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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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Richter J, Doktor F, Good H, Erdman L, Kim JK, Santos JD, Brownrigg N, Chua M, Lorenzo AJ, Rickard M, Mieghem TV, Shinar S. Trends in Management of Fetuses with Suspected Lower Urinary Tract Obstruction (LUTO): A High-Risk Fetal and Pediatric Center Experience in a Universal-Access-to-Care System. Eur J Pediatr Surg 2024; 34:91-96. [PMID: 37607585 DOI: 10.1055/s-0043-1772172] [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: 08/24/2023]
Abstract
INTRODUCTION Neonates with lower urinary tract obstruction (LUTO) experience high morbidity and mortality associated with the development of chronic kidney disease. The prenatal detection rate for LUTO is less than 50%, with late or missed diagnosis leading to delayed management and long-term sequelae in the remainder. We aimed to explore the trends in prenatal detection and management at a high-risk fetal center and determine if similar trends of postnatal presentations were noted for the same period. METHODS Prenatal and postnatal LUTO databases from a tertiary fetal center and its associated pediatric center between 2009 and 2021 were reviewed, capturing maternal age, gestational age (GA) at diagnosis, and rates of termination of pregnancy (TOP). Time series analysis using autocorrelation was performed to investigate time trend changes for prenatally suspected and postnatally confirmed LUTO cases. RESULTS A total of 161 fetuses with prenatally suspected LUTO were identified, including 78 terminations. No significant time trend was found when evaluating the correlation between time periods, prenatal suspicion, and postnatal confirmation of LUTO cases (Durbin-Watson [DW] = 1.99, p = 0.3641 and DW = 2.86, p = 0.9113, respectively). GA at referral was 20.0 weeks (interquartile range [IQR] 12, 35) and 22.0 weeks (IQR 13, 37) for TOP and continued pregnancies (p < 0.0001). GA at initial ultrasound was earlier in terminated fetuses compared to continued (20.0 [IQR 12, 35] weeks vs. 22.5 [IQR 13, 39] weeks, p < 0.0001). While prenatal LUTO suspicion remained consistently higher than postnatal presentations, the rates of postnatal presentations and terminations remained stable during the study years (p = 0.7913 and 0.2338), as were GA at TOP and maternal age at diagnosis (p = 0.1710 and 0.1921). CONCLUSION This study demonstrated that more severe cases of LUTO are referred earlier and are more likely to undergo TOP. No significant trend was detected between time and prenatally suspected or postnatally confirmed LUTO, highlighting the need for further studies to better delineate factors that can increase prenatal detection.
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Affiliation(s)
- Juliane Richter
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fabian Doktor
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
- University of Leipzig, Department of Pediatric Surgery, Leipzig, Germany
| | - Hayley Good
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Erdman
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada; Vector Institute, Toronto, Ontario, Canada
- Centre for Computational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jin K Kim
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natasha Brownrigg
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Chua
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Urology, St. Luke's Medical Center, Philippines
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shiri Shinar
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Hoselton AS, Finup J, Roedel M, Davidson E, Farhat W. A Case of Urethral Atresia: Emphasizing the Role of Parental Engagement. Urology 2024; 184:e243-e245. [PMID: 37956764 DOI: 10.1016/j.urology.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
Congenital urethral atresia is generally considered to be incompatible with life unless there is either a patent urachus or vesicoamniotic shunt. Here we present the case of a male neonate with anhydramnios detected at 28weeks gestation due to urethral atresia, who was born without evidence of either a patent urachus or vesicoamniotic shunt, who has survived and is not requiring respiratory support at age 5months. While this is a thought-provoking clinical case, it also highlights the importance of early and effective parental engagement in cases of complex congenital anomalies of the urinary tract.
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Affiliation(s)
| | - Jennika Finup
- University of Wisconsin - Madison, Department of Urology, Madison, WI
| | - Megan Roedel
- University of Wisconsin - Madison, Department of Urology, Madison, WI
| | - Emily Davidson
- University of Wisconsin - Madison, Department of Urology, Madison, WI
| | - Walid Farhat
- University of Wisconsin - Madison, Department of Urology, Madison, WI
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Rickard M, Kim JK, Van Mieghem T, Shinar S, McKay A, Santos JD, Brownrigg N, Keefe DT, Lorenzo AJ, Chua M. The Toronto nomogram: A Bayesian meta-regression derived prenatal ultrasound index to predict lower urinary tract obstruction and prune belly syndrome. Prenat Diagn 2024; 44:117-123. [PMID: 37165481 DOI: 10.1002/pd.6384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION A nomogram for predicting the diagnosis of lower urinary tract obstruction (LUTO) based on an antenatal ultrasound index generated from a Bayesian Meta-regression analysis has been in development and noted with superior diagnostic accuracy compared to the keyhole sign (KHS). We aim to assess the accuracy of the nomogram in expanded diagnostic utilization to predict LUTO. METHODOLOGY The validation of the nomogram for expanded diagnostic utilization was based on data from a prospective institutional antenatal clinic database between January 2020 and June 2022. Diagnostic accuracy indices were determined for confirmed postnatal diagnosis of LUTO or prune belly syndrome (PBS). Receiver operating characteristics (ROC) curves were generated to compare the area under the curve (AUC) of the nomogram versus KHS. RESULTS Based on 84 male fetuses with antenatal ultrasound of moderate-severe hydronephrosis (PUV n = 15, PBS n = 4), the KHS had 26.3% (95%CI 9.1-51.2) sensitivity and 100% (95%CI 94.4%-100%) specificity, with 14 false-negatives. The nomogram showed a 84.2 (95%CI 60.4%-96.6%) sensitivity and 95.4 (95%CI 87.1%-99%) specificity with three false-positives. The nomogram also had a superior AUC compared to KHS (0.98 vs. 0.63). CONCLUSION The nomogram can be used as a valuable tool to trigger further postnatal screening and provide individualized risk assessments to families during prenatal counseling.
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Affiliation(s)
- Mandy Rickard
- Divison of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jin Kyu Kim
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Shiri Shinar
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ashlene McKay
- Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joana Dos Santos
- Divison of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natasha Brownrigg
- Divison of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniel T Keefe
- Division of Pediatric Urology, Department of Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Armando J Lorenzo
- Divison of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Chua
- Divison of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Kohaut J, Fischer-Mertens J, Cernaianu G, Schulten D, Holtkamp G, Kohl S, Habbig S, Klein R, Kribs A, Gottschalk I, Berg C, Dübbers M. Postnatal surgical treatment and complications following intrauterine vesicoamniotic shunting with the SOMATEX® intrauterine shunt. A single center experience. J Pediatr Urol 2023; 19:567.e1-567.e6. [PMID: 37451915 DOI: 10.1016/j.jpurol.2023.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Intrauterine vesicoamniotic shunting (VAS) using a Somatex® shunt was shown to significantly affect survival of male fetuses with megacystis in suspected lower urinary tract obstruction (LUTO) [Figure 1]. Data on postnatal surgical management and complications are largely lacking. OBJECTIVE To describe the postnatal management of patients with prenatal VAS for megacystitis in suspected severe LUTO. STUDY DESIGN All male newborns with previous intrauterine VAS using a Somatex® shunt treated in our institution were retrospectively analyzed. We evaluated the spectrum of urethral pathologies and postnatal surgical management, especially focusing on shunt removal. RESULTS Between 2016 and 2022, 17 patients (all male) were treated postnatally in our institution after VAS for suspected severe LUTO. Five fetuses with dislocated shunts underwent re-implantation in utero. Overall, premature birth before the 38th week of gestation was observed in eight patients (8/17). Seven shunts could be removed without further anesthesia as a bedside procedure. Ten patients required surgical shunt removal under general anesthesia due to migration (59%). Laparoscopic shunt extraction was performed in 8/10 cases. Most frequently, dislocated shunts were located incorporated in the detrusor in eight cases and the removal required a bladder suture in 2/8 patients. In one case, the shunt was removed from the abdominal wall and in one case from the intestine wall [Figure 2]. Posterior urethral valves were found in 8/17 patients, 6/17 patients showed a urethral atresia and one patient had urethral duplication. In two patients, we identified a high grade bilateral vesicoureteral reflux without LUTO. CONCLUSION In our observation, more than half of the newborns with megacystis in suspected LUTO require a shunt removal surgery after early VAS using a Somatex® shunt. Urethral atresia may be found more frequently in these patients. These data should be taken into consideration for prenatal counselling of parents and planning of postnatal management.
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Affiliation(s)
- J Kohaut
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - J Fischer-Mertens
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - G Cernaianu
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - D Schulten
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - G Holtkamp
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - S Kohl
- Department of Pediatrics and Adolescent Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - S Habbig
- Department of Pediatrics and Adolescent Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - R Klein
- Department of Pediatrics and Adolescent Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - A Kribs
- Department of Pediatrics and Adolescent Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - I Gottschalk
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - C Berg
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - M Dübbers
- Division of Pediatric Surgery, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
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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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Kohl T, Fimmers R, Axt-Fliedner R, Degenhardt J, Brückmann M. Vesico-amniotic shunt insertion prior to the completion of 16 weeks results in improved preservation of renal function in surviving fetuses with isolated severe lower urinary tract obstruction (LUTO). J Pediatr Urol 2022; 18:116-126. [PMID: 35123910 DOI: 10.1016/j.jpurol.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 10/21/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this retrospective cohort study was to compare the outcome of human fetuses with isolated severe lower urinary tract obstructions (LUTO) that were first treated before the completion of 16 weeks of gestation to fetuses first treated later in gestation. PATIENTS AND METHODS Vesicoamniotic shunt insertion (VAS) was performed in 63 subsequent fetuses with LUTO between 12 + 5 and 30 + 3 weeks. The fetuses were analyzed in three groups: Group-I-fetuses underwent their first intervention until the completion of 16 weeks, Group-II-fetuses were first treated between 16 + 1 and 24 + 0 weeks and Group-III-fetuses beyond 24 + 1 weeks. Renal and pulmonary outcome parameters and complicating factors were assessed. RESULTS - All mothers tolerated the procedures well. Overall fetal survival was 47 of 63 (75%). The mean age at delivery of survivors was 35 weeks. 68% of Group-I-fetuses, 77% of group-II-fetuses, and 100% of group-III-fetuses survived beyond postnatal hospital discharge. Amongst the survivors the chance for normal renal function was higher for group I with 79% (15/19) compared to first fetal intervention after the completion of 16 weeks with 32% (9/28, p = 0.003, OR = 7.9 [2.0, 30.8] 95% CI). Clinically relevant pulmonary hypoplasia was observed in 11% of Group-I-, 27% of Group-II-, and 20% of Group-III-fetuses. CONCLUSIONS Early intervention in fetal LUTO before the completion of 16 weeks may achieve a higher rate of normal renal and pulmonary function in survivors than treatment beyond that point in time. This observation is important for the future management of this challenging patient population.
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Affiliation(s)
- Thomas Kohl
- German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT), Germany.
| | - Rolf Fimmers
- Department of Obstetrics and Gynecology, Mannheim University Hospital, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany; Department of Biometry, Bonn University Hospital, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Roland Axt-Fliedner
- Division of Prenatal Medicine, Giessen University Hospital, KlinikStraße 33, 35392, Giessen, Germany
| | - Jan Degenhardt
- Division of Prenatal Medicine, Giessen University Hospital, KlinikStraße 33, 35392, Giessen, Germany
| | - Moritz Brückmann
- Division of Prenatal Medicine, Giessen University Hospital, KlinikStraße 33, 35392, Giessen, Germany
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Rickard M, Santos JD, Keunen J, Lorenzo AJ. Prenatal Hydronephrosis: Bridging Pre- and Postnatal Management. Prenat Diagn 2022; 42:1081-1093. [PMID: 35165908 DOI: 10.1002/pd.6114] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
Urinary tract dilation (UTD), including hydronephrosis (HN) is the most common prenatally detected anomaly and affects up to 1-2% of pregnancies. Postnatally, it resolves without surgical intervention in approximately 75-80% of children, however this may take several years to occur, necessitating repeated clinic visits and additional invasive testing for many. For the remainder, a surgical intervention will be offered to relieve obstruction or to correct vesicoureteral reflux. During the monitoring period, many of these infants will be offered continuous antibiotic prophylaxis for the prevention of urinary tract infections, however this remains a controversial topic among pediatric urologists and nephrologists. Herein, we present an up-to-date review of the early management of prenatally detected UTD including timing of postnatal imaging, the use of antibiotics, when circumcision may be beneficial and long term outcomes of the most common HN etiologies. We also propose a decision making tool to help guide the care of infants with UTD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Mandy Rickard
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Johannes Keunen
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Capone V, Persico N, Berrettini A, Decramer S, De Marco EA, De Palma D, Familiari A, Feitz W, Herthelius M, Kazlauskas V, Liebau M, Manzoni G, Maternik M, Mosiello G, Schanstra JP, Vande Walle J, Wühl E, Ylinen E, Zurowska A, Schaefer F, Montini G. Definition, diagnosis and management of fetal lower urinary tract obstruction: consensus of the ERKNet CAKUT-Obstructive Uropathy Work Group. Nat Rev Urol 2022; 19:295-303. [PMID: 35136187 DOI: 10.1038/s41585-022-00563-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022]
Abstract
Fetal lower urinary tract obstruction (LUTO) is associated with high mortality and postnatal morbidity caused by lung hypoplasia and impaired kidney function. Specific diagnostic features that can guide clinical approach and decisions are lacking; thus, the European Reference Network for Rare Kidney Diseases established a work group to develop recommendations regarding the clinical definition, diagnosis and management of prenatally detected LUTO. The work group recommends the use of antero-posterior diameter of renal pelvis as the most reliable parameter for suspecting obstructive uropathies and for suspecting prenatal LUTO in the presence of fetal megacystis. Regarding prenatal and postnatal prognosis of fetuses with LUTO, the risk of fetal and neonatal death depends on the presence of oligohydramnios or anhydramnios before 20 weeks' gestation, whereas the risk of kidney replacement therapy cannot be reliably foreseen before birth. Parents of fetuses with LUTO must be referred to a tertiary obstetric centre with multidisciplinary expertise in prenatal and postnatal management of obstructive uropathies, and vesico-amniotic shunt placement should be offered in selected instances, as it increases perinatal survival of fetuses with LUTO.
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Affiliation(s)
- Valentina Capone
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Nicola Persico
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alfredo Berrettini
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Stèphane Decramer
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France.,Service de Néphrologie Pédiatrique, Hôpital des Enfants, CHU Toulouse, Toulouse, France.,Centre De Référence des Maladies Rénales Rares du Sud-Ouest (SORARE), Toulouse, France
| | - Erika Adalgisa De Marco
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Diego De Palma
- Nuclear Medicine Unit, "Circolo" Hospital, ASST-settelaghi, Varese, Italy
| | - Alessandra Familiari
- High Risk Pregnancy Unit, Department of Women, Children and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Wout Feitz
- Department of Urology, Division of Paediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Maria Herthelius
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Vytis Kazlauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Max Liebau
- Department of Pediatrics and Center for Molecular Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gianantonio Manzoni
- Pediatric Urology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Michal Maternik
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Giovanni Mosiello
- Bambino Gesù Pediatric Hospital, Division of Pediatric Urology/Neuro-Urology, Rome, Italy
| | - Joost Peter Schanstra
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France
| | - Johan Vande Walle
- Paediatric Nephrology and Rheumatology Section, Department of Paediatrics, Ghent University Hospital, Ghent, Belgium
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Pellegrino C, Capitanucci ML, Forlini V, Zaccara A, Lena F, Sollini ML, Castelli E, Mosiello G. Posterior urethral valves: Role of prenatal diagnosis and long-term management of bladder function; a single center point of view and review of literature. Front Pediatr 2022; 10:1057092. [PMID: 36683802 PMCID: PMC9853300 DOI: 10.3389/fped.2022.1057092] [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: 09/29/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Posterior Urethral Valves (PUV) are the most common cause of lower urinary tract obstruction. More severe forms are detected early in pregnancy (mainly type I), while other forms are usually discovered later in childhood when investigating lower urinary tract symptoms. Bladder dysfunction is common and is associated with urinary incontinence in about 55% (0%-72%). Despite the removal of the obstruction by urethral valve ablation, pathological changes of the urinary tract can occur with progressive bladder dysfunction, which can cause deterioration of the upper urinary tract as well. For this reason, all children with PUV require long-term follow-up, always until puberty, and in many cases life-long. Therefore, management of PUV is not only limited to obstruction relief, but prevention and treatment of bladder dysfunction, based on urodynamic observations, is paramount. During time, urodynamic patterns may change from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure (valve bladder). In the past, an aggressive surgical approach was performed in all patients, and valve resection was considered an emergency procedure. With the development of fetal surgery, vesico-amniotic shunting has been performed as well. Due to improvements of prenatal ultrasound, the presence of PUV is usually already suspected during pregnancy, and subsequent treatment should be performed in high-volume centers, with a multidisciplinary, more conservative approach. This is considered to be more effective and safer. Primary valve ablation is performed after clinical stability and is no longer considered an emergency procedure after birth. During childhood, a multidisciplinary approach (pediatric urologist, nephrologist, urotherapist) is recommended as well in all patients, to improve toilet training, using an advanced urotherapy program with medical treatments and urodynamic evaluations. The aim of this paper is to present our single center experience over 30 years.
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Affiliation(s)
- Chiara Pellegrino
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy
| | - Maria Luisa Capitanucci
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy
| | - Valentina Forlini
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy.,Pediatric Surgery Division, University of Genova, Genoa, Italy
| | - Antonio Zaccara
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy
| | - Federica Lena
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy.,Pediatric Surgery Division, University of Genova, Genoa, Italy
| | - Maria Laura Sollini
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy.,Division of Physical Rehabilitation, University of Tor Vergata, Rome, Italy
| | - Enrico Castelli
- Division of Neuro-Rehabilitation, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy
| | - Giovanni Mosiello
- ERN EUROGEN Affiliated Center, Division of Neuro-Urology and Surgery for Continence, Bambino Gesù Childrens' Hospital, IRCCS, Rome, Italy
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11
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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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12
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Safdar A, Singh K, Sun RC, Nassr AA. Evaluation and fetal intervention in severe fetal hydronephrosis. Curr Opin Pediatr 2021; 33:220-226. [PMID: 33651757 DOI: 10.1097/mop.0000000000001001] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fetal hydronephrosis secondary to congenital anomalies of the kidney and urinary tract (CAKUT) can adversely affect neonates in the postnatal period with long-term consequences. A prenatal diagnosis of CAKUT can have an early fetal intervention to minimize these consequences. This review aims to provide an overview of the possible fetal intervention with severe hydronephrosis. RECENT FINDINGS Clinical course and outcomes of CAKUT are predicted based on biochemical markers and radiological findings. In spite of advancements and accurately diagnosing the severity of hydronephrosis, there are many controversies surround on selection of cases with antenatal hydronephrosis (ANH) that will benefit from fetal intervention. Despite better diagnosis and techniques fetal intervention is limited to mainly lower urinary tract obstruction patients to improve amniotic fluid volume and assist in lung development. SUMMARY ANH can potentially detect the severity of congenital renal anomalies but unable to recognize a specific disease. A multidisciplinary approach is required to diagnose and properly stage cases of severe CAKUT and potential surgical intervention can be considered.
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Affiliation(s)
- Adnan Safdar
- Renal Section, Texas Children's Hospital, Baylor College of Medicine
| | - Kristianna Singh
- Renal Section, Texas Children's Hospital, Baylor College of Medicine
| | - Raphael C Sun
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
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