Prof Hashem AlMomani Pediatric Surgeon JORDAN UNIVERSITY HOSPITAL Definitions Hydronephrosis is dilatation of the pelvicalyceal system Hydronephrosis is not synonymous with obstruction obstruction ID: 999208
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1. ANTENATAL HYDRONEPHROSIS,Prof. Hashem Al-MomaniPediatric SurgeonJORDAN UNIVERSITY HOSPITAL
2. DefinitionsHydronephrosis: is dilatation of the pelvicalyceal system Hydronephrosis is not synonymous with obstruction.
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4. obstructionobstruction is defined as ‘‘a restriction to urinary outflow that, if untreated, leads to renal deterioration’’
5. incidenceThe incidence of prenatal hydronephrosis is 1 to 3 % of pregnancies17–30% are bilateral.
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7. Causes of antenatal hydronephrosisIntermittent hydronephrosisobstructionUreteropelvic junction obstructionUreterovesical junction obstruction (megaureter)Posterior urethral valvesVesicorenal reflux
8. Ureteropelvic junction obstruction
9. Ureterovesical junction obstruction (megaureter)
10. Posterior urethral valves
11. Vesicorenal reflux
12. Clinical PresentationSymptomatic : with infection or painasymptomatic prenatally detected hydronephrosis
13. CLINICAL PRESENTATIONINFANTSOLDER CHILDREN
14. INFANTSANTENATAL ULTRASOUNDABDOMINAL MASSHEMATURIAU.T.I.GASTROINTESTINAL DISTURBANCES
15. OLDER CHILDRENPAIN: ABDOMINAL OR FLANKHEMATURIA FOLLOWING MILD TRAUMAU.T.I.
16. Postnatal investigation of hydronephrosis
17. postnatal ultrasoundTiming of the first postnatal ultrasoundOn day 3 to 7At Birth: false negatives because of Dehydration A low glomerular filtration rate immediately after birth.
18. VCUGVURNeurogenic bladderPUV
19. renogramA renogram is usually obtained at 8–12 weeks to allow for maturation of kidney functionin suspected PUJ obstruction a renogram estimates baseline differential function and rapidity of radiotracer washout.
20. RenogramMAG-3 (mercaptoacetyl-triglycine) is used to evaluate differential function and drainage as in PUJ obstructionDMSA (Dimercapto-succinic acid ), deposits tracer in proximal tubular cells and is superior to MAG-3 in assessing cortical scars and function in the setting of reflux but is inferior in assessing drainage
21. renogram
22. Newer studiesMR- Urography3D-Ultrasound
23. MR- Urographydoes not use ionizing radiation.high-resolution anatomic images of the entire urinary tract, functional information about the concentration and excretion of the individual kidneys includes:differential renal function (DRF)renal transit time : If less than 245 seconds R/O Obstruction estimation of individual kidney glomerular filtration rate (GFR)
24. MIDURETERIC OBSTRUCTION
25. Postnatal imaging of prenatally detected hydronephrosisshowsresolution on postnatal ultrasound in 48% of patients, a non-obstructed hydronephrosis in 15%, ureteropelvic junction obstruction in 11%,vesicoureteral reflux in 9%, megaureter in 4%,multicystic dysplastic kidney in 2%ureterocele in 2%renal cyst in 2%posterior urethral valves in 1%
26. PUJ obstruction
27. Lt PUJ
28. Normal Nuclear Renogram
29. Nuclear Renogram of Kidney with Hydronephrosis(PUJ)
30. Management of PUJ obstructionObservation: US & diuretic renogramasymptomatic preserved renal function stable hydronephrosisIndications for surgery Increasing hydronephrosis on follow-up ultrasonography (increase in renal pelvic AP diameter 20 mm and above). Parenchymal thinning. Obstructive pattern on diuretic renogram Decreasing renal function (<40% differential renal function on diuretic renogram).
31. Vesicoureteric Reflux (VUR)Vesicoureteric reflux (VUR) is retrograde flow of urine from the bladder into the upper urinary tract.
32. Reflux Seen on Voiding Cystourethrogram (VCUG)
33. REFLUX AND INTRARENAL REFLUX
34. SCAR
35. ClassificationPrimary VURPrimary VUR is due to an anatomical abnormality of the vesicoureteric junction.Secondary VURSecondary VUR is due to: neuropathic bladder posterior urethral valve.
36. Grades of vesicoureteric reflux
37. Management of VURConservative (Medical Management)Continuous antibiotic prophylaxis: Antibiotics are given at ¼–½ of full doseRegular urine examination (microscopy and culture sensitivity).Treatment of bladder dysfunction:Regular voiding, double or triple voidingAnticholinergics like oxybutynin if bladder pressures are highTreatment of constipation if present.
38. Follow-Up Managementmonitoring of blood pressure, height, and weight, annually.yearly USG, MCUG, and DMSA are recommended.
39. Indications for SurgicalInterventionSymptomatic breakthrough urinary tract infection despite medical management.abnormalities such as paraureteric diverticulum or ureteric duplicationHigh-grade reflux (Grade IV or V) persisting after 12 months of agePersistent reflux in girls beyond puberty
40. Surgical Management Injection therapy (Deflux) is effective for low grade reflux (Grades I–III) Surgical: Ureteric reimplantation
41. Observation Prophylactic antibioticsRenal ultrasound every 2-12 monthsRepeat MAG-3 for worsening ultrasound or symptoms
42. Primary megaureterany ureter greater than 7 mm in diameter is considered a megaureter
43. CLASSIFICATIONRefluxingObstructedRefluxing, obstructedNonrefluxing, nonobstructed – This common variant is also called primary dilated megaureter.
44. Primary Megaureter Coexisting With Reflux
45. right primary megaureter plus reflux
46. management●Nonobstructive, nonrefluxing megaureter –nonoperatively.Surgical intervention in patients who develop symptoms, calculi, recurrent infection, hematuria, or a decrease in the function of the affected kidney.●Refluxing megaureter – ●Obstructed megaureter – Surgical intervention
47. Posterior urethral valves (PUV)Posterior urethral valves (PUV) are obstructing membranous folds within the lumen of the posterior urethra
48. Posterior Urethral Valves
49. Posterior Urethral Valves Seen on Voiding Cystourethrogram
50. POSTNATAL MANAGEMENT stabilization of the patient Temporary drainage of the urinary tract.PUV ablation.
51. THANK YOU