Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

Document Type

Journal Article

Publication Date

1-1-2018

Journal

Journal of Pediatric Surgery

Volume

53

Issue

1

DOI

10.1016/j.jpedsurg.2017.10.022

Keywords

Anorectal malformation; Cloaca; Cloacal reconstruction; Common channel; Imperforate anus; Urethral length; Urogenital sinus

Abstract

© 2017 Elsevier Inc. Background: Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3 cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra < 1 cm,.5 with an original 3 to 5 cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care. Methods: We prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded. Results: Of 31 primary cases, CC length was 1 to 3 cm in 20, 3 to 5 cm in 9, and greater than 5 cm in 2. In the 1 to 3 cm and the 3 to 5 cm groups, a urethra less than 1.5 cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5 cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3 cm CC group, 6 of 9 in the 3 to 5 cm CC group, and 2 of 2 in the greater than 5 cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3 years. Conclusion: Urethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented. Type of study: Clinical cohort study with no comparative group. Level of evidence: Level 4.

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