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Mark D Kilby - One of the best experts on this subject based on the ideXlab platform.
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an overview of the literature on congenital lower Urinary Tract Obstruction and introduction to the pluto trial percutaneous shunting in lower Urinary Tract Obstruction
Australian & New Zealand Journal of Obstetrics & Gynaecology, 2009Co-Authors: Katie R Morris, Mark D KilbyAbstract:Congenital lower Urinary Tract Obstruction (LUTO) comprises a heterogeneous group of pathologies causing Obstruction to the urethra, the most common being posterior urethral valves. Such pathology is often associated with high perinatal mortality and varying degrees of perinatal and infant morbidity. A high proportion of LUTO may be visualised during routine second trimester (and first trimester) ultrasound giving rise to the possibility of determining individual fetal prognosis and treatments such as vesico-amniotic shunting, with a view to altering pathogenesis. The aims of the percutaneous shunting in low Urinary Tract Obstruction (PLUTO) trial are to determine the effectiveness of these treatments and accuracy of the investigations with the primary outcome measures being perinatal mortality and postnatal renal function.
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fetal lower Urinary Tract Obstruction
Seminars in Fetal & Neonatal Medicine, 2007Co-Authors: David Lissauer, R K Morris, Mark D KilbyAbstract:Summary Fetal lower Urinary Tract Obstruction affects 2.2 per 10 000 births. It is a consequence of a range of pathological processes, most commonly posterior urethral valves (64%) or urethral atresia (39%). It is a condition of high mortality and morbidity associated with progressive renal dysfunction and oligohydramnios, and hence fetal pulmonary hypoplasia. Accurate detection is possible via ultrasound, but the underlying pathology is often unknown. In future, magnetic resonance imaging (MRI) may be increasingly used alongside ultrasound in the diagnosis and assessment of fetuses with lower Urinary Tract Obstruction. Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear. It is now possible to decompress the Obstruction in utero via percutaneous vesico-amniotic shunting or cystoscopic techniques. In appropriately selected fetuses intervention may improve perinatal survival, but long-term renal morbidity amongst survivors remains problematic.
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Congenital Urinary Tract Obstruction
Best Practice & Research in Clinical Obstetrics & Gynaecology, 2007Co-Authors: R K Morris, Mark D KilbyAbstract:Congenital Urinary Tract Obstruction is a heterogenous condition with a varying natural history. Accurate diagnosis within the late-first and second trimesters allows for counselling of the parents and planning of multi-disciplinary care for the pregnancy and newborn. Antenatal investigations to predict postnatal renal function are of varying accuracy. However, some factors have been shown to be predictive of poor outcome in terms of renal function at birth and infancy. There is the possibility of in-utero intervention in these fetuses.
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vesicoamniotic shunting for fetal lower Urinary Tract Obstruction an overview
Archives of Disease in Childhood-fetal and Neonatal Edition, 2007Co-Authors: R K Morris, Khalid S Khan, Mark D KilbyAbstract:Efficacy and complications of prenatal in utero treatment Lower Urinary Tract Obstruction (LUTO) is a heterogeneous group of pathologies, most commonly urethral atresia and posterior urethral valves (PUVs)1 that accounts for one third of renal Tract anomalies detected at autopsy after termination for ultrasound-diagnosed fetal anomaly.2 The affected fetus is typically male unless associated with bladder hypoperistalsis syndromes which carry a worse prognosis. PUV accounts for about half of the cases presenting with ultrasonic features of LUTO3 in some case cohorts. In 2005, data from the Northern Region Congenital Anomaly register were reported. Over a 14-year period, 113 cases of LUTO were identified, giving an incidence of 2.2 in 10 000 births.4 The importance of LUTO in terms of perinatal outcome lies in its clinical course, with long-term urethral Obstruction being potentially associated with cystic renal dysplasia, abnormal renal (glomerular and tubular) function leading to severe oligohydramnios, pulmonary hypoplasia and positional limb anomalies.5 Animal studies have shown a causal link between the distal renal Tract Obstruction in the fetus and these abnormalities. The fetal phenotype has been variously described as the effects of potential in utero treatment. Fetal LUTO, if untreated, carries a mortality of up to 45% mainly due to the severe oligohydramnios in the mid-trimester6 being associated with pulmonary hypoplasia. Even in those that survive the neonatal period, up to one third may develop end-stage chronic renal impairment, necessitating dialysis or transplantation.7 Congenital obstructive uropathy accounts for up to 60% of all paediatric renal transplants.8 It is therefore a morbid condition, although data informing this comes from small, uncontrolled selected series. For this reason, prenatal in utero treatment has been considered in “selected” cases in an attempt to bypass the congenital Urinary Tract Obstruction, modify pathogenesis and attenuate the secondary …
Mark P Johnson - One of the best experts on this subject based on the ideXlab platform.
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fetal lower Urinary Tract Obstruction
Clinics in Perinatology, 2009Co-Authors: Serena Wu, Mark P JohnsonAbstract:The authors present an overview of the prenatal diagnosis, evaluation, contemporary intervention, and antenatal management of lower Urinary Tract Obstruction. They review early experimental models that confirmed the relation between Urinary Tract Obstruction and renal fibrocystic dysplasia and that early in utero relief of the Obstruction could prevent irreversible renal injury. Subsequent studies of the electrolyte and protein concentrations in fetal urine from human cases established prognostic threshold values and helped to develop an algorithm to select candidates for antenatal therapy. Although shunting has improved survival, long-term morbidities remain a significant challenge.
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long term outcomes in children treated by prenatal vesicoamniotic shunting for lower Urinary Tract Obstruction
Obstetrics & Gynecology, 2005Co-Authors: Jeanmarc Biard, Mark P Johnson, Michael C Carr, Douglas R Wilson, Holly L Hedrick, Christina Pavlock, Scott N AdzickAbstract:OBJECTIVE: Limited information is available about long-term outcomes in children treated prenatally for lower Urinary Tract Obstruction. Our aim was to evaluate outcomes in children treated in utero with vesicoamniotic shunts. METHODS: Clinical outcomes in 20 pregnancies with a singleton male fetus, oligo/anhydramnios, and lower Urinary Tract Obstruction were studied using chart review and phone and written clinical questionnaire for parents, pediatricians, and urologists. RESULTS: Overall 1-year survival was 91%. Two neonatal deaths occurred from pulmonary hypoplasia. Mean gestational age at delivery was 34.6 weeks, mean days from shunting to delivery were 84.4, and mean birth weight was 2,574 g. Prenatal Urinary prognosis was good in 13, borderline in 2, and poor in 3 of the survivors. Mean age at follow-up was 5.83 years. Posterior urethral valves were confirmed in 7 males, urethral atresia in 4, and prune belly syndrome in 7. Eight children had acceptable renal function, 4 had mild insufficiency, and 6 required dialysis and eventual renal transplant. Eleven children had normal bladder function with spontaneous voiding, 6 required catheterization, and 1 child still had a vesicostomy. Height and weight were below the 25th percentile in 9 children. Persistent respiratory problems were present in 8, musculoskeletal problems in 9, and frequent Urinary Tract infections were reported in 9. Health-related quality of life results in our group with lower Urinary Tract Obstruction were similar to those in a healthy child population. CONCLUSION: Male children who underwent prenatal bladder shunting were neurodevelopmentally normal. Although one third of the surviving babies required dialysis and transplantation, the majority have acceptable renal and bladder function and report satisfactory quality of life. LEVEL OF EVIDENCE: III.
R K Morris - One of the best experts on this subject based on the ideXlab platform.
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congenital lower Urinary Tract Obstruction a population based epidemiological study
British Journal of Obstetrics and Gynaecology, 2012Co-Authors: R K Morris, G L Malin, A Tonks, J GardosiAbstract:Please cite this paper as: Malin G, Tonks A, Morris R, Gardosi J, Kilby M. Congenital lower Urinary Tract Obstruction: a population-based epidemiological study. BJOG 2012;119:1455–1464. Objective To determine the prevalence and outcome of lower Urinary Tract Obstruction (LUTO), including the sensitivity of antenatal diagnosis. Design A retrospective population-based study. Setting Regional population-based congenital anomalies register (WMCAR). Population Fetuses affected by LUTO delivered between 1995 and 2007 to women resident in the West Midlands. Methods Cases were selected from the WMCAR using codes and keyword terms from the International Classification of Diseases, tenth revision (ICD10). Diagnoses were validated using additional data sets from Regional Fetal Medicine, Perinatal Pathology and Paediatric services. Main outcome measures Rates of prevalence, prenatal diagnosis and mortality, with trends. Results There were 284 LUTO cases in 851 419 births during the study period, representing a total prevalence of 3.34 (2.95–3.72) per 10 000 births, and this prevalence did not change significantly over time. The prevalence of LUTO was significantly higher in Black and minority ethnic groups when compared with white Europeans (OR 2.38; 95% CI 1.87–3.03), and are associated with area-based deprivation measures (P < 0.01). Of all LUTO cases, 221 (77.8%) were isolated, and the remainder were associated with other structural or chromosomal anomalies. The most common subtype was posterior urethral valves (PUVs; n = 179, 63%). In total there were 211 (74.3%) cases of isolated, non-female, singleton fetuses that fitted the referral criteria for in utero vesico-amniotic shunting, giving a prevalence of 2.48 (2.14–2.81) per 10 000 live births. Within this group, the prenatal diagnosis rate was 46.9% (99/211). Conclusion This is the largest population-based study of LUTO that has been performed to date, and provides accurate estimates for prevalence. The low prevalence and relatively low rate of antenatal detection limit the number of cases amenable to prenatal surgical intervention.
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systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower Urinary Tract Obstruction
British Journal of Obstetrics and Gynaecology, 2010Co-Authors: R K Morris, G L Malin, Khalid S KhanAbstract:Please cite this paper as: Morris R, Malin G, Khan K, Kilby M. Systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower Urinary Tract Obstruction. BJOG 2010;117:382–390. Background Congenital lower Urinary Tract Obstruction is associated with high mortality and morbidity. Antenatal detection has improved with advances in ultrasound technology, and has allowed the option of antenatal intervention. Objectives To systematically review the literature to evaluate the effectiveness of antenatal interventions to improve perinatal survival and postnatal renal function in congenital lower Urinary Tract Obstruction. Search strategy Extensive electronic searches (database inception 2009) using Medical Subject Headings (MeSH) and keywords, without restrictions. Reference lists of included studies were checked, and all authors were contacted. Selection criteria Studies were selected according to a predefined protocol. The included studies were observational or randomised trials, where an intervention was performed in utero to treat congenital lower Urinary Tract Obstruction, compared with another intervention or no treatment. Data collection and analysis Data were exTracted on study design, quality and results to construct 2 × 2 tables. Meta-analysis was performed where possible. Peto ORs with 95% CIs were computed. Main results Prenatal bladder drainage improved perinatal survival compared with no treatment (OR 3.86, 95% CI 2.00–7.45). This effect was amplified in a subgroup with poor predicted prognosis (OR 12.85, 95% CI 1.25–153.03). However, although treatment increases survival, it appears that the residual risk of poor long-term postnatal renal function is uncertain (OR 0.50, 95% CI 0.13–1.90). Author’s conclusions Antenatal bladder drainage appears to improve perinatal survival in cases of congenital lower Urinary Tract Obstruction, but may confer a high residual risk of poor postnatal renal function, based on observational studies. Randomised research with long-term follow up is necessary to determine the role of antenatal treatment in clinical practice.
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fetal lower Urinary Tract Obstruction
Seminars in Fetal & Neonatal Medicine, 2007Co-Authors: David Lissauer, R K Morris, Mark D KilbyAbstract:Summary Fetal lower Urinary Tract Obstruction affects 2.2 per 10 000 births. It is a consequence of a range of pathological processes, most commonly posterior urethral valves (64%) or urethral atresia (39%). It is a condition of high mortality and morbidity associated with progressive renal dysfunction and oligohydramnios, and hence fetal pulmonary hypoplasia. Accurate detection is possible via ultrasound, but the underlying pathology is often unknown. In future, magnetic resonance imaging (MRI) may be increasingly used alongside ultrasound in the diagnosis and assessment of fetuses with lower Urinary Tract Obstruction. Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear. It is now possible to decompress the Obstruction in utero via percutaneous vesico-amniotic shunting or cystoscopic techniques. In appropriately selected fetuses intervention may improve perinatal survival, but long-term renal morbidity amongst survivors remains problematic.
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Congenital Urinary Tract Obstruction
Best Practice & Research in Clinical Obstetrics & Gynaecology, 2007Co-Authors: R K Morris, Mark D KilbyAbstract:Congenital Urinary Tract Obstruction is a heterogenous condition with a varying natural history. Accurate diagnosis within the late-first and second trimesters allows for counselling of the parents and planning of multi-disciplinary care for the pregnancy and newborn. Antenatal investigations to predict postnatal renal function are of varying accuracy. However, some factors have been shown to be predictive of poor outcome in terms of renal function at birth and infancy. There is the possibility of in-utero intervention in these fetuses.
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vesicoamniotic shunting for fetal lower Urinary Tract Obstruction an overview
Archives of Disease in Childhood-fetal and Neonatal Edition, 2007Co-Authors: R K Morris, Khalid S Khan, Mark D KilbyAbstract:Efficacy and complications of prenatal in utero treatment Lower Urinary Tract Obstruction (LUTO) is a heterogeneous group of pathologies, most commonly urethral atresia and posterior urethral valves (PUVs)1 that accounts for one third of renal Tract anomalies detected at autopsy after termination for ultrasound-diagnosed fetal anomaly.2 The affected fetus is typically male unless associated with bladder hypoperistalsis syndromes which carry a worse prognosis. PUV accounts for about half of the cases presenting with ultrasonic features of LUTO3 in some case cohorts. In 2005, data from the Northern Region Congenital Anomaly register were reported. Over a 14-year period, 113 cases of LUTO were identified, giving an incidence of 2.2 in 10 000 births.4 The importance of LUTO in terms of perinatal outcome lies in its clinical course, with long-term urethral Obstruction being potentially associated with cystic renal dysplasia, abnormal renal (glomerular and tubular) function leading to severe oligohydramnios, pulmonary hypoplasia and positional limb anomalies.5 Animal studies have shown a causal link between the distal renal Tract Obstruction in the fetus and these abnormalities. The fetal phenotype has been variously described as the effects of potential in utero treatment. Fetal LUTO, if untreated, carries a mortality of up to 45% mainly due to the severe oligohydramnios in the mid-trimester6 being associated with pulmonary hypoplasia. Even in those that survive the neonatal period, up to one third may develop end-stage chronic renal impairment, necessitating dialysis or transplantation.7 Congenital obstructive uropathy accounts for up to 60% of all paediatric renal transplants.8 It is therefore a morbid condition, although data informing this comes from small, uncontrolled selected series. For this reason, prenatal in utero treatment has been considered in “selected” cases in an attempt to bypass the congenital Urinary Tract Obstruction, modify pathogenesis and attenuate the secondary …
John W Brock - One of the best experts on this subject based on the ideXlab platform.
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Current State of Fetal Intervention for Lower Urinary Tract Obstruction.
Current Urology Reports, 2018Co-Authors: Douglass B Clayton, John W BrockAbstract:In this article, we explore the origins of intervention of fetal lower Urinary Tract Obstruction, and we specifically discuss the background and recent outcomes of vesicoamniotic shunt placement and fetal cystoscopy. The article seeks to provide a comprehensive overview of the field while bringing the reader quickly up to speed on the pertinent literature and the critical data that are available to guide decision-making regarding intervention. Appropriate patient selection for fetal intervention remains challenging despite advances in prenatal imaging. Both a randomized controlled trial and multiple systematic reviews show evidence of a perinatal survival benefit following fetal intervention but rates of renal morbidity remain very high. Despite 30 years of research, fetal lower Urinary Tract Obstruction remains a difficulty entity to treat. Intervention may lead to survival, but physicians and caregivers must remain alert for the distinct possibility of long-term renal morbidity in survivors.
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lower Urinary Tract Obstruction in the fetus and neonate
Clinics in Perinatology, 2014Co-Authors: Douglass B Clayton, John W BrockAbstract:This article summarizes the most recent literature regarding congenital lower Urinary Tract Obstruction in the fetus and newborn. Lower Urinary Tract Obstruction is a heterogeneous group of rare diagnoses that have significant potential for in utero mortality and long-term morbidity in survivors. The diagnosis and management of the most common causes are reviewed. In addition, the current state of prenatal intervention for congenital lower Urinary Tract Obstruction is discussed.
Scott N Adzick - One of the best experts on this subject based on the ideXlab platform.
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long term outcomes in children treated by prenatal vesicoamniotic shunting for lower Urinary Tract Obstruction
Obstetrics & Gynecology, 2005Co-Authors: Jeanmarc Biard, Mark P Johnson, Michael C Carr, Douglas R Wilson, Holly L Hedrick, Christina Pavlock, Scott N AdzickAbstract:OBJECTIVE: Limited information is available about long-term outcomes in children treated prenatally for lower Urinary Tract Obstruction. Our aim was to evaluate outcomes in children treated in utero with vesicoamniotic shunts. METHODS: Clinical outcomes in 20 pregnancies with a singleton male fetus, oligo/anhydramnios, and lower Urinary Tract Obstruction were studied using chart review and phone and written clinical questionnaire for parents, pediatricians, and urologists. RESULTS: Overall 1-year survival was 91%. Two neonatal deaths occurred from pulmonary hypoplasia. Mean gestational age at delivery was 34.6 weeks, mean days from shunting to delivery were 84.4, and mean birth weight was 2,574 g. Prenatal Urinary prognosis was good in 13, borderline in 2, and poor in 3 of the survivors. Mean age at follow-up was 5.83 years. Posterior urethral valves were confirmed in 7 males, urethral atresia in 4, and prune belly syndrome in 7. Eight children had acceptable renal function, 4 had mild insufficiency, and 6 required dialysis and eventual renal transplant. Eleven children had normal bladder function with spontaneous voiding, 6 required catheterization, and 1 child still had a vesicostomy. Height and weight were below the 25th percentile in 9 children. Persistent respiratory problems were present in 8, musculoskeletal problems in 9, and frequent Urinary Tract infections were reported in 9. Health-related quality of life results in our group with lower Urinary Tract Obstruction were similar to those in a healthy child population. CONCLUSION: Male children who underwent prenatal bladder shunting were neurodevelopmentally normal. Although one third of the surviving babies required dialysis and transplantation, the majority have acceptable renal and bladder function and report satisfactory quality of life. LEVEL OF EVIDENCE: III.
