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Alavi-Dunn N, Waisanen KM, Marrara JA, Zawerton A, Monteiro A, Saade K, Young E. Renal-Protective Urinoma Formation in a Newborn Boy With Posterior Urethral Valves. Cureus 2023; 15:e39880. [PMID: 37404433 PMCID: PMC10315171 DOI: 10.7759/cureus.39880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/06/2023] Open
Abstract
Posterior urethral valves (PUV) are an uncommon urologic congenital anomaly in males often discovered antenatally and more rarely after birth. PUV can lead to obstructive nephropathy and voiding dysfunction, putting patients at increased risk for irreversible renal damage and subsequent progression to end-stage renal disease. Much of the renal damage caused by PUV is proportional to the amount of time that the kidney has been experiencing retrograde pressure. Although much debate exists within the field, spontaneous decompression within the collecting system (e.g., "pop-off" valve) such as urinoma formation or spontaneous ascites has been found to relieve pressure on and thus protect the kidney, decreasing the risk of progression to advanced stages of chronic kidney disease. Despite the significant mass effect on the renal parenchyma, the pressure-relieving function of urinoma formation is a net protective factor allowing renal function to be preserved. We report a unique case of antenatal detection of PUV in a male with postnatal complicated urinoma formation secondary to forniceal rupture. Remarkably, despite significant external compression of the kidney and the development of urosepsis from infection of the urinoma with a multidrug-resistant organism that required percutaneous drainage, renal function was preserved throughout the disease course. After ablation of the PUV and drainage of the septic urinoma, the patient recovered rapidly after intervention and was ultimately discharged in stable condition.
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Affiliation(s)
| | | | | | - Ash Zawerton
- Urology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, USA
| | - Ajit Monteiro
- Pediatrics, Wayne State University Detroit Medical Center, Detroit, USA
| | - Kiana Saade
- Urology, University at Buffalo, Buffalo, USA
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Dhua AK, Anand S, Goel P, Yadav DK, Jain V, Verma A. Publication landscape of Posterior urethral valve- A scientometric study. J Pediatr Urol 2022; 18:650-660. [PMID: 36167650 DOI: 10.1016/j.jpurol.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 12/14/2022]
Abstract
UNLABELLED To assess the global research landscape in the field of Posterior urethral valve (PUV), a scientometric study was conducted to determine the quantity and quality of the research output and get insight into the key research areas and pattern of collaboration in the research community. METHODS Primary data was acquired from the Scopus® database. Various parameters like the total research productivity, citations, citations per publication, citations per year, citations per publication per year, the scientific output of countries, institutions, authors, and journals were calculated. Key research areas were inferred by examining the top-cited articles (citations >150). Collaborative maps were generated by calculating co-authorship links amongst countries and authors using VOSviewer software. RESULTS One thousand seven hundred fourteen results were found published from 1913 to 2019, receiving a total of 27,253 citations, authored by 5138 authors from 125 countries. The top three countries were the United States of America (USA), India, and the United Kingdom (UK). The leading institutes were the Children's Hospital Boston, USA (n = 48), All India Institute of Medical Sciences (AIIMS, Delhi), India (n = 38), and Great Ormond Street Hospital, UK (n- = 27). The journals which published the most articles on PUV were the Journal of Urology (n = 278), Journal of Pediatric Urology (n = 121), followed by Urology (n = 86). Leading authors were Glassberg, K. L and Bajpai M (n = 17, each), Canning DA & Kajbafzadeh, AM (n = 16, each), followed by Peters CA with 14 manuscripts. The top-cited documents (n = 10) received 2104 citations and were published between 1986 and 2010. The key areas of interest found were "long-term outcomes" (n = 4) and "fetal surgery" (n = 2). The most productive countries were also the most collaborative countries (the USA and UK). CONCLUSION In the research landscape of PUV, the USA, Children's Hospital Boston, and Glassberg, K. L, along with Bajpai, M were the top contributors in terms of the country, organization, and authors, respectively. The "Journal of Urology" and "Pediatric Nephrology" stands out in terms of bibliometric parameters considered. The hotspot topics based on the number of citations received were "long-term outcomes" and "fetal surgery" in PUV. The most productive countries were also the most collaborative countries (the USA and UK).
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Renal rupture in neonate with severe hydronephrosis. Asian J Surg 2022; 45:1724-1725. [DOI: 10.1016/j.asjsur.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/15/2022] [Indexed: 11/21/2022] Open
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Lin Y, Khong PL, Zou Z, Cao P. Evaluation of pediatric hydronephrosis using deep learning quantification of fluid-to-kidney-area ratio by ultrasonography. Abdom Radiol (NY) 2021; 46:5229-5239. [PMID: 34227014 DOI: 10.1007/s00261-021-03201-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Hydronephrosis is the dilation of the pelvicalyceal system due to the urine flow obstruction in one or both kidneys. Conventionally, renal pelvis anterior-posterior diameter (APD) was used for quantifying hydronephrosis in medical images (e.g., ultrasound, CT, and functional MRI). Our study aimed to automatically detect and quantify the fluid and kidney areas on ultrasonography, using a deep learning approach. METHODS An attention-Unet was used to segment the kidney and the dilated pelvicalyceal system with fluid. The gold standard for diagnosing hydronephrosis was the APD > 1.0 cm. For semi-quantification, we proposed a fluid-to-kidney-area ratio measurement, i.e., [Formula: see text], as a deep learning-derived biomarker. Dice coefficient, confusion matrix, ROC curve, and Z-test were used to evaluate the model performance. Linear regression was applied to obtain the fluid-to-kidney-area ratio cutoff for detecting hydronephrosis. RESULTS For regional kidney segmentation, the Dice coefficients were 0.92 and 0.83 for the kidney and dilated pelvicalyceal system, respectively. The sensitivity and specificity of detecting dilated pelvicalyceal system were 0.99 and 0.83, respectively. The linear equation was fluid-to-kidney-area ratio = (0.213 ± 0.004) × APD (in cm) for 95% confidence interval on the slope with R2 = 0.87. The fluid-to-kidney-area ratio cutoff for detecting hydronephrosis was 0.213. The sensitivity and specificity for detecting hydronephrosis were 0.90 and 0.80, respectively. CONCLUSION Our study confirmed the feasibility of deep learning characterization of the kidney and fluid, showing an automatic pediatric hydronephrosis detection.
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Keil C, Bedei I, Sommer L, Koemhoff M, Axt-Fliedner R, Köhler S, Weber S. Fetal therapy of LUTO (lower urinary tract obstruction) - a follow-up observational study. J Matern Fetal Neonatal Med 2021; 35:8536-8543. [PMID: 34652254 DOI: 10.1080/14767058.2021.1988562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Fetal megacystis (MC) can be severe and is mainly caused by fetal lower urinary tract obstruction (LUTO). Mortality of fetal LUTO can be high as a result of pulmonary hypoplasia and/or (chronic) renal insufficiency. Several technical procedures for vesicoamniotic shunting (VAS) were developed to improve fetal MC outcomes. MATERIAL AND METHODS We present the outcome of nine fetuses with MC who received VAS in the prenatal period (14 + 6 to 27 + 6 weeks GA) using the Somatex® intrauterine shunt system. MC was defined as an increased longitudinal measurement of the bladder >15 mm. The median follow-up time after birth was 18 months. RESULTS Eight Fetuses had uncomplicated VAS intervention. One case developed PPROM 24 h after VAS leading to abortion. Pregnancy was later terminated in further two cases. All six live-born infants received intensive care treatment. Invasive-mechanical ventilation was necessary in one case who died 24 h post-partum of severe cardiac depression. Five infants who survived the follow-up time developed chronic renal insufficiency (CRI), with one infant developing end-stage renal failure requiring peritoneal dialysis. CONCLUSION Overall, 5 of 9 LUTO fetuses (55%) undergoing VAS with the Somatex® intrauterine shunt system showed long-term survival beyond the neonatal period of 28 d (5/9; 55%) with varying morbidity.
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Affiliation(s)
- Corinna Keil
- Division of Prenatal Medicine and Therapy, Department of Obstetrics and Perinatal Medicine, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Ivonne Bedei
- Division of Prenatal Medicine and Therapy, Department of Obstetrics and Perinatal Medicine, University Hospital Giessen, Liebig University Giessen, Giessen, Germany
| | - Lara Sommer
- University Children Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Martin Koemhoff
- University Children Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Roland Axt-Fliedner
- Division of Prenatal Medicine and Therapy, Department of Obstetrics and Perinatal Medicine, University Hospital Giessen, Liebig University Giessen, Giessen, Germany
| | - Siegmund Köhler
- Division of Prenatal Medicine and Therapy, Department of Obstetrics and Perinatal Medicine, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Stefanie Weber
- University Children Hospital Marburg, Philipps University Marburg, Marburg, 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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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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Posterior urethral valves (PUVs): prenatal ultrasound diagnosis and management difficulties: a review of three cases. CASE REPORTS IN PERINATAL MEDICINE 2021. [DOI: 10.1515/crpm-2020-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Lower urinary tract obstruction (LUTO) has different etiologies. The most common form is posterior urethral valve (PUVs). It is a condition that can lead to end stage renal disease (ESRD) in later life and severe renal and pulmonary damage in utero. Those born alive may end up with residual kidney disease leading to life long morbidity or death. This condition can be diagnosed through prenatal ultrasound but because diagnosis is done late when kidney injury has already happened it does not guarantee healthy survival after birth. There are various treatments in utero and after birth but they all have their complications. In developing countries diagnosis is possible but in most cases pregnant women with fetuses with PUVs present very late in pregnancy. In utero interventions are in most cases not possible and the only way out is expectant management with serial ultrasound assessment until the fetus has achieved level of maturity at which time it is delivered and further postnatal evaluations and treatment given. This series is aimed at highlighting the prenatal ultrasound features of PUVs and the management challenges faced by physicians in developing countries.
Case presentation
The three cases were managed in three different hospitals. All the cases presented at different gestational ages and different levels of fetal affectation. Because of these, outcomes of management and prognosis of each case differ.
Conclusions
Fetal PUVs pose specific challenges in management because of late presentation and lack of resource for intervention even where cases present early with minimal renal damage.
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Irfan A, O'Hare E, Jelin E. Fetal interventions for congenital renal anomalies. Transl Pediatr 2021; 10:1506-1517. [PMID: 34189109 PMCID: PMC8192995 DOI: 10.21037/tp-2020-fs-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth O'Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Editorial: Urinary tract obstruction in children. Curr Opin Pediatr 2021; 33:217-219. [PMID: 33605626 DOI: 10.1097/mop.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dębska M, Koleśnik A, Kretowicz P, Olędzka A, Rebizant B, Gastoł P, Dębski R. Urethroplasty with balloon catheterization in fetal lower urinary tract obstruction: observational study of 10 fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:916-920. [PMID: 31763721 DOI: 10.1002/uog.21932] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 09/28/2019] [Accepted: 11/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To present the preliminary outcomes of fetal urethroplasty using a coronary angioplasty balloon catheter in lower urinary tract obstruction (LUTO). METHODS We included 10 consecutive male fetuses diagnosed with LUTO caused by presumed isolated posterior urethral valves (PUVs), who underwent urethroplasty with a balloon catheter in our center between 2015 and 2018. During urethroplasty, the fetal urethra was dilated using a balloon catheter (diameter, 0.014 inches; balloon size, 2 × 9 mm) inserted under ultrasonographic guidance via an 18-gauge needle introduced into the fetal bladder. RESULTS Mean gestational age at the time of urethroplasty was 17.8 (range, 16.5-20.4) weeks. All fetuses survived the procedure without any complications and there was no case of preterm prelabor rupture of the membranes. The procedure was successful in 5/10 (50%) fetuses, while in the other five (50%), we were unable to insert the balloon catheter into the urethra. In the five successfully treated cases, mean gestational age at delivery was 38 (range, 36-40) weeks and presence of PUVs was confirmed after birth. All five neonates micturated spontaneously and presented with normal urine output after birth. During the follow-up period, the parameters of kidney function were within normal limits in two neonates, whereas signs of impaired renal function were seen in another two. The other was diagnosed with renal insufficiency and required kidney transplant with bladder sparing at 2 years of age. CONCLUSIONS Urethroplasty with a balloon catheter is a new prenatal treatment option for fetuses with PUVs. By restoring fetal micturition, the procedure can preserve normal urinary bladder and kidney function. Although data on its efficacy and potential to differentiate the etiology of LUTO are sparse, a significant advantage of this method is its safety for the fetus and the mother. Even if the neonates develop renal insufficiency, they may be eligible for kidney transplant with connection to their own bladder, without the need for urostomy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Dębska
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - A Koleśnik
- Cardiac Catheterization Laboratory, Children's Memorial Health Institute, Warsaw, Poland
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - P Kretowicz
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - A Olędzka
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - B Rebizant
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - P Gastoł
- Department of Pediatric Urology, Children's Memorial Health Institute, Warsaw, Poland
| | - R Dębski
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
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Danacıoğlu YO, Karaman Mİ, Çaşkurlu T, Sılay MS. Congenital megalourethra and posterior urethral valve in a patient with Down syndrome. Turk J Urol 2020; 45:S181-S184. [PMID: 33120010 DOI: 10.5152/tud.2018.70852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 12/04/2017] [Indexed: 11/22/2022]
Abstract
Megalourethra is a rare congenital anomaly of the urethra that develops as a consequence of dysgenesis of the corpus cavernosum and corpus spongiosum. Herein, we present three congenital abnormalities in one newborn ie; Down syndrome, posterior urethral valve (PUV) and scaphoid megalourethra. The patient was treated successfully by ablation PUV and reduction uretrophlasty. The postoperative period was uneventful and the renal functions could be preserved in the long term.
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Affiliation(s)
- Yavuz Onur Danacıoğlu
- Department of Pediatric Urology, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Muhammet İhsan Karaman
- Department of Pediatric Urology, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Turhan Çaşkurlu
- Department of Pediatric Urology, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Mesrur Selçuk Sılay
- Department of Pediatric Urology, Medeniyet University School of Medicine, İstanbul, Turkey
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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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14
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Fetal repair of myelomeningocele: current status and urologic implications. J Pediatr Urol 2020; 16:3-9. [PMID: 31902678 DOI: 10.1016/j.jpurol.2019.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/30/2019] [Indexed: 11/21/2022]
Abstract
Over the last 40 years, vast changes have occurred in the care of children with open neural tube defects. Not only has newborn survival dramatically improved but survival into adulthood has improved as well. Now, the ability to accurately identify and repair myelomeningocele (MMC) lesions before birth has become a reality. Pioneering efforts at several institutions in the United States paved the way for such advancements in care. Substantial data now exist to support the positive benefits of fetal MMC repair from a neurosurgical standpoint, chiefly the significant reduction in hindbrain herniation, decrease in shunt-dependent hydrocephalus, and improvement in lower-extremity motor function. However, until only recently, the urological impact of fetal repair has not been nearly as positive overall. Multiple retrospective reports of newborn bladder function from the United States suggest that prenatal repair has provided neither short-term nor long-term improvements in bladder function. Yet, the retrospective nature of these data and their focus upon urodynamic studies (UDS) parameters have hampered the ability to draw conclusions. Recently, published data from the landmark Management of Myelomeningocele Study indicate that fetal repair may improve certain aspects of bladder function when compared with conventional repair. This review provides an overview of the history and timeline of fetal repair in the United States and brings the reader quickly up to date on the current impact of repair on both neurosurgical and urological outcomes.
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15
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Renal outcomes of neonates with early presentation of posterior urethral valves: a 10-year single center experience. J Perinatol 2020; 40:112-117. [PMID: 31471579 PMCID: PMC7223871 DOI: 10.1038/s41372-019-0489-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/30/2019] [Accepted: 07/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Evaluate renal outcomes and early predictive factors in infants with congenital posterior urethral valves who required catheter or surgical urinary tract decompression within the first 7 days of life. STUDY DESIGN A 10-year retrospective study at a single hospital. Primary outcomes were estimated glomerular filtration rate (eGFR) and development of end stage renal disease (ESRD). RESULTS Of 35 infants, 50% developed eGFR <90 mL/min/1.73 m2 and 15% progressed to ESRD. Nadir creatinine, need for invasive ventilation in the newborn period, and need for surgical diversion after catheter diversion were associated with worse outcomes. 50% of infants requiring invasive ventilation as neonates developed eGFR <60 mL/min/1.73 m2 in childhood. CONCLUSIONS Half of infants with early presentation and intervention developed significant renal insufficiency in childhood, similar to children with later presentation or who had fetal intervention. Invasive ventilation in the newborn period and need for surgical urinary diversion are associated with worse outcomes.
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16
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Anhydramnios in the Setting of Renal Malformations: The National Institutes of Health Workshop Summary. Obstet Gynecol 2019; 131:1069-1079. [PMID: 29742659 DOI: 10.1097/aog.0000000000002637] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anhydramnios in the setting of severe malformations of the fetal kidney and urinary tract is associated with a high incidence of stillbirths and life-threatening complications, including severe pulmonary hypoplasia, umbilical cord compression, and perinatal asphyxia. To prevent such adverse outcomes, some centers in the United States and elsewhere are offering amniotic fluid restoration for women diagnosed with anhydramnios in the setting of fetal renal malformations. The procedures include infusions of amniotic fluid substitutes (normal saline), percutaneously or through an amnioport-an implanted system for serial or continuous infusion of normal saline to maintain the desired amniotic fluid volume. The procedures are intended to prevent pulmonary hypoplasia and allow the pregnancy to progress closer to term gestation, enabling postnatal renal management, including long-term dialysis and renal transplantation. However, these procedures have not been recommended as standard of care by the professional societies because there are many knowledge gaps, including few data on short-term and long-term renal outcomes. The available diagnostic methods do not provide reliable prognostic information, and the current maternal and fetal interventions have not been standardized. To address these unresolved issues and to propose a research agenda, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Diabetes and Digestive and Kidney Diseases invited a panel of experts to a workshop in August 2016. This report provides a summary of that meeting.
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17
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Sharma S, Joshi M, Gupta DK, Abraham M, Mathur P, Mahajan JK, Gangopadhyay AN, Rattan SK, Vora R, Prasad GR, Bhattacharya NC, Samuj R, Rao KLN, Basu AK. Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty. J Indian Assoc Pediatr Surg 2019; 24:4-14. [PMID: 30686881 PMCID: PMC6322183 DOI: 10.4103/jiaps.jiaps_148_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Joshi
- Consultant Pediatric Surgeon, Department of Pediatric Surgery, King Saud Hospital, Uneyzha City, Kingdom of Saudi Arabia
| | - Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mohan Abraham
- Department of Pediatric Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Praveen Mathur
- Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| | - J K Mahajan
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A N Gangopadhyay
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Simmi K Rattan
- Department of Pediatric Surgery, Maulana Azad Medical College, Delhi, India
| | - Ravindra Vora
- Department of Paediatric Surgery, Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India
| | - G Raghavendra Prasad
- Department of Paediatric Surgery, Deccan College of Medical Sciences, Hyderabad, India
| | - N C Bhattacharya
- Department of Paediatric Surgery, Gauhati Medical College, Guwahati, Assam, India
| | - Ram Samuj
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K L N Rao
- Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A K Basu
- Consultant Pediatric Surgeon, Institute of Child Health, Kolkata, West Bengal, India
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18
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Chiodini B, Ghassemi M, Khelif K, Ismaili K. Clinical Outcome of Children With Antenatally Diagnosed Hydronephrosis. Front Pediatr 2019; 7:103. [PMID: 30984723 PMCID: PMC6449796 DOI: 10.3389/fped.2019.00103] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/05/2019] [Indexed: 01/29/2023] Open
Abstract
Fetal renal pelvis dilation is a common condition, which is observed in 1-4. 5% of pregnancies. In many cases, this finding resolves spontaneously. However, sometimes it may be a signal of significant urinary tract pathologies. The main abnormalities found after birth are uretero-pelvic junction stenosis, primary vesicoureteral reflux, megaureter, duplex kidneys, and posterior urethral valves, with uretero-pelvic junction stenosis and primary vesicoureteral reflux accounting for most of the cases. Diagnosis, management, and prognosis at short and longer term of these conditions will be reviewed in this article.
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Affiliation(s)
- Benedetta Chiodini
- Department of Pediatric Nephrology, Hôpital des Enfants Reine-Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Mehran Ghassemi
- Department of Medical Imaging, Hôpital des Enfants Reine-Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Karim Khelif
- Department of Pediatric Urology, Hôpital des Enfants Reine-Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Khalid Ismaili
- Department of Pediatric Nephrology, Hôpital des Enfants Reine-Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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19
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Abstract
Advances made in the last several decades in the care of the fetus and newborn have had a significant impact on morbidity and mortality. Delayed umbilical cord clamping in the preterm newborn results in fewer transfusions for anemia, decreased intraventricular hemorrhage, and decreased necrotizing enterocolitis. Because of advances made in fetal ultrasound diagnosis and technological advances, fetal surgeries to treat congenital diaphragmatic hernia, myelomeningocele, twin-to-twin transfusion syndrome, fetal lower urinary tract obstructions, amniotic band syndrome, and congenital cystic adenoid malformation or congenital pulmonary airway malformations have improved the quality of life and survival for these patients.
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Affiliation(s)
- Karen M Frank
- Department of Nursing, Towson University, LI 322, 8000 York Road, Towson, MD 21252, USA.
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20
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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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21
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Urinary proteomics using capillary electrophoresis coupled to mass spectrometry for diagnosis and prognosis in kidney diseases. Curr Opin Nephrol Hypertens 2018; 25:494-501. [PMID: 27584928 DOI: 10.1097/mnh.0000000000000278] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Urine is the most useful of body fluids for biomarker research. Therefore, we have focused on urinary proteomics, using capillary electrophoresis coupled to mass spectrometry, to investigate kidney diseases in recent years. RECENT FINDINGS Several urinary proteomics studies for the detection of various kidney diseases have indicated the potential of this approach aimed at diagnostic and prognostic assessment. Urinary protein biomarkers such as collagen fragments, serum albumin, α-1-antitrypsin, and uromodulin can help to explain the processes involved during disease progression. SUMMARY Urinary proteomics has been used in several studies in order to identify and validate biomarkers associated with different kidney diseases. These biomarkers, with improved sensitivity and specificity when compared with the current gold standards, provide a significant alternative for diagnosis and prognosis, as well as improving clinical decision-making.
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22
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Iguchi N, Dönmez Mİ, Malykhina AP, Carrasco A, Wilcox DT. Preventative effects of a HIF inhibitor, 17-DMAG, on partial bladder outlet obstruction-induced bladder dysfunction. Am J Physiol Renal Physiol 2017; 313:F1149-F1160. [PMID: 28768664 DOI: 10.1152/ajprenal.00240.2017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/11/2017] [Accepted: 07/24/2017] [Indexed: 01/11/2023] Open
Abstract
Posterior urethral valves are the most common cause of partial bladder outlet obstruction (PBOO) in the pediatric population. Pathological changes in the bladder developed during PBOO are responsible for long-lasting voiding dysfunction in this population despite early surgical interventions. Increasing evidence showed PBOO induces an upregulation of hypoxia-inducible factors (HIFs) and their transcriptional target genes, and they play a role in pathophysiological changes in the obstructed bladders. We hypothesized that blocking HIF pathways can prevent PBOO-induced bladder dysfunction. PBOO was surgically created by ligation of the bladder neck in male C57BL/6J mice for 2 wk. PBOO mice received intraperitoneal injection of either saline or 17-DMAG (alvespimycin, 3 mg/kg) every 48 h starting from day 1 postsurgery. Sham-operated animals received injection of saline on the same schedule as PBOO mice and served as controls. The bladders were harvested after 2 wk, and basal activity and evoked contractility of the detrusor smooth muscle (DSM) were evaluated in vitro. Bladder function was assessed in vivo by void spot assay and cystometry in conscious, unrestrained mice. Results indicated the 17-DMAG treatment preserved DSM contractility and partially prevented the development of detrusor over activity in obstructed bladders. In addition, PBOO caused a significant increase in the frequency of micturition, which was significantly reduced by 17-DMAG treatment. The 17-DMAG treatment improved urodynamic parameters, including increases in the bladder pressure at micturition and nonvoid contractions observed in PBOO mice. These results demonstrate that treatment with 17-DMAG, a HIF inhibitor, significantly alleviated PBOO-induced bladder pathology in vivo.
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Affiliation(s)
- Nao Iguchi
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado; and
| | - M İrfan Dönmez
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado; and
| | - Anna P Malykhina
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado; and
| | | | - Duncan T Wilcox
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado; and .,Children's Hospital Colorado, Aurora, Colorado
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23
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Farrugia MK, Braun MC, Peters CA, Ruano R, Herndon CD. Report on The Society for Fetal Urology panel discussion on the selection criteria and intervention for fetal bladder outlet obstruction. J Pediatr Urol 2017; 13:345-351. [PMID: 28476482 DOI: 10.1016/j.jpurol.2017.02.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The Society for Fetal Urology panel section at the 2016 Fall Congress featured a multidisciplinary discussion on appropriate patient selection, the conservative versus surgical management, and postnatal renal outcome of fetuses with lower urinary tract obstruction (LUTO). SELECTION CRITERIA FOR INTERVENTION Rodrigo Ruano shared his experience of prenatal intervention, presenting the outcome of 111 fetuses with severe LUTO treated with vesicoamniotic shunting (VAS) (n = 16), cystoscopy (n = 34) or no intervention (n = 61) in a non-randomized series. Multivariate analysis at the 6-month follow-up suggested a significantly higher probability of survival with fetal intervention versus no intervention. A clear trend for normal renal function was present in the fetal cystoscopy group, but not in the VAS group. In cases in which there was a postnatal diagnosis of posterior urethral valves (n = 57), fetal cystoscopy was effective in improving both the 6-month survival rate and renal function, while VAS was associated with an improvement in the 6-month survival rate. In an attempt to better define which fetuses would benefit from intervention, Michael Braun explained the proposed LUTO classification system that incorporates: (1) fetal urinary biomarkers of renal injury; (2) amniotic fluid levels as a surrogate for the severity of obstruction; and (3) imaging studies to identify signs of renal dysplastic or cystic changes. Intervention was not recommended in patients at low risk of either renal disease or pulmonary hypoplasia (Stage 1). Vesicoamniotic shunting was performed in patients at high risk of either progressive renal injury or pulmonary hypoplasia without evidence of severe pre-existing renal damage (Stage 2). For those patients, who at the time of evaluation had evidence of severe renal disease (Stage 3), fetal intervention was individualized and often based on bladder capacity and bladder refilling after vesicocentesis. He went on to present the nephrologic outcome of fetuses managed over the last 3 years utilizing the selection criteria. Craig Peters supported the concept of selective criteria and discussed the cautious viewpoint, namely: (1) the procedure may be unnecessary, as it is possible for patients to do well, in spite of severe prenatal obstruction; and (2) the risk of giving partial treatment by allowing the baby to survive to delivery with the daunting postnatal journey of renal and pulmonary insufficiency. CONCLUSION Standardized patient selection utilizing a staging system is undoubtedly the way forward and will enable comparable long-term renal and bladder functional outcome studies.
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Affiliation(s)
- M K Farrugia
- Department of Paediatric Urology, Chelsea Children's Hospital at the Chelsea & Westminster Hospital, London, UK.
| | - M C Braun
- Department of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - C A Peters
- Department of Pediatric Urology, Children's Health System Texas and University of Texas Southwestern, Dallas, TX, USA
| | - R Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, USA
| | - C D Herndon
- Department of Pediatric Urology, Children's Hospital of Richmond, Richmond, VA, USA
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24
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Sarhan OM. Posterior urethral valves: Impact of low birth weight and preterm delivery on the final renal outcome. Arab J Urol 2017; 15:159-165. [PMID: 29071146 PMCID: PMC5653607 DOI: 10.1016/j.aju.2017.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/08/2017] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the relationship between low birth weight (LBW; <2.5 kg) and preterm delivery (<37 weeks gestational age) and final renal outcome in infants with posterior urethral valves (PUVs), emphasising the risk factors for the development of chronic kidney disease (CKD). Patients and methods A retrospective review was performed for all infants with PUVs who were treated between 1990 and 2010. In all, 52 infants were identified to have LBW and/or delivered preterm (Group 1). Infants in Group 1 were compared with a matching group (Group 2) of 60 full-term normal birth weight (NBW) infants with PUVs managed during the same period. The outcome of both groups was analysed. Results During follow-up, CKD developed in 17 (32.5%) and 22 patients (36.5%) in Groups 1 and 2, respectively (P = 0.812). Patients with LBW or delivered preterm had significantly higher incidence of oligohydramnios (P = 0.009), increased risk of vesicostomy (P < 0.001), longer hospital stay (P < 0.001), and higher incidence of vesico-ureteric reflux (VUR, P = 0.024). In the LBW patients, initial serum creatinine, nadir serum creatinine, oligohydramnios and Neonatal Intensive Care Unit (NICU) length of stay were significant predictors of final renal outcome (P < 0.001, P = 0.002, P = 0.004 and P = 0.012, respectively). Conclusion In our cohort of LBW and preterm delivery infants with PUVs, outcomes were similar to those of NBW full-term infants with PUVs but with an increased risk of vesicostomy, longer hospital stay, and higher incidence of VUR. LBW was associated with oligohydramnios, longer NICU admission, high initial and nadir serum creatinine, which were associated with a poor prognosis.
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Affiliation(s)
- Osama M Sarhan
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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25
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Farrugia MK. Fetal bladder outlet obstruction: Embryopathology, in utero intervention and outcome. J Pediatr Urol 2016; 12:296-303. [PMID: 27570093 DOI: 10.1016/j.jpurol.2016.05.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/17/2016] [Indexed: 11/17/2022]
Abstract
Fetal bladder outlet obstruction (BOO), most commonly caused by posterior urethral valves (PUV), remains a challenging and multi-faceted condition. Evolving techniques, and refinement in ultrasound, optics and instrumentation, have increased our rate of prenatal diagnosis, and enabled valve ablation not only in smaller newborns, but also in fetuses. Long-term outcome studies have raised our awareness of the silent damage caused by bladder dysfunction and polyuria and encouraged their proactive management. In spite of our best efforts, the proportion of boys with PUV who progress to chronic and end-stage renal disease (ESRD) has not changed in the last 25 years. Evidence suggests a reduction in perinatal mortality following prenatal intervention, probably resulting from amelioration of oligohydramnios at the crucial time of lung development between 16 and 28 weeks' gestation, but no improvement in postnatal renal outcome. There are no bladder functional outcome studies in patients who have undergone prenatal intervention and hence the long-term effect of in utero defunctionalisation of the bladder is not known. This aim of this review is to revisit the embryopathology of fetal BOO, in particular the renal and bladder structural and functional changes that occur with in utero obstruction. The effect of earlier prenatal diagnosis, and therapy, on postnatal outcome is also explored and compared with outcomes published for traditional postnatal treatment.
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Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea Children's Hospital at the Chelsea & Westminster Hospital Foundation Trust, London SW10 9NH, UK.
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26
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Ruano R, Sananes N, Wilson C, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Safdar A, Moaddab A, Meyer N, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Braun MC, Belfort MA. Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:476-482. [PMID: 26690832 DOI: 10.1002/uog.15844] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/31/2015] [Accepted: 12/15/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity. METHODS This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported. RESULTS Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR > 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR < 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR > 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR > 1) = 93.3%) were predictors of survival. CONCLUSIONS Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA. ,
| | - N Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C Wilson
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Au
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - P Gargollo
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Safdar
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - N Meyer
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France
| | - D L Cass
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O 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
| | - S Welty
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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27
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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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Polzin WJ, Lim FY, Habli M, Van Hook J, Minges M, Jaekle R, Crombleholme TM. Use of an Amnioport to Maintain Amniotic Fluid Volume in Fetuses with Oligohydramnios Secondary to Lower Urinary Tract Obstruction or Fetal Renal Anomalies. Fetal Diagn Ther 2016; 41:51-57. [PMID: 27287190 DOI: 10.1159/000445946] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 04/04/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We describe a technique to maintain amniotic fluid in fetuses with severe oligo-/anhydramnios secondary to lower urinary tract obstruction or fetal renal disease when urine production is inadequate to maintain a normal amniotic fluid volume (AFV). METHODS An amnioport was inserted into the amniotic space. The catheter was secured to prevent dislodgment and tunneled to a subcutaneous reservoir. The reservoir was accessed as necessary, infusing normal saline to maintain AFV. Pregnancy continued until term or indicated delivery. RESULTS Since 2010, 15 patients in this category were considered for an amnioport. Six chose comfort care and one elected percutaneous amnioinfusions. Nine amnioport procedures were performed in eight patients. There were no fetal deaths. All eight had successful restoration and maintenance of amniotic fluid. Delivery ranged from 9 to 96 days after placement (mean 63.7 days). One died due to unrecognized laryngeal web and another one died of pulmonary hypoplasia after preterm premature rupture of membranes. None of the remaining six had pulmonary hypoplasia. Three remain alive. DISCUSSION Severe oligo-/anhydramnios in the second trimester secondary to fetal anomalies is almost uniformly lethal due to pulmonary hypoplasia without restoration of amniotic fluid. The amnioport procedure may allow pulmonary survival but commits families to postnatal care decisions regarding pulmonary and renal complications.
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Ruano R, Safdar A, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Belfort MA, Braun MC. Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction. Pediatr Nephrol 2016; 31:605-12. [PMID: 26525197 DOI: 10.1007/s00467-015-3246-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 09/27/2015] [Accepted: 10/06/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). METHODS We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. RESULTS Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). CONCLUSION We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA.
| | - Adnan Safdar
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jason Au
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Patricio Gargollo
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Stephen Welty
- Department of Pediatrics, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - David R Roth
- Division of Pediatric Urology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Michael C Braun
- Renal Section, Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, Houston, TX, USA.,Texas Children's Fetal Center at the Texas Children's Hospital Pavilion for Women-Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
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Sadeghi-Bojd S, Kajbafzadeh AM, Ansari-Moghadam A, Rashidi S. Postnatal Evaluation and Outcome of Prenatal Hydronephrosis. IRANIAN JOURNAL OF PEDIATRICS 2016; 26:e3667. [PMID: 27307966 PMCID: PMC4906562 DOI: 10.5812/ijp.3667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/22/2015] [Accepted: 12/19/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prenatal hydronephrosis (PNH) is dilation in urinary collecting system and is the most frequent neonatal urinary tract abnormality with an incidence of 1% to 5% of all pregnancies. PNH is defined as anteroposterior diameter (APD) of renal pelvis ≥ 4 mm at gestational age (GA) of < 33 weeks and APD ≥ 7 mm at GA of ≥ 33 weeks to 2 months after birth. All patients need to be evaluated after birth by postnatal renal ultrasonography (US). In the vast majority of cases, watchful waiting is the only thing to do; others need medical or surgical therapy. OBJECTIVES There is a direct relationship between APD of renal pelvis and outcome of PNH. Therefore we were to find the best cutoff point APD of renal pelvis which leads to surgical outcome. PATIENTS AND METHODS In this retrospective cohort study we followed 200 patients 1 to 60 days old with diagnosis of PNH based on before or after birth ultrasonography; as a prenatal or postnatal detected, respectively. These patients were referred to the nephrology clinic in Zahedan Iran during 2011 to 2013. The first step of investigation was a postnatal renal US, by the same expert radiologist and classifying the patients into 3 groups; normal, mild/moderate and severe. The second step was to perform voiding cystourethrogram (VCUG) for mild/moderate to severe cases at 4 - 6 weeks of life. Tc-diethylene triamine-pentaacetic acid (DTPA) was the last step and for those with normal VCUG who did not show improvement in follow-up examination, US to evaluate obstruction and renal function. Finally all patients with mild/moderate to severe PNH received conservative therapy and surgery was preserved only for progressive cases, obstruction or renal function ≤35%. All patients' data and radiologic information was recorded in separate data forms, and then analyzed by SPSS (version 22). RESULTS 200 screened PNH patients with male to female ratio 3.5:1 underwent first postnatal control US, of whom 65% had normal, 18% mild/moderate and 17% severe hydronephrosis. 167 patients had VCUG of whom 20.82% with VUR. 112 patients performed DTPA with following results: 50 patients had obstruction and 62 patients showed no obstructive finding. Finally 54% of 200 patients recovered by conservative therapy, 12.5% by surgery and remaining improved without any surgical intervention. CONCLUSIONS The best cutoff point of anteroposterior renal pelvis diameter that led to surgery was 15 mm, with sensitivity 88% and specificity 74%.
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Affiliation(s)
- Simin Sadeghi-Bojd
- Research Center for Children and Adolescents, Zahedan University of Medical Sciences, Zahedan, IR Iran
- Corresponding author: Simin Sadeghi-Bojd, Research Center for Children and Adolescents, Zahedan University of Medical Sciences, Zahedan, IR Iran. Tel: +98-5412440482, Fax: +98-5413425596, E-mail:
| | - Abdol-Mohammad Kajbafzadeh
- Department of Urology, Pediatric Urology Research Center, Children’s Medical Center, Tehran University of Medical Sciences,Tehran, IR Iran
| | | | - Somaye Rashidi
- Research Center for Children and Adolescents, Zahedan University of Medical Sciences, Zahedan, IR Iran
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31
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Smith-Harrison LI, Hougen HY, Timberlake MD, Corbett ST. Current applications of in utero intervention for lower urinary tract obstruction. J Pediatr Urol 2015; 11:341-7. [PMID: 26441047 DOI: 10.1016/j.jpurol.2015.07.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/19/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Since the early 1980s with the inception of fetal intervention for obstructive uropathy, there have been creative attempts to improve both perinatal and long-term outcomes. Despite advances in technology and an improved understanding of lower urinary tract obstruction (LUTO) in the fetus, the results for these therapeutic interventions remain guarded and the long-term renal morbidity among survivors remains problematic. RECENT FINDINGS Fetal LUTO represents a range of disorders but the most common of these is posterior urethral valves (PUVs). Selection criteria for candidates of possible intervention have improved with our understanding of fetal renal physiology. Serial urinalysis has marginally improved our ability to predict those that may ultimately respond to treatment [1,2], but the potential in the development of biomarkers for renal development or maldevelopment holds greater promise [3]. Advancements in fetal surgery may result in less fetal and maternal morbidity, but limited long-term improvement in outcomes highlights the controversial nature of the various interventions [4-10]. We must counsel families that fetal surgery offers hope but we cannot allow them to hold unrealistic expectations for cure. SUMMARY In appropriately selected fetuses, intervention may improve perinatal survival but not without risk to mother and fetus. Long-term renal outcomes remain problematic amongst survivors. In the case of PUV, postnatal primary valve ablation remains the cornerstone of treatment for nephron preservation; however, our ability to mimic these results in the prenatal population remains poor [11]. Disease severity has likely predetermined those that will survive through the perinatal period with or without intervention. Nonetheless, our drive to assess and manage fetal obstructive uropathy perseveres so that we may ultimately relieve obstruction and preserve renal and lung function. We must maintain optimism that continued advances will ultimately improve outcomes, but also be realistic with our current expectations. This paper reviews the status of current in utero interventions and outcomes.
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Affiliation(s)
- L I Smith-Harrison
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Helen Y Hougen
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Matthew D Timberlake
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sean T Corbett
- University of Virginia Children's Hospital/University of Virginia School of Medicine, Charlottesville, VA, USA.
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Abstract
In utero fetal surgery interventions are currently considered in selected cases of congenital diaphragmatic hernia, cystic pulmonary abnormalities, amniotic band sequence, selected congenital heart abnormalities, myelomeningocele, sacrococcygeal teratoma, obstructive uropathy, and complications of twin pregnancy. Randomized controlled trials have demonstrated an advantage for open fetal surgery of myelomeningocele and for fetoscopic selective laser coagulation of placental vessels in twin-to-twin transfusion syndrome. The evidence for other fetal surgery interventions, such as tracheal occlusion in congenital diaphragmatic hernia, excision of lung lesions, fetal balloon cardiac valvuloplasty, and vesicoamniotic shunting for obstructive uropathy, is more limited. Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option for many of them; treatment can be lifesaving but in itself carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother. This makes conducting prospective or randomized trials difficult and explains the relative lack of good-quality evidence in this field. Moreover, there is scanty information on long-term outcomes. It is recommended that fetal surgery procedures be performed in centers with extensive facilities and expertise. The aims of this review were to describe the main fetal surgery procedures and their evidence-based results and to provide generalist obstetricians with an overview of current indications for fetal surgery.
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33
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Pejchinovski M, Hrnjez D, Ramirez-Torres A, Bitsika V, Mermelekas G, Vlahou A, Zürbig P, Mischak H, Metzger J, Koeck T. Capillary zone electrophoresis on-line coupled to mass spectrometry: A perspective application for clinical proteomics. Proteomics Clin Appl 2015; 9:453-68. [DOI: 10.1002/prca.201400113] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/21/2014] [Accepted: 01/14/2015] [Indexed: 12/21/2022]
Affiliation(s)
| | | | | | - Vasiliki Bitsika
- Biotechnology Division; Biomedical Research Foundation, Academy of Athens; Athens Greece
| | - George Mermelekas
- Biotechnology Division; Biomedical Research Foundation, Academy of Athens; Athens Greece
| | - Antonia Vlahou
- Biotechnology Division; Biomedical Research Foundation, Academy of Athens; Athens Greece
- School of Biomedical and Healthcare Sciences; Plymouth University, Plymouth; UK
| | | | - Harald Mischak
- Mosaiques Diagnostics GmbH; Hanover Germany
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; UK
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Mathis J, Raio L, Baud D. Fetal laser therapy: applications in the management of fetal pathologies. Prenat Diagn 2015; 35:623-36. [DOI: 10.1002/pd.4587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/21/2015] [Accepted: 02/26/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jérôme Mathis
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - Luigi Raio
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - David Baud
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
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35
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Spiro JE, Konrad M, Rieger-Fackeldey E, Masjosthusmann K, Amler S, Klockenbusch W, Schmitz R. Renal oligo- and anhydramnios: cause, course and outcome--a single-center study. Arch Gynecol Obstet 2015; 292:327-36. [PMID: 25676656 DOI: 10.1007/s00404-015-3648-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/03/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the outcome of patients with renal oligohydramnios and explore the impact of patient variables on outcome and prognosis. METHODS A retrospective single-center study was conducted analyzing 104 pregnancies complicated by oligohydramnios of renal origin from 2001 to 2011. Statistical analysis was performed to assess the influence of pre- and postnatal data on pregnancy outcome, morbidity and mortality. RESULTS Prenatal renal diagnoses were as follows: hydronephrosis/megaureter: n = 21 (20.2 %), aberrance in renal form or location: n = 7 (6.7 %), cystic renal disease: n = 28 (26.9 %), renal dysplasia: n = 24 (23.1 %), renal agenesis: n = 42 (30.4 %), posterior urethral valves: n = 11 (10.6 %). Hydronephrosis/megaureter and late onset of oligohydramnios were prognostic factors for fetal survival, whereas renal agenesis and associated anomalies had a negative impact on pregnancy outcome. Prenatal interventions did not improve prognosis. CONCLUSIONS Pregnancies complicated by renal oligohydramnios still have a poor outcome. Careful weighing of prognostic factors is necessary to decide about further therapeutic measures.
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Affiliation(s)
- Judith Eva Spiro
- Department of Gynecology and Obstetrics, University of Muenster, Muenster, Germany,
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Sharma G, Sharma A. Postnatal management of antenatally detected hydronephrosis. World J Clin Urol 2014; 3:283-294. [DOI: 10.5410/wjcu.v3.i3.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 08/05/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
With the increasing use of ultrasonography, congenital anomalies are often picked in utero. Antenatally detected hydronephrosis is amongst the most commonly detected abnormality. The management of this condition has raised considerable debate amongst clinicians dealing with it. This article is written with an idea to provide comprehensive information regarding the postnatal management of antenatally detected hydronephrosis. A detailed review of the current literature on this topic is provided. Also, guidelines have been given to facilitate the management of this condition.
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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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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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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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41
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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: 30] [Impact Index Per Article: 2.7] [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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Yamaçake KGR, Nguyen HT. Current management of antenatal hydronephrosis. Pediatr Nephrol 2013; 28:237-43. [PMID: 22836304 DOI: 10.1007/s00467-012-2240-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 05/31/2012] [Accepted: 05/31/2012] [Indexed: 12/01/2022]
Abstract
The strategy for the management of children with urinary tract anomalies has changed considerably as a result of the development of ultrasound equipment and techniques that allow for detailed fetal evaluation. Hydronephrosis is the most common urogenital anomaly detected, suggesting that an obstructive process may be potentially present. The goal of postnatal management is to identify and treat those patients whose renal function is at risk, while leaving alone the high percentage of patients who are at no risk of renal damage. This management involves a spectrum of radiological, medical, and surgical interventions for diagnosis, surveillance, and treatment. In this article, we review our current understanding of the natural history of antenatal hydronephrosis and its management.
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Affiliation(s)
- Kleiton G R Yamaçake
- Department of Urology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Hunnewell-353, Boston, MA 02115, USA
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43
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Tonni G, Vito I, Ventura A, Grisolia G, De Felice C. Fetal lower urinary tract obstruction and its management. Arch Gynecol Obstet 2012; 287:187-94. [PMID: 23138754 DOI: 10.1007/s00404-012-2615-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 10/25/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Prenatal counselling in case of fetal obstructive uropathies still represents a clinical dilemma, despite ultrasound detection of lower urinary tract obstruction has greatly advanced during recent years as well as fetal intervention techniques. MATERIALS AND METHODS A systematic review of the relevant literature on the topic was performed, with a special focus on the role of antenatal ultrasound, in utero treatment and prognosis. CONCLUSIONS A clinico-diagnostic flow chart was developed, with the specific aim of aiding health care givers in the clinical management and the parental decision-making process.
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Affiliation(s)
- Gabriele Tonni
- Department of Obstetrics and Gynecology, Gustalla Civil Hospital, AUSL Reggio Emilia Via Donatori Sangue, 2, 42016, Guastalla (RE), Italy.
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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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Abstract
Prenatal ultrasound is an integral part of caring for pregnant women in the United States. Although surprisingly few data exist to support the clinical benefit of screening ultrasound during pregnancy, its use continues to rise. Urologic anomalies are among the most commonly identified, with overall detection sensitivity approaching 90%. Prenatal hydronephrosis is the most frequently identified finding and predicting postnatal pathology based on its presence can be difficult. As the degree of fetal hydronephrosis increases so does the risk of true urinary tract pathology. Diagnoses that require more urgent care include causes of lower urinary tract obstruction and bladder and cloacal exstrophy.
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Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urology, Vanderbilt University, Nashville, TN 37232, USA.
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46
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Abstract
UNLABELLED Due to the progress in fetal surgery, it is important to acquire data about fetal pain. MATERIAL AND METHODS We performed a Medline research from 1995, matching the following key words: "pain" and "fetus", with the following: "subplate", "thalamocortical", "myelination", "analgesia", "anesthesia", "brain", "behavioral states", "substance p". We focused on: (a) fetal development of nociceptive pathways; (b) fetal electrophysiological, endocrinological and behavioral reactions to stimuli and pain. RESULTS We retrieved 217 papers of which 157 were highly informative; some reported similar data or were only case-reports, and were not quoted. Most endocrinological, behavioral and electrophysiological studies of fetal pain are performed in the third trimester, and they seem to agree that the fetus in the 3rd trimester can experience pain. But the presence of fetal pain in the 2nd trimester is less evident. In favor of a 2nd trimester perception of pain is the early development of spino-thalamic pathways (approximately from the 20th week), and the connections of the thalamus with the subplate (approximately from the 23rd week). Against this possibility, some authors report the immaturity of the cortex with the consequent lack of awareness, and the almost continuous state of sleep of the fetus. CONCLUSIONS Most studies disclose the possibility of fetal pain in the third trimester of gestation. This evidence becomes weaker before this date, though we cannot exclude its increasing presence since the beginning of the second half of the gestation.
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Affiliation(s)
- Carlo Valerio Bellieni
- Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Siena, Italy.
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Pohl M, Mentzel HJ, Vogt S, Walther M, Rönnefarth G, John U. Risk factors for renal insufficiency in children with urethral valves. Pediatr Nephrol 2012; 27:443-50. [PMID: 22009479 DOI: 10.1007/s00467-011-1999-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Revised: 07/27/2011] [Accepted: 08/25/2011] [Indexed: 11/24/2022]
Abstract
Posterior urethral valves (PUV) associated with renal dysplasia are one of the most common causes of end stage kidney disease (ESKD) in childhood. In order to identify risk factors for the progression of this condition to early renal failure, we have retrospectively analyzed the clinical course, renal function, and first postnatal renal ultrasound in a sample of 42 young male patients with PUV, who were followed at a single center. Twelve (28.6%) were diagnosed with ESKD at a median age of 11.3 years. Our comparison of PUV patients without decreased estimated glomerular filtration rate (eGFR) (group A; K/DOQI CKD stage 0-1) with PUV patients showing a decreased eGFR (group B; K/DOQI CKD stage 2-5) revealed the following significant risk factors for loss of eGFR: renal volume <3rd percentile (P < 0.001), elevated echogenicity (P = 0.001), pathologic corticomedullary differentiation (P < 0.001), >3 febrile urinary tract infections (P = 0.012), and decreased eGFR at 1 year of age (P < 0.001). Receiver operating characteristic curve analysis in the cohort confirms that patients showing a renal volume >88.2 ml/m(2) body surface area (BSA) are not at risk to develop K/DOQI CKD stage 5 (sensitivity 75%, specificity 77.3%, positive/negative predictive value 37.5/94.4%). Ultrasound promises to be a valuable tool for identifying endangered patients.
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Affiliation(s)
- Michael Pohl
- Department of Pediatric Nephrology, Children's Hospital, Friedrich Schiller University, Jena, Germany.
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49
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Pooh RK, Kurjak A. 3D/4D sonography moved prenatal diagnosis of fetal anomalies from the second to the first trimester of pregnancy. J Matern Fetal Neonatal Med 2011; 25:433-55. [DOI: 10.3109/14767058.2011.636107] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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50
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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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