Congenital Anomalies of the Urinary Tract

Abstract

The upper urinary tract forms as a consequence of the reciprocal inductive signals between the metanephric mesenchyme and ureteric bud. A clue to the timing of events leading to an abnormality of the upper urinary tract can be the presence also of associated anomalies of internal genitalia since separation of these systems occurs at about the 10th week of gestation. Prenatal sonography has facilitated the detection of urological abnormalities presenting with hydronephrosis. Hydronephrosis suggests obstruction, but by itself cannot be equated with it. Instead, further radiographic imaging is required to delineate anatomy and function. Now, moreover, non-surgical management of CAKUT should be considered whenever possible. Despite the widespread use of prenatal screening sonography that usually identifies the majority of congenital anomalies of the urinary tract, many children still present with febrile urinary tract infection (UTI). Regardless of the etiology for the presentation, the goal of management is preservation of renal function through mitigation of the risk for recurrent UTI and/or obstruction. In the past many children underwent surgical repair aimed at normalization of the appearance of the urinary tract. Today, management has evolved such that in most cases surgical reconstruction is performed only after a period of observation - with or without urinary prophylaxis. The opinions presented in this section are not espoused by all pediatric urologists but represent instead the practice that has evolved at Children's National Medical Center (Washington DC) based significantly on information obtained by nuclear renography, in addition to sonography and contrast cystography.

A Predictive Model of Postnatal Surgical Intervention in Children With Prenatally Detected Congenital Anomalies of the Kidney and Urinary Tract

“…Antenatal ultrasonography reveals an increasing number of renal anomalies in otherwise uncomplicated pregnancies. Thus, antenatal screening creates a clinical group of patients, often asymptomatic, for whom postnatal management and follow-up are required (35, 36). The main goal of fetal screening for uropathies is to prevent complications.…”

“…Currently, nonsurgical management of CAKUT should be considered whenever possible for infants with ANH. Nevertheless, there are still controversies regarding the best postnatal approach for many uropathies (34, 36–38). Unnecessary interventions must be avoided, but late procedures may enhance the risk of infection and renal parenchymal loss (34).…”

Approach to Pediatric Patients with UTI in the PICU

“…In comparison with adults, risk factors for urosepsis and complications of UTI in pediatric patients include congenital anomalies of the urinary tract, vesicoureteral reflux (VUR), ureteropelvic junction obstruction (UPJ), duplicated collecting system, and posterior urethral valves (PUVs), to name the most common. 8 Because children have developing immune systems, they are not immunocompetent and so are at greater risk of serious infection leading to urosepsis. 9 The incidence of identifying renal anomalies as a risk factor for urosepsis is highest in children younger than 2 years, but it can be seen in older children as well.…”

Characteristics and Findings of Childhood Urinary Tract Infection in the Last Decade

“…It is a well-known condition that causes morbidity and sequelae [1]. Although UTI itself does not seem to be a serious disease, it may indicate congenital anomalies of the kidney and urinary tract (CAKUT) or urological dysfunction, which may have an impact on a child's health later in life [2][3][4]. In the past, imaging studies -at least renal ultrasound (RUS) and voiding cystourethrogram (VCUG) -were recommended in the guidelines to be performed in young children with UTI for seeking CAKUT.…”