Case of the Month

Antenatal Hydronephrosis: Here Today,

Gone Tomorrow—One Way or Another
NYU Case of the Month, May 2017
Ellen Shapiro, MD, FACS, FAAP
Department of Urology, NYU Langone Medical Center, New York, NY

[Rev Urol. 2017;19(2):138–141 doi: 10.3909/riu0762]

© 2017 MedReviews®, LLC

Case 1 Postnatal Evaluation and Management

A 35-year-old pregnant woman underwent a
20-week structural ultrasound, and the fetus
was found to have a left anterior-posterior
renal pelvic diameter (APRPD) of 8 mm (uri-
nary tract dilation [UTD] A2-3 [A 5 antenatal])
and a normal-appearing right kidney. The ure-
ters of the fetus were not dilated and the blad-
der appeared normal. A slow but progressive
increase in the left APRPD was observed during
the third trimester of pregnancy. At 38 weeks,
the left APRPD was 2.2 cm with peripheral
caly-ceal dilation (UTD A2-3). The fetus was
female. The amniotic f luid volume was normal.
Vaginal delivery at 39 weeks was uneventful,
and the infant’s Apgar score was 91/95.
The first postnatal sonogram at 1 week of age
(Figure 1A) shows the left kidney ultrasound with
UTD P3 (P 5 postnatal). A voiding cystourethro-
gram (VCUG) showed no reflux. A renogram at
6 weeks of age showed that the right kidney con-
tributed 60% and the left contributed 40% to total
renal function. Following administration of furo-
semide, there was delayed drainage on the left side.
A second renal sonogram showed no improvement
in the hydronephrosis (Figure 1B). Surgery was
recommended, but the patient’s parents wanted
to wait until after a family function. A renal
sonogram at 3 months showed a slight worsening
of the left hydronephrosis (Figure 1C). A dismem-
bered left pyeloplasty was performed. No crossing

Figure 1. Postnatal sonograms of the patient in Case 1. (A) At 1 week, left kidney ultrasound with UTD P3. (B) No improvement in the hydro-
nephrosis. (C) Slight worsening of the left hydronephrosis. (D) At postoperative month 3, significant improvement in the hydronephrosis and
interval growth of the kidneys. P, postnatal; UTD, urinary tract dilation.

138 • Vol. 19 No. 2 • 2017 • Reviews in Urology


vessel was noted. At postoperative
month 3, renal ultrasound showed
significant improvement in the
hydronephrosis and interval
growth of the kidneys (Figure 1D).
Case 2
Prenatal Evaluation
and Delivery
A 31-year-old pregnant woman had
a normal 20-week structural ultra-
sound. At 32 weeks, the ultrasound
showed a right APRPD of 1.5 cm
with peripheral calyceal dilation
(UTD A2-3). The left kidney of
the fetus appeared entirely normal
and the ureters were not dilated.
The bladder of the fetus appeared
normal. At 37 weeks, the APRPD
was 2.0 cm (UTD A2-3). The fetus
was male. Amniotic fluid volume
was normal. Vaginal delivery at
40 weeks was uneventful, and the
infant’s Apgar score was 91/95.
Postnatal Evaluation and
Management
The first postnatal sonogram at
1 week of age (Figure 2A) shows the
right kidney ultrasound with UTD
P3. A VCUG showed no reflux. The
renogram at 6 weeks of age showed
that the right kidney contributed
35% and the left contributed 65% to
the total renal function. Following
administration of furosemide, poor
drainage was noted on the right side.
The patient returned at that time for
a review of the renal scan, and a sec-
ond renal sonogram showed a slight
improvement in the hydronephrosis
(Figure 2B); therefore, surgery was
Figure 2. Postnatal sonograms of the patient in Case 2. (A) At 1 week, right kidney ultrasound with UTD P3. (B) Slight improvement in
the hydronephrosis. (C) Definite improvement in the degree of right hydronephrosis. (D) At 1 year, almost complete resolution of the
severe hydronephrosis with decompression of the collecting system.
Antenatal Hydronephrosis: Here Today, Gone Tomorrow
not recommended. A renal sono-
gram at approximately 3 months
showed definite improvement in
the degree of right hydronephrosis
(Figure 2C). At 1 year, a renal ultra-
sound showed almost complete
resolution of the severe hydrone-
phrosis with decompression of the
collecting system (Figure 2D).
Comment
Antenatal hydronephrosis (ANH) is
observed in 1% to 2% of all pregnan-
cies and is one of the most common
congenital abnormalities.1 The esti-
mated birth rate of 4 million/year
in the United States means about
40,000 to 80,000 children are diag-
nosed annually with ANH.1
The Benefits of Diagnosing
ANH
Prenatal diagnosis of hydrone-
phrosis provides the opportunity
to avoid febrile urinary tract infec-
tions in infants and young children
and allows for early intervention in
cases with poor renal function asso-
ciated with severe hydronephro-
sis and concomitant compression
of renal parenchyma.2 Although
nephrogenesis is complete by 36
weeks’ gestation, the effect of sig-
nificant obstruction on ultimate
healthy nephron endowment is
unknown.
The Most Common Causes
of ANH
The differential diagnosis includes
transient hydronephrosis (most
common cause), ureteropelvic
Vol. 19 No. 2 • 2017 • Reviews in Urology • 139
junction obstruction, uretero-
vesical junction obstruction or
primary obstructed megaureter,
vesicoureteral reflux, multicys-
tic dysplastic kidney, ureterocele,
and ectopic ureter with and with-
out renal duplication, and poste-
rior urethral valves.2 Significant
obstruction is more commonly
associated with progressive, rather
than stable or improved, dilation
prenatally.
Observations on Ultrasound
That Lead to the Diagnosis
of ANH
The prenatal sonogram is usu-
ally performed in the second tri-
mester (16-20 wk) and again in
the third trimester (28-32 wk).2
The prenatal sonogram provides
information including the APRPD
measured on transverse image
at the maximal diameter of the
intrarenal pelvis, renal parenchy-
mal thickness and echogenicity
(when compared with the liver or
spleen), corticomedullary differ-
entiation and cortical cysts, caly-
ceal dilation of major and minor
calyces, ureteral dilation, bladder
wall thickening, and presence of
a ureterocele or dilated posterior
urethra. The National Institute
of Child Health and Human
Development’s 2014 Executive
Summary on Fetal Imaging
defined an abnormal APRPD as
(1) $ 4 mm in the second trimes-
ter, and (2) $ 7 mm at $ 32 weeks
with postnatal radiographic eval-
uation recommended.3
Antenatal Hydronephrosis: Here Today, Gone Tomorrow continued

Comparing the Prenatal

Finding on Sonogram to 16-27 wks  28 wks 16-27 wks  28 wks
the Postnatal Observations APRPD APRPD APRPD APRPD
A unified classification system with 4 to < 10 mm 7 to < 10 mm  7 mm  10 mm
standard terminology has recently
been developed for the diagnosis Central or no Peripheral
calyceal dilationa calyceal dilationa
and management of prenatal and
postnatal UTD. This system inte- Parenchymal Parenchymal
grates the current grading systems, thickness normal thickness abnormal
including the grading system of the
Society for Fetal Urology. Figures 3 Parenchymal Parenchymal
appearance normal appearance abnormal
and 4 show the UTD risk stratifi-
cation prenatally and postnatally, Ureters Ureters
respectively.2 normal abnormal
Classification between low and
increased risk (Figure 3]) is based Bladder Bladder
normal abnormal
on the presence of any increased
risk parameters. For example, a No unexplained Unexplained
fetus with an APRPD within the oligohydramnios oligohydramniosb
UTD A1 range but with periph-
eral calyceal dilation is classified as UTD A1: UTD A2-3:
UTD A2-3.2 The findings of renal LOW RISK INCREASED RISK
pelvic dilation may vary depend-
ing on the degree of pelvic dis- Figure 3. UTD risk stratification: prenatal presentation for UTD A1 (low risk) and UTD A2-3
tention and fetal hydration at the (increased risk). aCentral and peripheral calyceal dilation may be difficult to evaluate early in
gestation. bOligohydramnios is suspected to result from a genitourinary cause. A, antenatal;
time of the study. Pyelectasis on a APRPD, anterior-posterior renal pelvic diameter; UTD, urinary tract dilation.
mid-trimester prenatal ultrasound
has been related to trisomy 21,
but, as an isolated observation,
carries an odds ratio of 1.5 to 1.6
. 48 hours . 48 hours . 48 hours
for Down syndrome.4 Ureteral dila- APRPD APRPD APRPD
tion observed prenatally is classi- 10 to , 15 mm . 15 mm . 15 mm
fied as UTD A2-3 regardless of the
APRPD findings.2 Central Peripheral Peripheral
Stratification into intermedi- calyceal dilation calyceal dilation calyceal dilation
ate risk and high risk (Figure 4)
is based on the most concerning Parenchymal Parenchymal Parenchymal
postnatal ultrasound finding. For thickness normal thickness normal thickness abnl
example, if the APRPD is in the
UTD P1 range, but there is periph- Parenchymal Parenchymal Parenchymal
eral calyceal dilation, the classifi- appearance normal appearance normal appearance abnl

cation is UTD P2. Similarly, the

presence of parenchymal abnor- Ureters Ureters Ureters
normal abnormal abnormal
malities makes the classification
UTD P3, regardless of APRPD
measurement.2 Stratification of Bladder Bladder Bladder
normal normal abnormal
risk for bilateral involvement is
based on the grading of the UTD
of the more severely affected renal UTD P1: UTD P2: UTD P3:
LOW RISK INTERMEDIATE RISK HIGH RISK
unit.2 Ureteral dilation observed
postnatally is assigned category
UTD P2 regardless of the APRPD Figure 4. UTD risk stratification: postnatal presentation for UTD P1 (low risk), UTD P2 (intermediate risk),
and UTD P3 (high risk). APRPD, anterior-posterior renal pelvic diameter; P, postnatal; UTD, urinary tract
findings.2 dilation.

140 • Vol. 19 No. 2 • 2017 • Reviews in Urology


The timing of the first postnatal
sonogram remains controversial
and should be individualized. It
is recognized that because of the
infant’s physiologic dehydrated sta-
tus, a sonogram performed within
the first 48 hours will likely under-
estimate the degree of dilation
observed prenatally. This dehydra-
tion also affects bladder distention
during the study. If the study is per-
formed at ,48 hours, a follow-up
study must be performed. Usually,
the first postnatal ultrasound is
performed between > 48 hours and
, 4 weeks of age, unless posterior
urethral valves are suspected or
bilateral ANH was observed.2 The
timing of the first study and of sub-
sequent evaluations is dictated by
the degree of ANH, the findings
on the first postnatal study, and
parental concerns. In patients with
low-risk UTD P1, a second ultra-
sound should be performed at 1 to
6 months, whereas patients with
UTD P2 should be reimaged at 1 to
3 months.
Continuous antibiotic prophy-
laxis remains controversial and
is administered at the discretion
of the clinician. Antibiotics are
recommended for neonates and
infants with UTD P3 who will also
Antenatal Hydronephrosis: Here Today, Gone Tomorrow continued
undergo a VCUG.2 Administration
of amoxicillin at the time of the
VCUG is recommended.
A VCUG is recommended for
significant hydronephrosis (UTD
P3—although the degree of hydro-
nephrosis does not correlate with
the grade of reflux), ureteral dila-
tion, or other findings pre- and
postnatally (eg, abnormal paren-
chymal thickness or appearance,
bladder wall thickening).2 Whether
or not the VCUG is performed, it is
imperative that parents be educated
on the signs and symptoms of a uri-
nary tract infection in neonates and
infants. These include fever (usu-
ally observed after the first month
of life), poor feeding (“skipping a
meal”), excessive irritability, and
listlessness.
A renogram is recommended for
some patients with UTD P2 and for
all patients with UTD P3 during the
second month of life, as by this time
the glomerular filtration rate has
doubled.2 Findings of poor function
(,  40%) and poor to no demonstra-
ble drainage are indicative of sig-
nificant obstruction. These, in
addition to a history of progressive
increase in fetal renal pelvic dilation
during gestation, suggest the need
for intervention.5 Delaying surgery
Vol. 19 No. 2 • 2017 • Reviews in Urology • 141
with close follow-up is not necessar-
ily wrong, but, as one observes com-
pressed pyramids and cortical
parenchyma, it is obvious that kid-
ney function is compromised;
whether this affects ultimate
healthy nephron endowment is
unknown. It is also unknown
whether function in a presumed
obstructed kidney can always be
completely recovered. The key is to
intervene before the time of irrepa-
rable renal damage, because surgery
by a skilled surgeon has been proven
to be very effective, whether per-
formed via the open or the robot-
assisted laparoscopic approach.
References
1. Hamilton BE, Martin JA, Ventura SJ. Births: prelimi-
nary data for 2012. Natl Vital Stat Rep. 2013;62:1-20.
2. Nguyen HT, Benson CB, Bromley B, et al. Multidisci-
plinary consensus on the classification of prenatal and
postnatal urinary tract dilation (UTD classification
system). J Pediatr Urol. 2014;10:982-998.
3. Signorelli M, Cerri V, Taddei F, et al. Prenatal diag-
nosis and management of mild fetal pyelectasis: im-
plications for neonatal outcome and follow-up. Eur J
Obstet Gynecol Reprod Biol. 2005;118:154-159.
4. Bromley B, Lieberman E, Shipp TD, Benacerraf BR.
The genetic sonogram: a method of risk assess-
ment for Down syndrome in the second trimester.
J Ultrasound Med. 2002;21:1087-1096.
5. Signorelli M, Cerri V, Taddei F, et al. Prenatal diagno-
sis and management of mild fetal pyelectasis: implica-
tions for neonatal outcome and follow-up. Eur J Obstet
Gynecol Reprod Biol. 2005;118:154-159.