The diagnosis, evaluation and management of antenatal hydronephrosis has undergone a two stage paradigm shift since the advent of prenatal ultrasonography in the early 1980s. Initially the identification of a large number of asymptomatic infants appeared to afford the surgeon the opportunity for preemptive intervention. However, it has now become apparent that antenatal hydronephrosis (AH) is far more difficult to interpret thanoriginally perceived. The initial enthusiasm for surgery has now been replaced by a much more conservative approach to ureteropelvic junction(UPJ) obstruction, multi-cystic dysplastic kidney(MCDK), vesicoureteral reflux and the non-refluxing megaureter. This review will highlight the postnatal evaluation of AH and include an overview of the Society for Fetal Urology grading system for hydronephrosis. The differential diagnosis and treatment options for UPJ obstruction, vesicoureteral reflux, MCDK, duplication anomalies, megaureter, and posterior urethral valves will be discussed.

C.D. Anthony Herndon

Antenatal Hydronephrosis: Differential Diagnosis, Evaluation, and Treatment Options

The most common cause of lower urinary tract obstruction in male infants is posterior urethral valves. Although the incidence has remained stable, the neonatal mortality for this disorder has improved due to early diagnosis and intensive neonatal care, thanks in part to the widespread use of prenatal ultrasound evaluations. In fact, the most common reason for the diagnosis of posterior urethral valves presently is the evaluation of infants for prenatal hydronephrosis. Since these children are often diagnosed early, the urethral obstruction can be alleviated rapidly through catheter insertion and eventual surgery, and their metabolic derangements can be normalized without delay, avoiding preventable infant mortality. Of the children that survive, however, early diagnosis has not had much effect on their long-term prognosis, as 30% still develop renal insufficiency before adolescence. A better understanding of the exact cause of the congenital obstruction of the male posterior urethra, prevention of postnatal bladder and renal injury, and the development of safe methods to treat urethral obstruction prenatally (and thereby avoiding the bladder and renal damage due to obstructive uropathy) are the goals for the care of children with posterior urethral valves[1].

Steve J. Hodges

Bhavin Patel

Gordon McLorie

Anthony Atala

Posterior Urethral Valves

The majority of pregnant women in the U.S. undergo prenatal ultrasonography and approximately 0.5% of these examinations will detect fetal malformations. Up to one-half of these abnormalities include the genitourinary system and the most common urological finding is hydronephrosis. Some conditions associated with prenatal hydronephrosis portend a poor prognosis, while others can follow a fairly benign course. This review focuses on the definition and prenatal assessment of hydronephrosis, fetal intervention, and postnatal management.

Pravin K. Rao

Jeffrey S. Palmer

Prenatal and Postnatal Management of Hydronephrosis

Hydronephrosis is one of the most common abnormalities detected on routine prenatal ultrasounds, being noted in up to 1% of fetuses. Rarely, severe hydronephrosis coexists with oligohydramnios, which portends a poor prognosis. We review the most recent literature on the results of prenatal intervention in this setting. Presently, the first randomized controlled trial to address whether prenatal vesicoamniotic shunting improves survival and renal function is underway, and should address the value of prenatal intervention.

David M. Kitchens

C. D. Anthony Herndon

Prenatal Intervention for Lower Urinary Tract Obstruction

Almost one-quarter of the children referred to a pediatric urologist for obstructive uropathy suffer from an obstructive megaureter. However, not all megaureters are due to obstruction, as some may be the result of reflux and many simply represent a slightly skewed stage of development that can result in a normal urinary tract if observed. As the use of fetal ultrasonography has expanded, the majority of children with megaureters are now diagnosed early in their development, and physicians are faced with the complex task of distinguishing which children need medical intervention and which do not. The surgical treatments of megaureter are well established, relatively simple, and effective if performed in the correct candidates. Therefore, research efforts in this field have recently focused on improving our ability to diagnose clinically relevant obstructive uropathy and examining the developmental causes of megaureter, and how this disorder may be prevented.

David Werle

Megaureter

The treatment of the newborn diagnosed with a ureteropelvic obstruction prenatally should follow a systematic approach. Although a majority of patients can be followed without surgical intervention, controversy exists concerning appropriate follow-up. Furthermore, a significant number of patients will manifest mild disease and thus deserve abbreviated follow-up. Herein, an appropriate algorithm and a review of the literature are discussed.

The Management of Ureteropelvic Junction Obstruction Presenting with Prenatal Hydronephrosis

Radiologic imaging of the newborn detected prenatally with hydronephrosis should follow a systematic approach. Upper and lower urinary tract imaging should be performed in most cases in order to determine the etiology and gauge the use of future imaging. An overview of renal ultrasound, voiding cystourethrography, renal scintigraphy, and magnetic resonance urography in the setting of antenatal hydronephrosis are discussed.

Postnatal Imaging of Antenatal Hydronephrosis

Pre- and Postnatal Management of Hydronephrosis

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The Scientific World Journal

This Issue is now open for submissions.
Papers are published upon acceptance, regardless of the Special Issue publication date.

The Scientific World Journal

Pre- and Postnatal Management of Hydronephrosis

Pre- and Postnatal Management of Hydronephrosis

Articles

Antenatal Hydronephrosis: Differential Diagnosis, Evaluation, and Treatment Options

Posterior Urethral Valves

Prenatal and Postnatal Management of Hydronephrosis

Prenatal Intervention for Lower Urinary Tract Obstruction

Megaureter

The Management of Ureteropelvic Junction Obstruction Presenting with Prenatal Hydronephrosis

Postnatal Imaging of Antenatal Hydronephrosis

Pre- and Postnatal Management of Hydronephrosis