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1. MANAGEMENT OF ANTENATAL
HYDRONEPHROSIS
PRESENTEDBY-Dr.RISHABHSHUKLA
SENIORRESIDENT
MODERATOR-Prof.Dr.BHAWNA

2. INTRODUCTION
•HYDRONEPHROSIS-refers to a pathological condition
characterized by the distension of the renal pelvis
and calyces, as a result of stagnation or reflux of
urine.
•Ultrasound screening during pregnancy has resulted
in increasing recognition of fetalhydronephrosis.
•Antenatal Hydronephrosisis one of the most
commonly detected prenatal abnormality with
prevalence ranging from 0.6-5.4% of all pregnancies.
EkS, LidefeldtKJ, VarricioL. Fetalhydronephrosis;prevalence, natural history and postnatal consequences inanunselected population. ActaObstet
GynecolScand. 2007;86:1463-6.

3. PHYSIOLOGIC FETAL
HYDRONEPHROSIS
•Compared with a newborn, a fetushas:
1.A relatively high renal blood flow.
2.Higher glomerularfiltration rate.
3.A lower renal concentrating capacity.
•Therefore, a relatively high urine volume.
•In addition, as the compliance of the ureterincreases, it
becomes easier to expand.
•Since the fetaland neonatal kidneys are not fully
developed, the renal medullarycone may be transparent
under ultrasound examination, which leads to a wrong
diagnosis of hydronephrosis.

4. Differential Diagnosis Of Antenatally
Detected Hydronephrosis
Nguyen HT, et al. The Society for Fetal Urology consensus statement on the evaluation and management of antenatal
hydronephrosis. J PediatrUrol2010; 6: 212-31

5. PATHOPHYSIOLOGY OF UPPER
URINARY TRACT DILATATION
•Obstruction
•Vesicoureteralreflux
•Diuretic phenomenon
•Spontaneous or operative resolution of a
developmental anomaly

6. HYDRONEPHROSIS OBSTRUCTION

7. IMPORTANT EMBROYOLOGICAL
TIMINGS
•Genitourinary system starts formation from 4
th
wk
GA.
•Urine formation starts from 10
th
wk GA.
•Ultrasound milestones:
I.Bladder visible –10 wks GA
II.Kidneys detected –12-13 wks GA
III.Filling/emptying cycles -15wks GA
IV.Perinephricfat –20 wks GA
V.Ureters, renal pelvis, calyces –not visualised

8. Antenatal
monitoring
Fetal
interventions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

9. ANTENATAL DIAGNOSIS
•Severity grading of antenatal hydronephrosisis based on anteroposterior
diameter (APD) of renal pelvis.
•ANH is present if fetalrenal APD ≥ 4mm in 2
nd
trimester and ≥ 7mm in 3
rd
trimester.
•Hydronephrosisis further graded as mild, moderate & severe.
•While lower cut offs for defining HN increase the sensitivity for detecting
anomalies, it reduces the specificity.
•Metaanalysis(2006) found that risk of postnatal pathology increased with
the degree of antenatal pelvic dilatation from 11.9%for mild, 45.1% for
moderate & 88.3% for severe HN.
•While fetuseswith minimal pelvic dilatation have a low risk of postnatal
pathology, APD > 15mm in any trimester represents severe HN and
prompts close monitoring.
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Lee RS, CendronM, KinnamonDD, Nguyen HT. Antenatal hydronephrosisas a predictor of postnatal outcome: a metaanalysis. Pediatrics.
2006;118:586-93.
Nguyen HT, et al. The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis. J
PediatrUrol2010; 6: 212-31

10. ANTENATAL DIAGNOSIS
ClassificationRenal pelvic anteroposteriordiameter Risk of
Uropathology(%)
Second TrimesterThird Trimester
Mild 4-6 mm 7-9 mm 11.9%
Moderate 7-10 mm 10-15 mm 45.1%
Severe >10 mm >15 mm 88.3%
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11. ANTENATAL MONITORING
Atleast1 follow up scan
in 3
rd
trimester
Postnatal evaluation
UNILATERAL
HN
Frequent monitoring
needed.
4-6 weekly scans
recommended
depending on severity,
oligohydramnios.
Postnatal evaluation.
BILATERAL
HN
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12. ANTENATAL MONITORING
•If antenatal HN is detected, it is recommended that an
ultrasound at 16-20 wks GA also include evaluation of lower
urinary tract obstruction, renal dysplasia & extrarenal
malformations.
•Signs suggestive of lower urinary tract obstruction:
1.Bilateral HN
2.Oligohydramnios
3.Thick walled or dilated bladder.
•Other predictors of postnatal pathology includes:
Dilated posterior urethra, perinephricurinoma, progressive
calycealor uretericdilatation & features suggesting renal
dysplasia like cortical thinning, increased echogenicity, renal
cysts & poor corticomedullarydifferentiation.
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13. ANTENATAL MONITORING
•Multiple studies have shown that the likelihood of aneuploidyin
fetuseswith antenatal HN is low, and hence doesn't warrants
karyotypingin each case.
•The risk of aneuploidyis increased in fetuseswith ANH and a major
structural anomaly or with one or more additional soft signs.
•Soft signs includes-
1.Increased nuchaltranslucency
2.Absent nasal bone
3.Echogenicbowel
4.Echogenicfocus in heart
5.Shortened long bones
6.Choroid plexus cyst
7.Ventriculomegaly
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14. ANTENATAL MONITORING
•Almost 80% of fetusesdiagnosed with HN in 2
nd
trimester
show resolution or improvement.
•Persistent or worsening HN in 3
rd
trimester show higher rates
of postnatal pathology and warrant close watch.
•Multiple radiology studies have shown that 88% cases of mild
HN resolved in uteroor neonatal period, 33% neonates with
moderate or severe HN persisting in 3
rd
trimester required
postnatal surgery.
•Fetuseswith signs of lower urinary tract obstruction, esp
oligohydramniosneed frequent monitoring and may need
fetalor neonatal interventions.
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SairamS, Al-HabibA, SassonS, ThilaganathanB. Natural history of fetalhydronephrosisdiagnosed on mid-
trimester ultrasound. Ultrasound ObstetGynecol. 2001;17:191-6.

15. PRENATAL MONITORING ALGORITHM
SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of
antenatal hydronephrosis.Indian J Nephrol.2013;23:83–97

16. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

17. FETAL INTERVENTIONS
•Diagnostic and therapeutic interventions are recommended for
fetuseswith suspected lower urinary tract obstruction and
oligohydramnios.
•No recommendation for pregnancy terminationwith isolated HN.
•Before therapeutic interventions, fetalvesicocentesisfor
estimation of urine electrolytes, B2 microglobulinsand osmolalityis
performed to predict renal maturity and function.
•Predominant cause for lower urinary tract obstruction is PUV in
male fetusesand can be offered vesicoamnioticshunting or in utero
endoscopic ablation of valves.
•Therapeutic interventions are performed in 2
nd
trimester preferably.
•Metaanalysissuggest that vesicoamnioticshunting improves
perinatalsurvival in fetuseswith severe obstruction. But no
evidence of improvement in long term renal outcomes or reduced
mortality in less severe diseases.
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Clark TJ, Martin WL, DivakaranTG, Whittle MJ, KilbyMD, Khan KS. Prenatal bladder drainage in the management of
fetallower urinary tract obstruction: a systematic review and meta-analysis. ObstetGynecol. 2003;102:367–82
Fetuseslikely to benefit from the therapeutic interventions are-
Decreasing levels of fetalurine :
•Sodium (<100 mg/dL)
•Calcium (<8 mg/dL)
•Osmolality(<200 mOsm/ kg)
•β2 microglobulin(<4 mg/L)
•Protein (<20 mg/ dL)

18. FETAL INTERVENTIONS
•Predominant cause for lower urinary tract obstruction is Posterior
Urethral Valve in male fetusesand can be offered vesicoamniotic
shunting or in uteroendoscopic ablation of valves.
•Therapeutic interventions are performed in 2
nd
trimester preferably.
•Metaanalysissuggests that vesicoamnioticshunting improves
perinatalsurvival in fetuseswith severe obstruction. But no
evidence of improvement in long term renal outcomes or reduced
mortality in less severe diseases.
•Percutaneousshunting for lower urinary tract obstruction (PLUTO)
randomized trial suggests that although survival was higher in
fetusesundergoing vesicoamnioticshunting, the benefit remains
inconclusive as only 2 out of 31 fetusessurvived with normal renal
function at 2 years.
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Clark TJ, Martin WL, DivakaranTG, Whittle MJ, KilbyMD, Khan KS. Prenatal bladder drainage in the management of fetallower urinary tract obstruction: a systematic
review and meta-analysis. ObstetGynecol. 2003;102:367–82
Morris RK, MalinGL, Quinlan-Jones E, Middleton LJ, DiwakarL, Hemming K, Burke D, Daniels J, Denny E, Barton P, Roberts TE, Khan KS, DeeksJJ, KilbyMD. The Percutaneousshunting
in Lower Urinary Tract Obstruction (PLUTO) study and randomised controlled trial: evaluation of the effectiveness, cost-effectiveness and acceptability of percutaneousvesicoamniotic
shunting for lower urinary tract obstruction. Health TechnolAssess. 2013 Dec;17(59):1-232.

19. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

20. POSTNATAL MONITORING
•Severity of postnatal hydronephrosisshould be assessed as
per classification by Society of FetalUrology (SFU)or AP
Diameterof the renal pelvis.
SEVERITY GRADING

21. POSTNATAL MONITORING
•Severity of postnatal hydronephrosisshould be assessed as
per classification by Society of FetalUrology (SFU)or AP
Diameterof the renal pelvis.
•NEONATAL HYDRONEPHROSIS-defined as SFU grade ≥ 1 or
renal APD ≥ 7mm.
•Metaanalysissuggests that isolated ANH was 5 times more
likely to stabilize if associated with SFU grade 1-2 or APD
<12mm, than with SFU grade 3-4 or APD >12mm.
•SFU grade 3-4 was also found to be associated with high odds
for surgery.
•Postnatal ultrasound should also look for calycealor ureteric
dilatation, cortical cyst and echogenecity, bladder wall
abnormalities, ureterocoeleand bladder emptying.
SEVERITY GRADING
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SidhuG, BeyeneJ, RosenblumND. Outcome of isolated antenatal hydronephrosis: A systematic review and metaanalysis. PediatrNephrol. 2006;21:218-24.
ChertinB, Pollack A, KoulikovD, RabinowitzR, HainD, Hadas-HalprenI, et al. Conservative treatment of ureteropelvicjunction obstruction in children with
antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up. EurUrol. 2006;49:734-8.

22. POSTNATAL MONITORING
•First postnatal ultrasound examination–within 1
st
wk of life.
•Unilateral HN–within 3-7 days of life or before hospital discharge.
•Severe bilateral HN/ suspected posterior uretheralvalves–1
st
scan
within 24-48 hrs.
•USG in first few days of life underestimates the degree of pelvic
dilatation due to dehydration and a relatively low urine output. So,
delay beyond day 5 recommended usually.
•Evidence suggests that the risk of postnatal pathology was 10.8% in
infants with normal postnatal ultrasound, as against 54.7% in those
with persisting hydronephrosis.
FIRST ULTRASOUND
Passerotti CC, Kalish LA, Chow J, Passerotti AM, Recabal P, CendronM, et al. The predictive value of the first postnatal ultrasound in children with
antenatal hydronephrosis. J PediatrUrol. 2011;7:128-36.
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23. POSTNATAL MONITORING
•Neonates with antenatal hydronephrosisand a normal first week
USG examination should have a repeat study at 4-6 weeks of life.
•Infants with isolated mild unilateral or bilateral HN (SFU gr1-2)
should be followed up by sequential USG at 4-6wk to look for
progression/resolution.
•Follow up ultrasound studies are scheduled at 3-6 monthly interval
till 2yrs of life &yearlythereafter till resolution. (Max till 5-6 yrs of
life)
•Infants with SFU Gr3-4 or APD >10 mm at onset require closer
follow up.
•USG at 4-6 wks is more sensitive and specific for obstruction than
1
st
week of life USG.
(due to low urine flow secondary to low GFR and dehydration)
FOLLOW UP ULTRASOUND
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24. POSTNATAL EVALUATION ALGORITHM
SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of Antenatal hydronephrosis.Indian J
Nephrol.2013;23:83–97

25. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

26. MICTURATING CYSTOURETHROGRAM
•MCU is a dynamic test used to demonstrate the lower urinary tract
and helps to detect the existence of any vesicoureteralreflux,
bladder pathology & congenital or acquired anomalies of bladder
outflow tract.
•It is performed by passing a catheter through the urethra into the
bladder, filling the bladder with the contrast material and then
taking radiographs while the patient voids.
•Urograffin60% used which is diluted with normal saline.
•The estimated volume of contrast medium to be given is
determined by age except for children <1 yr, in whom it is
determined by weight.
1.<1 yr-capacity (ml)= wt (kg) ×7
2.<2 yr-capacity (ml)= {age (yrs)+2} ×30
3.>2yr-capacity (ml)= [{age(yrs)/2}+6] ×30
•MCU includes radiographs in the following phases–Scout film,
filling film, voiding film & post void film.
WHAT IS MCU ?

27. MICTURATING CYSTOURETHROGRAM
1.Unilateral or Bilateral Hydronephrosiswith SFU 3-
4 or APD >10mm or uretericdilatation.
2.Infants with mild grade of HN who show
progressive worsening hydronephrosisor
progressive thinning of parenchyma.
3.Infants with antenatallydetected hydronephrosis
who develop UTI.
WHOM TO PERFORM ON ?
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SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal
hydronephrosis.Indian J Nephrol.2013;23:83–97

28. MICTURATING CYSTOURETHROGRAM
1.Patients with ANH with suspected lower
urinary tract obstruction –24-72 hrs of life.
2.All others (indicated) cases of ANH –4-6
wksof life.
WHEN TO PERFORM ?
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SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal
hydronephrosis.Indian J Nephrol.2013;23:83–97

29. MICTURATING CYSTOURETHROGRAM
•Patients with Lower urinary tract obstruction.
eg. Posterior urethral valves are at high risk for progressive
kidney disease and recurrent UTI, and therefore early MCU is
indicated for prompt intervention.
•VesicouretericReflux is noted in 8-38% population with ANH
as compared to <1% in general population. Early diagnosis of
severe VUR help in early antibiotic start and prevent recurrent
UTI and its further sequelae.
WHY TO PERFORM ?
ZerinJM, Ritchey ML, Chang AC. Incidental vesicoureteralreflux in neonates with antenatallydetected hydronephrosisand other
renal abnormalities. Radiology. 1993;187:157-60.

30. MICTURATING CYSTOURETHROGRAM
NORMAL PUV VUR

31. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

32. DIURETIC RENOGRAPHY
•Renographyis imaging of the kidney using radionuclide
material (such as Tc-99m MAG3) and viewed with a
gamma camera.
•Also called Nuclear Renographyor Radioisotope
renographyor Renal Scintigraphy,
•When diuretics (IV Furosemide1mg/kg) is used to
facilitate renal excretion –Diuretic renography.
•Radiopharmaceutical materials used are:
▪Tc-99m-MAG3 (MercaptoAcetyl Tri Glycine)
▪Tc-99m-DTPA (DiethyleneTriaminePent Acetate)
▪Tc-99m-EC (Ethyl Cystiene)
WHAT ARE RENOGRAPHY SCANS ?

33. DIURETIC RENOGRAPHY
Pre requisites: ensure hydration. Oral hydration suffices.
Bladder catheterization not necessary (except in patient with
suspected abnormality or post micturationfilms showing persistent
contrast in bladder)
Injection of radionuclide material (or radioactive tracer)
into the intravenous system
The compound is usually localized/ excreted by a specific
organ (kidneys)
Radionuclidescontains radioactive atoms. When those
atoms decay, they emit gamma rays that are detected by
the gamma camera.
HOW IT WORKS ?

34. DIURETIC RENOGRAPHY
•Three basic classes of radionuclide are employed in nuclear renography.
1.Filtered agents–DTPA & MAG3
They are filtered through the glomerulus. So, useful in measuring perfusion,
function (GFR), drainage (obstruction)
2.Excreted agents–MAG3, EC & HIPURAN
They are excreted by the renal tubules. So, useful in evaluating tubular
function and in transplant cases.
3. Cortical imaging agents –DMSA & Glucoheptonate
these get accumulated in the cortex. So, useful in evaluating for renal
scarring, infarction, differential renal mass.
•DIURETIC SCAN–about 15 min after injection of the radionuclide, IV
furosemide(1mg/kg) is given.
If the obstruction is partial, it maybe detected only with high urine flow.
Lasixhelps to demostratepartial obstruction by maximising urine output.
WHICH RENOGRAPHY SCAN ?

35. DIURETIC RENOGRAPHY
•Nuclear renogramis always checked in 3 panels:
1.Perfusion
2.Drainage/function
3.Curves/analysis

36. DIURETIC RENOGRAPHY
•Nuclear renogramis always checked in 3 panels:
1.Perfusion
2.Drainage/function
3.Curves/analysis

37. DIURETIC RENOGRAPHY
•Useful in evaluating the physiology/functioningof the kidney by
monitoring flow of radioisotope and how efficiently the kidneys
absorb and pass it.
•Shows abnormalities in structure, size & shape of the kidneys.
•Differentiates between passive dilation and obstruction.
ADVANTAGES OF RENOGRAPHY
DISADVANTAGES OF RENOGRAPHY
•Radioactivity exposure
•Cannot differentiate between cyst & tumors
•It produces lower contrast images than KUB xray, CT & MRI
•Time consuming as it takes 30min –2 hours.

38. DIURETIC RENOGRAPHY
RISK OF RADIATION EXPOSURE

39. DIURETIC RENOGRAPHY
1.Infants with moderate to severe unilateral or bilateral
hydronephrosis(SFU grade 3-4, APD >10mm), with
absent vesicouretericreflux.
2.Infants with mild hydronephrosisand dilated ureters
and absent vesicouretericreflux.
3.Patients with vesicouretericreflux with worsening
hydronephrosis(to look for coexisting PUJ obstruction).
WHOM TO PERFORM ON ?
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SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal
hydronephrosis.Indian J Nephrol.2013;23:83–97

40. DIURETIC RENOGRAPHY
1.Preferably renographyis performed at 6-8wks of life. (
since renal functional immaturity before that results in
poor isotope intake).
2.Maybe performed earlier in patients with severe
hydronephrosisand cortical thinning.
3.Repeat renographymay be needed in few patients with
worsening of pelvicalycealdilatation on USG. (timing not
defined. Tracer used in first evaluation and timing of
diuretic administration should be similar in serial
evaluations)
WHEN TO PERFORM ?
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SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal hydronephrosis.Indian J
Nephrol.2013;23:83–97

41. DIURETIC RENOGRAPHY
•Normal renogramcurve has an early peak (2-5min),
rapidly descending phase and almost complete renal
emptying in 20 min.
•Satisfactory drainage spontaneously or post diuretic
administration rules out obstruction
•Differential renal function estimation: Normal 45-55%.
Any value less than 40% is significant.
•Otherparameters checked: Time for clearance of 50% of
radionucleotide(t1/2>20 min)
CLUES TO INTERPRETATION
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42. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

43. PROPHYLACTIC ANTIBIOTIC THERAPY
•Infants with ANH, including those in whom
hydronephrosishas resolved postnatallyhave an
increased risk of UTI.
•Rates of UTI depends on severity, duration of HN
& antibiotic use.
•Evidence shows that most of the cases of isolated
mild HN without prophylaxis, have similar
frequency of UTI in unilateral & bilateral cases.
•Colehoet al reported that infants with postnatal
renal APD≥10mm have significantly increased risk
of infections compared to the mild one.
WHY TO START ?
Coelho GM, Bouzada MC, Pereira AK, Figueiredo BF, LeiteMR, Oliveira DS, et al. Outcome of isolated antenatal hydronephrosis. A
prospective cohort study. PediatrNephrol2007;22:1727-34.

44. PROPHYLACTIC ANTIBIOTIC THERAPY
•Due to increased risk of UTI in infants with HN, the American Urological
Association (AUA) in 2009 recommended use of continuous antibiotic
prophylaxis (CAP) for the first yr of life. (1)
•More recent evidences suggested that not only may CAP not reduce the risk
of UTI, but it may contribute to the development of bacterial antibiotic
resistance.(2)
•The 2009 Canadian Urological Association (CUA) guidelines on HN stated
that the role of CAP is controversial, providing Grade D recommendation.(3)
•A meta-analysis showed that there was no difference in UTI rates for
patients with low grade (SFU I-II) HN receiving CAP compared to those
receiving no treatment (2.2% vs2.8%; p=0.15). However, in patients with
high grade (III-IV) HN, a significant decrease in UTI rates was observed in
those receiving CAP vsthose not receiving it. (14.6% vs28.9%; p<0.01) (4)
WHERE DOES EVIDENCE STAND ?
4. Braga LH, MijovicH, FarrokhyarF, Pemberton J, DeMariaJ, Lorenzo AJ. Antibiotic prophylaxis for urinary tract infections in antenatal
hydronephrosis. Pediatrics. 2013 Jan;131(1):e251-61.
1.Easterbrook B, CapolicchioJP, Braga LH. Antibiotic prophylaxis for prevention of urinary tract infections in prenatal hydronephrosis: An
updated systematic review.Can UrolAssoc J. 2017;11(1-2Suppl1):S3-S11.
2. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database SystRev.
2011 Mar 16;(3)
3. PsooyK, Pike J. Investigation and management of antenatallydetected hydronephrosis.Can UrolAssoc J. 2009;3(1):69-72

45. PROPHYLACTIC ANTIBIOTIC THERAPY
•Recent studies like RIVUR( Randomised Intervention for Children with
VesicoureteralReflux) found that ‘Among children with VUR after UTI,
antimicrobial prophylaxis was associated with a substantially reduced risk of
recurrence, but not of renal scarring’.
•Evidence based disadvantages for long term prophylactic antibiotics:
▪High incidence of antibiotic resistance.
▪Showed no evidence of it preventing renal scarring or long term sequelae.
▪Cumbersome daily dosing. (most of the positive result studies also looked
at a non compliance rate> 25%.)
•None of the studies justified giving long term antibiotic prophylaxis &
managing simple factors like constipation was far better in preventing UTI.
WHERE DOES EVIDENCE STAND ?
Carpenter MA, HobermanA, MattooTK, et al. The RIVUR trial: profile and baseline clinical associations of children with vesicoureteral
reflux.Pediatrics. 2013;132(1):e34-e45.

46. PROPHYLACTIC ANTIBIOTIC THERAPY
1.Infants with postnatallyconfirmed moderate to
severe hydronephrosis(SFU Gr3-4, APD >10mm),
while awaiting evaluation.
2.Infants with postnatallyconfirmed hydronephrosis
with uretericdilatation, while awaiting evaluation.
3.??Vesicouretericreflux
WHOM TO START ?
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Prophylactic antibiotics are not required in children with PUJ
obstruction, PUV.
Can be offered for post surgical period or neurogenicbladder
(on regular catheterization)
SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal
hydronephrosis.Indian J Nephrol.2013;23:83–97

47. PROPHYLACTIC ANTIBIOTIC THERAPY
•No specific evidence based recommendation
available.
•For our local Indian settings, prophylaxis can be
offered to infants with VUR as the risk of UTI is
higher in this age group and investigations are not
yet complete.
•However, even in this setting, beyond 1 yr age,
prophylaxis should not continue for more than 6
months after the last UTI.
•Also, the child gets older, diagnosing UTI is easier
& hence prophylaxis may not be needed.
CAP FOR VUR ?
Indian Society of PediatricNephrology, VijayakumarM, Kanitkar M, Nammalwar BR, Bagga A. Revised statement on management of urinary
tract infections. Indian Pediatr. 2011;48:709-17.

48. PROPHYLACTIC ANTIBIOTIC THERAPY
1.Oral Cephalexin(15 mg/kg/day) daily in first
3 months of life.
2.Post 3 months:
•Oral Cotrimoxazole(1-2mg/kg/day) daily.
•Oral Nitrofurantoin(1-2 mg/kg/day) daily.
WHAT TO START ?
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S

49. Antenatal
monitoring
Fetal
intervantions
Postnatal
monitoring
Micturating
cystourethrogram
Diuretic
renography
Antibiotic
prophylaxis
Surgical
interventions

50. SURGICAL MANAGEMENT
1.Infants with lower urinary tract obstruction.
2.Infants with obstructed hydronephrosiswith reduced
differential renal function and/or worsening functions
on repeat evaluations.
3.Patients with bilateral hydronephrosisor
Hydronephrosisin solitary kidney showing worsening
of dilatation and functional deterioration (reduction
in differential function by 5-10% on renography).
4.Large hydronephrosiswith pain, discomfort, palpable
renal lump or recurrent UTI.
WHOM TO OPERATE ?
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S
SinhaA, BaggaA, Krishna A, BajpaiM, SrinivasM, UppalR, et al. Revised guidelines on management of antenatal
hydronephrosis.Indian J Nephrol.2013;23:83–97

51. SURGICAL MANAGEMENT
•POSTERIOR URETHERAL
VALVES-early urethral
catheterization,
dyselectrolytemiacorrection
& CYSTOSCOPIC ABLATION
OF VALVES.
WHICH SURGICAL INTERVENTIONS ?
•PELVIURETERIC JUNCTION
OBSTRUCTION with differential
function <40%-PYELOPLASTY
(laparoscopic or
retroperitoneoscopic).

52. SURGICAL MANAGEMENT
1.Prevent loss of renal function
2.Reduces the degree of hydronephrosisand
associated symptoms.
3.Improve the renal pelvis evacuation.
WHY TO OPERATE ?
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S

53. SURGICAL MANAGEMENT
1.Prevent loss of renal function
2.Reduces the degree of hydronephrosisand
associated symptoms.
3.Improve the renal pelvis evacuation.
Study shows that pyeloplastydone in SFU grade
III-IV leads to significant improvement of split
renal function and parenchymalthickness with
minimal complications.
WHY TO OPERATE ?
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S
Bendre, P.S., Karkera, P.J. & Nanjappa, M. Functional outcome after neonatal pyeloplastyin antenatally
diagnosed uretero-pelvic junction obstruction.AfrJ Urol27,17 (2021)

54. SURGICAL MANAGEMENT
Infants with differential renal function
>40% can be managed conservatively. With
close follow up and serial USG monitoring.
WHOM NOT TO OPERATE ?
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S

55. TAKE HOME MESSAGE
•Significant proportion have transient hydronephrosis
that resolves in uteroor postnatally.
•Neonates having persistent hydronephrosisrequires
close follow up.
•Infants with moderate to severe HN are screened for
VUR or urinary tract obstruction, which requires
prompt intervention.
•Decisions regarding surgical interventions depend on a
combination of clinical & laboratory features and
results of sequential USG & diuretic renography.

56. THANK
YOU