In-utero vesico-amniotic shunting for fetal lower urinary obstruction (LUTO) is known to improve perinatal survival. More recently, studies including centres performing fetal cystoscopy, have suggested benefit on longer-term survival and renal outcome – within the limitations of small numbers and limited follow-up. These interventions carry significant risk, and therefore patient selection, and ... [Show full abstract] optimal timing, are key. The aim of this article is to explore ways of improving the accuracy of prenatal diagnosis, and of identifying risk factors for fetal and postnatal renal failure. The next step is that of using established staging and classification systems to select the patient group that may benefit from intervention, based on published outcomes. Several factors come into play when selecting the timing of intervention, especially if the aim is that of renal, and not only pulmonary, preservation. Lastly, current technologies and their shortfalls are discussed.