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Morin JP, Srinivas S, Wood RJ, Dajusta DG, Fuchs ME. Bladder Management and Continence in Girls With Cloacal Malformation After 3 Years of Age. J Pediatr Surg 2024:S0022-3468(24)00261-6. [PMID: 38734497 DOI: 10.1016/j.jpedsurg.2024.04.010] [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] [Accepted: 04/12/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Multiple factors impact ability to achieve urinary continence in cloacal malformation including common channel (CC) and urethral length and presence of spinal cord abnormalities. Few publications describe continence rates and bladder management in this population. We evaluated our cohort of patients with cloacal malformation to describe the bladder management and continence outcomes. METHODS We reviewed a prospectively collected database of patients with cloacal malformation managed at our institution. We included girls ≥3 years (y) of age and evaluated their bladder management methods and continence. Dryness was defined as <1 daytime accident per week. Incontinent diversions with both vesicostomy and enterovesicostomy were considered wet. RESULTS A total of 152 patients were included. Overall, 93 (61.2%) are dry. Nearly half (47%) voided via urethra, 65% of whom were dry. Twenty patients (13.1%) had incontinent diversions. Over 40% of the cohort performed clean intermittent catheterization (CIC), approximately half via urethra and half via abdominal channel. Over 80% of those performing CIC were dry. In total, 12.5% (n = 19) required bladder augmentation (BA). CC length was not associated with dryness (p = 0.076), need for CIC (p = 0.253), or need for abdominal channel (p = 0.497). The presence of a spinal cord abnormality was associated with need for CIC (p = 0.0117) and normal spine associated with ability to void and be dry (p = 0.004) CONCLUSIONS: In girls ≥ 3 y of age with cloacal malformation, 61.2% are dry, 65% by voiding via urethra and 82% with CIC. 12.5% require BA. Further investigation is needed to determine anatomic findings associated with urinary outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jacqueline P Morin
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Shruthi Srinivas
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel G Dajusta
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Molly E Fuchs
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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Davis M, Mohan S, Russell T, Feng C, Badillo A, Levitt M, Ho CP, Pohl HG, Varda BK. A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience. J Pediatr Urol 2023; 19:371.e1-371.e11. [PMID: 37037763 DOI: 10.1016/j.jpurol.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/20/2023] [Accepted: 03/11/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION/BACKGROUND Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs. OBJECTIVE 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying. STUDY DESIGN We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate = common channel [CC] <3-cm, severe = CC ≥ 3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy). RESULTS Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated. DISCUSSION Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function. CONCLUSION Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively.
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Affiliation(s)
- Meghan Davis
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Shruthi Mohan
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Teresa Russell
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina Feng
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Andrea Badillo
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Marc Levitt
- Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Christina P Ho
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA
| | - Hans G Pohl
- Children's National Hospital, Division of Urology, Washington D.C, USA
| | - Briony K Varda
- Children's National Hospital, Division of Urology, Washington D.C, USA; Children's National Hospital, Division of Colorectal and Pelvic Reconstruction, Washington D.C, USA.
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Bhagat AC, Gupta RS, Malik R. Antenatal diagnosis of hydrometrocolpos with Mullerian duplication on ultrasound and fetal MRI: case report and literature review. BJR Case Rep 2023; 9:20230024. [PMID: 37265753 PMCID: PMC10230225 DOI: 10.1259/bjrcr.20230024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 06/03/2023] Open
Abstract
Fetal abdomino-pelvic cystic lesions are uncommon and can have varied etio-pathogenesis. Most commonly they originate from the gastrointestinal or genitourinary tract. These include choledochal cyst, hydronephrosis, renal cyst, mesenteric/omental cyst, ovarian cyst, meconium pseudocyst, and hydrocolpos/hydrometrocolpos among others. Fetal hydrometrocolpos is rare with a reported incidence of 0.006% and its diagnosis requires a high index of suspicion. Antenatal ultrasound and magnetic resonance imaging (MRI) is invaluable in diagnostic evaluation. This case report describes the imaging features of antenatally detected congenital hydrometrocolpos with Mullerian duplication secondary to cloacal malformation using antenatal ultrasound and MRI. Per-operative findings and other possible differential diagnoses are discussed along with a brief review of literature.
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Affiliation(s)
| | | | - Rajesh Malik
- All India Institute of Medical Sciences, Bhopal, India
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Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems. J Pediatr Surg 2023; 58:189-197. [PMID: 36418202 DOI: 10.1016/j.jpedsurg.2022.10.023] [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: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
A basic premise in the care of complex patients is that experience, increased volume of cases, and an integrated, multi-disciplinary approach yields improved outcomes. Is this true using the example of the care of children with colorectal and pelvic reconstructive needs? This review gives a brief historical context on how care for this patient group evolved, delineates the key elements to create a collaborative care model, and describes multiple advances that have been developed, based on the model, which have improved patient care and quality of life. LEVEL OF EVIDENCE: Review.
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Lane VA, Lall A, Jaffray B. Single institution experience of cloacal malformation. J Pediatr Surg 2023; 58:270-274. [PMID: 36384941 DOI: 10.1016/j.jpedsurg.2022.10.035] [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: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The aim of this study is to report on the outcomes of patients born with cloacal malformation, managed at a single institution more than the last 28 years. The focus of this study is the long term renal and colorectal outcomes. METHODS Patients were identified from the departmental database from 1994 to 2021. The medical records and operative notes were retrospectively reviewed. RESULTS Twenty-one patients fulfilled the inclusion criteria. Eleven long common channel (LCC) and ten short common channel (SCC) cloacae patients were identified. Median age at the time of primary reconstruction was 11 months in both groups. In the LCC group, seven (63.6%) patients underwent a Total Urogenital Mobilisation (TUM), and 4 (36.4%) required a vaginal replacement. 6/11 (54.5%) of patients required drainage of a hydrocolpos. In the SCC group, four patients required a TUM, two patients underwent mobilisation of the rectum and vagina alone, and three underwent rectal mobilisation alone. Two patients have required renal transplant for congenital renal dysplasia, and two have developed chronic renal failure associated with the sequalae of vesicoureteric reflux. Eleven (52.3%) of the patients manage their bowels with an antegrade continent enema (ACE), and two of the LCC cloaca are defunctioned with a colostomy. Clean intermittent catheterisation is performed by 12 (57%) of the patients, either per urethra or via a Mitrofanoff channel. CONCLUSION The urinary and faecal continence are the main challenges in the management of cloaca patients. Many require surgical intervention to achieve social continence. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Victoria A Lane
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK
| | - Anupam Lall
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK
| | - Bruce Jaffray
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK.
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Gang S, Song SH, Kwon J, Kwon H, Ha S, Park J, Kim N, Yoon HM, Namgoong JM. Case report: Magnetic resonance imaging-based three-dimensional printing for reconstruction of complex cloacal malformations. Front Pediatr 2023; 11:1103401. [PMID: 36959843 PMCID: PMC10028276 DOI: 10.3389/fped.2023.1103401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/13/2023] [Indexed: 03/25/2023] Open
Abstract
Background Surgical reconstruction of the urinary tract, anus, and vagina is the definitive treatment for cloacal malformation. However, this procedure may be technically challenging in patients with a long common channel (>3 cm), because further reconstructive procedures, such as vaginal replacement or vaginal switch maneuver, may be required. Thus, accurate determination of spatial anatomy is essential during surgical planning. Three-dimensional (3D) reconstruction using rotational fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI) has recently been reported to help in determining the relationship between the rectum, vagina, and bladder, and provides a more accurate measurement of the channel length compared to conventional cloacography. MRI-based 3D reconstruction provides substantial information regarding soft tissue structures around the cloaca, including the pelvic floor musculature and anus. Case A 2-year-old girl with cloacal malformation required reconstructive surgery. Colostomy and cystostomy had been performed on the first day of her life. Preoperative loopogram revealed a cloaca with a long common channel (35 mm) and short urethra (9 mm), single vaginal opening in the bladder neck, and the colon anterior to the vagina with a fistula at the vaginal neck. Because the vagina was too short to be pulled through, 3D printing based on MRI was performed to visualize structural relationships prior to surgical correction. Saline was used for cloacal visualization. Furthermore, endoscopy-assisted urogenital mobilization was performed, and vaginal substitution was performed using the rectum. No postoperative complications were observed. Conclusions We believe this is the first report of the use of MRI-based 3D imaging and printing, with saline as a contrast agent during surgical planning for correction of cloacal malformation. MRI-based 3D printing is a potentially promising technique for surgical planning of cloacal malformation correction in patients with a long common channel, as it provides detailed information about the surrounding soft tissue structures without exposure to radiation or contrasting agents.
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Affiliation(s)
- Suiin Gang
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Hoon Song
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | | | - Hyunhee Kwon
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Suhyeon Ha
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Jueun Park
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Namkug Kim
- Department of Radiology, Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
- Correspondence: Jung-Man Namgoong
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Pelvic Organ Prolapse in Patients with Congenital Genitourinary Conditions. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Hao S, Shou M, Ma J, Shu Y, Yu Y. Correlation Analysis of Serum Pepsinogen, Interleukin, and TNF- α with Hp Infection in Patients with Gastric Cancer: A Randomized Parallel Controlled Clinical Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:9277847. [PMID: 36158129 PMCID: PMC9492331 DOI: 10.1155/2022/9277847] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 12/16/2022]
Abstract
Background Gastric cancer pathological biopsy and visual examination have been the gold standard for gastric cancer diagnosis, but their operation is costly, demanding, and risky, so it is especially important to find an effective examination method in clinical practice. Aims To investigate the correlation between serum pepsinogen I (PGI), pepsinogen II (PGII), pepsinogen I and II ratio (PGR), IL-6, and TNF-α and Helicobacter pylori (Hp) infection in patients with gastric cancer. Materials and Methods Fifty patients with Hp-infected gastric cancer admitted to the Department of Gastroenterology of our hospital from January 2019 to December 2021 were selected for the study as the observation group, and another 50 patients without Hp-infected gastric cancer were selected as the comparison group to compare the correlation analysis of PGI, PGII, PGR, IL-6, and TNF-α with Hp infection between the two groups after admission and treatment. Results After measurement, PGI and PGII in the observation group were significantly lower than those in the comparison group, and TNF-α, IL-18, and IL-6 in the observation group were significantly higher than those in the comparison group, and the comparative differences were all statistically significant (P < 0.05). The results of multivariate logistic regression model analysis of independent risk factors for gastric cancer showed that IL-18, hs-CRP, and tumor necrosis factor- (TNF-) α were risk factors for Hp infection in gastric cancer. Conclusion The expression of IL-18, hs-CRP, and TNF-α factors in Hp-infected gastric cancer patients is correlated. IL-6, IL-18, and TNF-α are involved in the entire process from the onset to the development of Hp-positive gastric mucosal inflammation in patients, which is of great value in the diagnosis of gastric cancer and helps to assess the degree of progression and prognosis of gastric cancer.
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Affiliation(s)
- Shunxin Hao
- Department of General Surgery, Wuhan University of Science and Technology Hospital, China 430065
| | - Minyue Shou
- The First Affiliated Hospital of Nanjing Medical University (Department of Oncology), China 210029
| | - Jing Ma
- Zhongshan Hospital Affiliated to Fudan University, China 200032
| | - Yongqian Shu
- The First Affiliated Hospital of Nanjing Medical University (Department of Oncology), China 210029
| | - Yuanyuan Yu
- Department of Geriatrics, Wuhan Hospital of Traditional Chinese Medicine, 49 Lihuangpi Road, Jiangan District, Wuhan City, Hubei Province, China
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Liao L, Peng Y, Lu J, Wang Z, Xu J, Chen X, Chen H, Zhang X. Effect of Vaginoscopy versus Conventional Hysteroscopy on Pain, Complications, and Patient Satisfaction in Patients with Endometrial Polyps. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3835941. [PMID: 35799662 PMCID: PMC9256323 DOI: 10.1155/2022/3835941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/24/2022]
Abstract
Background Hysteroscopy is considered the gold standard for diagnosing intrauterine pathology. Traditional hysteroscopy requires the placement of a vaginal speculum and cervical forceps, which are large in diameter, causing discomfort and pain to the patient and even causing vagal reflexes. Aims To investigate the impact and clinical value of vaginoscopy versus conventional hysteroscopy on pain, complications, and patient satisfaction in patients with endometrial polyps and to analyse the advantages of clinical application of vaginoscopy examination. Materials and Methods One hundred and twenty-five patients with endometrial polyps treated in our hospital from May 2021 to December 2021 were selected for this study and divided into 52 cases in the hysteroscopy group and 73 cases in the vaginoscopy group according to the random remainder grouping method. Conventional hysteroscopy was used, and in the vaginoscopy group, vaginoscopy was performed. The impact of pain, complications, patient satisfaction, and clinical value of the two groups was observed and compared. Results The time taken for the examination varied between the different hysteroscopic methods, with the hysteroscopy group taking the longest time compared to the vaginoscopy group (P < 0.01). The VAS scores immediately after the examination and 30 minutes after the examination were both significantly higher in the hysteroscopy group than in the vaginoscopy group (P < 0.01). The difference in NPY, PGE2, and 5-HT after the pain-causing mediator intervention was significantly better in the vaginoscopy group than in the hysteroscopy group. The difference in the incidence of complications such as abortion syndrome, cervical laceration, uterine perforation, and haemorrhage after treatment was significantly lower in the vaginoscopy group than in the hysteroscopy group. In the vaginoscopy group, the satisfaction rate was 91% significantly higher than that of the hysteroscopy group (P < 0.05). Conclusion The vaginoscopy technique shortens the examination and treatment time, reduces patient pain, improves patient compliance, reduces the use of preintervention drugs and anaesthetics, and reduces complications.
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Affiliation(s)
- Liyun Liao
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou Zhejiang, China 310006
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - Yangying Peng
- Huangyan Hospital of Wenzhou Medical University, Taizhou First People's Hospital, 318020, China
| | - Jianshuo Lu
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - Zhiying Wang
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - Jinyue Xu
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - Xuefeng Chen
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - HaiYing Chen
- Xiangshan First People's Hospital Medical and Health Group, 315700, China
| | - Xinmei Zhang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou Zhejiang, China 310006
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Taher H, Fares A, Wishahy AM. Laparoscopic resurrection of an old technique; a new approach for Total Urogenital Separation and Rectal pull through in patients with long channel Cloacal malformation. J Endourol 2022; 36:1177-1182. [PMID: 35152733 PMCID: PMC9422784 DOI: 10.1089/end.2021.0724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Aims: Before the significance of urethral length was highlighted in patients with cloacal malformation, total urogenital mobilization using a posterior sagittal approach was recommended for common channel (CC) length <3 cm, those >3 cm it was followed by urogenital separation. However, many urologists are advocating that the urethral length rather than length of the CC should influence the choice of operation. It is also recommended that total urogenital mobilization should be avoided in patients with short urethral length as intraoperative decision to shift to urogenital separation will risk devascularization of the urethra, advocating total urogenital separation (TUS) from the start; the later technique was deemed difficult using open approach. We describe our experience with laparoscopic TUS and rectal pull-through in patients with cloacal malformation. Methods: Six patients were operated for a period of 3 years from December 2017 to July 2021; they underwent laparoscopic TUS and rectal pull-through. Preoperative investigations included cystoscopy, genitogram, and MRI pelvis and abdominal ultrasound. IRB approval has been obtained from research ethical committee at Cairo University. Results: Six female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1 to 4 years. Length of the CC ranged between 2 and 5 cm. Proximal urethral length ranged between 0.5 and 1.5 cm and vaginal depth >3 cm. Average operative time was 4.25 hours. Postoperative period was 1–5 days and uneventful. On the long-term follow-up. No patient developed urethrovaginal fistula and one patient developed vaginal stenosis. All patients had no urinary problems, dry over 4-hour interval, voiding spontaneously, and had normal kidney functions. Conclusions: Laparoscopic urogenital separation, as well as vaginal and rectal pull-through for cloacal malformation, is feasible in cloacal malformation providing anatomical repair.
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Affiliation(s)
- Heba Taher
- Cairo University Kasr Alainy Faculty of Medicine, 63527, Cairo, Egypt
| | - Ahmed Fares
- Fayoum University Faculty of Medicine, 158405, pediatric surgery, Fayoum, Egypt
| | - Ahmed M.K Wishahy
- Cairo University Kasr Alainy Faculty of Medicine, 63527, pediatric surgery, Cairo, Egypt
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Versteegh HP, Gardner DS, Scriven L, Martens L, Kluivers K, Hewitt G, de Blaauw I, Wood RJ, Williams A, Sutcliffe J. Reconsidering Diagnosis, Treatment, and Postoperative Care in Children with Cloacal Malformations. J Pediatr Adolesc Gynecol 2021; 34:773-779. [PMID: 34419606 DOI: 10.1016/j.jpag.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/07/2021] [Indexed: 12/25/2022]
Abstract
Cloacal malformations are among the most complex types of anorectal malformation and are characterized by the urological, genital, and intestinal tracts opening through a single common channel in the perineum. Long-term outcome is affected by multiple factors, which include anatomical variants of the malformation itself, associated anomalies, and the surgical approach. Reconsidering these variables and their influence on "patient important" function might lead to strategies that are more outcome-driven than focused on the creation of normal anatomy. Key outcomes reflect function in each of the involved tracts and the follow-up needed should therefore not only include the classical fields of colorectal surgery and urology but also focus on items such as gynecology, sexuality, family-building, and quality of life as well as other psychological aspects. Involving patients and families in determining optimal treatment strategies and outcome measures could lead to improved outcomes for the individual patient. A strategy to support delivery of personalized care for patients with cloacal malformations by aiming to define the best functional outcomes achievable for any individual, then select the treatment pathway most likely deliver that, with the minimum morbidity and cost, would be attractive. Combining the current therapies with ongoing technological advances such as tissue expansion might be a way to achieve this.
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Affiliation(s)
- Hendt P Versteegh
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - David S Gardner
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lucy Scriven
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Nottingham, United Kingdom
| | - Lisanne Martens
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten Kluivers
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geri Hewitt
- Department of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Alun Williams
- Departments of Paediatric Surgery and Urology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Jonathan Sutcliffe
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, The General Infirmary at Leeds, Leeds, United Kingdom
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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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Long-term urologic and gynecologic follow-up and the importance of collaboration for patients with anorectal malformations. Semin Pediatr Surg 2020; 29:150987. [PMID: 33288143 PMCID: PMC8570052 DOI: 10.1016/j.sempedsurg.2020.150987] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Anorectal malformations (ARM) are well recognized to be associated with anomalies in other organ systems. The introduction of screening protocols has increased the diagnosis of these anomalies and greater collaboration with other specialties has influenced the treatment and follow-up of patients with ARMs. Much of the medical literature regarding the treatment of anorectal malformations has focused on technical details of operations and early post-surgical outcomes. Recently, an increase in published data regarding the long-term sequelae of an ARM diagnosis has resulted in an emphasis extended follow up in this population. Patient support groups have highlighted complex issues in ARM patients persist into adulthood have advocated for improved transitional care. This article describes the benefits of long-term follow-up and identifies key issues in ARM patients with respect to urologic and gynecologic health. A collaborative model of care is outlined and suggested timings of screening for potential problems is described.
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Levitt MA. New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update. Semin Pediatr Surg 2020; 29:150992. [PMID: 33288140 DOI: 10.1016/j.sempedsurg.2020.150992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives.
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Wood RJ, Reck-Burneo CA, Vilanova-Sanchez A, Levitt MA. Organizing the care of a patient with a cloacal malformation: Key steps and decision making for pre-, intra-, and post-operative repair. Semin Pediatr Surg 2020; 29:150988. [PMID: 33288135 DOI: 10.1016/j.sempedsurg.2020.150988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Demehri FR, Tirrell TF, Shaul DB, Sydorak RM, Zhong W, McNamara ER, Borer JG, Dickie BH. A New Approach to Cloaca: Laparoscopic Separation of the Urogenital Sinus. J Laparoendosc Adv Surg Tech A 2020; 30:1257-1262. [PMID: 33202165 DOI: 10.1089/lap.2020.0641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cloaca malformation repair strategy is strongly dictated by common channel and urethral lengths. Mid to long common channel cloacas are challenging and often require laparotomy for dissection of pelvic structures. The balance of common channel and urethral lengths often dictates the approach for reconstruction. Laparoscopy has been utilized for rectal dissection but not for management of the urogenital (UG) structures. We hypothesized that laparoscopy could be applied to UG separation in reconstruction of cloaca malformations. Methods: Records were reviewed for 9 children with cloaca who underwent laparoscopic rectal mobilization and UG separation. Clinical parameters reviewed included demographics, relevant anatomic lengths, operative duration, transfusion requirements, and perioperative complications. Results: Repair was perfomed at a median (interquartile range) age of 12 (7, 15) months. Common channel length as measured by cystoscopy was 3.5 (3.3, 4.5) cm. There were no intraoperative complications. Transfusion requirements were minimal. Postoperative length of stay was 6 (5, 11) days. One patient developed a urethral web and 2 developed vaginal stenosis. One patient later underwent a laparotomy for obstruction due to a twisted rectal pull-through. Conclusions: Laparoscopic rectal mobilization and UG separation in long common channel cloaca are safe and well tolerated. Laparoscopy affords full evaluation of Mullerian structures and enables separation of the common UG wall, which may ultimately enhance long-term urinary continence.
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Affiliation(s)
- Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Timothy F Tirrell
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald B Shaul
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Roman M Sydorak
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Erin R McNamara
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Zamir N. Cloacal Malformation in Female Children: Outcome of Initial Management. Pak J Med Sci 2020; 36:187-191. [PMID: 32063957 PMCID: PMC6994881 DOI: 10.12669/pjms.36.2.1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To document our experience of initial management of Cloacal malformation in female patients. Methods: A descriptive retrospective study was conducted in the Department of Pediatric Surgery of the National Institute of Child Health Karachi from January 2010 to September 2018. Female patients with diagnosis of Cloacal malformation were included in this study. Data regarding the age at presentation, mode of presentation, clinical features, presence of hydrocolpos, and associated anomalies were noted. Surgical procedures performed in these patients and the outcomes were also documented. Data was analyzed on SPSS Version 20. Results: Sixty females were included in the study. Age ranged from birth to three years with a median of four days. Patients admitted through emergency were 44 (73.33%) while 16 (26.66%) were admitted through outpatient clinic. Hydrocolpos was found in 15 (25.00%) patients. Five (8.33%) patients had massive abdominal distention and were presented with severe respiratory distress. Among them three had massive hydrocolpos, one patient had pneumoperitoneum secondary to Meckel’s perforation and one patient was having massive colonic dilatation. Hydronephrosis and hydroureter were found in 14 (23.33%) patients, while dilated bladder was found in three (5.00%) patients. After optimization of patients, bowel diversion was done as transverse colostomy in 39 (65.00%) patients, high sigmoid colostomy in 17(28.33%) patients while ileostomy was done in three (5.00%) patients. All patients with hydrocolpos had tube vaginostomy. None of the patients required bladder diversion and urinary tract dilatations were gradually subsided in nine patients in the post-operative period. Associated anomalies were found in 22(36.66%) of cases predominantly of sacral origin. Operative complications were found in 18(30.00%) patients, including stoma site in infection in 12(20.00%) patients, vaginal tube dislodgement in two patients, wrong placement of tube in one patient and vaginostomy stenosis in one case. While bowel stoma retraction occurred in four patients, prolapsed was found in three patients. Renal failure occurred in one patient. In total, 37(61.00%) patients had smooth recovery, 18(30.00%) patients had some complications, while Five (8.33%) patients were expired due to sepsis. Conclusions: Majority of cloacal malformations present in neonatal life. Initial management is an important step in dealing with these patients. Care must be taken during the abdominal exploration regarding drainage of hydrocolpos and appropriate placement of bowel stoma.
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Affiliation(s)
- Naima Zamir
- Dr. Naima Zamir, Associate Professor, National Institute of Child Health, Karachi, Pakistan
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