The Effect of Surgery Time on Prognosis in Meningomyelocele | MY Oncel, et al. lower durations of hospital stay and received shorter courses of antibiotics (p<0.001 for both) compared to patients in group 2 (Table 1). All the newborns, except one, remained problem free related to surgery after discharge. Only one of the newborns who had transposition of the great arteries died while under follow-up in another center. DISCUSSION NTDs are the second most frequently encountered congenital malformations after cardiac anomalies. Due to recent advances in ultrasonography and its widespread use during antenatal fol- low-up, early in utero recognition of the disorder is now possi- ble11,16). A diagnosis of MMC was made antenatally in 60% of our patients. Unfortunately, due to socio-cultural taboos regard- ing abortion, none of the families had consented to medical ter- mination of pregnancy7). Folic acid deficiency is the most widely recognized risk factor for the development of NTDs9). Preconceptional supplementa- tion of folic acid at a daily dose of 0.4 mg has been reported to decrease NTDs rates by 60-70%17). This highlights the impor- tance of antenatal folic acid supplementation for the prevention of NTDs. None of the mothers of the subjects included in this study had used any form of folic acid supplementation either before or during their pregnancies. MMC most commonly occurs in the lumbar area, with a re- ported frequency of 60-70%8,12). In our study, lumbosacral MMC was observed in 46.6%, with a lumbar localization present in 40% of patients (Table 2). Hydrocephaly and the Chiari II mal- formation are the most frequently observed anomalies in asso- ciation with MMC13). In our study population, hydrocephalus was present in 83.3% of patients, followed in decreasing order of other anomalies (Table 2). Taking this in to consideration, it is prudent that all patients with MMC should be screened for the presence of other anomalies that may be associated with the disorder, with the help of a careful physical examination, crani- al imaging studies and urinary system ultrasonography5,8). An early and aggressive surgical approach in babies diag- nosed with MMC has been shown to be associated with lower early morbidity and mortality rates2,3). In a retrospective study, early surgical intervention (<72 hours after birth) was found to be associated with a more favorable outcome in terms of urinary symptoms in patients with MMC, and investigators postulated that surgery within the first 24 hours increases the likelihood of maintaining urinary tract function15). In another study where the outcomes of prenatal (in utero) and postnatal surgery were compared, it was observed that prenatal intervention was associated with better motor de- velopment while also alleviating the need for shunt placement in most patients. However, authors stressed on the difficulty of the intrauterine procedure as well as the potential maternal and fetal risk posed by such surgery1,4). In a different study, correc- tive surgery was performed immediately after birth citing the added risk associated with in utero intervention for patients with MMC. Investigators reported on a low postoperative complica- tion rate and less severe neurodevelopmental retardation with this approach14). With this study, we managed to demonstrate that patients operated upon within the first 5 days of life had sig- nificantly lower durations of hospital stay while also requiring shorter courses of antibiotics (p<0.001). In light of these find- ings, it is recommended to perform surgery as soon as possible, particularly in patients diagnosed prenatally. CONCLUSION MMC is a congenital disorder with significant morbidity. Our study findings suggest that early surgical intervention was asso- ciated with a shorter duration of hospital stay and antibiotic therapy as well as a lower complication rates. National policies for prevention, in utero diagnosis, and early surgical interven- tion are required for better prognosis. References 1. Adzick NS, Thom EA, Spong CY, Brock JW 3rd, Burrows PK, Johnson MP, et al. : A randomized trial of prenatal versus postnatal repair of my- elomeningocele. N Engl J Med 364 : 993-1004, 2011 2. Adzick NS, Walsh DS : Myelomeningocele : prenatal diagnosis, patho- physiology and management. Semin Pediatr Surg 12 : 168-174, 2003 3. Bowman RM, McLone DG : Neurosurgical management of spina bifi- da: research issues. Dev Disabil Res Rev 16 : 82-87, 2010 4. 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Onrat ST, Seyman H, Konuk M : Incidence of neural tube defects in Afyonkarahisar, Western Turkey. Genet Mol Res 8 : 154-161, 2009 12. Padmanabhan R : Etiology, pathogenesis and prevention of neural tube defects. Congenit Anom (Kyoto) 46 : 55-67, 2006 13. Pinar H, Tatevosyants N, Singer DB : Central nervous system malforma- tions in a perinatal/neonatal autopsy series. Pediatr Dev Pathol 1 : 42-48, 1998 14. Pinto FC, Matushita H, Furlan AL, Alho EJ, Goldenberg DC, Bunduki V, et al. : Surgical treatment of myelomeningocele carried out at ‘time zero’ immediately after birth. Pediatr Neurosurg 45 : 114-118, 2009 15. Tarcan T, Onol FF, Ilker Y, Alpay H, SimŞek F, Ozek M : The timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with myelomeningocele. J Urol 176 : 1161-1165, 361