Pediatric Radiology (2022) 52:740–751

[Link]

NEONATAL IMAGING

2021 update on the urinary tract dilation (UTD) classification system:

clarifications, review of the literature, and practical suggestions
Hiep T. Nguyen1 · Andrew Phelps2 · Brian Coley3 · Kassa Darge4 · Audrey Rhee5 · Jeanne S. Chow6

Received: 30 March 2021 / Revised: 21 November 2021 / Accepted: 10 December 2021 / Published online: 4 January 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
In 2014, a multidisciplinary consensus on the classification of pre- and postnatal urinary tract dilation (UTD classification)
was developed. Its goal was to provide a standardized system for evaluating and reporting urinary tract dilation both in the
prenatal and postnatal periods. In this review, we summarize insights learned from the implementation of the UTD clas-
sification system since its inception, providing clarifications on common points of confusion. In addition, we review current
literature in the clinical validation of the UTD classification system to provide credence for its use in managing fetuses and
children with urinary tract dilation.

Keywords Children · Classification · Hydronephrosis · Kidneys · Postnatal · Prenatal · Ultrasound · Urinary tract · Urinary
tract dilation

Introduction obstruction, vesicoureteral reflux, posterior urethral valves/

bladder outlet obstruction, ureterocele or ureterovesical
Urinary tract dilation is detected in 1–2% of prenatal US junction obstruction/non-refluxing megaureter. In most
exams. With modern technology and equipment, the inci- cases, findings on US are principally used for determining
dence of urinary tract dilation is likely to be much higher subsequent radiologic evaluation, clinical follow-up and
than previously reported. Urinary tract dilation com- treatment. The rationale for evaluation is to prevent poten-
prises a spectrum of potential etiologies. In 70–80% of the tial complications such as urinary tract infection (UTI), uri-
cases, urinary tract dilation is transient or physiological. nary stone formation and renal dysfunction associated with
In the remaining patients, urinary tract dilation is caused the clinically significant uropathies. In contrast, the risks
by an underlying uropathy such as ureteropelvic junction of evaluation include: cost and invasiveness of additional
radiologic evaluation, unnecessary childhood radiation
and antibiotic exposure, and parental anxiety. The clinical
* Hiep T. Nguyen dilemma is to determine which fetuses/children with urinary
htn7377@[Link]
tract dilation require further evaluation and which do not.
1
Banner Children’s Specialist, Urology, There is considerable variability in the recommendations
Banner Desert Children’s Hospital, for further evaluation and follow-up of fetuses and children
1432 S. Dobson Road, #501, Mesa, AZ 85202, USA with urinary tract dilation. Consequently, the optimal man-
2
Department of Radiology, Oregon Health & Science agement schema is difficult to determine from outcome
University, Portland, OR, USA research. The wide range in clinical practice patterns stems,
3
Department of Radiology and Medical Imaging, Cincinnati in part, from the variability in how US findings are com-
Children’s Hospital Medical Center, Cincinnati, OH, USA municated. Historically, there was no uniformity on how to
4
Department of Radiology, Perelman School of Medicine, define, classify and grade urinary tract dilation either within
Children’s Hospital of Philadelphia, or between the pre- and postnatal periods. Several grad-
University of Pennsylvania, Philadelphia, PA, USA
ing systems were developed and utilized, leading to vari-
5
Department of Urology, Cleveland Clinic, able nomenclature. Moreover, different terminologies with
Cleveland, OH, USA
overlapping meanings were employed to describe urinary
6
Department of Radiology, Boston Children’s Hospital, tract dilation. Finally, there was no standardization on what
Boston, MA, USA
Pediatric Radiology (2022) 52:740–751 741

information needed to be obtained from the US evaluation, determining which children have obstructive uropathy. The
including whether and how any measurements should be fetal system is demarcated by an “A” (for antenatal) and the
obtained. infant system by a “P” (for postnatal). Other than normal,
In 2014, a panel of 13 clinicians who had specialized there are two antenatal categories (UTD A1 and A2-3) and
clinical and research experience with the perinatal diagnosis three postnatal categories (UTD P1, P2 and P3). The six
of urinary tract dilation from eight academic societies (the common urinary tract descriptors regardless of age are:
American College of Radiology, the American Institute of
Ultrasound in Medicine, the American Society of Pediatric 1) the anterior–posterior renal pelvic diameter (APRPD),
Nephrology, the Society for Fetal Urology, the Society for 2) calyceal dilation (central or peripheral),
Maternal–Fetal Medicine, the Society for Pediatric Urol- 3) renal parenchymal thickness (normal or abnormal),
ogy, the Society for Pediatric Radiology and the Society 4) renal parenchymal echogenicity (normal or abnormal),
of Radiologists in Ultrasound) collaborated to develop a 5) ureteral dilation (present or absent) and
unified grading system for perinatal urinary tract dilation 6) bladder abnormality (present or absent).
and to propose a standardized scheme for follow-up evalu-
ation [1]. The UTD classification system was for both fetal Oligohydramnios thought to be related to an abnormal
and postnatal US evaluation. It defined the method of US urinary tract is described in fetuses as well.
evaluation (such as imaging protocol and positioning) and Although these descriptors are detailed in prior papers
the parameters to be evaluated (i.e. anterior–posterior renal [1, 2], another explanation focusing on postnatal imaging is
pelvic diameter [APRPD], central vs. peripheral calyceal provided here, including common questions and errors. A
dilation, renal parenchymal thickness, renal parenchymal basic, but not always obvious, point is that the renal collect-
appearance, bladder abnormalities and ureteral abnormal- ing system must be abnormally dilated (abnormal APRPD or
ities). Based on the body of literature in 2014, the panel the presence of calyceal dilation) to use the UTD classifica-
defined what findings are considered normal and those that tion system. For example, an infant with dysplastic kidneys
have been associated with low, intermediate and high risks from autosomal-recessive polycystic kidney disease is not
of underlying or developing uropathies. Based on the risk included in the UTD classification system, nor is an infant
stratification, the panel proposed a schema for risk-based with ureteral dilation but no pelvic or calyceal dilation. This
management recommendations. system is intended to describe pre-surgical kidneys. In the
The panel recognized the inherent limitations of the pro- original paper [1], we initially excluded solitary and ectopic
posed classification system and management schema. They kidneys; however, this statement has been revised and the
were based on the literature at the time. Consequently, future position or number of kidneys does not affect their ability to
research will likely be needed to validate and potentially be characterized by the UTD classification system. As for
modify both the classification system and management duplex kidneys, each pole (e.g., upper and lower poles) can
schema. In addition, when the UTD classification system be described individually, and the overall grade is based on
was put into practice in 2014, it was expected at the time the highest grade in the corresponding units.
that refinement of the US parameter measurements would
likely be needed to properly characterize the severity of Anterior–posterior renal pelvic diameter
urinary tract dilation. Despite these limitations, the urinary
tract dilation consensus statement provides a framework for The anterior–posterior renal pelvic diameter (APRPD) is
health care providers to utilize a common grading system the maximum intrarenal diameter of the renal pelvis meas-
with standardized terminologies and management schema. ured in the transverse plane of the kidney, with an exception
In addition, it provides a systematic language that can unite made for antenatal studies where the intrarenal and extra-
future outcomes research. The purposes of this article are to renal pelvis are not distinguishable (Fig. 2). The optimum
summarize some of the lessons learned in using the UTD measurement is when the spine is closest to the transducer
classification system in clinical practice, provide clarifica- (antenatal) or the prone position (postnatal). The prone posi-
tions and suggest modifications based on current research. tion tends to increase the width of the pelvis compared to
the supine position [3]. Common errors include measuring
the pelvis in the sagittal plane or measuring the extrarenal
Description of the urinary tract dilation pelvis in infants.
(UTD) classification system With increasing degrees of pelvic and calyceal dilation,
the collecting system can become distorted, making it dif-
The UTD classification system is a unified method of ficult to determine the correct APRPD. The recommended
describing urinary tract dilation in fetuses and infants technique involves finding the edge of the renal paren-
using common terminology (Fig. 1) with the purpose of chyma, drawing a tangential line to the edges of the tissue
742 Pediatric Radiology (2022) 52:740–751

Fig. 1  Summary of the antenatal and postnatal criteria used for the be some degree of pelvic or calyceal dilation to use the UTD clas-
urinary tract dilation (UTD) classification system. In addition to nor- sification system. For example, an infant with renal dysplasia and no
mal (not included on the table), the UTD classification system has urinary tract dilation does not qualify for this classification system. In
two antenatal categories (UTD A1, UTD A2-3) and three postnatal addition to nondilated kidneys, the UTD classification system is not
categories (UTD P1, P2 and P3). The abnormalities in P2 and P3 are applicable to isolated hydroureter, multicystic dysplastic kidney or
combined in the antenatal category A2-3, thus the hyphenation. The postoperative kidneys. In these situations, or anytime UTD criteria do
normal thresholds of anteroposterior renal pelvis diameter (APRPD) not apply, the urinary tract should simply be described and not classi-
are dependent upon gestational age for antenatal classification and are fied. Abnl abnormality
independent of age for postnatal classification. Note that there must

in the transverse plane, and then measuring the widest

intrarenal diameter (Fig. 3). For the purpose of documen-
tation, the appropriately measured largest diameter should
be selected. The intrarenal (rather than the extrarenal) pel-
vis measurement is the more consistent measurement. As
the intrarenal pressure increases, this is transmitted to the
calyces and parenchyma.
Although threshold APRPD measurements are made for
A1, A2-3, P1, P2 and P3, the presence of calyceal dilation
or ureteral dilation lowers the APRPD threshold meas-
urement for a given UTD category (Fig. 1). For example,
a smooth renal pelvis with a 13-mm APRPD and with-
out calyceal dilation is classified as UTD P1 because the
APRPD is greater than 10 mm. However, the presence
of central calyceal dilation with a smaller 7-mm APRPD
is also classified as UTD P1 because of the presence
Fig. 2  Illustration demonstrates acceptable intrarenal locations for of central calyceal dilation. Similarly, a 7-mm APRPD
measuring anteroposterior renal pelvis diameter (APRPD). The larg-
and peripheral calyceal dilation is classified as UTD P2
est APRPD should be used for urinary tract dilation (UTD) classifica-
tion, and in this example, the largest measurement is indicated with because of the presence of peripheral calyceal dilation
a solid line, which happens to be located at the junction of the intra- (see next section). A 7-mm APRPD with a dilated ureter
renal and extrarenal pelvis. In postnatal studies, the intrarenal and is classified as a UTD P2 because of the ureteral dila-
extrarenal pelvis should be readily distinguishable. In antenatal stud-
tion. In the absence of calyceal or ureteral dilation, the
ies, in contrast, the intrarenal and extrarenal pelvis might not be dis-
tinguishable; therefore, it is acceptable in antenatal studies to report APRPD threshold measurements are used to define the
the largest renal pelvis diameter, even if it is extrarenal UTD category.
Pediatric Radiology (2022) 52:740–751 743

Fig. 3  Measuring anterior–posterior renal pelvic diameter (APRPD) of the renal parenchyma and the defined limit of the intrarenal pel-
in transverse US images of the right kidney in a 22-day-old girl vis. The dashed lines indicate valid intrarenal measurements, the larg-
demonstrating severe peripheral calyceal ballooning/dilation with est of which is indicated by the arrows. c Same image. The correct
thinning of the renal cortex. a APRPD is measured incorrectly at a APRPD is 16 mm and represents the widest intrarenal diameter. The
narrow intrarenal diameter (4 mm). b Same image. When determin- presence of thinning of the cortex with urinary tract dilation indicates
ing the APRPD, start by marking the edge of the renal parenchyma urinary tract dilation (UTD) classification P3
(arrows) and drawing a line connecting them to demarcate the edge

Renal pelvis, central calyces and peripheral calyces at the margins of the renal pelvis (Figs. 6, 7 and 8). These
branch into peripheral calyces, which cup the medullary pyr-
One of the benefits of the UTD classification system is that amids (Figs. 9 and 10) and balloon with progressive dilation
there is a description of the normal kidney. A normal renal (Fig. 11). Thus recognizing the cups and balloons of periph-
pelvis may or may not be distended by urine. A normally eral calyceal dilation is helpful to distinguish peripheral
distended pelvis has a smooth contour and APRPD up to from central calyceal dilation. Distinguishing central and
10 mm (Fig. 4). Unlike other classification systems, there peripheral calyceal dilation changes the classification level
is a distinction between “central” and “peripheral” calyces from UTD P1 to P2 and is a common source of confusion
(Fig. 5). Central calyces are the first part of the collecting and interobserver variability [4], so recognizing the cups
system beyond the renal pelvis. Whereas the normal dis- and balloons of peripheral calyceal dilation is important.
tended pelvis tends to be smooth and oval-shaped, the pres- In cases when there is a combination of patterns, the most
ence of central calyceal dilation leads to small protrusions abnormal pattern is used (e.g., if there is both central and

Fig. 4  Urinary tract dilation (UTD) classification P (normal). a, chyma appears normal with normal corticomedullary differentiation
b Sagittal (a) and transverse (b) US images of the right kidney in a and normal hypoechoic pyramids (outlined). These hypoechoic pyra-
23-day-old boy demonstrate right pelvic distension with the anterior– mids should not be confused for anechoic dilated calyces. The blad-
posterior renal pelvic diameter (APRPD) measuring 4 mm. The cali- der is normal and there was no ureteral dilation (not shown). Because
pers mark the upper and lower poles of the kidney. The APRPD is the the APRPD is less than 10 mm and the parenchyma appears normal,
widest intrarenal measurement in the transverse plane. The border of this is an example of UTD P (normal)
the pelvis is smooth. There is no calyceal dilation. The renal paren-
744 Pediatric Radiology (2022) 52:740–751

calyces replace the traditional anatomical terms “major” and

“minor” calyces to avoid confusing phrases such as “there is
major calyceal dilation,” which actually signifies less dila-
tion than if there is minor calyceal dilation.

Renal parenchyma

In the presence of renal urinary tract dilation, renal paren-

chymal abnormal echogenicity and thinning are features that
upgrade UTD classification to UTD A2-3 and P3. Urinary
tract dilation can lead to or be associated with cortical thin-
ning or dysplasia, the latter resulting in renal parenchyma
that is echogenic, has poor corticomedullary differentiation,
and is potentially interspersed with cysts or microcysts. Nor-
mal renal parenchymal thickness is subjectively assessed. It
is most easily evaluated when a contralateral normal kidney
is present to serve as an internal comparison. Naturally, the
greater the urinary tract dilation, the more likely the paren-
chyma is to be compressed. Compression and flattening of
the hypoechoic medullary pyramids are signs of parenchy-
mal thinning (Fig. 3). In infancy, the normal echogenicity of
Fig. 5  Illustration demonstrates the features of central and peripheral
calyceal dilation on postnatal US. The identification of any peripheral the kidney is different from that in older children and adults.
calyceal dilation (regardless of cupping or ballooning) corresponds The normal hypoechoic pyramids are distinctive (Fig. 4).
with urinary tract dilation (UTD) classification P2. Although balloon- These are not to be confused for the anechoic urine within
ing indicates greater dilation of the peripheral calyx than cupping of a dilated calyx (Fig. 9). Relative to the liver, the normal
the peripheral calyx, ballooning alone does not upgrade the UTD P2
classification; the only way for UTD P2 to be upgraded to UTD P3 is infant kidney might be slightly hyperechoic (especially in
if there is associated parenchymal thinning or abnormal echotexture, premature infants and near birth), isoechoic or hypoechoic
bladder abnormality or oligohydramnios (as would be expected later in childhood).

Ureters
peripheral calyceal dilation, UTD P2 is assigned because of
the peripheral calyceal dilation). It is best to look at both the Normal ureters are distended by urine, and visualizing this
sagittal and transverse planes to better identify the central does not mean that the ureter is abnormally dilated (Fig. 8).
and peripheral calyces. The terms “central” and “peripheral” Several studies have suggested that ureteral measurement of

Fig. 6  Urinary tract dilation (UTD) classification P1. a, b Sagittal subtle undulation of the margin of the pelvis, indicating central cal-
(a) and transverse (b) US images of the left kidney in a 24-day-old yceal dilation (arrowheads). The bladder is normal and there was no
boy demonstrate left pelvic distension with the anterior–posterior ureteral dilation (not shown). Even though the APRPD measures less
renal pelvic diameter (APRPD) measuring 3 mm. The APRPD is than 10 mm, the presence of central calyceal dilation indicates UTD
the widest intrarenal measurement in the transverse plane. There is P1
Pediatric Radiology (2022) 52:740–751 745

abnormal ureteral dilation with pelvic dilation and normal

renal parenchyma indicates UTD P2. Ureteral dilation with-
out pelvic or calyceal dilation is not classified by the UTD
classification system because pelvic dilation must be present.

Urinary bladder

In the presence of urinary tract dilation, the abnormal blad-

der wall might be thickened (such as from a bladder outlet
obstruction) or “contain” a ureterocele. Although a uretero-
cele is cystic dilation of the intravesical distal ureter, and not
a part of the bladder, it is considered part of the abnormal
bladder in this classification system because the ureterocele
is seen when visualizing the bladder (Fig. 12). Bladder find-
ings not specifically associated with bladder outlet obstruc-
tion, such as bladder debris or urachal remnants, are not
considered bladder abnormalities in the UTD classification
system.

Conception and implementation

of the urinary tract dilation (UTD)
classification system

One of the major benefits of the UTD classification system is

defining the normal kidney, especially in infants. Although
routine prenatal US screening had established normative
values for urinary tract dilation in fetuses [8–10], infants
were not routinely screened, so no normal values had been
established in infants. Hesitancy in describing a kidney as
normal led to descriptive terms including “pelviectasis,”
which were confusing to referring physicians and resulted
in unnecessary testing. Using normal kidneys on normal
spine MRIs in children, the APRPD of less than 10 mm was
Fig. 7  Urinary tract dilation (UTD) classification P1. a, b Sagittal (a) established to be normal [11]. If the APRPD measures less
and transverse (b) US images of the left kidney in a 16-day-old boy than 10 mm, the pelvis is smooth (i.e. there is no calyceal
demonstrate left pelvic distension with an undulating contour of cen-
dilation), and the renal parenchyma looks normal, then the
tral calyceal dilation (arrowheads). On the transverse image (b), the
anterior–posterior renal pelvic diameter (APRPD) measures 8 mm. kidney is considered normal. Clearly stating that a kidney
Notice how the dashed line is the correct measurement because it is normal reduces unnecessary confusion and testing. “Nor-
is the widest intrarenal diameter, bounded by the edges of the renal mal” implies a low risk for urinary tract obstruction and a
parenchyma. The sonographer’s calipers (+) are incorrectly placed
low risk for vesicoureteral reflux [12].
because they include a part of the extrarenal pelvis. The bladder is
normal and there was no ureteral dilation (not shown). Even though Because urinary tract abnormalities are more subtle and
the APRPD measures less than 10 mm, the presence of central cal- difficult to visualize on antenatal versus pediatric US exami-
yceal dilation indicates UTD P1 nations, there are only three antenatal categories (normal,
UTD A1 and UTD A2-3) compared to four postnatal cat-
egories (normal, UTD P1, UTD P2, UTD P3). The abnor-
3–4 mm is considered normal [5–7]; thus >4 mm might be malities in the postnatal P2 and P3 categories are combined
considered abnormal. It is important to exclude a distended in the antenatal A2-3 category, thus the hyphenation. The
bladder as a possible cause of transient ureteral dilation. The higher numbers (UTD 1–3) indicate a greater risk of under-
ureteric measurement is in reference to the distal ureter and lying or developing uropathy.
not the proximal ureter. A normal peristalsing or refluxing The grading system is based on a simplistic model for
ureter is dynamic, and the diameter can change. In those the progression of urinary tract dilation starting in the pel-
circumstances, the largest diameter is used. The presence of vis, then to the calyces, and leading to renal parenchymal
746 Pediatric Radiology (2022) 52:740–751

Fig. 8  Urinary tract dilation (UTD) classification P1. a–c Sagittal (APRPD) measures 5 mm. The distal right ureter is seen posterior
(a) and transverse (b) US images of the right kidney and transverse to the bladder (arrowhead in c). The diameter of the ureter is 2 mm
view of the bladder (c) in a 38-day-old boy demonstrate pelvic dis- and within the normal range of ≤ 4 mm. The bladder is normal. Even
tension with an undulating contour of central calyceal dilation. On though the APRPD measures less than 10 mm, the presence of cen-
the transverse image (b), the anterior–posterior renal pelvic diameter tral calyceal dilation indicates UTD P1

Fig. 9  Urinary tract dilation (UTD) classification P2. a–c Sagittal the widest intrarenal measurement in the transverse plane, c) meas-
(a, b) and transverse (c) US images of the right kidney in a 27-day- ures 7 mm, the presence of the peripheral calyceal dilation indicates
old boy demonstrate peripheral calyceal cupping (curved lines in a). UTD P2. The bladder was normal and there was no ureteral dilation
These are distinguished from the hypoechoic pyramids (arrowheads (not shown)
in b). Although the anterior–posterior renal pelvic diameter (APRPD,

Fig. 10  Urinary tract dilation (UTD) classification P2. a–c Sagittal (APRPD, b). The distal left ureter measures 6 mm in diameter (c).
(a) and transverse (b) US images of the left kidney and transverse Either peripheral calyceal dilation or hydroureter with pelvic disten-
image of the bladder (c) in a 16-day-old boy demonstrate peripheral sion is sufficient to be classified as P2. Hydroureter alone would not
calyceal cupping and 5-mm anterior–posterior renal pelvic diameter be classified by the UTD classification system
Pediatric Radiology (2022) 52:740–751 747

thinning and dysplasia. Because congenital bladder outlet

obstruction is considered a potential severe problem, blad-
der wall thickening with urinary tract dilation is in the most
severe category. Ureteral dilation is in the intermediate cate-
gory because common causes of ureteral dilation (reflux and
primary megaureter) without renal parenchymal abnormali-
ties often resolve. Grading is based on the most abnormal
feature. For example, given a kidney with APRPD of 11 mm
and peripheral calyceal dilation, the presence of peripheral
calyceal dilation leads to the grade UTD P2.
There is no cut-off age for using the UTD classification
system. The classification system was originally intended to
serve as a common language between antenatal and postnatal
US exams in the assessment of congenital urinary tract dila-
tion. However, some children have congenital urinary tract
dilation that is not discovered antenatally or in infancy. Thus,
at all ages we recommend using the standard six descrip-
tors of urinary tract dilation. Once the specific diagnosis is
made, such as ureteropelvic junction obstruction, the UTD
classification is not as important. A non-congenital cause of
urinary tract obstruction, such as stone or tumor, does not
qualify for the UTD classification system because the system
is meant for congenital anomalies. However, using the six
descriptors is useful for consistent language.
At the time of the consensus meeting in 2014, it was
clear that different physician groups and individuals within
each group described the urinary tract differently [13]. For
Fig. 11  Urinary tract dilation (UTD) classification P3. a, b Sagittal example, APRPD was routine on obstetrical US and rare
US images of the right kidney in a 22-day-old girl (same as in Fig. 3) on postnatal imaging. Urologists tended to use the Society
demonstrate severe peripheral calyceal ballooning/dilation (shapes
in b) with thinning of the renal cortex. The hypoechoic calyces are
of Fetal Urology (SFU) grading system, whereas pediatric
compressed (arrowheads in a). The presence of thinning cortex with radiologists used a mild to severe description for hydrone-
urinary tract dilation indicates UTD P3 phrosis. The challenge was to create a common language
that all groups agreed upon. The goal was not only to

Fig. 12  Urinary tract dilation (UTD) classification P3. a–c Sagittal The left kidney is not shown. Although these two features would indi-
(a) and transverse (b) US images of the left kidney and transverse cate UTD P2, the presence of bilateral ureteroceles (arrowheads in
image of the bladder (c) in a 33-day-old boy demonstrate periph- c) in the bladder indicates UTD P3. A ureterocele is cystic dilation
eral calyceal ballooning/dilation (oval in a) with a normal renal cor- of the intravesical ureter, and although it is a part of the distal ureter,
tex. The anterior–posterior renal pelvic diameter (APRPD) is 7 mm, it is considered a bladder abnormality in the UTD classification sys-
measured at the widest intrarenal pelvis in the transverse plane (b). tem because it is seen when visualizing the bladder. The ureters were
Note that the large extrarenal pelvis is not measured for the APRPD. dilated (not shown)
748 Pediatric Radiology (2022) 52:740–751

achieve clearer communication for good patient care, but Clinical validation
to promote better outcomes research for management.
The UTD classification system was approved by repre- Several studies have evaluated the correlation between the
sentatives from many professional organizations and is a UTD classification system and clinical outcomes. Bratina
compilation of existing systems with additional features and Kersnik Levart [14], Zhang et al. [15] and Kaspar et al.
that were missing and thought to be clinically relevant. [16] evaluated prenatal and postnatal US on a cohort of
The APRPD was previously only made in fetuses, and is infants using the UTD classification system. In all of these
now part of the postnatal UTD classification system. One studies, the authors observed a grade-dependent correlation
of the weaknesses of the SFU system is that the appear- between fetal urinary tract dilation and postnatal urologi-
ance of the ureters, bladder and renal echotexture are not cal abnormalities. The majority (88%) of UTD A2-3 cases
included in the descriptions, and those were added to the were P2 or P3 postnatally, and the higher UTD grades were
UTD classification system to give a more global picture correlated with lower probability of spontaneous resolution,
of the urinary tract. The authors of the consensus paper longer time to resolution, higher risk of UTIs, and higher
ask that urinary tract dilation replace other descriptions risk for surgical intervention [14].
such as hydronephrosis or pelvicaliectasis with the UTD Nelson et al. [12] used the UTD classification system on
classification descriptions to avoid confusion. a random selection of 494 infants (0–90 days old) undergo-
ing initial US evaluation at their institution for prenatally
diagnosed urinary tract dilation. They defined “composite”
outcomes as the presence of urinary tract infection, vesi-
Recent evaluation of the urinary tract coureteral reflux, ureteropelvic junction obstruction, non-
dilation (UTD) classification system refluxing megaureter, ureterocele, bladder outlet obstruction
and chronic kidney disease [12]. The authors observed a cor-
Improving the predictive value of US vis-à-vis prenatal/ relation between composite outcomes and the UTD grades
antenatal urinary tract dilation would of course be ben- (normal, 11%; P1, 11%; P2, 29%; and P3, 59%) [12]. In
eficial for patient care. It could expedite the evaluation of addition, they found a correlation between UTD grades and
those with concerning imaging, focus subsequent testing the likelihood of surgical intervention (normal, 1%; P1, 1%;
and perhaps most important, spare many children unneces- P2, 6%; and P3, 46%) as well as the approximate 3-year
sary invasive tests or subsequent low-to-infinitesimal-yield cumulative resolution of urinary tract dilation (normal, 90%;
follow-up US exams. P1, 80%; P2, 50%; and P3, 30%) [12]. Hodhod et al. [17] and
This presumes that: Cakici et al. [18] observed that higher UTD grades corre-
lated with a higher likelihood of surgical intervention. Braga
1) Such a predictive tool is based on sound data with suf- et al. [19] observed in their cohort of 401 children with uri-
ficient patient follow-up to make connections between nary tract dilation that the cumulative 3-year resolution rate
imaging and outcomes (which, granted, can be hard was 90% for P1, 81% for P2 and 71% for P3. The differences
because it would be unethical to truly randomize chil- compared to findings of Nelson et al. [12] are likely the
dren with severe imaging findings to intervention vs. result of variability in the indications for surgical interven-
non-intervention arms of a study). tion. Nevertheless, both Braga and Nelson’s studies observed
2) The tool is consistently used and the results are consist- a grade-dependent rate of urinary tract dilation resolution.
ent across users (high kappa). Based on the observation that normal and P1 had similar
3) There is agreement on the value and use of the tool. clinical outcomes [12], UTD P1 could be combined with
normal into one category. In other words, central calyceal
Prior to the UTD classification system, studying the dilation does not increase the likelihood of a significant
outcome of fetuses with urinary tract dilation was chal- uropathy. This is an important observation because P1
lenging because the terminology between prenatal and might no longer need to be considered a separate category.
postnatal descriptions of the urinary tract were different Prior to the UTD classification system, a survey of pediatric
and inconsistent. One major purpose of having a common radiologists showed how “central calyceal dilation resulted
language is to promote outcomes research. The recom- in many different descriptions including “normal,” “mild
mendations in the original paper were purposely loose, hydronephrosis,” “moderate hydronephrosis,” “pelviectasis”
representing the general consensus of the group because and “pelvicaliectasis,” and now we recognize that central
the data were relatively scant. The intention was that the calyceal dilation might be clinically similar to normal, espe-
new classification system would allow for research that cially in the prone position. The hope is that this can be
would refine the recommendations. used to decrease unnecessary testing. The data from these
studies are beginning to change and standardize clinical
Pediatric Radiology (2022) 52:740–751 749

management. For example, at Boston Children’s Hospital, Clinical use of the urinary tract dilation
children categorized as UTD P2 and UTD P3 are sent for (UTD) classification system
voiding cystourethrogram (VCUG) studies.
Some studies have also correlated UTD grades with the Despite its apparent advantages, the UTD classification sys-
results of other imaging modalities. Agard et al. [20] evalu- tem is not commonly used in clinical practice. Its highest
ated the correlation of UTD grade with findings on diuretic adoption is among pediatric radiologists; 59% of surveyed
renogram, specifically P2 and P3 because it is not recom- pediatric radiologists used the classification system based
mended that a functional scan be done in children with UTD on polling results at the 2021 Society for Pediatric Radiol-
P1. The authors observed that differential renal function ogy neonatal course; among pediatric urologists, only 19%
(DRF) <40% occurred in only 6% of children graded as P2 used the UTD classification system compared to 70% using
and 35% as P3, with a radioactive half-life >20 min in 31% the SFU grading system [25], despite the UTD classifica-
of children graded as P2 and in 79% graded as P3 [20]. Of tion system having a higher inter-rater reliability (k=0.68
the parameters measured in the UTD classification system, compared to 0.6 for the SFU grading system). Similarly,
the presence of parenchymal thinning was the most impor- Suson et al. [26] observed that when reviewing the litera-
tant factor in predicting both decreased DRF and prolonged ture between May 2017 and May 2019, only 6% of studies
radioactive half-life. In addition, Nelson et al. [12] found used the UTD classification system while 37% used the SFU
that the diagnosis of vesicoureteral reflux appears to be grading system and 33% used the APRPD system. Interest-
independent of UTD grade, and this is consistent with prior ingly, approximately 20% of the studies did not apply any
studies that have shown that the degree of “hydronephrosis” grading system when reporting on children with urinary tract
is independent of the degree of reflux [21]. dilation. On a positive note, because the UTD classification
system provided a strict framework for defining the grade of
Assessment of reliability of the urinary tract dilation UTD, Maizels et al. [27] developed a computer application
(UTD) classification system that serves as a training tool for teaching the UTD classifica-
tion system. This more uniform method of teaching the UTD
In statistical analysis, reliability is defined as the extent classification system should help improve both inter- and
to which the results can be reproduced when the test is intra-rater reliability. The Society for Pediatric Radiology
repeated under the same conditions. It is assessed in part by and authors of this paper are consolidating teaching materi-
evaluating the consistency of the results across time by the als to be shared, to increase accessibility and gain coopera-
same observer (intra-rater reliability) and across different tion from all society members.
observers (inter-rater reliability). The level of agreement is A common feedback from pediatric radiologists regard-
expressed statistically by the Cohen kappa coefficient (k). ing their hesitancy in using the UTD classification system
Kappa <0.6 indicates weak level of agreement, 0.6–0.79 is that their pediatric urology colleagues do not want to
moderate, 0.8–0.9 strong and >0.9 almost perfect. use it. In response, it is important to recognize that the
Since 2014, many studies have compared the inter- and UTD classification system is not just for urologists; conse-
intra-rater reliability of the UTD classification system. When quently, its adoption should be for many disciplines. More-
compared to the SFU hydronephrosis grading system, the over, using one system does not mean excluding another.
UTD classification system was found to have higher inter- Perhaps having both descriptive and UTD classification
rater reliability [4, 22–26] and similar intra-rater reliability systems included in the final radiology report is an accept-
[22]. For the UTD classification system, inter-rater reliabil- able compromise. Finally, it is important to recognize that
ity kappa values range from 0.60 to 0.77 and the intra-rater the purpose of using the UTD classification system is to
reliability kappa values from 0.74 to 0.92. The inter- and allow urologists, maternal–fetal medicine specialists and
intra-rater reliability for both the UTD and SFU grading other radiologists from within and outside institutions to
systems remained unchanged among specialties (pediatric read the imaging with the same language, which is espe-
urology, pediatric nephrology and pediatric radiology) and cially important when the images are not available. It is
among training levels [25]. well recognized that implementation can be challeng-
When evaluating the six specific descriptors in the ing and requires prior education. Beginning with piloting
UTD classification system, the lowest inter-rater reliability the classification system might provide a more acceptable
occurred in the assessments of calyceal dilation (distinguish- transition to adoption. It gives liberty to those who have
ing central from peripheral calyceal dilation) [4] and paren- strong opinions one way or another to voice them and to
chymal appearance (k=0.225) [24]. Interestingly, Calle-Toro provide suggestions for adjusting the classification system.
et al. [3] observed that by performing US in prone position, Another criticism of the UTD classification system is
the inter-rater reliability of calyceal assessment and APRPD that it can be complicated. However, it could be similarly
measurement became almost perfect.
750 Pediatric Radiology (2022) 52:740–751

said that describing urinary tract dilation is complicated. 7. Zelenko N, Coll D, Rosenfeld AT, Smith RC (2004) Normal
Thus, a classification system for UTD must be able to ureter size on unenhanced helical CT. AJR Am J Roentgenol
182:1039–1041
incorporate all the nuances of different clinical scenarios. 8. Chitty LS, Altman DG (2003) Charts of fetal size: kidney and
The multidisciplinary group of clinicians who developed renal pelvis measurements. Prenat Diagn 23:891–897
the UTD classification system attempted to develop a sim- 9. Odibo AO, Raab E, Elovitz M et al (2004) Prenatal mild pyelec-
plified classification system without numerous exceptions; tasis: evaluating the thresholds of renal pelvic diameter associ-
ated with normal postnatal renal function. J Ultrasound Med
however, they concluded that some exceptions and caveats 23:513–517
were necessary to account for the complex nature of uri- 10. van Vuuren SH, Damen-Elias HA, Stigter RH et al (2012) Size
nary tract dilation. and volume charts of fetal kidney, renal pelvis and adrenal
As data are accumulating in support of the UTD classi- gland. Ultrasound Obstet Gynecol 40:659–664
11. Schaeffer AJ, Kurtz MP, Logvinenko T et al (2016) MRI-based
fication system, the goal is that practitioners will use these reference range for the renal pelvis anterior-posterior diameter
data to develop a more uniform approach to testing and in children ages 0–19 years. Br J Radiol 89:20160211
patient management. As mentioned, some centers are using 12. Nelson CP, Lee RS, Trout AT et al (2019) The association of
the UTD classification system to triage patients; however, postnatal urinary tract dilation risk score with clinical out-
comes. J Pediatr Urol 15:341.e1–e6
national and international standards have not been made. 13. Swenson DW, Darge K, Ziniel SI, Chow JS (2015) Character-
That is the hope for the future. izing upper urinary tract dilation on ultrasound: a survey of
North American pediatric radiologists’ practices. Pediatr Radiol
45:686–694
14. Bratina P, Kersnik Levart T (2020) Clinical outcome is associ-
Conclusion ated with the urinary tract dilatation classification system grade.
Croat Med J 61:246–251
The UTD classification system provides a uniform system 15. Zhang H, Zhang L, Guo N (2020) Validation of "urinary tract
dilation" classification system: correlation between fetal hydro-
to describe antenatal and postnatal urinary tract dilation. nephrosis and postnatal urological abnormalities. Medicine
Seven years after initiation, research has shown that UTD 99:e18707
classification grading can predict clinical outcomes and has 16. Kaspar CDW, Lo M, Bunchman TE, Xiao N (2017) The ante-
similar to better inter- and intra-rater reliability compared natal urinary tract dilation classification system accurately
predicts severity of kidney and urinary tract abnormalities. J
to other systems. The goals now are to increase adoption Pediatr Urol 13:485.e1–e7
among different subspecialties and to create standardized 17. Hodhod A, Capolicchio JP, Jednak R et al (2016) Evaluation of
management plans to optimize patient care. urinary tract dilation classification system for grading postnatal
hydronephrosis. J Urol 195:725–730
18. Cakici EK, Aydog O, Eroglu FK et al (2019) Value of renal
pelvic diameter and urinary tract dilation classification in the
Declarations prediction of urinary tract anomaly. Pediatr Int 61:271–277
19. Braga LH, McGrath M, Farrokhyar F et al (2018) Society for
Conflicts of interest None Fetal Urology classification vs. urinary tract dilation grading
system for prognostication in prenatal hydronephrosis: a time
to resolution analysis. J Urol 199:1615–1621
20. Agard H, Massanyi E, Albertson M et al (2020) The different
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