Cincinnati Fetal Center

  • Bladder Outlet Obstruction

    Bladder outlet obstruction (BOO) is a condition that can develop during pregnancy. It is caused by a partial or complete blockage of the urethra. The urethra is the tube that allows the bladder to empty into the amniotic space, making it possible for the baby’s urine to maintain normal amniotic fluid levels.

    If not corrected, this blockage can cause backup of urine in the baby’s bladder and kidneys, which causes the bladder to enlarge and amniotic fluid levels to decrease.

    In severe cases, the baby cannot produce enough amniotic fluid, which can lead to damage to the bladder and kidneys and underdevelopment of the lungs, a life-threatening condition.

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    Incidence of Bladder Outlet Obstruction

    Bladder outlet obstruction occurs in approximately one in 4,000 live births and is more common in males than in females. The condition is sometimes called lower urinary tract obstruction (LUTO) or obstructive uropathy. It comes in a variety of forms:

    • Urethral atresia − a complete obstruction of the urethra
    • Posterior urethral valves (PUV) − when an abnormal fold of tissue in the urethra blocks urine from flowing freely (only in males)
    • Triad syndrome − when a mid-portion of the urethra is narrowed, making it very difficult for urine to pass
    • Cloacal malformation

    Babies born with bladder outlet obstruction can experience mild to severe problems. Among the more severe are kidney failure and respiratory insufficiency, a condition in which the lungs cannot keep up with the body’s oxygen needs.

    Compassionate, Expert Care

    The Cincinnati Fetal Center offers comprehensive diagnostic tests and the latest treatments for bladder outlet obstruction. Just as important, our team of specialists takes time to explain test results, answer questions and discuss treatment options. We understand that parents are facing difficult decisions, and we provide as much support as possible every step of the way. 

    From 2004 through 2013, physicians at the Fetal Center evaluated more than 243 patients for bladder outlet obstruction. Extensive experience and expertise allow our team to treat the most complex cases.

    Evaluation and Treatment Plan

    Bladder outlet obstruction can be diagnosed using ultrasound, which can provide details about the urinary tract and the amount of amniotic fluid in the womb. Additional tools can help refine the diagnosis. They include:

    • Tests of the baby’s urine to evaluate kidney function
    • Fetal MRI to detect changes not apparent on ultrasound and to diagnose associated physical abnormalities
    • Chromosome analysis
    • Echocardiography to detect any structural heart disease 

    The Fetal Center provides testing, a definitive diagnosis and a treatment plan, all within two to three days. After diagnostic tests have been completed, patients meet with members of our multidisciplinary team, which includes:

    • Maternal-fetal medicine specialist
    • Pediatric and fetal surgeon
    • Pediatric nephrologist
    • Pediatric colorectal surgeon
    • Pediatric renal transplant surgeon
    • Pediatric urologist
    • Neonatologist
    • Genetics counselor
    • Social worker 

    Our specialists talk with the patient about what the test results mean, what treatment options might be available, and the baby’s immediate, short- and long-term prognosis. Referring physicians are welcome to participate via video teleconferencing.

    Treatment Options

    The Fetal Center offers three fetal surgical options for patients who have received a diagnosis of bladder outlet obstruction. They include fetal vesicoamniotic  shunting, fetoscopic surgery to release the bladder outlet obstruction and open fetal vesicostomy. In addition, amnioport infusion may be offered as an adjunct therapy. 

    Babies most likely to benefit from surgery are those who are at risk of kidney injury and impairment of lung development due to bladder obstruction, but have not yet experienced irreversible kidney damage.  

    Deciding which treatment option to pursue, if any, is an emotional experience. The Fetal Center offers extensive counseling to patients about the diagnostic findings and treatment options, as well as a birth plan and the baby’s long-term prognosis. Our team is dedicated to giving parents the information and time they need to understand all of the various options and make the most appropriate decision for their family.  

    Fetal Vesicoamniotic Shunting

    This is the most common operation for bladder outlet obstruction.  It involves placing a shunt to allow urine to drain from the bladder into the amniotic space. This allows urine to bypass the obstruction and improves the baby’s lung development directly. However, kidney function is not always preserved. 

    Fetoscopic Surgery

    This surgery is sometimes recommended for babies prior to 20 weeks’ gestation who have posterior urethral valve (PUV) and whose bodies have lost the ability to produce adequate urine to maintain normal amniotic fluid volume. Fetoscopic surgery, sometimes called fetoscopic cystoscopy, involves creating small surgical openings that allow placement of a fiberoptic endoscope (camera) and an instrument to cut away the tissue causing the obstruction. This relatively new innovation is limited to very few patients.  

    Open Fetal Surgery for Vesicostomy   

    This procedure is offered to a small number of carefully selected patients. Vesicostomy can correct the condition and prevent ongoing injury to the developing kidney. In fetal vesicostomy, the fetal abdomen is opened below the umbilical cord insertion. The bladder is opened and sutured to the fetal skin, allowing urine to flow properly. 

    Serial Amniotic Fluid Infusion via Amnioport   

    This therapy is sometimes recommended for patients whose baby does not produce adequate amounts of urine during fetal development. This novel therapy involves placing a port to allow repeated fluid infusion into the amniotic sac to replenish amniotic fluid throughout pregnancy as a way to support lung development. Following delivery, dialysis may be offered if indicated until a kidney transplant can occur in selected cases.

    Post-Surgery Follow-Up Care

    Patients who undergo fetal surgery for bladder outlet obstruction must be monitored very closely until their baby is born. Many return home and are followed by their local care team. Others choose to remain in the Cincinnati area until their baby is born so that they can remain under the care of physicians at the Fetal Center. 

    Following delivery, babies with bladder outlet obstruction are transferred to a neonatal intensive care unit, such as the NICU at Cincinnati Children’s. There, pediatric neonatologists, urologists and nephrologists assess the baby’s condition and consider next steps. Treatment options depend on the type of obstruction, but in the early stages can include endoscopic surgery to remove PUVs and, in some cases, dialysis. Once the baby is older, options may include reconstructive surgery on the urinary tract. In severe cases, patients may require a kidney transplant. 

    Children with bladder outlet obstruction do not always grow and develop normally. Our team begins to address this concern in the NICU by working closely with renal dietitians and families to optimize the child’s growth through nutrition. Sometimes this involves the use of a feeding tube. Children with bladder outlet obstruction also are more susceptible to kidney infections and kidney failure. Some may experience long-term breathing problems, bladder dysfunction and kidney issues. Nephrologists, pulmonologists, pediatric surgeons and urologists at Cincinnati Children’s provide highly specialized, long-term follow-up care for these children. 

    Experience and Expertise

    Physicians at the Cincinnati Fetal Center have evaluated more than 243 patients for bladder outlet obstruction. Extensive experience and expertise allow our team to treat the most complex cases.

    Fetal Therapy for BOO / PUV Volume*
    Open fetal vesicostomy  6
    Fetoscopic interventions  9
    Vesicoamniotic shunt    27

    A total of six amnioports have been performed as an adjunct therapy for BOO / PUV and other genitourinary anomalies. 

    *Feb. 1, 2004, through Sept. 30, 2013


 
  • Lower urinary tract obstruction.

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    Bladder Outlet Obstruction in Fetus

    Lower urinary tract obstruction.

    Bladder outlet obstruction can cause multiple problems, including pulmonary hypoplasia (impaired development of the lungs), renal dysplasia (abnormal development of the kidneys), kidney failure, bladder dysfunction, oligohydramnios (a deficiency of amniotic fluid) or anhydramnios (absence of amniotic fluid).

  • Open Fetal Surgery for Max

    Max's condition was very serious. He had bladder outlet obstruction caused by posterior urethral valves. His parents decided that mom Beth would undergo open fetal surgery.

    Patient Story