ABSTRACT

Since its inception in the early 1980s, fetal surgery has undergone many changes. Early fetal surgery for bilateral hydronephrosis was primarily undertaken to prevent pulmonary hypoplasia. Hysterostomy at that time was utilized for fetal urinary diversion if the expected time to lung maturity was greater than 2-3 weeks.1 Evolving technology has allowed earlier diagnosis and less invasive ways of achieving fetal urinary diversion in pregnancies complicated by oligo-or anhydramnios. With the invention of more stable types of double pigtail shunts (Rocket Medical, Watford, England, Cook Urological, Indiana, USA), vesicoamniotic shunting has become more stable with fewer shunts becoming dislodged or removed. Shunting has proven useful in preserving amniotic fluid levels thereby allowing fetal pulmonary maturation, as demonstrated in outcomes with early efforts at urinary diversion.1 Outcomes in respect to preserving or improving renal or bladder function remain

controversial. The number of shunts dislodged is still a concern and the need for replacement is common despite advances in technology. Fetal cystoscopy is an evolving technique that may prove useful in diagnosis and management of obstructive lower urinary tract pathology in the fetus. The indications are similar to those for vesicoamniotic shunting and it has been used with success in experienced centers (Figure 25.1).