Urotrauma: aua guideline

https://peds.arizona.edu/sites/default/files/curriculum-files/cryptorchidismauaguideline2014_000.pdf

Evaluation and Treatment of Cryptorchidism: AUA Guideline

Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.

https://fetalmedicine.com/synced/fmf/2010_16.pdf

The making of fetal surgery.

The Factors in Successful Exstrophy Closure

Augmentation and Substitution Enterocystoplasty

Objective
To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO)

Methods
A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention

Results
Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61 Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 186 (95% CI, 101–342; P = 0048) and ARR, 173 (95% CI, 101–308; P = 004) respectively) A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 173 (95% CI, 097–308; P = 006)) but was not observed in the vesicoamniotic shunt group (ARR, 116 (95% CI, 086–155; P = 033)) In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6-month survival rate and renal function (ARR, 410 (95% CI, 175–962; P < 001) and 266 (95% CI, 125–570; P = 001) respectively) while vesicoamniotic shunting was associated only with an improvement in the 6-month survival rate (ARR, 376 (95% CI, 142–997; P < 001)) with no effect on renal function (ARR, 103 (95% CI, 049–217, P = 093))

Conclusion
Fetal cystoscopy and vesicoamniotic shunting improve the 6-month survival rate in cases of severe LUTO However, only fetal cystoscopy may prevent impairment of renal function in fetuses with posterior urethral valves Our data support the idea of performing a subsequent randomized controlled trial to compare the effectiveness of fetal cystoscopy vs vesicoamniotic shunting for severe fetal LUTO Copyright © 2014 ISUOG Published by John Wiley & Sons Ltd

Fetal intervention for severe lower urinary tract obstruction: a multicenter case–control study comparing fetal cystoscopy with vesicoamniotic shunting

Genital trauma due to animal bites

Objective

To report the experience with fetal cystoscopy and laser fulguration of posterior urethral values (PUV) for severe lower urinary tract obstruction (LUTO).



Methods

Between July 2006 and December 2008, fetal cystoscopy was offered to 23 patients whose fetuses presented with severe LUTO, favorable urinary analysis and gestational age <26 weeks. Fetal urinary biochemistry was evaluated before and after cystoscopy. All infants were followed 6–12 months after birth. Abnormal renal function was defined when serum creatinine higher than 50 µmol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred.



Results

Eleven patients decided to undergo fetal therapy and 12 elected to continue with expectant observation. There was no difference between both groups in gestation age at diagnosis and referral examinations. Urethral atresia was diagnosed in 4/11 (36.4%) fetuses by fetal cystoscopy. At 26 weeks, fetuses that were managed expectantly presented with worse urinary biochemistry results (p < 0.05). Survival rates and percentage of infants with normal renal function were significantly higher in the cystoscopic group than in the expectant group (p < 0.05).



Conclusions

Percutaneous fetal cystoscopy is feasible using a thinner special cannula for prenatal diagnosis and therapy of LUTO. Prenatal laser ablation of the PUV under cystoscopy may prevent renal function deterioration improving postnatal outcome. Copyright © 2009 John Wiley & Sons, Ltd.

Fetal cystoscopy for severe lower urinary tract obstruction—initial experience of a single center

Laparoscopic nephrectomy for wilms tumor after chemotherapy: initial experience

INTRODUCTION: Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20% of cryptorchid testicles are nonpalpable. In these cases, the videolaparoscopic technique is a useful alternative method for diagnosis and treatment. MATERIALS AND METHODS: We present data concerning 90 patients submitted to diagnostic laparoscopy for impalpable testicles. Forty-six patients (51.1%) had intra-abdominal gonads. In 25 testicles of 19 patients, we performed a two stage laparoscopic Fowler-Stephens orchiopexy. The other 27 patients underwent primary laparoscopic orchiopexy, in a total of 29 testicles. RESULTS: We obtained an overall 88% success rate with the 2 stage Fowler-Stephens approach and only 33% rate success using one stage Fowler-Stephens surgery with primary vascular ligature. There was no intraoperative complication in our group of patients. In the laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgeries. Hospital stay and convalescence were brief. CONCLUSIONS: In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the impalpable testis, which is why this technique has been routinely incorporated in our Department.

/pdf/laparoscopic-diagnosis-and-treatment-of-nonpalpable-testis-2668ok5p0k.pdf

Amilcar Martins Giron

Papers

Fetal intervention for severe lower urinary tract obstruction: a multicenter case–control study comparing fetal cystoscopy with vesicoamniotic shunting

Genital trauma due to animal bites

Fetal cystoscopy for severe lower urinary tract obstruction—initial experience of a single center

Laparoscopic nephrectomy for wilms tumor after chemotherapy: initial experience

Laparoscopic diagnosis and treatment of nonpalpable testis.