Recent Diagnostic and Therapeutic Approaches to Prenatally and Perinatally Diagnosed Hydronephrosis and their Implementation in the University Clinical Hospital Mostar
A shift of the diagnostics of urological malformations towards the foetal age by means of ultrasound, especially hydronephrosis which, apart from reflux, is the most frequent developmental urological disorder, opened many dilemmas and debates. In the course of more than three decades the application of this diagnostic approach to the problem of hydronephrosis became a routine clinical practice in all modern clinics. In this paper we present the problems related to this diagnostic method and its delayed application in the Mostar University Clinical Hospital. Along with the exposition of a general approach to the problem of hydronephrosis we briefly present our modest collection of cases which points to the most recent trend of a vigorous medical development in this region, despite unfavourable overall conditions which prevailed so far. The observation included 56 children with prenatal, perinatal and early age determination of pyelon dilatation by means of ultrasonic exploration who were treated surgically. Of this number 32 (57.14%) were male, and 24 (42.86%) female children. Of the observed patients 56 had unilateral and 6 had bilateral pyelon dilatation so that 62 kidneys in all were observed and treated. The dilatation was determined prenatally in 24 (38.7%) out of 62 kidneys observed in all, in 7 (11.29%) the disorder was observed perinatally and in remaining 31 cases (49.9%) it manifested during early childhood, school age, even at the age of pre-puberty. Of the children with prenatally and perinatally determined dilatation, in 14 (45.16%) out of 31 (100.0%) observed kidneys the ap radius of the dilated pyelon was between 10 – 15 mm, and in 17 (54.84%) more than 15 mm. Along with other examinations (MAG3 and DMSA) the patients were followed-up by ultrasonic exploration of the observed kidney for 6 to 30 (average 18) months after postnatal diagnosis; the ultrasonic exploration was repeated in intervals of 6 months. Within 12 months of birth surgical intervention on the pyeloureteral junction was done on all 17 kidneys with an ap radius of the pyelon greater than 15 mm, as well as on 4 kidneys in which ap radius was between 10 and 15 mm. In other 10 kidneys with prenatally and perinatally determined ap radius of 10 to 15 mm the follow-up period was 25 to 30 months (average 27,5). As the examinations (ultrasound, MAG3 and DMSA) even after this period showed no signs of regression of the dilatation, nor an improvement in patency this provided an indication for surgical intervention with the aim of establishing a normal flow across the pyeloureteral junction. Antibiotic prophylaxis was not applied systematically, but in a targeted manner if the uroinfection was confirmed clinically and in the lab. Through the presentation of cases we demonstrate the relationship of earlier and more recent procedures in the treatment of hydronephrosis in the gravitational area of the Mostar University Clinical Hospital. The fact that some children were subjected to surgical treatment due to hydronephrosis at the time of pre-puberty reflects earlier views on this clinical entity. The successfulness of surgical treatment of hydronephrosis in the observed patients is complete and comparable to medically more developed environments, and our diagnostic capabilities are getting close to that level too. We specially wish to stress the recent introduction of ultrasonic examination of pregnant women and foetus in the third trimester with the aim of an early detection of anomalies and malformations of the urotract as an indicator of a marked medical development. On the global level there are still inconclusive and opposing opinions on this subject, as is seen in recent literature. The controversies relate to the diagnostics as well as to therapy.
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