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Evaluating Practice Patterns in Postnatal Management of Antenatal Hydronephrosis: A National Survey of Canadian Pediatric Urologists and Nephrologists
Pediatric Urology Evaluating Practice Patterns in Postnatal Management of Antenatal Hydronephrosis: A National Survey of Canadian Pediatric Urologists and Nephrologists Luis H. P. Braga, Vladimir Ruzhynsky, Julia Pemberton, Forough Farrokhyar, Jorge DeMaria, and Armando J. Lorenzo OBJECTIVE
METHODS
RESULTS
CONCLUSION
To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada. A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality. A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P ¼ .02); in contrast, 73% of nephrologists and 38.2% of urologists (P ¼ .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P ¼ .02) would obtain this test for patients with unilateral high-grade isolated AHN. Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain highlevel evidence to develop management protocols for this common condition. UROLOGY -: -e-, 2014. 2014 Elsevier Inc.
A
ntenatal hydronephrosis (AHN) is one of the most common congenital anomalies detected in 1%-5% of all pregnancies.1 More than half of these cases resolve by the end of gestation or in the early postnatal period and as such are considered to represent transient physiological dilation of the collecting system. If persistent in the postnatal period, hydronephrosis is mainly due to the flow restriction at the level of the
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Surgery/Urology, McMaster University, McMaster Children’s Hospital, Hamilton, Ontario, Canada; the McMaster Pediatric Surgery Research Collaborative (MPSRC), McMaster University, Hamilton, Ontario, Canada; and the Division of Urology, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada Reprint requests: Luis H. P. Braga, M.D., Ph.D., M.Sc., Department of Surgery, McMaster University, HSC 4E, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. E-mail: [email protected] Submitted: July 12, 2013, accepted (with revisions): October 18, 2013
ª 2014 Elsevier Inc. All Rights Reserved
ureteropelvic junction, vesicoureteral reflux (VUR), or less commonly associated with other etiologies (such as primary megaureter, ureteroceles, and posterior urethral valves).2 Despite the high prevalence, definitive clinical guidelines for managing patients with AHN are lacking. In particular, 2 aspects of practice are controversial: prescription of continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram (VCUG). Many centers still advocate for CAP and VCUG for all children with AHN.2,3 However, it has been estimated that 50% of infants with mild AHN bear a similar risk of urinary tract infections (UTIs) as that of the general age-matched population.4 Thus, CAP may be of little benefit for these patients.1,5,6 Similarly, VCUG appears to be of little value for infants with postnatally persistent Society for Fetal Urology (SFU) grade I-II unilateral AHN.1,7 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.10.054
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Table 1. Indications for continuous antibiotic prophylaxis in antenatal hydronephrosis cases based on practice location Factors Influencing Decision About CAP Use
Unilateral Low-grade (I/II) AHN, n (%)
Bilateral Low-grade (I/II) AHN, n (%)
Unilateral High-grade (III/IV) AHN, n (%)
Bilateral High-grade (III/IV) AHN, n (%)
3/19 (16) 6/44 (14)
3/19 (16) 11/44 (25)
8/19 (42) 29/44 (66)
13/19 (68) 32/44 (73)
5/10 (50)
5/10 (50)
8/10 (80)
9/10 (90)
Freestanding children’s hospital University hospital (adult and pediatric) Community hospital AHN, antenatal hydronephrosis.
Recent publications highlight some differences in the management of infants with AHN, presenting variations across different institutions and among physicians.8,9 Nevertheless, the phenomenon is far from being fully understood and potentially impacted by specialty training and health-care system characteristics. Herein, we aim to further explore current care patterns by contrasting 2 pediatric specialty groups (nephrologists and urologists) that most commonly deal with this patient population, within a country that has a rather homogeneous health-care system. The present study was designed to gain an appreciation of the different postnatal treatment strategies for infants with AHN, with particular interest on indications for CAP and VCUG, hypothesizing that important differences in the preference by the 2 specialties will be detected. If so, it is hoped that the gathered data will provide support for prospective trials and ultimately vest interest in the establishment of evidence-based treatment guidelines.
MATERIALS AND METHODS Survey Design An anonymous survey was designed on the open source web application “Lime Survey” (http://www.limesurvey.org, accessed November 2012.). The survey was locally piloted among pediatric urologists and pediatric nephrologists to confirm content and face validity and to decrease measurement bias. The survey was subsequently refined to 20 questions that focused solely on the practice patterns surrounding CAP and VCUG evaluation in patients with AHN. The survey questions were divided into 3 main categories: (1) demographics, which assessed the area of specialization, practice location (community hospitals, university centers with adult or pediatric care, and freestanding pediatric hospitals), and number of cases assessed per year; (2) indications for prescribing CAP; and (3) indications and parameters for ordering VCUG. Ultrasound images and drawings of the SFU grading system for hydronephrosis were provided to standardize the interpretation of the survey.10 The term “ureteropelvic junction obstruction (UPJO)-like” was coined in reference to dilatation of the renal pelvis or calices without ureteral dilatation and was used interchangeably as isolated hydronephrosis without hydroureter. Primary megaureter was defined as hydroureteronephrosis without documented VUR, not necessarily solely reflecting cases with obstructed systems that would eventually benefit from surgical intervention. Dilation was considered to be “low grade” if labeled SFU grades I and II, while “high-grade” AHN was defined as SFU grades III and IV. The survey was sent to all members of the Canadian Association of Pediatric Nephrologists and Pediatric Urologists of 2
Canada twice within a 2-week period. Endorsement letters from the president of each association accompanied the invitation emails. All responses were kept confidential, and survey results were checked for completeness before analyses. Two reminders were sent out 2 and 4 weeks after the survey was live to further maximize the response rate.
Data and Statistical Analyses Data were explored graphically for trends and normality by generating histograms and box plots. Descriptive statistics, including means and percentages for dichotomous variables, were calculated where appropriate. For comparison of proportions, a 2-tailed chi-square statistical analysis with Yates correction was used to determine significant differences between groups. All analyses were performed using SPSS V17.0 (SPSS Inc, Chicago, IL), accepting a 0.05 threshold value for significance.
RESULTS The survey was distributed to a total of 139 pediatric specialists. The overall response rate was 63.3% (88 returned surveys; 95% confidence interval, 55.0%71.0%). The respondents identified themselves as pediatric nephrologists (n ¼ 46) or pediatric urologists (n ¼ 39), with only 3 failing to disclose this information. The respondents reported seeing an average of 50 patients with AHN each year (1-450). Overall, 49 physicians (61%) practiced in academic centers, 22 (27%) in freestanding children’s hospitals, 10 (12%) in community hospitals, and 7 (8%) did not identify their practice location. Physicians in freestanding children’s hospitals saw a mean of 79 (10-300) new patients with AHN per year, followed by doctors in academic centers (university hospitals with adult and pediatric practice) who treated a mean of 46 new patients with AHN per year (0-450), and finally those in community hospitals who managed a mean of 14 new patients with AHN seen per year (2-50). Physicians in community hospitals managed few AHN patients as compared with those practicing at university hospitals and freestanding children’s hospitals. Doctors working in low AHN volume hospitals were more likely to order a VCUG and prescribe CAP for patients with AHN than physicians practicing at high-volume centers, as presented in Tables 1 and 2. The respondents reported that AHN cases are typically initially assessed by urologists (35%), nephrologists (21%), general pediatricians (31%), both nephrologists and urologists (5%), family physicians (3%), and 4 did not specify (5%). Although more than 90% of urologists UROLOGY
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Table 2. Indications for voiding cystourethrogram in antenatal hydronephrosis cases based on practice location Practice Location
Unilateral Low-grade (I/II) AHN, n (%)
Bilateral Low-grade (I/II) AHN, n (%)
Unilateral High-grade (III/IV) AHN, n (%)
Bilateral High-grade (III/IV) AHN, n (%)
0/22 (0) 14/49 (29)
4/22 (18) 23/49 (47)
16/22 (73) 44/49 (90)
22/22 (100) 47/49 (96)
7/10 (70)
6/10 (60)
9/10 (90)
9/10 (90)
Freestanding children’s hospital University hospital (adult and pediatric) Community hospital Abbreviation as in Table 1.
Table 3. Factors influencing decision about prescribing continuous antibiotic prophylaxis in infants with antenatal hydronephrosis Field of Practice Practice Location Training or previous knowledge Concern for UTI Concern for VUR Concern for obstruction
PN, n (%) 3 17 3 3
(11.5) (65.4) (11.5) (11.5)
PU, n (%) 2 25 3 5
(5.7) (71.4) (8.6) (14.3)
PN, pediatric nephrologists; PU, pediatric urologists; UTI, urinary tract infection; VUR, vesicoureteral reflux; other abbreviation as in Table 1.
answered our questionnaire, the response rate for nephrologists was only 45% (P ¼ .04). Interestingly, barely 17 of 88 respondents (20%; 95% confidence interval, 12.4%-28.8%) reported following standardized protocols or guidelines for the management of infants with AHN at their institutions. Regarding the rationale for starting CAP in infants with AHN, both nephrologists and urologists (65.4% and 71.4%, respectively) indicated that concern for the development of UTIs was the main deciding factor for their recommendation. Several additional factors also contributed to the prescription of antibiotics, including training or previous knowledge, and concern for VUR and obstruction (Table 3). The severity of AHN also appeared to influence this practice (Table 4). There were no significant differences between the numbers of nephrologists and urologists initiating CAP in infants with either unilateral low-grade (SFU grade I and II) or unilateral highgrade (SFU grade III and IV) AHN. Specifically, 66.7% and 51.4% of nephrologists and urologists, respectively, would prescribe CAP for patients with high-grade unilateral antenatal hydronephrosis (AHN). Furthermore, both specialties were more likely to use CAP in patients with high-grade AHN (SFU grade III and IV) than in lowgrade AHN (Table 4), regardless of whether it was unilateral or bilateral. Although many of these percentages are similar, they reflect practice variation within each group. Specialists differed in their use of prophylaxis for patients with bilateral low-grade AHN (SFU grade I and II), with more nephrologists opting for CAP compared with urologists (29.6% vs 11.4%, respectively; P ¼ .02). The study also examined whether a diagnosis of unilateral isolated hydronephrosis (UPJO-like) or hydroureteronephrosis without VUR (primary megaureter) influenced the decision to institute CAP. There were differences between the specialists groups, with a greater UROLOGY
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Table 4. Number of pediatric nephrologists and pediatric urologists who would prescribe continuous antibiotic prophylaxis based on site(s) of involvement (unilateral vs bilateral) and antenatal hydronephrosis grade
SFU AHN Grade Laterality Grade I/II Grade III/IV
Proportion of PN and PU Who Prescribe CAP PN, n (%)
PU, n (%)
Unilateral 4/27 (14.8) 4/35 (11.4) Bilateral 8/27 (29.6) 4/35 (11.4) Unilateral 18/27 (66.7) 18/35 (51.4) Bilateral 21/27 (77.8) 22/35 (62.9)
P Value .23 .016 .483 .449
CAP, continuous antibiotic prophylaxis; SFU, Society for Fetal Urology; other abbreviations as in Tables 1 and 3.
proportion of nephrologists indicating that they would initiate CAP in the presence of high-grade hydronephrosis without hydroureter (73.1% of nephrologists vs 38.2% of urologists; P ¼ .02; Table 5). However, nephrologists and urologists responded similarly for infants with low-grade isolated hydronephrosis, where both groups were less inclined to initiate CAP. There was no significant difference in the proportion of nephrologists and urologists who recommended CAP for infants with low- or high-grade antenatal hydroureteronephrosis (primary megaureter). Furthermore, nephrologists and urologists were generally more likely to order CAP for patients with hydroureteronephrosis (primary megaureter) than for those with isolated hydronephrosis (UPJO-like) of the same grade; however, the caliber of either less than or greater than 10 mm of the ureter had no influence on recommending CAP. The use of VCUG was also investigated. A higher proportion of nephrologists indicated that they would order a VCUG for patients with unilateral low-grade AHN (31% of nephrologists vs 7.7% of urologists, P < .01). Similarly, the number of nephrologists who would recommend a VCUG for infants with unilateral high-grade AHN was significantly higher than that of urologists (96.6% vs 69.2%, respectively; P ¼ .02). However, there was no significant difference between nephrologists and urologists in ordering VCUG for bilateral low- or high-grade AHN.
COMMENT Although concern for developing a UTI was the major factor for instituting CAP by nephrologists and urologists, several important differences in AHN management were noted between representatives of these specialties. Generally, nephrologists and urologists appear to agree on the perceived lack of CAP benefit in children with 3
Table 5. Number of pediatric nephrologists and pediatric urologists who would prescribe continuous antibiotic prophylaxis based on antenatal hydronephrosis grade and underlying etiology Proportion of PN and PU Who Prescribe CAP Underlying Condition
SFU AHN Grade
Unilateral “UPJO-like”
Grade I/II Grade III/IV Grade I/II Grade III/IV
Primary megaureter
PN, n (%) 2/26 19/26 12/27 21/27
(7.7) (73.1) (44.4) (77.8)
P Value
PU, n (%) 0/35 13/34 11/35 25/35
(0.0) (38.2) (31.4) (71.4)
.095 .024 .183 .844
UPJO, ureteropelvic junction obstruction; other abbreviations as in Tables 1, 3 and 4.
unilateral low-grade AHN; however, there were important discrepancies for bilateral and high grades of AHN. Pediatric nephrologists institute CAP more readily for patients with bilateral low-grade AHN and high-grade unilateral hydronephrosis (without hydroureter). Moreover, compared with urologists, nephrologists are more likely to order VCUGs for unilateral low- and high-grade AHN. Overall, a significant practice variation was observed between the 2 specialties; a finding that can be at least partially explained by the absence of established AHN protocols in most academic centers across Canada. The paucity of evidence-based guidelines and the lack of consensus are also reflected in the practice variability patterns reported by others.1,11,12 Ismaili et al13 assessed investigation and treatment preferences for unilateral AHN among French-speaking pediatric nephrologists and urologists in Europe. In their study, 23% nephrologists and 31% urologists would start CAP immediately after birth. Although the difference between them was not statistically significant, the percentage is strikingly different when compared with our reported findings (14.8% and 11.4%, respectively). Interestingly, the results of another survey report that 56% of general pediatricians would routinely prescribe CAP for infants with AHN.14 Merguerian et al9 also surveyed pediatric urologists in the United States and Europe to assess the variability in AHN evaluation and management. The respondents from the United States prescribed CAP at birth more often compared with their European colleagues (77% vs 40%, respectively; P < .001). However, similar proportions of pediatric urologists in the United States and in Europe (65%-70%) prescribe CAP for high-grade AHN. Taken together, these findings point to a significant variation in CAP prescribing patterns for AHN, impacted by the physicians’ prior training, specialty, and geographical location. Undoubtedly, lack of consensus or widely followed management patterns is related to the paucity of high-level evidence-based data.1,11,12 As a result, authors draw conclusions based on their personal preferences, as well as biased and inconsistent literature. For example, even in the setting of conflicting information regarding the benefit of daily antibiotics,15 CAP has been recommended in cases of moderate and severe unilateral or bilateral AHN, as well as in the presence of hydroureteronephrosis, VUR, or obstructive drainage patterns.1,12,16,17 The rationale for using CAP in patients with mild but persistent AHN is less clear.5,6 Ultimately, physicians make their decisions about 4
prescription based on an apparent risk of AHN-associated increased morbidity and irreversible renal damage in the setting of a UTI.18 Perceived benefits are weighted against potential risks of side effects and antimicrobial resistance. Some authors suggest that CAP may be necessary in highrisk populations as the chances of developing a UTI increase with higher grades of AHN.11,19 Lee et al showed that children with grade IV AHN had a 40% rate of UTI compared with 33% with grade III, 14% with grade II, and 4% with grade I AHN. CAP significantly reduced the risk of febrile UTI in children with AHN in some series.11,20-22 These data may explain why 65%-71% of the presented survey respondents indicated that “concern for UTI” was the main influencing factor in their decision to prescribe CAP. As seen in other surveys, the decision to recommend CAP has not been unanimous among physicians of the different specialties. The results of our survey indicate that nephrologists are significantly more likely to recommend CAP for patients with unilateral high-grade AHN without hydroureter and in patients with bilateral low-grade AHN without hydroureter, when compared with urologists. This pattern may be due to a perceived higher risk of UTIrelated morbidity in these particular cases and a concern of undertreating potentially missed VUR, if no VCUG is obtained. In this regard, nephrologists were more inclined to order VCUGs for patients with both low- and high-grade unilateral hydronephrosis when compared with urologists. These findings contrast with those of Ismaili et al13 who indicated that urologists were significantly more likely to obtain this test compared with their nephrology peers (41% and 20%, respectively). Different geographical locations and intricacies of regional health-care systems may also contribute to practice variability. As noted by Merguerian et al,9 European respondents were more likely to order a VCUG for low-grade AHN than their American counterparts, whereas a similar more consistent management pattern for higher grades of dilation was observed between the 2 groups. This phenomenon was also evidenced in our study. Although significant differences in the preference for VCUG between nephrologists and urologists for infants with unilateral high-grade AHN were detected, a more consistent level of agreement among these professionals was observed in patients with bilateral high-grade AHN. Undoubtedly, a more selective approach is appealing and avoids or minimizes radiation exposure for many infants. The practice of regularly obtaining VCUGs is clearly impacted by the level of suspicion for important albeit UROLOGY
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infrequent underlying pathologies, such as posterior urethral valves, and a desire to establish the presence of more common causes of AHN. VCUG is a valuable tool to rule out VUR, helping confirm the diagnosis of isolated AHN (UPJO-like) or hydroureteronephrosis (primary megaureter). Nevertheless, it is important to remember that AHN is a rather poor indicator for reflux detection, even in cases where there is postnatal resolution23,24 and irrespective of the degree of dilation.25 Currently, no clear evidence exists to support or discourage VCUG evaluation of infants with AHN, and the clinical significance of VUR remains unproven.1,26 Although our survey may reflect individual apprehension by the respondents to miss diagnosing VUR, recent literature does suggest that this rationale may not necessarily apply to all patients, particularly those with low-grade AHN.5,7,27 There are important limitations that deserve acknowledgment. Particularly, unexplored survey reliability and differences in response rates from nephrologists vs urologists could have biased the presented results. Although cognitive interviews and a pilot study with a panel of experts were conducted to improve the content validity of our survey, a formal test-retest assessment was not performed.28 In addition, due to the lower proportion of participating nephrologists, a reporting bias whereby mostly those specialists concerned with the treatment of AHN may have taken place, thus skewing the presented results when stratified and contrasted against urologists’ preferences. Despite the lower proportion of responses from nephrologists, their representation across the country was good. Most institutions in Canada were represented within the survey, and given that members within each institution usually have similar practice patterns, nephrologists’ results were likely generalizable. Thus, we propose there is value in our findings. Most importantly, our data call attention to the important differences in the management among physicians who frequently deal with AHN. These disparities, which likely stem from the absence of high-level evidence, can have a significant impact in parental distress, morbidity, radiation exposure,29 and health-care costs.30
CONCLUSION The differences in the preference for prescribing CAP and recommending VCUGs for patients with AHN captured by this survey highlight the paucity of high-level data and well-defined clinical guidelines. Based on the disparities encountered, it appears that clinical equipoise exists, calling for the conduct of randomized placebo-controlled trials to improve the quality of evidence on this matter. References 1. 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;6:212-231. 2. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int. 2002;89:149-156.
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3. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103:843-852. 4. Lidefelt KJ, Herthelius M. Antenatal hydronephrosis: infants with minor postnatal dilatation do not need prophylaxis. Pediatr Nephrol. 2008;23:2021-2024. 5. Tombesi MM, Alconcher LF. Short-term outcome of mild isolated antenatal hydronephrosis conservatively managed. J Pediatr Urol. 2012;8:129-133. 6. Roth CC, Hubanks JM, Bright BC, et al. Occurrence of urinary tract infection in children with significant upper urinary tract obstruction. Urology. 2009;73:74-78. 7. Szymanski KM, Al-Said AN, Pippi Salle JL, Capolicchio JP. Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux? J Urol. 2012;188:576-581. 8. Ismaili K, Avni FE, Wissing KM, et al. Long-term clinical outcome of infants with mild and moderate fetal pyelectasis: validation of neonatal ultrasound as a screening tool to detect significant nephrouropathies. J Pediatr. 2004;144:759-765. 9. Merguerian PA, Herz D, McQuiston L, Van Bibber M. Variation among pediatric urologists and across 2 continents in antibiotic prophylaxis and evaluation for prenatally detected hydronephrosis: a survey of American and European pediatric urologists. J Urol. 2010; 184:1710-1715. 10. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol. 1993;23:478-480. 11. Braga LH, Mijovic H, Farrokhyar F, et al. Antibiotic prophylaxis for urinary tract infections in antenatal hydronephrosis. Pediatrics. 2013;131:e251-e261. 12. Psooy K, Pike J. Investigation and management of antenatally detected hydronephrosis. Can Urol Assoc J. 2009;3:69-72. 13. Ismaili K, Avni FE, Piepsz A, et al. Current management of infants with fetal renal pelvis dilation: a survey by French-speaking pediatric nephrologists and urologists. Pediatr Nephrol. 2004;19:966-971. 14. Yiee JH, Tasian GE, Copp HL. Management trends in prenatally detected hydronephrosis: national survey of pediatrician practice patterns and antibiotic use. Urology. 2011;78:895-901. 15. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2011; CD001534. 16. Peters CA, Skoog SJ, Arant BS Jr, et al. Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134-1144. 17. Tekgul S, Riedmiller H, Hoebeke P, et al. EAU guidelines on vesicoureteral reflux in children. Eur Urol. 2012;62:534-542. 18. Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003;18:362-365. 19. Lee JH, Choi HS, Kim JK, et al. Nonrefluxing neonatal hydronephrosis and the risk of urinary tract infection. J Urol. 2008;179:1524-1528. 20. Coelho GM, Bouzada MC, Lemos GS, et al. Risk factors for urinary tract infection in children with prenatal renal pelvic dilatation. J Urol. 2008;179:284-289. 21. Estrada CR Jr. Prenatal hydronephrosis: early evaluation. Curr Opin Urol. 2008;18:401-403. 22. Coelho GM, Bouzada MC, Pereira AK, et al. Outcome of isolated antenatal hydronephrosis: a prospective cohort study. Pediatr Nephrol. 2007;22:1727-1734. 23. Brophy MM, Austin PF, Yan Y, Coplen DE. Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis. J Urol. 2002;168:1716-1719. 24. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology. 1993;187:157-160. 25. Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics. 2006;118:586-593.
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26. Wheeler DM, Vimalachandra D, Hodson EM, et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004; CD001532. 27. Yerkes EB, Adams MC, Pope JC 4th, Brock JW 3rd. Does every patient with prenatal hydronephrosis need voiding cystourethrography? J Urol. 1999;162:1218-1220. 28. McGinn T, Guyatt G, Cook R, et al. Measuring agreement beyond chance. In: Guyatt G, Rennie D, Meade MO, et al., eds. User’s Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. United States of America: The McGraw-Hill Companies, Inc.; 2008. 29. Blaufox MD, Gruskin A, Sandler P, et al. Radionuclide scintigraphy for detection of vesicoureteral reflux in children. J Pediatr. 1971;79: 239-246. 30. Medina LS, Aguirre E, Altman NR. Vesicoureteral reflux imaging in children: comparative cost analysis. Acad Radiol. 2003;10:139-144.
APPENDIX 1. PUC SURVEY QUESTIONS ON ANTENATAL HYDRONEPHROSIS (AHN) Demographics
1. Do you work in an academic/university center or in private practice? 2. What is the percentage of pediatric urology covered by your practice? >90%; >80%; >50%; other 3. How many cases of AHN do you roughly see in a 12month period? 4. Are these cases typically seen by: Nephrology or Urology? 5. Does your institution have a uniform approach for management of AHN; in other words, do you and your partners of team members have the same approach for management of AHN? 6. Do you have a protocol for management of AHN at your institution? Voiding Cystogram (VCUG) 7. Do you order a VCUG for patients with unilateral SFU grade I or II AHN?
6
8. Do you order a VCUG for patients with unilateral SFU grade III or IV AHN? 9. Do you order a VCUG for patients with bilateral SFU grade I or II AHN? 10. Do you order a VCUG for patients with bilateral SFU grade III or IV AHN? Antibiotic (ATB) Prophylaxis 11. Do you give CAP for babies with unilateral SFU grade I or II AHN? 12. Do you give CAP for babies with bilateral SFU grade I or II AHN? 13. Do you give CAP for babies with unilateral SFU grade III or IV AHN? 14. Do you give CAP for babies with bilateral SFU grade III or IV AHN? 15. Do you give CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade I-II)? 16. Do you give CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade III-IV)? 17. Does the caliber/size of the ureter influence your decision of giving CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade I-II)? Ureter <10 mm; Ureter >10 mm; Ureteral tortuosity
18. Does the caliber/size of the ureter influence your decision of giving CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade III-IV)? Ureter <10 mm; Ureter >10 mm; Ureteral tortuosity
19. Do you give CAP for babies with unilateral antenatally diagnosed UPJO-like (isolated hydronephrosis grade I-II)? 20. Do you give CAP for babies with unilateral antenatally diagnosed UPJO-like (isolated hydronephrosis grade III-IV)?
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METHODS
RESULTS
CONCLUSION
To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada. A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality. A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P ¼ .02); in contrast, 73% of nephrologists and 38.2% of urologists (P ¼ .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P ¼ .02) would obtain this test for patients with unilateral high-grade isolated AHN. Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain highlevel evidence to develop management protocols for this common condition. UROLOGY -: -e-, 2014. 2014 Elsevier Inc.
A
ntenatal hydronephrosis (AHN) is one of the most common congenital anomalies detected in 1%-5% of all pregnancies.1 More than half of these cases resolve by the end of gestation or in the early postnatal period and as such are considered to represent transient physiological dilation of the collecting system. If persistent in the postnatal period, hydronephrosis is mainly due to the flow restriction at the level of the
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Surgery/Urology, McMaster University, McMaster Children’s Hospital, Hamilton, Ontario, Canada; the McMaster Pediatric Surgery Research Collaborative (MPSRC), McMaster University, Hamilton, Ontario, Canada; and the Division of Urology, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada Reprint requests: Luis H. P. Braga, M.D., Ph.D., M.Sc., Department of Surgery, McMaster University, HSC 4E, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. E-mail: [email protected] Submitted: July 12, 2013, accepted (with revisions): October 18, 2013
ª 2014 Elsevier Inc. All Rights Reserved
ureteropelvic junction, vesicoureteral reflux (VUR), or less commonly associated with other etiologies (such as primary megaureter, ureteroceles, and posterior urethral valves).2 Despite the high prevalence, definitive clinical guidelines for managing patients with AHN are lacking. In particular, 2 aspects of practice are controversial: prescription of continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram (VCUG). Many centers still advocate for CAP and VCUG for all children with AHN.2,3 However, it has been estimated that 50% of infants with mild AHN bear a similar risk of urinary tract infections (UTIs) as that of the general age-matched population.4 Thus, CAP may be of little benefit for these patients.1,5,6 Similarly, VCUG appears to be of little value for infants with postnatally persistent Society for Fetal Urology (SFU) grade I-II unilateral AHN.1,7 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.10.054
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Table 1. Indications for continuous antibiotic prophylaxis in antenatal hydronephrosis cases based on practice location Factors Influencing Decision About CAP Use
Unilateral Low-grade (I/II) AHN, n (%)
Bilateral Low-grade (I/II) AHN, n (%)
Unilateral High-grade (III/IV) AHN, n (%)
Bilateral High-grade (III/IV) AHN, n (%)
3/19 (16) 6/44 (14)
3/19 (16) 11/44 (25)
8/19 (42) 29/44 (66)
13/19 (68) 32/44 (73)
5/10 (50)
5/10 (50)
8/10 (80)
9/10 (90)
Freestanding children’s hospital University hospital (adult and pediatric) Community hospital AHN, antenatal hydronephrosis.
Recent publications highlight some differences in the management of infants with AHN, presenting variations across different institutions and among physicians.8,9 Nevertheless, the phenomenon is far from being fully understood and potentially impacted by specialty training and health-care system characteristics. Herein, we aim to further explore current care patterns by contrasting 2 pediatric specialty groups (nephrologists and urologists) that most commonly deal with this patient population, within a country that has a rather homogeneous health-care system. The present study was designed to gain an appreciation of the different postnatal treatment strategies for infants with AHN, with particular interest on indications for CAP and VCUG, hypothesizing that important differences in the preference by the 2 specialties will be detected. If so, it is hoped that the gathered data will provide support for prospective trials and ultimately vest interest in the establishment of evidence-based treatment guidelines.
MATERIALS AND METHODS Survey Design An anonymous survey was designed on the open source web application “Lime Survey” (http://www.limesurvey.org, accessed November 2012.). The survey was locally piloted among pediatric urologists and pediatric nephrologists to confirm content and face validity and to decrease measurement bias. The survey was subsequently refined to 20 questions that focused solely on the practice patterns surrounding CAP and VCUG evaluation in patients with AHN. The survey questions were divided into 3 main categories: (1) demographics, which assessed the area of specialization, practice location (community hospitals, university centers with adult or pediatric care, and freestanding pediatric hospitals), and number of cases assessed per year; (2) indications for prescribing CAP; and (3) indications and parameters for ordering VCUG. Ultrasound images and drawings of the SFU grading system for hydronephrosis were provided to standardize the interpretation of the survey.10 The term “ureteropelvic junction obstruction (UPJO)-like” was coined in reference to dilatation of the renal pelvis or calices without ureteral dilatation and was used interchangeably as isolated hydronephrosis without hydroureter. Primary megaureter was defined as hydroureteronephrosis without documented VUR, not necessarily solely reflecting cases with obstructed systems that would eventually benefit from surgical intervention. Dilation was considered to be “low grade” if labeled SFU grades I and II, while “high-grade” AHN was defined as SFU grades III and IV. The survey was sent to all members of the Canadian Association of Pediatric Nephrologists and Pediatric Urologists of 2
Canada twice within a 2-week period. Endorsement letters from the president of each association accompanied the invitation emails. All responses were kept confidential, and survey results were checked for completeness before analyses. Two reminders were sent out 2 and 4 weeks after the survey was live to further maximize the response rate.
Data and Statistical Analyses Data were explored graphically for trends and normality by generating histograms and box plots. Descriptive statistics, including means and percentages for dichotomous variables, were calculated where appropriate. For comparison of proportions, a 2-tailed chi-square statistical analysis with Yates correction was used to determine significant differences between groups. All analyses were performed using SPSS V17.0 (SPSS Inc, Chicago, IL), accepting a 0.05 threshold value for significance.
RESULTS The survey was distributed to a total of 139 pediatric specialists. The overall response rate was 63.3% (88 returned surveys; 95% confidence interval, 55.0%71.0%). The respondents identified themselves as pediatric nephrologists (n ¼ 46) or pediatric urologists (n ¼ 39), with only 3 failing to disclose this information. The respondents reported seeing an average of 50 patients with AHN each year (1-450). Overall, 49 physicians (61%) practiced in academic centers, 22 (27%) in freestanding children’s hospitals, 10 (12%) in community hospitals, and 7 (8%) did not identify their practice location. Physicians in freestanding children’s hospitals saw a mean of 79 (10-300) new patients with AHN per year, followed by doctors in academic centers (university hospitals with adult and pediatric practice) who treated a mean of 46 new patients with AHN per year (0-450), and finally those in community hospitals who managed a mean of 14 new patients with AHN seen per year (2-50). Physicians in community hospitals managed few AHN patients as compared with those practicing at university hospitals and freestanding children’s hospitals. Doctors working in low AHN volume hospitals were more likely to order a VCUG and prescribe CAP for patients with AHN than physicians practicing at high-volume centers, as presented in Tables 1 and 2. The respondents reported that AHN cases are typically initially assessed by urologists (35%), nephrologists (21%), general pediatricians (31%), both nephrologists and urologists (5%), family physicians (3%), and 4 did not specify (5%). Although more than 90% of urologists UROLOGY
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Table 2. Indications for voiding cystourethrogram in antenatal hydronephrosis cases based on practice location Practice Location
Unilateral Low-grade (I/II) AHN, n (%)
Bilateral Low-grade (I/II) AHN, n (%)
Unilateral High-grade (III/IV) AHN, n (%)
Bilateral High-grade (III/IV) AHN, n (%)
0/22 (0) 14/49 (29)
4/22 (18) 23/49 (47)
16/22 (73) 44/49 (90)
22/22 (100) 47/49 (96)
7/10 (70)
6/10 (60)
9/10 (90)
9/10 (90)
Freestanding children’s hospital University hospital (adult and pediatric) Community hospital Abbreviation as in Table 1.
Table 3. Factors influencing decision about prescribing continuous antibiotic prophylaxis in infants with antenatal hydronephrosis Field of Practice Practice Location Training or previous knowledge Concern for UTI Concern for VUR Concern for obstruction
PN, n (%) 3 17 3 3
(11.5) (65.4) (11.5) (11.5)
PU, n (%) 2 25 3 5
(5.7) (71.4) (8.6) (14.3)
PN, pediatric nephrologists; PU, pediatric urologists; UTI, urinary tract infection; VUR, vesicoureteral reflux; other abbreviation as in Table 1.
answered our questionnaire, the response rate for nephrologists was only 45% (P ¼ .04). Interestingly, barely 17 of 88 respondents (20%; 95% confidence interval, 12.4%-28.8%) reported following standardized protocols or guidelines for the management of infants with AHN at their institutions. Regarding the rationale for starting CAP in infants with AHN, both nephrologists and urologists (65.4% and 71.4%, respectively) indicated that concern for the development of UTIs was the main deciding factor for their recommendation. Several additional factors also contributed to the prescription of antibiotics, including training or previous knowledge, and concern for VUR and obstruction (Table 3). The severity of AHN also appeared to influence this practice (Table 4). There were no significant differences between the numbers of nephrologists and urologists initiating CAP in infants with either unilateral low-grade (SFU grade I and II) or unilateral highgrade (SFU grade III and IV) AHN. Specifically, 66.7% and 51.4% of nephrologists and urologists, respectively, would prescribe CAP for patients with high-grade unilateral antenatal hydronephrosis (AHN). Furthermore, both specialties were more likely to use CAP in patients with high-grade AHN (SFU grade III and IV) than in lowgrade AHN (Table 4), regardless of whether it was unilateral or bilateral. Although many of these percentages are similar, they reflect practice variation within each group. Specialists differed in their use of prophylaxis for patients with bilateral low-grade AHN (SFU grade I and II), with more nephrologists opting for CAP compared with urologists (29.6% vs 11.4%, respectively; P ¼ .02). The study also examined whether a diagnosis of unilateral isolated hydronephrosis (UPJO-like) or hydroureteronephrosis without VUR (primary megaureter) influenced the decision to institute CAP. There were differences between the specialists groups, with a greater UROLOGY
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Table 4. Number of pediatric nephrologists and pediatric urologists who would prescribe continuous antibiotic prophylaxis based on site(s) of involvement (unilateral vs bilateral) and antenatal hydronephrosis grade
SFU AHN Grade Laterality Grade I/II Grade III/IV
Proportion of PN and PU Who Prescribe CAP PN, n (%)
PU, n (%)
Unilateral 4/27 (14.8) 4/35 (11.4) Bilateral 8/27 (29.6) 4/35 (11.4) Unilateral 18/27 (66.7) 18/35 (51.4) Bilateral 21/27 (77.8) 22/35 (62.9)
P Value .23 .016 .483 .449
CAP, continuous antibiotic prophylaxis; SFU, Society for Fetal Urology; other abbreviations as in Tables 1 and 3.
proportion of nephrologists indicating that they would initiate CAP in the presence of high-grade hydronephrosis without hydroureter (73.1% of nephrologists vs 38.2% of urologists; P ¼ .02; Table 5). However, nephrologists and urologists responded similarly for infants with low-grade isolated hydronephrosis, where both groups were less inclined to initiate CAP. There was no significant difference in the proportion of nephrologists and urologists who recommended CAP for infants with low- or high-grade antenatal hydroureteronephrosis (primary megaureter). Furthermore, nephrologists and urologists were generally more likely to order CAP for patients with hydroureteronephrosis (primary megaureter) than for those with isolated hydronephrosis (UPJO-like) of the same grade; however, the caliber of either less than or greater than 10 mm of the ureter had no influence on recommending CAP. The use of VCUG was also investigated. A higher proportion of nephrologists indicated that they would order a VCUG for patients with unilateral low-grade AHN (31% of nephrologists vs 7.7% of urologists, P < .01). Similarly, the number of nephrologists who would recommend a VCUG for infants with unilateral high-grade AHN was significantly higher than that of urologists (96.6% vs 69.2%, respectively; P ¼ .02). However, there was no significant difference between nephrologists and urologists in ordering VCUG for bilateral low- or high-grade AHN.
COMMENT Although concern for developing a UTI was the major factor for instituting CAP by nephrologists and urologists, several important differences in AHN management were noted between representatives of these specialties. Generally, nephrologists and urologists appear to agree on the perceived lack of CAP benefit in children with 3
Table 5. Number of pediatric nephrologists and pediatric urologists who would prescribe continuous antibiotic prophylaxis based on antenatal hydronephrosis grade and underlying etiology Proportion of PN and PU Who Prescribe CAP Underlying Condition
SFU AHN Grade
Unilateral “UPJO-like”
Grade I/II Grade III/IV Grade I/II Grade III/IV
Primary megaureter
PN, n (%) 2/26 19/26 12/27 21/27
(7.7) (73.1) (44.4) (77.8)
P Value
PU, n (%) 0/35 13/34 11/35 25/35
(0.0) (38.2) (31.4) (71.4)
.095 .024 .183 .844
UPJO, ureteropelvic junction obstruction; other abbreviations as in Tables 1, 3 and 4.
unilateral low-grade AHN; however, there were important discrepancies for bilateral and high grades of AHN. Pediatric nephrologists institute CAP more readily for patients with bilateral low-grade AHN and high-grade unilateral hydronephrosis (without hydroureter). Moreover, compared with urologists, nephrologists are more likely to order VCUGs for unilateral low- and high-grade AHN. Overall, a significant practice variation was observed between the 2 specialties; a finding that can be at least partially explained by the absence of established AHN protocols in most academic centers across Canada. The paucity of evidence-based guidelines and the lack of consensus are also reflected in the practice variability patterns reported by others.1,11,12 Ismaili et al13 assessed investigation and treatment preferences for unilateral AHN among French-speaking pediatric nephrologists and urologists in Europe. In their study, 23% nephrologists and 31% urologists would start CAP immediately after birth. Although the difference between them was not statistically significant, the percentage is strikingly different when compared with our reported findings (14.8% and 11.4%, respectively). Interestingly, the results of another survey report that 56% of general pediatricians would routinely prescribe CAP for infants with AHN.14 Merguerian et al9 also surveyed pediatric urologists in the United States and Europe to assess the variability in AHN evaluation and management. The respondents from the United States prescribed CAP at birth more often compared with their European colleagues (77% vs 40%, respectively; P < .001). However, similar proportions of pediatric urologists in the United States and in Europe (65%-70%) prescribe CAP for high-grade AHN. Taken together, these findings point to a significant variation in CAP prescribing patterns for AHN, impacted by the physicians’ prior training, specialty, and geographical location. Undoubtedly, lack of consensus or widely followed management patterns is related to the paucity of high-level evidence-based data.1,11,12 As a result, authors draw conclusions based on their personal preferences, as well as biased and inconsistent literature. For example, even in the setting of conflicting information regarding the benefit of daily antibiotics,15 CAP has been recommended in cases of moderate and severe unilateral or bilateral AHN, as well as in the presence of hydroureteronephrosis, VUR, or obstructive drainage patterns.1,12,16,17 The rationale for using CAP in patients with mild but persistent AHN is less clear.5,6 Ultimately, physicians make their decisions about 4
prescription based on an apparent risk of AHN-associated increased morbidity and irreversible renal damage in the setting of a UTI.18 Perceived benefits are weighted against potential risks of side effects and antimicrobial resistance. Some authors suggest that CAP may be necessary in highrisk populations as the chances of developing a UTI increase with higher grades of AHN.11,19 Lee et al showed that children with grade IV AHN had a 40% rate of UTI compared with 33% with grade III, 14% with grade II, and 4% with grade I AHN. CAP significantly reduced the risk of febrile UTI in children with AHN in some series.11,20-22 These data may explain why 65%-71% of the presented survey respondents indicated that “concern for UTI” was the main influencing factor in their decision to prescribe CAP. As seen in other surveys, the decision to recommend CAP has not been unanimous among physicians of the different specialties. The results of our survey indicate that nephrologists are significantly more likely to recommend CAP for patients with unilateral high-grade AHN without hydroureter and in patients with bilateral low-grade AHN without hydroureter, when compared with urologists. This pattern may be due to a perceived higher risk of UTIrelated morbidity in these particular cases and a concern of undertreating potentially missed VUR, if no VCUG is obtained. In this regard, nephrologists were more inclined to order VCUGs for patients with both low- and high-grade unilateral hydronephrosis when compared with urologists. These findings contrast with those of Ismaili et al13 who indicated that urologists were significantly more likely to obtain this test compared with their nephrology peers (41% and 20%, respectively). Different geographical locations and intricacies of regional health-care systems may also contribute to practice variability. As noted by Merguerian et al,9 European respondents were more likely to order a VCUG for low-grade AHN than their American counterparts, whereas a similar more consistent management pattern for higher grades of dilation was observed between the 2 groups. This phenomenon was also evidenced in our study. Although significant differences in the preference for VCUG between nephrologists and urologists for infants with unilateral high-grade AHN were detected, a more consistent level of agreement among these professionals was observed in patients with bilateral high-grade AHN. Undoubtedly, a more selective approach is appealing and avoids or minimizes radiation exposure for many infants. The practice of regularly obtaining VCUGs is clearly impacted by the level of suspicion for important albeit UROLOGY
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infrequent underlying pathologies, such as posterior urethral valves, and a desire to establish the presence of more common causes of AHN. VCUG is a valuable tool to rule out VUR, helping confirm the diagnosis of isolated AHN (UPJO-like) or hydroureteronephrosis (primary megaureter). Nevertheless, it is important to remember that AHN is a rather poor indicator for reflux detection, even in cases where there is postnatal resolution23,24 and irrespective of the degree of dilation.25 Currently, no clear evidence exists to support or discourage VCUG evaluation of infants with AHN, and the clinical significance of VUR remains unproven.1,26 Although our survey may reflect individual apprehension by the respondents to miss diagnosing VUR, recent literature does suggest that this rationale may not necessarily apply to all patients, particularly those with low-grade AHN.5,7,27 There are important limitations that deserve acknowledgment. Particularly, unexplored survey reliability and differences in response rates from nephrologists vs urologists could have biased the presented results. Although cognitive interviews and a pilot study with a panel of experts were conducted to improve the content validity of our survey, a formal test-retest assessment was not performed.28 In addition, due to the lower proportion of participating nephrologists, a reporting bias whereby mostly those specialists concerned with the treatment of AHN may have taken place, thus skewing the presented results when stratified and contrasted against urologists’ preferences. Despite the lower proportion of responses from nephrologists, their representation across the country was good. Most institutions in Canada were represented within the survey, and given that members within each institution usually have similar practice patterns, nephrologists’ results were likely generalizable. Thus, we propose there is value in our findings. Most importantly, our data call attention to the important differences in the management among physicians who frequently deal with AHN. These disparities, which likely stem from the absence of high-level evidence, can have a significant impact in parental distress, morbidity, radiation exposure,29 and health-care costs.30
CONCLUSION The differences in the preference for prescribing CAP and recommending VCUGs for patients with AHN captured by this survey highlight the paucity of high-level data and well-defined clinical guidelines. Based on the disparities encountered, it appears that clinical equipoise exists, calling for the conduct of randomized placebo-controlled trials to improve the quality of evidence on this matter. References 1. 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;6:212-231. 2. Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int. 2002;89:149-156.
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3. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103:843-852. 4. Lidefelt KJ, Herthelius M. Antenatal hydronephrosis: infants with minor postnatal dilatation do not need prophylaxis. Pediatr Nephrol. 2008;23:2021-2024. 5. Tombesi MM, Alconcher LF. Short-term outcome of mild isolated antenatal hydronephrosis conservatively managed. J Pediatr Urol. 2012;8:129-133. 6. Roth CC, Hubanks JM, Bright BC, et al. Occurrence of urinary tract infection in children with significant upper urinary tract obstruction. Urology. 2009;73:74-78. 7. Szymanski KM, Al-Said AN, Pippi Salle JL, Capolicchio JP. Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux? J Urol. 2012;188:576-581. 8. Ismaili K, Avni FE, Wissing KM, et al. Long-term clinical outcome of infants with mild and moderate fetal pyelectasis: validation of neonatal ultrasound as a screening tool to detect significant nephrouropathies. J Pediatr. 2004;144:759-765. 9. Merguerian PA, Herz D, McQuiston L, Van Bibber M. Variation among pediatric urologists and across 2 continents in antibiotic prophylaxis and evaluation for prenatally detected hydronephrosis: a survey of American and European pediatric urologists. J Urol. 2010; 184:1710-1715. 10. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol. 1993;23:478-480. 11. Braga LH, Mijovic H, Farrokhyar F, et al. Antibiotic prophylaxis for urinary tract infections in antenatal hydronephrosis. Pediatrics. 2013;131:e251-e261. 12. Psooy K, Pike J. Investigation and management of antenatally detected hydronephrosis. Can Urol Assoc J. 2009;3:69-72. 13. Ismaili K, Avni FE, Piepsz A, et al. Current management of infants with fetal renal pelvis dilation: a survey by French-speaking pediatric nephrologists and urologists. Pediatr Nephrol. 2004;19:966-971. 14. Yiee JH, Tasian GE, Copp HL. Management trends in prenatally detected hydronephrosis: national survey of pediatrician practice patterns and antibiotic use. Urology. 2011;78:895-901. 15. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2011; CD001534. 16. Peters CA, Skoog SJ, Arant BS Jr, et al. Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134-1144. 17. Tekgul S, Riedmiller H, Hoebeke P, et al. EAU guidelines on vesicoureteral reflux in children. Eur Urol. 2012;62:534-542. 18. Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003;18:362-365. 19. Lee JH, Choi HS, Kim JK, et al. Nonrefluxing neonatal hydronephrosis and the risk of urinary tract infection. J Urol. 2008;179:1524-1528. 20. Coelho GM, Bouzada MC, Lemos GS, et al. Risk factors for urinary tract infection in children with prenatal renal pelvic dilatation. J Urol. 2008;179:284-289. 21. Estrada CR Jr. Prenatal hydronephrosis: early evaluation. Curr Opin Urol. 2008;18:401-403. 22. Coelho GM, Bouzada MC, Pereira AK, et al. Outcome of isolated antenatal hydronephrosis: a prospective cohort study. Pediatr Nephrol. 2007;22:1727-1734. 23. Brophy MM, Austin PF, Yan Y, Coplen DE. Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis. J Urol. 2002;168:1716-1719. 24. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology. 1993;187:157-160. 25. Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics. 2006;118:586-593.
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26. Wheeler DM, Vimalachandra D, Hodson EM, et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004; CD001532. 27. Yerkes EB, Adams MC, Pope JC 4th, Brock JW 3rd. Does every patient with prenatal hydronephrosis need voiding cystourethrography? J Urol. 1999;162:1218-1220. 28. McGinn T, Guyatt G, Cook R, et al. Measuring agreement beyond chance. In: Guyatt G, Rennie D, Meade MO, et al., eds. User’s Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. United States of America: The McGraw-Hill Companies, Inc.; 2008. 29. Blaufox MD, Gruskin A, Sandler P, et al. Radionuclide scintigraphy for detection of vesicoureteral reflux in children. J Pediatr. 1971;79: 239-246. 30. Medina LS, Aguirre E, Altman NR. Vesicoureteral reflux imaging in children: comparative cost analysis. Acad Radiol. 2003;10:139-144.
APPENDIX 1. PUC SURVEY QUESTIONS ON ANTENATAL HYDRONEPHROSIS (AHN) Demographics
1. Do you work in an academic/university center or in private practice? 2. What is the percentage of pediatric urology covered by your practice? >90%; >80%; >50%; other 3. How many cases of AHN do you roughly see in a 12month period? 4. Are these cases typically seen by: Nephrology or Urology? 5. Does your institution have a uniform approach for management of AHN; in other words, do you and your partners of team members have the same approach for management of AHN? 6. Do you have a protocol for management of AHN at your institution? Voiding Cystogram (VCUG) 7. Do you order a VCUG for patients with unilateral SFU grade I or II AHN?
6
8. Do you order a VCUG for patients with unilateral SFU grade III or IV AHN? 9. Do you order a VCUG for patients with bilateral SFU grade I or II AHN? 10. Do you order a VCUG for patients with bilateral SFU grade III or IV AHN? Antibiotic (ATB) Prophylaxis 11. Do you give CAP for babies with unilateral SFU grade I or II AHN? 12. Do you give CAP for babies with bilateral SFU grade I or II AHN? 13. Do you give CAP for babies with unilateral SFU grade III or IV AHN? 14. Do you give CAP for babies with bilateral SFU grade III or IV AHN? 15. Do you give CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade I-II)? 16. Do you give CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade III-IV)? 17. Does the caliber/size of the ureter influence your decision of giving CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade I-II)? Ureter <10 mm; Ureter >10 mm; Ureteral tortuosity
18. Does the caliber/size of the ureter influence your decision of giving CAP for babies with antenatally diagnosed primary megaureter (hydroureteronephrosis SFU grade III-IV)? Ureter <10 mm; Ureter >10 mm; Ureteral tortuosity
19. Do you give CAP for babies with unilateral antenatally diagnosed UPJO-like (isolated hydronephrosis grade I-II)? 20. Do you give CAP for babies with unilateral antenatally diagnosed UPJO-like (isolated hydronephrosis grade III-IV)?
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