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20th biannual meeting of the society for fetal urology 1
PEDIATRIC UROLOGY UPDATE
20th BIANNUAL MEETING OF THE SOCIETY FOR FETAL UROLOGY PATRICK H. MCKENNA
T
he focus of the spring meeting was to review the indications and timing of antenatal intervention for genitourinary abnormalities. Dr. Augusto Sola, Chief of Neonatology at Cedars Sinai Medical Center, Los Angeles, and Dr. Val Catanzarite, Director, Perinatal Ambulatory Services, Sharp Perinatal Center, San Diego, addressed the group from the neonatal and obstetrical perspective. This broadened the perspective beyond the primarily urologic membership. A series of case scenarios was developed with associated multiple-choice answers, which the members and invited speakers answered at the start of the meeting. The responses were tabulated and reviewed for purposes of stimulating discussion and determining management consensus. In addition, 14 centers presented specific cases where antenatal intervention had been performed or contemplated. There was consensus on several aspects of the antenatal management of fetuses with urologic abnormalities. The most obvious was that antenatal intervention is seldom indicated for these problems. It is well accepted, by all the specialties represented, that karyotype, echocardiography, assessment of potential renal function, and complete ultrasound examination of the fetus should be completed to exclude additional life-threatening abnormalities prior to intervention. Dr. Sola reviewed the low morbidity associated with early delivery after 33 weeks in fetuses with proven lung maturity, prompting a detailed discussion of early delivery as an option. He believes that the low risk and slightly higher costs associated with a stay in a
The Society for Fetal Urology is supported by a grant from the Connecticut Children’s Medical Center and Mallinckrodt. This update reports on the meeting that took place on May 29, 1998 during the American Urological Association Meeting in San Diego, California. From the Department of Pediatric Urology, Connecticut Children’s Medical Center, Hartford, Connecticut Reprint requests: Patrick H. McKenna, M.D., Connecticut Children’s Medical Center, 282 Washington Street, Hartford, CT 06106 Received: July 6, 1998, accepted: July 6, 1998 © 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
neonatal nursery of infants induced early is justified for severe urologic abnormalities, even if only unilateral. He also believes it would allow earlier postnatal evaluation and potential postnatal intervention. However, there is no scientific evidence that this is the case. Dr. Cendron, from Dartmouth in Lebanon, NH, presented a case where a fetus had a unilateral multicystic dysplastic kidney and a contralateral hydronephrotic kidney with decreasing amniotic fluid at 30 weeks. He advocated continued observation, and the fetus subsequently had an increase in amniotic fluid and delivered at term with no sequelae. Dr. Cooper, representing the Philadelphia Children’s Hospital group, presented a case where a fetus had improvement of oligohydramnios following a bladder tap, which allowed a delay of 1 month before a vesicoamniotic shunt was placed. Both these cases pointed out the need to follow the trend in amniotic fluid volume late in gestation, rather than making a decision based on one observation. Another area of consensus is the inability to be 100% accurate in the diagnosis, solely on the basis of antenatal ultrasound findings. Dr. DeMaria, from Hamilton, Ontario, and Drs. Baker and Docimo, from The Johns Hopkins Hospital, Baltimore, Md, presented cases that antenatally appeared to be bladder neck obstruction, but postnatally turned out to be Eagle-Barrett syndrome. Dr. DeMaria’s patient had oligohydramnios and a shunt was placed antenatally. The other case was followed without antenatal intervention. Dr. Bukowski, from the University of North Carolina, Chapel Hill, NC, presented a case in which the fetus appeared to have bladder neck obstruction antenatally but postnatally no valves were identified. Initial high voiding pressures were identified, which normalized over the first 10 months of observation. These cases reinforce the fact that accurate diagnosis can only be made with appropriate studies after delivery. Multiple centers presented cases that pointed out the high complication rate associated with antenatal intervention. Dr. Pugach, representing the Hospital for Sick Children, Toronto, presented 3 cases 0090-4295/98/$19.00 PII S0090-4295(98)00385-9 705
where shunt placement was associated with complications. His group advocates the concept that only specialized centers should perform these procedures. Dr. Coplen, from St. Louis Children’s Hospital, St. Louis, Mo, presented a case of iatrogenic gastroschisis secondary to placement of the vesicoamniotic shunt. Drs. Herndon and McKenna, from the University of Connecticut, presented the case of a fetus who survived a vascular injury secondary to a shunt placement at 24 weeks, which required a stat cesarean section and abdominal exploration. They reviewed a total of 26 articles with 222 cases and found a 45% complication rate associated with antenatal intervention. The most common complication was shunt malfunction, requiring shunt replacement. The most informative part of the conference was the analysis of the 7 case scenarios. In 2 cases, there was almost complete agreement on treatment. In the first patient, presenting at 32 weeks’ gestation with unilateral severe pyelocalyectasis and otherwise normal antenatal evaluation, the majority of the participants recommended no intervention. After being assured of lung maturity, a minority thought that early delivery was appropriate. In the second scenario of an 18-week fetus with bilateral hydronephrosis and low normal amniotic fluid, the majority would repeat the ultrasound in 2 to 4 weeks. A minority would recommend an aspiration and evaluation of urine electrolytes. The most controversial scenarios included a fetus at 20 weeks with severe hydroureteronephrosis on the right, mild hydronephrosis on the left, oligohydramnios, and poor prognosis on serial electrolytes from the bladder and right renal aspirates. Responses were split between placement of a vesicoamniotic shunt versus no intervention, because of probable poor survival. The other controversial scenario involved a 20-week fetus with bilateral
706
cystic kidneys, low normal amniotic fluid, a small amount of urine in the bladder, and otherwise normal survey. Half of the participants recommended serial observation, one third believed there should be no intervention since the baby would be unlikely to survive, a fifth of the participants would recommend termination of the pregnancy, and the remainder would aspirate a urine sample. In the case of oligohydramnios at 23 weeks in an infant with bilateral hydroureteronephrosis and serial bladder aspirates showing improving good prognosis based on aspirated urine electrolytes, the majority present at the meeting would recommend shunt placement. In the situation of bilateral hydroureteronephrosis, distended bladder, and normal amniotic fluid at 36 weeks, over a third of the respondents would induce the delivery; the remainder would not intervene. In the final case of a fetus at 28 weeks with a solitary kidney with moderate to severe pyelocalyectasis and normal amniotic fluid, two thirds responded they would not intervene, and a fifth would induce delivery when lung maturity is assured. In summary, the take-home messages are (1) antenatal intervention is seldom required for urologic abnormalities; (2) consideration should be given to early delivery in the infant over 33 weeks’ gestation with proven lung maturity; (3) in the absence of oligohydramnios, intervention is not indicated; (4) following the trend in findings antenatally is more important than relying on one study; (5) careful postnatal evaluation is required in patients with significant antenatal lesions because the antenatal diagnosis can be inaccurate; (6) each specialty brings a unique perspective to the decisionmaking process. The maternal fetal obstetrician, neonatologist, and urologist should all be involved in the decision whether to intervene on urologic abnormalities in the antenatal period.
UROLOGY 52 (4), 1998
20th BIANNUAL MEETING OF THE SOCIETY FOR FETAL UROLOGY PATRICK H. MCKENNA
T
he focus of the spring meeting was to review the indications and timing of antenatal intervention for genitourinary abnormalities. Dr. Augusto Sola, Chief of Neonatology at Cedars Sinai Medical Center, Los Angeles, and Dr. Val Catanzarite, Director, Perinatal Ambulatory Services, Sharp Perinatal Center, San Diego, addressed the group from the neonatal and obstetrical perspective. This broadened the perspective beyond the primarily urologic membership. A series of case scenarios was developed with associated multiple-choice answers, which the members and invited speakers answered at the start of the meeting. The responses were tabulated and reviewed for purposes of stimulating discussion and determining management consensus. In addition, 14 centers presented specific cases where antenatal intervention had been performed or contemplated. There was consensus on several aspects of the antenatal management of fetuses with urologic abnormalities. The most obvious was that antenatal intervention is seldom indicated for these problems. It is well accepted, by all the specialties represented, that karyotype, echocardiography, assessment of potential renal function, and complete ultrasound examination of the fetus should be completed to exclude additional life-threatening abnormalities prior to intervention. Dr. Sola reviewed the low morbidity associated with early delivery after 33 weeks in fetuses with proven lung maturity, prompting a detailed discussion of early delivery as an option. He believes that the low risk and slightly higher costs associated with a stay in a
The Society for Fetal Urology is supported by a grant from the Connecticut Children’s Medical Center and Mallinckrodt. This update reports on the meeting that took place on May 29, 1998 during the American Urological Association Meeting in San Diego, California. From the Department of Pediatric Urology, Connecticut Children’s Medical Center, Hartford, Connecticut Reprint requests: Patrick H. McKenna, M.D., Connecticut Children’s Medical Center, 282 Washington Street, Hartford, CT 06106 Received: July 6, 1998, accepted: July 6, 1998 © 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
neonatal nursery of infants induced early is justified for severe urologic abnormalities, even if only unilateral. He also believes it would allow earlier postnatal evaluation and potential postnatal intervention. However, there is no scientific evidence that this is the case. Dr. Cendron, from Dartmouth in Lebanon, NH, presented a case where a fetus had a unilateral multicystic dysplastic kidney and a contralateral hydronephrotic kidney with decreasing amniotic fluid at 30 weeks. He advocated continued observation, and the fetus subsequently had an increase in amniotic fluid and delivered at term with no sequelae. Dr. Cooper, representing the Philadelphia Children’s Hospital group, presented a case where a fetus had improvement of oligohydramnios following a bladder tap, which allowed a delay of 1 month before a vesicoamniotic shunt was placed. Both these cases pointed out the need to follow the trend in amniotic fluid volume late in gestation, rather than making a decision based on one observation. Another area of consensus is the inability to be 100% accurate in the diagnosis, solely on the basis of antenatal ultrasound findings. Dr. DeMaria, from Hamilton, Ontario, and Drs. Baker and Docimo, from The Johns Hopkins Hospital, Baltimore, Md, presented cases that antenatally appeared to be bladder neck obstruction, but postnatally turned out to be Eagle-Barrett syndrome. Dr. DeMaria’s patient had oligohydramnios and a shunt was placed antenatally. The other case was followed without antenatal intervention. Dr. Bukowski, from the University of North Carolina, Chapel Hill, NC, presented a case in which the fetus appeared to have bladder neck obstruction antenatally but postnatally no valves were identified. Initial high voiding pressures were identified, which normalized over the first 10 months of observation. These cases reinforce the fact that accurate diagnosis can only be made with appropriate studies after delivery. Multiple centers presented cases that pointed out the high complication rate associated with antenatal intervention. Dr. Pugach, representing the Hospital for Sick Children, Toronto, presented 3 cases 0090-4295/98/$19.00 PII S0090-4295(98)00385-9 705
where shunt placement was associated with complications. His group advocates the concept that only specialized centers should perform these procedures. Dr. Coplen, from St. Louis Children’s Hospital, St. Louis, Mo, presented a case of iatrogenic gastroschisis secondary to placement of the vesicoamniotic shunt. Drs. Herndon and McKenna, from the University of Connecticut, presented the case of a fetus who survived a vascular injury secondary to a shunt placement at 24 weeks, which required a stat cesarean section and abdominal exploration. They reviewed a total of 26 articles with 222 cases and found a 45% complication rate associated with antenatal intervention. The most common complication was shunt malfunction, requiring shunt replacement. The most informative part of the conference was the analysis of the 7 case scenarios. In 2 cases, there was almost complete agreement on treatment. In the first patient, presenting at 32 weeks’ gestation with unilateral severe pyelocalyectasis and otherwise normal antenatal evaluation, the majority of the participants recommended no intervention. After being assured of lung maturity, a minority thought that early delivery was appropriate. In the second scenario of an 18-week fetus with bilateral hydronephrosis and low normal amniotic fluid, the majority would repeat the ultrasound in 2 to 4 weeks. A minority would recommend an aspiration and evaluation of urine electrolytes. The most controversial scenarios included a fetus at 20 weeks with severe hydroureteronephrosis on the right, mild hydronephrosis on the left, oligohydramnios, and poor prognosis on serial electrolytes from the bladder and right renal aspirates. Responses were split between placement of a vesicoamniotic shunt versus no intervention, because of probable poor survival. The other controversial scenario involved a 20-week fetus with bilateral
706
cystic kidneys, low normal amniotic fluid, a small amount of urine in the bladder, and otherwise normal survey. Half of the participants recommended serial observation, one third believed there should be no intervention since the baby would be unlikely to survive, a fifth of the participants would recommend termination of the pregnancy, and the remainder would aspirate a urine sample. In the case of oligohydramnios at 23 weeks in an infant with bilateral hydroureteronephrosis and serial bladder aspirates showing improving good prognosis based on aspirated urine electrolytes, the majority present at the meeting would recommend shunt placement. In the situation of bilateral hydroureteronephrosis, distended bladder, and normal amniotic fluid at 36 weeks, over a third of the respondents would induce the delivery; the remainder would not intervene. In the final case of a fetus at 28 weeks with a solitary kidney with moderate to severe pyelocalyectasis and normal amniotic fluid, two thirds responded they would not intervene, and a fifth would induce delivery when lung maturity is assured. In summary, the take-home messages are (1) antenatal intervention is seldom required for urologic abnormalities; (2) consideration should be given to early delivery in the infant over 33 weeks’ gestation with proven lung maturity; (3) in the absence of oligohydramnios, intervention is not indicated; (4) following the trend in findings antenatally is more important than relying on one study; (5) careful postnatal evaluation is required in patients with significant antenatal lesions because the antenatal diagnosis can be inaccurate; (6) each specialty brings a unique perspective to the decisionmaking process. The maternal fetal obstetrician, neonatologist, and urologist should all be involved in the decision whether to intervene on urologic abnormalities in the antenatal period.
UROLOGY 52 (4), 1998