1- Prenatal management
Counselling the parents is one of the most important aspects of care. The prognosis for an hydronephrotic kidney, even if severely affected, is hopeful. An hydronephrotic kidney may still be capable of providing meaningful renal function, whereas a severely hypoplastic and dysplastic kidney has a hopeless outlook. It is important to explain to the parents the timing and accuracy of establishing the definitive diagnosis for their child. In some cases, there is an obvious indication of severity, including massive bilateral dilatation, bilateral evidence of hypoplastic dysplasia, progressive bilateral dilatation with oligohydramnios, and pulmonary hypoplasia. Intrauterine intervention is rarely indicated and should only be performed in well-experienced centres.
2- Ureteropelvic junction obstruction
It is most important to make the decision on the basis of serial investigations, applying the same technique and performed by the same institution under standardized circumstances. Symptomatic obstruction (recurrent flank pain, urinary tract infection) requires surgical correction using a pyeloplasty, according to the standardized open technique of Hynes and Anderson. Recently, increasingly more data have become available supporting the use of a laparoscopic or retroperitoneoscopic approach to achieve a dismembered pyeloplasty.
In addition, laparoscopic suturing has been improved by the use of robotics. However, these methods lack very long-term data and will require time to be fully proven. In asymptomatic cases, conservative follow-up can be the treatment of choice.
Indications for surgical intervention are an impaired split renal function (< 40%), a decrease of split renal function of more than 10% in subsequent studies, increased anteroposterior diameter on the ultrasound, and grade III and IV dilatation as defined by the Society for Fetal Urology.
Concerning the treatment options of secondary megaureters (treatment of Vesicoureteric reflux in children.
If a functional study reveals and confirms adequate ureteral drainage, conservative management is the best option. Initially, low-dose prophylactic antibiotics within the first year of life are recommended for prevention of urinary tract infections, although there are no prospective randomised trials to evaluate this regimen.
With spontaneous remission rates of up to 85% in primary megaureter cases, surgical management is no longer recommended, except for megaureters with recurrent UTI, deterioration of split renal function and significant obstruction.
The initial approach to the ureter can be either intravesical, extravesical, or combined. Straightening the ureter is necessary without devascularisation. Ureteral tapering should enhance urinary flow into the bladder. The ureter must be tapered to achieve a diameter for an antireflux repair. There are several tailoring techniques, e.g. ureteral imbrication or excisional tapering.
With the use of routine perinatal sonography, hydronephrosis caused by UPJ or UVJ obstruction is now increasingly recognised. Meticulous and repeat postnatal evaluation is mandatory to try to identify any obstructive cases at risk of renal deterioration and requiring surgical reconstruction. Surgical methods are fairly standardized and have a good clinical outcome.