Farrugia M K, Braun M C, Peters C A, Ruano R, Herndon C D
Department of Paediatric Urology, Chelsea Children's Hospital at the Chelsea & Westminster Hospital, London, UK.
Department of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
J Pediatr Urol. 2017 Aug;13(4):345-351. doi: 10.1016/j.jpurol.2017.02.021. Epub 2017 Mar 24.
The Society for Fetal Urology panel section at the 2016 Fall Congress featured a multidisciplinary discussion on appropriate patient selection, the conservative versus surgical management, and postnatal renal outcome of fetuses with lower urinary tract obstruction (LUTO).
Rodrigo Ruano shared his experience of prenatal intervention, presenting the outcome of 111 fetuses with severe LUTO treated with vesicoamniotic shunting (VAS) (n = 16), cystoscopy (n = 34) or no intervention (n = 61) in a non-randomized series. Multivariate analysis at the 6-month follow-up suggested a significantly higher probability of survival with fetal intervention versus no intervention. A clear trend for normal renal function was present in the fetal cystoscopy group, but not in the VAS group. In cases in which there was a postnatal diagnosis of posterior urethral valves (n = 57), fetal cystoscopy was effective in improving both the 6-month survival rate and renal function, while VAS was associated with an improvement in the 6-month survival rate. In an attempt to better define which fetuses would benefit from intervention, Michael Braun explained the proposed LUTO classification system that incorporates: (1) fetal urinary biomarkers of renal injury; (2) amniotic fluid levels as a surrogate for the severity of obstruction; and (3) imaging studies to identify signs of renal dysplastic or cystic changes. Intervention was not recommended in patients at low risk of either renal disease or pulmonary hypoplasia (Stage 1). Vesicoamniotic shunting was performed in patients at high risk of either progressive renal injury or pulmonary hypoplasia without evidence of severe pre-existing renal damage (Stage 2). For those patients, who at the time of evaluation had evidence of severe renal disease (Stage 3), fetal intervention was individualized and often based on bladder capacity and bladder refilling after vesicocentesis. He went on to present the nephrologic outcome of fetuses managed over the last 3 years utilizing the selection criteria. Craig Peters supported the concept of selective criteria and discussed the cautious viewpoint, namely: (1) the procedure may be unnecessary, as it is possible for patients to do well, in spite of severe prenatal obstruction; and (2) the risk of giving partial treatment by allowing the baby to survive to delivery with the daunting postnatal journey of renal and pulmonary insufficiency.
Standardized patient selection utilizing a staging system is undoubtedly the way forward and will enable comparable long-term renal and bladder functional outcome studies.
胎儿泌尿外科学会在2016年秋季大会上的专题讨论部分，针对下尿路梗阻（LUTO）胎儿的合适患者选择、保守治疗与手术治疗以及出生后肾脏转归进行了多学科讨论。
罗德里戈·鲁阿诺分享了他的产前干预经验，介绍了111例严重LUTO胎儿在非随机系列研究中接受羊膜腔分流术（VAS）（n = 16）、膀胱镜检查（n = 34）或未干预（n = 61）后的转归情况。6个月随访时的多变量分析表明，与未干预相比，胎儿干预后的生存概率显著更高。胎儿膀胱镜检查组出现肾功能正常的明显趋势，但VAS组未出现。在出生后诊断为后尿道瓣膜的病例（n = 57）中，胎儿膀胱镜检查在提高6个月生存率和肾功能方面均有效，而VAS与6个月生存率的提高相关。为了更好地确定哪些胎儿将从干预中获益，迈克尔·布劳恩解释了拟议的LUTO分类系统，该系统纳入：（1）肾损伤的胎儿尿液生物标志物；（2）作为梗阻严重程度替代指标的羊水水平；（3）用于识别肾发育异常或囊性改变迹象的影像学检查。对于肾病或肺发育不全低风险患者（1期），不建议进行干预。对于有进行性肾损伤或肺发育不全高风险且无严重既往肾损伤证据的患者（2期），实施羊膜腔分流术。对于那些在评估时已有严重肾病证据的患者（3期），胎儿干预是个体化的，通常基于膀胱容量以及膀胱穿刺术后膀胱再充盈情况。他接着介绍了过去3年依据选择标准进行管理的胎儿的肾脏转归情况。克雷格·彼得斯支持选择标准的概念，并讨论了谨慎的观点，即：（1）该手术可能不必要，因为尽管产前梗阻严重，患者仍可能情况良好；（2）让婴儿存活至分娩并经历严峻的出生后肾和肺功能不全过程会带来部分治疗的风险。
利用分期系统进行标准化患者选择无疑是前进的方向，将有助于开展具有可比性的长期肾脏和膀胱功能转归研究。
