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: firstname.lastname@example.org (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 . 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) . 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 . 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 . Hence, >10 mm to be more suggestive of PUJ pathology . 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 . 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 . 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 . 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 . 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.  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.  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.  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 . 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 . in 14/22 renal units associated HU (63.6%) and not Moreover, Logvinenko et al.  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.  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.  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  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.  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 . 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. . VUR Grades 3 are associated with a dilated pelvi-  Kim YS, Do SH, Hong CH, Kim MJ, Choi SK, Han SW. Does calyceal system and ureter [4,21]. 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Arab Journal of Urology
– Taylor & Francis
Published: Jun 1, 2018
Keywords: APD; antero-posterior diameter; CI; confidence interval; fUTI; febrile UTI; OR; odds ratio; PH; postnatal hydronephrosis; NU; normal ureter; HU; hydroureter; HGH; high-grade postnatal hydronephrosis; (N)(P)PV; (negative) (positive) predictive value; SFU; Society for Fetal Urology; PUJO; PUJ obstruction; US; ultrasonography; VCUG; voiding cysto-urethrogram; Voiding cystourethrography; Congenital hydronephrosis; Vesico-ureteric reflux; Pelvi-ureteric junction obstruction