Ultrasound guided balloon catheterisation: a new method of fetal lower urinary tract obstruction management
Abstract
Objectives: Fetal lower urinary tract obstruction (LUTO), most often associated with presence of posterior urethral valves, poses high risk of perinatal mortality or postnatal renal failure. Looking for a method of causative treatment we have developed a technique of fetal urethroplasty with a coronary angioplasty balloon catheter inserted under an ultrasonographic guidance via an 18-gauge needle introduced transabdominally to fetal bladder.
Material and methods: We have used this procedure in three women with singleton pregnancies (two primiparas and one multipara, 32–35 years of age), diagnosed with fetal megacystis at 12–16 weeks of gestation. Urethral catheterization was carried out at 16–18 weeks and an unobstructed urine flow was achieved in all three cases immediately after the procedure, followed by a resolution of megacystis and normalization of amniotic fluid volume.
Results: In all three cases, the post-procedure period was uneventful. In the first two fetuses, amniotic fluid volume remained normal until 30 weeks of gestation when a gradual development of oligohydramnios and some signs of renal cystic dysplasia were observed. Nevertheless, both pregnancies were continued till term (37 and 39 weeks, respectively) and two boys without signs of pulmonary hypoplasia were delivered. The third patient is currently 25 weeks pregnant; volume of amniotic fluid in her fetus is normal and no signs of urinary flow obstruction or renal dysplasia have been recorded thus far.
Conclusions: Although some technical aspects of the procedure still need to be established, it seems worth consideration as a form of potentially least traumatic intrauterine intervention in fetuses with lower urinary tract obstruction.
Keywords: posterior urethral valvesballoon urethroplastyintrauterine treatmentmegacystisrenal dysplasia
References
- Lissauer D, Morris RK, Kilby MD. Fetal lower urinary tract obstruction. Semin Fetal Neonatal Med. 2007; 12(6): 464–470.
- Wu S, Johnson MP. Fetal lower urinary tract obstruction. Clin Perinatol. 2009; 36(2): 377–390.
- Tonni G, Vito I, Ventura A, et al. Fetal lower urinary tract obstruction and its management. Arch Gynecol Obstet. 2013; 287(2): 187–194.
- Clayton DB, Brock JW. Lower urinary tract obstruction in the fetus and neonate. Clin Perinatol. 2014; 41(3): 643–659.
- Ruano R, Safdar A, Au J, et al. Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction. Pediatr Nephrol. 2016; 31(4): 605–612.
- Ruano R, Yoshisaki CT, Salustiano EMA, et al. Early fetal cystoscopy for first-trimester severe megacystis. Ultrasound Obstet Gynecol. 2011; 37(6): 696–701.
- Morris RK, Quinlan-Jones E, Kilby MD, et al. Systematic review of accuracy of fetal urine analysis to predict poor postnatal renal function in cases of congenital urinary tract obstruction. Prenat Diagn. 2007; 27(10): 900–911.
- Agarwal SK, Fisk NM. In utero therapy for lower urinary tract obstruction. Prenat Diagn. 2001; 21(11): 970–976.
- Ruano R, Yoshizaki CT, Giron AM, et al. Cystoscopic placement of transurethral stent in a fetus with urethral stenosis. Ultrasound Obstet Gynecol. 2014; 44(2): 238–240.
- Hofmann R, Becker T, Meyer-Wittkopf M, et al. Fetoscopic placement of a transurethral stent for intrauterine obstructive uropathy. J Urol. 2004; 171(1): 384–386.
- Harrison MR, Golbus MS, Filly RA, et al. Fetal surgery for congenital hydronephrosis. N Engl J Med. 1982; 306(10): 591–593.
- Freedman AL, Johnson MP, Smith CA, et al. Long-term outcome in children after antenatal intervention for obstructive uropathies. Lancet. 1999; 354(9176): 374–377.
- Holmes N, Harrison MR, Baskin LS. Fetal surgery for posterior urethral valves: long-term postnatal outcomes. Pediatrics. 2001; 108(1): E7.
- McLorie G, Farhat W, Khoury A, et al. Outcome analysis of vesicoamniotic shunting in a comprehensive population. J Urol. 2001; 166(3): 1036–1040.
- Biard JM, Johnson MP, Carr MC, et al. Long-term outcomes in children treated by prenatal vesicoamniotic shunting for lower urinary tract obstruction. Obstet Gynecol. 2005; 106(3): 503–508.
- Morris RK, Malin GL, Quinlan-Jones E, et al. Percutaneous vesicoamniotic shunting in Lower Urinary Tract Obstruction (PLUTO) Collaborative Group. Percutaneous vesicoamniotic shunting versus conservative management for fetal lower urinary tract obstruction (PLUTO): a randomised trial. Lancet. 2013; 382(9903): 1496–1506.
- Sananes N, Favre R, Koh CJ, et al. Urological fistulas after fetal cystoscopic laser ablation of posterior urethral valves: surgical technical aspects. Ultrasound Obstet Gynecol. 2015; 45(2): 183–189.
- Dangel J, Debska M, Koleśnik A, et al. [The first successful fetal aortic balloon valvuloplasty in Poland]. Ginekol Pol. 2011; 82(8): 632–636.
- Dangel J, Dębska M, Koleśnik A, et al. Successful aortic valvuloplasties in fetuses – the new era and new challenge for Polish perinatal cardiology. Echo Płodu. 2012; 2: 16–20.
- Dębska M, Szymkiewicz-Dangel J, Koleśnik A, et al. [Fetal cardiac interventions - are we ready for them?]. Ginekol Pol. 2015; 86(4): 280–286.
