Therapeutic intervention for fetal lower urinary tract obstruction: Current evidence and future strategies

Farrugia, Marie‐Klaire; Kilby, Mark D.

doi:10.1016/j.jpurol.2021.01.034

Cited by 10 publications

(6 citation statements)

References 36 publications

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“…• Element Considerations for Fetal Identification, Counseling, Informed Consent, and Maternal Preparation. Subject directed reviews for fetal LUTO provide comprehensive summation for element identification and consideration [11][12][13][14][15].…”

Section: Results/interventions: Identification Of Potential Evidenced-based Protocol Elements For Development Of An Eras-luto Guidelinementioning

confidence: 99%

“…The fetal imaging details, from the detailed ultrasound ± MRI technology, provide understanding for the extent of renal morbidity, but can create clinical variance secondary to the expertise in the LUTO diagnostic and prognostic interpretation (Table 1) [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25].…”

Section: Results/interventions: Identification Of Potential Evidenced-based Protocol Elements For Development Of An Eras-luto Guidelinementioning

confidence: 99%

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Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

Wilson¹,

Nelson²

2021

Fetal Diagn Ther

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Background: Pregnancies that are prenatally identified to have fetal anomalies are complex and require expert multidisciplinary care. As many conditions can impact the fetus prenatally and require intervention, an enhanced recovery after surgery (ERAS) for lower urinary tract obstruction (LUTO) is being evaluated to determine the level of evidenced-based data available. Problem: The percutaneous ultrasound-guided fetal surgery procedure for bladder neck obstruction is the focus for elements of preoperative counseling, intraoperative procedure/risk complications, and postoperative management. Methods: A quality improvement review Squire 2.0 (2000–2020) was undertaken for the percutaneous LUTO fetal surgery shunting (lower urinary tract obstruction), process and procedure which require 2 process pathways, one to evaluate the fetal candidate and a second to treat. This structured review is focused on identifying the process elements to allow the determination of the number of evidenced-based elements that would allow for audit and measurement of the clinical element variance for comparative feedback to the individual surgical provider or surgery center. Interventions: Titles and abstracts were screened to identify potentially relevant articles with priority given to meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series. Results: A series of potential clinical elements for the diagnostic fetal evaluation and for the 3 protocol areas of surgical care for the procedures (pre-, intra-, and postoperative care) are identified using an ERAS-like process. Conclusions: The identified clinical elements have the potential for ERAS-LUTO fetal therapy guideline. Multidisciplinary collaboration (surgeon, anesthesia, nursing, imaging, and laboratory) is required for ERAS quality improvement in the pre-, intra-, and postoperative processes. Process elements in each of the operative areas can be audited, evaluated, compared, and modified/improved.

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Section: Results/interventions: Identification Of Potential Evidenced-based Protocol Elements For Development Of An Eras-luto Guidelinementioning

confidence: 99%

Section: Results/interventions: Identification Of Potential Evidenced-based Protocol Elements For Development Of An Eras-luto Guidelinementioning

confidence: 99%

Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

Wilson¹,

Nelson²

2021

Fetal Diagn Ther

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“…17 In order to predict postnatal renal function in LUTO, parameters such as changes of the fetal renal cortex, amount of AF volume, and fetal urine biochemistry are taken into account. 18 In the literature, presence of urinoma in the setting of LUTO was described as neither a good nor a bad sign regarding renal function. 2 In their retrospective study, Tang et al 19 however, they did not explicitly mention whether urinomas were part of their sonographic evaluation or not.…”

Section: Urinoma and Lower Urinary Tract Obstructionmentioning

confidence: 99%

Prenatal diagnosis and outcome of fetal urinomas in relation to the underlying etiology

et al. 2023

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ObjectiveEvaluation of course and outcome of pregnancies with prenatally diagnosed fetal urinoma in a single center over a 20‐year period.MethodsRetrospective study including all prenatally suspected or diagnosed fetal urinomas. Cases were analyzed by ultrasound findings during pregnancy, comparing urinomas caused by lower urinary tract obstruction (LUTO) and ureteropelvic or ureterovesical junction obstruction (UPJO/UVJO). Course of pregnancy and outcomes were compared according to the underlying etiology.Results87 cases of fetal urinomas were identified between 2002 and 2022. The underlying etiology was LUTO in 56.3% and UPJO/UVJO in 43.7%. Complications mainly included oligo‐ or anhydramnios, thoracic hypoplasia as well as associated renal abnormalities. Postnatally, loss of function (LOF) in kidneys affected by urinomas was seen in 78.6% of children overall, but significantly more often in cases of UPJO/UVJO than in LUTO (86.2% vs. 70.2%, p < 0.05).ConclusionAssociation of prenatal urinoma and postnatal LOF of the affected kidney is high, especially in cases caused by UPJO/UVJO. In survivors with urinoma caused by UPJO/UVJO, the general prognosis is excellent if the contralateral kidney was normal. In survivors with urinomas caused by LUTO, long‐term prognosis depends on postnatal renal and pulmonary function.

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“…Predicting ESRD prenatally is particularly challenging, as even fetuses with normal fluid levels at mid-gestation can develop worsening renal function during the remainder of the pregnancy and ultimately ESRD post-birth. 15,19,20 Johnsen et al studied 32 LUTO fetuses with normal amniotic fluid that were followed for at least 24 months postnatally at 11 North American Fetal Therapy Network (NafNet) centers and found that approximately one-third of these children require renal replacement therapy at follow-up. 15 Surrogate markers of disease severity such as development of oligohydramnios and/or anhydramnios during the course of pregnancy, renal dysplasia (e.g.…”

Section: Prenatal Evaluation and Stagingmentioning

confidence: 99%

“…While the staging system has not reached universal adoption yet, it does highlight the spectrum of clinical LUTO phenotypes and suggests that not all LUTO cases should undergo in‐utero therapy. Predicting ESRD prenatally is particularly challenging, as even fetuses with normal fluid levels at mid‐gestation can develop worsening renal function during the remainder of the pregnancy and ultimately ESRD post‐birth 15,19,20 . Johnsen et al.…”

Section: Fetal Megacystis and Lower Urinary Tract Obstruction (Luto)mentioning

confidence: 99%

Development and validation of a novel fetal vesico‐amniotic shunt, the vortex shunt

Blumenfeld,

Sheth,

Johnson

et al. 2023

Prenatal Diagnosis

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Fetal lower urinary tract obstruction (LUTO) is a severe malformation associated with an up to 80% mortality risk as well as significant renal and pulmonary morbidity in survivors. Fetal vesico‐amniotic shunts (VAS) bypass the bladder obstruction, improve amniotic fluid volume and enhance in‐utero pulmonary development. VAS has been shown to reduce respiratory morbidity and mortality in the neonatal period without proven benefit on long‐term renal and bladder function. Clinically available shunts are associated with an up to 80% dislodgement rate, leading to repeat invasive procedures which increase fetal and maternal risks. We developed a novel “Vortex” shunt, which incorporates enhanced fixation to reduce dislodgement, a one‐way valve to optimize in‐utero bladder function, and enhanced sonographic echogenicity that optimizes the accurate deployment. Following the validation of these characteristics in initial benchtop experiments we have moved to feasibility studies in the fetal lamb model. We hope that the Vortex shunt may ultimately facilitate shunt deployment, reduce dislodgement risk, improve neonatal morbidity and mortality, and decrease the significant healthcare expenditures associated with long‐term morbidity in LUTO survivors. In this manuscript, we review the natural history of LUTO, the risks and benefits of clinically available fetal shunts, and our development and early validation experiments.

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Therapeutic intervention for fetal lower urinary tract obstruction: Current evidence and future strategies

Cited by 10 publications

References 36 publications

Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

Prenatal diagnosis and outcome of fetal urinomas in relation to the underlying etiology

Development and validation of a novel fetal vesico‐amniotic shunt, the vortex shunt

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