Outcome and cost analysis of operative versus nonoperative management of neonatal multicystic dysplastic kidneys.

PURPOSE

We determine whether nephrectomy or observation is the more appropriate treatment of neonates with multicystic dysplastic kidney in terms of medical care and cost-effectiveness.

MATERIALS AND METHODS

We retrospectively reviewed our 10-year clinical experience with 17 female and 32 male neonates presenting with multicystic dysplastic kidney who were followed with serial renal ultrasound. The literature also was reviewed.

RESULTS

Nephrectomy was performed in 12 patients (24%) for various reasons, of which family request at concomitant surgery was the most common (7). No kidney was removed due to hypertension or tumor. In the remaining 37 patients followup continues (mean 42 months) with involution developing in 9 multicystic dysplastic kidneys (24%) and 9 patients (24%) lost to followup. The total cost of 1-hour outpatient simple nephrectomy was estimated at $5,000 to $7,000 and, when performed as a concomitant procedure, it cost $2,000 to $5,000, the equivalent charges incurred for 17 to 28 serial ultrasound studies performed by a radiologist. Our review of the literature revealed that children with multicystic dysplastic kidney are at minimal risk for hypertension, pain and infection. The most important reason to perform screening renal ultrasound in this condition is to detect earlier stage Wilms tumor (3 to 10-fold the general pediatric population risk of 1/10,000 cases). With a maximum risk of 0.1% for Wilms tumor controversy exists as to whether any screening program is necessary. When screening is instituted, options include monthly parental abdominal palpation versus serial renal ultrasound. Because Wilms tumor has a rapid growth rate, when screening renal ultrasound is instituted, it must be performed no less than every 3 months until age 8 years (total of 32 studies) to screen effectively for early stage tumors.

CONCLUSIONS

The risks associated with multicystic dysplastic kidney are slight. Early nephrectomy is more cost-effective than observation in neonates with multicystic dysplastic kidney only when observation involves screening with ultrasonography every 3 months until age 8 years. Extensive parental counseling should be provided on the slight but definite risks of this condition.