Vesicoamniotic Shunting before 17 + 0 Weeks in Fetuses with Lower Urinary Tract Obstruction (LUTO): Comparison of Somatex vs. Harrison Shunt Systems

Abstract

(1) Background: The aim of this study was to compare perinatal outcomes and complication rates of vesicoamniotic shunting (VAS) before 17 + 0 weeks in isolated LUTO (lower urinary tract obstruction) with the Somatex® intrauterine shunt vs. the Harrison fetal bladder shunt. (2) Methods: This is a retrospective cohort study in two tertiary fetal medicine centers. From 2004–2014, the Harrison fetal bladder shunt was used, and from late 2014–2017, the Somatex shunt. Obstetrics and pediatric charts were reviewed for complications, course of pregnancy, perinatal outcome, and postnatal renal function. (3) Results: Twenty-four fetuses underwent VAS with a Harrison (H) shunt and 33 fetuses with a Somatex (S) shunt. Live birth rates and survival to last follow-up were significantly higher in the Somatex group, at 84.8% and 81.8%, respectively, vs. 50% and 33.3% in the Harrison group (p = 0.007 and p < 0.001). The dislocation rate in the Somatex group (36.4%) was significantly lower than in the Harrison group (87.5%) (p < 0.001). The median time to dislocation was significantly different, at 20.6 days (H) vs. 73.9 days (S) (p = 0.002), as was gestational age at dislocation (17 (H) vs. 25 (S) weeks, p < 0.001). Renal function was normal in early childhood in 51% (S) vs. 29% (H) (p = 0.11). (4) Conclusions: VAS before 17 + 0 weeks gestational age with a Somatex shunt improves perinatal survival significantly and might even have a positive effect on renal function, probably due to the lower dislocation rates. A normal amount of amniotic fluid in the third trimester was the best predictor of normal renal function in early childhood.

Prenatal diagnosis and outcome of fetal urinomas in relation to the underlying etiology

“…The benefits of VAS are still controversially discussed; although it has been associated with improved neonatal survival, it failed to significantly reduce the incidence of ESRF in affected children 22 . Recent studies, however, suggest that renal function might be salvaged when the earlier VAS is performed 23 . To what extent VAS might or might not be beneficial in cases of PUV and urinoma formation already taken place could be the subject of future studies.…”

“…22 Recent studies, however, suggest that renal function might be salvaged when the earlier VAS is performed. 23 To what extent VAS might or might not be beneficial in cases of PUV and urinoma formation already taken place could be the subject of future studies. Other prenatal interventions in PUV with urinoma include urinoma drainage, shunting, and PAS in the presence of urinary ascites.…”

Single-center outcome analysis of 46 fetuses with megacystis after intrauterine vesico-amniotic shunting with the Somatex®intrauterine shunt

“…As postnatal therapy of megacystis is frequently too late to rescue kidney and respiratory function, several antenatal treatment options have been developed to enable continuous urinary drainage of megacystis into the amniotic cavity, including serial vesicocentesis [ 9 – 11 ], vesico-amniotic shunting (VAS) [ 12 – 26 ] or cystoscopic laser valve ablation [ 21 , 27 , 28 ]. All previously published series on antenatal interventions including our own previous studies [ 20 , 24 , 25 ] showed an increase in perinatal survival with the best renal and respiratory outcome after VAS. Indeed, data on intervention-related complications, intrauterine demise, preterm rupture of membrane and preterm delivery varied considerably between the published series, as the numbers of treated fetuses were small and VAS was performed by different operators in different centers at varying gestational ages with different shunt systems.…”

“…or I.G.) using a technique as previously described by Strizek et al [ 24 , 25 ]. Genetic testing was offered to all patients, but was not mandatory prior to intrauterine intervention.…”

“…In addition, the ideal gestational age for VAS is still unclear, as VAS before 17 weeks has been deemed unsuitable due to an assumed increased complication rate. However, in a previous comparative study we could show that VAS with the Somatex®shunt can already be performed safely before 17 + 0 weeks and survival rates as well as kidney und pulmonary function improved with the earlier gestational age at intervention [ 25 ]. Regardless of any intrauterine intervention, the outcome of megacystis remains difficult to predict due to the heterogenic underlying pathology and the high prevalence of complex concomitant urinary, anorectal and genital anomalies [ 29 ].…”