Fetal surgical intervention for myelomeningocele: lessons learned, outcomes, and future implications

Abstract

Fetal myelomeningocele (fMMC) closure (spina bifida aperta) has become a care option for patients that meet inclusion criteria, but it is clear that fetal intervention, while improving outcomes, is not a cure. This review will: (1) focus on the rationale for fMMC surgery based on preclinical studies and observations that laid the foundation for human pilot studies and a randomized controlled trial; (2) summarize important clinical outcomes; (3) discuss the feasibility, efficacy, and safety of recent developments in fetal surgical techniques and approaches; and (4) highlight future research directions. Given the increased risk of maternal and fetal morbidity associated with prenatal intervention, accompanied by the increasing number of centres performing interventions worldwide, teams involved in the care of these patients need to proceed with caution to maintain technical expertise, competency, and patient safety. Ongoing assessment of durability of the benefits of fMMC surgery, as well as additional refinement of patient selection criteria and counselling, is needed to further improve outcomes and reduce the risks to the mother and fetus. What this paper adds High‐quality prospective studies are needed to broaden the indication for fetal surgery in the general myelomeningocele population. Innovative minimally invasive approaches have had promising results, yet lack comprehensive and robust experimental or clinical evaluation. Important information to help families make informed decisions regarding fetal surgery for myelomeningocele is provided.

Hydrogel and neural progenitor cell delivery supports organotypic fetal spinal cord development in an ex vivo model of prenatal spina bifida repair

“…4 Despite the promising clinical results associated with prenatal repair, bowel and bladder control continue to be ongoing challenges for these children, and more than half with spina bifida still cannot ambulate independently despite in utero repair. [25][26][27] Accordingly, novel experimental approaches aimed at further improving neurologic outcomes in these children have been pursued by multiple laboratories worldwide. [28][29][30] In this study, we developed an injectable hydrogel patch containing human neural progenitor cells as proof of concept for a cell-based tissue engineering strategy for fetal MMC repair.…”

SARS‐CoV2 (COVID‐19) infection: is fetal surgery in times of national disasters reasonable?

“…17 A clear example of such scenario is prenatal spina bifida closure, which is always done under general anaesthesia and inherently has an increased risk of post-operative severe respiratory problems. 18 Delaying fetal surgery seems more prudent, or even postponing repair until after birth, if it cannot be done in the optimal gestational age window, because fetal benefits decrease with gestation, with unproven benefits beyond 26 weeks of gestation. 19 For any SARS-CoV2-positive women, it is obvious that investigational procedures or interventions with unproven benefit (Table 1), should not be performed.…”

Advances and Trends in Pediatric Minimally Invasive Surgery

“…Altogether, fetoscopy is effective for treating several fetal anomalies at present. In the future continuous refinement of the techniques and technologic advances will allow the use of fetoscopy more extensively and aid entry to treatment for other pathologies, such as in utero gastroschisis repair, for carefully selected fetuses [72,[82][83][84].…”