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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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Abdelmalak Abokandil M, Waheeb S, Eltagy G, Khairi A, Farghaly Y, Aly S. Correlation between Common Channel Length and Urethral Length in Cloacal Malformations. Eur J Pediatr Surg 2022; 32:310-315. [PMID: 33677823 DOI: 10.1055/s-0041-1725189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION This research aimed to study the relationship between common channel length and urethral length in cloaca patients by different diagnostic modalities and the ability of common channel length to predict the urethral length. MATERIALS AND METHODS The study was conducted on 30 cases of cloaca managed at Alexandria University Children Hospital and Cairo University Children Hospital from August 2018 to December 2019. Preoperative assessment included cystovaginoscopy and magnetic resonance imaging (MRI) studies with a recording of common channel length and urethral length by each modality. RESULTS There is substantial similarity between MRI and cystoscopy in measuring common channel length; 11 patients had common channel length 1 to 3 cm by cystoscopy. It is the same number by MRI measurement. Nineteen patients had common channel length 3 to 5 cm by cystoscopy and MRI. In total, 16 had urethral length <1.5 cm by MRI, while 14 patients with urethral length <1.5 cm by cystoscopy. However, there is a moderate negative correlation by MRI between common channel length and urethral length, while by cystovaginoscope, there is no significant correlation between common channel length and urethral length. CONCLUSION Applying MRI or cystoscopy in the preoperative assessment of cloaca cases is equivalent to measuring common channel length, not measuring urethral length. Besides that, the common channel length cannot predict the urethral length.
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Affiliation(s)
| | - Saber Waheeb
- Department of Pediatric Surgery, Alexandria University, Alexandria, Egypt
| | - Gamal Eltagy
- Department of Pediatric Surgery, Cairo University, Cairo, Egypt
| | - Ahmad Khairi
- Department of Pediatric Surgery, Alexandria University, Alexandria, Egypt
| | - Yasmine Farghaly
- Department of Radiology, Alexandria University, Alexandria, Egypt
| | - Salmaa Aly
- Community and Public Health Department, Alexandria University, Alexandria, Egypt
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Arafa A. Laparoscopic Rectal and Vaginal Pull-Through in the Same Setting in Cloaca with Common Channel of More Than 3 cm Separation. J Laparoendosc Adv Surg Tech A 2021; 31:964-967. [PMID: 33979547 DOI: 10.1089/lap.2020.0828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim of the Study: This study aims at evaluating the feasibility and outcome of a laparoscopically assisted rectal and vaginal pull-through procedure in the same setting for cases of long common channel in a cloaca >3 cm in length. Methods: I have 4 cases with a cloaca with long common channel >3 cm in length diagnosed by cloacogram and cystoscopy. As for the ages of our cases, two of them were 1 year old, and the other 2 cases were 2 years old. Laparoscopic rectal and vaginal pull-through in the same setting was performed in all cases. The operative time was 3 hours. A tension-free anastomosis of the rectum in anal complex was carried out; also anastomosis of vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through. This is to avoid perineal or perirectal dissection. Results: Frequent anal and vaginal dilation after 2 weeks from operation was carried out. Our cases have not demonstrated any stricture, or urethrovaginal fistula. This procedure resulted in a good cosmetic and unimpaired functional outcome. It has been conducted also to avoid excessive perineal dissection, and reduce risk of urinary incontinence by evading the occurrence of urethral sphincter damage. Conclusion: Laparoscopic-assisted rectal and vaginal pull-through is a new approach for long common channel cloaca that avoids perineal dissection, reducing dissection, and risk of urinary incontinence. This technique should be used and implemented on a wide scale.
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Affiliation(s)
- Ahmed Arafa
- Department of Pediatric Surgery, Cairo University, Cairo, Egypt
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Treatment guidelines for persistent cloaca, cloacal exstrophy, and Mayer–Rokitansky–Küster–Häuser syndrome for the appropriate transitional care of patients. Surg Today 2019; 49:985-1002. [DOI: 10.1007/s00595-019-01810-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/26/2019] [Indexed: 11/30/2022]
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Abstract
PURPOSE We assessed the surgical outcome of cloacal malformation (CM) with emphasis on need and timing of vaginal replacement. METHODS An ambispective study of CM was carried out including prospective cases from April 2014 to December 2017 and retrospective cases that came for routine follow-up. Early vaginal replacement was defined as that done at time of bowel pull through. Surgical procedures and associated complications were noted. The current state of urinary continence, faecal continence and renal functions was assessed. RESULTS 18 patients with CM were studied with median age at presentation of 5 days (1 day-4 years). 18;3;2 babies underwent colostomy; vaginostomy; vesicostomy. All patients underwent posterior sagittal anorectovaginourethroplasty (PSARVUP)/ Pull through at a median age of 13 (4-46) months. Ten patients had long common channel length (> 3 cm). Six patients underwent early vaginal replacement at a median age of 14 (7-25) months with ileum; sigmoid colon; vaginal switch; hemirectum in 2;2;1;1. Three with long common channel who underwent only PSARVUP had inadequate introitus at puberty. Complications included anal mucosal prolapse, urethrovaginal fistula, perineal wound dehiscence, pyometrocolpos, bladder injury and pelvic abscess. Persistent vesicoureteric reflux remained in 8. 5;2 patients had urinary; faecal incontinence. 2 patients of uterus didelphys are having menorrhagia. One patient succumbed to sepsis at 7 months age. Renal functions remained normal in 16. One patient is undergoing dialysis. CONCLUSION Early vaginal replacement in CM is feasible. Patients with inadequate introitus may suffer from menorrhagia. A regular follow-up is mandatory.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Room no. 4001-2, Ansari Nagar, New Delhi, 110029, India.
| | - Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Room no. 4001-2, Ansari Nagar, New Delhi, 110029, India
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Yang R, Liu L, Li G, Yu J. Efficacy of solifenacin in the prevention of short-term complications after laparoscopic radical prostatectomy. J Int Med Res 2017; 45:2119-2127. [PMID: 28661264 PMCID: PMC5805213 DOI: 10.1177/0300060517713405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective To evaluate the efficacy of solifenacin in the prevention of short-term
complications after laparoscopic radical prostatectomy (LRP). Methods This randomized placebo-controlled study enrolled patients with
histologically proven prostate cancer who underwent LRP. The patients were
randomized to receive either solifenacin (5 mg once daily; study group) or
placebo (control group) for the 15-day period beginning on the first day
after surgery. The mean duration of detrusor overactivity (DO), the
frequency of DO, the duration of macroscopic haematuria, and the days before
catheter removal were recorded. The International Continence Society Short
Form Male questionnaire, bladder neck stenosis episodes, and maximum urinary
flow rate were evaluated at 1 month after surgery. The side-effects after
using solifenacin were also recorded. Results A total of 120 patients were randomly assigned to the study group
(n = 62) or the control group
(n = 58). There were significantly lower rates of DO
episodes during the daytime and night-time, haematuria and transient
incontinence in the study group compared with the control group. Conclusion Solifenacin was a well-tolerated and effective treatment for the prevention
of complications after LRP, with the main advantage compared with placebo
being the decreased frequency of DO episodes during the daytime and
night-time.
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Affiliation(s)
- Ranxing Yang
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lijie Liu
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gaofeng Li
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jianjun Yu
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai, China
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Kittur DH, Vora RM. Persistent Cloaca: A Long-term Follow-up Study. J Indian Assoc Pediatr Surg 2017; 22:126-127. [PMID: 28413311 PMCID: PMC5379873 DOI: 10.4103/0971-9261.202685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Dinesh H Kittur
- Ankur Paed Surgical Clinic, Rajarampuri, Kolhapur, Maharashtra, India
| | - Ravindra M Vora
- S J K C Trust's Paediatric Surgery Centre and Postgraduate Institute, Sangli, Maharashtra, India
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Bal HS, Sen S, Sam C, Chacko J, Mathai J, Regunandan SR. Urogenital Management in Cloaca: An Alternative Approach. J Indian Assoc Pediatr Surg 2017; 22:108-113. [PMID: 28413306 PMCID: PMC5379868 DOI: 10.4103/0971-9261.202683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: In the management of cloaca, there is concern that dissection of the urogenital sinus in early childhood with the aim of total anatomical correction is hazardous. Avoiding such mobilization and providing mitrofanoff channel, when needed, till peripubertal period reduces complications and is technically easier. Materials and Methods: Forty-three cases of cloaca were managed in the period 2004–2016. Case records and radiology were reviewed retrospectively. The follow-up evaluation was done by looking into voiding history, bowel movements, and menstruation history. Results: There were three groups of children, namely, those with no reconstruction done elsewhere except a diverting fecal stoma (Group I, n = 25), those who had undergone anorectal correction elsewhere with no attempt at urogenital reconstruction (Group IIA, n = 13), and those with attempted bowel and genitourinary reconstruction elsewhere (Group IIB, n = 5). The Group I children (one still awaiting reconstruction) underwent early rectal reconstruction followed by expectant management of the urogenital apparatus. The 18 referred cases had multiple problems, chiefly urogenital, of congenital or iatrogenic origin. While urinary reconstruction included bladder augmentation, ileal neobladder, bladder neck closure, and ureteric reimplantation, the foundation of urinary management was intermittent catheterization through mitrofanoff stoma and the avoidance of any dissection of the cloacal common channel. Surgery on the genital tracts included drainage of hydrocolpos, perineal surgery for low vaginae and abdominoperineal vaginoplasty for high vaginae in the peripubertal period with or without bowel supplementation. Spontaneous voiding was maintained in 17 of 25 (68%) Group I girls (including one death later from intestinal complications), 7 of 13 (54%), Group IIA girls, and 1 of 5 (20%) Group IIB girls. Painless menstruation was noted in eight postpubertal girls, three through the cloacal channel (awaiting reconstruction) and five through the reconstructed vagina. Most of the children are on a bowel management program for fecal cleanliness with washouts through the neoanus or Malone's stoma. Conclusion: We report a nonconventional approach to cloaca based on avoiding dissection of or around the common channel for urethrovaginal reconstruction, opting for mitrofanoff stoma for intermittent catheterization, when needed, and late vaginal reconstruction. We believe this approach has reduced the overall need for intermittent catheterization.
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Affiliation(s)
- Harshjeet Singh Bal
- Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sudipta Sen
- Department of Pediatric Surgery, PSG IMS and R Centre, Coimbatore, Tamil Nadu, India
| | - Cenita Sam
- Department of Pediatric Surgery, PSG IMS and R Centre, Coimbatore, Tamil Nadu, India
| | - Jacob Chacko
- Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Mathai
- Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - S R Regunandan
- Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India
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Abstract
Cloacal anomalies are the most complex and severe form of congenital anorectal malformations (ARM) and urogenital malformations, and it has been well documented that increased severity of ARM leads to worse outcomes. While short-term data on persistent cloaca are available, a paucity of data on long-term outcomes exists, largely because of a lack of uniform terminology, inclusion with other ARM and evolution of the operative technique. On comprehensive review of the published literature on long-term urological outcomes in patients with cloacal anomalies, we found a significant risk of chronic kidney disease and incontinence, however, with improvements in surgical technique, outcomes have improved. Continence often requires intermittent catheterization and in some cases, bladder augmentation. The complexity of cloacal malformations and associated anomalies make long-term multidisciplinary follow-up imperative.
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Affiliation(s)
- Brian T Caldwell
- Department of Pediatric Urology, Children׳s Hospital Colorado, 13123 East, 16th Ave Box 463, Aurora, Colorado 80045.
| | - Duncan T Wilcox
- Department of Pediatric Urology, Children׳s Hospital Colorado, 13123 East, 16th Ave Box 463, Aurora, Colorado 80045
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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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Fernando MA, Creighton SM, Wood D. The long-term management and outcomes of cloacal anomalies. Pediatr Nephrol 2015; 30:759-65. [PMID: 25217327 PMCID: PMC4372671 DOI: 10.1007/s00467-014-2875-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 05/03/2014] [Accepted: 06/02/2014] [Indexed: 12/03/2022]
Abstract
Cloacal anomalies occur when failure of the urogenital septum to separate the cloacal membrane results in the urethra, vagina, rectum and anus opening into a single common channel. The reported incidence is 1:50,000 live births. Short-term paediatric outcomes of surgery are well reported and survival into adulthood is now usual, but long-term outcome data are less comprehensive. Chronic renal failure is reported to occur in 50 % of patients with cloacal anomalies, and 26-72 % (dependant on the length of the common channel) of patients experience urinary incontinence in adult life. Defaecation is normal in 53 % of patients, with some managed by methods other than surgery, including medication, washouts, stoma and antegrade continent enema. Gynaecological anomalies are common and can necessitate reconstructive surgery at adolescence for menstrual obstruction. No data are currently available on sexual function and little on the quality of life. Pregnancy is extremely rare and highly risky. Patient care should be provided by a multidisciplinary team with experience in managing these and other related complex congenital malformations. However, there is an urgent need for a well-planned, collaborative multicentre prospective study on the urological, gastrointestinal and gynaecological aspects of this rare group of complex conditions.
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Affiliation(s)
- M. Ashani Fernando
- Department of Urology, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
| | - Sarah M. Creighton
- Department of Women’s Health, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
| | - Dan Wood
- Department of Urology, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
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Versteegh HP, Wolffenbuttel KP, Sloots CE, Madern GC, van den Hoek J, Wijnen RM, de Blaauw I. Effects of Reconstructive Surgery on Bladder Function in Patients with Anorectal Malformations. J Urol 2014; 192:1789-93. [DOI: 10.1016/j.juro.2014.06.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Hendt P. Versteegh
- Department of Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Katja P. Wolffenbuttel
- Department of Pediatric Urology, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Cornelius E.J. Sloots
- Department of Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Gerard C. Madern
- Department of Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Joop van den Hoek
- Department of Pediatric Urology, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Rene M.H. Wijnen
- Department of Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, the Netherlands
- Department of Pediatric Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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Versteegh HP, Sloots CEJ, Wolffenbuttel KP, de Jong JR, Sleeboom C, Feitz WF, van Heurn LWE, van der Zee DC, Wijnen RMH, de Blaauw I. Urogenital function after cloacal reconstruction, two techniques evaluated. J Pediatr Urol 2014; 10:1160-4. [PMID: 24957462 DOI: 10.1016/j.jpurol.2014.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/21/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Current surgical techniques for cloacal reconstruction are posterior sagittal anorecto vagino urethroplasty (PSARVUP) and posterior sagittal anorectoplasty (PSARP) with total urogenital mobilization (TUM). The aim of this study was to explore the results of reconstructive cloaca surgery in the Netherlands and evaluate urogenital function after PSARVUP and TUM. PATIENTS AND METHODS Medical records from five pediatric surgical departments in the Netherlands were studied for patients with cloacal malformations treated between 1985 and 2009. Forty-two patients were eligible, and patients with short common channels were categorized into PSARVUP and TUM groups. Groups were compared using Fisher's exact test. RESULTS Median age at time of surgery was 9 months (range 1-121). In 24 patients (57%) a PSARVUP was done, in 18 patients (43%) TUM. Median follow-up was 142 months (range 15-289). At follow-up spontaneous voiding was seen in 29 patients (69%). Clean intermittent catheterization (CIC) was needed in 14 patients (33%); a urinary diversion was created in 10 patients (24%). In total 32 patients (76%) were dry with no involuntary loss of urine per urethra. Recurrent urinary tract infections were seen in 23 patients (55%). When comparing PSARVUP and TUM groups in our series of patients with short common channels, there were no differences in urological outcome. Normal menstruation was present in 11 of the 20 patients who reached puberty (55%). CONCLUSION Urogenital functional outcome after reconstructive surgery for cloacal malformations was similar in PSARVUP and TUM groups in patients with short common channels. A thorough urological follow-up is needed to establish the long-term bladder function and urinary incontinence results to prevent long-term risks of recurrent UTI. Albeit without differences between PSARVUP and TUM groups, 45% of the patients present with abnormal or absent menstruations. Gynecological follow-up is mandatory in all patients with cloacal malformations 6 months after the first sign of puberty.
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Affiliation(s)
- Hendt P Versteegh
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Cornelius E J Sloots
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Katja P Wolffenbuttel
- Dept. of Pediatric Urology, Erasmus MC-Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Justin R de Jong
- Pediatric Surgical Center Amsterdam, Emma Children's Hospital AMC & VU University Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Christien Sleeboom
- Pediatric Surgical Center Amsterdam, Emma Children's Hospital AMC & VU University Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Wout F Feitz
- Dept. of Pediatric Urology, Radboud University Medical Center - Amalia Children's Hospital, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - L W Ernest van Heurn
- Dept. of Pediatric Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - David C van der Zee
- Dept. of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Rene M H Wijnen
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Ivo de Blaauw
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands; Dept. of Surgery - Pediatric Surgery, Radboud University Medical Center - Amalia Children's Hospital, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Impact of spinal dysraphism on urinary and faecal prognosis in 25 cases of cloacal malformation. J Pediatr Urol 2014; 10:1199-205. [PMID: 25113956 DOI: 10.1016/j.jpurol.2014.05.012] [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: 04/07/2014] [Accepted: 05/13/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Urinary and faecal continence are key challenges goal of cloacal malformation management. Most well-known prognostic factors are the length of common channel (CC) and the presence of a sacral defect, but the impact of associated spinal dysraphism is less well documented. The aim of this study was to investigate the impact of different types of dysraphism on urinary and faecal continence in this patient population. MATERIALS AND METHODS From 1991 to 2011, charts and office notes of 25 patients with cloacal malformation were retrospectively reviewed. At last clinic visit, urinary and faecal continence status according to Krickenbeck criteria were correlated with the length of CC, the presence of a sacral defect (sacral ratio), and the presence of different types of spinal cord dysraphism using magnetic resonance imaging (MRI) and Fisher's exact test. RESULTS Mean follow-up was 8 years (4 months-21 years). The sacral ratio was abnormal (below 0.74) in 18 cases out of 25 (72%). MRI review showed normal spinal cord in eight out of 23 cases (Group 1), spinal cord anomaly in 15 out of 23 cases (65%) including nine cases of tethered cord complex (Group 2) and six cases of a short spinal cord (Group 3). While statistical analysis showed a difference regarding urinary prognosis between the groups (p=0.005), no significant difference was found regarding faecal prognosis. None of the six patients with short spinal cord were continent for both urinary and faecal prognosis. CONCLUSIONS This is the first study, which highlights the impact of different types of spinal dysraphism on functional outcome in patients with cloaca. Short spinal cord seemed to carry the worst prognosis. A prospective study with a larger series is mandatory to confirm these preliminary results.
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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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Palmer BW, Trojan B, Griffin K, Reiner W, Wisniewski A, Frimberger D, Kropp BP. Total and partial urogenital mobilization: focus on urinary continence. J Urol 2012; 187:1422-6. [PMID: 22341265 DOI: 10.1016/j.juro.2011.12.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE Total and partial urogenital mobilization procedures are the most common contemporary vaginoplasty surgeries for patients with congenital adrenal hyperplasia, urogenital sinus and cloacal anomalies. There is controversy regarding the urinary continence outcomes of these procedures. We reviewed the urinary continence outcomes of children who underwent total or partial urogenital mobilization at our institution and reviewed the literature to determine the continence rates of these procedures. MATERIALS AND METHODS We retrospectively reviewed 25 patients who underwent total or partial urogenital mobilization with a focus on postoperative continence status. Continence was defined as parental report of full toilet training with no accidents during the day and rare accidents (fewer than 2 per month) at night after age 3 years. RESULTS A total of 14 congenital adrenal hyperplasia, 5 urogenital sinus and 6 cloacal anomaly cases were managed by total (18) or partial (7) urogenital mobilization procedures with a mean followup of 4.41 years (range 0.21 to 12.1). In our cohort 21 of 22 patients (95.5%) were continent by age 3 years and there were no urinary complications. A total of 111 patients were identified in the literature with congenital adrenal hyperplasia or urogenital sinus, with 107 in 7 studies being continent (96.4%) by age 3 to 4 years. In 4 studies 32 patients were identified with cloacal anomalies who underwent total or partial urogenital mobilization, of whom 28 (87.5%) were continent by age 3 to 4 years. CONCLUSIONS There was no significant difference between total and partial urogenital mobilization procedures regarding postoperative urinary continence in our cohort and the literature. The urinary continence rate was 96% in the congenital adrenal hyperplasia/urogenital sinus group and 89.5% in the cloacal group.
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Affiliation(s)
- Blake W Palmer
- Department of Pediatric Urology, University of Oklahoma, Oklahoma City, Oklahoma 73104, USA.
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Therapeutic strategy for persistent cloaca: the efficacy of antegrade continent enema as a salvage surgery. Pediatr Surg Int 2011; 27:505-8. [PMID: 21240612 DOI: 10.1007/s00383-010-2819-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study is to evaluate our therapeutic strategy for persistent cloaca from the viewpoint of long-term functional outcome. MATERIALS AND METHODS This study covers 17 cases of persistent cloaca treated at our institution and followed for more than 3 years. As a definitive repair for anorectal and urogenital systems, simultaneous surgery with posterior sagittal approach or anorecto-urethrovagino-plasty (PSARUVP) was performed. The length of the common channel and the shape of the vagina determined the vaginoplasty methods. Fecal function was assessed with the scoring system of the Japan Study Group of Anorectal Anomalies. RESULTS Anorectoplasty was performed with the posterior sagittal approach in 15 cases and with the perineal approach in two. Vaginoplasty was performed with total urogenital mobilization in nine cases, rectal interposition in four, vaginal flap in two and with other methods. Fecal function was classified as good in three cases, moderate in ten, and poor in four. In the poor cases, Malone's antegrade continence enema (MACE) was performed, which improved fecal function significantly. CONCLUSION PSARUVP might be the optimal surgery for persistent cloaca at present; however, satisfactory fecal function could not be achieved in those cases with a longer common channel. MACE effectively compensated for the poor outcome and was especially successful at eliminating incontinence.
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Saxena AK. Congenital Anomalies of Soft Tissues: Birth Defects Depending on Tissue Engineering Solutions and Present Advances in Regenerative Medicine. TISSUE ENGINEERING PART B-REVIEWS 2010; 16:455-66. [DOI: 10.1089/ten.teb.2009.0700] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Amulya K. Saxena
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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