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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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Matsell DG, Yu S, Morrison SJ. Antenatal Determinants of Long-Term Kidney Outcome in Boys with Posterior Urethral Valves. Fetal Diagn Ther 2015; 39:214-21. [DOI: 10.1159/000439302] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/06/2015] [Indexed: 11/19/2022]
Abstract
Background: Posterior urethral valves (PUV) are the most important cause of end-stage renal disease (ESRD) in young boys. The objective of this report was to define the antenatal determinants of long-term postnatal renal outcome in this condition. Design: This was a retrospective cohort analysis. The primary outcome was the development of ESRD defined as starting dialysis or receiving a preemptive kidney transplant. Results: Eighty-two cases of PUV were identified, with 17 (21%) developing ESRD at 6.1 ± 7.1 years. Cases developing ESRD were more likely diagnosed antenatally (41 vs. 19%, p = 0.05), had a younger gestational age (35.5 ± 3.4 weeks vs. 37.3 ± 2.1 weeks, p = 0.02), and on antenatal ultrasound scan were more likely to have oligohydramnios (60 vs. 26%, p = 0.02), renal cortical cysts (47 vs. 17%, p = 0.02), and the combination of oligohydramnios, renal cortical cysts, and increased renal echogenicity (47 vs. 9%, p = 0.002). Conclusions: In boys with PUV, decreased gestational age, oligohydramnios, renal cysts, and the combination of oligohydramnios, cortical cysts, and echogenic kidneys were associated with ESRD, while the combination was an independent predictor of poor long-term postnatal kidney function.
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Prenatal Urinoma Related to Ureteropelvic Junction Obstruction: Poor Prognosis of the Affected Kidney. Urology 2010; 76:190-4. [DOI: 10.1016/j.urology.2010.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 03/01/2010] [Accepted: 03/09/2010] [Indexed: 11/20/2022]
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Ruano R, Duarte S, Bunduki V, Giron AM, Srougi M, Zugaib M. Fetal cystoscopy for severe lower urinary tract obstruction--initial experience of a single center. Prenat Diagn 2010; 30:30-9. [PMID: 19967749 DOI: 10.1002/pd.2418] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report the experience with fetal cystoscopy and laser fulguration of posterior urethral values (PUV) for severe lower urinary tract obstruction (LUTO). METHODS Between July 2006 and December 2008, fetal cystoscopy was offered to 23 patients whose fetuses presented with severe LUTO, favorable urinary analysis and gestational age <26 weeks. Fetal urinary biochemistry was evaluated before and after cystoscopy. All infants were followed 6-12 months after birth. Abnormal renal function was defined when serum creatinine higher than 50 micromol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred. RESULTS Eleven patients decided to undergo fetal therapy and 12 elected to continue with expectant observation. There was no difference between both groups in gestation age at diagnosis and referral examinations. Urethral atresia was diagnosed in 4/11 (36.4%) fetuses by fetal cystoscopy. At 26 weeks, fetuses that were managed expectantly presented with worse urinary biochemistry results (p < 0.05). Survival rates and percentage of infants with normal renal function were significantly higher in the cystoscopic group than in the expectant group (p < 0.05). CONCLUSIONS Percutaneous fetal cystoscopy is feasible using a thinner special cannula for prenatal diagnosis and therapy of LUTO. Prenatal laser ablation of the PUV under cystoscopy may prevent renal function deterioration improving postnatal outcome.
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Affiliation(s)
- Rodrigo Ruano
- Obstetrics Department, Faculty of Medicine, São Paulo University, Rua Valentim Magalhães 100, São Paulo, SP, Brazil.
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Abstract
The authors present an overview of the prenatal diagnosis, evaluation, contemporary intervention, and antenatal management of lower urinary tract obstruction. They review early experimental models that confirmed the relation between urinary tract obstruction and renal fibrocystic dysplasia and that early in utero relief of the obstruction could prevent irreversible renal injury. Subsequent studies of the electrolyte and protein concentrations in fetal urine from human cases established prognostic threshold values and helped to develop an algorithm to select candidates for antenatal therapy. Although shunting has improved survival, long-term morbidities remain a significant challenge.
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Affiliation(s)
- Serena Wu
- General Surgery, The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Morris RK, Malin GL, Khan KS, Kilby MD. Antenatal ultrasound to predict postnatal renal function in congenital lower urinary tract obstruction: systematic review of test accuracy. BJOG 2009; 116:1290-9. [PMID: 19438489 DOI: 10.1111/j.1471-0528.2009.02194.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- R K Morris
- The School of Clinical and Experimental Medicine (Reproduction, Genes and Development), College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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Abstract
This review aims to outline the management of a fetus in whom a distended bladder or an absent bladder has been identified during prenatal fetal screening. The causes, pre-delivery and immediate post-delivery treatment options are discussed, as well as prognosis.
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Affiliation(s)
- Jenny Yiee
- David Geffen School of Medicine, University of California-Los Angeles, CA 90095, USA
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Yiee J, Wilcox D. Management of fetal hydronephrosis. Pediatr Nephrol 2008; 23:347-53. [PMID: 17671800 DOI: 10.1007/s00467-007-0542-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 04/24/2007] [Accepted: 05/26/2007] [Indexed: 11/30/2022]
Abstract
Prenatally detected hydronephrosis has become a common diagnosis for both pediatric nephrologists and urologists. Hydronephrosis is most commonly assessed by the Society for Fetal Urology grading system or anterior-posterior diameter of the renal pelvis in the transverse plane. Some cases of bilateral obstruction, most commonly from posterior urethral valves, can be life-threatening and require close monitoring or, occasionally, fetal intervention. The majority are unilateral and of no threat to the growing fetus. The crux of postnatal management is the separation of the minority of patients whose renal function is at risk from the majority who will suffer no renal consequences. This management involves a regimen of ultrasounds, voiding cystourethrograms, and nuclear renograms for diagnosis and surveillance. Recent literature has been aimed at the timing and necessity of these studies in order to minimize extraneous studies without compromising renal function.
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Affiliation(s)
- Jenny Yiee
- Urology, University of California at Los Angeles, Los Angeles, CA, USA
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Walsh CA, Rausch ME, Baxi LV. Intrauterine cystocentesis to facilitate vaginal delivery in a fetus with trisomy 13. J OBSTET GYNAECOL 2007; 27:735-6. [PMID: 17999310 DOI: 10.1080/01443610701667155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- C A Walsh
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA.
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10
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Abstract
INTRODUCTION AND AIM Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. This study evaluated the long-term outcome of managing patients with posterior urethral valves (PUV), highlighting the effect of antenatal vesicoamniotic shunt placement for patients who underwent fetal surgery. METHODS The medical records of 58 patients with PUV were retrospectively reviewed from June 1998 to June 2004. On the basis of prenatal assessment of sonographic findings and serial urinary electrolytes and protein measurements, patients were divided into two groups: group 1 comprised patients who had antenatal vesicoamniotic shunt placement whereas group 2 comprised patients who underwent postnatal surgical correction of PUV. Their outcomes and long-term results were evaluated. RESULTS Patients were followed up from 6 months to 6(1/2) years (mean 3.9 years). Group 1 included 12 patients who had vesicoamniotic shunt placement and were confirmed postnatally to have PUV. Four patients out of 12 died (33.3%); three out of the eight living patients had perinatal complications. Of the eight living patients, three (37.5%) underwent valve ablation and five (62.5%) underwent urinary diversion (three vesicostomies and two cutaneous ureterostomies). Renal function returned to normal in only four patients (50%). Radiological abnormalities (hydronephrosis and/or reflux) resolved in three (37.5%) patients, was downgraded in one (12.5%) patient and persisted in four patients (50%). Group 2 included 46 patients who were treated postnatally. Thirty-five patients (76%) underwent primary valve ablation, while 11 (24%) underwent urinary diversion (seven vesicostomies, four cutaneous ureterostomy and one pyelostomy). Renal function returned to normal in all patients who underwent valve ablation, except in three, while renal function returned to normal in only three of 11 patients who underwent urinary diversion. Radiological hydronephrosis and/or reflux resolved in 28 patients (60.9%), was downgraded in six patients (13%) and persisted in 12 patients (26.1%). CONCLUSIONS Antenatal vesicoamniotic shunt placement makes no difference to the outcome and long-term results of patients with PUV and debate about its efficacy on renal outcome remains. Primary valve ablation is the keystone of treatment for patients with PUV that might achieve the primary goal of nephron preservation. The lowest creatinine concentration in the first year of life is the most appropriate predictor of future renal function.
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Affiliation(s)
- Mamdouh A Salam
- Pediatric Surgery Department, Ain Shams University, Cairo, Egypt.
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11
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Kim SK, Won HS, Shim JY, Kim KS, Lee PR, Kim A. Successful vesicoamniotic shunting of posterior urethral valves in the first trimester of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:666-8. [PMID: 16254891 DOI: 10.1002/uog.2604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Prenatal ultrasonography early in gestation allows diagnosis of posterior urethral valves. We report on a fetus with posterior urethral valves treated using vesicoamniotic shunting at 13 + 5 weeks' gestation. A double-basket catheter was used for shunting. A 2582-g male neonate was delivered at 33 weeks' gestation, and the infant continued to show normal renal function at 3 years of age. To the best of our knowledge this is the first report of successful vesicoamniotic shunt placement using a double-basket catheter in the first trimester of pregnancy.
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Affiliation(s)
- S K Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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12
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Lunacek A, Oswald J, Schwentner C, Gassner I, Bartsch G, Radmayr C. Prenatal puncture of a unilateral hydronephrosis leading to fetal urinoma and postnatal nephrectomy. Urology 2004; 63:982-4. [PMID: 15135002 DOI: 10.1016/j.urology.2004.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2003] [Revised: 01/20/2004] [Accepted: 01/20/2004] [Indexed: 10/26/2022]
Abstract
Fetal pelvicaliceal dilatation due to ureteropelvic junction obstruction is the most common cause of antenatal hydronephrosis; it rarely leads to a spontaneous rupture resulting in urinoma formation. Antenatal intervention has been recommended only in those cases of large urinomas that seem to interfere with the function of other organ systems (eg, pulmonary hypoplasia secondary to diaphragmatic elevation). We report the case of a fetal intervention (transuterine puncture) in a unilateral massive hydronephrosis leading to a perirenal urinoma and the preterm birth of a female infant. Postnatally, mechanical ventilation and oxygen were required, as was forced percutaneous urinoma drainage. Evaluation revealed a fistula formation between the perirenal space and the kidney's collecting system, possibly due to the fetal intervention. Unfortunately the kidney function was very poor, and surgery to remove the impaired kidney and the urinoma was performed. We discuss the possible effects of fetal intervention in cases of obstructive uropathy and the postnatal risks associated with it.
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Affiliation(s)
- Andreas Lunacek
- Department of Pediatric Urology, Medical University of Innsbruck, Innsbruck, Austria
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13
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Abstract
Significant advances have been made recently in elucidating the cellular consequences of urinary tract obstruction during renal development. Urinary tract obstruction impairs growth and maturation of the kidney, and can also cause renal maldevelopment. This includes a reduction in the number of nephrons, tubular atrophy, and progressive interstitial fibrosis. Apoptosis (programmed cell death) accounts for much of the loss of tubular epithelial cells. Factors contributing to apoptosis include stretching of cells in dilated tubules, altered renal production of growth factors, and infiltration of the renal interstitium by macrophages. Two major controversies remain regarding the surgical management of congenital obstructive nephropathy: first, which fetuses with bladder outlet obstruction should undergo prenatal intervention, and second, which infants should undergo early pyeloplasty for ureteropelvic junction obstruction? Even after successful surgery for congential obstructive nephropathy, all patients should be followed for hypertension, proteinuria, or renal deterioration.
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Affiliation(s)
- Robert L Chevalier
- Department of Pediatrics, Children's Medical Center, University of Virginia, Charlottesville, VA 22908, USA.
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Affiliation(s)
- A R Aslan
- Division of Urology, Albany Medical College, Albany NY 12208, USA
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McLORIE GORDON, FARHAT WALID, KHOURY ANTOINE, GEARY DENNIS, RYAN GREGORY. OUTCOME ANALYSIS OF VESICOAMNIOTIC SHUNTING IN A COMPREHENSIVE POPULATION. J Urol 2001. [DOI: 10.1016/s0022-5347(05)65913-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- GORDON McLORIE
- From the Divisions of Pediatric Urology and Nephrology, Hospital for Sick Children, and Division of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - WALID FARHAT
- From the Divisions of Pediatric Urology and Nephrology, Hospital for Sick Children, and Division of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - ANTOINE KHOURY
- From the Divisions of Pediatric Urology and Nephrology, Hospital for Sick Children, and Division of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - DENNIS GEARY
- From the Divisions of Pediatric Urology and Nephrology, Hospital for Sick Children, and Division of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - GREGORY RYAN
- From the Divisions of Pediatric Urology and Nephrology, Hospital for Sick Children, and Division of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Herndon CD, Ferrer FA, Freedman A, McKenna PH. Consensus on the prenatal management of antenatally detected urological abnormalities. J Urol 2000. [PMID: 10958739 DOI: 10.1016/s0022-5347(05)67248-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The incidence of an antenatally detected genitourinary abnormality is 0.5% of all pregnancies assessed, and rarely is antenatal intervention indicated. A survey of pediatric urologists was undertaken to evaluate current practice patterns and recommendations regarding the need to intervene in the antenatal period. MATERIALS AND METHODS A survey instrument was mailed to all members of the Society for Fetal Urology. There were 7 case scenarios that addressed critical decision points in patients with antenatally detected genitourinary abnormalities. RESULTS A total of 112 of 188 Society for Fetal Urology members (60%) completed the survey. Observation with serial ultrasound was recommended for a 32-week fetus with ureteropelvic junction obstruction. For a 36-week fetus with suspected posterior urethral valves without oligohydramnios most respondents elected no intervention with a minority favoring early delivery. For a 23-week fetus with suspected posterior urethral valves and oligohydramnios with normal bladder electrolytes most respondents agreed with a vesicoamniotic shunt. There was no clear consensus for a 20-week fetus with suspected posterior urethral valves, oligohydramnios and a nonfunctioning right kidney. Most respondents recommended serial ultrasound to follow an 18-week fetus with suspected posterior urethral valves and normal amniotic fluid. Antenatal intervention was not recommended for a 20-week fetus with bilateral renal cystic disease, and most respondents elected no intervention for a 28-week fetus with a solitary kidney with suspected ureteropelvic junction obstruction and normal amniotic fluid. CONCLUSIONS Situations that warrant antenatal intervention for a genitourinary abnormality are exceedingly low and may include cases of oligohydramnios, suspected favorable renal function and the absence of life threatening congenital abnormalities. In cases with normal amniotic fluid antenatal intervention is not recommended regardless of the detected abnormality. There is an emerging trend toward early delivery of fetuses with severe genitourinary abnormalities, normal amniotic fluid and confirmed lung maturity.
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Affiliation(s)
- C D Herndon
- Department of Pediatric Urology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
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18
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Herndon CD, Ferrer FA, Freedman A, McKenna PH. Consensus on the prenatal management of antenatally detected urological abnormalities. J Urol 2000; 164:1052-6. [PMID: 10958739 DOI: 10.1097/00005392-200009020-00032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The incidence of an antenatally detected genitourinary abnormality is 0.5% of all pregnancies assessed, and rarely is antenatal intervention indicated. A survey of pediatric urologists was undertaken to evaluate current practice patterns and recommendations regarding the need to intervene in the antenatal period. MATERIALS AND METHODS A survey instrument was mailed to all members of the Society for Fetal Urology. There were 7 case scenarios that addressed critical decision points in patients with antenatally detected genitourinary abnormalities. RESULTS A total of 112 of 188 Society for Fetal Urology members (60%) completed the survey. Observation with serial ultrasound was recommended for a 32-week fetus with ureteropelvic junction obstruction. For a 36-week fetus with suspected posterior urethral valves without oligohydramnios most respondents elected no intervention with a minority favoring early delivery. For a 23-week fetus with suspected posterior urethral valves and oligohydramnios with normal bladder electrolytes most respondents agreed with a vesicoamniotic shunt. There was no clear consensus for a 20-week fetus with suspected posterior urethral valves, oligohydramnios and a nonfunctioning right kidney. Most respondents recommended serial ultrasound to follow an 18-week fetus with suspected posterior urethral valves and normal amniotic fluid. Antenatal intervention was not recommended for a 20-week fetus with bilateral renal cystic disease, and most respondents elected no intervention for a 28-week fetus with a solitary kidney with suspected ureteropelvic junction obstruction and normal amniotic fluid. CONCLUSIONS Situations that warrant antenatal intervention for a genitourinary abnormality are exceedingly low and may include cases of oligohydramnios, suspected favorable renal function and the absence of life threatening congenital abnormalities. In cases with normal amniotic fluid antenatal intervention is not recommended regardless of the detected abnormality. There is an emerging trend toward early delivery of fetuses with severe genitourinary abnormalities, normal amniotic fluid and confirmed lung maturity.
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Affiliation(s)
- C D Herndon
- Department of Pediatric Urology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
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19
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Abstract
Obstructive uropathy is a significant source of morbidity and mortality in the neonate and infant, despite advances in postnatal management. Diagnosis is typically made early in the second trimester on the basis of sonographic measurements. In utero therapy holds promise for improved outcomes by preventing progressive urinary tract damage and permitting drainage of urine into the amniotic space to minimize the pulmonary sequelae of oligohydramnios. Multiple studies with animal models have showed the benefits of midgestational intervention, but large prospective, randomized studies have not yet been performed to confirm these findings in humans. Standardization of the diagnostic evaluation allows for refined patient selection, resulting in improved postnatal outcomes after fetal vesicoamniotic shunting. Research into the role of specific growth factors and immunoproteins in renal development and function may further improve patient selection and outcome. This article reviews diagnosis, technique, and outcomes for fetal treatment of obstructive uropathy.
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Affiliation(s)
- D S Walsh
- Center for Fetal Diagnosis and Treatment, the Children's Hospital of Philadelphia, PA 19104, USA
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20
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Abstract
Our understanding of the causes, mechanisms, and prenatal management of fetal obstructive uropathy has increased significantly. Improved methods of prenatal evaluation have allowed the better selection of fetuses for invasive therapy, and studies indicate better survival and renal outcomes in carefully selected cases. New biological markers in fetal urine may provide a better understanding of the pathological processes of renal damage, additional prognostic markers, and lead to non-surgical approaches to preventing renal damage.
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Affiliation(s)
- M P Johnson
- Department of Pediatric General and Thoracic Surgery, Children's Hospital of Philadelphia, PA 19104, USA
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21
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Shaaban AF, Kim HB, Milner R, Crombleholme T. The role of ultrasonography in fetal surgery and invasive fetal procedures. Semin Roentgenol 1999; 34:62-77. [PMID: 9988864 DOI: 10.1016/s0037-198x(99)80021-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- A F Shaaban
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA 19104, USA
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Peters CA. Lower urinary tract obstruction: clinical and experimental aspects. BRITISH JOURNAL OF UROLOGY 1998; 81 Suppl 2:22-32. [PMID: 9602792 DOI: 10.1046/j.1464-410x.1998.0810s2022.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- C A Peters
- Department of Urology, Children's Hospital, Boston, MA, USA
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Prenatally Detected Posterior Urethral Valves: Qualitative Assessment of Second Trimester Scans and Prediction of Outcome. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64379-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Radhakrishnan J, Lievano G. Postnatal management of hydronephrosis diagnosed in utero. Indian J Pediatr 1997; 64:303-12. [PMID: 10771852 DOI: 10.1007/bf02845199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In this review we identify the causes of antenatal hydronephrosis and detail management options. A large majority of these patients can be treated safely and effectively after birth.
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Affiliation(s)
- J Radhakrishnan
- Division of Pediatric Surgery and Urology, University of Illinois, Chicago, USA
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