1
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Vinit N, Ville Y, Blanc T. [In utero surgery for lower urinary tract obstruction]. Med Sci (Paris) 2023; 39:227-233. [PMID: 36943119 DOI: 10.1051/medsci/2023030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Prenatal therapy for LUTO (Lower Urinary Tract Obstruction) is debated due to mixed results regarding postnatal renal function following fetal cystoscopy or vesicoamniotic shunting. Current literature is, however, limited by the inability to determine the cause of the obstruction using plain sonography and the lack of selection criteria for fetuses who may benefit from prenatal therapy. Fetal cystoscopy may serve as a diagnostic tool and would offer a more "physiologic" treatment for bladder outlet obstruction. However, it carries additional technical issues due to inappropriate instrumentation.
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Affiliation(s)
- Nicolas Vinit
- Service de chirurgie viscérale et urologie pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, 149 rue de Sèvres, 75015 Paris, France - UFR de médecine Paris Centre, université Paris Cité, Paris, France
| | - Yves Ville
- Service d'obstétrique, médecine et chirurgie fœtale, Hôpital Necker-Enfants Malades, AP-HP, 149 rue des Sèvres, 75015 Paris, France - UFR de médecine Paris Centre, université Paris Cité, Paris, France
| | - Thomas Blanc
- Service de chirurgie viscérale et urologie pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, 149 rue de Sèvres, 75015 Paris, France - UFR de médecine Paris Centre, université Paris Cité, Paris, France
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2
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Abdelhalim A, Hafez AT. Antenatal and postnatal management of posterior urethral valves: where do we stand? AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00238-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Posterior urethral valve (PUV) is the leading etiology of lower urinary tract obstruction (LUTO) in boys and is an important cause of end-stage renal disease (ESRD) in children. The aim of this article is to review the current status on antenatal intervention for PUV as well as postnatal medical and surgical management.
Main body
MEDLINE, EMBASE, Pubmed and Google Scholar search was conducted throughout December 2020 using the keywords: posterior urethral valves, congenital urinary obstruction, antenatal, valve bladder syndrome, medical, anticholinergics, alpha blocker, antibiotics, biofeedback, diversion, augmentation cystoplasty and renal transplantation. Only papers written in English were included. The relevant literature was summarized. Despite advances in antenatal intervention for fetal LUTO, it remains associated with considerable fetal and maternal morbidity. Patient selection criteria for antenatal intervention are greatly debated. Fetal intervention has resulted in improved perinatal survival in properly selected cases, with a questionable benefit to postnatal renal function. There is decent evidence supporting the use of anticholinergics in infants and young children following valve ablation, with less robust evidence advocating alpha blockers, overnight catheter drainage and biofeedback. The role of urinary diversion remains contentious. Optimizing bladder dynamics is crucial for successful renal transplantation outcomes.
Conclusion
While antenatal intervention has failed to improve renal function outcomes of PUV, patient-centered medical and sometimes surgical interventions can help delay the progression of chronic kidney disease. Lifelong monitoring and management of the associated bladder dysfunction is indispensable even after successful renal transplantation.
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3
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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]
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4
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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.
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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
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5
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Dębska M, Koleśnik A, Kretowicz P, Olędzka A, Rebizant B, Gastoł P, Dębski R. Urethroplasty with balloon catheterization in fetal lower urinary tract obstruction: observational study of 10 fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:916-920. [PMID: 31763721 DOI: 10.1002/uog.21932] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 09/28/2019] [Accepted: 11/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To present the preliminary outcomes of fetal urethroplasty using a coronary angioplasty balloon catheter in lower urinary tract obstruction (LUTO). METHODS We included 10 consecutive male fetuses diagnosed with LUTO caused by presumed isolated posterior urethral valves (PUVs), who underwent urethroplasty with a balloon catheter in our center between 2015 and 2018. During urethroplasty, the fetal urethra was dilated using a balloon catheter (diameter, 0.014 inches; balloon size, 2 × 9 mm) inserted under ultrasonographic guidance via an 18-gauge needle introduced into the fetal bladder. RESULTS Mean gestational age at the time of urethroplasty was 17.8 (range, 16.5-20.4) weeks. All fetuses survived the procedure without any complications and there was no case of preterm prelabor rupture of the membranes. The procedure was successful in 5/10 (50%) fetuses, while in the other five (50%), we were unable to insert the balloon catheter into the urethra. In the five successfully treated cases, mean gestational age at delivery was 38 (range, 36-40) weeks and presence of PUVs was confirmed after birth. All five neonates micturated spontaneously and presented with normal urine output after birth. During the follow-up period, the parameters of kidney function were within normal limits in two neonates, whereas signs of impaired renal function were seen in another two. The other was diagnosed with renal insufficiency and required kidney transplant with bladder sparing at 2 years of age. CONCLUSIONS Urethroplasty with a balloon catheter is a new prenatal treatment option for fetuses with PUVs. By restoring fetal micturition, the procedure can preserve normal urinary bladder and kidney function. Although data on its efficacy and potential to differentiate the etiology of LUTO are sparse, a significant advantage of this method is its safety for the fetus and the mother. Even if the neonates develop renal insufficiency, they may be eligible for kidney transplant with connection to their own bladder, without the need for urostomy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Dębska
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - A Koleśnik
- Cardiac Catheterization Laboratory, Children's Memorial Health Institute, Warsaw, Poland
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - P Kretowicz
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - A Olędzka
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - B Rebizant
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - P Gastoł
- Department of Pediatric Urology, Children's Memorial Health Institute, Warsaw, Poland
| | - R Dębski
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
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6
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [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: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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7
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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.
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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
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8
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Vinit N, Grevent D, Millischer-Bellaiche AE, Pandya VM, Sonigo P, Delmonte A, Sarnacki S, Aigrain Y, Boddaert N, Bessières B, Benchimol G, Salomon LJ, Stirnemann JJ, Blanc T, Ville Y. Biometric and morphological features on magnetic resonance imaging of fetal bladder in lower urinary tract obstruction: new perspectives for fetal cystoscopy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:86-95. [PMID: 31006924 DOI: 10.1002/uog.20297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/03/2019] [Accepted: 04/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Incompatibility between currently available fetoscopes and the anatomical constraints of the distended fetal bladder, with the resulting curvature around the bladder neck, account for most technical difficulties during fetal cystoscopy in lower urinary tract obstruction (LUTO). The aim of this anatomical study was to assess by magnetic resonance imaging (MRI) the variation in three bladder angles (bladder-neck angle (BNA), vesicourethral angle (VUA) and angle between bladder dome and posterior urethra (DUA)), according to gestational age (GA), bladder volume and the presence of LUTO. METHODS From our fetal medicine database, we retrieved for review 46 MRI examinations of male fetuses between 2015 and 2019, including 17 with LUTO, examined at a mean GA of 28.1 (range, 17.3-35.0) weeks and 29 age-matched controls, examined at 29.9 (range, 21.9-35.0) weeks. We measured bladder volume, bladder-wall thickness and the three bladder angles, and used the Mann-Whitney U-test to compare values between groups. Variations according to GA and bladder volume were determined using analysis of variance (ANOVA). A reliability study was performed using the Bland-Altman method and Lin's correlation coefficient was calculated. RESULTS Both bladder volume and bladder-wall thickness were significantly greater in the LUTO group (P < 0.01). BNA was significantly larger in LUTO compared with control fetuses: the mean (range) was 127.1° (101.6-161.6°) vs 111.2° (88.5-157.3°) (P < 0.01). DUA averaged 117° and showed no difference between the groups (P = 0.92). No statistical comparison was performed on VUA since this was not measurable in most control fetuses. ANOVA showed no variation of any angle with bladder volume in both LUTO fetuses and control fetuses. BNA in LUTO fetuses was the only angle to vary with GA, being larger after, compared with at or before, 25 weeks (P = 0.04). The reliability study showed an acceptable bias for both intra- and interobserver reproducibility for all three angles. CONCLUSION The findings that BNA is increased by approximately 15° in fetuses with LUTO and DUA averages 117° could aid in development of a customized fetal cystoscope and help to overcome the current technical challenges of fetal cystoscopy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Vinit
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
| | - D Grevent
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, APHP, Paris, France
- INSERM U1000 and UMR1163, Imagine Institute, Paris, France
| | - A-E Millischer-Bellaiche
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - V M Pandya
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - P Sonigo
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - A Delmonte
- IMAG2 Laboratory, Imagine Institute, Paris, France
| | - S Sarnacki
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- IMAG2 Laboratory, Imagine Institute, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Y Aigrain
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - N Boddaert
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, APHP, Paris, France
- INSERM U1000 and UMR1163, Imagine Institute, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - B Bessières
- Department of Histology, Embryology and Cytogenetics, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - G Benchimol
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - L J Salomon
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - J J Stirnemann
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - T Blanc
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Y Ville
- EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institue, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
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9
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Herbst KW, Tomlinson P, Lockwood G, Mosha MH, Wang Z, D'Alessandri-Silva C. Survival and Kidney Outcomes of Children with an Early Diagnosis of Posterior Urethral Valves. Clin J Am Soc Nephrol 2019; 14:1572-1580. [PMID: 31582461 PMCID: PMC6832049 DOI: 10.2215/cjn.04350419] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Posterior urethral valve is the most common cause of bladder outlet obstruction in infants. We aimed to describe the rate and timing of kidney-related and survival outcomes for children diagnosed with posterior urethral valves in United States children's hospitals using the Pediatric Health Information System database. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study included children hospitalized between January 1, 1992 and December 31, 2006, who were in their first year of life, had a diagnosis of congenital urethral stenosis, and underwent endoscopic valve ablation or urinary drainage intervention, or died. Records were searched up to December 31, 2018 for kidney-related mortality, placement of a dialysis catheter, and kidney transplantation. Cox regression analysis was used to identify risk factors, and Kaplan-Meier survival analysis used to determine time-to-event probability. Subgroup survival analysis was performed with outcomes stratified by the strongest identified risk factor. RESULTS Included were 685 children hospitalized at a median age of 7 (interquartile range, 1-37) days. Thirty four children (5%) died, over half during their initial hospitalization. Pulmonary hypoplasia was the strongest risk factor for death (hazard ratio, 7.5; 95% confidence interval [95% CI], 3.3 to 17.0). Ten-year survival probability was 94%. Fifty-nine children (9%) underwent one or more dialysis catheter placements. Children with kidney dysplasia had over four-fold risk of dialysis catheter placement (hazard ratio, 4.6; 95% CI, 2.6 to 8.1). Thirty-six (7%) children underwent kidney transplant at a median age of 3 (interquartile range, 2-8) years. Kidney dysplasia had a nine-fold higher risk of kidney transplant (hazard ratio, 9.5; 95% CI, 4.1 to 22.2). CONCLUSIONS Patients in this multicenter cohort with posterior urethral valves had a 5% risk of death, and were most likely to die during their initial hospitalization. Risk of death was higher with a diagnosis of pulmonary hypoplasia. Kidney dysplasia was associated with a higher risk of need for dialysis/transplant. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_10_03_CJN04350419.mp3.
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Affiliation(s)
| | - Paul Tomlinson
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Gina Lockwood
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | | | - Zhu Wang
- Department of Epidemiology and Biostatistics, University of Texas Health San Antonio, San Antonio, Texas
| | - Cynthia D'Alessandri-Silva
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
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10
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Vinit N, Gueneuc A, Bessières B, Dreux S, Heidet L, Salomon R, Lapillonne A, De Bernardis G, Salomon LJ, Stirnemann JJ, Blanc T, Ville Y. Fetal Cystoscopy and Vesicoamniotic Shunting in Lower Urinary Tract Obstruction: Long-Term Outcome and Current Technical Limitations. Fetal Diagn Ther 2019; 47:74-83. [PMID: 31401627 DOI: 10.1159/000500569] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In utero therapeutic approaches for lower urinary tract obstruction (LUTO) have been developed to salvage the fetal kidney function. OBJECTIVE The aim of this work was to report the long-term survival, nephrological, and urological outcome of children treated prenatally for LUTO using operative fetal cystoscopy (FC) and vesicoamniotic shunting (VAS) or both. METHODS A retrospective study of 48 procedures (23 FC, 25 VAS) was performed on 33 patients (between 2008 and 2018). Reviewed data included prenatal management and clinical follow-up by a pediatric nephrologist and a pediatric urologist. Both intention-to-treat and per-protocol analyses were conducted. RESULTS The median follow-up was 3.6 years (0.5-7) for FC and 2.5 years (1.1-5.1) for VAS. There was no difference between FC and VAS in terms of survival (92 vs. 83%, p = 1), complication rate (74 vs. 92%, p = 0.88), or chronic kidney disease (58 vs. 50%, p = 1). The number of procedures was higher in the VAS group: 1.7 (1-3) versus 1.1 (1-2), p = 0.01. With a 30% rate of technical failure, FC added diagnostic value in 3 out of 21 cases. CONCLUSIONS No difference was found between FC and VAS regarding survival, long-term kidney function, or urological outcome. Despite overly optimistic reports on FC, it lacks reproducibility due to posterior-urethra inadequate visualization and inappropriate instrumentation.
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Affiliation(s)
- Nicolas Vinit
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Alexandra Gueneuc
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Bettina Bessières
- Department of Histology, Embryology and Cytogenetics, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sophie Dreux
- Department of Biochemistry-Hormonology, Robert Debré Hospital, APHP, Paris, France
| | - Laurence Heidet
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Rémi Salomon
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,Paris Descartes University, Paris, France
| | - Alexandre Lapillonne
- Department of Neonatology, Necker-Enfants Malades, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Gaston De Bernardis
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Julien J Stirnemann
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Thomas Blanc
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,INSERM U1151-CNRS UMR 8253, Paris Descartes University, Necker-Enfants Maladies Institute, Necker-Enfants Malades Hospital, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France, .,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France,
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11
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Ruano R, Vega B. Fetal surgery: how recent technological advancements are extending its applications. Expert Rev Med Devices 2019; 16:643-645. [PMID: 31283889 DOI: 10.1080/17434440.2019.1641404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Rodrigo Ruano
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine , Rochester , MN , USA.,b Division of Pediatrics, Mayo Clinic College of Medicine , Rochester , MN , USA.,c Center for Regenerative Medicine, Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Beatriz Vega
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine , Rochester , MN , USA
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12
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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13
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Practical Management of Fetal Obstructive Uropathy. JOURNAL OF FETAL MEDICINE 2018. [DOI: 10.1007/s40556-017-0147-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Johnson MP, Wilson RD. Shunt-based interventions: Why, how, and when to place a shunt. Semin Fetal Neonatal Med 2017; 22:391-398. [PMID: 28964685 DOI: 10.1016/j.siny.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The broad categories of surgical fetal therapy can be separated into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques that require only puncture of the uterus with single or multiple small ports. Benefits of fetoscopic or ultrasound-guided fetal intervention include decreased uterine irritability, decreased incidence of preterm labor, and avoidance of risks associated with hysterotomy and commitment to cesarean delivery for future pregnancies. Fetal abnormalities potentially amenable to ultrasound-guided drainage techniques include thoracic fluid-filled lesions and lower urinary tract obstruction.
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Affiliation(s)
- Mark P Johnson
- The Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - R Douglas Wilson
- Departments of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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15
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Farrugia MK, Braun MC, Peters CA, Ruano R, Herndon CD. Report on The Society for Fetal Urology panel discussion on the selection criteria and intervention for fetal bladder outlet obstruction. J Pediatr Urol 2017; 13:345-351. [PMID: 28476482 DOI: 10.1016/j.jpurol.2017.02.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The Society for Fetal Urology panel section at the 2016 Fall Congress featured a multidisciplinary discussion on appropriate patient selection, the conservative versus surgical management, and postnatal renal outcome of fetuses with lower urinary tract obstruction (LUTO). SELECTION CRITERIA FOR INTERVENTION Rodrigo Ruano shared his experience of prenatal intervention, presenting the outcome of 111 fetuses with severe LUTO treated with vesicoamniotic shunting (VAS) (n = 16), cystoscopy (n = 34) or no intervention (n = 61) in a non-randomized series. Multivariate analysis at the 6-month follow-up suggested a significantly higher probability of survival with fetal intervention versus no intervention. A clear trend for normal renal function was present in the fetal cystoscopy group, but not in the VAS group. In cases in which there was a postnatal diagnosis of posterior urethral valves (n = 57), fetal cystoscopy was effective in improving both the 6-month survival rate and renal function, while VAS was associated with an improvement in the 6-month survival rate. In an attempt to better define which fetuses would benefit from intervention, Michael Braun explained the proposed LUTO classification system that incorporates: (1) fetal urinary biomarkers of renal injury; (2) amniotic fluid levels as a surrogate for the severity of obstruction; and (3) imaging studies to identify signs of renal dysplastic or cystic changes. Intervention was not recommended in patients at low risk of either renal disease or pulmonary hypoplasia (Stage 1). Vesicoamniotic shunting was performed in patients at high risk of either progressive renal injury or pulmonary hypoplasia without evidence of severe pre-existing renal damage (Stage 2). For those patients, who at the time of evaluation had evidence of severe renal disease (Stage 3), fetal intervention was individualized and often based on bladder capacity and bladder refilling after vesicocentesis. He went on to present the nephrologic outcome of fetuses managed over the last 3 years utilizing the selection criteria. Craig Peters supported the concept of selective criteria and discussed the cautious viewpoint, namely: (1) the procedure may be unnecessary, as it is possible for patients to do well, in spite of severe prenatal obstruction; and (2) the risk of giving partial treatment by allowing the baby to survive to delivery with the daunting postnatal journey of renal and pulmonary insufficiency. CONCLUSION Standardized patient selection utilizing a staging system is undoubtedly the way forward and will enable comparable long-term renal and bladder functional outcome studies.
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Affiliation(s)
- M K Farrugia
- Department of Paediatric Urology, Chelsea Children's Hospital at the Chelsea & Westminster Hospital, London, UK.
| | - M C Braun
- Department of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - C A Peters
- Department of Pediatric Urology, Children's Health System Texas and University of Texas Southwestern, Dallas, TX, USA
| | - R Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, USA
| | - C D Herndon
- Department of Pediatric Urology, Children's Hospital of Richmond, Richmond, VA, USA
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16
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Abstract
Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.
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Affiliation(s)
- H Kitagawa
- Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - K C Pringle
- Paediatric Surgery, Department of Obstetrics and Gynaecology, University of Otago, Wellington, P.O. Box 7343, Wellington South, 6242, Wellington, New Zealand
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17
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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.
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Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea Children's Hospital at the Chelsea & Westminster Hospital Foundation Trust, London SW10 9NH, UK.
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18
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Ruano R, Sananes N, Wilson C, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Safdar A, Moaddab A, Meyer N, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Braun MC, Belfort MA. Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:476-482. [PMID: 26690832 DOI: 10.1002/uog.15844] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/31/2015] [Accepted: 12/15/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity. METHODS This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported. RESULTS Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR > 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR < 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR > 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR > 1) = 93.3%) were predictors of survival. CONCLUSIONS Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA. ,
| | - N Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C Wilson
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Au
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - P Gargollo
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Safdar
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - N Meyer
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France
| | - D L Cass
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - S Welty
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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19
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Kurtz MP, Koh CJ, Jamail GA, Sangi-Haghpeykar H, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Braun MC, Roth DR, Belfort MA, Ruano R. Factors associated with fetal shunt dislodgement in lower urinary tract obstruction. Prenat Diagn 2016; 36:720-5. [PMID: 27247093 DOI: 10.1002/pd.4850] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/19/2016] [Accepted: 05/29/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify factors associated with fetal shunt dislodgement in lower urinary tract obstruction (LUTO). METHODS We conducted a retrospective study of 42 consecutive fetuses with a diagnosis of LUTO in a tertiary fetal center between April 2013 and November 2015. Possible factors associated with prenatal shunt dislodgment were evaluated in fetuses who underwent shunt placement, including gestational age at diagnosis, gestational age at procedure, presence of 'keyhole sign', initial fetal bladder volume and wall thickness, prenatal ultrasonographic renal characteristics, amniotic fluid volume, presence of ascites prior to shunting, and type of fetal shunt. RESULTS Nineteen (46.3%) fetuses underwent shunt placement at a median gestational age of 19 (range: 16.3-31.1) weeks. Shunt dislodgement occurred in 10 (52.6%) patients. A total of 35 procedures were performed; among which 16 (45.7%) were repeat procedures. The only prenatal factor associated with shunt dislodgement was the type of the shunt; Kaplan-Meier analysis indicated that the Rocket was associated with increased likelihood of remaining orthotopic (p = 0.04). CONCLUSION Fetal shunt dislodgement occurs in approximately half of the patients and appears to be associated with the type of the shunt. Future research is necessary to develop better shunt systems and to investigate different fetal therapeutic approaches. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Michael P Kurtz
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Grace Anne Jamail
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, 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, Houston, TX, USA
| | - David R Roth
- Division of Pediatric Urology, 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, Houston, TX, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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20
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Ruano R, Safdar A, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Belfort MA, Braun MC. Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction. Pediatr Nephrol 2016; 31:605-12. [PMID: 26525197 DOI: 10.1007/s00467-015-3246-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 09/27/2015] [Accepted: 10/06/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). METHODS We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. RESULTS Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). CONCLUSION We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA.
| | - Adnan Safdar
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jason Au
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Patricio Gargollo
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Stephen Welty
- Department of Pediatrics, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - David R Roth
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael C Braun
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
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21
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Sananes N, Cruz-Martinez R, Favre R, Ordorica-Flores R, Moog R, Zaloszy A, Giron AM, Ruano R. Two-year outcomes after diagnostic and therapeutic fetal cystoscopy for lower urinary tract obstruction. Prenat Diagn 2016; 36:297-303. [DOI: 10.1002/pd.4771] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolas Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center; Texas Children's Hospital; Houston TX USA
- INSERM; UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - Rogelio Cruz-Martinez
- Department of Fetal Surgery; Children's and Women's Specialty Hospital of Queretaro; Queretaro Mexico
- Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología; UNAM-Juriquilla; Queretaro Mexico
| | - Romain Favre
- Maternal Fetal Medicine Department; Strasbourg University Hospital; Strasbourg France
| | - Ricardo Ordorica-Flores
- Department of Pediatric Surgery; Children's Hospital Mexico ‘Federico Gomez’ (HIMFG); Mexico City Mexico
| | - Raphaël Moog
- Pediatric Surgery Department; Strasbourg University Hospital; Strasbourg France
| | - Ariane Zaloszy
- Pediatric Nephrology Department; Strasbourg University Hospital; Strasbourg France
| | - Amilcar Martins Giron
- Department of Urology; Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center; Texas Children's Hospital; Houston TX USA
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22
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Smith-Harrison LI, Hougen HY, Timberlake MD, Corbett ST. Current applications of in utero intervention for lower urinary tract obstruction. J Pediatr Urol 2015; 11:341-7. [PMID: 26441047 DOI: 10.1016/j.jpurol.2015.07.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/19/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Since the early 1980s with the inception of fetal intervention for obstructive uropathy, there have been creative attempts to improve both perinatal and long-term outcomes. Despite advances in technology and an improved understanding of lower urinary tract obstruction (LUTO) in the fetus, the results for these therapeutic interventions remain guarded and the long-term renal morbidity among survivors remains problematic. RECENT FINDINGS Fetal LUTO represents a range of disorders but the most common of these is posterior urethral valves (PUVs). Selection criteria for candidates of possible intervention have improved with our understanding of fetal renal physiology. Serial urinalysis has marginally improved our ability to predict those that may ultimately respond to treatment [1,2], but the potential in the development of biomarkers for renal development or maldevelopment holds greater promise [3]. Advancements in fetal surgery may result in less fetal and maternal morbidity, but limited long-term improvement in outcomes highlights the controversial nature of the various interventions [4-10]. We must counsel families that fetal surgery offers hope but we cannot allow them to hold unrealistic expectations for cure. SUMMARY In appropriately selected fetuses, intervention may improve perinatal survival but not without risk to mother and fetus. Long-term renal outcomes remain problematic amongst survivors. In the case of PUV, postnatal primary valve ablation remains the cornerstone of treatment for nephron preservation; however, our ability to mimic these results in the prenatal population remains poor [11]. Disease severity has likely predetermined those that will survive through the perinatal period with or without intervention. Nonetheless, our drive to assess and manage fetal obstructive uropathy perseveres so that we may ultimately relieve obstruction and preserve renal and lung function. We must maintain optimism that continued advances will ultimately improve outcomes, but also be realistic with our current expectations. This paper reviews the status of current in utero interventions and outcomes.
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Affiliation(s)
- L I Smith-Harrison
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Helen Y Hougen
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Matthew D Timberlake
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sean T Corbett
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
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Garabedian C, Jouannic JM, Benachi A, Sénat MV, Favre R, Houfflin-Debarge V. Thérapie fœtale et fœtoscopie : une réalité clinique en 2015. ACTA ACUST UNITED AC 2015; 44:597-604. [DOI: 10.1016/j.jgyn.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 05/11/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
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Mathis J, Raio L, Baud D. Fetal laser therapy: applications in the management of fetal pathologies. Prenat Diagn 2015; 35:623-36. [DOI: 10.1002/pd.4587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/21/2015] [Accepted: 02/26/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jérôme Mathis
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - Luigi Raio
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - David Baud
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
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Ruano R, Sananes N, Sangi-Haghpeykar H, Hernandez-Ruano S, Moog R, Becmeur F, Zaloszyc A, Giron AM, Morin B, Favre R. Fetal intervention for severe lower urinary tract obstruction: a multicenter case-control study comparing fetal cystoscopy with vesicoamniotic shunting. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:452-458. [PMID: 25157756 DOI: 10.1002/uog.14652] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 07/26/2014] [Accepted: 08/07/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO). METHODS A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively. Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention. Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention. RESULTS Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61. Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis. In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 1.86 (95% CI, 1.01-3.42; P = 0.048) and ARR, 1.73 (95% CI, 1.01-3.08; P = 0.04) respectively). A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 1.73 (95% CI, 0.97-3.08; P = 0.06)) but was not observed in the vesicoamniotic shunt group (ARR, 1.16 (95% CI, 0.86-1.55; P = 0.33)). In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6-month survival rate and renal function (ARR, 4.10 (95% CI, 1.75-9.62; P < 0.01) and 2.66 (95% CI, 1.25-5.70; P = 0.01) respectively) while vesicoamniotic shunting was associated only with an improvement in the 6-month survival rate (ARR, 3.76 (95% CI, 1.42-9.97; P < 0.01)) with no effect on renal function (ARR, 1.03 (95% CI, 0.49-2.17, P = 0.93)). CONCLUSION Fetal cystoscopy and vesicoamniotic shunting improve the 6-month survival rate in cases of severe LUTO. However, only fetal cystoscopy may prevent impairment of renal function in fetuses with posterior urethral valves. Our data support the idea of performing a subsequent randomized controlled trial to compare the effectiveness of fetal cystoscopy vs vesicoamniotic shunting for severe fetal LUTO.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA; Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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Sananes N, Favre R, Koh CJ, Zaloszyc A, Braun MC, Roth DR, Moog R, Becmeur F, Belfort MA, Ruano R. Urological fistulas after fetal cystoscopic laser ablation of posterior urethral valves: surgical technical aspects. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:183-189. [PMID: 24817027 DOI: 10.1002/uog.13405] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 04/23/2014] [Accepted: 04/25/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To describe the surgical technical aspects associated with the development of urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV). METHODS The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the USA, France and Brazil were reviewed, with particular emphasis on surgical technical aspects of the procedure and the complications encountered. RESULTS A total of 40 fetal cystoscopies were performed at the three institutions. Laser fulguration of the PUV was performed in 23 of these cases, with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) of these infants. Urological fistulas were diagnosed postnatally in four (10%) newborns. The presence of fistulas was associated with a higher gestational age at diagnosis of PUV (P < 0.01) and with the use of semi-curved rather than curved sheaths (P < 0.01), the use of a diode laser (P < 0.01) and the use of higher laser power and energy (P < 0.01 and P < 0.01, respectively), as well as with less operator experience (P < 0.01) and with absence of fetal anesthesia/immobilization (P = 0.02). CONCLUSION Urological fistulas are a severe complication of fetal cystoscopic laser fulguration of PUV and are associated with type, energy and power settings of the laser and instrumentation. The use of appropriate technique and proper training of the operator are necessary to perform this fetal intervention safely.
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Affiliation(s)
- N Sananes
- Department of Obstetrics and Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; INSERM, UMR-S 1121, Biomatériaux et Bioingénierie, Strasbourg, France
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Martínez JM, Masoller N, Devlieger R, Passchyn E, Gómez O, Rodo J, Deprest JA, Gratacós E. Laser Ablation of Posterior Urethral Valves by Fetal Cystoscopy. Fetal Diagn Ther 2015; 37:267-73. [DOI: 10.1159/000367805] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/15/2014] [Indexed: 11/19/2022]
Abstract
Objective: To report the results of fetal cystoscopic laser ablation of posterior urethral valves (PUV) in a consecutive series in two referral centers. Methods: Twenty pregnant women with a presumptive isolated PUV were treated with fetal cystoscopy under local anesthesia. Identification and fulguration of the PUV by one or several firing-contacts with diode laser were attempted. Perinatal and long-term outcomes were prospectively recorded. Results: The median gestational age at procedure was 18.1 weeks (range 15.0-25.6), and median operation time was 24 min (range 15-40). Access to the urethra was achieved in 19/20 (95%) cases, and postoperative, normalization of bladder size and amniotic fluid was observed in 16/20 (80%). Overall, there were 9 (45%) terminations of pregnancy and 11 women (55%) delivered a liveborn baby at a mean gestational age of 37.3 (29.1-40.2) weeks. No infants developed pulmonary hypoplasia and all were alive at 15-110 months. Eight (40% of all fetuses, 72.7% of newborns) had normal renal function and 3 (27.3%) had renal failure awaiting renal transplantation. Conclusion: Fetoscopic laser ablation for PUV can achieve bladder decompression and amniotic fluid normalization with a single procedure in selected cases with anyhydramnios. There is still a significant risk of progression to renal failure pre or postnatally.
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Ruano R, Yoshizaki CT, Giron AM, Srougi M, Zugaib M. Cystoscopic placement of transurethral stent in a fetus with urethral stenosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:238-240. [PMID: 24375864 DOI: 10.1002/uog.13293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 12/14/2013] [Accepted: 12/17/2013] [Indexed: 06/03/2023]
Abstract
We report the case of a fetus with severe megabladder, displaying the 'keyhole' sign on ultrasound imaging, that underwent cystoscopy at 22 weeks' gestation. There was a familial history of mild urethral atresia. Fetal cystoscopy revealed congenital urethral atresia. A guide wire was advanced through the fetal urethra and a transurethral vesicoamniotic stent was placed successfully. The fetus was delivered at 36 weeks' gestation and postnatal cystoscopy confirmed the absence of posterior urethral valves or urethral atresia. The infant was 5 years old with normal renal function at the time of writing. We conclude that fetal cystoscopic placement of a transurethral stent for congenital urethral stenosis is feasible.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Kilby MD, Morris RK. Fetal therapy for the treatment of congenital bladder neck obstruction. Nat Rev Urol 2014; 11:412-9. [DOI: 10.1038/nrurol.2014.132] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tonni G, Vito I, Ventura A, Grisolia G, De Felice C. Fetal lower urinary tract obstruction and its management. Arch Gynecol Obstet 2012; 287:187-94. [PMID: 23138754 DOI: 10.1007/s00404-012-2615-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 10/25/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Prenatal counselling in case of fetal obstructive uropathies still represents a clinical dilemma, despite ultrasound detection of lower urinary tract obstruction has greatly advanced during recent years as well as fetal intervention techniques. MATERIALS AND METHODS A systematic review of the relevant literature on the topic was performed, with a special focus on the role of antenatal ultrasound, in utero treatment and prognosis. CONCLUSIONS A clinico-diagnostic flow chart was developed, with the specific aim of aiding health care givers in the clinical management and the parental decision-making process.
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Affiliation(s)
- Gabriele Tonni
- Department of Obstetrics and Gynecology, Gustalla Civil Hospital, AUSL Reggio Emilia Via Donatori Sangue, 2, 42016, Guastalla (RE), Italy.
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Deprest J, Emonds MP, Richter J, DeKoninck P, Van Mieghem T, Van Schoubroeck D, Devlieger R, De Catte L, Lewi L. Amniopatch for iatrogenic rupture of the fetal membranes. Prenat Diagn 2011; 31:661-6. [PMID: 21656529 DOI: 10.1002/pd.2780] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/14/2011] [Accepted: 04/17/2011] [Indexed: 11/10/2022]
Abstract
With the increased use of invasive fetal procedures, the number of women facing post-procedure membrane rupture is increasing. Here we review the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects by describing the mechanisms of action of the amniopatch procedure as well as published experience. In cases of iatrogenic preterm pre-labour rupture of the membranes, amniopatch effectively seals the fetal membranes in over two-thirds of cases. There is a risk of 16% of in utero fetal death, which may occur at varying intervals from the procedure and often for unknown reasons. Amniopatch has also been used as a treatment of chorionic membrane separation. In summary, current experience suggests that in cases of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch is an option.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
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Deprest J, Van Mieghem T, Emonds MP, Richter J, De Koninck P, Zia S, Van Keirsbilck J, Sandaite I, Olde Damink L, Lewi L. [Amniopatch to treat iatrogenic rupture of the fetal membranes]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2011; 39:378-382. [PMID: 21596607 DOI: 10.1016/j.gyobfe.2011.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 03/23/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE With the increased use of invasive fetal procedures, the number of patients facing postprocedure membrane rupture is increasing. We aimed to describe the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects. PATIENTS AND METHODS We describe the mechanisms of action of the amniopatch procedure as well as published experience. RESULTS Amniopatch effectively sealed the fetal membranes in over two thirds of published cases (n=44). There is a risk of 17% of in utero fetal death, which may occur remotely from the procedure and is often unexplained. DISCUSSION AND CONCLUSION In case of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch may be offered.
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Affiliation(s)
- J Deprest
- Département d'obstétrique et de gynécologie, division femme et enfant, hôpital universitaire Gasthuisberg, Leuven, Belgique.
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Morris RK, Ruano R, Kilby MD. Effectiveness of fetal cystoscopy as a diagnostic and therapeutic intervention for lower urinary tract obstruction: a systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:629-637. [PMID: 21374748 DOI: 10.1002/uog.8981] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To determine the effectiveness of fetal cystoscopy in the prenatal diagnosis of and intervention for congenital lower urinary tract obstruction. METHODS This study was a literature search using MEDLINE, Embase, Cochrane Library, MEDION, Web of Science reference lists and contact with experts. All studies reporting on fetal cystoscopy in lower urinary tract obstruction with data for a 2 × 2 table were selected for review. No language restrictions were applied. There was independent selection of studies, data extraction and quality assessment by two reviewers. Peto odds ratios were calculated as a summary measure of effect. RESULTS A total of 2071 citations were identified and 66 papers selected for detailed evaluation, from which four papers with a total of 63 patients were selected for inclusion. Two papers had results for the use of cystoscopy in diagnosis, showing that fetal cystoscopy altered the ultrasound diagnosis of the underlying pathology in 36.4 and 25.0% of fetuses, respectively. Compared to no treatment, fetal cystoscopic intervention demonstrated an odds ratio for improved perinatal survival of 20.51 (95% CI, 3.87-108.69). However, comparing vesicoamniotic shunt (VAS) with fetal cystoscopy there appeared to be no significant improvement in the perinatal survival odds ratio of 1.49 (95% CI, 0.13-16.97). These results had wide CIs and for cystoscopy vs. VAS, all results crossed the line of no effect. CONCLUSION There is little published evidence for the effectiveness of therapeutic fetal cystoscopy as an intervention for congenital lower urinary tract obstruction and the quality of this evidence is poor. It should thus be considered to be an 'experimental intervention' and subjected to further investigation.
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Affiliation(s)
- R K Morris
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Ruano R, Yoshisaki CT, Salustiano EMA, Giron AM, Srougi M, Zugaib M. Early fetal cystoscopy for first-trimester severe megacystis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:696-701. [PMID: 21337440 DOI: 10.1002/uog.8963] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To report the feasibility of early fetal cystoscopy for the prenatal diagnosis and therapy of severe first-trimester megacystis. METHODS Between January 2008 and February 2010, early fetal cystoscopy at 16 weeks of gestation was offered to 15 patients whose fetuses presented with severe first-trimester megacystis. All infants were followed up for 6-12 months after birth. Autopsy was always performed whenever fetal or neonatal deaths occurred. RESULTS Seven patients decided to undergo fetal therapy, and eight elected to continue with expectant observation. One fetus died before early fetal cystoscopy was performed. Therefore, six fetuses underwent early fetal cystoscopy. Urethral atresia was diagnosed in three fetuses during fetal cystoscopy and confirmed at autopsy following termination of pregnancy at 19-20 weeks in all cases. Posterior urethral valves were diagnosed and successfully fulgurated by laser during early cystoscopy in three fetuses, two of which survived with normal renal and bladder function after birth; the remaining fetus had a postnatal diagnosis of megacystis-microcolon intestinal hypoperistalsis syndrome and died neonatally. In the expectantly managed group, no survivals were observed, even among cases with 'isolated' posterior urethral valves. CONCLUSIONS Percutaneous early fetal cystoscopy is feasible for prenatal diagnosis and therapy of severe megacystis.
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Affiliation(s)
- R Ruano
- Obstetrics Department, Faculty of Medicine, São Paulo University, São Paulo, Brazil.
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Ruano R. Fetal surgery for severe lower urinary tract obstruction. Prenat Diagn 2011; 31:667-74. [PMID: 21413041 DOI: 10.1002/pd.2736] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/21/2011] [Accepted: 02/13/2011] [Indexed: 11/11/2022]
Abstract
Fetal interventions have been proposed for treatment of severe lower urinary tract obstruction (LUTO), as this condition is associated with high rates of perinatal mortality and postnatal renal impairment. The rationale for in utero treatment for those cases is based on the possibility of relieving the obstruction, improving the amniotic fluid volume, and preventing renal and bladder damage. Candidates for fetal intervention should be rigorously selected based on the confirmation of severe LUTO (dilated bladder and bilateral hydronephrosis), oligohydramnios or anyhydramnios and 'favorable' fetal urinalysis (dependent on gestational age). Nowadays there are two different therapeutic options with specific technical approaches. Vesico-amniotic shunting is an easier procedure, but with a higher frequency of related complications. Fetal cystoscopy can be used for diagnostic purpose and for treatment of posterior urethral valves, with suggestive advantage of allowing a more physiological release of the obstruction. According to the literature, estimated survival rates and postnatal normal renal function frequencies are approximately 40 and 50% after vesico-amniotic shunting and 75 and 65% after fetal cystoscopy, respectively.
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Affiliation(s)
- Rodrigo Ruano
- Obstetrics Department, Faculty of Medicine, São Paulo University, São Paulo, Brazil.
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Humphrey RJ, Grieci T, Schmidt J, Gagnon R, Han V, Bütter A. Feasibility of vesicoamniotic shunt insertion in an inanimate model: comparison of fetoscopic and ultrasound-guided techniques. Fetal Diagn Ther 2011; 30:48-52. [PMID: 21346321 DOI: 10.1159/000323917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 12/22/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine the feasibility of fetoscopic vesicoamniotic shunt insertion (F-VASI) in an inanimate model and to compare F-VASI to ultrasound (US)-guided VASI (US-VASI) with respect to accuracy of shunt placement and overall success rate. METHODS An inanimate second-trimester fetus with a replaceable bladder balloon was suspended in a pressurized water tank and localized with US. Fetal position was randomized, the operator was blinded and a 5-Fr Harrison Shunt® decompressed the bladder in both groups. Thirty shunt insertions were performed per group. RESULTS Procedure time was longer for F-VASI (15.0 vs. 2.8 min, p < 0.05), although it decreased with practice. F-VASI and US-VASI were similar for adequate depth of insertion (27/30 vs. 27/30, p = 1.0), placement within 1 cm of midline (27/30 vs. 25/30, p = 0.42), bladder puncture (28/30 vs. 28/30, p = 1.0), and overall success rate (27/30 vs. 23/30, p = 0.3). CONCLUSIONS F-VASI is feasible in an inanimate model. Overall success rate was similar between the groups, although procedure time was longer for F-VASI. Further study is required to determine whether shunt migration is decreased with F-VASI.
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Affiliation(s)
- R J Humphrey
- Division of General Surgery, London Health Sciences Centre, St. Joseph's Hospital, London, Ontario, Canada
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Kajbafzadeh AM, Rasouli MR, Dianat S, Nezami BG, Mahboubi AH, Sina A. Urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome: long-term results. J Pediatr Surg 2010; 45:2217-21. [PMID: 21034947 DOI: 10.1016/j.jpedsurg.2010.06.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 05/25/2010] [Accepted: 06/28/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of the study was to evaluate the efficacy and safety of urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome (PBS). METHODS During a 10-year period, 7 infants with PBS and urethral hypoplasia presented either with open urachus or surgically created urinary diversion referred to our hospital. Five milliliters of normal saline was pushed via a 22-gauge plastic angiocatheter into the urethra with simultaneous finger pressure on the perineum to occlude the proximal urethra that was repeated with higher volumes of the solution (up to 20 mL). The procedure was continued until a 6F or 8F feeding tube catheter confirmed the urethral patency. Hydrodistension was repeated in 3-month intervals till complete patency was confirmed by imaging. RESULTS Median age of the infants was 6 (1-8) months. All urethral hydrodistension were successful after 1 to 3 sessions. Follow-up imaging studies showed significant improvement in all patients except one. Natural and surgically created urinary diversions were closed in 6 infants. CONCLUSIONS The hydrodistension create an equal and constant pressure into the urethral wall without any urethral damage. This technique can be considered along with the other available methods for management of urethral hypoplasia in selected cases of PBS.
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Affiliation(s)
- Abdol-Mohammad Kajbafzadeh
- Pediatric Urology Research Center, Department of Pediatric Urology, Children's Hospital Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
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Deprest JA, Flake AW, Gratacos E, Ville Y, Hecher K, Nicolaides K, Johnson MP, Luks FI, Adzick NS, Harrison MR. The making of fetal surgery. Prenat Diagn 2010; 30:653-67. [PMID: 20572114 DOI: 10.1002/pd.2571] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospitals KU Leuven, Leuven, Belgium.
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Minimally invasive fetoscopic interventions: an overview in 2010. Surg Endosc 2010; 24:2056-67. [DOI: 10.1007/s00464-010-0879-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 08/14/2009] [Indexed: 10/19/2022]
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Ruano R, Duarte S, Bunduki V, Giron AM, Srougi M, Zugaib M. Fetal cystoscopy for severe lower urinary tract obstruction--initial experience of a single center. Prenat Diagn 2010; 30:30-9. [PMID: 19967749 DOI: 10.1002/pd.2418] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report the experience with fetal cystoscopy and laser fulguration of posterior urethral values (PUV) for severe lower urinary tract obstruction (LUTO). METHODS Between July 2006 and December 2008, fetal cystoscopy was offered to 23 patients whose fetuses presented with severe LUTO, favorable urinary analysis and gestational age <26 weeks. Fetal urinary biochemistry was evaluated before and after cystoscopy. All infants were followed 6-12 months after birth. Abnormal renal function was defined when serum creatinine higher than 50 micromol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred. RESULTS Eleven patients decided to undergo fetal therapy and 12 elected to continue with expectant observation. There was no difference between both groups in gestation age at diagnosis and referral examinations. Urethral atresia was diagnosed in 4/11 (36.4%) fetuses by fetal cystoscopy. At 26 weeks, fetuses that were managed expectantly presented with worse urinary biochemistry results (p < 0.05). Survival rates and percentage of infants with normal renal function were significantly higher in the cystoscopic group than in the expectant group (p < 0.05). CONCLUSIONS Percutaneous fetal cystoscopy is feasible using a thinner special cannula for prenatal diagnosis and therapy of LUTO. Prenatal laser ablation of the PUV under cystoscopy may prevent renal function deterioration improving postnatal outcome.
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Affiliation(s)
- Rodrigo Ruano
- Obstetrics Department, Faculty of Medicine, São Paulo University, Rua Valentim Magalhães 100, São Paulo, SP, Brazil.
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Beck V, Pexsters A, Gucciardo L, van Mieghem T, Sandaite I, Rusconi S, DeKoninck P, Srisupundit K, Kagan KO, Deprest J. The use of endoscopy in fetal medicine. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10397-010-0565-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Morris RK, Malin GL, Khan KS, Kilby MD. Systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction. BJOG 2010; 117:382-90. [DOI: 10.1111/j.1471-0528.2010.02500.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Deprest JA, Devlieger R, Srisupundit K, Beck V, Sandaite I, Rusconi S, Claus F, Naulaers G, Van de Velde M, Brady P, Devriendt K, Vermeesch J, Toelen J, Carlon M, Debyser Z, De Catte L, Lewi L. Fetal surgery is a clinical reality. Semin Fetal Neonatal Med 2010; 15:58-67. [PMID: 19913467 DOI: 10.1016/j.siny.2009.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
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Abstract
The term congenital ‘bladder outlet obstruction (BOO)’ describes the collection of conditions in which the normal, urethral egress of urine from the fetal bladder is impaired. The term is interchangeable with fetal ‘lower urinary tract obstruction’, as used by other authors. After considering normal urinary tract embryology, we describe the epidemiology of congenital BOO and the primary anatomical disorders associated with it. We then proceed to describe its fetal and postnatal clinical manifestations and then consider therapies and interventions which have been used to manage the condition. We not only focus on urethral and bladder disease with constitutes BOO itself, but also describe associated kidney disorders which, via chronic renal excretory failure, are important causes of morbidity. Rather than provide an exhaustive review, we emphasise studies published in the last decade, and therefore readers are referred to other reviews citing numerous earlier references.
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Ruano R, Pimenta EJ, Duarte S, Zugaib M. Four-dimensional ultrasonographic imaging of fetal lower urinary tract obstruction and guidance of percutaneous cystoscopy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:250-252. [PMID: 19173237 DOI: 10.1002/uog.6292] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- R Ruano
- Universidade de São Paulo, Faculdade de Medicina, Obstetrics Department, São Paulo, Brazil.
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Klaritsch P, Albert K, Van Mieghem T, Gucciardo L, Done’ E, Bynens B, Deprest J. Instrumental requirements for minimal invasive fetal surgery. BJOG 2008; 116:188-97. [DOI: 10.1111/j.1471-0528.2008.02021.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Fetal surgery has emerged from the realm of medical curiosity into an exciting, multidisciplinary specialty now capable of improving patient outcomes for a wide variety of diseases. Recent advances allow prenatal providers to both accurately diagnose and treat many fetal anomalies while maintaining maternal safety. As the initial postnatal health care providers to the majority of these newborns, neonatologists need to be familiar with some of the more recent state-of-the-art procedures currently being used. In this review, the authors discuss the prenatal evaluation process and various operative approaches (ie, open hysterotomy, fetoscopy, and percutaneous) to conduct fetal surgery. They then analyze the effectiveness of some of the more established and experimental prenatal therapies that are being performed for a number of fetal anomalies, including twin-twin transfusion syndrome, thoracic malformations, airway obstruction, congenital diaphragmatic hernia, myelomeningocele, and aortic valve stenosis.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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