Antenatal hidronefrozun postnatal güncel yönetimi

Antenatal hidronefrozlu bir hastanın postnatal değerlendirilmesindeki en kritik nokta, böbrek fonksiyonları riskte olan hasta grubunu erken dönemde tesbit ederek izlem ve tedavi protokollerini oluşturmaktır. Ancak tüm antenatal hidronefrozlu bebeklerin postnatal dönemde rutin radyolojik değerlendirmelere alınması da radyasyon riski taşımaktadır ve ek maliyetler getirmektedir. Özellikle vezikoüreteral reflü taramasında kullanılan işeme sistoüretrografisi hem hastada hem de ailede anksiyete oluşturmaktadır.Antenatal hidronefrozlu bir bebeğin postnatal izlem ve tedavisi, hidronefrozun izole olup olmamasına, hidronefrozun derecesine, diferansiyel böbrek fonksiyonlarına, hastanın semptomatik ya da asemptomik olmasına göre farklılıklar gösterir. İzole hafif antenatal hidronefrozlar genellikle spontan regresyon gösterir. Son zamanlarda, asemptomatik olguların ayrıntılı radyolojik değerlendirmeye alınmasına ve antibiyotik profilaksisi uygulamasına gerek olmadığı yönünde görüşler ağırlık kazanmaktadır. Orta ve ileri derecede antenatal hidronefrozlarda ise üriner anomali görülme insidansı daha yüksektir. Bu hasta grubunda hidronefroza neden olan üreteropelvik bileşke darlığı, vezikoüreteral reflü ve posterior üretral valv gibi patolojileri erken dönemde tanımlamak, gerekli izlem ve tedavinin planlaması ve üst üriner sistemin korunması açısından önem taşımaktadır. Vezikoüreteral reflülü ve üreteropelvik bileşke darlığı olan olgularda böbrek fonksiyonları açısından risk faktörleri dikkate alınarak hastanın konservatif olarak izlenmesine ya da cerrahi yapılmasına karar verilir. Vezikoüreteral reflü ve üreteropelvik bileşke darlığı için açık cerrahi yöntemlerin sonuçları son derece başarılı iken son zamanlarda minimal invaziv tekniklerin de benzer başarıları yakaladıkları bildirilmektedir.

Anahtar Kelimeler:

Antenatal hidronefroz, postnatal yönetim, üreteropelvik bileşke darlığı, vezikoüreteral reflü, posterior üretral valv

Postnatal current management of antenatal hydronephrosis

The most critical point in the postnatal evaluation of a patient with antenatal hydronephrosis is to diagnose the patients whose renal fonctions are at risk in an early stage and to plan the follow-up and treatment modalities in this group of patients. However, routine radiological evaluation of every patient with antanatal hydronephrosis carries the risk of radiation with additional cost. Moreover, performance of voiding cysto-urethra graphy, for the diagnosis of vesicoureteral reflux, causes anxiety for both the patient and the parents. The postnatal evaluation and management of patients with antenatal hydronephrosis vary depending on the degree of hydronephrosis, the presence of associated anomalies, the differencial renal functions and the clinical findings of the patient. Isolated mild antenatal hydronephrosis usually regresses spontaneously. The latest consensus suggests that extensive radiological evaluation and antibiotic prophylaxis in asympthomatic patients with mild antenatal hydronephrosis are not necessary. However, the insidence of significant urological pathologies in moderate and severe antenatal hydronephrosis is high. Therefore, diagnosing the underlying pathologies such as ureteropelvic junction obstruction, vesicouereteral reflux and posterir urethral valv in the early period and planning the management strategies are important to prevent the upper urinary tractus. Patients with vesicoureteral reflux and ureteropelvic junction obstruction are either operated or conservatively followed-up depending on the risk factors affecting the renal functions of the patient. Open surgical techniques for the treatment of vesicouereteral reflux and ureteropelvic junction obstruction are very successful. However, the same success rates have also been reported recently by minimal invazive surgery

Keywords:

Antenatal hydronephrosis, postnatal management, ureteropelvic junction obstruction, vesicoureteral reflux, posterior uretral valv,

PDF

___

Lim DJ, Park YJ, Kim JH, Paick SH, Oh SJ, Choi H. Clinical characteristics and outcome of hyydronephrosis detected by prenatal ultrasonography. J Korean Med Sci 2003; 18:859- 62.
Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993, 23: 478-80.
Ismaili K, Hall M, Donner C, Thomas D, Vermeylen D, Avni FE. Results of systematic screening for minor degrees of fe- tal renal pelvis dilatation in an unselected population. Am J Obstet Gynecol 2003; 188: 242-6.
Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta analysis. Pediatrics 2006; 118:586-93.
Ismaili K, Avni FE, Piepsz A, et al. Current management of infants with fetal renal pelvis dilatation: a survey by French- speaking pediatric nephrologists and urologists. Pediatr Nephrol 2004; 19: 966-71.
Ahmad G, Green P. Outcome of fetal pyelectasis diagnosed antenatally. J Obstet Gynaecol 2005; 25:119-22.
Nguyen HT, Herndon CD, Cooper C, et al. The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis. J Pediatr Urol 2010; 6:212-31.
Gloor JM, Ramsey PS, Ogburn PL Jr, Danilenko-Dixon DR, Dimarco CS, Ramin KD. The association of isolated mild fetal hydronephrosis with postnatal vesicoureteral reflux. J Matern Fetal Neonatal Med 2002; 12:196-200.
Phan V, Traubici J, Hershenfield, Stephans D, Rosenblum ND, Geary DF. Vesicoureteral reflux in infants with isolated antenatal hydronephrosis. Pediatr Nephrol 2003; 18: 1224- 8.
Zhang PL, Peters CA, Rosen S. Ureteropelvic junction obs- truction: morphological and clinical studies. Pediatr Neph- rol 2000; 14: 820-6.
Misra D, Kempley ST, Hird MF. Are patients with antena- tally diagnosed hydronephrosis being over-investigated and overtreated? Eur J Pediart Surg 1999; 9: 303–6.
Thompson RH, Chen JJ, Pugach J, Naseer S, Steinhardt GF. Cessation of prophylactic antibiotics for managing persis- tent vesicoureteral reflux. J Urol 2001; 166:1465–9.
Cooper CS, Chung BI, Kirsh AJ, Canning DA, Snyder HM. The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol 2000; 163:269–72.
Linshaw M. Asymptomatic bacteriuria and vesicoureteral reflux in children. Kidney Int 1996; 50:312–29.
Estrada CR, Peters CA, Retik AB, Nguyen HT. vesicoure- teral reflux and urinary tract infection in children with a history of prenatal hydronephrosis: should voiding cysto- urethrography be performed in cases of postnatally persis- tent grade II hydronephrosis? J Urol 2009; 181:801-6.
Roth CC, Hubanks JM, Bright BC, Heinlen J, Donovan BO, Kropp BP et al. Occurrence of urinary tract infection in children with significant upper urinary tract obstruction. Urology 2009: 73:74-8.
Anderson NG, Fischer J, Leighton D, Hector-Taylor J, McE- wing RL. Management in children of mild postnatal renal dilatation but without vesicoureteral reflux. Pediatr Nephrol 2010; 25:477-48.
Wollenberg A, Neuhaus TJ, Willi UV, Wisser J. Outcome of fetal renal pelvic dilatation diagnosed during the third tri- mester. Ultrasound Obstet Gynecol 2005; 25:483-88.
Riccabona M, Avni FE, Blickman JG, et al. Imaging re- commendations in paediatric uroradiology: minutes of the ESPR workgroup session on urinary tract infection, fetal hydronephrosis, urinary tract ultrasonography and voiding cystourethrography. Barcelona Spain. Pediatr Radiol 2007; 38: 138-45.
Yamaçake KGR, Nguyen HT. Current management of ante- natal hydronephrosis. Pediatr Nephrol 2013; 28:237-43.
Coelho GM, Bouzada MC, Lemos GS, Pereira AK, Lima BP, Oliveira EA. Risk factor for urinary tract infection in children with prenatal renal pelvic dilatation. J Urol 2008; 179: 284-9.
Van Eerde AM, Meutgeert MH, de Jong TP, Giltay JC. Ve- sico-ureteral reflux in children with prenatally detected hydronephrosis: a systematic review. Ultrasound Obstet Gynecol 2007; 29: 463-9.
Valent-Moricb, Zigman T, Cuk M, Zaja-Franulovic O, Ma- lenica M. Postnatal evaluation and outcome of infants with antenatal hydronephrosis. Acta Clin Creat 2011; 50:451-5.
Önen A. [Prenatal diagnosis, follow-up and treatment of fetal uriner tract anomalies]. Klinik Çocuk Forumu 2007; 7:39-46.
Gloor JM. Management of prenatally detected fetal hydro- nephrosis. Mayo Clin Proc 1995; 70:145-52.
Kitagawa H, Pringle KC, Stone P, Flower J, Murakami N, Robinson R. Postnatal follow-up of hydronephrosis detec- ted by prenatal ultrasound the natural history. Fetal Diagn Ther 1998; 13:19-25.
Sürer İ, Güven A. [Antenatally diagnosed hydronephro- sis]. Türkiye Klinikleri J Pediatr Surg – Special Topics 2008; 1:84-90.
Karaca İ, Şencan A, Sayan A, Ortaç R, Mir E. Ureteral fib- roepithelial polyps in children. Pediatr Surg Int 1997; 12: 603-4.
Sinha A, Arvind B, Krishna A, et al. Revised guidelines on management of antenatal hydronephrosis. Indian Pediatr 2013; 50: 215-31.
Chertin B, Rolle U, Farkas A, Puri P. Does delaying pyelop- lasty affect renal function in children with a prenatal diag- nosis of pelvi-ureteric junction obstruction? BJU Int 2002; 90:72-5.
Finnell SM, Carroll AE, Downs SM. Subcommittee on uri- nary tract infection. Technical report-Diagnosis and mana- gement of an initial UTI in febrile infants and young child- ren. Pediatrics 2011; 128: e749-70.
Günşar C, Şencan A, Karaca İ, Ceylan H, Fesçekoğlu O, Mir E. [Surgically treated ureteropelvic junction obstruction above 1 year of age: 10 year-experience]. Pediatrik Cerrahi Dergisi 2002; 16: 41-6.
Brophy MM, Austin PF, Yan Y, Coplen DE. Vesicoureteral reflux and clinical outcomes in infants with prenatally de- tected hydronephrosis. J Urol 2002; 168: 1716-9.
Farhat W, McLorie G, Geary D, et al. The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis. J Urol 2000; 164: 1057-60.
Fefer S, Ellsworth P. Prenatal hydronephrosis. Pediatr Clin North Am 2006; 53: 429-47.
Elder JS. Antenatal hydronephrosis. Fetal and neonatal ma- nagement. Pediatr Clin North Am 1997; 44:1299-1321.
Ismaili K, Avni FE, Hall M. results of systematic voiding cystourethrography in infants with antenatally diagnosed renal pelvis dilatation. 2002; J Pediatr 141: 21-4.
Vates TS, Shull MJ, Underberg-Davis SJ, Fleisher MH. Complications of voiding cystourethrography in the eva- luation of infants with prenatally detected hydronephrosis. 1999; J Urol 162: 1221-3.
Tekgül S, Riedmiller H, Hoebeke P, et al. Eur Urol 2012; 62: 534-42.
American Academy of Paediatrics task force on circumci- sion. Circumcision policy statement. Pediatrics 2012; 130: 585-6.
Alconcher LF, Tombesi M. Mild antenatal hydronephrosis: management controversies. Pediatr Nephrol 2004; 19: 819- 20.
Fonseca FF, Tanno FY, Nguyen HT. Current options in the management of primary vesicoureteral reflux in children. Pediatr Clin North Am 2012; 59: 819-34.
Zoantz MR. [Vesicoureteral reflux]. In: Graham SD, Keane TE, eds. Arıkan N (çeviri editörü), Glenn’s Urologic Surgery. 7. Baskı. Ankara: Güneş Tıp Kitabevleri; 2011. s 665-76.
Austin JC, Canning DA. [Megaureter]. In: Graham SD, Ke- ane TE, eds. Arıkan N (çeviri editörü), Glenn’in Ürolojik Cerrahisi. 7. Baskı. Ankara: Güneş Tıp Kitabevleri; 2011. s 649-54.