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Advances in Fetal Surgical Repair of Open Spina Bifida. Obstet Gynecol 2023; 141:505-521. [PMID: 36735401 DOI: 10.1097/aog.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023]
Abstract
Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.
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Lee SY, Papanna R, Farmer D, Tsao K. Fetal Repair of Neural Tube Defects. Clin Perinatol 2022; 49:835-848. [PMID: 36328602 DOI: 10.1016/j.clp.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Myelomeningocele is the most common congenital neurologic defect, and the only nonlethal disease addressed by fetal surgery. A randomized control trial has established amelioration of the Arnold-Chiari II malformation, reduced ventriculoperitoneal shunt rate, and improvement in distal neurologic function in patients that receive in utero repair. Long-term follow-up of these school-age children demonstrates the persistence of these effects. The use of stem cells in fetal repair is being investigated to further improve distal motor function.
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Affiliation(s)
- Su Yeon Lee
- Department of Surgery, Division of Pediatric, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Room 5107, Sacramento, CA 95817, USA.
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Science Center at Houston, 6410 Fannin Street, Suite 210, Houston, TX 77030, USA
| | - Diana Farmer
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Sacramento, CA 95817, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, UT Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA
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Wei X, Ma W, Gu H, Liu D, Luo W, Bai Y, Wang W, Lui VCH, Yang P, Yuan Z. Transamniotic mesenchymal stem cell therapy for neural tube defects preserves neural function through lesion-specific engraftment and regeneration. Cell Death Dis 2020; 11:523. [PMID: 32655141 PMCID: PMC7354991 DOI: 10.1038/s41419-020-2734-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 12/24/2022]
Abstract
Neural tube defects (NTDs) lead to prenatal mortality and lifelong morbidity. Currently, surgical closure of NTD lesions results in limited functional recovery. We previously suggested that nerve regeneration was critical for NTD therapy. Here, we report that transamniotic bone marrow-derived mesenchymal stem cell (BMSC) therapy for NTDs during early development may achieve beneficial functional recovery. In our ex vivo rat embryonic NTD model, BMSCs injected into the amniotic cavity spontaneously migrated into the defective neural tissue. Hepatocyte growth factor and its receptor c-MET were found to play critical roles in this NTD lesion-specific migration. Using the in vivo rat fetal NTD model, we further discovered that the engrafted BMSCs specifically differentiated into the cell types of the defective tissue, including skin and different types of neurons in situ. BMSC treatment triggered skin repair in fetuses, leading to a 29.9 ± 5.6% reduction in the skin lesion area. The electrophysiological functional recovery assay revealed a decreased latency and increased motor-evoked potential amplitude in the BMSC-treated fetuses. Based on these positive outcomes, ease of operation, and reduced trauma to the mother and fetus, we propose that transamniotic BMSC administration could be a new effective therapy for NTDs.
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Affiliation(s)
- Xiaowei Wei
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Wei Ma
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Hui Gu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Dan Liu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Wenting Luo
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, PR China
| | - Weilin Wang
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, PR China
| | - Vincent Chi Hang Lui
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
| | - Peixin Yang
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Zhengwei Yuan
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China.
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Wei X, Cao S, Ma W, Zhang C, Gu H, Liu D, Luo W, Bai Y, Wang W, Yuan Z. Intra-Amniotic Delivery of CRMP4 siRNA Improves Mesenchymal Stem Cell Therapy in a Rat Spina Bifida Model. MOLECULAR THERAPY. NUCLEIC ACIDS 2020; 20:502-517. [PMID: 32330869 PMCID: PMC7177192 DOI: 10.1016/j.omtn.2020.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/13/2020] [Indexed: 11/16/2022]
Abstract
Neural tube defects (NTDs) result in prenatal mortality and lifelong morbidity, and available treatments have limited efficacy. We previously suggested that prenatal bone marrow-derived mesenchymal stem cell (BMSC) transplantation could treat neuron deficiency in NTD rats; however, BMSC-based therapy is limited by the low survival rate of BMSCs when used to treat severe NTDs. Herein, a new therapy using combined BMSC transplantation and small interfering RNA of collapsin response mediator protein 4 (CRMP4 siRNA), which was identified as a novel potential target for the NTD treatment, is proposed. The intra-amniotic CRMP4 siRNA, BMSC, and CRMP4 siRNA + BMSC injections repaired skin lesions, improved motor neural function, reduced neuronal apoptosis, and promoted expression of neural differentiation-related molecules and neurotrophic factors in the spinal cord of spina bifida rat fetuses. Therapeutic effects in the CRMP4 siRNA + BMSC injection group were superior to those of the CRMP4 siRNA only or BMSC only injection groups. CRMP4 siRNA + BMSC injection resulted in a 45.38% reduction in the skin lesion area and significantly shorter latency and higher amplitude of motor-evoked potentials (MEPs) in spina bifida fetuses. Our results suggest that intrauterine Ad-CRMP4 siRNA delivery with BMSCs is an innovative platform for developing fetal therapeutics to safely and efficaciously treat NTDs.
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Affiliation(s)
- Xiaowei Wei
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Songying Cao
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China.
| | - Wei Ma
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Chaonan Zhang
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Hui Gu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Dan Liu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Wenting Luo
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, P.R. China
| | - Weilin Wang
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, P.R. China
| | - Zhengwei Yuan
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang 110004, P.R. China.
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Stein R, Bogaert G, Dogan HS, Hoen L, Kocvara R, Nijman RJM, Quadackers JSLT, Rawashdeh YF, Silay MS, Tekgul S, Radmayr C. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment. Neurourol Urodyn 2019; 39:45-57. [PMID: 31724222 DOI: 10.1002/nau.24211] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia. AIMS Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC). MATERIAL AND METHODS After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment. DISCUSSION AND CONCLUSIONS The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.
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Affiliation(s)
- Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Guy Bogaert
- Department of Urology, University of Leuven, Belgium
| | - Hasan S Dogan
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
| | - Lisette Hoen
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Radim Kocvara
- Department of Urology, 1st Faculty of Medicine in Praha, General Teaching Hospital, Charles University, Prague, Czech Republic
| | - Rien J M Nijman
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Rijks Universiteit Groningen, Groningen, The Netherlands
| | - Josine S L T Quadackers
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Rijks Universiteit Groningen, Groningen, The Netherlands
| | | | - Mesrur S Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Serdar Tekgul
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
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Beuriat PA, Poirot I, Hameury F, Demede D, Sweeney KJ, Szathmari A, Di Rocco F, Mottolese C. Low level myelomeningoceles: do they need prenatal surgery? Childs Nerv Syst 2019; 35:957-963. [PMID: 30915531 DOI: 10.1007/s00381-019-04123-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/08/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery? OBJECTIVE To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients. MATERIALS AND METHODS Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0-97 days). RESULTS Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school. CONCLUSIONS The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.
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Affiliation(s)
- Pierre-Aurelien Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Isabelle Poirot
- Department of Pediatric Rehabilitation l'ESCALE, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Frederic Hameury
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Delphine Demede
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Kieron J Sweeney
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Alexandru Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Federico Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France.
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Beuriat PA, Szathmari A, Rousselle C, Sabatier I, Di Rocco F, Mottolese C. Complete Reversibility of the Chiari Type II Malformation After Postnatal Repair of Myelomeningocele. World Neurosurg 2017; 108:62-68. [DOI: 10.1016/j.wneu.2017.08.152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/15/2022]
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Kabagambe SK, Chen YJ, Vanover MA, Saadai P, Farmer DL. New directions in fetal surgery for myelomeningocele. Childs Nerv Syst 2017; 33:1185-1190. [PMID: 28497181 DOI: 10.1007/s00381-017-3438-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/28/2017] [Indexed: 01/07/2023]
Abstract
The treatment of children with myelomeningocele (MMC) has improved over time, from supportive management to early postnatal closure to prenatal repair of the defect. The Management of Myelomeningocele Study (MOMS) showed that prenatal repair of MMC resulted in improved neurological outcomes compared to postnatal closure. Follow-up studies showed that prenatal repair was, as with any other fetal intervention, associated with higher rates of obstetrical complications. There was no significant difference in urological outcomes. Long-term follow-up of ambulatory status, executive functioning, and urological outcomes is needed to determine the durable effects of fetal MMC repair on mobility, functional independence, and the prevalence of renal insufficiency in patients with MMC who survive to adulthood. The future of fetal MMC repair consists of developing strategies to reduce maternal morbidity and improve infant outcomes. Fetoscopic MMC repair has been suggested as an alternative to open repair that may reduce obstetrical complications and the need for cesarean delivery in subsequent pregnancies. Translational research using mesenchymal stromal cells to augment fetal repair of ovine MMC has shown improvement in motor function.
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Affiliation(s)
- Sandra K Kabagambe
- Department of Surgery, University of California, Davis Health Systems, 2315 Stockton Blvd, OP512, Sacramento, CA, 95817, USA.
| | - Y Julia Chen
- Department of Surgery, University of California, Davis Health Systems, 2315 Stockton Blvd, OP512, Sacramento, CA, 95817, USA
| | - Melissa A Vanover
- Department of Surgery, University of California, Davis Health Systems, 2315 Stockton Blvd, OP512, Sacramento, CA, 95817, USA
| | - Payam Saadai
- Department of Surgery, University of California, Davis Health Systems, 2315 Stockton Blvd, OP512, Sacramento, CA, 95817, USA
| | - Diana L Farmer
- Department of Surgery, University of California, Davis Health Systems, 2315 Stockton Blvd, OP512, Sacramento, CA, 95817, USA
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