Comparison of open fetal, fetoscopic and postnatal surgical repair for open spina bifida: decision analysis

Currently, there are several surgical approaches to manage fetal open spina bifida (OSB), namely postnatal surgical repair, open fetal surgery and its minimally invasive alternative, fetoscopic repair. Our objective was to determine the optimal surgical approach for OSB, weighing the benefits and risks to the fetus and the pregnant woman.

We assessed the health outcomes of open fetal, fetoscopic and postnatal surgical repair for pregnant women (mean ± SD age, 31 ± 3 years) with a singleton pregnancy and their offspring with OSB using a decision analytic model. We projected expected quality-adjusted life years (QALYs) associated with each of the interventions, discounted at 1.5% annually over the lifetime time horizon for pregnant women and their offspring. Secondary maternal outcomes during the pregnancy included delivery mode and complications such as chorioamnionitis, uterine dehiscence, placental abruption, pulmonary embolism and death. Offspring outcomes included preterm birth, perinatal and postnatal mortality, cerebrospinal fluid (CSF) diversion surgery by 12 months of age and wheelchair use at 30 months of age. Our model was populated using data from the published literature and by consultation with clinical experts. Deterministic and probabilistic sensitivity analyses were conducted.

Fetoscopic and open fetal surgery resulted in an identical number of expected QALYs (38.02 per mother-offspring dyad) and translated into a QALY gain of 1.70 per dyad compared with postnatal repair. With respect to QALYs gained, the probabilistic analyses showed that fetoscopic surgery was the preferred strategy in 51% of simulations, and open fetal surgery in the remaining 49% of simulations. When compared with postnatal repair, both open fetal and fetoscopic surgery showed that the gains in QALYs were most sensitive to the disutility associated with CSF diversion surgery and to the rate of wheelchair use. When comparing open fetal and fetoscopic approaches, the results were highly sensitive to the accuracy of all treatment effect estimates.

In the management of fetal OSB, both fetoscopic and open fetal surgery demonstrate superior QALY gains compared with postnatal repair, largely related to a reduced number of individuals who use a wheelchair or require CSF diversion surgery. Given similar effectiveness of fetoscopic and open fetal surgery, an individual risk assessment is essential to guide decision-making between these two surgical approaches. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.