Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization

Abstract

Objective A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal–fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin‐over‐biocellulose for antenatal fetoscopic repair (SAFER) technique, on long‐term postnatal outcome. Methods This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12‐ and 30‐month follow‐up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. Results A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow‐up at 12 months of age and 59 had follow‐up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. Conclusion Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long‐term neurological outcomes similar to those reported in the literature after hysterotomy‐assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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

“…Lapa et al tested the patch in fetal rabbit and sheep models before applying it clinically for fetoscopic SBA surgery. 16,22,[44][45][46] In her initial study in the rabbit model, the repaired defect healed completely, with the patch remaining in place, and "without any signs of tissue rejection" at term. 22 We documented similar effects with both Duragen and Durepair in the same model she used.…”

Biocellulose patch technique for fetoscopic repair of open spina bifida in twin pregnancy

“…An ethical discussion regarding fetal surgery in twins discordant for diaphragmatic hernia concluded that certain maternal–fetal surgical interventions may be ethically permissible if the risk to the unaffected twin is minimal and the procedure improves the likelihood of survival of the compromised fetus 17 . Although OSB is not lethal, the benefits of prenatal surgery are established 1,2,8,20,21 . We believe the risk to the unaffected twin may be minimized by delaying surgery to 28–30 gestational weeks to mitigate the risk of extremely preterm birth in case delivery is required during surgery.…”

Advances in Fetal Surgical Repair of Open Spina Bifida

“…102,119,154 Short-term neurologic outcomes by 12 months of life were similar: 43.8% of patients undergoing fetoscopic repair required a ventriculoperitoneal shunt insertion or other CSF diversion procedure compared with 40.8% of patients in the original MOMS trial. 102,119 Recently, several collaborating centers published long-term neurologic outcomes at 30 months of life, demonstrating a 46-54% independent ambulation rate in patients undergoing prenatal fetoscopic repair 156,157 compared with the 42% independent ambulation rate at 30 months of life observed in the original MOMS trial. 102 In addition, 61% of patients undergoing fetoscopic repair demonstrated independent voiding without clean intermittent catheter use at 30 months of life 156 compared with 38% of patients after open prenatal repair at the long-term follow-up (mean age 7.4 years).…”