Open Fetal Microneurosurgery for Intrauterine Spina Bifida Repair

Abstract

<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 <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.

Doppler changes in umbilical artery, middle cerebral artery, cerebroplacental ratio and ductus venosus during open fetal microneurosurgery for intrauterine open spina bifida repair

“…Intrauterine spina bifida repair was performed by open fetal microneurosurgery as previously described by our group 14 , which is characterized by a mini‐hysterotomy (15 mm diameter), minimal fetal manipulation and maintenance of a constant volume of amniotic fluid during the whole procedure (Figure 1). Briefly, under maternal regional and general anesthesia with sevoflurane, a maternal laparotomy was performed with a low transverse abdominal incision for exteriorization of the uterus.…”

“…These Doppler changes may be a manifestation of fetal distress during the surgical procedure. Recently, our group developed an alternative technique for intrauterine OSB repair, fetal microneurosurgery, which is characterized by a small uterine incision, reduced fetal manipulation and maintenance of a normal amniotic fluid volume throughout the procedure 14 . The aim of this study was to evaluate fetal hemodynamic parameters during this novel surgical approach to fetal OSB repair.…”

Open intrauterine repair of spina bifida aperta: Historical aspects, current availability, and clinical outcomes from the Latin American Spina Bifida Consortium

“…At several of our centers, the hysterotomy was performed using a scalpel and blunt dissection, in association with interrupted stitches in order to control bleeding from the uterine incision. At two centers, 25,27 however, electrocautery was preferred for performing the hysterotomy. Although this technique has the advantage of allowing better control of the bleeding from the uterine incision site, it has the disadvantage of producing thermal injury to the surrounding tissue.…”

“…Indeed, the pioneering work and experience of this group supported the launch of the fetal surgery program in Chile just a few months after the MOMS trial was published. 23,24 Similarly, Chilean specialists subsequently helped in the implementation of fetal surgery programs for open IRSBA in Queretaro, Mexico, in December 2016 25 ; in Lima, Peru, in June 2017 26 ; and in Bogota, Colombia, in September 2019.…”

The Antenatal and Postnatal Consequences of Antenatal Exposure to Prolonged Low Dose Indomethacin

“…Indomethacin has also been used in women with a short cervix [ 2 ] and at the time of and following cervical cerclage [ 3 , 4 ]. It is also used at the time of therapeutic in utero interventions [ 5 ]. Despite its potential uses, indomethacin is seldom prescribed in pregnancy because of antenatal concerns of the ductus arteriosus (DA) constriction, although the risk of this remains unclear.…”