Repeat fetoscopic laser surgery for postlaser twin anemia polycythemia sequence and recurrent twin-to-twin transfusion syndrome: matched outcomes in a single-center cohort‡.

Background: Fetoscopic laser surgery aims to treat Twin-to-Twin Transfusion Syndrome with a single procedure. In rare cases, missed or recanalized anastomoses lead to recurrent disease, either postlaser Twin Anemia Polycythemia Sequence (TAPS) or recurrent Twin-to-Twin Transfusion Syndrome (TTTS). Repeat laser surgery is one possible treatment.

Objectives: To describe our diagnostic and treatment criteria for recurrent disease along with technical strategies to perform repeat laser. We explore the clinical implications of repeat laser surgery by comparing characteristics and outcomes to patients matched for TTTS disease severity that was successfully treated by a single laser surgery.

Study design: We performed a single-center, matched-case, retrospective analysis. Patients who underwent repeat laser surgery for disease recurrence are described in detail and were matched in a ratio of 1:3 to patients whose TTTS was treated with a single fetoscopic laser surgery. Patients were matched for disease stage, co-existing fetal growth restriction, and gestational age (GA) epoch at first laser (<18, 18-23.9, and ≥24). Gestational age at delivery was the primary outcome measure. Demographics, pregnancy characteristics, procedure details, complications, obstetric, and twin survival outcomes were compared. Continuous data were analyzed using Student's t or Wilcoxon Rank-Sum test and categorical data were analyzed using Chi squared or Fisher's exact test.

Results: Sixteen (4.8%) of 334 patients met our criteria for recurrent disease after Solomon laser for TTTS: 12 had postlaser TAPS, three had recurrent TTTS, and two had both postlaser TAPS and recurrent TTTS. Repeat laser was performed in 11 (69%) patients. Techniques for repeat laser included carbon dioxide insufflation (2/11), amnioexchange (2/11), contralateral trochar entry (8/11), intentional septostomy (4/11), and entry into the opposite sac (2/11). There was no difference in median gestational age at delivery (31 vs 32.5 weeks, p = 0.228), double birth survival (72.7% vs 87.9%, p = 0.34), or overall perinatal survival (86% vs 91%, p = 0.89) between patients who underwent repeat laser and matched controls.

Conclusions: We suggest a standardized approach to diagnosis of postlaser TAPS and recurrent TTTS and technical considerations for performing repeat laser. In patients eligible for repeat laser surgery, it is possible to achieve acceptable outcomes that are comparable to outcomes after single laser in patients matched for TTTS disease severity. These findings should be corroborated in a larger multicenter study, but may be useful to help patient counseling and management when repeat laser surgery is considered for recurrent disease.