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Gottschalk I, Berg C, Menzel T, Abel JS, Kribs A, Dübbers M, Kohaut J, Weber LT, Taylan C, Habbig S, Liebau MC, Boemers TM, Weber EC. Single-center outcome analysis of 46 fetuses with megacystis after intrauterine vesico-amniotic shunting with the Somatex®intrauterine shunt. Arch Gynecol Obstet 2024; 309:145-158. [PMID: 36604332 PMCID: PMC10770195 DOI: 10.1007/s00404-022-06905-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To assess the spectrum of underlying pathologies, the intrauterine course and postnatal outcome of 46 fetuses with megacystis that underwent intrauterine vesico-amniotic shunting (VAS) with the Somatex® shunt in a single center. METHODS Retrospective analysis of 46 fetuses with megacystis that underwent VAS either up to 14 + 0 weeks (early VAS), between 14 + 1 and 17 + 0 weeks (intermediate VAS) or after 17 + 0 weeks of gestation (late VAS) in a single tertiary referral center. Intrauterine course, underlying pathology and postnatal outcome were assessed and correlated with the underlying pathology and gestational age at first VAS. RESULTS 46 fetuses underwent VAS, 41 (89%) were male and 5 (11%) were female. 28 (61%) fetuses had isolated and 18 (39%) had complex megacystis with either aneuploidy (n = 1), anorectal malformations (n = 6), cloacal malformations (n = 3), congenital anomalies overlapping with VACTER association (n = 6) or Megacystis-Microcolon Intestinal-Hypoperistalsis Syndrome (MMIHS) (n = 2). The sonographic 'keyhole sign' significantly predicted isolated megacystis (p < 0.001). 7 pregnancies were terminated, 4 babies died in the neonatal period, 1 baby died at the age of 2.5 months and 34 (74%) infants survived until last follow-up. After exclusion of the terminated pregnancies, intention-to-treat survival rate was 87%. Mean follow-up period was 24 months (range 1-72). The underlying pathology was highly variable and included posterior urethral valve (46%), hypoplastic or atretic urethra (35%), MMIHS or prune belly syndrome (10%) and primary vesico-ureteral reflux (2%). In 7% no pathology could be detected postnatally. No sonographic marker was identified to predict the underlying pathology prenatally. 14 fetuses underwent early, 24 intermediate and 8 late VAS. In the early VAS subgroup, amnion infusion prior to VAS was significantly less often necessary (7%), shunt complications were significantly less common (29%) and immediate kidney replacement therapy postnatally became less often necessary (0%). In contrast, preterm delivery ≤ 32 + 0 weeks was more common (30%) and survival rate was lower (70%) after early VAS compared to intermediate or late VAS. Overall, 90% of liveborn babies had sufficient kidney function without need for kidney replacement therapy until last follow-up, and 95% had sufficient pulmonary function without need for mechanical respiratory support. 18% of babies with complex megacystis suffered from additional health restrictions due to their major concomitant malformations. CONCLUSIONS Our data suggest that VAS is feasible from the first trimester onward. Early intervention has the potential to preserve neonatal kidney function in the majority of cases and enables neonatal survival in up to 87% of cases. Despite successful fetal intervention, parents should be aware of the potential of mid- or long-term kidney failure and of additional health impairments due to concomitant extra-renal anomalies that cannot be excluded at time of intervention.
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Affiliation(s)
- I Gottschalk
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - C Berg
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - T Menzel
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - J S Abel
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - A Kribs
- Department of Neonatology, University Hospital of Cologne, Cologne, Germany
| | - M Dübbers
- Division of Pediatric Surgery, University Hospital of Cologne, Cologne, Germany
| | - J Kohaut
- Division of Pediatric Surgery, University Hospital of Cologne, Cologne, Germany
| | - L T Weber
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - C Taylan
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - S Habbig
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - M C Liebau
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - T M Boemers
- Department of Pediatric Surgery and Urology, Children´S Academic Hospital Amsterdamer Cologne, Cologne, Germany
| | - E C Weber
- Division of Prenatal Medicine, Fetal Surgery and Gynecological Ultrasound, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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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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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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Current State of Fetal Intervention for Obstructive Uropathy–Focus on Bladder. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00600-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Monteiro S, Nassr AA, Yun PS, Voigt R, Koh CJ, Roth DR, Braun M, Angelo J, Moscardo I, Espinoza J, Shamshirsaz AA, Belfort M, Ruano R, Sanz Cortes M. Neurodevelopmental Outcome in Infants with Lower Urinary Tract Obstruction Based on Different Degrees of Severity. Fetal Diagn Ther 2020; 47:587-596. [PMID: 32146466 DOI: 10.1159/000504977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine postnatal neurodevelopmental (ND) outcomes for children with congenital lower urinary tract obstruction (LUTO) based on disease severity. METHODS Twenty male infants with LUTO were classified prenatally as Stage 1 (normal amniotic fluid and renal function; n = 5), Stage 2 (signs of obstruction with preserved renal function; n = 13), and Stage 3 (signs of severe renal damage; n = 2). ND status was assessed using the Developmental Profile-3 test in 5 developmental domains (physical, adaptive behavior, social-emotional, cognitive, and communication). Each domain was considered to be delayed if standard scores were 2 or more SD below the mean. ND outcomes were compared between cases with an expected normal renal function (LUTO Stage 1) and those with impaired renal function (LUTO Stages 2 and 3). Results from cases with Stage 2 were also compared to those from Stage 3. ORs were calculated to predict risk for adverse ND outcome for each domain considering prenatal and postnatal factors. RESULTS Gestational age (GA) at the diagnosis of LUTO was similar between both groups (Stage 1: 24.85 ± 7.87 vs. Stages 2 and 3: 21.4 ± 4.31 weeks; p = 0.24). Twelve of 15 cases with Stage 2 or 3 underwent vesicoamniotic shunt placement compared to none of Stage 1 fetuses (p < 0.01). No differences in GA at delivery were detected between the groups (37.9 ± 1.6 vs. 35.1 ± 3.6 weeks; p = 0.1). One of the infants in the Stage 2 and 3 groups received a kidney transplant during follow-up. One case (20%) from Stage 1 group required dialysis during the first 6 months of life, and 1 case from Stage 2 to 3 group required it during the first 6 months (p = 1.0), whereas 3 additional cases needed dialysis from 6 to 24 months (p = 0.6). Mean age at Developmental Profile 3 (DP-3) testing was 20.3 ± 12.3 months (Stage 1: 11.2 ± 8.6 vs. Stages 2 and 3: 23.4 ± 13.4 months; p = 0.07). Fifteen of the 20 patients (75%) had no ND delays. Of the 5 patients with ND delays, 4 received dialysis. No differences in ND outcomes between infants with LUTO Stage 1 and those with Stages 2 and 3 were detected except for a trend toward better physical development in Stage 1 (102.6 ± 11.6 vs. 80.7 ± 34.9; p = 0.05). Infants diagnosed with LUTO Stage 3 showed significantly lower adaptive scores than those diagnosed with Stage 2 (Stage 2: 101.9 ± 22.3 vs. Stage 3: 41.5 ± 30.4; p = 0.04) and a nonsignificant trend for lower results in physical (85.8 ± 33.0 vs. 47.5 ± 38.9; p = 0.1) and socio-emotional (94.7 ±17.9 vs. 73.5 ± 13.4; p = 0.1) domains. Infants who received dialysis showed 15-fold increased risk (95% CI 0.89-251) for delayed socio-emotional development (p = 0.06). Diagnosis of fetal renal failure increased the risk for delays in the adaptive domain 30-fold (95% CI 1.29-93.1; p = 0.03). Infants with abnormal renal function had 19 times (95% CI 1.95-292) increased risk for delays in the physical domain (p = 0.03). CONCLUSIONS While most patients with LUTO do not exhibiting ND delays, our results support the importance of ND monitoring, especially in severe forms of LUTO, as increased severity of this condition may be associated with poorer ND outcomes.
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Affiliation(s)
- Sonia Monteiro
- Department of Developmental Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Peter S Yun
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert Voigt
- Department of Developmental Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Chester J Koh
- Division of Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - David R Roth
- Division of Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Braun
- Department of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Angelo
- Department of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Isabel Moscardo
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.,Department of Obstetrics and Gynecology, Hospital Clinic, Valencia, Spain
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, New York, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA,
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Saccone G, D'Alessandro P, Escolino M, Esposito R, Arduino B, Vitagliano A, Quist-Nelson J, Berghella V, Esposito C, Zullo F. Antenatal intervention for congenital fetal lower urinary tract obstruction (LUTO): a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019; 33:2664-2670. [PMID: 30501534 DOI: 10.1080/14767058.2018.1555704] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: To evaluate the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction (LUTO) in improving perinatal survival and postnatal renal function.Methods: Electronic databases were searched from their inception until May 2018. Selection criteria included randomized controlled trials and nonrandomized studies including fetuses with ultrasound evidence of LUTO evaluating antenatal intervention for improving perinatal outcomes. Any type of antenatal bladder drainage technique was analyzed. The primary outcome was perinatal survival. The secondary outcome was postnatal survival with normal renal function. The summary measures were reported as summary odds ratio (OR) with 95% of confidence interval (CI).Results: Ten articles with a total of 355 fetuses were included in the meta-analysis. Inclusion criteria of the selected studies were singleton pregnancy with severe LUTO confirmed on detailed fetal ultrasound examination. Nine studies analyzed the efficacy of vesico-amniotic shunt performed in the second trimester. The overall estimate survival was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.54, 95% CI: 1.14-5.67). 64/112 fetuses (57.1%) survived in the vesico-amniotic shunt group compared to 52/134 (38.8%) in the control group. Five studies reported on postnatal renal function between 6 months and 2 years. Rate of good postnatal renal function was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.09, 95% CI: 0.74-5.9). Fetal cystoscopy was performed in only two included studies. Overall, 45 fetuses underwent fetal cystoscopy. The perinatal survival was higher in the cystoscopy group compared to the conservative management group (OR: 2.63, 95% CI: 1.07-6.47). Normal renal function was noted in 13/34 fetuses in the cystoscopy group versus 12/61 in the conservative management group at 6 months follow-up (OR: 1.75, 95% CI: 1.05-2.92)Conclusions: Antenatal bladder drainage appears to improve perinatal survival in cases of LUTO.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Pietro D'Alessandro
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Maria Escolino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Rosanna Esposito
- Department of Tanslational Medical Sciences (DISMET), Pediatric Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Bruno Arduino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Amerigo Vitagliano
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Ciro Esposito
- Department of Tanslational Medical Sciences (DISMET), Pediatric Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
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Khanna K, Dhua AK, Bhatnagar V. Antenatally Diagnosed Surgical Conditions: Fetus As Our Patient. Indian J Pediatr 2018; 85:1101-1109. [PMID: 29968133 DOI: 10.1007/s12098-018-2732-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/30/2018] [Indexed: 12/30/2022]
Abstract
In today's era of improved antenatal care and screening modalities (3D high-resolution fetal ultrasound, fetal magnetic resonance imaging, fetal echocardiography, maternal serum markers and fetal blood sampling), an early diagnosis of surgical fetal abnormalities is routinely possible. A thorough knowledge about the incidence of such defects, the means of detection and evaluation, the scope of fetal intervention, postnatal management and long-term outcomes of common surgical conditions diagnosed antenatally is essential. This knowledge would not only help in proper patient care and management but also to ensure appropriate counselling of the expectant parents. This article highlights the fetal anomalies which are amenable to some form of fetal intervention from a pediatric surgical perspective as also those which can be treated after birth.
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Affiliation(s)
- Kashish Khanna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anjan Kumar Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Abstract
PURPOSE OF THE REVIEW In this article, we explore the origins of intervention of fetal lower urinary tract obstruction, and we specifically discuss the background and recent outcomes of vesicoamniotic shunt placement and fetal cystoscopy. The article seeks to provide a comprehensive overview of the field while bringing the reader quickly up to speed on the pertinent literature and the critical data that are available to guide decision-making regarding intervention. RECENT FINDINGS Appropriate patient selection for fetal intervention remains challenging despite advances in prenatal imaging. Both a randomized controlled trial and multiple systematic reviews show evidence of a perinatal survival benefit following fetal intervention but rates of renal morbidity remain very high. Despite 30 years of research, fetal lower urinary tract obstruction remains a difficulty entity to treat. Intervention may lead to survival, but physicians and caregivers must remain alert for the distinct possibility of long-term renal morbidity in survivors.
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Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA.
| | - John W Brock
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA
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Nassr AA, Shazly SAM, Abdelmagied AM, Araujo Júnior E, Tonni G, Kilby MD, Ruano R. Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: an updated systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:696-703. [PMID: 27270578 DOI: 10.1002/uog.15988] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the effect on perinatal and postnatal survival of vesicoamniotic shunt (VAS) as treatment for fetal lower urinary tract obstruction (LUTO). METHODS An electronic search of Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus using relevant search terms was conducted from inception to June 2015 to identify studies comparing outcomes of VAS vs conservative management for treatment of LUTO. Cohort studies and clinical trials were considered eligible. Single-arm studies and studies that did not report survival were excluded. Sample size and language were not criteria for exclusion. Two reviewers extracted independently data in a standardized form, including study characteristics and results. Primary outcomes were perinatal and postnatal survival. Secondary outcome was postnatal renal function. Data on fetal survival were expressed as odds ratio (OR) and 95% CI. RESULTS Of the 423 abstracts retrieved, nine studies were eligible for inclusion. These studies included 112 fetuses treated with VAS and 134 that were managed conservatively. There was heterogeneity in study design. Although the data demonstrated a difference in effect estimates between the study arms in terms of perinatal survival (OR, 2.54 (95% CI, 1.14-5.67)), there was no difference in 6-12-month survival (OR, 1.77 (95% CI, 0.25-12.71)) or 2-year survival (OR, 1.81 (95% CI, 0.09-38.03)). In addition, there was no difference in effect on postnatal renal function between fetuses that underwent intervention and those that did not (OR, 2.09 (95% CI, 0.74-5.94)). CONCLUSIONS Available data seem to support an advantage for perinatal survival in fetuses treated with VAS compared with conservative management. However, 1-2-year survival and outcome of renal function after VAS procedure remain uncertain. Further studies are necessary to evaluate the effectiveness of fetal intervention for LUTO based on different severity of the disease, due to the very low quality of the studies according to GRADE guidelines. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - S A M Shazly
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - A M Abdelmagied
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - G Tonni
- Prenatal Diagnostic Service, Department of Obstetrics and Gynecology, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - M D Kilby
- Centre for Women's and Children's Health, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Ruano
- Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic, Rochester, MN, USA
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Morris RK, Middleton LJ, Malin GL, Quinlan-Jones E, Daniels J, Khan KS, Deeks J, Kilby MD. Outcome in fetal lower urinary tract obstruction: a prospective registry study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:424-431. [PMID: 25689128 DOI: 10.1002/uog.14808] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/26/2015] [Accepted: 01/27/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe influences on decision-making and prognostic variables in the prenatal management of fetal lower urinary tract obstruction (LUTO). METHODS This was a prospective registry study of pregnant women with a male fetus with LUTO from centers within the British Isles and The Netherlands. Women and/or their clinicians were given the treatment option of either conservative management or vesicoamniotic shunting (VAS). Baseline characteristics of women in the registry, reasons for entry to the registry and pregnancy outcomes were assessed. The main study outcomes were survival to 28 days after delivery, further survival to 2 years and renal function. Logistic regression analysis was used to examine prognostic variables that affected outcome. Results were compared with those of women in a randomized controlled trial (RCT) who were allocated randomly to a treatment option. RESULTS Forty-five women were registered, of whom 78% (35/45) underwent conservative management. Twenty-seven women entered the registry owing to their clinician's preference for management and 18 because of their own preference. Compared to the conservative-management group of the RCT, a higher proportion of women in the registry opting for conservative management had a normal amniotic fluid volume at diagnosis (P = 0.05) and a diagnosis of LUTO ≥ 24 weeks' gestation (P = 0.003). On multivariable logistic regression analysis, these variables showed a significant association with perinatal survival (P < 0.001). Survival to 28 days after delivery was higher in the conservative-management group, at 69% (24/35), compared to 40% (4/10) in the VAS group (P = 0.02) but this difference had limited statistical significance owing to small study size (relative risk, 0.58 (95% CI, 0.26-1.29); P = 0.14). CONCLUSION In our prospective registry, the majority of fetuses with LUTO received conservative management, which was associated with better short- and long-term outcomes. A significant proportion of these pregnancies had normal amniotic fluid volume and a gestational age at diagnosis of ≥ 24 weeks, characteristics shown to be associated with improved survival.
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Affiliation(s)
- R K Morris
- Centre for Women's & Children's Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - L J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - G L Malin
- Centre for Women's & Children's Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - E Quinlan-Jones
- Centre for Women's & Children's Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J Daniels
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - K S Khan
- Centre for Women's & Children's Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J Deeks
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - M D Kilby
- Centre for Women's & Children's Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
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Martínez JM, Masoller N, Devlieger R, Passchyn E, Gómez O, Rodo J, Deprest JA, Gratacós E. Laser Ablation of Posterior Urethral Valves by Fetal Cystoscopy. Fetal Diagn Ther 2015; 37:267-73. [DOI: 10.1159/000367805] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/15/2014] [Indexed: 11/19/2022]
Abstract
Objective: To report the results of fetal cystoscopic laser ablation of posterior urethral valves (PUV) in a consecutive series in two referral centers. Methods: Twenty pregnant women with a presumptive isolated PUV were treated with fetal cystoscopy under local anesthesia. Identification and fulguration of the PUV by one or several firing-contacts with diode laser were attempted. Perinatal and long-term outcomes were prospectively recorded. Results: The median gestational age at procedure was 18.1 weeks (range 15.0-25.6), and median operation time was 24 min (range 15-40). Access to the urethra was achieved in 19/20 (95%) cases, and postoperative, normalization of bladder size and amniotic fluid was observed in 16/20 (80%). Overall, there were 9 (45%) terminations of pregnancy and 11 women (55%) delivered a liveborn baby at a mean gestational age of 37.3 (29.1-40.2) weeks. No infants developed pulmonary hypoplasia and all were alive at 15-110 months. Eight (40% of all fetuses, 72.7% of newborns) had normal renal function and 3 (27.3%) had renal failure awaiting renal transplantation. Conclusion: Fetoscopic laser ablation for PUV can achieve bladder decompression and amniotic fluid normalization with a single procedure in selected cases with anyhydramnios. There is still a significant risk of progression to renal failure pre or postnatally.
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Morris RK, Daniels J, Deeks J, Field D, Kilby MD. The challenges of interventional trials in fetal therapy. Arch Dis Child Fetal Neonatal Ed 2014; 99:F448-50. [PMID: 25056356 DOI: 10.1136/archdischild-2013-305624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- R Katie Morris
- Centre for Women's & Children Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Daniels
- Centre for Women's & Children Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Deeks
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - D Field
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - M D Kilby
- Centre for Women's & Children Health and the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Birmingham, UK
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Abstract
This article summarizes the most recent literature regarding congenital lower urinary tract obstruction in the fetus and newborn. Lower urinary tract obstruction is a heterogeneous group of rare diagnoses that have significant potential for in utero mortality and long-term morbidity in survivors. The diagnosis and management of the most common causes are reviewed. In addition, the current state of prenatal intervention for congenital lower urinary tract obstruction is discussed.
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Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA.
| | - John W Brock
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA
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Diwakar L, Morris RK, Barton P, Middleton LJ, Kilby MD, Roberts TE. Evaluation of the cost effectiveness of vesico-amniotic shunting in the management of congenital lower urinary tract obstruction (based on data from the PLUTO Trial). PLoS One 2013; 8:e82564. [PMID: 24376546 PMCID: PMC3869698 DOI: 10.1371/journal.pone.0082564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022] Open
Abstract
Objective To determine the cost-effectiveness of in-utero percutaneous Vesico Amniotic Shunt (VAS) in the management of fetal lower urinary tract obstruction (LUTO) Design Model based economic analysis using data from the randomised controlled arm of the PLUTO (percutaneous vesico-amniotic shunting for lower urinary tract obstruction) trial. Setting Fetal medicine departments in United Kingdom, Ireland and Netherlands. Population or Sample Pregnant women with a male, singleton fetus with LUTO. Methods Costs and outcomes were prospectively collected in the trial; three separate base case analyses were performed using the intention to treat (ITT), per protocol and uniform prior methods. Deterministic and probabilistic sensitivity analyses were performed to explore data uncertainty. Main Outcome Measures Survival at 28 days, 1 year and disease free survival at 1 year. Results VAS was more expensive but appeared to result in higher rates of survival compared with conservative management in patients with LUTO. Using ITT analysis the incremental cost effectiveness ratios based on outcomes of survival at 28 days, 1 year, or 1 morbidity-free year on the VAS arm were £15,506, £15,545, and £43,932, respectively. Conclusions VAS is a more expensive option compared to the conservative approach in the management of individuals with LUTO. Data from the RCT suggest that VAS improves neonatal survival but does not result in significant improvements in morbidity. Our analysis concludes that VAS is not likely to be cost effective in the management of these patients given the NICE (National Institute of Health and Clinical Excellence) cost threshold of £20,000 per QALY.
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Affiliation(s)
- Lavanya Diwakar
- Health Economics Unit, School of Health and Population Sciences, The Public Health Building, University of Birmingham, Birmingham, United Kingdom
| | - Rachel K Morris
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom ; Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Pelham Barton
- Health Economics Unit, School of Health and Population Sciences, The Public Health Building, University of Birmingham, Birmingham, United Kingdom
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Mark D Kilby
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom ; Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, The Public Health Building, University of Birmingham, Birmingham, United Kingdom
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Prune-belly syndrome detected by ultrasound in the first trimester and the usefulness of vesicocentesis as a modality of treatment. Obstet Gynecol Sci 2013; 56:265-8. [PMID: 24328013 PMCID: PMC3784146 DOI: 10.5468/ogs.2013.56.4.265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/11/2013] [Accepted: 03/11/2013] [Indexed: 11/08/2022] Open
Abstract
Prune-belly syndrome may be related to lower urinary tract obstruction (LUTO). LUTO in the early gestational age exacerbates fetal renal function and may require intrauterine intervention. If early developed LUTO causes bladder distension and abdominal musculature deficiency, it will result in prune belly syndrome. Therefore, early detection of the disease and proper treatment before the renal impairment is important. However, there are few literatures concerning the treatment of prune belly syndrome in the first trimester. We report a case of prune belly syndrome diagnosed at 11+6 weeks of gestation and the value of vesicocentesis as a modality of treatment. Ultrasound showed dilated fetal bladder and vesicocentesis was successful in reducing the volume of the bladder. However, the pregnancy was terminated upon request.
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Morris RK, Malin GL, Quinlan-Jones E, Middleton LJ, Hemming K, Burke D, Daniels JP, Khan KS, Deeks J, Kilby MD. Percutaneous vesicoamniotic shunting versus conservative management for fetal lower urinary tract obstruction (PLUTO): a randomised trial. Lancet 2013; 382:1496-506. [PMID: 23953766 PMCID: PMC3898962 DOI: 10.1016/s0140-6736(13)60992-7] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fetal lower urinary tract obstruction (LUTO) is associated with high perinatal and long-term childhood mortality and morbidity. We aimed to assess the effectiveness of vesicoamniotic shunting for treatment of LUTO. METHODS In a randomised trial in the UK, Ireland, and the Netherlands, women whose pregnancies with a male fetus were complicated by isolated LUTO were randomly assigned by a central telephone and web-based randomisation service to receive either the intervention (placement of vesicoamniotic shunt) or conservative management. Allocation could not be masked from clinicians or participants because of the invasive nature of the intervention. Diagnosis was by prenatal ultrasound. The primary outcome was survival of the baby to 28 days postnatally. All primary analyses were done on an intention-to-treat basis, but these results were compared with those of an as-treated analysis to investigate the effect of a fairly large proportion of crossovers. We used Bayesian methods to estimate the posterior probability distribution of the effectiveness of vesicoamniotic shunting at 28 days. The study is registered with the ISRCTN Register, number ISRCTN53328556. FINDINGS 31 women with singleton pregnancies complicated by LUTO were included in the trial and main analysis, with 16 allocated to the vesicoamniotic shunt group and 15 to the conservative management group. The study closed early because of poor recruitment. There were 12 livebirths in each group. In the vesicoamniotic shunt group one intrauterine death occurred and three pregnancies were terminated. In the conservative management group one intrauterine death occurred and two pregnancies were terminated. Of the 16 pregnancies randomly assigned to vesicoamniotic shunting, eight neonates survived to 28 days, compared with four from the 15 pregnancies assigned to conservative management (intention-to-treat relative risk [RR] 1·88, 95% CI 0·71-4·96; p=0·27). Analysis based on treatment received showed a larger effect (3·20, 1·06-9·62; p=0·03). All 12 deaths were caused by pulmonary hypoplasia in the early neonatal period. Sensitivity analysis in which non-treatment-related terminations of pregnancy were excluded made some slight changes to point estimates only. Bayesian analysis in which the trial data were combined with elicited priors from experts suggested an 86% probability that vesicoamniotic shunting increased survival at 28 days and a 25% probability that it had a large, clinically important effect (defined as a relative increase of 55% or more in the proportion of neonates who survived). There was substantial short-term and long-term morbidity in both groups, including poor renal function-only two babies (both in the shunt group) survived to 2 years with normal renal function. Seven complications occurred in six fetuses from the shunt group, including spontaneous ruptured membranes, shunt blockage, and dislodgement. These complications resulted in four pregnancy losses. INTERPRETATION Survival seemed to be higher in the fetuses receiving vesicoamniotic shunting, but the size and direction of the effect remained uncertain, such that benefit could not be conclusively proven. Our results suggest that the chance of newborn babies surviving with normal renal function is very low irrespective of whether or not vesicoamniotic shunting is done. FUNDING UK National Institute of Health Research, Wellbeing of Women, Hannah Eliza Guy Charity (Birmingham Children's Hospital Charity).
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Affiliation(s)
- Rachel K Morris
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Gemma L Malin
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Elisabeth Quinlan-Jones
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Karla Hemming
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Danielle Burke
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jane P Daniels
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Khalid S Khan
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jon Deeks
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Mark D Kilby
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
- Correspondence to: Prof Mark D Kilby, University of Birmingham & Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham B15 2TG, UK
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Clayton DB, Brock JW. Paediatric urology: vesicoamniotic shunting for fetal LUTO--questions linger. Nat Rev Urol 2013; 10:624-5. [PMID: 24145471 DOI: 10.1038/nrurol.2013.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Douglass B Clayton
- Division of Paediatric Urology, Monroe Carell Jr Children's Hospital at Vanderbilt, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN 37232, USA
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Haeri S, Ruano SH, Farah LMS, Joffe R, Ruano R. Prenatal cytogenetic diagnosis from fetal urine in lower urinary tract obstruction. Congenit Anom (Kyoto) 2013; 53:89-91. [PMID: 23751043 DOI: 10.1111/cga.12007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/25/2012] [Indexed: 11/26/2022]
Abstract
The aim of this study was to test if prenatal cytogenetic diagnosis can be performed on fetal urine in fetal lower urinary tract obstruction. In this retrospective cohort study of fetuses with lower urinary tract obstruction (LUTO) over a 4-year period at one institution, cytogenetic evaluation was attempted on fetal urine samples as well as amniotic fluid specimens. A total of 11 cases, ranging in gestational age from 15 to 25 weeks, underwent amniocentesis and vesicocentesis. Traditional cytogenetic evaluation was successfully completed in amniotic fluid and fetal urine samples in all 11 cases (100%). The karyotype was normal in seven (64%), trisomy 21 in two (18%), Trisomy 13 in one (9%), and partial chromosome 4 deletion in one (9%). Traditional cytogenetic evaluation can be successfully performed on fetal urine samples in cases of lower urinary tract obstruction.
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Affiliation(s)
- Sina Haeri
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA
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20
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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: 23] [Impact Index Per Article: 2.1] [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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Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M, Uppal R, Agarwal I. Revised guidelines on management of antenatal hydronephrosis. Indian J Nephrol 2013; 23:83-97. [PMID: 23716913 PMCID: PMC3658301 DOI: 10.4103/0971-4065.109403] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.
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Affiliation(s)
- A. Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A. Bagga
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A Krishna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, India
| | - M. Bajpai
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - M. Srinivas
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - R. Uppal
- Uppal Radiology Center, Christian Medical College, Vellore, Tamil Nadu, India
| | - I. Agarwal
- Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India
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Abstract
Congenital urinary tract obstruction (diagnosed antenatally by ultrasound screening) is one of the main causes of end-stage kidney disease in children. The extent of kidney injury in early gestation and the resultant abnormality in kidney development determine fetal outcome and postnatal renal function. Unfortunately, the current approach to diagnostic evaluation of the severity of injury has inherently poor diagnostic and prognostic value because it is based on the assessment of fetal tubular function from fetal urine samples rather than on estimates of the dysplastic changes in the injured developing kidney. To improve the outcome in children with congenital urinary tract obstruction, new biomarkers reflecting these structural changes are needed. Genomic and proteomic techniques that have emerged in the past decade can help identify the key genes and proteins from biological fluids, including amniotic fluid, that might reflect the extent of injury to the developing kidney.
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Tzschoppe A, Rauh M, Goecke TW, Yazdi B, Hart N, Siemer J, Schild RL, Dötsch J. Sex-specific differences in the concentration of tubular parameters in the amniotic fluid of second trimester fetuses. Prenat Diagn 2012; 32:476-9. [DOI: 10.1002/pd.3846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Anja Tzschoppe
- Department of Paediatrics and Adolescent Medicine; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Manfred Rauh
- Department of Paediatrics and Adolescent Medicine; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Tamme W. Goecke
- Department of Obstetrics & Gynaecology; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Britta Yazdi
- Department of Obstetrics & Gynaecology; University of Freiburg; Freiburg; Germany
| | - Nicola Hart
- Department of Obstetrics & Gynaecology; Städtisches Klinikum München; Munich; Germany
| | - Jörn Siemer
- Department of Obstetrics & Gynaecology; Ludmillenstift Meppen; Meppen; Germany
| | - Ralf L. Schild
- Department of Obstetrics & Gynaecology; Diakonische Dienste Hannover; Hannover; Germany
| | - Jörg Dötsch
- Department of Paediatrics and Adolescent Medicine; University of Cologne; Cologne; Germany
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Prenatal ultrasonography: implications for pediatric urology. J Pediatr Urol 2011; 7:118-25. [PMID: 21227755 DOI: 10.1016/j.jpurol.2010.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 12/07/2010] [Indexed: 11/24/2022]
Abstract
Prenatal ultrasonography has become a critical and integral component of the obstetric care of women worldwide. As a result, a number of congenital anomalies are now routinely being detected prior to birth. Anomalies affecting the genitourinary system are among those most commonly detected, and thus pediatric urologists are increasingly being asked to provide parental counseling in such situations. However, much of the data needed to enhance these discussions and provide informed consent are absent from the literature. In this review, we hope to address the published literature describing the rapidly expanding role of ultrasound in prenatal care. More importantly, however, we hope to provide some insight into the manner in which prenatal ultrasound and subsequent urologic anomaly diagnosis has affected the practice of pediatric urology.
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Abstract
Antenatal sonography has markedly increased the detection of urogenital anomalies, including those conditions that lead to significant morbidity and mortality. Prenatal intervention is feasible to arrest and sometimes reverse the sequelae of bladder outlet obstruction but not necessarily renal damage. Myelomeningoceles, the most severe form of spina bifida, can be corrected in utero, with improvements in hydrocephalus seen along with a decreased incidence of ventricular shunting postnatally. Medical therapy to prevent virilization associated with congenital adrenal hyperplasia has been successful, with improved ability to detect its presence prenatally now possible. As further techniques evolve to correct underlying disease processes, it becomes important to critically assess the therapies, particularly with long-term outcome data.
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Affiliation(s)
- Michael C Carr
- Division of Urology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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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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The pediatric surgeons' contribution to in utero treatment of twin-to-twin transfusion syndrome. Ann Surg 2009; 250:456-62. [PMID: 19644353 DOI: 10.1097/sla.0b013e3181b45794] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination of endoscopic fetal surgery-specific techniques and surgical restraint. SUMMARY BACKGROUND DATA TTTS is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of placental vessels (LASER) causes premature rupture of membranes (PROM) in 10% to 20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of >=1 twin of 75% to 80%. METHODS We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe TTTS. Pregnancies with TTTS (stages I-IV) managed in the last 8 years were reviewed. LASER was offered in stage III/IV only. RESULTS Ninety-eight cases of TTTS were managed in a pediatric surgery/maternal-fetal medicine collaborative Fetal Treatment Program-39 were observed (40%) and 59 underwent LASER (60%). Survival of >= twin was seen in 82.7%, and overall survival was 69.4%. These survival rates are similar to, or better than, other comparable series with similar stage distribution (low:high stage ratio 1:1) in which all patients underwent LASER. PROM rate was 4%. CONCLUSIONS Reserving LASER treatment for severe TTTS results in outcomes similar to, or better than, LASER for all stages. Applying fetal surgery-specific endoscopic techniques, including port-site sealing, reduces postoperative complications.
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31
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Abstract
The authors present an overview of the prenatal diagnosis, evaluation, contemporary intervention, and antenatal management of lower urinary tract obstruction. They review early experimental models that confirmed the relation between urinary tract obstruction and renal fibrocystic dysplasia and that early in utero relief of the obstruction could prevent irreversible renal injury. Subsequent studies of the electrolyte and protein concentrations in fetal urine from human cases established prognostic threshold values and helped to develop an algorithm to select candidates for antenatal therapy. Although shunting has improved survival, long-term morbidities remain a significant challenge.
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Affiliation(s)
- Serena Wu
- General Surgery, The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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32
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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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MORRIS RK, KILBY MD. An overview of the literature on congenital lower urinary tract obstruction and introduction to the PLUTO trial: Percutaneous shunting in lower urinary tract obstruction. Aust N Z J Obstet Gynaecol 2009; 49:6-10. [DOI: 10.1111/j.1479-828x.2008.00940.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Abstract
During intrauterine life the fetus is bathed in amniotic fluid which provides a low resistance space for free movement and a buffer against external trauma. This fluid is produced in early pregnancy largely as a maternal dialysate, then as a fetal transudate. Fetal urine is the most important source of amniotic fluid after 16 weeks gestation. The control of amniotic fluid is complex and poorly understood; it arises from secondary partitioning of water within the fetoplacental extracellular space and reflects fetal fluid balance.
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35
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Abstract
From the moment of implantation until delivery some 37 weeks later, the human embryo or fetus is surrounded by fluid. Initially this fluid is a transudate from maternal and embryonic tissues which provides nutrients for the growing embryo. Starting in early pregnancy, the fetal kidneys begin to contribute substantial quantities of urine to the amniotic fluid volume. At mid pregnancy, when the skin becomes keratinized, the kidneys become the main source of amniotic fluid. Fetal swallowing is the main route of amniotic fluid removal. Although fetal urine production and swallowing have been studied in both human pregnancy and animal models, the knowledge from these investigations is not sufficiently extensive to explain overall amniotic fluid volume regulation. None the less, it is clear that the amniotic fluid is in a dynamic, ever-changing state. The production rate of the fetal urine in the human fetus at term (800–1200ml/day) is sufficient to replace completely the entire amniotic volume every 12–24 hours1. While the fetus is producing large volumes of urine, the volume of amniotic fluid is normally maintained within a very narrow range. Deviations from the normal range are often associated with significant perinatal morbidity and mortality.
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36
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Mure PY, Mouriquand P. Upper urinary tract dilatation: prenatal diagnosis, management and outcome. Semin Fetal Neonatal Med 2008; 13:152-63. [PMID: 17988967 DOI: 10.1016/j.siny.2007.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Upper urinary tract dilatation is one of the most common abnormalities detected on prenatal ultrasound scanning. It is commonly due to transient urine flow impairment (UFI) at the level of the pelvi-ureteric and vesico-ureteric junctions, which improves with time in most cases. It is usually in the neonatal period that the diagnosis is confirmed and during the first 18 months of life that the prognosis of the dilatation is defined.
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Affiliation(s)
- Pierre-Yves Mure
- Department of Paediatric Urology, Claude Bernard University Lyon I, Hôpital Debrousse, 29 Rue Soeur Bouvier, Lyon cedex 05, France.
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37
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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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38
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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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39
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Clifton MS, Harrison MR, Ball R, Lee H. Fetoscopic Transuterine Release of Posterior Urethral Valves: A New Technique. Fetal Diagn Ther 2007; 23:89-94. [DOI: 10.1159/000111585] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 10/26/2006] [Indexed: 11/19/2022]
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40
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Kilby M, Khan K, Morris K, Daniels J, Gray R, Magill L, Martin B, Thompson P, Alfirevic Z, Kenny S, Bower S, Sturgiss S, Anumba D, Mason G, Tydeman G, Soothill P, Brackley K, Loughna P, Cameron A, Kumar S, Bullen P. PLUTO trial protocol: percutaneous shunting for lower urinary tract obstruction randomised controlled trial. BJOG 2007; 114:904-5, e1-4. [PMID: 17567421 DOI: 10.1111/j.1471-0528.2007.01382.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The primary objective is to determine whether intrauterine vesicoamniotic shunting for fetal bladder outflow obstruction, compared with conservative, noninterventional care, improves prenatal and perinatal mortality and renal function. The secondary objectives are to determine if shunting for fetal bladder outflow obstruction improves perinatal morbidity, to determine if improvement in outcomes is related to prognostic assessment at diagnosis and, if possible, derive a prognostic risk index and to determine the safety and long-term efficacy of shunting. DESIGN A multicentre randomised controlled trial (RCT). SETTING Fetal medicine units. POPULATION Pregnant women with singleton, male fetus with isolated lower urinary tract obstruction (LUTO). METHODS Following ultrasound diagnosis of LUTO in a male fetus and exclusion of other structural and chromosomal anomalies, participation in the trial will be discussed with the mother and written information given. Consent for participation in the trial will be taken and the mother randomised via the internet to either insertion of a vesicoamniotic shunt or expectant management. During pregnancy, both groups will be followed with regular ultrasound scans looking at viability, renal measurements and amniotic fluid volume. Following delivery, babies will be followed up by paediatric nephrologists/urologists at 4-6 weeks, 12 months and 3 and 5 years to assess renal function via serum creatinine, renal ultrasound and need for dialysis/transplant. MAIN OUTCOME MEASURES The main outcome measures will be perinatal mortality rates and renal function at 4-6 weeks and 12 months measured via serum creatinine, renal ultrasound and need for dialysis/transplant. FUNDING Wellbeing of Women. ESTIMATED COMPLETION DATE: September 2010. TRIAL ALGORITHM: [flowchart: see text].
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41
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Hubert KC, Palmer JS. Current diagnosis and management of fetal genitourinary abnormalities. Urol Clin North Am 2007; 34:89-101. [PMID: 17145364 DOI: 10.1016/j.ucl.2006.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prenatal assessment with ultrasonography provides excellent imaging of fluid-filled structures (eg, hydronephrosis, renal cysts, and dilated bladder) and renal parenchyma. This information allows for the generation of a differential diagnosis, identification of associated anomalies, and assessment of the prenatal and postnatal risks of a given anomaly. This enhances parental education and prenatal and postnatal planning. This article discusses the current methods of diagnosis and management of fetal genitourinary anomalies, and also the postnatal evaluation and treatment of these conditions.
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Affiliation(s)
- Katherine C Hubert
- Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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42
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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: 100] [Impact Index Per Article: 5.9] [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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43
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Abstract
INTRODUCTION AND AIM Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. This study evaluated the long-term outcome of managing patients with posterior urethral valves (PUV), highlighting the effect of antenatal vesicoamniotic shunt placement for patients who underwent fetal surgery. METHODS The medical records of 58 patients with PUV were retrospectively reviewed from June 1998 to June 2004. On the basis of prenatal assessment of sonographic findings and serial urinary electrolytes and protein measurements, patients were divided into two groups: group 1 comprised patients who had antenatal vesicoamniotic shunt placement whereas group 2 comprised patients who underwent postnatal surgical correction of PUV. Their outcomes and long-term results were evaluated. RESULTS Patients were followed up from 6 months to 6(1/2) years (mean 3.9 years). Group 1 included 12 patients who had vesicoamniotic shunt placement and were confirmed postnatally to have PUV. Four patients out of 12 died (33.3%); three out of the eight living patients had perinatal complications. Of the eight living patients, three (37.5%) underwent valve ablation and five (62.5%) underwent urinary diversion (three vesicostomies and two cutaneous ureterostomies). Renal function returned to normal in only four patients (50%). Radiological abnormalities (hydronephrosis and/or reflux) resolved in three (37.5%) patients, was downgraded in one (12.5%) patient and persisted in four patients (50%). Group 2 included 46 patients who were treated postnatally. Thirty-five patients (76%) underwent primary valve ablation, while 11 (24%) underwent urinary diversion (seven vesicostomies, four cutaneous ureterostomy and one pyelostomy). Renal function returned to normal in all patients who underwent valve ablation, except in three, while renal function returned to normal in only three of 11 patients who underwent urinary diversion. Radiological hydronephrosis and/or reflux resolved in 28 patients (60.9%), was downgraded in six patients (13%) and persisted in 12 patients (26.1%). CONCLUSIONS Antenatal vesicoamniotic shunt placement makes no difference to the outcome and long-term results of patients with PUV and debate about its efficacy on renal outcome remains. Primary valve ablation is the keystone of treatment for patients with PUV that might achieve the primary goal of nephron preservation. The lowest creatinine concentration in the first year of life is the most appropriate predictor of future renal function.
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Affiliation(s)
- Mamdouh A Salam
- Pediatric Surgery Department, Ain Shams University, Cairo, Egypt.
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44
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Kim SK, Won HS, Shim JY, Kim KS, Lee PR, Kim A. Successful vesicoamniotic shunting of posterior urethral valves in the first trimester of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:666-8. [PMID: 16254891 DOI: 10.1002/uog.2604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Prenatal ultrasonography early in gestation allows diagnosis of posterior urethral valves. We report on a fetus with posterior urethral valves treated using vesicoamniotic shunting at 13 + 5 weeks' gestation. A double-basket catheter was used for shunting. A 2582-g male neonate was delivered at 33 weeks' gestation, and the infant continued to show normal renal function at 3 years of age. To the best of our knowledge this is the first report of successful vesicoamniotic shunt placement using a double-basket catheter in the first trimester of pregnancy.
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Affiliation(s)
- S K Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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45
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Anumba DO, Scott JE, Plant ND, Robson SC. Diagnosis and outcome of fetal lower urinary tract obstruction in the northern region of England. Prenat Diagn 2005; 25:7-13. [PMID: 15662711 DOI: 10.1002/pd.1074] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We reviewed the prenatal and postnatal management of fetal lower urinary tract obstruction (LUTO) in a large geographically defined population. METHODS The records of 113 cases of LUTO seen over a 14-year period were examined. The predictive accuracy of prenatal findings for chronic renal failure (CRF) and a comparison of prenatal-suspected and non-suspected cases were made. RESULTS The incidence of LUTO was 2.2 in 10 000 births. During the study period, prenatal detection improved from 33 to 62%. Sensitivity of prenatal ultrasound detection of renal dysplasia and fetal urinary sodium, calcium, and beta2-microglobulin for CRF or renal dysplasia on autopsy were 59, 33, 66, and 63% respectively. Compared to undetected cases, those detected prenatally had higher mortality and a higher rate of CRF at 24 months (17% vs 57%, p < 0.01). CONCLUSION Our observations confirm the poor prognosis associated with fetal LUTO. The value of serial fetal urine biochemistry, other prenatal predictors of postnatal renal function, and the benefits of vesicoamniotic shunting require larger series and longer follow-up.
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Affiliation(s)
- Dilly O Anumba
- Department of Obstetrics and Gynaecology, University of Sheffield, Sheffield, UK.
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46
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Abstract
PURPOSE We evaluate the feasibility of applying minimally invasive techniques for fetal vesicostomy. We also evaluate whether transuterine fetal vesicostomy can be performed laparoscopically. MATERIALS AND METHODS A total of 25 pregnant ewes were time dated at approximately 90 days of gestation. With the animals under general anesthesia a low open abdominal incision was made and the uterus was brought out through the incision. With a 14 gauge needle the amniotic sac was filled with 1 to 2 l warm glycine. Three to 4, 5/12 blunt tip balloon trocars were placed in the uterus. Using laparoscopic techniques, a low transverse incision was made in the fetal abdomen, the bladder was opened at the dome and 2 running sutures were placed approximating the fetal abdominal wall to the edge of the fetal bladder. The trocar sites in the uterus were closed, and the maternal abdominal incision was closed. RESULTS Of the 25 pregnant ewes the technique was developed in the initial 15. In the subsequent 10 animals the complete procedure was accomplished successfully. Following these 10 procedures 5 abortions occurred on postoperative day 2, and there was 1 intrauterine fetal demise. Three fetuses were alive and delivered by cesarean section on postoperative days 10, 30 and 31. In the first fetus in which we used an interrupted suture for the vesicostomy a large hernia was noted at the vesicostomy site. The other 2 fetuses had a patent, well healed vesicostomy and were alive at cesarean section delivery on postoperative days 10 and 31. The last fetus was allowed to deliver at term by standard vaginal delivery. The fetus was alive and well, and the vesicostomy had strictured down to a pinhole in size, which was not unexpected as it was not an obstructed model. CONCLUSIONS Although technically challenging, transuterine laparoscopic fetal vesicostomy is technically feasible in the ewe model. Continued evaluation of this technique should include intensive fetal monitoring and the use of tocolytics to decrease the incidence of spontaneous abortion.
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Affiliation(s)
- Lee E Ponsky
- Section of Laparoscopic and Minimally Invasive Surgery and Pediatric Urology, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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47
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López Pereira P, Martinez Urrutia MJ, Jaureguizar E. Initial and long-term management of posterior urethral valves. World J Urol 2004; 22:418-24. [PMID: 15558286 DOI: 10.1007/s00345-004-0460-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 03/30/2004] [Indexed: 10/26/2022] Open
Abstract
Posterior urethral valves are the most common cause of congenital obstructive uropathy, resulting in renal failure in childhood. Nowadays, in most cases, diagnosis is suggested by antenatal ultrasound. However, antenatal intervention has not resulted in a significantly improved outcome. Endoscopic valve ablation is the initial treatment in most of these neonates, but others procedures, like vesicostomy or ureterostomy, can also be justified in some particular cases in order to improve renal function prognosis. Different factors like bladder dysfunction, VUR, polyuria and proteinuria, can be responsible for the slow and progressive deterioration in renal function that some of these patients show over the years. By treating them all, we may prevent or delay the onset of end stage renal disease.
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Affiliation(s)
- P López Pereira
- University Hospital La Paz Unidad de Urologia Infantil, Paseo de la Castellana 261, 28046 Madrid, Spain.
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48
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Abstract
Antenatal sonography has increased the detection of urogenital anomalies markedly, including conditions that lead to significant morbidity and mortality. Prenatal intervention is feasible to arrest and sometimes reverse the sequelae of bladder-outlet obstruction, but not necessarily renal damage. Myelomeningoceles, the most severe form of spina bifida,can be corrected in utero, with improvements in hydrocephalus and a decreased incidence of ventricular shunting postnatally. Medical therapy to prevent virilization associated with congenital adrenal hyperplasia has been successful, with improved ability to detect its presence prenatally. As techniques evolve to correct underlying disease processes,it becomes important to assess the therapies critically, particularly with long-term outcome data.
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Affiliation(s)
- Michael C Carr
- Division of Urology, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 3rd Floor, Wood Building, Philadelphia, PA 19104-4399, USA.
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49
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Abstract
Some anomalies of the kidney and urinary tract evolving in utero may compromise the renal function in the newborn. Early therapeutic options do exist, especially in obstructive nephropathies. The decision depends on a correct evaluation of the foetal enal function and prognosis, which is based on a range of methods: ultrasound echography, biochemical analysis of foetal urine, and, more recently, foetal serum markers such a beta-2 micro globulin. These methods are reviewed.
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Affiliation(s)
- Y Dumez
- Service de médecine foetale, Hôpital Necker, 149, rue de Sèvres, 75015 Paris, France.
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50
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Kilby MD, Somerset DA, Khan KS. Potential for correction of fetal obstructive uropathy: time for a randomized, controlled trial? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 23:527-530. [PMID: 15170790 DOI: 10.1002/uog.1073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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