Congenital obstructive uropathy is a relatively common developmental malformation, and severely affected fetuses die soon after birth from oligohydramnios-induced pulmonary hypoplasia or renal failure. Prenatal ultrasonography can reliably diagnose the specific anatomic defect, and using fetal urine sampling we can determine the extent of renal damage in utero with reasonable certainty. With these diagnostic tools and an understanding of the natural history of congenital obstructive uropathy we can now make rational decisions regarding treatment. Clinical experience has demonstrated that the selected fetus may benefit from in utero decompression, either by percutaneous shunt placement or open fetal surgery. However, each of these procedures has certain risks that must be carefully weighed against the expected benefits. Future techniques using fetoscopic surgery may provide the ideal therapeutic approach.