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Fetoscopic Laser Valve Ablation in the Posterior Urethral Valve Case with Intrauterine Diagnosis

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Fetoscopic Laser Valve Ablation in the Posterior Urethral Valve Case with Intrauterine Diagnosis A L J O A T U N R I N R A E L P Case Report P L E R A Perinatal Journal 2020;28(3):206–211 I N N R A U T A L J O ©2020 Perinatal Medicine Foundation Fetoscopic laser valve ablation in the posterior urethral valve case with intrauterine diagnosis Selahattin Kumru1 İD , Serdar Kaya2 İD 1Perinatology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey 2Perinatology Division, Department of Obstetrics and Gynecology, Ba¤c›lar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey Abstract Özet: ‹ntrauterin tan› alan posterior üretral valv olgusunda fetoskopik lazer valv ablasyonu Objective: We aimed to present the procedure of intrauterine per- Amaç: Alt üriner sistem obstrüksiyonu tan›s› alan bir fetüse uygu- cutaneous fetoscopic laser valve ablation performed on a fetus diag- lanan intrauterin perkütan fetoskopik lazer valv ablasyonu ifllemi- nosed with lower urinary tract obstruction. ni sunmay› amaçlad›k. Case: Bilateral hydroureteronephrosis, dilated bladder and oligo/ Olgu: Yirmi bir yafl›nda, düzenli takipleri olmayan gebenin fetal anhydramnios were found in the fetal ultrasonography examination ultrasonografik de¤erlendirilmesinde bilateral hidroüreteronefroz, of a 21-year-old pregnant woman who did not have regular follow- dilate mesane, oligo/anhidramniyoz saptand› ve olguda posterior ups, and the lower urinary tract obstruction consistent with the pos- üretral valv ile uyumlu alt üriner sistem obstrüksiyonu düflünüldü. terior urethral valve was considered in the case. The patient who was Ard›fl›k uygulanan vezikosentez sonucu kötü prognozlu saptanan found to have poor prognosis as a result of vesico synthesis carried hastaya, takip ve tedavi seçenekleri hakk›nda bilgi verildi ve 27. ge- out consecutively was informed about the follow-up and treatment belik haftas›nda perkütan fetoskopik lazer ile posterior üretral valv options, and the posterior urethral valve ablation was performed by ablasyonu yap›ld›. ‹fllem sonras› amniyon s›v›s› normal s›n›rda sey- the percutaneous fetoscopic laser on 27 weeks of gestation. The retti ve miad›nda do¤um gerçekleflti. Postpartum kreatinin yük- amniotic fluid was at normal levels after the procedure, and the labor sekli¤i olan yenido¤ana evre 2 böbrek yetmezli¤i tan›s› konuldu ve was carried out at term. The newborn with elevated postpartum cre- takiplerinde diyaliz ihtiyac› olmad›. Kreatinin de¤erleri gerileyen atinine was diagnosed with stage 2 renal failure, but dialysis was not yenido¤an ayaktan takip edilmek üzere taburcu edildi. required during the follow-ups. The newborn was discharged for Sonuç: Alt üriner sistem obstrüksiyonu varl›¤›nda intrauterin mü- outpatient follow-up upon the reduced creatinine levels. dahalenin sa¤kal›m› art›r›c› etkisi dikkate al›narak gebeli¤in deva- Conclusion: By taking the survival enhancing effect of the intrauter- m›n› isteyen olgularda seçenek olabilece¤i olabilece¤ini düflünüyo- ine intervention into account in the presence of lower urinary tract ruz. Aile obstrüksiyonun düzeltilmesine yönelik intrauterin müda- obstruction, we considered that intrauterine intervention can be an halenin fayda ve riskleri hakk›nda ayr›nt›l› bilgilendirilmelidir. option in the cases who prefer to continue their pregnancies. The families should be informed in detail about the benefits and risks of intrauterine intervention to repair the obstruction. Keywords: Posterior urethral valve, lower urinary tract obstruc- Anahtar sözcükler: Posterior üretral valv, alt üriner sistem obstrük- tion, fetoscopic laser ablation. siyonu, fetoskopik lazer ablasyon. Introduction also one of the most common reasons for renal failure Lower urinary tract obstruction (LUTO) which may be associated with severe bilateral hydroureteronephrosis [1,2] an important reason for fetal morbidity and mortality by and renal dysplasia in infants and children. Its inci- leading to oligohydramnios and pulmonary hypoplasia is dence is 2.2 per 10,000 live births, and 62% of the cases Correspondence: Serdar Kaya, MD. Perinatology Division, Department of Obstetrics and Gynecology, Ba¤c›lar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. e-mail: [email protected] / Received: May 28, 2020; Accepted: July 24, 2020 Please cite this article as: Kumru S, Kaya S. Fetoscopic laser valve ablation in the posterior urethral valve case with intrauterine diagnosis. Perinatal Journal 2020;28(3):206–211. doi:10.2399/prn.20.0283004 ORCID ID: S. Kumru 0000-0001-6615-7666; S. Kaya 0000-0002-4092-7316 Fetoscopic laser valve ablation in the posterior urethral valve case with intrauterine diagnosis [2] are diagnosed prenatally. LUTO can also be defined as Table 1. Fetal urinalysis results and prognostic criteria of the case. the bladder outlet obstruction. While posterior urethral valve (PUV) (68%), urethral atresia (28%) and urethral Analysis Good Poor results prognosis[5] prognosis[5] stenosis (10%) are the most common reasons for Sodium 106 mEq/L <90 mEq/L >100 mEq/L LUTO, anterior urethral valve, ureterocele and mega- Chlorine 90 mEq/L <80 mEq/L >90 mEq/L loureter are the rare reasons for LUTO. It was reported Calcium 9 mg/dL <7 mg/dL >8 mg/dL that the anomaly blocking the urinary flow in PUV is the Osmolality 219 mOsm/L <180 mOsm/L >200 mOsm/L “congenital obstructive urethral membrane” which β2-microglobulin 15 mg/L <6 mg/L >10 mg/L [1] develops during the embryonic period. Independent Total protein 129 mg/dL <20 mg/dL >40 mg/dL from the etiology, the distal obstruction of the urinary tract causes urinary flow to decrease and leads to urinary congestion proximal to the lesion. In the selected cases among PUV cases, vesicoamniotic shunting and fetal repair current renal damage, but that it may increase the cystoscopy were offered as the procedure options to survival rate by providing improvement in the fluid of decrease fetal mortality and morbidity, and it was sug- the baby. As the family wanted to continue the pregnan- gested that the procedure decreased fetal mortality and cy and requested the procedure to increase the survival limited or repaired renal damage.[3,4] In the current rate, it was decided to perform percutaneous fetoscopic report, we aimed to present a PUV case that we per- laser ablation at 27 weeks of gestation. After the mater- formed percutaneous fetoscopic laser ablation. nal epidural anesthesia, fentanyl (15 μg/kg) and pancuro- nium (2 mg/kg) were administered to provide fetal anes- thesia and inactivity.[6] After performing appropriate Case Report maternal abdominal skin incision, surgical sheath with A 21-year-old patient, who was pregnant for the first 3.3 mm curve (11540 KEK, Karlz Storz, Tuttlingen, time and did not undergo routine gestational follow-ups Germany) was inserted via ultrasonographic guidance and was referred to our clinic at 25 weeks of gestation and fetal bladder was entered on craniocaudal direction. when fetal pyelectasis was found at 24 weeks of gestation, Ureteral orifices, trabeculation on the bladder wall and was evaluated. Oligo/anhydramnios, dilated fetal blad- bladder neck were displayed (Supplementary material: der, increased wall thickness and keyhole sign were S-Video 1. The laser ablation procedure and imaging dilated found in the ultrasonography examination (Fig. 1). The posterior urethra). After the dilated posterior urethra was right renal pelvis was 23 mm and the left renal pelvis was found, Nd-YAG laser ablation (neodymium-yttrium- 31 mm, and it was observed that there was advanced aluminum-garnet) was performed on the membranous pelvicalyceal dilatation and renal parenchyma got thin- ner (bilateral hydronephrosis) and hyperechogenic. It was considered that the condition was consistent with PUV. It was found in the urinalysis results obtained by two vesico syntheses conducted with 48-hour interval that the prognosis was poor[5] (Table 1). The amniocen- tesis was performed due to the increased chromosomal disorders in the lower urinary tract obstructions and the chromosomal analysis result was reported as normal karyotype. The family was informed about LUTO, oligo/anhydramnios and potential complications (renal damage, pulmonary hypoplasia, perinatal mortality, structural deformity, preterm labor). They were informed about conservative approach, gestational ter- mination and intrauterine procedure and the options were offered. It was reported that the intervention was not a routine procedure in such a case and it will not Fig. 1. Dilated bladder and posterior urethra. Volume 28 | Issue 3 | December 2020 207 Kumru S, Kaya S formation considered to cause obstruction in this area nios and sometimes anhydramnios are the other ultra- and to be posterior urethral valve, and urethral passage sonographic findings.[1] The sensitivity and specificity of was ensured (Supplementary material: S-Video 2. The ultrasonography in the diagnosis of LUTO are 85% ablation of obstructive membrane by laser). It was observed and 80%, respectively.[9] The obstruction in the urinary that the bladder became smaller and amniotic fluid flow prevents urine to reach amniotic cavity and causes increased after the procedure, and the procedure was oligo/anhydramnios. Amniotic fluid has a significant completed without any complication. While amniotic role in the development of lungs being particularly fluid was within normal limits during entire pregnancy explicit in the canalicular phase between 16 and 28 according to the follow-ups after the procedure, the weeks of gestation.[1] The pulmonary hypoplasia associ- diameters of bladder and renal pelvis reduced and no fur- ated with anhydramnios is the most important compli- ther problem occurred. When it was 39 weeks and 2 cation developing due to the loss of urinary flow days, a male fetus with a weight of 3270 and 9/10 Apgar towards amniotic cavity, and it was reported that the score was delivered. The newborn without any respira- oligohydramnios which develops in pregnancies before tory distress was hospitalized at the neonatology clinic 25 weeks of gestation and takes more than 2 weeks has [10] with the diagnosis of stage 2 kidney failure[7] upon the higher mortality.
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