Prenatal bladder drainage in the management of fetal lower urinary tract obstruction: a systematic review and meta-analysis

doi:10.1016/S0029-7844(03)00577-5

Obstetrics & Gynecology

Volume 102, Issue 2, August 2003, Pages 367-382

https://doi.org/10.1016/S0029-7844(03)00577-5 Get rights and content

Abstract

Objective

To estimate the effect of prenatal bladder drainage on perinatal survival in fetuses with lower urinary tract obstruction.

Data sources

Relevant articles were identified by searching the databases MEDLINE (1966–2002), EMBASE (1988–2002), and the Cochrane library (2000;4).

Methods of study selection

Studies were selected if the effect of prenatal bladder drainage (vesicocentesis, vesicoamniotic shunt, or open fetal bladder surgery) on perinatal survival was reported in fetuses with ultrasonic evidence of lower urinary tract obstruction. Study selection, quality assessment, and data abstraction were performed independently and in duplicate.

Tabulation, integration, and results

Sixteen observational studies that included nine case series (147 fetuses) and seven controlled series (195 fetuses) were identified. Study characteristics and quality were recorded for each study. Data on the effect of bladder drainage on perinatal survival were abstracted. Where controlled data were available, 2 × 2 tables were generated to compare the effects of bladder drainage versus no bladder drainage on perinatal survival. Pooled odds ratios (ORs) were used as summary measures of effect, and the results were stratified according to predicted fetal prognoses (based on ultrasound features and fetal urinary electrolytes). Among controlled studies, bladder drainage appeared to improve perinatal survival relative to no drainage (OR 2.5; 95% confidence interval [CI] 1.1, 5.9; P = .03). However, this observation was largely because among the subgroup of fetuses with a poor prognosis there was a marked improvement (OR 8.1; 95% CI 1.2, 52.9; P = .03). Improved perinatal outcome was also suggested in those fetuses considered to have a good prognosis (OR 2.8; 95% CI 0.7, 10.8; P = .13).

Conclusion

There is a lack of high quality evidence to reliably inform clinical practice regarding prenatal bladder drainage in fetuses with ultrasonic evidence of lower urinary tract obstruction. The limited available evidence suggests that prenatal bladder drainage may improve perinatal survival in these fetuses, particularly those with poor predicted prognoses. Further research in the form of a multicenter randomized controlled trial is required to assess the short- and long-term effects of this intervention.

Section snippets

Sources

Relevant literature was identified by searching general bibliographic databases, MEDLINE (1966–2002), and EMBASE (1988–2002) using a combination of the key words “congenital urinary obstruction,” “invasive procedure,” and “prenatal diagnosis”; their word variants; and MeSH. In addition, the Cochrane Library (2000, issue 4) was searched. Reference lists of all known reviews and primary studies were checked and the specialist journal Prenatal Diagnosis was manually searched. Unpublished data were

Study selection

Two reviewers (TJC and WLM) independently extracted data from all articles meeting the selection criteria, including data on features of methodological quality. Quality assessment involved scrutinizing study designs and the relevant features of population, intervention, and outcome¹⁷:

1.
Study design. Randomized controlled trials (RCTs) where intervention (vesicocentesis, vesicoamniotic shunt insertion, or open shunt insertion–corrective surgery) was compared with no intervention were considered

Results

As shown in Figure 1, the electronic search yielded 362 citations, of which 30 were considered potentially relevant. Examination of their full texts revealed that eight were duplicates and six did not meet the selection criteria (see Appendix). Thus, a total of 16 primary studies (all in English), including 342 fetuses were selected for review (Table 1). No randomized trials were identified. Nine studies were case series (147 fetuses) and seven were controlled studies (195 fetuses).

Details of

Conclusion

Our review shows that there is a lack of high-quality evidence to reliably inform clinical practice regarding prenatal bladder drainage in fetuses with ultrasonic evidence of lower urinary tract obstruction. The limited available evidence suggests that in utero fetal bladder drainage may improve perinatal survival in these fetuses, and this finding is consistent whether voluntary termination of pregnancies is included or excluded. Those fetuses with poor predicted prognoses, as determined by

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Fetal lower urinary tract obstruction (LUTO) is classically based on prenatal ultrasound identification of a dilated/ thick-walled bladder, bilateral hydronephrosis, dilated ureters and a dilated posterior urethra (also known as the “keyhole sign”) in a male fetus. Although the most common underlying diagnosis is posterior urethral valves, the prenatal appearance may be similar with urethral atresia or stenosis, the Prune-Belly Syndrome, or even a cloacal anomaly in a female. These conditions form part of the Congenital Anomalies of Kidney and Urinary Tract (CAKUT) spectrum, which is the commonest cause of end-stage renal disease in children. Although it is difficult to predict postnatal renal function from the prenatal appearance, studies have recently identified predictive features (based on ultrasound findings and fetal biochemistry), and established staging systems to assist with counselling, and, where indicated, patient selection for in-utero intervention. Current in-utero therapy includes amnio-infusion, vesico-amniotic shunting, and fetal cystoscopy with valve ablation or urethral stenting. Postnatal survival and renal functional outcomes, complications and management uncertainties are described, highlighting areas of future development.
Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction
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Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients.
We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016).
31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034).
Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031).
The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year.
This is a prognostic study with Level IV evidence.
Outcomes in fetuses diagnosed with megacystis: Systematic review and meta-analysis
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To explore the outcomes and prognostic factors associated with fetal megacystis (enlarged bladder).
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The search identified 558 articles in total, and 13 studies (1675 fetuses) were included in this systematic review. The overall incidences of chromosomal abnormalities and associated structural anomalies in fetal megacystis were 10% and 24%, respectively. Spontaneous resolution of megacystis occurred in 32% of fetuses, and 44% of fetuses were born alive and survived until the follow-up. The odds ratio of survival with oligohydramnios was 0.14, and the mean difference in gestational age at diagnosis between survival and non-survival was 3.43 weeks. No significant difference in survival rate was observed between the genders, and an intrauterine intervention did not significantly improve the prognosis.
A considerable proportion of fetuses with megacystis are born with a good prognosis. Oligohydramnios and lower gestational age at diagnosis are associated with worse outcomes.
Prenatal renal parenchymal area as a predictor of early end-stage renal disease in children with vesicoamniotic shunting for lower urinary tract obstruction
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Citation Excerpt :
In order to prevent such complications, research has been directed at circumventing the pathology by in utero vesicocentesis or vesicoamniotic shunting (VAS). It has been shown that VAS and other bladder drainage techniques for fetal LUTO will ameliorate pulmonary hypoplasia and will increase survival rates in patients with an initial poor prognosis [8]. However, it remains uncertain if these interventions have significant benefit for renal function in humans.
Vesicoamniotic shunting (VAS) and other bladder drainage techniques for fetal lower urinary tract obstruction (LUTO) have been proven to ameliorate pulmonary hypoplasia and increase survival in patients with an initial poor prognosis. Currently there are limited prognostic tools available during gestation to evaluate and predict postnatal renal function.
The aim was to describe the prenatal growth of the renal parenchymal area (RPA) in patients with LUTO and determine its application as a predictor of renal function at one year of life.
The study population comprised a retrospective cohort of all infants who survived the fetal VAS to birth. Renal growth and size were measured using imageJ software to calculate the RPA in sequential prenatal ultrasounds. The parenchymal area was measured from the image of each kidney with the greatest longitudinal length. These measurements were further correlated and analyzed as a predictor of end-stage renal disease (ESRD) within the first year of life.
Etiologies of LUTO in the 15 male fetuses included eight posterior urethral valves, four Eagle–Barrett/prune belly syndrome, two urethral atresia, and one megacystis microcolon intestinal hypoperistalsis syndrome. All patients had patent shunts, in place, at birth. Furthermore, ultrasonographic parameters such as oligohydramnios, keyhole sign, and bladder wall thickness showed no statistical difference between groups. Renal parenchymal growth correlated with postnatal renal function in both the ESRD (r = 0.409, p = 0.018) and the non-ESRD (r = 0.657, p < 0.001) groups. Most notably, RPA during the 3rd trimester predicted ESRD with the best cut-off point determined to be 8 cm² (sensitivity, 0.714; specificity, 0.882; and positive likelihood ratio, 6.071) (Table).
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RPA measurement during the prenatal period could play an important role as a non-invasive tool to predict postnatal renal function and to anticipate postnatal clinical interventions.

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ReviewsPrenatal bladder drainage in the management of fetal lower urinary tract obstruction: a systematic review and meta-analysis

Abstract

Objective

Data sources

Methods of study selection

Tabulation, integration, and results

Conclusion

Section snippets

Sources

Study selection

Results

Conclusion

J Pediatr Surg

Lancet

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Lancet

J Urol

Am J Obstet Gynecol

Am J Obstet Gynecol

J Pediatr Surg

Clin Obstet Gynecol

Urinary tract obstruction

Fetal urethral obstructionUS evaluation

Radiology

Antenatal diagnosis of renal tract anomalies by ultrasound

Pediatr Nephrol

Pre-natal diagnosisHow useful is it?

Br J Urol

Prenatal diagnosis and treatment of fetal hydronephrosis

Semin Perinatol

Catheter shunts for fetal hydronephrosis and hydrocephalus. Report of the International Fetal Surgery Registry

N Engl J Med

Reviews
Prenatal bladder drainage in the management of fetal lower urinary tract obstruction: a systematic review and meta-analysis