ENDOUROLOGY & LAPAROSCOPY

Laparoscopic transuterine fetal vesicostomy: a feasibility study
Ponsky LE, Cherullo EE, Banks KL, Ross JH
From the Section of Laparoscopic and Minimally Invasive Surgery and Pediatric Urology, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
J Urol. 2004; 172 (6 Pt 1): 2391-4

• Purpose: We evaluate the feasibility of applying minimally invasive techniques for fetal vesicostomy. We also evaluate whether transuterine fetal vesicostomy can be performed laparoscopically.
• Materials and Methods: A total of 25 pregnant ewes were time dated at approximately 90 days of gestation. With the animals under general anesthesia a low open abdominal incision was made and the uterus was brought out through the incision. With a 14 gauge needle the amniotic sac was filled with 1 to 2 L warm glycine. Three to 4, 5/12 blunt tip balloon trocars were placed in the uterus. Using laparoscopic techniques, a low transverse incision was made in the fetal abdomen, the bladder was opened at the dome and 2 running sutures were placed approximating the fetal abdominal wall to the edge of the fetal bladder. The trocar sites in the uterus were closed, and the maternal abdominal incision was closed.
• Results: Of the 25 pregnant ewes the technique was developed in the initial 15. In the subsequent 10 animals the complete procedure was accomplished successfully. Following these 10 procedures 5 abortions occurred on postoperative day 2, and there was 1 intrauterine fetal demise. Three fetuses were alive and delivered by cesarean section on postoperative days 10, 30 and 31. In the first fetus in which we used an interrupted suture for the vesicostomy a large hernia was noted at the vesicostomy site. The other 2 fetuses had a patent, well healed vesicostomy and were alive at cesarean section delivery on postoperative days 10 and 31. The last fetus was allowed to deliver at term by standard vaginal delivery. The fetus was alive and well, and the vesicostomy had strictured down to a pinhole in size, which was not unexpected as it was not an obstructed model.
• Conclusions: Although technically challenging, transuterine laparoscopic fetal vesicostomy is technically feasible in the ewe model. Continued evaluation of this technique should include intensive fetal monitoring and the use of tocolytics to decrease the incidence of spontaneous abortion.
  
  
• Editorial Comment
  Fetal bilateral hydronephrosis with oligohydramnios is an indication for evaluation and potential fetal intervention. Currently, when fetal lungs are immature with good renal function, vesical decompression can be performed in utero percutaneously with the placement of a shunt (stent) but the results are suboptimal due to malfunction of the stents often requiring manipulation or replacement.
  The authors studied the feasibility of laparoscopic technique to perform transuterine fetal vesicostomy using an animal model.
  Interesting technical aspects should be noted; i.e., the exchange of the amniotic fluid with warm glycine to optimize visualization and cauterization, the use of blunt tip balloon trocar to prevent fluid leakage through port sites and closure of port sites with endoscopic gastrointestinal anastomosis staplers. Clearly, the development of this technique required several steps including a significant number of animals culminating with 1 strictured and 2 well healed patent vesicostomies. The authors should be congratulated for the well designed and pioneering study.

Dr. Fernando J. Kim
Assistant Professor of Urology
University of Colorado Health Sciences Center
Denver, Colorado, USA