F Fontanella1, P N Adama van Scheltema2, L Duin1, T E Cohen-Overbeek3, E Pajkrt4, M N Bekker5,6, C Willekes7, D Oepkes2, C M Bilardo1,8. 1. Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 2. Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands. 3. Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands. 4. Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands. 5. Department of Obstetrics, Gynecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands. 6. Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands. 7. Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands. 8. Department of Obstetrics, Gynecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands.
Abstract
OBJECTIVE: To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS: This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS: In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS: Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis.
OBJECTIVE: To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS: This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS: In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS: Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis.
Authors: Valentina Capone; Nicola Persico; Alfredo Berrettini; Stèphane Decramer; Erika Adalgisa De Marco; Diego De Palma; Alessandra Familiari; Wout Feitz; Maria Herthelius; Vytis Kazlauskas; Max Liebau; Gianantonio Manzoni; Michal Maternik; Giovanni Mosiello; Joost Peter Schanstra; Johan Vande Walle; Elke Wühl; Elisa Ylinen; Aleksandra Zurowska; Franz Schaefer; Giovanni Montini Journal: Nat Rev Urol Date: 2022-02-08 Impact factor: 16.430