Four‐dimensional ultrasonographic imaging of fetal lower urinary tract obstruction and guidance of percutaneous cystoscopy

Abstract

Fetal cystoscopy may be an option for the treatment of severe lower urinary tract obstruction 1 -7 . In the present case the use of four-dimensional (4D) ultrasonography was helpful in the identification of the urethral obstruction and guidance of percutaneous cystoscopy.A 34-year-old pregnant woman, gravida 2 para 1 (one previous vaginal delivery), was referred at 20 weeks' gestation because her male fetus presented with distended bladder, dilated proximal urethra ('keyhole sign') ( Figure 1a), bilateral hydroureters and hyperechogenic kidneys with severe hydronephrosis, ascites and anhydramnios. Amniocentesis was performed and normal fetal karyotype was observed. Renal function (sodium concentration of 120 mEq/L, chloride concentration of 95 mEq/L and osmolarity of 255 mOsm) was assessed by percutaneous puncture of the fetal right kidney. At 22 weeks' gestation fetal cystoscopy was performed under maternal epidural anesthesia and fetal anesthesia (15 µg/kg of fentanyl and 2 mg/kg pancuronium), after the parents' informed consent and the approval of the local ethics committee were obtained. A 2.2-mm slightly curved operating sheath was introduced into the fetal dilated bladder through the maternal abdomen, uterine walls and amniotic cavity under two-dimensional (2D) Figure 1 (a) Two-dimensional ultrasound image (parasagittal section) revealing a distended bladder (DB) and dilated urethra (DU) at 20 weeks' gestation. (b) Three-dimensional surface-rendered ultrasound image of fetal distended bladder (DB), dilated upper posterior urethra (DU), hydroureters (HyUr) and a septum (s) that seemed to obstruct bladder drainage. P, placenta.

Two‐year outcomes after diagnostic and therapeutic fetal cystoscopy for lower urinary tract obstruction

“…Fetal cystoscopy allows an endoscopic examination of the dilated posterior urethra and identification of PUV, UA, or US. Previous studies have demonstrated that the etiology of LUTO is one of the major factors associated with prognosis …”

“…11,[13][14][15] Fetal cystoscopy has been described as an alternative option to VAS by avoiding amnioinfusion, by providing an etiological diagnosis for the obstruction prior to prenatal management, and consequently by directing the specific prenatal treatment for the cause of LUTO. [16][17][18][19][20][21][22][23][24][25] However, there are limited data on outcomes after fetal cystoscopy, especially those outcomes related to long-term follow-up. In addition, significant perinatal complications have been reported related to the surgical techniques.…”

Non-operative management of acute cholecystitis in the elderly (Br J Surg 2012; 99: 1254–1261)

“…Because congenital LUTO is associated with increased perinatal and infant mortality and morbidity, a series of antenatal interventions have been proposed in an attempt to prevent postnatal complications4, 13, 15–20, 28–34. The optimal management of fetuses with LUTO continues to be one of the most challenging subjects in the field of fetal intervention and therapy3.…”

“…Percutaneous fetal cystoscopy has been reported as an alternative therapeutic option for the in‐utero treatment of LUTO. It has theoretical advantages over VAS, as it allows anatomical diagnosis and ablation of the PUV (if visualized) by direct instrumentation of the proximal urethra4, 15–21, 29, 32. However, if urethral atresia is identified, ablation cannot be performed and prenatal therapy is not possible, unless a VAS is placed in situ .…”

Feasibility of Vesicoamniotic Shunt Insertion in an Inanimate Model: Comparison of Fetoscopic and Ultrasound-Guided Techniques

“…Fetal cystoscopy appears promising as both a diagnostic and therapeutic intervention. However, it remains technically challenging and requires refinements in current equipment to improve its overall success rate [19][20][21] . In our study, despite a trend towards increased overall success rate with F-VASI, there was no statistically significant difference compared with US-VASI (90 vs. 77%, p = 0.3).…”