title: Fetal intervention for severe lower urinary tract obstruction: a multicenter case-control study comparing fetal cystoscopy with vesicoamniotic shunting.
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)).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA; Texas Children's Fetal Center, Texas Children's Hospital Pavilion for Women, Houston, TX, USA.
authors.forename: R
authors.initials: R
authors.lastname: Ruano
authors.forename: N
authors.initials: N
authors.lastname: Sananes
authors.forename: H
authors.initials: H
authors.lastname: Sangi-Haghpeykar
authors.forename: S
authors.initials: S
authors.lastname: Hernandez-Ruano
authors.forename: R
authors.initials: R
authors.lastname: Moog
authors.forename: F
authors.initials: F
authors.lastname: Becmeur
authors.forename: A
authors.initials: A
authors.lastname: Zaloszyc
authors.forename: A M
authors.initials: AM
authors.lastname: Giron
authors.forename: B
authors.initials: B
authors.lastname: Morin
authors.forename: R
authors.initials: R
authors.lastname: Favre
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods*; D016022:Case-Control Studies; D015331:Cohort Studies; D003558:Cystoscopy / Q000379:methods*; D005260:Female; D005315:Fetal Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D046128:Fetal Therapies / Q000379:methods*; D006801:Humans; D059411:Lower Urinary Tract Symptoms / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D011247:Pregnancy; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D016216:Ultrasonography, Prenatal / Q000379:methods; D014522:Urethral Diseases / Q000000981:diagnostic imaging / Q000601:surgery; D014524:Urethral Obstruction / Q000000981:diagnostic imaging / Q000601:surgery; D001748:Urinary Bladder Neck Obstruction / Q000601:surgery; D014551:Urinary Tract / Q000002:abnormalities / Q000000981:diagnostic imaging
keywords: fetal cystoscopy; fetal surgery; fistula; lower urinary tract obstruction; posterior urethral valves