A comparison of prenatal and postnatal repair of myelomeningocele: a systematic review and meta- analysis

Background: Myelomeningocele (MMC), the most severe form of spina bifida, is associated with lifelong disability due to incomplete neural tube closure. Traditionally repaired postnatally, prenatal surgical intervention has emerged as a promising alternative, potentially preventing neurological deterioration. This meta-analysis aimed to compare prenatal and postnatal surgical repair of MMC in terms of motor function, ambulation, shunt dependency, and mortality. Methods: A comprehensive search of PubMed, Scopus, and Cochrane databases was conducted through May 2025. Eligible studies included randomized controlled trials and cohort studies comparing prenatal and postnatal MMC repair. Primary outcomes were motor function and walking independence. Secondary outcomes included ventriculoperitoneal (VP) shunt placement and neonatal mortality. Risk of bias was assessed using the Cochrane RoB2 and Newcastle–Ottawa Scale. Results: Four studies (N=516 patients) met inclusion criteria. Prenatal repair significantly improved functional mobility (RR = 2.45, 95% CI: 1.72–3.47, p < 0.00001, I² = 0%) and walking independence (RR = 2.33, 95% CI: 1.52–3.55, p < 0.0001, I² = 13%). A trend toward reduced VP shunt placement was observed in the prenatal group (RR = 0.52, p = 0.06), though not statistically significant. Mortality was slightly higher in the prenatal group (RR = 1.49, p = 0.48), but without significance. Conclusion: Prenatal MMC repair yields superior motor outcomes and greater walking independence without significantly affecting mortality. While shunt dependency may be reduced, further research is required to confirm long-term safety and optimize patient selection. Prenatal surgery should be considered in specialized centers with multidisciplinary expertise.