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Shalash B, Ernst M, Stout M, Asti L, McLeod DJ. Clearance While Upright on Initial Diuretic Renography Predicts the Need for Surgery in Children With Congenital Hydronephrosis. Urology 2024; 184:212-216. [PMID: 38040296 DOI: 10.1016/j.urology.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To improve the predictive ability of diuretic renography (DR) for surgical intervention in children with congenital hydronephrosis (CH) and concern for ureteropelvic junction obstruction. METHODS Children with CH born between 2007 and 2021 who underwent initial DR prior to 6months of life, had both clearance while upright (CUP) and T ½ reported, and did not have immediate surgical intervention after the first DR were retrospectively evaluated for surgical intervention during the period of clinical observation. Once the optimal cut-points were identified for CUP and T ½, they were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In total 65 patients were included in the final analysis with 33 (50.8%) undergoing surgical intervention (pyeloplasty) and 32 (49.2%) still on observation at last follow-up. The optimal cut-points for predicting surgical intervention were 28.1 minutes for T ½ and 22.4% for CUP. Applying the CUP cut-point of 22.4% we achieved a sensitivity of 60.6% (95% CI: 43.9-77.3), specificity of 96.9% (95% CI: 90.1-100.0), positive predictive value of 95.2% (95% CI: 86.1-100.0), and negative predictive value of 70.5% (95% CI: 57.0-83.9). CONCLUSION A low CUP accurately predicts surgical intervention in children with CH who are initially observed. Although there is no singular measure on DR that can with absolute certainty predict future clinical course, our data do suggest there is utility in incorporating CUP (if <22.4%) into the decision process. Further research is necessary to help guide the management of children with intermediate CUP values.
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Affiliation(s)
- Bayan Shalash
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Michael Ernst
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH
| | - Megan Stout
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lindsey Asti
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Daryl J McLeod
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH; The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH.
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Khondker A, Kwong JCC, Chancy M, D'Souza N, Kim K, Kim JK, Tse LN, Chua M, Yadav P, Erdman L, Weaver J, Lorenzo AJ, Rickard M. Predicting obstruction risk using common ultrasonography parameters in paediatric hydronephrosis with machine learning. BJU Int 2024; 133:79-86. [PMID: 37594786 DOI: 10.1111/bju.16159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE To sensitively predict the risk of renal obstruction on diuretic renography using routine reported ultrasonography (US) findings, coupled with machine learning approaches, and determine safe criteria for deferral of diuretic renography. PATIENTS AND METHODS Patients from two institutions with isolated hydronephrosis who underwent a diuretic renogram within 3 months following renal US were included. Age, sex, and routinely reported US findings (laterality, kidney length, anteroposterior diameter, Society for Fetal Urology [SFU] grade) were abstracted. The drainage half-times were collected from renography and stratified as low risk (<20 min, primary outcome), intermediate risk (20-60 min), and high risk of obstruction (>60 min). A random Forest model was trained to classify obstruction risk, here named the 'Artificial intelligence Evaluation of Renogram Obstruction' (AERO). Model performance was determined by measuring area under the receiver-operating-characteristic curve (AUROC) and decision curve analysis. RESULTS A total of 304 patients met the inclusion criteria, with a median (interquartile range) age of diuretic renogram at 4 (2-7) months. Of all patients, 48 (16%) were low risk, 102 (33%) were intermediate risk, 156 (51%) were high risk of obstruction based on diuretic renogram. The AERO achieved a binary AUROC of 0.84, multi-class AUROC of 0.74 that was superior to the SFU grade, and external validation (n = 64) binary AUROC of 0.76. The most important features for prediction included age, anteroposterior diameter, and SFU grade. We deployed our application in an easy-to-use application (https://sickkidsurology.shinyapps.io/AERO/). At a threshold probability of 30%, the AERO would allow 66 more patients per 1000 to safely avoid a renogram without missing significant obstruction compared to a strategy in which a renogram is routinely performed for SFU Grade ≥3. CONCLUSIONS Coupled with machine learning, routine US findings can improve the criteria to determine in which children with isolated hydronephrosis a diuretic renogram can be safely avoided. Further optimisation and validation are required prior to implementation into clinical practice.
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Affiliation(s)
- Adree Khondker
- Temerty Faculty of Medicine, University of Toronto, Toronto, Onterio, Canada
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
| | - Jethro C C Kwong
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Onterio, Canada
- Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Onterio, Canada
| | - Margarita Chancy
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
| | - Neeta D'Souza
- Department of Urology, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kellie Kim
- Temerty Faculty of Medicine, University of Toronto, Toronto, Onterio, Canada
| | - Jin K Kim
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Onterio, Canada
| | - Lai Nam Tse
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
| | - Michael Chua
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Onterio, Canada
| | - Priyank Yadav
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
| | - Lauren Erdman
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
- Vector Institute, Toronto, Onterio, Canada
| | - John Weaver
- Department of Urology, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Onterio, Canada
| | - Mandy Rickard
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Onterio, Canada
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Hester AG, Krill A, Shalaby-Rana E, Rushton HG. Initial observational management of hydronephrosis in infants with reduced differential renal function and non-obstructive drainage parameters. J Pediatr Urol 2022; 18:661.e1-661.e6. [PMID: 35989171 DOI: 10.1016/j.jpurol.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/03/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hydronephrosis secondary to ureteropelvic junction (UPJ) obstruction is a common finding in infants with prenatally-diagnosed hydronephrosis and often results in pyeloplasty due to obstructive drainage parameters and/or renal function compromise. However, little is known regarding the natural history of hydronephrosis with reduced differential renal function (DRF) but non-obstructive drainage. OBJECTIVE We sought to explore our experience with initial observational management of these patients. STUDY DESIGN A retrospective review of our institutional database of all diuretic MAG-3 renal scans obtained between 2000 and 2016 was performed. We included patients with antenatally-detected unilateral hydronephrosis ≥ SFU grade 2, first MAG-3 scan prior to 18months of age, DRF <40% and post-furosemide half-time (T1/2) <20 min. Exclusion criteria were: hydroureter, VUR, solitary kidney, duplication anomalies. Outcomes of interest were a progression of T1/2 ≥ 20 min and/or further decline in DRF >5%. RESULTS Of 704 patients with unilateral hydronephrosis, 91 had DRF≤40%, of which 29 (18 boys, 11 girls) met our inclusion criteria and were followed for a mean of 2.8 years (1.4 months-6.6 years). Mean age at first sonogram was 2.3 months. 2 patients had SFU grade 2, 16 had grade 3, and 9 had grade 4 hydronephrosis, and 2 unknown grade. Median half-time on initial MAG-3 scan across all patients was 10 min (3-20 min). Initial MAG3 scan was performed at a median of 2.3 months of age (0.3-17 months). 22/29 patients had >1 MAG3 scan. Of the 7 remaining, 5 were lost to follow-up and 2 demonstrated improvement in hydronephrosis. Worsening drainage occurred in 10/22(45%), median final T1/2 was 45.5 min 8 of these underwent pyeloplasty and 2 were lost to follow up. 4/22 patients (18%) had progressive decline in DRF (mean 8.3%, range 6-10%). 3/4 maintained non-obstructive drainage patterns and stable/improved hydronephrosis, and 1 underwent pyeloplasty. 13/18 remaining patients had stable DRF and 5 had improvement in DRF. 7(39%) of these underwent surgery for worsening drainage (Summary Figure). Overall, 7/29(24%) patients had sufficient resolution of hydronephrosis to be discharged from our care, 8(28%) are under continued observation, 9(31%) underwent pyeloplasty, and 5(17%) were lost to follow-up. In the observational group [median follow-up 4.5 years (3.7-6.6 years)], all 8 demonstrated improved non-obstructive drainage (T1/2 <20 minutes) and/or improvement in hydronephrosis. 4/10(40%) with DRF <35% underwent pyeloplasty versus 5/19(26%) with DRF 35-40%(p=0.67). CONCLUSION Initial observational management of unilateral hydronephrosis with reduced DRF and nonobstructive drainage is recommended as most kidneys maintain nonobstructive drainage and do not demonstrate further decline in DRF. Even when DRF decreases, the majority remain non-obstructive. Worsening drainage over time more often leads to the decision for pyeloplasty rather than change in DRF.
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Affiliation(s)
- Austin G Hester
- Division of Urology, Children's National Medical Center, Washington, DC, USA.
| | - Aaron Krill
- Division of Urology, Children's National Medical Center, Washington, DC, USA
| | - Eglal Shalaby-Rana
- Department of Radiology, Children's National Medical Center, Washington, DC, USA
| | - H Gil Rushton
- Division of Urology, Children's National Medical Center, Washington, DC, USA
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Hedayati R, Hekmat S, Rastgou F, Yaghoobi N, Firoozabadi H, Bitarafan-Rajabi A, Malek H, Arabshameli S. Role of Technetium-99m-Ethylenedicysteine in the Calculation of Differential Renal Function: A Comparison Study with Dimercaptosuccinic Acid Renal Scintigraphy. Indian J Nucl Med 2021; 36:21-24. [PMID: 34040291 PMCID: PMC8130686 DOI: 10.4103/ijnm.ijnm_94_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose of the Study: The aim of our study was to compare the technetium-99m (Tc-99m)-ethylenedicysteine (EC) renography calculation of differential renal function (DRF) with this measurement using Tc-99m-dimercaptosuccinic acid (DMSA) scintigraphy. Materials and Methods: Patients referred to our department were included in our study, and both DMSA and EC scans were performed for each patient according to the standard imaging protocols. A checklist was filled for each patient. Statistical analysis was performed using correlation and regression methods. Results: Forty-two patients (mean age: 3.6 ± 3.4 years), including 32 boys and 10 girls, participated in our study. The results of EC scintigraphy were significantly correlated with the values of DMSA scintigraphy (P < 0.001). Performing linear regression, EC renography significantly (P < 0.001) predicted the DRF as it was calculated by DMSA scintigraphy (R2 = 0.92, P < 0.001). This test was significant in both male and female subgroups (P < 0.001). Conclusions: Overall, our study findings were similar to the reported results in the other reviewed studies, showing that Tc-99m-EC can be considered as an alternative for DMSA scintigraphy, providing interchangeable results.
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Affiliation(s)
- Raheleh Hedayati
- Department of Nuclear Medicine, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Hekmat
- Department of Nuclear Medicine, School of Medicine, Hasheminejad Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Fereydoun Rastgou
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Yaghoobi
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Firoozabadi
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Bitarafan-Rajabi
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Malek
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Somaie Arabshameli
- Department of Nuclear Medicine and Molecular Imaging, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Passoni NM, Peters CA. Managing Ureteropelvic Junction Obstruction in the Young Infant. Front Pediatr 2020; 8:242. [PMID: 32537441 PMCID: PMC7267033 DOI: 10.3389/fped.2020.00242] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
In the last decade, management of congenital UPJ obstruction has become progressively observational despite the lack of precise predictors of outcome. While it is clear that many children will have resolution of their hydronephrosis and healthy kidneys, it is equally clear that there are those in whom renal functional development is at risk. Surgical intervention for the young infant, under 6 months, has become relatively infrequent, yet can be necessary and poses unique challenges. This review will address the clinical evaluation of UPJO in the very young infant and approaches to determining in whom surgical intervention may be preferable, as well as surgical considerations for the small infant. There are some clinical scenarios where the need for intervention is readily apparent, such as the solitary kidney or in child with infection. In others, a careful evaluation and discussion with the family must be undertaken to identify the most appropriate course of care. Further, while minimally invasive pyeloplasty has become commonly performed, it is often withheld from those under 6 months. This review will discuss the key elements of that practice and offer a perspective of where minimally invasive pyeloplasty is of value in the small infant. The modern pediatric urologist must be aware of the various possible clinical situations that may be present with UPJO and feel comfortable in their decision-making and surgical care. Simply delaying an intervention until a child is bigger may not always be the best approach.
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