Endoscopic third ventriculostomy versus ventriculoperitoneal shunting for hydrocephalus treatment following prenatal and postnatal myelomeningocele repair

Purpose: It is not known how responses to endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting (VPS) for myelomeningocele (MMC)-associated hydrocephalus vary with timing of MMC repair. Therefore, we compare the use of ETV and VPS after prenatal and postnatal MMC repair. Methods: We retrospectively identified MMC patients who underwent prenatal or postnatal repair and VPS or ETV ± choroid plexus cauterization (CPC) between 2015 and 2024 at Washington University in St. Louis. Need for shunt or ETV revision (defined as surgical revision of shunt or ETV) and differences in preoperative and postoperative head circumference and imaging measures were examined. Results: One hundred two patients (41% prenatal, 59% postnatal repair) were initially identified. Fourteen (33%) of those repaired prenatally (36% ETV ± CPC vs 64% VPS) and 39 (65%) of those repaired postnatally (10% ETV ± CPC vs 90% VPS) required CSF diversion. After prenatal repair, revision was required in 40% following ETV ± CPC versus 11% following VPS (∆29%; 95% CI − 19%, 77%; p = 0.207). After postnatal repair, revision rates were similar (p = 0.923). ETV ± CPC was associated with shorter survival until revision (prenatal repair, 12.9 months, 95% CI 1.4–24.5; postnatal repair, 29.1 months, 95% CI 13.2–44.9) compared to VPS (prenatal repair, 49.4 months, 95% CI 30.9–68.0; postnatal repair, 48.0 months, 95% CI 40.8–55.2). Conclusion: Those treated with ETV have less time to failure than those treated with VPS regardless of timing of MMC repair. A clinically meaningful increase in need for revision after ETV ± CPC versus VPS after prenatal repair cannot be excluded. This may have implications for hydrocephalus treatment and follow-up in children with MMC, meriting further study in a larger, multicenter cohort.