There are some children who come to the clinic when the hydrocele is already very serious, at first thought that it is difficult to detect the hidden onset of hydrocele, but did not expect the parents to say: they knew it before the birth, and saw that there is nothing wrong with the birth of the child, so they did not see the doctor. There are also some nephrolithiasis after surgery, they lost contact, and when they come back again, the problem has dragged on too much to turn back.
So it is important to warn all parents of children with hydrocele a word of caution: follow-up review is important!!!
Prenatal hydronephrosis, although the vast majority of children can have improvement after birth without the need for surgery. However, it is important to follow up to determine which child needs surgery, which child does not, and when surgery is needed.
Above: Grading of fetal hydronephrosis
The ultrasound “hydronephrosis reduction” within 3 days after birth is not reliable, because the child is in the dehydration period at that time. Even if the first ultrasound is “normal”, it is still necessary to check again after 4 weeks.
There is no uniform plan for what kind of examination should be performed after birth. I can only talk about the follow-up of hydronephrosis with my own experience, which is purely for reference only (taking obstructive hydronephrosis at the pelvic ureteral junction as an example).
After the child is born, I recommend ultrasound once a month*3 times, then once every three months*3 times, then once every six months*2 times, and then once a year*for life.
During the follow-up, if the hydronephrosis tends to worsen, it is necessary to increase the density of follow-up review and promptly operate when there is an indication for surgery.
Flowing water does not rot, and the household pivot is not worm-eaten. In children with hydronephrosis, it is best to have a routine urine test at each fever to rule out urinary tract infection. Especially in infants and newborns, with low resistance, hydrocele combined with urinary tract infection has a lot of chances and is prone to recurrence.
CT, MR, nuclear, IVP, cystourethrography, etc. are only needed in special cases (e.g. considering surgery or differential diagnosis).
Here is the focus on the follow-up after surgery
Again, the goal of treatment for hydronephrosis is not to eliminate the fluid, but to unblock the channels. Often parents mistakenly believe that if the surgeon drains the fluid from the kidney during surgery, there will be no fluid. The kidney is the place where urine is produced, and this production is constant, and it is impossible to release the urine in the kidney cleanly. Even if it is cleared at once, it will soon be full again. After the channel is cleared, the urine can be drained away in time, and the hydronephrosis will be stabilized or reduced to some extent, which is “good”.
Is there any case that the fluid will disappear completely after surgery? Yes, one in a hundred, depending on luck, no need to hope. The cases of complete disappearance of hydrocele are almost exclusively seen in mild to moderate hydrocele that is operated on at a very young age.
Surgery for hydrocele, whether open or lumpectomy, whether fleshman or robotic, is also not a panacea. The surgical approach is different and the problems are unique, so I will mainly talk about some of the main common things (infection and fluid retention).
When discharged from the hospital after a successful recovery from surgery, parents must ask the surgeon if the child has an indwelling double J tube in the ureter. If there is an indwelling, be sure to ask about the time of tube removal, I tend to remove the tube 4-6 weeks after surgery; there are some that require delayed removal (usually not more than three months), I will be sure to give special instructions. If the tube is left in place for too long, the plastic will deteriorate, stones will grow on top of the tube, and urinary tract infections will be difficult to cure.
Above: Schematic diagram of surgery for obstructive hydronephrosis at the ureteropelvic junction (with double J tube left in place)
During the period when the double J tube is left in place, the ultrasound value of hydronephrosis will be greatly improved compared with the preoperative period, and there is no need to review the ultrasound frequently during this period. However, the urinary routine needs to be reviewed several times during this period, because urinary tract infections are sometimes very troublesome. There may be some red blood cells (occult blood) in the urine routine during the tube retention period, which will disappear after the child is less active and the tube is removed.
After removal of the double J-tube, the hydronephrosis usually returns to its preoperative level, even more “severe” for a certain period of time, and then gradually “falls back” and can “fluctuate”. It is generally believed that the hydrocele will be more “stable” only one year after surgery.
After the removal of the double J tube (from the beginning of the operation if the double J tube is not left in place), I recommend ultrasound examination once a month*3 times, then once every three months*3 times, then once every six months*2 times, and then once a year*for life. During the follow-up, if there is a tendency for the hydronephrosis to worsen, the density of follow-up review needs to be increased.
A urine test should be taken at the same time as each follow-up. If there are signs of urinary tract infection such as increased white blood cells in the urine routine, be sure to send a urine culture before using antibiotics! It is likely that a negative culture will result from the use of antibiotics. If you can figure out what bacterial infection it is and have the drug sensitivity results, the treatment selection will be more targeted.
Many people ask if it is possible to review locally, that depends on whether your local ultrasound report is standardized enough (I still recommend returning to the hospital for review), it is reasonable to say that hydronephrosis is very easy to see and distinguish under ultrasound. A standard ultrasound report of hydronephrosis should at least include the size of the kidney, the thickness of the renal cortex, the anterior and posterior diameter of the renal pelvis, and the dilatation of the ureter. The anteroposterior diameter of the renal pelvis and the thickness of the renal cortex are very important indicators in evaluating the severity of hydronephrosis.
For comparison purposes, I recommend taking the post-urinary values uniformly.
Above: The thickness of the renal parenchyma is shown in C, and the anterior-posterior diameter of the renal pelvis is shown in D.
The subjective “mild,” “moderate,” or “severe” hydronephrosis conclusion of the doctor is not important, but the objective and specific values described by the ultrasonographer are more important. It is understandable that there may be a difference of a few millimeters in the values depending on the time of the examination, the machine and the doctor. Large trends of variation are far more important than one-time data.
The items of urine routine will vary from hospital to hospital, for example, the items of emergency urine routine in our hospital are less than the items of general urine routine. However, the initial screening for the presence of urinary tract infection is generally possible.
If hydronephrosis is found to be increasing during the review, it may be anastomotic edema or anastomotic stenosis. There are various ways to deal with it, for example, it can be performed: transcystoscopic reinsertion of double J tube, or renal pelvic puncture drainage, which can cope with anastomotic edema. In the case of anastomotic stenosis, a percutaneous nephrological stenosis dissection or reperforming a pelvic ureteral anastomosis is required.
Treatment of urinary tract infections requires early initiation of antibiotics, adequate doses of antibiotics, antibiotics that are effective against the infected bacteria, and treatment that is long enough. There is no need to talk about antibiotics and care should be taken not to abuse them.