Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium

Fetoscopic repair of open spina bifida between 26 0/7 and 27 6/7 gestational weeks and postnatal cerebrospinal fluid diversion

OBJECTIVE

To assess the rate and risk factors for cerebrospinal fluid (CSF) diversion among cases of prenatal repair of open spina bifida (OSB) performed from 26 0/7 to 27 6/7 gestational weeks, given a traditional cutoff of 25 6/7 weeks.

METHODS

This is a descriptive study of patients who underwent fetoscopic OSB repair (2019-2023) from 26 0/7 to 27 6/7 gestational weeks. Data were collected prospectively and examined as predictors of CSF diversion (ventriculoperitoneal shunt or endoscopic third ventriculostomy) within the first 12 months of life.

RESULTS

Of 42 study patients, CSF diversion was required in 12 cases (28.6%). In bivariate analysis, only preoperative ventricular size was associated with the CSF diversion procedure (largest ventricle 14.5 ± 3.0 vs 11.9 ± 2.5 mm, p = .015). Multiple logistic regression showed that cases with preoperative ventriculomegaly ≥15 mm appeared more likely to have CSF diversion (OR 5.23, 95% CI 0.98-28.09, p = .054). Neither level of the lesion nor myeloschisis was associated with CSF diversion.

CONCLUSION

Prenatal OSB repair from 26 0/7 to 27 6/7 gestational weeks was associated with a 28.6% risk of postnatal CSF diversion at 12 months of life. Results are similar to those in which repair is performed ≤25 6/7 weeks.

WHAT’S ALREADY KNOWN ABOUT THIS TOPIC?

Approximately 40% of patients undergoing prenatal open spina bifida (OSB) repair need CSF diversion at 1 year of life.The upper limit for percutaneous fetoscopic OSB repair has been 25 6/7 gestational weeks; few data exist regarding outcomes of prenatal repair after 25 weeks.

WHAT DOES THIS STUDY ADD?

OSB repair at 26 0/7-27 6/7 gestational weeks appeared to provide a similar benefit in reducing CSF diversion risk at 1 year of life.

Proof of concept testing of a vascular closure device for use in fetal surgery

OBJECTIVE

Prior clinical findings have demonstrated that maternal laparotomy with trans-amniotic trans-uterine suturing of the fetoscopic port site during in utero myelomeningocele repair reduces the risk of membrane rupture. However, due to laparotomy-associated morbidity, we aimed to explore the feasibility of using a vascular closure device for percutaneous trans-amniotic trans-uterine suturing.

METHODS

This IRB and IACUC-exempt study utilized 2 strategies for proof-of-concept testing of using the Abbott Perclose™ ProStyle™ Device for suture placement; 1. Ultrasound guided application on a high fidelity maternal abdominal uterus model used for fetal procedures and 2. Placement under direct visualization with sheep undergoing cesarean delivery for other research purposes. In the high-fidelity uterus model, the Abbott Perclose™ ProStyle™ device was used to place a transuterine/transamniotic stitch with accompanying video recording of the approach (https://go.screenpal.com/watch/cZfhoDVsYvW password: perclose). Regarding the second approach, at the time of a cesarean section, 12 French Checkflo® cannulas were inserted into the sheep amniotic space via different approaches: (1) Seldinger technique, (2) Seldinger technique insertion of Checkflo® cannula and subsequent use of the Abbott Perclose™ ProStyle™ device to suture the port site after check flow removal, (3) Abbott Perclose™ ProStyle™ device utilized in what is described as a "pre-close" technique, where prior to cannula placement, trans-uterine trans-amniotic stitches are placed followed by the insertion of a 12 French Checkflo® cannula over the same guidewire. Samples of the sutured uterine wall were sent to pathology and H&E staining was performed to assess uterine hole closure and amnion-to-uterus fixation.

RESULTS

The high-fidelity model confirmed that the Perclose™ ProStyle™ Device was easily visualized by ultrasound and suture deployment was without complication. In the animal model, the Perclose™ ProStyle™ device effectively sutured the amnion to the uterus in both the pre- and post-close approach. The pre-close technique achieved better amnion-to-uterus approximation and more appropriate uterine hole closure. H&E staining revealed that without suturing, amnion separation from the chorion layer occurred, and the uterine hole persisted. The post-close technique showed partial connection between the amnion and chorion, but inadequate uterine hole closure with amnion shift into the defect. Optimal closure, with secure amnion-to-chorion fixation and uterine closure, was achieved through the pre-close technique.

CONCLUSION

The Abbott Perclose™ ProStyle™ Device seems to be a feasible device for use of uterine port closure in maternal-fetal surgery, larger animal studies with mid-pregnancy application are needed to further validate or refute these findings.

Outcomes Following Fetoscopic Repair of Myelomeningocele: A Prospective Single-Center Experience

OBJECTIVE

Prenatal repair of myelomeningocele (MMC) improves fetal outcomes; however, open uterine surgery has associated morbidities. We report our institutional outcomes following laparotomy-assisted fetoscopic MMC repair.

METHODS

A prospective observational study, including a 1-year follow-up period, was conducted from April 2018 to March 2024. Similar study considerations from the 2011 Management of Myelomeningocele Study (MOMS) and 2019 MOMS Plus study were applied. Laparotomy-assisted repair utilized an extended Pfannenstiel incision and vertical midline fascial incision to exteriorize the uterus for trocar placement. Primary outcomes were ventriculoperitoneal (VP) shunt at 12 months or perinatal death. Secondary outcomes included select maternal and neonatal outcomes.

RESULTS

Of 39 qualifying patients, 10 underwent repair at a median GA of 25w4d (IQR 25w0d-26w6d). All pregnancies resulted in live births in a median GA of 36w1d (IQR 32w2d-37w0d). Preterm premature rupture of membranes was observed (PPROM) in five patients. Four patients delivered vaginally without complications. All trocar sites were noted to be intact at the time of cesarean deliveries. Two neonates required revision of MMC closure after birth. One patient required a VP shunt placement at 4 months of age.

CONCLUSION

Early results at our center demonstrate that laparotomy-assisted fetoscopic MMC repair is a safe option for qualified patients.

Outcome of Children With Prenatally Diagnosed Saccular Limited Dorsal Myeloschisis: The Importance of Accurate Diagnosis

OBJECTIVE

To describe outcomes at 36 months of age in children with prenatally diagnosed Limited Dorsal Myeloschisis (LDM) and compared to Myelomeningocele (MMC).

METHOD

This was a retrospective study of all successive patients with postnatal confirmation of a prenatal diagnosis of isolated LDM who were referred to a French National Reference center from 2014 to 2023 compared with MMC cases. Postnatal evaluation at 36 months of both dysraphisms comprised standardized multidisciplinary evaluations.

RESULTS

Of the 245 fetuses referred with suspected MMC, 19 were prenatally diagnosed with LDM. Nine children reached 36 (± 4) months of age. All were walking. Two required clean intermittent catheterization (CIC) and three required laxatives. Sphincter functions seem to be more dysfunctional in the case of sacral LDM. None were reported to have a ventricular shunt nor having neurodevelopment impairment. The LDM children differed from the MMC children in all functions with significantly more asymptomatic children in the LDM group (LDM: 5/9 vs. MMC: 0/12, p < 0.01), better motor (independent walking; LDM: 7/9 vs. MMC: 2/12; p < 0.01), urinary (need for CIC; LDM: 2/9 vs. MMC: 10/12; p < 0.01) and cognitive (neurodevelopmental impairment; LDM: 0/9 vs. MMC: 4/12, p = 0.10) functions.

CONCLUSION

LDM show better motor, urinary, and cognitive functions than MMC.

Maternal-fetal surgery for myelomeningocele longitudinal follow-up model: Mitigation of care fragmentation through care coordination and outcomes reporting

PurposeFollowing the Global Health Symposium at the Spina Bifida World Congress in 2023, the purpose of this work is to provide a historical overview and a state-of-the-art update on the current global practice of myelomeningocele (MMC) closure and to highlight the importance of care coordination and outcomes reporting to mitigate care fragmentation through a multidisciplinary approach.MethodsPanelists from the Spina Bifida World Congress Global Health Symposium reviewed their institutions' history and experience with risk for fragmentation of care following prenatal repair and proposed solutions to address fragmentation of care.ResultsNew and rapidly evolving in-utero approaches to MMC repair are increasingly accessible for patients worldwide but bring more complexity to follow-up care. There is a consensus that unifying multidisciplinary practices and evaluations across institutions and countries will help make care coordination more comprehensive and longitudinal, and that meeting these standards may decrease care fragmentation.ConclusionRegardless of the open spina bifida repair technique, longitudinal follow-up must be established after fetal surgery, not only for the optimal care of individual patients but also to mitigate care fragmentation, transparently evaluate and compare techniques (for example, through the North American Fetal Therapy Network, the National Spina Bifida Patient Registry, etc.), engage health care professionals, and provide evidence-based multidisciplinary care.

Minimally invasive surgery in the operating rooms near you

PURPOSE OF REVIEW

This review delineates the benefits of minimally invasive surgery (MIS) and its utilization at surgical centers and our institution. It further explores the literature for comparative outcomes of performing MIS to traditional open surgery for a variety of surgical subspecialties.

RECENT FINDINGS

In addition to its proven safety when compared to the open surgical technique, MIS has broad applications in many surgical subspecialties to enhance perioperative outcomes in both pediatric and adult patients.

SUMMARY

Although there are certain disadvantages with regard to cost of implementation in nascent communities and total operating time when the surgical complexity increases (such as utilizing a robotic approach), the added benefit of improved patient outcomes due to smaller incision sites is repeatedly proven in the literature making this technique globally essential.

Fetoscopic Robotic Open Spina Bifida Treatment (FROST): A Preclinical Feasibility and Learning Curve Study

OBJECTIVE

The primary aim was to assess the feasibility of robotic OSB repair in a simulation training model, documenting the learning curve and ensuring quality control among surgeons.

DESIGN

The learning curve was assessed using the cumulative summation test (LC-CUSUM). Following LC-CUSUM, six additional experiments were performed for competency-cumulative summation (C-CUSUM) analysis to ensure ongoing quality control.

SETTING

The simulator was created through 3D printing and hand sculpting, simulating a partially exteriorised uterus for laparotomy-assisted laparoscopic OSB surgery. It included a silicone uterus, placenta and foetal manikin with a simulated OSB lesion, replicating the lesion sac, paraspinal muscles and neural placode.

POPULATION

Four surgeons participated: an expert Maternal Fetal Medicine consultant, a neurosurgical consultant, a Maternal Fetal Medicine fellow and a neurosurgical resident.

METHODS

The surgical procedure included eight steps: uterine access, working space creation, lesion exposition, junctional zone dissection, skin mobilisation, dural patch application, closure of myofascial flaps and closure of skin. Success was defined by precise restoration (suture interval < 3 mm), foetal repair time ≤ 120 min and a GEARS score > 21/30.

MAIN OUTCOMES

Learning curve and competency were documented via LC-CUSUM and C-CUSUM.

RESULTS

Competence was achieved after 15-21 procedures, with novices reaching competency within this range. Participants maintained high performance in subsequent quality-controlled procedures.

CONCLUSION

Robotic-assisted foetal OSB surgery in a high-fidelity simulation is feasible, showing promising outcomes for a large animal model and clinical translation.

Impact of Prenatal Repair for Fetal Myelomeningocele on Gastrointestinal Function

OBJECTIVES

To assess the impact of postnatal, open fetal, and fetoscopic repairs for open neural tube defects (ONTDs) on bowel function and to assess the use of diet modification and medication use to achieve regular bowel function.

STUDY DESIGN

A retrospective cohort study was performed from 2011 to 2020 at our academic referral fetal center. Patients were stratified by route of surgery (postnatal, open prenatal, or fetoscopic prenatal). Bowel function was assessed by patient reported Bristol stool scale as well as a detailed review of current medication usage for bowel management. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. The primary outcome was bowel function assessed at 30-month follow up visit.

RESULTS

A total of 150 patients with fetal ONTD underwent repair at our institution. Forty-eight (32%) underwent postnatal repair, 34 (23%) open fetal surgery, and 68 (45%) fetoscopic repair. Eighty-six patients (57%) reported abnormal bowel function at 30 months of life. No differences were noted in abnormal bowel function between surgical approaches (postnatal 35% vs open prenatal 26%, and fetoscopic 49%, P = .08). Patients who underwent postnatal repair were more likely to require oral regimens to achieve normal bowel function compared with either prenatal surgery approach (postnatal 83% vs open prenatal 59%, and fetoscopic 69%, P = .046).

CONCLUSION

Abnormal bowel function remains a significant morbidity regardless of surgical approach for ONTD. Fetal surgery (open or fetoscopic) for ONTD may result in equivalent bowel function when compared with postnatal repair.

Intrauterine Therapy

Since the first intrauterine interventions were carried out in the 1970 s under what today would be considered basic conditions, the range of prenatal interventions has steadily expanded, as has the frequency with which these interventions are carried out at specialized centers. Although most of these procedures are minimally invasive, they are invariably associated with considerable risks for the fetus and, depending on the surgical method, also for the expectant mother. For this reason, most centers worldwide limit themselves to interventions for fetal diseases which, if untreated, have a fatal course or experience a significant deterioration in the postnatal prognosis during the course of intrauterine development. This is all the more significant as only a small proportion of prenatal interventions have been successfully investigated in controlled clinical trials. The only exceptions are laser therapy for feto-fetal transfusion syndrome, intrauterine closure of spina bifida, and tracheal occlusion for diaphragmatic hernia with severe pulmonary hypoplasia. This article is intended to provide an overview of the fetal conditions that are candidates for intrauterine therapy and of the evidence for the individual interventions.

Mode of Delivery and Subsequent Motor Function in Children With Myelomeningocele Without In Utero Repair

OBJECTIVE

To assess the association between mode of delivery and 2-year motor function in children with prenatal diagnosis of myelomeningocele.

METHODS

A multisite retrospective cohort study of children with myelomeningocele across 14 NAFTNet (North American Fetal Therapy Network) centers born between 2007 and 2020 who had a physical examination available at 2 years of life. Exclusion criteria were in utero myelomeningocele repair, postnatal myelomeningocele diagnosis, missing data on fetal presentation at delivery, and contraindications to labor. The primary outcome was the difference between the anatomic level of the spinal lesion and functional motor level at age 2 years. A general linear model was used to determine the effect of mode of delivery on the primary outcome, and multivariable analysis was performed to control for presence of labor, gestational age at delivery, defect size and origin level, and presence of ventriculomegaly.

RESULTS

Of 566 children with myelomeningocele, 305 met inclusion criteria, with 216 (70.8%) having been delivered by cesarean and 89 (29.2%) having been delivered vaginally. Children delivered by cesarean had a mean±SE level of motor function of 0.07±0.21 segments below the anatomic level at age 2 years compared with 0.57±0.32 for children delivered vaginally ( P =.19). After controlling for potential confounders, both groups improved in motor function by age 2 years compared with anatomic level. However, there was no difference in motor improvement between groups by mode of delivery (0.07 cesarean vs 0.57 vaginal delivery, adjusted difference 0.37 segments, P =.63).

CONCLUSION

In this multisite NAFTNet cohort, mode of delivery was not associated with lower-extremity motor function at age 2 years.

The first experience with 16 open microsurgical fetal surgeries for myelomeningocele in Germany

INTRODUCTION

Fetal surgery for spina bifida aperta has achieved great advancement in last decade offering three possible methods for surgical repair. Open fetal microsurgical repair still remains the gold standard considering long-term results available. Since 2016, we established a program offering this modality of treatment in Germany.

PATIENTS AND METHODS

All patients who underwent interdisciplinary prenatal evaluation following a standardized protocol between June 2016-June 2024. Sacral lesions were excluded. The surgical technique and protocol used were similar to that described in Management Of Myelomeningocele Study (MOMS).

RESULTS

Sixteen patients underwent surgery for spina bifida aperta without fetal nor maternal deaths. Microsurgical fetal repair was performed between 24th and 25th week of gestation age (GA) (Mean: 24 + 5 weeks GA). Lesion levels were mainly lumbosacral (n = 15) and one thoracolumbar (n = 1). Repair was successful in all 16 cases and with reversible hindbrain herniation at time of birth in 13/16 patients (81.3 %). Average time of delivery was 33 + 5 weeks GA, with 8 preterm deliveries occurring before 37 weeks GA; average birth weight was 2193 g. Maternal complications included 2 patients with uterine scar thinning. Hydrocephalus management was needed in 5/16 patiens (31.25 %) via ventriculo-peritoneal shunting.

CONCLUSION

Open fetal repair of spina bifida aperta in selected fetuses is safe and offers the unborn child a better quality of life but does not cure the disease and is not without risks or complications. Collaboration within the pediatric community is recommended to compile data in a common registry to develop standardized treatment and follow-up protocols.

Implementation of in utero laparotomy-assisted fetoscopic spina bifida repair in two centers in Latin America: rationale for this approach in this region

Background

Spina bifida (SB) is a severe congenital malformation that affects approximately 150,000 infants annually, predominantly in low- and middle-income countries, leading to significant morbidity and lifelong disabilities. In Latin America, the birth prevalence of SB is notably high, often exacerbated by limited healthcare resources and poor access to advanced medical care. The implementation of laparotomy-assisted fetoscopic in-utero SB repair programs in Latin America targets reducing prematurity rates and enabling vaginal births while preserving the benefits of decreased need for hydrocephalus treatment and improved mobility in children.

Objective

This study evaluated the safety, efficacy, and outcomes of laparotomy-assisted fetoscopic in-utero SB repair in Latin America compared to traditional open-hysterotomy methods.

Study design

This retrospective cohort study included 39 cases of laparotomy-assisted fetoscopic in-utero SB repair, with 14 cases from Mexico (2017-2021) and 25 cases from Colombia (2019-2024). These cases were compared to 78 cases from the MOMs trial and 314 from other Latin American centers using traditional open-hysterotomy methods. Statistical analyses included the Student's t-test, Kruskal-Wallis test, and Pearson's chi-square test.

Results

The gestational age (GA) at the time of surgery was significantly higher in fetoscopic centers (26±1.27 weeks) compared to the MOMs trial (23.6±1.42 weeks) and traditional hysterotomy methods (25.4±1 weeks) (P<.001). Mean GA at delivery was significantly earlier in the hysterotomy-based groups than in our fetoscopic group (MOMs: 34.1 [± 3.1] vs open-repair centers in LATAM: 34 [±3002] vs Fetoscopic: 35.3 [± 3.79] weeks; P values=.14 and 0004, respectively). Moreover, and the fetoscopic repair group exhibited a significantly lower rate of spontaneous preterm births (<34 weeks) at 15.8%, compared to 46.2% in the MOMs trial group and 49% in the other Latin American centers using traditional open-hysterotomy methods (P=.004 and .001, respectively). Additionally, the fetoscopic group had higher birthweights (2618±738g) and a lower cesarean delivery rate (65.8%) compared to the other groups (P<.001). Hydrocephalus treatment requirements at 12 months were similar across all groups. No maternal deaths or other outcomes such as pulmonary edema or need for maternal transfusion were noted in the fetoscopic SB repair group.

Conclusion

The laparotomy-assisted fetoscopic SB repair offers a feasible and safer alternative to traditional hysterotomy-based techniques in Latin America. This approach significantly reduces the rates of prematurity and cesarean deliveries, facilitating vaginal births and minimizing maternal morbidity. These findings support the broader adoption of fetoscopic SB repair in regions with a high prevalence of SB and suboptimal perinatal outcomes, underscoring its advantages over hysterotomy-based approaches.

The Intrauterine Treatment of Open Spinal Dysraphism

BACKGROUND

Open spinal dysraphism is a congenital malformation that causes major morbidity. Its consequences include sensory and motor impairment as well as bladder- and bowel dysfunction. It is often also associated with prenatal ventriculomegaly, which, in turn, necessitates postnatal treatment with a ventriculoperitoneal shunt in approximately 80% of cases. Prenatal therapy with coverage of neural tube defect can reduce the shunt rate and preserve motor function. In this review, we describe the different surgical procedures and their outcomes.

METHODS

This review is based on publications that were retrieved by a selective literature search in the MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane databases, employing pertinent keywords. Studies of all types (except case reports) that were published in English or German in the period 2010-2024 were included.

RESULTS

The randomized, controlled MOMS trial showed that intrauterine surgery for defect closure resulted in less progressive neural tissue damage than postnatal surgery and reduced the need for shunting by approximately half (40% vs. 82%). Since the publication of these results, various prenatal surgical procedures have been established, including hysterotomy-assisted, percutaneous fetoscopic, and laparotomy-assisted fetoscopic closure. The individual surgical methods yield comparable results in terms of motor function and shunt rate. A problem with these procedures is that they increase the likelihood of preterm birth, to an extent that varies from one type of procedure to another.

CONCLUSION

Prenatal surgery improves motor function and reduces the shunt rate but long-term outcomes beyond adolescence are still lacking. Transparent and interdisciplinary counseling is essential in prenatal communication to inform parents not only about the potential benefits of this treatment, but also about its limitations and risks.

Ethical challenges in conducting maternal-fetal surgery trials. A systematic review

OBJECTIVE

To present the ethical challenges embedded in published maternal-fetal surgery (MFS) trials and their potential solutions.

METHOD

Systematic review of normative and empirical literature. We selected articles based on predefined inclusion criteria. QUAGOL methodology was used for analysis.

RESULTS

Forty-three articles were included. We identified two main themes. First, clinical ethics issues. One of the main challenges is balancing rights of the fetus with the rights of the pregnant person. There seems to be an agreement that the pregnant person has the right to decide whether to participate regardless of fetal benefit. Second, research ethics issues. The main issues are difficulties in obtaining a sizeable sample, which lead to trials delays and cancellations, and in obtaining appropriate standardization. These difficulties have important ethical ramifications. For example, trial cancellations due the lack of proper sample size generate a waste of resources and pointlessly place participants at risk as conclusive evidence on MFS efficacy was not obtained.

CONCLUSIONS

We need to develop creative solutions that can prevent some of these ethical concerns. We need to involve all the relevant stakeholders in the development process. Further, researchers should discuss what practical issues they encountered and how they addressed them in their publications.

IMPACT STATEMENT

Understanding the ethical challenges embedded in MFS trials will help improving future trials and, consequently, clinical outcomes. To our knowledge, this is the first systematic review unveiling the ethical challenges in maternal-fetal surgery trials. To offer a complete overview of the challenges, we included both normative and empirical literature. We found that the main ethical challenges are practical difficulties that have important ethical ramification. E.g., difficulties in recruitment might hinder scientific validity, which in turn might lead to suboptimal treatment.

A new ex vivo model system to analyze factors affecting the integrity of fetal membranes in fetoscopic surgery

We developed an ex vivo model system to analyze the influence of relevant environmental and mechanical factors potentially affecting the integrity of fetal membranes during fetoscopic surgery. The set-up exposes amniochorion membranes to insufflation at predefined levels of gas pressure, flow, humidity, and temperature. Change in fetal membranes stiffness is quantified during the phase mimicking surgery through measurement of membranes' strain in response to cyclic overpressure. The trocar induced perforation creates a mechanical weakness whose stability is assessed by increasing the insufflation pressure until membrane rupture. Damage of the epithelial cells lining the amnion is assessed through live-dead staining. Initial experiments demonstrated the functionality of the new apparatus and the feasibility of the proposed protocols. Fetal membranes exposed to air with low humidity for approximately 1 h demonstrated significant embrittlement, while their mechanical integrity was maintained in case of gas insufflation at high humidity (air as well as CO2). Under dry circumstances, there was a significant rate of epithelial cell death. Separation of amnion and chorion in the region of the trocar site was visible in all experiments. This new model is a versatile platform for analyzing the mechanical, histological, and biological implications of fetoscopic surgery on fetal membranes.

The effect of using synthetic vs. biological dural substitutes during prenatal and postnatal repair of spina bifida on spinal cord tethering-a review of literature

Spina bifida is a congenital neural tube closure defect, with myelomeningocele being the most clinically significant open neural tube defect occurring in one in 1000 births worldwide as reported by Phillips LA et al. (Curr Probl Pediatr Adolesc Health Care 47(7):173-177, 2017) and Zerah M and Kulkarni AV (Handb Clin Neurol 112:975-991, 2013). With advances in fetal surgery, this condition can be corrected in utero. Despite such precision surgery, many complications may still arise, with consequent spinal cord tethering being a major one. When the roots of the spinal cord adhere to the spinal canal instead of floating freely within the dural sleeve within the canal, it is termed as "tethering" as discussed by Martínez-Lage JF et al. (Neurocirugia (Astur) 18(4):312-319, 2007). Tethering has a variety of complications, which are best avoided by analyzing the outcomes of the different dural substitutes and improving surgical techniques. This literature review evaluates the use of different dural substitutes in fetal and postnatal surgery, with their effects on spinal cord tethering. Finding a significant difference in spinal cord adherence outcomes between these two groups can help one introspect on the impact of ideal surgical techniques to be implemented, thus reducing subsequent tethering and other future surgical interventions.

Enhanced recovery after fetal spina bifida surgery: global practice

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients.

METHODS

In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20.

RESULTS

The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume.

CONCLUSIONS

The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

In Utero Gene Therapy and its Application in Genetic Hearing Loss

For monogenic genetic diseases, in utero gene therapy (IUGT) shows the potential for early prevention against irreversible and lethal pathological changes. Moreover, animal models have also demonstrated the effectiveness of IUGT in the treatment of coagulation disorders, hemoglobinopathies, neurogenetic disorders, and metabolic and pulmonary diseases. For major alpha thalassemia and severe osteogenesis imperfecta, in utero stem cell transplantation has entered the phase I clinical trial stage. Within the realm of the inner ear, genetic hearing loss significantly hampers speech, cognitive, and intellectual development in children. Nowadays, gene therapies offer substantial promise for deafness, with the success of clinical trials in autosomal recessive deafness 9 using AAV-OTOF gene therapy. However, the majority of genetic mutations that cause deafness affect the development of cochlear structures before the birth of fetuses. Thus, gene therapy before alterations in cochlear structure leading to hearing loss has promising applications. In this review, addressing advances in various fields of IUGT, the progress, and application of IUGT in the treatment of genetic hearing loss are focused, in particular its implementation methods and unique advantages.

Delivery Room Management of Infants with Surgical Conditions

Delivery room resuscitation of infants with surgical conditions can be complex and depends on an experienced and cohesive multidisciplinary team whose performance is more important than that of any individual team member. Existing resuscitation algorithms were not developed for infants with congenital anomalies, and delivery room resuscitation is largely dictated by expert opinion extrapolating physiologic expectations from infants without anomalies. As prenatal diagnosis rates improve, there is an increased ability to plan for the unique delivery room needs of infants with surgical conditions. In this review, we share expert opinion, including our center's delivery room management for neonatal noncardiac surgical conditions, and highlight knowledge gaps and the need for further studies and evidence-based practice to be incorporated into the delivery room care of infants with surgical conditions. Future research in this area is essential to move from an expert-based approach to a data-driven approach to improve and individualize delivery room resuscitation of infants with surgical conditions.

IFMSS at Forty: You Heard It Here First

BACKGROUND

The International Fetal Medicine and Surgery Society (IFMSS) was founded a little over 40 years ago, to offer a collegial, interdisciplinary forum for fetal specialists worldwide. Its inclusive culture has allowed innovations, successes, and failures to be reported freely. The present report examines progress in the field of fetal medicine, as reflected by the diversity and frequency of IFMSS presentations. We also test the hypothesis that throughout the decades, IFMSS has remained at the forefront of new developments in fetal diagnosis and therapy.

SUMMARY

The scientific programs of annual conferences were reviewed for title and subject and assigned one or more keywords, and a single category (resulting in absolute, rather than relative incidences of topics). Select procedures covered at IFMSS meetings were plotted over time against comparable queries in PubMed. 5,467 presentations were reviewed and categorized. Keywords were plotted as a heatmap, showing a gradual shift from mostly observational to increasingly invasive studies. The relative interest of particular topics varied widely over the years, from bladder obstruction and renal pathology in early meetings, to complicated twin gestations, to fetal surgery for diaphragmatic hernia and myelomeningocele. Reports on the treatment of twin-to-twin transfusion syndrome, fetal surgery for myelomeningocele and stem cell therapy preceded similar publications in the world literature by several years.

KEY MESSAGES

In its 40-year history, IFMSS has continued to offer an interdisciplinary forum for fetal medicine specialists, even as the topics of interests have evolved with the pace of technology, long-term follow-up, and new scientific discoveries.

Imaging Fetal Spine Malformations in the Context of In Utero Surgery

This review covers the embryology, definition, and diagnosis of open spinal dysraphism with a focus on fetal ultrasound and MR imaging findings. Differentiating open versus closed spinal dysraphic defects on fetal imaging will also be discussed. Current fetal surgery practices and imaging findings in the context of fetal surgery are also reviewed.

Fetal cardiovascular changes during open and fetoscopic in-utero spina bifida closure

OBJECTIVE

Fetoscopic closure of spina bifida using heated and humidified carbon dioxide gas (hhCO2) has been associated with lower maternal morbidity compared with open closure. Fetal cardiovascular changes during these surgical interventions are poorly defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR) < 110 bpm for 10 min) and changes in umbilical artery (UA) Doppler parameters during open vs fetoscopic closure.

METHODS

This was a prospective cohort study of 22 open and 46 fetoscopic consecutive in-utero closures conducted between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and UA Doppler velocimetry were obtained systematically during preoperative assessment, every 5 min during the intraoperative period, and during the postoperative assessment. FHR, UA pulsatility index (PI) and UA end-diastolic flow (EDF) were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocity was measured in the fetoscopic cohort. At each timepoint at which FHR was recorded, maternal heart rate and systolic and diastolic blood pressure were measured.

RESULTS

Fetal bradycardia occurred in 4/22 (18.2%) cases of open closure and 21/46 (45.7%) cases of fetoscopic closure (P = 0.03). FHR decreased gradually in both cohorts after administration of general anesthesia and decreased further during surgery. FHR was significantly lower during hour 2 of surgery in the fetoscopic-repair cohort compared with the open-repair cohort. The change in FHR from baseline in the final stage of fetal surgery was significantly more pronounced in the fetoscopic-repair cohort compared with the open-repair cohort (mean, -32.4 (95% CI, -35.7 to -29.1) bpm vs -23.5 (95% CI, -28.1 to -18.8) bpm; P = 0.002). Abnormal UA-EDF (defined as absent or reversed EDF) occurred in 3/22 (13.6%) cases in the open-repair cohort and 23/46 (50.0%) cases in the fetoscopic-repair cohort (P = 0.004). There were no differences in UA-EDF or UA-PI between closure techniques at the individual stages of assessment.

CONCLUSIONS

We observed a decrease in FHR and abnormalities in UA Doppler parameters during both open and fetoscopic spina bifida closure. Fetal bradycardia was more prominent during fetoscopic closure following hhCO2 insufflation, but FHR recovered after cessation of hhCO2. Changes in FHR and UA Doppler parameters during in-utero spina bifida closure were transient, no cases required emergency delivery and no fetoscopic closure was converted to open closure. These observations should inform algorithms for the perioperative management of fetal bradycardia associated with in-utero spina bifida closure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

The Road Well Traveled: Making Choices, Ensuring Progress While Heeding the "Clarion Call"

The career path of everyone is quite unique based on the goals and the choices we make, and success can take time to unfold. My career choices have been greatly influenced by remarkable mentors and opportunities. Reciprocally I have had the pleasure, as a faculty member, department chair, and medical school dean to mentor promising young physicians and scientists to launch successful careers. We need to continue to attract physicians and scientists to academic medicine to ensure that our field continues to innovate and improve the lives of our patients. To influence positive change, we must stay relentlessly focused and have faith that success will come.

Etiologically Based Functional Taxonomy of the Preterm Birth Syndrome

Preterm birth (PTB) is a complex syndrome traditionally defined by a single parameter, namely, gestational age at birth (ie, ˂37 weeks). This approach has limitations for clinical usefulness and may explain the lack of progress in identifying cause-specific effective interventions. The authors offer a framework for a functional taxonomy of PTB based on (1) conceptual principles established a priori; (2) known etiologic factors; (3) specific, prospectively identified obstetric and neonatal clinical phenotypes; and (4) postnatal follow-up of growth and development up to 2 years of age. This taxonomy includes maternal, placental, and fetal conditions routinely recorded in data collection systems.

Reflections upon the intrauterine repair of myelomeningocele

The intrauterine repair of myelomeningocele presents certain advantages and has gained widespread acceptance. It significantly reduces the incidence of Chiari-2 anomalies and hydrocephalus, and it is thought to enhance the neurologic outcome. Nevertheless, several issues remain unsettled and there are no negligible disadvantages. After working with patients with myelomeningocele for 30 years, I thought about how we currently treat them. There are ethical, organizational, neurological, obstetrical, and postnatal aspects worth discussing.

Length of hysterotomy for fetal spina bifida repair is associated with prematurity risk

OBJECTIVE

To investigate whether prenatal repair of spina bifida aperta through mini-hysterotomy results in less prematurity, as compared to standard hysterotomy, when adjusting for known prematurity risks.

METHODS

We performed a bi-centric, propensity score matched, controlled study, that is, adjusting for factors earlier reported to result in premature delivery or membrane rupture, in consecutive women having prenatal repair either through stapled hysterotomy or sutured mini-hysterotomy (≤3.5 cm). Matches were pairwise compared and cox-regression analysis was performed to define the hazard ratio of delivery <37 weeks.

RESULTS

Of 346 meeting the MOMS-criteria, 78 comparable pairs were available for matched-controlled analysis. Mini-hysterotomy patients were younger and had a higher BMI. Mini-hysterotomy was associated with a 1.67-lower risk of delivery <37 weeks (hazard ratio: 0.60; 95% CI: 0.42-0.85; p = 0.004) and 1.72 for delivery <34 + 6 weeks (hazard ratio: 0.58; 95% CI: 0.34-0.97; p = 0.037). The rate of intact uterine scar at birth (mini-hysterotomy: 98.7% vs. hysterotomy: 90.4%; p = 0.070), the rate of reversal of hindbrain herniation within 1 week after surgery (88.9% vs. 97.4%; p = 0.180) and the rate of cerebrospinal fluid leakage (0% vs. 2.7%; p = 0.50) were comparable.

CONCLUSION

Prenatal spina bidifa repair through mini-hysterotomy was associated with a later gestational age at delivery and a comparable intact uterus rate without apparent compromise in neuroprotection.

The impact of a biocellulose-based repair of fetal open spina bifida on the need to untether the cord: is it time to unify techniques for prenatal repair?

OBJECTIVE

To report the need for cord untethering after prenatal repair of open spina bifida using a unique biocellulose-based technique performed at a later gestational age.

METHODS

An observational cohort study was conducted to determine the incidence of tethered cord syndrome. Between May 2013 and May 2022, we performed 172 procedures using the percutaneous fetoscopic approach in fetuses at 26-28 weeks of gestation. After placode dissection, a biocellulose patch was placed to cover the placode, a myofascial flap (when possible) was dissected, and the skin was closed. Owing to death or loss to follow-up, 23 cases were excluded. Cord tethering syndrome was defined as symptoms of medullary stretching, and the infants were evaluated and operated on by local neurosurgeons after an magnetic resonance imaging examination. Infants over 30-month had ambulation and neurodevelopment evaluations (PEDI scale).

RESULTS

Among 172 cases operated at a median gestational age of 26.7 weeks and delivered at 33.2 weeks, 149 cases were available for postnatal follow-up, and cord untethering was needed in 4.4% of cases (6/136; excluding 13 cases younger than 12 months). Cerebrospinal fluid diversion and bladder catheterization were needed in 38% and 36% of cases, respectively. Of the 78 cases evaluated at 30 months, 49% were ambulating independently, and 94% had normal social function.

CONCLUSION

The biocellulose-based technique was associated with a low rate of cord tethering, wich may be attributed to the lack of the duramater suture during prenatal repair, the formation of a neoduramater and/or later gestational age of surgery.

Pain Scores after Open Fetal Spina Bifida Repair and Caesarean Section: A Longitudinal Cohort Study

INTRODUCTION

In fetal surgery, successful pain management is crucial for postoperative mobilization, prophylaxis of contractions, and fast recovery. This study analyzed patient's pain experience after open fetal spina bifida (fSB) repair in comparison to pain scores after the subsequent Caesarean section (C-section).

MATERIALS AND METHODS

Data were collected with a questionnaire given to 91 women, who had fSB repair and then C-section at our center between 2019 and 2022. It comprised 12 questions covering different aspects of pain experience and satisfaction with pain therapy and was answered by 67 women after fSB repair and 53 after C-section. Postoperative pain was rated on a Likert scale from 0 (slight/rarely) to 100 (strongest/always). Outcomes after fSB repair were compared to those after C-section. Additionally, subgroup analysis compared outcomes of women with different pain levels (group 1-5) after fSB repair.

RESULTS

Compared to women after C-section women after fSB repair reported significantly higher maximum pain scores (MPS) (p = 0.03), higher sleep disturbance due to pain (p = 0.03), and sedation rates (p = 0.001) as side effect from pain therapy. No differences were found regarding feelings of insecurity (p = 0.20) or helplessness (p = 0.40), as well as involvement in (p = 0.3) and satisfaction with pain therapy (p = 0.5). Subgroup analysis revealed that women with higher MPS after fSB repair were significantly more often non-Caucasians (p = 0.003) and more often affected by pain while lying in bed (p = 0.007) and during mobilization (p = 0.005). Additionally, they reported higher rates of dizziness (p = 0.02) and lower satisfaction rates with pain therapy (p = 0.03). Postoperative complication rate did not differ among groups.

CONCLUSION

Although women after fSB repair reported higher MPS compared to after C-section, the current pain management was generally perceived as satisfactory.

Initial experience with the anaesthetic management of fetoscopic spina bifida repair at a German University Hospital: A case series of 15 patients

Spina bifida aperta (SBA) is a serious neural tube defect that can lead to a range of disabilities and health complications in affected individuals. In recent years, fetoscopic surgical repair has emerged as a promising new approach to treat spina bifida prenatally, offering the potential for improved outcomes compared with traditional open surgery. As one of the few centres in Europe to offer this innovative technique, the Departments of Obstetrics and Gynaecology, Neurosurgery, and Anaesthesiology and Intensive Care Medicine at the University Medical Centre of Marburg (UKGM Marburg) have faced unique challenges in developing and establishing standards of care for the pregnant patients undergoing this complex procedure. In this publication, we aim to present details of our initial experience with the first 15 patients and propose a clinical concept for the rather complex perioperative management of these patients.

Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa

INTRODUCTION

In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals.

AIM

To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa.

METHODOLOGY

A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search.

RESULTS

Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge.

CONCLUSION

Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2022 CRD42022352115 .

Profile of a Multivariate Observation under Destructive Sampling-A Monte Carlo Approach to a Case of Spina Bifida

A biodegradable hybrid polymer patch was invented at the University of Cincinnati to cover gaps on the skin over the spinal column of a growing fetus, characterized by the medical condition spina bifida. The inserted patch faces amniotic fluid (AF) on one side and cerebrospinal fluid on the other side. The goal is to provide a profile of the roughness of a patch over time at 0, 4, 8, 12, and 16 weeks with a 95% confidence band. The patch is soaked in a test tube filled with either amniotic fluid (AF) or phosphate-buffered saline (PBS) in the lab. If roughness is measured at any time point for a patch, the patch is destroyed. Thus, it is impossible to measure roughness at all weeks of interest for any patch. It is important to assess the roughness of a patch because the rougher the patch is, the faster the skin grows under the patch. We use a model-based approach with Monte Carlo simulations to estimate the profile over time with a 95% confidence band. The roughness profiles are similar with both liquids. The profile can be used as a template for future experiments on the composition of patches.

Preterm membranes are mechanically more resistant than term membranes

OBJECTIVE

To compare the biomechanical properties of fetal preterm membranes (20 + 0 weeks to 30 + 0 weeks) to those of the term (37 + 0 to 41 + 0 weeks).

METHOD

Amnion and chorion were manually separated and samples were cut to the required geometry. Rectangular samples with (mode 1) and without (uniaxial) a notch, were tested for tearing energy, critical elongation, and tangent stiffness. Suture retention and inter-suture distance testing investigated the effect of suture placement.

RESULTS

From the 15 preterm and 10 term placentas studied, no notable differences were observed in uniaxial testing. Mode 1 fracture testing showed a difference in tearing energy between the preterm and term chorion (0.025 ± 0.005 vs. 0.017 ± 0.005 J/m-1 ; p = 0.027) but not in the amnion (0.030 ± 0.017 vs. 0.029 ± 0.009 J/m-1 ; p = 0.895). Both preterm amnion and chorion showed a higher critical elongation compared with term (1.229 ± 0.057 vs. 1.166 ± 0.046; p = 0.019 and 1.307 ± 0.049 vs. 1.218 ± 0.058; p = 0.012). Preterm amnion had a higher suture retention strength than its term counterpart (0.189 ± 0.065 vs. 0.121 ± 0.031 N; p = 0.023). In inter-suture distance tests, no significant interaction was observed beyond 3 mm, but the preterm chorion showed less interaction at 1-2 mm distances.

CONCLUSION

Preterm membranes have equivalent or superior tensile properties to term membranes. The chorion appears to contribute to the mechanical integrity of fetal membranes, particularly in preterm stages.

High-fidelity, low-cost synthetic training model for fetoscopic spina bifida repair

BACKGROUND

Fetoscopic spina bifida repair is increasingly being practiced, but limited skill acquisition poses a barrier to widespread adoption. Extensive training in relevant models, including both ex vivo and in vivo models may help. To address this, a synthetic training model that is affordable, realistic, and that allows skill analysis would be useful.

OBJECTIVE

This study aimed to create a high-fidelity model for training in the essential neurosurgical steps of fetoscopic spina bifida repair using synthetic materials. In addition, we aimed to obtain a cheap and easily reproducible model.

STUDY DESIGN

We developed a 3-layered, silicon-based model that resemble the anatomic layers of a typical myelomeningocele lesion. It allows for filling of the cyst with fluid and conducting a water tightness test after repair. A compliant silicon ball mimics the uterine cavity and is fixed to a solid 3-dimensional printed base. The fetal back with the lesion (single-use) is placed inside the uterine ball, which is reusable and repairable to allow for practicing port insertion and fixation multiple times. Following cannula insertion, the uterus is insufflated and a clinical fetoscopic or robotic or prototype instruments can be used. Three skilled endoscopic surgeons each did 6 simulated fetoscopic repairs using the surgical steps of an open repair. The primary outcome was surgical success, which was determined by water tightness of the repair, operation time <180 minutes and an Objective Structured Assessment of Technical Skills score of ≥18 of 25. Skill retention was measured using a competence cumulative sum analysis of a composite binary outcome of surgical success. Secondary outcomes were cost and fabrication time of the model.

RESULTS

We made a model that can be used to simulate the neurosurgical steps of spina bifida repair, including anatomic details, port insertion, placode release and descent, undermining of skin and muscular layer, and endoscopic suturing. The model was made using reusable 3-dimensional printed molds and easily accessible materials. The 1-time startup cost was €211, and each single-use, simulated myelomeningocele lesion cost €9.5 in materials and 50 minutes of working time. Two skilled endoscopic surgeons performed 6 simulated, 3-port fetoscopic repairs, whereas a third used a Da Vinci surgical robot. Operation times decreased by more than 30% from the first to the last trial. Six experiments per surgeon did not show an obvious Objective Structured Assessment of Technical Skills score improvement. Competence cumulative sum analysis confirmed competency for each surgeon.

CONCLUSION

This high-fidelity, low-cost spina bifida model allows simulated dissection and closure of a myelomeningocele lesion. VIDEO ABSTRACT.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Duration of fetoscopic spina bifida repair does not affect the central nervous system in fetal lambs

BACKGROUND

Prenatal spina bifida aperta repair improves neurologic outcomes yet comes with a significant risk of prematurity and uterine scar-related complications. To reduce such complications, different fetoscopic techniques, for example, with varying numbers of ports, are being explored. This has an effect on the duration of the procedure, potentially affecting central nervous system development. Both the condition and anesthesia can affect the central nervous system, particularly the hippocampus, a region crucial for prospective and episodic memory. Previous animal studies have shown the potential influence of anesthesia, premature delivery, and maternal surgery during pregnancy on this area.

OBJECTIVE

This study aimed to compare the effects of 2- vs 3-port fetoscopic spina bifida aperta repair in the fetal lamb model using neuron count of the hippocampus as the primary outcome.

STUDY DESIGN

Based on the hippocampal neuron count from previous lamb experiments, we calculated that we required 5 animals per group to achieve a statistical power of ≥ 80%. A spina bifida aperta defect was developed in fetal lambs at 75 days of gestation (term: 145 days). At 100 days, fetuses underwent either a 2-port or 3-port fetoscopic repair. At 143 days, all surviving fetuses were delivered by cesarean delivery, anesthetized, and transcardially perfused with a mixture of formaldehyde and gadolinium. Next, they underwent neonatal brain and spine magnetic resonance imaging after which these organs were harvested for histology. Hippocampus, frontal cortex, caudate nucleus, and cerebellum samples were immunostained to identify neurons, astrocytes, microglia, and markers associated with cell proliferation, myelination, and synapses. The degree of hindbrain herniation and the ventricular diameter were measured on magnetic resonance images and volumes of relevant brain and medulla areas were segmented.

RESULTS

Both treatment groups included 5 fetuses and 9 unoperated littermates served as normal controls. The durations for both skin-to-skin (341±31 vs 287±40 minutes; P=.04) and fetal surgery (183±30 vs 128±22; P=.01) were longer for the 2-port approach than for the 3-port approach. There was no significant difference in neuron density in the hippocampus, frontal cortex, and cerebellum. In the caudate nucleus, the neuron count was higher in the 2-port group (965±156 vs 767±92 neurons/mm2; P=.04). There were neither differences in proliferation, astrogliosis, synaptophysin, or myelin. The tip of the cerebellar vermis was closer to the foramen magnum in animals undergoing the 2-port approach than in animals undergoing the 3-port approach (-0.72±0.67 vs -2.47±0.91 mm; P=.009). There was no significant difference in the ratio of the hippocampus, caudate nucleus, or cerebellar volume to body weight. For the spine, no difference was noted in spine volume-to-body weight ratio for the lower (L1-L2), middle (L3-L4), and higher (L5-L6) levels. Compared with controls, in repaired animals, the cerebellar vermis tip laid closer to the foramen magnum, parietal ventricles were enlarged, and medulla volumes were reduced.

CONCLUSION

In the experimental spina bifida fetal lamb model, a 2-port repair took 40% longer than a 3-port repair. However, there was no indication of any relevant morphologic differences in the fetal brain.

Trends in the early care of infants with myelomeningocele in the United States 2012-2018

PURPOSE

The early care of children with spina bifida has changed with the increasing availability of fetal surgery and evidence that fetal repair improves the long-term outcomes of children with myelomeningocele. We sought to determine current trends in the prevalence and early care of children with myelomeningocele using a national administrative database.

METHODS

This is a retrospective, cross-sectional cohort study of infants with spina bifida admitted within the first 28 days of life using the 2012-2018 Healthcare Cost and Utilization Project National Inpatient Database. Patients with spina bifida were identified by ICD code and stratified into a cohort with a coded neonatal repair of the defect and those without a coded repair. This database had no identifier specific for fetal surgery, but it is likely that a substantial number of infants without a coded repair had fetal surgery.

RESULTS

We identified 5,090 patients with a coded repair and 5,715 without a coded repair. The overall prevalence of spina bifida was 3.94 per 10,000 live births. The percentage of patients without neonatal repair increased during the study period compared to those with repair (p = 0.0002). The cohort without neonatal repair had a higher risk of death (p < 0.001), prematurity (p < 0.001), and low birth weight (p < 0.001). More shunts were placed in patients who underwent neonatal repair (p < 0.001). Patients without neonatal repair were less likely to have public insurance (p = 0.0052) and more likely to reside in zip codes within the highest income quartile (p = 0.0002).

CONCLUSIONS

The prevalence of spina bifida from 2012 to 2018 was 3.94 per 10,000 live births, with an increasing number of patients without neonatal repair of the defect, suggesting increased utilization of fetal surgery. Patients without neonatal repair had a higher risk of death, prematurity, and low birth weight but were more likely to have commercial insurance and reside in high-income zip codes.

Implementation and Assessment of a Laparotomy-Assisted Three-Port Fetoscopic Spina Bifida Repair Program

Open spina bifida (OSB) is a congenital, non-lethal malformation with multifactorial etiology. Fetal therapy can be offered under certain conditions to parents after accurate prenatal diagnostic and interdisciplinary counseling. Since the advent of prenatal OSB surgery, various modifications of the original surgical techniques have evolved, including laparotomy-assisted fetoscopic repair. After a two-year preparation time, the team at the University of Giessen and Marburg (UKGM) became the first center to provide a three-port, three-layer fetoscopic repair of OSB via a laparotomy-assisted approach in the German-speaking area. We point out that under the guidance of experienced centers and by intensive multidisciplinary preparation and training, a previously described and applied technique could be transferred to a different setting.

Prenatal predictors of need for cerebrospinal fluid diversion in infants following prenatal repair of open spina bifida; systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate prenatal predictors of the need for cerebrospinal fluid diversion in infants following prenatal repair of open spina bifida.

DATA SOURCES

A systematic search was performed to identify relevant studies published from inception until June 2022 in the English language using the databases PubMed, Scopus, and Web of Science.

STUDY ELIGIBILITY CRITERIA

We included retrospective and prospective cohort studies and randomized controlled trials reporting on prenatal repair of open spina bifida.

METHODS

The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value.

RESULTS

A total of 9 studies including 948 pregnancies undergoing prenatal repair of open spina bifida were included in the final analysis. Prenatal factors that were significantly associated with the need for postnatal cerebrospinal fluid diversion were gestational age at surgery ≥25 weeks (odds ratio, 4.2; 95% confidence interval, 1.8-9.9; I2=54%; P=.001), myeloschisis (odds ratio, 2.2; 95% confidence interval, 1.1-4.1; I2=0.0%; P=.02), preoperative lateral ventricle width ≥15 mm (odds ratio, 4.5; 95% confidence interval, 2.9-6.9; I2=0.0%; P<.0001), predelivery lateral ventricle width (mm) (mean difference, 8.3; 95% confidence interval, 6.4-10.2; I2=0.0%; P<.0001), and preoperative lesion level at T12-L2 (odds ratio, 2.5; 95% confidence interval, 1.03-6.3; I2=68%; P=.04). Factors that significantly reduced the need for postnatal shunt placement were gestational age at surgery <25 weeks (odds ratio, 0.3; 95% confidence interval, 0.15-0.6; I2=67%; P=.001) and preoperative lateral ventricle width <15 mm (odds ratio, 0.3; 95% confidence interval, 0.2-0.4; I2=0.0%; P<.0001).

CONCLUSION

This study demonstrated that among fetuses that underwent surgical repair of open spina bifida, having gestational age at surgery of ≥25 weeks, preoperative lateral ventricle width of ≥15 mm, myeloschisis lesion type, and preoperative lesion level above L3 was predictive of the need for cerebrospinal fluid diversion during the first year of life.

Identifying predictive factors for bowel control in patients with spina bifida and spinal cord injuries

PURPOSE

This study aimed to assess our bowel management program (BMP) and identify predictive factors for bowel control in patients with Spina Bifida (SB) and Spinal Cord Injuries (SCI). Additionally, in patients with SB, we examined the impact of fetal repair (FRG) on bowel control.

METHODS

We included all patients with SB and SCI seen in the Multidisciplinary Spinal Defects Clinic at Children's Hospital Colorado from 2020 to 2023.

RESULTS

336 patients included. Fecal incontinence was present in 70% and bowel control in 30%. All patients with urinary control also had bowel control. Fecal incontinence prevalence was higher in patients with ventriculoperitoneal (VP) shunt (84%), urinary incontinence (82%), and wheelchair users (79%) compared to those who did not need a VP shunt (56%), had urinary continence (0%) and non-wheelchair users (52%), respectively (p =  < 0.001 in all three scenarios). After completing BMP, 90% remained clean for stool. There was no statistical significance when comparing bowel control in FRG with non-fetal repair group.

CONCLUSIONS

Urinary continence predicts bowel control in patients with SB and SCI. Risk factors for fecal incontinence were the need for a VP shunt, urinary incontinence, and wheelchair usage. We did not find any positive impact of fetal repair on bowel and urinary control.

Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects

BACKGROUND

In utero repair of open neural tube defects using an open hysterotomy approach (hereafter referred to as "open") has been shown to reduce the need for ventriculoperitoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "hybrid") is an alternative approach that may confer similar neurologic benefits while reducing the incidence of hysterotomy-related complications.

OBJECTIVE

This study aimed to analyze procedure-related maternal and fetal complications of in utero repair using the Clavien-Dindo classification, and to compare the outcomes of the hybrid and open approaches.

STUDY DESIGN

This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the Management of Myelomeningocele Study criteria and who underwent either hybrid or open fetal surgery were included. Maternal complications were classified using a unique adaptation of the Clavien-Dindo scoring system, allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery.

RESULTS

There were 146 fetuses with open neural tube defects who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent hybrid fetoscopic repair and 44 underwent open hysterotomy repair. Gestational age at the time of surgery was higher in the hybrid group than in the open group (25.1 vs 24.8 weeks; P=.004). Maternal body mass index was lower in the hybrid than in the open group (25.4 vs 27.1 kg/m2; P=.02). The duration of hybrid fetoscopic surgery was significantly longer in the hybrid than in the open group (250 vs 164 minutes; P<.001). There was a significantly lower Clavien-Dindo Grade III complication rate (4.9% vs 43.2%; P<.001) and a significantly lower overall comprehensive maternal complication index (8.7 vs 22.6; P=.021) in the hybrid group than in the open group. Gestational age at delivery was significantly higher in the hybrid group than in the open group (38.1 vs 35.8 weeks; P<.001), and this finding persisted when gestational age at delivery was analyzed using the World Health Organization definitions of preterm delivery.

CONCLUSION

Use of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero open neural tube defect repair provides a new method for objectively assessing different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The hybrid open neural tube defect repair was associated with lower rates of maternal adverse events , and later gestational age at delivery compared with the open approach.

The value and limitations of using predetermined criteria in decision making for maternal-fetal interventions

Maternal-fetal interventions-such as prenatal fetal myelomeningocele (MMC) repair-are at the forefront of clinical innovation within maternal-fetal medicine, pediatric surgery, and neonatology. Many centers determine eligibility for innovative procedures using pre-determined inclusion and exclusion criteria based on seminal studies, for example, the "Management of Myelomeningocele Study" for prenatal MMC repair. What if a person's clinical presentation does not conform to predetermined criteria for maternal-fetal intervention? Does changing criteria on a case-by-case basis (i.e., ad hoc) constitute an innovation in practice and flexible personalized care or transgression of commonly held standards with potential negative consequences? We outline principle-based, bioethically justified answers to these questions using fetal MMC repair as an example. We pay special attention to the historical origins of inclusion and exclusion criteria, risks and benefits to the pregnant person and the fetus, and team dynamics. We include recommendations for maternal-fetal centers facing these questions.

Prenatal repair of gastroschisis using partial carbon dioxide insufflation fetoscopy: lessons learned

We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.

Global Policy and Practice for Intrauterine Fetal Resuscitation During Fetal Surgery for Open Spina Bifida Repair

Importance

Globally accepted recommendations suggest that a woman should be between 19 weeks and 25 weeks plus 6 days of pregnancy to be considered eligible for fetal closure of open spina bifida. A fetus requiring emergency delivery during surgery is therefore potentially considered viable and thus eligible for resuscitation. There is little evidence, however, to support how this scenario is addressed in clinical practice.

Objective

To explore current policy and practice for fetal resuscitation during fetal surgery for open spina bifida in centers undertaking fetal surgery.

Design, Setting, and Participants

An online survey was designed to identify current policies and practices in place to support fetal surgery for open spina bifida, exploring experiences and management of emergency fetal delivery and fetal death during surgery. The survey was emailed to 47 fetal surgery centers in 11 countries where fetal spina bifida repair is currently performed. These centers were identified through the literature, the International Society for Prenatal Diagnosis center repository, and an internet search. Centers were contacted between January 15 and May 31, 2021. Individuals volunteered participation through choosing to complete the survey.

Main Outcomes and Measures

The survey comprised 33 questions of mixed multiple choice, option selection, and open-ended formats. Questions explored policy and practice supporting fetal and neonatal resuscitation during fetal surgery for open spina bifida.

Results

Responses were obtained from 28 of 47 centers (60%) in 11 countries. Twenty cases of fetal resuscitation during fetal surgery during the last 5 years were reported across 10 centers. Four cases of emergency delivery during fetal surgery after maternal and/or fetal complications during the last 5 years were reported across 3 centers. Fewer than half the 28 centers (n = 12 [43%]) had policies in place to support practice in the event of either imminent fetal death (during or after fetal surgery) or the need for emergency fetal delivery during fetal surgery. Twenty of 24 centers (83%) reported preoperative parental counseling on the potential need for fetal resuscitation prior to fetal surgery. The gestational age at which centers would attempt neonatal resuscitation after emergency delivery varied from 22 weeks and 0 days to more than 28 weeks.

Conclusions

In this global survey study of 28 fetal surgical centers, there was no standard practice about how fetal resuscitation or subsequent neonatal resuscitation was managed during open spina bifida repair. Further collaboration between professionals and parents is required to ensure sharing of information to support knowledge development in this area.

Risk factors for shunting at 12 months following open fetal repair of spina bifida by mini-hysterotomy

OBJECTIVES

Open spina bifida (OSB) is the most common neural tube defect. Prenatal repair reduces the need for ventriculoperitoneal shunting (VPS) due to hydrocephalus from 80-90% to 40-50%. We aimed to determine which variables work as risk factors for VPS at 12 months of age in our population.

METHODS

Thirty-nine patients underwent prenatal repair of OSB by mini-hysterotomy. The main outcome was occurrence of VPS in the first 12 months of life. Logistic regression was used to estimate the odds ratios (OR) between prenatal variables and the need for shunting.

RESULTS

VPS at 12 months occurred in 34.2% of the children. Larger ventricle size before surgery (62.5% ≥15 mm; 46.2% between 12 and 15 mm; 11.8% <12 mm; p=0.008), higher lesion level (80% >L2, vs. 17.9% ≤L3; p=0.002; OR, 18.4 [2.96-114.30]), and later gestational age at surgery (25.25 ± 1.18 vs. 24.37 ± 1.06 weeks; p=0.036; OR, 2.23 [1.05-4.74]) were related to increased need for shunting. In the multivariate analysis, larger ventricle size before surgery (≥15 mm vs. <12 mm; p=0.046; OR, 1.35 [1.01-1.82]) and higher lesion level (>L2 vs. ≤L3; p=0.004; OR, 39.52 [3.25-480.69]) were risk factors for shunting.

CONCLUSIONS

Larger ventricle size before surgery (≥15 mm) and higher lesion level (>L2) are independent risk factors for VPS at 12 months of age in fetuses undergoing prenatal repair of OSB by mini-hysterotomy in the studied population.

Local host response of commercially available dural patches for fetal repair of spina bifida aperta in rabbit model

OBJECTIVE

Fetal surgery for spina bifida aperta (SBA) by open hysterotomy typically repairs anatomical native tissue in layers. Increasingly, fetoscopic repair is performed using a dural patch followed by skin closure. We studied the host response to selected commercially available patches currently being used in a fetal rabbit model for spina bifida repair.

METHODS

SBA was surgically induced at 23-24 days of gestation (term = 31 days). Fetal rabbits were assigned to unrepaired (SBA group), or immediate repair with Duragen™ or Durepair™. Non-operated littermates served as normal controls. At term, spinal cords underwent immunohistochemical staining including Nissl and glial fibrillary acidic protein. We hypothesized that spinal cord coverage with a dural patch and skin closure would preserve motor neuron density within the non-inferiority limit of 201.65 cells/mm² and reduce inflammation compared to unrepaired SBA fetuses.

RESULTS

Motor neuron density assessed by Nissl staining was conserved both by Duragen (n = 6, 89.5; 95% CI -158.3 to -20.6) and Durepair (n = 6, 37.0; 95% CI -132.6 to -58.5), whereas density of GFAP-positive cells to quantify inflammation was lower than in unrepaired SBA-fetuses (SBA 2366.0 ± 669.7 cells/mm² vs. Duragen 1274.0 ± 157.2 cells/mm² ; p = 0.0002, Durepair 1069.0 ± 270.7 cells/mm² ; p < 0.0001).

CONCLUSIONS

Covering the rabbit spinal cord with either Duragen or Durepair followed by skin closure preserves motor neuron density and reduces the inflammatory response.

Open and endoscopic fetal myelomeningocele surgeries display similar in-hospital safety profiles in a large, multi-institutional database

BACKGROUND

Open intrauterine fetal myelomeningocele repair has demonstrated decreased ventriculoperitoneal shunting and improved motor outcomes despite maternal and fetal risks. Few data directly compare the safety of open vs endoscopic approaches.

OBJECTIVE

This study aimed to analyze in-hospital maternal and fetal outcomes of pregnant patients undergoing open vs endoscopic fetal myelomeningocele repair using a large, multi-center database.

STUDY DESIGN

This was a review of the Pediatric Health Information System database from October 1, 2015, to December 31, 2021. All patients who underwent open or endoscopic fetal myelomeningocele repair according to the International Classification of Diseases, Tenth Revision, were identified. Demographics, gestational age, and outcomes were analyzed. Descriptive and univariate statistics were used.

RESULTS

A total of 378 pregnant patients underwent fetal myelomeningocele repair. The approach was endoscopic in 143 cases (37.8%) and open in 235 cases (62.2%). Overall postprocedural outcomes included no maternal in-hospital mortalities or intensive care unit admissions, a median length of stay of 4 days (interquartile range, 4-5), 14 cases (3.7%) of surgical and postoperative complications, 6 cases (1.6%) of intrauterine infections, 12 cases (3.2%) of obstetrical complications (including preterm premature rupture of membranes), 3 cases (0.8%) of intrauterine fetal demise, and 16 cases (4.2%) of preterm delivery. Compared with an open approach, the endoscopic approach occurred at a later gestational age (25 weeks [interquartile range, 24-25] vs 24 weeks [interquartile range, 24-25]; P<.001) and had an increased rate of intrauterine infection (6 [4.2%] cases vs 0 [0%] case; P=.002). There was no difference between approaches in the rates of surgical complications, obstetrical complications, intrauterine fetal demise, or preterm deliveries.

CONCLUSION

Compared with an open approach, endoscopic fetal myelomeningocele repair displays a comparable rate of fetal complications, including intrauterine fetal demise and preterm delivery, and a similar in-hospital maternal safety profile despite an association with increased intrauterine infection.

Advances in Fetal Surgical Repair of Open Spina Bifida

Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.

A comparison of MRI appearance and surgical detethering rates between intrauterine and postnatal myelomeningocele closures: a single-center pilot matched cohort study

INTRODUCTION

Intrauterine myelomeningocele repair (IUMR) and postnatal myelomeningocele repair (PNMR) differ in terms of both setting and surgical technique. A simplified technique in IUMR, in which a dural onlay is used followed by skin closure, has been adopted at our institution. The goal of this study was to compare the rates of clinical tethering in IUMR and PNMR patients, as well as to evaluate the appearance on MRI.

METHODS

We conducted a retrospective review of 36 patients with MMC repaired at our institution, with 2:1 PNMR to IUMR matching based on lesion level. A pediatric neuroradiologist blinded to the clinical details reviewed the patients' lumbar spine MRIs for the distance from neural tissue to skin and the presence or absence of a syrinx. An EMR review was then done to evaluate for detethering procedures and need for CSF diversion.

RESULTS

Mean age at MRI was 4.0 years and mean age at last follow-up was 6.1 years, with no significant difference between the PNMR and IUMR groups. There was no significant difference between groups in the distance from neural tissue to skin (PNMR 13.5 mm vs IUMR 17.6 mm; p = 0.5). There was no difference in need for detethering operations between groups (PNMR 12.5% vs IUMR 16.7%; RR 0.75; CI 0.1-5.1).

CONCLUSIONS

There was no significant difference between postnatal- and intrauterine-repaired myelomeningocele on MRI or in need for detethering operations. These results imply that a more straightforward and time-efficient IUMR closure technique does not lead to an increased rate of tethering when compared to the multilayered PNMR.

Postnatal Surgical Correction of Myelomeningoceles: Preoperative and Intraoperative Risk Factors Associated with Postoperative Neurologic Outcomes

OBJECTIVE

Open spina bifida or myelomeningocele (MMC) is a congenital defect that results from failure of caudal neurulation. We present a case series of patients who were treated with postnatal surgical correction for MMC, evaluating the possible preoperative and intraoperative risk factors associated with neurologic outcomes.

METHODS

A retrospective chart review of patients who underwent postnatal surgical correction for MMCs over 11 years at our institution was performed. MMCs were classified based on their morphologic configuration into 3 types. Type I includes defects without a sac and there is cerebrospinal fluid (CSF) leak. Type II includes where there is a sac ≤4 cm, with or without CSF leak. Type III includes defects with a sac that are greater than 4 cm.

RESULTS

Fifty patients were included. The median age of gestation at surgery was 37.4 weeks. There were 30 females (60%). All mothers received adequate folate supplementation. All patients underwent surgical correction in the first 48 hours. Lower extremity motor function at the last clinical follow-up was normal in 34 patients (68%). CSF leak, infection, and mortality were 8%, 2%, and 0%, respectively. Twenty-one patients (42%) underwent ventriculoperitoneal shunt for hydrocephalus.

CONCLUSIONS

Despite there being no statistically significant associations with a timely closure, all cases were treated within the first 48 hours and this could influence the low complication rate. Individuals of Hispanic background who received appropriate folate supplementation still had high rates of MMC and we posit that this may be caused in part by a genetic/molecular predisposition.