Mears Alice L, Raza Syed A, Sinha Ajay K, Misra Divesh
Department of Paediatric Surgery, Royal London Hospital, Whitechapel Road, London E1 1BB, UK.
J Pediatr Urol. 2007 Aug;3(4):264-7. doi: 10.1016/j.jpurol.2006.11.009. Epub 2007 Mar 1.
Since 1995 we have, at our centre, adopted a selective approach to performing micturating cystourethrograms (MCUGs) on patients with antenatally diagnosed hydronephrosis. This study reviews the outcome of this policy.
We carry out MCUGs only if any of the following features are present on ultrasound: bilateral hydronephrosis, ureteric dilatation, renal scarring, bladder wall thickness greater than 5mm, or presence of a duplex system or ureterocele. Patients with simple unilateral hydronephrosis are excluded, and are managed with 6 months' trimethoprim prophylaxis and ultrasound surveillance with a minimum of 3 years' follow up.
Fifty-five patients were referred with an antenatal diagnosis of hydronephrosis between 1999 and 2002; 26 (47%) did not have an MCUG. Of these, five had increasing hydronephrosis and required surgery for pelvi-ureteric junction obstruction, and three had a multicystic dysplastic kidney on postnatal scanning. In the remaining 18 patients, the hydronephrosis resolved spontaneously, with no renal scars or asymmetry. During follow up, none of these patients had a urinary tract infection.
We believe that vesico-ureteric reflux in most antenatally diagnosed hydronephrotic kidneys is physiological rather than pathological, and resolves with time without causing long-term renal damage. This is a separate entity from, rather than a precursor of, the pathological symptomatic refluxing kidney in older, mainly female children. Taking a more conservative approach to the postnatal investigation of antenatally diagnosed hydronephrotic kidneys has not resulted in any missed damaged kidneys, but has reduced the number of invasive investigations performed. A careful protocol and detailed postnatal ultrasonography are important to prevent missed pathological cases.
自1995年起，我们中心对产前诊断为肾积水的患者采用了选择性进行排尿性膀胱尿道造影（MCUG）的方法。本研究回顾了该政策的结果。
仅当超声检查出现以下任何特征时，我们才进行MCUG：双侧肾积水、输尿管扩张、肾瘢痕形成、膀胱壁厚度大于5mm、或存在重复肾系统或输尿管囊肿。单纯性单侧肾积水的患者被排除在外，并采用甲氧苄啶预防6个月，并进行超声监测，至少随访3年。
1999年至2002年间，有55例患者因产前诊断为肾积水前来就诊；其中26例（47%）未进行MCUG。在这些患者中，5例肾积水加重，需要进行肾盂输尿管连接部梗阻手术，3例在出生后扫描时发现为多囊性发育不良肾。其余18例患者的肾积水自发消退，无肾瘢痕或不对称。在随访期间，这些患者均未发生尿路感染。
我们认为，大多数产前诊断为肾积水的肾脏中的膀胱输尿管反流是生理性的而非病理性的，并且会随着时间的推移而消退，不会造成长期肾损害。这是一个与年龄较大的主要为女性儿童的病理性症状性反流性肾脏不同的独立实体，而不是其先兆。对产前诊断为肾积水的肾脏进行产后检查采取更保守的方法并未导致任何受损肾脏被漏诊，但减少了侵入性检查的次数。仔细的方案和详细的产后超声检查对于防止漏诊病理性病例很重要。
