Early diagnosis and intervention in congenital lower urinary tract obstruction: time to revise our approach?

Congenital lower urinary tract obstruction (cLUTO) describes a heterogeneous spectrum of congenital lower urinary tract defects with variable postnatal outcomes, ranging from high morbidity and mortality to spontaneous resolution. In the past, fetal intervention studies aimed at mitigating the disease sequelae of cLUTO have yielded inconclusive results, which contributed to the current heterogeneous antenatal management of fetuses with cLUTO across fetal surgery centers. The recent development of first-trimester diagnostics and early vesico-amniotic shunting (VAS) (i.e., < 17 weeks of gestation) in Germany to decompress the urinary tract and preserve amniotic fluid volume throughout pregnancy has added another dimension to this heterogeneity, as retrospective studies suggest a potential benefit of this procedure for overall survival as well as postnatal pulmonary and kidney function. Despite these promising results, many questions remain unanswered before early VAS can be implemented as a standard antenatal treatment for cLUTO. These questions need to be addressed by large-scale, multidisciplinary prospective studies, which are difficult to conduct for various reasons. Here, we describe the current state of the art in cLUTO management, providing a multidisciplinary perspective that includes risks and benefits of early fetal medicine approaches in the clinical management of affected newborns. Furthermore, we outline future directions to overcome challenges in optimizing our approach to improve outcomes for children with cLUTO.