Prenatal urinary tract dilation is common, occurring in 1% of pregnancies. While it is benign in most circumstances, certain conditions such as urinary tract infection or kidney obstruction will predispose to significant morbidity.
Since the disease is being detected increasingly, pediatricians often are asked about the need for intervention. Yet the answer is not clear-cut.
Come hear the rationale for different approaches during the Point-Counterpoint Session “Perinatal Urinary Tract Dilation: Intervention or Observation? (D2166)” from 4-5 p.m. Sunday in Room 3022 of Moscone West.
C.D. Anthony Herndon, M.D., FAAP, professor of surgery/urology, division chief pediatric urology and co-surgeon in chief at Children’s Hospital of Richmond at Virginia Commonwealth University, will argue in favor of intervention. Poyyapakkam Srivaths, M.D., M.S., FAAP, associate professor of pediatrics, Renal Section, Baylor College of Medicine, will support observation.
“This point-counterpoint format will bring out the best of both worlds and hopefully leave the audience with a balanced approach,” Dr. Srivaths said.
Dr. Herndon pointed to several papers that support intervention, including the Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.
“The evaluation and management of prenatal urinary tract dilation has undergone a paradigm shift away from an indiscriminant approach towards postnatal screening in the majority of patients,” said Dr. Herndon, a member of the AAP Section on Urology Executive Committee. “This shift relies on the development of a risk stratification profile, which in turn is used to guide subsequent intervention inclusive of prophylactic antibiotics, lower urinary tract imaging and surgical intervention.”
Dr. Srivaths said evidence for the effectiveness of prenatal intervention even in the most severe cases of antenatal dilation (lower urinary tract dilation) is not very strong, and the only randomized controlled trial did not show clear benefit. The main evidence that supports watchful expectancy for the most common abnormality of the urinary tract, i.e., vesicoureteral reflux, came from the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study, which showed prophylactic antibiotics did not prevent renal scarring.
“The observation position is a nuanced one since it involves a triaged approach for expectant management,” Dr. Srivaths said. “This position also is influenced by the fact that renal survival is not affected very much by any of the interventions.”
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