and an APD value. All infants were followed for a minimum of 6 months. Figure 1 describes
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standardized follow-up protocol for prenatal HN. Those with bilateral prenatal HN were
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categorized based on the kidney with a higher grade of SFU or UTD or APD.

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Statistical Analyses and Sample Size Calculation

Continuous data with normal distribution were reported as a mean ± standard deviation

(SD). Univariate analyses comparing HN resolution rates between SFU and UTD grading

systems were conducted using the chi-squared test. Tables were created to illustrate the

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cumulative rate of unresolved prenatal HN by SFU grades, UTD groups, APD cut-off values and

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HN etiologies over time. Differences between overall HN resolution times for each SFU grade

and UTD groups, APD cut-offs and HN etiologies were assessed using the log-rank test. A priori

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defined subgroup analyses explored resolution patterns according to 3 different HN etiologies:

isolated HN (UPJO-like), hydroureteronephrosis (PM) and VUR (Supplementary Tables).

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Statistical analyses were conducted using SPSS version 22, where p<0.05 was considered
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statistically significant.

Based on expected resolution rates of 64% and 29% for patients with low and high grade
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prenatal HN at 18 months 7, respectively, and assuming 90% power and an α error of 5%, the
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required sample size to properly answer the research question was 400 patients, accounting for
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10% loss to follow-up. We assumed the accrual time for study period to be 84 months.
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RESULTS

The study population consisted of 401 prenatal HN patients, including 76 females

(19%) and 325 (81%) males. Mean ± SD patient age at the first clinic visit was 4.5±5 months

(Table 1). Mean renal pelvis APD at first clinic visit was comparable for patients with SFU grade

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I/II HN versus those with UTD 1. Similarly, comparable renal pelvis APD were also seen in

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children with SFU grade III compared to those with UTD 2, and in patients with SFU grade IV

vs. those with UTD 3. Overall, 328 (82%) of 401 children showed resolution of their HN over a

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mean follow-up of 24±18 (min 6, max 107) months.

The cumulative rate of resolved HN in 401 patients was 36% at year 1, 66% at 2 years,

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83% at 3 years, 92% at 4 years, 95% at 5 years and 97% after 6 years. Cumulative rates of HN
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resolution when patients were classified using the SFU grading system and UTD risk groups are

demonstrated in Table 2. The cumulative resolution rate at 3 years was 98% for SFU grade I HN
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patients, 87% for SFU grade II, 76% for SFU grade III and 57% for SFU grade IV. Likewise, the
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3-year HN resolution rate was 90% for UTD P1 patients, 81% for UTD P2 and 71% for UTD P3
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group.

When the same patients were stratified by initial renal pelvis APD cut-offs of ≤16mm and
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>16mm, the overall cumulative HN resolution rates for these 2 subgroups were significantly
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different (p<0.001). Similar findings were observed when APD cut-offs ≤20mm and >20mm
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were compared (p=0.003). (Table 3).

Table 4 showed that patients with PM had significantly lower overall cumulative HN

spontaneous resolution rates when compared to those with isolated HN and VUR [classified with

either the SFU (p=0.009) or UTD (p=0.048) system].

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Separate subgroup analyses involving cumulative HN resolution rates in patients with

isolated HN (UPJO-like), PM and VUR (classified with either the SFU or UTD system) are

displayed in supplementary tables 1-3.

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DISCUSSION

There is a large body of evidence exploring outcomes in prenatal HN. The majority of

these have focused on somewhat subjective endpoints (such as the “need” for surgical

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intervention), or development of urinary tract infections. However, there remains paucity of data

in the literature regarding information frequently asked by parents and caretakers: time to HN

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resolution. Although previous studies have provided prognostic data based on different HN

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grades, most have solely focused on the SFU grading system or renal pelvis APD
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measurements . To our knowledge, none has compared how the SFU and UTD grading

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systems perform in regard to their ability to inform time to HN resolution. This is a critical
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question, as the UTD classification system is expected to be increasingly employed by healthcare

providers from different specialties that deal with this patient population. Although this system
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has been designed through a multidisciplinary consensus and has gained increased popularity

across different specialties and countries, its value stills needs to be validated. Our analyses
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indicate that both the SFU and UTD classifications similarly discriminate patients in terms of
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HN resolution rates.
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In addition, regardless of the classification system used to grade HN, higher grades of

prenatal HN were associated with longer spontaneous resolution times. As seen in Table 2, the
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cumulative rates of HN resolution based on the SFU classification for grade I-IV were 98%,
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87%, 76%, and 57%, respectively at 3 years. When looking at the UTD risks groups at year 3,

the cumulative rates of HN resolution resolved for UTD P1-P3 were 90%, 81% and 71%,

respectively.

This inverse relationship (between higher HN grades and resolution rates) has also been
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observed in other studies, regardless of the aetiology . Yang et al reported spontaneous

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UPJO-like HN resolution rates of 92% for SFU grade I, 87% for grade II, 30% for grade III and

0% for grade IV, at a mean interval of 13 months 12. Recently, Bader et al revealed that UTD P3

patients were significantly more likely to not resolve spontaneously and ultimately undergo

pyeloplasty, according to the United Kingdom criteria 13.

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This same pattern of HN resolution was also observed in children with PM

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(hydroureteronephrosis). Patients with SFU grades I-III showed a 71% resolution rate compared
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to 55% for those with grade IV at a mean follow-up of 36 months . Similarly, McLellan et al

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reported that PM patients with SFU grades I–III resolved spontaneously at a median age of 26

months, while those with SFU grade IV resolved slowly (median 49 months) and were more

likely to undergo surgery 8.

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Even when HN severity was graded by renal pelvis APD measurements, lower

HN grades cases resolved faster than the more severe ones, as seen in Table 3. Similar to our
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findings, Aksu et al observed a negative correlation between renal pelvis APD and HN resolution
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rate (p<0.01). Patients with APD ranges of 5–9mm, 10–14mm, and >15mm showed HN
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improvement of 22%, 6%, and 0%, respectively 14. Using a different definition to describe mild

HN, a systematic review by Sindhu et al revealed that all UPJO-like patients with APD <12mm
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resolved without specifying the time to resolution . In contrast, some authors have reported
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resolution rates of 52–65% in patients with APD >12mm while others have showed a 75%
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resolution rate for those with APD ranging from 13-19mm, and 43% for those with APD >19mm
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. To add to the variability on this issue, evidence has shown that 100% of patients with APD
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10–40mm resolved their HN as opposed to 0% when the APD was >40mm . This variation

probably occurs because their analyses have included surgical cases, strategy that introduces

challenges due to the subjective nature of “needing” surgical intervention, as well as the abrupt

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improvement in HN expected in most cases after surgery. In the present analysis, we have

strictly defined our patient population and have gone one-step further, calculating rates of HN

resolution according to the 3 different aetiologies, in an attempt to adjust for potential

confounding factors (Supplementary Tables 1-3).

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Finally, our study has to be contrasted with the findings reported by Hodhod et al. 22. In

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stark distinction to their results, we found that both SFU and UTD grading systems were equally

accurate at predicting time to HN resolution and discriminating resolution time according to HN

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severity. Hodhod et al reported that multivariate analyses favored the UTD classification as a

predictor of surgical intervention while the SFU grades predicted resolution. Due to the above-

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mentioned methodological differences, and the prospective nature of our analysis, as well as the
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attention to separate assessment of predictive variables (due to risk of multi-collinearity), our

results challenge their findings and provide reassurance that both systems provide similar
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predictive performance.
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As with most research studies, this prospective analysis also has limitations that deserve
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acknowledgement. Due to the absence of randomization, we could not adjust for any unknown

prognostic factors, which might have biased resolution rates. Second, it is important to note that
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the results of this study depend extensively on measurements of SFU and UTD grades in order to

track prenatal HN progression. Measurement bias could have been introduced if parents hydrated
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infants 30–60 minutes prior to receiving an ultrasound, indicating a protocol deviation. A prior
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study found APD measurements to experience a mean increase of 35% following hydration
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(p<0.01), with 31% of the kidneys showing >50% increase . Such significant changes in

measurement could have either lowered the resolution rates (due to inflated measurements) or

prolonged the time to resolution. Furthermore, assessments of prenatal HN using both grading

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systems can be limited by their low inter–rater reliability for moderate cases (SFU grade III,

UTD P2) 24-25.

Despite these limitations, we propose there is value in our data, as it is powered by a

considerable sample size combined with a strict requirement of two consecutive ultrasounds to

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document HN resolution. We present novel information on resolution rates for different HN

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aetiologies by comparing two grading systems, hoping to add knowledge to a growing body of

literature exploring this new UTD classification.

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CONCLUSION
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Based on our time to event analysis, children with higher HN grades (SFU III-IV and
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UTD P2-P3) had longer spontaneous resolution time when compared to lower grades (SFU I-II

and UTD P1), classified with either the SFU or UTD system. Approximately 90% of patients
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with SFU I-II / UTD P1, 75% of those with SFU III / UTD P2 and 50% of those with SFU IV /
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UTD P3 resolved their HN over a mean follow-up time of 2 years. Counselling families
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regarding the time to resolution of prenatal HN should remain the same whether using SFU or

UTD grading systems.

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REFERENCES

1. Woodward M and Frank D. Postnatal management of antenatal hydronephrosis. BJU

International 2002; 89: 149-56.

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2. Nguyen HT, Herndon CD, Cooper C, et al. The Society for Fetal Urology consensus

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statement on the evaluation and management of antenatal hydronephrosis. J Pediatr Urol

2010; 6: 212-31.

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3. Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the

classification of prenatal and postnatal urinary tract dilation (UTD classification system). J

Pediatr Urol 2014; 10(6): 982-98.

U
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4. Braga LH, McGrath M, Farrokhyar F, et al. Associations of Initial Society for Fetal

Urology Grades and Urinary Tract Dilation Risk Groups with Clinical Outcomes in
M

Patients with Isolated Prenatal Hydronephrosis. J Urol 2017; 197 (3 Pt 2): 831-7.
D

5. Dias CS, Silva JM, Pereira AK et al. Diagnostic accuracy of renal pelvic dilatation for
TE

detecting surgically managed ureteropelvic junction obstruction. J Urol 2013; 190(2): 661-

6.
EP

6. Dhillon HK. Prenatally diagnosed hydronephrosis: The Great Ormond Street experience.

Br J Urol 1998; 81 (2): 39-44.

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7. Gokaslan F, Yalcinkaya F, Fitoz S, et al. Evaluation and Outcome of Antenatal

AC

Hydronephrosis: A Prospective Study. Renal Failure 2012; 34: 718-21.

8. McLellan DL, Retik AB, Bauer SB, et al. Rate and predictors of spontaneous resolution of

prenatally diagnosed primary non-refluxing megaureter. J Urol 2002; 168: 2177-80.

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9. Jaswon MS, Dibble L, Puri S, et al. Prospective study of outcome in antenatally diagnosed

renal pelvis dilatation. Arch Dis Child Fetal Neonatal Ed 1999; 80: 135-8.

10. Sidhu G, Beyene J and Rosenblum ND. Outcome of isolated antenatal hydronephrosis: a

systematic review and meta-analysis. Pediatr Nephrol 2006; 21: 218-24.

PT
11. Zee RS, Herndon CDA, Cooper CS, et al. Time to resolution: A prospective evaluation

RI
from the Society of Fetal Urology hydronephrosis registry. J Pediatr Urol 2017; 13:316e1-

316e5.

SC
12. Yang Y, Hou Y, Niu ZB, et al. Long-term follow-up and management of prenatally

detected isolated hydronephrosis. J Pediatr Surg 2010; 45: 1701-6

U
AN
13. Bader M, Sur H, Robb A, et al. Efficacy of upper tract dilation classification in

predicating the need for pyeloplasty compared to the UK approach. European Society for
M

Pediatric Urology annual meeting. April 19-22, 2017.

14. Aksu N, Yavascan O, Kangun M, et al. Postnatal management of infants with antenatally
D

detected hydronephrosis. Pediatr Nephrol 2005; 20: 1253-9.

TE

15. Alconcher LF and Tombesi MM. Natural history of bilateral mild isolated antenatal

hydronephrosis conservatively managed. Pediatr Nephrol 2012; 27: 1119-23.

EP

16. Coelho GM, Bouzada MCF, Pereira AK, et al. Outcome of isolated antenatal
C

hydronephrosis: a prospective cohort study. Pediatr Nephrol 2007; 22: 1727-34.

AC

17. Takla NV, Hamilton BD, Cartwright PC, et al. Apparent unilateral ureteropelvic junction

obstruction in the newborn: expectations for resolution. J Urol 1998; 160 (6 Pt1): 2175-78.

18. Rodriguez LV, Lock J, Kennedy WA, et al. Evaluation of sonographic renal parenchymal

area in the management of hydronephrosis. J Urol 2001; 165: 548-51.

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19. Kletscher B, De Badiola F and Gonzalez R. Outcome of hydronephrosis diagnosed

antenatally. J Pediatr Surg 1991; 26: 455-9.

20. Ransley PG, Dhillon HK, Gordon I, et al. The postnatal management of hydronephrosis

diagnosed by prenatal ultrasound. J Urol 1990; 144: 584-7.

PT
21. Josephson S, Dhillon HK and Ransley PG. Post-natal management of antenatally detected,

RI
bilateral hydronephrosis. Urol Int 1993; 51: 79-84.

22. Hodhod A, Capolicchio JP, Jednak R, et al. M. Evaluation of urinary tract dilation

SC
classification for grading postnatal hydronephrosis. J Urol 2015; 195:725-30.

U
23. Gleason J, Bator E, Bowlin P, et al. The Impact of the State of Hydration on the Degree of
AN
Hydronephrosis in Children: Towards a Uniform Standard of Ultrasonographic

Assessment. Pediatric Urology Fall Congress. Oct 24–26, 2014.

M

24. Keays MA, Guerra LA, Mihill J, et al. Reliability assessment of society for fetal urology

ultrasound grading system for hydronephrosis. J Urol 2008; 180: 1680-2.

D

25. Rickard M, Lorenzo AJ, Farrokhyar F, et al. Six of one, half a dozen of the other: A
TE

measure of multidisciplinary inter/intra-rater reliability of SFU and UTD grading systems

for hydronephrosis. J Pediatr Urol. 2017; 1: 80e1-80e5.

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LEGEND

Table 1. Demographics and characteristics of study population (n=401)

Table 2. Cumulative rates of HN resolution based on SFU grading system and UTD risk groups

(n=401)

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Table 3. Cumulative rates of HN resolution based on APD cut-offs of (≤ 16 and >16) and (≤

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20 and >20) (n=401)

Table 4. Cumulative rates of HN resolution based on etiology according to SFU grading system

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and UTD risk groups (n=401)

Figure 1. Follow-up ultrasound (U/S) protocol timeline. Asterisk indicates at clinician

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discretion. VCUG interval was 6 to 12 weeks and to allow for proper kidney maturation, renal
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scan interval was 8 to 12 weeks (n=401)
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Supplementary Table 1- Cumulative rates of HN resolution for UPJO–like patients according

to SFU grading system and UTD risk groups (n=263)

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Supplementary Table 2- Cumulative rates of HN resolution for PM patients according to SFU

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grading system and UTD risk groups (n=61)

Supplementary Table 3- Cumulative rates of HN resolution for VUR patients according to SFU
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grading system and UTD risk groups (n=77)

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Table 1. Demographics and characteristics of study population (n=401)

Characteristic n = 401 (%)

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Mean age at Baseline (mos.) ± SD 4.5 ± 5.2

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Mean time to Follow-up (mos.) ± SD 24 ± 18

Gender

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Male 325 (81)
Female 76 (19)

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SFU Grade n Mean initial APD (mm)
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I 60 5

II 151 7
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III 157 12

IV 33 18
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UTD Risk Group n Mean initial APD (mm)

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P1 169 7
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P2 194 11

P3 38 17
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Table 2: Cumulative rate of HN resolution based on SFU grading system and UTD risk

groups (n=401)

Time SFU grade I SFU grade II SFU grade III SFU grade IV
n (%) n (%) n (%) n (%)

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6 months 60 (27) 151 (18) 157 (11) 33 (6)
Year 1 44 (57) 120( 37) 132 (32) 21 (11)

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Year 1.5 44 (78) 90 (59) 90 (45) 19 (25)
Year 2 12 ( 88) 55 (73) 69 (56) 15 (35)
Year 2.5 6, (94) 37 (82) 52 (66) 9 (50)

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Year 3 3 (98) 23 (87) 39 (76) 7 (57)
Year 3.5 17 (92) 27 (82) 5 (74)
Year 4 11 (95) 18 (86) 3 (83)

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Year 4.5 7 (96) 12 (88) 2 (91)
Year 5 5 (98) 10 (91)
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Log-rank p-value for overall HN resolution rate by SFU grade is < 0.001.
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Time UTD P 1 UTD P 2 UTD P 3

n (%) n (%) n (%)
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6 months 169 (22) 194 (20) 38 (11)

Year 1 130 (48) 145 (42) 25 (36)
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Year 1.5 85 (70) 94 (56) 17 (51)

Year 2 46 (80) 68 (69) 12 (59)
Year 2.5 30 (87) 43 (76) 12 (59)
Year 3 17 (90) 32 (81) 7 (71)
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Year 3.5 12 (92) 25 (84) 7 (71)

Year 4 9 (94) 16 (90) 3 (81)
Year 4.5 7 (96) 16 (90) 3 (81)
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Year 5 5 (99) 10 (92) 2 (100)

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Log-rank p-value for overall HN resolution rate by UTD grade is 0.011.

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Table 3: Cumulative rates of HN resolution based on APD cut-off of (≤ 16 and >16) and (≤

20 and >20) (n=401)

Time Baseline APD ≤ 16mm Baseline APD >16mm

PT
n=357 (%) n=44 (%)
Year 1 288 (10) 33 (36)
Year 2 146 (62) 24 (50)
Year 3 93 (80) 13 (61)

RI
Year 4 42 (91) 10 (65)
Year 5 15 (96) 8 (74)
Year 6 6 (98) 3 (90)

SC
Log-rank p-value for overall HN resolution rate by APD cut-off of >16 mm is <0.001

U
Time Baseline APD ≤ 20mm Baseline APD >20mm
n=383 (%) n=18 (%)
AN
Year 1 309 (35) 12 (9)
Year 2 161 (62) 9 (29)
Year 3 101 (78) 5 (43)
Year 4 48 (89) 5 (43)
M

Year 5 20 (95) 3 (81)

Year 6 8 (97) 1 (99)
D

Log-rank p-value for overall HN resolution rate by APD cut-off of >20 mm is 0.003
TE
C EP
AC
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Table 4. Cumulative rates of HN resolution based on etiology according to SFU grading

system and UTD risk groups (n=401)

Time VUR Primary non-refluxing megaureter UPJO-like

PT
n=77 (%) n=61 (%) n=263 (%)

Year 1 60 (36) 48 (29) 209 (38)

RI
Year 2 25 (64) 29 (47) 94 (72)

SC
Year 3 10 (81) 19 (64) 39 (87)

Year 4 3 (93) 9 (80) 19 (93)

Year 5 2 (96)
U 6 (90) 10 (96)
AN
Log-rank p-value for overall HN resolution rate (classified by SFU system) by etiology is 0.009
M

Time VUR Primary non-refluxing megaureter UPJO-like

D

n=77 (%) n=61 (%) n=263 (%)

TE

Year 1 60 (44) 45 (40) 195 (45)

Year 2 25 (70) 23 (61) 78 (77)

EP

Year 3 10 (83) 13 (71) 33(84)

Year 4 3 (94) 7 (80) 18 (93)

C
AC

Year 5 2 (97) 5 (97) 12 (92)

Log-rank p-value for overall HN resolution rate (classified by UTD system) by etiology is 0.048
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SFU I/II-UTD 1
Majority resolved and
discharged

PT
6 12 24 36 48 60

RI
Baseline u/s

SC
3d-6wks

U
AN
M
SFU III/IV-UTD2/3 u/s (months)

D
TE
EP
*VCUG & renal scan 8-12
weeks C
AC

3 6 9 12 18 24 36 48 60

Baseline u/s
3d-6wks
u/s (months)
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LIST OF ABBREVIATIONS

UTD – Urinary Tract Dilatation

HN − Hydronephrosis

SFU – Society for Fetal Urology

PT
UPJO-like – Ureteropelvic Junction Obstruction Like

RI
PM – Non-refluxing Primary Megaureter

VUR – Vesico-ureteral Reflux

SC
APD − Anterior-posterior Diameter

U
AN
M
D
TE
C EP
AC