Pediatr Radiol (2017) 47:1109–1115

DOI 10.1007/s00247-017-3883-0

PEDIATRIC ULTRASOUND

Classification of pediatric urinary tract dilation:

the new language
Jeanne S. Chow 1,2 & Jeffrey L. Koning 2 & Susan J. Back 3 & Hiep T. Nguyen 4 &
Andrew Phelps 5 & Kassa Darge 3

Received: 10 January 2017 / Revised: 27 February 2017 / Accepted: 28 April 2017 / Published online: 2 August 2017
# Springer-Verlag Berlin Heidelberg 2017

Abstract The multidisciplinary consensus on the classi- Introduction

fication of prenatal and postnatal urinary tract dilation
(UTD classification system) was created to unify the Urinary tract dilation (UTD) is present on 1–2% of obstetrical
language used to describe urinary tract dilation on ante- ultrasound (US) examinations [1]. The presence and descrip-
natal and postnatal ultrasound examinations and thereby tion of fetal urinary tract dilation are variably conveyed to
facilitate communication among providers and improve those caring for the newborn. This lack of optimal communi-
outcomes research. The background and new classifica- cation is multifactorial: fetal health care professionals might
tion system are described in this review, with imaging not know which pediatricians and specialists ultimately as-
examples. sume care of the baby, postnatal providers might not have
access to the reports or images from prenatal US examination,
and imaging specialists’ terminology to describe the urinary
Keywords Bladder . Children . Hydronephrosis . Kidney . tract varies considerably.
Ultrasound . Ureter . Urinary tract A recent survey showed that pediatric radiologists do not
have a standard method to describe urinary tract dilation. For
example, many antenatal imagers use the term “pyelectasis” to
describe the dilation of the renal pelvis, whereas postnatal im-
agers use terms such as “pelviectasis” and “hydronephrosis” to
* Jeanne S. Chow describe the same finding [2]. Antenatal imagers often do not
[email protected] describe calyceal dilation, partially because this anatomy can
be too small to resolve by fetal US. The anterior-posterior renal
1
Department of Urology,
pelvic diameter (APRPD) is frequently measured and recorded
Boston Children’s Hospital, on obstetrical US exams and therefore normal fetal values are
300 Longwood Ave., Boston, MA 02115, USA well established [3–5]. Because renal and bladder US exams
2
Department of Radiology, are performed for clinical indications, reported normal anterior-
Boston Children’s Hospital, posterior renal pelvic diameter values are based on smaller
Boston, MA, USA sample sizes and are less widely used [6–8]. Postnatal imagers
3
Department of Radiology, The Children’s Hospital of Philadelphia, rarely measure and report anterior-posterior renal pelvic diam-
Perelman School of Medicine, eter and inconsistently describe calyceal dilation [2].
University of Pennsylvania,
Philadelphia, PA, USA
The intended meaning of the terminology used to describe
4
antenatal and postnatal urinary tract imaging can be unclear to
Banner Children’s Specialists,
Cardon Children’s Medical Center,
pediatricians and specialists, which further confounds patient
Mesa, AZ, USA care. Does pelviectasis require follow-up and additional im-
5
Department of Radiology,
aging? Is pelvicaliectasis the same as hydronephrosis? Does
UCSF Benioff Children’s Hospital, hydronephrosis mean obstruction? These are only a few of the
San Francisco, CA, USA questions that arise. In an attempt to better describe the urinary
1110 Pediatr Radiol (2017) 47:1109–1115

Table 1 Prenatal urinary tract dilation (UTD) classificationa for UTD management of fetuses and children with urinary tract dila-
A1 and UTD A2–3
tion, including the following: American College of Radiology
UTD A1 UTD A2–3 (ACR), American Institute of Ultrasound in Medicine
(AIUM), American Society of Pediatric Nephrology
APRPD 16–27 weeks <4 mm 4–7 mm ≥7 mm (ASPN), Society for Fetal Urology (SFU), Society for
APRPD ≥28 weeks <7 mm 7–10 mm ≥10 mm Maternal-Fetal Medicine (SMFM), Society for Pediatric
Calyceal dilation None Central or none Peripheralb Urology (SPU), Society for Pediatric Radiology (SPR) and
Parenchymal thickness Normal Normal Abnormal Society of Radiologists in Ultrasound (SRU). These represen-
Parenchymal appearance Normal Normal Abnormal tatives made recommendations based on combining the cur-
Ureters Normal Normal Abnormal rent literature on imaging and best practices of antenatal and
Bladder Normal Normal Abnormal postnatal urinary tract dilation.
Oligohydramnios None None Unexplainedc The UTD classification system uses six US findings to
a describe the antenatal and postnatal urinary tract: (1)
Classification is based on the presence of the most concerning feature.
For example, a fetus with an anterior posterior renal pelvic diameter anterior-posterior renal pelvic diameter (APRPD), (2) calyceal
(APRPD) within the UTD A1 range but with ureteral dilation would be dilation with distinction between central and peripheral caly-
classified as UTD A2–3 ces postnatally, (3) renal parenchymal thickness, (4) renal pa-
b
Central versus peripheral calyceal dilation can be difficult to assess early renchymal appearance, (5) bladder abnormalities and (6) ure-
in gestation teral abnormalities (Tables 1 and 2). In the fetus, the quantity
c
Oligohydramnios thought to be the result of a genitourinary cause of amniotic fluid is also evaluated. To avoid the confusion
associated with the implied meanings of various terms for
tract, various classification systems had been developed, but urinary dilation, the consensus panel recommended using
none created a common language between antenatal and post- the term “dilation” and avoiding nonspecific terms such as
natal findings [9–13]. hydronephrosis, pyelectasis, pelviectasis and pelvic fullness.
As pediatric radiologists, we evaluate both fetuses and chil- The anterior-posterior renal pelvic diameter is the maximal
dren and would like to provide a clear assessment of the uri- intrarenal diameter of the renal pelvis taken in the transverse
nary tract to help guide patient management. The new multi- plane (Fig. 1). The measurement is made at the diameter of
disciplinary consensus on the classification of prenatal and greatest distension of the renal pelvis, which is not necessarily
postnatal urinary tract dilation (UTD classification system) at the parenchymal tip on the transverse scan. The largest
described here facilitates that goal [14] because it unifies the measurement of the renal pelvis should be the one used for
terminology for urinary tract dilation in the fetus and infant. the purpose of UTD classification, and this measurement can
be made anywhere within the renal pelvis bordered by renal
parenchyma in the transverse plane. Measurement of the
The UTD classification system extrarenal pelvis is not regarded as anterior-posterior renal
pelvic diameter. In the fetus, this is classically performed with
The UTD classification system was created by representatives the “spine up” — or closest to the transducer. In the infant, we
from eight societies who participate in the diagnosis and recommend that this measurement be made in the prone

Table 2 Postnatal urinary tract

dilation (UTD) classificationa for Normal UTD P1 UTD P2 UTD P3
UTD P1, UTD P2 and UTD P3
APRPD <10 mm ≥10–15 mm ≥15 mm >=10 mm
Calyceal dilation None Central only Peripheral –b
Parenchymal thickness Normal Normal Normal Abnormal
Parenchymal appearance Normal Normal Normal Abnormal
Ureters Normal Normal Abnormal –b
Bladder Normal Normal Normal Abnormal
a
Classification is based on the most concerning ultrasound finding. For example, if the anterior posterior renal
pelvic diameter (APRPD) is in the UTD P1 range but there is peripheral calyceal dilation, the classification is
UTD P2. The presence of parenchymal abnormalities denotes UTD P3 classification as long as there is urinary
tract dilation
b
Calyceal dilation and ureteral dilation, although frequently present in patients with UTD P3, are not necessarily
needed to qualify for UTD P3 if there is urinary tract dilation with either abnormal parenchymal thickness,
abnormal parenchymal appearance or abnormal bladder
Pediatr Radiol (2017) 47:1109–1115 1111

calyceal dilation (Fig. 1). If one were to communicate

that there is “major calyceal dilation,” this might be
misinterpreted as severe calyceal dilation. Minor calyces
are peripheral and cup the tips of the medullary pyra-
mids. Two or three minor calyces converge to form a
major calyx. Major calyces are more centrally located
and equivalent to the infundibula. The consensus panel
used the anatomical location to newly describe the ma-
jor calyces as central calyces and minor calyces as pe-
ripheral calyces. Of course, dilation is in a continuum
and it is not always possible to exactly distinguish cen-
tral from peripheral calyceal dilation, and in different
positions the degree of distension might change. Thus
it is appropriate to use the description of the most se-
vere finding.
When describing ureteral dilation, either all or part of
the ureter should be consistently dilated. A transient
mild dilation of the ureter from peristalsis is not
regarded as pathological ureteral dilation. An extrarenal
pelvis should not be confused with proximal ureteral
dilation. Unfortunately there are no standard cut-off
measurements for defining ureteral dilation. A normal
ureter is not constantly dilated, thus the label “ureteral
Fig. 1 Schematic illustration of urinary tract dilation (UTD) dilation” is subjective without actual measurement of
classification shows a transverse view of mid/interpolar kidney. a The ureteral diameter. A ureteral dilation in the absence of
green arrows indicate acceptable locations for measuring the anterior-
pelvicalyceal dilation — i.e. anterior-posterior renal pel-
posterior renal pelvic diameter, which can be measured anywhere
within the renal pelvis bordered by renal parenchyma visualized during vic diameter <10 mm and no calyceal dilation — is not
prone imaging. Measurements of the extrarenal pelvis should not be included in this classification system, which has as its
included. The largest measurement should be the one used for the primary premise the dilation of the renal pelvis or renal
purpose of UTD classification. The gray arrow indicates the anterior-
calyx.
posterior diameter of the extrarenal pelvis, which should not be used for
UTD classification. The different degrees of calyceal dilation are shown The UTD classification system distinguishes antenatal
in clockwise fashion. The upper left corner shows normal (NL), where from postnatal findings, where the higher numbers (UTD 1–
fluid is confined to the pelvis. The upper right corner shows UTD P1 3) indicate greater risk of underlying or developing uropathy.
(P1), where there are varying degrees of central calyceal dilation. The
Because urinary tract abnormalities are more subtle and diffi-
lower right corner shows UTD P2 (P2), where there are varying degrees
of peripheral calyceal dilation, with fluid cupping around the medullary cult to visualize on fetal versus pediatric US examination (e.g.,
pyramid. The lower left corner shows UTD P3 (P3), where the renal distinguishing peripheral versus central calyces), there are on-
parenchyma is hyperechoic, cystic and thinned. Although this ly three antenatal categories (normal, UTD A1, UTD A2–3),
schematic illustration shows progressive increases in calyceal dilation,
compared to four postnatal categories (normal, UTD P1, UTD
note that the definition of UTD P3 is based on abnormal parenchyma or
bladder appearance in addition to UTD. b The longitudinal appearances P2 and UTD P3; Figs. 2, 3, 4, 5).
of the UTD classifications are shown in tabular format, with side-by-side Concluding that a kidney appears normal is as impor-
US and schematic images. Note that the renal pelvic diameter is not tant as describing an abnormality. The UTD classifica-
measured in the longitudinal plane. The P1 category demonstrates
tion system encourages the use of the word “normal” in
central calyceal dilation and the P2 category demonstrates peripheral
calyceal dilation (arrows). The P3 category shows abnormal the impression to prevent unnecessary follow-up, imag-
parenchymal thickness with cystic changes in the parenchyma ing or familial anxiety. However, describing the appear-
ance of a normal urinary tract does not preclude the
existence of underlying urological abnormalities, specif-
ically reflux. It is well known that a normal renal and
position because the prone position tends to exaggerate the bladder US does not exclude vesicoureteral reflux [15].
distension of the renal pelvis. However if measurements are Conversely, prenatal urinary tract dilation even of varied
more accurate in the supine position, that should be used. degrees does not increase the risk of reflux [16].
Central and peripheral calyces are terms that the The antenatal classification was based on the com-
UTD consensus committee created to avoid the poten- mon current practice of obstetrical imagers where find-
tially confusing interpretation of “major” and “minor” ings are interpreted based on whether they occur earlier
1112 Pediatr Radiol (2017) 47:1109–1115

Fig. 2 Postnatal US examination in a 6-week-old boy with normal which in this case is at the mid-intrarenal pelvis. b Sagittal US
kidneys. a Transverse US demonstrates an anterior posterior renal demonstrates normal renal parenchyma without any calyceal dilation.
pelvic diameter <10 mm, which is normal. The anterior-posterior renal The bladder was normal (not shown) and the ureters were not dilated
pelvic diameter is measured at the maximal diameter of intrarenal pelvis,

Fig. 3 Postnatal US examination in a 4-week-old girl with urinary tract parenchyma is otherwise normal. The bladder was normal and the
dilation (UTD) P1. a Transverse US demonstrates an APRPD <10 mm. b ureters were not dilated (not shown). APRPD anterior posterior renal
Sagittal US demonstrates central calyceal dilation (arrows). The renal pelvic diameter

Fig. 4 Postnatal US examination in a 5-week-old girl with urinary tract dilation. The renal parenchymal thickness and appearance are normal.
dilation (UTD) P2. a Transverse US demonstrates an APRPD <10 mm. b In addition, there were no bladder abnormalities and the ureters were
Sagittal US demonstrates peripheral (arrows) and central calyceal not dilated (not shown). APRPD anterior-posterior renal pelvic diameter
Pediatr Radiol (2017) 47:1109–1115 1113

Fig. 5 Postnatal US examination in a 6-day-old boy with urinary cysts (long arrow). b The bladder (seen in the sagittal plane) has a
tract dilation (UTD) P3. a Sagittal US of the right kidney thick and trabeculated wall (arrow). The boy was later diagnosed
demonstrates pelvic, central and peripheral calyceal dilation. The with posterior urethral valves
renal parenchyma is echogenic (short arrow) with small cortical

(16–27 weeks) or later (>28 weeks) in gestation. The was predicated on the anterior-posterior renal pelvic di-
system was predicated on the anterior-posterior renal ameter and calyceal dilation. Stratification is based on
pelvic diameter and calyceal dilation. Normal anterior- the most concerning US finding. If the renal pelvis
posterior renal pelvic diameter values are less than measures between 10 mm and 15 mm or there is central
4 mm before 28 weeks and less than 7 mm after calyceal dilation, then the urinary tract is graded UTD
28 weeks of gestation. If the only abnormal finding of P1. If the anterior-posterior renal pelvic diameter >15 mm
the urinary tract is increased anterior-posterior renal pel- or peripheral calyces are dilated then it is categorized as
vic diameter (4 to <7 mm early in gestation; 7 to UTD P2. Because stratification is based on the most
<10 mm later in gestation) or central calyceal dilation, concerning US finding, ureteral dilation with pelvic di-
then the urinary tract is classified as UTD A1. If the lation greater than 10 mm is UTD P2. If the renal
anterior-posterior renal pelvic diameter is >7 mm early parenchyma is of abnormal echogenicity or thickness
or >10 mm later in gestation or there is peripheral or bladder is abnormal when there is urinary tract dila-
calyceal dilation, then the kidney is upgraded to UTD tion, the urinary tract is upgraded to UTD P3 (Fig. 5,
A2–3. Any abnormal pelvic dilation combined with re- Table 2). If the parenchyma is abnormal and there is no
nal parenchymal abnormality (in thickness and appear- pelvic or calyceal dilation (e.g., autosomal-recessive
ance) or bladder abnormality and oligohydramnios sec- polycystic kidney disease or multicystic dysplastic kid-
ondary to poor renal function upgrade the kidney to a ney), then the kidney does not meet criteria to be clas-
UTD A2–3. Ureteral dilation, even without pelvic dila- sified by this system.
tion, is automatically a UTD A2–3 (Table 1). When reporting urinary tract dilation, a description of
With the exception of severe antenatal findings, the the six US imaging parameters should be included in
first postnatal US examination should occur at least the body of the report. The specific UTD category (nor-
48 hours or more after birth to avoid underestimating mal, UTD A1, UTD A2–3, UTD P1, UTD P2 or UTD
the degree of urinary tract dilation during a time of P3) should be in the impression. We recommend that
normal physiological oliguria. The criteria of the post- the UTD nomenclature not replace the descriptions of
natal classification are applied regardless of the child’s the abnormality in the impression of the report. For
age. A normal kidney has an anterior-posterior renal example, the impression might be “UTD P2 based on
pelvic diameter less than 10 mm measured in the trans- pelvic, calyceal and ureteral dilation, which raises the
verse plane and there should be no calyceal or ureteral concern for ureterovesical junction obstruction or re-
dilation. Normal renal echotexture depends on gestation- flux.” Ideally, US images should accompany the report.
al age, although it should be iso- to hypoechoic to the The consensus statement also proposed a manage-
adjacent solid organ at term or within the first few ment algorithm based on the antenatal and postnatal
months of age. The classification system distinguishes classifications (Tables 3 and 4). Because the consensus
dilation of central (major) calyces from peripheral was based on current but limited literature there was not
(minor) calyces (Fig. 3 and Fig. 4). Again the system enough evidence to assess the risk of uropathy based on
1114 Pediatr Radiol (2017) 47:1109–1115

Table 3 Management schema based on urinary tract dilation (UTD) classification system’s risk stratification of UTD A1 and UTD A2-3

UTD A1 (low risk) UTD A2-3 (increased risk)

Prenatal period One additional US examination at ≥32 weeks Initial US exam in 4–6 weeks
After birth Two additional US examinations: US exam at >48 h to 1 month*
1. >48 h to 1 month
2. 1–6 months later
Other Aneuploidy risk modification if indicated Specialist consultation, e.g.,
nephrology, urology

*Certain situations such as posterior urethral valves or bilateral severe hydronephrosis, for example, might require more expedient management

gender or laterality. This system and the management Rickard et al. [21] used it to evaluate the success of
recommendations are expected to be validated and mod- pyeloplasty in children with ureteropelvic junction ob-
ified with experience. struction. In this study a UTD <P1 defined success. In
addition to the UTD classification system, the authors
reported a percentage improvement of the
anteroposterior renal pelvic diameter (PI-APD). A PI-
Current literature using the UTD classification APD cutoff of 38% at the first postoperative US was
system previously shown to predict success of pyeloplasty [22].
In Rickard et al.’s [21] series 89/138 patients (64%) had
The UTD grading system correlates with the risk of a UTD <P1 and 81 of these (91%) had >40% PI-APD.
postnatal uropathy [14]. Since the original consensus
paper in 2014, Hodhod et al. [17] were the first to
assess the reliability of the UTD system in predicting
outcomes. They concluded that the grade of urinary Conclusion
tract dilation can be used to predict the resolution rate
of hydronephrosis. Additionally, when compared to the The UTD classification system and the recommendations of
Society for Fetal Urology system, the UTD system more the consensus panel were published in the Journal of
accurately predicted those who developed urinary tract Pediatric Urology in 2014 [14] and disseminated through let-
infections or needed surgery because of the inclusion of ters to the editor in multiple journals [23]. This classification
ureteral dilation in the classification system [17]. system standardized terminology to improve communication
However this is an important point that requires further and care of fetuses and infants with urinary tract dilation. The
research and discussion. When the appearance of the unified system is expected to facilitate future research and
kidney was normal according to the UTD system, the understanding of urinary tract disease. Several researchers
rate of urinary tract infection was no greater than in the have used this system to assess reliability and clinical out-
general population [18–20]. comes. Future research will build on this literature and help
Although the UTD classification system was not refine the classification and management set forth in this
intended to be used with the postsurgical kidney, guideline.

Table 4 Management schema

based on urinary tract dilation UTD P1 (low risk) UTD P2 (intermediate risk) UTD P3
(UTD) classification system risk
stratification of UTD P1, UTD P2 Follow-up US 1–6 months 1–3 months 1 month
and UTD P3 VCUG* Discretion of clinician Discretion of clinician Recommended
Antibiotics* Discretion of clinician Discretion of clinician Recommended
Functional scan Not recommended Discretion of clinician Discretion of clinician

*The choice to use antibiotics or recommend voiding cystourethrogram (VCUG) depends on the suspected
underlying pathology
Pediatr Radiol (2017) 47:1109–1115 1115

Acknowledgments Dr. J. S. Chow and Dr. K. Darge are pediatric radi- uroradiology task force session on childhood obstructive uropathy,
ologists and Dr. H. Nguyen a pediatric urologist who took part in the high-grade fetal hydronephrosis, childhood haematuria, and urolith-
multidisciplinary consensus on the classification of prenatal and postnatal iasis in childhood. ESPR annual congress, Edinburgh, UK,
urinary tract dilation. June 2008. Pediatr Radiol 39:891–898
12. Onen A (2007) An alternative grading system to refine the criteria
Compliance with ethical standards for severity of hydronephrosis and optimal treatment guidelines in
neonates with primary UPJ-type hydronephrosis. J Pediatr Urol 3:
Conflicts of interest The authors have no financial interests, investiga- 200–205
tional or off-label uses to disclose. 13. Ellenbogen PH, Scheible FW, Talner LB et al (1978) Sensitivity of
gray scale ultrasound in detecting urinary tract obstruction. AJR
Am J Roentgenol 130:731–733
14. Nguyen HT, Benson CB, Bromley B et al (2014) Multidisciplinary
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