1
|
Ochoa B, Weidler EM, Parks MA, Speck KE, van Leeuwen K. Novel Approaches to Patients with Differences of Sex Development. Adv Pediatr 2024; 71:151-167. [PMID: 38944480 DOI: 10.1016/j.yapd.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Patients with differences of sex development (DSDs) have complex anatomy and surgical needs related to both Mullerian and non-Mullerian structures. Approaches to vaginal reconstruction for these conditions are guided by individual anatomy, with the goal of establishing unobstructed outflow for the reproductive, urinary, and gastrointestinal tracts. Patients may have anatomy requiring vaginoplasty for either outflow tract obstruction or chosen sexual function. In this article, the authors focus on management of differences in vaginal anatomy with delayed vaginoplasty for the newborn with DSD.
Collapse
Affiliation(s)
- Brielle Ochoa
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Melissa A Parks
- Department of Gynecology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA
| | - Karen Elizabeth Speck
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E. Hospital Drive, SPC 4211, Ann Arbor, MI 48109, USA
| | - Kathleen van Leeuwen
- Department of Surgery, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85016, USA.
| |
Collapse
|
2
|
An Interdisciplinary Approach to Müllerian Outflow Tract Obstruction Associated with Cloacal Malformation and Cloacal Exstrophy. J Clin Med 2022; 11:jcm11154408. [PMID: 35956025 PMCID: PMC9369038 DOI: 10.3390/jcm11154408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 12/04/2022] Open
Abstract
People with cloacal malformation and 46,XX cloacal exstrophy are at risk of developing Müllerian outflow tract obstruction (OTO). Management of OTO requires expertise of many medical and surgical specialties. The primary presenting symptom associated with OTO is cyclical and later continuous pain and can be initially quelled with hormonal suppression as a temporizing measure to allow for patient maturation. The decision for timing and method of definitive treatment to establish a patent outflow tract that can also be used for penetrative sexual activity and potential fertility is a complicated one and incredibly variable based on patient age alone. To understand the management approach to OTO, we put forth five phases with associated recommendations: (1) caregiver and patient education and evaluation before obstruction; (2) presentation, diagnosis, and symptom temporization; (3) readiness assessment; (4) peri-procedural management; (5) long-term surveillance. This review will emphasize the importance of interdisciplinary team management of the complex shared medical, surgical, and psychological decision making required to successfully guide developing patients with outflow obstruction secondary to cloacal malformations and cloacal exstrophy through adolescence.
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Palm CA, Segev G, Shipov A, Balsa IM, Phillips KL, Culp WTN. Treatment of a Congenital Imperforate Vestibulovaginal Junction and Secondary Hydrocolpos With Endoscopic Laser Ablation in Two Dogs. Top Companion Anim Med 2021; 45:100576. [PMID: 34400380 DOI: 10.1016/j.tcam.2021.100576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/30/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Two dogs were evaluated for clinical signs including dysuria, stranguria, and/or dyschezia. Physical examination findings were consistent with a caudal abdominal and intra-pelvic mass. Imaging with abdominal ultrasonography confirmed the presence of a tubular fluid-filled structure. In 1 dog computed tomography identified the fluid-filled structure to be the vagina and hydrocolpos was suspected. Endoscopic evaluation of the urogenital tracts identified imperforate vaginas in both dogs, and endoscopic-guided laser ablation was used to create a vaginal opening into the vestibule. Initial response to treatment was positive in both dogs, although 1 dog developed a recurrence of hydrocolpos 1-month after treatment. Endoscopic laser ablation provided a minimally invasive option for opening an imperforate vagina and no procedural complications occurred. Further evaluation is needed to determine the long-term effectiveness of this procedure.
Collapse
Affiliation(s)
- Carrie A Palm
- University of California-Davis, School of Veterinary Medicine, Davis, CA, USA.
| | - Gilad Segev
- Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Anna Shipov
- Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Ingrid M Balsa
- University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Kathryn L Phillips
- University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - William T N Culp
- University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Bischoff A, Bealer J, Peña A. Controversies in anorectal malformations. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:323-330. [PMID: 30169187 DOI: 10.1016/s2352-4642(17)30026-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/13/2017] [Accepted: 06/22/2017] [Indexed: 01/20/2023]
Abstract
Anorectal malformations are uncommon but complex congenital anomalies that require an individualised strategy of care for each step of the treatment process. These steps, which include preoperative evaluation, operative reconstruction, and postoperative care, are each unique and vitally important to overall patient outcomes. In this Review, we discuss some of the pivotal decisions that should be made at each stage of patient care. Through this process, we highlight some of the more controversial aspects of caring for patients with anorectal malformation and offer insights into various management philosophies.
Collapse
Affiliation(s)
- Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.
| | - John Bealer
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Alberto Peña
- International Center for Colorectal and Urogenital Care, Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
8
|
Abstract
Similar to other anorectal malformations, cloaca also represents a spectrum of defects that goes from "benign" cloaca with a good functional prognosis that can be repaired with a relatively simple surgical technique, to very complex malformations with many anatomic variations that require different surgical maneuvers to be able to successfully reconstruct those patients. The group of patients born with a "benign" type of cloaca will have bowel and urinary control, will become sexually active and may get pregnant and deliver by cesarean section. All this is possible, provided the malformation is repaired with a meticulous and delicate technique. Fortunately this represents more than 50% of all cloacas. Our belief is that the surgical technique to repair this group of defects is reproducible and can be taught to pediatric surgical trainees. On the other hand, complex cloaca with a common channel longer than 3 cm should be repaired by surgeons fully dedicated to repair these malformations. The experience reported in this paper is based on 570 patients with cloaca operated by Dr. Alberto Peña and the author in the last 8 years.
Collapse
Affiliation(s)
- Andrea Bischoff
- International Center for Colorectal Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045.
| |
Collapse
|
9
|
Abstract
This is a summary of the milestones in the history of the treatment of cloacal malformations. It is based in a comprehensive literature review of the subject, from the early times, followed by a description of the evolution of the surgical maneuvers that were created, to be able to deal with the different anatomical variants of this complex congenital malformation.
Collapse
Affiliation(s)
- Alberto Peña
- International Center for Colorectal Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045.
| |
Collapse
|
10
|
Chalmers DJ, Rove KO, Wiedel CA, Tong S, Siparsky GL, Wilcox DT. Clean intermittent catheterization as an initial management strategy provides for adequate preservation of renal function in newborns with persistent cloaca. J Pediatr Urol 2015; 11:211.e1-4. [PMID: 26187141 DOI: 10.1016/j.jpurol.2015.05.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/27/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Persistent cloaca is a rare, congenital anomaly involving the genital, urinary, and rectal organ systems. While prompt bowel diversion is the standard of care, the optimal method of genitourinary decompression is unclear. Bladder outlet obstruction and hydrometrocolpos are common complications that can lead to obstructive uropathy, abdominal distention, infection, perforation, and acidosis. Proposed management strategies include early surgical diversion (vesicostomy, vaginostomy, ureterostomy, nephrostomy) or clean intermittent catheterization (CIC) of the common channel. We hypothesized that CIC is an adequate means of genitourinary decompression and preservation of renal function, regardless of the severity of cloacal anomaly. METHODS We reviewed all patients with persistent cloaca from a single, tertiary care center from 1995 to 2013. We collected data regarding renal function (serial serum creatinine prior to definitive reconstruction, and baseline estimated glomerular filtration rate [GFR]), presence of hydrocolpos, hydronephrosis, vesicoureteral reflux (VUR) or renal dysplasia, and length of the common channel. A linear mixed model was used to calculate creatinine change over time in relation to method of management and child age. Estimated GFR was calculated using the Schwartz equation for neonates = 0.45 × height in cm/serum creatinine in mg/dL. The t test was used for continuous data and Fisher's exact test was used for binomial data. A p value <0.05 was considered significant. RESULTS Twenty-five patients were identified. Nine (36%) patients underwent early surgical diversion versus 16 (64%) managed by CIC prior to formal reconstruction. Seven had short common channels (<3 cm) and 18 had long common channels (≥3 cm). Hydrocolpos was present in 14 (56%) of the patients. When comparing the two management groups, there was no significant difference in hydronephrosis, high-grade hydronephrosis (grades III-IV, p = 0.62), any VUR (p = 0.33), high-grade VUR (grades III-V, p = 0.62), hydrocolpos (p = 0.21), or renal dysplasia (p = 0.42). No significant differences were found between mean baseline GFR for diversion (22.9 mL/min per 1.73 m(2)) versus CIC (39.2 mL/min per 1.73 m(2), p = 0.22). There was no difference in creatinine trend between the two groups. DISCUSSION Currently, there is no consensus on the initial management of obstructive uropathy and resulting hydrocolpos in newborns with persistent cloaca. In addition to CIC, management strategies include surgical options such as vesicostomy, vaginostomy, or upper tract diversions such as ureterostomy or nephrostomy. Our results suggest that CIC is similar to these other proposed diversion procedures while minimizing morbidity. Creatinine trends over time were similar between the two groups and reached comparable nadirs. Limitations of our study include the retrospective nature of a small sample size. The primary risk is differences between the two groups that we were not able to appreciate. Furthermore, we did not attempt to assess the morbidity of the two different strategies. CONCLUSIONS CIC is an adequate initial management strategy to decompress the genitourinary tract in patients with persistent cloaca. CIC preserves renal function similar to early surgical decompression.
Collapse
Affiliation(s)
| | - Kyle O Rove
- Department of Surgery, Division of Urology, University of Colorado, Aurora, CO, USA
| | - Cole A Wiedel
- Department of Surgery, Division of Urology, University of Colorado, Aurora, CO, USA
| | - Suhong Tong
- Department of Biostatistics and Information, University of Colorado, Aurora, CO, USA
| | | | - Duncan T Wilcox
- Division of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA.
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|