Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in children with high-grade hydronephrosis
Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in...
Hodhod, Amr; Capolicchio, John-Paul; Jednak, Roman; El-Sherif, Eid; El-Doray, Abd El-Alim; El-Sherbiny, Mohamed
2018-06-01 00:00:00
Arab Journal of Urology (2018) 16, 238–244 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in children with high-grade hydronephrosis a,b, a a b Amr Hodhod , John-Paul Capolicchio , Roman Jednak , Eid El-Sherif , b a Abd El-Alim El-Doray , Mohamed El-Sherbiny Departments of Surgery and Pediatric Surgery, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada Department of Urology, Faculty of Medicine, Menoufia University, Al Minufya, Egypt Received 29 September 2017, Received in revised form 26 October 2017, Accepted 7 November 2017 Available online 13 December 2017 KEYWORDS Abstract Objective: To evaluate the utility of hydroureter (HU) to identify high- grade vesico-ureteric reflux (VUR) in patients with high-grade postnatal Voiding cys- hydronephrosis (PH). tourethrography; Patients and methods: We retrospectively reviewed patients’ charts that had ante- Congenital natal hydronephrosis from 2008 to 2014. Patients were excluded if they presented hydronephrosis; with febrile urinary tract infection (fUTI), neurogenic bladder, posterior urethral Vesico-ureteric reflux; valve, multi-cystic dysplastic kidney, and multiple congenital malformations. We Pelvi-ureteric junction reviewed postnatal ultrasonography images and patients with Society of Fetal Urol- obstruction ogy (SFU) Grades 3 and 4 hydronephrosis with a renal pelvic antero-posterior diam- eter of 10 mm were included. The ureter was assessed and considered dilated if the ABBREVIATIONS ureteric diameter was 4 mm. The voiding cystourethrogram (VCUG) studies, APD, antero-posterior fUTI incidence, and surgical reports were reviewed. diameter; Results: Of the 654 patients reviewed, we included 148 patients (164 renal units) CI, confidence interval; of whom 113 (76.4%) were male and 35 (23.6%) female. SFU Grade 3 PH was iden- fUTI, febrile UTI; tified in 49% of the renal units, with the remaining 51% being SFU Grade 4. HU OR, odds ratio; was found in 50/164 renal units and was not detected in the remaining 114 units. PH, postnatal hydro- VUR was diagnosed in four units (3.5%) without HU (low-grade VUR); whilst it Corresponding author at: Departments of Surgery and Pediatric Surgery, McGill University, The Montreal Children’s Hospital, Room B04.2916.1 GLEN, 1001 Boulevard De´ carie, Montre´ al, QC H4A 3J1, Canada. E-mail address: amr.hodhod@mail.mcgill.ca (A. Hodhod). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier https://doi.org/10.1016/j.aju.2017.11.004 2090-598X 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Influence of postnatal hydroureter in determining the need for VCUG 239 nephrosis; was detected in 19 units (38%) with HU (72.7% were high-grade VUR) (P < 0.001). NU, normal ureter; VUR was diagnosed on the contralateral side in four/105 patients with PH without HU, hydroureter; HU and diagnosed in 10/43 patients with PH with HU (P < 0.001). During a med- HGH, high-grade ian follow-up of 25.9 months, none of the renal units that had VUR without HU postnatal hydrone- developed UTI or had surgeries. phrosis; Conclusion: Low-grade uncomplicated VUR was diagnosed in 3.5% of renal (N)(P)PV, (negative) units without HU. Our results support limiting the use of VCUG to renal units with (positive) predictive PH if associated with HU. value; 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// SFU, Society for Fetal creativecommons.org/licenses/by-nc-nd/4.0/). Urology; PUJO, PUJ obstruc- tion; US, ultrasonography; VCUG, voiding cysto- urethrogram Introduction valve, multi-cystic dysplastic kidney, and patients with multiple congenital malformations. We collected patients’ demographic data, side of Antenatal hydronephrosis is one of the most common hydronephrosis, and laterality. Postnatal renal US congenital anomalies being diagnosed in 1–5% of all images were reviewed by a single investigator (A.H). All pregnancies [1]. PUJ obstruction (PUJO) has been investigations were blindly reviewed in relation to the out- found to be the most common cause of high-grade post- come. All abdominal US sessions within the first year of natal hydronephrosis (HGH) [2]. When primary PUJO life were reviewed. Ureteric diameter and renal pelvic is associated with VUR, low-grade reflux predominates antero-posterior diameter (APD) were measured in every [3]. On the other hand, high-grade VUR associated with US. Findings with the highest values were recorded. We secondary PUJO is more often associated with dilated only included patients with Society of Fetal Urology tortuous ureter [3,4]. (SFU) Grade 3 and 4 postnatal hydronephrosis (PH) with Most available protocols for the management of a renal pelvic antero-posterior diameter (APD) of 10 HGH recommend a voiding cystourethrogram (VCUG) mm. Renal units with a renal pelvic APD of10 mm were for all patients [1,5]. However, when VUR coexists with recruited, as the Society for Pediatric Urology (SPU) con- HGH without hydroureter (HU), it is of low-grade and sensus considered postnatal renal pelvis dilatation of tends to resolve spontaneously after surgery [3]. Hence, >10 mm to be more suggestive of PUJ pathology [6]. for better utilisation of resources, the re-evaluation of The renal pelvic APD was measured in the transverse the role of VCUG in the evaluation of HGH is plane of the kidney. SFU Grade 3 was defined as diffuse warranted. calyceal dilatation without parenchymal thinning and Our hypothesis was that in HGH, the absence of HU SFU Grade 4 was considered when calyceal dilatation on ultrasonography (US) excludes high-grade VUR in was associated with parenchymal thinning [7]. Moreover, the vast majority of cases, thus precluding the need for the status of the retro-vesical ureter was evaluated. The VCUG in the primary assessment of these patients. ureter was measured, if it could be visualised in any of Therefore, in the present study, we evaluated patients the reviewed US images, in the transverse plane. When with HGH and correlated the findings of VCUG with the ureter was not visualised, we considered its diameter the presence or absence of HU. to be 0 mm. The mean ureteric diameter up to the age of 3 years usually does not exceed 4 mm [8,9]. Hence, if Patient and methods the ureteric diameter was 4 mm with a full bladder, we considered it to be HU. Review of patients’ charts was initiated after receiving Cyclic VCUG was carried out in all patients, aiming the approval of the Local Review Board. We retrospec- to detect occult VUR that might not appear in standard tively reviewed all patients’ data presented to our ter- VCUG [10]. Cyclic VCUG was performed with two con- tiary care institution with antenatal hydronephrosis secutive fillings of contrast according to bladder capac- from January 2008 to June 2014. We included only ity according to age. VUR was looked for during the patients who had presented in the first year of life. Renal filling and voiding phases then, if present, the grade of units with single renal system were only included. We VUR was recorded. We graded VUR according to the excluded patients who presented initially with febrile International classification of VUR [11]. Surgical UTI (fUTI), neurogenic bladder, posterior urethral 240 Hodhod et al. reports were also reviewed regarding the type of opera- tion. Moreover, the clinical diagnosis was collected and follow up period was calculated. Those with HGH without a dilated ureter were con- sidered as isolated PH. PUJO was only considered if patient underwent pyeloplasty. Finally, the incidence of fUTI was recorded and was defined as a fever >39 C associated with pyuria and urine culture identified a single pathogen of >50 000 colony-forming units/mL. Urine samples for culture were obtained through catheterisation. The incidence of UTI was obtained from patients’ charts and urine culture reports. Our primary measure was to evaluate the absence of HU associated with a renal pelvic APD of 10 mm as a predictor of the absence of ipsilateral high-grade VUR. Our secondary analysis was to report the incidence of surgical interventions and fUTI occurrence of HGH with HU and those with normal ureter (NU). Patients with VUR had antibiotic prophylaxis if high grade (Grade 4 or 5), complicated with fUTI. All patients with suspected PUJO and associated with VUR received antibiotic prophylaxis. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS, version 20; Fig. 1 Flowchart of study design. SPSS Inc., IBM Corp., Armonk, NY, USA). The VCUG results, type of surgical intervention, and the PH and 49% (72/148) had bilateral PH. Of the patients incidence of fUTI were correlated to the presence or with bilateral PH, only 16/72 patients (32 units) had absence of HU. Categorical data were evaluated using bilateral SFU Grade 3 or 4 PH and the rest (56/72) the chi-squared test and continuous data were evaluated had only SFU Grade 3 or 4 PH on one side and a lesser with the Mann–Whitney U-test. Logistic regression was degree of PH on the other side. used to calculate the odds ratio (OR) to evaluate the The median (range) renal pelvic APD was 15 (10–48) likelihood of VUR in the presence of HU. Moreover, mm. HU was detected by US in 50/164 renal units in 44 the ability of ipsilateral HU on US to predict VUR in patients (30.5%) with a median (range) ureteric diame- HGH was evaluated for the sensitivity, specificity, posi- ter of 9 (4.8–18) mm. tive (PPV) and negative (NPV) predictive values. A P 0.05 was considered statistically significant. VUR Results Of 21 patients who were diagnosed with VUR, two had bilateral VUR. VUR was diagnosed in 13/113 males Of the 654 patients reviewed, 148 patients (164 renal (11.5%) and eight/35 females (22.9%) (P = 0.09). units) were included (Fig. 1). We excluded patients with For patients with NU, VUR was detected in only initial fUTI (15 patients), neurogenic bladder (seven), four/114 renal units (3.5%); whilst in the presence of posterior urethral valve (four), multi-cystic dysplastic HU, VUR was detected in 19/50 renal units (38%) (P kidney (five), and genetic or multiple congenital malfor- < 0.001). The median (range) ureteric diameter for mations (14). refluxing HU units was 10 (4.8–18) mm (Fig. 2), and 74% (14/19) of refluxing renal units were high grade. Patients’ demographics Notably, all units with VUR detected without HU were low grade (Table 1); and refluxing ureters were neither We included 113/148 (76.4) males and 35/148 (23.6) dilated nor tortuous on VCUG. females. In all, 70% of the included renal units were Moreover, VUR was diagnosed on the contralateral on the right side (115/164) and 30% were on the left side in four/105 (3.85%) patients with NU and in (49/164). The median (range) age at presentation was 10/43 (23.2%) with HU (P < 0.001). Clinical diagnoses, 14 (1–350) days. In all, 81 renal units (49%) were SFU with ureteric diameters, were identified and tabulated Grade 3 and the remaining 83 (51%) were SFU Grade (Table 2). 4. In all, 51% (76/148) of the patients had unilateral Influence of postnatal hydroureter in determining the need for VCUG 241 Fig. 2 Scatterplot of the grade of VUR in relation to ureteric diameter. A line is drawn at 4 mm diameter, i.e. limit of NU size. Table 1 Grades of VUR (per renal unit) in relation to dilated ureter and SFU grading. PH with HU PH with NU VCUG SFU Grade 3 SFU Grade 4 Total SFU Grade 3 SFU Grade 4 Total No reflux 16 15 31 53 57 110 Grade 1 0 2 2 2 0 2 Grade 2 1 0 1 1 0 1 Grade 3 2 0 2 1 0 1 Grade 4 4 5 9 0 0 0 Grade 5 1 4 5 0 0 0 Total renal units 24 26 50 57 57 114 Refluxing units 8 11 19 4 0 4 Table 2 Clinical diagnoses with ureteric diameters after initial investigations (renal units). Diagnosis HU NU Total, n (%) N (%) Ureteric diameter, N (%) Ureteric diameter, mm, median (range) mm, median (range) PUJO or isolated PH 5 (10) 7.85 (5–10) 110 (96.5) 0 (0–3.7) 115(70.1) VUR 13 (26) 7.7 (4.8–17.6) 0 (0) – 13 (7.9) Non-refluxing megaureter 27 (54) 8.5 (7–17.5) 0 (0) – 27 (16.5) Concomitant VUR and PUJO 2 (4) 15 (12–18) 4 (3.5) 0 (0–0) 6 (3.7) Ureterocele 3(6) 9 (8.5–10) 0 (0) – 3 (1.8) Total 50 (100) 114 (100) 164 (100) 56 patients (53 NU and 3 HU) were confirmed to have PUJO. 242 Hodhod et al. Two HU renal units were diagnosed as concomitant Table 3 Type of surgery in relation to presence or absence of PUJO and VUR and had ureteric diameters of 12 and HU. 16 mm. Conversely, ureteric diameters for NU units Surgery HGH with HGH with Total, with the same diagnosis were 0 mm. HU, n (%) NU, n (%) n (%) Using logistic regression analysis, NU units were less Anti-reflux measures 14 (63.6) 0 14 (18.4) likely to have VUR (OR 0.125, 95% CI 0.046–0.339). Pyeloplasty 3 (13.65) 53 (98.1) 56 (73.7) Low-grade VUR was likely to be associated with a Nephrectomy 2 (9.1) 1 (1.9) 3 (3.95) dilated ureter if associated with HGH (OR 0.026, 95% Ureterocele incision 3 (13.65) 0 3 (3.95) Total, n (%) 22 (100) 54 (100) 76 (100) CI 0.002–0.341). Sensitivity of US in VUR prediction in patients with HU was 82.6% (95% CI 61.2–95.1%), whilst the speci- ficity was 78% (95% CI 70.3–84.6%), the PPV was 38% up. Prophylactic antibiotics were prescribed for five of and the NPV was 96.5%. However, US had 100% sen- these six units. We noted that NU units with VUR, sitivity (95% CI 85–100%) and 88% specificity (95% CI either on the ipsilateral or the contralateral side, did 80.4–93.1%) for detection of high-grade VUR in not receive any type of surgical intervention. For HU patients with HU, with a PPV of 66.7% and NPV of 100%. units with concomitant PUJO and VUR (two units), one unit had pyeloplasty and the other underwent re- Antibiotic prophylaxis implantation. Discussion In all, 74% of patients with HU (32/43) received antibi- otic prophylaxis in comparison to 45% (47/105) of those with NU (P = 0.001). Notably, all patients with VUR, Despite VUR generally being more prevalent than either associated with HU or NU, had antibiotic pro- PUJO, PUJO or isolated hydronephrosis is the most phylaxis. Patients with HU who had VUR had a median common pathology in moderate and severe (range) antibiotic prophylaxis duration of 13 (5–48) hydronephrosis [2]. Many published reports have shown months. Of patients with NU and VUR, three units the association between PUJO and VUR, and all (in three patients) had surgical interventions (pyeloplas- endorse the futility of VCUG if PUJO is associated with ties) and received a median (range) duration of antibi- NU. However, none reported the importance of VCUG otic prophylaxis of 6 (5–12) months. in HGH globally, not only PUJO, in respect of the pres- ence of a dilated ureter [3,12,13]. In the present study, fUTI we evaluated the value of ureteric dilatation for exclud- ing VUR in renal units with HGH. The median (range) follow-up period was 25.9 (11.2– Ureteric diameter is usually <4 mm in the first 3 83.4) months. fUTI was reported in 12/104 NU patients years of life [8,9]. Fernbach et al. [7] proposed a grading (11.5%) and 16/44 HU patients (36.4%) during follow- system for HU and defined the lowest grade as a diam- up (P < 0.001). Notably, all patients with NU with eter of <7 mm. However, after a literature review, we VUR did not have UTIs during follow-up. Three of 12 found no data that this classification was further evalu- patients with NU and six of 16 patients with HU ated or used. Leroy et al. [4] considered HU when visu- (38%) who had UTIs were on antibiotic prophylaxis. alised retrovesically. In the present study, we considered HU if the retrovesical ureter exceeded the mean Surgical outcome (Table 3) diameter. The importance of HU detection with US had been In all, 46% (76/164) of the renal units were treated sur- presented in the literature [4,14–16]. Leroy et al. [4] con- gically. Surgical intervention was necessary in 44% cluded that high-grade VUR was found to be associated (22/50) of renal units with HU and in 47.4% (54/114) with dilated ureters with 73% sensitivity and 88% speci- of NU renal units (P = 0.707). It was noted that bilat- ficity. Furthermore, another study stated that 63% of eral HGH with NU had a higher incidence of surgical patients could avoid VCUG using the criteria of HU, intervention (P = 0.03). Pyeloplasty was the most com- renal duplication, and dysmorphia [17]. HU was evalu- monly performed surgery (98.1%) for renal units with ated in a paediatric population with UTI and was iden- NU (53/54 units). Anti-reflux measures were performed tified as being a helpful tool in VUR detection [15]. in 14/22 renal units associated HU (63.6%) and not Moreover, Logvinenko et al. [16] found that ureteric reported for renal units with NU. The remaining HU dilatation had a predictive value for VUR Grade >2 units that did not undergo surgical management (28/50 in children with UTI. In our present study, HGH, renal units) were managed conservatively. Of these remaining pelvic APD of >10 mm, and NU had 96.5% NPV for units, six of 28 units (21.5%) had fUTI during follow- VUR and 100% NPV for high-grade VUR. Influence of postnatal hydroureter in determining the need for VCUG 243 In the present study, despite 76% of included patients The present study had some limitations. First, the being male, females had twice the chance of getting nature of the study is retrospective. The follow-up per- VUR than males. Chand et al. [18] reported the same iod is relatively short. Thus, long-term studies are war- percentage of VUR incidence. ranted to evaluate the incidence of UTI in the absence Lee et al. [17] reported that HU, in association with of HU. any grade of pH, was an independent predictor of Conclusion VUR. Moreover, of the patients who underwent pyelo- plasty, three patients had concomitant low-grade VUR. Renal units with HGH, NU and renal pelvic APD of Interestingly, none of these patients had a UTI after >10 mm on US have a high NPV for the presence of pyeloplasty. None of our patients who underwent pyelo- VUR, suggesting the diagnosis of isolated PH. Hence, plasty and had associated VUR had UTIs during in the absence of HU, VCUG is of limited value in the follow-up. assessment of HGH. Concomitant PUJO and VUR are uncommon, with 8–11% of patients diagnosed initially as PUJO [3,19]. Conflict of interest In our present study, concomitant PUJO and VUR rep- resented 3.65% of HGH. All our patients who had sus- None. pected PUJO and VUR received antibiotic prophylaxis, as refluxing could result in pyonephrosis. References The association of PUJO and VUR can be classified into three groups: Group 1, includes primary PUJO that [1] Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal is associated with low-grade reflux; Group 2, contains hydronephrosis as a predictor of postnatal outcome: a meta- PUJO secondary VUR; and patients with VUR associ- analysis. Pediatrics 2006;118:586–93. [2] Passerotti CC, Kalish LA, Chow J, Passerotti AM, Recabal P, ated with pseudo PUJO (non-obstructive renogram) Cendron M, et al. The predictive value of the first postnatal constitute Group 3 [20]. VUR and PUJO are indepen- ultrasound in children with antenatal hydronephrosis. J Pediatr dent in Group 1 and mostly resolve spontaneously Urol 2011;7:128–36. [20]. VUR Grades 3 are associated with a dilated pelvi- [3] Kim YS, Do SH, Hong CH, Kim MJ, Choi SK, Han SW. Does calyceal system and ureter [4,21]. Despite undocumented every patient with ureteropelvic junction obstruction need voiding cystourethrography? J Urol 2001;165:2305–7. VUR resolution, our present results showed that all [4] Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman patients with PUJO who had NU with VUR did not A. Vesicoureteral reflux in children with urinary tract infection: develop any complications during the 30.1 months of comparison of diagnostic accuracy of renal US criteria. Radiology follow-up. 2010;255:890–8. Kim et al. [3] stated that low-grade VUR coexisting [5] Psooy K, Pike J. Investigation and management of antenatally detected hydronephrosis. Can Urol Assoc J 2009;3:69–72. with PUJO usually disappears after pyeloplasty. Fur- [6] Nguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, thermore, they reported that low-grade VUR was not Coleman B, et al. 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VCUG due to low clinical significance [24,25]. Compli- [10] Papadopoulou F, Efremidis SC, Oiconomou A, Badouraki M, cations of VCUG are numerous and unavoidable Panteleli M, Papachristou F, et al. Cyclic voiding cystourethrog- despite precautions [26] and include: ascending infec- raphy: is vesicoureteral reflux missed with standard voiding tion, urethral or bladder injury, radiation exposure, cystourethrography? Eur Radiol 2002;12:666–70. and renal pain in addition to sedation side-effects [27]. [11] Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tammi- nen-Mo¨ bius TE. International system of radiographic grading of A previous study at our institute found that VCUG is vesicoureteric reflux. International Reflux Study in Children. of limited use in terms of VUR screening for low-grade Pediatr Radiol 1985;15:105–9. PH [24]. 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Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in children with high-grade hydronephrosis
Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in children with high-grade hydronephrosis
Abstract
AbstractObjectiveTo evaluate the utility of hydroureter (HU) to identify high-grade vesico-ureteric reflux (VUR) in patients with high-grade postnatal hydronephrosis (PH).Patients and methodsWe retrospectively reviewed patients’ charts that had antenatal hydronephrosis from 2008 to 2014. Patients were excluded if they presented with febrile urinary tract infection (fUTI), neurogenic bladder, posterior urethral valve, multi-cystic dysplastic kidney, and multiple congenital malformations....
Arab Journal of Urology (2018) 16, 238–244 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE Influence of postnatal hydroureter in determining the need for voiding cystourethrogram in children with high-grade hydronephrosis a,b, a a b Amr Hodhod , John-Paul Capolicchio , Roman Jednak , Eid El-Sherif , b a Abd El-Alim El-Doray , Mohamed El-Sherbiny Departments of Surgery and Pediatric Surgery, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada Department of Urology, Faculty of Medicine, Menoufia University, Al Minufya, Egypt Received 29 September 2017, Received in revised form 26 October 2017, Accepted 7 November 2017 Available online 13 December 2017 KEYWORDS Abstract Objective: To evaluate the utility of hydroureter (HU) to identify high- grade vesico-ureteric reflux (VUR) in patients with high-grade postnatal Voiding cys- hydronephrosis (PH). tourethrography; Patients and methods: We retrospectively reviewed patients’ charts that had ante- Congenital natal hydronephrosis from 2008 to 2014. Patients were excluded if they presented hydronephrosis; with febrile urinary tract infection (fUTI), neurogenic bladder, posterior urethral Vesico-ureteric reflux; valve, multi-cystic dysplastic kidney, and multiple congenital malformations. We Pelvi-ureteric junction reviewed postnatal ultrasonography images and patients with Society of Fetal Urol- obstruction ogy (SFU) Grades 3 and 4 hydronephrosis with a renal pelvic antero-posterior diam- eter of 10 mm were included. The ureter was assessed and considered dilated if the ABBREVIATIONS ureteric diameter was 4 mm. The voiding cystourethrogram (VCUG) studies, APD, antero-posterior fUTI incidence, and surgical reports were reviewed. diameter; Results: Of the 654 patients reviewed, we included 148 patients (164 renal units) CI, confidence interval; of whom 113 (76.4%) were male and 35 (23.6%) female. SFU Grade 3 PH was iden- fUTI, febrile UTI; tified in 49% of the renal units, with the remaining 51% being SFU Grade 4. HU OR, odds ratio; was found in 50/164 renal units and was not detected in the remaining 114 units. PH, postnatal hydro- VUR was diagnosed in four units (3.5%) without HU (low-grade VUR); whilst it Corresponding author at: Departments of Surgery and Pediatric Surgery, McGill University, The Montreal Children’s Hospital, Room B04.2916.1 GLEN, 1001 Boulevard De´ carie, Montre´ al, QC H4A 3J1, Canada. E-mail address: amr.hodhod@mail.mcgill.ca (A. Hodhod). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier https://doi.org/10.1016/j.aju.2017.11.004 2090-598X 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Influence of postnatal hydroureter in determining the need for VCUG 239 nephrosis; was detected in 19 units (38%) with HU (72.7% were high-grade VUR) (P < 0.001). NU, normal ureter; VUR was diagnosed on the contralateral side in four/105 patients with PH without HU, hydroureter; HU and diagnosed in 10/43 patients with PH with HU (P < 0.001). During a med- HGH, high-grade ian follow-up of 25.9 months, none of the renal units that had VUR without HU postnatal hydrone- developed UTI or had surgeries. phrosis; Conclusion: Low-grade uncomplicated VUR was diagnosed in 3.5% of renal (N)(P)PV, (negative) units without HU. Our results support limiting the use of VCUG to renal units with (positive) predictive PH if associated with HU. value; 2017 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// SFU, Society for Fetal creativecommons.org/licenses/by-nc-nd/4.0/). Urology; PUJO, PUJ obstruc- tion; US, ultrasonography; VCUG, voiding cysto- urethrogram Introduction valve, multi-cystic dysplastic kidney, and patients with multiple congenital malformations. We collected patients’ demographic data, side of Antenatal hydronephrosis is one of the most common hydronephrosis, and laterality. Postnatal renal US congenital anomalies being diagnosed in 1–5% of all images were reviewed by a single investigator (A.H). All pregnancies [1]. PUJ obstruction (PUJO) has been investigations were blindly reviewed in relation to the out- found to be the most common cause of high-grade post- come. All abdominal US sessions within the first year of natal hydronephrosis (HGH) [2]. When primary PUJO life were reviewed. Ureteric diameter and renal pelvic is associated with VUR, low-grade reflux predominates antero-posterior diameter (APD) were measured in every [3]. On the other hand, high-grade VUR associated with US. Findings with the highest values were recorded. We secondary PUJO is more often associated with dilated only included patients with Society of Fetal Urology tortuous ureter [3,4]. (SFU) Grade 3 and 4 postnatal hydronephrosis (PH) with Most available protocols for the management of a renal pelvic antero-posterior diameter (APD) of 10 HGH recommend a voiding cystourethrogram (VCUG) mm. Renal units with a renal pelvic APD of10 mm were for all patients [1,5]. However, when VUR coexists with recruited, as the Society for Pediatric Urology (SPU) con- HGH without hydroureter (HU), it is of low-grade and sensus considered postnatal renal pelvis dilatation of tends to resolve spontaneously after surgery [3]. Hence, >10 mm to be more suggestive of PUJ pathology [6]. for better utilisation of resources, the re-evaluation of The renal pelvic APD was measured in the transverse the role of VCUG in the evaluation of HGH is plane of the kidney. SFU Grade 3 was defined as diffuse warranted. calyceal dilatation without parenchymal thinning and Our hypothesis was that in HGH, the absence of HU SFU Grade 4 was considered when calyceal dilatation on ultrasonography (US) excludes high-grade VUR in was associated with parenchymal thinning [7]. Moreover, the vast majority of cases, thus precluding the need for the status of the retro-vesical ureter was evaluated. The VCUG in the primary assessment of these patients. ureter was measured, if it could be visualised in any of Therefore, in the present study, we evaluated patients the reviewed US images, in the transverse plane. When with HGH and correlated the findings of VCUG with the ureter was not visualised, we considered its diameter the presence or absence of HU. to be 0 mm. The mean ureteric diameter up to the age of 3 years usually does not exceed 4 mm [8,9]. Hence, if Patient and methods the ureteric diameter was 4 mm with a full bladder, we considered it to be HU. Review of patients’ charts was initiated after receiving Cyclic VCUG was carried out in all patients, aiming the approval of the Local Review Board. We retrospec- to detect occult VUR that might not appear in standard tively reviewed all patients’ data presented to our ter- VCUG [10]. Cyclic VCUG was performed with two con- tiary care institution with antenatal hydronephrosis secutive fillings of contrast according to bladder capac- from January 2008 to June 2014. We included only ity according to age. VUR was looked for during the patients who had presented in the first year of life. Renal filling and voiding phases then, if present, the grade of units with single renal system were only included. We VUR was recorded. We graded VUR according to the excluded patients who presented initially with febrile International classification of VUR [11]. Surgical UTI (fUTI), neurogenic bladder, posterior urethral 240 Hodhod et al. reports were also reviewed regarding the type of opera- tion. Moreover, the clinical diagnosis was collected and follow up period was calculated. Those with HGH without a dilated ureter were con- sidered as isolated PH. PUJO was only considered if patient underwent pyeloplasty. Finally, the incidence of fUTI was recorded and was defined as a fever >39 C associated with pyuria and urine culture identified a single pathogen of >50 000 colony-forming units/mL. Urine samples for culture were obtained through catheterisation. The incidence of UTI was obtained from patients’ charts and urine culture reports. Our primary measure was to evaluate the absence of HU associated with a renal pelvic APD of 10 mm as a predictor of the absence of ipsilateral high-grade VUR. Our secondary analysis was to report the incidence of surgical interventions and fUTI occurrence of HGH with HU and those with normal ureter (NU). Patients with VUR had antibiotic prophylaxis if high grade (Grade 4 or 5), complicated with fUTI. All patients with suspected PUJO and associated with VUR received antibiotic prophylaxis. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS, version 20; Fig. 1 Flowchart of study design. SPSS Inc., IBM Corp., Armonk, NY, USA). The VCUG results, type of surgical intervention, and the PH and 49% (72/148) had bilateral PH. Of the patients incidence of fUTI were correlated to the presence or with bilateral PH, only 16/72 patients (32 units) had absence of HU. Categorical data were evaluated using bilateral SFU Grade 3 or 4 PH and the rest (56/72) the chi-squared test and continuous data were evaluated had only SFU Grade 3 or 4 PH on one side and a lesser with the Mann–Whitney U-test. Logistic regression was degree of PH on the other side. used to calculate the odds ratio (OR) to evaluate the The median (range) renal pelvic APD was 15 (10–48) likelihood of VUR in the presence of HU. Moreover, mm. HU was detected by US in 50/164 renal units in 44 the ability of ipsilateral HU on US to predict VUR in patients (30.5%) with a median (range) ureteric diame- HGH was evaluated for the sensitivity, specificity, posi- ter of 9 (4.8–18) mm. tive (PPV) and negative (NPV) predictive values. A P 0.05 was considered statistically significant. VUR Results Of 21 patients who were diagnosed with VUR, two had bilateral VUR. VUR was diagnosed in 13/113 males Of the 654 patients reviewed, 148 patients (164 renal (11.5%) and eight/35 females (22.9%) (P = 0.09). units) were included (Fig. 1). We excluded patients with For patients with NU, VUR was detected in only initial fUTI (15 patients), neurogenic bladder (seven), four/114 renal units (3.5%); whilst in the presence of posterior urethral valve (four), multi-cystic dysplastic HU, VUR was detected in 19/50 renal units (38%) (P kidney (five), and genetic or multiple congenital malfor- < 0.001). The median (range) ureteric diameter for mations (14). refluxing HU units was 10 (4.8–18) mm (Fig. 2), and 74% (14/19) of refluxing renal units were high grade. Patients’ demographics Notably, all units with VUR detected without HU were low grade (Table 1); and refluxing ureters were neither We included 113/148 (76.4) males and 35/148 (23.6) dilated nor tortuous on VCUG. females. In all, 70% of the included renal units were Moreover, VUR was diagnosed on the contralateral on the right side (115/164) and 30% were on the left side in four/105 (3.85%) patients with NU and in (49/164). The median (range) age at presentation was 10/43 (23.2%) with HU (P < 0.001). Clinical diagnoses, 14 (1–350) days. In all, 81 renal units (49%) were SFU with ureteric diameters, were identified and tabulated Grade 3 and the remaining 83 (51%) were SFU Grade (Table 2). 4. In all, 51% (76/148) of the patients had unilateral Influence of postnatal hydroureter in determining the need for VCUG 241 Fig. 2 Scatterplot of the grade of VUR in relation to ureteric diameter. A line is drawn at 4 mm diameter, i.e. limit of NU size. Table 1 Grades of VUR (per renal unit) in relation to dilated ureter and SFU grading. PH with HU PH with NU VCUG SFU Grade 3 SFU Grade 4 Total SFU Grade 3 SFU Grade 4 Total No reflux 16 15 31 53 57 110 Grade 1 0 2 2 2 0 2 Grade 2 1 0 1 1 0 1 Grade 3 2 0 2 1 0 1 Grade 4 4 5 9 0 0 0 Grade 5 1 4 5 0 0 0 Total renal units 24 26 50 57 57 114 Refluxing units 8 11 19 4 0 4 Table 2 Clinical diagnoses with ureteric diameters after initial investigations (renal units). Diagnosis HU NU Total, n (%) N (%) Ureteric diameter, N (%) Ureteric diameter, mm, median (range) mm, median (range) PUJO or isolated PH 5 (10) 7.85 (5–10) 110 (96.5) 0 (0–3.7) 115(70.1) VUR 13 (26) 7.7 (4.8–17.6) 0 (0) – 13 (7.9) Non-refluxing megaureter 27 (54) 8.5 (7–17.5) 0 (0) – 27 (16.5) Concomitant VUR and PUJO 2 (4) 15 (12–18) 4 (3.5) 0 (0–0) 6 (3.7) Ureterocele 3(6) 9 (8.5–10) 0 (0) – 3 (1.8) Total 50 (100) 114 (100) 164 (100) 56 patients (53 NU and 3 HU) were confirmed to have PUJO. 242 Hodhod et al. Two HU renal units were diagnosed as concomitant Table 3 Type of surgery in relation to presence or absence of PUJO and VUR and had ureteric diameters of 12 and HU. 16 mm. Conversely, ureteric diameters for NU units Surgery HGH with HGH with Total, with the same diagnosis were 0 mm. HU, n (%) NU, n (%) n (%) Using logistic regression analysis, NU units were less Anti-reflux measures 14 (63.6) 0 14 (18.4) likely to have VUR (OR 0.125, 95% CI 0.046–0.339). Pyeloplasty 3 (13.65) 53 (98.1) 56 (73.7) Low-grade VUR was likely to be associated with a Nephrectomy 2 (9.1) 1 (1.9) 3 (3.95) dilated ureter if associated with HGH (OR 0.026, 95% Ureterocele incision 3 (13.65) 0 3 (3.95) Total, n (%) 22 (100) 54 (100) 76 (100) CI 0.002–0.341). Sensitivity of US in VUR prediction in patients with HU was 82.6% (95% CI 61.2–95.1%), whilst the speci- ficity was 78% (95% CI 70.3–84.6%), the PPV was 38% up. Prophylactic antibiotics were prescribed for five of and the NPV was 96.5%. However, US had 100% sen- these six units. We noted that NU units with VUR, sitivity (95% CI 85–100%) and 88% specificity (95% CI either on the ipsilateral or the contralateral side, did 80.4–93.1%) for detection of high-grade VUR in not receive any type of surgical intervention. For HU patients with HU, with a PPV of 66.7% and NPV of 100%. units with concomitant PUJO and VUR (two units), one unit had pyeloplasty and the other underwent re- Antibiotic prophylaxis implantation. Discussion In all, 74% of patients with HU (32/43) received antibi- otic prophylaxis in comparison to 45% (47/105) of those with NU (P = 0.001). Notably, all patients with VUR, Despite VUR generally being more prevalent than either associated with HU or NU, had antibiotic pro- PUJO, PUJO or isolated hydronephrosis is the most phylaxis. Patients with HU who had VUR had a median common pathology in moderate and severe (range) antibiotic prophylaxis duration of 13 (5–48) hydronephrosis [2]. Many published reports have shown months. Of patients with NU and VUR, three units the association between PUJO and VUR, and all (in three patients) had surgical interventions (pyeloplas- endorse the futility of VCUG if PUJO is associated with ties) and received a median (range) duration of antibi- NU. However, none reported the importance of VCUG otic prophylaxis of 6 (5–12) months. in HGH globally, not only PUJO, in respect of the pres- ence of a dilated ureter [3,12,13]. In the present study, fUTI we evaluated the value of ureteric dilatation for exclud- ing VUR in renal units with HGH. The median (range) follow-up period was 25.9 (11.2– Ureteric diameter is usually <4 mm in the first 3 83.4) months. fUTI was reported in 12/104 NU patients years of life [8,9]. Fernbach et al. [7] proposed a grading (11.5%) and 16/44 HU patients (36.4%) during follow- system for HU and defined the lowest grade as a diam- up (P < 0.001). Notably, all patients with NU with eter of <7 mm. However, after a literature review, we VUR did not have UTIs during follow-up. Three of 12 found no data that this classification was further evalu- patients with NU and six of 16 patients with HU ated or used. Leroy et al. [4] considered HU when visu- (38%) who had UTIs were on antibiotic prophylaxis. alised retrovesically. In the present study, we considered HU if the retrovesical ureter exceeded the mean Surgical outcome (Table 3) diameter. The importance of HU detection with US had been In all, 46% (76/164) of the renal units were treated sur- presented in the literature [4,14–16]. Leroy et al. [4] con- gically. Surgical intervention was necessary in 44% cluded that high-grade VUR was found to be associated (22/50) of renal units with HU and in 47.4% (54/114) with dilated ureters with 73% sensitivity and 88% speci- of NU renal units (P = 0.707). It was noted that bilat- ficity. Furthermore, another study stated that 63% of eral HGH with NU had a higher incidence of surgical patients could avoid VCUG using the criteria of HU, intervention (P = 0.03). Pyeloplasty was the most com- renal duplication, and dysmorphia [17]. HU was evalu- monly performed surgery (98.1%) for renal units with ated in a paediatric population with UTI and was iden- NU (53/54 units). Anti-reflux measures were performed tified as being a helpful tool in VUR detection [15]. in 14/22 renal units associated HU (63.6%) and not Moreover, Logvinenko et al. [16] found that ureteric reported for renal units with NU. The remaining HU dilatation had a predictive value for VUR Grade >2 units that did not undergo surgical management (28/50 in children with UTI. In our present study, HGH, renal units) were managed conservatively. Of these remaining pelvic APD of >10 mm, and NU had 96.5% NPV for units, six of 28 units (21.5%) had fUTI during follow- VUR and 100% NPV for high-grade VUR. Influence of postnatal hydroureter in determining the need for VCUG 243 In the present study, despite 76% of included patients The present study had some limitations. First, the being male, females had twice the chance of getting nature of the study is retrospective. The follow-up per- VUR than males. Chand et al. [18] reported the same iod is relatively short. Thus, long-term studies are war- percentage of VUR incidence. ranted to evaluate the incidence of UTI in the absence Lee et al. [17] reported that HU, in association with of HU. any grade of pH, was an independent predictor of Conclusion VUR. Moreover, of the patients who underwent pyelo- plasty, three patients had concomitant low-grade VUR. Renal units with HGH, NU and renal pelvic APD of Interestingly, none of these patients had a UTI after >10 mm on US have a high NPV for the presence of pyeloplasty. None of our patients who underwent pyelo- VUR, suggesting the diagnosis of isolated PH. Hence, plasty and had associated VUR had UTIs during in the absence of HU, VCUG is of limited value in the follow-up. assessment of HGH. Concomitant PUJO and VUR are uncommon, with 8–11% of patients diagnosed initially as PUJO [3,19]. Conflict of interest In our present study, concomitant PUJO and VUR rep- resented 3.65% of HGH. 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Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis
The predictive value of the first postnatal ultrasound in children with antenatal hydronephrosis
Does every patient with ureteropelvic junction obstruction need voiding cystourethrography?
Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria
Investigation and management of antenatally detected hydronephrosis
Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system)
Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology
Normal ureteral diameter in infancy and childhood
Dimensions of the normal ureter in infancy and childhood
Cyclic voiding cystourethrography: is vesicoureteral reflux missed with standard voiding cystourethrography?
International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children
Children and adolescents with ureteropelvic junction obstruction: is an additional voiding cystourethrogram necessary? Results of a multicenter study
The role of voiding cystourethrography in asymptomatic unilateral isolated ureteropelvic junction obstruction: a retrospective study
Primary megaureter detected by prenatal ultrasonography: conservative management and prolonged follow-up
Meaning of ureter dilatation during ultrasonography in infants for evaluating vesicoureteral reflux
Predictive value of specific ultrasound findings when used as a screening test for abnormalities on VCUG
Groves DS1, Pohl HG. Evaluation of prenatal hydronephrosis: novel criteria for predicting vesicoureteral reflux on ultrasonography
Incidence and severity of vesicoureteral reflux in children related to age, gender, race and diagnosis
Prenatally detected ureteropelvic junction obstruction: clinical features and associated urologic abnormalities
Coexisting ureteropelvic junction obstruction and vesicoureteral reflux: diagnostic and therapeutic implications
Is sonographically demonstrated mild distal ureteric dilatation predictive of vesicoureteric reflux as seen on micturating cystourethrography?
Vesicoureteral reflux and urinary tract infection in children with a history of prenatal hydronephrosis–should voiding cystourethrography be performed in cases of postnatally persistent grade II hydronephrosis?
Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis
Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?
Micturating cystourethrograms are not necessary for all cases of antenatally diagnosed hydronephrosis
Symptomatic urinary tract infections following voiding cystourethrography
Complications associated with cystography in children
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