Current urologic management of cloacal exstrophy: experience with 11 patients

Urinary and bowel management in cloacal exstrophy: A long-term multi-institutional cross-sectional study

BACKGROUND

We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study.

METHODS

We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with <1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (<10 years), older children (10 to <18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs. >2000).

RESULTS

A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p < 0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p = 0.31) or based on birthyear (p = 0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p = 0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55-91%, p = 0.001), but not birth year (p = 0.85).

SUMMARY

We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness.

CONCLUSIONS

In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients.

Achieving urinary continence in cloacal exstrophy: The surgical cost

INTRODUCTION

Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night.

RESULTS

In total, 140 CE and CE variant patients have been managed at the authors' institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2-10). This included 1 bladder closure (range 1-3), 2 urinary continence procedures (range 1-4), and 1 (range 0-4) "other" genitourinary procedures. The median time to urinary continence was 11.0 years (95% CI [9.2-14.2]).

CONCLUSIONS

A majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

Disorders of the bladder and cloacal anomaly

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.

Initial bladder closure of the cloacal exstrophy complex: outcome related risk factors and keys to success

PURPOSE

This study examines a large single-institution experience with cloacal exstrophy patients, analyzing patient demographics and surgical strategies predictive of bladder closure outcomes.

METHODS

One hundred patients with cloacal exstrophy were identified. Complete closure history including demographics, operative history, and outcomes was available on 60 patients. Twenty-six patients with a history of failed initial bladder closure were compared to 34 with a history of successful initial bladder closure. Univariate logistic regression analysis was used to compare the two groups.

RESULTS

Median follow up time after initial closure was 9years (range: 13months-29years). A 1cm increase in pre-closure diastasis resulted in a 2.64 increase in the odds of initial closure failure (p=0.004). Protective strategies against failure included delaying closure (per month) (OR=0.894, p=0.009), employing pelvic osteotomies (OR=0.095, p<0.001), and applying external fixation (OR=0.024; p=0.001). Among patients who underwent osteotomy (31% of patients in the failed group, 82% in the successful group), a longer delay between osteotomy and closure (OR=0.033; p=0.005) was also protective against failure.

CONCLUSION

Patients with a large diastasis are more likely to fail initial closure. Delaying initial closure for at least 3months, performing pelvic osteotomy, and using an external fixation device post-operatively are strategies that improve closure success.

Cloacal exstrophy: a single center experience

OBJECTIVE

Cloacal exstrophy is an exceedingly rare and complex anomaly. The records of 23 patients treated in a tertiary care center with limited infrastructure were analyzed for anatomic types, associated anomalies, surgical procedures adopted, and the outcome.

MATERIALS AND METHODS

There were 14 males. Seventeen babies were preterm with an average weight of 1.92 kg. The time of presentation, gestational age, birth weight, position of the hemibladders and associated malformations were noted. Reconstruction procedures involved dismantling of the hemibladders and primary turn in, tubularization of the bowel with an end colostomy, and reconstruction of the abdominal wall. Results of the primary surgical repair, bowel function, and outcome of secondary procedures were analyzed.

RESULTS

The position of hemibladders was lateral in 11, upper confluent in 4 and lower confluent in 8. Associated anomalies were noted in 19 patients. Four patients presented late (>5 days). Five died preoperatively, all had major associated anomalies. Four of them were preterm with average weight of 1.4 kg. Two patients refused surgery. Single-stage surgical reconstruction was done in 15 patients. Five patients died postoperatively because of associated anomalies, prematurity, and sepsis. One patient is waiting for surgery. Six patients had follow-up at 3-42 months and are awaiting further reconstruction. Four patients were lost to follow-up.

CONCLUSIONS

Prematurity, late presentation, and sepsis are the major causes of high mortality noted in this series. In our experience, single-stage reconstruction without osteotomy gives satisfactory results.

Urological outcomes in the omphalocele exstrophy imperforate anus spinal defects (OEIS) complex: experience with 80 patients

OBJECTIVE

To review the urological management and outcomes of patients with the OEIS (omphalocele, exstrophy of the bladder, imperforate anus, spinal abnormalities) complex.

PATIENTS AND METHODS

80 patients with the OEIS complex managed at a single institution between 1974 and 2009 were reviewed.

RESULTS

37 had initial closure at our institution (2 failed - 5%); 22 with successful closure were referred for incontinence; 15 failed closure at an outside institution (2 of whom are awaiting closure); 6 are skin-covered variants. Osteotomy was performed in 39/43 (91%) with successful closure versus 8/17 (47%) who failed initial bladder closure. 40 were dry (56%), but most needed additional urinary reconstruction: 2 had small bowel neobladders; 32 (84%) had augmentation cystoplasty; 30 (79%) had a continent catheterizable channel; only 9 (24%) were continent with an intact urethra. Bladder neck reconstruction allowed dryness in 7 (18%). 45 patients had XY genotype--19 had female gender assignment at birth. All patients with XX genotype had female gender assignment.

CONCLUSIONS

Osteotomy improves success of initial bladder closure. A bladder neck procedure, catheterizable channel, and augmentation cystoplasty will be required in the majority of patients to attain urinary dryness.

Achieving urinary continence in cloacal exstrophy

Cloacal exstrophy is the most significant urological anomaly compatible with life. The development of urinary continence is compromised significantly by the anatomic and neurological deficits that are a part of this complex anomaly. Most children with cloacal exstrophy can eventually be made continent by the use of current reconstructive techniques. This article summarizes some of the challenges and reconstructive methods to permit eventual continence in children with cloacal exstrophy.

Cloacal exstrophy--pull-through or permanent stoma? A review of 53 patients

PURPOSE

Patients with cloacal exstrophy have complex anomalies of the genitourinary and gastrointestinal tract with a spectrum of colonic length. Often, colon is lost during the initial management by use of ileostomies and for urologic and genital reconstruction. It is a common belief that these patients require permanent stomas, which we hypothesized is inaccurate, and therefore reviewed our experience with exstrophy, focusing specifically on a patient's potential to undergo a colonic pull-through.

METHODS

All patients with exstrophy or exstrophy variant treated by the authors were retrospectively reviewed. Their ability to form solid stool was assessed via bowel management involving a constipating diet, antidiarrheals, bulking agents, and a daily enema through the stoma. Patients who underwent successful bowel management through the stoma were offered a pull-through.

RESULTS

Fifty-three patients were treated over a 26-year period, including typical cloacal exstrophy (27), or a covered variant (16), and complex anorectal malformations with short colon (10). Newborn operations (48 done at other institutions, 5 by us) involved ileostomy in 11 or end colostomy in 42. Eight patients with ileostomies suffered acidosis and failure to thrive and underwent "rescue" operations to incorporate all defunctionalized colon into the fecal stream. Four had colon used for their urologic reconstruction and 6 for their genital reconstruction, leaving them borderline or unable to form solid stool. Twenty-three are undergoing bowel management or being observed for growth of the colonic pouch to determine if they are pull-through candidates. Of the others, 90% (27/30) underwent colonic pull-through. Ten percent (3/30) had a permanent stoma. Of 20 available for follow-up after pull-through, 17 are clean with bowel management (85%), 2 (10%) have voluntary bowel movements with occasional soiling, and 1 is incontinent but noncompliant.

CONCLUSIONS

Indication for pull-through depends on successful bowel management through the stoma, which depends on the ability to form solid stool. To maximize this potential, it is crucial to use all available hindgut for the initial colostomy and avoid use of colon for urologic or genital reconstruction. Most patients have poor prognosis for bowel control but can remain clean with bowel management. Our experience indicates that a permanent stoma is not required for the most of these patients and that bowel management can keep them clean, which we believe provides them with a better quality of life. Using these criteria, most exstrophy patients, contrary to popular belief, are candidates for a pull-through.

First Stage Approximation of the Exstrophic Bladder in Patients With Cloacal Exstrophy—Should This be the Initial Surgical Approach in all Patients?

PURPOSE

Cloacal exstrophy is rare and it represents a reconstructive challenge. Options for managing the urinary tract include primary closure or approximation of the bladder halves in the midline with later closure. We present our observations and evolving thoughts concerning optimal treatment in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients with cloacal exstrophy seen in the last 5 years. Initial management was examined, including complete primary closure vs a staged approach. We noted midline defects, spinal cord abnormalities or other anatomical reasons that precluded primary closure.

RESULTS

Seven patients, including 5 females and 2 males, were identified. An omphalocele noted in all 7 patients was closed in 5 at initial operation. All underwent preservation of the hindgut in the fecal stream. Spinal cord tethering was noted in 7 of 7 cases. Complete primary bladder closure was performed in 3 of the 7 patients, while the size of the bladder plates or a large abdominal wall defect precluded closure in the remainder. Continence was not achieved in the 3 cases closed primarily. All patients achieving urinary continence underwent bladder neck closure and augmentation cystoplasty with a continent catheterizable channel.

CONCLUSIONS

Patients with cloacal exstrophy have anatomical issues that can prevent complete primary bladder closure or preclude the achievement of urinary continence. The high incidence of tethered cord places these patients at risk for upper tract changes and bladder decompensation during followup. Despite successful primary closure in 3 of 7 patients all have a tiny bladder and require secondary procedures to become continent. Extensive dissection during the first operation can contribute to more difficult dissection with potential increased morbidity during subsequent surgeries. Therefore, the best initial approach for the typical patient may be closure of the abdominal wall and approximation of the exstrophied bladder halves in the midline. Secondary closure with continent diversion and reconstruction of the external genitalia can be performed at ages 18 to 24 months.

Outcome of gastrocystoplasty in tertiary pediatric urology practice

PURPOSE

Although the use of stomach for bladder reconstruction has become popular during the last decade, it is not a panacea. We review our experience with gastrocystoplasty.

MATERIALS AND METHODS

We completed a retrospective chart review of 11 females and 12 males, 1.5 to 22.5 years old (mean age 10) who underwent gastrocystoplasty at Hôpital Sainte-Justine, Montreal, Quebec and Children's Hospital, Winnipeg, Manitoba, Canada between December 1990 and 1998. Primary diagnoses included spinal dysraphism in 14 patients, posterior urethral valves in 3, cloacal exstrophy in 2, cloacal outlet anomaly in 2, multiple failed ureteral reimplantations with bladder dysfunction in 1 and neurogenic bladder of uncertain etiology in 1. Three patients presented with chronic renal failure. Concurrent reconstructive surgery included ureteral reimplantation in 10 patients, bladder neck plasty in 4 or closure in 4, and continent urinary diversion in 5.

RESULTS

Acute postoperative complications included urosepsis in 2 cases, bowel obstruction in 2 and ureteral obstruction in 1. Followup ranged from 4 to 86 months (mean 45). Long-term complications consisted of intractable hematuria-dysuria syndrome in 5 cases, inability to catheterize in 3, perineal urinary fistula in 2, new onset hydronephrosis in 2, continent stomal stenosis in 1 and bladder calculus in 1. Proton pump inhibitors and/or histamine 2 antagonists were used in 16 of the 23 patients to prevent the hematuria-dysuria syndrome. In 5 cases the hematuria-dysuria syndrome was poorly controlled medically and 3 were converted to another form of urinary reconstruction. In 18 of 20 cases voiding cystourethrography revealed no vesicoureteral reflux, and in 18 of 21 ultrasound documented stable or improved upper tracts. Socially acceptable urinary continence was attained in 19 of the 21 patients.

CONCLUSIONS

The use of stomach for bladder augmentation may be considered in patients with cloacal exstrophy and/or metabolic acidosis. Histamine blockers and/or proton pump inhibitors may be required to prevent the hematuria-dysuria syndrome. Symptoms of the hematuria-dysuria syndrome may be disabling and may mandate alternative forms of urinary tract reconstruction.

Cloacal exstrophy: a unified management plan

BACKGROUND/PURPOSE

The belief that patients with cloacal exstrophy have a short and therefore useless colon is all too common. Frequently, the colon is used for urinary or vaginal reconstruction, and the possibility of a pull-through is lost. In the authors' experience, the use of a unified management plan allowed most patients to undergo pull-through and avoid a permanent stoma.

METHODS

Twenty-five patients were treated for cloacal exstrophy in the authors' institution from 1985 through 1999. In all patients, bladder closure, omphalocele repair, and creation of a colostomy were performed at birth. All available colon, no matter how small, was incorporated into the fecal stream. After at least 1 year, patients were assessed for the ability to form solid stool through their stoma. Normal colonic length, capacity to form solid stool, or success with a bowel management regimen through the stoma were considered indications for pull-through. Genitourinary reconstruction was contingent on the colorectal plan.

RESULTS

Colonic length ranged from normal in 12 patients, 40 to 70 cm in 3 patients, 10 to 30 cm in 4 patients, and less than 10 cm in 2 patients. All 25 patients underwent pull-through. Three are totally continent, 4 are continent with occasional soiling, 11 remain clean with a bowel management regimen, and 4 are too young to assess. One patient was clean, but now refuses bowel management. Two early patients, both with less than 10 cm of colon, now have ileostomies.

CONCLUSIONS

During neonatal repair, a colostomy should be formed incorporating all pieces of colon, no matter how small. With time, most patients will be able to form solid stool, and a pull-through should be undertaken if that ability exists. Decisions regarding genitourinary reconstruction should be made only after the gastrointestinal plan is established to achieve the optimal use of available bowel.