Early Human Development (2006) 82, 9 — 14

available at www.sciencedirect.com

www.elsevier.com/locate/earlhumdev

Management of neonatal hydronephrosis

James M. Belarmino a,*, Barry A. Kogan b,1
a
Albany Medical College, Division of Urology, MC 208, 23 Hackett Boulevard, Albany, NY 12208, USA
b
Urology, Surgery and Pediatrics, Albany Medical College, MC 208, 23 Hackett Boulevard, Albany, NY 12208, USA

KEYWORDS Abstract Management of neonatal hydronephrosis is a clinical challenge. The natural history of
Hydronephrosis; hydronephrosis has shown that most resolve spontaneously; however, there are a significant
Management; number that do not. Although hydronephrosis does not always mean obstruction, it becomes the
Neonatal; clinician’s role to determine when obstruction will eventually lead to renal damage. Work-up of
Ultrasound; hydronephrosis diagnosed prenatally starts with a postnatal ultrasound. Using the Society of Fetal
Voiding Urology (SFU) grading of hydronephrosis based on ultrasonography, a management and treatment
cystourethrogram; algorithm can be constructed. Other studies include a voiding cystourethrogram to evaluate for
Diuretic renography vesicoureteral reflux or in severe cases of bilateral hydronephrosis to evaluate for posterior
urethral valves. Diuretic renography is useful in many cases to evaluate the degree of obstruction
and determine differential renal function. The goal is to select the patients who would benefit
from early surgical intervention. To achieve that goal, aggressive observation is often required.
D 2005 Published by Elsevier Ireland Ltd.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.1. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2. Causes of neonatal hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2. Management of neonatal hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1. Prenatal evaluation and treatment: posterior urethral valves. . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2. Postnatal evaluation: upper tract hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3. Postnatal management: upper tract hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4. Postnatal evaluation and management: hydroureteronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Key guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4. Research directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

* Corresponding author. Tel.: +1 518 262 3296; fax: +1 518 262 6050.
E-mail addresses: jimmyb_md992001@yahoo.com (J.M. Belarmino)8 koganb@mail.amc.edu (B.A. Kogan).
1
Tel.: +1 518 262 3296; fax: +1 518 262 6050.

0378-3782/$ - see front matter D 2005 Published by Elsevier Ireland Ltd.

doi:10.1016/j.earlhumdev.2005.11.004
10 J.M. Belarmino, B.A. Kogan

1. Introduction

The introduction of fetal ultrasonography (US) has allowed

for the detection of many intrauterine anomalies. Indeed,
most anomalies are detected during routine fetal US done at
18—20 weeks gestation. Urinary tract anomalies are partic-
ularly readily identified. Of these, hydronephrosis is the most
SFU Grade 0
common, comprising 50% of congenital malformations [1].
Fetal hydronephrosis is found in 0.59% [2] to 1.4% of fetuses
[3]. However, hydronephrosis does not necessarily translate
into obstruction. Moreover, many cases of neonatal hydrone-
phrosis improve or resolve spontaneously without surgical SFU Grade III
intervention [2]. The dilemma becomes which renal units
would best be operated on and which can be observed. The
purpose of this article is to review the current literature on
the management of neonatal hydronephrosis, establish SFU Grade I
clinical guidelines and discuss future research directions to
help understand better the natural history of neonatal
hydronephrosis.

1.1. Definitions
To standardize and categorize neonatal hydronephrosis
better, the Society of Fetal Urology (SFU) developed a
grading system based on the long-axis sonographic appear-
ance of the renal parenchyma and pelvicalyceal system
(Table 1). In Fig. 1, examples of SFU grades 0 to IV are
depicted. Only grades III and IV are thought to be clinically
significant postnatally. Another description of the degree of
hydronephrosis is the measurement of the maximum antero-
posterior diameter of the pelvis, or the renal pelvic diameter
(RPD). Controversy exists pertaining to the threshold RPD
that is considered abnormal in the fetus [2] especially noting
that this may change with gestational age. Most clinicians
consider an RPD N 6 mm late in gestation to be indicative of
hydronephrosis worthy of postnatal follow-up [4].
1.2. Causes of neonatal hydronephrosis
The most common causes of neonatal hydronephrosis are
transient and physiologic hydronephrosis accounting for
approximately 60% of cases [2]. The natural history of these
Table 1 Society of Fetal Urology grading system of
congenital hydronephrosis
Grade Central renal complex Renal parenchymal
thickness
0 Intact Normal
I Slight splitting of pelvis Normal
II Evident splitting of Normal
pelvis and calices
III Wide splitting of Normal
pelvis and calices
IV Further splitting of Reduced
pelvis and calices
Ultrasonographic examination is based on the long axis of the
kidney to determine the degree of renal sinus splitting and renal
parenchymal thickness. Grades I and II usually resolve and can be
followed with periodic ultrasound; however, grades III and IV
should be followed with renography.
SFU Grade IV
SFU Grade II
Figure 1 Long-axis renal ultrasound views of representative
SFU grades 0 to IV.
cases appears to be benign. In one series [5], 45 infants with
hydronephrosis were followed for 30 months and mild
hydronephrosis was seen in 30. All did well. Of the 15
infants with severe hydronephrosis, most also did well, with
some showing improvement in function measured by diuret-
ic renography. In one somewhat atypical and unique series,
Koff and Campbell followed 104 patients for 5 years and only
seven (7%) required pyeloplasty, as determined by progres-
sion of hydronephrosis and/or greater than 10% reduction in
glomerular filtration rate on renography [6]. Although these
patients did better than most others in the literature, this
demonstrates that many cases, even severe ones may do
well.
Another common cause of neonatal hydronephrosis is
significant ureteropelvic junction obstruction (UPJO) which
accounts for approximately 10% of prenatal hydronephrosis.
The male-to-female ratio in infancy is 3:1 and the hydrone-
phrosis is bilateral in up to 20—25% of cases, though most
commonly the contralateral hydronephrosis is not significant
[2]. The etiology in neonates is usually an intrinsic stenosis
followed by a kink. It is usually suspected prenatally when
there is hydronephrosis with a very large renal pelvis (N 3 cm
in A—P diameter), no ureteral dilation and normal bladder
and normal amniotic fluid volume.
Vesicoureteral reflux is found in up to 33% of cases of
prenatal hydronephrosis [7]. Interestingly, males predomi-
nate in these cases and these infants have a high spontane-
ous resolution rate. In some series, 65% resolve within 2
years including an appreciable number of severe grades IV
and V reflux [2].
Ureterovesical junction obstruction constitutes about 4%
of the causes of neonatal hydronephrosis and is suggested
when the US shows a dilated ureter (N 7 mm) as well as
hydronephrosis and a voiding cystourethrogram (VCUG)
Management of neonatal hydronephrosis
Table 2 Causes of neonatal hydronephrosis
Causes of neonatal hydronephrosis
Transient hydronephrosis
Physiologic hydronephrosis
Ureteropelvic junction obstruction
Vesicoureteral reflux
Ureterovesical junction obstruction (megaureter)
Multicystic dysplastic kidney
Posterior urethral valve
Ureterocele
Dilation of one moiety of a duplex kidney
Transient and physiologic hydronephrosis are the most common
etiologies requiring periodic ultrasonographic follow-up. Ureter-
opelvic junction obstruction should be aggressively observed.
shows no reflux. Posterior urethral valves (PUV), multicystic
dysplastic kidney and ureteroceles constitute between 2%
and 4% of the cases [2]. Table 2 lists the principal causes of
neonatal hydronephrosis.
2. Management of neonatal hydronephrosis
2.1. Prenatal evaluation and treatment: posterior
urethral valves
Once diagnosed, the recommended follow-up of prenatal US
abnormalities is determined by the severity of the diagnosis.
In particular, those fetuses whose prenatal sonogram is
suggestive of PUV (a male baby with bilateral hydrone-
phrosis, dilated ureters and a dilated thick-walled bladder
and occasionally a bkey-holeQ sign indicative of a dilated
posterior urethra) require regular prenatal follow-up (Fig. 2)
Posterior urethral valves are life-threatening, so that follow-
up in utero to determine renal status and especially the
amount of amniotic fluid is important. Though rare, in utero
treatment may be indicated and if not, neonatal treatment
is mandatory.
Markers to prognosticate fetal renal function have been
evaluated [8]. The most crude of these is the amount of
amniotic fluid. If normal, this suggests reasonable renal
function and likely normal pulmonary function postnatally.
In contrast, oligohydramnios suggests both a poor renal and
pulmonary prognosis and if long standing, is incompatible
with survival. Ultrasound examination of the fetal kidneys is
also useful. Despite hydronephrosis, a good prognostic
indicator is corticomedullary differentiation in the kidneys.
In contrast, the finding of increased echogenicity or cortical
cysts is confirmation of renal dysplasia. Finally, aspiration of
fetal bladder urine for urinary proteins (albumin and beta2-
microglobulin) and electrolytes (sodium, chloride and os-
molality) can also be helpful. Some investigators suggest
that this be done only after aspirating the fetal bladder
completely, so that the urine being analyzed is fresh. Low
levels of urinary protein and evidence of tubular reabsorp-
tion, fetal urinary sodium less than 100 mmol/L, chloride
less than 90 mmol/L and an osmolality of less than 210
mOsm/L [9] all suggest good renal function (Table 3).
There are rare cases in which prenatal treatment of
urethral valves is warranted. In particular, intervention is
appropriate when the obstructive process leads to progres-
11
sive oligohydramnios. In these circumstances, the neonate’s
survival is at stake, as long-standing oligohydramnios will
most likely lead to pulmonary hypoplasia and neonatal
demise. Even in these circumstances, intervention is only
warranted if the ultrasound findings and urinary markers
suggest salvageable renal function. Otherwise, the attempt
will likely be futile. In those rare instances in which all the
criteria are met, the bladder is generally decompressed
using a percutaneously placed vesico-amniotic catheter. In a
few settings, percutaneous, endoscopic in utero ablation of
valves has been performed [9]. At this time, these proce-
dures should be attempted only in highly selected cases and
in highly specialized centers, as the procedure carries many
risks, including fetal injury or demise, maternal infection,
miscarriage, and spontaneous rupture of membranes with
premature labor [9]. Special note should be made that many
of these risks apply not only to the newborn, but to the
healthy mother as well.
There are at least two published reviews that address the
results of prenatal treatment of urethral valves. In one
review of 14 fetuses who underwent prenatal intervention
and who postnatally had PUV diagnosed, it was found that
favorable urinary electrolytes failed to consistently predict
postnatal renal function after intervention and there was a
43% fetal mortality rate [10]. Another study retrospectively
reviewed eight fetuses, of which four had PUV, who
underwent vesico-amniotic catheter placement and con-
cluded that the intra-uterine intervention benefited pulmo-
nary function and allowed for neonatal survival, but that
neither bladder nor kidney function improved [11]. This
creates an ethical dilemma of whether it is appropriate to
intervene to save the fetus, only to have the neonate born
with chronic renal insufficiency and the enormous medical
and social challenge that accompanies this condition.
2.2. Postnatal evaluation: upper tract
hydronephrosis
This section refers to the common condition of unilateral
prenatal hydronephrosis. In most of these cases, amniotic
fluid was normal and the neonate had normal pulmonary
Figure 2 Bladder ultrasound showing sonographic finding of
bladder outlet obstruction such as bladder wall thickening and
bkey-holeQ sign suggesting a dilated posterior urethra.
12
Table 3 Fetal urinary markers
Fetal urinary marker Normal range
Sodium 75—100 mg/dL
Calcium 8 mg/dL
Beta2-microglobulin Less than 4 mg/dL
Osmolality Less than 200 mOsm/L
Urinary fetal markers obtained from a freshly aspirated fetal bladder tap can be used to prognosticate fetal renal function for possible
prenatal intervention, although favorable markers do not always translate to favorable postnatal renal function.
development. These fetuses appear healthy in the nursery.
The challenge of postnatal management of these patients is
selecting those who would benefit from early surgical
intervention and avoiding surgery for those who have
hydronephrosis that will resolve spontaneously. In short,
the goal is to prevent renal damage, but not at the expense
of performing unnecessary surgery. Therefore, aggressive
observation has been recommended. This consists of serial
US, VCUG and selective diuretic renography.
Postnatal renal imaging should be performed, including
US and VCUG. In selected cases, radionuclide imaging is
used, and rarely, magnetic resonance imaging may be
useful. The first postnatal US should not be performed in
the first 2—3 days of life if possible, as the neonate has
relatively low urine output, and hence, this may falsely
underestimate the degree of hydronephrosis. If possible, the
first postnatal ultrasound should be performed at 7—10 days
of life [2]. The US can be graded by any standard scoring
system, for example, that proposed by the SFU.
An immediate VCUG should be obtained before dis-
charge from the hospital in any infant suspected to have
bladder outlet obstruction per prenatal US, typically within
48 h of birth [2]. However, in most cases of unilateral
hydronephrosis, we recommend that this be done elective-
ly at about 1 month of age. About a third of patients will
be shown to have reflux [7] and even a quarter of those
patients whose postnatal ultrasound is normal will have
reflux. Some controversy exists in this area as some
authors reserve VCUG for cases of bilateral hydronephrosis,
ureteral dilation or unstable hydronephrosis [12]. Nonethe-
less, we feel that the identification of reflux in a third of
these children is important (Table 4). Indeed, we recom-
mend that the child should be on prophylactic antibiotics,
usually amoxicillin (10 mg/kg/day) until reflux is eliminated
or continuously if reflux is found. Trimethoprim-sulfa-
methoxazole should not be used in the neonate because it
Table 4 Absolute clinical indications for voiding
cystourethrogram
Severe bilateral hydronephrosis
Suspected infravesical obstruction
Dilated ureter
Duplex kidney
Abnormal echogenicity
Abnormal bladder
Prior to pyeloplasty
Although there is debate about obtaining a VCUG in all neonatal
hydronephrosis, these are some absolute indications for the
study.
J.M. Belarmino, B.A. Kogan
Comment
Normal value decreases during gestation
Sensitive predictor of dysplasia
Greater than 13 mg/dL associated with fetal death
displaces bilirubin from albumin and is therefore dangerous
in the neonate.
Diuretic renography is the method of choice to evaluate
renal function and drainage in the significantly dilated
upper urinary tract system when there is no reflux. It is
relatively non-invasive and gives quantitative data on
function and drainage. The radionuclide of choice is 99m-
technetium mercaptoacetyl-triglycine (MAG 3) due to its
high initial renal uptake [12] but 99m-technetium diethyl-
triamine pentaacetic acid (DTPA) is also usable. If there is no
washout in the first 30 min of the study, a diuretic (usually
furosemide) is given to challenge the system. Hydronephro-
tic systems that are not obstructed will usually drain after
the diuretic, but those that are obstructed will not. Many
will fall in between and this is where an experienced
clinician is essential. The half-time (T 1/2) of drainage of
tracer has been described by Kass et al. to help objectively
evaluate obstruction [13]. A T 1/2 of less than 10 min is
unobstructed, T 1/2 greater than 20 min is obstructed and T 1/
2 between 10 and 20 min is equivocal. However, diuretic
renography and T 1/2 measurements are dependent on
technique, hydration status, renal function and anatomy.
For example, a very hydronephrotic, poorly functioning
kidney will not drain rapidly on renography even if not
obstructed. Because of the problems with interpreting
washout data on scans, some authors have touted differen-
tial or split renal function as the most important assessment
tool. For example, a differential function of less than 40% or
greater than a 5% decrease on serial studies has been used
by most authors as an indication for surgical repair [12].
However, the threshold for decision-making has been
controversial, with other investigators using values less than
35% or even as low as 25% [3]. Though more straightforward
than washout measurements, these calculations are also
very operator dependent [14]. Overall, diuretic renography
is a very useful test in these patients. However, while
thought to be bnon-invasiveQ the test requires an IV, a
bladder catheter and that the infant be immobilized for
about 60 min. Most parents do not agree that this is a non-
invasive test and it should be repeated judiciously.
Many investigators are experimenting with MR urogra-
phy as an alternative. This is particularly useful in
neonates who have severe hydronephrosis and poor renal
function [12]. With current MR urography, T2-weighted
sequences can evaluate neonatal hydronephrosis and
localize the site of obstruction. Determination of func-
tional impairment and evaluation of renal parenchyma can
be assessed using gadolinium enhanced T1-weighted
sequences. Unfortunately, at this time, sedation or anesthe-
sia is required to perform the study; hence, it has not gained
popularity.
Management of neonatal hydronephrosis
Table 5 Clinical parameters to indicate surgical
intervention
Reduced differential function, less than 40%
Deterioration of differential function greater than 5%
Sustained or increased hydronephrosis
Unilateral gross hydronephrosis, greater than 50 mm
Severe hydronephrosis in solitary kidney
Severe bilateral hydronephrosis, greater than 30 mm
Febrile breakthrough infection or symptoms
Clinical parameters that are useful for selecting aggressively
observed neonatal hydronephrosis for surgical intervention.
2.3. Postnatal management: upper tract
hydronephrosis
Management is based on the degree of hydronephrosis (after
proving there is no reflux) and whether one or both kidneys
are involved. For unilateral hydronephrosis, SFU grade I or II,
periodic repeat US is all that is necessary. Most all these
patients will do well [12]. For grades III or IV hydronephrosis,
we generally recommend that a diuretic renogram be
performed at 4—6 weeks of age. If the differential function
is greater than 40%, serial follow-up US is recommended. If
the function is less than 40% and washout is poor, then
because there is less margin for error, surgical reconstruction
is recommended in most cases. In the majority of the other
cases, the patient is followed using regular US examinations.
If hydronephrosis and parenchymal thinning is progressive
then repeat renography is performed, or some parents prefer
surgical intervention. If the hydronephrosis is stable, then
continued observation is best.
Several studies have looked at a comparison of patients
with Grade III and IV hydronephrosis randomized to surgery
or observation [3,15,16]. Although there are no major
differences in the outcomes over the first few years,
approximately 25% of those observed will come to surgical
repair in the first several years of life. The reasons generally
include increasing hydronephrosis, reduced function, uri-
nary tract infection or pain (Table 5).
2.4. Postnatal evaluation and management:
hydroureteronephrosis
When prenatal US shows hydroureteronephrosis and post-
natal VCUG shows no reflux, the diagnosis is almost always
an obstructed megaureter (usually a bfunctionalQ obstruc-
tion). Though this can be repaired surgically with a high
success rate, studies have shown that most of these cases
will resolve or stabilize spontaneously; hence, a period of
observation is most appropriate [17]. Because there is a high
rate of infection in these patients, prophylactic antibiotics
should be given. Follow-up is with periodic US and if the
hydronephrosis is stable or improved, observation is contin-
ued. As noted above, most cases will improve spontaneously.
3. Key guidelines
! Prenatal intervention for hydronephrosis is indicated only
in very select instances. Even when well selected,
intervention is highly controversial.
13
! Postnatal hydronephrosis does not equate to obstruction;
therefore, imaging studies should be used to help decide
whether there is obstruction.
! Postnatal imaging should include a renal ultrasound
performed after the first few days of life, preferably 7—
10 days, and a voiding cystourethrogram at about 1
month of age in prenatal unilateral hydronephrosis. When
hydronephrosis is significant, the functional study of
choice is the diuretic renogram (MAG3).
! Postnatal renal ultrasound and voiding cystourethrogram
should be done within 48 h of birth in prenatally
suspected bladder outlet obstruction.
! Antibiotic prophylaxis with oral amoxicillin (10 mg/kg/
day) should be given once the infant is born and
continued until reflux in ruled out.
! Indications for surgical intervention include reduced
differential function (b 40%), greater than 5% decrease
in baseline differential function, progressive increase in
hydronephrosis, severe hydronephrosis (N 50 mm), febrile
infection or poor parental compliance.
! Approximately 25% of those with significant hydrone-
phrosis (renal pelvic AP diameter N 3.0 cm) will ultimately
come to surgical correction.
4. Research directions
! Basic science research should be directed towards finding
new biomarkers of early renal injury due to obstruction.
! Research evaluating the predictive value of radiographic
findings (e.g., renal pelvic diameter and renal functional
measurements) using multivariate analysis to risk stratify
patients will be very useful.
! Research to help better select fetuses that would benefit
from prenatal treatment of urethral valves would be very
helpful.
5. Conclusion
Neonatal hydronephrosis remains a clinical challenge with
a wide grey zone. Determining when persistent postnatal
hydronephrosis will result in renal damage takes clinical
judgment and careful observation. Although a majority of
postnatal hydronephrosis will resolve spontaneously, select-
ing the group of children that will not resolve and more
important, may result in renal damage, requires careful
follow-up and good clinical judgment. With future clinical
and basic science research, the hope is that the grey zone
can become narrower, allowing for better selection of
appropriate patients for observation and for surgical
intervention.
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