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Abstract：
BACKGROUND: Preterm prelabor rupture of membranes (PPROM) remains a major complication of fetal laser surgery in the treatment of twin-to-twin transfusion syndrome (TTTS). The aim of the study was to determine the impact of cannula size on pregnancy outcomes, with a particular focus on PPROM.
METHODS: The protocol was developed and registered in the PROSPERO database under registration number CRD42022333630. The PubMed, Web of Science, and EMBASE databases were searched electronically on May 18, 2022, and updated on March 2, 2023, utilizing a combination of the relevant MeSH terms, keywords, and word variants for \"TTTS\" and \"laser\". Randomized controlled trials, prospective and retrospective cohorts, case-control studies, and case reports/series with more than five participants were considered eligible for inclusion. Studies reporting the cannula diameter and PPROM rate after laser surgery in the treatment of monochorionic pregnancies affected by TTTS between 16- and 26 weeks\' gestation were included. Data was extracted independently, and when appropriate, a random-effects meta-analysis was undertaken to calculate pooled estimates and their confidence intervals. Heterogeneity in the effect estimates of the individual studies was calculated using the I2 statistic. The primary outcome was PPROM rate. Secondary outcomes were survival rate, preterm birth, and incomplete surgery. The quality of the included studies was assessed using a modified quality in prognosis study tool.
RESULTS: We included a total of 22 studies, consisting of 3426 patients. Only one study was scored as low quality, seven as moderate quality, and the remaining 14 as high quality. The mean PPROM rate after laser surgery treating TTTS was 22.9%, ranging from 11.6% for 9 French (Fr) to 54.0% for 12 Fr. Subsequent meta-regression for the clinically relevant PPROM rate before 34 weeks of gestation, showed increased PPROM rates for increased cannula size (p-value 0.01).
CONCLUSIONS: This systematic review confirmed PPROM as a frequent complication of fetal laser surgery, with a mean PPROM rate of 22.9%. A larger cannula diameter relates to a significant higher PPROM risk for PPROM before 34 weeks gestation. Hence, the ideal balance between optimal visualization requiring larger port diameters and shorter operation time and more complete procedures that benefit from larger diameters is crucial to reduce iatrogenic PPROM rates.
METHODS: The protocol was developed and registered in the PROSPERO database under registration number CRD42022333630. The PubMed, Web of Science, and EMBASE databases were searched electronically on May 18, 2022, and updated on March 2, 2023, utilizing a combination of the relevant MeSH terms, keywords, and word variants for \"TTTS\" and \"laser\". Randomized controlled trials, prospective and retrospective cohorts, case-control studies, and case reports/series with more than five participants were considered eligible for inclusion. Studies reporting the cannula diameter and PPROM rate after laser surgery in the treatment of monochorionic pregnancies affected by TTTS between 16- and 26 weeks\' gestation were included. Data was extracted independently, and when appropriate, a random-effects meta-analysis was undertaken to calculate pooled estimates and their confidence intervals. Heterogeneity in the effect estimates of the individual studies was calculated using the I2 statistic. The primary outcome was PPROM rate. Secondary outcomes were survival rate, preterm birth, and incomplete surgery. The quality of the included studies was assessed using a modified quality in prognosis study tool.
RESULTS: We included a total of 22 studies, consisting of 3426 patients. Only one study was scored as low quality, seven as moderate quality, and the remaining 14 as high quality. The mean PPROM rate after laser surgery treating TTTS was 22.9%, ranging from 11.6% for 9 French (Fr) to 54.0% for 12 Fr. Subsequent meta-regression for the clinically relevant PPROM rate before 34 weeks of gestation, showed increased PPROM rates for increased cannula size (p-value 0.01).
CONCLUSIONS: This systematic review confirmed PPROM as a frequent complication of fetal laser surgery, with a mean PPROM rate of 22.9%. A larger cannula diameter relates to a significant higher PPROM risk for PPROM before 34 weeks gestation. Hence, the ideal balance between optimal visualization requiring larger port diameters and shorter operation time and more complete procedures that benefit from larger diameters is crucial to reduce iatrogenic PPROM rates.
摘要：
背景：早产胎膜破裂（PPROM）仍然是胎儿激光手术治疗双胎对双胎输血综合征（TTTS）的主要并发症。该研究的目的是确定套管大小对妊娠结局的影响，特别关注PPROM。
方法：该协议是在PROSPERO数据库中开发和注册的，注册号为CRD42022333630。PubMed,WebofScience,和EMBASE数据库于2022年5月18日进行了电子搜索，并于2023年3月2日使用相关MeSH术语进行了更新，关键词,和“TTTS”和“激光”的单词变体。随机对照试验,前瞻性和回顾性队列，病例对照研究，5名以上参与者的病例报告/系列被认为符合纳入条件.包括报告在16至26周妊娠期间受TTTS影响的单绒毛膜妊娠的激光手术后套管直径和PPROM率的研究。数据独立提取,在适当的时候,我们进行了随机效应荟萃分析,以计算汇总估计值及其置信区间.使用I2统计量计算了各个研究的效果估计中的异质性。主要结果是PPROM率。次要结果是生存率，早产,和不完整的手术。使用改良的预后研究工具质量评估纳入研究的质量。
结果：我们共纳入了22项研究，由3426名患者组成。只有一项研究被评为低质量，七是中等质量，剩下的14个是高质量的。激光手术治疗TTTS后的平均PPROM率为22.9%，从9法语（Fr）的11.6%到12法语的54.0%不等。妊娠34周前临床相关PPROM率的随后荟萃回归，显示随着套管大小的增加，PPROM率增加（p值0.01）。
结论：本系统评价证实PPROM是胎儿激光手术的常见并发症，平均PPROM率为22.9%。较大的套管直径与妊娠34周前PPROM的显著较高的PPROM风险相关。因此，需要更大端口直径的最佳可视化和更短的操作时间以及受益于更大直径的更完整的程序之间的理想平衡对于降低医源性PPROM率至关重要.
方法：该协议是在PROSPERO数据库中开发和注册的，注册号为CRD42022333630。PubMed,WebofScience,和EMBASE数据库于2022年5月18日进行了电子搜索，并于2023年3月2日使用相关MeSH术语进行了更新，关键词,和“TTTS”和“激光”的单词变体。随机对照试验,前瞻性和回顾性队列，病例对照研究，5名以上参与者的病例报告/系列被认为符合纳入条件.包括报告在16至26周妊娠期间受TTTS影响的单绒毛膜妊娠的激光手术后套管直径和PPROM率的研究。数据独立提取,在适当的时候,我们进行了随机效应荟萃分析,以计算汇总估计值及其置信区间.使用I2统计量计算了各个研究的效果估计中的异质性。主要结果是PPROM率。次要结果是生存率，早产,和不完整的手术。使用改良的预后研究工具质量评估纳入研究的质量。
结果：我们共纳入了22项研究，由3426名患者组成。只有一项研究被评为低质量，七是中等质量，剩下的14个是高质量的。激光手术治疗TTTS后的平均PPROM率为22.9%，从9法语（Fr）的11.6%到12法语的54.0%不等。妊娠34周前临床相关PPROM率的随后荟萃回归，显示随着套管大小的增加，PPROM率增加（p值0.01）。
结论：本系统评价证实PPROM是胎儿激光手术的常见并发症，平均PPROM率为22.9%。较大的套管直径与妊娠34周前PPROM的显著较高的PPROM风险相关。因此，需要更大端口直径的最佳可视化和更短的操作时间以及受益于更大直径的更完整的程序之间的理想平衡对于降低医源性PPROM率至关重要.
