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Ostertag-Hill CA, Delaplain PT, Lee T, Dickie BH. Updates on the Care of Cloacal Exstrophy. CHILDREN (BASEL, SWITZERLAND) 2024; 11:544. [PMID: 38790539 PMCID: PMC11120324 DOI: 10.3390/children11050544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
Cloacal exstrophy is the most severe congenital anomaly of the exstrophy-epispadias complex and is characterized by gastrointestinal, genitourinary, neurospinal, and musculoskeletal malformations. Individualized surgical reconstruction by a multidisciplinary team is required for these complex patients. Not infrequently, patients need staged surgical procedures throughout childhood and adolescence. Following significant improvements in medical care and surgical reconstructive techniques, nearly all patients with cloacal exstrophy now survive, leading to an increased emphasis on quality of life. Increased attention is given to gender identity and the implications of reconstructive decisions. Long-term sequelae of cloacal exstrophy, including functional continence and sexual dysfunction, are recognized, and many patients require ongoing complex care into adulthood.
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Affiliation(s)
- Claire A. Ostertag-Hill
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
| | - Patrick T. Delaplain
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
| | - Ted Lee
- Department of Urology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
| | - Belinda H. Dickie
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
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Fetal and Newborn Management of Cloacal Malformations. CHILDREN 2022; 9:children9060888. [PMID: 35740825 PMCID: PMC9221828 DOI: 10.3390/children9060888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022]
Abstract
Cloaca is a rare, complex malformation encompassing the genitourinary and anorectal tract of the female in which these tracts fail to separate in utero, resulting in a single perineal orifice. Prenatal sonography detects a few cases with findings such as renal and urinary tract malformations, intraluminal calcifications, dilated bowel, ambiguous genitalia, a cystic pelvic mass, or identification of other associated anomalies prompting further imaging. Multi-disciplinary collaboration between neonatology, pediatric surgery, urology, and gynecology is paramount to achieving safe outcomes. Perinatal evaluation and management may include treatment of cardiopulmonary and renal anomalies, administration of prophylactic antibiotics, ensuring egress of urine and evaluation of hydronephrosis, drainage of a hydrocolpos, and creation of a colostomy for stool diversion. Additional imaging of the spinal cord and sacrum are obtained to plan possible neurosurgical intervention as well as prognostication of future bladder and bowel control. Endoscopic evaluation and cloacagram, followed by primary reconstruction, are performed by a multidisciplinary team outside of the neonatal period. Long-term multidisciplinary follow-up is essential given the increased rates of renal disease, neuropathic bladder, tethered cord syndrome, and stooling issues. Patients and families will also require support through the functional and psychosocial changes in puberty, adolescence, and young adulthood.
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Bernardini LB, Dickie BH, Estroff JA. OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects. Neoreviews 2021; 22:e709-e718. [PMID: 34599071 DOI: 10.1542/neo.22-10-e709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Judy A Estroff
- Department of Radiology, Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA
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4
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Weiss DA, Oliver ER, Borer JG, Kryger JV, Roth EB, Groth TW, Shukla AR, Mitchell ME, Canning DA, Victoria T. Key anatomic findings on fetal ultrasound and MRI in the prenatal diagnosis of bladder and cloacal exstrophy. J Pediatr Urol 2020; 16:665-671. [PMID: 32773250 DOI: 10.1016/j.jpurol.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/12/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Prenatal determination of bladder exstrophy (BE) or cloacal exstrophy (CE), known also as the omphalocele-exstrophy-imperforate anus-spinal anomaly complex (OEIS), is challenging. Distinguishing between BE and CE is important because children with CE have many more challenges initially and during their lifetime. An accurate diagnosis is critical when counselling expectant parents. We hypothesized that there are key imaging features that can distinguish BE from CE, and that there are areas of diagnostic concordance and discordance between fetal ultrasound (fUS) and fetal MRI (fMRI) among these entities. MATERIALS AND METHODS We queried a single institutional IRB-approved registry of children with BE and CE to identify those with accessible fetal imaging from 2000 to 2018, and formal interpretations were collected. Two pediatric radiologists performed independent retrospective blinded review of the images. Criteria evaluated included: genitalia, kidneys, bowel appearance, presence of anal dimple, location of insertion of umbilical cord into the abdomen relative to the abdominal wall defect, umbilical vessels, bladder protuberance, presence of omphalocele, and spine/neural cord abnormalities. We evaluated concordance between radiologic interpretations and postnatal diagnosis, as well as between specific findings in the two diagnostic modalities. RESULTS Twenty-one infants born between 2000 and 2018 with BE or CE had fetal imaging for review: 15 had both fUS and fMRI, 2 had fUS alone, and 4 fMRI alone. There was 100% concordance between fUS and fMRI in evaluating kidneys, presence of anal dimple, location of abdominal insertion of umbilical cord relative to the defect, number of umbilical vessels, and spine abnormalities/level of neural cord termination. The following discrepancies were observed: 1) genitalia and bowel appearance, and bladder protuberance in 1/15 (6.7%); 2) presence of an omphalocele in 2/15 (13.3%). Of the initial radiologic interpretations, 4/17 (23.5%) of fUS and 2/19 (10.5%) of fMRI erroneously were interpreted as on the OEIS spectrum when the post-natal diagnosis was BE. Errors in diagnosis were due to a protuberant bladder plate extending beyond the plane of the abdominal wall with bowel loops posteriorly mimicking an omphalocele. In all of these BE cases, the abdominal wall defect was located inferior to the umbilical cord insertion on the abdominal wall. CONCLUSION An everting bladder plate with bowel loops posterior to the plate in classic BE may be misdiagnosed as CE. Identification of the location of umbilical cord insertion relative to the abdominal wall defect, with fetal US or MRI, results in the correct differentiation between BE and CE.
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Affiliation(s)
- Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - John V Kryger
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Elizabeth B Roth
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Travis W Groth
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Douglas A Canning
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Gondo K, Yokomine M, Yoshizato T, Furuta T, Ushijima K. Clues and pitfalls in prenatal diagnosis of classic cloacal exstrophy using ultrasonography and magnetic resonance imaging: A case with sequential observation from 17 to 30 weeks' gestation and literature review. J Obstet Gynaecol Res 2020; 46:1443-1449. [PMID: 32537902 DOI: 10.1111/jog.14310] [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: 01/20/2020] [Revised: 04/05/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
We observed a case of classic cloacal exstrophy (CE) from 17 to 30 weeks' gestation. At 17 weeks, an omphalocele and single umbilical artery (SUA) were diagnosed with a normal female karyotype on amniocentesis. A pelvic cystic adjacent to SUA, considered to be the bladder at 17 weeks, became swollen to form double cysts at 25 weeks. A phallus-like structure along the lower abdomen was additionally detected, leading to the diagnosis of CE. Fetal magnetic resonance imaging (MRI) at 30 weeks confirmed that the phallus-like structure was of intestinal origin. The presence of a non-visualizable bladder together with abdominal wall defect or omphalocele and an elephant trunk-like deformity are key findings in the prenatal diagnosis of classic CE. Fetal MRI was useful in confirming ultrasonographic findings and obtaining additional findings for the diagnosis of CE. We have discussed clues and potential pitfalls in diagnosing CE, with a review of the literature.
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Affiliation(s)
- Kanako Gondo
- Department of Obstetrics and Gynecology, School of Medicine, Kurume University, Kurume, Japan
| | - Masato Yokomine
- Department of Obstetrics and Gynecology, School of Medicine, Kurume University, Kurume, Japan
| | - Toshiyuki Yoshizato
- Department of Obstetrics and Gynecology, School of Medicine, Kurume University, Kurume, Japan
| | - Takuya Furuta
- Department of Pathology, School of Medicine, Kurume University, Kurume, Japan
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, School of Medicine, Kurume University, Kurume, Japan
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Gursoy Erzincan S, Sayin NC, Inan C, Uzun I, Yapici Ugurlar O, Varol FG. Fetal cloacal dysgenesis sequence presented with first trimester megacystis and associated umbilical cord abnormalities. J Obstet Gynaecol Res 2020; 46:527-530. [PMID: 31955475 DOI: 10.1111/jog.14204] [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: 06/18/2019] [Accepted: 12/31/2019] [Indexed: 11/30/2022]
Abstract
Cloacal dysgenesis sequence occurs as a result of complete developmental failure of the urorectal septum. Typically, the sequence is featured by a smooth perineum, without any urethral, genital or anal openings. Its clinical manifestation differs throughout gestation. We report an interesting case of first trimester megacystis with associated umbilical cord abnormalities in a female fetus having cloacal dysgenesis sequence. This rare association reflecting high urinary pressure should first suggest urethral atresia. Our case highlights the importance of routine inspection of umbilical cord in the workup of early megacystis in terms of both etiology and fetal diagnosis.
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Affiliation(s)
- Selen Gursoy Erzincan
- Faculty of Medicine, Department of Obstetrics & Gynecology, Division of Perinatology, Trakya University, Edirne, Turkey
| | - N Cenk Sayin
- Faculty of Medicine, Department of Obstetrics & Gynecology, Division of Perinatology, Trakya University, Edirne, Turkey
| | - Cihan Inan
- Faculty of Medicine, Department of Obstetrics & Gynecology, Division of Perinatology, Trakya University, Edirne, Turkey
| | - Isil Uzun
- Faculty of Medicine, Department of Obstetrics & Gynecology, Division of Perinatology, Trakya University, Edirne, Turkey
| | | | - Fusun G Varol
- Faculty of Medicine, Department of Obstetrics & Gynecology, Division of Perinatology, Trakya University, Edirne, Turkey
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Abstract
OBJECTIVE. The purpose of this article is to describe the imaging findings associated with complex fetal abdominal wall defects and provide an algorithmic method for arriving at a final diagnosis. CONCLUSION. Fetal ventral abdominal wall defects are a complex group of conditions with a broad spectrum of associated multisystem anomalies and manifestations. Correct characterization and classification of these defects require not only familiarity with imaging findings but also a systematic approach to avoid diagnostic confusion.
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Goncalves LF, Hill H, Bailey S. Prenatal and postnatal imaging techniques in the evaluation of disorders of sex development. Semin Pediatr Surg 2019; 28:150839. [PMID: 31668296 DOI: 10.1016/j.sempedsurg.2019.150839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Imaging of the reproductive tract is challenging and requires a general knowledge of congenital variations in anatomy. The anatomy of the developing fetus, whether a male phenotype or female phenotype, is also a dynamic process with many changes occurring during gestation. Families may ask details about the genitalia during prenatal imaging and when variations in what is thought to be normal are present, further investigation is sometimes needed to make sense of what is seen. This overview will describe categories of disorders of sex development (DSD), whether chromosomal or structural or both, and the current state of imaging of these anomalies.
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Affiliation(s)
- Luis F Goncalves
- Director of Fetal Imaging, Division of Pediatric Radiology, Phoenix Children's Hospital, Phoenix, AZ, United States.
| | - Halsey Hill
- St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Smita Bailey
- Division of Pediatric Radiology, Phoenix Children's Hospital, Phoenix, AZ, United States
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Coleman PW, Marine MB, Weida JN, Gray BW, Billmire DF, Brown BP. Fetal MRI in the Identification of a Fetal Ventral Wall Defect Spectrum. AJP Rep 2018; 8:e264-e276. [PMID: 30377551 PMCID: PMC6205859 DOI: 10.1055/s-0038-1675353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/17/2018] [Indexed: 02/06/2023] Open
Abstract
Objective To ascertain if useful criteria for prenatal diagnosis of fetal ventral body wall defects (VBWDs) exists by reviewing published literature on diagnosis of VBWD as compared with our own diagnostic experience. Study Design A comprehensive literature review of diagnostic criteria of fetal VBWD including pentalogy of Cantrell (POC), omphalocele, exstrophy, imperforate anus, spina bifida (OEIS), cloacal exstrophy, limb-body wall complex (LBWC), and body stalk anomaly was performed followed by a retrospective review of all fetal magnetic resonance imaging (MRI) examinations from our medical center over a 2-year period. Results Classically, OEIS is omphalocele, bladder exstrophy, imperforate anus, and spina bifida. POC is defects of the supraumbilical abdomen, sternum, diaphragm, pericardium, and heart. LBWC is two of the following: exencephaly or enencephaly with facial clefts, thoracoschisis or abdominoschisis, and limb defects. Twenty-four cases of VBWD on MRI over a 24-month period were identified with seven cases involving defects of additional organ systems. Six of these seven cases demonstrated findings from two or more of the traditional diagnoses POC, OEIS, and LBWC making diagnosis and counseling difficult. Conclusion There is a lack of consensus on useful diagnostic criteria within the published literature which is reflected in our own diagnostic experience and poses a challenge for accurate prenatal counseling.
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Affiliation(s)
- Peter W Coleman
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Megan B Marine
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jennifer N Weida
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Deborah F Billmire
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brandon P Brown
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
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10
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Abstract
OEIS complex describes a combination of birth defects, including omphalocele, extrophy of the bladder, imperforate anus, and spinal defects. OEIS complex involves abnormalities of almost every body system and shows variability from case to case. The etiology of OEIS complex is thought to be multifactorial. The prenatal diagnosis of OEIS complex is difficult; however, the diagnosis of OEIS mainly relies on sonographic findings. The major sonographic findings include nonvisualization of the bladder, persistent cloaca, omphalocele, and myelomeningocele. Significantly increased maternal serum alphafetoprotein is also reported. Surgical intervention has improved the survival of patients born with OEIS complex; however, the success of these procedures cannot guarantee a good quality of life. The survivors may suffer with long-term psychosexual developmental difficulties.
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Affiliation(s)
- Feixue Yang
- Florida Hospital College of Health Sciences, Orlando, FL
| | - Charlotte Henningsen
- Maternal Fetal Center, Winter Park, FL; Florida Hospital College of Health Sciences, Sonography Department, 800 Lake Estelle Drive, Orlando, FL 32803
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11
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Modern management of the exstrophy-epispadias complex. Surg Res Pract 2014; 2014:587064. [PMID: 25374956 PMCID: PMC4208497 DOI: 10.1155/2014/587064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/28/2013] [Accepted: 12/09/2013] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications.
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12
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[Fetal magnetic resonance imaging of thoracic and abdominal malformations]. Radiologe 2013; 53:123-9. [PMID: 23354851 DOI: 10.1007/s00117-012-2400-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CLINICAL/METHODICAL ISSUE Diagnosis and differential diagnosis of fetal thoracic and abdominal malformations. STANDARD RADIOLOGICAL METHODS Ultrasound and magnetic resonance imaging (MRI). METHODICAL INNOVATIONS In cases of suspected pathologies based on fetal ultrasound MRI can be used for more detailed examinations and can be of assistance in the differential diagnostic process. PERFORMANCE Improved imaging of anatomical structures and of the composition of different tissues by the use of different MRI sequences. ACHIEVEMENTS Fetal MRI has become a part of clinical routine in thoracic and abdominal malformations and is the basis for scientific research in this field. PRACTICAL RECOMMENDATIONS In cases of thoracic or abdominal malformations fetal MRI provides important information additional to ultrasound to improve diagnostic accuracy, prognostic evaluation and surgical planning.
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Abstract
BACKGROUND Prenatal ultrasonographic (US) diagnosis of cloacal exstrophy (CE) is challenging. OBJECTIVE To define the fetal MRI findings in CE. MATERIALS AND METHODS We performed a retrospective review of eight patients with CE. Imaging was performed between 22 weeks and 36 weeks of gestation with US in four and MRI in eight fetuses. Abdominal wall, gastrointestinal/genitourinary, and spine and limb abnormalities detected were compared with postnatal evaluation. RESULTS US failed to display CE in one of the four fetuses. Fetal MRI confirmed CE in all eight fetuses by demonstrating absence of a normal bladder and lack of meconium-filled rectum/colon, associated with protuberant pelvic contour and omphalocele. These findings correlated postnatally with CE, atretic hindgut and omphalocele. One fetus had imaging before rupture of the cloacal membrane, showing a protruding pelvic cyst. Absent bladder was noted in the remaining seven fetuses. Confirmed skin-covered spinal defects were noted in seven fetuses, low conus/tethered cord in one and clubfoot in three. Six fetuses had renal anomalies, two had hydrocolpos and one had ambiguous genitalia. CONCLUSION Fetal MRI provides a confident diagnosis of CE when a normal bladder is not identified, there is a protuberant abdominopelvic contour and there is absence of meconium-filled rectum and colon. Genitourinary and spinal malformations are common associations.
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Affiliation(s)
- Maria A Calvo-Garcia
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH 45229-3039, USA.
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14
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Goto S, Suzumori N, Obayashi S, Mizutani E, Hayashi Y, Sugiura-Ogasawara M. Prenatal findings of omphalocele-exstrophy of the bladder-imperforate anus-spinal defects (OEIS) complex. Congenit Anom (Kyoto) 2012; 52:179-81. [PMID: 22925220 DOI: 10.1111/j.1741-4520.2011.00342.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Omphalocele-exstrophy of the bladder (cloaca)-imperforate anus-spinal defects (OEIS) complex describes a rare grouping of more commonly occurring component malformations. We report two cases of OEIS complex diagnosed prenatally by ultrasound and magnetic resonance imaging (MRI). In both cases, OEIS complex was suspected by conventional sonography in the second trimester, and fetal MRI was performed at 27 and 32 weeks of gestation. Conventional sonography revealed low abdominal wall mass, spina bifida, absent bladder and ambiguous genitalia, but those findings were inconclusive. Using fetal MRI, we were able to detect omphalocele, imfraumbilical mass connected to gut tract, absent bladder, ambiguous external genitalia and spinal defect. Our findings suggest that fetal MRI is a useful tool for prenatal diagnosis of OEIS complex. MRI helps prenatal counseling and planning of postnatal early treatment strategy.
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Affiliation(s)
- Shinobu Goto
- Department of Obstetrics and Gynecology Division of Clinical and Molecular Genetics, Nagoya City University Graduate School of Medicine, Nagoya, Japan
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15
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Abstract
INTRODUCTION With the advance of prenatal imaging, more often pediatric surgeons are called for prenatal counseling in suspected cases of cloaca or cloacal exstrophy. This presents new challenges for pediatric surgeons since no specific guidelines have been established so far. The purpose of this review is to analyze our experience in prenatally diagnosed cloaca or cloacal exstrophy and to provide some guidelines for prenatal counseling of these complex congenital anomalies. METHODS A retrospective review of the medical charts of patients with prenatally diagnosed cloaca and cloacal exstrophy who received postnatal care in our institution between July 2005 and March 2012 was performed. Representative images of prenatal studies were selected from 13 cases to illustrate different scenarios and the recommendations given. In addition, a review of the literature was performed to support our advice to parents. RESULTS Eleven patients were female and two patients were male. The postnatal diagnoses were cloacal exstrophy (6), cloaca (5), posterior cloaca variant (1), and covered cloacal exstrophy (1). The selected abnormal prenatal imaging findings in these 13 patients included hydronephrosis (12), neural tube defect (8), omphalocele (7), lack of meconium at expected rectal location (7), vertebral anomaly (7), non-visualize bladder (5), distended bladder (5), hydrocolpos (4), dilated or echogenic bowel (3), umbilical cord cyst (3), separated pubic bones (2), and the "elephant trunk" sign (2). The prenatal diagnosis was correct in 10 cases, partially correct in two cases, and it was missed in one case. All parents received prenatal counseling depending on the specific diagnosis. CONCLUSION The continuous technologic innovations in prenatal imaging make it possible to prenatally diagnose more complex anomalies including cloaca and cloacal exstrophy with increased levels of confidence and enhance the benefit of prenatal counseling. Together, these allow the parents to be better prepared for the condition and the care team to provide the best possible initial management in order to improve the outcomes of these challenging patients.
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16
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Yamano T, Ando K, Ishikura R, Hirota S. Serial fetal magnetic resonance imaging of cloacal exstrophy. Jpn J Radiol 2011; 29:656-9. [DOI: 10.1007/s11604-011-0600-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 04/12/2011] [Indexed: 11/27/2022]
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Abstract
Cloacal exstrophy, one of the most severe congenital anomalies compatible with life, occurs in up to 1 in 200,000 lives births. The condition affects nearly every major organ system with severe neurologic, skeletal, gastrointestinal, and genitourinary ramifications. With increased understanding of the anatomy and embryology combined with refinements in prenatal diagnosis and postnatal care, there is now near-universal survival of patients with cloacal exstrophy. Functional and cosmetic outcomes have improved with modifications in surgical technique. However, debate continues regarding the issue of gender identity, and long-term data are still accruing with respect to the best strategy for management. Despite the extensive malformations noted, many patients have gone on to live fruitful lives.
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Affiliation(s)
- Timothy M Phillips
- Department of Urology, Pediatric Urology, Wilford Hall Medical Center, Lackland AFB, TX 78236, USA.
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18
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Woo LL, Thomas JC, Brock JW. Cloacal exstrophy: a comprehensive review of an uncommon problem. J Pediatr Urol 2010; 6:102-11. [PMID: 19854104 DOI: 10.1016/j.jpurol.2009.09.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 09/04/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To provide a comprehensive overview of the clinical features, diagnosis, current management strategies, and outcomes of cloacal exstrophy. METHODS A PUBMED/Medline search of the literature was performed on cloacal exstrophy focusing on associated anomalies, treatment, and quality of life issues. RESULTS The incidence of cloacal exstrophy is between 1 in 200,000 and 400,000 live births. Survival rates now approach 100% secondary to improved understanding of underlying abnormalities and advances in neonatal care and surgical technique. Important principles of initial management include proper nutritional support, early closure of exstrophy, and preservation of intestinal length. The achievement of urinary and fecal continence remains a challenge. Data for long-term outcomes are now emerging which provide new insight into issues of gender identity, function, and psychosocial development of these patients. CONCLUSION Cloacal exstrophy remains a rare and complex congenital anomaly, characterized by an array of anatomical defects affecting multiple organ systems. A multidisciplinary approach to management is advocated with a focus on optimization of patient function and quality of life.
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Affiliation(s)
- Lynn L Woo
- Division of Pediatric Urology, Monroe Carell Jr. Vanderbilt Children's Hospital, Nashville, TN 37232, USA.
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Tiblad E, Wilson RD, Carr M, Flake AW, Hedrick H, Johnson MP, Bebbington MW, Mann S, Adzick NS. OEIS sequence—a rare congenital anomaly with prenatal evaluation and postnatal outcome in six cases. Prenat Diagn 2008; 28:141-7. [DOI: 10.1002/pd.1940] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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20
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Abstract
Cloacal exstrophy is a complex congenital anomaly that affects both the gastrointestinal and genitourinary systems. It is characterized by an omphalocele, an exstrophied bladder, abnormal genitalia, and imperforate anus. Prior to 1960, there were no reported cases of survival, but because of advancements in neonatology, surgery, and anesthesiology, the survival rate has improved drastically. This case presentation of an infant born with cloacal exstrophy includes discussion of etiology, diagnosis, treatment, ethical issues, and nursing care.
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MESH Headings
- Abnormalities, Multiple/diagnosis
- Abnormalities, Multiple/etiology
- Abnormalities, Multiple/therapy
- Anus, Imperforate/diagnosis
- Anus, Imperforate/etiology
- Anus, Imperforate/therapy
- Bladder Exstrophy/diagnosis
- Bladder Exstrophy/etiology
- Bladder Exstrophy/therapy
- Cloaca/abnormalities
- Cloaca/embryology
- Clubfoot/diagnosis
- Clubfoot/etiology
- Clubfoot/therapy
- Hernia, Umbilical/diagnosis
- Hernia, Umbilical/etiology
- Hernia, Umbilical/therapy
- Humans
- Infant, Newborn
- Information Services
- Intensive Care, Neonatal
- Internet
- Male
- Meningomyelocele/diagnosis
- Meningomyelocele/etiology
- Meningomyelocele/therapy
- Neonatal Nursing
- Nurse's Role
- Parents/education
- Parents/psychology
- Penis/abnormalities
- Perioperative Care
- Prenatal Diagnosis
- Quality of Life
- Rare Diseases
- Social Support
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Keppler-Noreuil K, Gorton S, Foo F, Yankowitz J, Keegan C. Prenatal ascertainment of OEIS complex/cloacal exstrophy—15 new cases and literature review. Am J Med Genet A 2007; 143A:2122-8. [PMID: 17702047 DOI: 10.1002/ajmg.a.31897] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Omphalocele-exstrophy of the bladder-imperforate anus-spinal defects (OEIS) complex or cloacal exstrophy (EC), describes a rare grouping of more commonly occurring component malformations [Carey et al., 1978]. The etiology is unknown, but likely heterogeneous. While postnatal identification of its associated gastrointestinal, spinal, and genitourinary systems delineates the extent and natural history of OEIS complex, prenatal findings may provide additional information regarding early detection, possible causative factors, and outcome. The purposes of this study were to: (1) present the prenatal ascertainment of OEIS complex in this series of 15 cases identified through several different sources compared to the literature, and (2) discuss the relationship of these prenatal findings to possible abnormal developmental mechanisms causing OEIS complex. These 15 cases indicate that OEIS complex may be difficult to diagnose prenatally, and that the full extent of abnormalities may not be clear until postnatal exam. Confusion with limb-body wall complex (two of our cases) and pentalogy of Cantrell (one of our cases) can occur. Anal/gastrointestinal malformations and genital ambiguity are under-ascertained. Conversely, prenatal defects may resolve postnatally, yet may provide clues for pathogenetic mechanisms. For instance, the finding of nuchal thickening in our three cases (one reported) suggests vascular/hemodynamic compromise early in embryologic development, or intrathoracic compression leading to jugular lymphatic obstruction may play a role. The association of twinning and OEIS complex suggests they may occur as early as blastogenesis. Our three sets of discordant twins also suggest a non-genetic etiology for OEIS complex of uteroplacental insufficiency. This study also indicates that OEIS complex may be more common than previously thought.
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Affiliation(s)
- Kim Keppler-Noreuil
- Division of Medical Genetics, Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa 52242, USA.
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Abstract
Cloacal exstrophy is an extremely rare and devastating complex of congenital abnormalities resulting in multiple debilitating morbidities. Infants with this disorder require numerous surgical interventions to repair gastrointestinal, genitourinary, spinal, and orthopedic malformations. Treatment involves the combined efforts of many medical and nursing specialists. This article discusses the embryology, clinical presentation, and management (both early and long term) of cloacal exstrophy, with emphasis on gender reassignment issues and quality of life.
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MESH Headings
- Abnormalities, Multiple/diagnosis
- Abnormalities, Multiple/embryology
- Abnormalities, Multiple/psychology
- Abnormalities, Multiple/surgery
- Age Factors
- Anus, Imperforate/diagnosis
- Anus, Imperforate/embryology
- Anus, Imperforate/psychology
- Anus, Imperforate/surgery
- Bladder Exstrophy/diagnosis
- Bladder Exstrophy/embryology
- Bladder Exstrophy/psychology
- Bladder Exstrophy/surgery
- Body Image
- Cloaca/abnormalities
- Colostomy
- Delivery, Obstetric
- Humans
- Neonatal Nursing/methods
- Nurse's Role
- Nursing Assessment
- Osteotomy
- Parenteral Nutrition, Total
- Parents/education
- Parents/psychology
- Patient Care Planning
- Perioperative Care/methods
- Perioperative Care/nursing
- Psychology, Child
- Quality of Life
- Rare Diseases
- Traction
- Ultrasonography, Prenatal
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Affiliation(s)
- Susanne Jane Hyun
- Children's and Women's Health Center of British Columbia, Vancouver, Canada.
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Della Monica M, Nazzaro A, Lonardo F, Ferrara G, Di Blasi A, Scarano G. Prenatal ultrasound diagnosis of cloacal exstrophy associated with myelocystocele complex by the ‘elephant trunk-like’ image and review of the literature. Prenat Diagn 2005; 25:394-7. [PMID: 15909284 DOI: 10.1002/pd.1146] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A case of cloacal exstrophy (CE) was detected by ultrasound as early as 22 weeks of gestation in association with myelocystocele complex, an unusual form of occult spinal dysraphism often associated with such a disease. The ultrasonographic diagnosis was made through the detection of a wavy cord-like segment of soft tissue protruding from the anterior abdominal wall, just below the umbilical cord insertion, strongly resembling the trunk of an elephant. Our article enforces the suggestion that the ultrasound elephant trunk-like image should be added to the existing major criteria for making prenatal diagnosis of CE.
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Witters I, Deprest J, Van Hole C, Hanssens M, Devlieger H, Fryns JP. Anogenital malformation with ambiguous genitalia as part of the OEIS complex. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 24:797-798. [PMID: 15543545 DOI: 10.1002/uog.1776] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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Abstract
We present here a patient with exstrophy of the cloaca associated with severe lower limb defects. The limb malformations include, on the right, a split foot with distal separation of the tibia and fibula, and on the left, attachment of the lower half of the left leg with a two-toed foot at nearly a right angle to the mid left thigh. A review of the literature indicates that 17-26% of patients with cloacal exstrophy also have lower limb defects. We hypothesize that cloacal exstrophy and associated lower limb defects have a related pathogenesis and that both are related to deficiencies of caudal mesoderm or mesodermal differentiation signals. More cases of exstrophy of the cloaca with limb defects need to be reported to better characterize the limb anomalies and to more precisely determine their frequency.
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Affiliation(s)
- Mahim Jain
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana 46202-5251, USA
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