Establishing Prenatal Surgery for Myelomeningocele in Asia: The Singapore Consensus

Abstract

Objectives: The Management of Myelomeningocele Study (MOMS Trial) has inspired many fetal therapy centers (FTCs) to offer open fetal surgery for myelomeningocele (MMC). This is an initial effort to create a candidate model that can be applicable to many parts of Asia. Material and Methods: A limited selection of specialists from 4 established FTCs in Thailand, Hong Kong, India, and Singapore met for a round table discussion. Experts from Children's Hospital of Philadelphia (CHOP) involved in the Trial moderated the session. The practice suggestions in this statement were from a targeted literature review and expert opinion. Results: A high prevalence of MMC in Asia supports an effort to adopt the procedure, but only in established FTCs with good maternal and neonatal ancillary supports. The falling incidence of MMCs may affect case volume and maintenance of skill. A regional approach was recommended. Fetal benefits have to be weighed against maternal risks, with a consideration of recent outcome data from the endoscopic approach. Responsible FTCs need standardized diagnosis and management, with their long-term outcome data available for an audit. Conclusions: It is envisaged that the information presented by this multidisciplinary team would be useful for FTCs in Asia or elsewhere that plan to establish more advanced fetal care in the future.

Towards Guideline-Based Management of Tethered Cord Syndrome in Spina Bifida: A Global Health Paradigm Shift in the Era of Prenatal Surgery

“…As the surgical technique of prenatal MMC closure continues to evolve, its adoption in different regions of the world will continue to increase. 17 However, a trend towards an increased rate of secondary tethering following the use of this new prenatal approach has been documented. 47,48 Danzer et al 49 reported that 14 out of 42 children (33%) developed spinal cord tethering, despite the prenatal surgical repair.…”

“…This issue requires particular attention as children undergoing prenatal closure of the spinal defect may not receive longitudinal follow-up if the fragmentation of care is not explicitly addressed after fetal surgery, or as they transition from pediatric-centered to adult-centered healthcare. Chiefly as The Singapore Consensus demonstrates, 17 centers across Asia are adopting emerging fetal surgical management techniques; therefore the potential risk for observing an increase in the incidence of TCS is ongoing. Therefore, a clear and evidence-based approach to the definition and management of TCS is crucial to provide the best quality of care possible across the globe.…”

“…As such, a standardized approach to the diagnosis and management of TCS could also be employed throughout Asia to allow for proper analysis and comparison of surgical outcomes among different treatment centers. 17 Moreover, we contend that the use of a standardized criteria will play a fundamental role in the global initiative to standardize the care and treatment of individuals with TCS across the globe.…”

“…[14][15][16] Moreover, during the 2nd Asia Pacific Conference on Fetal Therapy in Singapore, a round table discussion was held to create a candidate model which can be applied in Asia to offer fetal surgery for MMC. 17 Presenting with 2 etiologies, tethered cord syndrome (TCS) is a common SB comorbidity, present as part of the congenital syndrome (primary) or as secondary to the open MMC closure, which has an incidence of 14%-32%. [18][19][20][21] When individuals with NTDs begin to display early symptoms of neurological deterioration such as impaired motor function, lumbosciatica, scoliotic and kyphotic spinal deformities, bowel/bladder incontinence, or foot deformities, then surgical untethering is paramount.…”

Review on myelomeningocele management and its current status in Saudi Arabia

“…30 However, there is still much debate among neurosurgeons related to the timing of VP shunt insertion, whether at the same time as or performed in a separate procedure after the MMC is repaired. In the decades since Epstein, 31 published his paper in 1985 that advocated for simultaneous MMC repair and VP shunting, many papers have been published. Most of these papers are retrospective studies, and they have featured small numbers of patients.…”