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Gazeu A, Collardeau-Frachon S. Practical Approach to Congenital Anomalies of the Kidneys: Focus on Anomalies With Insufficient or Abnormal Nephron Development: Renal Dysplasia, Renal Hypoplasia, and Renal Tubular Dysgenesis. Pediatr Dev Pathol 2024:10935266241239241. [PMID: 39270126 DOI: 10.1177/10935266241239241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
Congenital anomalies of the kidney and urinary tract (CAKUT) accounts for up to 30% of antenatal congenital anomalies and is the main cause of kidney failure in children worldwide. This review focuses on practical approaches to CAKUT, particularly those with insufficient or abnormal nephron development, such as renal dysplasia, renal hypoplasia, and renal tubular dysgenesis. The review provides insights into the histological features, pathogenesis, mechanisms, etiologies, antenatal and postnatal presentation, management, and prognosis of these anomalies. Differential diagnoses are discussed as several syndromes may include CAKUT as a phenotypic component and renal dysplasia may occur in some ciliopathies, tumor predisposition syndromes, and inborn errors of metabolism. Diagnosis and genetic counseling for CAKUT are challenging, due to the extensive variability in presentation, genetic and phenotypic heterogeneity, and difficulties to assess postnatal lung and renal function on prenatal imaging. The review highlights the importance of perinatal autopsy and pathological findings in surgical specimens to establish the diagnosis and prognosis of CAKUT. The indications and the type of genetic testing are discussed. The aim is to provide essential insights into the practical approaches, diagnostic processes, and genetic considerations offering valuable guidance for pediatric and perinatal pathologists.
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Affiliation(s)
- Alexia Gazeu
- Department of pathology, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, University Hospital of Lyon, Lyon Bron, France
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
| | - Sophie Collardeau-Frachon
- Department of pathology, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, University Hospital of Lyon, Lyon Bron, France
- Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
- Société française de Fœtopathologie, Soffoet, Paris, France
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2
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Heling KS, Chaoui R. Ultrasound Diagnosis of Malformations of the Fetal Kidneys and Urinary System. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:232-268. [PMID: 37769695 DOI: 10.1055/a-2132-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Malformations of the fetal kidneys and urinary system are common and easily visualized and diagnosed on ultrasound. This article presents the typical sonographic findings of these abnormalities during the various stages of pregnancy. Because malformations of the urogenital tract often have an association with genetic diseases/ciliopathies, these are also discussed. To complete the article, we provide a brief overview of the normal anatomy of the kidneys and urinary system. The normal anatomy and malformations of the genitalia will not be discussed in this article due to their complexity.
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Affiliation(s)
- Kai-Sven Heling
- Center for Prenatal Diagnostics, Friedrichstraße, Berlin, Germany
| | - Rabih Chaoui
- Center for Prenatal Diagnostics, Friedrichstraße, Berlin, Germany
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3
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Blumenfeld YJ, Sheth KR, Johnson E, Wall JK, Deprest JA, Russo FM, Danzer E. Development and validation of a novel fetal vesico-amniotic shunt, the vortex shunt. Prenat Diagn 2024; 44:158-166. [PMID: 38009470 DOI: 10.1002/pd.6470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
Fetal lower urinary tract obstruction (LUTO) is a severe malformation associated with an up to 80% mortality risk as well as significant renal and pulmonary morbidity in survivors. Fetal vesico-amniotic shunts (VAS) bypass the bladder obstruction, improve amniotic fluid volume and enhance in-utero pulmonary development. VAS has been shown to reduce respiratory morbidity and mortality in the neonatal period without proven benefit on long-term renal and bladder function. Clinically available shunts are associated with an up to 80% dislodgement rate, leading to repeat invasive procedures which increase fetal and maternal risks. We developed a novel "Vortex" shunt, which incorporates enhanced fixation to reduce dislodgement, a one-way valve to optimize in-utero bladder function, and enhanced sonographic echogenicity that optimizes the accurate deployment. Following the validation of these characteristics in initial benchtop experiments we have moved to feasibility studies in the fetal lamb model. We hope that the Vortex shunt may ultimately facilitate shunt deployment, reduce dislodgement risk, improve neonatal morbidity and mortality, and decrease the significant healthcare expenditures associated with long-term morbidity in LUTO survivors. In this manuscript, we review the natural history of LUTO, the risks and benefits of clinically available fetal shunts, and our development and early validation experiments.
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Affiliation(s)
- Yair J Blumenfeld
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Kunj R Sheth
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Johnson
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - James K Wall
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jan A Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Francesca M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Enrico Danzer
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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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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Griffith AM, Woodward PJ, Kennedy AM. Troubleshooting Tips for Diagnosing Complex Fetal Genitourinary Malformations. Radiographics 2024; 44:e230084. [PMID: 38127660 DOI: 10.1148/rg.230084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Fetal genitourinary anomalies can present a diagnostic challenge for the radiologist. The absence of a normally located kidney may represent agenesis or be secondary to a fusion or migration abnormality. A dilated renal pelvis should prompt evaluation for a specific cause, including ureteropelvic junction obstruction, reflux, or an obstructed duplicated system. Cystic parenchymal changes are characteristic of a multicystic dysplastic kidney but may also be seen in obstructive cystic dysplasia. There are numerous causes of megacystis including chromosomal (trisomy 18 syndrome), obstruction (posterior urethral valves, urethral atresia), or muscular dysfunction (prune belly syndrome, megacystis microcolon intestinal hypoperistalsis syndrome). Important mimics of a large bladder include hydrocolpos and urogenital sinus or cloacal malformation. Complications of genitourinary malformations are common and include oligohydramnios, urinary ascites, and urinoma. Making an accurate diagnosis often requires additional US views beyond those obtained in the standard fetal survey and occasionally performing fetal MRI. The appropriate use of orthogonal T2-weighted sequences, in conjunction with diffusion-weighted images for evaluation of the kidneys and gradient-recalled-echo sequences for evaluation of T1-hyperintense meconium in the colon, can play an integral role in diagnosis. Accurate diagnosis of fetal genitourinary malformations is vital to direct patient counseling and pregnancy management as outcomes are highly variable. Some conditions can be surgically corrected quite simply, some require multiple complex procedures, and some are lethal. The authors offer troubleshooting tips to narrow the differential diagnosis for four observations: unilateral absent kidney, dilated renal pelvis, cystic renal parenchyma, and megacystis and its mimics. ©RSNA, 2023 Test Your Knowledge questions are available in the Online Learning Center.
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Affiliation(s)
- April M Griffith
- From the Department of Radiology and Imaging Sciences, University of Utah Health, 30 N Mario Capecchi Dr, 2nd Floor South, Salt Lake City, UT 84112
| | - Paula J Woodward
- From the Department of Radiology and Imaging Sciences, University of Utah Health, 30 N Mario Capecchi Dr, 2nd Floor South, Salt Lake City, UT 84112
| | - Anne M Kennedy
- From the Department of Radiology and Imaging Sciences, University of Utah Health, 30 N Mario Capecchi Dr, 2nd Floor South, Salt Lake City, UT 84112
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Sourouni M, Haisch L, Oelmeier K, Möllers M, Willy D, Sondern K, Köster H, Steinhard J, Sandkötter J, Klockenbusch W, Schmitz R, Potratz J. Observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT): assessment and evaluation as predictive factor for acute postnatal outcome-a single center study. Front Pediatr 2023; 11:1145907. [PMID: 37404558 PMCID: PMC10317208 DOI: 10.3389/fped.2023.1145907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/06/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction To assess the observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT) and to explore its value as a potential predictive factor for postnatal outcome. Methods A retrospective single-center study was conducted on pregnancies complicated by CAKUT between 2007 and 2018. The lung-to-head ratio (LHR) was calculated for each fetus by two independent observers. Correlations between O/E LHR and various perinatal outcome factors were assessed with Spearman's rank correlation. Furthermore, nominal logistic regression was performed to assess O/E LHR as predictive factor for respiratory distress in newborn. Results Of 64 pregnancies complicated by CAKUT, 23 were terminated. In the 41 cases of continuation of pregnancy, newborn presenting respiratory distress with need for respiratory support in the delivery room showed earlier gestational age at onset of amniotic fluid abnormalities and at birth. Although median O/E LHR and median single deepest pocket (SDP) of amniotic fluid were significantly smaller in newborn that did develop respiratory distress with need of respiratory support in the delivery room, neither O/E LHR nor SDP were accurate predictors for the development of respiratory distress. Conclusions Our data show that O/E LHR alone cannot serve as a predictive marker for fetal outcome in pregnancies complicated by CAKUT, though it might still be a helpful parameter together with detailed renal ultrasound evaluation, onset of amniotic fluid abnormality and SDP, particularly in its extreme values.
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Affiliation(s)
- M. Sourouni
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
- Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - L. Haisch
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
| | - K. Oelmeier
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - M. Möllers
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - D. Willy
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - K. Sondern
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - H. Köster
- Gynaecologist’s Office of Dr. Natalia Ulrich, Berlin, Germany
| | - J. Steinhard
- Department of Fetal Cardiology, University Hospital of the Ruhr University Bochum, Bad Oeynhausen, Germany
| | - J. Sandkötter
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
| | - W. Klockenbusch
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - R. Schmitz
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - J. Potratz
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
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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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Postnatal Outcomes of Fetuses with Prenatal Diagnosis of 6-9.9 mm Pyelectasis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020407. [PMID: 36832536 PMCID: PMC9955995 DOI: 10.3390/children10020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/23/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
Pyelectasis, also known as renal pelvic dilatation or hydronephrosis, is frequently found on fetal ultrasound. This study correlated prenatally-detected, moderate pyelectasis with postnatal outcomes. This retrospective, observational study was conducted at a tertiary medical center in Israel. The study group consisted of 54 fetuses with prenatal diagnosis of pyelectasis on ultrasound scan during the second trimester, defined as anteroposterior renal pelvic diameter (APRPD) 6-9.9 mm. Long-term postnatal outcomes and renal-related sequelae were obtained using medical records and telephone-based questionnaires. The control group included 98 cases with APRPD < 6 mm. Results indicate that fetal pyelectasis 6-9.9 mm was more frequent among males (68.5%) than females (51%, p = 0.034). We did not find significant correlations between 6-9.9 mm pyelectasis and other anomalies or chromosomal/genetic disorders. Pyelectasis resolved during the pregnancy in 15/54 (27.8%) cases. There was no change in 17/54 (31.5%) and 22/54 (40.7%) progressed to hydronephrosis Among the study group, 25/54 (46.3%) were diagnosed with neonatal hydronephrosis. There were more cases of renal reflux or renal obstruction in the study group compared to the control group 8/54 (14.8%) vs. 1/98 (1.0%), respectively; p = 0.002. In conclusion, most cases of 6-9.9 mm pyelectasis remained stable or resolved spontaneously during pregnancy. There was a higher rate of postnatal renal reflux and renal obstruction in this group; however, most did not require surgical intervention.
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Mongia A, Milletti E, Bonari A, Lanzilao L, Pasquini L, Dani C, Fanelli A. Urine Biochemistry of a Human Fetus with Urinary Tract Obstruction - A Case Report. Fetal Pediatr Pathol 2023; 42:72-76. [PMID: 35225147 DOI: 10.1080/15513815.2022.2045403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Fetal lower urinary tract obstruction (LUTO) can be mild or severe with oligohydramnios, renal dysplasia and pulmonary hypoplasia. Fetal urine biochemical markers correlate with fetal prognosis and, if favorable, surgical intervention is feasible. METHODS We report a patient in her 18th gestational week whose fetus was diagnosed with LUTO and underwent fetal urine sampling for calcium, sodium, chloride, beta2-microglobulin and total protein of the routine LUTO panel, with the addition of creatinine, glucose, phosphate, urea, ammonia, albumin, and NGAL. RESULTS Although the routine fetal urine biochemistry seemed to be favorably trending favorably, sodium, beta2-microglobulin, glucose, and urea did not decrease to the reference ranges, and ammonia and creatinine were lower than the reference ranges. Ultrasound demonstrated no improvement of the obstruction. CONCLUSIONS This case highlights the need to acquire further experience with biochemical fetal urine markers in order to better manage LUTO.
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Affiliation(s)
- Alessandra Mongia
- Biochemistry Laboratory, Department of Diagnostics, Careggi University Hospital, Florence, Italy
| | - Eva Milletti
- Biochemistry Laboratory, Department of Diagnostics, Careggi University Hospital, Florence, Italy
| | - Alessandro Bonari
- Biochemistry Laboratory, Department of Diagnostics, Careggi University Hospital, Florence, Italy
| | - Luisa Lanzilao
- Biochemistry Laboratory, Department of Diagnostics, Careggi University Hospital, Florence, Italy
| | - Lucia Pasquini
- Fetal Medicine Unit, Department for Women and Children Health, Careggi University Hospital, Florence, Italy
| | - Carlo Dani
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Mother and Child Health, Careggi University Hospital, Florence, Italy
| | - Alessandra Fanelli
- Biochemistry Laboratory, Department of Diagnostics, Careggi University Hospital, Florence, Italy
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10
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Abstract
The most severe forms of congenital anomalies of the kidney and urinary tract present in fetal life with early pregnancy renal anhydramnios and are considered lethal due to pulmonary hypoplasia without fetal therapy. Due to the high rate of additional structural anomalies, genetic abnormalities, and associated syndromes, detailed anatomic survey and genetic testing are imperative when stratifying which pregnancies are appropriate for fetal intervention. Restoring amniotic fluid around the fetus is the principal goal of prenatal treatment. The ongoing multi-center Renal Anhydramnios Fetal Therapy (RAFT) trial is assessing the safety and efficacy of serial amnioinfusions to prevent pulmonary hypoplasia so that the underlying renal disease can be addressed.
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12
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Kohl S, Avni FE, Boor P, Capone V, Clapp WL, De Palma D, Harris T, Heidet L, Hilger AC, Liapis H, Lilien M, Manzoni G, Montini G, Negrisolo S, Pierrat MJ, Raes A, Reutter H, Schreuder MF, Weber S, Winyard PJD, Woolf AS, Schaefer F, Liebau MC. Definition, diagnosis and clinical management of non-obstructive kidney dysplasia: a consensus statement by the ERKNet Working Group on Kidney Malformations. Nephrol Dial Transplant 2022; 37:2351-2362. [PMID: 35772019 PMCID: PMC9681917 DOI: 10.1093/ndt/gfac207] [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: 02/28/2022] [Indexed: 12/31/2022] Open
Abstract
Kidney dysplasia is one of the most frequent causes of chronic kidney failure in children. While dysplasia is a histological diagnosis, the term 'kidney dysplasia' is frequently used in daily clinical life without histopathological confirmation. Clinical parameters of kidney dysplasia have not been clearly defined, leading to imprecise communication amongst healthcare professionals and patients. This lack of consensus hampers precise disease understanding and the development of specific therapies. Based on a structured literature search, we here suggest a common basis for clinical, imaging, genetic, pathological and basic science aspects of non-obstructive kidney dysplasia associated with functional kidney impairment. We propose to accept hallmark sonographic findings as surrogate parameters defining a clinical diagnosis of dysplastic kidneys. We suggest differentiated clinical follow-up plans for children with kidney dysplasia and summarize established monogenic causes for non-obstructive kidney dysplasia. Finally, we point out and discuss research gaps in the field.
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Affiliation(s)
- Stefan Kohl
- Department of Pediatrics, University Hospital of Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Fred E Avni
- Department of Pediatric Imaging, Jeanne de Flandre Hospital, Lille University Hospitals, Lille Cedex, France
| | - Peter Boor
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany,Medical Clinic II (Nephrology and Immunology), University Hospital RWTH Aachen, Aachen, Germany
| | - Valentina Capone
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - William L Clapp
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Diego De Palma
- Nuclear Medicine Unit, Circolo Hospital and Macchi Foundation, ASST-settelaghi, Varese, Italy
| | - Tess Harris
- The Polycystic Kidney Disease Charity, London, UK
| | - Laurence Heidet
- Laboratory of Hereditary Kidney Diseases, Université de Paris, Imagine Institute, INSERM UMR 1163, Paris, France,APHP, Service de Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Alina C Hilger
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany,Research Center On Rare Kidney Diseases (RECORD), University Hospital Erlangen, Erlangen, Germany
| | - Helen Liapis
- Nephrology Center, Ludwig Maximilian University (LMU), Munich, Germany
| | - Marc Lilien
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gianantonio Manzoni
- Pediatric Urology Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Susanna Negrisolo
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Marie-Jeanne Pierrat
- Federation of European Patient Groups affected by Rare/Genetic Kidney Diseases (FEDERG), Brussels, Belgium
| | - Ann Raes
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Heiko Reutter
- Research Center On Rare Kidney Diseases (RECORD), University Hospital Erlangen, Erlangen, Germany,Division of Neonatology and Pediatric Intensive Care Medicine, Department of Pediatric and Adolescent Medicine, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Stefanie Weber
- Department of Pediatric Nephrology, Marburg Kidney Research Center, Philipps University, Marburg, Germany
| | - Paul J D Winyard
- University College London Great Ormond Street, Institute of Child Health, London, UK
| | - Adrian S Woolf
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK,Royal Manchester Children's Hospital, Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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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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Vinit N, Bessières B, Spaggiari E, Heidet L, Gubler MC, Dreux S, Attie-Bitach T, Blanc T, Ville Y. Pathological and sonographic review of early isolated severe lower urinary tract obstruction and implications for prenatal treatment. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:513-521. [PMID: 34182598 DOI: 10.1002/uog.23718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/05/2021] [Accepted: 06/14/2021] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To identify favorable renal histology in fetuses with early severe lower urinary tract obstruction (LUTO) and determine the best timing and selection criteria for prenatal surgery. METHODS This multicenter, retrospective study included male fetuses with severe LUTO which died before 24 weeks of gestation during the period January 2000 to December 2018. Age-matched controls were used as reference standard for renal histology. Prenatal ultrasound features and fetal serum and/or urine β2microglobulin level were retrieved and kidney histology slides (hematein-eosin-safran and α-smooth-muscle-actin (αSMA) immunostaining) were prepared and reviewed. αSMA-positive staining of the blastema is due to its aberrant differentiation into myofibroblastic cells. Cases were sorted into histopathologic groups (favorable or unfavorable) according to the blastema's morphology and αSMA labeling and the data of these groups were compared. RESULTS Included in the study were 74 fetuses with a median gestational age at outcome of 17 + 6 (range, 13 + 0 to 23 + 5) weeks. Parenchymal organization was preserved in 48% of the kidneys. A blastema was present in 90% of the kidneys, but it was morphologically normal in only 9% and αSMA-negative in only 1% of them. Most (82%) fetuses had an unfavorable prognosis, and 36% of fetuses died ≤ 18 weeks and had severe renal lesions detected on histology (early unfavorable prognosis). A favorable renal prognosis was associated with an earlier gestational age (P = 0.001). Fetuses with LUTO had a significantly lower number of mature glomeruli (P < 0.001) compared with controls. However, there was no significant difference in the number of glomeruli generations between the early-unfavorable-prognosis group (≤ 18 weeks) and the group with a favorable prognosis (P = 0.19). A comparison of prenatal ultrasound features and biochemical markers between groups could not identify any prenatal selection criteria. CONCLUSIONS Before 18 weeks, around 30% of fetuses with severe LUTO still have potential for kidney development. Identification of these cases would enable them to be targeted for prenatal therapy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Vinit
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- EA FETUS 7328-PACT, Imagine Institute, Paris University, Paris, France
| | - B Bessières
- EA FETUS 7328-PACT, Imagine Institute, Paris University, Paris, France
- Department of Histology, Embryology and Cytogenetics, Fetal Pathology Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - E Spaggiari
- EA FETUS 7328-PACT, Imagine Institute, Paris University, Paris, France
- Department of Histology, Embryology and Cytogenetics, Fetal Pathology Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - L Heidet
- Department of Pediatric Nephrology, Reference Center for Inherited Renal Disease (MARHEA), Necker-Enfants Malades Hospital, APHP, Paris, France
- INSERM UMR 1163, Laboratory of Inherited Kidney Diseases, Imagine Institute, University of Paris, Paris, France
| | - M-C Gubler
- INSERM UMR 1163, Laboratory of Inherited Kidney Diseases, Imagine Institute, University of Paris, Paris, France
| | - S Dreux
- Department of Biochemistry-Hormonology, Robert Debré Hospital, APHP, Paris, France
| | - T Attie-Bitach
- EA FETUS 7328-PACT, Imagine Institute, Paris University, Paris, France
- Department of Histology, Embryology and Cytogenetics, Fetal Pathology Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
- Université Paris Cité, Paris, France
| | - T Blanc
- Department of Pediatric Surgery and Urology, Necker-Enfants Malades Hospital, APHP, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1151-CNRS UMR 8253, Paris University, Paris, France
| | - Y Ville
- EA FETUS 7328-PACT, Imagine Institute, Paris University, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
- Université Paris Cité, Paris, France
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15
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Sheth KR, Danzer E, Johnson E, Wall JK, Blumenfeld YJ. Development and in-vitro characterization of a novel fetal vesicoamniotic shunt - the Vortex Shunt. Prenat Diagn 2022; 42:164-171. [PMID: 35048376 DOI: 10.1002/pd.6096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To develop and test a novel vesicoamniotic shunt (VAS) to treat fetal lower urinary tract obstruction (LUTO), decrease dislodgement and optimize shunt deployment in-vitro. METHODS VAS design objectives included: 1) robust and atraumatic fixation elements, 2) kink resistant conduit to adjust to fetal movement and growth, 3) one-way pressure valve to facilitate bladder cycling, and 4) echogenic deployment visualization aids. The force to dislodge the novel Vortex shunt was compared with existing commercially available shunts in a bench-top porcine bladder model. Sonographic echogenicity was evaluated with ultrasound-guided deployment, and the shunt valve pressure measured. RESULTS A prototype novel Vortex shunt was developed using braided nitinol "umbrella-type" ends with a kink-resistant stem incorporating an internal one-way valve. The peak force required to dislodge the Vortex shunt was significantly higher than commercially available shunts (p<0.01). Shunt deployment in the bench-top model was easily confirmed with ultrasound guidance and the brisk decompression of the inflated porcine bladder thereafter. In-vitro valve gauge pressure testing mirrored bladder pressures in human LUTO cases. CONCLUSION In-vitro testing shows that the Vortex shunt may improve deployment, sonographic visualization, kink resistance, and dynamic size adjustment. Validation in preclinical animal models are warranted and currently underway. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kunj R Sheth
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Urology, Division of Pediatric Urology at Stanford University School of Medicine, Stanford, CA, 94305.,Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - Enrico Danzer
- Division on Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, 10065
| | - Eric Johnson
- Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - James K Wall
- Department of Bioengineering, Stanford University, Stanford, CA, 94305.,Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Surgery, Division of Pediatric Surgery at Stanford University School of Medicine, Stanford, CA, 94305
| | - Yair J Blumenfeld
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine and Obstetrics at Stanford University School of Medicine, Stanford, CA, 94305
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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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Prenatal Diagnosis of Severe Fetal Hydronephrosis Due to Pyeloureteral Junction Syndrome with False Neonatal Resolution. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2040017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A case of severe fetal hydronephrosis due to isolated bilateral stenosis of the pyelo-ureteral junction was diagnosed at our centre. Surprisingly, a negative renal ultrasound scan was performed on the 3rd postnatal day. An ultrasound follow-up showed severe bilateral pyelectasis a few weeks later. The infant underwent bilateral pyeloplasty at six months of age with an excellent outcome. Such a neonatal picture may be due to the reduction of urinary output secondary to excessive postnatal weight loss and dehydration. In this case, prenatal ultrasound result was more reliable than postnatal ultrasound, emphasizing the importance of postnatal urologic follow-up after prenatal indication.
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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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Lesieur E, Barrois M, Bourdon M, Blanc J, Loeuillet L, Delteil C, Torrents J, Bretelle F, Grangé G, Tsatsaris V, Anselem O. Megacystis in the first trimester of pregnancy: Prognostic factors and perinatal outcomes. PLoS One 2021; 16:e0255890. [PMID: 34492029 PMCID: PMC8423287 DOI: 10.1371/journal.pone.0255890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/26/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine whether bladder size is associated with an unfavorable neonatal outcome, in the case of first-trimester megacystis. MATERIALS AND METHODS This was a retrospective observational study between 2009 and 2019 in two prenatal diagnosis centers. The inclusion criterion was an enlarged bladder (> 7 mm) diagnosed at the first ultrasound exam between 11 and 13+6 weeks of gestation. The main study endpoint was neonatal outcome based on bladder size. An adverse outcome was defined by the completion of a medical termination of pregnancy, the occurrence of in utero fetal death, or a neonatal death. Neonatal survival was considered as a favorable outcome and was defined by a live birth, with or without normal renal function, and with a normal karyotype. RESULTS Among 75 cases of first-trimester megacystis referred to prenatal diagnosis centers and included, there were 63 (84%) adverse outcomes and 12 (16%) live births. Fetuses with a bladder diameter of less than 12.5 mm may have a favorable outcome, with or without urological problems, with a high sensitivity (83.3%) and specificity (87.3%), area under the ROC curve = 0.93, 95% CI (0.86-0.99), p< 0.001. Fetal autopsy was performed in 52 (82.5%) cases of adverse outcome. In the 12 cases of favorable outcome, pediatric follow-up was normal and non-pathological in 8 (66.7%). CONCLUSION Bladder diameter appears to be a predictive marker for neonatal outcome. Fetuses with smaller megacystis (7-10 mm) have a significantly higher chance of progressing to a favorable outcome. Urethral stenosis and atresia are the main diagnoses made when first-trimester megacystis is observed. Karyotyping is important regardless of bladder diameter.
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Affiliation(s)
| | - Mathilde Barrois
- Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
| | - Mathilde Bourdon
- Faculté de Médecine Paris Centre, Faculté de Santé, Université de Paris, Paris, France
- Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department “Infection, Immunity and Inflammation”, Université de Paris, Institut Cochin, Paris, France
| | - Julie Blanc
- Service de Gynécologie Obstétrique, Hôpital Nord, AP-HM, Chemin des Bourrely, Marseille, France
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Université Aix-Marseille, Marseille, France
| | - Laurence Loeuillet
- Service d’Histologie-Embryologie-Cytogénétique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Clémence Delteil
- Institut Médicolégal de Marseille, Hôpital Timone Adultes, Marseille, France
- CNRS, EFS, ADES UMR 7268, Aix-Marseille université, Marseille, France
| | - Julia Torrents
- Service d’Anatomo-Cytopathologie et Fœtopathologie, Hôpital de la Timone, Marseille, France
| | - Florence Bretelle
- Service de Gynécologie Obstétrique, Hôpital Nord, AP-HM, Chemin des Bourrely, Marseille, France
- Aix Marseille Univ, IRD, AP-HM, MEФI, Marseille, France
| | - Gilles Grangé
- Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
| | - Vassilis Tsatsaris
- Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
- Université de Paris, Inserm UMR-S 1139, Physiopathologie et Pharmacotoxicologie Placentaire Humaine, Paris, France
| | - Olivia Anselem
- Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
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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: 12] [Impact Index Per Article: 4.0] [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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21
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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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22
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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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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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Xu R, Zhou J, Zhou Q, Zeng S. Decreased biventricular myocardial deformation in fetuses with lower urinary tract obstruction. BMC Pregnancy Childbirth 2020; 20:459. [PMID: 32787795 PMCID: PMC7424985 DOI: 10.1186/s12884-020-03152-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To observe myocardial deformations in fetuses with isolated lower urinary tract obstruction (LUTO) and identify the correlation between myocardial deformation and the severity of obstruction. METHODS The strain (S), strain rate in systole (SRs) and strain rate in diastole (SRd) of the left and right ventricles at the first examination were prospectively analyzed and compared between fetuses with isolated LUTO and gestational age (GA)-matched normal control fetuses. Multiple regression analyses were used to assess the obstructive factors for impaired strain and strain rate, and the independent variables included bladder volume, sum of the bilateral pelvic diameters, sum of the bilateral ureteral diameters, mean bilateral renal artery pulsatility index, and amniotic fluid index. RESULTS Thirty-six fetuses with isolated LUTO and 36 normal controls were enrolled. Overall, decreased S, SRs and SRd of both ventricles were noted in fetuses with LUTO (p < 0.001). Moreover, S and SR were significantly negatively related to distended bladder volume (p < 0.001). CONCLUSIONS Fetuses with LUTO demonstrated decreased left and right myocardial deformation, and this impaired cardiac dysfunction was correlated with the urinary bladder volume. Evaluating the myocardial deformation in fetal LUTO could provide information to aid in parental counselling and intervention monitoring.
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Affiliation(s)
- Ran Xu
- Department of Urology, The Second Xiangya Hospital, Central South University, 410011, Changsha, Hunan, China
| | - Jiawei Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China
| | - Qichang Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China
| | - Shi Zeng
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China.
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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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26
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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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Valve Bladder Syndrome Associated with Posterior Urethral Valves: Natural History, Work-up, and Management. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00577-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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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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Herbst KW, Tomlinson P, Lockwood G, Mosha MH, Wang Z, D'Alessandri-Silva C. Survival and Kidney Outcomes of Children with an Early Diagnosis of Posterior Urethral Valves. Clin J Am Soc Nephrol 2019; 14:1572-1580. [PMID: 31582461 PMCID: PMC6832049 DOI: 10.2215/cjn.04350419] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Posterior urethral valve is the most common cause of bladder outlet obstruction in infants. We aimed to describe the rate and timing of kidney-related and survival outcomes for children diagnosed with posterior urethral valves in United States children's hospitals using the Pediatric Health Information System database. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study included children hospitalized between January 1, 1992 and December 31, 2006, who were in their first year of life, had a diagnosis of congenital urethral stenosis, and underwent endoscopic valve ablation or urinary drainage intervention, or died. Records were searched up to December 31, 2018 for kidney-related mortality, placement of a dialysis catheter, and kidney transplantation. Cox regression analysis was used to identify risk factors, and Kaplan-Meier survival analysis used to determine time-to-event probability. Subgroup survival analysis was performed with outcomes stratified by the strongest identified risk factor. RESULTS Included were 685 children hospitalized at a median age of 7 (interquartile range, 1-37) days. Thirty four children (5%) died, over half during their initial hospitalization. Pulmonary hypoplasia was the strongest risk factor for death (hazard ratio, 7.5; 95% confidence interval [95% CI], 3.3 to 17.0). Ten-year survival probability was 94%. Fifty-nine children (9%) underwent one or more dialysis catheter placements. Children with kidney dysplasia had over four-fold risk of dialysis catheter placement (hazard ratio, 4.6; 95% CI, 2.6 to 8.1). Thirty-six (7%) children underwent kidney transplant at a median age of 3 (interquartile range, 2-8) years. Kidney dysplasia had a nine-fold higher risk of kidney transplant (hazard ratio, 9.5; 95% CI, 4.1 to 22.2). CONCLUSIONS Patients in this multicenter cohort with posterior urethral valves had a 5% risk of death, and were most likely to die during their initial hospitalization. Risk of death was higher with a diagnosis of pulmonary hypoplasia. Kidney dysplasia was associated with a higher risk of need for dialysis/transplant. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_10_03_CJN04350419.mp3.
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Affiliation(s)
| | - Paul Tomlinson
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Gina Lockwood
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | | | - Zhu Wang
- Department of Epidemiology and Biostatistics, University of Texas Health San Antonio, San Antonio, Texas
| | - Cynthia D'Alessandri-Silva
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
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30
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Anhydramnios in the Setting of Renal Malformations: The National Institutes of Health Workshop Summary. Obstet Gynecol 2019; 131:1069-1079. [PMID: 29742659 DOI: 10.1097/aog.0000000000002637] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anhydramnios in the setting of severe malformations of the fetal kidney and urinary tract is associated with a high incidence of stillbirths and life-threatening complications, including severe pulmonary hypoplasia, umbilical cord compression, and perinatal asphyxia. To prevent such adverse outcomes, some centers in the United States and elsewhere are offering amniotic fluid restoration for women diagnosed with anhydramnios in the setting of fetal renal malformations. The procedures include infusions of amniotic fluid substitutes (normal saline), percutaneously or through an amnioport-an implanted system for serial or continuous infusion of normal saline to maintain the desired amniotic fluid volume. The procedures are intended to prevent pulmonary hypoplasia and allow the pregnancy to progress closer to term gestation, enabling postnatal renal management, including long-term dialysis and renal transplantation. However, these procedures have not been recommended as standard of care by the professional societies because there are many knowledge gaps, including few data on short-term and long-term renal outcomes. The available diagnostic methods do not provide reliable prognostic information, and the current maternal and fetal interventions have not been standardized. To address these unresolved issues and to propose a research agenda, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Diabetes and Digestive and Kidney Diseases invited a panel of experts to a workshop in August 2016. This report provides a summary of that meeting.
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31
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Arora M, Prasad A, Kulshreshtha R, Baijal A. Significance of third trimester ultrasound in detecting congenital abnormalities of kidney and urinary tract-a prospective study. J Pediatr Urol 2019; 15:334-340. [PMID: 31031163 DOI: 10.1016/j.jpurol.2019.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/13/2019] [Accepted: 03/29/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Antenatal hydronephrosis is defined as dilatation of the renal pelvis with or without dilatation of calyces in the developing fetus. Although second trimester scan is more sensitive in detecting congenital abnormalities of kidney and urinary tract (CAKUT), it has been suggested that the third trimester scan is more predictive of postnatal outcome. OBJECTIVES This study aims to determine the incidence of antenatal hydronephrosis at our institution and the significance of third trimester scan in detecting CAKUT postnatally. STUDY DESIGN It is a prospective observational study. During the 3-year study period from June 2013 to May 2016, all cases of antenatal hydronephrosis, defined as renal pelvic diameter (RPD) ≥4 mm in the second trimester and ≥7 mm in the third trimester scan, diagnosed in the fetal medicine unit of our hospital, were included and were followed up postnatally for 6 months. RESULTS In the fetal medicine unit, 32,443 women were screened for anomalies, and hydronephrosis was detected in 269 cases. Incidence of antenatal hydronephrosis was observed to be 0.83% in our institution. In second trimester scan, of 80 cases with the left hydronephrosis, only 22 (27.5%) had postnatal CAKUT and of 70 cases with the right hydronephrosis, 18 (25.7%) had CAKUT. In the third trimester scan, it was observed that with RPD >10 mm, on the left side hydronephrosis, 87% had CAKUT on postnatal scan, and 85% with the right hydronephrosis had CAKUT. CONCLUSION Sixty percent cases of hydronephrosis detected in the second trimester scan resolve in utero. In the third trimester scan with RPD <10 mm, the possibility of postnatal CAKUT is 23%, whereas if RPD is > 10 mm, then the possibility of postnatal CAKUT is 86%.
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Affiliation(s)
- M Arora
- Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - A Prasad
- Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.
| | - R Kulshreshtha
- Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - A Baijal
- Department of Fetal Medicine, Sir Ganga Ram Hospital, New Delhi, India
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32
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Graupner O, Enzensberger C, Götte M, Wolter A, Müller V, Kawecki A, Weber S, Degenhardt J, Herrmann J, Axt-Fliedner R. Myocardial function in fetuses with lower urinary tract obstruction: Is there a cardiac remodeling effect due to renal damage? Prenat Diagn 2019; 39:495-504. [PMID: 30957256 DOI: 10.1002/pd.5453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/25/2018] [Accepted: 03/11/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Cardiac remodeling due to renal dysfunction may have an impact on myocardial function (MF) of fetuses with lower urinary tract obstruction (LUTO). The aim was to identify possible differences in MF in LUTO fetuses compared with healthy controls and to look for interactions between urine biochemistry and MF indices. METHODS This is a cohort study consisting of 31 LUTO fetuses and 45 healthy controls. Subgroups were generated according to intrauterine therapy (group 1: LUTO after therapy, group 2: LUTO without therapy at the time of examination, and group 3: controls). MF indices were measured using pulsed wave tissue Doppler imaging and M-mode. Furthermore, results of fetal urine biochemistry were gathered retrospectively. RESULTS Among other findings, right ventricular (RV) e'/a' ratio was lower in group 1 compared with group 3 (p = .050). According to gestational age (GA) level-dependent analysis, RV isovolumetric relaxation time was significantly longer in group 2 compared with group 1 and group 3 at GA level 1 (19 wk of gestation). A significant positive correlation between RV e'/a' ratio and β-2-microglobulin as well as α-1-microglobulin and potassium could be observed. CONCLUSION We observed differences in MF and an association between ventricular filling pattern and renal protein secretion in LUTO fetuses. This can be interpreted as a sign of intrauterine cardiac remodeling.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Malena Götte
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Aline Wolter
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Vera Müller
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Andreea Kawecki
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Stefanie Weber
- Center for Pediatrics and Adolescent Medicine, Pediatric Nephrology, University Hospital UKGM, Philipps-University, Marburg, Germany
| | - Jan Degenhardt
- Pränatal plus, Praxis für Pränatale Medizin und Genetik, Köln, Germany
| | | | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
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Puttmann KT, White JT, Huang GO, Sheth K, Elizondo R, Zhu H, Braun MC, Mann DG, Olutoye OA, Tu DD, Ruano R, Belfort M, Brandt ML, Roth DR, Koh CJ. Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction. J Pediatr Surg 2019; 54:820-824. [PMID: 30049573 DOI: 10.1016/j.jpedsurg.2018.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/14/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients. METHODS We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016). RESULTS 31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031). CONCLUSIONS The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year. LEVEL OF EVIDENCE This is a prognostic study with Level IV evidence.
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Affiliation(s)
- Kathleen T Puttmann
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX.
| | - Jeffrey T White
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Gene O Huang
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Kunj Sheth
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Rodolfo Elizondo
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Huirong Zhu
- Outcomes & Impact Services, Texas Children's Hospital, Houston, TX
| | - Michael C Braun
- Renal Section, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - David G Mann
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX
| | | | - Duong D Tu
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Michael Belfort
- Department of Women Services, Texas Children's Hospital, Houston, TX
| | - Mary L Brandt
- Division of General Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - David R Roth
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX
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Kurtz MP, Nelson CP. Urology Mythbusters: should hydronephrosis grade be used to decide which newborns should undergo voiding cystourethrogram? J Pediatr Urol 2019; 15:93-96. [PMID: 30442542 DOI: 10.1016/j.jpurol.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 12/19/2022]
Abstract
In this episode of Mythbusters the premise that among infants with prenatally identified urinary tract dilation (UTD), voiding cystourethrogram (VCUG) should be performed in those with higher grade UTD but not in those with lower grade UTD is critically examined. It is concluded that severity of dilation is not strongly associated with risk of vesicoureteral reflux or other anomalies diagnosed by VCUG. Therefore, using hydronephrosis grade to decide which infants with UTD should undergo VCUG is not evidence based.
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Affiliation(s)
- Michael P Kurtz
- Boston Children's Hospital and Harvard Medical School, Boston MA United States
| | - Caleb P Nelson
- Boston Children's Hospital and Harvard Medical School, Boston MA United States.
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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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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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Sharma S, Joshi M, Gupta DK, Abraham M, Mathur P, Mahajan JK, Gangopadhyay AN, Rattan SK, Vora R, Prasad GR, Bhattacharya NC, Samuj R, Rao KLN, Basu AK. Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty. J Indian Assoc Pediatr Surg 2019; 24:4-14. [PMID: 30686881 PMCID: PMC6322183 DOI: 10.4103/jiaps.jiaps_148_18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Joshi
- Consultant Pediatric Surgeon, Department of Pediatric Surgery, King Saud Hospital, Uneyzha City, Kingdom of Saudi Arabia
| | - Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mohan Abraham
- Department of Pediatric Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Praveen Mathur
- Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| | - J K Mahajan
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A N Gangopadhyay
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Simmi K Rattan
- Department of Pediatric Surgery, Maulana Azad Medical College, Delhi, India
| | - Ravindra Vora
- Department of Paediatric Surgery, Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India
| | - G Raghavendra Prasad
- Department of Paediatric Surgery, Deccan College of Medical Sciences, Hyderabad, India
| | - N C Bhattacharya
- Department of Paediatric Surgery, Gauhati Medical College, Guwahati, Assam, India
| | - Ram Samuj
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K L N Rao
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A K Basu
- Consultant Pediatric Surgeon, Institute of Child Health, Kolkata, West Bengal, India
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Chen L, Guan J, Gu H, Zhang M. Outcomes in fetuses diagnosed with megacystis: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018; 233:120-126. [PMID: 30594021 DOI: 10.1016/j.ejogrb.2018.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/25/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To explore the outcomes and prognostic factors associated with fetal megacystis (enlarged bladder). STUDY DESIGN The MEDLINE and EMBASE databases were searched for studies reporting on outcomes of fetal megacystis. The outcomes observed were chromosomal abnormalities, associated structural anomalies, spontaneous resolution, and survival rates. We also evaluated the potential role of fetal gender, oligohydramnios, gestational age at diagnosis, and intrauterine intervention as prenatal prognostic factors. RESULTS The search identified 558 articles in total, and 13 studies (1675 fetuses) were included in this systematic review. The overall incidences of chromosomal abnormalities and associated structural anomalies in fetal megacystis were 10% and 24%, respectively. Spontaneous resolution of megacystis occurred in 32% of fetuses, and 44% of fetuses were born alive and survived until the follow-up. The odds ratio of survival with oligohydramnios was 0.14, and the mean difference in gestational age at diagnosis between survival and non-survival was 3.43 weeks. No significant difference in survival rate was observed between the genders, and an intrauterine intervention did not significantly improve the prognosis. CONCLUSIONS A considerable proportion of fetuses with megacystis are born with a good prognosis. Oligohydramnios and lower gestational age at diagnosis are associated with worse outcomes.
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Affiliation(s)
- Lizhu Chen
- Department of Ultrasound, Shengjing Hospital, China Medical University, Shenyang, China
| | - Johnny Guan
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Hui Gu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Mo Zhang
- Department of Urology, Shengjing Hospital, China Medical University, No. 36 Sanhao Street, Heping District, Shenyang, Liaoning 110004, China.
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Fontanella F, Duin LK, Adama van Scheltema PN, Cohen‐Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Gracchi V, Oepkes D, Bilardo CM. Prenatal diagnosis of LUTO: improving diagnostic accuracy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:739-743. [PMID: 29266464 PMCID: PMC6587765 DOI: 10.1002/uog.18990] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 11/13/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To propose a clinical score for the optimal antenatal diagnosis of fetal lower urinary tract obstruction (LUTO) in the second and third trimesters of pregnancy, as an alternative to the commonly used ultrasound triad of megacystis, keyhole sign and hydronephrosis. METHODS This was a national retrospective study carried out at the eight tertiary fetal medicine units (FMUs) in The Netherlands. Only cases referred for megacystis from the second trimester onwards and with a clear postnatal diagnosis were included in the study. At referral, data were collected on amniotic fluid volume, renal cortical appearance, bladder volume, hydronephrosis, fetal ascites, ureteral size, keyhole sign, fetal sex and gestational age. Multivariate analysis was performed, starting by including all antenatal variables, and then excluding the weakest predictors using the backward stepwise strategy. RESULTS Over a 7-year period, 312 fetuses with a diagnosis of megacystis were referred to the eight Dutch tertiary FMUs. A final diagnosis was achieved in 143 cases, including 124 of LUTO and 19 reclassified after birth as non-obstructive megacystis. The optimal bladder volume cut-off for prediction of LUTO was 35 cm3 (area under the curve (AUC) = 0.7, P = 0.03). The clinical score formulated on the basis of the multivariate analysis included fetal sex, degree of bladder distension, ureteral size, oligo- or anhydramnios and gestational age at referral. The combination of these five variables demonstrated good accuracy in discriminating LUTO from non-obstructive megacystis (AUC = 0.84, P < 0.001), compared with the poor performance of the ultrasound triad (AUC = 0.63, P = 0.07). CONCLUSIONS We propose a clinical score that combines five antenatal variables for the prospective diagnosis of congenital LUTO. This score showed good discriminative capacity in predicting LUTO, and better diagnostic accuracy compared with that of the classic ultrasound triad. Future studies to validate these results should be carried out in order to refine antenatal management of LUTO and prevent inappropriate fetal interventions. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F. Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - P. N. Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - E. Pajkrt
- Department of ObstetricsAcademic Medical Center AmsterdamAmsterdamThe Netherlands
| | - M. Bekker
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical CenterGrow School for Oncology and Medical BiologyMaastrichtThe Netherlands
| | - C. J. Bax
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisVU University Medical CenterAmsterdamThe Netherlands
| | - V. Gracchi
- Department of PediatricsUniversity Medical Center Groningen, University of GroningenThe Netherlands
| | - D. Oepkes
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
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Ruano R, Dunn T, Braun MC, Angelo JR, Safdar A. Lower urinary tract obstruction: fetal intervention based on prenatal staging. Pediatr Nephrol 2017; 32:1871-1878. [PMID: 28730376 DOI: 10.1007/s00467-017-3593-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/28/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022]
Abstract
The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Timothy Dunn
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Michael C Braun
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Adnan Safdar
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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Taghavi K, Sharpe C, Stringer MD, Zuccollo J, Marlow J. Fetal megacystis: Institutional experience and outcomes. Aust N Z J Obstet Gynaecol 2017; 57:636-642. [DOI: 10.1111/ajo.12655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 05/14/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Kiarash Taghavi
- Department of Paediatric Surgery; Wellington Children's Hospital; Wellington New Zealand
- Department of Paediatrics and Child Health; University of Otago; Wellington New Zealand
| | - Caitlin Sharpe
- School of Medicine; University of Otago; Wellington New Zealand
| | - Mark D. Stringer
- Department of Paediatric Surgery; Wellington Children's Hospital; Wellington New Zealand
- Department of Paediatrics and Child Health; University of Otago; Wellington New Zealand
| | - Jane Zuccollo
- Department of Pathology; Wellington Hospital; Wellington New Zealand
| | - Jay Marlow
- Maternal Fetal Medicine, Women's Health, Obstetrics and Maternity; Wellington Hospital; Wellington New Zealand
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Abstract
UNLABELLED Fetal megacystis is variably defined and understood. The literature on fetal megacystis was systematically reviewed, focusing on prenatal diagnosis, associations and outcomes. This yielded a total of 18 primary references and eight secondary references. Fetal megacystis has an estimated first-trimester prevalence of between 1:330 and 1:1670, with a male to female ratio of 8:1. In the first trimester, megacystis is most commonly defined as a longitudinal bladder dimension of ≥7 mm. Later in pregnancy, a sagittal dimension (in mm) greater than gestational age (in weeks) + 12 is often accepted. Megacystis can be associated with a thickened bladder wall, which has been objectively defined as >3 mm. Oligohydramnios is present in approximately half of all cases. The most common underlying diagnosis is posterior urethral valves (57%), followed by urethral atresia/stenosis (7%), prune belly syndrome (4%), megacystis-microcolon-intestinal-hypoperistalsis syndrome (MMIHS) (1%), and cloacal anomalies (0.7%). Karyotype anomalies are found in 15%, and include trisomy 18, trisomy 13 and trisomy 21. Ultrasound imaging alone is often insufficient to enable a definitive diagnosis, although it may indicate that a specific diagnosis is more likely. Overall, about 50% of reported fetuses with megacystis are terminated, but this proportion varies considerably between countries and over time. Prognostic stratification is evolving, with the most important factors being oligohydramnios, gestational age at diagnosis, degree of bladder enlargement, renal hyperechogenicity, karyotype, and sex. CONCLUSIONS This review demonstrated some consensus on the ultrasound criteria for defining fetal megacystis, and illustrated the spectrum of pathologies and their relative frequencies that can cause this condition. It also underlined important associated karyotype anomalies. To progress understanding of the natural history of enlarged fetal bladders, more accurate diagnostics are required, and risk stratification needs to be refined to facilitate prenatal counseling.
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Sakai T, Murakami Y, Okuda Y, Hamada R, Hamasaki Y, Ishikura K, Hataya H, Honda M. Prolonged respiratory disorder predicts adverse prognosis in infants with end-stage kidney disease. Pediatr Nephrol 2016; 31:2127-36. [PMID: 27271033 DOI: 10.1007/s00467-016-3430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/27/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Among comorbidities, pulmonary hypoplasia (PH) is known as a significant risk factor for mortality in infants with end-stage kidney disease (ESKD). However, the final outcomes of infants with both ESKD and PH are still not well defined, as the diagnosis modality, and definition of PH severity remain ambiguous. METHODS Children initiating peritoneal dialysis during infancy from 1990 to 2015 were followed until death, date of last contact, or the end of 2015. We examined the long-term outcome of children with congenital pulmonary disorders by studying infants with prolonged respiratory disorders of greater than 28 days duration after birth and evaluated risk factors for mortality. RESULTS Forty-six children were followed (median follow-up, 9.23 years), and classified as children without (n = 38; Group A) or with (n = 8; Group B) a prolonged respiratory disorder. Overall actuarial 5 year survival rate in this cohort was 79.5 %. The survival curve in Group B showed a significant decline compared with Group A. Prolonged respiratory disorder was significantly associated with mortality by multivariate analysis (hazard ratio, 8.32). CONCLUSIONS Infants who initiate peritoneal dialysis complicated by prolonged respiratory disorders have increased adverse risk factors for mortality; therefore, withholding aggressive treatment should be considered.
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Affiliation(s)
- Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan.
| | - Yoshitaka Murakami
- Department of Medical Statistics, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Ruano R, Sananes N, Wilson C, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Safdar A, Moaddab A, Meyer N, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Braun MC, Belfort MA. Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:476-482. [PMID: 26690832 DOI: 10.1002/uog.15844] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/31/2015] [Accepted: 12/15/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity. METHODS This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported. RESULTS Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR > 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR < 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR > 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR > 1) = 93.3%) were predictors of survival. CONCLUSIONS Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA. ,
| | - N Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C Wilson
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Au
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - P Gargollo
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Safdar
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - N Meyer
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France
| | - D L Cass
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - S Welty
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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45
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Kurtz MP, Koh CJ, Jamail GA, Sangi-Haghpeykar H, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Braun MC, Roth DR, Belfort MA, Ruano R. Factors associated with fetal shunt dislodgement in lower urinary tract obstruction. Prenat Diagn 2016; 36:720-5. [PMID: 27247093 DOI: 10.1002/pd.4850] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/19/2016] [Accepted: 05/29/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify factors associated with fetal shunt dislodgement in lower urinary tract obstruction (LUTO). METHODS We conducted a retrospective study of 42 consecutive fetuses with a diagnosis of LUTO in a tertiary fetal center between April 2013 and November 2015. Possible factors associated with prenatal shunt dislodgment were evaluated in fetuses who underwent shunt placement, including gestational age at diagnosis, gestational age at procedure, presence of 'keyhole sign', initial fetal bladder volume and wall thickness, prenatal ultrasonographic renal characteristics, amniotic fluid volume, presence of ascites prior to shunting, and type of fetal shunt. RESULTS Nineteen (46.3%) fetuses underwent shunt placement at a median gestational age of 19 (range: 16.3-31.1) weeks. Shunt dislodgement occurred in 10 (52.6%) patients. A total of 35 procedures were performed; among which 16 (45.7%) were repeat procedures. The only prenatal factor associated with shunt dislodgement was the type of the shunt; Kaplan-Meier analysis indicated that the Rocket was associated with increased likelihood of remaining orthotopic (p = 0.04). CONCLUSION Fetal shunt dislodgement occurs in approximately half of the patients and appears to be associated with the type of the shunt. Future research is necessary to develop better shunt systems and to investigate different fetal therapeutic approaches. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Michael P Kurtz
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Grace Anne Jamail
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Michael C Braun
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - David R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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46
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Quibel S, Brasseur-Daudruy M, Liard-Zmuda A, Gaillard P, Verspyck E. Posterior urethral valves: how the study of fetal micturition can help to reach the diagnosis? Prenat Diagn 2016; 36:794-5. [PMID: 27351949 DOI: 10.1002/pd.4865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/17/2016] [Accepted: 06/11/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Solene Quibel
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
| | | | - Agnes Liard-Zmuda
- Department of Pediatric Surgery, Rouen University Hospital, Rouen, France
| | - Pascale Gaillard
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
| | - Eric Verspyck
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
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47
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Ruano R, Safdar A, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Belfort MA, Braun MC. Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction. Pediatr Nephrol 2016; 31:605-12. [PMID: 26525197 DOI: 10.1007/s00467-015-3246-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 09/27/2015] [Accepted: 10/06/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). METHODS We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. RESULTS Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). CONCLUSION We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA.
| | - Adnan Safdar
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jason Au
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Patricio Gargollo
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Stephen Welty
- Department of Pediatrics, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - David R Roth
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael C Braun
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
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48
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Haeri S, Simon DH, Pillutla K. Serial amnioinfusions for fetal pulmonary palliation in fetuses with renal failure. J Matern Fetal Neonatal Med 2016; 30:174-176. [DOI: 10.3109/14767058.2016.1165202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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49
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Sananes N, Cruz-Martinez R, Favre R, Ordorica-Flores R, Moog R, Zaloszy A, Giron AM, Ruano R. Two-year outcomes after diagnostic and therapeutic fetal cystoscopy for lower urinary tract obstruction. Prenat Diagn 2016; 36:297-303. [DOI: 10.1002/pd.4771] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolas Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center; Texas Children's Hospital; Houston TX USA
- INSERM; UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - Rogelio Cruz-Martinez
- Department of Fetal Surgery; Children's and Women's Specialty Hospital of Queretaro; Queretaro Mexico
- Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología; UNAM-Juriquilla; Queretaro Mexico
| | - Romain Favre
- Maternal Fetal Medicine Department; Strasbourg University Hospital; Strasbourg France
| | - Ricardo Ordorica-Flores
- Department of Pediatric Surgery; Children's Hospital Mexico ‘Federico Gomez’ (HIMFG); Mexico City Mexico
| | - Raphaël Moog
- Pediatric Surgery Department; Strasbourg University Hospital; Strasbourg France
| | - Ariane Zaloszy
- Pediatric Nephrology Department; Strasbourg University Hospital; Strasbourg France
| | - Amilcar Martins Giron
- Department of Urology; Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center; Texas Children's Hospital; Houston TX USA
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50
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Abdennadher W, Chalouhi G, Dreux S, Rosenblatt J, Favre R, Guimiot F, Salomon LJ, Oury JF, Ville Y, Muller F. Fetal urine biochemistry at 13-23 weeks of gestation in lower urinary tract obstruction: criteria for in-utero treatment. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:306-311. [PMID: 25412852 DOI: 10.1002/uog.14734] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the value of fetal urine biochemistry before 23 weeks of gestation in cases of lower urinary tract obstruction (LUTO) to refine prognosis and to select potential candidates for in-utero intervention. METHODS This was a retrospective study including 72 cases of LUTO with fetal urine sampled before 23 weeks and assayed for total protein, β-2-microglobulin, sodium, chloride, calcium, phosphorus, glucose and gamma-glutamyl transpeptidase (GGTP). Two groups were defined according to renal outcome: 1) bilateral renal dysplasia on histological examination or renal failure at birth; 2) normal postnatal renal function or histologically normal appearance of the kidneys. Correlations between fetal urinary biochemical markers and postnatal renal function were studied. RESULTS LUTO was isolated in 56/72 (77.8%) cases and was associated with other malformations in 16/72 (22.2%) cases. High GGTP levels (236 IU/L vs 5 IU/L; P < 0.0001) were observed in fetal urine in the five cases of urodigestive fistula. A significant difference between outcome groups was observed for β-2-microglobulin (P = 0.0017), sodium (P = 0.0008), chloride (P = 0.0028) and calcium (P = 0.0092) but not for protein, glucose or phosphorus. Sensitivity and specificity in defining a poor renal prognosis were 80.6% and 89% for β-2-microglobulin, 61.3% and 100% for sodium and 64.5% and 100% for calcium, respectively. CONCLUSIONS Fetal urinalysis before 23 weeks of gestation allowed distinction between three groups: 1) fetuses with normal urine biochemistry for which fetal therapy should be discussed; 2) fetuses with abnormal urine biochemistry for which prognosis for renal outcome is poor and for which the benefit of fetal therapy is likely to be compromised; 3) fetuses with urodigestive fistula.
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Affiliation(s)
- W Abdennadher
- Department of Obstetrics and Gynaecology, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - G Chalouhi
- Department of Obstetrics and Gynaecology, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - S Dreux
- Department of Biochemistry, Hôpital Robert Debré, APHP, Paris, France
| | - J Rosenblatt
- Department of Obstetrics and Gynaecology, Hôpital Robert Debré, APHP, Paris, France
| | - R Favre
- Department of Obstetrics and Gynaecology, CMCO, Schiltigheim, France
| | - F Guimiot
- Department of Developmental Biology, Hôpital Robert Debré, APHP, Paris, France
| | - L J Salomon
- Department of Obstetrics and Gynaecology, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - J F Oury
- Department of Obstetrics and Gynaecology, Hôpital Robert Debré, APHP, Paris, France
| | - Y Ville
- Department of Obstetrics and Gynaecology, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - F Muller
- Department of Biochemistry, Hôpital Robert Debré, APHP, Paris, France
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