* Presented at the Seventieth Annual Meeting of the American Roentgen Ray Society, Washington, D.C., September 30-October 3, 1969. From the Departments of Radiology,t and Urology4 Columbia Presbyterian Medical Center (The Babies Hospital), New York, New York. § Currently at the Department of5urgery (Urology), Albert Einstein College Hospital, Bronx, New York. Formerly: Fellow in Pedia- tric Urology, Columbia Presbyterian Medical Center, New York, New York. 380 JUNE, I970 HYDRONEPHROSIS IN INFANTS AND CHILDREN- VALUE OF HIGH DOSAGE EXCRETORY UROGRAPHY IN PREDICTING RENAL SALVAGEABILITY* By WALTER E. BERDON, M.l).,t SELWYN B. LEVITT, M.l)., DAVII) H. BAKER, M.I).,t JOSHUA A. BECKER, M.l).,t and AURELLO C. [SON, M.D4 N E\V VO R K, N EV YO RK T HE use of higher doses of contrast media in excretory urograph has led to a better understanding of the factors in- volved in the visualization of the normal as well as the hsdronephrotic kidne.4’’1#{176}’ 14.16.19 At the same time it has provided the urologist with useful information to under- take procedures to salvage more hydro- nephrotic kidnevs.2”15’#{176}2’ The improved excretors urographic dem- onstration of hsdronephrosis has resulted in a dramatic decrease in the need for retrograde p’elographv in such cases. Ret- rograde ureteral catheterization has al- ways carried the disadvantage of potential ureteral edema with further obstruction and infection. The properl’ done high dos- age excretor’ urogram suffices in most patients not onls in defining the site of obstruction but in assessing the functional state of the residual kidney parench\’ma irrespective of the degree of hs’dronephrosis. In this report we will present a working classification of hvdronephrosis, based on high dosage excretory ii rograph’, correlat- ing earl and delayed roentgenographic findings. Although emphasized in the pe- diatric age group, these findings are equally applicable to adults if sufficient contrast medium is used. This grading of hydro- nephrosis has been correlated with progno- sis and, therefore, has encouraged our belief that even the advanced stages of hsdro- nephrosis ma\’ benefit from aggressive stir- gical treatmen t where obstruction exists.2’3 The type of “hvdronephrosis” discussed in this report is largel’ that related to actual obstruction (such as ureteropelvic junction or secondar- to posterior urethral valves or ureteral edema from instrumenta- tion) and not the medically reversed tire- teral dilatation seen in infants and children with urinary tract infection without actual obstruction. TECHNIQUE OF EXCRETORY UROGRAPHY IN INFANTS AND CHILDREN A. CHOICE OF CONTRAST AGENTS AND DOSAGE The 3 most commonly used urographic contrast agents (sodium diatrizoate*, me- glumine diatrizoatet and meglumine io- thalamatet) are triiodinated, contain be- tween 280 and 300 mg. of iodine/cc. with milliosmolality between i,ioo and 1,400 mOsm:l. (approximately 4 times that of blood). They differ in sodium content, with a range between mEqu./l. in meglumine iothalamate to 365 mEqu./l. in meglu- mine-sodium diatrizoate to 750 mEqu./l. for sodium diatrizoate. \Ve have found the sodium diatrizoate (hypaque-5o) the agent of choice, both in ease of injection through the often small (No. 21 or 23) scalp infusion intravenous sets and, more importantly, in giving greater urinary concentration of opaque agent than the same dose of either meglumine agents.3 All 3 agents are equally * Hypaque-5o (Winthrop). t Renografin-6o (Squibb). 1: Conray 280 (Nlallinckrodt). Downloaded from www.ajronline.org by 27.79.75.39 on 02/14/23 from IP address 27.79.75.39. Copyright ARRS. For personal use only; all rights reserved
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HYDRONEPHROSIS IN INFANTS AND CHILDREN— VALUE OF HIGH DOSAGE EXCRETORY UROGRAPHY IN PREDICTING RENAL SALVAGEABILITY* Presented at the Seventieth Annual Meeting of the American Roentgen Ray Society, Washington, D.C., September 30-October 3,
1969.
From the Departments of Radiology,t and Urology4 Columbia Presbyterian Medical Center (The Babies Hospital), New York,
New York.
tric Urology, Columbia Presbyterian Medical Center, New York, New York.
380
HYDRONEPHROSIS IN INFANTS AND CHILDREN- VALUE OF HIGH DOSAGE EXCRETORY
UROGRAPHY IN PREDICTING RENAL SALVAGEABILITY*
By WALTER E. BERDON, M.l).,t SELWYN B. LEVITT, M.l)., DAVII) H. BAKER, M.I).,t JOSHUA A. BECKER, M.l).,t and AURELLO C. [SON, M.D4
N E\V VO R K, N EV YO R K
T HE use of higher doses of contrast
media in excretory urograph has led
to a better understanding of the factors in-
volved in the visualization of the normal as
well as the hsdronephrotic kidne.4’’1#{176}’
14.16.19 At the same time it has provided the
urologist with useful information to under-
take procedures to salvage more hydro-
nephrotic kidnevs.2”15’#{176}2’
The improved excretors urographic dem-
onstration of hsdronephrosis has resulted in a dramatic decrease in the need for
retrograde p’elographv in such cases. Ret-
rograde ureteral catheterization has al-
ways carried the disadvantage of potential
ureteral edema with further obstruction
and infection. The properl’ done high dos-
age excretor’ urogram suffices in most
patients not onls in defining the site of obstruction but in assessing the functional
state of the residual kidney parench\’ma
irrespective of the degree of hs’dronephrosis.
In this report we will present a working classification of hvdronephrosis, based on
high dosage excretory ii rograph’, correlat-
ing earl and delayed roentgenographic
findings. Although emphasized in the pe-
diatric age group, these findings are equally
applicable to adults if sufficient contrast
medium is used. This grading of hydro- nephrosis has been correlated with progno-
sis and, therefore, has encouraged our belief
that even the advanced stages of hsdro- nephrosis ma\’ benefit from aggressive stir- gical treatmen t where obstruction exists.2’3
The type of “hvdronephrosis” discussed
in this report is largel’ that related to
actual obstruction (such as ureteropelvic
junction or secondar- to posterior urethral
valves or ureteral edema from instrumenta-
tion) and not the medically reversed tire-
teral dilatation seen in infants and children
with urinary tract infection without actual
obstruction.
A. CHOICE OF CONTRAST AGENTS AND DOSAGE
The 3 most commonly used urographic contrast agents (sodium diatrizoate*, me-
glumine diatrizoatet and meglumine io-
thalamatet) are triiodinated, contain be-
tween 280 and 300 mg. of iodine/cc. with
milliosmolality between i,ioo and 1,400
mOsm:l. (approximately 4 times that of
blood). They differ in sodium content, with
a range between mEqu./l. in meglumine
iothalamate to 365 mEqu./l. in meglu-
mine-sodium diatrizoate to 750 mEqu./l.
for sodium diatrizoate. \Ve have found the sodium diatrizoate (hypaque-5o) the agent
of choice, both in ease of injection through
the often small (No. 21 or 23) scalp infusion
intravenous sets and, more importantly, in giving greater urinary concentration of
opaque agent than the same dose of either
meglumine agents.3 All 3 agents are equally
* Hypaque-5o (Winthrop).
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Contrast agent: 50 per cent sodium diatrizoate (hypaque-5o, Winthrop); iodine content 300
mg./cc., sodium content 750 mEqu./l., osmolality 1,300 m0sm./l.
Below 2,500 grams
2-5 years
5-10 years
.\1u Its
30-45 CC.
I cc./kg.
VOL. 109, No. a Hydronephrosis in Infants and Children 383
“safe” in terms of the virtual absence, in the pediatric age group, of severe reactions
(shock, anaphylactoid signs). Dosage is “high” in the pediatric age
group (Table i) with a decreasing dosage of roughly 3 cc./kg. at birth to 2 cc./kg. for
older infants and toddlers to 1-2 cc./kg. for
the age group to io years, after which i
cc./kg. seems to be adequate for adult pa-
tients. In practice, these doses may be too
low for patients with elevated blood urea nitrogen and decreased creatinine clearance,
and too high for others, since an undesirable
excess diuresis max’ ensue leading to a rapid appearance of a dilute, poorly defined uro-
gram. As noted above, this has been more
ofa problem with meglumine agents5”4 and
has led to our continued preference for sodium diatrizoate.5
The neonatal dosage exceeds the seem- ing adult optimum of i cc./kg.’8 because
I cc./kg. is inadequate, in our experience, to obtain consistently adequate pyelograms
in infants. The reasons for this are not fully
understood but, in part, may be related to a lowered glomerular filtration rate in the first weeks or months of life. The new-
born 3 cc./kg. dose not infrequently causes
an excessive diuresis on early roentgeno-
grams, necessi tating delaed roentgeno-
grams (in normal patients) to show well
opacified calyceal systems. \Ve do not feel
that this reflects anything unique to new- borns’4 since the same dilutional effects have been noted after infusion pylography
in adults.
fusion of the hypertonic contrast agents.’2’
16,17,19,23 Serum milliosmolality rises for some
minutes12” and then drops as fluid shifts into the vascular compartment. Serum pH
drops for as long as 30-60 minutes’2”7’
even though the contrast agents are not acidic; this may be due to an osmotically
induced shift of bicarbonate poor fluid from
the intracellular compartment leading to a vascular dilu tional acidosis.’7’23 These are
physiologic, not toxic or allergic, reac-
tions and are to be found with either meg-
lumine or sodium agents, and with both iothalamate and diatrizoate compounds.’ We believe, in dealing with sick infants and children, that this high dosage is safe when
the patient is properly hydrated. We avoid
deliberate dehydration (although such de-
hydration may well improve the pyelo-
graphic image in adults).’ With morning
examinations, the breakfast is given in fluid
form.
domen the injection is made intravenously
through a scalp vein infusion set (usually
No. 21 or 23). A prone7 coned-down roent-
genogram of the kidneys is taken as soon
after the injection as possible. A full ab-
dominal prone film is exposed at minutes
as well as a lateral film; these are reviewed
after 90 second processing to determine if
more views are needed. The i minute roent-
genogram allows an estimate of renal pa-
renchymal outlines during the nephrogram
phase; the 5 minute roentgenogram (using
sodium diatrizoate) has shown excellent
visualization with ureteral filling and blad-
der opacification. The prone position7 not
only helps facilitate ureteral filling but dis-
places obscuring intestinal gas. Delayed
and voiding roentgenograms can then be
scheduled as needed. If necessary, a pneu-
matic compression paddle is used in the
prone position to further shift bowel gas.” The lateral roentgenogram has been
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382 Berdon et al. JUNE, 1970
Adults commonly present with this pat- Grade iii hydronephrosis, with same
GRADE I -HYDRONEPHROSIS
11G. 1 . Diagrammatic representation of early and
late roentgenographic findings in Grade I hy- (.1rone)h rosi s.
added for its value in detecting lumbosacral
vertebral and neural arch anomalies that
may accompany a neurogenic bladder.
There is only frustration and failure to be
expected i fureteral reimplantation is under-
taken in a child with absence ofmuch of the
sacrum and a neurogenic bladder.
ROENTGENOGRAPHIC GRADING
OF HYDRONEPHROSIS
are really part of a continuous spectrum (in
time) ranging from the acutel\ obstructed
previously normal kidney to a longstanding
unrecognized obstruction terminating in a
nonvisualized kidney. As long as there are
sufficient functioning glomeruli, there is
removal from the blood of the iodine-con-
taming contrast agent with concentration
within the renal tubules, with final opaci-
fication of the urine retained within the
renal pelvis and ureter. Blockage within the
urinary drainage tract at an’ point causes
proximal stasis wi th pvelocalyceal dilata-
tion and may result in renal parenchvmal
atrophs or destruction. It is in this spec-
trum that the arbitrary grading of hydro-
nephrosis is presented.
EXCELLENT PROGNOSIS (Fig. i)
children we have more commonly seen such
obstruction following ureteral trauma from
retrograde pyelographv (Fig. 2, 4-C) or
ureteral reimplantation (Fig. 3, 4 and B).
The early roentgenograms show (with
con ti nued glomerular filtra tion) a progres-
sively dense nephrogram surrounding the
“lucent” outline of the dilated calvces (Fig.
2’1; and 3/f), the “lucency” representing
nonopacified urine. La ter roentgenograms usually show progressive opacification of the
urine and its flow to the point of obstruc-
tion (Fig. 2B; and 3B).
GRADE II. LONGSTANDING, ALTHOUGH INCOMPLETE,
OBSTRUCTION; PROGNOSIS REMAINS GOOD (Fig. 4)
In children this has been encountered
both in ureteropelvic junction obstruction
and in lower urinary tract malformations
( inclu di ng posterior u rethral valves,
m arked vesicou reteral reflux, u reterovesical
obstruction). In these instances, the in-
volved kidney is salvageable. The accurate
roentgenographic diagnosis is achieved as a
combination of the high dosage employed
in the excretory urogram and the continued
although impaired glomerular filtration of
the kidney. The early roentgenograms
show the nephrogram outline of renal
parenchyma (Fig. 4) although this may
be thinned by either atrophy or poor
growth. The calyces, filled with nonopaci-
fled urine, are dilated. An unusual scal-
loped layering of contrast material out-
lines the walls of the dilated pelvicalyceal
system (Fig. 5’1). Delayed roentgeno-
grams, with full mixing of contrast agent
and urine, usually allow demonstration of
the point of obstruction of urine flow
(Fig. #{231}B).
can return to a normal growth pattern with
disappearance of most of the hydronephro-
Si5 (Fig. 5C) where a correctable “obstruc-
tion” exists.
STRUCTION; PROGNOSIS: SALVAGE POSSIBLE BUT LESS
LIKELY THAN IN GRADE II (Fig. 6)
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a ll
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b.... .l dysplastic l..... . .. . vesicoureteral r.... .... . . . . . _,.._ .ng system on right surrounded by nephrogram density on 5 minute roentgenogram. (B) One hour roentgenogram shows opacification and flow of urine to point of holdup. There was Spontaneous clearing in the next 2 weeks.
Hydronephrosis in Infants and ChildrenVOL. 109, No. 2 383
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DILATED CALYCES.
S OF CONTRAST
to POINT OF
l”ic;. . l)iagrammatic representation of early and late roentgenographic findings in Grade II hy- dronephrosis. Note layering of contrast medium
on early roentgenograms before full mixing occurs.
384 Berdon et al. JUNE, 1970
GRADE 1E-HYDRONEPHROSIS
EARLY NEPHROGRAM
OF NEPHROGRAN.
either more prolonged obstruction than in
Grade II or a more severe obstruction. It
also has been noted in cases of posterior
urethral valves (with and without reflux)
as well as in ureteropelvic obstruction.”9”1
The early roentgenograms (Fig. 71) show
a thinned nephrogram outline. On inter-
mediate roentgenograms (Fig. 7B) contrast
filled crescent-shaped spaces are noted.9
These surround the markedly dilated renal
pelvis which is still filled with nonopacifled
urine and appears “lucent.” The “cres-
cents” are felt to be dilated collecting
tubules’ turned 90 degrees so that they
parallel the renal outline rather than being
at right angles to it. On these roentgeno-
grams the calyces are ill-defined since they
are virtually effaced by the pronounced
dilatation of the renal pelvis. On late roent-
genograms the contrast medium slowly
opacifies the entire pelvis and ureter to the
point of obstruction (Fig. 7, C and D).
Even this advanced state of hydronephrosis
is, at times, reversible (Fig. 8, 1-C).
The required surgery will vary, depend-
ing on the functional state of the contra-
lateral kidney and the severity and cause
of the hydronephrosis. Ureteropelvic ob-
struction is best handled by primary plastic
operations (with or without temporary di-
version by means of nephrostom\ or pvelos-
tom)’) Ureterovesical obstru ction or
gross medically u n con trollei.l vesicoureteral
reflux may also need temporary diversion
be fore defin i ti ye u reteral reim plantation.
Some patients with tortuous atonic ureters
may require ileal conduit diversion (Fig.
8C).
(with its diuresis)”22 may actually induce a
“crisis” in these patients with flank pain
and a palpable mass. Such findings may
spontaneously regress and roen tgenograms
taken the next day show a less marked
hvdroneph rosis. \Veaver22 has studied such
osmotic diuresis in ureteropelvic obstruc-
tion (both in humans and in experimental
animals) ; the baseline intrapelvic pressures
(surprisingly normal in longterm obstruc-
tion) rapidly rise in response to the osmotic
diuresis and thereby overcome the uretero-
pelvic junction’s ability to decompress the
renal pelvis.22
KIDNEY; PROGNOSIS ESSENTIALLY NIL (Fig. 9)
Grade iv hydronephrosis represents
or a clinical failure to recognize hydro-
nephrotic Grades I, II and III before irre-
versible renal damage has occurred. The
causes include ureteropelvic and distal
ureteral (calculi, surgical damage) obstruc-
tion with the entire kidney involved (Fig.
io4). Segmental renal damage may occur
(Fig. ioB) as in renal duplication, with or
without ectopic ureterocele.6 In both groups
Grade iv hydronephrosis represents an ef-
fective cessation of glomerular filtration.
The aftected kidney is a shell and surgical
therapy is not curative, but directed at re-
moval (ifthese are signs ofinfection) of the
dead segment by either total or hemi-
nephrectomv. The early roentgenograms
rims (Fig. Jo, zi and B) that really reflect
vascular opacification rather than a true
nephrogram since there is no glomerular
filtration. Nonspecific “total body opaci-
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F’IG.5.(i)1r... ---..-- .--.-- 1...1.Right
hydronephrosis due to ureteropelvic obstruction shows layering of contrast medium along walls of dilated renal pelvis and calyces on supine 5 minute roentgenogram. There is large scrotal hernia present bilaterally.
( B)Prone 20 minute roentgenogram shows full mixing of urine and contrast material with demonstration of ureteropelvic obstruction. (C) Two and one half years later following right pyeloplasty. Note good
parenchymal growth. The renal function is normal.
\OL. 109, No. 2 Flydronephrosis in Infants and Children 3 85
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LATER
I
EARLY
DELAYED
GRADE -HYDRONEPHROS IS
FIG. 6. Diagrammatic representation of Grade HI
hydronephrosis. Early, intermediate and delayed roentgenographic 6 ndings. The “crescents” are contrast medium filled collecting tubules, not calyces.
fication” is also present since any vascula-
rized tissues become opaque and emphasize
the “lucent” urine within the hydroneph- rotic kidney.” Nephrotomography helps in
visualizing such kidneys in older children
FIG. 7. (‘1) Two month old male with left flank mass has Grade III obstruction at ureteropelvicjunction. One minute roentgenogram shows “lucent” renal pelvis surrounded by nephrogram of renal parenchyma.
(B) Ten minute roentgenogram shows “Crescents” filled with contrast agent. The renal pelvis is still “lucent” as no contrast material has reached its urine Contents as yet. (C) Sixty minute roentgenogram
shows beginning of pelvic and calyceal opacification although the main portion of contents of the renal pelvis remains unopacified. (D) Four hour roentgenogram, with full mixing of contrast material and
urine, shows ureteropelvic obstruction. The patient had nephrectomy although good amount of renal
parenchyma was noted in the specimen and infection was absent.
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URETEROCELE
SEG- ‘,
MENTAL
VOL. 109, No. a Hydronephrosis in Infants and Children 387
and in adults4 although less applicable to
crying, struggling infants (Fig. ioM. Late
roentgenograms fail to show opacification
of urine since glomerular filtration is
effectively ended.
roentgenologic evaluation of the over-all
ongoing process of hvdronephrosis. It
allows a functional as well as morphologic
ii nderstanding of the roen tgenographi c
findi ngs (nephrogram , crescen t sign, ca1’-
ceal scallopi ng) as mani festations of residu at glomerular function in the presence of renal
collecti ng to bular ectasi a and pelvicalvceal
dilatation, as well as raised intrapelvic pressure.”4’6’#{176}”” The Grade ii and
Grade iii kidneys can be salvaged with
proper therapy; Grade i kidney often
does so wi thou t an y specifi c therap’.
It also makes clear that h’dronephrotic
ki dneys described previously as “nonfu nc-
FIG. 9. Diagrammatic representation of both total (top) and segmental (bottom) shell of destroyed nonfunctioning renal parenchyma with nil prog- nosis for salvage.
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388 Berdon et al. JUNE, 1970
l”io. 10. (A) “Nonvisualized” right kidney on conventional intravenous pyelogram in adult shows “soap
bubble” rim of vascularized, although nonfunctioning, renal tissue surrounding hydronephrotic calyces on nephrotomogram with cc. 90 per Cent meglumine-sodium diatrizoate/Ib. (B) Segmental shell of
nonfunctioning kidney is noted with rim of density surrounding giant renal pelvis and ureter of upper
pole of right kidney in female infant with ectopic ureterocele. (Note lucent defect in bladder from uretero-
cele.) Heminephrectomy was performed because of infection.
tioning” or “possibly seen on delayed
roentgenograrns” (Fig. 7D) do, in fact,
show titlite diagnostic findings on early
roentgenograms (Fig. 7, ‘i and B), if
adequate dosage is used and the obscuring
intestinal gas removed, either by prone
positioning’ (with pneumatic paddle corn-
pression if necessary”) or by nephrotomog-
raph’ (Fig. io’i).
ability and choice of techniques for treating
Grade II and Grade iii h’dronephrosis.
Anderson2” wi th a one-stage pyeloplastv
for ureteropelvic obstruction has claimed
excellent results in the majority of patients.
Uson et al.,2#{176}dealing with pediatric patients,
have had improving results in recent ‘ears,
even in some instances of giant hvdro-
nephrosis where the kidney and its con-
tents weigh i-2 per cent of the total body
weight.2’
tion, as a rule, has a better surgical prog-
nosis than the examples of the infected
severe Grade Ii and Grade III hvdronephro-…
1969.
From the Departments of Radiology,t and Urology4 Columbia Presbyterian Medical Center (The Babies Hospital), New York,
New York.
tric Urology, Columbia Presbyterian Medical Center, New York, New York.
380
HYDRONEPHROSIS IN INFANTS AND CHILDREN- VALUE OF HIGH DOSAGE EXCRETORY
UROGRAPHY IN PREDICTING RENAL SALVAGEABILITY*
By WALTER E. BERDON, M.l).,t SELWYN B. LEVITT, M.l)., DAVII) H. BAKER, M.I).,t JOSHUA A. BECKER, M.l).,t and AURELLO C. [SON, M.D4
N E\V VO R K, N EV YO R K
T HE use of higher doses of contrast
media in excretory urograph has led
to a better understanding of the factors in-
volved in the visualization of the normal as
well as the hsdronephrotic kidne.4’’1#{176}’
14.16.19 At the same time it has provided the
urologist with useful information to under-
take procedures to salvage more hydro-
nephrotic kidnevs.2”15’#{176}2’
The improved excretors urographic dem-
onstration of hsdronephrosis has resulted in a dramatic decrease in the need for
retrograde p’elographv in such cases. Ret-
rograde ureteral catheterization has al-
ways carried the disadvantage of potential
ureteral edema with further obstruction
and infection. The properl’ done high dos-
age excretor’ urogram suffices in most
patients not onls in defining the site of obstruction but in assessing the functional
state of the residual kidney parench\’ma
irrespective of the degree of hs’dronephrosis.
In this report we will present a working classification of hvdronephrosis, based on
high dosage excretory ii rograph’, correlat-
ing earl and delayed roentgenographic
findings. Although emphasized in the pe-
diatric age group, these findings are equally
applicable to adults if sufficient contrast
medium is used. This grading of hydro- nephrosis has been correlated with progno-
sis and, therefore, has encouraged our belief
that even the advanced stages of hsdro- nephrosis ma\’ benefit from aggressive stir- gical treatmen t where obstruction exists.2’3
The type of “hvdronephrosis” discussed
in this report is largel’ that related to
actual obstruction (such as ureteropelvic
junction or secondar- to posterior urethral
valves or ureteral edema from instrumenta-
tion) and not the medically reversed tire-
teral dilatation seen in infants and children
with urinary tract infection without actual
obstruction.
A. CHOICE OF CONTRAST AGENTS AND DOSAGE
The 3 most commonly used urographic contrast agents (sodium diatrizoate*, me-
glumine diatrizoatet and meglumine io-
thalamatet) are triiodinated, contain be-
tween 280 and 300 mg. of iodine/cc. with
milliosmolality between i,ioo and 1,400
mOsm:l. (approximately 4 times that of
blood). They differ in sodium content, with
a range between mEqu./l. in meglumine
iothalamate to 365 mEqu./l. in meglu-
mine-sodium diatrizoate to 750 mEqu./l.
for sodium diatrizoate. \Ve have found the sodium diatrizoate (hypaque-5o) the agent
of choice, both in ease of injection through
the often small (No. 21 or 23) scalp infusion
intravenous sets and, more importantly, in giving greater urinary concentration of
opaque agent than the same dose of either
meglumine agents.3 All 3 agents are equally
* Hypaque-5o (Winthrop).
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Contrast agent: 50 per cent sodium diatrizoate (hypaque-5o, Winthrop); iodine content 300
mg./cc., sodium content 750 mEqu./l., osmolality 1,300 m0sm./l.
Below 2,500 grams
2-5 years
5-10 years
.\1u Its
30-45 CC.
I cc./kg.
VOL. 109, No. a Hydronephrosis in Infants and Children 383
“safe” in terms of the virtual absence, in the pediatric age group, of severe reactions
(shock, anaphylactoid signs). Dosage is “high” in the pediatric age
group (Table i) with a decreasing dosage of roughly 3 cc./kg. at birth to 2 cc./kg. for
older infants and toddlers to 1-2 cc./kg. for
the age group to io years, after which i
cc./kg. seems to be adequate for adult pa-
tients. In practice, these doses may be too
low for patients with elevated blood urea nitrogen and decreased creatinine clearance,
and too high for others, since an undesirable
excess diuresis max’ ensue leading to a rapid appearance of a dilute, poorly defined uro-
gram. As noted above, this has been more
ofa problem with meglumine agents5”4 and
has led to our continued preference for sodium diatrizoate.5
The neonatal dosage exceeds the seem- ing adult optimum of i cc./kg.’8 because
I cc./kg. is inadequate, in our experience, to obtain consistently adequate pyelograms
in infants. The reasons for this are not fully
understood but, in part, may be related to a lowered glomerular filtration rate in the first weeks or months of life. The new-
born 3 cc./kg. dose not infrequently causes
an excessive diuresis on early roentgeno-
grams, necessi tating delaed roentgeno-
grams (in normal patients) to show well
opacified calyceal systems. \Ve do not feel
that this reflects anything unique to new- borns’4 since the same dilutional effects have been noted after infusion pylography
in adults.
fusion of the hypertonic contrast agents.’2’
16,17,19,23 Serum milliosmolality rises for some
minutes12” and then drops as fluid shifts into the vascular compartment. Serum pH
drops for as long as 30-60 minutes’2”7’
even though the contrast agents are not acidic; this may be due to an osmotically
induced shift of bicarbonate poor fluid from
the intracellular compartment leading to a vascular dilu tional acidosis.’7’23 These are
physiologic, not toxic or allergic, reac-
tions and are to be found with either meg-
lumine or sodium agents, and with both iothalamate and diatrizoate compounds.’ We believe, in dealing with sick infants and children, that this high dosage is safe when
the patient is properly hydrated. We avoid
deliberate dehydration (although such de-
hydration may well improve the pyelo-
graphic image in adults).’ With morning
examinations, the breakfast is given in fluid
form.
domen the injection is made intravenously
through a scalp vein infusion set (usually
No. 21 or 23). A prone7 coned-down roent-
genogram of the kidneys is taken as soon
after the injection as possible. A full ab-
dominal prone film is exposed at minutes
as well as a lateral film; these are reviewed
after 90 second processing to determine if
more views are needed. The i minute roent-
genogram allows an estimate of renal pa-
renchymal outlines during the nephrogram
phase; the 5 minute roentgenogram (using
sodium diatrizoate) has shown excellent
visualization with ureteral filling and blad-
der opacification. The prone position7 not
only helps facilitate ureteral filling but dis-
places obscuring intestinal gas. Delayed
and voiding roentgenograms can then be
scheduled as needed. If necessary, a pneu-
matic compression paddle is used in the
prone position to further shift bowel gas.” The lateral roentgenogram has been
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382 Berdon et al. JUNE, 1970
Adults commonly present with this pat- Grade iii hydronephrosis, with same
GRADE I -HYDRONEPHROSIS
11G. 1 . Diagrammatic representation of early and
late roentgenographic findings in Grade I hy- (.1rone)h rosi s.
added for its value in detecting lumbosacral
vertebral and neural arch anomalies that
may accompany a neurogenic bladder.
There is only frustration and failure to be
expected i fureteral reimplantation is under-
taken in a child with absence ofmuch of the
sacrum and a neurogenic bladder.
ROENTGENOGRAPHIC GRADING
OF HYDRONEPHROSIS
are really part of a continuous spectrum (in
time) ranging from the acutel\ obstructed
previously normal kidney to a longstanding
unrecognized obstruction terminating in a
nonvisualized kidney. As long as there are
sufficient functioning glomeruli, there is
removal from the blood of the iodine-con-
taming contrast agent with concentration
within the renal tubules, with final opaci-
fication of the urine retained within the
renal pelvis and ureter. Blockage within the
urinary drainage tract at an’ point causes
proximal stasis wi th pvelocalyceal dilata-
tion and may result in renal parenchvmal
atrophs or destruction. It is in this spec-
trum that the arbitrary grading of hydro-
nephrosis is presented.
EXCELLENT PROGNOSIS (Fig. i)
children we have more commonly seen such
obstruction following ureteral trauma from
retrograde pyelographv (Fig. 2, 4-C) or
ureteral reimplantation (Fig. 3, 4 and B).
The early roentgenograms show (with
con ti nued glomerular filtra tion) a progres-
sively dense nephrogram surrounding the
“lucent” outline of the dilated calvces (Fig.
2’1; and 3/f), the “lucency” representing
nonopacified urine. La ter roentgenograms usually show progressive opacification of the
urine and its flow to the point of obstruc-
tion (Fig. 2B; and 3B).
GRADE II. LONGSTANDING, ALTHOUGH INCOMPLETE,
OBSTRUCTION; PROGNOSIS REMAINS GOOD (Fig. 4)
In children this has been encountered
both in ureteropelvic junction obstruction
and in lower urinary tract malformations
( inclu di ng posterior u rethral valves,
m arked vesicou reteral reflux, u reterovesical
obstruction). In these instances, the in-
volved kidney is salvageable. The accurate
roentgenographic diagnosis is achieved as a
combination of the high dosage employed
in the excretory urogram and the continued
although impaired glomerular filtration of
the kidney. The early roentgenograms
show the nephrogram outline of renal
parenchyma (Fig. 4) although this may
be thinned by either atrophy or poor
growth. The calyces, filled with nonopaci-
fled urine, are dilated. An unusual scal-
loped layering of contrast material out-
lines the walls of the dilated pelvicalyceal
system (Fig. 5’1). Delayed roentgeno-
grams, with full mixing of contrast agent
and urine, usually allow demonstration of
the point of obstruction of urine flow
(Fig. #{231}B).
can return to a normal growth pattern with
disappearance of most of the hydronephro-
Si5 (Fig. 5C) where a correctable “obstruc-
tion” exists.
STRUCTION; PROGNOSIS: SALVAGE POSSIBLE BUT LESS
LIKELY THAN IN GRADE II (Fig. 6)
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b.... .l dysplastic l..... . .. . vesicoureteral r.... .... . . . . . _,.._ .ng system on right surrounded by nephrogram density on 5 minute roentgenogram. (B) One hour roentgenogram shows opacification and flow of urine to point of holdup. There was Spontaneous clearing in the next 2 weeks.
Hydronephrosis in Infants and ChildrenVOL. 109, No. 2 383
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DILATED CALYCES.
S OF CONTRAST
to POINT OF
l”ic;. . l)iagrammatic representation of early and late roentgenographic findings in Grade II hy- dronephrosis. Note layering of contrast medium
on early roentgenograms before full mixing occurs.
384 Berdon et al. JUNE, 1970
GRADE 1E-HYDRONEPHROSIS
EARLY NEPHROGRAM
OF NEPHROGRAN.
either more prolonged obstruction than in
Grade II or a more severe obstruction. It
also has been noted in cases of posterior
urethral valves (with and without reflux)
as well as in ureteropelvic obstruction.”9”1
The early roentgenograms (Fig. 71) show
a thinned nephrogram outline. On inter-
mediate roentgenograms (Fig. 7B) contrast
filled crescent-shaped spaces are noted.9
These surround the markedly dilated renal
pelvis which is still filled with nonopacifled
urine and appears “lucent.” The “cres-
cents” are felt to be dilated collecting
tubules’ turned 90 degrees so that they
parallel the renal outline rather than being
at right angles to it. On these roentgeno-
grams the calyces are ill-defined since they
are virtually effaced by the pronounced
dilatation of the renal pelvis. On late roent-
genograms the contrast medium slowly
opacifies the entire pelvis and ureter to the
point of obstruction (Fig. 7, C and D).
Even this advanced state of hydronephrosis
is, at times, reversible (Fig. 8, 1-C).
The required surgery will vary, depend-
ing on the functional state of the contra-
lateral kidney and the severity and cause
of the hydronephrosis. Ureteropelvic ob-
struction is best handled by primary plastic
operations (with or without temporary di-
version by means of nephrostom\ or pvelos-
tom)’) Ureterovesical obstru ction or
gross medically u n con trollei.l vesicoureteral
reflux may also need temporary diversion
be fore defin i ti ye u reteral reim plantation.
Some patients with tortuous atonic ureters
may require ileal conduit diversion (Fig.
8C).
(with its diuresis)”22 may actually induce a
“crisis” in these patients with flank pain
and a palpable mass. Such findings may
spontaneously regress and roen tgenograms
taken the next day show a less marked
hvdroneph rosis. \Veaver22 has studied such
osmotic diuresis in ureteropelvic obstruc-
tion (both in humans and in experimental
animals) ; the baseline intrapelvic pressures
(surprisingly normal in longterm obstruc-
tion) rapidly rise in response to the osmotic
diuresis and thereby overcome the uretero-
pelvic junction’s ability to decompress the
renal pelvis.22
KIDNEY; PROGNOSIS ESSENTIALLY NIL (Fig. 9)
Grade iv hydronephrosis represents
or a clinical failure to recognize hydro-
nephrotic Grades I, II and III before irre-
versible renal damage has occurred. The
causes include ureteropelvic and distal
ureteral (calculi, surgical damage) obstruc-
tion with the entire kidney involved (Fig.
io4). Segmental renal damage may occur
(Fig. ioB) as in renal duplication, with or
without ectopic ureterocele.6 In both groups
Grade iv hydronephrosis represents an ef-
fective cessation of glomerular filtration.
The aftected kidney is a shell and surgical
therapy is not curative, but directed at re-
moval (ifthese are signs ofinfection) of the
dead segment by either total or hemi-
nephrectomv. The early roentgenograms
rims (Fig. Jo, zi and B) that really reflect
vascular opacification rather than a true
nephrogram since there is no glomerular
filtration. Nonspecific “total body opaci-
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F’IG.5.(i)1r... ---..-- .--.-- 1...1.Right
hydronephrosis due to ureteropelvic obstruction shows layering of contrast medium along walls of dilated renal pelvis and calyces on supine 5 minute roentgenogram. There is large scrotal hernia present bilaterally.
( B)Prone 20 minute roentgenogram shows full mixing of urine and contrast material with demonstration of ureteropelvic obstruction. (C) Two and one half years later following right pyeloplasty. Note good
parenchymal growth. The renal function is normal.
\OL. 109, No. 2 Flydronephrosis in Infants and Children 3 85
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LATER
I
EARLY
DELAYED
GRADE -HYDRONEPHROS IS
FIG. 6. Diagrammatic representation of Grade HI
hydronephrosis. Early, intermediate and delayed roentgenographic 6 ndings. The “crescents” are contrast medium filled collecting tubules, not calyces.
fication” is also present since any vascula-
rized tissues become opaque and emphasize
the “lucent” urine within the hydroneph- rotic kidney.” Nephrotomography helps in
visualizing such kidneys in older children
FIG. 7. (‘1) Two month old male with left flank mass has Grade III obstruction at ureteropelvicjunction. One minute roentgenogram shows “lucent” renal pelvis surrounded by nephrogram of renal parenchyma.
(B) Ten minute roentgenogram shows “Crescents” filled with contrast agent. The renal pelvis is still “lucent” as no contrast material has reached its urine Contents as yet. (C) Sixty minute roentgenogram
shows beginning of pelvic and calyceal opacification although the main portion of contents of the renal pelvis remains unopacified. (D) Four hour roentgenogram, with full mixing of contrast material and
urine, shows ureteropelvic obstruction. The patient had nephrectomy although good amount of renal
parenchyma was noted in the specimen and infection was absent.
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URETEROCELE
SEG- ‘,
MENTAL
VOL. 109, No. a Hydronephrosis in Infants and Children 387
and in adults4 although less applicable to
crying, struggling infants (Fig. ioM. Late
roentgenograms fail to show opacification
of urine since glomerular filtration is
effectively ended.
roentgenologic evaluation of the over-all
ongoing process of hvdronephrosis. It
allows a functional as well as morphologic
ii nderstanding of the roen tgenographi c
findi ngs (nephrogram , crescen t sign, ca1’-
ceal scallopi ng) as mani festations of residu at glomerular function in the presence of renal
collecti ng to bular ectasi a and pelvicalvceal
dilatation, as well as raised intrapelvic pressure.”4’6’#{176}”” The Grade ii and
Grade iii kidneys can be salvaged with
proper therapy; Grade i kidney often
does so wi thou t an y specifi c therap’.
It also makes clear that h’dronephrotic
ki dneys described previously as “nonfu nc-
FIG. 9. Diagrammatic representation of both total (top) and segmental (bottom) shell of destroyed nonfunctioning renal parenchyma with nil prog- nosis for salvage.
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388 Berdon et al. JUNE, 1970
l”io. 10. (A) “Nonvisualized” right kidney on conventional intravenous pyelogram in adult shows “soap
bubble” rim of vascularized, although nonfunctioning, renal tissue surrounding hydronephrotic calyces on nephrotomogram with cc. 90 per Cent meglumine-sodium diatrizoate/Ib. (B) Segmental shell of
nonfunctioning kidney is noted with rim of density surrounding giant renal pelvis and ureter of upper
pole of right kidney in female infant with ectopic ureterocele. (Note lucent defect in bladder from uretero-
cele.) Heminephrectomy was performed because of infection.
tioning” or “possibly seen on delayed
roentgenograrns” (Fig. 7D) do, in fact,
show titlite diagnostic findings on early
roentgenograms (Fig. 7, ‘i and B), if
adequate dosage is used and the obscuring
intestinal gas removed, either by prone
positioning’ (with pneumatic paddle corn-
pression if necessary”) or by nephrotomog-
raph’ (Fig. io’i).
ability and choice of techniques for treating
Grade II and Grade iii h’dronephrosis.
Anderson2” wi th a one-stage pyeloplastv
for ureteropelvic obstruction has claimed
excellent results in the majority of patients.
Uson et al.,2#{176}dealing with pediatric patients,
have had improving results in recent ‘ears,
even in some instances of giant hvdro-
nephrosis where the kidney and its con-
tents weigh i-2 per cent of the total body
weight.2’
tion, as a rule, has a better surgical prog-
nosis than the examples of the infected
severe Grade Ii and Grade III hvdronephro-…
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