Fetal lower urinary tract obstruction.

General Surgery, The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
Clinics in perinatology (Impact Factor: 2.13). 07/2009; 36(2):377-90, x. DOI: 10.1016/j.clp.2009.03.010
Source: PubMed

ABSTRACT The authors present an overview of the prenatal diagnosis, evaluation, contemporary intervention, and antenatal management of lower urinary tract obstruction. They review early experimental models that confirmed the relation between urinary tract obstruction and renal fibrocystic dysplasia and that early in utero relief of the obstruction could prevent irreversible renal injury. Subsequent studies of the electrolyte and protein concentrations in fetal urine from human cases established prognostic threshold values and helped to develop an algorithm to select candidates for antenatal therapy. Although shunting has improved survival, long-term morbidities remain a significant challenge.

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    ABSTRACT: Since the first human fetal surgery was reported in 1965, several different fetal surgical procedures have been developed and perfected, resulting in significantly improved outcomes for many fetuses. The currently accepted list of fetal conditions for which antenatal surgery is considered include lower urinary tract obstruction, twin-twin transfusion syndrome, myelomeningocele, congenital diaphragmatic hernia, neck masses occluding the trachea, and tumors such as congenital cystic adenomatoid malformation or sacrococcygeal teratoma when associated with development of fetal hydrops. Until recently, it has been difficult to determine the true benefits of several fetal surgeries because outcomes were reported as uncontrolled case series. However, several prospective randomized trials have been attempted and others are ongoing, supporting a more evidence-based approach to antenatal intervention. Problems that have yet to be completely overcome include the inability to identify ideal fetal candidates for antenatal intervention, to determine the optimal timing of intervention, and to prevent preterm birth after fetal surgery. Confronting a fetal abnormality raises unique and complex issues for the family. For this reason, in addition to a maternal-fetal medicine specialist experienced in prenatal diagnosis, a pediatric surgeon, an experienced operating room team including a knowledgeable anesthesiologist, and a neonatologist, the family considering fetal surgery should have access to psychosocial support and a bioethicist.
    Obstetrics and Gynecology 09/2014; 124(4). DOI:10.1097/AOG.0000000000000476 · 4.37 Impact Factor
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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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    ABSTRACT: Objective To describe the surgical technical aspects related to urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV).Methods The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the U.S.A., France and Brazil were reviewed with particular emphasis on surgical technical aspects and complications.ResultsA total of 40 fetal cystoscopies were performed at the three institutions, laser fulguration of the PUV was performed in 23 of these cases with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) infants. Urinary tract fistulas were diagnosed postnatally in four (10%) newborns. The fistulas were associated with higher gestational age at diagnosis (p=0.03), semi-curved rather than curved sheaths (p<0.01), the use of diode laser (p<0.01) and higher laser power and energy (p=0.02 and p=0.01, respectively).Conclusion Urological fistulas are a severe complication of fetal cystoscopic laser fulguration of PUV, which are associated with surgical technique such as type, energy and power settings of the laser and instrumentation. Use of correct instruments and proper training are necessary to safely perform this fetal intervention.
    Ultrasound in Obstetrics and Gynecology 05/2014; DOI:10.1002/uog.13405 · 3.14 Impact Factor


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