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Oyania F, Eze N, Aturinde M, Ullrich S, Mwesigwa M, Ozgediz DE. Identification of urological anomalies associated with anorectal malformation in southwestern Uganda: Limitations and opportunities. J Pediatr Urol 2024:S1477-5131(24)00420-0. [PMID: 39147608 DOI: 10.1016/j.jpurol.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/22/2024] [Accepted: 07/29/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION Anorectal malformations (ARMs) may be associated with congenital anomalies affecting other body parts namely vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb (VACTERL) with varying incidences of 7%-60% . Genitourinary defects might occur approximately in 50% of all patients with anorectal malformations hence patients should be evaluated from birth to rule out these defects. OBJECTIVE To identify urological anomalies associated with anorectal malformation in southwestern Uganda. STUDY DESIGN This was a descriptive retrospective cohort study conducted at our regional referral hospital in Southwestern Uganda involving patients who have undergone surgical correction of ARMs between June 2021 and July 2023. RESULTS The overall prevalence of renal anomalies in our study patient population was 18.05%. Of those with ARM-associated renal anomalies, Specific anomalies included; renal agenesis (6.8%), hydronephrosis, (4.5%), duplex collecting system (3.8%), crossed fused kidney (1.5%), and ectopic kidney (0.75%). (Table) DISCUSSION: We found that the prevalence of ARM-associated renal anomalies was 18.05%, and the commonest anomaly was unilateral agenesis (6.8%) similar to other studies. Previous data have shown renal anomalies are common anomalies in ARM. While the exact values vary across studies, they all concluded that the rate of associated anomalies is extremely high in ARMs and warrants a thorough preoperative investigation once the ARMs are detected. This finding therefore underscores the importance of thorough evaluation and a multidisciplinary approach of care and follow-up system for ARM management including urologists even when the children are asymptomatic now. The main limitation of our study was missing information on patients' charts, we were not able to get the diagnosis since most patients didn't have their discharge forms at the time of evaluation. CONCLUSION ARM associated with renal anomalies may remain undiagnosed and asymptomatic. Those identified as asymptomatic need to be followed in a multidisciplinary fashion including pediatric urologists.
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Affiliation(s)
- Felix Oyania
- Mbarara University of Science and Technology, Uganda.
| | | | | | - Sarah Ullrich
- Cincinnati Children's Hospital Medical Center, Uganda.
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Combs AJ. Commentary to does sacral ratio have any impact on success rate of biofeedback therapy in children with lower urinary tract dysfunction? J Pediatr Urol 2024; 20:596-597. [PMID: 38945788 DOI: 10.1016/j.jpurol.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 07/02/2024]
Affiliation(s)
- Andrew J Combs
- Division of Pediatric Urology, Children's National Medical Center, Washington D.C., USA.
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Zahir M, Sharifi-Rad L, Ladi-Seyedian SS, Kajbafzadeh AM. Does sacral ratio have any impact on success rate of biofeedback therapy in children with lower urinary tract dysfunction? J Pediatr Urol 2024; 20:589-595. [PMID: 38604908 DOI: 10.1016/j.jpurol.2024.03.025] [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: 08/09/2023] [Revised: 02/18/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION To evaluate the possible impact of patients' sacral ratios (SRs) on response to biofeedback (BF) therapy in pediatric patients with lower urinary tract dysfunction (LUTD). MATERIALS AND METHODS In this retrospective cohort conducted from 2016 to 2018 in our tertiary medical center, we included the medical records of all pediatric patients with LUTD who were nominated for BF due to having abnormal uroflowmetry patterns and simultaneous increase in electromyography (EMG) activity. Ten sessions of weekly animated BF were performed for each patient. All patients underwent a complete urological evaluation, uroflowmetry with simultaneous EMG and post-void residual measurement before and after treatment. SRs were calculated based on plain anteroposterior lumbosacral radiographs. Patients were then divided into normal SR (≥0.74) and low SR (<0.74) and outcomes were compared between them. RESULTS Of the total 86 patients included in our study, 48 (55.8%) had a normal SR (≥0.74), while 38 (44.2%) had a low SR (<0.74). Our data revealed that BF therapy significantly improved maximum and average urinary flow rates, urine volume, daytime urinary incontinence, enuresis, urinary urgency and constipation; irrespective of the patients' SRs (all P < 0.001). Our between-groups analyses showed that after the completion of BF, the SR ≥ 0.74 group had significantly higher maximum urinary flow rate (mean difference [95%CI]: 7.7 [5.4, 10.0], P < 0.001) (Figure) and urine volume (mean difference [95%CI]: 49.9 [19.5, 80.4], P = 0.002) and significantly lower diurnal urinary incontinence (4.2% vs. 21.1%, P = 0.020), enuresis (4.2% vs. 18.4%, P = 0.040) and constipation (2.1% vs. 23.7%, P = 0.004) compared to the SR < 0.74 group. DISCUSSION SR has been proposed as a reliable indicator of bony pelvis growth and subsequent lumbosacral neurodevelopment. Additionally, larger SR values are associated with better postoperative sphincter function in children with urological and anorectal malformations. Our results demonstrated that after completion of BF, the normal SR group had a significantly better improvement of some of the uroflowmetry indicators and LUTD-associated symptoms compared to the low SR group. CONCLUSION Our findings implied that although BF therapy is an efficient treatment for children with LUTD, irrespective of their sacral development; children with enhanced sacral development may benefit from better clinical response, especially in terms of LUTD-associated symptoms.
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Affiliation(s)
- Mazyar Zahir
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Lida Sharifi-Rad
- Department of Physical Therapy, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh-Sanam Ladi-Seyedian
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran.
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van der Steeg HJJ, van Rooij IALM, Iacobelli BD, Sloots CEJ, Morandi A, Broens PMA, Makedonsky I, Leon FF, Schmiedeke E, Vázquez AG, Miserez M, Lisi G, Midrio P, Amerstorfer EE, Fanjul M, Ludwiczek J, Stenström P, van der Steeg AFW, de Blaauw I. Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study. J Pediatr Surg 2022; 57:89-96. [PMID: 35317943 DOI: 10.1016/j.jpedsurg.2022.02.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome. METHODS A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome. RESULTS The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management. CONCLUSIONS Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hendrik J J van der Steeg
- Department of Surgery-Pediatric Surgery, Amalia Children's Hospital, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, Nijmegen 6500 HB, the Netherland.
| | - Iris A L M van Rooij
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud UMC, Nijmegen, the Netherland
| | - Barbara D Iacobelli
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Bambino Gesù Children's Hospital-Research Institute, Rome, Italy
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, the Netherland
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paul M A Broens
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, Groningen, the Netherland
| | - Igor Makedonsky
- Department of Pediatric Surgery, Children's Hospital Dnepropetrovsk, Dnepropetrovsk, Ukraine
| | | | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Urology, Center for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | | | - Marc Miserez
- Department of Abdominal Surgery, UZ Leuven, KU Leuven, Belgium
| | - Gabriele Lisi
- Department of Pediatric Surgery, University "Gabriele d'Annunzio " of Chieti-Pescara - "Santo Spirito" Hospital, Pescara, Italy
| | - Paola Midrio
- Department of Pediatric Surgery, Ca' Foncello Hospital, Treviso, Italy
| | - Eva E Amerstorfer
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Austria
| | - Maria Fanjul
- Department of Pediatric Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - Johanna Ludwiczek
- Department of Pediatric Surgery, Kepler Universitätsklinikum GmbH, Linz, Austria
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Alida F W van der Steeg
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherland; Department of Pediatric Surgery, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherland
| | - Ivo de Blaauw
- Department of Surgery-Pediatric Surgery, Amalia Children's Hospital, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, Nijmegen 6500 HB, the Netherland
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Perlman S, Shwartz I, Hazan Y, Weissbach A, Gilboa Y, Kravarusic D, Samuk I. Fetal Sacral Ratio: A Novel Method for Prenatal Sonographic Assessment of Sacral Abnormalities. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2005-2010. [PMID: 34792823 DOI: 10.1002/jum.15882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/25/2021] [Accepted: 10/30/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The sacral ratio (SR) was described as a postnatal X-ray-based method to detect sacral abnormalities and predict functional prognosis for fecal continence in children with anorectal malformations (ARMs). The present study aimed to describe a novel method of assessing sonographic fetal sacral ratio (f-SR) in a normal population of fetuses. METHODS Sixty three-dimensional (3D) ultrasound reconstruction images of the sacrum obtained from routine low-risk scans performed between 21 and 26 weeks of gestation served for measurement. The f-SR was calculated in a coronal view as the ratio between lines drawn at the upper and lower levels of the iliac bone and the 5th sacral vertebra. Bland-Altman plots assessed the inter- and intrareader variabilities of measurements. RESULTS The f-SR in the normal population of fetuses was 0.913 (±0.094). During the study period, three cases with ARM were examined and had a mean f-SR of 0.55. There was good repeatability of measurements and between readers' agreement. CONCLUSIONS The present study introduces a novel prenatal sonographic f-SR that can be reliably calculated on prenatal 3D ultrasound with good reliability and reproducibility. Future research will identify the clinical significance of f-SR abnormalities in ARM and their long-term impact on continence.
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Affiliation(s)
- Sharon Perlman
- Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itai Shwartz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yenon Hazan
- Ultrasound Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
- The Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Avichai Weissbach
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yinon Gilboa
- Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dragan Kravarusic
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Inbal Samuk
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Colorectal Service, Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Bahadir K, Arikan-Ergun B, Elhan AH, Ergun E, Aktug T. Development of Sacral Ratio Percentile Card for Children: A Preliminary Report. Eur J Pediatr Surg 2022; 32:67-72. [PMID: 34847576 DOI: 10.1055/s-0041-1739424] [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: 10/19/2022]
Abstract
INTRODUCTION Sacrospinal anomalies that may accompany anorectal malformations may cause fecal and urinary incontinence despite proper anomaly treatment. The sacral ratio has been suggested in the determination of both the prognosis in terms of incontinence and the need for further examination for sacrospinal anomalies. The normal and clinically decisive values of sacral ratio are given differently in publications. We aimed to determine the distribution of the sacral ratio in children under 12 months and to develop the sacral ratio percentile card that will enable one to give an age-independent parametric result in clinical evaluations. MATERIALS AND METHODS The files of patients under 1 year of age who had anteroposterior direct radiography including pelvis were reviewed retrospectively. Sacral ratio was studied for 360 patients, 30 patients per month. Percentile card was developed with LMS software and reference values were used as 1, 2, 3, 4, and 10%. RESULTS The lowest sacral ratio value was 0.514 and the highest value was 0.936. There was no statistical difference between the mean sacral ratio of the cases when they were classified on a monthly basis (p = 0.191). Low percentile values were found slightly different at first 4 months of age. CONCLUSION Although the mean of sacral ratio does not change significantly during the first year of life, values that are considered pathological for patients are within different percentile limits depending on age. Instead of using sacral ratio with some clinically decisive values, we think that parametric evaluation with the help of the percentile card will increase its clinical value.
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Affiliation(s)
- Kutay Bahadir
- Department of Pediatric Surgery, Ankara University School of Medicine, Ankara, Turkey
| | | | - Atilla Halil Elhan
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
| | - Ergun Ergun
- Department of Pediatric Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Tanju Aktug
- Department of Pediatric Surgery, Ankara University School of Medicine, Ankara, Turkey
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Krois W, Palmisani F, Gröpel P, Feil P, Metzelder ML, Patsch JM, Reck-Burneo CA. Assessment of sacral ratio in patients with anorectal malformations: Can magnetic resonance imaging replace conventional radiograph? J Pediatr Surg 2021; 56:1993-1997. [PMID: 33485613 DOI: 10.1016/j.jpedsurg.2021.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/23/2020] [Accepted: 01/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In patients with anorectal malformations (ARM), the sacral ratio (SR) serves as an established predictive marker for functional prognosis and is derived from conventional radiographs. More recently, magnetic resonance imaging (MRI) has emerged as a diagnostic alternative for preoperative/baseline assessment of patients with ARM. With this study we aimed to evaluate if the SR could be reliable be measured from MRI images and if it correlated to SR measurements obtained from radiographs. METHODS Two raters analyzed MRI data and conventional radiographs from thirty-one subjects (n = 17 with ARM; n = 14 controls). We calculated intra-class correlation coefficients (ICCs) to test inter-rater reliability and applied paired t-tests to examine if SR parameters from MRI were comparable with those from pelvic radiograph. We further computed Pearson's correlation coefficients to test the linear relationship between SR calculated from MRI and conventional radiographs. RESULTS The ARM and control groups did not statistically differ in their age and weight on the day of the MRI scan. Reliability analysis revealed an excellent inter-rater agreement for SR from radiograph parameters with an intraclass correlation coefficient (ICC) of 0.94, respectively of 0.86 for MRI (frontal plane), and of 0.84 for MRI (sagittal plane). The correlation coefficient between SR calculated from the sagittal MRI and SR calculated from radiograph images was significant and high (r = 0.80, P < 0.001). The SRs from MRI images did not significantly differ from SRs from radiographs, but were also not statistically equivalent. CONCLUSION Our results demonstrate that the SR can be derived from MRI images with good inter-rater reliability. The SR value is marginal higher when calculated on MRI, presumably due to inclusion of cartilaginous yet unossified structures.
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Affiliation(s)
- Wilfried Krois
- Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria.
| | - Francesca Palmisani
- Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Peter Gröpel
- University of Vienna, Department of Sport Science, Vienna, Austria
| | - Patricia Feil
- Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Martin L Metzelder
- Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Janina M Patsch
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Vienna, Austria
| | - Carlos A Reck-Burneo
- Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Long-term urological assessment and management of cloaca patients: A single tertiary institution experience. J Pediatr Surg 2021; 56:984-987. [PMID: 32778449 DOI: 10.1016/j.jpedsurg.2020.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Preserving renal function and achieving urinary continence are the most important urological goals in the management of cloaca patients. Many prognostic factors have been described, such as the length of the common channel (CC) and urethra, the presence of spinal dysraphism, and associated urological anomalies. The aim of this study was to analyze urinary continence status and need for reconstructive procedures and their correlation with urological risk factors in a series with a long-term follow-up. MATERIAL AND METHODS The institutional database of patients with anorectal malformations was reviewed. Patients with cloaca who underwent cloacal reconstructive surgery at our institution between January 1995 and May 2015 and who had a minimum postoperative follow-up of 5 years with complete urological care were included. Urologic and spinal anomalies, length of the CC, renal function, urodynamic study patterns, continence status, and urologic reconstructive surgeries were assessed. A CC was defined as long CC when its measure was longer than 3 cm in the cloacogram and then confirmed by cystoscopy. Descriptive statistical analysis was performed. RESULTS Fifty-five cloaca patients with a mean follow-up of 12 years (5-20) were included. A long CC was documented in 38 patients (69%). The sacral ratio (SR) was <0.4 in the AP projection in 30 (54.5%). Urodynamic evaluation revealed an inadequate detrusor contraction pattern in 65.4% of the cases. A CC >3 cm and SR <0.4 were significantly correlated with this urodynamic finding. A total of 50 patients (91%) achieved urinary continence, but only 30.9% had volitional voiding and 56% needed major urological reconstructive surgeries. Eighteen patients (32.7%) were in stage 2 or more of chronic kidney disease (<90 ml/min/1.73 m2) at the last follow-up visit. CONCLUSION Cloacal management requires a multidisciplinary and long-term follow-up. Early assessment of prognostic urological factors and accurate stratification of each patient are essential to avoid renal impairment and achieve urinary continence in the future. The length of the common channel and the presence of spinal dysraphism were correlated with the presence of neurovesical dysfunction specifically an abnormal bladder contraction efficiency. A significant number of these patients will need catheterization and reconstructive urinary tract surgeries to attain urinary continence. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level 3. Retrospective comparative study.
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Riahinejad M, Masoumi M, Farghadani M, Changanian P, Hosseinpour M. Sacrum Ultrasonography: An Accurate Alternative to Radiography for Measuring Sacral Ratio in Infants. Eur J Pediatr Surg 2021; 31:65-68. [PMID: 33027838 DOI: 10.1055/s-0040-1716879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The aim of this study was to compare the compliance of sacrum ultrasonography with radiography for the measuring of sacral ratio in infants. MATERIALS AND METHODS A total of 129 infants under the age of 6 months, who were a candidate for abdominal and/or pelvic radiographs, were assessed. Sacrum ultrasonography and radiography were performed by a single radiologist using the same device. The sacral ratio was calculated for all patients undergoing ultrasonography and radiography. Agreement between two methods was calculated by Bland-Altman's chart. RESULTS The mean of sacral ratio was 0.70 ± 0.11 radiographically and 0.72 ± 0.05 ultrasonographically. Based on Bland-Altman's chart, the mean difference between ultrasonography and radiology was 4.6 mm (confidence intervals of 8.18 ± 5.6). CONCLUSION Sacrum ultrasonography could be safely used in the investigation of sacral ratio to detect sacrum abnormalities in infants.
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Affiliation(s)
- Maryam Riahinejad
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Masoumi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Farghadani
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvaneh Changanian
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Hosseinpour
- Department of Pediatric Surgery, Imam Hossein Children Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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Chen Z, Zheng L, Zhang M, Zhang J, Kong R, Chen Y, Liang Z, Levitt MA, Wei CH, Wang Y. Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations. Front Pediatr 2021; 9:732524. [PMID: 34660489 PMCID: PMC8519007 DOI: 10.3389/fped.2021.732524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Sacral ratio (SR) is currently the only measurement to quantitatively evaluate sacral development in patients with anorectal malformations (ARM). This study proposes sacral curvature (SC) as a new indicator to qualitatively assess the sacrum and hypothesizes that sacral development, both quantitatively and qualitatively, can be an indicator to predict the type of ARM. The study aims to investigate the difference of SR and SC between ARM types and the association with the type of ARM. Methods and Materials: This study was retrospectively conducted between August 2008 and April 2019. Male patients with ARMs were enrolled and divided into three groups based on the types of ARM: (1) rectoperineal fistulae, (2) rectourethral-bulbar fistulae, and (3) rectourethral-prostatic or rectobladder-neck fistulae. SC was measured in the sagittal views of an MRI or a lateral radiograph of the sacrum. Results: Included in the study were 316 male patients with ARMs. SRs were 0.73 ± 0.12, 0.65 ± 0.12, and 0.57 ± 0.12 in perineal, bulbar, and prostatic/bladderneck fistula, respectively (p < 0.01). The SCs in perineal fistulae and bulbar fistulae were significantly higher than that in prostatic/bladderneck fistulae (0.25 ± 0.04, 0.22 ± 0.14, and 0.14 ± 0.18, p < 0.01). When SR ≥ 0.779, there was an 89.9% of possibility that the child has a perineal fistula. When SR ≤ 0.490 and SC ≤ 0, the possibilities of the child having prostatic/bladderneck fistulae were 91.6 and 89.5%, respectively. SC < 0 was also noted in 27 (27.8%), 19 (10.5%), and no (0%) patients of prostatic/bladderneck, bulbar, and perineal fistulae (p < 0.01), respectively. Sacral defect was noted in 63% of patients with SC ≤ 0, compared to none with SC > 0 (p < 0.01). Conclusions: The higher the rectal level is in an ARM, the lower are the objective measurements of the sacrum. SC ≤ 0 is associated with sacral defects and implies a high likelihood of prostatic/bladderneck fistulae.
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Affiliation(s)
- Zhen Chen
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lingling Zheng
- Clinical Data Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Minzhong Zhang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ruixue Kong
- Department of Nursing, Shandong Medical College, Ji'nan, China
| | - Yunpei Chen
- Center of Reproductive Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zijian Liang
- Center of Reproductive Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC, United States.,School of Medicine, The George Washington University, Washington, DC, United States
| | - Chin-Hung Wei
- Division of Pediatric Surgery, Department of Surgery, Shuang Ho Hospital, New Taipei City, Taiwan.,Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yong Wang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Metzger G, Cooper JN, Kabre RS, Mak GZ, Halleran DR, Boyd K, Chan S, Corea D, Dydynski P, Gill K, Kraus S, Sanchez R, Afrazi A, Calkins C, Linden AF, Downard C, Ehrlich PF, Fraser JD, Landman M, Leys CM, Rymeski B, Wood RJ, Levitt MA, Deans KJ, Bates DG, Minneci PC. Inter-rater Reliability of Sacral Ratio Measurements in Patients with Anorectal Malformations. J Surg Res 2020; 256:272-281. [DOI: 10.1016/j.jss.2020.06.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/27/2020] [Accepted: 06/16/2020] [Indexed: 01/19/2023]
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12
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Dewberry L, Peña A, Mirsky D, Ketzer J, Bischoff A. Sacral agenesis and fecal incontinence: how to increase the index of suspicion. Pediatr Surg Int 2019; 35:239-242. [PMID: 30392128 DOI: 10.1007/s00383-018-4402-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Sacral abnormalities range from missing the coccyx, a few sacral vertebrae, or hemi-sacrum, to complete absence with fused iliac bones. The purpose of this study was to review the association between sacral agenesis and fecal incontinence to help inform patient prognosis. METHODS A retrospective review was performed of patients who presented for bowel management due to sacral agenesis at a tertiary care children's hospital between 2016 and 2017 (n = 10). Data collection included: gender, time of diagnosis, sacral ratio, and associated anomalies. Patients with anorectal malformation and sacrococcygeal teratomas were excluded. RESULTS Four patients were female. Seven patients had a delayed diagnosis ranging from 22 months of age to 9 years. Most common symptoms included failure of age-appropriate toilet training and severe diaper rash. The sacral ratio was zero (6), 0.3 and 0.4 (2), and hemi-sacrum (2). Associated anomalies were present in five patients. CONCLUSION Sacral abnormalities should be suspected in patients who present with early severe diaper rash and those who fail to toilet train. An abdominal radiograph can evaluate the sacrum, when the sacral ratio is 0.4 or less, parents should be counseled regarding fecal incontinence and neurogenic bladder.
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Affiliation(s)
| | - Alberto Peña
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Box 323, Aurora, CO, 80045, USA
| | - David Mirsky
- Department of Radiology, Children's Hospital Colorado, Aurora, USA
| | - Jill Ketzer
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Box 323, Aurora, CO, 80045, USA
| | - Andrea Bischoff
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Box 323, Aurora, CO, 80045, USA.
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Morandi A, Ure B, Leva E, Lacher M. Survey on the management of anorectal malformations (ARM) in European pediatric surgical centers of excellence. Pediatr Surg Int 2015; 31:543-50. [PMID: 25840935 DOI: 10.1007/s00383-015-3700-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Various management strategies for anorectal malformations (ARM) have been proposed. The aim of this study was to assess the current management in centers of excellence in Europe. METHODS An online survey on the pre- and post-operative concepts, surgical techniques, and the management of complications was sent to the representative experts of 28 selected European centers of pediatric surgery with special expertise in the treatment of ARM. RESULTS The survey was completed by 25 experts from 14 countries. To assess the level of the rectal pouch in newborns 60% of participants perform a prone cross-table X-ray and 52% ultrasound. If an ostomy is required, 84% create divided Peña stomas. Primary repair in the newborn period is performed in females with rectoperineal (92%), rectovestibular (60%), and no fistula (32%), and in males with rectoperineal (92%), rectourinary (17%) and no fistula (38%). For 68 % of surgeons, the PSARP is the preferred surgical approach for "low" malformations. Laparoscopically assisted pull-throughs are routinely performed by 48% of experts for ARM with bladderneck and 28% for rectoprostatic fistula. 88% perform postoperative dilations. CONCLUSIONS The management of ARM in Europe is very heterogeneous. High-quality clinical studies are needed to provide scientific evidence for the optimal treatment strategies.
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Affiliation(s)
- Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca´Granda, Ospedale Maggiore Policlinico, Via Commenda 10, 20122, Milan, Italy,
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Yousefi P, Firouzifar M, Cyrus A. Correlation between sacral ratio and primary enuresis. J Nephropathol 2012; 1:183-7. [PMID: 24475413 DOI: 10.5812/nephropathol.8120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 08/12/2012] [Accepted: 08/20/2012] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 yr of age and has a high prevalence in school aged children. In primary enuresis (PE) children have never gained control over urination or has been dry for<6months. While in secondary enuresis children have developed incontinence after a period of at least 6 months of urinary control. OBJECTIVES The aim of this study was to investigate a possible relation between PE and sacral ratio (SR) in 5-9 aged children. PATIENTS AND METHODS 118 children with aged 5-9 year were enrolled in this case-control study. All them were divided into two aliquots groups of 59 patients. The case study (children with PE) and the control (children without PE) groups were matched in age and sex. SR based on antero-posterior plain radiograms of pelvis was calculated. Results were then analyzed using Chi square and student t-test as appropriate. RESULTS There were no significant differences between the two groups regarding age and gender. Mean SR in case and control group was 0.89 and 0.90, respectively. Moreover, there was no significant difference between the two groups (p=0.82). Only 1 child (1.6%) in case group showed abnormal SR while this was 7 children (11.9%) in the control group. CONCLUSIONS This study showed that, there was no significant difference between children with PE and those without PE in terms of SR. However, multicenter and larger sample size is recommended for definite decision of this finding.
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Affiliation(s)
- Parsa Yousefi
- Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | | | - Ali Cyrus
- Department of Urology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
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Schmiedeke E, Zwink N, Schwarzer N, Bartels E, Schmidt D, Grasshoff-Derr S, Holland-Cunz S, Hosie S, Jablonka K, Maerzheuser S, Reutter H, Lorenz C, Jenetzky E. Unexpected results of a nationwide, treatment-independent assessment of fecal incontinence in patients with anorectal anomalies. Pediatr Surg Int 2012; 28:825-30. [PMID: 22821084 DOI: 10.1007/s00383-012-3127-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the anorectal function in patients with anorectal malformations (ARM) in order to facilitate patient counseling and follow-up. METHODS Data were collected by the German network for urorectal malformations (CURE-Net) according to the International Krickenbeck consensus. Questionnaires on bowel function and a defecation protocol were completed by the families/patients. The clinical findings were assessed from the patients' clinical records. RESULTS Two hundred and ninety-seven patients with ARM were assessed, 175 patients gave complete data on continence, 52 of them were excluded due to mental retardation, age, and earlier type of pullthrough. Complete continence was found in 27 %, perineal fistula in 40 %, rectourethral/vesical in 10 %, vestibular in 24 %, cloaca in 0 %. Krickenbeck grade 1 soiling: 42 %, grade 2 and 3: 31 %. Forty-nine percent of the incontinent patients practiced bowel management, reaching continence in 19 %. The statement of constipation (67 %) was validated with the last clinical findings, showing coprostasis in 46 %, "Not suffering constipation" was confirmed in 61 % and falsified in 29 %. CONCLUSION ARM patients in Germany, as assessed by independent researchers, show a high rate of fecal incontinence and insufficiently treated constipation. Parents should be counseled accordingly and motivated to engage in consequent follow-up. Intensified efforts in the conservative treatment of constipation and fecal incontinence are crucial to improvement.
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Affiliation(s)
- Eberhard Schmiedeke
- Department of Pediatric Surgery and Urology, Centre for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany.
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Abstract
This article reviews the current status of anorectal malformations in the neonate. It begins by discussing the history, epidemiology, and embryology, followed by a discussion of the genetic process causing these diseases. Diagnosis and workup is then discussed, followed by specific details of the surgical treatment of these malformations. The article concludes with a brief review of the complications and long-term outcomes in these children.
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Affiliation(s)
- Richard S Herman
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
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Kim SM, Chang HK, Lee MJ, Shim KW, Oh JT, Kim DS, Kim MJ, Han SJ. Spinal dysraphism with anorectal malformation: lumbosacral magnetic resonance imaging evaluation of 120 patients. J Pediatr Surg 2010; 45:769-76. [PMID: 20385285 DOI: 10.1016/j.jpedsurg.2009.10.094] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 10/05/2009] [Accepted: 10/30/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE We evaluated the prevalence of spinal dysraphism (SD) in patients with anorectal malformation (ARM) by magnetic resonance imaging (MRI). METHODS From January 2002 to March 2009, 120 patients with ARM who underwent anorectal reconstruction were evaluated for SD with sacral plain film, spinal ultrasonography (US), and lumbosacral MRI. We adopted Krickenbeck international classification of ARM. RESULTS Spinal dysraphism was present in 41 (34.2%) of 120 patients with ARM, 3 (13.0%) of 23 patients with perineal fistula, 7 (29.2%) of 24 patients with vestibular fistula, 4 (36.4%) of 11 patients with rectovesical fistula, 18 (40.9%) of 44 patients with rectourethral fistula, and 9 (60.0%) of 15 patients with cloacal anomaly (P = .04). Among 41 patients having SD detected by MR, 26 patients (26/41; 63.4%) underwent detethering surgery for tethered spinal cord. The mean sacral ratio (SR) in patients who underwent detethering surgery (0.54 +/- 0.19) was significantly lower than in patients who did not undergo detethering surgery (0.69 +/- 0.13; P < .001). The optimal cutoff for the SR value predicting SD requiring detethering surgery was 0.605, with sensitivity of 65.4% and specificity of 77.7%. CONCLUSIONS Spinal dysraphism is common in patients with ARM, and its prevalence is higher in patients with complex ARM. Spinal anomalies can occur even with benign types of ARM and, therefore, that all patients should be screened. Magnetic resonance imaging is useful in detecting occult SD that may be missed by conventional radiologic evaluation, physical examination, and spinal US. We further recommend a lumbosacral MRI examination in those whose SR is lower than 0.6.
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Affiliation(s)
- Seong Min Kim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
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Macedo M, Martins JL, Freitas Filho LG. Sacral ratio and fecal continence in children with anorectal malformations. BJU Int 2004; 94:893-4. [PMID: 15476529 DOI: 10.1111/j.1464-410x.2004.05053.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the sacral ratio (SR) in patients with an anorectal malformation (ARM) and verify whether it has predictive value for fecal continence. PATIENT AND METHODS From January 1990 to April 2002, 42 patients (aged 3-14 years) with an ARM and having already been operated on were reassessed and enrolled in the study. Patients with solid or paste-like stools but no soiling were deemed continent, those with similar stool and episodes of soiling partially continent, and those with no sphincter control, incontinent. The fecal continence was always analysed by the same observer. Sacral radiographic images were reviewed and the SR calculated from anteroposterior and images in the lateral position. All images were obtained before surgery and analysed by the same observer, while a third analysed the results. Results were considered statistically significant at P < 0.001. RESULTS Seventeen patients were deemed continent, seven partially continent and 18 incontinent; there was no significant difference in SR among the three groups. When fecal continence was analysed in relation to changes in the findings on computed tomography of the lumbosacral spine, patients with sacral agenesis had a significantly higher frequency of fecal incontinence than the others, and all had a SR below 'normal'. CONCLUSION Although the SR was different in patients with sacral agenesis it was no different in continent, partially continent or incontinent patients, and thus it is of no practical value in identifying patients likely to have fecal incontinence.
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Affiliation(s)
- Mauricio Macedo
- Departments of Paediatric Surgery, Hospital Infantil Darcy Vargas, São Paulo, Brazil
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