Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery?

Abstract

Since the completion of the Management of Myelomeningocoele Study, maternalfetal surgery for spina bifida has become a valid option for expecting parents.More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach.Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence. | INTRODUCTIONAfter its publication in 2011, the Management of Myelomeningocele study (MOMS) has led to a widespread expansion of centers offering prenatal surgery for fetuses with a spina bifida. 1,2 The benefits of prenatal surgery are a reduction in the need for ventriculo-peritoneal (VP) shunt placement, as well as improved mental development, motor and urological outcomes. 1,3 The downside of open maternalfetal surgery is the high maternal morbidity and the risk of uterine rupture due to the large hysterotomy in current and subsequentThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data

“…confounding factors could be considered as second best. 31 This should also include factors unrelated to the severity of the condition but to the surgery and postnatal management center, including experience and case load, which may also influence outcome. 33,34 It may be wise to also apply that registration to the rarer forms of CDH, such as right-sided cases.…”

Maternal–Fetal Surgery: Does Recognising Fetal Patienthood Pose a Threat to Pregnant Women’s Autonomy?

“…The surgical technique used for this treatment is typically the invasive, open surgery variant of MFS [ 3 , 39 ]. In recent years there has been a move towards using fetoscopic techniques, but further clinical trials are required to determine their efficacy [ 36 ], and there is currently a lack of standardised procedures and high-quality evidence to ascertain their purported advantages over the open surgical procedure [ 54 ].…”

“…An evaluation of the MOMS trial outcomes acknowledged that the procedure carries non-negligible risks of adverse effects on the health of both pregnant women and fetuses, suggesting that the surgical technique needs to be improved [ 1 ]. At this point, both the open surgery and fetoscopic variant of MFS entail potential harms to the pregnant woman [ 54 ], though the more invasive variant has been shown to pose significantly higher risks [ 29 ]. There are also risks to fetal outcomes and the remainder of the pregnancy.…”

Getting earlier, smaller and regenerative: The next 10 years of in utero spina bifida repair

“…Collaborative prospective studies comparing different techniques will be needed to fast forward the field and minimize maternal morbidity without compromising fetal outcome. Those collaborative multicentre studies may also facilitate and accelerate the implementation of experimental therapies linked to regenerative medicine approaches aiming at improving neuro‐regeneration and minimally invasive healing 23 …”

“…Those collaborative multicentre studies may also facilitate and accelerate the implementation of experimental therapies linked to regenerative medicine approaches aiming at improving neuroregeneration and minimally invasive healing. 23 For the fetus, the principle objectives of surgery are to optimize motor outcome, improve hindbrain herniation and reduce the significant burden associated with shunted hydrocephalus. Current evidence suggests that prenatal surgery does not reverse these problems but rather halts their progression.…”