1- Radiology department, Kasr Alainy hospitals, Cairo University, Egypt.
2- Fetal medicine unit, Obstetrics and gynecology department, Kasr Alainy hospitals, Cairo University, Egypt. 

Case report

A 27-year old patient was referred to our institution at 25 weeks of pregnancy due to fetal renal abnormal cystic dilation. Our ultrasound examination revealed:

- Marked dilatation of renal pelvicalyceal system on the right side with severe blunting of major calyces yet, with normal renal parenchymal thickness and echogenicity.

- Severe dilation and tortuosity of ipsilateral ureter with dilated vesicoureteric junction.
- Adequate filling of the urinary bladder with normal wall thickness. 
- Mild fullness of the left renal pelvis with normal parenchymal thickness and echogenicity.

Our final diagnosis was primary grade V vesicoureteric reflux on the right side based on imaging findings of severe dilation and tortuosity of the ureter, marked dilation of ipsilateral vesicoureteric junction, and marked dilation of ipsilateral pelvicalyceal system with severe blunting of renal calyces. 

Normal urinary bladder wall thickness, absence of contralateral ureteral dilation as well as lack of intra luminal ureterocele could virtually exclude an obstructive cause for this severe vesicoureteric reflux. 

Probability of reflux on the left side could not be excluded. However, in early postnatal period; voiding cystourethrography was done and revealed unilateral severe VUR on the right side. 

Pediatric nephrologist consultation recommended postnatal follow up for about 2 years with prophylactic antibiotic therapy (to avoid recurrent UTI and pyelonephritis) because of probable spontaneous resolution despite its rare occurrence in case of grade V reflux. Ureteral implantation will be the method of choice if the condition persisted above 2 years in postnatal life.

Following images and videos show grade V vesicoureteral reflux: