Benefits and complications of fetal and postnatal surgery for open spina bifida: systematic review and proportional meta-analysis.

objectiveTo derive pooled estimates of maternal, fetal and pediatric outcomes up to the age of 30 months in patients undergoing pre- or postnatal surgery for open spina bifida (OSB).

methodsA systematic search was conducted in MEDLINE, PubMed (non-MEDLINE records), Embase, Web of Science, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, as well as 'gray' literature, for studies reporting on maternal, fetal and/or pediatric outcomes related to pre- or postnatal surgery for OSB. Only studies with inclusion criteria similar to those of the Management of Myelomeningocele Study were included. Study quality and risk of bias were assessed. Meta-analysis of single proportions was performed.

resultsNo case of maternal death was reported following prenatal surgery for OSB. Common maternal complications among those who underwent prenatal surgery included preterm prelabor rupture of membranes (open classical hysterotomy, 31%; open minihysterotomy, 33%; hybrid fetoscopy, 32%; percutaneous fetoscopy, 80%) and preterm birth before 32 weeks' gestation (open classical hysterotomy, 12%; open minihysterotomy, 15%; hybrid fetoscopy, 13%; percutaneous fetoscopy, 33%). Among patients who underwent open classical hysterotomy for OSB and later became pregnant again, 4% and 9% experienced placenta accreta spectrum disorder and uterine rupture, respectively, in any subsequent pregnancy. The most common neonatal complications were respiratory distress syndrome, apnea and postnatal surgical wound revision. Perinatal and infant death rates were similar regardless of whether the surgery was performed pre- or postnatally. The rate of cerebrospinal fluid diversion surgery at 12 months after birth was lower following prenatal surgery (open classical hysterotomy, 38%; open minihysterotomy, 17%; hybrid fetoscopy, 36%; percutaneous fetoscopy, 46%) compared with postnatal surgery (81%). The proportion of toddlers walking with or without assistive devices at 30 months after birth was higher in some prenatal surgery groups (open classical hysterotomy, 72%; open minihysterotomy, 66%; percutaneous fetoscopy, 81%) compared with the postnatal repair group (57%). The rate of clean intermittent catheterization for bladder management at 30 months after birth was 39% in the open classical hysterotomy group and 41% in the percutaneous fetoscopy group, compared with 53% in the postnatal surgery group. Each surgical approach was associated with a specific constellation of procedure-related complications.

conclusionsWe provide pooled estimates for maternal, fetal and pediatric outcomes for all currently used perinatal surgical approaches for OSB repair, each of which has its specific advantages and disadvantages. Our data should serve to inform clinical decision analysis to identify the best surgical approach for OSB cases. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.