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Background:
Fetal lower urinary tract obstruction (LUTO) is often secondary to posterior urethral valves (PUV) and is often diagnosed during the first trimester. PUV are also associated with high perinatal mortality with pulmonary hypoplasia and several renal impairment. Fetal antegrade cystoscopic laser ablation of PUV has previously been associated with promising results. We describe an international multi-institutional experience with fetal cystoscopy and fetal laser ablation of PUV.
Methods:
The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at one institution in the U.S. and two institutions outside the U.S. was reviewed with particular emphasis on surgical technical aspects and complications.
Results:
A total of 36 fetal cystoscopies were performed at the three institutions, and PUV was diagnosed in 22 of these cases for which fetal laser ablation was performed. When a curved sheath was not available due to regulatory restrictions, a semi-curved sheath was used, and urinary tract fistulae was diagnosed postnatally in 4 (18.2%) newborns, while no urologic fistula was noted with the use of a curved sheath (0%). Later gestational age at diagnosis (p=0.03), the use of a Diode laser (p<0.01), and higher laser power and energy settings (p=0.02 and p=0.01, respectively) were also associated with a higher incidence of fistulae.
Conclusion:
Fetal cystoscopy and laser ablation of PUV can be associated with higher rates of urological fistulae if a semi-curved sheath is used instead of a curved sheath. The ability to use internationally-developed pediatric medical devices in the U.S. may help prevent future complications, and programs such as the U.S. FDA’s P50 Pediatric Medical Device Consortia program should assist in improving the availability of needed pediatric medical devices in the U.S.