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Antenatal Hydronephrosis-Infant

Variant: 1   Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder Usually Appropriate O
Voiding urosonography Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
MRI abdomen and pelvis with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
Nuclear medicine cystography Usually Not Appropriate ☢☢
DTPA renal scan Usually Not Appropriate ☢☢☢
MAG3 renal scan Usually Not Appropriate ☢☢☢

Variant: 2   Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder follow-up in 1-6 months Usually Appropriate O
Voiding urosonography Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
MRI abdomen and pelvis with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
Nuclear medicine cystography Usually Not Appropriate ☢☢
DTPA renal scan Usually Not Appropriate ☢☢☢
MAG3 renal scan Usually Not Appropriate ☢☢☢

Variant: 3   Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder follow-up in 1-6 months Usually Appropriate O
Voiding urosonography May Be Appropriate O
Fluoroscopy voiding cystourethrography May Be Appropriate ☢☢
MRI abdomen and pelvis with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
Nuclear medicine cystography Usually Not Appropriate ☢☢
DTPA renal scan Usually Not Appropriate ☢☢☢
MAG3 renal scan Usually Not Appropriate ☢☢☢

Variant: 4   Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder follow-up in 1-6 months Usually Appropriate O
Fluoroscopy voiding cystourethrography Usually Appropriate ☢☢
MAG3 renal scan Usually Appropriate ☢☢☢
Voiding urosonography Usually Not Appropriate O
MRI abdomen and pelvis with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
Nuclear medicine cystography Usually Not Appropriate ☢☢
DTPA renal scan Usually Not Appropriate ☢☢☢

Variant: 5   Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder follow-up in 1-6 months Usually Appropriate O
Voiding urosonography Usually Appropriate O
Fluoroscopy voiding cystourethrography Usually Appropriate ☢☢
MAG3 renal scan Usually Appropriate ☢☢☢
Nuclear medicine cystography May Be Appropriate (Disagreement) ☢☢
MRI abdomen and pelvis with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
DTPA renal scan Usually Not Appropriate ☢☢☢

Variant: 6   Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
Procedure Appropriateness Category Peds Relative Radiation Level
US kidneys and bladder follow-up in 1-6 months Usually Appropriate O
MAG3 renal scan Usually Appropriate ☢☢☢
MRI abdomen and pelvis with IV contrast May Be Appropriate (Disagreement) O
MRI abdomen and pelvis without and with IV contrast May Be Appropriate O
DTPA renal scan May Be Appropriate ☢☢☢
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O

Panel Members
Brandon P. Brown, MD, MAa; Stephen F. Simoneaux, MDb; Cynthia K. Rigsby, MDc; Ramesh S. Iyer, MD, MBAd; Adina L. Alazraki, MDe; Dianna M. E. Bardo, MDf; Sherwin S. Chan, MD, PhDg; Tushar Chandra, MDh; Jonathan R. Dillman, MD, MSci; Scott R. Dorfman, MDj; Matthew D. Garber, MDk; Michael M. Moore, MDl; Jie C. Nguyen, MD, MSm; Craig A. Peters, MDn; Narendra S. Shet, MDo; Alan Siegel, MD, MSp; Muhammad Waseem, MD, MSq; Boaz Karmazyn, MDr.
Summary of Literature Review
Introduction/Background
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
A. US Kidneys and Bladder 
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
B. Fluoroscopic Voiding Cystourethrography
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
C. Voiding Urosonography
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
D. Nuclear Medicine Cystography
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
E. DTPA Renal Scan
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
F. MAG3 Renal Scan
Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
G. MRI Abdomen and Pelvis
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
A. US Kidneys and Bladder Follow-Up in 1–6 Months
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
B. Fluoroscopic Voiding Cystourethrography
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
C. Voiding Urosonography
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
D. Nuclear Medicine Cystography
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
E. DTPA Renal Scan
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
F. MAG3 Renal Scan
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
G. MRI Abdomen and Pelvis
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
A. US Kidneys and Bladder Follow-Up in 1–6 Months
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
B. Fluoroscopic Voiding Cystourethrography
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
C. Voiding Urosonography
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
D. Nuclear Medicine Cystography
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
E. DTPA Renal Scan
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
F. MAG3 Renal Scan
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
G. MRI abdomen and pelvis
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
A. US Kidneys and Bladder Follow-Up in 1–6 Months
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
B. Fluoroscopic Voiding Cystourethrography
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
C. Voiding Urosonography
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
D. Nuclear Medicine Cystography
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
E. DTPA Renal Scan
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
F. MAG3 Renal Scan
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
G. MRI Abdomen and Pelvis
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
A. US Kidneys and Bladder Follow-Up in 1–6 Months
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
B. Fluoroscopic Voiding Cystourethrography
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
C. Voiding Urosonography
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
D. Nuclear Medicine Cystography
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
E. DTPA Renal Scan
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
F. MAG3 Renal Scan
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
G. MRI Abdomen and Pelvis
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
A. US Kidneys and Bladder Follow-Up in 1–6 Months
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
B. DTPA Renal Scan
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
C. MAG3 Renal Scan
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
D. MRI Abdomen and Pelvis
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.