New directions in fetal surgery for myelomeningocele
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The treatment of children with myelomeningocele (MMC) has improved over time, from supportive management to early postnatal closure to prenatal repair of the defect. The Management of Myelomeningocele Study (MOMS) showed that prenatal repair of MMC resulted in improved neurological outcomes compared to postnatal closure. Follow-up studies showed that prenatal repair was, as with any other fetal intervention, associated with higher rates of obstetrical complications. There was no significant difference in urological outcomes. Long-term follow-up of ambulatory status, executive functioning, and urological outcomes is needed to determine the durable effects of fetal MMC repair on mobility, functional independence, and the prevalence of renal insufficiency in patients with MMC who survive to adulthood. The future of fetal MMC repair consists of developing strategies to reduce maternal morbidity and improve infant outcomes. Fetoscopic MMC repair has been suggested as an alternative to open repair that may reduce obstetrical complications and the need for cesarean delivery in subsequent pregnancies. Translational research using mesenchymal stromal cells to augment fetal repair of ovine MMC has shown improvement in motor function.
KeywordsMyelomeningocele Prenatal repair Fetal surgery Fetoscopic
Compliance with ethical standards
Conflict of interest
The authors report no conflict of interest.
This study was not funded.
- 7.Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, Anderson P, Mason CA, Collins JS, Kirby RS, Correa A, National Birth Defects Prevention N (2010) Updated National Birth Prevalence estimates for selected birth defects in the United States, 2004-2006. Birth Defects Research Part A, Clinical and Molecular Teratology 88:1008–1016CrossRefPubMedGoogle Scholar
- 12.Adzick NS, Thom EA, Spong CY, Brock JWI, Burrows PK, Johnson MP, Howell LJ, Farrell JA, Dabrowiak ME, Sutton LN, Gupta N, Tulipan NB, D'Alton ME, Farmer DL (2011) A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 364:993–1004CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Tulipan N, Wellons JC III, Thom EA, Gupta N, Sutton LN, Burrows PK, Farmer D, Walsh W, Johnson MP, Rand L, Tolivaisa S, D’alton ME, Adzick NS (2015) Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr 16:613–620CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Kulkarni AV, Riva-Cambrin J, Holubkov R, Browd SR, Cochrane DD, Drake JM, Limbrick DD, Rozzelle CJ, Simon TD, Tamber MS, III JCW, Whitehead WE, Kestle JRW, Network ftHCR (2016) Endoscopic third ventriculostomy in children: prospective, multicenter results from the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 18:423–429CrossRefPubMedGoogle Scholar
- 16.Kulkarni AV, Riva-Cambrin J, Browd SR, Drake JM, Holubkov R, Kestle JRW, Limbrick DD, Rozzelle CJ, Simon TD, Tamber MS, Wellons JC III, Whitehead WE (2014) Endoscopic third ventriculostomy and choroid plexus cauterization in infants with hydrocephalus: a retrospective Hydrocephalus Clinical Research Network study. J Neurosurg Pediatr 14:224–229CrossRefPubMedGoogle Scholar
- 19.Danzer E, Thomas NH, Thomas A, Friedman KB, Gerdes M, Koh J, Adzick NS, Johnson MP (2016) Long-term neurofunctional outcome, executive functioning, and behavioral adaptive skills following fetal myelomeningocele surgery. Am J Obstet Gynecol 214(269):e261–e268Google Scholar
- 24.Soni S, Moldenhauer JS, Spinner SS, Rendon N, Khalek N, Martinez-Poyer J, Johnson MP, Adzick NS (2016) Chorioamniotic membrane separation and preterm premature rupture of membranes complicating in utero myelomeningocele repair. Am J Obstet Gynecol 214(647):e641–e647Google Scholar
- 25.Johnson MP, Bennett KA, Rand L, Burrows PK, Thom EA, Thom LJ, Farrell JA, Dabrowiak ME, Brock JW, 3rd, Farmer DL, Adzick NS, Management of Myelomeningocele Study I (2016) The Management of Myelomeningocele Study: obstetrical outcomes and risk factors for obstetrical complications following prenatal surgery. Am J Obstet GynecolGoogle Scholar
- 26.Iqbal CW, Hirose S, Lee H (2014) Fetal therapy. In: Holcomb III GW, Murphy JD, Ostlie DJ (eds) Ashcraft’s pediatric surgery. Elsevier Health Sciences, pp 131–143Google Scholar
- 28.Kohl T, Tchatcheva K, Merz W, Wartenberg HC, Heep A, Muller A, Franz A, Stressig R, Willinek W, Gembruch U (2009) Percutaneous fetoscopic patch closure of human spina bifida aperta: advances in fetal surgical techniques may obviate the need for early postnatal neurosurgical intervention. Surg Endosc 23:890–895CrossRefPubMedGoogle Scholar
- 30.Kohl T (2014) Percutaneous minimally invasive fetoscopic surgery for spina bifida aperta. Part I: surgical technique and perioperative outcome. Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology 44:515–524CrossRefGoogle Scholar
- 31.Pedreira DA, Zanon N, de Sa RA, Acacio GL, Ogeda E, Belem TM, Chmait RH, Kontopoulos E, Quintero RA (2014) Fetoscopic single-layer repair of open spina bifida using a cellulose patch: preliminary clinical experience. The Journal of Maternal-Fetal & Neonatal Medicine : the Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet 27:1613–1619CrossRefGoogle Scholar
- 37.Kabagambe S, Chen Y, Farmer D (2016) Fetal surgery for myelomeningocele: a review of current clinical practice and translational research. Minerva PediatrGoogle Scholar
- 38.Araujo EJ, Tonni G, Martins WP (2016) Outcomes of infants followed-up at least 12 months after fetal open and endoscopic surgery for meningomyelocele: a systematic review and meta-analysis. J Evid Based MedGoogle Scholar
- 39.Araujo Junior E, Eggink AJ, van den Dobbelsteen J, Martins WP, Oepkes D (2016) Procedure-related complications of open vs endoscopic fetal surgery for treatment of spina bifida in an era of intrauterine myelomeningocele repair: systematic review and meta-analysis. Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology 48:151–160CrossRefGoogle Scholar
- 45.Watanabe M, Li H, Kim AG, Weilerstein A, Radu A, Davey M, Loukogeorgakis S, Sánchez MD, Sumita K, Morimoto N, Yamamoto M, Tabata Y, Flake AW (2016) Complete tissue coverage achieved by scaffold-based tissue engineering in the fetal sheep model of myelomeningocele. Biomaterials 76:133–143CrossRefPubMedGoogle Scholar