Surgical management of cloacal malformations: a review of 339 patients.

BACKGROUND/PURPOSE
The aim of this study was to describe lessons learned from the authors' series of patients with cloaca and convey the improved understanding and surgical treatment of the condition's wide spectrum of complexity.


METHODS
The medical records of 339 patients with cloaca operated on by the authors were retrospectively reviewed.


RESULTS
A total of 265 patients underwent primary operations, and 74 were secondary. All patients were approached posterior sagittally; 111 of them also required a laparotomy. The average length of the common channel was 4.7 cm for patients that required a laparotomy and 2.3 cm for those that did not. Vaginal reconstruction involved a vaginal pull-through in 196 patients, a vaginal flap in 38, vaginal switch in 30, and vaginal replacement in 75 (36 with rectum, 31 with ileum, and 8 with colon). One hundred twenty-two patients underwent a total urogenital mobilization. Complications included vaginal stricture or atresia in 17, urethral strictures in 6, and urethro-vaginal fistula in 19, all of which occurred before the introduction of the total urogenital mobilization. A total of 54% of all evaluated patients were continent of urine and 24% remain dry with intermittent catheterization through their native urethra and 22% through a Mitrofanoff-type of conduit. Seventy-eight percent of the patients with a common channel longer than 3 cm require intermittent catheterization compared with 28% when their common channel was shorter than 3 cm. Sixty percent of all cases have voluntary bowel movements (28% of them never soiled, and 72% soiled occasionally). Forty percent are fecally incontinent but remain clean when subjected to a bowel management program. Forty-eight patients born at other institutions with hydrocolpos were not treated correctly during the neonatal period. The surgeons failed to drain the dilated vaginas, which interfered with the drainage of the ureters and provoked urinary tract infections, pyocolpos, and/or vaginal perforation. In 24 patients, the colostomy was created too distally, and it interfered with the pull-through. Twenty-three patients suffered from colostomy prolapse. All of these patients required a colostomy, revision before the main repair. Thirty-six patients underwent reoperation because they had a persistent urogenital sinus after an operation done at another institution, and 38 patients underwent reoperation because they suffered from atresia or stenosis of the vagina or urethra. The series was divided into 2 distinct groups of patients: group A were those with a common channel shorter than 3 cm (62%) and group B had a common channel longer than 3 cm (38%).


CONCLUSIONS
The separation of these groups has important therapeutic and prognostic implications. Group A patients can be repaired posterior sagittally with a reproducible, relatively short operation. Because they represent the majority of patients, we believe that most well-trained pediatric surgeons can repair these type of malformations, and the prognosis is good. Group B patients (those with a common channel longer than 3 cm), usually require a laparotomy and have a much higher incidence of associated urologic problems. The surgeons who repair these malformations require special training in urology, and the operations are prolonged, technically demanding, and the functional results are not as good as in group A. It is extremely important to establish an accurate neonatal diagnosis, drain the hydrocolpos when present, and create an adequate, totally diverting colostomy, leaving enough distal colon available for the pull-through and fixing the colon to avoid prolapse. A correct diagnosis will allow the surgeon to repair the entire defect and avoid a persistent urogenital sinus. Cloacas comprise a spectrum of defects requiring a complex array of surgical decisions. The length of the common channel is an important determinant of the potential for urinary control, and predicts the extent of surgical repair.