Ppt on various features in USG in antenatal scans. Antenatal scans feature of hun for management postpartum

1. HYDROURETERONEPHROSI
S
Moderator – Dr. Deepthi

2. CONTENT
• Introduction
• Definition
• Etiology
• Pathophysiology
• Clinical features
• Investigation
• Treatment
• Study - methodology , sample size, assessment, grading and
recommendations for management.

3. INTRODUCTION
• It is one of the most common abnormalities detected on
prenatal ultrasonography (US), reported in approximately 1–
5% of all pregnancies.
• ANH represents a wide spectrum of urological conditions,
ranging from transient dilation of the collecting system to
clinically significant urinary tract obstruction or
vesicoureteric reflux (VUR).
• Defined as distention of the renal calyces and pelvis with
urine as a result of obstruction of the outflow of urine.
• Can be physiologic or pathologic, acute or chronic, unilateral
or bilateral.

4. • With the advent of routine prenatal US, children with urinary
tract obstruction or reflux are being detected prior to the
development of complications such as urinary tract infection
(UTI), kidney stones and renal dysfunction or failure.
• These complications might be averted by early diagnosis.
• Consequently, the goals in evaluating children with ANH are
to prevent these potential complications and to preserve
renal function.
• However, not all findings on prenatal USG represent
pathology; many are transient and have no clinical
significance.

5. DEFINITION
• Obstructive uropathy: Functional or anatomic obstruction of
urinary flow at any level of the urinary tract.
• Obstructive nephropathy: When the obstruction causes
functional or anatomic renal damage.

6. ETIOLOGY

7. CAUSES
• Unilateral - Intraluminal, Intramural, Extramural
• Bilateral

8. Causes of U/L obstruction
Extramural obstruction
• ■ Tumour from adjacent structures, e.g. Carcinoma of the
cervix, prostate, rectum, colon or caecum
• ■ Idiopathic retroperitoneal fibrosis
• ■ Retrocaval ureter

9. Intramural obstruction
• ■ Congenital stenosis, PUJO
• ■ Ureterocele and congenital small ureteric orifice
• ■ Stricture
• ■ Neoplasm of the ureter or bladder cancer involving the
ureteric orifice

10. Intraluminal obstruction
• ■ Calculus in the pelvis or ureter
• ■ Sloughed papilla in papillary necrosis

11. Causes of B/L Hydronephrosis
1) Congenital:
• – posterior urethral valves;
• – urethral atresia;
2) Acquired:
• – benign prostatic enlargement or carcinoma of the
prostate;
• – postoperative bladder neck scarring;
• – urethral stricture;
• – phimosis.

12. • Acute ureteral obstruction causes flank or abdominal pain.
There may be nausea and vomiting.
• Chronic ureteral obstruction can be silent or can cause
vague abdominal or typical flank pain

13. PATHOPHYSIOLOGY
Interruption to the urinary flow>>>>>>>>Increased ureteric
pressure>> >>>>>> decreased GFR
≥

14. CLINICAL FEATURES
• Mild pain or dull aching pain in the loin.
• Palpable kidney
• New onset HTN
• Recurrent UTIs
• Vomiting and diarrhea
• Pyelonephritis due to urine status
• Abdominal and flank painand hematuria due to renal stones.
• Attacks of acute renal colic may occur with no palpable swelling.
• Weak urine sream due to BOO or overflow incontinence due to infravesical obstruction.
• Failure to thrive
• Intermittent hydronephrosis (Dietl’s crisis): A swelling in the loin is associated with acute
renal pain. Some hours later the pain is relieved and the swelling disappears when a
large volume of urine is passed.

15. INVESTIGATIONS
• Urine analysis
• Assesment of renal function – MAG3 ,DMSA , DTPA
• USG
• VCUG - for lower urinary tract pathologies like VUR, PUV, bladder diverticulum,
ureterocele, etc.
• Colour doppler USG
• CT urography
• MR urography – for anatomical assessment.
• Isotope renography
• Very occasionally, a Whitaker test is indicated. A percutaneous puncture of the
kidney is made through the loin and fluid is infused at a constant rate(10ml/min)
with monitoring of intrapelvic pressure.

16. TREATMENT
• Pain management.
• Antibiotic (for prophylaxis and treatment)
• Renal drainage – stenting/nephrostomy
• Treat the cause
• Pyeloplasty – (Eg. Anderson-Hynes pyeloplasty).
• Endoscopic pyelolysis

18. METHODOLOGY
• A literature search of PubMed, OVID, EMBASE and the
Cochrane Library databases from 1993 to July 2009 was
performed for articles reporting on children with prenatal
hydronephrosis and who had postnatal evaluation.
• Ten terms for hydronephrosis were combined
(hydronephrosis, pelviectasis, pelvocaliectasis, pyelectasis,
hydroureteronephrosis, renal pelvic dilation (RPD), antero-
posterior diameter (APD), oligohydramnios, calyceal dilation,
and ureteral dilation)

19. STUDY SAMPLE
• The article excluded were those that only had non human
subjects, editorials, letters and comments.
• Summary and general recommendations were given based
on current clinical evidence available.
• No meta analysis or literature othe than already reported
ones were done.

20. Fetal urinary tract: anatomy,
physiology and US appearance
• Around the 5th
week of gestation, the ureteric buds arise
from the posterior aspect of the lower portion of the
mesonephric ducts. They grow posteriorly into the sacral
portion of the intermediate mesoderm, the metanephric
blastema.
• The complex interaction between these two structures
leads to renal development that continues throughout
gestation and is completed just before the 36th
week of
gestation.
• The fetal kidneys have a lobulated external appearance and
ascend from their pelvic position.

22. How to identify?
• Visualised on ultrasound as early as 12-13 weeks of
gestation but distinct architecture seen during 20th
week of
gestation .
• Seen as a cystic structure between two umbilical arteries.
• Its capacity reaches 10cc by 30 weeks of gestation.

24. ASSESSMENT OF ANH
• Currently, the measurement of the APD of the renal pelvis as
visualized in the transverse plane is the most studied
parameter for assessing ANH in utero.
• APD is a surrogate measurement of potential disease, but
cannot specifically identify pathology.
• Disadvantages:
• Intra and inter observer difference.
Does not take into consideration the calyceal dilatation &
parenchymal changes such as increased echogenicity or
parenchymal thinning.

25. Normal calyceal measurements:
Degrees of ANH:

26. SFU grading
• The Society for Fetal Urology introduced a 5 point numerical
grading system based on postnatal appearance of renal pelvis ,
calyces and parenchyma.

35. REFERENCES
• Nelson textbook of Paediatrics 21st
edition
• The Society for Fetal Urology consensus statement on the
evaluation and management of antenatal hydronephrosis
Hiep T. Nguyen a, C.D. Anthony Herndon b, Christopher
Cooper c, John Gatti d, Andrew Kirsch e, Paul Kokorowski a,
Richard Lee a, Marcos Perez-Brayfield f, Peter Metcalfe g,
Elizabeth Yerkes h, Marc Cendron a, Jeffrey B. Campbell

36. THANK YOU