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Objective To explore the value of renal parenchyma-to-hydronephrosis area ratio (PHAR) in detecting trends of hydronephrosis (HN) improvement or worsening and response to surgical intervention. Methods Initial and follow-up sagittal renal ultrasound images of patients entered into a prenatal HN database from 2008 to 2016, with baseline Society for Fetal Urology (SFU) grades III and IV HN and without vesicoureteral reflux, were evaluated using National Institutes of Health-sponsored image-processing software. Renal parenchymal area, hydronephrosis area (HA), PHAR, anteroposterior diameter (APd), and SFU grade were captured at baseline and most recent visit. Data were analyzed based on the need for surgical intervention to address obstruction. Results Out of 193 infants (159 boys; 135 left side), 58 (30%) underwent surgery. Patients managed surgically compared with those managed nonsurgically had worse baseline HN severity markers: SFU grade (3.6 ± 0.5 vs 3.1 ± 0.4; P .001), urinary tract dilation classification (2.7 ± 0.5 vs 2.2 ± 0.4; P .001), APd (20.3 ± 10.1 vs 12.8 ± 8.0; P .001), HA (10.0 ± 6.6 vs 4.7 ± 2.8; P .001), and PHAR (1.3 ± 1.0 vs 3.0 ± 2.9; P .001); but both patient groups had similar renal parenchymal area (9.4 ± 3.5 vs 9.7 ± 2.8; P = .5). At last follow-up, the following discrepancies persisted: SFU grade (2.3 ± 1.0 vs 1.7 ± 1.0; P .001), urinary tract dilation classification (1.5 ± 0.7 vs 1.0 ± 0.7; P .001), APd (11.7 ± 8.0 vs 7.7 ± 5.7; P .001), and HA (6.4 ± 5.1 vs 3.6 ± 2.7; P .001); however, PHAR was equalized for both groups (7.2 ± 14.0 vs 7.1 ± 6.1; P = .9). Conclusion By concurrently considering changes in renal parenchyma and degree of HN, we found that PHAR appears to be a promising parameter that reflects similarities between patients managed surgically and those managed nonsurgically, despite initial discrepancies. Our data suggest that this variable may provide reassurance and a more objective assessment of improvement after surgery compared with other traditional ultrasound outcome measures.

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