Open Fetal Vesicostomy for Posterior Urethral Valves
An ultrasound revealed that the child, at 20 weeks’ gestation, Meg Brinker was carrying had a distended bladder and accompanying oligohydramnios. Assuming her child, Adin, had an obstruction, Meg’s doctors referred her to the Cincinnati Children's Fetal Care Center.
William Polzin, MD, associate director of the Fetal Care Center, performed a series of diagnostic tests including ultrasonography and bladder taps, as well as an MRI, which revealed posterior urethral valves (PUVs). PUVs are found only in males and have an incidence of one in 5,000 births. The mortality rate in these patients has been reported to be as high as 63 percent, but 100 percent when it is associated with severe oligohydramnios owing to pulmonary hypoplasia.
Because oligohydramnios occurring before 24 weeks of gestation profoundly affects fetal lung development, doctors from the Fetal Care Center, including Polzin, Timothy Crombleholme, MD, Foong-Yen Lim, MD, and Pramod P. Reddy, MD, determined intervention was necessary and met with Meg and her husband, Ray, to outline the treatment options. With the counseling of the fetal team, Meg and Ray opted for open fetal surgery and fetal vesicostomy (sewing the bladder open on the baby’s lower abdomen) rather than a shunting procedure to increase the likelihood of preserving Adin’s kidney function.
While vesicoamniotic bladder shunts have become the standard approach in this problem, recent evidence shows that these children develop renal failure leading to dialysis and kidney transplantation as toddlers. Open fetal vesicostomy is the most definitive way to decompress the urinary tract obstructed by PUV and prevent ongoing damage to the developing kidney. On April 5, 2007, Crombleholme, Reddy, Polzin and Lim performed a fetal vesicostomy by open fetal surgery on Adin, who was at 22 weeks' gestation. The procedure successfully restored amniotic fluid dynamics and enabled him to have a little over six more weeks of prenatal development.
Adin was born early on May 19, 2007, at 29 weeks, weighing in at 2 pounds, 9 ounces, with normally functioning lungs and kidneys as a result of the fetal surgery. On July 12, when he had reached 6 pounds, Adin underwent treatment of his posterior urethral valves allowing takedown of the vesicostomy. He was able to go home two weeks later, just two months after his birth. He now has normal kidney and bladder function, and Meg reports that, at 5 months, Adin weighs a little over 10 pounds, is eating well and continues to thrive.
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