Fetoscopy for meningomyelocele repair: past, present and future

Abstract

Meningomyelocele is a malformation with high prevalence, and one of its main comorbidities is Arnold-Chiari malformation type II. The intrauterine repair of this defect has been studied to reduce the progressive spinal cord damage during gestation. The purpose of the present review was to describe the evolution of fetal surgery for meningomyelocele repair. Searches on PubMed database were conducted including articles published in the last 10 years. Twenty-seven articles were selected, 16 experimental studies and 11 studies in humans. A recent study demonstrated that the fetal correction results in better prognosis of neurological and psychomotor development, but open surgery, which has being used widely, has considerable maternal risks. Studies in animal and human models show that the endoscopic approach is feasible and leads to lower maternal morbidity rates. Two endoscopic techniques are currently under assessment - one in Germany and another in Brazil, and we believe that the endoscopic approach will be the future technique for prenatal repair of this defect.

Figure 1. Concentric diagram of the 78 articles primarily selected. The majority were non-randomized human studies (approximately 58.6%) and experimental studies (36%), with few articles related to legal aspects and the randomized study Management of myelomeningocele Study. Most articles covered the endoscopic approach

Figure 2. Side effects studies MOMS

Figure 3. Illustration of the endoscopic technique for myelomeningocele repair, developed by Pedreira et al.⁽²⁸⁾

Figura 1. Diagrama concêntrico dos 78 artigos primariamente selecionados. Observa-se o predomínio de estudos em humanos não randomizados (aproximadamente 58,6%) e de estudo experimentais (36%), com poucos artigos relacionados à discussão legal e ao estudo randomizado Management of Myelomeningocele Study. Destacam-se os artigos relacionados à abordagem endoscópica

Figura 2. Efeitos secundários estudos MOMS

Gráfico elaborado a partir dos dados do estudo Management of Myelomeningocele Study ⁽⁷⁾ mostra redução expressiva de casos com malformação de Arnold-Chiari II bem como menores taxas de derivação ventrículo-peritoneal em crianças submetidas à correção fetal da meningomielocele (64 e 40%, respectivamente), quando comparadas à cirurgia pós-natal (96 e 82%, respectivamente). Esse mesmo grupo apresentou o dobro de chance de deambular (42%), em comparação aos neonatos corrigidos após o nascimento (21%). Em contraste, observou-se maior prematuridade no grupo de cirurgia fetal.

Figura 3. Ilustração da técnica endoscópica para correção da meningomielocele, desenvolvida por Pedreira et al.⁽²⁸⁾