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Wang Z, Yu Y, Jin L, Tan X, Liu B, Zhang Z, Wang Z, Long C, Shen L, Wei G, He D. HucMSC exosomes attenuate partial bladder outlet obstruction-induced renal injury and cell proliferation via the Wnt/β-catenin pathway. Eur J Pharmacol 2023:175523. [PMID: 36736526 DOI: 10.1016/j.ejphar.2023.175523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/03/2023]
Abstract
Bladder outlet obstruction (BOO) can cause serious complications including kidney damage; nevertheless, there are currently no animal models for studying BOO-induced kidney damage. Mesenchymal stem cells (MSCs) are widely used in therapeutic studies of renal fibrosis. However, MSC-derived exosomes show improved safety profile and more controllable characteristics compared with those of MSCs. Herein, we established a kidney injury mouse model of partial bladder outlet obstruction (PBOO) and evaluated the effects of human umbilical cord MSC-derived exosomes (hucMSC-Exos) on PBOO-induced reflux kidney injury in this model. Exosomes were isolated from a hucMSC-conditioned medium, purified by ultracentrifugation, and examined. Living image was performed to indicate the distribution of hucMSC-Exos. The PBOO-treated mice interacted with PBS (phosphate-buffered saline) or hucMSC-Exos. Morphologic changes and expression of interstitial-fibrosis-related, cell proliferation and Wnt/β-catenin signaling-pathway indices were evaluated. At 7 days after induction of PBOO, structural destruction of renal tubules was observed. Expression of the interstitial markers and the cellular-proliferation index increased significantly in the PBOO group compared with the control group (p < 0.05). The isolated exosomes were 30-150 nm in diameter, showing a round shape and bilayer membrane structure with CD63, TSG101, Alix expressed, enriched in the kidney of the PBOO group. Administering hucMSC-Exos to post-PBOO mice reversed renal injury and suppressed expression of Wnt/β-catenin signaling pathway-related proteins. hucMSC-Exos inhibited PBOO-induced kidney injury and cellular proliferation and suppressed the Wnt/β-catenin signaling pathway. Our findings will spur the development of novel hucMSC-Exo-mediated therapies for treating patients with renal fibrosis.
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Affiliation(s)
- Zhaoying Wang
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Yihang Yu
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Liming Jin
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Xiaojun Tan
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Bo Liu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, 400014, PR China; Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Zhaoxia Zhang
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Zhang Wang
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Chunlan Long
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Lianju Shen
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Guanghui Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, PR China; Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China
| | - Dawei He
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, PR China; Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, 400014, PR China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, PR China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, PR China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, PR China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, PR China.
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Parikh N, Gargollo P, Granberg C. Collateral Damage From Fetal Interventions: Increasing the Complexity of Complex Patients. Urology 2022; 169:211-213. [PMID: 35623501 DOI: 10.1016/j.urology.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/08/2022] [Accepted: 05/14/2022] [Indexed: 11/15/2022]
Abstract
Fetal interventions are often key to fetal survival and growth; however, they can often have complications causing significant morbidity and mortality. This case highlights not only a complication of fetal surgery, but also a very unusual diagnosis. We present the case of a male fetus who was diagnosed with urethral atresia and subsequently underwent 2 vesicoamniotic shunt placements. At birth, he was diagnosed with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome and was noted to have rectovesical and vesicocutaneous fistulae likely iatrogenically created from shunt placement. While fetal interventions are often required, a multidisciplinary team approach is often necessary as complications occur.
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Affiliation(s)
- Niki Parikh
- Department of Urology, Mayo Clinic, Rochester, MN..
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Abdelhalim A, Hafez AT. Antenatal and postnatal management of posterior urethral valves: where do we stand? AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00238-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Posterior urethral valve (PUV) is the leading etiology of lower urinary tract obstruction (LUTO) in boys and is an important cause of end-stage renal disease (ESRD) in children. The aim of this article is to review the current status on antenatal intervention for PUV as well as postnatal medical and surgical management.
Main body
MEDLINE, EMBASE, Pubmed and Google Scholar search was conducted throughout December 2020 using the keywords: posterior urethral valves, congenital urinary obstruction, antenatal, valve bladder syndrome, medical, anticholinergics, alpha blocker, antibiotics, biofeedback, diversion, augmentation cystoplasty and renal transplantation. Only papers written in English were included. The relevant literature was summarized. Despite advances in antenatal intervention for fetal LUTO, it remains associated with considerable fetal and maternal morbidity. Patient selection criteria for antenatal intervention are greatly debated. Fetal intervention has resulted in improved perinatal survival in properly selected cases, with a questionable benefit to postnatal renal function. There is decent evidence supporting the use of anticholinergics in infants and young children following valve ablation, with less robust evidence advocating alpha blockers, overnight catheter drainage and biofeedback. The role of urinary diversion remains contentious. Optimizing bladder dynamics is crucial for successful renal transplantation outcomes.
Conclusion
While antenatal intervention has failed to improve renal function outcomes of PUV, patient-centered medical and sometimes surgical interventions can help delay the progression of chronic kidney disease. Lifelong monitoring and management of the associated bladder dysfunction is indispensable even after successful renal transplantation.
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Sugibayashi R, Wada S, Ozawa K, Muromoto J, Oi R, Yamamoto R, Ishii K, Sago H. Prenatally diagnosed lower urinary tract obstruction: A 15-year experience at two tertiary centers in Japan. J Obstet Gynaecol Res 2021; 47:3091-3099. [PMID: 34155735 DOI: 10.1111/jog.14908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/22/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
AIM To examine the outcomes of prenatally diagnosed lower urinary tract obstruction (LUTO) with current management using vesicoamniotic shunting (VAS). METHODS A retrospective study of prenatally diagnosed LUTO before 26 weeks of gestation at two tertiary centers in Japan between March 2002 and September 2017. LUTO was diagnosed by ultrasound demonstration of an enlarged fetal bladder associated with hydronephrosis and/or hydroureters. VAS was offered for fetuses with LUTO at ≤26 weeks of gestational age, in the presence of oligohydramnios or decreasing amniotic fluid and a favorable fetal urinary analysis. RESULTS Among 87 fetuses with LUTO, 46 (53%) were terminated before 22 weeks of gestation. Eight cases (9%) underwent VAS and one underwent fetoscopic urethrotomy. The live birth rates in the VAS and expectant groups were 100% (8/8) and 56% (18/32), respectively (p = 0.034), and the survival rates at 6 months old with a normal renal function were 38% (3/8) and 16% (5/32), respectively (p = 0.608). The etiology varied with six cases of associated anomalies among 23 diagnosed cases. Among the nine cases of posterior urethral valve (PUV), only one fetus underwent VAS at 25 weeks of gestation, ultimately surviving with mild renal dysfunction. Among the other eight cases of PUV that were managed expectantly, two died, and only one of the six survivors showed a normal renal function. CONCLUSIONS More than half of the prenatally diagnosed LUTO cases were terminated. VAS seemed effective for achieving a perinatal survival, regardless of etiology. The outcomes were poor in cases of expectantly managed PUV.
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Affiliation(s)
- Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Oi
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Jank M, Stein R, Younsi N. Postnatal Management in Congenital Lower Urinary Tract Obstruction With and Without Prenatal Vesicoamniotic Shunt. Front Pediatr 2021; 9:635950. [PMID: 33937148 PMCID: PMC8079780 DOI: 10.3389/fped.2021.635950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/22/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose: Congenital lower urinary tract obstruction (cLUTO) includes a heterogeneous group of conditions caused by a functional or mechanical outlet obstruction. Early vesicoamniotic shunting (VAS) possibly reduces the burden of renal impairment. Postpartum, pediatric urologists are confronted with neonates who have a shunt in place and a potentially impassable urethra with a narrow caliber. Early management of these patients can be challenging. Here, we would like to share the approach we have developed over time. Materials and Methods: We conducted a single-center retrospective analysis from 2016 to 2020 and included all patients diagnosed with cLUTO. Data focusing on time point and type of intervention was collected. Furthermore, patients with temporary diversion via a percutaneous VAS were selected for a more detailed review. Results: In total, 71 cases of cLUTO were identified during the study period. Within this group, 31 neonates received postnatal management and surgical intervention in our center. VAS was performed in 55% of these cases (N = 17). The postnatal treatment varied between transurethral or suprapubic catheterization and early Blocksom vesicostomy. In five infants with VAS, the urinary drainage was secured through the existing VAS by inserting a gastric tube (N = 1) or a 4.8 Fr JJ-stent (N = 4). To our knowledge, this is the first report of a stent-in-stent scheme, which can remain indwelling until the definite treatment. Conclusion: Having a secure urine drainage through a VAS allows the often premature infant to grow until definite surgery can be performed. This avoids placing a vesicostomy, which requires anesthesia.
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Affiliation(s)
- Marietta Jank
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany.,Department of Pediatric Surgery, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Raimund Stein
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Nina Younsi
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
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6
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Xu R, Zhou J, Zhou Q, Zeng S. Decreased biventricular myocardial deformation in fetuses with lower urinary tract obstruction. BMC Pregnancy Childbirth 2020; 20:459. [PMID: 32787795 PMCID: PMC7424985 DOI: 10.1186/s12884-020-03152-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To observe myocardial deformations in fetuses with isolated lower urinary tract obstruction (LUTO) and identify the correlation between myocardial deformation and the severity of obstruction. METHODS The strain (S), strain rate in systole (SRs) and strain rate in diastole (SRd) of the left and right ventricles at the first examination were prospectively analyzed and compared between fetuses with isolated LUTO and gestational age (GA)-matched normal control fetuses. Multiple regression analyses were used to assess the obstructive factors for impaired strain and strain rate, and the independent variables included bladder volume, sum of the bilateral pelvic diameters, sum of the bilateral ureteral diameters, mean bilateral renal artery pulsatility index, and amniotic fluid index. RESULTS Thirty-six fetuses with isolated LUTO and 36 normal controls were enrolled. Overall, decreased S, SRs and SRd of both ventricles were noted in fetuses with LUTO (p < 0.001). Moreover, S and SR were significantly negatively related to distended bladder volume (p < 0.001). CONCLUSIONS Fetuses with LUTO demonstrated decreased left and right myocardial deformation, and this impaired cardiac dysfunction was correlated with the urinary bladder volume. Evaluating the myocardial deformation in fetal LUTO could provide information to aid in parental counselling and intervention monitoring.
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Affiliation(s)
- Ran Xu
- Department of Urology, The Second Xiangya Hospital, Central South University, 410011, Changsha, Hunan, China
| | - Jiawei Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China
| | - Qichang Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China
| | - Shi Zeng
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Hunan, 410011, Changsha, China.
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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Warring SK, Novoa V, Shazly S, Trinidad MC, Sas DJ, Schiltz B, Prieto M, Terzic A, Ruano R. Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives. Mayo Clin Proc Innov Qual Outcomes 2020; 4:391-409. [PMID: 32793867 PMCID: PMC7411166 DOI: 10.1016/j.mayocpiqo.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.
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Key Words
- AF, amniotic fluid
- AFI, AF index
- AFV, AF volume
- BRA, bilateral renal agenesis
- CRA, congenital renal anomaly
- DOL, day of life
- GA, gestational age
- IQR, interquartile range
- LUTO, lower urinary tract obstruction
- MVP, maximal vertical pocket
- PD, peritoneal dialysis
- PPROM, preterm premature rupture of membranes
- SAT, serial amnioinfusion therapy
- WHO, World Health Organization
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Affiliation(s)
- Simrit K Warring
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Victoria Novoa
- Department of Obstetrics & Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Sherif Shazly
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Mari Charisse Trinidad
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - David J Sas
- Division of Pediatric Nephrology, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Brenda Schiltz
- Division of Pediatric Critical Care Medicine, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Mikel Prieto
- Department of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Andre Terzic
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
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Cheung KW, Morris RK, Kilby MD. Congenital urinary tract obstruction. Best Pract Res Clin Obstet Gynaecol 2019; 58:78-92. [PMID: 30819578 DOI: 10.1016/j.bpobgyn.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/01/2019] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
Congenital bladder neck obstruction (or lower urinary tract obstruction [LUTO]) describes a heterogeneous group of congenital anomalies presenting with similar prenatal ultrasonographic findings of dilated posterior urethra, megacystis, hydronephrosis, oligohydramnios and often with associated renal dysplasia. Untreated LUTO has high rate of perinatal morbidity and mortality from associated pulmonary hypoplasia and early-onset renal failure in infancy. Ultrasonographic features and prospective fetal urinalysis may help in predicting the overall prognosis of congenital LUTO. Currently, fetal vesicoamniotic shunt (of various designs), and fetal cystoscopy and fulguration of the obstruction are potential prenatal interventions. Retrospective and prospective cohort studies and a relatively small randomized controlled trial have demonstrated these treatments may possibly improve perinatal survival. Despite this, concerns remain as to the high rates of renal impairment observed in paediatric survivors. A clinical prospective scoring/staging system may improve prenatal diagnostic criteria and case selection for fetal therapy.
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Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China; The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.
| | - Rachel Katie Morris
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Mark David Kilby
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
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10
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Kurtz MP, Koh CJ, Jamail GA, Sangi-Haghpeykar H, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Braun MC, Roth DR, Belfort MA, Ruano R. Factors associated with fetal shunt dislodgement in lower urinary tract obstruction. Prenat Diagn 2016; 36:720-5. [PMID: 27247093 DOI: 10.1002/pd.4850] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/19/2016] [Accepted: 05/29/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify factors associated with fetal shunt dislodgement in lower urinary tract obstruction (LUTO). METHODS We conducted a retrospective study of 42 consecutive fetuses with a diagnosis of LUTO in a tertiary fetal center between April 2013 and November 2015. Possible factors associated with prenatal shunt dislodgment were evaluated in fetuses who underwent shunt placement, including gestational age at diagnosis, gestational age at procedure, presence of 'keyhole sign', initial fetal bladder volume and wall thickness, prenatal ultrasonographic renal characteristics, amniotic fluid volume, presence of ascites prior to shunting, and type of fetal shunt. RESULTS Nineteen (46.3%) fetuses underwent shunt placement at a median gestational age of 19 (range: 16.3-31.1) weeks. Shunt dislodgement occurred in 10 (52.6%) patients. A total of 35 procedures were performed; among which 16 (45.7%) were repeat procedures. The only prenatal factor associated with shunt dislodgement was the type of the shunt; Kaplan-Meier analysis indicated that the Rocket was associated with increased likelihood of remaining orthotopic (p = 0.04). CONCLUSION Fetal shunt dislodgement occurs in approximately half of the patients and appears to be associated with the type of the shunt. Future research is necessary to develop better shunt systems and to investigate different fetal therapeutic approaches. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Michael P Kurtz
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Grace Anne Jamail
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Michael C Braun
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - David R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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11
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Akkurt MO, Yavuz A, Sezik M, Ozkaya MO. An unusual complication of vesicoamniotic shunt: coiling of the shunt around lower extremity associated with dislodgement. J OBSTET GYNAECOL 2015; 36:261-2. [PMID: 26491896 DOI: 10.3109/01443615.2015.1049254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M O Akkurt
- a Suleyman Demirel University, School of Medicine, Department of Obstetrics and Gynaecology , Division of Perinatology , Isparta , Turkey
| | - A Yavuz
- a Suleyman Demirel University, School of Medicine, Department of Obstetrics and Gynaecology , Division of Perinatology , Isparta , Turkey
| | - M Sezik
- a Suleyman Demirel University, School of Medicine, Department of Obstetrics and Gynaecology , Division of Perinatology , Isparta , Turkey
| | - M O Ozkaya
- a Suleyman Demirel University, School of Medicine, Department of Obstetrics and Gynaecology , Division of Perinatology , Isparta , Turkey
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12
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Orumuah AJ, Oduagbon OE. Presentation, management, and outcome of posterior urethral valves in a Nigerian tertiary hospital. Afr J Paediatr Surg 2015; 12:18-22. [PMID: 25659544 PMCID: PMC4955488 DOI: 10.4103/0189-6725.150937] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Posterior urethral valves (PUV) remain the most common cause of bladder outlet obstruction and renal insufficiency in male children. The aim of this study was to evaluate the presentation, management, challenges, and outcome of the disease in a Nigerian tertiary health institution. PATIENTS AND METHODS Retrospectively, medical records of male children with a diagnosis of PUVs over a 10 year period (2003-2012) were retrieved. All data in relation to the study objectives were recorded and analyzed. RESULTS A total of 44 patients was managed for PUV within the period. The mean age of presentation was 3.95 years with 56.8% of the patients presenting after the age of 1 year. Voiding dysfunction noted in 40 (91.0%) patients was the most common mode of presentation. The most common finding on physical examination was a palpable bladder while urinary tract infection noted in 23 (52.3%) patients was the most common complication noted. Abdominal ultrasonography revealed dilated posterior urethra in 16 (36.4%) cases, while micturating cystourethrogram revealed a dilated proximal urethra in all 35 cases in which it was done, diverticulum in 6 and vesicoureteric reflux in 9. The creatinine value at presentation ranged between 0.4 mg/dl and 4.0 mg/dl with a mean of 1.02 ± 0.93 mg/dl. Urethroscopy in 37 patients confirmed type I and type III PUV in 35 and 2 patients, respectively. Valve ablation with a diathermy bugbee electrode provided relief of obstructions in the 37 patients who underwent the procedure without any significant immediate complication. The period of follow-up ranged between 2 weeks and 3 years with a mean of 10.2 months. There was sustained improvement in urine stream, reduction in the mean creatinine concentration and incidence of UTI during follow-up. However, patients with significantly impaired renal function had a poorer outcome. CONCLUSION Many patients with PUV presented late within the reviewed period. Valve ablation provided relief of obstruction in most of the cases. There is a need to counsel parents/guardians on the need for long-term follow-up.
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Affiliation(s)
- Agbugui Jude Orumuah
- Department of Surgery, Urology Unit, University of Benin Teaching Hospital, Benin City, Nigeria
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13
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Liu DB, Armstrong WR, Maizels M. Hydronephrosis: prenatal and postnatal evaluation and management. Clin Perinatol 2014; 41:661-78. [PMID: 25155734 DOI: 10.1016/j.clp.2014.05.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antenatal hydronephrosis (ANH) is one of the most frequently detected abnormalities found on routine prenatal ultrasounds, affecting 1% to 4.5% of all pregnancies. Despite its prevalence, there continues to be uncertainty regarding the clinical impact after birth. Prognosis depends on the severity of the dilation. Expectant prenatal management is the rule with fetal intervention rarely needed in a few select cases. Ureteropelvic junction obstruction and vesicoureteral reflux are the most common postnatal diagnoses. A renal and bladder ultrasound is essential in the follow-up of patients with ANH and helps dictate further investigation with voiding cystourethrography and/or diuretic renography.
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Affiliation(s)
- Dennis B Liu
- Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA.
| | - William R Armstrong
- Department of Urology, University of Illinois Chicago College of Medicine, 820 South Wood Street, M/C 955, Chicago, IL 60612, USA
| | - Max Maizels
- Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA
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14
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Dias T, Sairam S, Kumarasiri S. Ultrasound diagnosis of fetal renal abnormalities. Best Pract Res Clin Obstet Gynaecol 2014; 28:403-15. [PMID: 24524801 DOI: 10.1016/j.bpobgyn.2014.01.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 12/14/2022]
Abstract
Development of the urogenital system in humans is a complex process; consequently, renal anomalies are among the most common congenital anomalies. The fetal urinary tract can be visualised ultrasonically from 11 weeks onwards, allowing recognition of megacystis at 11-14 weeks, which warrants comprehensive risk assessment of possible underlying chromosomal aneuploidy or obstructive uropathy. A mid-trimester anomaly scan enables detection of most renal anomalies with higher sensitivity. Bilateral renal agenesis can be confirmed ultrasonically, with empty renal fossae and absent bladder filling, along with severe oligohydramnios or anhydramnios. Dysplastic kidneys are recognised as they appear large, hyperechoic, and with or without cystic spaces, which occurs within the renal cortex. Presence of dilated ureters without obvious dilatation of the collecting system needs careful examination of the upper urinary tract to exclude duplex kidney system. Sonographically, it is also possible to differentiate between infantile type and adult type of polycystic kidney diseases, which are usually single gene disorders. Upper urinary tract dilatation is one of the most common abnormalities diagnosed prenatally. It is usually caused by transient urine flow impairment at the level of the pelvi-ureteric junction and vesico-ureteric junction, which improves with time in most cases. Fetal lower urinary tract obstruction is mainly caused by posterior urethral valves and urethral atresia. Thick bladder walls and a dilated posterior urethra (keyhole sign) are suggestive of posterior urethral valves. Prenatal ultrasounds cannot be used confidently to assess renal function. Liquor volume and echogenicity of renal parenchyma, however, can be used as a guide to indirectly assess the underlying renal reserve. Renal tract anomalies may be isolated but can also be associated with other congenital anomalies. Therefore, a thorough examination of the other systems is mandatory to exclude possible genetic disorders.
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Affiliation(s)
- Tiran Dias
- Department of Obstetrics and Gynecology, District General Hospital, Ampara, Sri Lanka.
| | - Shanthi Sairam
- Fetal Medicine and Fetal Cardiology, Mediscan, Chennai, India
| | - Shanya Kumarasiri
- Department of Obstetrics and Gynecology, District General Hospital, Ampara, Sri Lanka
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15
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Thorson W, Diaz-Horta O, Foster J, Spiliopoulos M, Quintero R, Farooq A, Blanton S, Tekin M. De novo ACTG2 mutations cause congenital distended bladder, microcolon, and intestinal hypoperistalsis. Hum Genet 2013; 133:737-42. [PMID: 24337657 DOI: 10.1007/s00439-013-1406-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 12/06/2013] [Indexed: 02/01/2023]
Abstract
Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is characterized by prenatal-onset distended urinary bladder with functional intestinal obstruction, requiring extensive surgical intervention for survival. While it is believed to be an autosomal recessive disorder, most cases are sporadic. Through whole-exome sequencing in a child with MMIHS, we identified a de novo mutation, p.R178L, in the gene encoding the smooth muscle gamma-2 actin, ACTG2. We subsequently detected another de novo ACTG2 mutation, p.R178C, in an additional child with MMIHS. Actg2 transcripts were primarily found in murine urinary bladder and intestinal tissues. Structural analysis and functional experiments suggested that both ACTG2 mutants interfere with proper polymerization of ACTG2 into thin filaments, leading to impaired contractility of the smooth muscle. In conclusion, our study suggests a pathogenic mechanism for MMIHS by identifying causative ACTG2 mutations.
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Affiliation(s)
- Willa Thorson
- Dr. John T. Macdonald Department of Human Genetics and John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, 1501 NW 10th Avenue, BRB-610 (M-860), Miami, FL, 33136, USA
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16
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Navarro Rodríguez M, López-Tarragona R, Jerónimo Franco I, Carmona Sánchez E. Megavejiga fetal: caso clínico. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2013. [DOI: 10.1016/j.gine.2012.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Ethun CG, Zamora IJ, Roth DR, Kale A, Cisek L, Belfort MA, Haeri S, Ruano R, Welty SE, Cassady CI, Olutoye OO, Cass DL. Outcomes of fetuses with lower urinary tract obstruction treated with vesicoamniotic shunt: a single-institution experience. J Pediatr Surg 2013; 48:956-62. [PMID: 23701767 DOI: 10.1016/j.jpedsurg.2013.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this manuscript was to examine the outcomes of patients with lower urinary tract obstruction (LUTO) treated with vesicoamniotic shunt (VAS) to improve the quality of prenatal consultation and therapy. METHODS The medical records of all patients diagnosed with LUTO at our center between January 2004 and March 2012 were reviewed retrospectively. RESULTS Of 14 male fetuses with LUTO, all with characteristic ultrasound findings, 11 underwent intervention. One patient received vesicocentesis alone, while 10 had VAS. Two fetuses additionally underwent cystoscopy (one with attempted valve ablation), and two had peritoneoamniotic shunts. Of 16 total VAS, 13 were placed successfully, 8 dislodged (median 7 days), and 1 obstructed (84 days). Two fetuses suffered in utero demise, and two have unknown outcomes. LUTO was confirmed in six of eight live-born fetuses. One patient died in the neonatal period, while seven survived. All six available at follow-up (median 3.7 years), had significant genitourinary morbidity. Five patients had chronic kidney disease, but only one has required dialysis and transplant. Three had respiratory insufficiency, and one required a tracheostomy. CONCLUSION Despite significant perinatal and long-term morbidity, VAS offers patients faced with a poor prognosis an improved chance of survival. Our results underscore the need for further research into the diagnosis and treatment of LUTO.
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Affiliation(s)
- Cecilia G Ethun
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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18
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Malin G, Tonks AM, Morris RK, Gardosi J, Kilby MD. Congenital lower urinary tract obstruction: a population-based epidemiological study. BJOG 2012; 119:1455-64. [DOI: 10.1111/j.1471-0528.2012.03476.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Morris RK, Kilby MD. Long-term renal and neurodevelopmental outcome in infants with LUTO, with and without fetal intervention. Early Hum Dev 2011; 87:607-10. [PMID: 21839591 DOI: 10.1016/j.earlhumdev.2011.07.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 07/05/2011] [Indexed: 12/29/2022]
Abstract
Congenital lower urinary tract obstruction (LUTO) is a heterogeneous group of pathologies, the most common being posterior urethral valves (PUV) or urethral atresia. The bladder neck obstruction in utero leads to a spectrum of disease including mild oligohydramnios with normal renal function to a picture of severe oligohydramnios associated with chronic obstructive macro/microcystic renal parenchymal disease leading to chronic renal impairment. These anomalies may be isolated or complex; the latter being associated with other structural or chromosomal abnormalities. If isolated, the congenital bladder neck obstruction may be amenable to in-utero therapy. In a significant proportion of babies affected by LUTO there is severe oligohydramnios (occurring before 20 weeks gestation) and associated with pulmonary hypoplasia, a scenario almost always associated with perinatal death. For those babies that survive the perinatal period there is a significant risk of renal impairment, often necessitating renal dialysis or transplantation in childhood. In addition, there may be other morbidities such as chronic filling anomalies of the bladder that may require treatment.
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Affiliation(s)
- R Katie Morris
- Clinical Lecturer in Fetal Medicine, School of Clinical and Experimental Medicine, University of Birmingham, c/o Birmingham Women's NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG, United Kingdom.
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20
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Morris RK, Malin GL, Khan KS, Kilby MD. Systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction. BJOG 2010; 117:382-90. [DOI: 10.1111/j.1471-0528.2010.02500.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Affiliation(s)
- Miho Watanabe
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
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22
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Emery SP, Schneck FX, Kauffman DE, Hill LM. Prenatal diagnosis of lower urinary tract obstruction associated with penoscrotal transposition. Prenat Diagn 2009; 29:1089-90. [DOI: 10.1002/pd.2351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Is Cystatin C a Promising Parameter to Determine Postnatal Outcome of Prenatally Diagnosed Infravesical Obstruction? J Urol 2009; 182:1542-7. [DOI: 10.1016/j.juro.2009.06.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Indexed: 11/19/2022]
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24
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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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25
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Passerotti CC, Barnewolt C, Xuewu J, Passerotti AMA, Ward V, Dunning P, Retik AB, Nguyen HT. In Utero Treatment for Bladder Outlet Obstruction Using Robot Assisted Laparoscopic Techniques. J Urol 2008; 180:1790-4; discussion 1794. [DOI: 10.1016/j.juro.2008.03.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Indexed: 10/21/2022]
Affiliation(s)
- Carlo C. Passerotti
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Carol Barnewolt
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Jiang Xuewu
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Ana Maria A.M.S. Passerotti
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Valerie Ward
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Patricia Dunning
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Alan B. Retik
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Hiep T. Nguyen
- Departments of Urology (Robotic Research and Training Center) and Radiology (CB, VW, PD), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
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26
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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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27
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Abstract
Fetal surgery has emerged from the realm of medical curiosity into an exciting, multidisciplinary specialty now capable of improving patient outcomes for a wide variety of diseases. Recent advances allow prenatal providers to both accurately diagnose and treat many fetal anomalies while maintaining maternal safety. As the initial postnatal health care providers to the majority of these newborns, neonatologists need to be familiar with some of the more recent state-of-the-art procedures currently being used. In this review, the authors discuss the prenatal evaluation process and various operative approaches (ie, open hysterotomy, fetoscopy, and percutaneous) to conduct fetal surgery. They then analyze the effectiveness of some of the more established and experimental prenatal therapies that are being performed for a number of fetal anomalies, including twin-twin transfusion syndrome, thoracic malformations, airway obstruction, congenital diaphragmatic hernia, myelomeningocele, and aortic valve stenosis.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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28
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Abstract
Congenital urinary tract obstruction is a heterogenous condition with a varying natural history. Accurate diagnosis within the late-first and second trimesters allows for counselling of the parents and planning of multi-disciplinary care for the pregnancy and newborn. Antenatal investigations to predict postnatal renal function are of varying accuracy. However, some factors have been shown to be predictive of poor outcome in terms of renal function at birth and infancy. There is the possibility of in-utero intervention in these fetuses.
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Affiliation(s)
- R K Morris
- Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, University of Birmingham, Birmingham B15 2TG, UK.
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29
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Abstract
Fetal lower urinary tract obstruction affects 2.2 per 10,000 births. It is a consequence of a range of pathological processes, most commonly posterior urethral valves (64%) or urethral atresia (39%). It is a condition of high mortality and morbidity associated with progressive renal dysfunction and oligohydramnios, and hence fetal pulmonary hypoplasia. Accurate detection is possible via ultrasound, but the underlying pathology is often unknown. In future, magnetic resonance imaging (MRI) may be increasingly used alongside ultrasound in the diagnosis and assessment of fetuses with lower urinary tract obstruction. Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear. It is now possible to decompress the obstruction in utero via percutaneous vesico-amniotic shunting or cystoscopic techniques. In appropriately selected fetuses intervention may improve perinatal survival, but long-term renal morbidity amongst survivors remains problematic.
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Affiliation(s)
- David Lissauer
- Division of Reproductive and Child Health, Birmingham Women's Hospital, University of Birmingham, Birmingham, B15 2TG, UK
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30
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Kemper MJ, Mueller-Wiefel DE. Prognosis of antenatally diagnosed oligohydramnios of renal origin. Eur J Pediatr 2007; 166:393-8. [PMID: 17205244 DOI: 10.1007/s00431-006-0368-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Accepted: 11/07/2006] [Indexed: 12/12/2022]
Abstract
Although clinical outcome data on fetuses with oligohydramnios of renal origin are scarce, prognosis is regarded as poor due to a high risk of renal dysfunction and pulmonary hypoplasia. This review aims to summarize the current knowledge and clinical experience with patients presenting antenatally with renal oligohydramnios. By reviewing the underlying mechanisms, complications, and outcome data, we hope to further improve antenatal counseling and postnatal care. We conclude that prognosis of ROH has changed in recent years. While early data before the introduction of sophisticated neonatal intensive care and renal replacement therapy indicated a poor prognosis, nowadays, a much more optimistic prognosis of children after renal oligohydramnios can be expected from the recent publications in the literature.
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Affiliation(s)
- Markus J Kemper
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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31
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Morris RK, Khan KS, Kilby MD. Vesicoamniotic shunting for fetal lower urinary tract obstruction: an overview. Arch Dis Child Fetal Neonatal Ed 2007; 92:F166-8. [PMID: 17449853 PMCID: PMC2675321 DOI: 10.1136/adc.2006.099820] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Efficacy and complications of prenatal in utero treatment
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Affiliation(s)
- R K Morris
- Division of Reproductive and Child Health, Birmingham Women's Hospital, University of Birmingham, Birmingham B15 2TG, UK
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32
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Morris RK, Quinlan-Jones E, Kilby MD, Khan KS. Systematic review of accuracy of fetal urine analysis to predict poor postnatal renal function in cases of congenital urinary tract obstruction. Prenat Diagn 2007; 27:900-11. [PMID: 17610312 DOI: 10.1002/pd.1810] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the clinical usefulness of analysis of fetal urine in the prediction of poor postnatal renal function in cases of congenital urinary tract obstruction. METHODS A systematic review was performed. We conducted extensive electronic searches (database inception-2006). The reference lists of articles obtained were searched for any further articles. Two reviewers independently selected the articles in which the accuracy of fetal urinalysis was evaluated to predict poor postnatal renal function. There were no language restrictions. Data were extracted on study characteristics, quality and results, to construct 2 x 2 tables. Likelihood ratios for positive (LR+) and negative (LR-) test results were generated for the different fetal urinary analytes at various thresholds. RESULTS There were 23 articles that met the selection criteria, including a total of 572 women and 63 2 x 2 tables. The two most accurate tests were calcium > 95th centile for gestation (LR + 6.65, 0.23-190.96; LR - 0.19, 0.05-0.74) and sodium > 95th centile for gestation (LR + 4.46, 1.71-11.6; LR - 0.39, 0.17-0.88). beta(2)-microglobulin was found to be less accurate (LR + 2.92, 1.28-6.69; LR - 0.53, 0.24-1.17). CONCLUSION The current evidence demonstrates that none of the analytes of fetal urine investigated so far can be shown to yield clinically significant accuracy to predict poor postnatal renal function.
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Affiliation(s)
- R K Morris
- Division of Reproductive and Child Health, Birmingham Women's Hospital, University of Birmingham, Birmingham, UK
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Kitagawa H, Pringle KC, Koike J, Nagae H, Zuccollo J, Sato Y, Seki Y, Fujiwaki S, Wakisaka M, Nakada K. Early bladder wall changes after creation of obstructive uropathy in the fetal lamb. Pediatr Surg Int 2006; 22:875-9. [PMID: 16953456 DOI: 10.1007/s00383-006-1755-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vesico-amniotic shunting of obstructive uropathy in fetal lambs produced a thick-walled, poorly compliant bladder. We report the early histological changes in the obstructed bladder wall. We created an obstructive uropathy in fetal lambs at 60 days gestation by ligating the urethra and urachus. Vesicostomy or vesico-amniotic shunt tube insertion and biopsy of the bladder wall were performed 21 days later. The fetuses were delivered at term (145 days) and the kidneys and bladder sampled for histology. Colloidal iron (Col Fe), and alpha-smooth muscle actin (alpha-SMA) immunohistochemical stains were used for these samples. Seventeen fetuses were shunted with 15 biopsies taken at that time. Six (shunt failure or missed urachal ligation) were excluded. All biopsies taken at shunting had positive Col Fe and alpha-SMA. Term lambs had mild multicystic dysplastic kidney (MCDK) in five, severe MCDK in two, and hydronephrosis in four. All bladders had small volume and were severely fibrotic. Fetal shunt operations 3 weeks after the creation of obstructive uropathy provided partial preservation of renal histology but did not preserve normal bladder histology. We suggest that the high hyaluronic acid synthesis activity or hyperplasia of the myofibroblasts in the dilated fetal bladder wall at the time of shunting results in irreversible damage to the developing bladder muscle and fibrosis.
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Affiliation(s)
- Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
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Abstract
Hydronephrosis is the most common genitourinary tract anomaly identified on prenatal ultrasound studies. Ureteropelvic junction obstruction accounts for approximately 50% of the cases of prenatally detected hydronephrosis. Postnatal evaluation allows for the identification of the cause and further management. Rarely, in utero intervention may be performed for severe oligohydramnios associated with hydronephrosis. Prenatal consultation with a pediatric urologist is useful in decreasing parental anxiety and facilitating postnatal management.
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Affiliation(s)
- Sergio Fefer
- Division of Urology, University of Massachusetts Memorial Hospital, 55 Lake Avenue North, Worcester, MA 01655, USA
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Kitagawa H, Pringle KC, Koike J, Zuccollo J, Seki Y, Wakisaka M, Sato Y, Sato H, Nagae H, Nakada K. Vesicoamniotic shunt for complete urinary tract obstruction is partially effective. J Pediatr Surg 2006; 41:394-402. [PMID: 16481258 DOI: 10.1016/j.jpedsurg.2005.11.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The long-term outcome for children after antenatal intervention for obstructive uropathies is disappointing. We reported that renal dysplastic changes are well established 3 weeks after obstruction in a fetal lamb model. We used this model to explore renal development and bladder function after fetal intervention. METHODS We created an obstructive uropathy in fetal lambs at 60 days gestation by ligating the urethra and urachus. A vesicostomy (female) or urethrostomy (male) were performed 21 days later. The fetuses were killed at term (145 days) and bladder volume and compliance were measured. The urinary tract was processed for histologic examination. RESULTS Twenty two fetuses were shunted. Nine were miscarried or were still-born. Thirteen survived, and 11 had a successful shunt with a small bladder (8 +/- 5 mL) compared with controls (71 +/- 19 mL) (P < .05). Shunted bladders had poor compliance. Histologically, they had thickened submucosal connective tissue with hypertrophied muscle. Histology of the renal tissue demonstrated relatively well-preserved renal architecture with reduced nephron mass (oligonephronia) in 2 lambs and multicystic dysplastic change in 3. Six (55%) had normal nephrogenesis. CONCLUSIONS In our model, shunt operations after obstructive uropathy fail to preserve bladder function. Shunting ameliorated the development of cystic dysplasia, but half of the lambs had oligonephronia or multicystic dysplastic kidney. These might develop renal failure later in life.
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Affiliation(s)
- Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan.
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Robyr R, Benachi A, Daikha-Dahmane F, Martinovich J, Dumez Y, Ville Y. Correlation between ultrasound and anatomical findings in fetuses with lower urinary tract obstruction in the first half of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:478-482. [PMID: 15816021 DOI: 10.1002/uog.1878] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The prognosis of fetal lower urinary tract obstruction (LUTO) depends upon renal function and also upon the underlying etiology. Precise identification of the latter remains a challenge antenatally. Our objective was to examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO. METHODS Detailed postmortem examination was carried out after termination of pregnancy in 24 male fetuses presenting before 25 weeks of gestation with ultrasound evidence of isolated severe LUTO. RESULTS All fetuses had megacystis and hyperechogenic kidneys. There was anhydramnios/oligohydramnios and pelvicalyceal dilatation in 20 and 15 cases, respectively. Posterior urethral valves (PUV) were suspected antenatally in 20 cases and urethral atresia was not suspected antenatally. However, postmortem examination of the urethra demonstrated atresia in six cases, severe stenosis in eight cases, PUV in nine cases and an apparently normal urethra in one case. Renal dysplasia was found in all cases but one. Urethral atresia was the most common urethral anomaly at 12-17 weeks. Hydronephrosis was more frequent in cases with PUV (8/9) and urethral stenosis (6/8) than with urethral atresia (0/6). In LUTO presenting in the first and second trimester, hyperechogenic kidneys were predictive of renal dysplasia in 95% of cases. The association of a sagittal diameter of the bladder of at least 40 mm with hydronephrosis before 28 weeks was predictive of PUV with a positive (PPV) and negative (NPV) predictive value of 44.4% and 66.6%, respectively. Absence of hydronephrosis and a sagittal diameter of the bladder of less than 40 mm were predictive of urethral atresia or stenosis with a PPV and NPV of 100% and 47.6%, respectively. The absence of hydronephrosis was predictive of urethral atresia with a PPV and NPV of 66.6% and 100%, respectively. CONCLUSION LUTO in a male fetus presenting with megacystis in the first or second trimester of pregnancy is as likely to reflect urethral atresia or stenosis as it is PUV. The size of the bladder and the presence of hydronephrosis should be considered in order to improve prenatal diagnosis and counseling.
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Affiliation(s)
- R Robyr
- Department of Obstetrics and Gynecology, Paris-Ouest University, CHI Poissy-St-Germain, Paris, France
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Eckoldt F, Heling KS, Woderich R, Wolke S. Posterior Urethral Valves: Prenatal Diagnostic Signs and Outcome. Urol Int 2004; 73:296-301. [PMID: 15604570 DOI: 10.1159/000081586] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 05/12/2004] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Urethral valves can be of enormous clinical importance. Both the prognosis for an affected fetus and the indication for a prenatal therapeutic intervention depend to a high degree on the accuracy of the prenatal diagnosis. PATIENTS AND METHODS The sonographic findings and the results of the postnatal diagnostic workup of 24 boys treated for urethral valves in our institute are analyzed in the present paper. RESULTS Out of a group of 900 children, diagnosed prenatally as having urinary tract anomalies, the postnatal diagnostic workup revealed 24 boys suffering from posterior urethral valves. The combination of megacystis, oligohydramnios, and bilateral renal abnormalities was present in 3 boys, and it was only in these cases that urethral valves were correctly identified as the underlying pathology. The largest group (n = 16) of these fetuses presented with bilateral hydronephrosis with and without megaureter. Megacystis in any combination with other findings was detected only in 4 patients. Oligohydramnios as a sign of impaired renal function was observed in four pregnancies. Four children suffered postnatally from beginning renal insufficiency. Eight infants (33%) required some form of respiratory support. This group included the 4 newborns with oligohydramnios during the pregnancy. CONCLUSIONS Posterior urethral valves represent a rare but severe congenital malformation. They can disrupt the development of the entire urinary tract and may be life-limiting to the affected boy. Only rarely, however, are they manifested as the complete pathological picture on prenatal ultrasound. In most cases, bilateral impairment of the fetal renal development suggests severe subvesical obstruction. Thus in cases with bilateral renal impairment on prenatal ultrasonography, posterior urethral valves are to be excluded postnatally. Oligohydramnios is a predictor of a poor outcome of the renal function.
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Affiliation(s)
- Felicitas Eckoldt
- Klinik und Poliklinik für Kinderchirurgie des Otto-Heubner-Centrums für Kinder- und Jugendmedizin, Berlin, Deutschland.
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Abstract
Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.
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Affiliation(s)
- Jeffrey L Zitsman
- Children's Hospital of New York Presbyterian, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Abstract
Prenatal chromosome diagnosis has been a rapidly changing field over the past 10 years for both sampling methodologies and molecular techniques to complement chromosome analysis. This review summarizes current techniques used by the clinician and their risks, and selected aspects of cytogenetic and molecular techniques used by the laboratories. Within the next 3 to 5 years, DNA techniques are expected to complement, and potentially replace, aspects of current cytogenetic and FISH techniques, and provide more detailed information on the genetic status of the fetus.
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Affiliation(s)
- Alan E Donnenfeld
- Genzyme Genetics, Department of Obstetrics and Gynecology, Drexel University College of Medicine, 819 Locust Street, Philadelphia, PA 19107, USA.
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Donnenfeld AE, Lockwood D, Custer T, Lamb AN. Prenatal diagnosis from fetal urine in bladder outlet obstruction: success rates for traditional cytogenetic evaluation and interphase fluorescence in situ hybridization. Genet Med 2002; 4:444-7. [PMID: 12509716 DOI: 10.1097/00125817-200211000-00008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To determine the optimal approach to the prenatal chromosome analysis of fetal urine from fetuses with bladder outlet obstruction. METHODS Retrospective evaluation of traditional cytogenetic and interphase fluorescence in situ hybridization (FISH) analysis on fetal urine specimens from fetuses with bladder outlet obstruction. RESULTS Traditional cytogenetic analysis was successful on 71 (95%) of 75 samples, and FISH was informative on 20 (65%) of 31 specimens. The combination of traditional cytogenetic analysis and FISH yielded a 96% diagnostic success rate. The mean turnaround time was 8 days (range 5-14) for traditional cytogenetic analysis and 1.6 days (range 1.0-4.0) for FISH. Chromosome abnormalities were detected in 6 (7.9%) of 76 pregnancies. CONCLUSION Traditional cytogenetic analysis achieves a high success rate (95%) and is superior to FISH for chromosome evaluation of fetal urine. However, FISH, when informative, can complement traditional cytogenetics as it will expeditiously rule out common trisomies in fetuses with bladder outlet obstruction.
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Abstract
We present a comprehensive and current review of the etiology, evaluation, treatment, and outcome of antenatal hydronephrosis. When a diagnosis of antenatal hydronephrosis is made, many questions regarding pregnancy, prenatal care, intervention, and what may be expected after birth are raised. Debate and controversy exist on the diagnosis and subsequent evaluation and management of the child with antenatal hydronephrosis. A review of the literature and our own experience with antenatal hydronephrosis are presented in order to guide the physician who is caring for mother and child.
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Affiliation(s)
- Christopher S Cooper
- Division of Pediatric Urology, Children's Hospital of Iowa, University of Iowa, 200 Hawkins Drive, Iowa City 52242, USA.
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Roth KS, Carter WH, Chan JC. Obstructive nephropathy in children: long-term progression after relief of posterior urethral valve. Pediatrics 2001; 107:1004-10. [PMID: 11331678 DOI: 10.1542/peds.107.5.1004] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Approximately one third of children with end-stage renal disease have the illness because of urinary tract malformations, obstructive uropathy, and hypoplasia/dysplasia. The significant drop in infant mortality from obstructive uropathies in recent decades, attributable to prenatal diagnosis with renal ultrasonography and coordinated surgical and medical care, necessitated a reevaluation of the long-term outcome. METHODS To that end, we examined the long-term progression of obstructive nephropathy after neonatal relief of posterior urethral valves in our center over a span of 21 years, with diagnosis and care being provided by the same pediatric and urology team. RESULTS The 10 consecutive cases of posterior urethral valves represented 7% of all patients with congenital malformative uropathies seen over this period. The following procedures were performed: primary valve ablation (90%) and vesicostomy (40%). Seventy percent of patients progressed to end-stage renal disease over a (mean +/- standard error of the mean) follow-up of 11.3 +/- 2.1 years. The linear plot of the log of the inverse of serum creatinine versus time suggested unrelenting progression. The rate of progression was rapid after serum creatinine exceeded 5 mg/dL but the rate was slow and steady from serum creatinine of 1.5 to 5 mg/dL. CONCLUSIONS To test the effect of a therapeutic intervention to ameliorate the rate of progression, this steady and prolonged progression of 0.5 mg/dL per year between serum creatinine concentration of 1.5 to 5 mg/dL would seem the optimal study.
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Affiliation(s)
- K S Roth
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia 23298-0498, USA
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Saphier CJ, Gaddipati S, Applewhite LE, Berkowitz RL. Prenatal diagnosis and management of abnormalities in the urologic system. Clin Perinatol 2000; 27:921-45. [PMID: 11816494 DOI: 10.1016/s0095-5108(05)70058-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We have reviewed the prenatal diagnosis and management of abnormalities in the urologic system. Urologic anomalies may be caused by embryologic aberrations, genetic disease, or a nonrandom association with other structural abnormalities. There is a wide range of prognoses, depending on the cause and the impact of the anomaly on the production of amniotic fluid. Management focuses on obtaining an accurate prenatal diagnosis, providing appropriate counseling, and ensuring the proper surveillance or treatment before and after birth.
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Affiliation(s)
- C J Saphier
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York, USA.
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