Search

Antenatal hydronephrosis is the most frequent urinary tract anomaly detected on prenatal ultrasonography. It occurs approximately twice as often in males as in females. Most antenatal hydronephrosis is transient with little long-term significance, and few children with antenatal hydronephrosis will have significant obstruction, develop symptoms or complications, and require surgery. Some children will be diagnosed with more serious conditions, such as posterior urethral valves. Early detection of obstructive uropathy is necessary to mitigate the potential morbidity from loss of renal function. Imaging is an integral part of screening, diagnosis, and monitoring of children with antenatal hydronephrosis. Optimal timing and appropriate use of imaging can reduce the incidence of late diagnoses and prevent renal scarring and other complications. In general, follow-up neonatal ultrasound is recommended for all cases of antenatal hydronephrosis, while further imaging, including voiding cystourethrography and nuclear scintigraphy, is recommended for moderate or severe cases, or when renal parenchymal or bladder wall abnormalities are suspected. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Summary Introduction Antenatal hydronephrosis is defined as dilatation of the renal pelvis with or without dilatation of calyces in the developing fetus. Although second trimester scan is more sensitive in detecting congenital abnormalities of kidney and urinary tract (CAKUT), it has been suggested that the third trimester scan is more predictive of postnatal outcome. Objectives This study aims to determine the incidence of antenatal hydronephrosis at our institution and the significance of third trimester scan in detecting CAKUT postnatally. Study design It is a prospective observational study. During the 3-year study period from June 2013 to May 2016, all cases of antenatal hydronephrosis, defined as renal pelvic diameter (RPD) ≥4 mm in the second trimester and ≥7 mm in the third trimester scan, diagnosed in the fetal medicine unit of our hospital, were included and were followed up postnatally for 6 months. Results In the fetal medicine unit, 32,443 women were screened for anomalies, and hydronephrosis was detected in 269 cases. Incidence of antenatal hydronephrosis was observed to be 0.83% in our institution. In second trimester scan, of 80 cases with the left hydronephrosis, only 22 (27.5%) had postnatal CAKUT and of 70 cases with the right hydronephrosis, 18 (25.7%) had CAKUT. In the third trimester scan, it was observed that with RPD >10 mm, on the left side hydronephrosis, 87% had CAKUT on postnatal scan, and 85% with the right hydronephrosis had CAKUT. Conclusion Sixty percent cases of hydronephrosis detected in the second trimester scan resolve in utero. In the third trimester scan with RPD 10 mm, then the possibility of postnatal CAKUT is 86%. Table 1 . Incidence of hydronephrosis in 32 weeks scan as per the renal pelvic diameter Renal pelvic diameter (mm) Timing ( Timing (>32 weeks) Incidence of CAKUT in Postnatal scans Left Right Left Right Left Right 4–7 56 51 12 8 nil 1 (12.5%) 7–10 21 18 55 64 15 (27%) 16 (25%) >10 3 1 69 46 60 (87%) 39 (85%) Total 80 70 136 118 75 (55%) 56 (47%) Download : Download high-res image (314KB) Download : Download full-size image Flowchart 1- selection criteria (based on RPD) and number of cases recruited. RPD, renal pelvic diameter.

Summary Background The benefits and harms of continuous antibiotic prophylaxis (CAP) versus observation in patients with antenatal hydronephrosis (ANH) are controversial. Objective The aim was to determine the effectiveness of CAP for ANH, and if beneficial to determine the best type and regimen of antibiotic and the most harmful to provide guidance for clinical practice. Methods A systematic literature search was performed in databases including Medline, Embase, and Cochrane in June 2015. The protocol was prospectively registered to PROSPERO (CRD42015024775). The search started from 1980, when maternal ultrasound was first introduced into clinical practice. Eligible studies were critically evaluated for risk of bias using Revman software. The outcomes included reduction in urinary tract infections (UTI), drug-related adverse events and kidney functions. Results Of 797 articles identified, 57 full text articles and six abstracts were eligible for inclusion (2 randomized controlled trials, 11 non-randomized comparative studies, and 50 case series). It remains unclear whether CAP is superior to observation in decreasing UTIs. No conclusion could be drawn for drug-related adverse events and kidney function because of lack of data. Children who were not circumcised, with ureteral dilatation, and high-grade hydronephrosis may be more likely to develop UTI, and CAP may be warranted for these subgroups of patients. A majority of the studies had low-to-moderate quality of evidence and with high risk of bias. Conclusions The benefits of CAP in a heterogeneous group of children with ANH involving different etiologies remains unproven. However, the evidence in the form of prospective and retrospective observational studies has shown that it reduces febrile UTI in particular subgroups.

Objective To evaluate maternal urinary CA19-9 as a potential marker to diagnose severe antenatal hydronephrosis (ANH) during pregnancy and to compare the values with those in normal pregnancies as controls. Patients and Methods A total of 20 women in their third pregnancy trimester were enrolled. An anteroposterior pelvic diameter (APD) of ≥15 was considered as severe ANH. Case group consisted of 10 women with a diagnosis of severe ANH. Ten women with similar age, gestational age, fetal sex, normal ultrasonography, and no history of any congenital anomalies were chosen as controls. Urine samples were collected and maternal urinary CA19-9 was measured. The levels in case and control groups were compared using Mann-Whitney U test. Results Each group consisted of nine mothers with male fetuses and one with female fetus. The APD in the ANH group ranged from 17 to 40 mm. Five of 10 children in the ANH group also had contralateral APD of ≥4 mm (bilateral ANH). The mean age and gestational age of pregnant women in the two groups were comparable. The mean maternal CA19-9 was significantly higher in the ANH group compared with the controls (mean: 134.5 U/mL vs 22.2 U/mL, P Conclusion To our best knowledge, this is the first time that maternal urinary CA19-9 has been used as a marker for ANH. Based on these pilot data, CA19-9 levels are significantly higher in the urine of pregnant women carrying fetuses with severe ANH, and it may have the potential to serve as a noninvasive and useful biomarker to diagnose ANH.

Bladder diverticula can be either congenital or acquired. They are the formation of a urothelial hernia through the muscle wall fibers of the bladder. Congenital bladder diverticula are rare and there are no previous reports showing them to have been found through an antenatal ultrasound exam revealing the presence of hydronephrosis. Here we describe the case of a large congenital bladder diverticulum revealed through an antenatal hydronephrosis diagnosis and whose proximity to the ureter led to its removal and a ureteral reimplantation.

Summary Introduction Diagnosing obstruction and thus, assessment of need for surgery in the management of antenatal hydronephrosis may be challenging. Current diagnostic tests are not capable of indicating which patients are at risk for obstructive nephropathy. Biomarkers may play an important role in distinguishing these patients. Objective The aim of this study is to evaluate if urinary biomarkers could differentiate obstruction (OBS) from non-obstructive dilation (NOD) in patients with antenatal hydronephrosis (AH) that underwent pyeloplasty due to loss of differential renal function (DRF). Study design Children with a history of AH and postnatal anteroposterior (AP) diameter ≥15 mm were included in this study of prospectively collected data between 2010 and 2018. The OBS group included patients who underwent pyeloplasty due to solely ≥10% subsequent decrease in DRF on a MAG-3 scan during follow-up. Patients with stable or improving hydronephrosis with no significant reduction in ipsilateral DRF ( Results There were 24 children in the OBS and 27 children in the NOD groups. The control group consisted of 27 healthy children. The pre-operative bladder urine levels of biomarkers of the OBS group were significantly higher than in the NOD and control group (p Conclusion In this novel study, which focused on scintigraphic DRF loss, KIM-1 was the most successful among all the biomarkers evaluated. Combination of IP-10, Ca19-9 and KIM-1 resulted increased diagnostic ability. Summary Table . Overview of all biomarkers. Cut-off value Sensitivity Specificity AUC IP-10 135.0 ng/mgCr 75% 66% 0.735 KIM-1 0.89 ng/mgCr 79.2% 88% 0.802 MCP-1 367.6 pg/mgCr 62.5% 52% 0.660 NGAL 16.1 ng/mgCr 70.8% 70.4% 0.669 Ca 19-9 55.5 U/mgCr 75% 66% 0.676 ROC: Receiver operating characteristics, IP-10: interferon gamma-induced protein 10, MCP-1: monocyte chemotactic protein 1, NGAL: Neutrophil gelatinase-associated lipocalin, KIM-1: kidney injury molecule-1, Ca 19-9: Carbohydrate antigen 19-9, Cr: creatinine, U: Unit.

Objective To find out the relative prevalence of renal anomalies detected in the antenatal period, and to look at factors that predict the postnatal outcome. Methods In this prospective study, all antenatal-detected renal anomalies booked at the tertiary health centre were evaluated and counselled. Aspects such as type of renal anomaly, oligohydramnios and presence of additional anomalies were noted. Stillborn babies underwent autopsy; all live born babies were followed for one year. Appropriate statistical analyses were performed to compare the antenatal factors with outcomes. Results Renal anomalies were detected in 136 out of 587 cases with major fetal anomalies. Most of the women were primiparous (65.4%). The mean gestation at presentation was 30 weeks; in 12 cases, diagnosis was possible before 20 weeks (8.8%). Antenatal hydronephrosis was the most commonly seen anomaly, with 61 cases; this was followed by bilateral cystic kidney in 50 cases. Out of the 136 cases, 12 (8.8%) underwent termination of pregnancy and 60 (44.1%) babies were stillborn. Autopsy was performed in 58 out of 72 (80.6%) cases after consent. Karyotyping was performed in 49 cases and abnormalities were detected in two (4.1%) of them. A total of 64 (47.1%) babies were live born; after one year, 49 (36.0%) of them were alive. Postnatal survival was highest in unilateral disease (85.7%). In cases with oligohydramnios, there was only 3.4% survival after one year; none of the cases with cystic kidney and oligohydramnios survived. The period of gestation at presentation of non-survivors was 25.9 weeks compared to 32.5 weeks with survivors. Among the cases with extra renal anomaly, 7.0% survived; none of the cases with associated cranio-vertebral defect or polydactyly survived after a year. Conclusion Out of the different renal pathologies that were diagnosed, survival was highest in the unilateral group. The factors associated with poor prognosis included bilateral disease, absence of amniotic fluid and presence of associated malformation.

Objective The postnatal management of mild antenatal hydronephrosis (ANH) remains controversial. The purpose of this study was to evaluate the incidence of UTI and VUR in children with mild ANH in order to determine the necessity of antibiotic prophylaxis (ABP) and VCUG. Method The data of 1511 patients with various grades of ANH who were referred to Department of Urology, Boston Children's Hospital between January 1998 and January 2010 were reviewed and 760 patients who had mild ANH were identified. The inclusion criteria were: 1) A confirmed report of ANH or actual prenatal ultrasound (US) images. 2) Postnatal evaluation and management conducted at the hospital. 3) Persistent mild hydronephrosis on the first US done between two weeks and three months of age. 4) No other US findings such as ureteral dilatation, duplication anomalies or bladder abnormalities. 5) At least one three-month follow up. Univariate statistical analysis was performed using a Student's t test. Results Of the 760 patients who were identified, 608 (80%) were males, and 225 (30%) had bilateral mild hydronephrosis. Of these, 475 patients (63%) underwent an initial screening VCUG. VUR was identified in 13 patients (1.7%) with grades varying from 1 to 5. At follow up, hydronephrosis resolved in 67% of the renal units and worsened in 3.3%. Among the 692 patients with available follow-up data, 23 (3.3%) had a documented UTI. Twelve of these children had an initial screening VCUG that was negative for VUR. Of these 12 patients, seven underwent a subsequent RNC with none having VUR; five of the 12 patients did not undergo a repeat evaluation for VUR (four had a UTI after the screening VCUG and one had an afebrile UTI). Eleven of the 23 children with mild ANH did not have an initial screening VCUG, and all underwent a subsequent VCUG/RNC. Only two children were then found to have VUR Grade 4–5. Conclusion The incidence of UTI and VUR in children with mild ANH is low. Consequently, routine VCUG screening for VUR and the use of long-term ABP is not necessary for all patients with asymptomatic mild AHN. Evaluation for VUR in children with mild ANH should be reserved for those who subsequently present with a UTI.

Antenatal hydronephrosis (ANH) is one of the most frequently detected abnormalities found on routine prenatal ultrasounds, affecting 1% to 4.5% of all pregnancies. Despite its prevalence, there continues to be uncertainty regarding the clinical impact after birth. Prognosis depends on the severity of the dilation. Expectant prenatal management is the rule with fetal intervention rarely needed in a few select cases. Ureteropelvic junction obstruction and vesicoureteral reflux are the most common postnatal diagnoses. A renal and bladder ultrasound is essential in the follow-up of patients with ANH and helps dictate further investigation with voiding cystourethrography and/or diuretic renography.

Background The efficacy and utility of continuous antibiotic prophylaxis (CAP) in children with congenital antenatal hydronephrosis (ANH) is uncertain. The literature has both supportive and contradictory evidence. The growing trend not to place children with ANH on CAP has created varied clinical practice based on anecdotal individual case characteristics. Our goal was to compare individual infant characteristics between those children who were maintained on CAP to those that were not to try to determine predisposing risk factors to febrile. Methods All electronic medical records (EMRs) of children referred to our institution for congenital ANH over a period from 2001 to 2011 were examined. We excluded those referred for urinary tract infection (UTI) who had a history of congenital ANH. We also excluded those with incomplete records, or follow-up less than 2 years. Children were divided into two groups: those maintained on CAP (YCAP) and those not maintained on CAP (NCAP). Our primary endpoint was febrile UTI. Follow-up was at least 24 months. Demographic, perinatal and postnatal clinical data were recorded. Statistical analysis was performed using STATA Version 11.1. Results Of the 405 children fitting inclusion criteria, 278 (68.6%) children were maintained on CAP and 127 (31.4%) were not on CAP. The incidence of prematurity, oligohydramnios, perinatal respiratory complications, use of perinatal antibiotics, circumcision status, renal anomalies, associated medical diagnoses, and low birth weight did not differ between the two groups. Overall the incidence of febrile UTI during the follow-up period was 22.2%. The incidence of febrile UTI between the YCAP and NCAP groups was significant (YCAP = 7.9% and NCAP 18.7%, p = 0.021). Multivariate logistic regression using CAP as the dichotomous dependent variable revealed that ureteral dilation, high-grade vesicoureteral reflux (VUR), and ureterovesical junction (UVJ) obstruction were independent risk factors for febrile UTI. More specifically, children with ureteral dilation >11 mm NOT maintained on CAP had a 5.54 (OR = 5.54; CI = 3.15–7.42, p = 0.001) fold increased risk of febrile UTI compared to those maintained on CAP. Conclusions The presence of ureteral dilation, high grade VUR, and UVJ obstruction were independent risk factors for development of UTI in children with congenital ANH. Therefore CAP may have a significant role in reducing the risk of febrile UTI in children with ANH with those identifiable risk factors, but otherwise seems unnecessary.

The objective of the study was to evaluate the predictive value of distal ureteral diameter ratio (UDR) on outcome of primary vesicoureteral reflux (VUR) and reflux resolution after endoscopic injection.Three hundred eighty-three patients treated for primary VUR between January 2010 and October 2015 were retrospectively reviewed. The parameters analyzed were age at diagnosis, sex, grade and lateralite of VUR, complaints at admission (febrile urinary tract infection, antenatal hydronephrosis, family history),bladder-bowel dysfunction (urgency, incontinence, constipation), dimercaptosuccinic acid (DMSA) scintigraphy findings, follow-up period, clinical course (spontaneous resolution or surgical correction), time of spontaneous resolution, surgical treatment time and age, materials used for injection and success of endoscopic injection. Ureteral diameter ratio was calculated on the initial VCUG at the time of the diagnosis as the largest ureteral diameter within the false pelvis divided by the distance between L1-L3.The correlation between UDR, clinical outcome (spontaneous resolution/surgical correction) and success of endoscopic injection was evaluated by logistic regression analysis. To compare the effect of UDR and grade of reflux on spontaneous resolution, multivariate logistic regression analysis was performed in three models together with sex, age, resolution time, presence of febrile UTI and DMSA scan findings.Three hundred eighty-three patients were enrolled. There was a strong correlation between UDR and grade of reflux (p 0,0001). Ureteral diameter ratio was higher in patients whose complaints at admission were family history and febrile UTI, but this correlation was not statistically significant (p 0.05). When the correlation between UDR and the DMSA scan findings was evaluated, UDR was found to be significantly higher in patients with moderate and severe scarring. Bladder-bowel dysfunction was present in 111 patients (28.9%). There was no significant correlation between BBD and UDR (p 0.05). 62 patients showed spontaneous resolution in a median duration of 1.55 years. The predictive value of UDR for spontaneous resolution was more significant than grade (p 0.001).There was no spontaneous resolution in patients with UDR over 0.45.321 patients underwent operation (248 endoscopic injection, 17 ureteroneocystostomy, 56 endoscopic injection+ureteroneocystostomy). When the predictive value of the reflux grade and UDR in the success rate of endoscopic correction was compared, UDR was shown to be significantly more predictive than the grade of reflux (p 0.05). Ureteral diameter ratio was significantly higher in patients whose injection treatment was unsuccessful. Each 0.05 unit increase in UDR affected the success of endoscopic injection negatively (95% CI:0.001-0.071).Ureteral diameter ratio is an objective measurement of VUR and appears to be a new predictive tool for clinical outcome and success after endoscopic injection.

Summary Introduction While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care. Material and methods A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded. Results and discussion Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time. Conclusions We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.

Hydronephrosis is commonly caused by dysfunction of the pelviureteric junction (PUJ). Other causes, which are usually associated with hydroureter as well hydronephrosis, include vesicoureteric reflux, vesicoureteric obstruction and bladder pathology. Common causes of PUJ dysfunction include intrinsic stenosis and aberrant lower pole vessels. Surgery, usually an Anderson–Hynes type pyeloplasty, is indicated in patients with pain, infection or haematuria. Surgery may be performed open or laparoscopically. Asymptomatic patients, often detected during antenatal screening, require a baseline MAG3 scan and serial monitoring with ultrasound scanning. Surgery is indicated in this cohort if there is increasing hydronephrosis with an anterior posterior diameter (APD) greater than 3 cm, function below 40% or a drop in function of more than 10% on serial MAG3 scans.

Purpose The majority of cases of antenatal hydronephrosis (ANH) resolve postnatally. The purpose of this study was to determine independent predictors for resolution of ANH using a multivariable analysis model. Methods A retrospective study was performed on 100 children (80 males and 20 females, 118 renal units) referred to a single pediatric urology clinic with the diagnosis of ANH. Patients with ultimately resolved ANH were compared to unresolved cases in a univariate analysis in terms of sex, laterality, severity of ANH using Society for Fetal Urology (SFU) grading, antero-posterior pelvic diameter (APD), parenchymal thickness, renographic differential function and development of clinical complications, followed by a Cox proportional hazard model for multivariable analysis. Results Median follow up was 34 months (range 3–204). Hydronephrosis in 62 units resolved spontaneously and pyeloplasty was done in 29. The remaining 27 units had persistent uncomplicated hydronephrosis at last follow up. Multivariate analysis showed larger APD (hazard ratio 0.54; 95%CI 0.36–0.80) and SFU grade 4 (HR 0.34; 95%CI 0.13–0.90) to be associated with a significantly lower likelihood of resolution. The mean initial APD in resolved cases was 9.4 mm as opposed to 29.0 mm in cases requiring surgery. Conclusion Large initial APD has predictive value for surgical intervention. This model is helpful in counseling families about the potential outcomes of ANH.

Purpose No method exists for predicting which child with vesicoureteral reflux (VUR) will have surgery. Our goals were to analyze practice patterns at a major pediatric center and to identify factors predisposing children to surgery for specific indications. Materials and methods We analyzed a cohort of 3738 children presenting with primary VUR (1996–2005). Surgical indications included: 1) breakthrough urinary tract infection (UTI), 2) non-resolution over 3 years, 3) renal scan abnormality and 4) parent/surgeon preference. Logistic regression was applied to a random 60% subset of children. Validation in the remaining 40% was done using receiver operating characteristic curve analysis and the Hosmer and Lemeshow goodness-of-fit test. Results Independent predictors of surgery included higher age at presentation, antenatal hydronephrosis (ANH), bilateral VUR and VUR grade. Predictors of surgery for a breakthrough UTI included female gender, increasing age, and bilateral and high-grade VUR. Girls were less likely than boys to be operated for renal scan abnormality or parent/surgeon preference. ANH was a predictor of surgery for decreased function and parent/surgeon preference. The model had fair discrimination (c-statistic = 0.68–0.76) and high calibration ( p ≥ 0.24). Probabilities of surgery were calculated. Conclusions Higher age at presentation, being followed for ANH, and bilateral and high-grade VUR are independent predictors of VUR-corrective surgery. Predictors of surgery vary with indication. Our methods allow comparison of urological practice patterns and outcomes between institutions by taking into account indications for surgery.

Hydronephrosis is often caused by pelviureteric junction dysfunction (PUJD). It is frequently detected during antenatal screening. Common causes of PUJD include intrinsic stenosis and aberrant lower pole vessels. Surgery, usually an Anderson–Hynes type pyeloplasty, is indicated in patients with symptoms such as pain, infection or haematuria. Asymptomatic patients require a baseline MAG3 scan and serial monitoring with ultrasound scanning. Surgery is indicated if there is increasing hydronephrosis with an anterior posterior diameter (APD) >3 cm, function below 40% or a drop in function of >10% on repeat MAG3.

Abnormalities of the urinary tract (AUTAs) are some of the commonest abnormalities detected in the foetus due to increased resolution of the ultrasound machines, detailed foetal scanning at 20 weeks of gestation and the increase in foetal medicine specialists. Even minor abnormalities can cause considerable anxiety to prospective parents and appropriate information and counselling needs to be provided. More severe abnormalities will usually be referred to specialist centres where counselling can be provided by the paediatric nephrouroradiology team. Severe oligohydramnios usually portends a poor prognosis but counselling about the foetal outcome is never dogmatic. There are few indications for antenatal intervention involving vesicoamniotic shunts. Severe abnormalities are best delivered at a centre with regional nephrourology expertise. However, most abnormalities are not severe and are unilateral with a good prognosis for long-term kidney function. There needs to be a proper mechanism for communication with neonatal staff so that severe abnormalities are referred at birth and more minor abnormalities are investigated in an appropriate manner. The natural history of many AUTAs has still not been defined and the management of conditions such as asymptomatic moderate hydronephrosis due to pelviureteric junction obstruction (or hold-up) needs to be discussed at a nephrouroradiology meeting.

OBJECTIVES The optimal timing of pyeloplasty for children diagnosed with ureteropelvic junction obstruction (UPJO) after workup for antenatal hydronephrosis is disputed. We sought to examine the potential costs and clinical outcomes of treatment protocols featuring different indications for pediatric pyeloplasty using Markov models. METHODS Cost and outcomes analysis using Markov modeling was performed for three treatment algorithms: medical management, immediate pyeloplasty (during the first year of life), and pyeloplasty after no improvement on imaging. The costs were determined from the perspective of the medical institution. The variables tracked during Markov model simulation included age at resolution of UPJO, the proportion of patients with worsened hydronephrosis, the number of pyeloplasties, the number of pyelonephritis episodes, and costs. Sensitivity analyses were performed to determine which elements affected the model and to determine threshold values. RESULTS Immediate pyeloplasty and pyeloplasty after no improvement on imaging resulted in rapid resolution of UPJO (mean age at resolution younger than 2 years) with lower rates of worsened hydronephrosis and pyelonephritis compared with observation alone. For the surgical protocols, the costs per resolved case of UPJO were greater than those for medical management alone at the probability values tested in the Markov models. The sensitivity analysis of all variables over realistic ranges demonstrated that the costs of surgery, annual antibiotics and imaging, and the rate of pyelonephritis were critical in determining the costs. CONCLUSIONS Pediatric urologists should include practice-specific features such as the costs of surgery, annual antibiotics and imaging, and pyelonephritis rates when considering efficacious, yet less costly, treatment protocols for UPJO.

Objective To examine whether routine ureteric stenting influences outcome of pyeloplasty for pelvi-ureteric junction obstruction (PUJO). Patients and methods A 10-year review was conducted of 105 consecutive open Anderson–Hynes dismembered pyeloplasties performed for PUJO, covering two periods: (1) pyeloplasties performed without ureteric stents (1994–1998) and (2) pyeloplasties performed with ureteric stents (1999–2003). Outcomes (expressed as means ± SEM) of unstented patients (UPs; n = 47) and stented patients (SPs; n = 58) were compared and results analysed using ANOVA and chi-square tests. Results Fifty-five patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4 ± 7.1 months) with one or more of the following: pain (n = 30, 63.8%), urinary tract infection (n = 16; 34.0%), haematuria (n = 3, 6.4%), abdominal mass (n = 3, 6.4%), acute renal failure (n = 2, 4.3%), incidental finding (n = 4, 8.5%). Pyeloplasty was performed (at mean age 58.9 ± 5.3 months) for one or more of the following: pain (n = 40, 38.1%), haematuria (n = 6, 5.7%), urinary tract infection (n = 18, 17.1%), poor initial or deteriorating function (n = 29, 27.6%), severe or deteriorating hydronephrosis (n = 41, 39.0%), calculus (n = 1, 0.95%). Recognised complications of surgery were significantly higher in UPs (5 of 47; 10.6%) than SPs (0 of 58); P = 0.016. These were leakage (n = 4, 8.5%) and obstruction by blood clot (n = 1, 2.1%). Nine SPs (15.5%) developed stent-related complications, including stent migration (n = 5, 8.6%), infection (n = 3, 5.2%) and calculus (n = 1, 1.7%). SPs had significantly shorter hospital stay (2.71 ± 0.25 days) than UPs (4.30 ± 0.38 days); P

Paediatric urologists manage congenital and acquired anomalies of the genitourinary tract in children. Many of the congenital conditions are now diagnosed in utero. This contribution reviews the post-natal investigation and management of the following conditions: antenatal hydronephrosis, obstructions at the pelviuretic and vesicoureterric junctions, vesicoureteric reflux, megaureters, multicystic dysplastic kidneys, posterior urethral valves and hypospadias.

Increased recognition of the association between urinary tract infections and reflux, sibling screening, and the evaluation of antenatal hydronephrosis have resulted in an increase in the diagnosis of reflux early in life. Although many children would sustain no untoward affects of their condition if reflux were left untreated, the disease can be severe and even life threatening. Although antireflux operations have been refined and improved, it remains difficult to determine which individuals truly benefit from these operations. A large prospective randomized placebo-antibiotic-operation study with long-term follow-up is needed, as is the development of nomograms, to assess the individual child's risk of adverse outcomes.

It took more than half of a century for urologists to recognize that hydronephrosis is not necessarily equivalent to obstruction. Keeping this important truism in mind, particularly when dealing with antenatal hydronephrosis, one must also remember that hydronephrosis is not a normal condition. It is conceivable that although the initial intrinsic stenosis or ureterovascular obstruction may not be clinically significant in terms of renal functional damage, as compensatory renal pelvic dilatation develops, secondary obstructive elements may be recruited to create an insertional anomaly and peripelvic fibrosis. The individual types of UPJ obstruction that are seen in diagnostic studies or on the operating table may represent isolated "snapshots" of evolving pathophysiologic processes. If this is true, patients with asymptomatic congenital hydronephrosis, although lacking obvious renal function loss, require long-term follow-up.

In 1% of pregnancies, a significant structural fetal anomaly is detected by antenatal sonography. 38 Approximately half of these anomalies involve the central nervous system, whereas 20% are genitourinary, 15% are gastrointestinal and 8% are cardiopulmonary. Prenatal sonography allows the recognition of urologic abnormalities that otherwise would not be identified until later in life, when symptoms of pyelonephritis, stone disease, abdominal pain, or renal colic occur. 26 The probability of detecting a genitourinary abnormality depends on the experience and skill of the sonographer and usually is better late in gestation, when the fetus is larger and an anomaly is easier to image. 33 Most structural abnormalities of the urinary tract are characterized by hydronephrosis, which generally is assumed to be obstructive; however, often hydronephrosis is not caused by obstruction; examples include vesicoureteral reflux, multicystic kidney, and certain abnormalities of the ureteropelvic and ureterovesical junction. An abnormality involving the genitourinary tract may be suspected in as many as 1 in 100 pregnancies, depending on the sonogram criteria. 42,56 The goal of management is to recognize and treat congenital anomalies that may adversely affect renal function or cause urinary infection or sepsis.

End stage renal failure (ESRF) due to urinary tract infection (UTI) is the commonest potentially preventable cause of ESRF in children and adults. Despite this the simple answer to the question posed in the title is that there is no good evidence to support the proposition that modem management of UTI has affected the incidence of ESRF either in children or in adults. There is, however, overwhelming evidence that modem approaches to UTI should reduce the incidence of ESRF. This paradox is worth exploring because in many respects UTI could be considered a paradigm of present day paediatrics. It is difficult to demonstrate a direct link between UTI and the remote outcome of ESRF which may be delayed for decades after the initial insult and even more difficult, if not impossible, to demonstrate that any intervention has affected this outcome. There is a danger if health provision is increasingly dependent on demonstration of measurable, often short-term, improvements in outcome that problems such as UTI that cannot be encapsulated in such a simple way will not receive the attention they deserve. There are many other problems in paediatrics which are similarly threatened. A further difficulty is that almost all reports of management of UTI have identified deficiencies in clinical practice which reduce the impact of rational management based on research findings and this further hinders the demonstration of an improving outcome. For a variety of reasons the evidence with regards to the impact of the management of antenatal hydronephrosis is even more debatable.

PubMedID: 26590736 Background Urinary tract infection (UTI) is a common bacterial illness in children. Delay in the treatment of UTI may lead to acute renal parenchymal damage and subsequent renal scarring. It is well established that several risk factors increase the tendency for UTI - one being labial adhesion (LA). Objective The purpose of this study was to emphasize the importance of genital examination in girls with nephrourologic symptoms, particularly UTIs, in order to detect LA. Material and methods Data were collected from the files of 46 girls with LA, including: the girl's age, thickness of LA, any recurrence and treatment options of LA, and the reason for admission to hospital. The LAs were grouped in terms of thickness as thin, moderate and dense, and also partial or complete. Results The average age of the girls at the first visit was 51.9 ± 37.57 months (min-max: 3.5-157 months). Twenty-seven (58.7%) of the girls had history of recurrent UTI. There was a marked association between the presence of UTI and the type of adhesions. The percentages of UTIs in girls with complete and partial LA were 84.0% and 28.6%, respectively (P < 0.05). The percentages of UTIs in girls with thick and thin LA were 100% and 44.1%, respectively (P < 0.05). None of the girls' primary care physicians or pediatricians recognized LA at the time of a periodic health examination. Discussion In the present study, girls with complete and thick LA had a greater tendency towards having UTIs than those with partial and thin LA, respectively. After treatment of LA, the UTIs did not recur in any girls. None of the girls in this study had undergone a previous genital examination. Therefore, this study suggests that physicians do not often perform genital examinations. Limitations of this study were the small sample size and the short follow-up period. In addition, although all of the girls were examined by the same physician, the thickness of the membrane is subjective and solely depends on the physician's experience. Conclusions This study showed that although genital examination is a routine part of a physical examination, it is not always performed. Therefore, it is recommend that genital examination should be performed in girls with nephrourologic complaints, particularly for UTI. By timeously determining the presence of LA, many unnecessary and invasive investigations could be avoided in these children. Reason for admission to the Pediatric Nephrology department. Reason for admissionNumber of patients% of patientsUTIa27a58.7Hematuria24.3Hydronephrosisb7b15.2Urinary frequency24.3Urinary incontinence12.2Pseudoincontinence12.2Abdominal and back pain12.2Others510.9Total46100.0Five patients with UTI had additional complaints (hematuria, antenatal hydronephrosis, urinary incontinence, stains on underclothes, and recurrent convulsions).Five patients with hydronephrosis had the diagnosis of antenatal hydronephrosis. © 2016 Journal of Pediatric Urology Company.

Many imaging modalities are available to study children with urologic disorders. Ultrasonography, renal scintigraphy, and voiding cystourethrography are best for study of patients with infection and antenatal hydronephrosis; intravenous urography, for hematuria and wetting; ultrasonography and CT, for tumor; and CT, for trauma.

Although congenital hydronephrosis is a common fetal disorder, ultrasonographic criteria for prenatal diagnosis remain poorly defined. In this study prenatal ultrasonographic findings were correlated with postnatal outcome in 63 fetuses with suspected hydronephrosis. Prenatal ultrasonographic measurements included length, anteroposterior diameter, and transverse diameter of the kidney and renal pelvis, as well as dorsal renal parenchymal thickness. In 45 of the 63 fetuses, hydronephrosis was confirmed postnatally. These infants were divided into two groups on the basis of renal status: (1) abnormal renal function and/or surgery required (n = 31) and (2) normal renal function with no surgery required (n = 14). The anteroposterior diameter of the renal pelvis was the simplest and most sensitive technique for prenatal diagnosis of congenital hydronephrosis, allowing identification of 100% of cases. Postnatal follow-up studies are warranted if an anteroposterior pelvic diameter is greater than or equal to 4 mm before 33 weeks or greater than or equal to 7 mm after 33 weeks.

Summary Introduction The clinical tests currently in use for obstructive nephropathy (such as renal ultrasonography, differential radionuclide renal scans and urinary creatinine concentration data) are not efficient predictors of the subsequent clinical course. Novel and simple biomarkers are required which, if proven, could be clinically beneficial in determining if a patient is eligible for surgery or reno-protective therapy. More recently, the interest of clinicians has focused on the potential of urinary neutrophil gelatinase-associated lipocalin (uNGAL), urinary kidney injury molecule-1 (uKIM-1) and urinary liver-type fatty acid-binding proteins (uL-FABP) as biomarkers for renal function in children with hydronephrosis (HN). Objective The purpose of this study was to investigate possible clinical applications of uNGAL, uKIM-1 and uL-FABP as beneficial non-invasive biomarkers to determine whether or not surgical intervention is required in children with HN. Study design Renal ultrasonography and radionuclide renal scans were used as diagnostic tools to detect HN. Patients were divided into two groups based on the antero-posterior diameter of their renal pelvis and the presence of dysfunction. Group 1 included 26 children with severe HN (with dysfunction), and group 2 consisted of 36 children with mild HN (without dysfunction). Urine samples were collected from 62 children with HN and 20 healthy children. Results Hydronephrosis was more common in males than in females, with a male to female ratio of 9:1 in the study sample. The incidence of left kidney involvement (32 patients) was slightly higher than right kidney involvement (28 patients). Compared with controls and group 2, the ratio of uNGAL to creatinine was significantly higher in group 1 ( p p r = 0.582, p r = 0675, p Discussion The results clearly demonstrated that children with hydronephrosis and dysfunction had significantly increased uNGAL, and uNGAL/Cr concentrations. However, uKIM-1, uKIM-1/Cr, uL-FABP and uL-FABP/Cr concentrations were not significantly different when compared with controls. These results support the use of uNGAL concentrations as an early marker for renal dysfunction in HN. Conclusions The study clearly demonstrated that pediatric patients with hydronephrosis and dysfunction had significantly higher uNGAL to creatinine concentrations as compared with controls. Table . Urine concentration of KIM-1/Cr, NGAL/Cr and L-FABP/Cr in patients and controls. Parameters Group 1 (HN with obstruction) Group 2 (HN without obstruction) Control group NGAL/Cr (ng/mg Cr) a 1.8 (0 – 16) 0.9 (0 – 21) 0.5 (0 – 14) KIM-1/Cr (ng/mg Cr) 169 (39 – 2809) 215 (37 – 1351) 159 (6 – 525) L-FABP/Cr (ng/mg Cr) 1.2 (0 – 15) 1.5 (0 – 11) 0.8 (0 – 7) Cr: creatinine; HN: hydronephrosis, KIM-1: kidney injury molecule-1; L-FABP: liver fatty-acid-binding protein; NGAL: neutrophil gelatinase-associated lipocalin. a p

Disagreement exists over the ability of different diagnostic tests to define obstruction, indications and timing of surgery and which patients will benefit from surgical intervention in antenatal hydronephrosis (ANH) due to ureteropelvic junction obstruction (UPJO). We try to find a way to predict which patients of ANH due to UPJO will eventually need surgery during conservative management.Prospective single centre study involving 122 renal units at a referral centre in India. Patients on conservative management were followed using a standard protocol and operated for pre-defined indications defining failure of conservative management. Patients who underwent surgery were compared with the non-operated group in terms of sex, side, baseline grade of hydronephrosis, maximum anterioposterior diameter on first postnatal ultrasound and differential renal function on first renal scan.A total of 109 renal units qualified for conservative management. Of those, 23.9% required operative intervention during follow-up. Median time to failure of conservative management was 37 weeks. The median follow-up of non-operated cases was 54 months. Univariate analysis revealed that society of fetal urology (SFU) grade of hydronephrosis, anteroposterior diameter (APD), cortical thickness (CT), and pre-operative differential renal function (DRF) had a significant association with surgery (P0.05). Multivariate analysis revealed APD and pre-operative DRF as the only independent predictors for requiring surgery, while CT and initial SFU grade of hydronephrosis were not. Receiver operating curve analysis showed that an APD of 24.3 mm could predict the need for surgery, with a sensitivity of 73.1% and a specificity of 88.0%.APD and DRF are the predictive factors for surgery. We stop short of recommending surgery only on the basis of APD. Instead we recommend that efforts be made to improve the specificity of this criterion, or by using APD in perspective with the differential renal function. We can reduce the burden of investigations in those with APD24 mm while those with APD24 mm can be more comprehensively monitored.

The incidence of recurrent urinary tract infection (UTI) in children with primary vesico-ureteric reflux (VUR) presenting symptomatically is well documented. The risk of UTI in asymptomatic primary VUR diagnosed on investigation of antenatal hydronephrosis (ANH) is less clear. Paradoxically, several previous studies have suggested a lower risk (1-25%). We ascertain the incidence of UTI amongst antenatally-presenting primary VUR and explore risk factors.All patients16 years managed for primary VUR between 1997 and 2013 were retrospectively reviewed. Patients were identified by searching 'VUR, vesicoureteric reflux' and 'vesico' in the clinical database. Sex, follow up, antibiotic prophylaxis, age at UTI, grade of VUR, radioisotope imaging findings (CRN-congenital reflux nephropathy, NRD-new renal defects), evidence of bladder dysfunction, surgical intervention and resolution were recorded. UTI diagnosis was based on positive urine culture with symptoms including fever. SPSS statistical package and Pearson's Chi-squared test were used to explore significance.Of 308 patients with primary VUR aged16 years treated, 242 were diagnosed following presentation with UTI. The remaining 66 (21%) were initially asymptomatic, and VUR was diagnosed on investigation of ANH. All were given prophylaxis from birth. Six months to 16years (median 6years) follow-up was available for 54 (42 males, 12 females). All but two patients had grade III-V VUR (96%), bilaterally in 41 (76%). CRN was evident in 30 (56%; all male) and bladder dysfunction in 12 (22%; 10 males). Twenty-eight patients (52%) developed a UTI. The risk of UTI was 58% in girls, 33% in boys without CRN and 57% in boys with CRN (p = 0.17). Bladder dysfunction was a significant risk factor for UTI (p = 0.03). All 8 (15%; 7 males) with NRD had had a UTI. A single UTI appeared responsible for the majority of NRD (6/8; 75%). UTI occurred in 6/27 (22%) boys after circumcision compared to 17/25 (68%) prior/without circumcision (p0.05).The incidence of UTI in VUR detected after presentation with ANH was 52%. CRN and bladder dysfunction were risk factors for developing a UTI. Circumcision appears to significantly reduce the risk of infection. Antenatal presentation of primary VUR does not carry a reduced risk of UTI. A single UTI, in half before the age of six months, seemed responsible for the majority of NRD. In boys, the highest risk of UTI is in the first few months of infancy, despite antibiotic prophylaxis, and other interventions, particularly circumcision, should therefore be considered as early as possible.

A major limitation of this observational study is the lack of a comparison group during the study period. A small comparative study prior to the one they are describing does not qualify. Observational studies provide weaker empirical evidence than do experimental studies because of the potential for large confounding biases. Theother limitation is their sample size. Based on the incidence of UTI on and off prophylaxisprovidedby theauthors (8%and13%), thenumber of children required in each arm would be over 900 (alpha 0.05 and power 0.8). The value of this cohort study is to provide preliminary evidence that can be used as a basis for designing a stronger experimental study, such as a randomized controlled study, to answer the question they posed.

a predictor of urologic anomalies after birth Ravi de Roo, Emily Kleinrouweler, Tonny Bouts, Ben Mol, Eva Pajkrt Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, Netherlands, Emma Childrens Hospital, Academic Medical Center, Department of Pediatric Nephrology, Amsterdam, Netherlands OBJECTIVE: When antenatal hydronephrosis (ANH, defined as anteroposterior pelvic diameter (APPD) 5-7mm) is diagnosed at the 20 weeks anomaly scan, (inter-)national guidelines recommend follow-up at 30 weeks. Fetuses with APPD 10mm are referred for postnatal work up. To evaluate the usefulness of these guidelines, we estimated the prognostic value of degree of ANH at the 20 and 30 weeks scan for postnatal urologic anomalies, surgery and solitary functioning kidney in our center. STUDY DESIGN: We performed a historical cohort study of all fetuses with isolated ANH 5mm at the 20 weeks anomaly scan diagnosed between 2000 and 2009 at the Academic Medical Center. Cases were identified from the hospital owned prenatal database. Data of the 30 weeks follow-up scan were collected from the same database and findings of postnatal nephrologic examination of the infants from pediatric medical records. Logistic regression analyses were performed to study the association between degree of ANH at the 20 and 30 weeks scan and urologic anomalies after birth, need for surgical intervention, and disorders resulting in a solitary functioning kidney. RESULTS: We identified 332 cases, of which 290 (87%) had complete data available for the 30 weeks scan and, when indicated, postnatal examination. In 192/290 cases (66%), APPD had normalized at the 30 weeks scan. Of the 98 cases with APPD 10mm at 30 weeks, 50/98 (51%) were diagnosed with urological abnormalities after birth. Of these 50 cases, surgical intervention was required in 26 (52%) and 12 (24%) ended up with a solitary functioning kidney. The odds of urologic anomalies, the need for surgery, and the occurrence of solitary functioning kidney all increased with the severity of ANH at the 20 as well as the 30 weeks scan (all p 0.001). CONCLUSION: Screening for ANH at the 20 weeks scan allows early identification of neonates with urologic anomalies. Most cases of ANH at 20 weeks will have normalized at 30 weeks, thus the current criteria are on the safe side. However, the consequences of a urologic anomaly are such that guidelines should not be changed. 343 Small-for-gestational age, cesarean delivery for non-reassuring fetal heart status and composite neonatal morbidity Eugene Chang, Scott Sullivan, Suneet Chauhan, Adam Sandlin, Joshua Dahlke, Elena Igwe, Everett Magann, Kristi Anderson, Alfred Abuhamad Medical University of South Carolina, Department of Obstetrics and Gynecology, Charleston, SC, Medical University of South Carolina, Obstetrics & Gynecology, Charleston, SC, Eastern Virginia Medical School, Department of Obstetrics and Gynecology, Norfolk, VA, University of Arkansas for Medical Sciences, Department of Obstetrics & Gynecology, Little Rock, AR, Naval Medical Center Portsmouth, Department of Obstetrics and Gynecology, Portsmouth, VA, Temple University Hospital, Department of Obstetrics and Gynecology, Philadelphia, PA, Mississippi progestogen trial, Naval Medical Center Portsmouth, Department of Obstetrics and Gynecology, Portsmouth, VA OBJECTIVE: The ACOG practice bulletin on intrauterine growth restriction (IUGR), states that these pregnancies are at increased risk of cesarean delivery for non-reassuring fetal status (CD NRFS) but does not specify the rate or the risk factors. The aim of the secondary analysis of our retrospective study was to determine the rate and risk factors for CD NRFS for women in labor, and composite neonatal morbidity (CNM). STUDY DESIGN: All non-anomalous singletons with a sonographic exam before 22 weeks and small-for-gestational age (SGA; birth weight 10% for GA using Alexander nomogram) that delivered at four centers in 2009 were identified. If IUGR was suspected antenatally, SGA was considered detected and undetected otherwise. CNM included thrombocytopenia, RDS, proven sepsis, grade III/IV IVH, seizure, or death. Mann-Whitney test and multi-variable logistic regression models were used and odds ratio (OR), with 95% confidence intervals (CI) were calculated. RESULTS: At 4 centers, in 2009, there were 11,487 births and 8% (929) were SGA that met the inclusion criteria. Of the 731 (78%) women who labored, the rate of CD NRFS was 22% (160). Significant risk factors for CD NRFS are listed below. The binomial multi-variable stepwise regression model yielded a Cox and Snell R2 of 0.165 (p .005). Compared to SGA who delivered vaginally, the CNM was www.AJOG.org Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging Poster Session II

Purpose Comparing ultrasound (US) scan and nuclear renography findings in patients who underwent pyeloplasty with and without pelvic reduction in a randomized prospective study. Material and Methods 42 patients, all prenatally diagnosed with unilateral hydronephrosis, were included. Hydronephrosis was confirmed postnatally. 20 were randomly selected to undergo pyeloplasty with pelvic reduction and 22 underwent pelvis sparing pyeloplasty. Patients were evaluated with MAG-3 scans on 6th and US scans on 1st, 3rd and 6th months postoperatively. Mean follow up was 37±5, 6 weeks. Statistical analyses were performed using chi-square test and significance was set as p Results The AP pelvic diameter decreased significantly in the pelvic reduction group compared to pelvis sparing group in the first and third month US scans. However the difference was not significant on the 6th month. The improvements on the US findings for the pelvis sparing group catch up the pelvic reduction group later in postoperative period. Pelvic reduction significantly improved the renal wash out time (T ½) in MAG 3 renography when compared to pyeloplasty group without reduction at postoperative 6th month. Differential renal function (DRF) was found to be not affected from pelvic reduction. Conclusions Resolution of AP diameter in US scan is more prominent in the pelvic reduction group at earlier stages of the postoperative period. Although T ½ decreases more prominently at the pelvic reduction group, the employability of this is still indecisive. This feature can reveal possible surgical failures earlier and strengthen the values of US and renography postoperatively.

Purpose “Genuine” paediatric posterior urethral strictures are uncommon and their true existence as distinct from posterior urethral valves is questioned. We report on the treatment and outcome of such strictures. Material and Methods Eleven cases over a 9 year period were identified from departmental records and case notes were analysed retrospectively. Results Eleven strictures were identified in a nine year period. The age at presentation had a bimodal distribution, with 6/11 presenting in the first year of life, of which 4 had observed antenatal hydronephrosis. 4/11 presented after the age of 11 years. 1 patient presented aged 3 years. 7 patients underwent optical urethrotomy as the primary treatment which was curative in 42 % and 58% required further intervention with 1 requiring anastomotic urethroplasty, which was considered indicative of failed primary treatment. 3 children were treated by urethral dilatation, of which 66 % required further intervention, and 1 was referred for anastomotic urethroplasty. 1 patient was treated by primary anastomotic urethroplasty with a durable result. Conclusions All patients who underwent, or were referred for anastomotic urethroplasty were older than 13 years. This outcome, in conjunction with the bimodal age distribution at presentation would suggest a different aetiology in older children. Consequently, we would urge caution in classifying strictures in ambulant children as genuinely congenital, as strictures in this population may represent the long term manifestation of unrecorded bulbar urethral trauma received in infancy. We believe that there exists an uncommon group of patients who develop a congenital bulbar stricture which is distinct from posterior urethral valves or post traumatic strictures, which may be a remnant of the cloacal membrane. Optical urethrotomy or dilatation is durable when treated in infancy but older patients do not experience prolonged resolution and we would recommend treatment along adult lines.

Purpose The evaluation and management of prenatally diagnosed hydronephrosis is variable. This study identifies variability in the current practice of pediatric urology in dealing with the commonly identified prenatal ultrasound finding of hydronephrosis. We examine the role of radiographic testing and antibiotic prophylaxis in evaluation and treatment of this condition. Moreover we report results based on practitioner demographics such as location and length of practice. Material and Methods A web-based survey link was sent to pediatric urologists on the American Academy of Pediatrics and European Society of Pediatric Urology mailing list. Respondents answered questions concerning demographics and practice patterns/influences concerning their use of radiographic tests and prophylactic antibiotics in the evaluation and treatment of antenatal hydronephrosis. Results One-hundred-fifty-six respondents completed the survey representing mostly pediatric urologists in academic and private practice in North America (50%) and Europe (40%). Respondents were split nearly evenly when asked whether radiographic factors influenced their decisions to obtain further imaging or to place infants on prophylactic antibiotics. Even among those reporting that radiographic findings influenced their decision for prophylaxis the parameters that triggered intervention demonstrated variability. Radiographic studies reportedly used to further evaluate infants with postnatal hydronephrosis also varied markedly. North American physicians were more likely to prescribe antibiotics for any prenatal hydronephrosis (72% vs. 37%, p Conclusions There is considerable variation in resource utilization in the evaluation and treatment of antenatal hydronephrosis among pediatric urologists. This variability is most likely due to the absence of meaningful clinical data and guidelines. This should prompt pediatric urologists to collaborate, design and carry out prospective, controlled trials to help guide evaluation of this common pathology.