0:00

This nest example is a one day old infant who had, um,

0:05

prenatal UTD two slash three.

0:07

So high risk, um, antenatal congenital hydro necrosis

0:11

who presented on day of life one for follow up, um,

0:15

ultrasound postnatally.

0:17

Um, typically we wait until after 48 hours of life,

0:21

but in cases where there is a sufficient concern, we'll go,

0:25

uh, onto postnatal imaging prior to 48 hours of life.

0:29

So the first thing we'll start with is our urinary bladder.

0:31

Here. We're in the sagittal, uh, longitudinal plane.

0:35

Now we're the transverse plane

0:36

and unfortunately this urinary bladder is not very well

0:39

distended to be able to comment one way

0:41

or the other about normal versus abnormal

0:43

bladder wall thickening.

0:45

But we go to the level of the kidneys

0:48

and here we have our right kidney

0:49

with a nice normal adrenal gland,

0:51

um, superior to the right kidney.

0:53

We have ectasis at a minimum of this kidney.

0:58

Um, we'll keep imaging to see if we see any ectasis here.

1:02

We have measured our AP renal pelvis diameter only at four

1:05

millimeters, and so far I'm not seeing any either central

1:08

or peripheral ectasis.

1:10

One note about the normal appearance of a,

1:13

uh, a newborn kidney.

1:15

They often have this layering academic appearance

1:19

of the renal pyramids.

1:21

Um, in the olden days,

1:22

back in the day when I first started training, we used

1:25

to call this tam horse wall proteinuria.

1:27

Um, but uh,

1:29

there's no tam horse wall protein in the on urine analysis

1:33

of these infants.

1:34

And so we just call this transient, uh, renal p uh,

1:38

renal pyramid hyper genicity.

1:40

It is a normal finding in infants in the first few

1:43

weeks to months of life.

1:45

Okay, so continuing

1:46

to look at the urinary tract dilatation of this right kidney.

1:49

Um, in the, uh, supine position, we only have ectasis,

1:54

no ectasis, either central or peripheral.

1:57

Moving on to the left kidney,

1:59

however, we not only have ectasis,

2:01

but I'm starting to see some central ectasis

2:04

and we'll keep going and we'll see if we see any

2:06

peripheral ectasis either.

2:08

Here we have a nice normal left adrenal gland.

2:11

The adrenal gland should look like an Oreo cookie.

2:13

Um, the, you know, birth is a stressful time

2:16

and so we have relative hypertrophy of, um,

2:20

the neonatal adrenal gland as stress kind

2:23

of goes away over the first weeks, uh, of life,

2:26

these will involute

2:27

and are typically not visualized by about six, uh, weeks

2:30

of age in, in a normal infant.

2:33

So continuing to look at this left kidney, um,

2:36

we have an AP renal pelvis diameter.

2:38

Um, I'm not sure if we're within the parenchyma here,

2:41

but it's at least five millimeters.

2:43

Um, the good news is the AP renal pelvis diameter matters

2:46

less once we start to see this central

2:49

and peripheral ectasis.

2:52

Um, so let's go to our cinematic images to make sure

2:55

that we, um, believe

2:57

that there's not only central, but there's also

2:58

Also peripheral ectasis.

3:00

Yeah, so look at this image here.

3:03

Ectasis, which was smaller than one centimeter,

3:05

which is the cutoff needed to be considered UT DP one.

3:09

But this infant, again, you grade, uh, you assign the, uh,

3:13

the UTD classification based on the presence

3:16

of the most severe finding.

3:18

So there is not only central ectasis,

3:20

but we start to see peripheral ectasis.

3:23

Um, these CAEs here are not toothpick, um,

3:26

sharp, they are blunted.

3:28

And so this is peripheral ectasis. So this is UT DP two.

3:31

So at a minimum, this patient will get a follow-up, um,

3:35

postnatal ultrasound, um, within one to six months of age.

3:40

Um, and at the discretion of the referring physician

3:43

or if this patient presents with, uh, urin, uh,

3:47

a urinary tract infection, this patient will go on to VCUG.

3:51

So this patient about a year of life, uh, later, uh,

3:55

was referred for voiding cyst urethrogram to, uh, help,

3:59

help, uh, identify the etiology

4:01

of the urinary tract dilatation.

4:03

So we start out with the scout image

4:05

to make sure there's no abnormal calcifications,

4:07

no abnormal mass effect, um, you know, nothing funky

4:11

or unexpected, no vertebral body anomalies associated.

4:15

And then we'll go on to place a,

4:16

a catheter in the urinary bladder

4:18

and we will start to fill the urinary bladder.

4:21

It's important to get an early voiding image, um, on VCOG

4:26

because we don't wanna miss a ureteral.

4:29

So a ureteral on the early feeling image will look like a

4:33

loosened round defect at the level of the ureteral.

4:37

If it's an, uh, ortho topically inserting ureter,

4:40

it'll be at the level of the, uh, bladder trigone.

4:44

As we continue to fill, we have more, uh, distension

4:47

of the urinary bladder by contrast.

4:50

Um, as we continue to fill.

4:53

Um, then once we think that the patient is about to void

4:56

or we think that the urinary bladder is adequately

4:58

distended, we will get oblique images to try to, uh,

5:02

visualize number one, the urea vesicular junction.

5:05

But then number two, um,

5:06

if we have a distended urinary bladder in the anterior only

5:10

projection, if you have a little bit

5:12

of reflux contrast in the distal ureter only,

5:15

that will be obscured on the frontal projection

5:17

by the distended urinary bladder.

5:19

Hence, we get these oblique images.

5:21

So we can see a normal insertion

5:23

of this left ureter at the level of the u um, uh,

5:27

uh, bladder trigone.

5:29

But we see contrast reflux all the way to the level

5:31

of the collecting system, which is just at the outside,

5:34

just at the edge of this, um, fluoroscopic spot image here,

5:37

we opened up our field of view to see

5:39

that there is reflux all the way

5:41

to the level of the renal pelvis.

5:42

On that left side, we get an exposure to attempt to try

5:46

to visualize more detail of CES

5:48

to see if there's intrarenal reflux,

5:50

which we don't see on this image.

5:53

We go to the, uh, contralateral oblique to make sure there's

5:56

No, no reflux intravenous

5:58

or, uh, reflux contrast into the distal right ureter

6:01

of this infant, which we don't see this male.

6:04

Uh, we always wanna make sure we have a normal urethra.

6:08

And so, uh, this is a nice comparison to that case

6:11

of posterior urethral valves

6:12

where the posterior urethra is similar caliber

6:15

to the anterior urethra on this voiding last image hold.

6:21

Um, as we are imaging, we are of course looking

6:24

to see if there's any reflux,

6:25

intravenous contrast on the contralateral side.

6:27

We start to see a little bit

6:29

of reflux contrast into the distal ureter on this right

6:32

side of this patient.

6:35

Uh, we go back up

6:36

and look at the kidneys as reflux increases

6:39

when the patient voids.

6:40

And we can see not only, uh, uh, reflux contrast

6:44

to the level of the pelvis, but we see the central

6:46

and peripheral CAEs.

6:47

Um, and so, uh, we will grade this based on, um, uh,

6:52

the level of severity of reflux contrast.

6:55

Since these CAEs are not pointy like a toothpick,

6:59

they're just a little bit blunted.

7:00

This is grade three.

7:02

So grade three re we've grade, uh,

7:05

vesco ureteral reflux grade one.

7:07

It's just in the distal ureter grade two.

7:09

It reaches the level of the renal pelvis,

7:11

but we don't have dilation of the collecting system.

7:14

Grade three not only is a reflux to the level

7:16

of the collecting system,

7:17

but there is some mild dilation of the, um, uh, caly

7:22

grade four, you have, um, more dilation.

7:24

And then grade five is severe ulous dilation

7:27

of the renal collecting systems.

7:30

And this is our final image in this patient.

7:32

We always wanna also make sure that that refluxed contrast

7:36

voids, that there's not a concomitant, uh, uro, uh,

7:39

ureteral pelvic junction obstruction, A UPJ obstruction

7:43

with concomitant reflux.

7:44

But this patient just had sico ral reflux grade three on the

7:48

left, grade one on the right.