title: Urological fistulas after fetal cystoscopic laser ablation of posterior urethral valves: surgical technical aspects.
abstract: OBJECTIVE
  To describe the surgical technical aspects associated with the development of urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV).
  
  
  METHODS
  The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the USA, France and Brazil were reviewed, with particular emphasis on surgical technical aspects of the procedure and the complications encountered.
  
  
  RESULTS
  A total of 40 fetal cystoscopies were performed at the three institutions. Laser fulguration of the PUV was performed in 23 of these cases, with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) of these infants. Urological fistulas were diagnosed postnatally in four (10%) newborns. The presence of fistulas was associated with a higher gestational age at diagnosis of PUV (P < 0.01) and with the use of semi-curved rather than curved sheaths (P < 0.01), the use of a diode laser (P < 0.01) and the use of higher laser power and energy (P < 0.01 and P < 0.01, respectively), as well as with less operator experience (P < 0.01) and with absence of fetal anesthesia/immobilization (P = 0.02).
  
  
  CONCLUSIONS
  Urological fistulas are a severe complication of fetal cystoscopic laser fulguration of PUV and are associated with type, energy and power settings of the laser and instrumentation. The use of appropriate technique and proper training of the operator are necessary to perform this fetal intervention safely.
authors.affiliation: Department of Obstetrics and Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; INSERM, UMR-S 1121, Biomatériaux et Bioingénierie, Strasbourg, France.
authors.forename: N
authors.initials: N
authors.lastname: Sananes
authors.forename: R
authors.initials: R
authors.lastname: Favre
authors.forename: C J
authors.initials: CJ
authors.lastname: Koh
authors.forename: A
authors.initials: A
authors.lastname: Zaloszyc
authors.forename: M C
authors.initials: MC
authors.lastname: Braun
authors.forename: D R
authors.initials: DR
authors.lastname: Roth
authors.forename: R
authors.initials: R
authors.lastname: Moog
authors.forename: F
authors.initials: F
authors.lastname: Becmeur
authors.forename: M A
authors.initials: MA
authors.lastname: Belfort
authors.forename: R
authors.initials: R
authors.lastname: Ruano
mesh_terms: D001938:Brazil; D003558:Cystoscopy; D004564:Electrocoagulation / Q000009:adverse effects* / Q000379:methods; D005602:France; D006801:Humans; D007231:Infant, Newborn; D053685:Laser Therapy / Q000009:adverse effects* / Q000379:methods; D008297:Male; D011183:Postoperative Complications / Q000209:etiology*; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States; D014521:Urethra / Q000601:surgery*; D014524:Urethral Obstruction / Q000601:surgery*; D014548:Urinary Fistula / Q000209:etiology*
keywords: fetal cystoscopy; fetal surgery; fistula; lower urinary tract obstruction; urethral valves