Open Fetal Surgery
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Championed by Michael Harrison, the inception of open fetal surgery dates back to 1978 at the University of California, San Francisco but it was not until 1983 that the first human open fetal intervention was performed. This was a case of lower urinary tract obstruction managed by open ureterostomies . Fetal surgery poses a unique challenge as it involves two patients: the mother and her fetus. This particular scenario has only been observed in transplantation from a living donor. Because of the risk to the mother (who derives no direct benefit from fetal surgery) open fetal surgery was initially performed only for lethal conditions. Recently, the indications have been expanded to include myelomeningocele as a randomized controlled trial showed decreased morbidity associated with fetal intervention.
The goal of fetal surgery is to improve the health of the future child. To reach this goal there is risk imposed upon the mother. Due to the inherent ethical issues associated with the balance of fetal and maternal health, a symposium of fetal experts convened and developed five criteria that must be met for fetal surgery to be be performed . These criteria are adhered to regardless of the type or invasiveness of the intervention which can range from percutaneous radiofrequency ablation to fetoscopy to open fetal surgery and ex utero intrapartum treatment.
An accurate diagnosis and staging is possible with the exclusion of associated anomalies.
The natural history of the disease is documented and prognosis is established.
Currently, there is no effective postnatal therapy.
In utero surgery is proven feasible in animal models reversing deleterious effects of the condition.
There have been interventions performed in specialized multidisciplinary fetal treatment centers within strict protocols and approval of the local ethics committee with informed consent of the mother or parents.