Fetal hydrolaparoscopy and endoscopic cystotomy in complicated cases of lower urinary tract obstruction

OBJECTIVE: Vesicoamniotic shunting may be difficult or impossible in select ed cases of fetal lower obstructive uropathy. The purpose of this article i s to describe the performance of fetal hydrolaparoscopy and endoscopic feta l cystotomy in two fetuses with complicated lower obstructive uropathy. STUDY DESIGN: Fetal hydrolaparoscopy-endoscopic fetal cystotomy was perform ed in a patient with a markedly thickened bladder that could not be entered percutaneously. A peritoneoamniotic (bridge) shunt was also placed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a second patie nt with a collapsed bladder from a previous vesicocentesis, because vesicoi nfusion resulted in further ascites. Fetal cystoscopy was performed after e ndoscopic fetal cystotomy, and posterior urethral valves were ablated with neodymium:yttrium-aluminum-garnet laser energy. A vesicoamniotic shunt was left in place. RESULTS: Adequate bladder drainage was obtained in both cases. The first ba by required bilateral nephrotomy and a permanent cystotomy at birth and is scheduled for a bladder expansion procedure at the age of 1 year. The secon d patient had premature rupture of membranes and fetal death from treatment of this complication 5 days after the original procedure. CONCLUSION: Fetal hydrolaparoscopy-endoscopic fetal cystotomy can be perfor med in complicated cases of lower obstructive uropathy. The procedure invol ves the creation of a defect in the bladder dome under direct endoscopic vi sualization within a spontaneous or intentional hydroperitoneum. Peritoneoa mniotic shunting, vesicoamniotic shunting, or ablation of posterior urethra l valves may then be performed. Fetal hydrolaparoscopy-endoscopic fetal cys totomy should be reserved only for complicated cases of lower obstructive u ropathy in which conventional vesicoamniotic shunting is not safely possibl e. Further experience with fetal hydrolaparoscopy-endoscopic fetal cystotom y is necessary to establish its risks and benefits.