How to investigate the individual anatomy of cloacas, at birth and beforereconstruction

Paola MidrioPediatric Surgery Unit Cà Foncello Regional Hospital – Treviso, ITALY

Investigation at birth:

INSPECTION, abdominal us,

(abdominal x-ray + echo)

Investigate anatomy of cloaca at birth: is this normal?

´ How many orifices?´ Normal position?´ Normal size?

´ Abdominal and renal US´à PSARP/ colostomy

Investigate anatomy of cloaca at birth: is this normal?

´How many orifices?´Normal position?´Normal size?

´ Abdominal and renal US´à PSARP/ colostomy

Investigate anatomy of cloaca at birth: is thisnormal? Case 1

´ Male or female?´ How many orifices?´ Observe micturation and

defecation (it may take 12 hours)´ ….meantime ask for abdominal

and renal US

´ US described 2 normal kidneys, double uterus, normal ovaries, no abdominal mass à girl –colostomy

Case 1Micturation and defecation

Case 2

´ Prenatal diagnosis of a girl

´ Male or female?´ Orifices??´ Urine and meconium?

´ Abdominal US + laparoscopyà girl, colostomy

Case 3

Prenatal diagnosis of a girl

Orifices?Empty “scrotum”

US: 2 normal kidneys and bladder , apparently no uterus/ovariesY chromatin test

No urine, nomal stooling

à Y positivityà Left testis in the scrotumà vesicostomy

Case 4

Prenatal diagnosisof bilateral kidneydisplasia, girl

Orifices?

Abdominal and renal US (kidneys displasia)

Micturation and defecation throughmiddle hole

-à peritoneal dyalisis for renal failure at 1 year

What do you see?

Courtesy of E.Leva, MD

What do you see?

Intestine?Heart shadow?Vertebra?Ribs?

Investigation before reconstruction:

colostogram, genitoscopy and more

Investigation before reconstruction: colostogram

Before reconstruction: colostogram

´ Information:´ Quality of sacrum´ Lenght of colon´ Morphology of

pelvic organs´ Lenght of common

channel (difficult!)

movie

Before reconstruction: genitoscopy

´ Combined 3D rotational fluoroscopic-MRI cloacagram procedure definesluminal and extraluminal pelvic anatomy prior to surgical reconstruction of cloacal and other complex pelvic malformations. Jarboe MD, Pediatr Surg Int. 2012 Aug;28(8):757-63.

´ MRI of persistent cloaca: can it substitute conventional imaging? Mohammad SA1, Eur J Radiol. 2013 Feb;82(2):241-51 MRI is a valuable tool in exploring the different internal anatomical features of the cloacal anomaly; and when combined with endoscopy, MRI can make other preoperativeconventional imaging unnecessary.

´ Magnetic resonance imaging of anorectal malformations.Podberesky DJ. Magn Reson Imaging Clin N Am. 2013 Nov;21(4):791-812.

Before reconstruction: MRI

Before reconstruction: MRI

Courtesy of

prof. I. de Blaauw

C.E.J Sloots, MD

In summary: at birth

´ ACCURATE general inspection

´ Abdominal and renal US

´ (Plain X-ray)

In summary: before reconstruction (3-6 months)

´ Colostogram

´ Cysto-vaginoscopy with measure of common channel

´ Pelvic MRI ?