Fetal Myelomeningocele Closure Research Articles

Laparoscopic repair of uterine dehiscence after open maternal-fetal surgery

A healthy 27-year old G3P3 was referred for preconception advice 3 years after she underwent open fetal myelomeningocele closure. In her previous pregnancy, she had a posterofundal hysterotomy at 25+2 weeks of gestation for fetal myelomeningocele closure. The uterus was then closed in a single full-thickness layer, incorporating the membranes and decidua, with an additional running locked suture to relieve tension on the scar. She had an uncomplicated pregnancy with a scheduled lower uterine segment transverse cesarean delivery at 36+3 weeks’ gestation. At the time of cesarean delivery, the hysterotomy scar from her fetal surgery appeared intact and was not revised.

MP53-11 URODYNAMIC FINDINGS IN PATIENTS AFTER FETAL MYELOMENINGOCELE UMBILICAL CORD PATCH CLOSURE

You have accessJournal of UrologyCME1 Apr 2023MP53-11 URODYNAMIC FINDINGS IN PATIENTS AFTER FETAL MYELOMENINGOCELE UMBILICAL CORD PATCH CLOSURE Cheryl Samuels and Jason Au Cheryl SamuelsCheryl Samuels More articles by this author and Jason AuJason Au More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We seek to characterize the urodynamic findings of patients after fetal myelomeningocele (MMC) closure with a novel umbilical cord (UC) patch. METHODS: After IRB approval, patient characteristics, ultrasound, urodynamic, serum creatinine, and voiding cystourethrogram (VCUG) data were extracted in a retrospective fashion from two patient cohorts from 2020-2022: study cohort was comprised of patients who had undergone fetal myelomeningocele closure with UC patch and a control cohort of standard postnatal myelomeningocele repairs without patch. Patients were excluded if there was incomplete one-year urodynamic data. Fisher’s Exact Test and unpaired T test were calculated (Graph Pad Prism 9). RESULTS: Fourteen patients were included for analysis: 6 UC patch and 8 controls. No differences in demographics were noted (Figure 1). No significant urodynamic or VCUG differences were noted (Figure 2). No significant differences in hydronephrosis, UTIs, serum creatinine or vesicostomy status were noted (Figure 3). CONCLUSIONS: Despite use of a novel UC patch for fetal MMC repair, no significant urodynamic differences are noted at one year. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e716 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cheryl Samuels More articles by this author Jason Au More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term neurological cognitive, behavioral, functional, and quality of life outcomes after fetal myelomeningocele closure: a systematic review.

Myelomeningocele is a lifelong condition that features several comorbidities, such as hydrocephalus, scoliosis, club foot, and lower limb sensory and motor disabilities. Its management has progressed over time, ranging from supportive care to early postnatal closure to prenatal closure of the defect. Recent research discovered that fetal myelomeningocele closure (fMMC) provided superior neurological outcomes to those of postnatal closure. When performed at 12 months of age, fMMC can avert or delay the need for a ventriculoperitoneal shunt and reversed the hindbrain herniation. Moreover, fMMC reportedly enhanced motor function and mental development at 30 months of age. However, its long-term outcomes remain dubious. This systematic review aimed to determine the long-term neurological cognitive, behavioral, functional, and quality of life (QoL) outcomes after fMMC. The PubMed, Directory of Open Access Journals, EBSCO, and Cochrane databases were extensively searched for articles published in 2007-2022. Meta-analyses, clinical trials, and randomized controlled trials with at least 5 years of follow-up were given priority. A total of 11 studies were included. Most studies revealed enhanced long-term cognitive, behavioral, functional, and QoL outcomes after fMMC. Our results suggest that fMMC substantially enhanced patients' long-term neurological cognitive, behavioral, functional, and QoL outcomes.

Placental Location in Maternal-Fetal Surgery for Myelomeningocele

Introduction: Uterine incision based on the placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regard to maternal or fetal outcomes. Objective: The aim of this study was to investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for fetal myelomeningocele (fMMC) closure. Methods: Data from the international multicenter prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, December 15, 2010–June 31, 2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. Results: The placental location for 623 patients was evenly distributed between anterior (51%) and posterior (49%) locations. Intraoperative fetal bradycardia (8.3% vs. 3.0%, p = 0.005) and performance of fetal resuscitation (3.6% vs. 1.0%, p = 0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the 2 groups. However, thinning of the hysterotomy site (27.7% vs. 17.7%, p = 0.008) occurred more frequently in cases of an anterior placenta. Gestational age (GA) at delivery (p = 0.583) and length of stay in the neonatal intensive care unit (p = 0.655) were similar between the 2 groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with the placental location. Conclusions: An anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied, but the aggregate data from the fMMC Consortium did not show a significant impact on the GA at delivery or maternal or fetal clinical outcomes.

Fetal Surgery for Open Spina Bifida in Canada: Initial Results.

Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017-2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R² = 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.

Open Fetal Surgical Outcomes for Myelomeningocele Closure Stratified by Maternal Body Mass Index in a Large Single-Center Cohort

Background: Open maternal-fetal surgery for in utero closure of myelomeningocele (MMC) has become an accepted treatment option for prenatally diagnosed open neural tube defects. Historically, this option has been limited to women with BMI < 35 due to concern for increasing complications in patients with obesity. Objective: The aim of this study was to evaluate maternal, obstetric, and fetal/neonatal outcomes stratified by maternal BMI classification in women who undergo open maternal-fetal surgery for fetal myelomeningocele (fMMC) closure. Methods: A single-center fMMC closure registry was queried for maternal demographics, preoperative factors, fetal surgery outcomes, delivery outcomes, and neonatal outcomes. Data were stratified based on maternal BMI: <30, 30–34.99, and ≥35–40, corresponding to normal weight/overweight, obesity class I, and obesity class II. Statistical analysis was performed using statistical software SAS v.9.4 (SAS Institute Inc., Cary, NC, USA). Results: A total of 264 patients were analyzed, including 196 (74.2%) with BMI <30, 54 (20.5%) with BMI 30–34.99, and 14 (5.3%) with BMI ≥ 35–40. Maternal demographics and preoperative characteristics were similar among the groups. Operative time increased with increasing BMI; otherwise, perioperative outcomes were similar among the groups. Obstetric and neonatal outcomes were similar among the groups. Conclusion: Increasing maternal BMI did not result in a negative impact on maternal, obstetric, and fetal/neonatal outcomes in a large cohort of patients undergoing open maternal-fetal surgery for fMMC closure. Further study is warranted to determine the generalizability of these results.

Detailed Analysis of Hydrocephalus and Hindbrain Herniation After Prenatal and Postnatal Myelomeningocele Closure: Report From a Single Institution.

The Management of Myelomeningocele Study (MOMS) demonstrated that fetal myelomeningocele (fMMC) closure results in improved hydrocephalus and hindbrain herniation when compared to postnatal closure. To report on the outcomes of a single institution's experience in the post-MOMS era, with regard to hydrocephalus absence and hindbrain herniation resolution. A single-center retrospective study of a subset of post-MOMS patients who underwent fetal/postnatal myelomeningocele closure was performed. Primary outcomes included cerebrospinal fluid (CSF) diversion status and hindbrain herniation resolution. Families were contacted via telephone for outcome information if care was transitioned to outside institutions. Univariate/multivariable analyses were performed using several prenatal and postnatal variables. From January 2011 to May 2016, data were reviewed from families of 62 postnatal and 119 fMMC closure patients. In the postnatal group, 80.6% required CSF diversion compared to 38.7% fetal cases (P<.01). Hindbrain herniation resolution occurred in 81.5% fetal repairs compared to 32.6% postnatal (P<.01). In the fetal group, fetal/premature neonatal demise occurred in 6/119 (5.0%) patients. There was a 42.0% decrease (95% CI -55.2 to -28.8) and 48.9% increase (95% CI 33.7 to 64.1) in risk difference for CSF diversion and hindbrain herniation resolution, respectively, in the fetal group. On univariate analysis for both groups, prenatal atrial diameter, frontal-occipital horn ratio, and hindbrain herniation resolution were significantly associated with the absence of clinical hydrocephalus. The treatment of hydrocephalus was significantly delayed in the fetal group compared to the postnatal group (10 mo vs 13.8 d). This study demonstrates the benefits of fMMC closure with regard to CSF dynamics.

Improved Postoperative Metrics with Modified Myofascial Closure in Fetal Myelomeningocele Repair.

The effect of modifications in fetal myelomeningocele (fMMC) closure techniques has not been extensively studied. To study the effect of a modified closure technique on fMMC postnatal patient outcomes: hydrocephalus, hindbrain herniation, and cyst development. We performed single-center retrospective study of a subset of post-MOMS (Management of Myelomeningocele Study) trial patients who underwent fMMC closure. After January 2015, the fetal myofascial closure technique was modified. Needlepoint monopolar cautery was used to raise dural lined myofascial flaps to create a more robust closure. Outcomes between the pre- and postmodification groups were compared with regard to hindbrain herniation, hydrocephalus, and cyst development. Families who transitioned care to local institutions were contacted via telephone for outcome information. From January 2011 to May 2016, data were reviewed from 119 fMMC closure patients. Patients without full follow-up data were excluded from the final analysis. Cerebrospinal fluid diversion was seen in 32 of 74 patients with the standard technique compared to 14 of 45 with the modified closure and was significantly decreased in postmodification when compared to that of the MOMS trial (P=.01). Hindbrain herniation resolution was significantly decreased in both the pre- and postmodification groups compared to that of the MOMS trial (P<.01). Prior to January 2015 with standard closure, 23 cysts required resection whereas no cysts required resection in the modified repair group (P<.01). Modified myofascial closure for fMMC closure is safe and feasible. The new approach reflects a decreased rate of cyst development requiring surgical resection, and a trend for improved rates of hindbrain herniation and hydrocephalus.

817: Perinatal outcomes after fetal resuscitation during fetal MMC closure

Fetal complications including extreme prematurity are known risks of fetal myelomeningocele (fMMC) closure. The objective of this study was to evaluate the rate of fetal resuscitation during fMMC closure, including incidence of delivery and evaluation of neonatal outcomes in these cases. An international multicenter registry was created to track and report maternal, obstetric, and fetal/neonatal outcomes for cases of open maternal-fetal surgery for MMC closure. Data are collected from each center and entered into a combined de-identified dataset using REDCap. Fetal resuscitation was defined as need for chest compression, fetal medication or transfusion. Intraoperative and neonatal outcomes in cases requiring fetal resuscitation were analyzed using descriptive statistics. Centers participating in the registry have obtained local IRB approval and executed data use agreements. A total of 750 cases of fMMC closure have been entered into the registry. Of those, fetal resuscitation was required in 14 cases (1.9%). Of the 14 resuscitation cases, 12received fetal medications, 8 received chest compressions, and 4 received fetal transfusion. For these 14 cases, median gestational age at the time of fetal surgery was 24.4 weeks (range 22.6-25.9) and median gestational age at delivery was 31.8 weeks (range 23.7-37.3). Of these, 4 were delivered on the day of maternal-fetal surgery and 1 was delivered within 1 week of maternal-fetal surgery. Four out of 14 resulted in perinatal death (29%). All 4 of these were delivered within 1 week of maternal-fetal surgery. Only 1 out of 5 that required delivery survived. Need for fetal resuscitation during fMMC closureis uncommon, with the need for immediate delivery being a rare event. Survival is poor when delivery is required. This data is useful for counseling patients prior to the procedure and can be helpful with complex decisions regarding neonatal resuscitation efforts.

Fetal surgical intervention for myelomeningocele: lessons learned, outcomes, and future implications.

Fetal myelomeningocele (fMMC) closure (spina bifida aperta) has become a care option for patients that meet inclusion criteria, but it is clear that fetal intervention, while improving outcomes, is not a cure. This review will: (1) focus on the rationale for fMMC surgery based on preclinical studies and observations that laid the foundation for human pilot studies and a randomized controlled trial; (2) summarize important clinical outcomes; (3) discuss the feasibility, efficacy, and safety of recent developments in fetal surgical techniques and approaches; and (4) highlight future research directions. Given the increased risk of maternal and fetal morbidity associated with prenatal intervention, accompanied by the increasing number of centres performing interventions worldwide, teams involved in the care of these patients need to proceed with caution to maintain technical expertise, competency, and patient safety. Ongoing assessment of durability of the benefits of fMMC surgery, as well as additional refinement of patient selection criteria and counselling, is needed to further improve outcomes and reduce the risks to the mother and fetus. WHAT THIS PAPER ADDS: High-quality prospective studies are needed to broaden the indication for fetal surgery in the general myelomeningocele population. Innovative minimally invasive approaches have had promising results, yet lack comprehensive and robust experimental or clinical evaluation. Important information to help families make informed decisions regarding fetal surgery for myelomeningocele is provided.

Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele

Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n= 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

213: Fetal myelomeningocele closure: outcomes from the fMMC consortium registry sponsored by NAFTNet

213: Fetal myelomeningocele closure: outcomes from the fMMC consortium registry sponsored by NAFTNet

1: Subsequent pregnancy outcomes after open maternal-fetal surgery for fetal myelomeningocele closure

Limited data is available regarding subsequent pregnancy outcomes after maternal-fetal surgery via hysterotomy. The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open fetal surgery (OFS) for myelomeningocele (MMC) closure. An international multicenter registry (North American Fetal Therapy Network/ fMMC Consortium Outcomes Registry) was created to track and report maternal, obstetric, fetal/neonatal and subsequent pregnancy outcomes following maternal-fetal surgery for MMC. Subsequent pregnancy outcome variables were collected via maternal questionnaire. Data are collected from each center and entered into a combined de-identified dataset using REDCap. Subsequent pregnancy outcomes data were analyzed using descriptive statistics. Centers participating in the registry obtained local IRB approval and executed data use agreements. A total of 52 subsequent pregnancies in 40 women were reported after OFS for MMC. Of these 40 women, 32 had 1 subsequent pregnancy, 5 women had 2, 2 women had 3, and 1 woman had 4 pregnancies after OFS, all singleton gestations. There are 10 that are ongoing or have missing outcome data. The live birth rate among those with complete data was 63%. Among the 52 subsequent pregnancies, 7 (13.5%) resulted in miscarriage < 20 weeks. Of the 35 pregnancies progressing > 20 weeks EGA, uterine rupture occurred in 11.4% (4/35) and OFS uterine incision thinning/dehiscence was described in 8.6% (3/35) at delivery. The mean GA at uterine rupture was 29 weeks (range 26-32); Two fetal deaths were reported as a result of uterine rupture. Placenta accreta was reported in a single case. Among live births, the mean GA at delivery was 36.2 weeks (range 26.4-38.4). Blood transfusion at delivery was required in 11.1%. All patients delivered via cesarean with 89.2 % via a low transverse uterine incision. Recurrence of fetal spina bifida was noted in 2 pregnancies. The risk of uterine rupture or dehiscence, with its associated risk of fetal morbidity and mortality, in subsequent pregnancies after open fetal surgery is significant. This risk should be included in the pre-operative counseling for patients who are candidates for maternal-fetal surgery. The risk for abnormal placentation requires additional investigation. Guidelines for management of pregnancies following OFS should be developed to address these risks.

Two-Port Endoscopic Fetal Closure of Myelomeningocele

Introduction: Open neural tube defects are a common congenital abnormality with significant consequences for affected children and their families. Issues include paraplegia, walking difficulties, bowel and bladder incontinence, and hydrocephalus. The 2011 Management of Myelomeningocele Study established fetal closure as a treatment option.1 Fetal closure reduces the incidence of hydrocephalus and improves motor outcomes compared with conventional postnatal closure. Open prenatal closure, however, necessitates hysterotomy and significantly increases the risk of preterm delivery and uterine dehiscence.2 Endoscopic approaches eliminating the need for hysterotomy have been described.3–5 Here we demonstrate our two-port endoscopic technique. Materials and Methods: The mother is at 26 weeks gestation and ultrasonography work-up has revealed a myelomeningocele defect of the fetus at the L3-S1 levels. A transverse abdominal opening is made for uterine exposure. Two ports are placed 6 cm apart with ultrasound guidance into the fundus of the uterus. A total of 300 cc of amniotic fluid are removed and the uterus is insufflated with humidified CO2 gas. The fetus and myelomeningocele defect are observed under endoscopic guidance. Endoscopic closure of the myelomeningocele is done in two major steps. First, the neural placode is released through sharp circumferential dissection of the arachnoid lying between the neural placode margin and the junctional zone. Second, the defect is closed primarily with interrupted vertical mattress sutures. Closure is facilitated with the use of relaxing flank incisions and retention sutures. Results: The child was born term at 39 weeks through vaginal delivery. Her neurologic examination demonstrates intact spinal function inclusive of the S1 level. Conclusions: Endoscopic fetal closure of myelomeningocele is technically feasible and can be accomplished through a two-port technique utilizing single layer closure. The avoidance of hysterotomy with this method may reduce the risk of preterm delivery and uterine dehiscence. No competing financial interests exist. Runtime of video: 6 mins 19 secs Related Presentations: Podium Presentation (ID 83697), IPEG's 26th Annual Congress for Endosurgery in Children, July 20, 2017, London, England.

Fetal Myelomeningocele Closure: Technical Considerations

Myelomeningocele (MMC) is one of the most common serious congenital malformations. Typically this condition has been treated with closure of the MMC defect shortly after birth. In general, surgery for MMC aims to provide a multilayered closure to provide protection to the neural elements, prevent leakage of spinal fluid and reduce infection risks. A randomized controlled trial, the Management of Myelomeningocele Study (MOMS), has shown that closure during the fetal period can be performed relatively safely and can result in significant benefit to the child. Whereas the surgical technique of prenatal closure of an MMC defect is similar to a postnatal closure, there are some important technical differences. The goal of this paper is to describe the technique of fetal closure of MMC defects, highlight the unique steps that are needed for this surgery and delineate some potential pitfalls.

Reducing perinatal complications and preterm delivery for patients undergoing in utero closure of fetal myelomeningocele: further modifications to the multidisciplinary surgical technique.

OBJECT.: As more pediatric neurosurgeons become involved with fetal myelomeningocele closure efforts, examining refined techniques in the overall surgical approach that could maximize beneficial outcomes becomes critical. The authors compared outcomes for patients who had undergone a modified technique with those for patients who had undergone fetal repair as part of the earlier Management of Myelomeningocele Study (MOMS). Demographic and outcomes data were collected for a series of 43 delivered patients who had undergone in utero myelomeningocele closure at the Fetal Center at Vanderbilt from March 2011 through January 2013 (the study cohort) and were compared with data for 78 patients who had undergone fetal repair as part of MOMS (the MOMS cohort). For the study cohort, no uterine trocar was used, and uterine entry, manipulation, and closure were modified to minimize separation of the amniotic membrane. Weekly ultrasound reports were obtained from primary maternal-fetal medicine providers and reviewed. A test for normality revealed that distribution for the study cohort was normal; therefore, parametric statistics were used for comparisons. The incidence of premature rupture of membranes (22% vs 46%, p = 0.011) and chorioamnion separation (0% vs 26%, p < 0.001) were lower for the study cohort than for the MOMS cohort. Incidence of oligohydramnios did not differ between the cohorts. The mean (± SD) gestational age of 34.4 (± 6.6) weeks for the study cohort was similar to that for the MOMS cohort (34.1 ± 3.1 weeks). However, the proportion of infants born at term (37 weeks or greater) was significantly higher for the study cohort (16 of 41; 39%) than for the MOMS cohort (16 of 78; 21%) (p = 0.030). Compared with 10 (13%) of 78 patients in the MOMS cohort, only 2 (4%) of 41 infants in the study cohort were delivered earlier than 30 weeks of gestation (p = 0.084, approaching significance). For the study cohort, 2 fetal deaths were attributed to the intervention, and both were believed to be associated with placental disruption; one of these mothers had previously unidentified thrombophilia. Mortality rates did not statistically differ between the cohorts. These early results suggest that careful attention to uterine entry, manipulation, and closure by the surgical team can result in a decreased rate of premature rupture of membranes and chorioamnion separation and can reduce early preterm delivery. Although these results are promising, their confirmation will require further study of a larger series of patients.

Maternal, Fetal, and Neonatal Care in Open Fetal Surgery for Myelomeningocele

Fetal myelomeningocele closure (fMMC) was demonstrated in a randomized, prospective clinical trial to improve outcomes for children diagnosed prenatally. Complex care of the maternal/fetal dyad undergoing fetal surgery requires a well-coordinated multidisciplinary team. Nurses in many roles are essential members of the team that cares for these women across the continuum. In this article we discuss the care of the woman, fetus, and family from initial contact through the discharge of the neonate.

In utero intervention for urologic diseases

The burgeoning use of prenatal ultrasonography has prompted discussion of the feasibility and capabilities of fetal intervention for urologic disorders. On the basis of the capabilities of fetal intervention, three prenatally diagnosed anomalies are of primary interest to urologists: congenital adrenal hyperplasia (CAH), lower urinary tract obstruction (LUTO) and myelomeningocele. Various interventions (surgical or pharmacological) are being developed for fetuses with these diagnoses. For fetuses with CAH or LUTO, successful outcomes have certainly been demonstrated, although no results from prospective randomized trials have been published. In utero treatment of CAH is accomplished through oral administration of glucocorticoids to the expectant mother. However, the long-term effects of this strategy have been insufficiently studied and remain undetermined. In the fetus with a LUTO, prenatal intervention has primarily been accomplished by placement of a vesicoamniotic shunt. Although this technique results in improved perinatal survival according to several systematic reviews of the literature, the data originate from small, heterogeneous populations of patients. By contrast, a randomized controlled trial of fetal myelomeningocele closure resulted in greatly reduced rates of both ventriculoperitoneal shunt placement and hydrocephalus. The future of fetal intervention in urology is contingent upon improved methods of studying the clinical outcomes of such treatments.

Long-Term Urological Impact of Fetal Myelomeningocele Closure

Long-Term Urological Impact of Fetal Myelomeningocele Closure

Long-Term Urological Impact of Fetal Myelomeningocele Closure

Between 1997 and 2002 a large number of fetal myelomeningocele closures were performed at our institution. Previously early reports showed little improvement in neonatal bladder function after fetal back closure. We evaluated the long-term urological impact of this procedure. Using a combination of retrospective review and survey questionnaire we reviewed the records of 28 patients in whom fetal myelomeningocele closure was done at our institution between 1997 and 2002. The areas addressed included medical management for neurogenic bladder and bowel, need for lower urinary tract reconstruction and functional bladder assessment by videourodynamics. Parameters after fetal myelomeningocele closure were compared to those of 33 age and sex matched patients with myelomeningocele who underwent standard postnatal closure. We reviewed the records of 28 patients after fetal myelomeningocele closure. At a mean age of 9.6 years 23 used clean intermittent catheterization to manage the bladder, 24 required a bowel regimen to manage constipation and 6 underwent lower urinary tract reconstruction with enterocystoplasty and a catheterizable bladder channel. Videourodynamics performed in 14 patients at a mean age of 7.4 years revealed decreased bladder capacity in 71%, detrusor overactivity in 35% and increased detrusor pressure in 25%. Compared to age and sex matched children who underwent postnatal closure we noted no significant differences in bladder management, urinary tract surgery or urodynamics. Neurogenic bowel and bladder management continues to be a significant issue for patients after fetal myelomeningocele closure. After fetal surgery patients should be followed closely, similar to patients who undergo postnatal closure.