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In-utero Closure Of Complex Myelomeningocele Defects With Bipedicle Fasciocutaneous Flaps: A Cohort Study.
Matthew E. Pontell, MD1, Aaron Yengo-Kahn, MD2, Emily Taylor, WHNP-BC3, J Michael Newton, MD, PhD4, Kelly A. Bennett, MD, MS, FRCS(C)4, John C. Wellons, III, MD, MSPH5, Stephane A. Braun, MD, FRCS(C)6.
1Vanderbilt University Medical Center, Nashville, TN, USA, 2Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA, 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA, 4The Fetal Center at Vanderbilt, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA, 5The Fetal Center at Vanderbilt, Department of Pediatric Neurosurgery, Department of Neurologic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA, 6The Fetal Center at Vanderbilt, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Abstract:
Purpose: The Management of Myelomeningocele Study (MOMS) concluded that prenatal myelomeningocele (MMC) repair improved postnatal outcomes. This study presents the use of intrauterine bipedicled flaps for closure of MMCs not amenable to primary linear repair.
Methods: A single-institution review was conducted of all patients who underwent in-utero MMC repair from 2011-2021. Univariate analysis was conducted using Fisher's exact and t-test calculations.
Results: Twenty-two patients underwent intrauterine bipedicled fasciocutaneous flap closure, while 64 underwent primary linear closure. Maternal cohorts did not differ significantly with respect to age at time of fetal surgery, gravidity, parity, BMI, fetal lesion level or gestational age at the time of MMC repair. Operative times were longer in the flap cohort (32.5土9.93 vs. 18.7土4.88 minutes, p<0.01); however, there were no significant differences in maternal blood loss (94.32土66.44 vs. 81.11土52.64 milliliters, p=0.35), need for fetal (0%) or maternal (0%) transfusion, gestational age at delivery (231.64土31.77 vs. 240.18土17.93 days, p=0.13) or MMC repair site dehiscence (5% vs. 10.17%, p=0.67). There were no significant differences in major intra-uterine or postnatal complications. The flap cohort had a lower rate of cerebrospinal fluid diversion prior to discharge (0% vs. 7.02%, p<0.01).
Conclusion: While fetal MMC repair has become standard of care for certain patients, it is difficult to identify high-tension lesions preoperatively. This study suggests that bipedicle flaps can achieve tension-free MMC closure without increasing risks to the mother or fetus.


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