Prenatal Hydronephrosis - Does Every Infant Need a Screening VCUG?
Ala'a Farkouh, MD, Matthew Buell, MD, Cayde Ritchie, MD, Michaela Sabbah, BS, Chloe Elias, BS, Arthur Lee, BS, Joshua Pearce, HSD, David Chamberlin, MD, Joshua Chamberlin, MD.
Loma Linda University Health, Loma Linda, CA, USA.
BACKGROUND: Prenatal hydronephrosis (PNH) occurs in 1-2% of all pregnancies and may be associated with vesicoureteral reflux (VUR). Controversy exists regarding the utility of a screening voiding cystourethrogram (VCUG) to detect VUR in all children with PNH, reflected in the AUA VUR guidelines. VCUGs are often unpleasant, invasive, and expose the child to ionizing radiation. We sought to identify risk factors in children with PNH that are predictive of VUR on screening VCUG.
Methods: We reviewed a prospectively maintained database of children prenatally diagnosed with hydronephrosis that were followed by pediatric urology at a single tertiary academic institution, between August 2012 and July 2022. We evaluated the children with PNH who underwent a screening VCUG. VCUGs were performed at the provider’s discretion. We evaluated factors including sex, hydronephrosis grade, bilateral hydronephrosis, and hydroureter on postnatal renal bladder ultrasound. The primary outcome was the presence of VUR on VCUG. The secondary outcome was the development of a UTI, defined as pyuria and a positive single-organism culture. Risk analysis and Chi-squared test were performed, with p<0.05 considered significant.
Results: A total of 412 children were identified in the database, 319 (77.4%) met inclusion criteria of PNH with a screening VCUG. Of the 319 patients, 43 (13.5%) were found to have VUR on VCUG (Grade 1: 36.6%, Grade 2: 14.6%, Grade 3: 9.8%, Grade 4: 14.6%, Grade 5: 24.4%). The majority were male at 224 (70.2%). Hydroureter was associated with the presence of VUR (OR=2.45, 95% CI [1.13, 5.3]; p=0.02). In contrast, female sex (OR=1.48, 95% CI [0.76, 2.9]; p=0.25), bilateral hydronephrosis (OR=0.89, 95% CI [0.43, 1.9]; p=0.75), and high grade (SFU 3-4) hydronephrosis (OR=0.75, 95% CI [0.38, 1.5]; p=0.42) were not associated with the presence of VUR in the setting of PNH. Children with PNH and VUR a had higher UTI rate than those with PHN and no VUR (16.3% vs 5.8%; p=0.013).
Conclusions: Consistent with the AUA VUR guidelines, children with PNH and hydroureter are at increased risk of VUR and benefit from screening VCUG. In contrast, we found that female sex, bilateral hydronephrosis, and high grade hydronephrosis were not predictive of VUR. This data supports the selective use of screening VCUGs in children with prenatal hydronephrosis, further studies are needed.
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