<b><i>Objectives:</i></b> The aim of the study was to describe the feasibility of open fetal microneurosurgery for intrauterine spina bifida (SB) repair and to compare perinatal outcomes with cases managed using the classic open fetal surgery technique. <b><i>Methods:</i></b> In this study, we selected a cohort of consecutive fetuses with isolated open SB referred to our fetal surgery center in Queretaro, Mexico, during a 3.5-year period (2016–2020). SB repair was performed by either classic open surgery (6- to 8-cm hysterotomy with leakage of amniotic fluid, which was replaced before uterine closure) or open microneurosurgery, which is a novel technique characterized by a 15- to 20-mm hysterotomy diameter, reduced fetal manipulation by fixing the fetal back, and maintenance of normal amniotic fluid and uterine volume during the whole surgery. Perinatal outcomes of cases operated with the classic open fetal surgery technique and open microneurosurgery were compared. <b><i>Results:</i></b> Intrauterine SB repair with a complete 3-layer correction was successfully performed in 60 cases either by classic open fetal surgery (<i>n</i> = 13) or open microneurosurgery (<i>n</i> = 47). No significant differences were observed in gestational age (GA) at fetal intervention (25.4 vs. 25.1 weeks, <i>p</i> = 0.38) or surgical times (107 vs. 120 min, <i>p</i> = 0.15) between both groups. The group with open microneurosurgery showed a significantly lower rate of oligohydramnios (0 vs. 15.4%, <i>p</i> = 0.01), preterm rupture of the membranes (19.0 vs. 53.8%, <i>p</i> = 0.01), higher GA at birth (35.1 vs. 32.7 weeks, <i>p</i> = 0.03), lower rate of preterm delivery &#x3c;34 weeks (21.4 vs. 61.5%, <i>p</i> = 0.01), and lower rate of perinatal death (4.8 vs. 23.1%, <i>p</i> = 0.04) than the group with classic open surgery. During infant follow-up, the rate of hydrocephalus requiring ventriculoperitoneal shunting was similar between both groups (7.5 vs. 20%, <i>p</i> = 0.24). All patients showed an intact hysterotomy site at delivery. <b><i>Conclusion:</i></b> Intrauterine spina repair by open fetal microneurosurgery is feasible and was associated with better perinatal outcomes than classic open fetal surgery.

This study on fetuses with isolated left-sided congenital diaphragmatic hernia (CDH) and severe pulmonary hypoplasia provides evidence that fetal endoscopic tracheal occlusion may be of benefit in improving neonatal survival in settings with neonatal intensive care limitations, such as unavailability and/or inexperience in the use of extracorporeal membrane oxygenation therapy, and thus a high neonatal mortality rate. What are the clinical implications of this work? The outcomes reported in this study may be of interest to centers in which termination of pregnancy is illegal and neonatal management is considered suboptimal, as they demonstrate that fetal intervention in experienced fetal surgery centers represents an improvement in neonatal survival for fetuses with isolated severe left-sided CDH.

ObjectiveTo describe changes in fetal Doppler parameters during a novel technique for open fetal microneurosurgery for open spina bifida (OSB) repair. MethodsThis was a prospective study of 44 fetuses undergoing open fetal surgery for OSB repair using a novel microneurosurgery approach that is characterized by a mini‐hysterotomy (diameter of 15 mm), minimal fetal manipulation and maintenance of a constant normal amniotic fluid volume throughout the procedure. Doppler velocimetry of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) was performed before the start of surgery and at prespecified timepoints during fetal surgery. UA pulsatility index (PI) > 95th percentile, DV‐PI > 95th percentile, MCA‐PI < 5th percentile and cerebroplacental ratio (CPR) < 5th percentile were considered abnormal. ResultsMedian gestational age at fetal surgery was 25.2 weeks (range, 22.9–27.9 weeks). Doppler recordings were successfully obtained in all cases during all timepoints throughout the surgery. As compared with Doppler values before surgery, there was a significant increase in the proportion of fetuses with MCA‐PI < 5th percentile (63.6% vs 13.6%; P < 0.001), CPR < 5th percentile (65.9% vs 15.9%; P < 0.001) and DV‐PI > 95th percentile (22.7% vs 0%; P = 0.01) and a non‐significant increase in the proportion of fetuses with UA‐PI > 95th percentile (11.4% vs 0%; P = 0.12) during fetal surgery. None of the fetuses showed absent or reversed end‐diastolic velocity in the UA or absent or reversed DV a‐wave at any stage during OSB repair. All abnormal Doppler parameters returned to normal after surgery. ConclusionsDuring open fetal surgery for OSB repair, a small hysterotomy, reduced fetal manipulation and maintenance of a normal amniotic fluid volume seem to prevent severe fetal Doppler abnormalities. The mild Doppler changes observed during fetal surgery could be a manifestation of fetal adaptation to the stress of fetal surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Objective: To assess the effect of Fetal Endoscopic Tracheal Occlusion (FETO) on neonatal survival in fetuses with left congenital diaphragmatic hernia (CDH) and moderate lung hypoplasia.Study Design: CDH fetuses with moderate pulmonary hypoplasia (observed/ expected lung area to head ratio between 26% and 35%, or between 36% and 45% with liver herniation) were prospectively recruited. Included patients were matched to a control group who were ineligible for FETO. Primary outcomes were survival at 28 days, at discharge, and at 6 months of age, respectively.Results: 58 cases were recruited, 29 treated with FETO and 29 matched controls.Median gestational age (GA) at balloon placement and removal were 29.6 and 33.6 weeks, respectively. FETO group showed significantly lower GA at delivery (35.2 vs. 37.1 weeks, respectively, p < 0.01), higher survival at 28 days (51.7 vs. 24.1%, respectively, p = 0.03), at discharge (48.3 vs. 24.1%, respectively, p = 0.06), and at six months of age (41.4 vs. 24.1%, respectively, p = 0.16), and significantly lower length of ventilatory support (17.8 vs. 32.3 days, p = 0.01) and NICU stay (34.2 vs. 58.3 days, p = <0.01) compared to controls. Conclusion:FETO was associated with a non-significant increase in survival and significantly lower neonatal respiratory morbidity among CDH fetuses with moderate lung hypoplasia. Key PointsWhat's already known about this topic? � Fetal endoscopic tracheal occlusion (FETO) has shown an improvement on neonatal survival in fetuses with severe lung hypoplasia.� Fetuses with congenital diaphragmatic hernia and moderate lung hypoplasia, that is those with O/E-LHR between 26% and 35% or between 36% and 45% and liver herniation, are associated with survival rates around 50%.

Background To describe the perinatal outcomes of fetoscopic urethral meatotomy (FUM) in fetuses with lower urinary tract obstruction (LUTO) by congenital megalourethra. Study design Between 2012 and 2020, 226 cases with LUTO were referred to our fetal surgery center in Queretaro, Mexico. We report the perinatal outcome of cases with LUTO by congenital megalourethra that were selected for FUM in an attempt to release the penile urethral obstruction. Results Congenital megalourethra was diagnosed in 10 cases (4.4%) but only 3 cases (30%) with obstructive megalourethra and megacystis were selected for fetal surgery. Fetoscopic urethral metatotomy was successfully performed in all three cases at a median gestational age (GA) of 21.4 (18.0–26.7) weeks and with a median surgical time of 27 (12–43) min. A resolution of urethral dilatation and subsequent reduction of the penile length and normalization of both the bladder size and amniotic fluid were observed in all cases. The median GA at delivery was 35.2 (range: 30.6–38.0) weeks. There were no fetal deaths but one neonatal death (33%) secondary to renal failure and preterm delivery. Conclusion In fetuses with LUTO by congenital obstructive megalourethra, FUM is feasible and is associated with good perinatal outcomes.