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Birkemeier K. MR Imaging of the Fetal Genitourinary Tract. Magn Reson Imaging Clin N Am 2024; 32:529-551. [PMID: 38944439 DOI: 10.1016/j.mric.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Fetal MR imaging overcomes many of the technical barriers of ultrasound and is an important diagnostic tool for fetal genitourinary (GU) anomalies. It is suited for evaluation of GU anomalies because of the fluid-sensitive sequences and superior soft tissue contrast. Often GU malformations are part of a multisystem genetic or congenital condition, and imaging the entire fetus with MR adds additional clarity about the extent of disease. It adds confidence to diagnoses of renal agenesis, urinary tract dilation, cystic disease, and tumors. It is particularly useful to delineate anatomy in complex GU malformations. This additional information guides counseling.
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Affiliation(s)
- Krista Birkemeier
- Department of Radiology, McLane Children's Medical Center, Baylor Scott & White Health, Texas A&M School of Medicine, 2401 South 31st Street, MS-01-W256, Temple, TX 76508, USA.
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Kobayashi T, Iwatani S, Mimura H, Yoshimoto S. Expectant management of pregnancy involving fetus with lower urinary tract obstruction. Congenit Anom (Kyoto) 2024; 64:182-183. [PMID: 38745500 DOI: 10.1111/cga.12572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Takao Kobayashi
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
| | - Sota Iwatani
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
| | - Hitomi Mimura
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
| | - Seiji Yoshimoto
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
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Okpaise OO, Tonni G, Werner H, Araujo Júnior E, Lopes J, Ruano R. Three-dimensional real and virtual models in fetal surgery: a real vision. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:303-311. [PMID: 36565438 DOI: 10.1002/uog.26148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Affiliation(s)
- O O Okpaise
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - G Tonni
- Prenatal Diagnostic Centre, Department of Obstetrics and Neonatology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, Reggio Emilia, Italy
| | - H Werner
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Medical School, Municipal University of São Caetano do Sul (USCS), Bela Vista Campus, São Paulo, Brazil
| | - J Lopes
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
- Institute for Pure and Applied Mathematics, Rio de Janeiro, Brazil
| | - R Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA
- Maternal-Fetal-Children Service of Excellence, Americas Group, United Health Care Brazil, São Paulo, Brazil
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Gottschalk I, Berg C, Menzel T, Abel JS, Kribs A, Dübbers M, Kohaut J, Weber LT, Taylan C, Habbig S, Liebau MC, Boemers TM, Weber EC. Single-center outcome analysis of 46 fetuses with megacystis after intrauterine vesico-amniotic shunting with the Somatex®intrauterine shunt. Arch Gynecol Obstet 2024; 309:145-158. [PMID: 36604332 PMCID: PMC10770195 DOI: 10.1007/s00404-022-06905-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To assess the spectrum of underlying pathologies, the intrauterine course and postnatal outcome of 46 fetuses with megacystis that underwent intrauterine vesico-amniotic shunting (VAS) with the Somatex® shunt in a single center. METHODS Retrospective analysis of 46 fetuses with megacystis that underwent VAS either up to 14 + 0 weeks (early VAS), between 14 + 1 and 17 + 0 weeks (intermediate VAS) or after 17 + 0 weeks of gestation (late VAS) in a single tertiary referral center. Intrauterine course, underlying pathology and postnatal outcome were assessed and correlated with the underlying pathology and gestational age at first VAS. RESULTS 46 fetuses underwent VAS, 41 (89%) were male and 5 (11%) were female. 28 (61%) fetuses had isolated and 18 (39%) had complex megacystis with either aneuploidy (n = 1), anorectal malformations (n = 6), cloacal malformations (n = 3), congenital anomalies overlapping with VACTER association (n = 6) or Megacystis-Microcolon Intestinal-Hypoperistalsis Syndrome (MMIHS) (n = 2). The sonographic 'keyhole sign' significantly predicted isolated megacystis (p < 0.001). 7 pregnancies were terminated, 4 babies died in the neonatal period, 1 baby died at the age of 2.5 months and 34 (74%) infants survived until last follow-up. After exclusion of the terminated pregnancies, intention-to-treat survival rate was 87%. Mean follow-up period was 24 months (range 1-72). The underlying pathology was highly variable and included posterior urethral valve (46%), hypoplastic or atretic urethra (35%), MMIHS or prune belly syndrome (10%) and primary vesico-ureteral reflux (2%). In 7% no pathology could be detected postnatally. No sonographic marker was identified to predict the underlying pathology prenatally. 14 fetuses underwent early, 24 intermediate and 8 late VAS. In the early VAS subgroup, amnion infusion prior to VAS was significantly less often necessary (7%), shunt complications were significantly less common (29%) and immediate kidney replacement therapy postnatally became less often necessary (0%). In contrast, preterm delivery ≤ 32 + 0 weeks was more common (30%) and survival rate was lower (70%) after early VAS compared to intermediate or late VAS. Overall, 90% of liveborn babies had sufficient kidney function without need for kidney replacement therapy until last follow-up, and 95% had sufficient pulmonary function without need for mechanical respiratory support. 18% of babies with complex megacystis suffered from additional health restrictions due to their major concomitant malformations. CONCLUSIONS Our data suggest that VAS is feasible from the first trimester onward. Early intervention has the potential to preserve neonatal kidney function in the majority of cases and enables neonatal survival in up to 87% of cases. Despite successful fetal intervention, parents should be aware of the potential of mid- or long-term kidney failure and of additional health impairments due to concomitant extra-renal anomalies that cannot be excluded at time of intervention.
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Affiliation(s)
- I Gottschalk
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - C Berg
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - T Menzel
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - J S Abel
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - A Kribs
- Department of Neonatology, University Hospital of Cologne, Cologne, Germany
| | - M Dübbers
- Division of Pediatric Surgery, University Hospital of Cologne, Cologne, Germany
| | - J Kohaut
- Division of Pediatric Surgery, University Hospital of Cologne, Cologne, Germany
| | - L T Weber
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - C Taylan
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - S Habbig
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - M C Liebau
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - T M Boemers
- Department of Pediatric Surgery and Urology, Children´S Academic Hospital Amsterdamer Cologne, Cologne, Germany
| | - E C Weber
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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Hasegawa T, Takano S, Masuda K, Fujiwara Y, Miyahara A, Miura M. Retrospective Analysis of Neonatal Surgery at Tottori University over the Past Ten Years. Yonago Acta Med 2023; 66:413-421. [PMID: 38028267 PMCID: PMC10674064 DOI: 10.33160/yam.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023]
Abstract
Background In recent years, the number of neonatal surgeries has been on the rise despite the decline in the number of births, and we examined the actual trends and problems at Tottori University Hospital located in the Sanin region. Methods Medical records were retrospectively searched for patients who underwent major surgery during the neonatal period (within 30 days of age) at the Tottori University Hospital over the past 10 years (Jan. 2011 to Dec. 2020). Results Sixty-five cases were included. Early birth infants (< 37 gestational weeks) comprised 15 cases (23%) and low birth weight (< 2500 g) infants involved 27 cases (42%). In the latter half (2016-2020), early birth and low birth weight infants were significantly less than in the first half (2011-2015). The common diseases were anorectal malformation (14 cases), esophageal atresia (10), duodenal atresia (10), and diaphragmatic hernia (9). Prenatal diagnosis was obtained in 26 cases (40%), with high diagnostic rate obtained in duodenal atresia (100%), abdominal wall defect (100%), ileal atresia (75%), meconium peritonitis (67%), and diaphragmatic hernia (67%). Fifty-five cases (85%) were operated on within 7 days of age. Other major malformations were associated in 23 cases (35%). There were 6 deaths (9%), of which 3 cases were low birth weight infants with gastrointestinal perforation, 2 cases with severe chromosomal abnormalities (esophageal atresia, omphalocele), and 1 case with diaphragmatic hernia with severe pulmonary hypertension. Home medical care has been required with gastrostomy tube in 2 cases. Conclusion Neonatal surgery at Tottori University has been well performed as required with acceptable results along with the progression of other perinatal care. However, further investigation for improvements in premature delivery or organ hypoplasia may be required.
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Affiliation(s)
- Toshimichi Hasegawa
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Shuichi Takano
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Kohga Masuda
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Ayako Miyahara
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Mazumi Miura
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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Flores-Torres J, Sanchez-Valle A, Duncan JR, Panzarino V, Rodriguez JM, Kirby RS. Lower Urinary Tract Obstruction in Newborns. Adv Pediatr 2023; 70:131-144. [PMID: 37422291 DOI: 10.1016/j.yapd.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
Lower urinary tract obstruction (LUTO) is a rare birth defect with a prevalence between 1 in 5,000 and 1 in 25,000 pregnancies. LUTO is one of the most common causes of congenital abnormalities of the renal tract. Several genetic conditions have been associated with LUTO. Most common causes of LUTO are posterior urethral valves and urethral atresia. Despite available prenatal and postnatal treatments, LUTO is a significant cause of morbidity and mortality in newborns causing significant end stage renal disease and pulmonary hypoplasia.
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Affiliation(s)
- Jaime Flores-Torres
- Division of Neonatology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa General Hospital, 5 Tampa General Circle HMT 4th Floor, Suite 450, Tampa, FL 33606, USA.
| | - Amarilis Sanchez-Valle
- Division of Genetics and Metabolism, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa General Hospital, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Jose R Duncan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa General Hospital, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Valerie Panzarino
- Division of Pediatric Nephrology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa General Hospital, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Jessica Marie Rodriguez
- Division of Pediatric Nephrology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa General Hospital, Tampa, FL, USA; Johns Hopkins All Children's Hospital, St. Joseph's Hospital, 601 5th Street South, Suite 304,Street, Petersburg, FL 33701, USA
| | - Russell S Kirby
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B Downs Boulevard, MDC56, Tampa, FL 33612, USA
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Cassart M. Fetal uropathies: pre- and postnatal imaging, management and follow-up. Pediatr Radiol 2023; 53:610-620. [PMID: 35840694 DOI: 10.1007/s00247-022-05433-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/15/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
Abstract
Congenital uropathies are the most common fetal anomalies. They include a wide spectrum of anomalies ranging from mild pelvis dilation to complex urinary tract malformations. Prenatal imaging not only allows for their diagnosis but, in experienced hands, it can differentiate obstructive from refluxing or malformative uropathies. Such precise prenatal information allows for intervention before birth in select cases or for adapting the postnatal workup to provide a better long-term outcome. For the different types of congenital uropathies, we describe their prenatal presentations on US and the complementary role of fetal MRI where indicated. We correlate these findings with postnatal workup and summarize the updated neonatal diagnostic and clinical/surgical management.
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Affiliation(s)
- Marie Cassart
- Radiology Department, Iris South Hospitals, Site Elterbeek-Ixelles, 63 Rue Jean Paquot, 1050, Brussels, Belgium.
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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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Cardenas MC, Cheek-Norgan EH, Branda ME, Norgan AP, Schenone MH, Lemens MA, Chakraborty R, Ruano R, Enninga EAL. Fetal surgery is not associated with increased inflammatory placental pathology. Prenat Diagn 2023; 43:382-392. [PMID: 36688485 PMCID: PMC10132489 DOI: 10.1002/pd.6319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Fetal surgery has improved neonatal outcomes; however, it is unknown if the intervention contributes to the developmental of inflammatory pathologies in the placenta. Here, an association between fetal surgery and placental pathology was examined. METHOD This case-control study compared pregnancies with fetal surgery (n = 22), pregnancies with an indication for fetal surgery but without an intervention being done (n = 13), and gestational-age and fetus-number matched controls (n = 36). Data on maternal, infant, and placental outcomes were abstracted. Additionally, immunohistochemistry identified expression of lymphoid and myeloid cells in the placenta on a subset of cases. Comparisons were performed using Kruskal-Wallis or Pearson's chi-squared tests. RESULTS Maternal characteristics were comparable between groups. Most fetal interventions were for diaphragmatic hernia, spina bifida, or twin-to-twin transfusion syndrome. Fetuses who were operated on before birth were more likely to be born preterm (p = 0.02). There was no increase in the rate of observed placental pathologies or immune cell infiltration in fetal surgery cases compared to controls. CONCLUSION The data suggest that fetal surgery is not associated with increased inflammatory or morphologic pathology in the placenta. This observation supports the growing field of fetal surgery.
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Affiliation(s)
- Maria C. Cardenas
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Megan E. Branda
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Andrew P. Norgan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Rana Chakraborty
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, FL (present address)
| | - Elizabeth Ann L. Enninga
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
- Department of Immunology, Mayo Clinic, Rochester, MN
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Duci M, Pulvirenti R, Fascetti Leon F, Capolupo I, Veronese P, Gamba P, Tognon C. Anesthesia for fetal operative procedures: A systematic review. FRONTIERS IN PAIN RESEARCH 2022; 3:935427. [PMID: 36246050 PMCID: PMC9554945 DOI: 10.3389/fpain.2022.935427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.
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Affiliation(s)
- Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
- Correspondence: Francesco Fascetti Leon
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Veronese
- Maternal-fetal Medicine Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
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Wada S, Ozawa K, Sago H. New challenges of fetal therapy in Japan. J Obstet Gynaecol Res 2022; 48:2100-2111. [PMID: 35676616 PMCID: PMC9544758 DOI: 10.1111/jog.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
Aim To review new challenges of fetal therapy in Japan after the establishment of four existing fetal therapies as standard prenatal care with National Health Insurance coverage over the past 20 years. Methods Reported studies and our current research activities related to four fetal therapies newly performed in Japan were reviewed. Results Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) aims to occlude the trachea using a detachable balloon to promote lung growth. Following the recent successful completion of an international randomized controlled trial for CDH, in which we participated, FETO is offered for severe left CDH to perform balloon insertion at 27–29 weeks and removal at 34 weeks of gestation. Fetal cystoscopy (FC) for low urinary tract obstruction was introduced to overcome the demerits of vesicoamniotic shunting. FC may provide a proper diagnosis by visual observation of the urethra and physiological treatment of the posterior urethral valve. The effectiveness of open fetal surgery for myelomeningocele (MMC), direct surgery with laparotomy and hysterotomy, for ameliorating hindbrain herniation and the motor function was demonstrated, but it was also associated with substantial maternal and fetal risks. Fetal aortic valvuloplasty (FAV), ultrasound‐guided fetal aortic balloon dilation for critical aortic stenosis with evolving hypoplastic left heart syndrome may improve left heart development and maintain biventricular circulation. Feasibility and safety studies for FC, MMC open fetal surgery, and FAV are currently ongoing. Conclusions Clinical research on FETO, FC, MMC open fetal surgery, and FAV has proceeded with careful preparations in Japan.
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Affiliation(s)
- Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Slagle C, Schuh M, Grisotti G, Riddle S, Reddy P, Claes D, Lim FY, VanderBrink B. In utero renal failure. Semin Pediatr Surg 2022; 31:151195. [PMID: 35725056 DOI: 10.1016/j.sempedsurg.2022.151195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States.
| | - Meredith Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Gabriella Grisotti
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Stefanie Riddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States
| | - Pramod Reddy
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Donna Claes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Brian VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
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Lombel RM, Brakeman PR, Sack BS, Butani L. Urologic Considerations in Pediatric Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:308-317. [PMID: 36084977 DOI: 10.1053/j.ackd.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
Common causes of pediatric ESRD are distinct from those seen in the adult population. In the pediatric population, the most common are congenital anomalies of the kidney and urinary tract (CAKUT), affecting approximately 30% of children with CKD. These structural anomalies often require coordinated care with the pediatric urology team to address voiding issues, bladder involvement, and the potential need for surgical intervention. For pediatric nephrologists and urologists, common CAKUT that are encountered include antenatal hydronephrosis, obstructive uropathies (eg, posterior urethral valves), and vesicoureteral reflux. As more pediatric patients with CAKUT, CKD, and ESRD transition to adult care, it is important for receiving adult nephrologists to understand the clinical presentation, natural history, and prognosis for these diagnoses. This review outlines the diagnosis and potential interventions for these conditions, including strategies to address bladder dysfunction that is often seen in children with CAKUT. A discussion of these management decisions (including surgical intervention) for CAKUT, which are quite common to pediatric nephrology and urology practices, may provide unique learning opportunities for adult nephrologists who lack familiarity with these pediatric conditions.
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Affiliation(s)
- Rebecca M Lombel
- Division of Pediatric Nephrology, University of Michigan, Ann Arbor, MI.
| | - Paul R Brakeman
- Division of Pediatric Nephrology, University of California, San Francisco, San Francisco, CA
| | - Bryan S Sack
- Division of Pediatric Urology, University of Michigan, Ann Arbor, MI
| | - Lavjay Butani
- Division of Pediatric Nephrology, University of California Davis Medical Center, Sacramento, CA
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14
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Strizek B, Spicher T, Gottschalk I, Böckenhoff P, Simonini C, Berg C, Gembruch U, Geipel A. Vesicoamniotic Shunting before 17 + 0 Weeks in Fetuses with Lower Urinary Tract Obstruction (LUTO): Comparison of Somatex vs. Harrison Shunt Systems. J Clin Med 2022; 11:jcm11092359. [PMID: 35566484 PMCID: PMC9101314 DOI: 10.3390/jcm11092359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: The aim of this study was to compare perinatal outcomes and complication rates of vesicoamniotic shunting (VAS) before 17 + 0 weeks in isolated LUTO (lower urinary tract obstruction) with the Somatex® intrauterine shunt vs. the Harrison fetal bladder shunt. (2) Methods: This is a retrospective cohort study in two tertiary fetal medicine centers. From 2004−2014, the Harrison fetal bladder shunt was used, and from late 2014−2017, the Somatex shunt. Obstetrics and pediatric charts were reviewed for complications, course of pregnancy, perinatal outcome, and postnatal renal function. (3) Results: Twenty-four fetuses underwent VAS with a Harrison (H) shunt and 33 fetuses with a Somatex (S) shunt. Live birth rates and survival to last follow-up were significantly higher in the Somatex group, at 84.8% and 81.8%, respectively, vs. 50% and 33.3% in the Harrison group (p = 0.007 and p < 0.001). The dislocation rate in the Somatex group (36.4%) was significantly lower than in the Harrison group (87.5%) (p < 0.001). The median time to dislocation was significantly different, at 20.6 days (H) vs. 73.9 days (S) (p = 0.002), as was gestational age at dislocation (17 (H) vs. 25 (S) weeks, p < 0.001). Renal function was normal in early childhood in 51% (S) vs. 29% (H) (p = 0.11). (4) Conclusions: VAS before 17 + 0 weeks gestational age with a Somatex shunt improves perinatal survival significantly and might even have a positive effect on renal function, probably due to the lower dislocation rates. A normal amount of amniotic fluid in the third trimester was the best predictor of normal renal function in early childhood.
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Affiliation(s)
- Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
| | - Theresa Spicher
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
| | - Ingo Gottschalk
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, 50937 Cologne, Germany; (I.G.); (C.B.)
| | - Paul Böckenhoff
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
| | - Corinna Simonini
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
| | - Christoph Berg
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, 50937 Cologne, Germany; (I.G.); (C.B.)
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (B.S.); (T.S.); (P.B.); (C.S.); (U.G.)
- Correspondence: ; Tel.: +49-228-287-37116
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15
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Capone V, Persico N, Berrettini A, Decramer S, De Marco EA, De Palma D, Familiari A, Feitz W, Herthelius M, Kazlauskas V, Liebau M, Manzoni G, Maternik M, Mosiello G, Schanstra JP, Vande Walle J, Wühl E, Ylinen E, Zurowska A, Schaefer F, Montini G. Definition, diagnosis and management of fetal lower urinary tract obstruction: consensus of the ERKNet CAKUT-Obstructive Uropathy Work Group. Nat Rev Urol 2022; 19:295-303. [PMID: 35136187 DOI: 10.1038/s41585-022-00563-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022]
Abstract
Fetal lower urinary tract obstruction (LUTO) is associated with high mortality and postnatal morbidity caused by lung hypoplasia and impaired kidney function. Specific diagnostic features that can guide clinical approach and decisions are lacking; thus, the European Reference Network for Rare Kidney Diseases established a work group to develop recommendations regarding the clinical definition, diagnosis and management of prenatally detected LUTO. The work group recommends the use of antero-posterior diameter of renal pelvis as the most reliable parameter for suspecting obstructive uropathies and for suspecting prenatal LUTO in the presence of fetal megacystis. Regarding prenatal and postnatal prognosis of fetuses with LUTO, the risk of fetal and neonatal death depends on the presence of oligohydramnios or anhydramnios before 20 weeks' gestation, whereas the risk of kidney replacement therapy cannot be reliably foreseen before birth. Parents of fetuses with LUTO must be referred to a tertiary obstetric centre with multidisciplinary expertise in prenatal and postnatal management of obstructive uropathies, and vesico-amniotic shunt placement should be offered in selected instances, as it increases perinatal survival of fetuses with LUTO.
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Affiliation(s)
- Valentina Capone
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Nicola Persico
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alfredo Berrettini
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Stèphane Decramer
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France.,Service de Néphrologie Pédiatrique, Hôpital des Enfants, CHU Toulouse, Toulouse, France.,Centre De Référence des Maladies Rénales Rares du Sud-Ouest (SORARE), Toulouse, France
| | - Erika Adalgisa De Marco
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Diego De Palma
- Nuclear Medicine Unit, "Circolo" Hospital, ASST-settelaghi, Varese, Italy
| | - Alessandra Familiari
- High Risk Pregnancy Unit, Department of Women, Children and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Wout Feitz
- Department of Urology, Division of Paediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Maria Herthelius
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Vytis Kazlauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Max Liebau
- Department of Pediatrics and Center for Molecular Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gianantonio Manzoni
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Michal Maternik
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Giovanni Mosiello
- Bambino Gesù Pediatric Hospital, Division of Pediatric Urology/Neuro-Urology, Rome, Italy
| | - Joost Peter Schanstra
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France
| | - Johan Vande Walle
- Paediatric Nephrology and Rheumatology Section, Department of Paediatrics, Ghent University Hospital, Ghent, Belgium
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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16
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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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17
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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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Riddle S, Tabbah S, McKinney D, Kingma P. Complex Fetal Care Case: Amniotic Fluid Replacement in Severe Bladder Outlet Obstruction. Neoreviews 2021; 21:e425-e430. [PMID: 32482707 DOI: 10.1542/neo.21-6-e425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stefanie Riddle
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, and
| | - Sammy Tabbah
- Cincinnati Fetal Center, Cincinnati, OH.,Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David McKinney
- Cincinnati Fetal Center, Cincinnati, OH.,Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paul Kingma
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, and
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19
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Keefe DT, Kim JK, Mackay E, Chua M, Van Mieghem T, Yadav P, Lolas M, Santos JD, Skreta M, Erdman L, Weaver J, Fermin AS, Tasian G, Lorenzo AJ, Rickard M. Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta-analysis. Prenat Diagn 2021; 41:1039-1048. [PMID: 34318486 DOI: 10.1002/pd.6025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lower urinary tract obstruction (LUTO) is a rare but critical fetal diagnosis. Different ultrasound markers have been reported with varying sensitivity and specificity. AIMS The objective of this systematic review and meta-analysis was to identify the diagnostic accuracy of ultrasound markers for LUTO. MATERIALS AND METHODS We performed a systematic literature review of studies reporting on fetuses with hydronephrosis or a prenatally suspected and/or postnatally confirmed diagnosis of LUTO. Bayesian bivariate random effects meta-analytic models were fitted, and we calculated posterior means and 95% credible intervals for the pooled diagnostic odds ratio (DOR). RESULTS A total of 36,189 studies were identified; 636 studies were available for full text review and a total of 42 studies were included in the Bayesian meta-analysis. Among the ultrasound signs assessed, megacystis (DOR 49.15, [15.28, 177.44]), bilateral hydroureteronephrosis (DOR 41.33, [13.36,164.83]), bladder thickening (DOR 13.73, [1.23, 115.20]), bilateral hydronephrosis (DOR 8.36 [3.17, 21.91]), male sex (DOR 8.08 [3.05, 22.82]), oligo- or anhydramnios (DOR 7.75 [4.23, 14.46]), and urinoma (DOR 7.47 [1.14, 33.18]) were found to be predictive of LUTO (Table 1). The predictive sensitivities and specificities however are low and wide study heterogeneity existed. DISCUSSION Classically, LUTO is suspected in the presence of prenatally detected megacystis with a dilated posterior urethra (i.e., the keyhole sign), and bilateral hydroureteronephrosis. However, keyhole sign has been found to have modest diagnostic performance in predicting the presence of LUTO in the literature which we confirmed in our analysis. The surprisingly low specificity may be influenced by several factors, including the degree of obstruction, and the diligence of the sonographer at searching for and documenting it during the scan. As a result, providers should consider this when establishing the differential for a fetus with hydronephrosis as the presence or absence of keyhole sign does not reliably rule in or rule out LUTO. CONCLUSIONS Megacystis, bilateral hydroureteronephrosis and bladder wall thickening are the most accurate predictors of LUTO. Given the significant consequences of a missed LUTO diagnosis, clinicians providing counselling for prenatal hydronephrosis should maintain a low threshold for considering LUTO as part of the differential diagnosis.
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Affiliation(s)
- Daniel T Keefe
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jin Kyu Kim
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael Chua
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Priyank Yadav
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Marisol Lolas
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Marta Skreta
- Centre for Computational Medicine, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Lauren Erdman
- Centre for Computational Medicine, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - John Weaver
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Antoine Selman Fermin
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory Tasian
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
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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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21
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Narang K, Ibirogba ER, Sangi-Haghpeykar H, Ruano R. Obstetric outcomes after fetal intervention – a single-center descriptive review. J Matern Fetal Neonatal Med 2021; 35:7102-7108. [DOI: 10.1080/14767058.2021.1943658] [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]
Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eniola R. Ibirogba
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
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22
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Lin TY, Wataganara T, Shaw SW. From non-invasive to invasive fetal therapy: A comprehensive review and current update. Taiwan J Obstet Gynecol 2021; 60:595-601. [PMID: 34247794 DOI: 10.1016/j.tjog.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
"Fetus as patient" indicates fundamental concept of fetal therapy. With advance in maternal serum analysis and fetal imaging, prenatal screening has become standard of care. Accurate diagnosis in early gestation allows intervention to reverse pathophysiology and delay progression immediately. Non-invasive, minimally invasive and invasive therapies demonstrate their therapeutic potential in certain diseases. Recently, stem cell and gene therapies have been developed to avoid irreversible impairment. To elevate efficacy of treatment modality, extensive studies should be conducted according to regulatory authority. Striking a balance between scientific and ethical integrity is essential, so long-term follow up should be arranged for protecting mother and fetus.
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Affiliation(s)
- Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Steven W Shaw
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom.
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Sugibayashi R, Wada S, Ozawa K, Muromoto J, Oi R, Yamamoto R, Ishii K, Sago H. Prenatally diagnosed lower urinary tract obstruction: A 15-year experience at two tertiary centers in Japan. J Obstet Gynaecol Res 2021; 47:3091-3099. [PMID: 34155735 DOI: 10.1111/jog.14908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/22/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
AIM To examine the outcomes of prenatally diagnosed lower urinary tract obstruction (LUTO) with current management using vesicoamniotic shunting (VAS). METHODS A retrospective study of prenatally diagnosed LUTO before 26 weeks of gestation at two tertiary centers in Japan between March 2002 and September 2017. LUTO was diagnosed by ultrasound demonstration of an enlarged fetal bladder associated with hydronephrosis and/or hydroureters. VAS was offered for fetuses with LUTO at ≤26 weeks of gestational age, in the presence of oligohydramnios or decreasing amniotic fluid and a favorable fetal urinary analysis. RESULTS Among 87 fetuses with LUTO, 46 (53%) were terminated before 22 weeks of gestation. Eight cases (9%) underwent VAS and one underwent fetoscopic urethrotomy. The live birth rates in the VAS and expectant groups were 100% (8/8) and 56% (18/32), respectively (p = 0.034), and the survival rates at 6 months old with a normal renal function were 38% (3/8) and 16% (5/32), respectively (p = 0.608). The etiology varied with six cases of associated anomalies among 23 diagnosed cases. Among the nine cases of posterior urethral valve (PUV), only one fetus underwent VAS at 25 weeks of gestation, ultimately surviving with mild renal dysfunction. Among the other eight cases of PUV that were managed expectantly, two died, and only one of the six survivors showed a normal renal function. CONCLUSIONS More than half of the prenatally diagnosed LUTO cases were terminated. VAS seemed effective for achieving a perinatal survival, regardless of etiology. The outcomes were poor in cases of expectantly managed PUV.
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Affiliation(s)
- Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Oi
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Posterior urethral valves (PUVs): prenatal ultrasound diagnosis and management difficulties: a review of three cases. CASE REPORTS IN PERINATAL MEDICINE 2021. [DOI: 10.1515/crpm-2020-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Lower urinary tract obstruction (LUTO) has different etiologies. The most common form is posterior urethral valve (PUVs). It is a condition that can lead to end stage renal disease (ESRD) in later life and severe renal and pulmonary damage in utero. Those born alive may end up with residual kidney disease leading to life long morbidity or death. This condition can be diagnosed through prenatal ultrasound but because diagnosis is done late when kidney injury has already happened it does not guarantee healthy survival after birth. There are various treatments in utero and after birth but they all have their complications. In developing countries diagnosis is possible but in most cases pregnant women with fetuses with PUVs present very late in pregnancy. In utero interventions are in most cases not possible and the only way out is expectant management with serial ultrasound assessment until the fetus has achieved level of maturity at which time it is delivered and further postnatal evaluations and treatment given. This series is aimed at highlighting the prenatal ultrasound features of PUVs and the management challenges faced by physicians in developing countries.
Case presentation
The three cases were managed in three different hospitals. All the cases presented at different gestational ages and different levels of fetal affectation. Because of these, outcomes of management and prognosis of each case differ.
Conclusions
Fetal PUVs pose specific challenges in management because of late presentation and lack of resource for intervention even where cases present early with minimal renal damage.
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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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26
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Advances and Trends in Pediatric Minimally Invasive Surgery. J Clin Med 2020; 9:jcm9123999. [PMID: 33321836 PMCID: PMC7764454 DOI: 10.3390/jcm9123999] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.
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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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28
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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Narang K, Elrefaei A, Wyatt MA, Warner LL, Abrao Trad AT, Segura LG, Bendel-Stenzel E, Ahn ES, Arendt KW, Qureshi MY, Ruano R. Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review. Mayo Clin Proc Innov Qual Outcomes 2020; 4:717-724. [PMID: 32839753 PMCID: PMC7437475 DOI: 10.1016/j.mayocpiqo.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To cope with the changing health care services in the era of SARS-CoV-2 pandemic. We share the institutional framework for the management of anomalous fetuses requiring fetal intervention at Mayo Clinic, Rochester, Minnesota. To assess the success of our program during this time, we compare intraoperative outcomes of fetal interventions performed during the pandemic with the previous year. Patients We implemented our testing protocol on patients undergoing fetal intervention at our institution between March 1, and May 15, 2020, and we compared it with same period a year before. A total of 17 pregnant patients with anomalous fetuses who met criteria for fetal intervention were included: 8 from 2019 and 9 from 2020. Methods Our testing protocol was designed based on our institutional perinatal guidelines, surgical requirements from the infection prevention and control (IPAC) committee, and input from our fetal surgery team, with focus on urgency of procedure and maternal SARS-CoV-2 screening status. We compared the indications, types of procedures, maternal age, gestational age at procedure, type of anesthesia used, and duration of procedure for cases performed at our institution between March 1, 2020, and May 15, 2020, and for the same period in 2019. Results There were no statistically significant differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures (P values were all >.05) between the pre–SARS-CoV-2 pandemic in 2019 and the SARS-CoV-2 pandemic in 2020. Conclusions Adoption of new institutional protocols during SARS-CoV-2 pandemic, with appropriate screening and case selection, allows provision of necessary fetal intervention with maximal benefit to mother, fetus, and health care provider.
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Key Words
- ACOG, American College of Obstetrics and Gynecology
- AFPS, American Foundation for Patient Safety
- AGP, aerosol-generating procedures
- ASA, American Society of Anesthesiology
- CDH, congenital diaphragmatic hernia
- COVID-19, coronavirus-2019
- FETO, fetoscopic endoluminal tracheal occlusion
- GA, general anesthesia
- IFMSS, International Fetal Medicine and Surgery Society
- LUTO, lower urinary tract obstruction
- MAC, monitored anesthesia care
- NAFTNet, North American Fetal Therapy Network
- SMFM, Society for Maternal and Fetal Medicine
- TAPS, twin anemia polycythemia sequence
- TTTS, twin-to-twin transfusion syndrome
- WHO, World Health Organization
- qRT-PCR, quantitative real time polymerase chain reaction
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Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Amro Elrefaei
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Michelle A Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lindsay L Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ayssa Teles Abrao Trad
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Edward S Ahn
- Division of Neurosurgery, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Katherine W Arendt
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - M Yasir Qureshi
- Pediatric Cardiology Division, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
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30
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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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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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32
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Current State of Fetal Intervention for Obstructive Uropathy–Focus on Bladder. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00600-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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33
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Katsoufis CP. Clinical predictors of chronic kidney disease in congenital lower urinary tract obstruction. Pediatr Nephrol 2020; 35:1193-1201. [PMID: 31197474 DOI: 10.1007/s00467-019-04280-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/07/2019] [Accepted: 05/23/2019] [Indexed: 12/28/2022]
Abstract
Congenital lower urinary tract obstruction is associated with oligohydramnios and significant perinatal mortality and long-term chronic kidney disease. The counseling of families facing this diagnosis, especially when prenatal intervention is proposed, is fraught with ambiguity. This review aims to equip the provider with the current evidence behind the conventional and novel biomarkers predictive of chronic kidney disease. The relevant clinical predictors are categorized by when they are identified, antenatally or postnatally, and as either anatomic or chemical. They are considered for their prognostic value and the challenges in obtaining them, specifically the risk to the fetus in the case of prenatal biomarkers. Serum creatinine in infancy is the traditional chemical biomarker of kidney function and continues to be a consistent predictor of future serum creatinine. β-2 microglobulin may provide earlier information regarding fetal glomerular and tubular function and is also predictive of long-term serum creatinine. Renal parenchymal area is an anatomic surrogate of nephron mass that is used in both prenatal and postnatal settings. Understanding the anatomic and chemical biomarkers is essential for future refinement of the staging algorithm used to distinguish which patients may benefit from early in utero intervention.
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Affiliation(s)
- Chryso Pefkaros Katsoufis
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, P.O. Box 016960 (M-714), Miami, FL, 33101, USA.
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34
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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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35
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Strizek B, Gottschalk I, Recker F, Weber E, Flöck A, Gembruch U, Geipel A, Berg C. Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex ® intrauterine shunt. Arch Gynecol Obstet 2020; 302:133-140. [PMID: 32449061 PMCID: PMC7266802 DOI: 10.1007/s00404-020-05598-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/08/2020] [Indexed: 11/30/2022]
Abstract
Purpose The objective was to evaluate the feasibility of vesicoamniotic shunting (VAS) in the first trimester with the Somatex® intrauterine shunt and report on complications and neonatal outcome. Methods Retrospective cohort study of all VAS before 14 weeks at two tertiary fetal medicine centres from 2015 to 2018 using a Somatex® intrauterine shunt. All patients with a first trimester diagnosis of megacystis in male fetuses with a longitudinal bladder diameter of at least 15 mm were offered VAS. All patients that opted for VAS after counselling by prenatal medicine specialists, neonatologists and pediatric nephrologists were included in the study. Charts were reviewed for complications, obstetric and neonatal outcomes. Results Ten VAS were performed during the study period in male fetuses at a median GA of 13.3 (12.6–13.9) weeks. There were two terminations of pregnancy (TOP) due to additional malformations and one IUFD. Overall there were four shunt dislocations (40%); three of those between 25–30 weeks GA. Seven neonates were born alive at a median GA of 35.1 weeks (31.0–38.9). There was one neonatal death due to pulmonary hypoplasia. Neonatal kidney function was normal in the six neonates surviving the neonatal period. After exclusion of TOP, perinatal survival was 75%, and 85.7% if only live-born children were considered. Conclusion VAS in the first trimester is feasible with the Somatex® Intrauterine shunt with low fetal and maternal complication rates. Neonatal survival rates are high due to a reduction in pulmonary hypoplasia and the rate of renal failure at birth is very low. VAS can be safely offered from the late first trimester using the Somatex® intrauterine shunt.
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Affiliation(s)
- B Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - I Gottschalk
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, Cologne, Germany
| | - F Recker
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - E Weber
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - A Flöck
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - U Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - A Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - C Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, Cologne, Germany
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36
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Warner LL, Arendt KW, Ruano R, Qureshi MY, Segura LG. A call for innovation in fetal monitoring during fetal surgery. J Matern Fetal Neonatal Med 2020; 35:1817-1823. [DOI: 10.1080/14767058.2020.1767575] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lindsay L. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Katherine W. Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M. Yasir Qureshi
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Leal G. Segura
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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37
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Ibirogba ER, Haeri S, Ruano R. Fetal lower urinary tract obstruction: What should we tell the prospective parents? Prenat Diagn 2020; 40:661-668. [PMID: 32065667 DOI: 10.1002/pd.5669] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/28/2020] [Accepted: 02/12/2020] [Indexed: 11/07/2022]
Abstract
Fetal lower urinary tract obstruction (LUTO), which often results in marked perinatal morbidity and mortality, is caused by a heterogeneous group of anatomical defects that lead to blockage of the urethra. The classic prenatal presentation of LUTO includes megacystis with hydronephrosis. While mild forms of the disease can be associated with favorable outcomes, more severe disease commonly leads to dysplastic changes in the fetal kidneys, and ultimately oligohydramnios, which can result in secondary pulmonary hypoplasia and renal failure at birth. The aim of this review is to provide practitioners with a general overview of the diagnosis and treatment of LUTO based on disease severity, along with some points to consider when counseling prospective parents of fetuses with this condition.
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Affiliation(s)
- Eniola Raheem Ibirogba
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sina Haeri
- St. David's Women's Center of Texas, Austin Maternal-Fetal Medicine, Austin, Texas
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
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38
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Beksac MS, Beksac AT, Tanacan A, Mumusoglu S, Katlan D, Celik HT. Antenatal hydronephrosis and fetal urine sampling. Congenit Anom (Kyoto) 2020; 60:4-9. [PMID: 30629771 DOI: 10.1111/cga.12324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/30/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
The aim of this study is to evaluate the significance of renal pelvis aspiration (RPA) in the management of antenatal hydronephrosis (AHN). This study enrolled 15 AHN cases (one twin pregnancy) that necessitated RPA for AHN. Chromosomal abnormalities, gene disorders, and additional life-threatening congenital abnormalities were eliminated prior to intrauterine interventions. Urine analysis were performed for the evaluation of renal function. Normal renal function was observed in six neonates/infants (40%) (group 1), whereas impaired renal function and various type of urinary system anomalies were observed in 9 neonates/infants (60%) (group 2) during the short-term and longitudinal follow-up periods. There were statistically significant differences in the oligohydroamniosis rate, mean fetal urine sodium value, mean fetal urine β2-microglobulin, mean gestational week at birth, and mean birthweight values between the groups (P = 0.007, P < 0.001, P = 0.035, P < 0.001, and P = 0.001, respectively). Renal pelvis aspiration and urine analysis were substantial for the management of AHN in necessary cases. β2-microglobulin and sodium are clinically useful markers to detect the presence of severe renal damage due to obstructive uropathy and thus, important adjuvants in the proper selection of fetuses for further antenatal interventions.
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Affiliation(s)
- Mehmet Sinan Beksac
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara, Turkey
| | | | - Atakan Tanacan
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Sezcan Mumusoglu
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Doruk Katlan
- Department of Obstetrics and Gynecology, Süleymaniye Research and Training Hospital, Istanbul, Turkey
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Perlman S, Borovitz Y, Ben-Meir D, Hazan Y, Nagar R, Bardin R, Brusilov M, Dekel B, Achiron R, Gilboa Y. Prenatal diagnosis and postnatal outcome of anterior urethral anomalies. Prenat Diagn 2019; 40:191-196. [PMID: 31654578 DOI: 10.1002/pd.5582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/24/2019] [Accepted: 09/15/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Anterior urethral anomalies (AUA) which present as anterior urethral valve, stenosis or atresia, are a rare cause for congenital urinary tract obstruction. We present our AUA prenatal diagnosis case series. METHODS Fetuses presenting with prenatal findings suggestive for AUA according to postnatal reported clinical and imaging signs (urinary tract dilatation, dilated bladder, enlarged edematous fetal penis, dilatation of the fetal urethra and diverticula) were followed prospectively. RESULTS Six fetuses were diagnosed with AUA. Diagnosis was confirmed upon examination of the neonate or the abortus. All cases presented with variable degrees of urinary tract dilatation. Four fetuses who presented with additional congenital anomalies of the kidneys and urinary tract (CAKUT) developed intra-uterine or early postnatal renal failure, while two isolated AUA cases have a normal renal outcome. CONCLUSIONS AUA is a rare diagnosis. However, high index of suspicion and careful sonographic assessment of the male fetal urethra in cases referred for urinary tract dilatation may enable appropriate parent counseling, optimal prenatal surveillance and timed postnatal urological intervention. As in other lower urinary tract obstructions, future renal function seems to correlate with associated CAKUT, therefore close follow up throughout pregnancy and meticulous sonographic assessment is recommended.
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Affiliation(s)
- Sharon Perlman
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Borovitz
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Schneider Children's Medical Center, Nephrology Institute, Petach Tikva, Israel
| | - David Ben-Meir
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Urology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Yenon Hazan
- Ultrasound Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel.,Hadassah and the Hebrew University Medical School, Jerusalem, Israel
| | - Ran Nagar
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ron Bardin
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Michael Brusilov
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Ultrasound Unit, Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Benjamin Dekel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Division of Pediatric Nephrology, Edmond and Lily Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Pediatric Stem Cell Research Institute, Edmond and Lily Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Reuven Achiron
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yinon Gilboa
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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40
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Duin LK, Fontanella F, Groen H, Adama van Scheltema PN, Cohen-Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Oepkes D, Bilardo CM. Prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO)-Development and internal validation. Prenat Diagn 2019; 39:1235-1241. [PMID: 31659787 DOI: 10.1002/pd.5573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop a prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO) based on fetal ultrasound parameters and amniotic fluid volume. METHODS Retrospective nationwide cohort study of fetuses with postnatally confirmed LUTO and known eGFR. Fetuses treated with fetal interventions such as vesico-amniotic shunting or cystoscopy were excluded. Logistic regression analysis was used to identify prognostic ultrasound variables with respect to renal outcome following multiple imputation of missing data. On the basis of these fetal renal parameters and amniotic fluid volume, a model was developed to predict postnatal renal function in fetuses with LUTO. The main study outcome was an eGFR less than 60 mL/min * 1.73 m2 based on the creatinine nadir during the first year following diagnosis. Model performance was evaluated by receiver operator characteristic (ROC) curve analysis, calibration plots, and bootstrapping. RESULTS Hundred one fetuses with a confirmed diagnosis of LUTO were included, eGFR less than 60 was observed in 40 (39.6%) of them. Variables predicting an eGFR less than 60 mL/min * 1.73m2 included the following sonographic parameters: hyperechogenicity of the renal cortex and abnormal amniotic fluid volume. The model showed fair discrimination, with an area under the ROC curve of 0.70 (95% confidence interval, 0.59-0.81, 0.66 after bootstrapping) and was overall well-calibrated. CONCLUSION This study shows that a prediction model incorporating ultrasound parameters such as cortical appearance and abnormal amniotic fluid volume can fairly discriminate an eGFR above or below 60 mL/min * 1.73m2 . This clinical information can be used in identifying fetuses eligible for prenatal interventions and improve counseling of parents.
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Affiliation(s)
- Leonie K Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Federica Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Phebe N Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Pajkrt
- Department of Obstetrics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Mireille Bekker
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christine Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Caterina M Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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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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42
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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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43
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Rocha NP, Bastos FM, Vieira ÉL, Prestes TR, Silveira KDD, Teixeira MM, Simões e Silva AC. The protective arm of the renin‐angiotensin system may counteract the intense inflammatory process in fetuses with posterior urethral valves. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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44
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Rocha NP, Bastos FM, Vieira ÉLM, Prestes TRR, Silveira KDD, Teixeira MM, Simões E Silva AC. The protective arm of the renin-angiotensin system may counteract the intense inflammatory process in fetuses with posterior urethral valves. J Pediatr (Rio J) 2019. [PMID: 29534877 DOI: 10.1016/j.jped.2018.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Posterior urethral valve is the most common lower urinary tract obstruction in male children. A high percentage of patients with posterior urethral valve evolve to end-stage renal disease. Previous studies showed that cytokines, chemokines, and components of the renin-angiotensin system contribute to the renal damage in obstructive uropathies. The authors recently found that urine samples from fetuses with posterior urethral valve have increased levels of inflammatory molecules. The aim of this study was to measure renin-angiotensin system molecules and to investigate their correlation with previously detected inflammatory markers in the same urine samples of fetuses with posterior urethral valve. METHODS Urine samples from 24 fetuses with posterior urethral valve were collected and compared to those from 22 healthy male newborns at the same gestational age (controls). Renin-angiotensin system components levels were measured by enzyme-linked immunosorbent assay. RESULTS Fetuses with posterior urethral valve presented increased urinary levels of angiotensin (Ang) I, Ang-(1-7) and angiotensin-converting enzyme 2 in comparison with controls. ACE levels were significantly reduced and Ang II levels were similar in fetuses with posterior urethral valve in comparison with controls. CONCLUSIONS Increased urinary levels of angiotensin-converting enzyme 2 and of Ang-(1-7) in fetuses with posterior urethral valve could represent a regulatory response to the intense inflammatory process triggered by posterior urethral valve.
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Affiliation(s)
- Natalia P Rocha
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil
| | - Fernando M Bastos
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Serviço de Medicina Fetal, Belo Horizonte, MG, Brazil
| | - Érica L M Vieira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil
| | - Thiago R R Prestes
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil
| | - Katia D da Silveira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil
| | - Mauro M Teixeira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais (UFMG), Instituto de Ciências Biológicas, Departamento de Bioquímica e Imunologia, Laboratório de Imunofarmacologia, Belo Horizonte, MG, Brazil
| | - Ana Cristina Simões E Silva
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica (LIIM), Belo Horizonte, MG, Brazil.
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45
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Fontanella F, van Scheltema PNA, Duin L, Cohen-Overbeek TE, Pajkrt E, Bekker MN, Willekes C, Oepkes D, Bilardo CM. Antenatal staging of congenital lower urinary tract obstruction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:520-524. [PMID: 29978555 DOI: 10.1002/uog.19172] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Fontanella
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - L Duin
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T E Cohen-Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M N Bekker
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Willekes
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C M Bilardo
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands
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46
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Abstract
Fetal surgery is an established but still rapidly evolving specialty, born from the rationale that destructive embryologic processes, recognized early in gestation, can be curtailed by prenatal correction. As more and more centers begin offering fetal interventions, quality of care must be verified through transparency about clinical capabilities and resources. Level designations should be assigned based on capability, as in trauma and neonatal ICU centers for excellence, and volume requirements must be set for fetal surgery certification. Regionalization of this specialty care may be required to optimize outcomes.
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Affiliation(s)
- Heron D Baumgarten
- Department of Surgery, Abramson Research Center, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA
| | - Alan W Flake
- Department of Surgery, Abramson Research Center, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA.
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47
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Gueneuc A, Chalouhi GE, Borali D, Mediouni I, Stirnemann J, Ville Y. Fetoscopic Release of Amniotic Bands Causing Limb Constriction: Case Series and Review of the Literature. Fetal Diagn Ther 2019; 46:246-256. [PMID: 30726851 DOI: 10.1159/000495505] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/14/2018] [Indexed: 11/19/2022]
Abstract
The aim of this study was to review the perioperative complication rates and neonatal outcomes after fetoscopic release of amniotic bands that caused bilateral limb constrictions. We present 5 cases of limb constriction by amniotic bands occurring spontaneously or following fetoscopic surgery and also include a review of 21 previously published cases. The cases were analyzed for indication, surgical technique, and postoperative follow-up. In our population and the literature, the majority of the children acquired a functional limb (75%), with few perioperative complications (15%). Fetal morbidity was mainly linked to the consequences of preterm premature rupture of the membranes (38.4%) and preterm birth (34.7 GW). The mortality rate was low (7.7%). This review only describes amniotic bands causing limb constriction, and illustrates that fetoscopic surgery for their release is technically feasible with an acceptable perioperative complication rate. However, the 75% success rate is very likely to be an overestimation of the true success rate. In view of these observations we cannot recommend treatment for cases where the fetus has been extensively affected by the bands. We believe, however, that we could consider this technique for a fraction of amniotic band syndrome cases isolated to the limb constrictions. This kind of surgery should be proposed as a potential treatment for amniotic band syndrome.
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Affiliation(s)
- Alexandra Gueneuc
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, APHP, Paris, France
| | - Gihad E Chalouhi
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France, .,National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, APHP, Paris, France, .,Faculty of Medicine, Saint Joseph University, Beirut, Lebanon,
| | - Denisa Borali
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Imen Mediouni
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, APHP, Paris, France
| | - Julien Stirnemann
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, APHP, Paris, France
| | - Yves Ville
- Fetal Medicine Unit, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Université Paris Descartes, APHP, Paris, France
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Cheung KW, Morris RK, Kilby MD. Congenital urinary tract obstruction. Best Pract Res Clin Obstet Gynaecol 2019; 58:78-92. [PMID: 30819578 DOI: 10.1016/j.bpobgyn.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/01/2019] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
Congenital bladder neck obstruction (or lower urinary tract obstruction [LUTO]) describes a heterogeneous group of congenital anomalies presenting with similar prenatal ultrasonographic findings of dilated posterior urethra, megacystis, hydronephrosis, oligohydramnios and often with associated renal dysplasia. Untreated LUTO has high rate of perinatal morbidity and mortality from associated pulmonary hypoplasia and early-onset renal failure in infancy. Ultrasonographic features and prospective fetal urinalysis may help in predicting the overall prognosis of congenital LUTO. Currently, fetal vesicoamniotic shunt (of various designs), and fetal cystoscopy and fulguration of the obstruction are potential prenatal interventions. Retrospective and prospective cohort studies and a relatively small randomized controlled trial have demonstrated these treatments may possibly improve perinatal survival. Despite this, concerns remain as to the high rates of renal impairment observed in paediatric survivors. A clinical prospective scoring/staging system may improve prenatal diagnostic criteria and case selection for fetal therapy.
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Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China; The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.
| | - Rachel Katie Morris
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Mark David Kilby
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
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49
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Saccone G, D'Alessandro P, Escolino M, Esposito R, Arduino B, Vitagliano A, Quist-Nelson J, Berghella V, Esposito C, Zullo F. Antenatal intervention for congenital fetal lower urinary tract obstruction (LUTO): a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019; 33:2664-2670. [PMID: 30501534 DOI: 10.1080/14767058.2018.1555704] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: To evaluate the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction (LUTO) in improving perinatal survival and postnatal renal function.Methods: Electronic databases were searched from their inception until May 2018. Selection criteria included randomized controlled trials and nonrandomized studies including fetuses with ultrasound evidence of LUTO evaluating antenatal intervention for improving perinatal outcomes. Any type of antenatal bladder drainage technique was analyzed. The primary outcome was perinatal survival. The secondary outcome was postnatal survival with normal renal function. The summary measures were reported as summary odds ratio (OR) with 95% of confidence interval (CI).Results: Ten articles with a total of 355 fetuses were included in the meta-analysis. Inclusion criteria of the selected studies were singleton pregnancy with severe LUTO confirmed on detailed fetal ultrasound examination. Nine studies analyzed the efficacy of vesico-amniotic shunt performed in the second trimester. The overall estimate survival was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.54, 95% CI: 1.14-5.67). 64/112 fetuses (57.1%) survived in the vesico-amniotic shunt group compared to 52/134 (38.8%) in the control group. Five studies reported on postnatal renal function between 6 months and 2 years. Rate of good postnatal renal function was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.09, 95% CI: 0.74-5.9). Fetal cystoscopy was performed in only two included studies. Overall, 45 fetuses underwent fetal cystoscopy. The perinatal survival was higher in the cystoscopy group compared to the conservative management group (OR: 2.63, 95% CI: 1.07-6.47). Normal renal function was noted in 13/34 fetuses in the cystoscopy group versus 12/61 in the conservative management group at 6 months follow-up (OR: 1.75, 95% CI: 1.05-2.92)Conclusions: Antenatal bladder drainage appears to improve perinatal survival in cases of LUTO.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Pietro D'Alessandro
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Maria Escolino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Rosanna Esposito
- Department of Tanslational Medical Sciences (DISMET), Pediatric Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Bruno Arduino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Amerigo Vitagliano
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Ciro Esposito
- Department of Tanslational Medical Sciences (DISMET), Pediatric Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
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50
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Bañuelos Marco B, González R, Ludwikowski B, Lingnau A. Effectiveness of Prenatal Intervention on the Outcome of Diseases That Have a Postnatal Urological Impact. Front Pediatr 2019; 7:118. [PMID: 31001504 PMCID: PMC6454137 DOI: 10.3389/fped.2019.00118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/11/2019] [Indexed: 01/04/2023] Open
Abstract
We reviewed the literature addressing outcomes of fetal intervention of conditions that require post-natal urological management including lower urinary tract obstruction, hydrometrocolpos, congenital adrenal hyperplasia, and myelomeningocele. Despite several decades of fetal intervention for these conditions, benefits remain elusive in part because of the enormous difficulty of conducting prospective randomized studies. In this review, we reached the following conclusions: Prenatal intervention in lower urinary tract obstruction (LUTO) improves survival in the worst cases by improving pulmonary function and it may be advantageous for renal function, particularly in patients with adverse urine parameters.Prenatal treatment of female fetuses at risk of having congenital adrenal hyperplasia (CAH) reduces virilization. Non-invasive fetal DNA analysis allows earlier diagnosis, reducing the risk of treating with dexamethasone males and non-affected fetuses.Fetal treatment of myelomeningocele (MMC) is gaining momentum. Prospective studies including standardized urologic evaluation will determine if the encouraging results reported by some hold on the long term follow-up.
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Affiliation(s)
| | - Ricardo González
- Department of Urology, Charité Medical University of Berlin, Berlin, Germany.,Pediatric Surgery and Urology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Barbara Ludwikowski
- Pediatric Surgery and Urology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - Anja Lingnau
- Department of Urology, Charité Medical University of Berlin, Berlin, Germany
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