research article Outcomes of Prenatally Diagnosed Moderate to Severe Hydronephrosis at a Single Institution
Kathryn Trandem1,2, Jeffrey T. White1,2, Amay V. Singh1,2, Sheila L. Ryan1,2, Duong Tu1,2, Chester J. Koh1,2, Nicolette Janzen1,2, Edmond T. Gonzales1,2, David R. Roth1,2, Abhishek Seth1,2*
1Department of
Urology, Baylor College of Medicine, Houston, Texas, USA
2Department of Surgery, Texas Children’s Hospital, Houston, Texas, USA
*Corresponding author: Abhishek Seth, Baylor College of Medicine / Texas Children’s Hospital, 6701 Fannin Street, Houston, Texas 77030, USA. Tel: +18328223174; Fax: +18328253159; Email: aseth@bcm.edu
Received
Date: 18 July, 2018; Accepted Date: 30 July, 2018;
Published Date: 02 August, 2018
Citation: Trandem K, White JT, Singh AV, Ryan SL, Tu D, et al. (2018) Outcomes of Prenatally Diagnosed Moderate to Severe Hydronephrosis at a Single Institution. J Urol Ren Dis 2018: 1106. DOI: 10.29011/2575-7903.001106
1. Abstract
1.1. Background: The best treatment for neonates with prenatally diagnosed severe Hydronephrosis (HN) secondary to Ureteropelvic Junction Obstruction (UPJO) is still debated. Some argue for early operation to protect renal function, while others argue for operation only after compromised renal function, worsening HN, febrile UTI or symptomatology. We hypothesized that initial postnatal grade 4 HN secondary to UPJO would require operation more frequently than grade 3 HN and that most children would not require surgery.
1.2. Methods: A retrospective, single center chart review was performed on 202 patients with prenatally diagnosed HN and unilateral postnatal SFU grade 3 or 4 HN presenting between 2001-2015. Children with confounding urinary anomalies such as bilateral HN, Lower Urinary Tract Obstruction (LUTO) or Vesicoureteral Reflux (VUR) were excluded.
1.3. Results: Two hundred two neonates were diagnosed with unilateral SFU grade 3 or 4 HN and renal scans consistent with UPJO. The majority was male (71%) and affected the left kidney (63%). On initial ultrasound, 39% of children presented with SFU grade 3 HN, and 61% presented with SFU grade 4 HN. An initial renal differential function 10% or greater was found in 13% of patients; they underwent immediate surgical correction. Eighty-seven percent underwent initial surveillance. With a mean follow-up of 44 months, 167 of 176 (95%) children who initially underwent observation progressed to surgery, with the majority occurring shortly after the first year (mean 17 months, median 7 months). There was no difference in operation rate between initial grade 3 or 4 HN (93 vs 96%, respectively). Indications given for surgery varied widely, with worsening HN (39%) or renal differential of greater than or equal to 10% (27%) being the most common. Postoperative complications occurred in 13% with urinary tract infection as most common.
1.4. Conclusions: The majority of children with prenatally diagnosed SFU grade 3 or 4 HN secondary to UPJO progressed to surgical correction (193 of 202, 96%). Surgical rate was no different whether the initial HN was grade 3 or grade 4.
2.
Keywords: Hydronephrosis;
Outcome Assessment; Prenatal
Diagnosis; Ureteral Obstruction; Ureteropelvic Junction Obstruction
Figure 1: CONSORT
Diagram showing inclusion criteria. Children were included in the study only
if they had prenatally diagnosed post-natal unilateral obstruction SFU grade 3
or 4 HN secondary to UPJO and no confounding factors. Twenty-six children
underwent immediate surgical correction for reduced renal function while 176
children were observed through repeat renal ultrasounds and/or a nuclear renal
scan.
Figure 2: Total patient’s
time to surgical repair.
Figure 3: Indications for
surgery after failing observation.
|
Characteristic |
Overall (N = 202) |
|
Gender |
|
|
Male, n (%) |
144 (71) |
|
Female, n (%) |
58 (28) |
|
Race |
|
|
Caucasian, n (%) |
98 (48) |
|
Black, n (%) |
17 (8.4) |
|
Hispanic, n (%) |
67 (33) |
|
Asian/Pacific Islander, n (%) |
9 (4.4) |
|
Native American, n (%) |
1 (0.5) |
|
Unable to determine, n (%) |
10 (4.9) |
|
Side of Affected Kidney |
|
|
Right n (%) |
75 (37) |
|
Left n (%) |
127 (62) |
|
SFU Grade |
|
|
Grade III, n (%) |
78 (38) |
|
Grade IV, n (%) |
121 (59) |
|
Unable to determine, n (%) |
3 (1.5) |
|
Age at last Follow-Up (months) |
|
|
Mean (SD) |
44 (38) |
Table 1: Demographics.
|
Total patients undergoing surgery for UPJO, n (%) 193 (95.5%) |
|
|
Patients who failed initial observation, n (%) 167 (94.9%) |
|
|
Surgical Approach* |
(N=217) |
|
Laparoscopic pyeloplasty#, n (%) |
27 (12.4) |
|
Open pyeloplasty, n (%) |
167 (77.0) |
|
Ureteral stent/PCN, n (%) |
5 (2.3) |
|
Endopyelotomy, n (%) |
3 (1.4) |
|
Nephrectomy, n (%) |
5 (2.3) |
|
Prenatal aspiration, n (%) |
1 (0.5) |
|
No surgical procedure, n (%) |
9 (4.1) |
|
* Some children required more than one surgical correction |
|
|
# Includes robotic-assisted laparoscopic pyeloplasty |
|
Table 2: Observation & Surgical Correction.
|
Post-operative Complications* |
N(%) |
|
Clavien-Dindo Grade II |
9 (34.6) |
|
(UTI or pyelonephritis, treated with antibiotics, not requiring further surgery) |
|
|
Clavien-Dindo Grade IIIb |
17 (65.3) |
|
(Possibly required >1 intervention) |
|
|
Cystoscopy, RPG and/or ureteral stent |
6 |
|
Percutaneous nephrostomy tube |
2 |
|
Percutaneous drain for infected urinoma |
1 |
|
Endopyelotomy |
2 |
|
Lap or open redo pyeloplasty |
7 |
|
Nephrectomy |
3 |
|
*Complications presented in 26 of 193 patients (13.4%) |
|
Table 3: Post-operative Complications.