ANAHEIM, CA (UroToday.com) - The first lecture of the day was presented by Katherine D. Wenstrom, MD, Professor of Maternal Fetal Medicine from Vanderbilt University Medical Center. It was entitled "Prenatal Diagnosis: Neural Tube Defects and Genitourinary Anomalies." She stated that the most common birth defects are hypospadias and genitourinary (GU) obstructions. Birth defects associated with the highest mortality are renal agenesis and congenital diaphragmatic hernia. More than $200 million dollars are spent on gastroschesis and GU obstruction alone.

From 1970 to 1987, bilateral and unilateral renal agenesis rates remained constant. Obstruction steadily increased, while dysgenesis increased by 10 fold. Maternal cocaine use increased the maternal fetal factor for GU abnormalities by 5 fold. From 1984 to 2002, 6725 pyeloplasties and 1033 endopyelotomies were performed. For patients under a year of age, the there was an increase in the diagnosis of obstruction from 94 to 156/100000 live births.

Dr. Wenstrom stated that prenatal diagnosis prepares the family, health care providers, and rarely prenatal therapy or choice of termination. The prenatal diagnostic modalities available to day include ultrasound; MRI; chorioniv villus sampling (Placenta); vesicocentesis (karyotype and chemistry sampling; and amniocentesis. The accuracy of prenatal diagnosis is poor. Ultrasound misses the diagnosis 20% of the time. However, neural tube defects are diagnosed 98% of the time by ultrasound alone, 90% by MSAFP alone, and 100% by both. The RADIUS study was a prospective randomized trial of 15,935 low risk pregnant women who underwent antenatal screening. The following table shows the results:

The take home message is that a multidisciplinary team is crucial to the care of the fetus. "Evaluate the fetus from head to toe, literally," was the quote of the day. Dr. Brock from Vanderbilt asked if there was connection between Down's Syndrome and hydronephrosis. The answer was that a large number of Down's Syndrome babies have hydronephrosis, but the correlation between hydronephrosis and predicting Down Syndrome is the rarity rather than the rule.

The next lecture entitled, "Assessment of Neural tube defects in fetuses: accuracy of imaging," was given by Dr. Stuart Bauer from the Boston Children's Hospital, Boston, Massachusetts. He stated that there is good correlation of postnatal findings to prenatal imaging. In cases of neural tube defects in relation to the bladder function, post natal urodynamics do not correlate with prenatal imaging. Prenatal evaluation does not predict the risk for deterioration in infants with myelomeningocele (MMC). He emphasized that we need post natal urodynamics. He finds that high level MMC have an upper motor neuron type of urodynamic finding, and interestingly so does the lower defect! He ends by stating ultrasound is equivalent to MRI, so why get the MRI?

The last lecture of the day entitled, "MOMS Trial: The workings of a multidisciplinary Trial" was given by John W. Brock, III, MD from Vanderbilt University. He summarized 11 steps to a successful trial. The steps are as follows:

• 1. Hypothesis
• 2. Preliminary data with animal studies
• 3. Human study/feasibility
• 4. Collaborative efforts
• 5. Goals of trial: teams, aims, proposal of grant
• 6. Study Design
• 7. Inclusion/exclusion criteria
• 8. Individual center study design (IRB, ethics, personnel)
• 9. Centralized vs. noncentralized (consistent counseling for informed consent)
• 10. Randomization pathways
• 11. Trial addendums/supplements - change may be needed but primary project must not be interrupted.

Case presentations followed with the award for best case presentation going to "Anencephalic Renal Donor Transplantation to a monoamniotic Monochorionic twin with Bilateral Renal Agenesis," by Cofer et al. Congratulations to all the participants for a job well done.

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Written by Pasquale Casale, MD, a Contributing Editor with UroToday.

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