Long-term urological outcomes in six sets of conjoined twins

The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report

Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise.A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In August 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect.The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up.

The surgical principles of conjoined twin separation

The surgical management of conjoined twin separation is a complex, multidisciplinary process that requires extensive pre operative planning and organization for optimal outcomes. Identification of detailed anatomic relationships is necessary prior to the separation. The use of 3D modeling is extremely helpful for conceptualization of the operation. The principles of the separation are dependent on the type of twin, although each variant of symmetric twins has certain commonalities related to their embryology that can be considered when planning the operation. The use of tissue expansion in the pre operative planning stage is highly recommended due to known issues with closure after separation. In order to ensure a safe, successful operation, we recommend organized pre operative planning meetings with at least one simulation of the separation event with multidisciplinary involvement.

Urological management

The pediatric urologists role is confined to ischio-, para-, and pygopagus conjoined twins. The aim is to preserve renal function, to address problems with urinary continence, and to optimize genital issues with particular reference to sexual and reproductive function. Full urological imaging is essential prior to separation for planning and for the operation itself.