Journal of pediatric urology · 2026
Success and timing of urethral endoscopies in congenital lower urinary tract obstruction (cLUTO) patients after early versus late vesicoamniotic shunting (VAS).
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Jank Marietta, Rost Annika, Stein Raimund, Younsi Nina
Аннотация
BACKGROUND: Fetal intervention via vesicoamniotic shunt (VAS) in congenital lower urinary tract obstruction (cLUTO) aims to improve survival and mitigate pulmonary hypoplasia. Today, early VAS is increasingly utilized to preserve renal function. However, appropriate patient selection, VAS-associated complications and long-term management remain challenging.
OBJECTIVE: To investigate surgical management of the urethra and its outcome in cLUTO patients with early and late VAS.
METHODS: We performed a single-center retrospective cohort study in cLUTO patients with prenatal intervention between 01/2017 and 12/2022.
RESULTS: VAS was performed in 42 patients, of which 21 received early VAS at <17 weeks and 18 cases late VAS at ≥17 weeks of gestation. In three patients, the exact time-point of VAS was unknown. Urethral hypoplasia and PUV (posterior urethral valves) with concomitant urethral hypoplasia were more frequent in early VAS (early VAS: 43 % versus late VAS: 6 %). In the late VAS group, PUV was the prevailing pathology (61 %). After birth, more patients with late VAS had a urethral caliber allowing spontaneous voiding or urethral catheter placement (early VAS: 0 % versus late VAS: 28 %). In the early VAS group, 83 % of initial endoscopies were unsuccessful compared to 29 % in late VAS (p < 0.001). The Cox model showed that the likelihood of ever having a successful endoscopy was significantly higher at a faster rate in late VAS [2.26 (1.02; 4.97) p = 0.04], compared to early VAS. Six early VAS cases required repeat endoscopies, which was not the case in the late VAS group.
DISCUSSION: Our results show an association of early VAS with a decreased number of successful endoscopic interventions/evaluations. It remains highly speculative whether this is due to the severity of the underlying condition or a hypoplastic urethra as a result of early bypass in pregnancy. Based on our experience, we put forward an algorithm to guide attending pediatric urologists and surgeons. Our study's limitations are its retrospective design, small sample size, reliance on information provided by caregivers regarding urinary diversion and voiding at the last follow-up and the variation in follow-up durations.
CONCLUSION: Our data suggests that early VAS patients are less likely to undergo a successful endoscopic intervention/evaluation and if so, to a later time. To reduce the risk of iatrogenic urethral stenosis from early urethral instrumentation and allow the infant to thrive, we propose urinary diversion via tubes or vesicostomy until endoscopy and/or complex reconstructive procedures are feasible.
OBJECTIVE: To investigate surgical management of the urethra and its outcome in cLUTO patients with early and late VAS.
METHODS: We performed a single-center retrospective cohort study in cLUTO patients with prenatal intervention between 01/2017 and 12/2022.
RESULTS: VAS was performed in 42 patients, of which 21 received early VAS at <17 weeks and 18 cases late VAS at ≥17 weeks of gestation. In three patients, the exact time-point of VAS was unknown. Urethral hypoplasia and PUV (posterior urethral valves) with concomitant urethral hypoplasia were more frequent in early VAS (early VAS: 43 % versus late VAS: 6 %). In the late VAS group, PUV was the prevailing pathology (61 %). After birth, more patients with late VAS had a urethral caliber allowing spontaneous voiding or urethral catheter placement (early VAS: 0 % versus late VAS: 28 %). In the early VAS group, 83 % of initial endoscopies were unsuccessful compared to 29 % in late VAS (p < 0.001). The Cox model showed that the likelihood of ever having a successful endoscopy was significantly higher at a faster rate in late VAS [2.26 (1.02; 4.97) p = 0.04], compared to early VAS. Six early VAS cases required repeat endoscopies, which was not the case in the late VAS group.
DISCUSSION: Our results show an association of early VAS with a decreased number of successful endoscopic interventions/evaluations. It remains highly speculative whether this is due to the severity of the underlying condition or a hypoplastic urethra as a result of early bypass in pregnancy. Based on our experience, we put forward an algorithm to guide attending pediatric urologists and surgeons. Our study's limitations are its retrospective design, small sample size, reliance on information provided by caregivers regarding urinary diversion and voiding at the last follow-up and the variation in follow-up durations.
CONCLUSION: Our data suggests that early VAS patients are less likely to undergo a successful endoscopic intervention/evaluation and if so, to a later time. To reduce the risk of iatrogenic urethral stenosis from early urethral instrumentation and allow the infant to thrive, we propose urinary diversion via tubes or vesicostomy until endoscopy and/or complex reconstructive procedures are feasible.