Fetal Surgery for Myelomeningocele: A Systematic Review and Meta-Analysis of Outcomes in Fetoscopic versus Open Repair

Abstract

Background/Objectives: The Management of Myelomeningocele (MMC) Study (MOMS) showed that prenatal repair of MMC resulted in improved neurological outcomes but was associated with high rates of obstetrical complications. This study compares outcomes of open and fetoscopic MMC repair. Data Sources: PubMed and Embase studies reporting outcomes of fetal MMC repair published since the completion of the MOMS. Results: We analyzed 11 studies and found no difference in mortality or the rate of shunt placement for hydrocephalus. Percutaneous fetoscopic repair was associated with higher rates of premature rupture of membranes (91 vs. 36%, p < 0.01) and preterm birth (96 vs. 81%, p = 0.04) compared to open repair, whereas fetoscopic repair via maternal laparotomy reduced preterm birth. The rate of dehiscence and leakage from the MMC repair site was higher after both types of fetoscopic surgery (30 vs. 7%, p < 0.01), while the rate of uterine dehiscence was higher after open repair (11 vs. 0%, p < 0.01). Discussion: Fetoscopic repair is a promising alternative to open fetal MMC repair with a lower risk of uterine dehiscence; however, fetoscopic techniques should be optimized to overcome the high rate of dehiscence and leakage at the MMC repair site. A fetoscopic approach via maternal laparotomy reduces the risk of preterm birth.

A study to assess global availability of fetal surgery for myelomeningocele

“…Repair techniques for fetoscopic surgery vary widely and more so than for open surgery. Apparently, this is still a technique in progress, and the optimal surgical technique remains to be defined . There is currently insufficient evidence to recommend one method of fetoscopic repair to another.…”

“…It is apparent from conference abstracts and discussions that many other centres worldwide are now offering fetal surgery for MMC, with a variety of inclusion criteria and surgical techniques in use. This has become even more apparent with the introduction of fetoscopic surgery, which to our knowledge, does not currently allow a conventional, anatomical multilayered repair, yet for which multiple surgical techniques exist . Because of the fast‐growing number of centres and evolution of techniques, we aimed to map the current practice through a survey to establish the provision of fetal surgery for MMC worldwide, to document variations in patient inclusion criteria and surgical techniques at different centres.…”

Prenatal diagnosis, natural history, postnatal treatment and outcome of 222 cases of spina bifida: experience of a tertiary center

“…The Society for Maternal–Fetal Medicine stated recently that, although open fetal surgery for myelomeningocele repair has potential benefits, there are significant maternal and fetal complications and implications, so it should be offered only to selected patients in a referral center. Percutaneous fetoscopic repair of SB is likely to have less severe maternal complications, although the rate of dehiscence and leakage from the myelomeningocele repair site can be higher, and long‐term outcome has yet to be reported.…”

Partial amniotic carbon dioxide insufflation for fetal surgery

“…The debate concerning the optimal surgical approach for fetoscopic MMC repair is ongoing, as discussed in several recent papers on this subject, and is thus not the focus of this review . However, optimization of the PACI technique may also influence clinical outcomes and is potentially relevant to other surgeries, such as fetoscopic laser coagulation …”