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Harris KT, Kong L, Vargas M, Hou V, Pyrzanowski JL, Desanto K, Wilcox DT, Wood D. Considerations and Outcomes for Adolescents and Young Adults With Cloacal Anomalies: A Scoping Review of Urologic, Colorectal, Gynecologic and Psychosocial Concerns. Urology 2024; 183:264-273. [PMID: 37839472 DOI: 10.1016/j.urology.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/07/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023]
Abstract
The objective of this scoping review is to provide a summary of the current literature regarding adolescents and young adults with histories of cloacal anomalies. Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews were used. Data were categorized into four domains-urologic, colorectal, gynecologic/obstetric, and sexual/psychosocial. The current literature has poor study quality and mostly consists of retrospective studies of small cohorts with varying definitions of outcomes. Women with cloacal anomalies are at high risk for urologic dysfunction but can maintain kidney health and achieve social continence with medical and surgical management. Sexual function and adult healthcare transition are areas ripe for improved future research.
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Affiliation(s)
- Kelly T Harris
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO.
| | - Lily Kong
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Maria Vargas
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Vincent Hou
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Jennifer L Pyrzanowski
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Kristen Desanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Duncan T Wilcox
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Dan Wood
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
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Reppucci ML, Alaniz VI, Wehrli LA, Torre LDL, Wood D, Wilcox DT, Appiah LC, Peña A, Bischoff A. Reproductive and Family Building Considerations for Female Patients with Anorectal And Urogenital Malformations. J Pediatr Surg 2023; 58:1450-1457. [PMID: 36229236 DOI: 10.1016/j.jpedsurg.2022.09.004] [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: 06/15/2022] [Revised: 09/04/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about fertility and pregnancy outcomes in patients with anorectal malformations (ARM), particularly those with long common channel cloaca and cloacal exstrophy who may have impaired fertility. The purpose of this study is to describe pregnancy and offspring data from a cohort of patients with ARM. METHODS A retrospective review of female patients with ARM from our database, which includes patients operated on since 1980, was performed as well as a review of the literature. Demographic, operative, and self-reported fertility, obstetric, and offspring data were collected. RESULTS There were 37 females identified in our database who reported any pregnancy or having children. There were 59 pregnancies, 48 (81.3%) of which resulted in live birth. The most common mode of delivery was cesarean delivery. There were five patients with long channel cloaca (>3 cm) and one with cloacal exstrophy that reported 11 total pregnancies, eight of which resulted in live birth. Four cloaca patients in which the native vagina was pulled through were able to conceive spontaneously. Three patients with cloacal anomalies required in vitro fertilization to conceive; one was unsuccessful. No patients who underwent bowel partial vaginal replacement became pregnant. Women with ARM face many unique challenges in assisted reproduction, pregnancy, and delivery owing to their anatomy and associated anomalies. CONCLUSIONS Women with recto-perineal, recto-vestibular, and cloacas in which the native vagina was pulled through are capable of spontaneous pregnancy. Assisted reproduction, however, may be needed those with more complex anomalies and surgical repairs. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marina L Reppucci
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Veronica I Alaniz
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Lea A Wehrli
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Luis de La Torre
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Dan Wood
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Duncan T Wilcox
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Leslie C Appiah
- Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Alberto Peña
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA.
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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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Vilanova-Sanchez A, McCracken K, Halleran DR, Wood RJ, Reck-Burneo CA, Levitt MA, Hewitt G. Obstetrical Outcomes in Adult Patients Born with Complex Anorectal Malformations and Cloacal Anomalies: A Literature Review. J Pediatr Adolesc Gynecol 2019; 32:7-14. [PMID: 30367985 DOI: 10.1016/j.jpag.2018.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/22/2022]
Abstract
Patients born with complex anorectal malformations often have associated Müllerian anomalies, which might affect fertility and obstetrical outcomes. Other vertebral-anorectal-tracheoesophageal-renal-limb associations, such as renal or cardiac anomalies, could also affect pregnancy intention, fertility rates, and recommendations about mode of delivery or obstetrical outcomes. Associated conditions present at birth, like hydrocolpos, could also potentially affect fertility. Depending on the complexity of the anomaly, primary reconstruction might include vaginoplasty, vaginal interposition, perineal body reconstruction, and extensive pelvic dissection. After the initial reconstruction, patients might have multiple additional surgeries for stoma reversal, bladder augmentation, and creation of conduits, all with potential for pelvic adhesions. Pregnancy intention, fertility rates, mode of delivery, and obstetrical outcomes data are limited in this patient population, making it challenging to counsel patients and their families. We sought to evaluate all available literature in an attempt to better counsel families. A PubMed literature search was undertaken to review this topic. Search terms of "cloaca," "anorectal malformation," "pregnancy," "cloacal exstrophy," "vaginal delivery," and "cesarean section" were used and citation lists from all identified articles were checked to ensure that all possible articles were included in the review. We also outline comorbidities from the fetal period to adulthood that might affect reproductive health. Of the articles on anorectal and cloacal anomalies, 13 reports were identified that covered obstetrical outcomes. They were in patients with previous anorectal malformation, cloaca, and cloacal exstrophy repair. Twenty-four pregnancies were reported in 16 patients. Two ectopic pregnancies, 5 spontaneous miscarriages, 1 triplet pregnancy, and 16 singleton pregnancies were reported with a total of 19 live births. Regarding the method of conception, 15/18 pregnancies occurred spontaneously and 3/18 were via assisted reproductive technology with in vitro fertilization. There were 19 live births, of which at least 8 were preterm. Müllerian anatomy was reported in 8 of 13 articles. Only 2 patients underwent vaginal delivery (1 patient with repaired cloaca malformation had an operative vaginal delivery and 1 patient with repaired imperforate anus with rectovaginal fistula had a normal spontaneous vaginal delivery). The remaining patients all underwent a cesarean section. There were no reported cases of maternal mortality, and maternal morbidity was limited to recurrent urinary tract infections and worsening chronic kidney disease. There is a paucity of information regarding obstetrical outcomes in adult anorectal and cloaca patients. However, patients with previous cloacal repairs have achieved pregnancy spontaneously, as well as with in vitro fertilization. Patients with repaired cloacal malformations are at increased risk of preterm birth and cesarean delivery. Most patients with cloacal anomalies have an associated Müllerian anomaly and therefore have an increased risk of preterm labor. From our review we conclude that contraception should be offered to patients not desiring pregnancy, and cesarean section is likely the preferred mode of delivery. On the basis of this review, we recommend proactive data collection of all such patients to document outcomes and collaboration among providers and between centers devoted to this complex patient population.
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Affiliation(s)
| | | | | | | | | | | | - Geri Hewitt
- Nationwide Children's Hospital, Columbus, Ohio
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Abstract
Children with anorectal malformations (ARM) constitute a significant group within a pediatric surgery practice. It is important with female cases of anorectal malformations to consider the association of gynecologic anomalies, especially at the time of the definitive repair. However, it is critical to consider the association of such gynecologic anomalies when caring for patients with a cloacal anomaly. If not recognized, an opportunity to diagnose and treat such anomalies may be missed with the possibility of negative implications for future reproductive capacity. With the knowledge of the associated anomalies and long-term sequelae, surgeons can provide better care for girls and important counseling for parents. Knowledge of reproductive related issues in females with cloaca allows the pediatric surgeon an opportunity both, to provide optimal surgical management in infancy, childhood, and into young adulthood and to collaborate medically and surgically with an experienced gynecologist in patients with more complex anatomic variations. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.
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Affiliation(s)
- Lesley Breech
- University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 2026, Cincinnati, Ohio 45229.
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The Great Divide: Understanding Cloacal Septation, Malformation, and Implications for Surgeons. Pediatr Surg Int 2014; 30:1089-95. [PMID: 25217828 PMCID: PMC4302733 DOI: 10.1007/s00383-014-3593-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2014] [Indexed: 12/28/2022]
Abstract
The anorectal and urogenital systems arise from a common embryonic structure termed cloaca. Subsequent development leads to the division/septation of the cloaca into the urethra, urinary bladder, vagina, anal canal, and rectum. Defective cloacal development and the resulting anorectal and urogenital malformations are some of the most severe congenital anomalies encountered in children. In the most severe form in females, the rectum, vagina, and urethra fail to develop separately and drain via a single common channel known as a cloaca into the perineum. In this review, we summarize our current knowledge of embryonic cloaca development and malformation, and compare them to what has already been described in the literature. We describe the use of mouse models of cloaca malformation to understand which signaling pathways and cellular mechanisms are involved in the process of normal cloaca development. We also discuss the embryological correlation of the epithelial and stromal histology found in step sections of the common channel in 14 human cloaca malformations. Finally, we highlight the significance of these findings, compare them to prior studies, and discuss their implications for the pediatric surgeons. Understanding and identifying the molecular basis for cloaca malformation could provide foundation for tissue engineering efforts that in the future would reflect better surgical reconstruction and improved quality of life for patients.
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