What is the management and treatment of Pelviectasis (pelvic dilation)?

Management and Treatment of Pelviectasis (Pelvic Dilation)

Pelviectasis typically resolves or improves in most patients during the first 2 years of life without specific intervention, requiring primarily monitoring rather than invasive treatment. 1

Definition and Diagnosis

• Pelviectasis refers to dilation of the renal pelvis, commonly detected on prenatal or postnatal ultrasound 2
• Diagnosis is primarily made through imaging studies:
  • Ultrasound is the first-line imaging modality for diagnosis and follow-up 3
  • MR Defecography provides high soft-tissue contrast resolution for direct visualization of pelvic organs when needed 4
  • Cystocolpoproctography (CCP) may be used for detecting associated pelvic floor abnormalities 4

Classification

• Pelviectasis is typically classified based on the anteroposterior pelvic diameter:
  • Stage I: < 1 cm
  • Stage II: 1-1.5 cm
  • Stage III: 1.6-2 cm
  • Stage IV: > 2 cm 2

Management Approach

Initial Evaluation

• Comprehensive ultrasound assessment to determine:

  • Unilateral vs bilateral involvement
  • Degree of dilation (anteroposterior diameter)
  • Presence of calyceal involvement
  • Associated urinary tract abnormalities 3, 5

• Voiding cystourethrography (VCUG) should be performed in children with pelviectasis regardless of:

  • Stage of dilation
  • Side affected
  • Sex of the patient 2

Treatment Algorithm

1. Isolated mild pelviectasis without calyceal involvement:

   • Observation with serial ultrasound monitoring
   • No specific therapeutic intervention required 5

2. Moderate to severe pelviectasis or cases with calyceal involvement:

   • More frequent ultrasound monitoring
   • Evaluation for vesicoureteral reflux (VUR) with VCUG
   • Assessment for obstruction with diethylenetriamine pentaacetic acid (DTPA) scan when clinically indicated 1, 6

3. Cases with confirmed obstruction or significant VUR:

   • Surgical intervention may be necessary:
     • Pyeloplasty for ureteropelvic junction obstruction
     • Urethral reimplantation for severe VUR
     • Valve ablation for posterior urethral valves 2

4. Urinary tract infection management:

   • Prompt antibiotic treatment
   • Follow-up imaging to assess for resolution or progression 3

Follow-up Protocol

• For mild isolated pelviectasis:

  • Ultrasound follow-up at 3-6 month intervals initially
  • Continue monitoring until resolution or stabilization 1

• For moderate to severe cases:

  • More frequent ultrasound monitoring (every 1-3 months)
  • Additional imaging studies as clinically indicated 6

Prognosis

• Isolated pelviectasis resolves or improves in approximately 82% of patients during the first 2 years of life 1
• Deterioration occurs in only about 5% of cases 1
• Renal growth, measured by renal length, typically remains normal 1

Important Considerations and Pitfalls

• The presence of vesicoureteral reflux does not correlate with the degree of pelviectasis - 74% of patients with VUR have an anteroposterior diameter of ≤1 cm 2
• Prenatal ultrasound is less sensitive than postnatal ultrasound in revealing obstructive uropathies 3
• An anteroposterior diameter <10 mm on neonatal ultrasound often has no pathologic significance as these typically normalize spontaneously within 1 year 3
• Progression from mild pyelectasis to hydronephrosis can occur in approximately 27% of cases, highlighting the importance of follow-up 6
• Surgical intervention is typically required in only a small percentage of cases, primarily those with confirmed obstruction or significant VUR 2, 6