Figure 2: Management and expected outcomes of Congenital Hydronephrosis [1-7].

Image Credits: Yesenia Brito, Cristian J. Contreras Flores, Ana I. Gonzalez, Arielle N. Washington, Mohamed N. Jabri

While the initial renal ultrasound is deferred until the second day of neonatal life, the debate over using a cystourethrogram persists [10]. Nevertheless, it is recommended for all patients with antenatal hydronephrosis. In cases of suspected bladder outlet obstruction, a voiding cystourethrogram is performed within the first few days of life, and to rule out vesicoureteral reflux, it is carried out within the first month of life [10]. A radionuclide renal scan serves as a valuable guide for intervention by highlighting the differential function and drainage of the hydronephrotic fetal kidney. Implementing the Society for Fetal Urology's grading system for hydronephrosis is essential for classifying the degree of nephrosis of the fetal kidney. Despite this, prenatal hydronephrosis may often resolve spontaneously with the maturation of tubular function and an increasing ability for reabsorption [10]. In cases necessitating surgical intervention for severe hydronephrosis, treatment options include pyeloplasty for pelvic-ureteric junction obstruction when renal function is below 40%, nephrectomy for dysplastic non-functional kidneys, endoscopic valve ablation for posterior urethral valves, and ureteric reimplantation for vesicoureteric reflux [12]. This comprehensive approach underscores the nuanced management required in pediatric urology, balancing conservative strategies with targeted interventions based on the severity and nature of the condition.

While children with mild antenatal renal pelvic dilatation can often be discharged early, those with moderate to severe hydronephrosis necessitate vigilant monitoring by a multidisciplinary team. A study by Wolleneberg and colleagues [13] revealed that two-thirds of patients with severe antenatal renal pelvic dilatation required postnatal treatment, underscoring the importance of close follow-up in a specialized pediatric center. This approach involves a collaborative effort among various specialists to ensure comprehensive care for these children [13]. As the natural history and course of prenatally detected hydronephrosis are still being clinically defined, it becomes evident that collaborative efforts are indispensable. Through these collaborative efforts, proper clinical support can be provided, shedding light on the nuanced aspects of prenatally diagnosed hydronephrosis [14]. This multidisciplinary approach ensures thorough care and advances our understanding of the condition's complexities.

Over the past decade, prenatally detected hydronephrosis treatment management has significantly transformed. Previously, early surgical intervention upon diagnosis was the preferred approach, but there has been a paradigm shift towards a preference for close observation until indications of renal compromise become apparent. This updated strategy is grounded in the understanding that mild hydronephrosis commonly resolves spontaneously, restoring renal function to normal levels. A study analyzed by Koff, Jung Lim, and colleagues reported an encouraging 85% resolution of renal pelvic dilatation without surgical intervention in patients with prenatal hydronephrosis [15].

In essence, mild fetal hydronephrosis is often benign, and surgical intervention is usually unnecessary. However, the potential for poor outcomes increases for moderate to severe cases, necessitating surgical intervention. Consequently, managing fetal hydronephrosis requires a meticulous diagnostic protocol, emphasizing the critical importance of close antenatal and postnatal follow-up. For our case, surgical management is not expected to become necessary. However, it is important to continue monitoring renal anatomy and function until there is a complete resolution of the condition. Surgical intervention becomes a consideration if signs of renal compromise manifest [14]. This nuanced approach acknowledges the spectrum of severity in fetal hydronephrosis and underscores the need for personalized care based on the evolving clinical picture.

The case report on bilateral congenital hydronephrosis in a newborn male provides significant insights relevant to current practices in pediatric urology. Highlighting a case of prenatal detection and postnatal confirmation and management, the study underscores the evolving approach towards conservative management in the field. This reflects a broader trend in pediatric urology where the reliance on antenatal ultrasounds has facilitated early detection and tailored interventions, aiming to optimize renal function preservation while minimizing invasive procedures. The study's emphasis on regular monitoring and nuanced treatment decisions based on ultrasound findings and progression aligns with current recommendations advocating personalized care strategies. These findings contribute to the ongoing discourse on the best practices for managing congenital hydronephrosis, stressing the importance of a multidisciplinary approach involving neonatologists, pediatric nephrologists, and radiologists to ensure comprehensive care. This case report enhances our understanding of congenital hydronephrosis management and reinforces the need for ongoing research to refine the criteria for intervention versus continued observation.