Journal Club Dr. H. Al-Hazmi

Prenatally diagnosed hydronephrosis:the Great Ormond street experince H.K. DHILLON The department of paediatric urology,The hospital for sick children, Great Ormond Street,London,UK BJU,April,1998

The natural history series  115 children  From  Total 148 kidney - 77:Unilateral - 33:Bilateral - 5 : Solitary  Follow up from 5 to 16 yeats

Protocol:  All hydronephrotic kidneys classified into one of 3 functional group according to DTPA study  poorly : 40%

 U/S: in first week  Functional imaging (DTPA) with differential function : 4-6 weeks  On initial image: 40%: re-imaged at 3mo.

 At 3mo. : - still moderate  pyeloplasty - good function  conservative  Conservative F/UP: U/S andDTPA: at 6mo.,1 year then annually till age of 5year then 5,10 and 15 years

 Indication for surgery: - If renal function < 40% -symptoms : UTI or pain  All infant taking trimithoprim

RESULTS  POOR FUNCTION: -10 Kidneys -3  pyeloplasty -7  nephrectomy

 MODERET FUNCTION: -28 kidneys -5 managed conservatively - 23 underwent pyeloplasty 12  improved togood function 10  same level

 GOOD FUNCTION: -110 Kidneys -6  early pyeloplasty -104  protocol 27  pyeloplasty

conclusion   NO INDICATION FOR IMMEDIATE PYELOPLASTY IN INFANTS WITH PRENATALLY DIAGNOSED HYDRONEPHROSIS WHO DEMONESTRATE GOOD FUNCTION POSTNATALLY

RANDOMIZED CLINICAL TRIAL:  April 1988 and continued for 5 years  All infant had prenatally diagnosed hydronephrosis,unilateral,3-6mo. age > 14mm (a-p) on U/S and > 40% on DTPA  Randomized to either surgery or conservative follow-up

 Surgical group followed with U/S and DTPA at 3mo.,1and5 year post op.  Conservative group followed with U/S and DTPA AT 3mo., one year then annually  Surgery indicated if renal function 10%

RESULTS  75 patient (39 surgical group +36 conservative group)  In surgical group all had good post op. result  In conservative group -12 remain stable -17 hydronephrosis improved spontaneously -7 required surgery

 The out com of differential renal function did not showed any difference between the groups  All pt.who need pyeloplasty had a minimum dilatation of 20mm  U/S the most useful imaging modality for identifying the population at risk for surgery

conclusion  The concept of measuring the degree of renal pelvic dilatation on U/S allow children to divided in 3 groups 1- 50mm: early surgical intervention mm:surgery only with reduced function,symptoms,increasing dilatation,and severe hydronephrosis in solitary kidney