Elsevier

Urology

Volume 83, Issue 4, April 2014, Pages 909-914
Urology

Pediatric Urology
Evaluating Practice Patterns in Postnatal Management of Antenatal Hydronephrosis: A National Survey of Canadian Pediatric Urologists and Nephrologists

https://doi.org/10.1016/j.urology.2013.10.054Get rights and content

Objective

To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada.

Methods

A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality.

Results

A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P = .02); in contrast, 73% of nephrologists and 38.2% of urologists (P = .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P = .02) would obtain this test for patients with unilateral high-grade isolated AHN.

Conclusion

Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain high-level evidence to develop management protocols for this common condition.

Section snippets

Survey Design

An anonymous survey was designed on the open source web application “Lime Survey” (http://www.limesurvey.org, accessed November 2012.). The survey was locally piloted among pediatric urologists and pediatric nephrologists to confirm content and face validity and to decrease measurement bias. The survey was subsequently refined to 20 questions that focused solely on the practice patterns surrounding CAP and VCUG evaluation in patients with AHN.

The survey questions were divided into 3 main

Results

The survey was distributed to a total of 139 pediatric specialists. The overall response rate was 63.3% (88 returned surveys; 95% confidence interval, 55.0%-71.0%). The respondents identified themselves as pediatric nephrologists (n = 46) or pediatric urologists (n = 39), with only 3 failing to disclose this information. The respondents reported seeing an average of 50 patients with AHN each year (1-450). Overall, 49 physicians (61%) practiced in academic centers, 22 (27%) in freestanding

Comment

Although concern for developing a UTI was the major factor for instituting CAP by nephrologists and urologists, several important differences in AHN management were noted between representatives of these specialties. Generally, nephrologists and urologists appear to agree on the perceived lack of CAP benefit in children with unilateral low-grade AHN; however, there were important discrepancies for bilateral and high grades of AHN. Pediatric nephrologists institute CAP more readily for patients

Conclusion

The differences in the preference for prescribing CAP and recommending VCUGs for patients with AHN captured by this survey highlight the paucity of high-level data and well-defined clinical guidelines. Based on the disparities encountered, it appears that clinical equipoise exists, calling for the conduct of randomized placebo-controlled trials to improve the quality of evidence on this matter.

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    Financial Disclosure: The authors declare that they have no relevant financial interests.

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