1
|
Buijtendijk MF, Bet BB, Leeflang MM, Shah H, Reuvekamp T, Goring T, Docter D, Timmerman MG, Dawood Y, Lugthart MA, Berends B, Limpens J, Pajkrt E, van den Hoff MJ, de Bakker BS. Diagnostic accuracy of ultrasound screening for fetal structural abnormalities during the first and second trimester of pregnancy in low-risk and unselected populations. Cochrane Database Syst Rev 2024; 5:CD014715. [PMID: 38721874 PMCID: PMC11079979 DOI: 10.1002/14651858.cd014715.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Prenatal ultrasound is widely used to screen for structural anomalies before birth. While this is traditionally done in the second trimester, there is an increasing use of first-trimester ultrasound for early detection of lethal and certain severe structural anomalies. OBJECTIVES To evaluate the diagnostic accuracy of ultrasound in detecting fetal structural anomalies before 14 and 24 weeks' gestation in low-risk and unselected pregnant women and to compare the current two main prenatal screening approaches: a single second-trimester scan (single-stage screening) and a first- and second-trimester scan combined (two-stage screening) in terms of anomaly detection before 24 weeks' gestation. SEARCH METHODS We searched MEDLINE, EMBASE, Science Citation Index Expanded (Web of Science), Social Sciences Citation Index (Web of Science), Arts & Humanities Citation Index and Emerging Sources Citation Index (Web of Science) from 1 January 1997 to 22 July 2022. We limited our search to studies published after 1997 and excluded animal studies, reviews and case reports. No further restrictions were applied. We also screened reference lists and citing articles of each of the included studies. SELECTION CRITERIA Studies were eligible if they included low-risk or unselected pregnant women undergoing a first- and/or second-trimester fetal anomaly scan, conducted at 11 to 14 or 18 to 24 weeks' gestation, respectively. The reference standard was detection of anomalies at birth or postmortem. DATA COLLECTION AND ANALYSIS Two review authors independently undertook study selection, quality assessment (QUADAS-2), data extraction and evaluation of the certainty of evidence (GRADE approach). We used univariate random-effects logistic regression models for the meta-analysis of sensitivity and specificity. MAIN RESULTS Eighty-seven studies covering 7,057,859 fetuses (including 25,202 with structural anomalies) were included. No study was deemed low risk across all QUADAS-2 domains. Main methodological concerns included risk of bias in the reference standard domain and risk of partial verification. Applicability concerns were common in studies evaluating first-trimester scans and two-stage screening in terms of patient selection due to frequent recruitment from single tertiary centres without exclusion of referrals. We reported ultrasound accuracy for fetal structural anomalies overall, by severity, affected organ system and for 46 specific anomalies. Detection rates varied widely across categories, with the highest estimates of sensitivity for thoracic and abdominal wall anomalies and the lowest for gastrointestinal anomalies across all tests. The summary sensitivity of a first-trimester scan was 37.5% for detection of structural anomalies overall (95% confidence interval (CI) 31.1 to 44.3; low-certainty evidence) and 91.3% for lethal anomalies (95% CI 83.9 to 95.5; moderate-certainty evidence), with an overall specificity of 99.9% (95% CI 99.9 to 100; low-certainty evidence). Two-stage screening had a combined sensitivity of 83.8% (95% CI 74.7 to 90.1; low-certainty evidence), while single-stage screening had a sensitivity of 50.5% (95% CI 38.5 to 62.4; very low-certainty evidence). The specificity of two-stage screening was 99.9% (95% CI 99.7 to 100; low-certainty evidence) and for single-stage screening, it was 99.8% (95% CI 99.2 to 100; moderate-certainty evidence). Indirect comparisons suggested superiority of two-stage screening across all analyses regarding sensitivity, with no significant difference in specificity. However, the certainty of the evidence is very low due to the absence of direct comparisons. AUTHORS' CONCLUSIONS A first-trimester scan has the potential to detect lethal and certain severe anomalies with high accuracy before 14 weeks' gestation, despite its limited overall sensitivity. Conversely, two-stage screening shows high accuracy in detecting most fetal structural anomalies before 24 weeks' gestation with high sensitivity and specificity. In a hypothetical cohort of 100,000 fetuses, the first-trimester scan is expected to correctly identify 113 out of 124 fetuses with lethal anomalies (91.3%) and 665 out of 1776 fetuses with any anomaly (37.5%). However, 79 false-positive diagnoses are anticipated among 98,224 fetuses (0.08%). Two-stage screening is expected to correctly identify 1448 out of 1776 cases of structural anomalies overall (83.8%), with 118 false positives (0.1%). In contrast, single-stage screening is expected to correctly identify 896 out of 1776 cases before 24 weeks' gestation (50.5%), with 205 false-positive diagnoses (0.2%). This represents a difference of 592 fewer correct identifications and 88 more false positives compared to two-stage screening. However, it is crucial to acknowledge the uncertainty surrounding the additional benefits of two-stage versus single-stage screening, as there are no studies directly comparing them. Moreover, the evidence supporting the accuracy of first-trimester ultrasound and two-stage screening approaches primarily originates from studies conducted in single tertiary care facilities, which restricts the generalisability of the results of this meta-analysis to the broader population.
Collapse
Affiliation(s)
- Marieke Fj Buijtendijk
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Bo B Bet
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Harsha Shah
- Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Tom Reuvekamp
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Timothy Goring
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel Docter
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Melanie Gmm Timmerman
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Yousif Dawood
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Malou A Lugthart
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Bente Berends
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jacqueline Limpens
- Medical Library, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Eva Pajkrt
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Maurice Jb van den Hoff
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, Netherlands
| | - Bernadette S de Bakker
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
2
|
Pierucci UM, Paraboschi I, Mantica G, Costanzo S, Riccio A, Selvaggio GGO, Pelizzo G. Antenatal Determinants of Postnatal Renal Function in Fetal Megacystis: A Systematic Review. Diagnostics (Basel) 2024; 14:756. [PMID: 38611669 PMCID: PMC11012172 DOI: 10.3390/diagnostics14070756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Introduction: To evaluate the clinical usefulness of demographic data, fetal imaging findings and urinary analytes were used for predicting poor postnatal renal function in children with congenital megacystis. Materials and methods: A systematic review was conducted in MEDLINE's electronic database from inception to December 2023 using various combinations of keywords such as "luto" [All Fields] OR "lower urinary tract obstruction" [All Fields] OR "urethral valves" [All Fields] OR "megacystis" [All Fields] OR "urethral atresia" [All Fields] OR "megalourethra" [All Fields] AND "prenatal ultrasound" [All Fields] OR "maternal ultrasound" [All Fields] OR "ob-stetric ultrasound" [All Fields] OR "anhydramnios" [All Fields] OR "oligohydramnios" [All Fields] OR "renal echogenicity" [All Fields] OR "biomarkers" [All Fields] OR "fetal urine" [All Fields] OR "amniotic fluid" [All Fields] OR "beta2 microglobulin" [All Fields] OR "osmolarity" [All Fields] OR "proteome" [All Fields] AND "outcomes" [All Fields] OR "prognosis" [All Fields] OR "staging" [All Fields] OR "prognostic factors" [All Fields] OR "predictors" [All Fields] OR "renal function" [All Fields] OR "kidney function" [All Fields] OR "renal failure" [All Fields]. Two reviewers independently selected the articles in which the accuracy of prenatal imaging findings and fetal urinary analytes were evaluated to predict postnatal renal function. Results: Out of the 727 articles analyzed, 20 met the selection criteria, including 1049 fetuses. Regarding fetal imaging findings, the predictive value of the amniotic fluid was investigated by 15 articles, the renal appearance by 11, bladder findings by 4, and ureteral dilatation by 2. The postnatal renal function showed a statistically significant relationship with the occurrence of oligo- or anhydramnion in four studies, with an abnormal echogenic/cystic renal cortical appearance in three studies. Single articles proved the statistical prognostic value of the amniotic fluid index, the renal parenchymal area, the apparent diffusion coefficient (ADC) measured on fetal diffusion-weighted MRI, and the lower urinary tract obstruction (LUTO) stage (based on bladder volume at referral and gestational age at the appearance of oligo- or anhydramnios). Regarding the predictive value of fetal urinary analytes, sodium and β2-microglobulin were the two most common urinary analytes investigated (n = 10 articles), followed by calcium (n = 6), chloride (n = 5), urinary osmolarity (n = 4), and total protein (n = 3). Phosphorus, glucose, creatinine, and urea were analyzed by two articles, and ammonium, potassium, N-Acetyl-l3-D-glucosaminidase, and microalbumin were investigated by one article. The majority of the studies (n = 8) failed to prove the prognostic value of fetal urinary analytes. However, two studies showed that a favorable urinary biochemistry profile (made up of sodium < 100 mg/dL; calcium < 8 mg/dL; osmolality < 200 mOsm/L; β2-microglobulin < 4 mg/L; total protein < 20 mg/dL) could predict good postnatal renal outcomes with statistical significance and urinary levels of β2-microglobulin were significantly higher in fetuses that developed an impaired renal function in childhood (10.9 ± 5.0 mg/L vs. 1.3 ± 0.2 mg/L, p-value < 0.05). Conclusions: Several demographic data, fetal imaging parameters, and urinary analytes have been shown to play a role in reliably triaging fetuses with megacystis for the risk of adverse postnatal renal outcomes. We believe that this systematic review can help clinicians for counseling parents on the prognoses of their infants and identifying the selected cases eligible for antenatal intervention.
Collapse
Affiliation(s)
- Ugo Maria Pierucci
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | - Irene Paraboschi
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy;
| | - Guglielmo Mantica
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy;
| | - Sara Costanzo
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | - Angela Riccio
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | | | - Gloria Pelizzo
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy;
| |
Collapse
|
3
|
Richter J, Doktor F, Good H, Erdman L, Kim JK, Santos JD, Brownrigg N, Chua M, Lorenzo AJ, Rickard M, Mieghem TV, Shinar S. Trends in Management of Fetuses with Suspected Lower Urinary Tract Obstruction (LUTO): A High-Risk Fetal and Pediatric Center Experience in a Universal-Access-to-Care System. Eur J Pediatr Surg 2024; 34:91-96. [PMID: 37607585 DOI: 10.1055/s-0043-1772172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Neonates with lower urinary tract obstruction (LUTO) experience high morbidity and mortality associated with the development of chronic kidney disease. The prenatal detection rate for LUTO is less than 50%, with late or missed diagnosis leading to delayed management and long-term sequelae in the remainder. We aimed to explore the trends in prenatal detection and management at a high-risk fetal center and determine if similar trends of postnatal presentations were noted for the same period. METHODS Prenatal and postnatal LUTO databases from a tertiary fetal center and its associated pediatric center between 2009 and 2021 were reviewed, capturing maternal age, gestational age (GA) at diagnosis, and rates of termination of pregnancy (TOP). Time series analysis using autocorrelation was performed to investigate time trend changes for prenatally suspected and postnatally confirmed LUTO cases. RESULTS A total of 161 fetuses with prenatally suspected LUTO were identified, including 78 terminations. No significant time trend was found when evaluating the correlation between time periods, prenatal suspicion, and postnatal confirmation of LUTO cases (Durbin-Watson [DW] = 1.99, p = 0.3641 and DW = 2.86, p = 0.9113, respectively). GA at referral was 20.0 weeks (interquartile range [IQR] 12, 35) and 22.0 weeks (IQR 13, 37) for TOP and continued pregnancies (p < 0.0001). GA at initial ultrasound was earlier in terminated fetuses compared to continued (20.0 [IQR 12, 35] weeks vs. 22.5 [IQR 13, 39] weeks, p < 0.0001). While prenatal LUTO suspicion remained consistently higher than postnatal presentations, the rates of postnatal presentations and terminations remained stable during the study years (p = 0.7913 and 0.2338), as were GA at TOP and maternal age at diagnosis (p = 0.1710 and 0.1921). CONCLUSION This study demonstrated that more severe cases of LUTO are referred earlier and are more likely to undergo TOP. No significant trend was detected between time and prenatally suspected or postnatally confirmed LUTO, highlighting the need for further studies to better delineate factors that can increase prenatal detection.
Collapse
Affiliation(s)
- Juliane Richter
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fabian Doktor
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
- University of Leipzig, Department of Pediatric Surgery, Leipzig, Germany
| | - Hayley Good
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Erdman
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada; Vector Institute, Toronto, Ontario, Canada
- Centre for Computational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jin K Kim
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natasha Brownrigg
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Chua
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Urology, St. Luke's Medical Center, Philippines
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shiri Shinar
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Nulens K, Lorenzo AJ, Dos Santos J, Ellul K, Rickard M. Fetal urinary tract dilation: What to tell the parents. Prenat Diagn 2024; 44:148-157. [PMID: 38117007 DOI: 10.1002/pd.6497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/04/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
Urinary tract dilation (UTD), which refers to the abnormal dilation of the urinary collection system, is the most common finding on prenatal ultrasound and presents with varying severity, presentation, etiology, and prognosis. Prenatal classification and risk stratification aim to prevent postnatal complications, such as urinary tract infections and further kidney dysfunction. Parents expecting a child with UTD should be counseled by a multidisciplinary team consisting of maternal-fetal medicine specialists, and pediatric urology and nephrology providers. This review summarizes the key points in the diagnostic evaluation and management during the prenatal and initial postnatal period, focusing on the information that should be provided to future parents. We address frequently asked parental questions and concerns that our multidisciplinary clinical practice faces.
Collapse
Affiliation(s)
- Katrien Nulens
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Katie Ellul
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Shannon KJ, VanLoh S, Espinoza J, Sanz-Cortes M, Donepudi R, Shamshirsaz AA, Koh CJ, Roth DR, Braun MC, Angelo J, Belfort MA, Nassr AA. Fetal bladder morphology as a predictor of outcome in fetal lower urinary tract obstruction. Prenat Diagn 2024; 44:124-130. [PMID: 36919753 DOI: 10.1002/pd.6343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE We evaluate survival of fetuses with severe Lower Urinary Tract Obstruction (LUTO) based on bladder morphology. We hypothesize that fetuses with a "floppy" appearing bladder on initial prenatal ultrasound will have worse infant outcomes than fetuses with full/rounded bladders. METHOD We retrospectively reviewed all cases of LUTO evaluated in our fetal center between January 2013 and December 2021. Ultrasonographic assessment, renal biochemistry, and bladder refilling contributed to a "favorable" or "unfavorable" evaluation. Bladder morphology on initial ultrasound was classified as "floppy" or "full/rounded." Vesicoamniotic shunting was offered for favorably evaluated fetuses. Baseline demographics, ultrasound parameters, prenatal evaluations of fetal renal function, and infant outcomes were collected. Fetuses diagnosed with severe LUTO were included in analysis using descriptive statistics. The primary outcome measured was survival at 6 months of life. RESULTS 104 LUTO patients were evaluated; 24 were included in analysis. Infant survival rate at 6 months was 60% for rounded bladders and 0% for floppy bladders (p = 0.003). Bladder refill adequacy was lower in fetuses with floppy bladders compared with rounded bladders (p value < 0.00001). CONCLUSION We propose that bladder morphology in fetuses with severe LUTO may be a prognostication factor for predicting infant outcomes and provides a valuable, noninvasive assessment tool.
Collapse
Affiliation(s)
| | - Sarah VanLoh
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Magdalena Sanz-Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - David R Roth
- Division of Pediatric Urology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Michael C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Angelo
- Division of Pediatric Nephrology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
6
|
Blumenfeld YJ, Sheth KR, Johnson E, Wall JK, Deprest JA, Russo FM, Danzer E. Development and validation of a novel fetal vesico-amniotic shunt, the vortex shunt. Prenat Diagn 2024; 44:158-166. [PMID: 38009470 DOI: 10.1002/pd.6470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
Fetal lower urinary tract obstruction (LUTO) is a severe malformation associated with an up to 80% mortality risk as well as significant renal and pulmonary morbidity in survivors. Fetal vesico-amniotic shunts (VAS) bypass the bladder obstruction, improve amniotic fluid volume and enhance in-utero pulmonary development. VAS has been shown to reduce respiratory morbidity and mortality in the neonatal period without proven benefit on long-term renal and bladder function. Clinically available shunts are associated with an up to 80% dislodgement rate, leading to repeat invasive procedures which increase fetal and maternal risks. We developed a novel "Vortex" shunt, which incorporates enhanced fixation to reduce dislodgement, a one-way valve to optimize in-utero bladder function, and enhanced sonographic echogenicity that optimizes the accurate deployment. Following the validation of these characteristics in initial benchtop experiments we have moved to feasibility studies in the fetal lamb model. We hope that the Vortex shunt may ultimately facilitate shunt deployment, reduce dislodgement risk, improve neonatal morbidity and mortality, and decrease the significant healthcare expenditures associated with long-term morbidity in LUTO survivors. In this manuscript, we review the natural history of LUTO, the risks and benefits of clinically available fetal shunts, and our development and early validation experiments.
Collapse
Affiliation(s)
- Yair J Blumenfeld
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Kunj R Sheth
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Johnson
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - James K Wall
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jan A Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Francesca M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Enrico Danzer
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
7
|
Rickard M, Lorenzo AJ, Richter J, Brownrigg N, Kim JK, Chua M, Goraya N, Khondker A, Yadav P, Keefe DT, Shinar S, Dos Santos J. Implementation of a standardized clinical pathway in a dedicated posterior urethral valves clinic: short-term outcomes. Pediatr Nephrol 2023; 38:3735-3744. [PMID: 37322171 DOI: 10.1007/s00467-023-06040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND To determine if the implementation of a posterior urethral valves (PUV) clinic and standardized management pathway improves the short-term kidney outcomes of infants with PUV. METHODS From 2016-2022, 50 consecutive patients were divided into groups after the implementation of the clinic (APUV, n = 29) and before (BPUV, n = 21) during a comparable timeframe. Assessed data included age at initial visit, timing and type of surgery, frequency of follow-up visits, medications, nadir creatinine, and development of CKD/kidney failure. Data are shown as median with interquartile range (IQR) and odds ratios (OR) with 95% confidence interval (CI). RESULTS APUV had higher rates of prenatal diagnoses (12/29 vs. 1/21; p = 0.0037), earlier initial surgical intervention (8 days; IQR 0, 105 vs. 33 days; IQR 4, 603; p < 0.0001), and higher rates of primary diversions (10/29 vs. 0/21; p = 0.0028). Standardized management led to earlier initiation of alpha blockers (326 days; IQR 6, 860 vs. 991; IQR 149, 1634; p = 0.0019) and anticholinergics (57 days; IQR 3, 860 vs. 1283 days; IQR 477, 1718; p < 0.0001). Nadir creatinine was reached at earlier ages in APUV (105 days; IQR 2, 303 vs. 164 days; IQR 21, 447; p = 0.0192 BPUV). One patient progressed to CKD5 in APUV compared to CKD3, CKD5 and one transplant in BPUV. CONCLUSION Implementing the PUV clinic with standardized treatment expedited postnatal management and resulted in a higher number of cases detected prenatally, a shift in primary treatment, younger ages at initial treatment, reduced time to nadir creatinine, and timely initiation of supportive medications. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Mandy Rickard
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada.
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juliane Richter
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
| | - Natasha Brownrigg
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
| | - Jin K Kim
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
| | - Michael Chua
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Urology, St. Luke's Medical Center, Quezon, Philippines
| | - Noreen Goraya
- Department of Social Work, The Hospital for Sick Children, Toronto, ON, Canada
| | - Adree Khondker
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Priyank Yadav
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Renal Sciences, Lucknow, India
| | - Daniel T Keefe
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Shiri Shinar
- Ontario Fetal Center, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
8
|
O'Keefe H, Shenfine R, Brown M, Beyer F, Rankin J. Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy. BMJ Open 2023; 13:e064774. [PMID: 36609326 PMCID: PMC9827258 DOI: 10.1136/bmjopen-2022-064774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 12/04/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age. DESIGN This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO. PARTICIPANTS Deaths from conception to one adjusted year of age. SEARCH METHODS MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021. DIAGNOSTIC TESTS Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy. DATA COLLECTION AND ANALYSIS Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect. MAIN OUTCOME MEASURES Direction of effect was expressed as percentage of patients per study. FINDINGS We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results. CONCLUSIONS Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.
Collapse
Affiliation(s)
- Hannah O'Keefe
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebekka Shenfine
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Melissa Brown
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Beyer
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
9
|
Abstract
The most severe forms of congenital anomalies of the kidney and urinary tract present in fetal life with early pregnancy renal anhydramnios and are considered lethal due to pulmonary hypoplasia without fetal therapy. Due to the high rate of additional structural anomalies, genetic abnormalities, and associated syndromes, detailed anatomic survey and genetic testing are imperative when stratifying which pregnancies are appropriate for fetal intervention. Restoring amniotic fluid around the fetus is the principal goal of prenatal treatment. The ongoing multi-center Renal Anhydramnios Fetal Therapy (RAFT) trial is assessing the safety and efficacy of serial amnioinfusions to prevent pulmonary hypoplasia so that the underlying renal disease can be addressed.
Collapse
|
10
|
Jørgensen PH, Olsen TE, Henriksen BM, Thorup JM. Lower urinary tract obstruction caused by fibroepithelial polyp in a newborn boy. Urol Case Rep 2022; 45:102182. [PMID: 36016721 PMCID: PMC9396535 DOI: 10.1016/j.eucr.2022.102182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/20/2022] [Accepted: 07/31/2022] [Indexed: 11/05/2022] Open
Abstract
In this rare case we report a 3-week-old boy with postnatal continues stomach pains, crying and severe dysuria, caused by bladder outlet obstruction due to a histopathological confirmed fibroepithelial polyp in the prostatic urethra. The condition was diagnosed and fully treated with ultrasound and a therapeutic cystoscopy.
Collapse
|
11
|
Richter J, Rickard M, Kim JK, Erdman L, Lorenzo AJ, Chua M. Predicting the Future of Patients with Obstructive Uropathy—A Comprehensive Review. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00272-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
12
|
Wada S, Ozawa K, Sago H. New challenges of fetal therapy in Japan. J Obstet Gynaecol Res 2022; 48:2100-2111. [PMID: 35676616 PMCID: PMC9544758 DOI: 10.1111/jog.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
Aim To review new challenges of fetal therapy in Japan after the establishment of four existing fetal therapies as standard prenatal care with National Health Insurance coverage over the past 20 years. Methods Reported studies and our current research activities related to four fetal therapies newly performed in Japan were reviewed. Results Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) aims to occlude the trachea using a detachable balloon to promote lung growth. Following the recent successful completion of an international randomized controlled trial for CDH, in which we participated, FETO is offered for severe left CDH to perform balloon insertion at 27–29 weeks and removal at 34 weeks of gestation. Fetal cystoscopy (FC) for low urinary tract obstruction was introduced to overcome the demerits of vesicoamniotic shunting. FC may provide a proper diagnosis by visual observation of the urethra and physiological treatment of the posterior urethral valve. The effectiveness of open fetal surgery for myelomeningocele (MMC), direct surgery with laparotomy and hysterotomy, for ameliorating hindbrain herniation and the motor function was demonstrated, but it was also associated with substantial maternal and fetal risks. Fetal aortic valvuloplasty (FAV), ultrasound‐guided fetal aortic balloon dilation for critical aortic stenosis with evolving hypoplastic left heart syndrome may improve left heart development and maintain biventricular circulation. Feasibility and safety studies for FC, MMC open fetal surgery, and FAV are currently ongoing. Conclusions Clinical research on FETO, FC, MMC open fetal surgery, and FAV has proceeded with careful preparations in Japan.
Collapse
Affiliation(s)
- Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
13
|
Slagle C, Schuh M, Grisotti G, Riddle S, Reddy P, Claes D, Lim FY, VanderBrink B. In utero renal failure. Semin Pediatr Surg 2022; 31:151195. [PMID: 35725056 DOI: 10.1016/j.sempedsurg.2022.151195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States.
| | - Meredith Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Gabriella Grisotti
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Stefanie Riddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States
| | - Pramod Reddy
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Donna Claes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Brian VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| |
Collapse
|
14
|
Lombel RM, Brakeman PR, Sack BS, Butani L. Urologic Considerations in Pediatric Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:308-317. [PMID: 36084977 DOI: 10.1053/j.ackd.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
Common causes of pediatric ESRD are distinct from those seen in the adult population. In the pediatric population, the most common are congenital anomalies of the kidney and urinary tract (CAKUT), affecting approximately 30% of children with CKD. These structural anomalies often require coordinated care with the pediatric urology team to address voiding issues, bladder involvement, and the potential need for surgical intervention. For pediatric nephrologists and urologists, common CAKUT that are encountered include antenatal hydronephrosis, obstructive uropathies (eg, posterior urethral valves), and vesicoureteral reflux. As more pediatric patients with CAKUT, CKD, and ESRD transition to adult care, it is important for receiving adult nephrologists to understand the clinical presentation, natural history, and prognosis for these diagnoses. This review outlines the diagnosis and potential interventions for these conditions, including strategies to address bladder dysfunction that is often seen in children with CAKUT. A discussion of these management decisions (including surgical intervention) for CAKUT, which are quite common to pediatric nephrology and urology practices, may provide unique learning opportunities for adult nephrologists who lack familiarity with these pediatric conditions.
Collapse
Affiliation(s)
- Rebecca M Lombel
- Division of Pediatric Nephrology, University of Michigan, Ann Arbor, MI.
| | - Paul R Brakeman
- Division of Pediatric Nephrology, University of California, San Francisco, San Francisco, CA
| | - Bryan S Sack
- Division of Pediatric Urology, University of Michigan, Ann Arbor, MI
| | - Lavjay Butani
- Division of Pediatric Nephrology, University of California Davis Medical Center, Sacramento, CA
| |
Collapse
|
15
|
Capone V, Persico N, Berrettini A, Decramer S, De Marco EA, De Palma D, Familiari A, Feitz W, Herthelius M, Kazlauskas V, Liebau M, Manzoni G, Maternik M, Mosiello G, Schanstra JP, Vande Walle J, Wühl E, Ylinen E, Zurowska A, Schaefer F, Montini G. Definition, diagnosis and management of fetal lower urinary tract obstruction: consensus of the ERKNet CAKUT-Obstructive Uropathy Work Group. Nat Rev Urol 2022; 19:295-303. [PMID: 35136187 DOI: 10.1038/s41585-022-00563-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022]
Abstract
Fetal lower urinary tract obstruction (LUTO) is associated with high mortality and postnatal morbidity caused by lung hypoplasia and impaired kidney function. Specific diagnostic features that can guide clinical approach and decisions are lacking; thus, the European Reference Network for Rare Kidney Diseases established a work group to develop recommendations regarding the clinical definition, diagnosis and management of prenatally detected LUTO. The work group recommends the use of antero-posterior diameter of renal pelvis as the most reliable parameter for suspecting obstructive uropathies and for suspecting prenatal LUTO in the presence of fetal megacystis. Regarding prenatal and postnatal prognosis of fetuses with LUTO, the risk of fetal and neonatal death depends on the presence of oligohydramnios or anhydramnios before 20 weeks' gestation, whereas the risk of kidney replacement therapy cannot be reliably foreseen before birth. Parents of fetuses with LUTO must be referred to a tertiary obstetric centre with multidisciplinary expertise in prenatal and postnatal management of obstructive uropathies, and vesico-amniotic shunt placement should be offered in selected instances, as it increases perinatal survival of fetuses with LUTO.
Collapse
Affiliation(s)
- Valentina Capone
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Nicola Persico
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alfredo Berrettini
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Stèphane Decramer
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France.,Service de Néphrologie Pédiatrique, Hôpital des Enfants, CHU Toulouse, Toulouse, France.,Centre De Référence des Maladies Rénales Rares du Sud-Ouest (SORARE), Toulouse, France
| | - Erika Adalgisa De Marco
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Diego De Palma
- Nuclear Medicine Unit, "Circolo" Hospital, ASST-settelaghi, Varese, Italy
| | - Alessandra Familiari
- High Risk Pregnancy Unit, Department of Women, Children and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Wout Feitz
- Department of Urology, Division of Paediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Maria Herthelius
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Vytis Kazlauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Max Liebau
- Department of Pediatrics and Center for Molecular Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gianantonio Manzoni
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Michal Maternik
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Giovanni Mosiello
- Bambino Gesù Pediatric Hospital, Division of Pediatric Urology/Neuro-Urology, Rome, Italy
| | - Joost Peter Schanstra
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France
| | - Johan Vande Walle
- Paediatric Nephrology and Rheumatology Section, Department of Paediatrics, Ghent University Hospital, Ghent, Belgium
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| |
Collapse
|
16
|
Sheth KR, Danzer E, Johnson E, Wall JK, Blumenfeld YJ. Development and in-vitro characterization of a novel fetal vesicoamniotic shunt - the Vortex Shunt. Prenat Diagn 2022; 42:164-171. [PMID: 35048376 DOI: 10.1002/pd.6096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To develop and test a novel vesicoamniotic shunt (VAS) to treat fetal lower urinary tract obstruction (LUTO), decrease dislodgement and optimize shunt deployment in-vitro. METHODS VAS design objectives included: 1) robust and atraumatic fixation elements, 2) kink resistant conduit to adjust to fetal movement and growth, 3) one-way pressure valve to facilitate bladder cycling, and 4) echogenic deployment visualization aids. The force to dislodge the novel Vortex shunt was compared with existing commercially available shunts in a bench-top porcine bladder model. Sonographic echogenicity was evaluated with ultrasound-guided deployment, and the shunt valve pressure measured. RESULTS A prototype novel Vortex shunt was developed using braided nitinol "umbrella-type" ends with a kink-resistant stem incorporating an internal one-way valve. The peak force required to dislodge the Vortex shunt was significantly higher than commercially available shunts (p<0.01). Shunt deployment in the bench-top model was easily confirmed with ultrasound guidance and the brisk decompression of the inflated porcine bladder thereafter. In-vitro valve gauge pressure testing mirrored bladder pressures in human LUTO cases. CONCLUSION In-vitro testing shows that the Vortex shunt may improve deployment, sonographic visualization, kink resistance, and dynamic size adjustment. Validation in preclinical animal models are warranted and currently underway. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Kunj R Sheth
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Urology, Division of Pediatric Urology at Stanford University School of Medicine, Stanford, CA, 94305.,Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - Enrico Danzer
- Division on Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, 10065
| | - Eric Johnson
- Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - James K Wall
- Department of Bioengineering, Stanford University, Stanford, CA, 94305.,Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Surgery, Division of Pediatric Surgery at Stanford University School of Medicine, Stanford, CA, 94305
| | - Yair J Blumenfeld
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine and Obstetrics at Stanford University School of Medicine, Stanford, CA, 94305
| |
Collapse
|
17
|
Fontanella F, Groen H, Duin LK, Suresh S, Bilardo CM. Z-scores of fetal bladder size for antenatal differential diagnosis between posterior urethral valves and urethral atresia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:875-881. [PMID: 33864313 PMCID: PMC9299997 DOI: 10.1002/uog.23647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To construct reference values for fetal urinary bladder distension in pregnancy and use Z-scores as a diagnostic tool to differentiate posterior urethral valves (PUV) from urethral atresia (UA). METHODS This was a prospective cross-sectional study in healthy singleton pregnancies aimed at constructing nomograms of fetal urinary bladder diameter and volume between 15 and 35 weeks' gestation. Z-scores of longitudinal bladder diameter (LBD) were calculated and validated in a cohort of fetuses with megacystis with ascertained postnatal or postmortem diagnosis, collected from a retrospective, multicenter study. Correlations between anatomopathological findings, based on medical examination of the infant or postmortem examination, and fetal megacystis were established. The accuracy of the Z-scores was evaluated by receiver-operating-characteristics (ROC)-curve analysis. RESULTS Nomograms of fetal urinary bladder diameter and volume were produced from three-dimensional ultrasound volumes in 225 pregnant women between 15 and 35 weeks of gestation. A total of 1238 urinary bladder measurements were obtained. Z-scores, derived from the fetal nomograms, were calculated in 106 cases with suspected lower urinary tract obstruction (LUTO), including 76 (72%) cases with PUV, 22 (21%) cases with UA, four (4%) cases with urethral stenosis and four (4%) cases with megacystis-microcolon-intestinal hypoperistalsis syndrome. Fetuses with PUV showed a significantly lower LBD Z-score compared to those with UA (3.95 vs 8.83, P < 0.01). On ROC-curve analysis, we identified 5.2 as the optimal Z-score cut-off to differentiate fetuses with PUV from the rest of the study population (area under the curve, 0.84 (95% CI, 0.748-0.936); P < 0.01; sensitivity, 74%; specificity, 86%). CONCLUSIONS Z-scores of LBD can distinguish reliably fetuses with LUTO caused by PUV from those with other subtypes of LUTO, with an optimal cut-off of 5.2. This information should be useful for prenatal counseling and management of LUTO. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- F. Fontanella
- Department of Obstetrics and GynaecologyIsala HospitalZwolleThe Netherlands
| | - H. Groen
- Department of Epidemiology‐HPC FA40, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics and GynaecologyIsala HospitalZwolleThe Netherlands
| | - S. Suresh
- Mediscan Ultrasound CenterChennaiIndia
| | - C. M. Bilardo
- Department of Obstetrics and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Amsterdam UMC, Location VUAmsterdamThe Netherlands
| |
Collapse
|
18
|
Patwa P, Sharma C, Shekhar S, Jhirwal M. Bilateral Fetal Hydronephrosis presenting with Complete Penoscrotal Transposition at Birth: What to tell the Prospective Parents? JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-021-00324-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
19
|
Naini AR, Kapkanova N, Zelesco M. Fetal urinary ascites and spontaneous bladder rupture—A rare case of anterior urethral valves: A case report. SONOGRAPHY 2021. [DOI: 10.1002/sono.12285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Anitha Reddy Naini
- Department of Medical Imaging Fiona Stanley Hospital Murdoch Western Australia Australia
| | - Natasha Kapkanova
- Department of Medical Imaging Fiona Stanley Hospital Murdoch Western Australia Australia
| | - Marilyn Zelesco
- Department of Medical Imaging Fiona Stanley Hospital Murdoch Western Australia Australia
| |
Collapse
|
20
|
Keefe DT, Kim JK, Mackay E, Chua M, Van Mieghem T, Yadav P, Lolas M, Santos JD, Skreta M, Erdman L, Weaver J, Fermin AS, Tasian G, Lorenzo AJ, Rickard M. Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta-analysis. Prenat Diagn 2021; 41:1039-1048. [PMID: 34318486 DOI: 10.1002/pd.6025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lower urinary tract obstruction (LUTO) is a rare but critical fetal diagnosis. Different ultrasound markers have been reported with varying sensitivity and specificity. AIMS The objective of this systematic review and meta-analysis was to identify the diagnostic accuracy of ultrasound markers for LUTO. MATERIALS AND METHODS We performed a systematic literature review of studies reporting on fetuses with hydronephrosis or a prenatally suspected and/or postnatally confirmed diagnosis of LUTO. Bayesian bivariate random effects meta-analytic models were fitted, and we calculated posterior means and 95% credible intervals for the pooled diagnostic odds ratio (DOR). RESULTS A total of 36,189 studies were identified; 636 studies were available for full text review and a total of 42 studies were included in the Bayesian meta-analysis. Among the ultrasound signs assessed, megacystis (DOR 49.15, [15.28, 177.44]), bilateral hydroureteronephrosis (DOR 41.33, [13.36,164.83]), bladder thickening (DOR 13.73, [1.23, 115.20]), bilateral hydronephrosis (DOR 8.36 [3.17, 21.91]), male sex (DOR 8.08 [3.05, 22.82]), oligo- or anhydramnios (DOR 7.75 [4.23, 14.46]), and urinoma (DOR 7.47 [1.14, 33.18]) were found to be predictive of LUTO (Table 1). The predictive sensitivities and specificities however are low and wide study heterogeneity existed. DISCUSSION Classically, LUTO is suspected in the presence of prenatally detected megacystis with a dilated posterior urethra (i.e., the keyhole sign), and bilateral hydroureteronephrosis. However, keyhole sign has been found to have modest diagnostic performance in predicting the presence of LUTO in the literature which we confirmed in our analysis. The surprisingly low specificity may be influenced by several factors, including the degree of obstruction, and the diligence of the sonographer at searching for and documenting it during the scan. As a result, providers should consider this when establishing the differential for a fetus with hydronephrosis as the presence or absence of keyhole sign does not reliably rule in or rule out LUTO. CONCLUSIONS Megacystis, bilateral hydroureteronephrosis and bladder wall thickening are the most accurate predictors of LUTO. Given the significant consequences of a missed LUTO diagnosis, clinicians providing counselling for prenatal hydronephrosis should maintain a low threshold for considering LUTO as part of the differential diagnosis.
Collapse
Affiliation(s)
- Daniel T Keefe
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jin Kyu Kim
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael Chua
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Priyank Yadav
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Marisol Lolas
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Marta Skreta
- Centre for Computational Medicine, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Lauren Erdman
- Centre for Computational Medicine, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - John Weaver
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Antoine Selman Fermin
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory Tasian
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| |
Collapse
|
21
|
Two Cases of Fetal Lower Urinary Tract Obstruction (LUTO) with Similar Presentations Before But Contrasting Outcomes After Fetoscopic Laser Fulguration of Posterior Urethral Valves. JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-021-00308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
22
|
Sugibayashi R, Wada S, Ozawa K, Muromoto J, Oi R, Yamamoto R, Ishii K, Sago H. Prenatally diagnosed lower urinary tract obstruction: A 15-year experience at two tertiary centers in Japan. J Obstet Gynaecol Res 2021; 47:3091-3099. [PMID: 34155735 DOI: 10.1111/jog.14908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/22/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
AIM To examine the outcomes of prenatally diagnosed lower urinary tract obstruction (LUTO) with current management using vesicoamniotic shunting (VAS). METHODS A retrospective study of prenatally diagnosed LUTO before 26 weeks of gestation at two tertiary centers in Japan between March 2002 and September 2017. LUTO was diagnosed by ultrasound demonstration of an enlarged fetal bladder associated with hydronephrosis and/or hydroureters. VAS was offered for fetuses with LUTO at ≤26 weeks of gestational age, in the presence of oligohydramnios or decreasing amniotic fluid and a favorable fetal urinary analysis. RESULTS Among 87 fetuses with LUTO, 46 (53%) were terminated before 22 weeks of gestation. Eight cases (9%) underwent VAS and one underwent fetoscopic urethrotomy. The live birth rates in the VAS and expectant groups were 100% (8/8) and 56% (18/32), respectively (p = 0.034), and the survival rates at 6 months old with a normal renal function were 38% (3/8) and 16% (5/32), respectively (p = 0.608). The etiology varied with six cases of associated anomalies among 23 diagnosed cases. Among the nine cases of posterior urethral valve (PUV), only one fetus underwent VAS at 25 weeks of gestation, ultimately surviving with mild renal dysfunction. Among the other eight cases of PUV that were managed expectantly, two died, and only one of the six survivors showed a normal renal function. CONCLUSIONS More than half of the prenatally diagnosed LUTO cases were terminated. VAS seemed effective for achieving a perinatal survival, regardless of etiology. The outcomes were poor in cases of expectantly managed PUV.
Collapse
Affiliation(s)
- Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Oi
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
23
|
Posterior urethral valves (PUVs): prenatal ultrasound diagnosis and management difficulties: a review of three cases. CASE REPORTS IN PERINATAL MEDICINE 2021. [DOI: 10.1515/crpm-2020-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Lower urinary tract obstruction (LUTO) has different etiologies. The most common form is posterior urethral valve (PUVs). It is a condition that can lead to end stage renal disease (ESRD) in later life and severe renal and pulmonary damage in utero. Those born alive may end up with residual kidney disease leading to life long morbidity or death. This condition can be diagnosed through prenatal ultrasound but because diagnosis is done late when kidney injury has already happened it does not guarantee healthy survival after birth. There are various treatments in utero and after birth but they all have their complications. In developing countries diagnosis is possible but in most cases pregnant women with fetuses with PUVs present very late in pregnancy. In utero interventions are in most cases not possible and the only way out is expectant management with serial ultrasound assessment until the fetus has achieved level of maturity at which time it is delivered and further postnatal evaluations and treatment given. This series is aimed at highlighting the prenatal ultrasound features of PUVs and the management challenges faced by physicians in developing countries.
Case presentation
The three cases were managed in three different hospitals. All the cases presented at different gestational ages and different levels of fetal affectation. Because of these, outcomes of management and prognosis of each case differ.
Conclusions
Fetal PUVs pose specific challenges in management because of late presentation and lack of resource for intervention even where cases present early with minimal renal damage.
Collapse
|
24
|
Nassr AA, Erfani H, Espinoza J, Sanz Cortes M, Donepudi R, Koh CJ, Roth DR, Braun MC, Angelo JR, Belfort MA, Shamshirsaz AA. Novel scoring system for determining fetal candidacy for prenatal intervention for severe congenital lower urinary tract obstruction. Eur J Obstet Gynecol Reprod Biol 2021; 262:118-123. [PMID: 34010724 DOI: 10.1016/j.ejogrb.2021.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate a novel scoring system that combines several prenatal parameters for selecting ideal candidates for fetal intervention, and for predicting postnatal survival in patients with severe fetal lower urinary tract obstruction (LUTO). METHODS We retrospectively reviewed all cases of severe LUTO evaluated for fetal intervention in a single large fetal center between January 2013 and December 2017. A scoring system for determining fetal candidacy for intervention was retrospectively developed based on postnatal outcomes. The proposed scoring system included fetal urinary biochemistry, renal ultrasound parameters, initial bladder volume, and degree of bladder refill. Relevant demographic characteristics, ultrasound reports and laboratory results were reviewed. Receiver operating characteristic (ROC) curves were used to select the cut-off values for initial bladder volume and degree of bladder refill and to evaluate the performance of the scoring system in predicting postnatal death. RESULTS Of the 79 LUTO patients evaluated, 31 were eligible for the study. The overall 6-month postnatal survival was 64.5 % (20/31). A scoring system (0-8) was suggested with 2 points for unfavorable biochemistry, 4 points for ultrasound evidence of dysplastic kidneys, 1 point for inadequate initial bladder volume and 1 point for inadequate bladder refill. Scores>3 (N = 7) were associated with 0 % 6-month survival. The ROC curve for predicting postnatal mortality showed area under curve (AUC) of 0.82 (95 % CI 0.65-0.99). Subgroup analysis within subjects who underwent fetal intervention (N = 22) also confirmed the significance of the distribution of the scoring system between groups who survived and those who did not after adjustment for GA at delivery (p = 0.01). CONCLUSION We propose a novel scoring system for antenatal evaluation of patients with severe LUTO which may be useful in selecting those candidates most appropriate for intervention and in counseling parents about predicted postnatal outcome.
Collapse
Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States.
| | - Hadi Erfani
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Jimmy Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Magdalena Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Roopali Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - David R Roth
- Renal Section, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Michael C Braun
- Renal Section, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States
| |
Collapse
|
25
|
Irfan A, O'Hare E, Jelin E. Fetal interventions for congenital renal anomalies. Transl Pediatr 2021; 10:1506-1517. [PMID: 34189109 PMCID: PMC8192995 DOI: 10.21037/tp-2020-fs-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.
Collapse
Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth O'Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
26
|
Koch A, Favre R, Weingertner AS, Zaloszyc A, Kohler M, Guerra F, Rosenblatt J, Muller F, Dreux S, Sananès N. Evaluation of Sequential Urine Analysis when Selecting Candidates for Vesicoamniotic Shunting in Lower Urinary Tract Obstruction. Fetal Diagn Ther 2021; 48:265-271. [PMID: 33756463 DOI: 10.1159/000514911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of our study was to assess the utility of sequential fetal urine analysis in severe lower urinary tract obstruction (LUTO) when selecting cases suitable for vesicoamniotic shunting. MATERIAL AND METHODS This was a retrospective cohort study of cases of severe LUTO treated in our fetal medicine center from 1994 to 2013. Two fetal bladder samples were taken 24-48 h apart to assess renal function. A vesicoamniotic shunt was inserted in case of improvement in urinary biochemistry between the 2 samples. We assessed perinatal morbidity and mortality and renal function at 5 years. RESULTS Among a total of 26 LUTO cases with sequential urine analysis, 5 showed normal urinary biochemistry, 13 were abnormal, and 8 improved between the 2 samples. These 8 cases underwent vesicoamniotic shunt placement, leading to the birth of 6/8 (75%) live infants, 5/6 (83%) of whom had normal renal function at 5 years. The 5 cases with normal biochemistry occasioned 2 neonatal deaths and 3 children with normal renal function at 5 years. Elective termination of pregnancy was requested by parents for the fetuses exhibiting abnormal biochemistry. CONCLUSION An improvement in urinary biochemistry between 2 sequential fetal bladder punctures in severe LUTO could be an effective criterion in the selection of candidates for vesicoamniotic shunting. However, the benefit of a shunt in fetuses with normal amniotic fluid remains to be evaluated in clinical trials.
Collapse
Affiliation(s)
- Antoine Koch
- Maternal Fetal Medicine Department, Strasbourg University Hospital, Strasbourg, France,
| | - Romain Favre
- Maternal Fetal Medicine Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Ariane Zaloszyc
- Pediatric Nephrology Department, Strasbourg University Hospital, Strasbourg, France
| | - Monique Kohler
- Maternal Fetal Medicine Department, Strasbourg University Hospital, Strasbourg, France
| | - Fernando Guerra
- Maternal Fetal Medicine Department, Strasbourg University Hospital, Strasbourg, France
| | - Jonathan Rosenblatt
- Maternal Fetal Medicine Department, Robert Debré Hospital, AP-HP, Paris, France
| | - Françoise Muller
- Biochemistry-Hormonology Department, Robert Debré Hospital, AP-HP, Paris, France
| | - Sophie Dreux
- Biochemistry-Hormonology Department, Robert Debré Hospital, AP-HP, Paris, France
| | - Nicolas Sananès
- Maternal Fetal Medicine Department, Strasbourg University Hospital, Strasbourg, France.,INSERM, UMR-S 1121, "Biomatériaux et Bioingénierie", Strasbourg, France
| |
Collapse
|
27
|
Selection of candidates for foetal intervention in congenital lower urinary tract obstruction. Curr Opin Obstet Gynecol 2021; 33:123-128. [PMID: 33620890 DOI: 10.1097/gco.0000000000000693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Congenital lower urinary tract obstruction (LUTO) is a rare group of conditions characterized by high perinatal morbidity and mortality if associated with oligohydramnios or anhydramnios in early pregnancy. Although foetal intervention has the potential to improve perinatal survival in a select group of foetuses with LUTO, the actual selection of those candidates most likely to benefit from intervention remains challenging. RECENT FINDINGS Foetuses with LUTO who are potential candidates for prenatal intervention should undergo detailed multidisciplinary evaluation to ensure proper assessment and counselling. Using a combination of multiple ultrasound-based renal parameters, including measurement of foetal bladder volumes before and after vesicocentesis and kidney size and morphology, combined with repeated foetal urine biochemistry may allow for better selection than any single test. SUMMARY Foetal intervention should be offered to women carrying a foetus with LUTO only after appropriate evaluation and counselling. A combined approach utilizing ultrasound and biochemical measurements of foetal renal function appears best. Research focusing on the development of more accurate markers is needed.
Collapse
|
28
|
Abstract
Fetal lower urinary tract obstruction (LUTO) is classically based on prenatal ultrasound identification of a dilated/ thick-walled bladder, bilateral hydronephrosis, dilated ureters and a dilated posterior urethra (also known as the "keyhole sign") in a male fetus. Although the most common underlying diagnosis is posterior urethral valves, the prenatal appearance may be similar with urethral atresia or stenosis, the Prune-Belly Syndrome, or even a cloacal anomaly in a female. These conditions form part of the Congenital Anomalies of Kidney and Urinary Tract (CAKUT) spectrum, which is the commonest cause of end-stage renal disease in children. Although it is difficult to predict postnatal renal function from the prenatal appearance, studies have recently identified predictive features (based on ultrasound findings and fetal biochemistry), and established staging systems to assist with counselling, and, where indicated, patient selection for in-utero intervention. Current in-utero therapy includes amnio-infusion, vesico-amniotic shunting, and fetal cystoscopy with valve ablation or urethral stenting. Postnatal survival and renal functional outcomes, complications and management uncertainties are described, highlighting areas of future development.
Collapse
Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea and Westminster and Imperial College Hospitals, United Kingdom of Great Britain and Northern Ireland; Imperial College London, United Kingdom of Great Britain and Northern Ireland.
| |
Collapse
|
29
|
Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
30
|
Ibirogba ER, Haeri S, Ruano R. Fetal lower urinary tract obstruction: What should we tell the prospective parents? Prenat Diagn 2020; 40:661-668. [PMID: 32065667 DOI: 10.1002/pd.5669] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/28/2020] [Accepted: 02/12/2020] [Indexed: 11/07/2022]
Abstract
Fetal lower urinary tract obstruction (LUTO), which often results in marked perinatal morbidity and mortality, is caused by a heterogeneous group of anatomical defects that lead to blockage of the urethra. The classic prenatal presentation of LUTO includes megacystis with hydronephrosis. While mild forms of the disease can be associated with favorable outcomes, more severe disease commonly leads to dysplastic changes in the fetal kidneys, and ultimately oligohydramnios, which can result in secondary pulmonary hypoplasia and renal failure at birth. The aim of this review is to provide practitioners with a general overview of the diagnosis and treatment of LUTO based on disease severity, along with some points to consider when counseling prospective parents of fetuses with this condition.
Collapse
Affiliation(s)
- Eniola Raheem Ibirogba
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sina Haeri
- St. David's Women's Center of Texas, Austin Maternal-Fetal Medicine, Austin, Texas
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| |
Collapse
|
31
|
Duin LK, Fontanella F, Groen H, Adama van Scheltema PN, Cohen-Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Oepkes D, Bilardo CM. Prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO)-Development and internal validation. Prenat Diagn 2019; 39:1235-1241. [PMID: 31659787 DOI: 10.1002/pd.5573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop a prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO) based on fetal ultrasound parameters and amniotic fluid volume. METHODS Retrospective nationwide cohort study of fetuses with postnatally confirmed LUTO and known eGFR. Fetuses treated with fetal interventions such as vesico-amniotic shunting or cystoscopy were excluded. Logistic regression analysis was used to identify prognostic ultrasound variables with respect to renal outcome following multiple imputation of missing data. On the basis of these fetal renal parameters and amniotic fluid volume, a model was developed to predict postnatal renal function in fetuses with LUTO. The main study outcome was an eGFR less than 60 mL/min * 1.73 m2 based on the creatinine nadir during the first year following diagnosis. Model performance was evaluated by receiver operator characteristic (ROC) curve analysis, calibration plots, and bootstrapping. RESULTS Hundred one fetuses with a confirmed diagnosis of LUTO were included, eGFR less than 60 was observed in 40 (39.6%) of them. Variables predicting an eGFR less than 60 mL/min * 1.73m2 included the following sonographic parameters: hyperechogenicity of the renal cortex and abnormal amniotic fluid volume. The model showed fair discrimination, with an area under the ROC curve of 0.70 (95% confidence interval, 0.59-0.81, 0.66 after bootstrapping) and was overall well-calibrated. CONCLUSION This study shows that a prediction model incorporating ultrasound parameters such as cortical appearance and abnormal amniotic fluid volume can fairly discriminate an eGFR above or below 60 mL/min * 1.73m2 . This clinical information can be used in identifying fetuses eligible for prenatal interventions and improve counseling of parents.
Collapse
Affiliation(s)
- Leonie K Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Federica Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Phebe N Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Pajkrt
- Department of Obstetrics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Mireille Bekker
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christine Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Caterina M Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
32
|
Nassr AA, Shamshirsaz AA, Erfani H, Espinoza J, Sanz Cortes M, Koh CJ, Roth DR, Angelo JR, Mandy GT, Braun MC, Ruano R, Belfort MA. Outcome of fetuses with lower urinary tract obstruction and normal amniotic fluid volume in second trimester of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:500-505. [PMID: 30977189 DOI: 10.1002/uog.20288] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/15/2019] [Accepted: 04/05/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Congenital lower urinary tract obstruction (LUTO) is a rare condition with high perinatal mortality and morbidity when associated with severe oligohydramnios or anhydramnios in the second trimester of pregnancy. Severe pulmonary hypoplasia and end-stage renal disease are the underlying causes of poor neonatal outcome in these cases. However, little is known about the subset of fetal LUTO that is associated with a normal volume of amniotic fluid at midgestation. The objective of the current study was to describe the natural history, underlying causes, survival and postnatal renal function outcomes in pregnancies with fetal LUTO and normal amniotic fluid volume during the second trimester of pregnancy. METHODS This was a retrospective study of all pregnancies with fetal LUTO and normal amniotic fluid volume in the second trimester that received prenatal and postnatal care at our quaternary care institution between 2013 and 2017. Data on demographic characteristics, fetal interventions, perinatal survival, need for neonatal respiratory support, postnatal renal function and need for dialysis at the age of 1 and 24 months were analyzed. RESULTS Of the 18 fetuses that met the study criteria, 17 (94.4%) survived the perinatal period. Eleven (61.1%) pregnancies developed oligohydramnios in the third trimester, six of which were eligible for and underwent fetal intervention with vesicoamniotic shunt placement, which was performed successfully in all six cases. Two (11.1%) neonates required respiratory support owing to pulmonary hypoplasia. At the age of 2 years, 14 children had follow-up information available, two (14.3%) of whom had normal renal function, eight (57.1%) had developed some degree of chronic kidney disease (Stage 1-4) and four (28.6%) had developed end-stage renal disease (ESRD), including two who had already manifested ESRD in the neonatal period. CONCLUSIONS Most fetuses diagnosed prenatally with LUTO that is associated with a normal volume of amniotic fluid at midgestation will have a favorable outcome in terms of perinatal survival and few will need long-term respiratory support. However, these children are still at increased risk for chronic renal disease, ESRD and need for renal replacement therapy. Larger multicenter studies are needed to characterize the prenatal factors associated with postnatal renal function, and to investigate the role of fetal intervention in the group of fetuses that present with late-onset oligohydramnios and evidence of preserved fetal renal function. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J R Angelo
- Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - G T Mandy
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M C Braun
- Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| |
Collapse
|
33
|
Kostic D, Dos Santos Beozzo GPN, do Couto SB, Kato AHT, Lima L, Palmeira P, Krebs VLJ, Bunduki V, Francisco RPV, Zugaib M, de Carvalho WB, Koch VHK. First-year profile of biomarkers for early detection of renal injury in infants with congenital urinary tract obstruction. Pediatr Nephrol 2019; 34:1117-1128. [PMID: 30694385 DOI: 10.1007/s00467-019-4195-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. Use of renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and prevention or minimization of definitive renal damage. METHODS This longitudinal, prospective study analyzed the first-year profile of two serum renal biomarkers: creatinine (sCr) and cystatin C (sCyC); and six urinary renal biomarkers: neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-β1), retinol-binding protein (RBP), cystatin C (uCyC), and microalbuminuria (μALB) in a cohort of 37 infants with UTO divided into three subgroups: 14/37 with unilateral hydro(uretero)nephrosis, 13/37 with bilateral hydro(uretero)nephrosis, and 10/37 patients with lower urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. RESULTS All urine biomarkers showed significantly higher values at the first month of life (p ≤ 0.009), while NGAL (p = 0.005), TGF-ß1 (p < 0.001), and μALB (p < 0.001) were high since birth compared to controls. Best single biomarker performances were RBP in bilateral hydronephrosis and LUTO subgroups and KIM-1 in unilateral hydronephrosis subgroup. Best biomarker combination results for all subgroups were obtained by matching RBP with TGF-ß1 or KIM-1 and NGAL with CyC ([AUC] ≤ 0.934; sensitivity ≤ 92.4%; specificity ≤ 92.8%). CONCLUSIONS RBP, NGAL, KIM-1, TGF-ß1, and CyC, alone and especially in combination, are relatively efficient in identifying surgically amenable congenital UTO and could be of practical use in indicating on-time surgery.
Collapse
Affiliation(s)
- Dusan Kostic
- Pediatric Nephrology Unit, Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, CEP: 05403-000, SP, Brazil.
| | | | - Saulo Brasil do Couto
- Pediatric Nephrology Unit, Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, CEP: 05403-000, SP, Brazil
| | - André Henrique Teruaki Kato
- Pediatric Nephrology Unit, Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, CEP: 05403-000, SP, Brazil
| | - Laila Lima
- Laboratory of Clinical Investigations (LIM-36)-Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Patricia Palmeira
- Laboratory of Clinical Investigations (LIM-36)-Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vera Lúcia Jornada Krebs
- Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Victor Bunduki
- Department of Obstetrics and Gynecology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Marcelo Zugaib
- Department of Obstetrics and Gynecology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Werther Brunow de Carvalho
- Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vera Hermina Kalika Koch
- Pediatric Nephrology Unit, Department of Pediatrics, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, CEP: 05403-000, SP, Brazil
| |
Collapse
|
34
|
The role of renal biomarkers to predict the need of surgery in congenital urinary tract obstruction in infants. J Pediatr Urol 2019; 15:242.e1-242.e9. [PMID: 30979613 DOI: 10.1016/j.jpurol.2019.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/08/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage. OBJECTIVE The aim of the study was to investigate a selection of promising biomarkers of renal injury with the intention of evaluating and comparing their profile with clinically based decisions for surgical intervention of infants with congenital obstructive uropathies. STUDY DESIGN The first-year profile of renal biomarkers, serum creatinine (sCr), serum and urine cystatin C (CyC), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-β1), retinol-binding protein (RBP), and microalbuminuria (μALB), was analyzed in a cohort of 37 infants with congenital UTO, divided into three subgroups, 14 cases with grade III unilateral hydro(uretero)nephrosis, 13 cases with grade III bilateral hydro(uretero)nephrosis, and 10 cases with low urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. Serum and urine samples were stored at -70 °C and thereafter analyzed by quantitative enzymatic immunoassay. RESULTS Compared with the control group (Figure), all renal biomarker values were significantly increased in patients (P ≤ 0.02). In the unilateral hydronephrosis and LUTO group, RBP (P ≤ 0.043), NGAL (P ≤ 0.043), KIM-1 (P ≤ 0.03), and TGF-β1 (P ≤ 0.034) values dropped significantly after surgery. Neutrophil gelatinase-associated lipocalin alone and in combination with urine and serum CyC demonstrated the best performance in determining the need for surgery (area under the curve, 0.801 and 0.881, respectively). Biomarker profile analysis was suggestive of surgical intervention in 55.4% (7/13) of non-operated cases, and most of the biomarker values were above the cutoff levels within at least 3 months before the clinically based surgical decision in 58% (14/24) of all operated patients. DISCUSSION To the best of the authors' knowledge, this is the first study to present the clinical use of selected group of serum and urinary biomarkers in the setting of UTO to distinguish between patients who would benefit from surgery intervention. The most promising results were obtained using NGAL, RBP, TGF-β1, and KIM-1, especially in the unilateral hydro(uretero)nephrosis and LUTO subgroups when compared with the control group. CONCLUSIONS Urine biomarkers, alone and in combination, demonstrated high potential as a non-invasive diagnostic tool for identifying infants who may benefit from earlier surgical intervention.
Collapse
|
35
|
Puttmann KT, White JT, Huang GO, Sheth K, Elizondo R, Zhu H, Braun MC, Mann DG, Olutoye OA, Tu DD, Ruano R, Belfort M, Brandt ML, Roth DR, Koh CJ. Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction. J Pediatr Surg 2019; 54:820-824. [PMID: 30049573 DOI: 10.1016/j.jpedsurg.2018.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/14/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients. METHODS We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016). RESULTS 31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031). CONCLUSIONS The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year. LEVEL OF EVIDENCE This is a prognostic study with Level IV evidence.
Collapse
Affiliation(s)
- Kathleen T Puttmann
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX.
| | - Jeffrey T White
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Gene O Huang
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Kunj Sheth
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Rodolfo Elizondo
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Huirong Zhu
- Outcomes & Impact Services, Texas Children's Hospital, Houston, TX
| | - Michael C Braun
- Renal Section, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - David G Mann
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX
| | | | - Duong D Tu
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Michael Belfort
- Department of Women Services, Texas Children's Hospital, Houston, TX
| | - Mary L Brandt
- Division of General Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - David R Roth
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| |
Collapse
|
36
|
Cheung KW, Morris RK, Kilby MD. Congenital urinary tract obstruction. Best Pract Res Clin Obstet Gynaecol 2019; 58:78-92. [PMID: 30819578 DOI: 10.1016/j.bpobgyn.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/01/2019] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
Congenital bladder neck obstruction (or lower urinary tract obstruction [LUTO]) describes a heterogeneous group of congenital anomalies presenting with similar prenatal ultrasonographic findings of dilated posterior urethra, megacystis, hydronephrosis, oligohydramnios and often with associated renal dysplasia. Untreated LUTO has high rate of perinatal morbidity and mortality from associated pulmonary hypoplasia and early-onset renal failure in infancy. Ultrasonographic features and prospective fetal urinalysis may help in predicting the overall prognosis of congenital LUTO. Currently, fetal vesicoamniotic shunt (of various designs), and fetal cystoscopy and fulguration of the obstruction are potential prenatal interventions. Retrospective and prospective cohort studies and a relatively small randomized controlled trial have demonstrated these treatments may possibly improve perinatal survival. Despite this, concerns remain as to the high rates of renal impairment observed in paediatric survivors. A clinical prospective scoring/staging system may improve prenatal diagnostic criteria and case selection for fetal therapy.
Collapse
Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China; The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.
| | - Rachel Katie Morris
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Mark David Kilby
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|
37
|
Chen L, Guan J, Gu H, Zhang M. Outcomes in fetuses diagnosed with megacystis: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018; 233:120-126. [PMID: 30594021 DOI: 10.1016/j.ejogrb.2018.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/25/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To explore the outcomes and prognostic factors associated with fetal megacystis (enlarged bladder). STUDY DESIGN The MEDLINE and EMBASE databases were searched for studies reporting on outcomes of fetal megacystis. The outcomes observed were chromosomal abnormalities, associated structural anomalies, spontaneous resolution, and survival rates. We also evaluated the potential role of fetal gender, oligohydramnios, gestational age at diagnosis, and intrauterine intervention as prenatal prognostic factors. RESULTS The search identified 558 articles in total, and 13 studies (1675 fetuses) were included in this systematic review. The overall incidences of chromosomal abnormalities and associated structural anomalies in fetal megacystis were 10% and 24%, respectively. Spontaneous resolution of megacystis occurred in 32% of fetuses, and 44% of fetuses were born alive and survived until the follow-up. The odds ratio of survival with oligohydramnios was 0.14, and the mean difference in gestational age at diagnosis between survival and non-survival was 3.43 weeks. No significant difference in survival rate was observed between the genders, and an intrauterine intervention did not significantly improve the prognosis. CONCLUSIONS A considerable proportion of fetuses with megacystis are born with a good prognosis. Oligohydramnios and lower gestational age at diagnosis are associated with worse outcomes.
Collapse
Affiliation(s)
- Lizhu Chen
- Department of Ultrasound, Shengjing Hospital, China Medical University, Shenyang, China
| | - Johnny Guan
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Hui Gu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Mo Zhang
- Department of Urology, Shengjing Hospital, China Medical University, No. 36 Sanhao Street, Heping District, Shenyang, Liaoning 110004, China.
| |
Collapse
|
38
|
Fontanella F, Duin LK, Adama van Scheltema PN, Cohen‐Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Gracchi V, Oepkes D, Bilardo CM. Prenatal diagnosis of LUTO: improving diagnostic accuracy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:739-743. [PMID: 29266464 PMCID: PMC6587765 DOI: 10.1002/uog.18990] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 11/13/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To propose a clinical score for the optimal antenatal diagnosis of fetal lower urinary tract obstruction (LUTO) in the second and third trimesters of pregnancy, as an alternative to the commonly used ultrasound triad of megacystis, keyhole sign and hydronephrosis. METHODS This was a national retrospective study carried out at the eight tertiary fetal medicine units (FMUs) in The Netherlands. Only cases referred for megacystis from the second trimester onwards and with a clear postnatal diagnosis were included in the study. At referral, data were collected on amniotic fluid volume, renal cortical appearance, bladder volume, hydronephrosis, fetal ascites, ureteral size, keyhole sign, fetal sex and gestational age. Multivariate analysis was performed, starting by including all antenatal variables, and then excluding the weakest predictors using the backward stepwise strategy. RESULTS Over a 7-year period, 312 fetuses with a diagnosis of megacystis were referred to the eight Dutch tertiary FMUs. A final diagnosis was achieved in 143 cases, including 124 of LUTO and 19 reclassified after birth as non-obstructive megacystis. The optimal bladder volume cut-off for prediction of LUTO was 35 cm3 (area under the curve (AUC) = 0.7, P = 0.03). The clinical score formulated on the basis of the multivariate analysis included fetal sex, degree of bladder distension, ureteral size, oligo- or anhydramnios and gestational age at referral. The combination of these five variables demonstrated good accuracy in discriminating LUTO from non-obstructive megacystis (AUC = 0.84, P < 0.001), compared with the poor performance of the ultrasound triad (AUC = 0.63, P = 0.07). CONCLUSIONS We propose a clinical score that combines five antenatal variables for the prospective diagnosis of congenital LUTO. This score showed good discriminative capacity in predicting LUTO, and better diagnostic accuracy compared with that of the classic ultrasound triad. Future studies to validate these results should be carried out in order to refine antenatal management of LUTO and prevent inappropriate fetal interventions. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- F. Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - P. N. Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - E. Pajkrt
- Department of ObstetricsAcademic Medical Center AmsterdamAmsterdamThe Netherlands
| | - M. Bekker
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical CenterGrow School for Oncology and Medical BiologyMaastrichtThe Netherlands
| | - C. J. Bax
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisVU University Medical CenterAmsterdamThe Netherlands
| | - V. Gracchi
- Department of PediatricsUniversity Medical Center Groningen, University of GroningenThe Netherlands
| | - D. Oepkes
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| |
Collapse
|
39
|
Iuculano A, Peddes C, Monni G. Early fetal megacystis: Is it possible to predict the prognosis in the first trimester? J Perinat Med 2018; 46:1035-1039. [PMID: 29369818 DOI: 10.1515/jpm-2017-0351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the best management of fetal megacystis diagnosed in the first trimester and define the prognosis and the most appropriate follow-up as early as possible. METHODS This is a retrospective study of first-trimester fetal megacystis diagnosed in pregnant women who performed a combined screening for fetal aneuploidy. Megacystis was defined as a longitudinal bladder diameter (LBD) greater than 7 mm. All fetuses were divided into two groups according to the LBD: Group A with LBD > 15 mm and Group B with LBD < 15 mm. The fetal karyotype and associated anomalies were evaluated. Ultrasound monitoring was performed every 2 weeks (a second ultrasound scan after 2 weeks from diagnosis and a third ultrasound scan 2 weeks after the second one). RESULTS Twenty-six cases were identified between 2011 and 2016; three cases of aneuploidy were excluded from the study. Of the remaining 23 cases, 11 were included in Group A and 12 in Group B. All Group A fetuses had an adverse outcome. In Group B: five (41.7%) cases had an adverse outcome and seven (58.3%) had a spontaneous resolution of megacystis. The ultrasound findings of both the ultrasound scans, the second and the third, were 100% concordant. CONCLUSION An ultrasound scan performed 2 weeks after the megacystis diagnosis can predict the outcome in fetuses with an LBD < 15 mm as early as the end of the first trimester. The outcome of euploid fetuses with an LBD < 15 mm was favorable in 58.3% of the cases.
Collapse
Affiliation(s)
- Ambra Iuculano
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Cagliari, Italy
| | - Cristina Peddes
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Cagliari, Italy
| | - Giovanni Monni
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Via E. Jenner n/n, 09121 Cagliari, Italy
| |
Collapse
|
40
|
Abstract
Congenital anomalies of the kidneys and the urinary tract (CAKUT) are one of the most common sonographically identified antenatal malformations. Dilatation of the renal pelvis accounts for the majority of cases, but this is usually mild rather than an indicator of obstructive uropathy. Other conditions such as small through large hyperechogenic and/or cystic kidneys present a significant diagnostic dilemma on routine scanning. Accurate diagnosis and prediction of prognosis is often not possible without a positive family history, although maintenance of adequate amniotic fluid is usually a good sign. Both pre- and postnatal genetic screening is possible for multiple known CAKUT genes but less than a fifth of non-syndromic sporadic cases have detectable monogenic mutations with current technology. In utero management options are limited, with little evidence of benefit from shunting of obstructed systems or installation of artificial amniotic fluid. Often outcome hinges on associated cardiac, neurological or other abnormalities, particularly in syndromic cases. Hence, management centres on a careful assessment of all anomalies and planning for postnatal care. Early delivery is rarely indicated since this exposes the baby to the risks of prematurity in addition to their underlying CAKUT. Parents value discussions with a multidisciplinary team including fetal medicine and paediatric nephrology or urology, with neonatologists to plan perinatal care and clinical geneticists for future risks of CAKUT.
Collapse
Affiliation(s)
- Angela Yulia
- Fetal Medicine Unit, Elizabeth Garrett Anderson Hospital, University College Hospitals London, Huntley Street, London WC1N 6AU, UK.
| | - Paul Winyard
- Fetal Medicine Unit, Elizabeth Garrett Anderson Hospital, University College Hospitals London, Huntley Street, London WC1N 6AU, UK; Nephro-Urology Group, Developmental Biology and Cancer programme, University College London Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK.
| |
Collapse
|
41
|
Nassr AA, Erfani H, Fisher JE, Ogunleye OK, Espinoza J, Belfort MA, Shamshirsaz AA. Fetal interventional procedures and surgeries: a practical approach. J Perinat Med 2018; 46:701-715. [PMID: 28599395 DOI: 10.1515/jpm-2017-0015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/19/2017] [Indexed: 12/25/2022]
Abstract
Abstract
The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.
Collapse
Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.,Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - James E Fisher
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Oluseyi K Ogunleye
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX 77030, USA,
| |
Collapse
|
42
|
Jeong BD, Won HS, Lee MY. Perinatal Outcomes of Fetal Lower Urinary Tract Obstruction After Vesicoamniotic Shunting Using a Double-Basket Catheter. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2147-2156. [PMID: 29498072 DOI: 10.1002/jum.14565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/17/2017] [Accepted: 12/06/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To evaluate the perinatal survival and renal function of fetuses with lower urinary tract obstruction (LUTO) who underwent vesicoamniotic shunting using a double-basket catheter METHODS: We retrospectively reviewed 32 fetuses with LUTO who underwent vesicoamniotic shunting using a double-basket catheter between 1998 and 2013. RESULTS Among the 32 fetuses examined, 5 died because of termination of pregnancy, and 2 died in utero. The median gestational age at diagnosis was 15.5 (range, 10.0-27.3) weeks, and that at initial shunting was 17.1 (range, 12.3-32.2) weeks. Shunt dislocation or occlusion occurred in 18 of 42 procedures (42.8%). The median gestational age at delivery for the 25 live births was 35.5 (range, 28-40) weeks. Postnatal diagnosis revealed posterior urethral valves in 15 fetuses, a cloacal anomaly in 7, and urethral stenosis in 3. Three neonatal deaths occurred, resulting in an overall perinatal survival rate of 68.8% (22 of 32). The rates of normal renal function were 40.6% (13 of 32) at 28 days and 40% (10 of 25) at 2 years after birth. The absence of oligohydramnios after shunting was the only prognostic factor for normal renal function at 2 years (P < .05). CONCLUSIONS Vesicoamniotic shunting may be helpful for fetuses with LUTO.
Collapse
Affiliation(s)
- Ba-Da Jeong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
43
|
Abstract
PURPOSE OF THE REVIEW In this article, we explore the origins of intervention of fetal lower urinary tract obstruction, and we specifically discuss the background and recent outcomes of vesicoamniotic shunt placement and fetal cystoscopy. The article seeks to provide a comprehensive overview of the field while bringing the reader quickly up to speed on the pertinent literature and the critical data that are available to guide decision-making regarding intervention. RECENT FINDINGS Appropriate patient selection for fetal intervention remains challenging despite advances in prenatal imaging. Both a randomized controlled trial and multiple systematic reviews show evidence of a perinatal survival benefit following fetal intervention but rates of renal morbidity remain very high. Despite 30 years of research, fetal lower urinary tract obstruction remains a difficulty entity to treat. Intervention may lead to survival, but physicians and caregivers must remain alert for the distinct possibility of long-term renal morbidity in survivors.
Collapse
Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA.
| | - John W Brock
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA
| |
Collapse
|
44
|
Ruano R, Dunn T, Braun MC, Angelo JR, Safdar A. Lower urinary tract obstruction: fetal intervention based on prenatal staging. Pediatr Nephrol 2017; 32:1871-1878. [PMID: 28730376 DOI: 10.1007/s00467-017-3593-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/28/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022]
Abstract
The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Timothy Dunn
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Michael C Braun
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Adnan Safdar
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| |
Collapse
|
45
|
Current Strategy of Fetal Therapy II: Invasive Fetal Interventions. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
46
|
Nassr AA, Shazly SAM, Abdelmagied AM, Araujo Júnior E, Tonni G, Kilby MD, Ruano R. Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: an updated systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:696-703. [PMID: 27270578 DOI: 10.1002/uog.15988] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the effect on perinatal and postnatal survival of vesicoamniotic shunt (VAS) as treatment for fetal lower urinary tract obstruction (LUTO). METHODS An electronic search of Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus using relevant search terms was conducted from inception to June 2015 to identify studies comparing outcomes of VAS vs conservative management for treatment of LUTO. Cohort studies and clinical trials were considered eligible. Single-arm studies and studies that did not report survival were excluded. Sample size and language were not criteria for exclusion. Two reviewers extracted independently data in a standardized form, including study characteristics and results. Primary outcomes were perinatal and postnatal survival. Secondary outcome was postnatal renal function. Data on fetal survival were expressed as odds ratio (OR) and 95% CI. RESULTS Of the 423 abstracts retrieved, nine studies were eligible for inclusion. These studies included 112 fetuses treated with VAS and 134 that were managed conservatively. There was heterogeneity in study design. Although the data demonstrated a difference in effect estimates between the study arms in terms of perinatal survival (OR, 2.54 (95% CI, 1.14-5.67)), there was no difference in 6-12-month survival (OR, 1.77 (95% CI, 0.25-12.71)) or 2-year survival (OR, 1.81 (95% CI, 0.09-38.03)). In addition, there was no difference in effect on postnatal renal function between fetuses that underwent intervention and those that did not (OR, 2.09 (95% CI, 0.74-5.94)). CONCLUSIONS Available data seem to support an advantage for perinatal survival in fetuses treated with VAS compared with conservative management. However, 1-2-year survival and outcome of renal function after VAS procedure remain uncertain. Further studies are necessary to evaluate the effectiveness of fetal intervention for LUTO based on different severity of the disease, due to the very low quality of the studies according to GRADE guidelines. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - S A M Shazly
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - A M Abdelmagied
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - G Tonni
- Prenatal Diagnostic Service, Department of Obstetrics and Gynecology, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - M D Kilby
- Centre for Women's and Children's Health, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Ruano
- Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
47
|
Nassr AA, Koh CK, Shamshirsaz AA, Espinoza J, Sangi-Haghpeykar H, Sharhan D, Welty S, Angelo J, Roth D, Belfort MA, Braun M, Ruano R. Are ultrasound renal aspects associated with urinary biochemistry in fetuses with lower urinary tract obstruction? Prenat Diagn 2016; 36:1206-1210. [DOI: 10.1002/pd.4958] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/20/2016] [Accepted: 10/31/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Ahmed A. Nassr
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
- Department of Obstetrics and Gynecology, Women's Health Hospital; Assiut University; Asiut Egypt
| | - Chester Koh Koh
- Division of Pediatric Urology; Texas Children's Hospital Pavilion for Women; Houston TX USA
| | - Alireza A. Shamshirsaz
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
| | - Dina Sharhan
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
| | - Stephen Welty
- Department of Pediatrics; Baylor College of Medicine and Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women; Houston TX USA
| | - Joseph Angelo
- Renal Section; Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital; Houston TX USA
| | - David Roth
- Division of Pediatric Urology; Texas Children's Hospital Pavilion for Women; Houston TX USA
| | - Michael A. Belfort
- Department of Obstetrics and Gynecology; Baylor College of Medicine and Texas Children's Fetal Center; Houston TX USA
| | - Michael Braun
- Renal Section; Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital; Houston TX USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology; Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine; Rochester MN USA
| |
Collapse
|
48
|
Farrugia MK. Fetal bladder outlet obstruction: Embryopathology, in utero intervention and outcome. J Pediatr Urol 2016; 12:296-303. [PMID: 27570093 DOI: 10.1016/j.jpurol.2016.05.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/17/2016] [Indexed: 11/17/2022]
Abstract
Fetal bladder outlet obstruction (BOO), most commonly caused by posterior urethral valves (PUV), remains a challenging and multi-faceted condition. Evolving techniques, and refinement in ultrasound, optics and instrumentation, have increased our rate of prenatal diagnosis, and enabled valve ablation not only in smaller newborns, but also in fetuses. Long-term outcome studies have raised our awareness of the silent damage caused by bladder dysfunction and polyuria and encouraged their proactive management. In spite of our best efforts, the proportion of boys with PUV who progress to chronic and end-stage renal disease (ESRD) has not changed in the last 25 years. Evidence suggests a reduction in perinatal mortality following prenatal intervention, probably resulting from amelioration of oligohydramnios at the crucial time of lung development between 16 and 28 weeks' gestation, but no improvement in postnatal renal outcome. There are no bladder functional outcome studies in patients who have undergone prenatal intervention and hence the long-term effect of in utero defunctionalisation of the bladder is not known. This aim of this review is to revisit the embryopathology of fetal BOO, in particular the renal and bladder structural and functional changes that occur with in utero obstruction. The effect of earlier prenatal diagnosis, and therapy, on postnatal outcome is also explored and compared with outcomes published for traditional postnatal treatment.
Collapse
Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea Children's Hospital at the Chelsea & Westminster Hospital Foundation Trust, London SW10 9NH, UK.
| |
Collapse
|
49
|
Intrauterine vesicoamniotic shunting for fetal megacystis. Arch Gynecol Obstet 2016; 294:1175-1182. [PMID: 27394921 DOI: 10.1007/s00404-016-4152-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To examine the outcome of fetuses with megacystis treated with vesicoamniotic shunting (VAS) from 14 weeks onward. METHODS Retrospective review of all fetuses that received VAS at two centres from 2004 to 2012. RESULTS 53 fetuses with megacystis were included in the study. Mean gestational age at diagnosis was 16.4 weeks. Mean gestational age at first shunt placement was 17.8 weeks. The first shunt placement was performed before 16 weeks in 18 (34 %) cases. The mean number of shunts was 1.38. Dislocation occurred in 35 (66 %). TOP was performed in 21 (39.6 %), intrauterine death occurred in two (3.8 %) and spontaneous abortion in three cases (5.7 %). Of the 27 (50.9 %) live births, 17 (32.1 %) infants survived. Normal renal function was present in 10 cases, 4 have compensated renal failure and 3 infants had renal transplantation. Oligohydramnios was significantly associated with non-survival and renal insufficiency. The gestational age at VAS was neither correlated with renal function after birth nor with the survival in our cohort. Conversely, the interval between first shunt placement and delivery was positively correlated with survival and normal renal function. The gestational age at delivery was significantly higher in survivors and those born with normal renal function. CONCLUSION Despite intervention, the morbidity and mortality of megacystis is still high. We failed to demonstrate that early intervention is associated with an improved rate of normal renal function after birth. Oligohydramnios was the only parameter identifying fetuses with unfavourable outcome, while all other parameters were inconclusive.
Collapse
|
50
|
Aulbert W, Kemper MJ. Severe antenatally diagnosed renal disorders: background, prognosis and practical approach. Pediatr Nephrol 2016; 31:563-74. [PMID: 26081158 DOI: 10.1007/s00467-015-3140-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/12/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022]
Abstract
Nowadays most renal disorders, especially urinary tract malformations and renal cystic disease, are diagnosed antenatally. In cases of severe bilateral disease, intrauterine renal dysfunction may lead to renal oligohydramnios (ROH), resulting in pulmonary hypoplasia which affects perinatal mortality and morbidity as well as the long-term outcome. However, some infants may only have mild pulmonary and renal disease, and advances in postnatal and dialysis treatment have resulted in improved short- and long-term outcome even in those infants with severe ROH. Here, we review the current state of knowledge and clinical experience of patients presenting antenatally with severe bilateral renal disorders and ROH. By addressing underlying mechanisms, intrauterine tools of diagnosis and treatment as well as published outcome data, we hope to improve antenatal counselling and postnatal care. KEY SUMMARY POINTS: 1. Nowadays most renal disorders are diagnosed antenatally, especially urinary tract malformations and renal cystic disease. 2. Severe kidney dysfunction may lead to renal oligohydramnios, which can cause pulmonary hypoplasia and is a risk factor of perinatal mortality and postnatal renal outcome. However, as considerable clinical heterogeneity is present, outcome predictions need to be treated with caution. 3. Advances in postnatal and dialysis treatment have resulted in improved short- and long-term outcomes even in infants with severe renal oligohydramnios. 4. A multidisciplinary approach with specialist input is required when counselling a family with an ROH-affected fetus as the decision-making process is very challenging.
Collapse
Affiliation(s)
- Wiebke Aulbert
- Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Markus J Kemper
- Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| |
Collapse
|