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Lower urinary tract obstruction: fetal intervention based on prenatal staging

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Abstract

The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.

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    Authors and Affiliations

    1. Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA

      Rodrigo Ruano

    2. Renal Section, Baylor College of Medicine and Texas Children’s Fetal Center – Texas Children’s Hospital Pavilion for Women, Houston, TX, USA

      Timothy Dunn, Michael C. Braun, Joseph R. Angelo & Adnan Safdar

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    1. Rodrigo Ruano
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    2. Timothy Dunn
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    3. Michael C. Braun
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    4. Joseph R. Angelo
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    5. Adnan Safdar
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    Correspondence to Rodrigo Ruano.

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    1. b; 2. a; 3. d; 4. d; 5. d

    Rodrigo Ruano, Timothy Dunn, Michael C. Braun, Joseph R. Angelo, and Adnan Safdar contributed equally to this work.

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    Ruano, R., Dunn, T., Braun, M.C. et al. Lower urinary tract obstruction: fetal intervention based on prenatal staging. Pediatr Nephrol 32, 1871–1878 (2017). https://doi.org/10.1007/s00467-017-3593-8

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