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Fontanella F, Groen H, Duin LK, Suresh S, Bilardo CM. Z-scores of fetal bladder size for antenatal differential diagnosis between posterior urethral valves and urethral atresia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:875-881. [PMID: 33864313 PMCID: PMC9299997 DOI: 10.1002/uog.23647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To construct reference values for fetal urinary bladder distension in pregnancy and use Z-scores as a diagnostic tool to differentiate posterior urethral valves (PUV) from urethral atresia (UA). METHODS This was a prospective cross-sectional study in healthy singleton pregnancies aimed at constructing nomograms of fetal urinary bladder diameter and volume between 15 and 35 weeks' gestation. Z-scores of longitudinal bladder diameter (LBD) were calculated and validated in a cohort of fetuses with megacystis with ascertained postnatal or postmortem diagnosis, collected from a retrospective, multicenter study. Correlations between anatomopathological findings, based on medical examination of the infant or postmortem examination, and fetal megacystis were established. The accuracy of the Z-scores was evaluated by receiver-operating-characteristics (ROC)-curve analysis. RESULTS Nomograms of fetal urinary bladder diameter and volume were produced from three-dimensional ultrasound volumes in 225 pregnant women between 15 and 35 weeks of gestation. A total of 1238 urinary bladder measurements were obtained. Z-scores, derived from the fetal nomograms, were calculated in 106 cases with suspected lower urinary tract obstruction (LUTO), including 76 (72%) cases with PUV, 22 (21%) cases with UA, four (4%) cases with urethral stenosis and four (4%) cases with megacystis-microcolon-intestinal hypoperistalsis syndrome. Fetuses with PUV showed a significantly lower LBD Z-score compared to those with UA (3.95 vs 8.83, P < 0.01). On ROC-curve analysis, we identified 5.2 as the optimal Z-score cut-off to differentiate fetuses with PUV from the rest of the study population (area under the curve, 0.84 (95% CI, 0.748-0.936); P < 0.01; sensitivity, 74%; specificity, 86%). CONCLUSIONS Z-scores of LBD can distinguish reliably fetuses with LUTO caused by PUV from those with other subtypes of LUTO, with an optimal cut-off of 5.2. This information should be useful for prenatal counseling and management of LUTO. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F. Fontanella
- Department of Obstetrics and GynaecologyIsala HospitalZwolleThe Netherlands
| | - H. Groen
- Department of Epidemiology‐HPC FA40, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics and GynaecologyIsala HospitalZwolleThe Netherlands
| | - S. Suresh
- Mediscan Ultrasound CenterChennaiIndia
| | - C. M. Bilardo
- Department of Obstetrics and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Amsterdam UMC, Location VUAmsterdamThe Netherlands
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2
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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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3
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Abstract
Fetal lower urinary tract obstruction (LUTO) is classically based on prenatal ultrasound identification of a dilated/ thick-walled bladder, bilateral hydronephrosis, dilated ureters and a dilated posterior urethra (also known as the "keyhole sign") in a male fetus. Although the most common underlying diagnosis is posterior urethral valves, the prenatal appearance may be similar with urethral atresia or stenosis, the Prune-Belly Syndrome, or even a cloacal anomaly in a female. These conditions form part of the Congenital Anomalies of Kidney and Urinary Tract (CAKUT) spectrum, which is the commonest cause of end-stage renal disease in children. Although it is difficult to predict postnatal renal function from the prenatal appearance, studies have recently identified predictive features (based on ultrasound findings and fetal biochemistry), and established staging systems to assist with counselling, and, where indicated, patient selection for in-utero intervention. Current in-utero therapy includes amnio-infusion, vesico-amniotic shunting, and fetal cystoscopy with valve ablation or urethral stenting. Postnatal survival and renal functional outcomes, complications and management uncertainties are described, highlighting areas of future development.
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Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea and Westminster and Imperial College Hospitals, United Kingdom of Great Britain and Northern Ireland; Imperial College London, United Kingdom of Great Britain and Northern Ireland.
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4
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Warring SK, Novoa V, Shazly S, Trinidad MC, Sas DJ, Schiltz B, Prieto M, Terzic A, Ruano R. Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives. Mayo Clin Proc Innov Qual Outcomes 2020; 4:391-409. [PMID: 32793867 PMCID: PMC7411166 DOI: 10.1016/j.mayocpiqo.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.
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Key Words
- AF, amniotic fluid
- AFI, AF index
- AFV, AF volume
- BRA, bilateral renal agenesis
- CRA, congenital renal anomaly
- DOL, day of life
- GA, gestational age
- IQR, interquartile range
- LUTO, lower urinary tract obstruction
- MVP, maximal vertical pocket
- PD, peritoneal dialysis
- PPROM, preterm premature rupture of membranes
- SAT, serial amnioinfusion therapy
- WHO, World Health Organization
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Affiliation(s)
- Simrit K Warring
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Victoria Novoa
- Department of Obstetrics & Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Sherif Shazly
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Mari Charisse Trinidad
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - David J Sas
- Division of Pediatric Nephrology, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Brenda Schiltz
- Division of Pediatric Critical Care Medicine, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Mikel Prieto
- Department of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Andre Terzic
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
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5
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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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6
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Abstract
Fetal surgery and fetal therapy involve surgical interventions on the fetus in utero to correct or ameliorate congenital abnormalities and give a developing fetus the best chance at a healthy life. Historical use of biomaterials in fetal surgery has been limited, and most biomaterials used in fetal surgeries today were originally developed for adult or pediatric patients. However, as the field of fetal surgery moves from open surgeries to minimally invasive procedures, many opportunities exist for innovative biomaterials engineers to create materials designed specifically for the unique challenges and opportunities of maternal-fetal surgery. Here, we review biomaterials currently used in clinical fetal surgery as well as promising biomaterials in development for eventual clinical translation. We also highlight unmet challenges in fetal surgery that could particularly benefit from novel biomaterials, including fetal membrane sealing and minimally invasive myelomeningocele defect repair. Finally, we conclude with a discussion of the underdeveloped fetal immune system and opportunities for exploitation with novel immunomodulating biomaterials.
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Affiliation(s)
- Sally M Winkler
- Department of Bioengineering, University of California, Berkeley, CA, USA. and University of California, Berkeley-University of California, San Francisco Graduate Program in Bioengineering, Berkeley, CA, USA
| | - Michael R Harrison
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Phillip B Messersmith
- Department of Bioengineering, University of California, Berkeley, CA, USA. and Department of Materials Science and Engineering, University of California, Berkeley, CA, USA and Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
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7
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Elbanna WSS, Oun IA, Ellatif EMA, Hablas WR, El Shaikh WI, Wafa YA. Evaluation of Fetoscopy Role in Fetal Surgery and Fetal Medicine. OPEN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2018; 08:946-957. [DOI: 10.4236/ojog.2018.811096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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8
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She F, Dong S, Yuan B, Gao X. Diagnosis of fetal megacystis with chromosomal abnormality by 2D prenatal ultrasound: A case report. Medicine (Baltimore) 2017; 96:e8589. [PMID: 29145274 PMCID: PMC5704819 DOI: 10.1097/md.0000000000008589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE The pathogenesis of fetal megacystis is divided into obstructive and nonobstructive. Megacystis combined with chromosomal abnormalities is rare and most of the cases are nonobstructive. PATIENT CONCERNS The fetus showed posterior urethral obstructive megacystis with features of bladder enlargement, "keyhole" feature, and thick bladder wall. DIAGNOSES Here, we present a case of fetal megacystis diagnosed by ultrasound at pregnancy week 15+2 and with multisystem abnormalities. OUTCOMES Moreover, the fetus showed edema, umbilical cord cyst, cardiac dysplasia, hook-shaped hand, and strephenopodia. These abnormalities strongly suggested chromosomal abnormalities. The fetus was diagnosed with trisomy 18 by amniocentesis. Posterior urethral obstructive megacystis was confirmed by pathology. LESSONS In conclusion, this case suggests that in the presence of fetal megacystis and multisystem abnormalities, causes should be investigated and the possibility of chromosomal abnormalities should be considered in the presence of multisystem developmental abnormalities.
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Affiliation(s)
- Fuman She
- Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital
| | | | - Bibo Yuan
- Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital
| | - Xiaoli Gao
- Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital
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9
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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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10
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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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11
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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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12
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Haeri S. Fetal Lower Urinary Tract Obstruction (LUTO): a practical review for providers. Matern Health Neonatol Perinatol 2015; 1:26. [PMID: 27057343 PMCID: PMC4823687 DOI: 10.1186/s40748-015-0026-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/02/2015] [Indexed: 11/10/2022] Open
Abstract
Fetal lower urinary tract obstruction (LUTO) is a serious condition, which commonly results in marked perinatal morbidity and mortality. The characteristic prenatal presentation of LUTO includes an enlarged bladder with bilateral obstructive uropathy. While mild forms of the disease result in minimal clinical sequelae, the more severe forms commonly lead to oligohydramnios, dysplastic changes in the fetal kidneys, and ultimately result in secondary pulmonary hypoplasia. The aim of this review is to provide practitioners with a practical and concise overview of the presentation, evaluation, and treatment of LUTO.
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Affiliation(s)
- Sina Haeri
- St. David's Women's Center of Texas, Austin Maternal-Fetal Medicine, 12200 Renfert Way, G-3, Austin, Austin, TX 78758 USA
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13
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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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14
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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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15
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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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16
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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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