Introduction: Bladder outlet obstruction can have devastating consequences. Given the poor outcome, in utero intervention has been advocated in attempt to salvage pulmonary and renal function. We evaluated whether by adapting current robotic-assisted laparoscopic techniques to access the fetus in utero, laparoscopic decompression of the obstructed bladder can be performed efficiently.

Methods: At 95 days of gestation, twenty fetal sheep underwent ligation of the urethra and urachus. Two to five days later, a robotic-assisted laparoscopic vesicostomy was performed. Ultrasound (US) evaluation of the kidneys and bladder were performed before each procedure. At 135 days of gestation, the urinary tract was evaluated to assess the adequacy of the bladder decompression and the patency of the vesicostomy.

Results: After 48 hours of undergoing ligation, all fetuses had bilateral moderate hydronephrosis and a markedly distended bladder. In the first 10 fetuses, the vesicostomy could not be completed laparoscopically due to limitation in visualization. Additional modifications in trocar placement and gas infusion allowed vesicostomy to be completed laparoscopically in the last 8 fetuses in 2.5 to 4 hours. Decompression of the urinary tract and patency of the vesicostomy were observed in all of these fetuses, postoperatively.

Conclusion: We developed specific modifications in current robotic-assisted laparoscopic techniques and instrumentation to allow for the in utero treatment of bladder outlet obstruction. This procedure can be performed efficiently and may provide advantages over conventional surgeries for fetal intervention.