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In utero intervention for urologic diseases

Nature Reviews Urology volume 9, pages 207–217 (2012)Cite this article

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Abstract

The burgeoning use of prenatal ultrasonography has prompted discussion of the feasibility and capabilities of fetal intervention for urologic disorders. On the basis of the capabilities of fetal intervention, three prenatally diagnosed anomalies are of primary interest to urologists: congenital adrenal hyperplasia (CAH), lower urinary tract obstruction (LUTO) and myelomeningocele. Various interventions (surgical or pharmacological) are being developed for fetuses with these diagnoses. For fetuses with CAH or LUTO, successful outcomes have certainly been demonstrated, although no results from prospective randomized trials have been published. In utero treatment of CAH is accomplished through oral administration of glucocorticoids to the expectant mother. However, the long-term effects of this strategy have been insufficiently studied and remain undetermined. In the fetus with a LUTO, prenatal intervention has primarily been accomplished by placement of a vesicoamniotic shunt. Although this technique results in improved perinatal survival according to several systematic reviews of the literature, the data originate from small, heterogeneous populations of patients. By contrast, a randomized controlled trial of fetal myelomeningocele closure resulted in greatly reduced rates of both ventriculoperitoneal shunt placement and hydrocephalus. The future of fetal intervention in urology is contingent upon improved methods of studying the clinical outcomes of such treatments.

Key Points

  • Prenatal ultrasonography has dramatically changed the practice of pediatric urology

  • Congenital adrenal hyperplasia, lower urinary tract obstruction and myelomeningocele are the current focus of fetal urologic intervention

  • Prenatal dexamethasone treatment of fetuses with congenital adrenal hyperplasia has demonstrated success in the few reports available, but this intervention has yet to be studied prospectively

  • In fetuses with lower urinary tract obstruction, perinatal survival is improved by prenatal vesicoamniotic shunting, but the risk of compromised postnatal renal function remains high

  • A randomized controlled trial has demonstrated clear and objective evidence of a neurological benefit for fetal myelomeningocele closure

  • The scientific methods for studying and reporting fetal intervention in urology must be improved

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Figure 1: Adrenal steroid synthesis.
Figure 2: Posterior urethral dilatation (keyhole sign).
Figure 3: Fetal megacystis.
Figure 4: Bilateral hydronephrosis.
Figure 5: Percutaneous insertion of the vesicoamniotic shunt (Harrison type).

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  1. Department of Urologic Surgery, Division of Pediatric Urology, Vanderbilt University, 2200 Children's Way, Suite 4102, Nashville, 37232-9820, TN, USA

    Douglass B. Clayton

  2. Division of Pediatric Urology, Monroe J. Carell Jr Children's Hospital at Vanderbilt, 4102 Doctors' Office Tower, 2200 Children's Way, Nashville, 37232-9820, TN, USA

    John W. Brock III

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D. Clayton researched data for the article, substantially contributed to the discussion of its content, wrote and reviewed and edited the manuscript before submission. J. W. Brock III substantially contributed to the discussion of the articles' content and reviewed and edited the manuscript before submission.

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Clayton, D., Brock, J. In utero intervention for urologic diseases. Nat Rev Urol 9, 207–217 (2012). https://doi.org/10.1038/nrurol.2012.9

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