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Advances in prenatal diagnosis including improvements in ultrasonography have revealed the natural history of fetal sacrococcygeal teratomas, and this natural history differs substantially from that for postnatally diagnosed sacrococcygeal teratoma. A fetal sacrococcygeal teratoma may lead to perinatal morbidity and mortality by a variety of mechanisms. Adverse clinical sequelae of a sacrococcygeal teratoma can be prevented by accurate prenatal assessment and appropriate obstetrical and perinatal management. Development of fetal hydrops and/or placentomegaly predicts fetal demise. Fetal surgical intervention has proven successful in highly selected cases.

The increasing use of routine prenatal imaging and diagnosis has provided a better understanding of the natural history of obstructive uropathy. Fortunately, most disorders portend little clinical significance prenatally, although a select subset can incur irreversible renal injury and pulmonary hypoplasia depending on the onset, duration, severity, and level of obstruction. In these cases, timely antenatal evaluation and prenatal intervention can provide an optimal postnatal outcome. The natural history, evaluation, and management of fetal obstructive uropathies are discussed.

There are a growing number and variety of fetal disorders that may benefit from intervention prior to birth. Despite the diversity, there are common pathophysiologic denominators or patterns that tie together many seemingly disparate disorders. The purpose of this article was not to review disorders presented in other, accompanying articles but, rather, to present pathophysiologic patterns that common influence fetal surgery within a cohesive framework.

The impetus for the development of minimal access techniques for fetal surgery was the unusual occurrence with open hysterotomy of preterm labor, premature rupture of membranes, and the maternal complications resulting from tocolytic therapy. This strategy involves a constellation of techniques that allow surgical procedures to be performed inside the uterus without a hysterotomy. The unique requirements of this approach necessitated modifications of existing endoscopic techniques, development of novel fetoscopic instruments, and utilization of the expertise of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life-threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel techniques, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of intervention.

Most prenatally diagnosed lung lesions can be managed successfully during the neonatal period. Prenatal imaging and experimental models have provided a comprehensive understanding of the pathophysiology, natural history, and prognosis of intrathoracic and mediastinal lesions. Clinical experience has demonstrated that progression to nonimmune hydrops fetalis and pulmonary hypoplasia is a harbinger of fetal or neonatal demise. Advances in fetal anesthesia, tocolysis, and surgical techniques have made fetal surgery a viable in utero option to ameliorate life-threatening masses. Congenital cystic adenomatoid malformation, bronchopulmonary sequestration, and congenital hydrothorax are the most common abnormalities amenable to surgical intervention. The natural history, evaluation, and treatment of intrathoracic and mediastinal lesions are discussed.