Journal of Pediatric Urology (2010) 6, 212e231

FETAL UROLOGY

The Society for Fetal Urology consensus statement

on the evaluation and management of
antenatal hydronephrosis
Hiep T. Nguyen a,*, C.D. Anthony Herndon b, Christopher Cooper c,
John Gatti d, Andrew Kirsch e, Paul Kokorowski a, Richard Lee a,
Marcos Perez-Brayfield f, Peter Metcalfe g, Elizabeth Yerkes h,
Marc Cendron a, Jeffrey B. Campbell i

a
Department of Urology, Children’s Hospital, Boston, MA, USA
b
Division of Urology, Children’s Hospital of Alabama, Birmingham, AL, USA
c
Department of Urology, University of Iowa Medical Center, Iowa City, IA, USA
d
Department of Urology, Children’s Mercy Hospital, Kansas City, KA, USA
e
Department of Urology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
f
Division of Urology, HIMA-San Pablo, University of Puerto Rico, San Juan PR, Puerto Rico
g
Department of Urology, Stollery Children’s Hospital, Edmonton, Alberta, Canada
h
Department of Urology, Children’s Memorial Hospital, Chicago, IL, USA
i
Department of Pediatric Urology, The Children’s Hospital, Aurora, CO, USA

Received 26 January 2010; accepted 13 February 2010

Available online 15 April 2010

KEYWORDS Abstract The evaluation and management of fetuses/children with antenatal hydronephrosis
Hydronephrosis; (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation,
Radiological imaging; intervention or observation? Though the literature is quite extensive, it is plagued with bias
Children; and conflicting data, creating much confusion as to the optimal care of patients with ANH.
Prenatal diagnosis In this article, we summarized the literature and proposed recommendations for the evalua-
tion and management of ANH.
ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Urology, Children’s Hospital Boston, 300 Longwood Avenue, Hunnewell-353, Boston, MA 02115,
USA. Tel.: þ1 617 355 6842; fax: þ1 617 730 0474.
E-mail address: hiep.nguyen@childrens.harvard.edu (H.T. Nguyen).

1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2010.02.205
Consensus statement for prenatal hydronephrosis
Introduction
Dilation of the fetal renal collecting system, antenatal
hydronephrosis (ANH), is one of the most common abnor-
malities detected on prenatal ultrasonography (US),
reported in approximately 1e5% of all pregnancies. ANH
represents a wide spectrum of urological conditions,
ranging from transient dilation of the collecting system to
clinically significant urinary tract obstruction or vesicoure-
teric reflux (VUR). With the advent of routine prenatal US,
children with urinary tract obstruction or reflux are being
detected prior to the development of complications such as
urinary tract infection (UTI), kidney stones and renal
dysfunction or failure. These complications might be
averted by early diagnosis. Consequently, the goals in
evaluating children with ANH are to prevent these potential
complications and to preserve renal function. However, not
all findings on prenatal US represent pathology; many are
transient and have no clinical significance. The dilemma
therefore is to distinguish children who require follow up
and intervention from those who do not.
While the use of prenatal US as a screening tool for
identifying urological anomalies has not been shown to
improve postnatal outcomes, more patients are undergoing
prenatal counseling for the discovery of ANH [1]. Currently,
the definition of ANH is variable, and the clinical
management of ANH has not been systematically defined.
Consequently, the diagnosis of ANH may cause significant
parental anxiety and physician uncertainty when it comes
to pre- and postnatal management. In addition, because its
evaluation can be quite extensive, the management of
ANH has a significant cost impact on our current health-
care system. Concerns over litigation due to failure to
diagnose an anomaly may also shape the postnatal evalu-
ation. This consensus statement reviews the current
literature on the diagnosis and management of ANH and
proposes a unified approach to the care of the fetus/child
with ANH.
Methodology
A literature search of PubMed, OVID, EMBASE and the
Cochrane Library databases from 1993 to July 2009 was
performed for articles reporting on children with prenatal
hydronephrosis and who had postnatal evaluation. Ten
terms for hydronephrosis were combined (hydronephrosis,
pelviectasis, pelvocaliectasis, pyelectasis, hydro-
ureteronephrosis, renal pelvic dilation (RPD), antero-
posterior diameter (APD), oligohydramnios, calyceal dila-
tion, and ureteral dilation) with six terms for prenatal
(prenatal, newborn, antenatal, fetal, prenatal diagnosis
and natural history). Reference lists of research articles,
reviews, and texts were simultaneously searched to ensure
that we acquired all of the relevant articles. We excluded
articles that only contained non-human subjects, edito-
rials, letters, and comments. We did include some case
reports for rare entities and reviews/practice guidelines for
references and assessment of current practice recommen-
dations. We screened 3581 citations; 410 articles were
reviewed in depth because they contained information
pertinent to the topics discussed below.
213
The current literature was summarized and general
recommendations were developed based upon current
available clinical evidence. To date, there are no compre-
hensive prospective studies that correlate the risk of
pathology with varying degrees of ANH or those aspects of
ANH that predict postnatal diagnosis or kidney outcome. In
addition, given the broad nature of this topic and lack of an
adequate number of prospective studies, we were unable
to perform any additional, detailed meta-analysis of the
literature other than those already reported. Consequently,
this consensus statement is limited by the generally retro-
spective nature of the data available. Recommendations
proposed in this statement may change in the future
depending on the results of prospective studies.
Fetal urinary tract: anatomy, physiology and
US appearance
Around the 5th week of gestation, the ureteric buds arise
from the posterior aspect of the lower portion of the
mesonephric ducts. They grow posteriorly into the sacral
portion of the intermediate mesoderm, the metanephric
blastema. The complex interaction between these two
structures leads to renal development that continues
throughout gestation and is completed just before the 36th
week. The fetal kidneys have a lobulated external
appearance and ascend from their pelvic position during
the 6e9th week. They can be well visualized by US at the
12e13th week, with distinct renal architecture seen by the
20th week (Fig. 1). From the 12th week to the 40th week,
the renal length increases from 1.0 to 2.7 cm, APD from 0.8
to 2.6 cm, and transverse diameter from 0.9 to 2.6 cm [2].
Urine formation is first seen at the 5e8th week; however, it
is principally an unmodified plasma filtrate since tubular
function starts around the 14th week. The urine output is
Figure 1 Normal appearance of a fetal kidney (arrow). Note
the presence of the renal pyramids (dark, less echogenic
structures within the kidney), which can be mistaken for
dilated calyces.
214
approximately 5 cc/h at the 20th week and increases to
50 cc/h by the 40th week [3].
At about the same time that the ureteric buds appear,
the partitioning of the cloaca begins, forming the urogen-
ital sinus anteriorly and the anal canal posteriorly. The
upper part of the urogenital sinus between the allantois
and the mesonephric ducts then differentiates to form the
bladder. The fetal bladder can be visualized on US by the
10e14th week, and its emptying can be seen by the 15th
week (Fig. 2). The bladder capacity is observed to range
from 10 cc at the 30th week to 50 cc at term [3].
Early in gestation the amniotic fluid is principally
a transudate of the amnion, while later it is composed of
fetal urine and lung fluid. The amniotic volume becomes
principally dependent on urine production around the 16th
week, ranging from 380 cc at the 20th week to 800 cc at the
28e40th week [4]. A rough estimate of the amount of
amniotic fluid can be determined by US, by measuring the
amniotic fluid index (AFI). The AFI is the score obtained by
adding centimeters of depth of four pockets of fluid.
Polyhydramnios is defined as an amniotic volume greater
than 1500 cc (AFI > 20e24). The etiology for poly-
hydramnios includes esophageal obstruction, multicystic
kidney, mesoblastic nephroma, and some urinary obstruc-
tive processes. In contrast, oligohydramnios is defined as an
amniotic volume less than 500 cc, as indicated by the
absence of pockets of fluid greater than 2 cm on US or
AFI < 5e6. The etiology for oligohydramnios includes
amnion nodosum, amniotic fluid leak, urinary tract
obstruction, and renal dysplasia. The consequences of
having oligohydramnios include the development of
pulmonary hypoplasia, Potter’s syndrome (flat nose,
recessed chin, low-set ears, bowed legs, small chest, tales
equinovares, and hypoplastic hands) and limb deformities.
Figure 2 Normal appearance of a fetal bladder (B). It can be
recognized as a cystic structure in between the umbilical
arteries (as seen by Doppler).
H.T. Nguyen et al.
Defining ANH
Currently, the measurement of the APD of the renal pelvis
as visualized in the transverse plane is the most studied
parameter for assessing ANH in utero [5e9]. APD is
a surrogate measurement of potential disease, but cannot
specifically identify pathology. A simple threshold APD
value which separates normal from abnormal does not
exist, as even severe cases of ANH have the potential to
resolve without incident while mild degrees of ANH have
the potential to progress [6]. Potential factors affecting
APD include gestational age [10e12], hydration status of
the mother [13,14], and the degree of bladder distention
[15]. Since the dimensions of the renal pelvis may normally
increase with gestational age, most investigators have
adjusted threshold APD values for early and later gesta-
tional age.
Varying the minimal APD threshold for normal can
significantly alter the positive predictive value of APD as
a measure of ANH and postnatal pathology (Table 1). To
date there is no consensus on the optimal APD threshold for
determining the need for postnatal follow up. Coplen et al.
[16]. suggests that a cut-off of 15 mm is ideal for deter-
mining obstruction, yielding a sensitivity of 73% and speci-
ficity of 82%. Ismaili et al. [17]. noted that a late
gestational age cut-off of 10 would detect only 23% of
abnormal kidneys, whereas a cut-off of 7 mm detected 68%.
One large meta-analysis estimated that only 11.9% of total
pathology presented with late gestational age APD less than
9 mm, while 39% of total pathology was noted at APD levels
less than 15 [18]. Other investigators have demonstrated
similar results [19]. What appears certain is that lower cut-
offs will be more sensitive in detecting postnatal pathology;
however, the trade off is in higher false positive rates. It is
also apparent that the likelihood of pathology increases
with increasing APD. Large prospective studies to correlate
the degree of ANH with risk of pathology are clearly needed
to provide answers to these questions.
The use of APD has certain disadvantages and limita-
tions. APD is only one measurement of collecting system
dilatation and may not accurately reflect the degree of
hydronephrosis. There have been no formal studies to
determine the inter- and intra-observer reproducibility of
APD measurement. Additionally, APD does not consider
calyceal dilation or parenchymal changes (such as
increased echogenicity or parenchymal thinning) that may
reflect more severe cases of obstruction.
Grading system
A number of grading systems have been utilized, each with its
own unique characteristics and limitations. Perhaps the most
basic is the traditional grading system, in which the grade of
hydronephrosis is characterized as mild, moderate, or
severe. The utility of this system has been improved by the
use of the terms pelviectasis (dilation of the renal pelvis),
pelvicaliectasis (dilation of the renal pelvis and calyces), and
caliectasis (dilation of the calyces) to describe the extent of
the hydronephrosis. The highly subjective nature of this
system inevitably results in poor inter-rater reliability. A
more objective measure of the degree of hydronephrosis is
Consensus statement for prenatal hydronephrosis 215

Table 1 True positive (TP) and positive predictive value (PPV) of urological pathology based upon APD.
Reference No. of pts APD (mm) % ANH % TP % PPV
Economou (1994) [143] 6645 2e3 1.96 0.04 2.3
Persutte (1997) [144] 5529 4 5.50 0.50 9.2
Morin (1996) [145] 5900 4 2.20 0.08 2.9
Owen (1996) [146] 3804 5 0.80 0.30 40
Langer (1996) [147] 2170 5 4.40 0.60 14
Livera (1989) [148] 3521 5 0.85 0.17 20
Fasolato (1998) [149] 1775 6 3.80 0.50 18
Arger (1985) [8] 6279 10 1.26 0.55 44
Rosendahl (1990) [150] 4586 10 0.39 0.28 77
Johnson (1992) [151] 7502 10 0.37 0.16 43
Gunn (1988) [152] 3228 15 1.92 0.22 11

APD. There is near uniform agreement that an APD greater
than 15 mm represents severe or significant hydronephrosis,
and most would agree that a value of 4e5 mm is an appro-
priate threshold for considering the APD to be abnormal
[16,18,20e25]. With this in mind, ANH can be classified in the
2nd and 3rd trimester using APD thresholds for which the best
available evidence provides prognostic information (Table
2). An estimate of the distribution of severity of ANH is
provided in Table 3.
In 1993, the Society for Fetal Urology (SFU) proposed a 5-
point numerical grading system based on the postnatal
appearance of the renal pelvis, calyces, and renal paren-
chyma (Fig. 3) [26]. This grading system is a spectrum, with
grade 1 demonstrating normal parenchymal thickness and
only renal pelvis splitting, and grade 4 revealing distention of
the renal pelvis and calyces in addition to parenchymal
thinning. This system has been shown to have good intra-
rater, but modest inter-rater, reliability [27]. One of the
limitations of this system is the difficulty in classifying
a kidney with segmental calyceal dilation or renal paren-
chymal thinning. It has been proposed that sub-classifying
SFU grade 4 hydronephrosis into segmental (4A) and diffuse
(4B) cortical thinning may improve inter-rater reliability and
clinical correlation [27,28]. The Japanese Society of Pedi-
atric Urology has also proposed a (minor) modification of the
SFU grading system in an effort to improve inter-rater reli-
ability [29]. As an alternative to the SFU grading system,
Shapiro et al. [30] have proposed a hydronephrosis index (HI),
a quantitative measure in which HI (percentage) Z
100  (renal area e renal pelvis/calyces)/(renal area). The
HI appears to correlate well with SFU grades 3 and 4 hydro-
nephrosis, and may be more sensitive at detecting a change
in the degree of hydronephrosis [31].
Other sonographic parameters
In addition to the degree of hydronephrosis, a number of
other sonographic parameters have been utilized to predict
Table 2 Definition of ANH by APD.
Degree of ANH 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
postnatal outcomes. Renal findings such as poor cortico-
medullary differentiation (lack of US visualization of the
renal pyramids) [32], increased echogenicity [33], and
the presence of renal cysts[34] have been associated with
the loss of functional renal parenchyma. The presence of
a perinephric urinoma can be seen in association with
severe urinary obstruction [35]. ANH is more likely to be
associated with postnatal pathology when it is associated
with parenchymal thinning, calyceal dilatation, ureteral
dilatation, chromosomal anomalies or multiple system
malformations [28,36e38]. Maizels et al. have reported
that patients with ANH (APD >4 mm) and abnormal addi-
tional features (enlarged renal length, caliectasis,
progressive caliectasis, a duplex kidney, ureterectasis,
and/or a dilated bladder) required extensive postnatal
urologic care and were 12.9 times more likely to die than
when additional features were normal [39]. Fetal bladder
sagittal length has also been found to be predictive of
postnatal renal function; Maizels et al. reported an
increasing incidence of postnatal azotemia and surgical
intervention in fetuses with progressive bladder and upper
urinary tract dilation [40]. It is well recognized that the
degree of hydronephrosis can vary with distension of the
fetal bladder. In an effort to account for this variability,
Leung et al. have proposed a different hydronephrosis
index (HI), where HI Z APD/urinary bladder volume, and
have established normative values from 20 to 38 weeks
gestation [15].
Oligohydramnios appears to be one of the most important
predictive factors for postnatal pathology. In patients with
ANH (APD > 5 mm), multivariate analyses have identified
oligohydramnios and megacystis to be predictive of urethral
obstruction, and oligohydramnios to be predictive of chronic
renal failure or death [42,43]. Similarly, in patients with
posterior urethral valves (PUV), multivariate analysis has
identified oligohydramnios to be predictive of chronic
renal failure [44]. Zaccara et al. have also reported
Table 3 Estimated breakdown of ANH by severity.
Degree of ANH % of ANH
Mild 56.7e88
Moderate 10.2e29.8
Severe 1.5e13.4
Adapted from Ahmad and Green (2005) [20].
216 H.T. Nguyen et al.

Figure 3 The Society for Fetal Urology Hydronephrosis Grading System (http://www.uab.edu/images/peduro/SFU/sfu_grading_
on_web/sfu_grading_on_web.htm).

oligohydramnios (AFI < 25th percentile) to be predictive of
chronic renal failure or death in patients with PUV [41]. Oli-
gohydramnios, dilated posterior urethra (keyhole sign), ANH,
thick-walled bladder, and increased renal echogenicity are
worrisome signs for severe bladder outlet obstruction that
warrant counseling and possible fetal intervention such as
early delivery or vesicoamniotic shunting [44e46].
Predictive value of APD-defined ANH for pathology
Based on a large systematic review of the current litera-
ture, the risk of any postnatal pathology is 11.9% for mild,
45.1% for moderate, and 88.3% for severe ANH [18]. The
most common postnatal pathologic findings and their rela-
tive frequencies are presented in Table 4.
An association between increasing incidence of post-
natal pathology and degree of hydronephrosis holds true for
most diagnoses. Key exceptions to this trend include VUR
and distal ureteral obstruction. The incidence of VUR
between groups of children with mild, moderate, and
severe ANH is not significantly different (P Z 0.10) [18].
Furthermore, the reported incidence of VUR in children
with ANH may not be appreciably different from the
general population [47]. This implies that the presence or
severity of ANH may have no reflection upon the presence
of VUR, and further belies the efficacy of renal US in
screening for VUR. Distal ureteral obstruction becomes
more likely as the ANH increases from mild to moderate;
however, there is a slight decrease in likelihood in the
severe category. This may reflect the preponderance of

Table 4 Risk of specific postnatal pathologic conditions by the degree of ANH.

% ANH [95% CI]
Mild Moderate Severe
UPJ 4.9 [2.0e11.9] 17.0 [7.6e33.9] 54.3 [21.7e83.6]
VUR 4.4 [1.5e12.1] 14.0 [7.1e25.9] 8.5 [4.7e15.0]
PUV 0.2 [0.0e1.4] 0.9 [0.2e2.9] 5.3 [1.2e21.0]
Ureteral obstruction 1.2 [0.2e8.0] 9.8 [6.3e14.9] 5.3 [1.4e18.2]
Other 1.2 [0.3e4.0] 3.4 [0.5e19.4] 14.9 [3.6e44.9]
Other Z prune belly syndrome, VATER syndrome, solitary kidney, renal mass, and unclassified.
Adapted from Lee et al. (2006) [18].
Consensus statement for prenatal hydronephrosis
type I and II megaureters, which can have significant
ureteral dilatation with fewer renal pelvic effects [48].
Rather than relying on a single antenatal study to
determine postnatal pathology, additional examinations
are often used to help identify fetuses at higher risk. Many
investigators report the use of repeat examinations peri-
odically during the antenatal period [18]. At least one
retrospective investigation suggested that a second US later
in the pregnancy that has stable or reduced moderate ANH
(APD < 10) near uniformly predicts eventual resolution
without surgical intervention [25]. Additional prospective
investigations into the prognostic value of repeated
prenatal measures of APD may prove useful in reducing the
need for postnatal evaluation.
The etiology of ANH and the incidence of
postnatal pathology
The etiology of ANH includes: transient dilation of the
collecting system, upper/lower urinary tract obstructive
uropathy, and non-obstructive processes such as VUR,
megaureters, and prune belly syndrome (Table 5).
Transient hydronephrosis
Most children with an antenatal history of renal pelvis and
calyces dilation ultimately resolve their hydronephrosis.
The etiology of this finding may be related to a narrowing of
the ureteropelvic junction (UPJ) or natural kinks and folds
that occur early in development that resolve as the patient
matures. The differentiation of transient hydronephrosis
versus clinically significant UPJ obstruction remains one of
the most controversial challenges in modern pediatric
urology. Nevertheless, the incidence of transient hydro-
nephrosis ranges from 41 to 88%[1,36,49] (Fig. 4). Most
children with a pelvic dilation less than 6 mm diagnosed
during the 2nd trimester or less than 8 mm diagnosed during
the 3rd trimester have transient hydronephrosis [1]. In
contrast, the incidence of transient hydronephrosis is only
40% in children with an APD less than 10e12 mm detected
during the 3rd trimester [36,50].
UPJ obstruction
The finding of pelvicalyceal dilatation without ureteral
dilatation, commonly unilateral, is highly suggestive of UPJ
Table 5 The etiology of ANH.
Etiology Incidence
Transient hydronephrosis 41e88%
UPJ obstruction 10e30%
VUR 10e20%
UVJ obstruction/megaureters 5e10%
Multicystic dysplastic kidney 4e6%
PUV/urethral atresia 1e2%
Ureterocele/ectopic ureter/duplex system 5e7%
Others: prune belly syndrome, cystic kidney Uncommon
disease, congenital ureteric strictures and
megalourethra
217
obstruction (Fig. 5) [38]. Its incidence in children with ANH
varies greatly between studies from 5% to 64% of patients
[49,51,52]. The variability corresponds to differences in the
management of these children, from early surgery to close
observation until renal function deterioration or progres-
sion of hydronephrosis occurs. Currently, the incidence of
UPJ obstruction in children with ANH is approximately 10e
30%. Several retrospective studies reported a surgical
intervention rate of 38e52% [53,54]. However, randomized
trials suggested that only 19e25% of children with prena-
tally diagnosed UPJ obstruction require surgical interven-
tion [55,56]. There exists an increased incidence of other
urological abnormalities, such as VUR and multicystic
dysplastic kidney (MCDK), with UPJ obstruction [57].
Vesicoureteric reflux
The finding of a variable degree of hydronephrosis or
hydroureteronephrosis may suggest the possibility of VUR
(Fig. 6); however, no reliable findings definitively diagnose
reflux on fetal US [58]. Numerous studies have demonstrated
that VUR occurs in 10e20% of patients with ANH [59e61]. The
incidence of reflux appears to increase with the degree of
sonographic dilation postnatally; however, the degree of
dilation does not correlate with the grade of VUR [59]. In
addition, a normal postnatal US does not exclude reflux
[61e63]. In one prospective study [64], 15% of children with
mild prenatal hydronephrosis (>4 mm to <10 mm) had VUR
and 43% of these children had a normal postnatal renal US.
Ureterovesical junction (UVJ) obstruction/
megaureters
The combination of prenatal hydronephrosis and ureteral
dilation and a normal bladder suggests a megaureter (Fig. 7).
Megaureters can be refluxing, obstructed, non-refluxing/
non-obstructed, and refluxing/obstructed. Prenatal ultra-
sonography has lead to more frequent postnatal diagnosis of
primary megaureters [65e67]. Few studies have focused on
the prenatally detected megaureter, and none correlated
prenatal findings with postnatal outcomes. In children with
ANH, the incidence of primary megaureters is approximately
5e10%. The majority (up to 72%) will spontaneously resolve
during postnatal follow up [68,69].
Multicystic dysplastic kidney
The presence of multiple, non-communicating cysts of
various sizes and no evidence of identifiable renal paren-
chyma is characteristic of an MCDK (Fig. 8). Most patients
are identified prenatally after 16 weeks of gestation. In
some patients, MCDK may be confused with UPJ obstruc-
tion. In children with ANH, the reported incidence of MCDK
is approximately 4e6% [1,51,70]. A renal length of <62 mm
as measured on the first postnatal US is associated with
complete involution of MCDK after birth [71].
Posterior urethral valves/urethral atresia
The identification of: 1) prenatal hydronephrosis (often
bilateral); 2) dilated, thick-walled bladder that fails to
218
Figure 4 Transient hydronephrosis in the right kidney as seen on the prenatal US that resolved completely by the first postnatal US.
empty; 3) dilated posterior urethra; and 4) decreased
amniotic fluid suggests the presence of lower urinary tract
obstruction (LUTO) (Fig. 9). Unlike the unilateral upper
tract dilation found commonly on prenatal ultrasonography,
LUTO carries a worse prognosis with increase mortality and
morbidity due to pulmonary hypoplasia and renal damage
[72]. The incidence of LUTO ranges from 1 in 2000e25,000
live births [73e75]. In general, the sensitivity in accurately
diagnosing LUTO ranges from 21% to 100%, with an average
of approximately 50% [75e78]. LUTO diagnosed during the
1st and 2nd trimester is equally likely from PUV or varying
degrees of urethral atresia [79]. However, the earlier the
prenatal diagnosis of LUTO is made the more likely it is to
be associated with urethral atresia [76,80,81].
Ureterocele/ectopic ureter/duplex system
The finding of upper pole hydroureteronephrosis with
a thin-walled cystic structure in the base of the bladder is
Figure 5 The appearance of a UPJ obstruction on the
prenatal US. Note the dilated renal pelvis and calyces without
an associated dilated ureter.
H.T. Nguyen et al.
suggestive of the diagnosis of a ureterocele (Fig. 10), while
the same finding without an associated intravesical cystic
structure is suggestive of an ectopic ureter. These two
etiologies of ANH are commonly associated with a duplex
system. Ureterocele, ectopic ureters and duplex systems
are often readily identified on prenatal ultrasonography,
with an incidence of 5e7% [1,51,70]. Although the
pathology is easily suspected prenatally, postnatal work up,
including a voiding cystourethrogram (VCUG) and possible
renal scan, is required to clearly define the anatomy and to
guide further management. Interestingly, prenatal identi-
fication does not appear to improve the rate of renal
salvage in patients with duplication anomalies [82].
Other more infrequent conditions presenting with
prenatal hydronephrosis include prune belly syndrome,
cystic kidney disease, congenital ureteric strictures, and
megalourethra. Unlike the other causes of ANH, these are
uncommon.
The natural history of ANH
The current literature is replete with retrospective reviews
of children with a history of ANH focusing primarily on
specific outcome diagnoses. These generally apply a wide
range of inclusion criteria or definitions of hydronephrosis
and limited correlation of pre- and postnatal degree of
hydronephrosis. However, there are a limited number of
prospective studies[21,83e85] and meta-analyses[18,86]
that allow some conclusions regarding the natural history
of ANH.
With regard to variation during pregnancy, it appears
that resolution of hydronephrosis during the prenatal
period carries little likelihood of any clinically significant
postnatal sequelae. The vast majority of the cases of
hydronephrosis diagnosed during the second trimester have
been noted to resolve during follow-up imaging in the third
trimester. Additionally, with rare exceptions, hydro-
nephrosis that resolved or improved from the second to
third trimester has not been associated with clinically
significant postnatal pathology. In contrast, cases in which
the hydronephrosis was stable/persistent or worsened
during pregnancy have been much more variable. There is
Consensus statement for prenatal hydronephrosis
Figure 6 The appearance of VUR on the prenatal US. Note the change in the degree of hydronephrosis (arrows) during scanning
(S Z spine).
some correlation with the more severe grades of hydro-
nephrosis and subsequent postnatal abnormalities requiring
surgical intervention, but those with and without pathology
in this group are fairly evenly split.
The timing of diagnosis may have useful prognostic
value. Those diagnosed in the first trimester with hydro-
nephrosis are more likely to have a poor outcome.
However, most studies related to early diagnosis are
focused, retrospective reviews that work backwards from
a grim outcome and lack any perspective of the incidence
or scope of earliest diagnosis. In comparison, those diag-
nosed during the second trimester have an overall favorable
prognosis. The hydronephrosis tends to resolve or improve
in the majority (approximately 80%), and few ultimately
will require surgical intervention (<5%) [24,49]. The
favorable prognosis is better supported for those with
milder hydronephrosis and represents the majority of cases
in large, screened populations [25]. In contrast, those
diagnosed in the 3rd trimester appear to have higher rates
of postnatally confirmed pathology that may require oper-
ative intervention [19]. Given the variable timing of ante-
natal US, this may represent the same patient population
found to have persistent or worsening hydronephrosis and
significant pathology in the 2nd trimester.
The postnatal evaluation of ANH is widely variable due
to the diversity in the definitions of hydronephrosis and
Figure 7 The appearance of a UVJ obstruction on the
prenatal US. Note the kidney is minimally dilated (thick arrow)
while there is significant dilation of the ureter (thin arrow).
219
specific inclusion criteria used in the studies reported in the
literature. It appears that about 30e40% of ANH persists
postnatally, and of that roughly the same percentage will
resolve spontaneously (Table 6). The timing of resolution is
quite variable, occurring during the first few years of life.
This variability may be due to the limited follow up in most
studies. Despite the variability in underlying diagnoses, the
trend is for earlier resolution with milder grades of hydro-
nephrosis, with the majority of SFU grade 1e2 hydro-
nephrosis resolving by 18 months of age [1]. If increasing
hydronephrosis occurs, it generally does so early in life,
often during the first year. Finally, operative repair
(primarily for UPJ obstruction) has been required in
approximately 25% of cases, with a range from 5% to 50%
depending on the study [7,50,87]. The actual likelihood of
surgery is perhaps the least valuable parameter, given the
variable criteria used for selection and the differing
considerations for surgical intervention. Severe pathology
and surgical intervention are much more common with
Figure 8 The appearance of an MCDK on the prenatal US.
Note the multiple, non-communicating cysts of various sizes.
220 H.T. Nguyen et al.

Figure 9 The appearance of PUV on the prenatal US. Note the dilated ureter and renal pelvis (first panel) accompanied by
a dilated bladder with a dilated posterior urethra (arrow).

higher degrees of hydronephrosis (SFU grade 3e4) [56]; However, in the presence of increasing oligohydramnios,
however, multiple studies have also shown the need for fetal intervention such as vesicoamniotic shunting may be
surgical intervention in a small percentage of those with offered. The ideal time period to offer prenatal interven-
mild degrees of hydronephrosis [88]. tion for suspected bladder outlet obstruction appears to be
the mid-second trimester. This will allow for the return of
Antenatal radiological evaluation for ANH amniotic fluid, in an effort to promote fetal lung develop-
ment. A gross predictor of renal function may be obtained
by performing a fetal bladder tap and analysis of fetal urine
In the United States, most prenatal US scans are performed
biochemistries and electrolytes (reviewed by Clark et al.,
in the mid-second trimester. It is generally recommended
2003) [90]. Due to the first pass of urine into the bladder, it
that the prenatal identification of hydronephrosis
is recommended to make all decisions based on a repeat
(APD > 4 mm in the 2nd or > 7 mm in the 3rd trimester)
fetal bladder tap within 48 h of the initial bladder decom-
warrants further follow up in the prenatal period.
pression. If favorable urine electrolytes are obtained (Table
Depending on the gender, gestational age, presence of
7), fetal intervention may be offered as an option. In terms
ureteral dilation, presence of bilaterality, amniotic fluid
of renal salvage, to date no randomized trial with data
volume status and APD of the renal pelvis, some patients
exists (reviewed by Morris and Kilby, 2009) [91]. Currently,
should be regularly imaged throughout pregnancy, while
the PLUTO trial is underway in order to clarify the utility of
others may have a repeat US deferred until late in the 3rd
fetal bladder diversion or vesicoamniotic shunting for fetal
trimester. When the diagnosis is uncertain, magnetic reso-
survival, fetal lung development and renal salvage. Several
nance imaging (MRI) may be helpful in providing additional
centers in the US have specialized in prenatal intervention.
anatomical information.
The presence of mild hydronephrosis will be the most
common classification of renal dilation identified. A repeat
US is recommended, and the timing of this study is left to
the discretion of the obstetrician. Most of these cases will
have at least one repeat US performed in the 3rd trimester
to gauge progression or resolution. A significant number of
these cases will resolve completely and may not need
further follow up [24]. The supportive data for this
recommendation are anecdotal but it appears to be
reasonable. In situations in which mild hydronephrosis is
diagnosed or persists during the 3rd trimester, postnatal
imaging is warranted. In comparison, the risk of postnatal
urinary tract anomalies is much greater in patients in whom
an increase in the degree of hydronephrosis between the
2nd and 3rd trimester is detected or is moderate/severe,
i.e. >10 mm in the 3rd trimester [89]. Consequently,
further postnatal evaluation in these patients is highly
recommended.
The presence of findings suspicious for PUV (oligohy-
dramnios, dilated bladder, bilateral hydroureteronephrosis,
male gender) warrants monitoring throughout pregnancy. A
level 3 US should be performed to exclude other organ
system abnormalities. Depending on the severity of oligo- Figure 10 The appearance of a ureterocele (U) on the
hydramnios, fetal imaging every 4 weeks may be needed. prenatal US (B Z bladder).
Consensus statement for prenatal hydronephrosis 221

Table 6 Incidence of ANH resolution during the 3rd trimester and after birth.
Reference APD (mm) (gestational age at diagnosis) Resolution
3rd trimester After birth
Livera (1989) [148] >10 (at 28 wks) 54%
Corteville (1991) [153] >4 (<33 wks) 29% 31%
>7 (>33 wks)
Mandell (1991) [154] >5 (<20 wks) 21% 55%
>8 (>20 wks)
Adra (1995) [155] >4 (<33 wks) 31% 36%
>7 (>33 wks)
Podevin (1996) [156] >4 (<24 wks) 56% 43%
>8 (>32 wks)
Morin (1996) [145] >4 (<20 wks) 45% 27%
>10 (>24 wks)
Stocks (1996) [157] >4 (<33 wks) 30%
>7 (>33 wks)
Persutte (1997) [144] 4e10 (>28 wks) 6% 34%
Dudley (1997) [158] >5 (14e18 wks) 36%
Jawson (1999) [84] > 5 (16e26 wks) 55%
Chudleigh (2001) [159] > 5 (16e26 wks) 56%
Sairam (2001) [49] >4 (<23 wks) 67% 64%
>10 (>28 wks)
Feldman et al. (2001) [24] >4 (<20 wks) 47%
>7 (>30 wks)
Signorelli et al. (2005) [25] 4e10 (>28 wks) 18% 56%

Most recently, the Philadelphia group presented their long-
term data for a select group of patients, which included
only patients with favorable urine electrolytes and 2nd
trimester intervention [92]. Although this paper suffered
from selection bias, it appears that patients with bladder
outlet obstruction benefited from targeted prenatal inter-
vention. For further discussions on management and
controversies in fetal intervention, refer to recent reviews
by Wu and Johnson [93], Thomas [94], Morris and Kilby [95],
and Yiee and Wilcox [96].
Imaging modalities used in the evaluation of
ANH
Renal/bladder ultrasound
US is the most common imaging modality utilized to
monitor the urinary tract in the pediatric population. Its
ease of use and absence of radiation make it an excellent
instrument to follow renal dilation that is identified both
prenatally and postnatally. However, hydration status,
bladder filling and operator skill have been shown to
influence the predictive value of this imaging modality [97].
Infants are relatively dehydrated at birth, which impacts
the recommended timing of the initial renal/bladder US. In
the absence of LUTO, the initial scan should be performed
no sooner than the second day of life. Factors such as renal
length, AP renal pelvis diameter), presence of renal cyst,
renal parenchymal thickness and ureteral dilatation should
be measured. It is important to image the urinary bladder
as well as upper urinary system during the assessment. For
example, a ureterocele resulting in hydronephrosis may be
identified in the bladder. When comparing serial US scans,
the degree of hydration and status of bladder filling should
be taken into account.
While US imaging provides adequate anatomic detail in
the absence of radiation exposure, it is a relatively poor
independent predictor of those patients that will need
surgical intervention [98]. In order to standardize evalua-
tions, it is recommended that all postnatal images be
interpreted with the SFU classification system. It should be

Table 7 Favorable urinary electrolytes and their predictive values for the absence of renal dysplasia.
Urinary compound Sensitivity Specificity Positive predictive value Negative predictive value
Sodium < 100 mg/dl 0.56 0.64 0.56 0.88
Calcium < 8 mg/dl 1.00 0.27 0.43 1.00
Osmolality < 200 mOsm/L 0.83 0.82 0.71 0.90
Beta-2 Microglobulin < 4 mg/L 0.17 0.36 1.00 0.44
Total protein < 20 mg/dL 0.67 0.91 0.80 0.83
Adapted from Johnson et al. (1994) [160].
222
noted that renal US protocols vary widely amongst different
centers, which may impact grading and the requirement for
additional imaging. For example, at some institutions, the
radiologists require the patient to be nil per os for 4 h prior
to the image. In contrast, aggressive hydration and pre-
imaging Lasix are given at other institutions. This
dichotomy without question will impact significantly not
only the grading of the hydronephrosis but in some cases
the indication for surgical intervention.
Doppler US, as an adjunct to US, contributes additional
information based on the fact that obstruction causes an
increase in intrarenal arterial resistance resulting in
a relative reduction in diastolic flow compared to systolic
flow. Numerous studies have been performed evaluating
the role of duplex Doppler for the diagnosis of renal
obstruction with mixed results [99,100]. The use of duplex
Doppler for the evaluation of renal obstructive disorders is
currently controversial and, as a result, not widely utilized.
Voiding cystourethrogram/radionuclide cystogram
It is generally recommended that a VCUG be performed
when the anatomy of the lower urinary tract needs to be
visualized (e.g. diagnosis of PUV, bladder diverticulum,
ureteroceles). In contrast, a radionuclide cystogram is
recommended for surveillance of VUR or diagnosis of VUR in
siblings due to the lower degree of radiation exposure
[101]. A lack of agreement exists concerning the need for
a postnatal VCUG in the presence of antenatal hydro-
nephrosis. This issue is further discussed below, in the
postnatal radiological evaluation of ANH.
Renal scintigraphy
Once hydronephrosis is detected by other imaging methods,
usually US, dynamic renal scintigraphy (DRS) is considered
to be an adjunct test that serves to estimate differential
renal function and characterize the severity of obstruction.
In general, DRS should be performed after 6 weeks to allow
for renal maturation. In the United States, a single US
finding of grade IV hydronephrosis usually prompts a follow-
up DRS. The European Society for Pediatric Radiology
recommends two renal US scans over at least 3 months prior
to obtaining a DRS [102]. Differential renal function < 40%
with impaired drainage (as indicated by T½ > 20 min), or
worsening renal function by DRS is often the impetus for
pyeloplasty in patients being observed with UPJ obstruc-
tion. In addition, DRS is a useful method for serial follow up
and postoperative assessment of patients with UPJ
obstruction and megaureter.
Radiopharmaceuticals used for DRS are Tc-MAG3 and Tc-
DTPA (see Table 8). Tc-MAG3 is 90% bound to plasma
proteins and is principally cleared by tubular secretion. In
addition to demonstrating parenchymal and collecting
system definition, it also provides excellent functional
quantification. These qualities and the fact that it requires
lower radiation doses than other radiopharmaceuticals,
make it the current agent of choice for evaluating renal
function and drainage. In contrast, Tc-DTPA has little
plasma protein binding and is cleared almost exclusively by
glomerular filtration. It is rapidly filtered into the urine
and therefore provides excellent visualization of the
H.T. Nguyen et al.
pelvicalyceal system, ureter and bladder, but may not be
retained in the renal parenchyma long enough for good
visualization of parenchymal abnormalities. Also, since Tc-
DTPA relies principally on glomerular filtration, results are
often suboptimal in infants with immature kidneys and
a low glomerular filtration rate (GFR) or in patients with
compromised renal function. In these scenarios Tc-MAG3 is
the preferred agent. Tc-DMSA is unique among the other
commonly used radiopharmaceuticals in that it tightly
binds to the renal tubular cells and only a small amount is
excreted into the urine. Therefore, it allows excellent
visualization of the renal parenchyma and is primarily used
for evaluating cortical lesions such as scars that occur as
a result of pyelonephritis or for the evaluation of renal
dysplasia. However, due to the long biological half time,
a higher overall radiation dose is delivered to the patient
from the study.
In an attempt to promote standardization of the tech-
nique, the SFU and the Pediatric Nuclear Medicine Council of
the Society for Nuclear Medicine published guidelines for the
‘Well-tempered Diuresis Renogram’ in 1992 [103]. Its
purpose was to allow easy comparison between studies and
institutions. The guidelines standardize many of the facets of
the study, including intravenous hydration, bladder catheter
placement, patient position, data acquisition and analysis,
timing of diuretic administration, and regions of interest for
which to monitor the diuretic effect. However, in practice,
local protocols are still frequently used which makes
comparing results from different centers problematic.
The classic recommendation for surgical intervention is
an obstructive wash-out curve in which the T½ exceeds
20 min and a significant discrepancy in split renal function
(<40%) is detected. One caveat to split renal function is the
patient with severe bilateral hydronephrosis or obstruction.
In this setting, split renal function is not an accurate indi-
cator of overall renal function because of the absence of
a normal contralateral kidney with which to compare the
hydronephrotic kidney. In this scenario, the renal unit that
demonstrates the least function should undergo repair.
Although the indications for surgical intervention may
appear straightforward, the drainage curve alone may be
significantly altered if the child is dehydrated or furosemide
is given too early in the massively hydronephrotic kidney. In
addition, the actual renal function may be significantly
over-represented in the large hydronephrotic kidney. Based
on these inherent weaknesses of the study, the authors use
the renal scan to document baseline renal function and as
a complement to the renal US more than an independent
predictor of obstruction.
Magnetic resonance urography
As an imaging modality, MRU offers the advantages of
providing a functional assessment and superior imaging
detail without neonatal radiation exposure. MRU is still in
its infancy in terms of development and application for
prenatal hydronephrosis. A majority of the data for this
modality come from the Emory group. MRU provides
excellent anatomic imaging as well as functional determi-
nation in the classification of obstructed systems [104e
107]. In 2006, Kirsch et al. presented data that demon-
strated an improvement in renal transit time as well as the
Consensus statement for prenatal hydronephrosis
Table 8 Common radiopharmaceuticals used in renal scintigraphy.
Radiopharmaceutical Renal handling
99m
Tc-Mercaptoacetyltriglycine (Tc-MAG3) Principally cleared by tubular secretion
99m
Tc-Dimercaptosuccinic acid (Tc-DMSA) Localizes and binds to the proximal convoluted
tubules
99m
Tc-Diethylenetriamine pentaacetic Glomerular filtration dependent for clearance
acid (Tc-DTPA)
Patlak score, which is a determinant of single kidney GFR
[108]. As a determinant of predicting the need for pyelo-
plasty, Kaneyama et al. looked at the level of ureteral
insertion into the renal pelvis. This group found that a ratio
of greater than 0.3 for distance of ureteral insertion to the
length of the calyx was predictive of the need for surgical
intervention in UPJ obstruction [109].
Unfortunately, the level of scientific evidence in favor of
the use of MRU for the evaluation of prenatal hydro-
nephrosis is fairly poor. Few studies available for evaluation
are controlled [110]. In addition, issues such as cost,
availability of appropriate software and technology, and
the need for sedation or anesthesia in most patients
significantly limit the widespread application of this
imaging modality.
Postnatal radiological evaluation of ANH
The initial postnatal evaluation of fetal hydronephrosis
depends in part on the degree of hydronephrosis seen
during fetal evaluation. A recent retrospective study of
nearly 8000 neonates showed that even in a low-risk pop-
ulation (fetal pelvic APD of 5 mm) the majority were
found to have an increase in degree of hydronephrosis,
while some had a non-progressing condition [111].
Currently, no distinguishing features exist that differen-
tiate which of these children will develop progressive
evidence of obstruction on subsequent postnatal follow up.
One of the most important distinctions in the assessment of
these children is determining which patients benefit from
surgery. This distinction is important since unnecessary
intervention exposes patients needlessly to the morbidity
of surgery, while inappropriate observation places patients
at risk of infection and renal parenchymal loss. Regardless,
except in the most severe cases, most urologists will
initially follow hydronephrotic kidneys with serial radio-
logical exams and use decreasing differential renal function
or worsening hydronephrosis as an indicator that surgery or
advanced imaging may be required.
The initial postnatal evaluation includes US, DRS and, more
recently at some centers, MRI for the evaluation of hydro-
nephrosis. Each of these diagnostic modalities has relative
advantages and disadvantages (Table 9). Currently, no study is
considered a gold standard for the evaluation of renal
obstructive disorders and complete assessment typically
involves a series of studies including US and DRS. In general,
these studies provide either good anatomical or good func-
tional information whereas none of these studies, save MRI,
provide both. Some tests are more invasive than others, which
also influences test selection. Consequently, a thoughtful
223
Application
Renography
Renal parenchymal imaging
Renography
diagnostic strategy is necessary to proceed with appropriate
management at minimal cost and morbidity to the patient.
Which neonates require postnatal evaluation?
The degree of hydronephrosis is used to assist in decision
making with regard to diagnostic imaging and treatment,
and additionally provides some prognostic information. For
example, SFU grades I and II hydronephrosis tend to resolve
with time and usually only require US surveillance. It has
been suggested that in cases of complete resolution of
hydronephrosis, a repeat sonogram should be performed
after 3 weeks when neonatal oliguria is no longer a con-
founding variable. In one study [25], 18% of cases of fetal
hydronephrosis normalized and only one case required
surgery (ureteral reimplantation) at follow up. An addi-
tional study documented two cases of complete hydro-
nephrosis resolution where pyeloplasty was ultimately
required [112]. In most studies that follow patients with
mild pelviectasis (RPD < 10 mm), no significant uropathy is
detected. However, close clinical follow up may be needed
to monitor for UTI and progression of mild hydronephrosis
during infancy [21]. One recent study showed a 12-fold
increase in risk of pyelonephritis during infancy when
hydronephrosis was detected in the first year of life [113].
These risk factors need to be discussed with the family.
Because there are inaccuracies in the interpretation of
hydronephrosis, the less severe cases (SFU grades IIIII)
present a more controversial diagnostic dilemma. In many
cases of moderate hydronephrosis (SFU grade III), DRS may
be helpful in determining the timing and role of further
studies. For example, a normal DRS would be followed by
US, while an indeterminate DRS may require additional DRS
or MRU. Erickson et al. reported that no cases of SFU III
hydronephrosis have required surgery [114]. In contrast,
Chertin et al. have shown that 50% of children followed
conservatively went on to surgery [53]. However, one must
recognize that the criteria for surgical intervention are
variable and may be further confounded by the surgeon’s
and parents’ wishes. For severe hydronephrosis (SFU IV),
a functional evaluation is recommended since these
patients are more likely to have significant urologic
pathology and require surgical intervention. SFU IV hydro-
nephrosis should prompt either DRS or MRU. For solitary
kidneys or bilateral renal involvement, MRU may be supe-
rior as individual kidney function (GFR) may be assessed.
However, cost, expertise, and availability limit the use of
MRU currently. Likewise, DRS and MRU may not be available
universally, and in such cases intravenous urogram may be
the only test used.
224 H.T. Nguyen et al.

Table 9 The advantages and disadvantages of various diagnostic modalities for the assessment of ANH.
Imaging study Advantages Disadvantages
Intravenous urogram Good anatomy if function is good Inaccurate if poor function, nephrotoxic
contrast, radiation exposure
Whitaker test Only study that measures directly the pressure Invasive, not reproducible, no functional
in the renal pelvis/bladder information, radiation exposure
US Inexpensive, portable, no contrast or radiation No functional information, limited anatomy
exposure
DRS Good functional and drainage information Limited information in bilateral disease, no
anatomical information, interpretive error, 15%
false negative/positives
Gadolinium-enhanced MRU Superior anatomical and functional information Expensive, not yet widely available due to the
even if poor function or bilateral disease, no complexicity of the software protocol needed
radiation, contrast non-nephrotoxic to process the MRI information, requires
sedation and monitoring

Many protocols call for a VCUG to rule out VUR, espe-
cially in cases where the degree of hydronephrosis is
moderate to severe. However, the likelihood of VUR, as
opposed to obstructive conditions, decreases as the degree
of hydronephrosis worsens [18]. Nonetheless, the presence
or absence of VUR may affect surgical approach and need
for antibiotic prophylaxis.
The timing of postnatal evaluation of
hydronephrosis
For unilateral fetal hydronephrosis with a normal contra-
lateral kidney, postnatal evaluation should begin within the
first week of life with a renal US [7,97]. Patients with an
increased risk of UTI (e.g. girls, uncircumcised boys,
moderate to severe antenatal hydronephrosis, familial
VUR, etc.) should be placed on prophylactic antibiotics
until the evaluation is performed and management dis-
cussed with the family [113]. For bilateral hydronephrosis
and hydronephrosis in solitary kidneys or in patients with
suspected bladder outlet obstruction, early postnatal
imaging is suggested. Typically this occurs at the birthing
hospital prior to newborn discharge from the hospital.
The role of VCUG in the evaluation of
hydronephrosis
VUR is considered to be a significant abnormality in some
large neonatal series. However, it may not be considered as
such in others. For example, if the fetal population consisted
primarily of males with pyelectasis, then the diagnosis of
high-grade VUR appears more prevalent [115]. In the United
States and other countries where the practice of circumci-
sion is common, it raises the question of the clinical rele-
vance of making the diagnosis of VUR in a newborn boy at low
risk of UTI throughout his lifetime. Most patients with VUR
and low-grade hydronephrosis can be followed without
surgical intervention [116]. High-grade VUR, however, may
predict renal damage and may permit earlier diagnosis and
need for long-term nephrologic care. In such cases, efforts
should be directed at decreasing the risk of UTIs [61].
VCUG is frequently performed in conjunction with renal
studies to rule out VUR as the cause of hydronephrosis. The
presence of a dilated ureter lying posterior to the bladder
helps distinguish megaureter from UPJ obstruction. When
either diagnosis is a consideration, a VCUG to rule out VUR
as the cause of dilatation should be performed. It should
be kept in mind that VUR may coexist with UPJ obstruction
in as many as 10% of children [117]. Currently, there is no
clear evidence to support or to avoid postnatal imaging for
VUR. Neither the grade of the hydronephrosis nor gender is
a predictive factor for VUR in children with ANH. The
overall incidence of VUR is up to 30% in children with ANH,
including those with resolved hydronephrosis [7,18]. It
remains unproven whether the identification and treat-
ment of children with VUR confers any clinical benefit
[118].
Follow-up evaluation for ANH
Numerous studies have demonstrated that a single normal
US within the first week of life is not adequate to verify
absence of obstruction. A second US is recommended at 1
month of age as initial follow-up testing. The incidence of
late worsening or recurrent hydronephrosis is approxi-
mately 1e5%, with this risk applying to all grades of initial
hydronephrosis [112,119,120]. When there is late worsening
or recurrence, the severity of hydronephrosis is quite
significant, being of grade IIIIV, and the majority of the
patients are likely to be symptomatic [119]. The timing of
late worsening or recurrence has been observed to range
from a few months to 5e6 years [112]. Consequently, long-
term follow up is recommended, but the appropriate length
of surveillance has yet to be determined. It also remains to
be determined whether such follow up is warranted and
cost-effective given the low incidence of late-occurring
significant obstruction. Consequently, some practitioners
have recommended discharging children with mild or grade
III hydronephrosis on the 1-month US from further
surveillance with the recommendation of seeing the child
again for UTI or pain [19,102], while others have recom-
mended serial US and UTI surveillance every 6 or 12
months[22] or in 2e3 years [121]. Future prospective
studies will be needed to determine the most cost-effective
and clinically appropriate follow-up protocol for children
with ANH.
Consensus statement for prenatal hydronephrosis 225

Role of antibiotic prophylaxis in children with of 14 cases of rare chromosomal abnormalities, three had
ANH mild pyelectasis and a fourth was diagnosed with a horse-
shoe kidney. In a review of prenatal detection of trisomy
21, 9.1% had some degree of hydronephrosis [127], and it
The rationale for antibiotic prophylaxis in children with
was found to be more common in fetuses with trisomy 21
a history of ANH includes prevention of UTIs, as infants with
compared to normal controls (17% vs 5%) [128]. Staebler
hydronephrosis are at increased risk [113]. The risk of UTI
et al. [129]. corroborated the increased incidence of
increases with increasing grade of hydronephrosis [21,122].
serious abnormalities: significant chromosomal abnormali-
Rates appear to be as high as 40% in children with SFU IV
ties were detected in 9% of fetuses with antenatal anom-
hydronephrosis [122], with another study estimating the
alies (including 3/22 of those with genito-urinary findings)
cumulative incidence of UTI as 39%, 18% and 11% at 36
and there was a 19% abnormality rate in fetuses with
months of age for severe, moderate and mild RPD,
multiple anomalies (3/16 of these patients had a genito-
respectively [21]. Several studies report a higher rate in
urinary abnormality). Another review found karyotype
girls compared to boys [21,113]. Children with hydro-
abnormalities in 0.125% of patients with an isolated genital
nephrosis and obstructive drainage patterns on renal scan
finding on US (sexual ambiguity) and 0.027% with an iso-
are at increased risk compared to those without obstructive
lated finding of hydronephrosis [129,130]. ANH, in isolation,
patterns [122,123]. An increased risk is also associated with
had the lowest correlation with karyotype abnormalities of
hydroureteronephrosis[124] even without reflux or without
all organ systems examined [129]. Therefore, several
an obstructive pattern on renal scan [122]. These obser-
authors do not believe that the risk of chromosome analysis
vations suggest that increased stasis and easier access to
(0.5e1% fetal loss) is justified for a low-risk diagnosis such
a urinary reservoir (such as in the case of hydroureter)
as unilateral hydronephrosis or MCDK. However, Nicolaides
increase the chance of developing a UTI.
et al. [131]. do advocate aggressive screening, as they
Of the studies reviewed, none were prospective
detected chromosomal anomalies in 12% of their cases, and
randomized trials between antibiotics and no antibiotics in
in 3% of isolated mild hydronephrosis.
children with ANH. Therefore, the efficacy of antibiotic
The vast majority of patients with ANH will be born
prophylaxis has not been proven. High rates of UTI have been
without major anomalies, but prognostic information
noted despite prophylactic antibiotics in children with
regarding future siblings may still be relevant. With respect
hydronephrosis [21]. Alconcher and Tombesi[125] similarly
to a UPJ obstruction, an entity named genuine hereditary
reported no statistical difference in the incidence of UTI in
hydronephrosis (GHH) has been shown to have an autosomal
children with ANH on or off prophylactic antibiotics. In
dominant inheritance and complete penetrance with linkage
contrast, Estrada et al. [126]. observed that in children with
analysis locating the gene to chromosome 6 p [132,133].
a history of prenatal hydronephrosis with persistent grade II
Other families with multiple affected siblings have shown an
hydronephrosis secondary to VUR, the use of prophylactic
autosomal dominant inheritance but with an incomplete
antibiotics significantly reduced the risk of febrile UTIs. At
penetrance pattern [134,135]. VUR has a well-documented
present, unless part of a controlled trial, it seems prudent to
familial inheritance pattern, with siblings of the index case
consider use of a prophylactic antibiotic in an effort to
reported to have a 5e50% risk of VUR [136e138]. Recent
prevent infant UTIs in high-risk populations, such as those
work demonstrated several loci potentially responsible for
with higher grades of hydronephrosis, hydro-
VUR, accounting for the significant variability seen clinically
ureteronephrosis, VUR, or obstructive drainage patterns.
[139e141]. PUV have been reported to occur in families
[142], but no genetic link has been identified and these cases
Chromosomal evaluation for children with ANH account for only a small minority.
While ANH is more common in fetuses with serious
ANH has been linked to a number of extra-genitourinary chromosomal anomalies, most sources do not recommend
disorders, and its presence may be useful in their evalua- routine karyotyping for all cases of isolated hydronephrosis.
tion and diagnosis. A review published in 1998 revealed that However, this may be considered in the presence of

Table 10 Recommendations for the prenatal evaluation of ANH.

Time of detection of ANH Severity of ANH APD (mm) Recommendations
2nd Trimester Mild <7 Consider 3rd Trimester US
Moderate 7e10 3rd Trimester US
Severe >10 Repeat US in 3e4 weeks
3rd Trimester Mild <9 Postnatal evaluation
Moderate 9e15 Postnatal evaluation
Severe >15 Repeat US in 2e3 weeks
Special considerations
Unclear anatomy Consider MRI
Oligohydramnios Consider fetal urine sampling
PUV suspected Consider fetal intervention, serial vesicocentesis, early
Increased renal echogenicity delivery or termination based upon case-by-case analysis
226 H.T. Nguyen et al.

Table 11 Recommendations for the postnatal evaluation of ANH.

Degree of unilateral Recommendation Results of postnatal US Recommendation for Recommendation for
ANH for prophylactic (at 2e4 weeks)a VCUGb, d follow-up US
antibiotics (based
on prenatal US)
Mild Noc Resolved (No hydro.) Noc 1 year
Mild (SFU IeII) No/Yesc 1 year
Moderate/Severe Yes (2e4 weeks) 3e6 months
(SFU IIIeIV) (if þ VUR, Abx)
Moderate Yes Resolved (No hydro.) Noc (stop Abx) 1 year
Mild/Moderate/Severe Yes (2e4 weeks) 3e6 months
(SFU IeIV) (if þ VUR, Abx) (if e
VUR, consider MAG3)
Severe Yes Resolved/Mild/ Yes (2e4 weeks) 3e6 months
Moderate/Severe (if þ VUR, Abx) (if e
(SFU 0eIV) VUR, recommend MAG3)
Special conditions Recommendation When to obtain Recommendation for Recommendation for
for prophylactic postnatal US? VCUGb follow-up US
antibiotics (based
on prenatal US)
Bilateral moderate Yes 1e3 days Yes (1e7 days) Depending on pathology
or severe ANH after birth (if þ VUR, Abx)
(if e VUR, may need
MAG3/DMSA)
(if þ PUV, consider
surgery)
Bladder/urethral Yes 1e3 days Yes (1e7 days) Depending on pathology
abnormalities: after birth (if þ VUR, Abx)
Diverticulum (if e VUR, may need
Bladder wall MAG3/DMSA)
thickening (if þ PUV, consider
Ureterocele surgery)
Dilated posterior
urethra
Dilated ureter Yes 2e4 weeks Yes (1e7 days) (if þ VUR, Depending on pathology
Abx) (if e VUR, consider
MAG3)
Decreased amniotic Yes 1e3 days Yes (1e7 days) Depending on pathology
fluid after birth (if þ VUR, Abx)
(if e VUR, consider
MAG3/DMSA)
(if þ PUV, consider
surgery)
Abx Z antibiotics.
a
If compliance is a concern, US should be obtained within the first day of life.
b
If VCUG is recommended, prophylatic antibiotics should also be instituted.
c
Polling of the SFU membership indicated that when there is unilateral mild ANH that does not persist postnatally, only 25% would
institute antibiotic prophylaxis and obtain a VCUG; when unilateral mild ANH does persist postnatally, 50% would do so. Consequently,
the risk/benefits of antibiotics and VCUG should be discussed with the family to determine the appropriate choice for the individual
patient.
d
Gender or race may influence the decision to obtain a postnatal VCUG.

multiple system anomalies. The presence of ANH in
a patient likely increases the chances it will be seen in
a sibling, but these rates have not yet been published.
Recommendations
As evidenced by the current literature, the optimal
schedule for pre- and postnatal evaluation of children with
ANH is unclear. We suggest an individualized approach,
based on the general schedule given in Tables 10 and 11.
Research priorities
Collectively, the findings in this manuscript identify an
obvious need for evidence-based conclusions on prenatal
hydronephrosis. This consensus statement is sound but
Consensus statement for prenatal hydronephrosis
a majority of its recommendations are not based on evidence
that is level 1 or 2. Although there is a dire need for random-
ized studies, their development and subsequent imple-
mentation are extremely difficult to execute and will likely
not occur for this diagnosis. One alternative to randomized
clinical trials is a registry that serves as a data repository from
which future hypotheses can be formulated and tested. The
Prenatal Hydronephrosis Registry serves as such a repository
that may serve to facilitate the development of future care
pathways and clinical practice guidelines for the treatment of
conditions that present with prenatal hydronephrosis.
Conflict of interest
None of the authors have any financial or personal rela-
tionships with other people or organizations that could
inappropriately influence (bias) this work. None of the
authors have any financial interest in the execution of the
study or the publication of the paper.
Disclosures
None.
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