title: Procedure-related complications of open vs endoscopic fetal surgery for treatment of spina bifida in an era of intrauterine myelomeningocele repair: systematic review and meta-analysis.
abstract: OBJECTIVE
  To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery.
  
  
  METHODS
  Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic.
  
  
  RESULTS
  The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%).
  
  
  CONCLUSIONS
  Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands.|Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.
authors.forename: E
authors.initials: E
authors.lastname: Araujo Júnior
authors.affiliation: Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
authors.forename: A J
authors.initials: AJ
authors.lastname: Eggink
authors.affiliation: Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: van den Dobbelsteen
authors.affiliation: Department of Obstetrics and Gynecology, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil.
authors.forename: W P
authors.initials: WP
authors.lastname: Martins
authors.affiliation: Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: D
authors.initials: D
authors.lastname: Oepkes
mesh_terms: D005260:Female; D005332:Fetoscopy / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D007231:Infant, Newborn; D008591:Meningomyelocele / Q000601:surgery*; D064887:Observational Studies as Topic; D011183:Postoperative Complications / Q000209:etiology; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D016135:Spinal Dysraphism / Q000601:surgery*; D016896:Treatment Outcome
keywords: fetoscopy; open fetal surgery; perinatal complications; spina bifida; systematic review