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Macedo A, Leal da Cruz M. Response to JPUROL-D-24-00330 which is commenting on original publication JPUROL-D-24-00017. J Pediatr Urol 2024:S1477-5131(24)00316-4. [PMID: 39183075 DOI: 10.1016/j.jpurol.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 08/27/2024]
Affiliation(s)
- Antonio Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil; Department of Urology, CACAU-NUPEP, São Paulo, Brazil
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Macedo A, Campelo TR, Aragon RG, Macedo EL, Garrone G, Ottoni SL, Leal da Cruz M. Prospective trial of a uniform protocol for managing infants with neurogenic bladder. J Pediatr Urol 2024:S1477-5131(24)00287-0. [PMID: 39232867 DOI: 10.1016/j.jpurol.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 09/06/2024]
Abstract
INTRODUCTION Since the Management of Myelomeningocele Study (MOMS) publication in 2011 we have designed a prospective protocol for surveillance of neurogenic bladder according to the Leal da Cruz categorization system (J Urol, 2015) that guides us on treatment. Our institution was the precursor of in-utero myelomeningocele (MMC) in Latin America, so our database was biased mostly for patients that underwent fetal surgery for MMC closure. We have demonstrated that in-utero MMC closure does not improve bladder function in opposition to the data from the urological branch of the MOMS study (10), but our control group was based on a historical cohort, before the onset of in-utero MMC repair in our division (15) Since 2018, we have identified an increasing number of referrals of postnatal operated MMC patients to our group just for urological follow up. We decided then to start this prospective protocol for all neurogenic patients and provide a contemporary database to record differences in early bladder function, presence of hydronephrosis and vesicoureteral reflux, treatment, initial outcome and indication of surgery among three mains groups (in-utero MMC repair, post-natal repair and miscellaneous other cases of neurogenic bladder). We want to present preliminary data of this cohort in the period of time 2018 to 2023 (5 years). There was not an exclusion criteria, all patients with neuropathic bladder were included in this study. MATERIALS AND METHODS We evaluated our database of all neurogenic bladder (NB) patients aged <1 year who started urological treatment in our institution from 2018. We evaluated diagnosis, age at first visit, clinical data, prevalence of hydronephrosis and (vesicoureteral reflux) VUR, bladder pattern according to the Leal da Cruz categorization system (1), treatment, time of follow-up, number of clinical visits and (urodynamic evaluation) UE performed, final bladder status and surgeries performed. RESULTS We identified 43 were aged <1 year with a mean age of 4.5 months (median 3.5) at first urological appointment. Diagnosis was myelomeningocele in 33 patients and miscellaneous in 10. From the MMC group, 24 were operated in-utero and 9 post-natal. The initial bladder pattern in the whole group showed 23 (53.5%) high risk, 11 normal (25.6%), 5 underactive bladder (11.6%) and 4 incontinent (9.3%). Mean follow-up was 24 months, mean age at last UE (cases with minimum of 2): 37 months, mean UE per patient: 2. At present, 28 patients perform clean intermittent catheterization (CIC), 23 with anticholinergics and 15 are only under surveillance. VUR was seen in 11/43 cases: 25.6%. Urological surgery has been performed in 4 patients: bladder augmentation in 3 and vesicostomy in 1. Bladder categorization for high-risk and normal patterns were respectively 62.5% and 25% for in utero and 44.4% and 22.2% for postnatal repair and detailed statistical analysis did not present statistical significance of in utero and postnatal groups. CONCLUSION Our study can conclude in a contemporary prospective study the findings of elevated incidence of high-risk patterns irrespectively of in-utero or post-natal repair (62.5% and 44.4%). We acknowledge that even though this is not new information and besides the still limited follow up, this cohort is one of the very few that follow and compare in one single institution with comparable UE for in-utero and post-natal MMC repair population, having also a miscellaneous group of NB as a pictorial report of also a similar initial distribution of bladder patterns. We plan to report in the future in a larger cohort the continuation of this study.
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Affiliation(s)
- Antonio Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil; Department of Urology, CACAU-NUPEP, São Paulo, Brazil
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Fazelinia H, Ding H, Taylor D, Spruce L, Roof J, Weiss D, Fesi J, Ischiropoulos H, Zderic S. Stratification of neurogenic bladder risk in spina bifida using the urinary peptidome. Am J Physiol Renal Physiol 2024; 326:F241-F248. [PMID: 37916288 PMCID: PMC11198971 DOI: 10.1152/ajprenal.00267.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023] Open
Abstract
Neurogenic bladder poses a major morbidity in children with spina bifida (SB), and videourodynamic studies (VUDS) are used to stratify this risk. This small-scale pilot study utilized current mass-spectrometry-based proteomic approaches to identify peptides or proteins in urine that may differentiate children at high risk of developing renal complications from a neurogenic bladder. Twenty-two urine samples of which nine had high bladder pressure storage that put the upper urinary tract at risk, while 13 with a lower risk for renal compromise were analyzed. More than 1,900 peptides across all 22 samples were quantified, and 115 peptides differed significantly (P < 0.05) between the two groups. Using machine learning approaches five peptides that showed the greatest differences between these two clinical categories were used to build a classifier. We tested this classifier by blind analysis of an additional six urine samples and showed that it correctly assigned the unknown samples in their proper risk category. These promising results indicate that a urinary screening test based on peptides could be performed on a regular basis to stratify the neurogenic bladder into low or high-risk categories. Expanding this work to larger cohorts as well as across a broad spectrum of urodynamics outcomes may provide a useful diagnostic test for neurogenic bladder.NEW & NOTEWORTHY This approach could help risk stratify the neurogenic bladder in patients with spina bifida and could allow us to safely defer on up to 1/3 of urodynamic studies. These pilot data justify a larger trial before this approach becomes a clinical tool.
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Affiliation(s)
- Hossein Fazelinia
- Proteomics Core Laboratory, Children's Hospital of Philadelphia Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Hua Ding
- Proteomics Core Laboratory, Children's Hospital of Philadelphia Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Deanne Taylor
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Lynn Spruce
- Proteomics Core Laboratory, Children's Hospital of Philadelphia Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Jennifer Roof
- Proteomics Core Laboratory, Children's Hospital of Philadelphia Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Dana Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Joanna Fesi
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Harry Ischiropoulos
- Proteomics Core Laboratory, Children's Hospital of Philadelphia Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Stephen Zderic
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Rizzo G, Pavjola M, Pietrolucci ME. Expert ultrasonographic evaluation in fetuses with spina bifida: An essential prerequisite to select candidate to fetal surgery. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:415-416. [PMID: 36893036 DOI: 10.1002/jcu.23363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 06/18/2023]
Abstract
Suggested management flowchart in presence of a prenatal diagnosis of open spina bifida.
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Affiliation(s)
- Giuseppe Rizzo
- Departement of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Maqina Pavjola
- Departement of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Maria Elena Pietrolucci
- Departement of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
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Thompson DNP, De Vloo P, Deprest J. Fetal Surgery for Myelomeningocele: Neurosurgical Perspectives. Adv Tech Stand Neurosurg 2023; 47:25-48. [PMID: 37640871 DOI: 10.1007/978-3-031-34981-2_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
More than 30 years have elapsed since it was recognised that folic acid supplementation could substantially reduce the risk of open neural tube defects (ONTDs). During that time, many countries have adopted policies of food fortification with demonstrable reduction in the incidence of both cranial and spinal ONTDs. Improved prenatal detection and termination has also resulted in a reduction in the number of affected live births. Nonetheless, in the USA about 1500 children, and in the UK around 500 children are born each year with myelomeningocele (MMC) and so the management of MMC and its complications continues to constitute a significant clinical workload for many paediatric neurosurgical units around the world.Until recently, the options available following antenatal diagnosis of MMC were termination of pregnancy or postnatal repair. As a result of the MOMS trial, prenatal repair has become an additional option in selected cases (Adzick et al., N Engl J Med 364(11):993-1004, 2011). Fetal surgery for myelomeningocele is now offered in more than 30 centres worldwide. The aim of this chapter is to review the experimental basis of prenatal repair of MMC, to critically evaluate the neurosurgical implications of this intervention and to describe the technique of 'open' repair, comparing this with emerging minimally invasive alternatives.
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Affiliation(s)
- Dominic N P Thompson
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | | | - Jan Deprest
- Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
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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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Mangano FT, Altaye M, Stevenson CB, Yuan W. The Construction of a Predictive Composite Index for Decision-Making of CSF Diversion Surgery in Pediatric Patients following Prenatal Myelomeningocele Repair. AJNR Am J Neuroradiol 2022; 43:1214-1221. [PMID: 35902125 PMCID: PMC9575433 DOI: 10.3174/ajnr.a7585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/06/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a wide range of clinical and radiographic factors affecting individual surgeons' ultimate decision for CSF diversion for pediatric patients following prenatal myelomeningocele repair. Our aim was to construct a composite index (CSF diversion surgery index) that integrates conventional clinical measures and neuroimaging biomarkers to predict CSF diversion surgery in these pediatric patients. MATERIALS AND METHODS This was a secondary retrospective analysis of data from 33 patients with prenatal myelomeningocele repair (including 14 who ultimately required CSF diversion surgery). Potential independent variables, including the Management of Myelomeningocele Study Index (a dichotomized variable based on the shunt-placement criteria from the Management of Myelomeningocele Study), postnatal DTI measures (fractional anisotropy and mean diffusivity in the genu of the corpus callosum and the posterior limb of internal capsule), fronto-occipital horn ratio at the time of DTI, gestational ages, and sex, were evaluated using stepwise logistic regression analysis to identify the most important predictors. RESULTS The CSF diversion surgery index model showed that the Management of Myelomeningocele Study Index and fractional anisotropy in the genu of the corpus callosum were significant predictors (P < .05) of CSF diversion surgery. The predictive value of the CSF diversion surgery index was also affected by fractional anisotropy in the posterior limb of the internal capsule and sex with marginal effect (.05<P < .10), but not by the fronto-occipital horn ratio (P > .10). The overall CSF diversion surgery index model fit the data well with statistical significance (eg, likelihood ratio: P < .001), with the performance (sensitivity = 78.6%; specificity = 86.5%, overall accuracy = 84.8%) superior to all individual indices in sensitivity and overall accuracy, and most of the individual indices in specificity. CONCLUSIONS The CSF diversion surgery index model outperformed all single predictor models and, with additional validation, may potentially be developed and incorporated into a sensitive and robust clinical tool to assist clinicians in hydrocephalus management.
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Affiliation(s)
- F T Mangano
- From the Division of Pediatric Neurosurgery (F.T.M., C.B.S.).,University of Cincinnati College of Medicine (F.T.M., M.A., C.B.S., W.Y.), Cincinnati, Ohio
| | - M Altaye
- Division of Biostatistics and Epidemiology (M.A.).,University of Cincinnati College of Medicine (F.T.M., M.A., C.B.S., W.Y.), Cincinnati, Ohio
| | - C B Stevenson
- From the Division of Pediatric Neurosurgery (F.T.M., C.B.S.).,University of Cincinnati College of Medicine (F.T.M., M.A., C.B.S., W.Y.), Cincinnati, Ohio
| | - W Yuan
- Pediatric Neuroimaging Research Consortium (W.Y.), Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio .,University of Cincinnati College of Medicine (F.T.M., M.A., C.B.S., W.Y.), Cincinnati, Ohio
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Macedo A, Ottoni SL, Moron A, Cavalheiro S, da Cruz ML. In utero myelomeningocele repair and high-risk bladder pattern. a prospective study. Int Braz J Urol 2022; 48:672-678. [PMID: 35373958 PMCID: PMC9306372 DOI: 10.1590/s1677-5538.ibju.2022.0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives High-risk bladder pattern can be defined by Urodynamic Evaluation (UE) as overactive bladder with detrusor leak point pressure higher than 40 cmH2O and/or higher filling pressures also above 40 cmH2O. We wanted to evaluate response to treatment in myelomeningocele patients operated in utero in this subgroup. Patients and Methods From our prospective cohort of in utero MMC we have identified patients in the high-risk group. Treatment consisted of anticholinergics (Oxybutynin 0.2 mg/Kg) 2 or 3 times daily in association with CIC. At every UE, patients were reclassified in high-risk or low-risk patterns. Patients not responding were proposed bladder reconstruction or diversion according to age. Results Between 2011 to 2020, we have been following 121 patients and 60 (49.6%) of them were initially categorized as high-risk. The initial UE was performed at a mean age of 7.9 months and detrusor overactivity was found in 83.3% (mean maximum pressure of 76.5cmH20). When evaluating patients with 2 or more UE, we identified 44 patients (follow-up: 36.8months). It was observed in the group of patients who underwent 2 to 5 UE, that response to treatment was validated by the finding of 40% of low-risk bladder patterns in the second UE and between 62% to 64% in the third to the fifth UE. The incidence of surgery was 13.3%. Conclusions Early urological treatment of high-risk bladder pattern was effective in approximately 60%. We reinforce the need to correctly treat every patient with myelomeningocele, in accordance with UE, whether undergoing in utero or postnatal treatment.
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Affiliation(s)
- Antonio Macedo
- Departamento de Pediatria, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil.,Departamento de Urologia, CACAU-NUPEP, São Paulo, Brasil
| | | | - Antonio Moron
- Departamento de Obstetrícia-Medicina Fetal, Universidade Federal de São Paulo - Unifesp, São Paulo, Brasil.,Hospital Maternidade Santa Joana, São Paulo, Brasil
| | - Sergio Cavalheiro
- Hospital Maternidade Santa Joana, São Paulo, Brasil.,Departamento de Neurocirurgia, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
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Theodorou CM, Jackson JE, Stokes SC, Pivetti CD, Kumar P, Paxton ZJ, Matsukuma KE, Yamashiro KJ, Reynaga L, Hyllen AA, de Lorimier AJ, Hassan M, Wang A, Farmer DL, Saadai P. Early investigations into improving bowel and bladder function in fetal ovine myelomeningocele repair. J Pediatr Surg 2022; 57:941-948. [PMID: 35093254 PMCID: PMC10372624 DOI: 10.1016/j.jpedsurg.2021.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSC-ECM would also improve bowel and bladder function. METHODS MMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs (n = 3). RESULTS Eighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs (p = 1). Void volumes were similar (PMSC-ECM 6.1 ml/kg vs. normal 8.8 ml/kg, p = 0.4). Resting mean anal pressures were similar between cohorts (27.0 mmHg PMSC-ECM vs. normal 23.5 mmHg, p = 0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs (p = 0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts. CONCLUSION Ovine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human patients.
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Affiliation(s)
- Christina M Theodorou
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States.
| | - Jordan E Jackson
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Sarah C Stokes
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Christopher D Pivetti
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Zachary J Paxton
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Karen E Matsukuma
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, United States
| | - Kaeli J Yamashiro
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Alicia A Hyllen
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Arthur J de Lorimier
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Maheen Hassan
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Aijun Wang
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Diana L Farmer
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Payam Saadai
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
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Macedo A, Ottoni SL, Garrone G, Moron A, Cavalheiro S, Leal da Cruz M. In utero myelomeningocele repair and incidence of lower urinary tract surgery. Results of a prospective study. J Pediatr Urol 2021; 17:769-774. [PMID: 34452829 DOI: 10.1016/j.jpurol.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The purpose of this study was to determine the incidence of lower urinary tract surgery in patients with myelomeningocele (MMC) operated in utero as well as in the subgroup of patients with a minimum age of 5 years. METHODS We use a previously published protocol to categorize bladder patterns and propose the treatment: high risk pattern-anticholinergics and clean intermittent catheterization (CIC); incontinent and normal patterns-clinical surveillance and underactivity pattern- CIC. Non-response to clinical treatment with maintenance of detrusor pressure higher than 40 cmH20 with worsening of hydronephrosis or recurrent urinary infection were imperative indications for surgery and urinary incontinence due to sphincter deficiency and leakage pressure below 40 cmH20 in patients aged 5 years and older were possible indications too. We identified the prevalence of urinary tract surgery and concomitant treatment of constipation and refractory fecal incontinence by convenience, the technique performed and surgery outcomes. RESULTS A total of 122 patients are part of the prospective protocol. The first UE was performed in 119 patients (median age of 4 months). The categorization of the bladder pattern was high risk in 52.1%, incontinent in 25.2%, hypocontractile 4.2% and normal in 18.5%. Current follow-up was 29.9 months (1-99 months). Surgery was performed on 10 patients (8.4%): 3 vesicostomies, 2 surgeries to treat vesicoureteral reflux, 6 bladder augmentations, 3 ACE and a sling surgery. Considering only patients older than 5 years, we identified 65 patients and seven surgeries performed (10.8%). DISCUSSION Most bladder reconstruction studies are case series of single institutions or cooperative services, most of which are retrospective. The prospective clinical interpretation and imaging and urodynamic exams over time allowed us prospectively to define the risk of surgery in patients with myelomeningocele operated in utero. It must be considered that the response to the initial urological treatment and even the failure that leads to the need for surgery have to be evaluated in a context of follow-up time. For this reason we have studied separately patients over 5 years-old and also the group considered to be at greatest risk for surgery, the high-risk group of the categorization already described. CONCLUSION We found an incidence of 10.8% of surgeries in patients over 5 years-old and 12.9% for the high-risk group. This information may be useful to educate parents when stating urological treatment.
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Affiliation(s)
- Antonio Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil; Department of Urology, CACAU-NUPEP, São Paulo, Brazil
| | | | | | - Antonio Moron
- Departament of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil; Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Sergio Cavalheiro
- Departament of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil; Santa Joana Maternity Hospital, São Paulo, Brazil
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Metcalfe PD. Practice-changing publications: Pediatric urology - focus on treatment of spina bifida. Can Urol Assoc J 2021; 15:324-325. [PMID: 34665123 DOI: 10.5489/cuaj.7590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Peter D Metcalfe
- Department of Surgery, Division of Pediatric Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
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Lapa DA, Chmait RH, Gielchinsky Y, Yamamoto M, Persico N, Santorum M, Gil MM, Trigo L, Quintero RA, Nicolaides KH. Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:582-589. [PMID: 33880811 PMCID: PMC9293198 DOI: 10.1002/uog.23658] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 06/02/2023]
Abstract
OBJECTIVE A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D. A. Lapa
- Fetal Therapy Team CoordinatorHospital Infantil SabaraSão PauloBrazil
- Fetal Therapy GroupHospital Israelita Albert EinsteinSão PauloBrazil
| | - R. H. Chmait
- Los Angeles Fetal Surgery, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| | - Y. Gielchinsky
- Fetal Therapy, Helen Schneider Hospital for WomenRabin Medical CenterPetah TikvaIsrael
| | | | - N. Persico
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoMilanItaly
| | - M. Santorum
- Fetal Medicine Research InstituteKing's College HospitalLondonUK
| | - M. M. Gil
- Department of Obstetrics and GynecologyHospital Universitario de TorrejónMadridSpain
- School of MedicineUniversidad Francisco de VitoriaMadridSpain
| | - L. Trigo
- Fetal Therapy GroupHospital Israelita Albert EinsteinSão PauloBrazil
- BCNatal Fetal Medicine Research CenterBarcelonaSpain
| | | | - K. H. Nicolaides
- Fetal Medicine Research InstituteKing's College HospitalLondonUK
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Yerkes EB, Cheng EY, Wiener JS, Austin JC, Tu DD, Joseph DB, Routh JC, Tanaka ST. Translating pediatric urodynamics from clinic into collaborative research: Lessons and recommendations from the UMPIRE study group. J Pediatr Urol 2021; 17:716-725. [PMID: 34412976 DOI: 10.1016/j.jpurol.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/02/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
Pediatric patients present unique challenges in the performance and interpretation of urodynamic studies. Interpretation of urodynamics to guide clinical management at an institutional level is accepted as reliable. Challenges arise however when multi-site collaborations incorporate urodynamics into study design to determine primary or secondary outcomes or to direct decision-making. Although standardized terminology has been established by ICCS, the application of this shared language to performance and interpretation of pediatric urodynamics to across multiple sites may not be intuitive or reliable. With a primary goal of defining the care necessary to protect future renal function, the UMPIRE protocol (Urologic Management to Preserve Initial REnal function) utilizes a urodynamics-based risk stratification to determine medical management for infants with myelomeningocele. Iterative changes in the protocol are based upon the clinical progress of the enrolled children. Despite a team experienced in subtleties of urodynamics and despite efforts to minimize variability across sites, the UMPIRE study group identified several areas in which the language of urodynamics required additional clarification or creation of more explicit definitions to standardize performance and interpretation across sites. This article reviews the foundations of current urodynamics practice, describes limitations and challenges unique to pediatric studies, and the shares the humble lessons learned by the UMPIRE study group on their journey toward standardized urodynamic language for management of infants and children with myelomeningocele.
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Affiliation(s)
- Elizabeth B Yerkes
- Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611, USA.
| | - Earl Y Cheng
- Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611, USA
| | - John S Wiener
- Duke University Medical Center, Box 3831, Durham, NC, 27710, USA
| | | | - Duong D Tu
- Texas Children's Hospital / Baylor College of Medicine, 6701 Fannin St, Suite 620, Houston, TX, 77030, USA
| | - David B Joseph
- Children's of Alabama, 1600 7th Ave South, Lowder 318, Birmingham, AL, 35233, USA
| | - Jonathan C Routh
- Duke University Medical Center, Box 3831, Durham, NC, 27710, USA
| | - Stacy T Tanaka
- Vanderbilt University Medical Center, 2200 Children's Way. 4102 DOT, Nashville, TN, 37232, USA
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14
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Tanaka ST, Yerkes EB, Routh JC, Tu DD, Austin JC, Wiener JS, Vasquez E, Joseph DB, Ahn JJ, Wallis MC, Williams T, Rose C, Baum MA, Cheng EY. Urodynamic characteristics of neurogenic bladder in newborns with myelomeningocele and refinement of the definition of bladder hostility: Findings from the UMPIRE multi-center study. J Pediatr Urol 2021; 17:726-732. [PMID: 34011486 PMCID: PMC11008495 DOI: 10.1016/j.jpurol.2021.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Infants with myelomeningocele are at risk for chronic kidney disease caused by neurogenic bladder dysfunction. Urodynamic evaluation plays a key role to risk stratify individuals for renal deterioration. OBJECTIVE To present baseline urodynamic findings from the Urologic Management to Preserve Initial Renal function for young children with spina bifida (UMPIRE) protocol, to present the process that showed inadequacies of our original classification scheme, and to propose a refined definition of bladder hostility and categorization. STUDY DESIGN The UMPIRE protocol follows a cohort of newborns with myelomeningocele at nine children's hospitals in the United States. Infants are started on clean intermittent catheterization shortly after birth. If residual volumes are low and there is no or mild hydronephrosis, catheterization is discontinued. Baseline urodynamics are obtained at or before 3 months of age to determine further management. Based on protocol-specific definitions, urodynamic studies were reviewed by the clinical site in addition to a central review team; and if necessary, by all site urologists to achieve 100% concurrence. RESULTS We reviewed 157 newborn urodynamic studies performed between May 2015 and September 2017. Of these 157 infants, 54.8% were boys (86/157). Myelomeningocele closure was performed in-utero in 18.4% (29/157) and postnatally in 81.5% (128/157) of newborns. After primary review, reviewers agreed on overall bladder categorization in 50% (79/157) of studies. Concurrence ultimately reached 100% with further standardization of interpretation. We found that it was not possible to reliably differentiate a bladder contraction due to detrusor overactivity from a volitional voiding contraction in an infant. We revised our categorization system to group the "normal" and "safe" categories together as "low risk". Additionally, diagnosis of detrusor sphincter dyssynergia (DSD) with surface patch electrodes could not be supported by other elements of the urodynamics study. We excluded DSD from our revised high risk category. The final categorizations were high risk in 15% (23/157); intermediate risk in 61% (96/157); and low risk in 24% (38/157). CONCLUSION We found pitfalls with our original categorization for bladder hostility. Notably, DSD could not be reliably measured with surface patch of electrodes. The effect of this change on future renal outcomes remains to be defined.
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Affiliation(s)
- Stacy T Tanaka
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way. 4102 DOT, Nashville, TN, 37232,, USA.
| | - Elizabeth B Yerkes
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611,, USA
| | - Jonathan C Routh
- Division of Urology, Box 383, Duke University Medical Center, Durham, NC, 27710,, USA
| | - Duong D Tu
- Division of Urology, Texas Children's Hospital/Baylor College of Medicine, 6701 Fannin St, Suite 620. Houston, TX, 77030,, USA
| | - J Christopher Austin
- Department of Urology, Oregon Health Sciences University, Pediatric Urology, CDW6, 3181 SW Sam Jackson Park Road. Portland, OR, 97239,, USA
| | - John S Wiener
- Division of Urology, Box 383, Duke University Medical Center, Durham, NC, 27710,, USA
| | - Evalynn Vasquez
- Division of Urology, Children's Hospital Los Angeles, 4650 Sunset Blvd. MS#114. Los Angeles, CA, 90027,, USA
| | - David B Joseph
- Department of Urology, Children's of Alabama. 1600 7th Ave South, Birmingham, AL, 35233,, USA
| | - Jennifer J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, 4800 Sand Point Way NE OA.9.220. Seattle, WA, 98105,, USA
| | - M Chad Wallis
- Division of Urology, Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3550. Salt Lake City, UT, 84113-1100, USA
| | - Tonya Williams
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, MS S106-3, 4700 Buford Hwy. Atlanta, GA, 30341-3717,, USA
| | - Charles Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop E-87. Atlanta, GA, 30329-4018,, USA
| | - Michelle A Baum
- Division of Nephrology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3038. Boston, MA, 02115,, USA
| | - Earl Y Cheng
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611,, USA
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Johal N, Cao KX, Xie B, Millar M, Davda R, Ahmed A, Kanai AJ, Wood DN, Jabr RI, Fry CH. Contractile and Structural Properties of Detrusor from Children with Neurogenic Lower Urinary Tract Dysfunction. BIOLOGY 2021; 10:biology10090863. [PMID: 34571740 PMCID: PMC8471516 DOI: 10.3390/biology10090863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 12/11/2022]
Abstract
Simple Summary Disorders of bladder function can result from congenital spinal cord developmental defects and can remain in a significant number of patients despite surgical improvements to repair the primary defect. We studied the ability of bladder wall muscle from such patients to contract, a function essential to void collected urine and avoid urinary tract infections and potential damage to the kidneys. Tissue was taken when patients were several years old, at the time of surgical operations to improve bladder function. This tissue would otherwise have been discarded and was collected with the full ethical approval and consent of parents or guardians. We found that the ability of the bladder wall samples to contract was impaired and was generally stiffer; both of which would make it more difficult for the bladder to void urine. These functional changes were associated with a replacement of muscle with connective tissue (fibrosis). The experiments provide a pathway to devise strategies that might improve bladder function in these patients through reversal of the intrinsic tissue pathways that increase fibrosis. Abstract Neurogenic lower urinary tract (NLUT) dysfunction in paediatric patients can arise after congenital or acquired conditions that affect bladder innervation. With some patients, urinary tract dysfunction remains and is more difficult to treat without understanding the pathophysiology. We measured in vitro detrusor smooth muscle function of samples from such bladders and any association with altered Wnt-signalling pathways that contribute to both foetal development and connective tissue deposition. A comparator group was tissue from children with normally functioning bladders. Nerve-mediated and agonist-induced contractile responses and passive stiffness were measured. Histology measured smooth muscle and connective tissue proportions, and multiplex immunohistochemistry recorded expression of protein targets associated with Wnt-signalling pathways. Detrusor from the NLUT group had reduced contractility and greater stiffness, associated with increased connective tissue content. Immunohistochemistry showed no major changes to Wnt-signalling components except down-regulation of c-Myc, a multifunctional regulator of gene transcription. NLUT is a diverse term for several diagnoses that disrupt bladder innervation. While we cannot speculate about the reasons for these pathophysiological changes, their recognition should guide research to understand their ultimate causes and develop strategies to attenuate and even reverse them. The role of changes to the Wnt-signalling pathways was minor.
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Affiliation(s)
- Navroop Johal
- Department of Urology, Great Ormond St Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (N.J.); (K.X.C.)
| | - Kevin X. Cao
- Department of Urology, Great Ormond St Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (N.J.); (K.X.C.)
| | - Boyu Xie
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK; (B.X.); (R.I.J.)
| | - Michael Millar
- Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK;
| | - Reena Davda
- Departments of Oncology and Urology, University College London Hospital, London W1G 8PH, UK; (R.D.); (D.N.W.)
| | - Aamir Ahmed
- Centre for Stem Cell Regeneration, King’s College London, London WC2R 2LS, UK;
| | - Anthony J. Kanai
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Dan N. Wood
- Departments of Oncology and Urology, University College London Hospital, London W1G 8PH, UK; (R.D.); (D.N.W.)
| | - Rita I. Jabr
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK; (B.X.); (R.I.J.)
| | - Christopher H. Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK; (B.X.); (R.I.J.)
- Correspondence:
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16
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Comparison of risk of anticholinergic utilization for treatment of neurogenic bladder between in utero or postnatal myelomeningocele repair. J Pediatr Urol 2021; 17:525.e1-525.e7. [PMID: 34074608 DOI: 10.1016/j.jpurol.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/05/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION In utero myelomeningocele (MMC) repair has resulted in significant decrease in need for shunt-dependent hydrocephalus, however its impact on bladder function remains less clear. Neurogenic detrusor overactivity (NDO) due to MMC can be addressed with combination of clean intermittent catheterization (CIC) and anticholinergic (AC) therapy to minimize its effect on bladder function and upper urinary tract. The aim of this study was to compare the risk of postnatal AC utilization for in patients that underwent either postnatal or in utero MMC repair related to neurogenic bladder (NGB) management. We hypothesized that postnatal MMC repair would be associated with increased risk of postnatal AC utilization compared to in utero MMC repair. MATERIAL AND METHODS All newborns with MMC in our hospital undergo prospective surveillance radiographic and urodynamic testing as part of institutional MMC protocol. Those MMC patients born between 2013 and 2018 at our institution, who underwent in utero or postnatal MMC repair were retrospectively analyzed. We identified postnatal AC utilization from electronic medical records and recorded indications for AC therapy according to the urodynamic, radiographic and clinical findings related to NGB management. RESULTS 97 patients fulfilled the inclusion criteria. 56 patients underwent a postnatal and 41 an in utero repair. Median follow-up for the in utero and postnatal MMC repair groups was the same at 37 months (p = 0.53). More newborns from the postnatal group were discharged from birth hospital performing CIC (91.1% vs. 58.5%, p < 0.0001), however upon last follow up no difference existed between the groups on use of CIC (83.9% postnatal group % vs. 82.9% in utero group, p = 0.78). At last follow up, postnatal AC utilization was observed in 75% of postnatal MMC group compared to 78.1% of the in utero MMC repair group, p = 0.81 (Figure). The median time to AC utilization was 6.9 months and 8.8 months in the in utero and postnatal groups, respectively (p = 0.28). DISCUSSION We observed no reduction in risk of AC utilization with in utero repair which refuted the hypothesis of our study. Indications for AC utilization were urodynamic abnormalities such as NDO (81.3% in utero vs. 81% postnatal) or impaired bladder compliance (53.1% in utero vs. 64.3% postnatal). CONCLUSIONS We found no difference in risk of postnatal AC utilization between in utero or postnatal MMC repair. CIC rates were higher at birth hospital discharge in the postnatal repair group, however at last follow up CIC rates did not differ between groups.
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Yamashiro KJ, Farmer DL. Fetal myelomeningocele repair: a narrative review of the history, current controversies and future directions. Transl Pediatr 2021; 10:1497-1505. [PMID: 34189108 PMCID: PMC8192992 DOI: 10.21037/tp-20-87] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Fetal surgery is a relatively new field of medicine. The purpose of this narrative review is to present the history of how fetal surgery became the standard of care for myelomeningocele (MMC), the current controversies of this treatment, and active areas of research that may change how MMC is treated. Fetal surgery for MMC emerged out of the University of California, San Francisco in the 1980s in the laboratory of Dr. Michael Harrison. Initial research focused on testing the hypothesis that the in utero repair of MMC could improve outcomes in the ovine model. Evidence from this model suggested that in utero repair decreases the secondary damage to the exposed neural tissue and improves post-natal neurologic outcomes, opening the door for human intervention. This was followed by the Management of Myelomeningocele Study (MOMS), which was a multicenter randomized controlled trial comparing the prenatal versus postnatal MMC repair. The MOMS trial was stopped early due to the improved outcomes of the prenatal repair, establishing the open fetal MMC repair as the standard of care. Since the MOMS trial, two primary areas of controversy have arisen: the operative approach and criteria for the repair. The three operative approaches include open, endoscopic and a hybrid approach combining open and endoscopic. Several of the inclusion and exclusion criteria from the MOMS trial have been challenged, to include body mass index, gestational diabetes, other fetal abnormalities, maternal infections and Rh alloimmunization. New areas of research have also emerged, exploring cell based therapies to improve fetal outcomes, alternatives to fetal surgery and alternatives to primary skin closure of the fetus.
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Affiliation(s)
- Kaeli J Yamashiro
- Department of Surgery, University of California-Davis, Sacramento, CA, USA
| | - Diana L Farmer
- Department of Surgery, University of California-Davis, Sacramento, CA, USA
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18
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Hughes TL, Simmons KL, Tejwani R, Barton KD, Wiener JS, Todd Purves J, Routh JC. Sexual Function and Dysfunction in Individuals with Spina Bifida: A Systematic Review. Urology 2021; 156:308-319. [PMID: 33930458 DOI: 10.1016/j.urology.2021.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To conduct a systematic review of self-reported experiences of sexual function and dysfunction in individuals with spina bifida (SB). MATERIALS AND METHODS Medline, Embase, and Web of Science were systematically searched. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia. Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia. RESULTS Systematic search yielded 23 studies representing 1441 patients (816 males, 625 females). Eight utilized questionnaires validated in non-SB adults; the remainder used semi-structured interviews and non-validated instruments. Eleven assessed dysfunctions in both sexes, 10 in males, and 2 in females. Erectile function and orgasm were the most commonly assessed outcomes in males and females respectively. 12%-88% of males experienced erectile dysfunction; a majority (51%-90%) reported normal ejaculatory function. Many females were unable to experience orgasm (28%-63%). CONCLUSION Males with SB report significant erectile and ejaculatory dysfunction. Both sexes report impaired orgasms and genital sensitivity. SB-specific instruments assessing sexual dysfunction are needed in order to improve multidisciplinary care for this population.
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Affiliation(s)
- Taylor L Hughes
- School of Medicine, Duke University Medical Center, Durham, NC
| | | | - Rohit Tejwani
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Karen D Barton
- Duke University Medical Center Library & Archives, Durham, NC
| | - John S Wiener
- Division of Urology, Duke University Medical Center, Durham, NC
| | - J Todd Purves
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC.
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19
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Kunpalin Y, Richter J, Mufti N, Bosteels J, Ourselin S, De Coppi P, Thompson D, David AL, Deprest J. Cranial findings detected by second-trimester ultrasound in fetuses with myelomeningocele: a systematic review. BJOG 2021; 128:366-374. [PMID: 32926566 PMCID: PMC8436766 DOI: 10.1111/1471-0528.16496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/14/2022]
Abstract
Background Abnormal intracranial findings are often detected at mid‐trimester ultrasound (US) in fetuses with myelomeningocele (MMC). It is unclear whether these findings constitute a spectrum of the disease or are an independent finding, which should contraindicate fetal surgery. Objective To ascertain the spectrum and frequency of US‐detected cranial findings in fetuses with MMC. Search strategy MEDLINE, Embase, Web of Science and CENTRAL were searched from January 2000 to June 2020. Selection criteria Study reporting incidence of cranial US findings in consecutive cases of second‐trimester fetuses with MMC. Data collection and analysis Publication quality was assessed by Newcastle–Ottawa Scale (NOS) and modified NOS. Meta‐analysis could not be performed as a result of high clinical diversity and study heterogeneity. Main results Fourteen cranial US findings were reported in 15 studies. Findings in classic Chiari II malformation (CIIM) spectrum included posterior fossa funnelling (96%), small transcerebellar diameter (82–96%), ‘banana’ sign (50–100%), beaked tectum (65%) and ‘lemon’ sign (53–100%). Additional cranial findings were small biparietal diameter (BPD) and head circumference (HC) (<5th centile; 53 and 71%, respectively), ventriculomegaly (45–89%), abnormal pointed shape of the occipital horn (77–78%), thinning of the posterior cerebrum, perinodular heterotopia (11%), abnormal gyration (3%), corpus callosum disorders (60%) and midline interhemispheric cyst (42%). Conclusions We identified 14 cranial findings by second‐trimester US in fetuses with MMC. The relatively high incidence of these findings and their unclear prognostic significance might not contraindicate fetal surgery in the case of normal fetal genetic testing. Some cranial findings may independently affect postnatal outcome, however. Long‐term detailed follow‐up is required to investigate this. Tweetable abstract A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele. A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.
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Affiliation(s)
- Y Kunpalin
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Richter
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - N Mufti
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - J Bosteels
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Cochrane Belgium, Belgian Centre for Evidence-Based Medicine (Cebam), Leuven, Belgium
| | - S Ourselin
- School of Biomedical Engineering & imaging Sciences, King's College London, London, UK
| | - P De Coppi
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of General Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - D Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
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Moehrlen U, Ochsenbein N, Vonzun L, Mazzone L, Horst M, Schauer S, Wille DA, Hagmann C, Kottke R, Grehten P, Casanova B, Strübing N, Moehrlen T, Tharakan S, Padden B, Bassler D, Zimmermann R, Meuli M. Fetal surgery for spina bifida in Zurich: results from 150 cases. Pediatr Surg Int 2021; 37:311-316. [PMID: 33432393 DOI: 10.1007/s00383-020-04824-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Over the past 10 years, over 150 fetal spina bifida surgeries were performed at the Zurich Center for Fetal Diagnosis and Therapy. This study looks at surrogates for success and failure of this approach. METHODS We focused on key outcome parameters including hydrocephalus shunt rate at one year, bladder control at 4, independent ambulation at 3 years, and maternal, fetal, and neonatal complications. RESULTS From the first 150 patients undergoing fetal surgery for spina bifida, 148 (98.7%) were included in the study. Maternal-fetal surgery was uneventful in 143/148 (97%) cases. Intraoperative problems included resuscitation in 4/148 fetuses (2.7%). 1/148 fetuses (0.7%) died on postoperative day 4. Maternal complications included chorioamniotic membrane separation in 22/148 (15%), lung embolism in 3/148 (2.1%), chorioamnionitis in 2/148 (1.4%), AV-block III and uterine rupture in 1/148 each (0.7%). 1/148 (0.7%) newborn death was recorded. Hindbrain herniation was identified preoperatively in 132/148 (90%) fetuses and resolved completely in 119/132 (90%). At one year, 39/106 (37%) children had required a CSF diversion. At 4 years, 4/34 patients (12%) had normal bladder control. At 3 years, 48/57 (84%) walked independently. CONCLUSION A majority of patients benefitted from prenatal intervention, in that the shunt rate was lower and the rates of continent and walking patients were higher than reported with postnatal care.
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Affiliation(s)
- Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland. .,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland. .,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
| | - Nicole Ochsenbein
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Maya Horst
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Sonja Schauer
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - David Alexander Wille
- Division of Pediatric Neurology, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- Division of Intensive Care and Neonatology, University Children' Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Raimund Kottke
- Division of Diagnostic Imaging, MR-Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Patrice Grehten
- Division of Diagnostic Imaging, MR-Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Barbara Casanova
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Nele Strübing
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Theres Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Sasha Tharakan
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Beth Padden
- Division of Pediatric Rehabilitation, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
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21
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Gerber JA, Stocks BT, Zhu H, Castillo H, Castillo J, Borden AN, Tu DD, Whitehead WE, Austin PF. Prevalence of high-risk bladder categorization with prenatal and postnatal myelomeningocele repair types. Neurourol Urodyn 2021; 40:829-839. [PMID: 33604950 DOI: 10.1002/nau.24629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/05/2021] [Accepted: 01/27/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Urologic substudies of prenatal myelomeningocele (MMC) closure have focused primarily on continence without significant clinical benefit. Fetoscopic MMC repair (FMR) is a newer form of prenatal intervention and touts added benefits to the mother, but urological outcomes have yet to be analyzed. We set out to focus on bladder safety rather than continence and examined bladder outcomes with different prenatal MMC repairs (FMR and prenatal open [POMR]) and compared bladder-risk-categorization to traditional postnatal repair (PSTNR). METHODS An IRB-approved retrospective analysis of all patients undergoing all forms of MMC repairs with inclusion and exclusion criteria based on the MOMS trial was performed. Bladder safety assessment required initial urodynamic studies (UDS), renal bladder ultrasound (RBUS), and/or voiding cystourethrogram (VCUG) within the 1st year of life. Follow-up analyses within the cohorts required follow-up studies within 18 months after initial evaluations. Outcomes assessed included bladder-risk-categorization based on the CDC UMPIRE study (high, intermediate, and safe), hydronephrosis (HN), and vesicoureteral reflux (VUR). A single reader evaluated each UDS. RESULTS Initial UDS in 93 patients showed that the prevalence of high-risk bladders were 35% FMR versus 36% PSTNR and 60% POMR. Follow-up UDS showed only 8% of FMR were high-risk compared to 35% POMR and 36% PSTNR. Change from initial to follow-up bladder-risk-category did not reach significance (p = .0659); however, 10% PSTNR worsened to high-risk on follow-up, compared to none in either prenatal group. Subanalysis of follow-up UDS between the prenatal cohorts also was not significant (p = .055). Only 8% of FMR worsened or stayed high-risk compared to 35% with POMR (p = .1). HN was significantly different at initial and subsequent follow up between the groups with the least in the FMR group. CONCLUSIONS Early outcome UDS analyses demonstrated lower incidence of high-risk bladders in FMR patients with a trend toward clinically significant improvement compared to POMR in regard to all evaluated metrics. Larger, prospective, confirmatory studies are needed to further evaluate the potential benefits on FMR on bladder safety and health.
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Affiliation(s)
- Jonathan A Gerber
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Blair T Stocks
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Huirong Zhu
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Heidi Castillo
- Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jonathan Castillo
- Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra N Borden
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Duong D Tu
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - William E Whitehead
- Department of Neurosurgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Paul F Austin
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
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22
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Di Mascio D, Greco F, Rizzo G, Khalil A, Buca D, Sorrentino F, Vasciaveo L, Greco P, Nappi L, D'Antonio F. Diagnostic accuracy of prenatal ultrasound in identifying the level of the lesion in fetuses with open spina bifida: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2021; 100:210-219. [PMID: 32979219 DOI: 10.1111/aogs.14001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The role of prenatal ultrasound in correctly identifying the level of the lesion in fetuses with open spina bifida has yet to be determined. The primary aim of this systematic review was to report the diagnostic accuracy of ultrasound in determining the level of the lesion in fetuses with open spina bifida. The secondary aim was to elucidate whether prenatal magnetic resonance imaging (MRI) improves the diagnostic performance of prenatal imaging in correctly identifying the level of the lesion. MATERIAL AND METHODS Inclusion criteria were studies reporting the agreement between ultrasound, MRI and postnatal or postmortem assessment of fetuses with spina bifida. Agreement was defined as: complete (when the upper level of the lesion detected prenatally was the same recorded at postnatal or postmortem evaluation), within one (when the upper level of the lesion recorded prenatally was within one vertebral body higher or lower than that reported postnatally) and within two vertebral bodies (when the upper level of the lesion recorded prenatally was within two vertebral bodies higher or lower than that reported postnatally or postmortem evaluation). Meta-analyses of proportions were used to combine data. RESULTS Fourteen studies (655 fetuses) were included. Ultrasound was able to identify the correct level of the lesion in 40.9% (95% confidence interval [CI] 26.9-55.6) of cases. The upper level of the lesion recorded on ultrasound was within one vertebral body in 76.2% (95% CI 65.0-85.9) of cases and within two segments in 92.4% (95% CI 84.3-97.7). Fetal MRI detected the exact level of the lesion in 42.5% (95% CI 35.9-45.2) of cases; the level of the lesion recorded on MRI was higher in 26.4% (95% CI 20.0-33.3) of cases and lower in 32.4% (95% CI 25.5-39.7) than that confirmed postnatally. The upper level of the lesion recorded on MRI was within one vertebral body in 76.2% (95% CI 65.9-85.2) of cases and within two segments in 94.2% (95% CI 90.2-97.2). CONCLUSIONS Both ultrasound and MRI have a moderate diagnostic accuracy in identify the upper level of the lesion in fetuses with open spina bifida.
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Affiliation(s)
- Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Greco
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Giuseppe Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Danilo Buca
- Center for Fetal Care and High-risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Felice Sorrentino
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Lorenzo Vasciaveo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Department of Morphology, Surgery and Experimental Medicine, Section of Obstetrics and Gynecology, University of Ferrara, S. Anna University Hospital, Cona, Ferrara, Italy
| | - Luigi Nappi
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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23
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Kunpalin Y, Subramaniam S, Perin S, Gerli MFM, Bosteels J, Ourselin S, Deprest J, De Coppi P, David AL. Preclinical stem cell therapy in fetuses with myelomeningocele: A systematic review and meta-analysis. Prenat Diagn 2021; 41:283-300. [PMID: 33427329 PMCID: PMC7611444 DOI: 10.1002/pd.5887] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/16/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We performed a systematic review to summarize the efficacy and safety of in utero stem cells application in preclinical models with myelomeningocele (MMC). METHODS The study was registered with PROSPERO (CRD42019160399). We searched MEDLINE, Embase, Web of Science, Scopus and CENTRAL for publications articles on stem cell therapy in animal fetuses with MMC until May 2020. Publication quality was assessed by the SYRCLE's tool. Meta-analyses were pooled if studies were done in the same animal model providing similar type of stem cell used and outcome measurements. Narrative synthesis was performed for studies that could not be pooled. RESULTS Nineteen and seven studies were included in narrative and quantitative syntheses, respectively. Most used mesenchymal stem cells (MSCs) and primarily involved ovine and rodent models. Both intra-amniotic injection of allogeneic amniotic fluid (AF)-MSCs in rat MMC model and the application of human placental (P)-MSCs to the spinal cord during fetal surgery in MMC ovine model did not compromise fetal survival rates at term (rat model, relative risk [RR] 1.03, 95% CI 0.92-1.16; ovine model, RR 0.94, 95% CI 0.78-1.13). A single intra-amniotic injection of allogeneic AF-MSCs into rat MMC model was associated with a higher rate of complete defect coverage compared to saline injection (RR 16.35, 95% CI 3.27-81.79). The incorporation of human P-MSCs as a therapeutic adjunct to fetal surgery in the ovine MMC model significantly improved sheep locomotor rating scale after birth (mean difference 5.18, 95% CI 3.36-6.99). CONCLUSIONS Stem cell application during prenatal period in preclinical animal models is safe and effective.
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Affiliation(s)
- Yada Kunpalin
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Sindhu Subramaniam
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Silvia Perin
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mattia F M Gerli
- Great Ormond Street Institute of Child Health, University College London, London, UK.,Division of Surgery and Interventional Science, Royal Free Hospital, University College London, London, UK
| | - Jan Bosteels
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Cochrane Belgium, Belgian Centre for Evidence-Based Medicine (Cebam), Leuven, Belgium
| | - Sebastien Ourselin
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Jan Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
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24
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Riley JS, Antiel RM, Flake AW, Johnson MP, Rintoul NE, Lantos JD, Traynor MD, Adzick NS, Feudtner C, Heuer GG. Pediatric neurosurgeons' views regarding prenatal surgery for myelomeningocele and the management of hydrocephalus: a national survey. Neurosurg Focus 2020; 47:E8. [PMID: 31574481 DOI: 10.3171/2019.7.focus19406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for myelomeningocele (MMC). The present study sought to determine how MOMS influenced the clinical recommendations of pediatric neurosurgeons, how surgeons' risk tolerance affected their views, how their views compare to those of their colleagues in other specialties, and how their management of hydrocephalus compares to the guidelines used in the MOMS trial. METHODS A cross-sectional survey was sent to all 154 pediatric neurosurgeons in the American Society of Pediatric Neurosurgeons. The effect of surgeons' risk tolerance on opinions and counseling of prenatal closure was determined by using ordered logistic regression. RESULTS Compared to postnatal closure, 71% of responding pediatric neurosurgeons viewed prenatal closure as either "very favorable" or "somewhat favorable," and 51% reported being more likely to recommend prenatal surgery in light of MOMS. Compared to pediatric surgeons, neonatologists, and maternal-fetal medicine specialists, pediatric neurosurgeons viewed prenatal MMC repair less favorably (p < 0.001). Responders who believed the surgical risks were high were less likely to view prenatal surgery favorably and were also less likely to recommend prenatal surgery (p < 0.001). The management of hydrocephalus was variable, with 60% of responders using endoscopic third ventriculostomy in addition to ventriculoperitoneal shunts. CONCLUSIONS The majority of pediatric neurosurgeons have a favorable view of prenatal surgery for MMC following MOMS, although less so than in other specialties. The reported acceptability of surgical risks was strongly predictive of prenatal counseling. Variation in the management of hydrocephalus may impact outcomes following prenatal closure.
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Affiliation(s)
- John S Riley
- 1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan M Antiel
- 2Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alan W Flake
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Mark P Johnson
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - John D Lantos
- 5Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; and
| | | | - N Scott Adzick
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania
| | - Chris Feudtner
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania
| | - Gregory G Heuer
- 3University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Pennsylvania.,4The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Pennsylvania.,6Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
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25
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Macedo A, Di Migueli RDD, Cavalheiro S, Moron A, da Cruz ML. In utero myelomeningocele repair: The natural history of patients with incontinent pattern (sphincteric deficiency: leakage below 40 CMH20). Neurourol Urodyn 2020; 39:2373-2378. [PMID: 32918741 DOI: 10.1002/nau.24497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Since 2011 we have been following prospectively myelomeningocele patients treated in utero with particular interest to patients with sphincter weakness/deficiency. We investigated the changes of bladder pattern and upper urinary tract with time in children who underwent in utero repair and had low-pressure incontinence based on urodynamic evaluation (UE). MATERIALS AND METHODS From the 120 patients in our database, 117 had at least one UE. Of these, 30 were classified as incontinent when leaking at low pressure (<40 cmH20). We reviewed clinical evaluation, urinary tract ultrasound, voiding cystourethrography (VCUG), and other UE parameters at first and last evaluation. RESULTS We found 30 cases (25.64%). Mean age at initial evaluation was 4.97 months followed by UE done initially at mean age of 5.73 months. Follow-up was 28.4 months. Febrile urinary tract infection has been found in four patients (13.3%), hydronephrosis in four patients, and bladder neck thickening in three (10%). The VCUG showed vesicoureteral reflux in three cases (3/27, 11.1%). A total of 90% of patients had detrusor overactivity with mean maximum detrusor pressure (33.37 cmH20). Only 16.67% of patients showed normal bladder capacity. From the 30 patients, 23 had at least two UE. We noticed a change of bladder pattern as follows: six patients became of high-risk pattern, five normal, and two with underactive bladder pattern. The average interval between the first and last UE was 25.5 months (median: 15 months). CONCLUSION We concluded that 43.47% of patients with low DLPP have kept the incontinent pattern. If the initial LPP was below 30 cmH20, 70% remained with the incontinet pattern.
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Affiliation(s)
- Antonio Macedo
- Department of Urology, CACAU-NUPEP, São Paulo, São Paulo, Brazil.,Department of Pediatrics, Federal University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Sérgio Cavalheiro
- Departament of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, São Paulo, Brazil
| | - Antonio Moron
- Santa Joana Maternity Hospital, São Paulo, São Paulo, Brazil.,Departament of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
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26
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Mazzone L, Hölscher AC, Moehrlen U, Gobet R, Meuli M, Horst M. Urological Outcome after Fetal Spina Bifida Repair: Data from the Zurich Cohort. Fetal Diagn Ther 2020; 47:882-888. [PMID: 32894833 DOI: 10.1159/000509392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) represents a severe burden for patients with open spina bifida (OSB). The effect of fetal OSB repair on the urological outcome remains unclear, as controversial data exist. The aim of this study was to further increment existing outcome data and to demonstrate that our earlier published positive preliminary results are not erratic. METHODS Data from standardized urological follow-up appointments of patients with fetal OSB repair operated at our center were analyzed. Data were obtained from urodynamic studies (UDSs) and radiologic exams performed in the newborn (gestational age 37-39 weeks), at ages of 6, 12, 18, and 24 months, and then at yearly intervals. RESULTS Of 82 patients (mean age 2.6 years, range 6 months to 7 years), 26 (32%) had a normal bladder function as demonstrated by UDSs. Of the 56 (68%) patients with NLUTD, 29 (51%) patients showed initially a normal UDS, but developed NLUTD in the follow-up, 19 (66%) of them spontaneously and another 10 (34%) in association with growth and development, or surgery of inclusion cysts. Radiologic abnormalities (upper tract dilatation and vesico-uretero-renal reflux) were seen in 15%, mainly patients with NLUTD. CONCLUSION Our results add an important set of information to the existing body of evidence. The data reconfirm our earlier published favorable preliminary results and support other studies that show a possible benefit of prenatal OSB repair on the urological outcome, but they also demonstrate that the positive effect remains limited.
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Affiliation(s)
- Luca Mazzone
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland, .,Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland, .,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland,
| | - Alice Catherine Hölscher
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Rita Gobet
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Maya Horst
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
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27
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Rintoul NE, Keller RL, Walsh WF, Burrows PK, Thom EA, Kallan MJ, Howell LJ, Adzick NS. The Management of Myelomeningocele Study: Short-Term Neonatal Outcomes. Fetal Diagn Ther 2020; 47:865-872. [PMID: 32866951 PMCID: PMC7845433 DOI: 10.1159/000509245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/06/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Management of Myelomeningocele Study was a multicenter randomized trial to compare prenatal and standard postnatal repair of myelomeningocele (MMC). Neonatal outcome data for 158 of the 183 randomized women were published in The New England Journal of Medicine in 2011. OBJECTIVE Neonatal outcomes for the complete trial cohort (N = 183) are presented outlining the similarities with the original report and describing the impact of gestational age as a mediator. METHODS Gestational age, neonatal characteristics at delivery, and outcomes including common complications of prematurity were assessed. RESULTS Analysis of the complete cohort confirmed the initial findings that prenatal surgery was associated with an increased risk for earlier gestational age at birth. Delivery occurred before 30 weeks of gestation in 11% of neonates that had fetal MMC repair. Adverse pulmonary sequelae were rare in the prenatal surgery group despite an increased rate of oligohydramnios. There was no significant difference in other complications of prematurity including patent ductus arteriosus, sepsis, necrotizing enterocolitis, periventricular leukomalacia, and intraventricular hemorrhage. CONCLUSION The benefits of prenatal surgery outweigh the complications of prematurity.
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Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Roberta L Keller
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, USA
| | - William F Walsh
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pamela K Burrows
- The Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Elizabeth A Thom
- The Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology & Informatics, Perlelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Ben Miled S, Loeuillet L, Duong Van Huyen JP, Bessières B, Sekour A, Leroy B, Tantau J, Adle-Biassette H, Salhi H, Bonnière-Darcy M, Tessier A, Martinovic J, Causeret F, Bruneau J, Saillour Y, James S, Ville Y, Attie-Bitach T, Encha-Razavi F, Stirnemann J. Severe and progressive neuronal loss in myelomeningocele begins before 16 weeks of pregnancy. Am J Obstet Gynecol 2020; 223:256.e1-256.e9. [PMID: 32283072 DOI: 10.1016/j.ajog.2020.02.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/31/2020] [Accepted: 02/10/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite undisputable benefits, midtrimester prenatal surgery is not a cure for myelomeningocele (MMC): residual intracranial and motor deficits leading to lifelong handicap question the timing of prenatal surgery. Indeed, the timing and intensity of intrauterine spinal cord injury remains ill defined. OBJECTIVE We aimed to describe the natural history of neuronal loss in MMC in utero based on postmortem pathology. STUDY DESIGN Pathology findings were analyzed in 186 cases of myelomeningocele with lesion level between S1 and T1. Using a case-control, cross-sectional design, we investigated the timewise progression and topographic extension of neuronal loss between 13 and 39 weeks. Motor neurons were counted on histology at several spinal levels in 54 isolated MMC meeting quality criteria for cell counting. These were expressed as observed-to-expected ratios, after matching for gestational age and spinal level with 41 controls. RESULTS Chiari II malformation increased from 30.7% to 91.6% after 16 weeks. The exposed spinal cord displayed early, severe, and progressive neuronal loss: the observed-to-expected count dropped from 17% to ≤2% after 16 weeks. Neuronal loss extended beyond the lesion to the upper levels: in cases <16 weeks, the observed-to-expected motor neuron count was 60% in the adjacent spinal cord, decreasing at a rate of 16% per week. Progressive loss was also found in the upper thoracic cord, but in much smaller proportions. The observed-over-expected ratio of motor neurons was not correlated with the level of myelomeningocele. CONCLUSIONS Significant neuronal loss is present ≤16 weeks in the exposed cord and progressively extends cranially. Earlier prenatal repair (<16 weeks) could prevent Chiari II malformation in 69.3% of cases, rescue the 17% remaining motor neurons in the exposed cord, and prevent the extension to the upper spinal cord.
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Affiliation(s)
- Selima Ben Miled
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute
| | - Laurence Loeuillet
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | | | - Bettina Bessières
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Amel Sekour
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Brigitte Leroy
- Department of Pathology, Poissy Saint Germain-en-Laye Hospital, Versailles Saint-Quentin-en-Yvelines University
| | - Julia Tantau
- Department of Pathology, Poissy Saint Germain-en-Laye Hospital, Versailles Saint-Quentin-en-Yvelines University
| | - Homa Adle-Biassette
- Department of Neuropathology, Lariboisière Hospital, AP-HP and Paris Diderot University
| | - Houria Salhi
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Maryse Bonnière-Darcy
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Aude Tessier
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Jelena Martinovic
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Frédéric Causeret
- Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, & IMAGINE Institute
| | - Julie Bruneau
- Department of Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Yoann Saillour
- Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, & IMAGINE Institute
| | - Syril James
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute
| | - Tania Attie-Bitach
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; INSERM UMR 1163, IMAGINE Institute
| | - Ferechte Encha-Razavi
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute.
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Weiner HL, Adelson PD, Brockmeyer DL, Maher CO, Gupta N, Smyth MD, Jea A, Blount JP, Riva-Cambrin J, Lam SK, Ahn ES, Albert GW, Leonard JR. Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach. J Neurosurg Pediatr 2020; 25:640-647. [PMID: 32109872 PMCID: PMC7164397 DOI: 10.3171/2019.12.peds19449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery. METHODS The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling. RESULTS Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon. CONCLUSIONS The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
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Affiliation(s)
- Howard L. Weiner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Douglas L. Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Cormac O. Maher
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan
| | - Nalin Gupta
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, California
| | - Matthew D. Smyth
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - Sandi K. Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward S. Ahn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory W. Albert
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jeffrey R. Leonard
- Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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30
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Abstract
Open neural tube defects or myelomeningoceles are a common congenital condition caused by failure of closure of the neural tube early in gestation, leading to a number of neurologic sequelae including paralysis, hindbrain herniation, hydrocephalus and neurogenic bowel and bladder dysfunction. Traditionally, the condition was treated by closure of the defect postnatally but a recently completed randomized controlled trial of prenatal versus postnatal closure demonstrated improved neurologic outcomes in the prenatal closure group. Fetal surgery, or more precisely maternal-fetal surgery, raises a number of ethical issues that we address including who the patient is, informed consent, surgical innovation and equipoise as well maternal assumption of risk. As the procedure becomes more widely adopted into practice, we suggest close monitoring of new fetal surgery centers, in order to ensure that the positive results of the trial are maintained without increased risk to both the mother and fetus.
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31
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Danzer E, Joyeux L, Flake AW, Deprest J. Fetal surgical intervention for myelomeningocele: lessons learned, outcomes, and future implications. Dev Med Child Neurol 2020; 62:417-425. [PMID: 31840814 DOI: 10.1111/dmcn.14429] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2019] [Indexed: 12/23/2022]
Abstract
Fetal myelomeningocele (fMMC) closure (spina bifida aperta) has become a care option for patients that meet inclusion criteria, but it is clear that fetal intervention, while improving outcomes, is not a cure. This review will: (1) focus on the rationale for fMMC surgery based on preclinical studies and observations that laid the foundation for human pilot studies and a randomized controlled trial; (2) summarize important clinical outcomes; (3) discuss the feasibility, efficacy, and safety of recent developments in fetal surgical techniques and approaches; and (4) highlight future research directions. Given the increased risk of maternal and fetal morbidity associated with prenatal intervention, accompanied by the increasing number of centres performing interventions worldwide, teams involved in the care of these patients need to proceed with caution to maintain technical expertise, competency, and patient safety. Ongoing assessment of durability of the benefits of fMMC surgery, as well as additional refinement of patient selection criteria and counselling, is needed to further improve outcomes and reduce the risks to the mother and fetus. WHAT THIS PAPER ADDS: High-quality prospective studies are needed to broaden the indication for fetal surgery in the general myelomeningocele population. Innovative minimally invasive approaches have had promising results, yet lack comprehensive and robust experimental or clinical evaluation. Important information to help families make informed decisions regarding fetal surgery for myelomeningocele is provided.
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Affiliation(s)
- Enrico Danzer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Luc Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, Division of Woman and Child, Fetal Medicine Unit, University Hospital Gasthuisberg, Leuven, Belgium
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jan Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, Division of Woman and Child, Fetal Medicine Unit, University Hospital Gasthuisberg, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, London, UK
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32
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Fetal repair of myelomeningocele: current status and urologic implications. J Pediatr Urol 2020; 16:3-9. [PMID: 31902678 DOI: 10.1016/j.jpurol.2019.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/30/2019] [Indexed: 11/21/2022]
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.
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33
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Blount JP, Bowman R, Dias MS, Hopson B, Partington MD, Rocque BG. Neurosurgery guidelines for the care of people with spina bifida. J Pediatr Rehabil Med 2020; 13:467-477. [PMID: 33325414 PMCID: PMC7838965 DOI: 10.3233/prm-200782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myelomeningocele (MMC) arises from an early neural developmental anomaly and results in a variety of structural abnormalities and associated functional neurologic deficits. As such, neurologic issues are central to virtually all clinical problems. Neurosurgical intervention strives to correct or improve these defects and prevent secondary complications. These interventions include closure of the open myelomeningocele and management (across the life span) of hydrocephalus, the Chiari II malformation (C2M) and tethered spinal cord (TSC). The development of pre-natal closure techniques and reports of improved outcome with in-utero closure (IUMC) have revolutionized the neurosurgical approach to myelomeningocele. Controversies remain surrounding patient selection, maternal risks, technique of IUMC (endoscopic vs. open) and long-term outcomes. However, real gains include reduced rates of hydrocephalus, modestly improved motor capabilities and reduction in C2M morbidity. For many decades, the cornerstone of treatment of hydrocephalus for many decades has been the placement and support of ventricular shunts. Endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation (ETV/CPC) is an appealing alternate strategy that avoids the morbidity and complications associated with shunts. The exact criteria for ETV-CPC candidacy and best metrics for outcome analysis remain active areas of debate and controversy. Similarly, neurosurgical management C2M, has centered upon the indications and clinical thresholds for performing posterior fossa surgical decompression. Tethered spinal cord management incorporates the diagnosis and surgical management of adhesions formed at the initial closure site, the consequent longitudinal traction related stress on the cord and the resulting neurologic signs and symptoms.
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Affiliation(s)
- Jeffrey P Blount
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robin Bowman
- Department of Neurosurgery, Lurie Children's Hospital of Chicago and Northwestern University College of Medicine, Chicago, IL, USA
| | - Mark S Dias
- Department of Neurosurgery, Penn State Hershey Children's Hospital and Penn State College of Medicine, Hershey, PA, USA
| | - Betsy Hopson
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael D Partington
- Department of Neurosurgery, Children's Mercy Hospital and University of Kansas School of Medicine, Kansas City, KA, USA
| | - Brandon G Rocque
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
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34
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Baskin LS. Bladder function and fetal treatment of myelomeningocele. BJU Int 2019; 123:560-561. [PMID: 30854800 DOI: 10.1111/bju.14674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laurence S Baskin
- Pediatric Urology, Urology UCSF Benioff Children's Hospitals, University of California, San Francisco, CA, USA
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35
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Weiss DA, Lee AS, Flanders TM, Long CJ, van Batavia JP, Zderic SA, Heuer GG. Neurological dysfunction of the bladder from myelomeningocele. Neurosurg Focus 2019. [DOI: 10.3171/2019.7.focus19468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Myelomeningocele (MMC) affects approximately 2000 infants in the US yearly and causes long-term damage to the genitourinary system. There is a wide spectrum of effects on the bladder and urethral sphincter that do not correlate with the level of the spinal cord defect. The bladder changes can provide a safe storage pressure, often at the expense of continence, or can create a hostile environment leading to increased pressure on the kidneys and eventually to chronic kidney disease. The ultimate goals in management are to maintain a safe system that prevents renal deterioration, while providing social continence and independence in the long term. This review intends to provide an overview of the effects of MMC on the genitourinary system, regardless of intervention, in order to understand the pathophysiology of the disease.
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Affiliation(s)
- Dana A. Weiss
- Division of Urology, Children’s Hospital of Philadelphia
| | - Albert S. Lee
- Department of Urology, Einstein Medical Center, Philadelphia
| | - Tracy M. Flanders
- Department of Neurosurgery, University of Pennsylvania, Philadelphia; and
| | | | | | | | - Gregory G. Heuer
- Division of Neurosurgery, Children’s Hospital of Philadelphia, Pennsylvania
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36
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Kessler BA, Catalino MP, Quinsey C, Goodnight W, Elton S. Cost of prenatal versus postnatal myelomeningocele closure for both mother and child at 1 year of life. Neurosurg Focus 2019; 47:E15. [PMID: 31574469 DOI: 10.3171/2019.7.focus19417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prenatal myelomeningocele (MMC) closure has been performed in the United States for 2 decades. While prior work has focused on clinical outcomes of prenatal MMC closure, the cost of this procedure in comparison with that of postnatal MMC closure is unclear. The authors' aim was to compare the cost of prenatal versus postnatal MMC closure for both the child and mother at 1 year. METHODS A prospective database of patients undergoing prenatal and postnatal MMC closure between 2011 and 2018 with 1-year follow-up was retrospectively reviewed. Charge data for relevant admissions were converted to a cost estimate using the authors' institution's Medicare hospital-specific cost-to-charge ratio. Children, mothers, and mother/child pairs were considered separately. The primary outcome was cost. Secondary outcomes included the need for hydrocephalus treatment, length of stay (LOS), and readmissions. Other covariates included gestational age at birth, MMC lesion level, and obstetric complications. RESULTS The median cost of care for children in the prenatal group was greater, although not significantly so, at $58,406.71 (IQR $16,900.24-$88,951.01) compared with $49,889.95 (IQR $38,425.18-$115,163.86) for children in the postnatal group (p = 0.204). The median cost for mothers in the prenatal group was significantly greater at $24,548.29 (IQR $20,231.55-$36,862.31) compared with $5087.30 (IQR $4430.72-$5362.56) (p < 0.001). The median cost for mother/child pairs in the prenatal group was $102,377.75 (IQR $37,384.30-$118,527.74) compared with $55,667.82 (IQR $42,840.78-$120,058.06) (p = 0.45). Children in the prenatal group had a lower gestational age at birth (235.81 days vs 265.77 days, p < 0.001) and fewer readmissions (33.3% vs 72.7%, p < 0.001), and hydrocephalus treatment was less common (33.3% vs 90.9%, p < 0.001). Index LOS did not differ between children in the prenatal and postnatal groups (26.8 days vs 23.5 days, p = 0.63). Mothers in the prenatal group had longer LOS (15.92 days vs 4.68 days, p < 0.001) and more readmissions (18.5% vs 0.0%, p = 0.06). CONCLUSIONS The median cost of prenatal versus postnatal MMC closure did not significantly differ from a hospital perspective at 1 year, although variability in cost was high for both groups. When considering the mother alone, prenatal MMC closure was costlier. Future work is needed to assess cost from a patient and societal perspective both at 1 year and beyond.
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Affiliation(s)
| | | | | | - William Goodnight
- 2Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Ghidini A, Bianchi DW, Levy B, Van Mieghem T, Deprest J, Chitty LS. In case you missed it: The prenatal diagnosis editors bring you the most significant advances of 2018. Prenat Diagn 2019; 39:61-69. [PMID: 30593668 DOI: 10.1002/pd.5407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Alessandro Ghidini
- Antenatal Testing Center Alexandria Hospital, Alexandria, VA, USA.,Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, D.C., USA
| | - Diana W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Brynn Levy
- Departments of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Jan Deprest
- Departments of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Lyn S Chitty
- North East Thames Regional Genetics Service, Great Ormond Street NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
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Abstract
Myelomeningocele is a congenital malformation that causes a spectrum of morbidity. With the standard of care now being in utero repair, the spectrum of morbidity has changed. The purpose of this article is to review the diagnosis, workup and treatment options of fetal myelomeningocele. We also review the obstetrical, neurological, gastrointestinal, urinary, and orthopedic outcomes of the in utero myelomeningocele repair.
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Affiliation(s)
- Kaeli J Yamashiro
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA.
| | - Laura A Galganski
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA
| | - Shinjiro Hirose
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA
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39
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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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Moldenhauer JS, Flake AW. Open fetal surgery for neural tube defects. Best Pract Res Clin Obstet Gynaecol 2019; 58:121-132. [PMID: 31078425 DOI: 10.1016/j.bpobgyn.2019.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 10/27/2022]
Abstract
The most common congenital defect of the central nervous system is myelomeningocele (MMC), which results in significant physical limitations for those affected. Neurologic injury associated with MMC begins with abnormal neurulation and is perpetuated by subsequent traumatic and toxic injury sustained in utero. Treatment historically has involved surgical closure of the MMC after birth along with neonatal management of the associated sequelae including cerebrospinal fluid diversion by ventricular shunting. With improvements in prenatal diagnosis, a defined antenatal natural history, and the concept of fetal intervention to arrest or reverse ongoing in utero damage, maternal-fetal surgery for MMC closure developed as a feasible therapy. Animal studies and early human studies investigating in utero MMC closure were promising, leading to Management of Myelomeningocele Study (MOMS trial). This prospective randomized multicenter trial comparing in utero fetal MMC (fMMC) closure to routine postnatal closure demonstrated a decreased need for shunting, reversal of hindbrain herniation, and improved neurologic function in the prenatal repair group, although maternal complications and prematurity were more frequently encountered. Because of the conclusion of the MOMS trial, fMMC closure has become a standard of care option for pregnancies complicated by a prenatal diagnosis of spina bifida. This article will provide background to the scope of MMC, review the MOMS trial data, and highlight the current clinical status of open fMMC closure.
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Affiliation(s)
- Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard Philadelphia, PA 19104, USA.
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard Philadelphia, PA 19104, USA.
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Macedo A, Cavalheiro S, Moron A, Lobountchenko T, Dini FS, Ottoni SL, Garrone G, Ligori R, Leal da Cruz M. Urinary and Fecal Continence in 5-Year-Old Patients Who Underwent in utero Myelomeningocele Repair: A Prospective Study. Fetal Diagn Ther 2019; 46:319-322. [PMID: 30884481 DOI: 10.1159/000496791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION After the successful results of in utero myelomeningocele (MMC) repair presented by the Management of Myelomeningocele Study, the concept of fetal surgery was introduced in our institution in 2011. Since then, we have been able to follow prospectively a group of patients with attention to urological care. In the present study, we were interested in estimating urinary and fecal continence in this new subset of patients. MATERIAL AND METHODS We selected from our database patients aged 5 years or older for evaluation of urinary and fecal continence. We reviewed all charts and completed a questionnaire to study aspects of urinary and fecal continence. RESULTS We identified 14 patients, i.e., 4 (28.6%) males and 10 (71.4%) females. The mean age at MMC surgery was 25.6 gestational weeks. The uro-dynamic class was high-risk in 6 (42.9%), incontinent in 4 (28.6%), hypocontractile in 1 (7.1%), and normal in 3 (21.4%) patients. Three patients had undergone surgery (2 augmentations, i.e., 1 in association with a left colon ACE Macedo-Malone procedure and 1 mini-sling urethroplasty). Twelve patients underwent clean intermittent catheterization (CIC) (85.7%). Only 3 (21.4%) patients had no urinary leakage. Eleven patients (78.6%) used diapers. Eight patients (57.2%) underwent retrograde rectal irrigation and 11 (78.6%) complained of fecal loss. Eleven patients (78.6%) did not report an impact on their self-esteem. CONCLUSION Despite the use of CIC in 85.7% of the cases, the continence rate in MMC patients operated on in utero was low and 78.6% of the patients used diapers. This data can be used to educate parents about future conditions of their 5-year-old children and may stimulate the debate regarding further attempts (surgical or not) to improve fecal and urinary continence.
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Affiliation(s)
- Antonio Macedo
- Department of Urology, CACAU-NUPEP, São Paulo, Brazil.,Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Sérgio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Antonio Moron
- Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
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Sileo FG, Pateisky P, Curado J, Evans K, Hettige S, Thilaganathan B. Long-term neuroimaging and neurological outcome of fetal spina bifida aperta after postnatal surgical repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:309-313. [PMID: 30663167 DOI: 10.1002/uog.20215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Parents faced with the choice between postnatal management and prenatal surgery for spina bifida need to have up-to-date information on the expected outcomes. The aim of this study was to report the long-term physical and neurological outcomes of infants with prenatally diagnosed isolated spina bifida that underwent postnatal surgical repair and were managed by a multidisciplinary team from a large tertiary center. METHODS This was a retrospective cohort study of all cases of fetal spina bifida managed in a tertiary unit between October 1999 and January 2018. All cases of fetal spina bifida from the local health region were routinely referred to the tertiary unit for further perinatal management. Details on surgical procedures and neonatal neurological outcomes were obtained from institutional case records. Ambulatory status, bladder and bowel continence and neurodevelopment were assessed at a minimum of 3 years. RESULTS During the study period, 241 pregnancies with isolated spina bifida were seen in the unit. Of these, 84 (34.9%) women opted to continue with the pregnancy after multidisciplinary counseling by clinicians. Sixty-seven infants underwent postnatal repair of spina bifida aperta and were included in the analysis. After birth, hindbrain herniation was observed in 91.5% of infants with only seven requiring surgical decompression. Ventriculoperitoneal shunt placement was needed in 64.2% of infants, while normal cognitive development or mild impairment was demonstrated in 85.4% of cases with data for this outcome available, at a mean age of 8 years. Cumulatively, 40% of infants were walking independently or using minor support, and normal or mild impairment of bladder and bowel function was reported in 45.5% and 44.4% of infants, respectively. CONCLUSIONS Neurodevelopmental and neurological outcomes between prenatal and postnatal repair are similar. As with fetal surgery, conventional postnatal surgery is associated with the reversal of hindbrain herniation. Similarly, postnatal ventriculoperitoneal shunt placement appears to be required mainly in fetuses without evidence of significant fetal ventriculomegaly. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F G Sileo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - P Pateisky
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Curado
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - K Evans
- Department of Paediatric Urology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - S Hettige
- Department of Paediatric Neurosurgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Masini L, De Luca C, Noia G, Caruso A, Lanzone A, Rendeli C, Ausili E, Massimi L, Tamburrini G, Apicella M, De Santis M. Prenatal diagnosis, natural history, postnatal treatment and outcome of 222 cases of spina bifida: experience of a tertiary center. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:302-308. [PMID: 30288814 DOI: 10.1002/uog.20136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 04/19/2018] [Accepted: 09/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To report on the prenatal ultrasonographic diagnosis of spina bifida (SB) and its natural history, treatment and long-term outcome in a large tertiary referral center. METHODS All cases of SB diagnosed between February 1980 and December 2015 in the Obstetric Prenatal Diagnosis Day Unit of the Obstetrics and Gynecology Department at the Catholic University of the Sacred Heart, Rome, were reviewed. All infants with an open defect were delivered by elective Cesarean section and underwent early repair of the spinal defect. A ventriculoperitoneal (VP) shunt and/or third ventriculostomy was performed when needed. Complete postnatal follow-up was carried out by our multidisciplinary team in the majority of cases. The cohort was analyzed in two groups: Group 1 included patients referred between February 1980 and December 1999; Group 2 included patients referred between January 2000 and December 2015. RESULTS There was a total of 222 cases of SB with a prenatal diagnosis rate of 94.6% (n = 210), with the majority of defects being meningomyeloceles (n = 142 (64.0%)), affecting the lumbosacral level (n = 110 (49.5%)) and being ≥ 2 cm in size (n = 163/195 (83.6%)). There were 174 (78.4%) live births, with more terminations in Group 2 (26.1%) than in Group 1 (10.8%; P = 0.003). Postnatal surgical repair was conducted in 157 cases (99.4% of eligible cases), with death of an infant who was operated on occurring more often in Group 1 (14.1%) than in Group 2 (4.2%; P = 0.03). VP shunt placement was required in 60.3% of infants operated on after January 2000. Long-term follow-up was available for 136 children (111 with open defects and 25 with closed defects). Infants born since 2000 with an open defect had normal ambulation or a mild defect in 50% of cases and normal or mild deficit of sphincter function in 37.8% of cases. An intelligence quotient of ≥ 70 was observed in the majority of children (81.4%; 35/43 cases). Worse motor function was associated with progressive prenatal ventriculomegaly, level of lesion and VP shunt placement. CONCLUSIONS We describe the prenatal diagnosis, natural history and long-term outcome of a large contemporary cohort of SB fetuses and infants. In an era of pioneering fetal surgical techniques for in-utero SB repair, it is important to acknowledge that advances in conventional neonatology and pediatric neurosurgery have allowed increased life expectancy and improved quality of life in patients with SB. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L Masini
- Department of Women and Child Health, Obstetrics and Neonatology Area, Centro Studi per la Tutela della Salute della Madre e del Concepito, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C De Luca
- Department of Women and Child Health, Obstetrics and Neonatology Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Noia
- Department of Women and Child Health, Obstetrics and Neonatology Area, Centro Studi per la Tutela della Salute della Madre e del Concepito, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Caruso
- Department of Women and Child Health, Obstetrics and Neonatology Area, Centro Studi per la Tutela della Salute della Madre e del Concepito, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Lanzone
- Department of Women and Child Health, Obstetrics and Neonatology Area, Centro Studi per la Tutela della Salute della Madre e del Concepito, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Rendeli
- Spina Bifida Center, Department of Women and Child Health, Paediatrics Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - E Ausili
- Spina Bifida Center, Department of Women and Child Health, Paediatrics Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Massimi
- Paediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Tamburrini
- Paediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - M Apicella
- Department of Women and Child Health, Obstetrics and Neonatology Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - M De Santis
- Department of Women and Child Health, Obstetrics and Neonatology Area, Centro Studi per la Tutela della Salute della Madre e del Concepito, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Macedo A, Ottoni SL, Garrone G, Liguori R, Cavalheiro S, Moron A, Leal Da Cruz M. In utero myelomeningocoele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function? BJU Int 2019; 123:676-681. [PMID: 30548158 DOI: 10.1111/bju.14639] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the first 100 cases of in utero myelomeningocoele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function. PATIENTS AND METHODS We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak-point pressure >40 cm H2 O and high filling pressures also >40 cm H2 O), incontinent, and underactivity (underactive bladder with post-void residual urine), and patients were treated accordingly. RESULTS We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico-ureteric reflux. CONCLUSION The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.
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Affiliation(s)
- Antonio Macedo
- Department of Urology, CACAU-NUPEP, São Paulo, Brazil.,Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Antonio Moron
- Santa Joana Maternity Hospital, São Paulo, Brazil.,Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil
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AlRefai A, Drake J, Kulkarni AV, Connor KL, Shannon P, Toi A, Chitayat D, Blaser S, Church PT, Abbasi N, Ryan G, Van Mieghem T. Fetal myelomeningocele surgery: Only treating the tip of the iceberg. Prenat Diagn 2018; 39:10-15. [PMID: 30536580 DOI: 10.1002/pd.5390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fetal myelomeningocele (fMMC) surgery improves infant outcomes when compared with postnatal surgery. Surgical selection criteria and the option of pregnancy termination, however, limit the number of cases that are eligible for prenatal surgery. We aimed to quantify what proportion of cases could ultimately benefit from fetal therapy. METHODS We retrospectively reviewed all cases of fMMC referred to a large tertiary care center over a 10-year period and assessed their eligibility for fetal surgery, pregnancy termination rates, and actual uptake of the surgery. RESULTS Of 158 cases, 67 (42%) were ineligible for fetal surgery based on surgical exclusion criteria. Eleven fetuses (7%) had chromosomal anomalies, 10 of which (91%) had other anomalies on ultrasound. Thirty-four patients had a combination of maternal and fetal contraindications. Of the remaining 91 eligible cases (58%), 45 (49%) pregnancies were terminated, leaving only 46 (29% of initial 158 cases) as potential candidates for fetal repair. Actual uptake of fetal surgery was 15% (n = 14 of 91), but this increased after a national program was started. CONCLUSION Only a minority of fMMC cases will ultimately undergo fetal surgery. These numbers support the centralization of care in expert centers.
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Affiliation(s)
- Alyaa AlRefai
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - James Drake
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kristin L Connor
- Department of Health Sciences, Carleton University, Ottawa, Canada
| | - Patrick Shannon
- Department of Pathology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ants Toi
- Department of Radiology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - David Chitayat
- Department of Medical Genetics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Susan Blaser
- Department of Radiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paige T Church
- Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital and University of Toronto, Toronto, Canada
| | - Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
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Joyeux L, Danzer E, Flake AW, Deprest J. Fetal surgery for spina bifida aperta. Arch Dis Child Fetal Neonatal Ed 2018; 103:F589-F595. [PMID: 30006470 DOI: 10.1136/archdischild-2018-315143] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/04/2022]
Abstract
Spina bifida aperta (SBA) is one of the most common congenital malformations. It can cause severe lifelong physical and neurodevelopmental disabilities. Experimental and clinical studies have shown that the neurological deficits associated with SBA are not simply caused by incomplete neurulation at the level of the lesion. Additional damage is caused by prolonged exposure of the spinal cord and nerves to the intrauterine environment and a suction gradient due to cerebrospinal fluid leakage, leading to progressive downward displacement of the hindbrain. This natural history can be reversed by prenatal repair. A randomised controlled trial demonstrated that mid-gestational maternal-fetal surgery for SBA decreases the need for ventriculoperitoneal shunting and hindbrain herniation at 12 months and improves neurological motor function at 30 months of age. This came at the price of maternal and fetal risks, the most relevant ones being increased prematurity and a persistent uterine corporeal scar. Recently minimally invasive fetal approaches have been introduced clinically yet they lack extensive experimental or clinical trials. We aim to provide clinicians with the essential information necessary to counsel SBA parents as the basis for considering referral of selected patients to expert fetal surgery centres. We review the reported clinical outcomes and discuss recent developments of potentially less invasive fetal SBA approaches.
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Affiliation(s)
- Luc Joyeux
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium
| | - Enrico Danzer
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Center for Fetal Research, Abramson Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Center for Fetal Research, Abramson Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Division Woman and Child, Fetal Medicine Unit, Clinical Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, London, UK
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Abstract
Intrauterine surgery shows that the prognosis of neonates with myelomeningocele (MMC) has improved, both in survival and in quality of life. In order to study the current efficacy of intrauterine surgery for MMC and to make an ethical analysis of its proportionality, we conducted a PubMed search using the keywords "myelomeningocele", "intrauterine surgery", "MOMS", and "trial". Thirty-eight articles were found. The literature investigated the risks and benefits of intrauterine surgery based on the physiological parameters of MMC. Intrauterine surgery produces clear benefits. However, it also has disadvantages, such as premature birth, fetal or neonatal death, and uterine complications. The option of surgery is positive. However, since the intervention is risky, the final decision must be prudential, and thus should involve an ethical analysis of therapeutic proportionality. This requires a specific clinical evaluation of the fetus ensuring fetal survival in all cases and minimizing the risks arising from extremely premature birth.
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Affiliation(s)
- Agustín Silberberg
- a Department of Bioethics , Hospital Universitario Austral, Universidad Austral , Buenos Aires , Argentina
| | - Josefina Robetto
- b Chair of Pathophysiology, Facultad de Ciencias Biomédicas , Universidad Austral , Buenos Aires , Argentina
| | - Magdalena Grillo
- c Medical Student, Facultad de Ciencias Biomédicas , Universidad Austral , Buenos Aires , Argentina
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Abstract
The landscape of genetic testing and screening has changed tremendously since the initial description of the molecular structure of DNA. Given this, it is critical that providers reflect on the goals of prenatal screening and diagnostic testing, and how these tests impact perinatal outcomes. The participants of this workshop were in agreement that the goal of prenatal genetic testing should be focused on improving outcomes for women and families. While prenatal testing has historically focused on the option for pregnancy termination, increasing numbers of prenatal and perinatal treatments are available. As more in utero therapies are developed, the detection of disorders that are amenable to, and would benefit from, prenatal or immediate neonatal targeted therapy will increasingly be a focus of prenatal testing. Prenatal genetic testing must also balance the ethical principles of autonomy and distributive justice. The workshop participants agreed that stakeholders such as medical professionals, professional societies, insurers, commercial laboratories, and the public should consider and come to agreement regarding the appropriate objectives for and use of these tests.
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Affiliation(s)
- Stephanie Dukhovny
- Department of OBGYN, Maternal Fetal Medicine, Oregon Health & Sciences University, 3181 SW Sam Jackson Park Road, Portland OR 97239, United States.
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th St, 7th floor, San Francisco CA 94143, United States.
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Pastuszka A, Bohosiewicz J, Koszutski T. Prenatal myelomeningocele repair improves urinary continence and reduces the risk of constipation. Neurourol Urodyn 2018; 37:2792-2798. [PMID: 30058735 DOI: 10.1002/nau.23771] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/01/2018] [Indexed: 11/07/2022]
Abstract
AIMS The aim of the study was to evaluate the lower urinary tract function, frequency UTI, the degree of social urine continence, and the occurrence of constipation in children who underwent prenatal or postnatal surgery for MMC. MATERIALS AND METHODS Seventy-two patients with MMC were assessed and divided into the prenatal group (36 patients) and the postnatal one (36 patients). All children, regardless the time of operation, received the same treatment after birth. The urodynamic tests, USG, cystourethrography were performed in all patients along with evaluation of the UTI's, social urine continence, and presence of constipation. RESULTS Urodynamic and imaging studies showed no differences between the test groups. Children from the prenatally operated group showed statistically significant lower number of urinary tract infections, better urine continence, and less frequent constipation. CONCLUSIONS Prenatal MMC repair ensures statistically significant improvement of the degree of social urinary continence, reducing the risk of urinary infections and constipation. Time of MMC repair does not statistically influence the urodynamic tests results and the urodynamic parameters are not the prognostic elements to assess the social urinary continence possibility in patients with the neurogenic bladder.
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Affiliation(s)
- Agnieszka Pastuszka
- Chair and Department of Descriptive and Topographic Anatomy, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Zabrze, Poland
| | - Janusz Bohosiewicz
- Higher School of Strategic Planning in Dąbrowa Górnicza, Śląski Uniwersytet Medyczny w Katowicach, Klinika Chirurgii i Urologii Dziecięcej, Katowice, Poland
| | - Tomasz Koszutski
- Clinical Department of Children's Surgery, Department of Children's Surgery and Urology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Katowice, Poland
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Dudley AG, Adams MC, Brock JW, Clayton DB, Joseph DB, Koh CJ, Merguerian PA, Pope JC, Routh JC, Thomas JC, Tu DD, Wallis MC, Wiener JS, Yerkes EB, Lauderdale CJ, Shannon CN, Tanaka ST. Interrater Reliability in Interpretation of Neuropathic Pediatric Urodynamic Tracings: An Expanded Multicenter Study. J Urol 2018; 199:1337-1343. [DOI: 10.1016/j.juro.2017.12.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Anne G. Dudley
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Mark C. Adams
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - John W. Brock
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Douglass B. Clayton
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - David B. Joseph
- Department of Urology, University of Alabama Birmingham, Children’s of Alabama, Birmingham, Alabama
| | - Chester J. Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children’s Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Paul A. Merguerian
- Division of Urology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | - John C. Pope
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Jonathan C. Routh
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
| | - John C. Thomas
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Duong D. Tu
- Division of Pediatric Urology, Department of Surgery, Texas Children’s Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - M. Chad Wallis
- Division of Urology, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - John S. Wiener
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth B. Yerkes
- Division of Urology, Ann and Robert Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chelsea J. Lauderdale
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stacy T. Tanaka
- Division of Pediatric Urology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
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