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Vinay C, Zameer MM, Rao S, D’Cruz A. Redo Surgeries in Anorectal Malformations: A Single-center Experience. J Indian Assoc Pediatr Surg 2024; 29:28-32. [PMID: 38405235 PMCID: PMC10883175 DOI: 10.4103/jiaps.jiaps_101_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 02/27/2024] Open
Abstract
Aims and Objectives Complications following posterior sagittal anorectoplasty (PSARP) for ARM are well known. In this article, we present our experience of managing five patients who required major redo surgeries for complications resulting from previous attempts to correct ARM. Materials and Methods We reviewed all patients who underwent major redo surgeries in our hospital for complications from previous repairs for ARM, from June 2013 to June 2019. Data was obtained from hospital records and analysed. Results Five patients whose ages ranged from 5 months to 14 years were included in the study. Four were boys and 1 was a girl. All patients had undergone PSARP in other hospitals. The presentations were retained distal bowel causing urinary retention and constipation (n=1), pulled through proximal urethra and bladder neck presenting as passage of urine from neo-anus (n=1), retained common channel (of cloaca) causing a 'H' type configuration (n=1), mispositioned neo-anus (n=1) following a primary PSARP and lastly undivided recto-urethral fistula causing fecaluria (n=1). All of them underwent redo repairs by posterior sagittal approach with documented improvement in their symptoms. Two of them required total bowel management to remain clean. Conclusion All the complications reported here have been described in literature nevertheless, this report will add to the body of experience. Posterior sagittal approach (PSA) has proved to be very successful technique in correcting these complications.
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Affiliation(s)
- C. Vinay
- Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India
| | - M. M. Zameer
- Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India
| | - Sanjay Rao
- Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India
| | - Ashley D’Cruz
- Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India
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Davis M, Mohan S, Russell T, Feng C, Badillo A, Levitt M, Ho CP, Pohl HG, Varda BK. A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience. J Pediatr Urol 2023; 19:371.e1-371.e11. [PMID: 37037763 DOI: 10.1016/j.jpurol.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/20/2023] [Accepted: 03/11/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION/BACKGROUND Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs. OBJECTIVE 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying. STUDY DESIGN We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate = common channel [CC] <3-cm, severe = CC ≥ 3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy). RESULTS Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated. DISCUSSION Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function. CONCLUSION Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively.
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Affiliation(s)
- Meghan Davis
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Shruthi Mohan
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Teresa Russell
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina Feng
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Andrea Badillo
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Marc Levitt
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina P Ho
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Hans G Pohl
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Briony K Varda
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA.
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King SK, Levitt MA. Advances in the Management of the Neonate Born with an Anorectal Malformation. Clin Perinatol 2022; 49:965-979. [PMID: 36328611 DOI: 10.1016/j.clp.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Anorectal malformations occur in 1 in 3000 to 5000 children, and present with a marked variety in type and severity. Most of the malformations are diagnosed in the early neonatal period, as an antenatal diagnosis remains relatively elusive. Following diagnosis, an accurate assessment and focused management is crucial to reduce the potential for morbidity and mortality. This review focuses on the investigation and management of newborns with anorectal malformations, and the introduction of novel assessment tools for the more complex malformation types.
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Affiliation(s)
- Sebastian K King
- Colorectal and Pelvic Reconstruction Service, Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne 3052, Australia; Department of Paediatrics, University of Melbourne, Australia; F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC, USA; The George Washington School of Medicine, Washington, DC, USA
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An Alternative Approach to Single-Stage Cloaca Repair: Image-Guided Anorectoplasty with Delayed Vaginoplasty. J Pediatr Adolesc Gynecol 2022; 35:496-500. [PMID: 35124215 DOI: 10.1016/j.jpag.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/15/2022] [Accepted: 01/28/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cloacal anomalies occur when a fetus's rectum, vagina, and urethra fail to separate and result in 1 common channel at birth. They are commonly managed by complex reconstruction in the first year of life. This manuscript presents an alternative approach to management in patients with absent or nondilated Mullerian structures. CASE Image-guided, combined endoscopic and laparoscopic surgery (CELS) was used to perform an anorectal pull-through at 5 months of age on a patient with persistent cloaca and no definite vaginal or uterine structures seen on MRI and endoscopy. Urogenital reconstruction is delayed until adolescence. SUMMARY AND CONCLUSION We hypothesize that performing a minimally invasive anorectoplasty on patients with complicated anatomy and low risk for hydrocolpos could potentially result in improved urologic function and better psychosocial outcomes. Delaying vaginoplasty will enable determination of the function of remnant Mullerian structures and allow the patient to direct the augmentation approach.
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Pathak M, Saxena AK. Laparoscopic management of common cloaca: Current status. J Pediatr Urol 2022; 18:142-149. [PMID: 35101384 DOI: 10.1016/j.jpurol.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 12/15/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022]
Abstract
AIM This study reviewed the literature on the laparoscopic management of cloaca. METHODS A Medline and Embase search was performed for "laparoscopy" and "cloaca." Articles for which full-text in English was not available, duplicate articles, and review articles were excluded. Demographic characteristics, duration of follow-up, length of common channel, postoperative complications, and functional outcomes were analyzed. RESULTS The database search retrieved 81 articles after excluding unrelated articles and identified new articles through cross-referencing 14 articles (72 patients) for this review. The rectal pouch was situated below the pubococcygeal (PC) line in three patients. In all other patients, the rectum was located above the PC line. Only the rectal component of the malformation was repaired laparoscopically in 80% (58/72). Fourteen patients underwent laparoscopic mobilization of the rectum and urogenital component. The length of the common channel was more than 3 cm in all these fourteen patients. The most common complication was rectal prolapse (n = 11). Functional evaluation by Krickenbeck scoring system was reported in 32 patients, of which 6/32 (18.75%) had fecal soiling > Grade 2. DISCUSSION Until recently, laparoscopy for the common cloaca was almost exclusively used in patients with low urogenital sinus with high rectal pouch. Moreover, only the rectal component was repaired laparoscopically. Recently, laparoscopic rectal mobilization and urogenital separation was described for patients with common channel length ≥3 cm. It has been reported that laparoscopic vaginal mobilization is easy and more complete by this technique and may avoid vaginal replacement in most of these patients with the long common channel. However, only two studies have reported this technique, and its reproducibility and long-term results are still awaited. Another interesting observation was the increasing use of urethral length along with common channel length in determining the appropriate procedure for the patients with common cloaca. Recent studies propose that the urogenital separation technique be preferred over urogenital mobilization in patients with the short urethra. Nonetheless, we still don't have long-term comparative data to demonstrate that the functional outcomes are better with this new algorithm. We conclude that the persistent cloaca needs an individualized approach, and laparoscopy can be utilized to mobilize the high rectum and is also helpful for the urogenital separation in patients with common channel length >3 cm. However, at present, there is no conclusive evidence to support that laparoscopic repair has a better functional outcome than the open approach.
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Affiliation(s)
- Manish Pathak
- Department of Pediatric Surgery, All India Institute of Medical Sciences Jodhpur, Jodhpur, India.
| | - Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London, United Kingdom
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Versteegh HP, Gardner DS, Scriven L, Martens L, Kluivers K, Hewitt G, de Blaauw I, Wood RJ, Williams A, Sutcliffe J. Reconsidering Diagnosis, Treatment, and Postoperative Care in Children with Cloacal Malformations. J Pediatr Adolesc Gynecol 2021; 34:773-779. [PMID: 34419606 DOI: 10.1016/j.jpag.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/07/2021] [Indexed: 12/25/2022]
Abstract
Cloacal malformations are among the most complex types of anorectal malformation and are characterized by the urological, genital, and intestinal tracts opening through a single common channel in the perineum. Long-term outcome is affected by multiple factors, which include anatomical variants of the malformation itself, associated anomalies, and the surgical approach. Reconsidering these variables and their influence on "patient important" function might lead to strategies that are more outcome-driven than focused on the creation of normal anatomy. Key outcomes reflect function in each of the involved tracts and the follow-up needed should therefore not only include the classical fields of colorectal surgery and urology but also focus on items such as gynecology, sexuality, family-building, and quality of life as well as other psychological aspects. Involving patients and families in determining optimal treatment strategies and outcome measures could lead to improved outcomes for the individual patient. A strategy to support delivery of personalized care for patients with cloacal malformations by aiming to define the best functional outcomes achievable for any individual, then select the treatment pathway most likely deliver that, with the minimum morbidity and cost, would be attractive. Combining the current therapies with ongoing technological advances such as tissue expansion might be a way to achieve this.
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Affiliation(s)
- Hendt P Versteegh
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - David S Gardner
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lucy Scriven
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lisanne Martens
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten Kluivers
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geri Hewitt
- Department of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Alun Williams
- Departments of Paediatric Surgery and Urology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Jonathan Sutcliffe
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, The General Infirmary at Leeds, Leeds, United Kingdom
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Does a standardized operative approach in cloacal reconstruction allow for preservation of a patent urethra? J Pediatr Surg 2021; 56:2295-2298. [PMID: 33485615 DOI: 10.1016/j.jpedsurg.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cloacal malformations are recognized as a particularly challenging congenital condition to manage and they present with a wide spectrum of anatomical configurations making surgical repair very complicated. Urethral necrosis or urethral loss is a known and devastating complication of cloacal repair. The surgical repair of these malformations has evolved over time and historically only common channel (CC) length was measured. More recently, it has been advocated that the urethral length and the CC are both important in determining surgical repair. The purpose of our study is to evaluate if this surgical approach allows for preservation of a patent urethra. METHODS A prospective database of all cloaca patients maintained with IRB approval (IRB# STUDY00000721) was retrospectively reviewed. We included any girl with cloacal malformation who underwent primary repair at our institution between May 2014 and December 2019. Standardized preop evaluation with endoscopy and 3-dimentional imaging to assess urethral length and CC length. These measurements were used to determine operative approach. Girls with CC < 1 cm undergo posterior sagittal anorectoplasty and introitoplasty (PSARP + I), those with CC measuring 1-3 cm and urethra > 1.5 cm undergo total urogenital mobilization (TUM) and those with CC > 3 cm or urethra < 1.5 cm undergo urogenital separation (UGS). Postoperative urethral patency was determined at the time of cystoscopy and exam under anesthesia (EUA) 4-6 weeks postoperatively by visualizing a viable and healthy urethra that is catheterizable. RESULTS A total of 59 patients met inclusion criteria with a median age of 11.6 months. Four girls underwent PSARP + I, 19 girls had a TUM and 36 girls underwent a UGS. All of the girls who had PSARP +I (n = 4) or TUM (n = 19) had a viable and patent urethra that was catheterizable at the cystoscopy and EUA 4-6 weeks postoperatively. Of the 36 girls who had UGS, all but 2 (5.6%) had a viable and patent urethra that catheterized without problems. Overall, 97% of girls in this cohort had a patent urethra after cloacal repair using this surgical protocol. CONCLUSIONS The use of a standard protocol that considers urethral and common channel length for cloacal repairs results in a viable and patent urethra in 97% of patients. LEVEL OF EVIDENCE Level II.
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Tirrell TF, McNamara ER, Dickie BH. Reoperative surgery in anorectal malformation patients. Transl Gastroenterol Hepatol 2021; 6:43. [PMID: 34423164 DOI: 10.21037/tgh-20-214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 11/06/2022] Open
Abstract
Currently accepted primary repair of congenital anorectal malformations (ARMs) includes a posterior sagittal incision, which allows for optimal visualization and identification of important pelvic structures and anatomical features. Reconstructive surgery involves meticulous dissection and separation of pelvic structures, and careful reconstruction can result in good functional outcomes for many patients, who live without ongoing sequelae from their malformation. However, some patients may require reoperative procedures for anatomic or functional reasons. Males and females present with slightly different symptoms and should be approached differently. Males are most likely to require reoperations for anorectal or urethral pathologies, but the urinary system is often spared in females-they instead must contend with Mullerian duct anomalies, of which there are many varieties. Depending on the original malformation and severity of symptoms, redo surgery may be needed to optimize function and quality of life. Surgical management with reoperative surgery in ARMs ranges from straightforward to complex, depending on the issue. One must weigh the risks of reoperative surgery and potentially creating more scarring against the need for a better anatomical and functional outcome. Current management trends and practice patterns with regards to reoperative surgery in ARM patients are not widely studied or standardized but we provide an overview of the more common pathologies, preoperative evaluation and workup required to identify the issues, and options for reoperative repair in these patients.
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Affiliation(s)
| | - Erin R McNamara
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Colostomy Takedown: Ischemic Complication following Anorectal Malformation Surgery. Case Rep Surg 2021; 2021:8870631. [PMID: 33520325 PMCID: PMC7817294 DOI: 10.1155/2021/8870631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Anorectal malformations (ARM) are complex disorders that often require staged reconstructions. We present a case and imaging findings of a child who developed issues following colostomy closure due to segmental colonic ischemia. Case Presentation. A 3-year-old female with Currarino syndrome presented with abdominal distention, blood-flecked stools, and prolonged cecostomy flush time. For her anorectal malformation, a colostomy was initially placed. A new colostomy was created at posterior sagittal anorectoplasty (PSARP) to allow the distal rectum to reach the anus without tension. Differentials for her presenting symptoms included a mislocation of the anus, stenosis at the anoplasty site, stricture within the colon, or sacral mass from Currarino syndrome, causing obstructive symptoms. Workup at our hospital included an anorectal exam under anesthesia (EUA), which showed a well-located anus with without stenosis at the anoplasty site, and an antegrade contrast study revealed a featureless descending colon with a 3-4 mm stricture in the distal transverse colon at the site of the previous colostomy, without an obstructing presacral mass. To alleviate this obstruction, the child underwent removal of the chronically ischemic descending colon and a redo-PSARP, where the distal transverse colon was brought down to the anus. She is now able to successfully perform antegrade flushes. Conclusion Patients who have had prior surgeries for ARM repair are at a higher risk of complications, including strictures or ischemic complications at areas of previous surgery or colostomy placement. A thorough preoperative workup, including contrast studies, can alert the surgeon to these potential pitfalls.
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Bjørsum-Meyer T, Lund L, Christensen P, Jakobsen MS, Asmussen J, Qvist N. Impact of Spinal Defects on Urinary and Sexual Outcome in Adults With Anorectal Malformations-A Cross-sectional Study. Urology 2020; 139:207-213. [PMID: 32032684 DOI: 10.1016/j.urology.2020.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the impact of spinal defects on urinary function, sexual outcome and quality of life in adult patients born with anorectal malformations. MATERIALS AND METHODS A prospective cohort study at Odense University Hospital in Denmark was conducted. From 1985 to 2000, 93 patients were found eligible for participation. Twenty-seven (29%) consented to participate. One patient refrained from clinical examinations. Patients were examined with magnetic resonance imaging, uroflowmetry, and validated questionnaires on urinary function, sexual function, and quality of life. RESULTS There were 14 were females and 13 were males, median age of 25 (range 19-31) years and 23 (18-32) years, respectively. The type of anorectal malformations in females were vestibular fistula (n = 6), anocutaneous fistula (n = 4), anal stenosis (n = 3), and cloaca (n = 1). In males the type of malformations were anocutaneous fistula (n = 4), bulbar fistula (n = 4), rectovesical fistula (n = 2), anal stenosis (n = 1), rectal atresia (n = 1), and anal atresia with no fistula (n = 1). Patients with spinal defects had a lower average voiding rate compared to patients with normal spinal anatomy (P .03), a lower voiding-related quality of life (P .02), and a tendency was observed toward a worse total urinary incontinence-related quality of life score (P .06). Moreover in patients with spinal defect a tendency was seen toward a worse general quality of life (P .09). CONCLUSION Spinal defects detected by magnetic resonance imaging in adults with anorectal malformations were found to be associated with urinary voiding function.
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Affiliation(s)
- Thomas Bjørsum-Meyer
- Department of Surgery, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Faculty of Health Science, Department of Clinical research, Odense, Denmark.
| | - Lars Lund
- Department of Surgery, Odense University Hospital, Odense, Denmark; Department of Urology, Odense University Hospital, Odense, Denmark
| | | | | | - Jon Asmussen
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Niels Qvist
- Department of Surgery, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Faculty of Health Science, Department of Clinical research, Odense, Denmark
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AbouZeid AA, Radwan AB, Eldebeiky M, Hay SA. Persistent cloaca: persistence of the challenge. ANNALS OF PEDIATRIC SURGERY 2020. [DOI: 10.1186/s43159-019-0010-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Persistent cloaca or cloacal anomalies represent a special category of anorectal anomalies affecting the female sex with a reported incidence of about one in 25,000 live birth.
The study included 34 cases of cloaca that were managed at our unit between 2003 through 2017. We retrospectively reviewed patients’ records that included clinical presentation, investigations, operative data, and follow-up notes.
Anatomically, we stratified cloaca into three types according to the level of urogenital confluence. A low confluence (type 1) was defined by being at or below the level of the lower border of pubic symphysis with a short common channel (11 cases). A high confluence (type 3) was defined by being at or above the level of the upper border of pubic symphysis (9 cases). Between the low and high types, we defined an intermediate type (type 2) where the urogenital confluence was behind the mid-portion of pubic symphysis (14 cases).
Results
Renal anomalies were common association: solitary kidney in seven, pelvic kidney in two, and urinary tract dilatation (hydroureteronephrosis) in 12 cases. At follow-up, chronic renal insufficiency was detected in seven cases
The prognosis for urinary continence was excellent in low confluence (type 1) cloaca. On the other hand, urinary incontinence was common among type 3 (high confluence) cloaca (62.5%).
Conclusion
Renal anomalies represent a common association with cloaca and a major cause of morbidity. Efforts should be directed to preserve renal function during the initial management, and to preserve the continence potential following the definitive repair.
Level of evidence
This is a case series with no comparison group (level IV).
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Reck-Burneo CA, Lane V, Bates DG, Hogan M, Thompson B, Gasior A, Weaver L, Dingemans AJM, Maloof T, Hoover E, Gagnon R, Wood R, Levitt M. The use of rotational fluoroscopy and 3-D reconstruction in the diagnosis and surgical planning for complex cloacal malformations. J Pediatr Surg 2019; 54:1590-1594. [PMID: 31027906 DOI: 10.1016/j.jpedsurg.2019.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/29/2019] [Accepted: 03/29/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cloacal malformations, a confluence of the urinary tract, vagina and rectum into a single common channel, has a broad and complex anatomic spectrum requiring an imaging tool for visualization, measurement, and surgical planning for the reconstruction of these structures. We evaluated the role of 3-D fluoroscopy for this purpose, as it offers a combination of spatial correlation with precise anatomic measurements. METHODS We examined our imaging protocol for patients with a cloacal malformation and report our experience with rotational fluoroscopy and 3-D reconstruction in 16 consecutive patients referred for cloacal reconstruction. The length of the common channel (CC), the length of the urethra from the bladder neck to the common channel, and the height (and existence or absence) of a vagina or vaginas were determinants of the surgical procedures used for the repair. RESULTS We performed 16 consecutive 3-D cloacagrams (age range 4 months to 9 years) using a new protocol (Figure 1) that provided the following data which helped with surgical planning: Gynecologic: 3 cases with a single vagina, 5 cases with a duplicated Mullerian system (3 of which were asymmetric) and 2 cases with high vaginas requiring vaginal replacement. Colorectal: Four had a high rectum requiring an abdominal approach, and 6 had a rectum reachable via a posterior sagittal approach. Urologic: Two ectopic ureters requiring reimplantation, 3 patients had vesicoureteral reflux (1 bilateral, 2 unilateral), 1 patient had no bladder, and 7 had a normal sized bladder. Common channel length and urethral length were demonstrated in all cases and used to decide between a total urogenital mobilization or a separation of vagina(s) from the common channel, urogenital separation. CONCLUSION The 3-D cloacagram can help predict the surgical plan for urologic, gynecologic, and colorectal components of the cloacal repair. It can predict the CC length as well as the length of the urethra. It helps with predicting the need for vaginal replacement and whether an abdominal approach is needed for the rectum. Its effectiveness is based on the ability to adequately distend structures and see their distal most extent, an advantage over other modalities such as MRI. Added benefits (particularly from the 3D view) include a better spatial understanding of the defect and the diagnosis of concomitant urological abnormalities such as vesicoureteral reflux and ectopic ureters. Disadvantages to this procedure include the need for general anesthesia and a higher exposure to radiation. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Carlos A Reck-Burneo
- Medical University of Vienna, Department of Pediatric Surgery, Waehringer Guertel 18-20 - 1090 Vienna - Austria.
| | - Victoria Lane
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive Columbus, OH 43205, USA
| | - Mark Hogan
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive Columbus, OH 43205, USA
| | - Ben Thompson
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive Columbus, OH 43205, USA
| | - Alessandra Gasior
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Laura Weaver
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Alexander J M Dingemans
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Tassiana Maloof
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Erin Hoover
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Renae Gagnon
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Richard Wood
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
| | - Marc Levitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Children's Drive Columbus, OH 43205, USA
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Transition of care: a growing concern in adult patients born with colorectal anomalies. Pediatr Surg Int 2019; 35:233-237. [PMID: 30392127 DOI: 10.1007/s00383-018-4401-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Traditionally, the care of children and adults has been arbitrarily separated into pediatric and adult medicine and surgery. Despite progress in pediatric surgical techniques, patients born with congenital anomalies still suffer from significant functional sequelae, which persist into adulthood. We aim to describe some of the most common problems experienced by adult patients with congenital colorectal malformations. METHODS Following IRB approval, we performed a retrospective database review of all adult patients who were treated by our group from 1983 until 2017. RESULTS We identified 88 cases. 51 patients had ARM, 18 cloacas, 9 presacral masses, 3 HD, 2 spina bifida and 5 with other diagnoses (3 vaginal anomalies, 1 cloacal exstrophy, 1 obstructed seminal vesical). The specific problems addressed were: complications from previous operations (41), rectal prolapse (25), fecal incontinence (11), gynecologic concerns (12), urologic concerns (6), and recurrent recto urogenital fistula (3). We performed 83 surgical interventions, including 13 rectal prolapse repair, 13 continent appendicostomies, 44 PSARP or redo PSARP, 11 resections of presacral masses, 11 vaginoplasties, 2 examinations under anesthesia, and 2 Mitrofanoff procedures. Five patients were treated medically (bowel management program, obstetric, urologic evaluation). CONCLUSION There is a growing need to better prepare adult providers to assume the care of patients born with congenital colorectal disease as these patients transition to adulthood. A collaboration between specialized pediatric referral centers with adult colorectal surgeons, urologists and gynecologists is a potential pathway for the adequate transition of care.
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Wood RJ, Reck-Burneo CA, Levitt MA. Cloacal Malformations: Technical Aspects of the Reconstruction and Factors Which Predict Surgical Complexity. Front Pediatr 2019; 7:240. [PMID: 31259166 PMCID: PMC6587123 DOI: 10.3389/fped.2019.00240] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/28/2019] [Indexed: 01/24/2023] Open
Abstract
Cloacal malformations are rare anomalies which occur in one in 50,000 live births. Anatomically these anomalies are defined by the presence of a single perineal orifice. There is however a substantial range in their complexity. Defining these differences is key to surgical planning and timely referral of selected cases to centers with the capabilities to manage the most challenging cases. Traditionally the common channel length as measured during cysto-vaginoscopy has been used to differentiate between patients that can be repaired with a reproducible operation and those requiring a more complex repair. The quality and range of imaging available has advanced and thus a more detailed anatomic picture is now possible to help with pre-operative planning. Cross sectional imaging with 3D reconstruction has enhanced the understanding of the anatomic variations in these patients. In addition, the sacral ratio, previously thought to only have an influence on long term continence predictions, has been shown to not only forecast the presence of urological anomalies, but also the complexity of the malformation. In principle, cloacal malformations have two major components to the reconstruction. First, the rectum needs to be separated from the urogenital tract and second, the urogenital sinus needs to be managed to create a urethral orifice and vaginal introitus. The length of the urethra has been shown to be vital in deciding between the two main surgical maneuvers; a total urogenital mobilization (TUM) and a urogenital separation. The technical demands of a urogenital separation are significant and discussed here in detail. The need for vaginal replacement adds further complexity to the care of these patients and has also been shown to be related to the length of the urethra. Predicting complexity in an accurate and non-invasive way will facilitate the care of the most complex cloacal malformations and improve outcomes.
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Affiliation(s)
- Richard J Wood
- Center for Colorectal and Pelvic Reconstruction at Nationwide Children's Hospital, Columbus, OH, United States
| | | | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction at Nationwide Children's Hospital, Columbus, OH, United States
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Said H, Syed SS, Zeinelabdeen A, Fayez MN. Closure of a Recurrent Urethrovaginal Fistula in a Girl with Cloacal Anomaly Using Deflux Injection. European J Pediatr Surg Rep 2018; 6:e52-e55. [PMID: 30027025 PMCID: PMC6051767 DOI: 10.1055/s-0038-1660805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 04/25/2018] [Indexed: 11/13/2022] Open
Abstract
In a girl born with cloaca, both hemivaginae and rectum were located above the bladder neck, and both ureters were connected to the hemivaginae. After diverting colostomy and cystovaginoscopy on the second day of life, the repair of cloaca was performed at 10 months of age by posterior sagittal anorecto vaginoplasty (PSARVP), including laparotomy and bilateral ureteric reimplantation. Eight months after the surgery, she developed a vesicovaginal fistula, which was repaired and closed by open surgery through the bladder. Three months after this procedure, a tiny urethrovaginal fistula was noticed, which was closed at the age of 2 years using hook diathermy to refresh the edges and was then closed by Deflux injection. The proper closure of the urethrovaginal fistula was confirmed by radiology and cystoscopy 3 months after the surgery. This report shows that injection of Deflux into a tiny urethrovaginal fistula following refreshing the edges may be a valid treatment option in selected cases.
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Affiliation(s)
- Hanan Said
- Department of Paediatric Surgery, International Medical Center, Jeddah, Jeddah, Saudi Arabia
| | - Salahuddin S Syed
- Department of Paediatric Surgery, Children Hospital, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - Ali Zeinelabdeen
- Department of Paediatric Surgery, King Fahd Armed Forces Hospital, Jeddah, Western, Saudi Arabia
| | - Mohamed Negm Fayez
- Department of Paediatric Surgery, King Fahd Armed Forces Hospital, Jeddah, Western, Saudi Arabia
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Višnjić S, Bastić M, Marčec M, Mesić M. Short-term "double natural orifice catheterization": Nonoperative management of hydrocolpos in persistent cloaca patients - case series. J Pediatr Surg 2018; 53:718-721. [PMID: 28728829 DOI: 10.1016/j.jpedsurg.2017.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Management of hydrocolpos in cloaca patients is of clinical importance. We report a nonoperative method for the management of hydrocolpos in the form of initial catheter decompression, followed by an endoscopy with catheters placement into both the bladder and vagina, and leaving these catheters for 9 and 14days respectively. METHODS The medical records of six cloaca patients with hydrocolpos in the last 12years were reviewed. The outcomes measured were the renal function, bladder emptying, the presence/resolution of hydronephrosis, and the recurrence of hydrocolpos. RESULTS Complete drainage of hydrocolpos was achieved in four out of six cases and partial drainage in two. On common channel endoscopy, in four patients the structures were identified and balloon catheters inserted. After catheter removal, the vagina and urinary tract remained adequately drained through the natural cloacal opening with no post-micturition residual urine, resolution of hydroneprosis within 60days, preserved renal function, and no hydrocolpos reaccumulation. CONCLUSION Initial decompression and short time catheterization can be the definite solution for some cloaca patients with hydrocolpos. Our case-series showed a success rate in two-thirds of patients by achieving the three main goals; permanent hydrocolpos derivation, undisturbed voiding, and preservation of renal function. LEVEL OF EVIDENCE Study can be classified as a Treatment Study, LEVEL IV Case series with no comparison group.
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Affiliation(s)
- Stjepan Višnjić
- Children's Hospital Zagreb, Klaićeva 16, 10 000 Zagreb, Croatia.
| | - Mislav Bastić
- Children's Hospital Zagreb, Klaićeva 16, 10 000 Zagreb, Croatia
| | - Mateja Marčec
- Children's Hospital Zagreb, Klaićeva 16, 10 000 Zagreb, Croatia
| | - Marko Mesić
- Children's Hospital Zagreb, Klaićeva 16, 10 000 Zagreb, Croatia
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Vilanova-Sanchez A, Reck CA, McCracken KA, Lane VA, Gasior AC, Wood RJ, Levitt MA, Hewitt GD. Gynecologic anatomic abnormalities following anorectal malformations repair. J Pediatr Surg 2018; 53:698-703. [PMID: 28797517 DOI: 10.1016/j.jpedsurg.2017.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/24/2017] [Accepted: 07/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND/AIM Patients may present with gynecologic concerns after previous posterior sagittal anorectoplasty (PSARP) for repair of an anorectal malformation (ARM). Common findings include an inadequate or shortened perineal body, as well as introital stenosis, retained vaginal septum, and remnant rectovestibular fistula. An inadequate or shortened perineal body may impact fecal continence, sexual function and recommendations regarding obstetrical mode of delivery. We describe our experience with female patients referred to our center for evaluation of their previously repaired ARM, with a specific focus on perineal body anatomy and concomitant gynecologic abnormalities. We outline our collaborative evaluation process and findings as well as subsequent repair and outcomes. MATERIAL/METHODS A single site retrospective chart review from May 2014 to May 2016 was performed. Female patients with a history of prior ARM repair who required subsequent reoperative surgical repair with perineoplasty were included. The decision for reoperation was made collaboratively after a multidisciplinary evaluation by colorectal surgery, urology, and gynecology which included examination under anesthesia (EUA) with cystoscopy, vaginoscopy, rectal examination, and electrical stimulation of anal sphincters. The type of original malformation, indication for reoperative perineoplasty, findings leading to additional procedures performed at time of perineoplasty, postoperative complications, and the length of follow up were recorded. RESULTS During the study period 28 patients were referred for evaluation after primary ARM repair elsewhere and 15 patients (60%) met inclusion criteria. Thirteen patients (86.6%) originally had a rectovestibular fistula with prior PSARP and 2 patients (13.4%) originally had a cloacal malformation with prior posterior sagittal anorectovaginourethroplasty. The mean age at the time of the subsequent perineoplasty was 4.6years (0.5-12). Patients had an inadequate perineal body requiring reoperative perineoplasty due to: anterior mislocation of the anus (n=11, 73.3%), prior perineal wound dehiscence with perineal body breakdown (n=2, 13.4%), acquired rectovaginal fistula (n=1, 6.6%), and posterior mislocated introitus with invasion of the perineal body (n=1, 6.6%). During the preoperative evaluation, additional gynecologic abnormalities were identified that required concomitant surgical intervention including: introital stenosis (n=4, 26.6%), retained vaginal septum (n=3, 20%) and remnant recto vestibular fistula (n=2, 13.3%). CONCLUSIONS Patients with a previously repaired ARM may present with gynecologic concerns that require subsequent surgical intervention. The most common finding was an inadequate perineal body, but other findings included introital stenosis, retained vaginal septum and remnant recto vestibular fistula. Multidisciplinary evaluation to assess and identify abnormalities and coordinate timing and surgical approach is crucial to assure optimal patient outcomes. TYPE OF STUDY Case series with no comparison group. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alejandra Vilanova-Sanchez
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA.
| | - Carlos A Reck
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Kate A McCracken
- Pediatric and adolescent Gynecology, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Victoria A Lane
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Alessandra C Gasior
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Richard J Wood
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Marc A Levitt
- Pediatric Surgery, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Geri D Hewitt
- Pediatric and adolescent Gynecology, Center for Colorectal and Pelvic reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
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18
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Wood RJ, Reck-Burneo CA, Dajusta D, Ching C, Jayanthi R, Bates DG, Fuchs ME, McCracken K, Hewitt G, Levitt MA. Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning. J Pediatr Surg 2017; 53:S0022-3468(17)30644-9. [PMID: 29132797 DOI: 10.1016/j.jpedsurg.2017.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care. METHODS We prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded. RESULTS Of 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years. CONCLUSION Urethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented. TYPE OF STUDY Clinical cohort study with no comparative group. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Richard J Wood
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Carlos A Reck-Burneo
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Daniel Dajusta
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Christina Ching
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Rama Jayanthi
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Molly E Fuchs
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine McCracken
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Geri Hewitt
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Marc A Levitt
- The Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
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Ahn JJ, Shnorhavorian M, Amies Oelschlager AME, Ripley B, Shivaram GM, Avansino JR, Merguerian PA. Use of 3D reconstruction cloacagrams and 3D printing in cloacal malformations. J Pediatr Urol 2017; 13:395.e1-395.e6. [PMID: 28673795 DOI: 10.1016/j.jpurol.2017.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/26/2017] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Cloacal anomalies are complex to manage, and the anatomy affects prognosis and management. Assessment historically includes examination under anesthesia, and genitography is often performed, but these do not consistently capture three-dimensional (3D) detail or spatial relationships of the anatomic structures. Three-dimensional reconstruction cloacagrams can provide a high level of detail including channel measurements and the level of the cloaca (<3 cm vs. >3 cm), which typically determines the approach for surgical reconstruction and can impact long-term prognosis. Yet this imaging modality has not yet been directly compared with intra-operative or endoscopic findings. OBJECTIVES Our objective was to compare 3D reconstruction cloacagrams with endoscopic and intraoperative findings, as well as to describe the use of 3D printing to create models for surgical planning and education. STUDY DESIGN An IRB-approved retrospective review of all cloaca patients seen by our multi-disciplinary program from 2014 to 2016 was performed. All patients underwent examination under anesthesia, endoscopy, 3D reconstruction cloacagram, and subsequent reconstructive surgery at a later date. Patient characteristics, intraoperative details, and measurements from endoscopy and cloacagram were reviewed and compared. One of the 3D cloacagrams was reformatted for 3D printing to create a model for surgical planning. RESULTS Four patients were included for review, with the Figure illustrating 3D cloacagram results. Measurements of common channel length and urethral length were similar between modalities, particularly with confirming the level of cloaca. No patient experienced any complications or adverse effects from cloacagram or endoscopy. A model was successfully created from cloacagram images with the use of 3D printing technology. DISCUSSION Accurate preoperative assessment for cloacal anomalies is important for counseling and surgical planning. Three-dimensional cloacagrams have been shown to yield a high level of anatomic detail. Here, cloacagram measurements are shown to correlate well with endoscopic and intraoperative findings with regards to level of cloaca and Müllerian development. Measurement discrepancies may be due to technical variation indicating a need for further evaluation. The translation of the cloacagram images into a 3D printed model demonstrates potential applications of these models for pre-operative planning and education of both families and trainees. CONCLUSIONS In our series, 3D reconstruction cloacagrams yielded accurate measurements of urethral length and level of cloaca common channel and urethral length, similar to those found on endoscopy. Three-dimensional models can be printed from using cloacagram images, and may be useful for surgical planning and education.
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Affiliation(s)
| | | | | | - Beth Ripley
- University of Washington School of Medicine, Seattle, WA, USA
| | - Giridhar M Shivaram
- Seattle Children's Hospital, Seattle, WA, USA; University of Washington School of Medicine, Seattle, WA, USA
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Abstract
Female patients with congenital adrenal hyperplasia (CAH) have varying degrees of atypical genitalia secondary to prenatal and postnatal androgen exposure. Surgical treatment is focused on restoring normal genitalia anatomy by bringing the vagina to the normal position on the perineum, separating the distal vagina from the urethra, forming a normal introitus and preserving sexual function of the clitoris by accepting moderate degrees of hypertrophy as normal and strategically reducing clitoral size only in the most severely virilized patients. There remains a need for continued monitoring of patients as they go through puberty with the possibility of additional surgery for vaginal stenosis. Anatomically based surgery and refinement in surgical techniques with acceptance of moderate degrees of clitoral hypertrophy as normal should improve long-term outcomes.
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Affiliation(s)
- Laurence S Baskin
- UCSF Benioff Children's Hospital, 1825 Fourth St, 5th Floor, San Francisco, CA 94143.
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21
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Lane VA, Skerritt C, Wood RJ, Reck C, Hewitt GD, McCracken KA, Jayanthi VR, DaJusta D, Ching C, Deans KJ, Minneci PC, Levitt MA. A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM). J Pediatr Surg 2016; 51:1864-1870. [PMID: 27554917 DOI: 10.1016/j.jpedsurg.2016.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population. METHODS The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016. RESULTS 56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common. CONCLUSION The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.
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Affiliation(s)
- Victoria A Lane
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Clare Skerritt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Carlos Reck
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Geri D Hewitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Kate A McCracken
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Gynecology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Venkata R Jayanthi
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Daniel DaJusta
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christina Ching
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA; Section of Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Katherine J Deans
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Peter C Minneci
- Center for Outcomes Research (CSOR), Nationwide Children's Hospital, Columbus, OH, USA.
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction (CCPR), Nationwide Children's Hospital, Columbus, OH, USA.
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Anorektale Malformationen. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wang C, Li L, Cheng W, Liu S, Diao M, Li X, Qiao G, Zhang Z, Chen Z. A new approach for persistent cloaca: Laparoscopically assisted anorectoplasty and modified repair of urogenital sinus. J Pediatr Surg 2015; 50:1236-40. [PMID: 25981991 DOI: 10.1016/j.jpedsurg.2015.04.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/21/2015] [Accepted: 04/22/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study is to describe the surgical technique and evaluate midterm outcomes of the technique: laparoscopically assisted anorectoplasty (LAARP) and modified repair of urogenital sinus. METHOD Seven patients with persistent cloaca underwent LAARP and modified repair of urogenital sinus between November 2005 and December 2010. The ages of the patients at the time of operation were 6 months to 15 years. Distal colostogram and micturating cystogram were performed preoperatively to identify the type of persistent cloaca. The rectal pouch was above the pubococcygeal line in all patients. The operations were carried out using 3 trocars. CO2 pressure was maintained at 8-12 mm Hg. RESULT Laparoscopically assisted anorectoplasty and modified repair of urogenital sinus were successfully performed in all cases. Mean operation time was 125.7±8.4 minutes (range, 110-135 minutes). Intraoperative blood loss was minimal. There were no intraoperative complications. Follow-up was obtained in all patients. The median follow-up period was 5.7±2.1years (range, 4-9 years). Mucosal prolapse occurred in 2 cases (28.6%). No urethrovaginal fistula, acquired anorectal atresia or urethral injury was observed. Only 1 patient (14.3%) was incontinent of urine occasionally but urine retention or vesicoureteral reflux was not observed. Two patients (28.5%) had 2-4 stools per day but no social problem. Only 1 patient (14.3%) had constipation and required laxatives. CONCLUSION Anoplasty, vaginoplasty and urethroplasty can be performed simultaneously in patients with persistent cloaca through LAARP and modified repair of urogenital sinus.
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Affiliation(s)
- Chen Wang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China; Peking Union Medical College, Beijing, People's Republic of China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China.
| | - Wei Cheng
- Department of Surgery, United Family Hospital, Beijing, China; Department of Pediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia.
| | - Shuli Liu
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Xu Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Guoliang Qiao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Zheng Zhang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Zheng Chen
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
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Versteegh HP, Sutcliffe JR, Sloots CEJ, Wijnen RMH, de Blaauw I. Postoperative complications after reconstructive surgery for cloacal malformations: a systematic review. Tech Coloproctol 2015; 19:201-7. [PMID: 25702171 PMCID: PMC4412430 DOI: 10.1007/s10151-015-1265-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/30/2014] [Indexed: 01/20/2023]
Abstract
The repair of cloacal malformations is most often performed using a posterior sagittal anorecto-vagino-urethroplasty (PSARVUP) or total urogenital mobilization (TUM) with or without laparotomy. The aim of this study was to systematically review the frequency and type of postoperative complication seen after cloacal repair as reported in the literature. A systematic literature search was conducted according to preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA). Eight records were eligible for this study which were qualitatively analyzed according to the Rangel score. Overall complication rates reported in included studies ranged from 0 to 57 %. After meta-analysis of data, postoperative complications were seen in 99 of 327 patients (30 %). The most common reported complications were recurrent or persistent fistula (n = 29, 10 %) and rectal prolapse (n = 27, 10 %). In the PSARVUP group, the complication rate was 40 % and in the TUM group 30 % (p = 0.205). This systematic review shows that postoperative complications after cloacal repair are seen in 30 % of the patients. The complication rates after PSARVUP and TUM were not significantly different. Standardization in reporting of surgical complications would inform further development of surgical approaches. Other techniques aiming to lower postoperative complication rates may also deserve consideration.
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Affiliation(s)
- H P Versteegh
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB, Rotterdam, The Netherlands,
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d’Ovidio D, Melidone R, Rossi G, Albarella S, Noviello E, Fioretti A, Meomartino L. Multiple Congenital Malformations in a Ferret (Mustela putorius furo). J Exot Pet Med 2015. [DOI: 10.1053/j.jepm.2014.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The incidence of congenital urachal, bladder, and cloacal anomalies is low. Urachal remnants are the result of failure or delay in obliteration of the allantois. Exstrophy of the bladder or cloaca can be diagnosed on prenatal ultrasonography and represent a deviation from the normal embryologic sequence. Persistent cloaca is an anomaly occurring in girls, in which a common cavity exists into which the intestinal, urinary, and reproductive tracts all open. It is also often diagnosed on prenatal imaging.
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Affiliation(s)
- Angela M Arlen
- Children's Healthcare of Atlanta, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA.
| | - Edwin A Smith
- Children's Healthcare of Atlanta, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA; Georgia Urology, PA, 5445 Meridian Mark Road, Suite 420, Atlanta, GA 30342, USA
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Early versus late reconstruction of cloacal malformations: the effects on postoperative complications and long-term colorectal outcome. J Pediatr Surg 2014; 49:556-9. [PMID: 24726112 DOI: 10.1016/j.jpedsurg.2013.10.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 09/26/2013] [Accepted: 10/22/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Patients with a cloacal malformation generally undergo reconstructive surgery within the first years of life. However, the ideal age for surgery has rarely been mentioned. The aim of this study was to report differences in outcome between early (<6 months) and late repair of cloacal malformations. METHODS Charts of patients with a cloacal malformation treated in 5 pediatric surgical centers between 1985 and 2009 were retrospectively studied for associated anomalies, postoperative complications, and colorectal and urological outcome. RESULTS Forty-two patients were eligible for this study, giving a mean exposure of less than 1 patient yearly per center. Forty-five percent of the patients had a short common channel (>3 cm), and 14% had a long common channel. Length of common channel was missing in 41% of the patients. Median age of the cloacal reconstruction was 9 months (range 1-121 months). Twelve patients (29%) underwent an early surgical repair (within the first 6 months of age; median 3 months), and 30 (71%) patients underwent a late repair (after 6 months of age; median 14 months). Eighteen postoperative complications (<30 days) had been documented in 15 patients (35%), with significant more perineal wound dehiscences in patients with an early repair (42% vs. 10%, p=0.031). There were no differences in complication rate between patients with short and long common channels. Mean follow-up was 142 months (range 15-289). At the last follow-up, 10 patients (24%) had voluntary bowel movements. Fourteen patients (33%) had complaints of soiling, 25 (60%) were constipated, with no differences between the early and late repair groups. Patients in the late repair group as well as the group of patients with a short common channel were more frequently able to void spontaneously. CONCLUSIONS Postoperative complications are common in patients with cloacal malformations. Early repair is associated with more wound dehiscences, however, without affecting long-term functional outcome. All centers had limited annual exposure of less than 1 patient. In these clinical settings, ideal age of cloacal reconstruction seems to be between 6 and 12 months. In general, centralized care for these complex malformations may be the crucial factor for reducing postoperative complications and better long-term outcome.
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Capito C, Belarbi N, Paye Jaouen A, Leger J, Carel JC, Oury JF, Sebag G, El-Ghoneimi A. Prenatal pelvic MRI: additional clues for assessment of urogenital obstructive anomalies. J Pediatr Urol 2014; 10:162-6. [PMID: 24054781 DOI: 10.1016/j.jpurol.2013.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/23/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Ultrasound prenatal evaluation of pelvic cystic mass can be challenging. After having ruled out a cloaca anterior to a large hydrocolpos, it is important to differentiate between combined urogenital anomalies such as urogenital sinus and isolated genital anomalies. PATIENTS AND METHODS We reviewed the charts of 13 women referred for a third trimester pelvic MRI for cystic pelvic mass discovered in second trimester ultrasound. We evaluated MRI compared with postnatal surgical findings in order to determine clues for improving prenatal diagnoses. RESULTS MRI excluded the diagnosis of cloacal malformation in nine cases with no false negative. Once a cloaca is ruled out, a different signal between the bladder and the hydrocolpos on T2 sequences is in favor of an isolated genital obstruction. In contrast, in case of urogenital sinus, the vagina is filled with a mixture of genital secretions and urine, which gives it an MRI signal similar to the bladder on T2 sequences. CONCLUSION Third trimester fetal MRI is an essential exam for characterization of pelvic cystic mass diagnosed by ultrasound. This exam appears valuable for invalidating the diagnosis of cloacal malformation and for differentiating between isolated genital obstruction and urogenital sinus.
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Affiliation(s)
- Carmen Capito
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Viscérale et d'Urologie Pédiatriques, centre de référence de maladies endocriniennes Rares de la Croissance, F-75019 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France.
| | - Nadia Belarbi
- AP-HP, Hôpital Robert Debré, Service de Radiologie Pédiatrique, Paris, France.
| | - Annabel Paye Jaouen
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Viscérale et d'Urologie Pédiatriques, centre de référence de maladies endocriniennes Rares de la Croissance, F-75019 Paris, France.
| | - Juliane Leger
- Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France; AP-HP, Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Institut National de la Santé et de la Recherche Médicale Unité UMR 676, F-75019 Paris, France.
| | - Jean-Claude Carel
- Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France; AP-HP, Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Institut National de la Santé et de la Recherche Médicale Unité UMR 676, F-75019 Paris, France.
| | - Jean-François Oury
- Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France; AP-HP, Hôpital Robert Debré, Service de Gynécologie, Obstétrique et Diagnostic Prénatal, F-75019 Paris, France.
| | - Guy Sebag
- AP-HP, Hôpital Robert Debré, Service de Radiologie Pédiatrique, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France.
| | - Alaa El-Ghoneimi
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Viscérale et d'Urologie Pédiatriques, centre de référence de maladies endocriniennes Rares de la Croissance, F-75019 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France.
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Abstract
Thirty-three years ago, on 10 August 1980, in Mexico City, the first patient with an anorectal malformation was operated on using the posterior sagittal approach. At that time it was not obvious that we were actually opening a "Pandora's box" that continues to give many positive surprises, a few disappointments, and the constant hope that each day we can learn more about how to improve the quality of life of children born with all different types of anorectal malformations. In November 2012, patient number 3000 in our database was operated in the city of Cochabamba, Bolivia; during one of our International Courses of Anorectal Malformations and Colorectal Problems in Children. The goal of this article is to give a brief update on the current management of patients with anorectal malformation, based on the multiple lessons learned during this period.
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Affiliation(s)
- Andrea Bischoff
- Division of Pediatric Surgery, Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH 45229, USA.
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Current world literature. Curr Opin Urol 2012; 22:521-8. [PMID: 23034511 DOI: 10.1097/mou.0b013e3283599868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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