Fetal intervention for severe lower urinary tract obstruction: a multicenter case–control study comparing fetal cystoscopy with vesicoamniotic shunting

• Published in: Ultrasound in obstetrics & gynecology Vol. 45; no. 4; pp. 452 - 458
• Main Authors: Ruano, R., Sananes, N., Sangi‐Haghpeykar, H., Hernandez‐Ruano, S., Moog, R., Becmeur, F., Zaloszyc, A., Giron, A. M., Morin, B., Favre, R.
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01.04.2015; Wiley Subscription Services, Inc
• Subjects: Anastomosis, Surgical - methods; Case-Control Studies; Cohort Studies; Cystoscopy - methods; Female; fetal cystoscopy; Fetal Diseases - diagnostic imaging; Fetal Diseases - surgery; fetal surgery; Fetal Therapies - methods; fistula; Humans; lower urinary tract obstruction; Lower Urinary Tract Symptoms - diagnostic imaging; Lower Urinary Tract Symptoms - surgery; Male; posterior urethral valves; Pregnancy; Retrospective Studies; Survival Rate; Treatment Outcome; Ultrasonography, Prenatal - methods; Urethral Diseases - diagnostic imaging; Urethral Diseases - surgery; Urethral Obstruction - diagnostic imaging; Urethral Obstruction - surgery; Urinary Bladder Neck Obstruction - surgery; Urinary Tract - abnormalities; Urinary Tract - diagnostic imaging; fetal cystoscopy; fetal surgery; fistula; posterior urethral valves; lower urinary tract obstruction
• ISSN: 0960-7692; 1469-0705
• DOI: 10.1002/uog.14652

ABSTRACT Objective To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO). Methods A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively. Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention. Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention. Results Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61. Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis. In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 1.86 (95% CI, 1.01–3.42; P = 0.048) and ARR, 1.73 (95% CI, 1.01–3.08; P = 0.04) respectively). A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 1.73 (95% CI, 0.97–3.08; P = 0.06)) but was not observed in the vesicoamniotic shunt group (ARR, 1.16 (95% CI, 0.86–1.55; P = 0.33)). In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6‐month survival rate and renal function (ARR, 4.10 (95% CI, 1.75–9.62; P < 0.01) and 2.66 (95% CI, 1.25–5.70; P = 0.01) respectively) while vesicoamniotic shunting was associated only with an improvement in the 6‐month survival rate (ARR, 3.76 (95% CI, 1.42–9.97; P < 0.01)) with no effect on renal function (ARR, 1.03 (95% CI, 0.49–2.17, P = 0.93)). Conclusion Fetal cystoscopy and vesicoamniotic shunting improve the 6‐month survival rate in cases of severe LUTO. However, only fetal cystoscopy may prevent impairment of renal function in fetuses with posterior urethral valves. Our data support the idea of performing a subsequent randomized controlled trial to compare the effectiveness of fetal cystoscopy vs vesicoamniotic shunting for severe fetal LUTO. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Linked Comment: Ultrasound Obstet Gynecol 2015; 45: 375–376