Fetal Surgery for Posterior Urethral Valves: Long-Term Postnatal Outcomes

Holmes, Nicholas M.; Harrison, Michael R.; Baskin, Laurence S.

doi:10.1542/peds.108.1.e7

Cited by 208 publications

(116 citation statements)

References 36 publications

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“…The situation in humans is surely much more complex. Harrison and coworkers found improved renal histology and function after relief of urethral obstruction in animals but not in humans (17,18). The main reason, in many cases, is that Expression of PAX2 remained at a normal level and similar among the CK, KCO, and KCD groups (p Ͼ 0.05).…”

Section: Discussionmentioning

confidence: 99%

Does Intervention in Utero Preserve the Obstructed Kidneys of Fetal Lambs? A Histological, Cytological, and Molecular Study

et al. 2009

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Ureteropelvic junction obstruction is a common cause of end-stage nephropathy in children. Our aim was to investigate whether relief of obstruction in utero can alleviate the development of nephropathy. A silastic tube was tied around the left superior segment ureter to induce unilateral partial ureteral obstruction in 22 fetal sheep at 75-85 d of gestation. Three weeks later, the tubes were removed to relieve the obstruction in 10 of the 22 lambs. A sham operation was performed on four fetuses (the control). At birth, the lambs were killed, and their kidneys were removed to study the changes in histology, podocytes, and expression of paired-box 2 (PAX2) and VEGF. In the obstructed kidneys, we observed cysts of various sizes in the cortex, fibrosis in the interstitial tissue, much decreased number of glomeruli, severe podocyte foot process fusion, and markedly increased PAX2 and decreased VEGF expressions. However, relief of obstruction preserved the number of glomeruli, significantly increased VEGF expression, reduced fusion of the podocyte foot processes, and restored expression of PAX2 to some extent. Thus, relief of obstruction in utero may prevent or attenuate the development of nephropathy in lambs. (1)]. At present, infants suffering from UPJO are either simply followed up or given surgical treatment based on hydronephrosis grade or renal function condition. However, Murer et al (2) found that the recovery from renal function injury even after the relief of UPJO was not assured in some children. Intervention in utero may help these patients. Chevalier et al (3) found that the relief of obstruction markedly reduced tubular atrophy and interstitial fibrosis in developing kidneys. However, Josephson et al (4) found that renal damage persisted despite very early efforts to remove obstruction. Because there is no consistent evidence linking recovery from renal damage to relief of UPJO in utero in humans, we decided to study this issue in fetal lambs.Podocytes are needed to maintain normal renal function; yet, they are easily injured by various abnormal situations. To our knowledge, changes in podocytes in obstructed kidneys have rarely been studied.Paired-box 2 (PAX2) is an important regulatory factor that functions early in the development of the kidney, and is restricted to the developing kidney. In damaged kidneys, PAX2 expression seems to be related to the proliferation of cystic renal epithelia, which is common in obstructed kidneys. VEGF is needed to maintain the renal blood vessel system. Decrease in VEGF will lead to fibrosis, another very common condition in obstructed kidneys.In this study, whether the relief of UPJO in utero in lambs would attenuate the development of nephropathy was investigated by observing changes in histology, podocytes, and expression of PAX2 and VEGF in kidneys after ureteral obstruction relief in utero. MATERIALS AND METHODSSevere unilateral partial ureteral obstruction was produced in 22 sheep fetuses at 75-85 d of gestation. In brief, open hysterotomy was perfo...

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Section: Discussionmentioning

confidence: 99%

Does Intervention in Utero Preserve the Obstructed Kidneys of Fetal Lambs? A Histological, Cytological, and Molecular Study

et al. 2009

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“…Long-term postnatal outcomes in children after intrauterine VAS were a subject of many previous studies. Freedman et al [12] and Holmes et al [13] performed this procedure in 34 and 14 fetuses with LUTO, respectively, with 60% and 57% survival rates, and normal kidney function in 43% and 37% of the cases, respectively. These findings are consistent with the results of other studies in which VAS resulted in normalization of fluid volume and normal renal function in only 50% [14] and 45% of neonates [15].…”

Section: Discussionmentioning

confidence: 99%

Ultrasound guided balloon catheterisation: a new method of fetal lower urinary tract obstruction management

et al. 2017

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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.

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“…It has been reported that the long-term outcomes indicate that VAS at 18 to 30 weeks may not change the prognosis of renal function and that fetal surgery for obstructive uropathy should be performed only for the carefully selected patient who has severe oligohydramnios and 'normal'-appearing kidneys. 42 To preserve renal function, however, earlier VAS may be preferable (Fig. 52).…”

Section: Urinary Tract Abnormalitymentioning

confidence: 99%

Three-dimensional/Four-dimensional Sonography moved Prenatal Diagnosis of Fetal Anomalies from the Second to the First Trimester of Pregnancy

Pooh¹,

Kurjak²,

Chervenak³

2012

Donald School Journal of Ultrasound in Obstetrics and Gynecology

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The introduction of three-dimensional (3D)/four-dimensional (4D) sonography with high-frequency transvaginal transducer has resulted in remarkable progress in ultrasonographic visualization of early embryos and fetuses and development of new fields of 3D sonoembryology. With the proper use of this new diagnostic modality and with experienced examiner, both structural and functional development in the first trimester of gestation can be assessed more objectively and reliable.Indeed, new technology moved embryology from postmortem studies to the in vivo environment. Furthermore, there are good reasons to believe that 3D/4D sonography moved prenatal diagnosis of fetal abnormalities from the second to the first trimester of pregnancy. We will try to illustrate it with the number of convincing figures.

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Fetal Surgery for Posterior Urethral Valves: Long-Term Postnatal Outcomes

Cited by 208 publications

References 36 publications

Does Intervention in Utero Preserve the Obstructed Kidneys of Fetal Lambs? A Histological, Cytological, and Molecular Study

Does Intervention in Utero Preserve the Obstructed Kidneys of Fetal Lambs? A Histological, Cytological, and Molecular Study

Ultrasound guided balloon catheterisation: a new method of fetal lower urinary tract obstruction management

Three-dimensional/Four-dimensional Sonography moved Prenatal Diagnosis of Fetal Anomalies from the Second to the First Trimester of Pregnancy

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