Fetoscopic transuterine release of posterior urethral valves: a new technique.
ABSTRACT Fetal urinary tract obstruction with oligohydramnios produces pulmonary hypoplasia and renal dysplasia. Decompression of the obstructed urinary tract may restore amniotic fluid and allow lung growth, but transabdominal catheter shunt decompression is often inadequate and does not allow for cycling of the bladder, while open procedures cause significant maternal morbidity. Disruption of the anatomic obstruction, usually posterior urethral valves in a male fetus, would be ideal but has proven technically difficult. Here we describe a new technique of percutaneous fetal cystoscopy and disruption of posterior urethral valves, and the case report of our first application of this technique. We pre-sent a case of a 17-week male fetus with posterior urethral valves which underwent fetal cystoscopy for mechanical disruption of posterior urethral valves. This minimally invasive approach to disruption of posterior urethral valves in a fetus is a novel method for decompressing the urinary tract. The technique offers a minimal degree of maternal morbidity and, if instituted early enough, can restore amniotic fluid volume, avert fatal pulmonary hypoplasia and may preserve renal function.
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ABSTRACT: Lower urinary tract obstruction (LUTO) comprises a heterogeneous group of pathologies associated with early-onset oligohydramnios and cystic renal disease that have high rates of perinatal morbidity (from renal disease) and mortality (from pulmonary hypoplasia). The use of prenatal detailed ultrasonography and fetal urine analysis has been only partially successful in identifying fetuses with LUTO with relatively good prognosis that would benefit from in utero therapy. The most common prenatal therapy is vesicoamniotic shunting. Newer techniques, such as fetal cystoscopy, have potential for enhancing prenatal triage and simultaneously delivering treatment. Vesicoamniotic shunting seems to improve perinatal survival, but whether this treatment or conservative management is used, the surviving children have a high rate of end-stage renal failure requiring dialysis and transplantation. Further investigation of long-term outcomes of vesicoamniotic shunting and fetal cystoscopy is hoped to delineate the risks and benefits of these prenatal treatments and inform management strategies.Nature Reviews Urology 06/2014; · 4.52 Impact Factor
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ABSTRACT: The burgeoning use of prenatal ultrasonography has prompted discussion of the feasibility and capabilities of fetal intervention for urologic disorders. On the basis of the capabilities of fetal intervention, three prenatally diagnosed anomalies are of primary interest to urologists: congenital adrenal hyperplasia (CAH), lower urinary tract obstruction (LUTO) and myelomeningocele. Various interventions (surgical or pharmacological) are being developed for fetuses with these diagnoses. For fetuses with CAH or LUTO, successful outcomes have certainly been demonstrated, although no results from prospective randomized trials have been published. In utero treatment of CAH is accomplished through oral administration of glucocorticoids to the expectant mother. However, the long-term effects of this strategy have been insufficiently studied and remain undetermined. In the fetus with a LUTO, prenatal intervention has primarily been accomplished by placement of a vesicoamniotic shunt. Although this technique results in improved perinatal survival according to several systematic reviews of the literature, the data originate from small, heterogeneous populations of patients. By contrast, a randomized controlled trial of fetal myelomeningocele closure resulted in greatly reduced rates of both ventriculoperitoneal shunt placement and hydrocephalus. The future of fetal intervention in urology is contingent upon improved methods of studying the clinical outcomes of such treatments.Nature Reviews Urology 02/2012; 9(4):207-17. · 4.79 Impact Factor
Article: Fetal Surgery: An Overview.[Show abstract] [Hide abstract]
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.Obstetrical & gynecological survey. 04/2014; 69(4):218-228.