Erratum to “Cloaca reconstruction: A new algorithm which considers the role of urethral length in determining surgical planning” [YJPSU 53/1 (2018) 90-95](S0022346817306449)(10.1016/j.jpedsurg.2017.10.022)

Document Type

Journal Article

Publication Date



Journal of Pediatric Surgery








© 2018 The publisher regrets to inform that in regard to the manuscript titled “Cloaca Reconstruction: A New Algorithm which Considers the Role of Urethral Length in Determining Surgical Planning” by R. J. Wood, et al, published in the January 2018 APSA issue of the Journal, a very significant Discussion was missed to be included as part of the article. It is as below. The publisher would like to apologise for any inconvenience caused. UNIDENTIFIED SPEAKER: Wow, that was beautifully presented work, and it sounds like it's going to help a lot of these children. My question is, what do you think the difference is? Does it have to do with the urethral sphincter mechanism and those with longer urethras generally have more native sphincter-type function? RICHARD WOOD: I think it's probably multifaceted. Thank you for the question. I think we certainly are concerned that in patients with a very short urethra and just by bringing the bladder neck really low, it appears to affect their function. We haven't noted with the patients that we've left the common channel with the urethra that they have had a difficulty to empty. Obviously that's something that one needs to look at and see whether over the long term more patients need intermittent cath, but that has not been our experience for now. I don't know entirely. I just feel that most children with a urogenital sinus have a normal bladder function, and a lot of kids with cloaca have abnormal bladder function. If the urologists think it's that important to maintain the urethral length in patients with normal bladders, how much more so is it important for us to maintain that in children who in many cases have abnormalities to their bladder function. So we're not entirely sure why, but it would appear that there is benefit. JASON FRISCHER (Cincinnati, OH): Great presentation and thank you for challenging us to try to continue to make and have better outcomes in this patient population. Couple questions. One, when you measure the urethral length, you showed a cloacagram, but I assume you also perform a cystoscopy. Which measurement do you use as your more preferred measurement for determining that 1.5-cm length? My other question is, does age play a role when you are performing this? In a 2 year old, you're doing redo operations. Does urethral length in a 2 year old, or if a patient was diverted and you just encountered them at 2 years of age, is that a different length than a 3 month old that you are doing your original cloacagram? And then third question is more of a comment. I guess we really need to know what the functional outcomes of these patients are, and so do you have any data on that? I look forward to this presentation in 3-5 years again. RICHARD WOOD: Thank you very much. To answer your first question, we do measure and use the cloacagram. We will present that data in time when I think we have enough to significantly say, but my impression is the cloacagram may be better because we can – I think we can kid ourselves when we're doing the cystoscopy by applying pressure. Same problem with ultrasound of the perineum. Functional outcomes, whereas we don't have a lot of data yet and we have to wait for these patients to get older, I think we have anatomical data that the urethra is surviving, and they are not leaking, but we don't have functional data yet. All our patients get urodynamics before surgery, and we follow them with urodynamics and other parameters, so hopefully we will be able to present that data in time. JASON FRISCHER: And age? RICHARD WOOD: We haven't specifically used this protocol for the redos, but we are mindful of it because I think a lot of times the decisions are often made on the urethra by the time they come to for redo, but I think it is something we definitely consider in every single patient and the goal to maintain as much urinary continence as possible is certainly forefront to the discussion. Thank you. W. HARDY HENDREN (Duxbury, MA): I don't have a question, but I would like to say that I agree completely with the message that you've just given us and to add that the time to do it is the first operation if you're lucky enough to get one with the first operation. I got many of these kids who had had 2-3 operations before, and it's tougher each time, so the time to do it is initially if it looks too short. Thank you. RICHARD WOOD: Thank you very much. MARC LEVITT (Columbus, OH): If I may, I don't mean to follow Dr. Hendren, but I just want to thank him for a career of service on this very difficult patient population and also to Dr. Pena who made a lot of strides in addition to Dr. Hendren's work. I was there looking over Dr. Pena's and Dr. Hendren's shoulder when Alberto for the first time showed Dr. Hendren what the urogenital mobilization was all about, and I remember the fascination in his eyes that it was going to advance the field, and in fact it did. What this paper was meant to show is that it was an incredible advance, but it cannot be applied too broadly. We have to go back to the original principles that Dr. Hendren gave us of the importance of the bladder neck, the urethral length, and urinary continence in order to get the best possible result. Thank you.[Figure presented]

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