Fetal lower urinary tract obstruction: What should we tell the prospective parents?

Ibirogba, Eniola R.; Haeri, Sina; Ruano, Rodrigo

doi:10.1002/pd.5669

Cited by 18 publications

(15 citation statements)

References 53 publications

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“…Of these papers, 594 were excluded based on exclusion criteria. A total of 46 studies were ultimately included in the Bayesian meta‐analysis (Table ) 8,9,16–59 …”

Section: Resultsmentioning

confidence: 99%

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Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta‐analysis

Keefe

Kim

Mackay³

et al. 2021

Prenatal Diagnosis

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Background Lower urinary tract obstruction (LUTO) is a rare but critical fetal diagnosis. Different ultrasound markers have been reported with varying sensitivity and specificity. Aims The objective of this systematic review and meta‐analysis was to identify the diagnostic accuracy of ultrasound markers for LUTO. Materials and Methods We performed a systematic literature review of studies reporting on fetuses with hydronephrosis or a prenatally suspected and/or postnatally confirmed diagnosis of LUTO. Bayesian bivariate random effects meta‐analytic models were fitted, and we calculated posterior means and 95% credible intervals for the pooled diagnostic odds ratio (DOR). Results A total of 36,189 studies were identified; 636 studies were available for full text review and a total of 42 studies were included in the Bayesian meta‐analysis. Among the ultrasound signs assessed, megacystis (DOR 49.15, [15.28, 177.44]), bilateral hydroureteronephrosis (DOR 41.33, [13.36,164.83]), bladder thickening (DOR 13.73, [1.23, 115.20]), bilateral hydronephrosis (DOR 8.36 [3.17, 21.91]), male sex (DOR 8.08 [3.05, 22.82]), oligo‐ or anhydramnios (DOR 7.75 [4.23, 14.46]), and urinoma (DOR 7.47 [1.14, 33.18]) were found to be predictive of LUTO (Table 1). The predictive sensitivities and specificities however are low and wide study heterogeneity existed. Discussion Classically, LUTO is suspected in the presence of prenatally detected megacystis with a dilated posterior urethra (i.e., the keyhole sign), and bilateral hydroureteronephrosis. However, keyhole sign has been found to have modest diagnostic performance in predicting the presence of LUTO in the literature which we confirmed in our analysis. The surprisingly low specificity may be influenced by several factors, including the degree of obstruction, and the diligence of the sonographer at searching for and documenting it during the scan. As a result, providers should consider this when establishing the differential for a fetus with hydronephrosis as the presence or absence of keyhole sign does not reliably rule in or rule out LUTO. Conclusions Megacystis, bilateral hydroureteronephrosis and bladder wall thickening are the most accurate predictors of LUTO. Given the significant consequences of a missed LUTO diagnosis, clinicians providing counselling for prenatal hydronephrosis should maintain a low threshold for considering LUTO as part of the differential diagnosis.

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“…Of these papers, 594 were excluded based on exclusion criteria. A total of 46 studies were ultimately included in the Bayesian meta‐analysis (Table ) 8,9,16–59 …”

Section: Resultsmentioning

confidence: 99%

“…Other etiologies include urethral atresia, urethral stenosis, anterior urethral valves, and prune belly syndrome (PBS). Cases in females are less common and attributed to other conditions such as a prolapsed ureterocele and cloacal anomalies 4,5 …”

Section: Introductionmentioning

confidence: 99%

Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta‐analysis

Keefe

Kim

Mackay³

et al. 2021

Prenatal Diagnosis

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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%

“…A number of prognostic tools have been developed to enhance the opportunity for optimal maternal counseling, understanding of the fetal morbidity and informed choice. [11,15,37] later modified to add a stage IV category with no fetal therapy but with maternal counseling for the prediction of in utero renal failure, the high risk of early neonatal death, and the maternal option for pregnancy termination [15]. • LUTO staging based on criteria at referral (bladder volume/ amniotic fluid volume/gestational age) [38].…”

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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Prenatal hydronephrosis: Bridging pre‐ and postnatal management

et al. 2022

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Urinary tract dilation (UTD), including hydronephrosis (HN) is the most common prenatally detected anomaly and affects up to 1%–2% of pregnancies. Postnatally, it resolves without surgical intervention in approximately 75%–80% of children, however this may take several years to occur, necessitating repeated clinic visits and additional invasive testing for many. For the remainder, a surgical intervention will be offered to relieve obstruction or to correct vesicoureteral reflux. During the monitoring period, many of these infants will be offered continuous antibiotic prophylaxis for the prevention of urinary tract infections, however this remains a controversial topic among pediatric urologists and nephrologists. Herein, we present an up‐to‐date review of the early management of prenatally detected UTD including timing of postnatal imaging, the use of antibiotics, when circumcision may be beneficial and long term outcomes of the most common HN etiologies. We also propose a decision making tool to help guide the care of infants with UTD.

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Fetal lower urinary tract obstruction: What should we tell the prospective parents?

Cited by 18 publications

References 53 publications

Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta‐analysis

Predictive accuracy of prenatal ultrasound findings for lower urinary tract obstruction: A systematic review and Bayesian meta‐analysis

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

Prenatal hydronephrosis: Bridging pre‐ and postnatal management

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