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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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Duin LK, Fontanella F, Groen H, Adama van Scheltema PN, Cohen-Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Oepkes D, Bilardo CM. Prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO)-Development and internal validation. Prenat Diagn 2019; 39:1235-1241. [PMID: 31659787 DOI: 10.1002/pd.5573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop a prediction model of postnatal renal function in fetuses with lower urinary tract obstruction (LUTO) based on fetal ultrasound parameters and amniotic fluid volume. METHODS Retrospective nationwide cohort study of fetuses with postnatally confirmed LUTO and known eGFR. Fetuses treated with fetal interventions such as vesico-amniotic shunting or cystoscopy were excluded. Logistic regression analysis was used to identify prognostic ultrasound variables with respect to renal outcome following multiple imputation of missing data. On the basis of these fetal renal parameters and amniotic fluid volume, a model was developed to predict postnatal renal function in fetuses with LUTO. The main study outcome was an eGFR less than 60 mL/min * 1.73 m2 based on the creatinine nadir during the first year following diagnosis. Model performance was evaluated by receiver operator characteristic (ROC) curve analysis, calibration plots, and bootstrapping. RESULTS Hundred one fetuses with a confirmed diagnosis of LUTO were included, eGFR less than 60 was observed in 40 (39.6%) of them. Variables predicting an eGFR less than 60 mL/min * 1.73m2 included the following sonographic parameters: hyperechogenicity of the renal cortex and abnormal amniotic fluid volume. The model showed fair discrimination, with an area under the ROC curve of 0.70 (95% confidence interval, 0.59-0.81, 0.66 after bootstrapping) and was overall well-calibrated. CONCLUSION This study shows that a prediction model incorporating ultrasound parameters such as cortical appearance and abnormal amniotic fluid volume can fairly discriminate an eGFR above or below 60 mL/min * 1.73m2 . This clinical information can be used in identifying fetuses eligible for prenatal interventions and improve counseling of parents.
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Affiliation(s)
- Leonie K Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Federica Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Phebe N Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Pajkrt
- Department of Obstetrics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Mireille Bekker
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christine Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Leiden University Medical Center, Leiden, The Netherlands
| | - Caterina M Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center Groningen, Groningen, The Netherlands.,Department of Obstetrics, Gynaecology and Prenatal Diagnosis, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Iuculano A, Peddes C, Monni G. Early fetal megacystis: Is it possible to predict the prognosis in the first trimester? J Perinat Med 2018; 46:1035-1039. [PMID: 29369818 DOI: 10.1515/jpm-2017-0351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the best management of fetal megacystis diagnosed in the first trimester and define the prognosis and the most appropriate follow-up as early as possible. METHODS This is a retrospective study of first-trimester fetal megacystis diagnosed in pregnant women who performed a combined screening for fetal aneuploidy. Megacystis was defined as a longitudinal bladder diameter (LBD) greater than 7 mm. All fetuses were divided into two groups according to the LBD: Group A with LBD > 15 mm and Group B with LBD < 15 mm. The fetal karyotype and associated anomalies were evaluated. Ultrasound monitoring was performed every 2 weeks (a second ultrasound scan after 2 weeks from diagnosis and a third ultrasound scan 2 weeks after the second one). RESULTS Twenty-six cases were identified between 2011 and 2016; three cases of aneuploidy were excluded from the study. Of the remaining 23 cases, 11 were included in Group A and 12 in Group B. All Group A fetuses had an adverse outcome. In Group B: five (41.7%) cases had an adverse outcome and seven (58.3%) had a spontaneous resolution of megacystis. The ultrasound findings of both the ultrasound scans, the second and the third, were 100% concordant. CONCLUSION An ultrasound scan performed 2 weeks after the megacystis diagnosis can predict the outcome in fetuses with an LBD < 15 mm as early as the end of the first trimester. The outcome of euploid fetuses with an LBD < 15 mm was favorable in 58.3% of the cases.
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Affiliation(s)
- Ambra Iuculano
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Cagliari, Italy
| | - Cristina Peddes
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Cagliari, Italy
| | - Giovanni Monni
- Department of Prenatal and Preimplantation Genetic Diagnosis and Fetal Therapy, Ospedale Microcitemico, Via E. Jenner n/n, 09121 Cagliari, Italy
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Deshpande AV. Current strategies to predict and manage sequelae of posterior urethral valves in children. Pediatr Nephrol 2018; 33:1651-1661. [PMID: 29159472 DOI: 10.1007/s00467-017-3815-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
Posterior urethral valves (PUV) constitute a significant urological cause of chronic kidney disease (CKD) in children. The condition is characterised by the unique pathophysiology of the evolution of bladder dysfunction after relief of obstruction, which contributes to CKD. Improvements in prenatal diagnosis followed by selective foetal intervention have not yet produced improvement in long-term renal outcomes, although better patient selection may alter this in the future. Proactive management with surveillance, pharmacotherapy, timed voiding, double voiding, and/or assisted bladder-emptying, is being increasingly offered to those with severe bladder dysfunction and has the potential of reducing the burden of renal disease. Clinicians are currently able to counsel regarding the prognosis using serum creatinine and other emerging markers. However, much of this work remains to be validated. Satisfactory graft survival rates are now reported with aggressive management of bladder dysfunction in children who are candidates for renal transplantation. Knowledge gaps exist in identifying early markers of renal injury, risk stratification, and in understanding patient and carer perspectives in PUV.
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Affiliation(s)
- Aniruddh V Deshpande
- Department of Paediatric Urology and Surgery, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia. .,Priority Research Centre GrowupWell, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia.
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Nassr AA, Shazly SAM, Abdelmagied AM, Araujo Júnior E, Tonni G, Kilby MD, Ruano R. Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: an updated systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:696-703. [PMID: 27270578 DOI: 10.1002/uog.15988] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the effect on perinatal and postnatal survival of vesicoamniotic shunt (VAS) as treatment for fetal lower urinary tract obstruction (LUTO). METHODS An electronic search of Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus using relevant search terms was conducted from inception to June 2015 to identify studies comparing outcomes of VAS vs conservative management for treatment of LUTO. Cohort studies and clinical trials were considered eligible. Single-arm studies and studies that did not report survival were excluded. Sample size and language were not criteria for exclusion. Two reviewers extracted independently data in a standardized form, including study characteristics and results. Primary outcomes were perinatal and postnatal survival. Secondary outcome was postnatal renal function. Data on fetal survival were expressed as odds ratio (OR) and 95% CI. RESULTS Of the 423 abstracts retrieved, nine studies were eligible for inclusion. These studies included 112 fetuses treated with VAS and 134 that were managed conservatively. There was heterogeneity in study design. Although the data demonstrated a difference in effect estimates between the study arms in terms of perinatal survival (OR, 2.54 (95% CI, 1.14-5.67)), there was no difference in 6-12-month survival (OR, 1.77 (95% CI, 0.25-12.71)) or 2-year survival (OR, 1.81 (95% CI, 0.09-38.03)). In addition, there was no difference in effect on postnatal renal function between fetuses that underwent intervention and those that did not (OR, 2.09 (95% CI, 0.74-5.94)). CONCLUSIONS Available data seem to support an advantage for perinatal survival in fetuses treated with VAS compared with conservative management. However, 1-2-year survival and outcome of renal function after VAS procedure remain uncertain. Further studies are necessary to evaluate the effectiveness of fetal intervention for LUTO based on different severity of the disease, due to the very low quality of the studies according to GRADE guidelines. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - S A M Shazly
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - A M Abdelmagied
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - G Tonni
- Prenatal Diagnostic Service, Department of Obstetrics and Gynecology, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - M D Kilby
- Centre for Women's and Children's Health, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Ruano
- Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic, Rochester, MN, USA
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Aulbert W, Kemper MJ. Severe antenatally diagnosed renal disorders: background, prognosis and practical approach. Pediatr Nephrol 2016; 31:563-74. [PMID: 26081158 DOI: 10.1007/s00467-015-3140-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/12/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022]
Abstract
Nowadays most renal disorders, especially urinary tract malformations and renal cystic disease, are diagnosed antenatally. In cases of severe bilateral disease, intrauterine renal dysfunction may lead to renal oligohydramnios (ROH), resulting in pulmonary hypoplasia which affects perinatal mortality and morbidity as well as the long-term outcome. However, some infants may only have mild pulmonary and renal disease, and advances in postnatal and dialysis treatment have resulted in improved short- and long-term outcome even in those infants with severe ROH. Here, we review the current state of knowledge and clinical experience of patients presenting antenatally with severe bilateral renal disorders and ROH. By addressing underlying mechanisms, intrauterine tools of diagnosis and treatment as well as published outcome data, we hope to improve antenatal counselling and postnatal care. KEY SUMMARY POINTS: 1. Nowadays most renal disorders are diagnosed antenatally, especially urinary tract malformations and renal cystic disease. 2. Severe kidney dysfunction may lead to renal oligohydramnios, which can cause pulmonary hypoplasia and is a risk factor of perinatal mortality and postnatal renal outcome. However, as considerable clinical heterogeneity is present, outcome predictions need to be treated with caution. 3. Advances in postnatal and dialysis treatment have resulted in improved short- and long-term outcomes even in infants with severe renal oligohydramnios. 4. A multidisciplinary approach with specialist input is required when counselling a family with an ROH-affected fetus as the decision-making process is very challenging.
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Affiliation(s)
- Wiebke Aulbert
- Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Markus J Kemper
- Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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