What should be done for a 5-year-old child with a renal pelvis dilatation of 56mm on ultrasound (USG) scan, which has increased from 28mm 6 months ago?

Management of Severe Renal Pelvis Dilatation in a 5-Year-Old Child

A 5-year-old child with a renal pelvis dilatation that has increased from 28mm to 56mm over 6 months requires urgent urological and nephrological consultation for evaluation and surgical intervention due to the significant risk of kidney damage.

Evaluation Required

• Immediate referral to pediatric urology and/or nephrology specialist is necessary due to the significant increase in renal pelvis dilatation, which places this child at high risk for kidney deterioration 1

• Voiding cystourethrography (VCUG) should be performed to evaluate for vesicoureteral reflux (VUR), which is a common cause of urinary tract dilation 1

• Renal functional imaging (nuclear scan) should be obtained to assess kidney function and determine if obstruction is present 1

• Evaluation for urinary tract infection (UTI) should be performed, as children with significant urinary tract dilation are at increased risk 1

Rationale for Intervention

• The significant increase in renal pelvis dilatation from 28mm to 56mm over just 6 months indicates a potentially obstructive process that requires intervention 2

• A renal pelvis dilatation of 56mm far exceeds the 15mm threshold that has been shown to correctly identify obstruction in 80% of cases (sensitivity 73%, specificity 82%) 2

• This degree of dilatation places the child at high risk for:

  • Progressive kidney damage
  • Deterioration of renal function
  • Urinary tract infections 1, 3

Management Algorithm

1. Immediate specialist consultation

   • Pediatric urology and nephrology consultation should be obtained without delay 1

2. Imaging studies

   • VCUG to evaluate for VUR 1
   • Renal functional imaging (MAG3 or DMSA scan) to assess kidney function and obstruction 1

3. Antibiotic prophylaxis

   • Should be initiated if ureteral dilation ≥7mm is present (which is likely given the severe renal pelvis dilatation) 1

4. Surgical intervention

   • Surgical correction is indicated due to:

     • The large size of dilatation (56mm)
     • Rapid progression (doubled in 6 months)
     • High likelihood of obstruction 2

   • The most common surgical procedure would be pyeloplasty if ureteropelvic junction obstruction is confirmed 4

Important Considerations

• Conservative management is typically appropriate for mild to moderate dilatation (10-15mm) 5, but not for severe dilatation of 56mm that has rapidly progressed 2

• While many cases of mild urinary tract dilation resolve spontaneously (64-75% according to meta-analyses), severe and progressive dilatation as seen in this case is unlikely to resolve without intervention 1

• The significant increase in size over a short period strongly suggests an obstructive process rather than a non-obstructive dilatation 4, 2

• Delaying intervention in cases of significant obstruction can lead to irreversible kidney damage and loss of renal function 3

Follow-up After Intervention

• Regular ultrasound monitoring to assess resolution of dilatation 1

• Continued evaluation for UTIs, especially if the child develops fever 1

• Long-term monitoring of kidney function and growth 1

• If VUR is identified, management according to grade and clinical course will be necessary 1