In utero endoscopic treatment of posterior urethral valves: Preliminary experience

Fetal cystoscopy was performed in nine fetuses with sonographic evidence of lower urinary tract obstruction and normal urinary electrolytes. Posterior urethral valves (PUV) were thought to be present in all cases. Endoscopic fulguration of the valves was performed with YAG-laser energy or electrosurgery using an operating 2.4-mm endoscope. Urethral patency was documented with vesicoinfusion and color Doppler by noting passage of fluid from the fetal bladder into the amniotic cavity. A vesicoamniotic shunt was not typically placed at this setting. Three of nine cases did not have PUV: one fetus had urethral atresia, another had ambiguous genitalia and the third had anal atresia, rectovesical fistula and anterior obstruction. Six of nine cases were confirmed postnatally to have had PUV and urethral patency was documented in four of these six cases (66%). The amniotic fluid volume recovered spontaneously in three of these four cases and was maintained postoperatively. The urethra was not clinically patent in the remaining two cases, but pathological confirmation could not be obtained. Three of nine fetuses survived the neonatal period: two with PUV and the one with urethral atresia. All three babies died of unrelated complications. Two of nine fetuses had failed a pre-cystoscopy shunt. A post-cystoscopy shunt also failed in an additional fetus. While there are no long-term survivors in this series, our early experience shows that urethral patency can be achieved in utero with preservation of renal function and pulmonary development. Further experience is required to improve the diagnosis of PUV and to develop a better technique for eliminating the obstruction.