Sanz-Cortes Magdalena, Whitehead William E, Johnson Rebecca M, Aldave Guillermo, Castillo Heidi, Desai Nilesh K, Donepudi Roopali, Joyeux Luc, King Alice, Kralik Stephen F, Lepard Jacob, Mann David G, McClugage Samuel G, Nassr Ahmed A, Naus Claire, Nguyen Gabrielle, Castillo Jonathan, Ravindra Vijay M, Sutton Caitlin D, Weiner Howard L, Belfort Michael A
1Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, Texas.
2Texas Children's Fetal Center, Houston, Texas.
J Neurosurg Pediatr. 2024 Nov 1;35(1):10-21. doi: 10.3171/2024.7.PEDS24200. Print 2025 Jan 1.
This study reports the infant to preschool outcomes of a laparotomy-assisted, two-port fetoscopic myelomeningocele (MMC) repair and compares the results with those of a contemporary, same-center cohort that underwent either fetal MMC surgery via hysterotomy or postnatal MMC repair.
All MMC closures between December 2011 and July 2021 were screened. Singleton pregnancies with hindbrain herniation and MMC between T1 and S1 were included. Fetuses were excluded for genetic abnormalities, severe kyphosis, and other congenital anomalies. The pregnant woman determined the method of MMC repair (fetoscopic, hysterotomy, or postnatal repair).
Two hundred MMC closures met the study criteria (100 fetoscopic, 41 hysterotomy, and 59 postnatal). The median length of follow-up was beyond 46 months for all groups. The median gestational age at delivery was 38.1 weeks (IQR 35.1, 39.1 weeks) for the fetoscopic group, 35.7 weeks (IQR 33.6, 37.0 weeks) for the hysterotomy group, and 38.6 weeks (IQR 37.7, 39.0 weeks) for the postnatal group. Vaginal delivery occurred in 51% of the fetoscopic cases, and there were no instances of uterine dehiscence or rupture. Treatment for hydrocephalus in the 1st year occurred in 35% (95% CI 27%-50%) of fetoscopic, 33% (95% CI 20%-50%) of hysterotomy, and 81% (95% CI 70%-90%) of postnatal repair cases. At 30 months, patients who underwent fetal intervention were twice as likely to be community ambulators (with or without devices) as those who underwent postnatal repair (52% [95% CI 42%-62%] of fetoscopic, 54% [95% CI 39%-68%] of hysterotomy, and 24% [95% CI 14%-36%] of postnatal cases). Surgery for symptomatic tethered cord occurred in 12% (95% CI 7%-19%) of fetoscopic, 17% (95% CI 8%-31%) of hysterotomy, and 2% (95% CI 1%-8%) of postnatal repair cases. Surgery for symptomatic spinal inclusion cysts was required in 4% (95% CI 1%-9%) of fetoscopic, 7% (95% CI 2%-18%) of hysterotomy, and none (95% CI 0%-8%) of the postnatal cases.
Laparotomy-assisted, two-port fetoscopic repair provides significant benefits for maternal health. It negates the risk of uterine rupture for the index pregnancy and subsequent pregnancies and allows for vaginal delivery. The benefits to the fetus are the same as those of hysterotomy repairs, with a lower risk of prematurity. There was no difference in the rate of surgery for tethered cord or spinal inclusion cysts between fetoscopic and hysterotomy procedures. Overall, laparotomy-assisted, two-port fetoscopic repair is safer for the fetus and the mother than fetal MMC surgery via hysterotomy.
本研究报告剖腹术辅助两孔胎儿镜下脊髓脊膜膨出（MMC）修复术的婴幼儿至学龄前结局，并将结果与同期在同一中心接受经子宫切开术的胎儿MMC手术或出生后MMC修复术的队列进行比较。
对2011年12月至2021年7月期间所有MMC闭合手术进行筛查。纳入单胎妊娠、存在后脑疝且MMC位于T1至S1之间的病例。排除存在基因异常、严重脊柱后凸及其他先天性异常的胎儿。由孕妇决定MMC修复方法（胎儿镜手术、子宫切开术或出生后修复）。
200例MMC闭合手术符合研究标准（100例胎儿镜手术、41例子宫切开术、59例出生后修复）。所有组的中位随访时间均超过46个月。胎儿镜手术组的中位分娩孕周为38.1周（四分位间距35.1，39.1周），子宫切开术组为35.7周（四分位间距33.6，37.0周），出生后修复组为38.6周（四分位间距37.7，39.0周）。51%的胎儿镜手术病例经阴道分娩，未发生子宫裂开或破裂情况。第一年接受脑积水治疗的比例在胎儿镜手术病例中为35%（95%置信区间27%-50%），子宫切开术病例中为33%（95%置信区间20%-50%），出生后修复病例中为81%（95%置信区间70%-90%）。在30个月时，接受胎儿干预的患者成为社区步行者（使用或不使用辅助装置）的可能性是接受出生后修复患者的两倍（胎儿镜手术组为52%[95%置信区间42%-62%]，子宫切开术组为54%[95%置信区间39%-68%]，出生后修复病例组为24%[95%置信区间14%-36%]）。症状性脊髓栓系手术在胎儿镜手术病例中的发生率为12%（95%置信区间7%-19%），子宫切开术病例中为17%（95%置信区间8%-31%），出生后修复病例中为2%（95%置信区间1%-8%）。症状性脊柱包涵囊肿手术在胎儿镜手术病例中的需要率为4%（95%置信区间1%-9%），子宫切开术病例中为7%（95%置信区间2%-18%），出生后修复病例中无一例（95%置信区间0%-8%）。
剖腹术辅助两孔胎儿镜修复术对母体健康有显著益处。它消除了本次妊娠及后续妊娠子宫破裂的风险，并允许经阴道分娩。对胎儿的益处与子宫切开术修复相同，早产风险较低。胎儿镜手术与子宫切开术在脊髓栓系或脊柱包涵囊肿手术率方面无差异。总体而言，剖腹术辅助两孔胎儿镜修复术对胎儿和母亲而言比经子宫切开术的胎儿MMC手术更安全。
