Evaluation of Urinary Tract Dilation Classification System

for Grading Postnatal Hydronephrosis

Amr Hodhod,* John-Paul Capolicchio, Roman Jednak, Eid El-Sherif,
Abd El-Alim El-Doray and Mohamed El-Sherbiny
From the Departments of Surgery and Pediatric Surgery, Montreal Childrens Hospital, McGill University, Montreal,
Quebec, Canada (AH, JPC, RJ, MEl-S), and Department of Urology, Faculty of Medicine, Menoufia University,
Al Minufya, Egypt (AH, EEl-S, AEl-AEl-D)

Purpose: We assessed the reliability and validity of the Urinary Tract Dilation
Abbreviations
classification system as a new grading system for postnatal hydronephrosis.
and Acronyms
Materials and Methods: We retrospectively reviewed charts of patients who
APD anteroposterior diameter
presented with hydronephrosis from 2008 to 2013. We included patients diag-
nosed prenatally and those with hydronephrosis discovered incidentally during P postnatal category
the first year of life. We excluded cases involving urinary tract infection, PUV posterior urethral valves
neurogenic bladder and chromosomal anomalies, those associated with extra- SFU Society for Fetal Urology
urinary congenital malformations and those with followup of less than 24 months UTD Urinary Tract Dilation
without resolution. Hydronephrosis was graded postnatally using the Society for UTI urinary tract infection
Fetal Urology system, and then the management protocol was chosen. All units
VUR vesicoureteral reflux
were regraded using the Urinary Tract Dilation classification system and
compared to the Society for Fetal Urology system to assess reliability. Univariate
Accepted for publication October 18, 2015.
and multivariate analyses were performed to assess the validity of the Urinary No direct or indirect commercial incentive
Tract Dilation classification system in predicting hydronephrosis resolution and associated with publishing this article.
The corresponding author certifies that, when
surgical intervention.
applicable, a statement(s) has been included in
Results: A total of 490 patients (730 renal units) were eligible to participate. The the manuscript documenting institutional review
Urinary Tract Dilation classification system was reliable in the assessment of board, ethics committee or ethical review board
study approval; principles of Helsinki Declaration
hydronephrosis (parallel forms 0.92). Hydronephrosis resolved in 357 units (49%), were followed in lieu of formal ethics committee
and 86 units (12%) were managed by surgical intervention. The remainder of approval; institutional animal care and use
renal units demonstrated stable or improved hydronephrosis. Multivariate committee approval; all human subjects provided
written informed consent with guarantees of
analysis revealed that the likelihood of surgical intervention was predicted confidentiality; IRB approved protocol number;
independently by Urinary Tract Dilation classification system risk group, while animal approved project number.
Society for Fetal Urology grades were predictive of likelihood of resolution. * Correspondence: Room B04.2916.3, Glen
Campus, 1001 Blvd. D
ecarie, McGill University
Conclusions: The Urinary Tract Dilation classification system is reliable for Health Center, Montreal, Quebec H4A 3J1,
evaluation of postnatal hydronephrosis and is valid in predicting surgical Canada (e-mail: amrwuk@yahoo.co.uk).
intervention.

Key Words: diagnosis, hydronephrosis, multivariate analysis,

patient outcome assessment

HYDRONEPHROSIS is the most common for grading prenatal hydronephrosis.

abnormality that can be detected However, the Society for Fetal Urol-
prenatally and is present in about 1% ogy grading system is the most pop-
to 4.5% of pregnancies.1e4 Multiple ular for postnatal assessment of
classification systems have been used hydronephrosis.5e8 The Society for

0022-5347/16/1953-0725/0 http://dx.doi.org/10.1016/j.juro.2015.10.089
THE JOURNAL OF UROLOGY
2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
Vol. 195, 725-730, March 2016
Printed in U.S.A.
www.jurology.com j 725
726 URINARY TRACT DILATION CLASSIFICATION FOR GRADING HYDRONEPHROSIS
Fetal Urology grading system has limitations, such
as inability to distinguish between segmental and
diffuse parenchymal thinning, and the difference
between grade 3 and 4 disease is unclear.9e11
In 2014 a new classification system was intro-
duced to satisfy the need for a unified system
for prenatal and postnatal evaluation of hydro-
nephrosis. The new UTD classification system
stratifies hydronephrosis according to risk, aiming
to define a certain management pathway for each
risk group.12 The authors used many parameters
that had not been used before, such as ureteral
dilation, bladder status and renal parenchymal
appearance. Moreover they redefined normal
hydronephrosis variants and suggested that these
cases be discharged from the clinic.
The UTD classification system was introduced to
replace the SFU system and other grading systems.
It consists of 6 parameters, namely APD of the renal
pelvis, urinary tract dilation, parenchymal thick-
ness, parenchymal appearance, ureteral status and
bladder status.12 By comparison, the SFU system
evaluates hydronephrosis through 2 parameters
only, ie urinary tract dilation and parenchymal
thickness.7 Therefore, we hypothesized that the
UTD classification system is superior to the SFU
system. However, reliability and validity have not
previously been assessed. We evaluated the reli-
ability of the postnatal UTD classification system by
comparing it with the widely used SFU system.
Moreover, we studied the validity of the UTD clas-
sification system through prediction of outcome
(resolution and surgical intervention).
PATIENTS AND METHODS
We retrospectively reviewed the charts of all patients
presenting with hydronephrosis from January 2008 to
April 2013. We included all patients diagnosed prenatally
and those with hydronephrosis discovered incidentally
during the first year of life.
Patients with urinary tract infection, associated
neurogenic bladder, multicystic dysplastic kidney, chro-
mosomal anomalies or associated extraurinary congenital
Table 1. Grading parameters for UTD and SFU classification systems
APD (mm) Dilation
UTD classification:
Normal Less than 10 Pelvic
P1 10e15 Central calyceal
P2 15 or Greater Peripheral calyceal
P3 15 or Greater Peripheral calyceal
SFU grade:
0 e None
1 e Pelvic splitting
2 e Pelvic + few calyces
3 e Pelvic + all calyces
4 e Pelvic + all calyces
* Ureterocele is graded P3 since it is considered a bladder abnormality in the UTD classification system.
malformations were excluded. We also excluded patients
with followup less than 24 months, unless the hydro-
nephrosis had already resolved before then.
Patient demographic data were recorded. Hydro-
nephrosis was graded on postnatal ultrasound using the
SFU system. According to hydronephrosis grade, subse-
quent investigations such as voiding cystourethrography
and renography were carried out when clinically war-
ranted. Voiding cystourethrography was indicated in all
patients with high grade hydronephrosis (SFU grade 3 or
4), hydroureter or prior UTI. Renography was requested
for all patients with high grade hydronephrosis or wors-
ening hydronephrosis at followup. Management protocol,
whether conservative or surgical, was chosen and dis-
cussed with the parents.
Conservative treatment entailed periodic abdominal
ultrasound and antibiotic prophylaxis in patients with
high grade hydronephrosis and/or high grade VUR or
recurrent UTIs. Further investigations were carried out
when clinically warranted. Surgical management was
performed in cases of persistent or worsening high grade
hydronephrosis, renal function less than 40% or deterio-
ration of renal function more than 10%, recurrent UTIs
(especially with development of renal scarring on dimer-
captosuccinic acid scan), persistent high grade VUR,
presence of large or obstructive ureterocele or PUV.
We reviewed the initial abdominal ultrasound images
for all included cases, and 1 author (AH) regraded cases
blindly according to the UTD and SFU classification sys-
tems.7,12 Definition of both grading systems is provided in
table 1. We stratified renal units in patients with prenatal
hydronephrosis and normal postnatal ultrasound as
grade 0. UTD P2 was considered in the presence of pe-
ripheral calyceal dilation, dilated ureter and/or APD
greater than 15 mm.12 Moreover, presence of abnormal
bladder, parenchymal thinning and/or abnormal paren-
chymal appearance was stratified as UTD P3.
Outcome of hydronephrosis was reviewed concerning
resolution and surgical intervention. Resolved hydro-
nephrosis was defined as spontaneous disappearance of
hydronephrosis during conservative management. Renal
units with nonresolved hydronephrosis and subjected to
surgery were censored during statistical analysis.
SPSS, version 20 was used to record patient data and
for statistical analysis. The UTD classification system was
compared to the widely used reliable SFU system to
assess reliability using parallel forms analysis. The test is
Parenchymal Thickness Parenchymal Appearance Ureter Bladder
Normal Normal Normal Normal
Normal Normal Normal Normal
Normal Normal Abnormal Normal
Abnormal Abnormal Abnormal Abnormal*
Normal e e e
Normal e e e
Normal e e e
Normal e e e
Thin e e e
 URINARY TRACT DILATION CLASSIFICATION FOR GRADING HYDRONEPHROSIS 727

considered reliable when it equals 0.7 or more. The Fisher system was considered reliable for assessment of
exact test was used to evaluate categorical parameters prenatal hydronephrosis (parallel forms 0.92).
regarding normal units and dilated ureters. The number of normal renal units was 194
Univariate and multivariate analyses of hydro- (26.6%) in 149 patients according to the UTD
nephrosis resolution and surgical intervention were per-
classification system, compared to 73 (10%) in 57
formed using Cox regression survival analysis. Univariate
patients with SFU grade 0 hydronephrosis
analysis parameters included gender, prenatal presenta-
tion, laterality, dilated ureter on ultrasound, prophylactic (p <0.001). UTI was diagnosed in 2 of 149 patients
antibiotics, SFU grading system and UTD classification with normal renal units, compared to 3 of 57 with
system. Univariate parameters with a p value of less than SFU grade 0 (p 0.13). Moreover, 1 of 194 normal
0.1 were included in the multivariate Cox regression renal units was operated on, compared to 1 of 73
analysis. A p value of less than 0.05 was considered with SFU grade 0 hydronephrosis (p 0.48). To
significant. study the possible economic impact of following
patients with normal variant urinary tract dilation,
we excluded those who needed followup due to
RESULTS higher contralateral UTD grade and those already
Of 647 cases reviewed 157 were excluded from the discharged from care when the first postnatal ul-
study. Excluded patients had presented with initial trasound demonstrated SFU grade 0. There were
UTI (15 patients), neurogenic bladder (6), multi- 56 patients (11.4% of all included patients) who had
cystic dysplastic kidney (5) and genetic or multiple a median followup of 12.17 months (range 1.97
congenital malformations (13). In addition, 118 pa- to 61.37). In this subgroup the mean number of ul-
tients with a followup of less than 24 months and trasounds requested during followup was 1.6 (range
nonresolved hydronephrosis were excluded. 1 to 6).
A total of 490 cases (730 renal units) were Of 86 cases (112 renal units) with ureteral dila-
included in the study, with 250 involving unilateral tion (none of which was associated with ureterocele
and 240 bilateral disease. Of the patients 376 (77%) or PUV) 31 (31, 36%) manifested UTI during fol-
were male and 114 (23%) were female. Median age lowup (p <0.001), compared to 12 of 28 (25%)
at presentation was 27 days (range 1 to 350). managed by surgical intervention (p <0.001). All
Hydronephrosis was diagnosed prenatally in 654 renal units manifesting UTI or treated with surgical
renal units (90%) and discovered incidentally dur- intervention were considered UTD P2 (22 units)
ing the first year of life in 76 (10%). Incidental cases or P3 (25).
consisted of postnatally diagnosed bilateral hydro- Univariate assessment revealed that the UTD
nephrosis in infants with prenatal unilateral dis- and SFU classification systems were significantly
ease (62 renal units), UTI (3) and undocumented associated with resolution and surgical interven-
causes (11). Hydronephrosis was right sided in 299 tion. Multivariate analysis showed that the SFU
renal units (41%) and left sided in 431 (59%). grading system was an independent predictor of
Grading of hydronephrosis using the UTD and SFU hydronephrosis resolution (table 3), while the UTD
systems is outlined in table 2.
Median followup was 21.7 months (range 1.97 to
83.4). Of the patients 49% (357 renal units) had
Table 3. Univariate and multivariate analyses of
resolution with a median followup of 19.8 months, hydronephrosis resolution
while 11.8% (65 patients, 86 renal units) underwent
Univariate Analysis Multivariate Analysis
surgical intervention. The remainder of the renal
units showed stable or improved hydronephrosis. HR CI p Value HR CI p Value
Using the test of reliability, the UTD classification Gender 0.891 0.650e1.22 0.470
Presentation 0.664 0.497e0.889 0.006 0.818 0.558e1.783 0.305
Laterality 0.780 0.6 e1.013 0.062 1.313 0.966e1.783 0.082
Dilated ureter 0.546 0.385e0.774 0.001 1.613 0.737e3.528 0.213
Table 2. Grading of renal units with hydronephrosis according No antibiotic 2.487 1.894e3.264 <0.001 1.837 1.292e2.613 <0.001
to UTD and SFU classification systems prophylaxis
SFU grade:
No. UTD Classification 0 1 <0.001 1 0.005
SFU Grade Normal P1 P2 P3 Total No. (%) 1 0.912 0.655e1.269 0.589 d d d
2 0.490 0.361e0.665 <0.001 0.313 0.11 e0.892 0.03
0 63 0 10 0 73 (10) 3 0.177 0.115e0.273 <0.001 0.176 0.063e0.490 0.001
1 131 0 6 1 138 (18.9) 4 0.115 0.046e0.287 <0.001 0.256 0.002e2.993 0.277
2 0 260 30 2 292 (40) UTD P:
3 0 30 108 7 145 (19.9) Normal 1 <0.001 1 0.524
4 0 0 0 82 82 (11.2) 1 0.472 0.373e0.596 <0.001 1.201 0.420e3.437 0.733
2 0.246 0.176e0.346 <0.001 0.724 0.233e2.251 0.576
Total No. (%) 194 (26.6) 290 (39.7) 154 (21.1) 92 (12.6) 730 (100) 3 0.119 0.052e0.270 <0.001 0.386 0.038e3.922 0.421
728 URINARY TRACT DILATION CLASSIFICATION FOR GRADING HYDRONEPHROSIS

classification system was an independent predictor
of surgical intervention (table 4). Antibiotic pro-
phylaxis was associated with surgical intervention,
while no antibiotic prophylaxis was associated with
resolution. The association of antibiotic prophylaxis
with surgery may be related to the fact that it was
prescribed for patients with high grade hydro-
nephrosis, high grade VUR or UTI, who are more
likely to require surgery. On the other hand, anti-
biotic prophylaxis was not prescribed for patients
with low grade hydronephrosis, who are more likely
to have resolution.
DISCUSSION
There are multiple grading systems for the evalua-
tion of prenatal hydronephrosis. Many of them are
subjective, such as the SFU system, which gained
popularity for grading postnatal hydronephrosis,
and others are objective, such as APD of the renal
pelvis, which is used extensively for prenatal
grading of hydronephrosis.6,7 Due to its modest
interrater reliability, the SFU system has under-
gone multiple modifications.9e11
Moreover, none of the available hydronephrosis
grading systems can effectively define hydro-
nephrosis status inclusive of the prenatal and post-
natal periods. The need for a new unified grading
system that can be used for evaluation of prenatal as
well as postnatal hydronephrosis led Nguyen et al to
develop the UTD classification system.12
Some may argue that grouping patients with
known differences in natural history, such as VUR,
nonrefluxing hydroureter, ureteroceles and PUV, in
our study population invalidates our results. How-
ever, the UTD classification system aims to catego-
rize patients into appropriate risk groups to direct
Table 4. Univariate and multivariate analyses of surgical
intervention
Univariate Analysis Multivariate Analysis
HR CI p Value HR
Gender 1.549 0.922e2.602 0.098 1.170 0.858e1.462
Presentation 0.355 0.132e0.957 0.042 1.428 0.321e6.366
Laterality 2.888 1.671e4.992 <0.001 1.6 0.874e2.927
Dilated ureter 0.579 0.367e0.912 0.004 1.022 0.582e1.793
No antibiotic 1.719 1.106e2.672 0.016 0.416 0.232e0.747
prophylaxis
SFU grade:
0 0.038 0.005e0.277 <0.001 0.001 0 e2.58
1 0 0 e4.01 0.920 d d d
2 0.028 0.01 e0.078 <0.001 0.108 0.008e1.439
3 0.299 0.14 e0.374 <0.001 0.766 0.228e2.573
4 1 <0.001 1
UTD P:
Normal 0.016 0.002e0.117 <0.001 0 0 e3.23
1 0.007 0.001e0.53 <0.001 0.053 0.004e0.747
2 0.204 0.123e0.339 <0.001 0.724 0.004e0.747
3 1 <0.001 1 0.045
further imaging, treatment and followup regardless
of the diagnosis. For that reason the UTD classifi-
cation system has included new variables such
as bladder and ureteral status. Therefore, in the
current study we did not classify patients with
postnatal hydronephrosis according to diagnosis.
Moreover, limiting the study to a certain diagnosis,
such as ureteropelvic junction obstruction, would
remove 2 important parameters from the UTD
classification system, namely ureteral and bladder
status. This omission might lead one to the incorrect
conclusion that the UTD classification system has no
advantage over the SFU grading system.
In the current study we used the SFU grading
system that was introduced in 1993 and evaluated
for reliability by Keays et al11 and later by Kim
et al.13 Modifications introduced in 2010 have not
been evaluated for reliability.7,14
The UTD classification system was observed to be
reliable compared to the SFU system regarding
diagnosis of hydronephrosis. According to UTD
classification system, 194 renal units (149 patients)
had normal variant hydronephrosis. The febrile UTI
rate was 1.34% (2 of 149 patients), which resembles
the risk of UTI in the general pediatric popula-
tion.15,16 Harding et al stated that the greater inci-
dence of complications for minimal hydronephrosis
applies to patients with ureteral and calyceal dila-
tion.17 Moreover, they recommend discharging these
patients from care after a single postnatal ultra-
sound, except in the presence of ureteral or calyceal
dilation. According to our results, significantly
more patients can be categorized as having normal
ureters according to the UTD classification system
compared to those diagnosed with SFU grade 0, with
a low risk of UTI or surgical intervention. Therefore,
we support discharging these patients from care for
better resource utilization and to avoid an unnec-
essary psychological burden on the parents, and
suggest that there is no need for a urology visit or
ultrasound examination except in the presence of a
UTI or renal pain.
CI p Value Ureteral dilation is considered a risk factor for
UTI.18 A survey of multiple studies concerning
0.405
0.640 management of megaureter demonstrated that
0.128 29.2% of discovered megaureters would require
0.940 initial surgical intervention and 19% of conserva-
0.003
tively managed ureters may be treated with sur-
gery.19 Our study revealed that 42% of dilated
0.963 ureters manifested UTI or were treated with surgi-
0.092 cal intervention. Thus, inclusion of ureteral dilation
0.667 within the grading parameters of the UTD classifi-
0.57 cation system will remedy a significant pitfall of the
0.96 SFU grading system.
0.03 In this study the UTD classification system was
0.013 predictive of surgical intervention, while the SFU
grading system was not. This capability allows
 URINARY TRACT DILATION CLASSIFICATION FOR GRADING HYDRONEPHROSIS 729

better identification of which cases will likely
require surgical intervention, and thus in which
close followup is more appropriate. Multivariate
analysis showed that the UTD classification system
is a valid prognostic tool in predicting surgical
intervention, while SFU grades were predictive of
the likelihood of resolution. Longpre et al found that
APD was the only independent predictor of the
likelihood of surgery, while SFU grade 4 and APD
independently predicted the likelihood of resolu-
tion.20 Their results are similar to ours in that APD
is a parameter of the UTD classification system.
There are some parameters within the UTD
classification system that are vague in definition,
such as parenchymal thickness and ureteral dila-
tion, which may be confusing during assessment.
Thus, further studies could be directed to define the
parenchymal thinning and hydroureter clearly.
Moreover, protocols of management should be
justified for each risk group through prospective
studies.
In the current study the postnatal UTD classi-
fication system proved to be reliable and to have
some advantages over the SFU grading system.
Potential advantages of the UTD classification
system include its criteria for defining the normal
variant and using ureteral dilation as a parameter
of risk categorization. Moreover, it is a valid pre-
dictor of surgical intervention. Although the SFU
grading system was demonstrated in this study to
be more predictive of hydronephrosis resolution,
this finding may simply be related to the structure
of the UTD classification system, since any unit
with a dilated ureter is considered UTD P2 even
without hydronephrosis. Further studies evalu-
ating the association between prenatal and post-
natal diagnoses and outcome may reveal a unique
correlation.
Our study has some limitations, including its
retrospective nature. In addition, the multiple
urologists included may have different thresholds
for antibiotic prophylaxis prescription as well as
timing and decision regarding surgical interven-
tion. However, the involvement of multiple urol-
ogists is reflective of the common practice.
Furthermore, the followup is relatively short for
evaluating outcomes of hydronephrosis. However,
our results are comparable to those of other
studies.20,21
CONCLUSIONS
The UTD classification system is reliable for the
evaluation of postnatal hydronephrosis and is valid
in predicting surgical intervention. Inclusion of
ureteral dilation as a risk parameter in the UTD
classification system provides a marked advantage
over the SFU grading system. Moreover, the UTD
classification system, through its definition of
normal variants, may decrease the need for ultra-
sound examinations and doctor visits, allowing
better resource utilization.

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