title: Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique.
abstract: To describe development of a two-port fetoscopic technique for spina bifida repair in the exteriorized, carbon dioxide-filled uterus and report early results of two cohorts of patients: the first 15 treated with an iterative technique and the latter 13 with a standardized technique.
  
  
  
  This was a retrospective cohort study (2014-2016). All patients met Management of Myelomeningocele Study selection criteria. The intraoperative approach was iterative in the first 15 patients and was then standardized. Obstetric, maternal, fetal, and early neonatal outcomes were compared. Standard parametric and nonparametric tests were used as appropriate.
  
  
  
  Data for 28 patients (22 endoscopic only, four hybrid, two abandoned) are reported, but only those with a complete fetoscopic repair were analyzed (iterative technique [n=10] compared with standardized technique [n=12]). Maternal demographics and gestational age (median [range]) at fetal surgery (25.4 [22.9-25.9] compared with 24.8 [24-25.6] weeks) were similar, but delivery occurred at 35.9 (26-39) weeks of gestation with the iterative technique compared with 39 (35.9-40) weeks of gestation with the standardized technique (P<.01). Duration of surgery (267 [107-434] compared with 246 [206-333] minutes), complication rates, preterm prelabor rupture of membranes rates (4/12 [33%] compared with 1/10 [10%]), and vaginal delivery rates (5/12 [42%] compared with 6/10 [60%]) were not statistically different in the iterative and standardized techniques, respectively. In 6 of 12 (50%) compared with 1 of 10 (10%), respectively (P=.07), there was leakage of cerebrospinal fluid from the repair site at birth. Management of Myelomeningocele Study criteria for hydrocephalus-death at discharge were met in 9 of 12 (75%) and 3 of 10 (30%), respectively, and 7 of 12 (58%) compared with 2 of 10 (20%) have been treated for hydrocephalus to date. These latter differences were not statistically significant.
  
  
  
  Fetoscopic open neural tube defect repair does not appear to increase maternal-fetal complications as compared with repair by hysterotomy, allows for vaginal delivery, and may reduce long-term maternal risks.
  
  
  
  ClinicalTrials.gov, https://clinicaltrials.gov, NCT02230072.
authors.affiliation: Departments of Obstetrics and Gynecology, Neurosurgery, Surgery, Anesthesiology, Pediatrics, and Radiology, Baylor College of Medicine, and Texas Children's Fetal Center, Houston, Texas; and the Departments of Obstetrics and Gynecology and Surgery, Vall D'Hebron Hospital, Barcelona, Spain.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Belfort
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
authors.forename: Alireza A
authors.initials: AA
authors.lastname: Shamshirsaz
authors.forename: Zhoobin H
authors.initials: ZH
authors.lastname: Bateni
authors.forename: Oluyinka O
authors.initials: OO
authors.lastname: Olutoye
authors.forename: Olutoyin A
authors.initials: OA
authors.lastname: Olutoye
authors.forename: David G
authors.initials: DG
authors.lastname: Mann
authors.forename: Jimmy
authors.initials: J
authors.lastname: Espinoza
authors.forename: Erin
authors.initials: E
authors.lastname: Williams
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Lee
authors.forename: Sundeep G
authors.initials: SG
authors.lastname: Keswani
authors.forename: Nancy
authors.initials: N
authors.lastname: Ayres
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Cassady
authors.forename: Amy R
authors.initials: AR
authors.lastname: Mehollin-Ray
authors.forename: Magdalena
authors.initials: M
authors.lastname: Sanz Cortes
authors.forename: Elena
authors.initials: E
authors.lastname: Carreras
authors.forename: Jose L
authors.initials: JL
authors.lastname: Peiro
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Ruano
authors.forename: Darrell L
authors.initials: DL
authors.lastname: Cass
mesh_terms: D000328:Adult; D002245:Carbon Dioxide / Q000627:therapeutic use*; D065634:Cerebrospinal Fluid Leak / Q000175:diagnosis / Q000209:etiology; D057186:Comparative Effectiveness Research; D005260:Female; D005332:Fetoscopy / Q000009:adverse effects / Q000379:methods; D005865:Gestational Age; D006801:Humans; D020883:Hysterotomy / Q000009:adverse effects / Q000379:methods; D007231:Infant, Newborn; D007327:Insufflation / Q000009:adverse effects / Q000379:methods; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000175:diagnosis*; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D016135:Spinal Dysraphism / Q000175:diagnosis / Q000601:surgery
chemical_list: D002245:Carbon Dioxide