Fetal repair of myelomeningocele: current status and urologic implications
Douglass B Clayton1, John C Thomas1, John W Brock1
1Department of Urology, Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
Insights
Fetal myelomeningocele (MMC) repair in the US shows improved neurosurgical outcomes but mixed urological results. Recent studies suggest potential bladder function benefits compared to traditional methods.
Area of Science:
- Pediatric Surgery
- Neuroscience
- Urology
Background:
- Open neural tube defect care has evolved significantly over 40 years.
- Improved survival rates for children with myelomeningocele (MMC) into adulthood.
- Fetal repair of MMC lesions is now a clinical reality.
Purpose of the Study:
- To review the history and current impact of fetal MMC repair in the United States.
- To assess neurosurgical and urological outcomes of prenatal MMC repair.
- To update readers on advancements in MMC care.
Main Methods:
- Review of historical data and pioneering efforts in fetal MMC repair.
- Analysis of neurosurgical outcomes including hindbrain herniation and hydrocephalus.
- Evaluation of urological outcomes, including bladder function and urodynamic studies (UDS).
Main Results:
- Fetal MMC repair demonstrates significant neurosurgical benefits: reduced hindbrain herniation, decreased shunt-dependent hydrocephalus, and improved lower-extremity motor function.
- Urological outcomes from fetal MMC repair have been less consistently positive, with some studies showing no short-term or long-term bladder function improvements.
- Recent data from the Management of Myelomeningocele Study suggest potential improvements in certain bladder functions with fetal repair compared to conventional repair.
Conclusions:
- Fetal MMC repair offers substantial neurosurgical advantages.
- The urological benefits of fetal MMC repair require further investigation, despite recent promising findings.
- Continued research is crucial to optimize both neurosurgical and urological outcomes for fetal MMC repair.
Abstract:
Over the last 40 years, vast changes have occurred in the care of children with open neural tube defects. Not only has newborn survival dramatically improved but survival into adulthood has improved as well. Now, the ability to accurately identify and repair myelomeningocele (MMC) lesions before birth has become a reality. Pioneering efforts at several institutions in the United States paved the way for such advancements in care. Substantial data now exist to support the positive benefits of fetal MMC repair from a neurosurgical standpoint, chiefly the significant reduction in hindbrain herniation, decrease in shunt-dependent hydrocephalus, and improvement in lower-extremity motor function. However, until only recently, the urological impact of fetal repair has not been nearly as positive overall. Multiple retrospective reports of newborn bladder function from the United States suggest that prenatal repair has provided neither short-term nor long-term improvements in bladder function. Yet, the retrospective nature of these data and their focus upon urodynamic studies (UDS) parameters have hampered the ability to draw conclusions. Recently, published data from the landmark Management of Myelomeningocele Study indicate that fetal repair may improve certain aspects of bladder function when compared with conventional repair. This review provides an overview of the history and timeline of fetal repair in the United States and brings the reader quickly up to date on the current impact of repair on both neurosurgical and urological outcomes.
