Comparison of two fetoscopic open neural tube defect (ONTD) repair techniques: Single-layer vs three-layer closure.

Belfort, M A; Whitehead, W E; Shamshirsaz, A A; Espinoza, J; Nassr, A A; Lee, T C; Olutoye, O O; Keswani, S G; Cortes, M Sanz

OBJECTIVES We previously reported on a fetoscopic repair for open neural tube defect (ONTD) using a single layer closure (SLC). Because of a high rate of cerebrospinal fluid (CSF) leak at birth we developed a 3 layer closure (3LC) comprising a bovine collagen patch, a myofascial layer and a skin layer, using the same exteriorized uterus, fetoscopic technique. METHODS Prospective cohort study: 32 consecutive SLC controls were compared with 18 consecutive 3LC cases. All patients satisfied Management of Myelomeningocele Study (MOMS) criteria. Obstetric, maternal, fetal, and early neonatal outcomes were compared. RESULTS Maternal demographics and gestational age at fetal surgery (24.9 ± 0.7 vs. 25.0 ± 0.5 weeks; p = NS) and at delivery (36.5 ± 3.5 vs. 37.6 ± 3.1 weeks; p = 0.14) were similar for SLC vs. 3LC, respectively. PPROM < 37 weeks (28% vs. 29%; p = NS), timing of PPROM (32.3 ± 3.4 vs. 32.7 ± 1.9 weeks; p = NS), and vaginal delivery (50% vs. 47%; p = 0.8) were similar for SLC vs. 3LC respectively. SLC showed a significantly higher rate of CSF leak (8/32 (25%) vs. 3LC (0/17 (0%); p = 0.02), and a lower rate of reversal of hind brain herniation at 6 weeks postoperatively (SLC = 18/30 (60%) vs. 3LC = 14/15 (93%); p 0.02). The rates of meeting MOMS criteria for hydrocephalus (SLC = 23/31 (74%) vs. 3LC = 7/12 (58%); p = 0.31) and requiring treatment for hydrocephalus at 12 months (15/32 (47%) SLC controls vs. 4/12 (33%) 3LC; p=0.14) were similar. CONCLUSIONS Compared to SLC, 3LC preserves the fetal and obstetric benefits of fetoscopic repair, and shows improved rates of CSF leakage and reversal of hindbrain herniation at 6 weeks postoperatively. ClinicalTrials.gov NCT02230072 and NCT03794011 This article is protected by copyright. All rights reserved.