Systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction

Abstract

Background Congenital lower urinary tract obstruction is associated with high mortality and morbidity. Antenatal detection has improved with advances in ultrasound technology, and has allowed the option of antenatal intervention.Objectives To systematically review the literature to evaluate the effectiveness of antenatal interventions to improve perinatal survival and postnatal renal function in congenital lower urinary tract obstruction.Search strategy Extensive electronic searches (database inception 2009) using Medical Subject Headings (MeSH) and keywords, without restrictions. Reference lists of included studies were checked, and all authors were contacted.Selection criteria Studies were selected according to a predefined protocol. The included studies were observational or randomised trials, where an intervention was performed in utero to treat congenital lower urinary tract obstruction, compared with another intervention or no treatment.Data collection and analysis Data were extracted on study design, quality and results to construct 2 · 2 tables. Meta-analysis was performed where possible. Peto ORs with 95% CIs were computed.Main results Prenatal bladder drainage improved perinatal survival compared with no treatment (OR 3.86, 95% CI 2.00-7.45). This effect was amplified in a subgroup with poor predicted prognosis (OR 12.85, 95% CI 1.25-153.03). However, although treatment increases survival, it appears that the residual risk of poor long-term postnatal renal function is uncertain (OR 0.50, 95% CI 0.13-1.90).Author's conclusions Antenatal bladder drainage appears to improve perinatal survival in cases of congenital lower urinary tract obstruction, but may confer a high residual risk of poor postnatal renal function, based on observational studies. Randomised research with long-term follow up is necessary to determine the role of antenatal treatment in clinical practice.

Early vesico-amniotic shunting — does it change the prognosis in fetal lower urinary tract obstruction diagnosed in the first trimester?

“…Nephrogenesis is mostly complete by the end of the first half of the pregnancy and in severe cases it is unlikely that urinary system decompression allows kidney regeneration. In contrast based on literature [8], long-term survival and morbidity of fetuses with mild forms of LUTO appears unchanged by fetal intervention.…”

Congenital lower urinary tract obstruction: a population‐based epidemiological study

“…Several therapeutic options exist, with percutaneous vesicoamniotic shunting (VAS) being the classic treatment for selected cases. 10 This procedure carries potential risks to the mother (e.g. infection) and fetus (e.g.…”

Avances en terapia fetal

“…[56][57] Se han ideado numerosos procedimientos como las vesicocentesis seriadas y la colocación de catéter vésico-amniótico para disminuir los efectos de la obstrucción intra-útero. Una revisión sistemática de la literatura 56 no solo no pudo demostrar ningún beneficio a favor de la intervención prenatal para preservar la función renal sino que, de hecho, las posibilidades de supervivencia con función renal normal podrían estar disminuidas. Los resultados de un estudio clínico aleatorizado aún no publicado (PLUTO trial) avalarían estas conclusiones, por lo que esta intervención prenatal no pareciera ser recomendable hoy en la mayoría de los casos.…”