T2-based magnetic resonance genitography in children with complex anorectal malformations: experience at a tertiary pediatric hospital in Latin America

In children with anorectal malformations (ARMs), it is essential to have a diagnostic imaging method that helps with the evaluation of the internal anatomy. In patients with a persistent cloaca, an ARM variant, in which the measurement of the urethral channel and common channel determines surgical management, there are multiple options for imaging. Magnetic resonance imaging (MRI) is an excellent method for this purpose, from which accurate measurements of channel length can be obtained. Additionally, the use of volumetric/isotropic sequences allows multiplanar reformatting. We present our experience with pelvic MRI and intracavitary non-paramagnetic contrast (MR genitography). This method uses volumetric T2-weighted images and the instillation of saline solution as a contrast agent to distinguish the common channel, length of the urethra, anatomy of the vagina, and presence and location of the rectal fistula. We believe this technique to be particularly useful for those working in settings with limited MRI resources.

Cloacal Dysgenesis Sequence in a Preterm Neonate

BACKGROUND Cloaca malformations result from a disproportion of apoptosis, cell growth, and maturation. The range of cloacal malformations is extensive and diverse, with a lack of a straightforward classification system. Cloacal dysgenesis sequence (CDS), also known as urorectal septum malformation sequence, is a rare cloaca variant described as the absence of a perineal orifice. Prenatal magnetic resonance imaging and antenatal ultrasounds may reveal a cloacal malformation; however, many patients are not diagnosed with cloacal malformation until birth. CASE REPORT We present a case of a female neonate delivered by a 23-year-old G2P1T1A0L0 mother who had received comprehensive prenatal care. During pregnancy, bilateral multicystic dysplastic kidneys were identified prenatally, leading to the in utero placement of a vesicoamniotic shunt. The physical exam revealed a distended abdomen with reduced abdominal musculature and laxity, ascites, a vesicoamniotic shunt in place, absent urethra, ambiguous genitalia with no vaginal opening, no perineal opening, and clubfoot. Abdominal radiograph showed findings consistent with significant abdominal ascites. An exploratory laparotomy was performed that included diverting colostomy, mucous fistula creation, tube vaginostomy, removal of the vesicoamniotic shunt, and suprapubic tube placement. The patient recovered well from this operation with no complications. CONCLUSIONS CDS is an uncommon condition in pediatric patients, and although sonographic findings can reveal urinary tract abnormalities, prenatal imaging might not always identify CDS. Our case underscores the uniqueness of the case and the significance of early detection and immediate medical and surgical intervention.

Fetal ascites in cloacal malformations-a red flag

INTRODUCTION

Cloacal malformation is a rare anomaly that remains a diagnostic challenge prenatally, despite the current advances in ultrasonography and MRI. This condition can in some, present with isolated ascites or with other findings, such as a pelvic cyst or upper urinary tract dilatation. In a minority, the ascites may be progressive, questioning the role of antenatal intervention.

METHODS

We report on ten patients that have been identified from our Cloaca database between 2010 and 2022.

RESULTS

The presence of ascites was associated with extensive bowel adhesions and matting, leading to a challenging initial laparotomy and peri-operative course.

CONCLUSIONS

Antenatal finding of ascites in newborns with cloacal malformations should raise a red flag. The surgeon and anaesthetist should be prepared for the operative difficulties secondary to bowel adhesions and the higher risk of haemodynamic instability at the initial surgery. An experienced team at initial laparotomy in such patients is vital.

LEVEL OF EVIDENCE

II.

Prenatal ultrasound findings of covered bladder exstrophy and persistent cloaca

Unlike classic exstrophy, covered bladder exstrophy is a rare variant characterized by a cycling bladder and intact abdominal wall. We present a case of covered bladder exstrophy diagnosed prenatally and associated persistent cloaca (PC) noted only after delivery. This case report demonstrates that prenatal diagnosis of covered bladder exstrophy is possible and PC can present without any abdominal cysts, bowel, or renal findings. Covered bladder exstrophy should be considered in the differential of cystic protrusion of the bladder to the abdominal wall.

Preoperative evaluation of persistent cloaca using contrast-enhanced ultrasound in an infant

Persistent cloaca (PC) is the most intricate anorectal malformation. Contrast-enhanced ultrasound (CEUS) is safe for hepatic, renal, splenic, vascular, and intracavitary assessment in children, but it is little applied for cloacal malformation. Our results demonstrate that CEUS can not only display the uterine, vagina, bladder, urethra, rectum, and rectovaginal fistula, but also measure the length of the common channel, bladder neck to the common channel, and distal urethra to the perineum. To our knowledge this may be the first report of preoperative evaluation by CEUS in an infant with PC.

Gynecological anomalies in patients with anorectal malformations

PURPOSE

The association of gynecological anomalies in all anorectal malformations (ARM) is firmly established. Our goal is to study this pathology in our patients to focus attention to this important issue.

METHODS

Retrospective study of female patients operated for ARM and who underwent magnetic resonance imaging in our center. The type of malformation, the presence and type of vaginal, uterine, tubaric and urological anomalies were studied.

RESULTS

63 patients were included: 34.9% cloaca, 28.6% vestibular and 12.7% perineal. Half of patients had some type of müllerian anomaly; 19 vaginal, most frequent being the longitudinal vaginal septum (66.7%); 30 had uterine alterations, most frequent being the uterus didelphys (60%). Eighty percent of patients with complex ARM (cloaca, exstrophy) presented some type of gynecological malformation compared to 21.8% found in simple ARM (stenosis, perineal, vestibular) (p < 0.001). Vaginal anomalies are associated with a uterine anomaly in 100% of cases. Conversely, patients with uterine anomalies have concurrent vaginal anomaly in 63.3% of cases.

CONCLUSION

Screening for gynecological anomalies is indicated in all patients with ARM. We recommend a vaginal examination in any girl with ARM during definitive repair and a subsequent MRI during follow-up. Collaboration with a gynecologist is essential.

The spectrum of cloacal malformations: how to differentiate each entity prenatally with fetal MRI

The term cloacal malformation is commonly used to describe the classic cloacal malformation where there is a single common urogenital and intestinal channel located at the expected site of the urethra. There is, however, a spectrum of cloacal abnormalities that differ from this classic type and are less well discussed in the radiologic and surgical literature. The aim of this pictorial essay is to familiarize radiologists with the anatomy, appropriate terminology and key prenatal imaging findings that differentiate the six entities that constitute the spectrum of cloacal abnormalities.

Cloacal Duplication: Single-center Experience in the Management of a Rare Anomaly

Cloacal duplication is an exceedingly rare group of anomalies with a limited number of cases reported so far. The anomaly may be confined to partial bladder duplication or it may involve complete duplication of the urogenital tract, hindgut, spine, lower limbs, and vascular structures. Every case is unique and ought to be approached individually. By means of imaging studies and endoscopy, anatomic details should be carefully defined before endorsing surgical correction. A satisfactory outcome can be achieved in the majority of cases. In this report, we describe 3 girls with cloacal duplication, and review pertinent imaging and surgical management.

Prenatal sonographic diagnosis of urorectal septum malformation sequence and chromosomal microarray analysis: A case report and review of the literature

INTRODUCTION

Urorectal septum malformation sequence (URSMS) is a rare congenital abnormal syndrome that is caused by the incomplete division of the cloaca. Based on whether the cloaca membrane breaks down or not, the URSMS are classified as full and partial forms. The prenatal diagnosis of URSMS remains challenging because of poor recognition to this malformation and the relatively non-specific sonographic features. We report a prenatally sonographic diagnosed case of the partial URSMS, and review the literature to summarize the prenatal features.

CASE REPORT AND REVIEW

A 37-year old woman was referred at 24 weeks of gestation for fetal abdominal cyst. Detailed sonographic examination was done and revealed the vesicocolic fistula, distended colon, absence of perianal hypoechoic ring, pyelectasis, and small stomach bubble. The URSMS was suspected.Amniocentesis was done and karyotyping revealed 46,XY. Furthermore, chromosomal microarray analysis (CMA) was performed for the first time in URSMS and an alteration of 111.8Kb deletion was detected in 16p13.3 which was located inside the RBFOX1 gene. Parental studies showed that the deletion was inherited from the father who has nomal clinical phenotype.The woman elected to terminate the pregnancy at 25 weeks gestation and postmortem examination confirmed the diagnosis of partial URSMS.The published studies were reviewed and 28 cases of URSMS with conducted prenatal ultrasonography were collected in this report. The most common sonographic description, as suspicious signs of URSMS, were severe oligohydramnios or anhydramnios, urinary tract anomalies, fetal intra-abdominal cysts, and dilated bowel. Also, enterolithiasis and vesicocolic fistula were relatively infrequent but highly specific feature of URSMS.

CONCLUSIONS

URSMS is difficult to be diagnosed prenatally. However, it has characteristic features that can be detected by fetal ultrasonography, and a precise prenatal sonographic examination is crucial for diagnosing URSMS. Besides, more genomic profiling studies are needed to elucidate the causality.

Cloacal malformation: embryology, anatomy, and prenatal imaging features

Cloacal malformation is a rare but important anomaly. Prenatal diagnosis is possible with knowledge of the distinctive imaging features. The purpose of this case series is to illustrate characteristic prenatal sonographic and magnetic resonance imaging features of cloacal malformation using imaging from 6 cases seen at a single academic center to augment published data. The imaging feature common to all cases was a central cystic pelvic mass containing a characteristic fluid-fluid level. Additional anomalies include uterine and vaginal duplication, hydronephrosis, and lumbosacral anomalies. Prenatal magnetic resonance imaging showed the absence of the normal T1-hyperintense meconium-filled rectum in all cases. Prenatal diagnosis may affect immediate neonatal care (eg, immediate drainage of hydrocolpos) with an ultimate improved outcome.

Persistent cloaca presenting with a perineal cyst: Prenatal ultrasound and magnetic resonance imaging findings

A 40-year-old, primigravid woman presented at 23 weeks of gestation for evaluation of an extra-abdominal echogenic cystic mass of the fetus. Amniocentesis revealed a karyotype of 46,XX. Prenatal ultrasound showed a two-vessel umbilical cord, hydrocolpos, and distended bladder, urethra, and colon, and a perineal cystic mass. The kidneys and amniotic fluid amount were normal. Fetal magnetic resonance imaging revealed ascites, hydrocolpos, distended urinary bladder and colon, high rectum, and a perineal cyst. The fetus postnatally manifested persistent cloaca. The perineum was distended and smooth, without patent anal, vaginal, and urethral openings. The external genitalia were ambiguous with no labia majora, labia minora, or clitoris. The perineal cyst had a very small single orifice. We suggest that cloacal anomalies be considered in any female fetus with hydrocolpos, distended bladder and colon, ascites, and a perineal cyst.

Antenatal diagnosis of bladder/cloacal exstrophy: challenges and possible solutions

OBJECTIVE

To identify the pitfalls in accurate antenatal diagnosis of bladder exstrophy (BE) and cloacal exstrophy (CE), and thus understand the challenges for antenatal counselling.

METHODS

A prospectively maintained bladder exstrophy database of antenatal and live born referrals for BE/CE was used to identify patients. Data were collected about the antenatal scan findings and the outcome of pregnancy.

RESULTS

Between 2003 and 2009, 40 new babies with BE/CE were referred and of them 10 had an antenatal diagnosis. Five patients did not have a diagnosis despite suspicious findings noted on antenatal scans and another three had a wrong diagnosis of BE/CE. Of the 16 referrals with antenatal suspicion of BE/CE, 5 opted for termination. At the 20-week scan, it was possible to identify the gender of the fetus in 3/16 cases only.

CONCLUSIONS

Only a quarter of the babies born with BE/CE had received an antenatal diagnosis. Raising awareness about the condition amongst radiographers, and facilitating further scanning by a specialist fetal management unit if suspicious findings are noted, is crucial for improving the rate of detection. An antenatal diagnosis may not be reliable, and difficulty in identifying gender at the 20-week scan adds to the complexity of antenatal counselling. Magnetic resonance imaging and karyotyping may provide additional helpful information.

Persistent cloaca: a 10-year review of prenatal diagnosis

OBJECTIVE

The purpose of this study was to review antenatal sonographic findings in children born with persistent cloaca.

METHODS

Infants (n =145) with persistent cloaca followed at a center for colorectal congenital anomalies were identified by a retrospective chart review. Fifty female infants with a persistent cloaca met inclusion criteria and had prenatal records and imaging studies available for review. Sonographic data were retrospectively abstracted from charts.

RESULTS

Anomalies were detected in 27 of 50 cases (54%). A correct antenatal diagnosis of persistent cloaca occurred in 3 of 50 (6%). Common findings misinterpreted on antenatal sonography include urinary tract anomalies, dilated bowel, and a cystic pelvic mass (representing hydrocolpos).

CONCLUSIONS

Antenatal diagnosis of persistent cloaca is difficult. Persistent cloaca should be considered in the differential diagnosis if urinary tract malformations, dilated bowel loops, or cystic pelvic masses are visualized by prenatal diagnosis.

Fetal hydrometrocolpos, uterus didelphys with low vaginal and anal atresia: difficulties in differentiation from a complex cloacal malformation: a case report

Hydrometrocolpos, occurring in approximately 1/6000 newborn girls, can be caused by a stenotic urogenital sinus, a severe cloacal malformation, but also by other conditions such as an imperforate hymen, a midline vaginal septum and vaginal atresia. The prenatal differential diagnosis of this wide spectrum of conditions is not easy and requires a multidisciplinary approach with follow-up scans and MRI to access the severity of the condition. A non-consanguineous couple was referred in the first pregnancy at 30 weeks. The father, 30 years of age, of Kaukasian origin, and the mother of Asian origin, 26 years of age. Ultrasound at 30 weeks revealed ambiguous genitalia (with suspicion of clitoral hypertrophy), a septated structure located behind the bladder compatible with hydrometrocolpos with a uterine malformation (uterus didelphys), a single umbilical artery, mild ascites and growth on the tenth centile. The differential diagnosis included a vaginal atresia, a urogenital sinus and a more severe cloacal malformation. After serial scans, MRI and counselling by an experienced surgeon the preferential diagnosis of a cloacal malformation was made and a late pregnancy termination was performed. Pathological examination revealed: low vaginal atresia with uterus didelphys, anal atresia with rectovaginal fistula and a normal urinary tractus. The differential diagnosis between hydrometrocolpos due to vaginal atresia or due to a more severe cloacal malformation is not straightforward. Care should be taken in decision making and counselling patients with these complex prenatal malformations.

Fetal MRI clues to diagnose cloacal malformations

BACKGROUND

Prenatal US detection of cloacal malformations is challenging and rarely confirms this diagnosis.

OBJECTIVE

To define the prenatal MRI findings in cloacal malformations.

MATERIALS AND METHODS

We performed a retrospective study of patients with cloacal malformations who had pre- and post-natal assessment at our institution. Fetal MRI was obtained in six singleton pregnancies between 26 and 32 weeks of gestation. Imaging analysis was focused on the distal bowel, the urinary system and the genital tract and compared with postnatal clinical, radiological and surgical diagnoses.

RESULTS

The distal bowel was dilated and did not extend below the bladder in five fetuses. They had a long common cloacal channel (3.5-6 cm) and a rectum located over the bladder base. Only one fetus with a posterior cloacal variant had a normal rectum. Three fetuses had increased T2 signal in the bowel and two increased T1/decreased T2 signal bladder content. All had renal anomalies, four had abnormal bladders and two had hydrocolpos.

CONCLUSION

Assessment of the anorectal signal and pelvic anatomy during the third trimester helps to detect cloacal malformations in the fetus. The specificity for this diagnosis was highly increased when bowel fluid or bladder meconium content was identified.

Prenatal diagnosis of cloacal malformations

INTRODUCTION

Prenatal diagnosis of anorectal malformations currently occurs in 0-15.9% of screened cases. In cloacas, these numbers are unknown. We speculate that some images from prenatal ultrasound studies may suggest the diagnosis of cloaca, but are not recognized because of a lack of suspicion for this diagnosis.

METHODS

A retrospective review of the medical records of 489 patients born with cloaca was performed; 95 of them had prenatal ultrasound reports that represent the material analyzed for this study. A literature review was performed, finding 31 publications, with 68 cloaca patients detected by prenatal images. The abnormal findings of our patients were compared with those described in the literature to determine the most common abnormal prenatal images found in patients with cloaca.

RESULTS

The 95 ultrasound reports found in our patients described 270 abnormalities, the most frequent were: abdominal/pelvic cystic/mass (39), hydronephrosis (36), oligohydramnios (23), distended bowel/bowel obstruction (19), ascites (15), 2 vessel cord (14), dilated bladder (14), dilated ureter (14), polyhydramnios (10), echogenic bowel (8), multicystic kidney (8), "ambiguous genitalia" (7), hydrops fetalis (7), hydrocolpos (4), absent kidney (3), abnormal spine (3), and anorectal atresia (3). In spite of these findings, the radiologists who interpreted the studies only suspected a cloaca in 6 cases (6%). The literature review showed 212 abnormalities in 68 demonstrated cloaca patients. The most frequent were: abdominal/pelvic cystic/mass (46), hydronephrosis (44), ascites (21), oligohydramnios (20), distended bowel (11), multicystic dysplastic kidney (7), ambiguous genitalia (6), non-visualization of the bladder (6), two-vessel cord (5), dilated bladder (5), intraabdominal calcification (4), polyhydramnios (4), enterolithiasis (4), hydrometrocolpos (3), and dilated ureter (3).

CONCLUSION

We conclude that it is possible to suspect the diagnosis of cloaca, prenatally, more frequently than what currently occurs, looking at the same images but with an increased index of suspicion for cystic abdominal masses and a combination of gastrointestinal and urological abnormalities.

Prenatal ultrasonographic and magnetic resonance imaging findings of congenital cloacal anomalies associated with meconium peritonitis

BACKGROUND/PURPOSE

Cloacal malformations are rare anomalies, occurring in females, and in which they demonstrate a single perineal orifice for urethra, vagina, and rectum. Prenatal ultrasonograms (US) of cloacal malformations sometimes show ascites, hydrocolpos, and hydronephrosis. We herein describe the characteristic prenatal US and magnetic resonance imaging (MRI) findings of the cloacal malformations associated with meconium peritonitis.

METHODS

The pre- and postnatal records of 11 newborn patients with cloacal malformations, treated in our hospital from 1988 to 2004, were reviewed. All fetuses underwent prenatal US by experienced obstetricians, whereas in addition, fetal MRI was performed in 1 patient.

RESULTS

The prenatal US and/or MRI findings showed fetal ascites, a multicystic pelvic mass, oligohydramnios, and bilateral hydronephrosis in 5 of 11 patients with cloacal malformations. In these 5 cases, postnatal examinations showed associated hydrocolpos, hydrometrocolpos, and bilateral hydronephrosis; furthermore, 4 of these 5 cases also showed meconium peritonitis at laparotomy.

CONCLUSIONS

The prenatal US and MRI findings, showing fetal ascites, multicystic pelvic mass, bilateral hydronephrosis, and oligohydraminios are highly suggestive of the cloacal malformations associated with meconium peritonitis.

[Prenatal diagnosis of pelvic floor malformations]

Pelvic floor malformations are congenital defects in the pelvic and perineal area, which are derived from a defective development of the cloaca membrane, the uro-rectal septum, the mesonephric and para-mesonephric ducts and the urogenital sinus. These are complex anomalies with a profound emotional impact on parents. The prenatal diagnosis is possible favoring the prenatal counseling for the parents and expediting the post-natal evaluation and management. Aim of the present paper is to review the current criteria for the prenatal diagnosis of the following malformations: anorectal anomalies, cloacal anomalies, persistence of the urogenital sinus, bladder and cloacal exstrophy and ambiguous genitalia.

Cloacal anomaly simulating megalocystis in the first trimester

We present a case of cloacal anomaly that simulated megalocystis in the first trimester of gestation of a female fetus. During the second trimester, repeated paracentesis was necessary to treat increasing ascites, oligohydramnios, and hydronephrosis. Our data support findings that ascites presenting with a multiloculated cystic structure on sonography during the second trimester may be typical for cloacal anomalies. Active treatment of the fetal ascites is recommended to improve the child's prospects for survival.

Calcified meconium: an important sign in the prenatal sonographic diagnosis of cloacal malformation

Cloacal malformation is a rare abnormality, characterized by direct communication between the gastrointestinal, urinary, and genital structures, resulting in a single perineal opening. Prenatal diagnosis is difficult because of nonvisualization of the communication. We report a case of prenatal diagnosis of this condition, in which the recognition of calcified meconium in the colon and urinary tract provided an important clue.

A chicken model to study the embryology of cloacal exstrophy

BACKGROUND/PURPOSE

The embryology of bladder and cloacal exstrophy is a mystery. Reasons for this are the lack of human embryos showing these malformations as well as the scarcity of appropriate animal models. Here, the authors present cases of cloacal exstrophies found in chick embryos subsequent to the application of suramin and trypan blue. This animal model might facilitate insight into the embryology of cloacal exstrophy.

METHODS

Fertilized chicken eggs were incubated at 38 degrees C and 75% humidity. Embryos were treated in ovo on incubation day 3. The egg shell was windowed, and solutions of suramin (stage 13, 2 x 40 microL/0.2%) or trypan blue (stage 14, 2 x 80 microL/0.03%) were injected into the coelomic cavity. The window was closed, and the embryos were reincubated until examination on incubation day 8. Fifty embryos were treated in each group.

RESULTS

Among the surviving embryos, cloacal exstrophy was found in 2 cases in the suramin-treated group (2 of 29, 6.9%) and in 4 cases in the trypan blue-treated group (4 of 20, 20%).

CONCLUSIONS

Suramin and trypan blue can induce cloacal exstrophy in chick embryos. The authors now are modifying their experimental protocols to increase the incidence of this malformation. This model might facilitate studies on the morphogenesis of cloacal exstrophy.

Spinal lipoma associated with terminal syringohydromyelia and a spinal arachnoid cyst in a patient with cloacal exstrophy

CASE REPORT

A 2-year-old girl presented with repaired cloacal exstrophy and a subcutaneous mass at the midline of the lumbosacral region. Neurological examination revealed mild paraparesis with bilateral lower-extremity hyperreflexia and sensory disturbance below the level of L4. A CT scan showed asymmetrical spina bifida on the right side extending from L2 to L5, and symmetrical spina bifida below S1. Magnetic resonance imaging showed a low-set conus with terminal syringohydromyelia, lumbosacral lipoma, and the extradural arachnoid cysts at Th12-L4 compressing the spinal dural sac from behind. Surgical removal of the arachnoid cyst and lipoma relieved spinal dural sac compression and the tethered spinal cord. The patient showed an improvement in the lower-extremity hyperreflexia postoperatively.

CONCLUSION

The rare association of the cloacal exstrophy with the multiple spinal cord abnormalities as shown in the present case indicates that detailed routine screening of the spinal cord is necessary for the careful planning of treatment in patients with anorectal anomalies.