Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution?

Abstract

The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.

Comparison of umbilical cord occlusion methods: Radiofrequency ablation versus laser photocoagulation

“…A multi‐center retrospective review reported the RFA UCO outcomes significantly differed between centers that had performed ≥6 cases and those that had performed ≤5 cases . Prior studies have suggested that the learning curve for selective laser photocoagulation of communicating vessels for TTTS stabilizes after 25 cases . This study compared the surgical outcomes from 2 different time frames.…”

“…16 Prior studies have suggested that the learning curve for selective laser photocoagulation of communicating vessels for TTTS stabilizes after 25 cases. 17,18 This study compared the surgical outcomes from 2 different time frames. Prior to the year 2014, the preferred method of UCO was via laser, while after 2014, the preferred method of UCO was RFA.…”

A novel “video‐game” simulator for training fetoscopic laser coagulation of anastomoses in twin‐to‐twin transfusion syndrome

“…1 This procedure is technically complex with significant risks of fetal and/or maternal complications and universal provision continues to be challenging. 2 Surgical training with twin-twin simulators has been proposed in order to help centres meet these challenges. Recent publications have described TTTS simulators, both physical 3,4 and digital.…”

The Rationale for Fetal Therapy

“…Examples for approaches that aim to achieve a prenatal cure include fetal blood transfusions for anemia [22] and fetoscopic laser dichorionization of the placenta in TTTS [39]. In addition to the appropriate care setting, the ability to achieve the intended outcome with these low-to medium-complexity therapies relies on operator experience and ongoing caseload [40][41][42][43][44]. Because the mortality of the underlying conditions in the absence of treatment is high, thresholds for the establishment of treatment centers are lower than for more complex treatments.…”