SURGICAL RECONSTRUCTION OF CLOACAL MALFORMATION CAN ALTER BLADDER FUNCTION: A COMPARATIVE STUDY WITH ANORECTAL ANOMALIES

Increased risk of chronic kidney disease in children with anorectal malformations

BACKGROUND

Anorectal malformations (ARM) are often accompanied by urological anomalies, which can contribute to the development of chronic kidney disease (CKD).

OBJECTIVE

This study aimed to investigate the prevalence of kidney and urinary tract anomalies, as well as bladder dysfunction, and their potential impact on the development of CKD in children with ARM.

STUDY DESIGN

This single-center, retrospective study included 175 children with ARM, after excluding 75 children with missing data. Clinical and radiological findings and serum creatinine levels were obtained from medical records. Anorectal malformations were classified as "high" and "low" type based on the Wingspread classification, and also further classified by fistula type and sex distribution according to the Krickenbeck International Classification. CKD was defined and staged according to the KDIGO (Kidney Disease Improving Global Outcomes) guidelines.

RESULTS

The median age of the patients was 9.7 years, with a male-to-female ratio of 1.13:1. Among the 175 patients, 97 (55 %) had intermediate or low-type ARM, and 78 (45 %) had high-type ARM. Kidney and/or urinary tract anomalies were identified in 85 patients (48.5 %), with 63 having kidney anomalies and 71 having urinary tract anomalies. The most common urinary tract anomaly was vesicoureteral reflux (n = 58). Bladder dysfunction was observed in 56 patients (32 %). CKD was diagnosed in 30 patients (17 %); six of them were in CKD stage 5, and the remaining 24 were in stages 2-4. The development of CKD was more common in both females and males with kidney anomalies (p < 0.001), urinary tract anomalies (p < 0.001 and p = 0.002, respectively), bladder dysfunction (p < 0.001), urinary tract infection (p < 0.001), in addition females with persistent cloaca (p = 0.023) and spinal anomalies (p = 0.013). Kidney anomalies and bladder dysfunction were independently associated with the development of CKD (p < 0.001 and p = 0.046, respectively).

DISCUSSION

This study highlights that approximately half of the children with ARM had kidney and urinary tract anomalies, and one-third had bladder dysfunction. Additionally, almost one-fifth of the patients developed CKD, mostly in the early stages. Our findings also suggest that both kidney anomalies and bladder dysfunction are significant risk factors for CKD development in children with ARM.

CONCLUSION

This study emphasizes the presence of kidney anomalies, along with bladder dysfunction as risk factors for CKD. Physicians should take care to monitor and manage these risks to minimize the long-term impacts on kidney health in children with ARM.

The effect of surgical reconstruction on bladder function in cloacal malformation: A study of urodynamics

BACKGROUND

Girls with cloacal malformation are at risk of bladder dysfunction, with nearly 90% exhibiting some degree of dysfunction. Surgical dissection, particularly with total urogenital mobilization (TUM), has been hypothesized as a cause of worsening bladder function despite this population commonly having associated vertebral and spinal cord abnormalities that may also explain bladder dysfunction. More recently there has been great effort to select the appropriate surgical technique for cloacal repair in each patient in order to minimize dissection and potential damage to the bladder. We aimed to evaluate the effect of surgical cloacal repair on bladder function based on pre and post-surgery urodynamics (UDS) testing.

METHODS

A prospectively collected database of patients with anorectal malformation at a single center was queried for girls with cloacal malformations who had undergone surgical repair from 2015 to 2022. It is our current protocol to perform UDS before and after cloacal repair. Only patients who completed both pre and post-surgery UDS were included. UDS were evaluated and classified using the UMPIRE protocol.

RESULTS

A total of 48 patients were included in the cohort. The majority of patients (79.2%) had stable or improved UDS post-op leaving 10 patients (20.8%) who had worsening UDS. Long common channel (≥3 cm) was the only factor significantly associated with worsening UDS. (p = 0.03) Nearly 30% (n = 8) of those undergoing UGS had worse post-op UDS compared to 9.5% (n = 2) with TUM. All patients who worsened UDS initially had safe UDS that changed to intermediate, except for one who worsened to hostile in the setting of significant social challenges and non-compliance. Only common channel length was predictive of worsening UDS, while the type of surgical approach and spine status were not. While the overall risk of worsening UDS after TUM is only 9.5%, patients with normal spines undergoing TUM had the lowest risk, seen in only one in 15 patients (6.6%).

CONCLUSIONS

Common channel length was the most significant predictor of worsening UDS, while spine status and surgical technique (TUM vs UGS) did not significantly impact this finding. By following this established surgical protocol based on common channel and urethral lengths, is rare for the surgical cloacal repair to result in worsening post-op UDS, particularly in those undergoing TUM for short common channel and normal spine.

Outcomes of one-stage feminizing genitoplasty in children with congenital adrenal hyperplasia and severe virilization

PURPOSE

To present our surgical experience and outcomes in congenital adrenal hyperplasia (CAH) patients with severe virilization using a combined technique of total urogenital mobilization (TUM) and a modified pull-through vaginoplasty to perform a safe and effective one-stage feminizing genital reconstruction for these children.

METHODS

Fourteen CAH patients with severe virilization, defined by a Prader IV and V rating of the external genitalia, underwent TUM followed by a limited vaginal pull-through procedure from June 2016 to December 2020. Postoperative anatomical and cosmetic outcomes, and urinary continence, were evaluated.

RESULTS

Out of the 14 cases in this study, 8 were classified as prader IV and 6 as Prader V. The median age at surgery was 11 months (range 6-36 months), and the mean urethral length was 1.4 cm (range 1.2-1.8 cm). The median follow-up period was 4 years. Our cosmetic outcomes were good in 11 (78.5%), satisfactory in 2, and poor in one case. All patients achieved age-appropriate toilet training without urinary incontinence.

CONCLUSION

Adopting our surgical approach of TUM with modified pull-through vaginoplasty has simplified feminizing surgical reconstruction in CAH cases with severe genital atypia and a very high vaginal confluence with short urethral length, yielding adequate introitus with good anatomical and cosmetic appearance and adequate urinary continence outcomes.

Partial urogenital mobilization in cloacal malformation: is it a viable option?

INTRODUCTION

Total Urogenital Mobilization (TUM) has been the standard surgical approach for the urogenital complex in Cloacal Malformations (CM) since its inception in 1997. Partial Urogenital Mobilization (PUM) in CM remains an under-utilized or under-reported option. The main anatomical difference between TUM and PUM is the division of the pubo-urethral ligaments.

OBJECTIVE

We explored the feasibility of PUM in a select subset of our patients with CM and report early outcomes.

STUDY DESIGN

We retrospectively reviewed prospectively collected data of all our CM patients who had primary reconstruction at our centre from 2012 to 2020. We included in our review the patients who underwent PUM. Mullerian abnormalities, spinal cord involvement, common channel length (CC), urethral length (UL), surgical reconstruction, and outcomes including urinary continence, recurrent UTI, ultrasound and preoperative DMSA/MAG3, cystovaginoscopy post-reconstruction, and post-void residuals were noted.

RESULTS

Fifty-three patients had primary reconstruction, and of these, eleven had a common channel less than 3 cm. Of the eleven, only one underwent TUM. In the PUM group, two underwent filum untethering (20%). Mullerian duplication was noted in 5 patients (50%). The median CC length = 1.6 cm (range = 1.5cm-2.7 cm), and median UL = 1.5 cm (range = 1.5cm-2.5 cm). Follow-up ranged from 9 to 134months (median = 63months). Post-reconstruction all had a separate urethral and vaginal opening on examination and cysto-vaginoscopy. The continence outcomes are summarized in Fig.1.

DISCUSSION

Although TUM is the most common solution for the urogenital complex in CM, a subset would be suitable for PUM, and this option is under-utilized or under-reported in literature. We presume that many who had TUM probably only needed a PUM, and therefore could report better outcomes from a bladder function aspect. It is important to differentiate the two, and outcomes should be appropriately categorized. Our default approach is a PUM in all CM with less than 3 cm common channel. Only the lateral and posterior aspects of the urogenital complex are mobilized and if the urethra did not reach a satisfactory level for easy intermittent catheterization, then we proceed to a TUM dividing the pubo-urethral ligaments. PUM avoids the potential complications related to dividing the pubo-urethral ligament in TUM. It may also avoid the need for CIC which is encountered in patients who undergo TUM.

CONCLUSION

PUM is a viable alternative in cloacal malformations with good outcomes in those with a common channel under 3 cm. This of course requires appropriate patient selection and accurate categorization of interventions to understand the true outcomes.

A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience

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.

Anatomy, physiology, and evaluation: Bowel, bladder, and sexual disorders

Our present understanding of bowel and bladder control has changed dramatically with the introduction of functional imagining technologies such as PET, SPECT, fMRI scanning, and near-infrared spectroscopy of the brain. Urologists tend to see control of urination and defecation as processes that occurred at or below the level of the pons for the most part. In this chapter, we examine the control of storing and emptying of urine and stool from what will be a more neurocentric perspective, integrating the frontal lobes into the process and moving beyond the pons on which most of the literature has focused in the past. Utilizing this approach gives us a better understanding of why there is an overlapping of neuropsychiatric problems in many patients with voiding dysfunction.

An Alternative Approach to Single-Stage Cloaca Repair: Image-Guided Anorectoplasty with Delayed Vaginoplasty

BACKGROUND

Cloacal anomalies occur when a fetus's rectum, vagina, and urethra fail to separate and result in 1 common channel at birth. They are commonly managed by complex reconstruction in the first year of life. This manuscript presents an alternative approach to management in patients with absent or nondilated Mullerian structures.

CASE

Image-guided, combined endoscopic and laparoscopic surgery (CELS) was used to perform an anorectal pull-through at 5 months of age on a patient with persistent cloaca and no definite vaginal or uterine structures seen on MRI and endoscopy. Urogenital reconstruction is delayed until adolescence.

SUMMARY AND CONCLUSION

We hypothesize that performing a minimally invasive anorectoplasty on patients with complicated anatomy and low risk for hydrocolpos could potentially result in improved urologic function and better psychosocial outcomes. Delaying vaginoplasty will enable determination of the function of remnant Mullerian structures and allow the patient to direct the augmentation approach.

The correlation between the transverse rectal diameter and urodynamic findings in children with neurogenic bowel and bladder dysfunction

BACKGROUND

The aim of this study was to examine the correlation between the transverse rectal diameter and urodynamic findings in children with neurogenic bowel and bladder dysfunction.

METHODS

Between 2014 and 2022, we prospectively evaluated 81 consecutive spina bifida children with neurogenic bowel and bladder dysfunction (35 boys and 46 girls, mean age 9.5 ± 3.4 years). All patients underwent echosonographic measurement of transverse rectal diameter and urodynamic studies.

RESULTS

We found a strong negative correlation between transverse rectal diameter and maximum bladder capacity (r = -0.682, p < 0.001) and compliance (r = -0.690, p < 0.001). There was also a strong positive correlation between transverse rectal diameter and maximal detrusor pressure (r = 0.650, p < 0.001), leak point pressure (r = 0.793, p < 0.001), and PVR (r = 0.762, p < 0.001). In ROC analysis, transverse rectal diameter demonstrated good performance for distinguishing children with upper urinary tract deterioration, with an AUC of 0.857 (95% CI 0.761-0.953). A transverse rectal diameter ≥40 mm was 83.3% sensitive and 100% specific for the diagnosis of unfavorable urodynamic patterns.

CONCLUSION

There is a correlation between the transverse rectal diameter and urodynamic findings in children with neurogenic bowel and bladder dysfunction. Ultrasonographically assessed transverse rectal diameter of ≥40 mm may be used as a risk factor for upper urinary tract deterioration (unfavorable urodynamic findings). We suggest the transverse rectal diameter echosonographic measurement use as an integral part of the diagnostic approach in children with neurogenic bowel and bladder dysfunction, as it can help decision-making while waiting for urodynamic testing.

Long-term urological assessment and management of cloaca patients: A single tertiary institution experience

PURPOSE

Preserving renal function and achieving urinary continence are the most important urological goals in the management of cloaca patients. Many prognostic factors have been described, such as the length of the common channel (CC) and urethra, the presence of spinal dysraphism, and associated urological anomalies. The aim of this study was to analyze urinary continence status and need for reconstructive procedures and their correlation with urological risk factors in a series with a long-term follow-up.

MATERIAL AND METHODS

The institutional database of patients with anorectal malformations was reviewed. Patients with cloaca who underwent cloacal reconstructive surgery at our institution between January 1995 and May 2015 and who had a minimum postoperative follow-up of 5 years with complete urological care were included. Urologic and spinal anomalies, length of the CC, renal function, urodynamic study patterns, continence status, and urologic reconstructive surgeries were assessed. A CC was defined as long CC when its measure was longer than 3 cm in the cloacogram and then confirmed by cystoscopy. Descriptive statistical analysis was performed.

RESULTS

Fifty-five cloaca patients with a mean follow-up of 12 years (5-20) were included. A long CC was documented in 38 patients (69%). The sacral ratio (SR) was <0.4 in the AP projection in 30 (54.5%). Urodynamic evaluation revealed an inadequate detrusor contraction pattern in 65.4% of the cases. A CC >3 cm and SR <0.4 were significantly correlated with this urodynamic finding. A total of 50 patients (91%) achieved urinary continence, but only 30.9% had volitional voiding and 56% needed major urological reconstructive surgeries. Eighteen patients (32.7%) were in stage 2 or more of chronic kidney disease (<90 ml/min/1.73 m2) at the last follow-up visit.

CONCLUSION

Cloacal management requires a multidisciplinary and long-term follow-up. Early assessment of prognostic urological factors and accurate stratification of each patient are essential to avoid renal impairment and achieve urinary continence in the future. The length of the common channel and the presence of spinal dysraphism were correlated with the presence of neurovesical dysfunction specifically an abnormal bladder contraction efficiency. A significant number of these patients will need catheterization and reconstructive urinary tract surgeries to attain urinary continence.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level 3. Retrospective comparative study.

Long-term urologic and gynecologic follow-up and the importance of collaboration for patients with anorectal malformations

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.

Clinical and urodynamic outcomes in children with anorectal malformation subtype of recto-bladder neck fistula

INTRODUCTION

Patients with anorectal malformations (ARMs) have a high incidence of genitourinary anomalies. Those with a recto-bladder neck fistula may represent a high-risk group, but their long-term urologic outcomes are poorly described.

OBJECTIVE

To evaluate the clinical and urodynamic outcomes in a large cohort of patients with an ARM subtype of recto-bladder neck fistula.

MATERIALS AND METHODS

A retrospective cohort study was performed of patients who had been treated for a recto-bladder neck fistula at the present institution since 2007. The primary outcomes were the ability to achieve urinary continence after 4 years of age, and development of a mildly decreased glomerular filtration rate (GFR) or worse (<89 ml/min/1.73 m²). Continence was defined as the ability to store urine for 3-4 h during the day and 8 h overnight without leakage.

RESULTS

Demographic and clinical data are provided in the Summary Table. The most recent urodynamic findings included the presence of detrusor overactivity in 30 (75%) patients, median leak point pressure of 56.0 cmH₂O (range, 14-140), median functional cystometric capacity at 40 cmH₂O of 125.5% age-expected capacity (range, 36-473%), and median maximum cystometric capacity of 131.0% age-expected capacity (range, 44-473%). A mildly decreased GFR or worse developed in 13 (24%) patients. Of the 52 (78%) patients who were followed by pediatric urology at the present institution with a median follow-up of 30.9 months (range, 0.0-86.8), 35 (67%) were at least 4 years of age and could be assessed for continence. Continence was achieved in five (14%) patients voiding spontaneously and 15 (43%) performing CIC. Recurrent urinary tract infections (UTI) (OR 0.70, P = 0.006) were an independent predictor of incontinence, while urethral anomalies (OR 1.40, P = 0.03) were an independent predictor of chronic kidney disease (CKD) on multiple logistic regression analysis.

DISCUSSION

The findings favorably compared with other studies, but were more robust due to the size of the cohort and breadth of urologic evaluation. Limitations included the retrospective design at a single institution. Incomplete clinical data and misclassification of continence may have lead to bias.

CONCLUSIONS

This large cohort of patients with an ARM subtype of recto-bladder neck fistula had a high incidence of genitourinary anomalies. They were rarely able to achieve continence with spontaneous voiding alone and were at risk of developing CKD, both of which were likely multifocal in origin. Long-term urologic follow-up is warranted for patients with a recto-bladder neck fistula.

Urogenital Management in Cloaca: An Alternative Approach

Introduction:

In the management of cloaca, there is concern that dissection of the urogenital sinus in early childhood with the aim of total anatomical correction is hazardous. Avoiding such mobilization and providing mitrofanoff channel, when needed, till peripubertal period reduces complications and is technically easier.

Materials and Methods:

Forty-three cases of cloaca were managed in the period 2004–2016. Case records and radiology were reviewed retrospectively. The follow-up evaluation was done by looking into voiding history, bowel movements, and menstruation history.

Results:

There were three groups of children, namely, those with no reconstruction done elsewhere except a diverting fecal stoma (Group I, n = 25), those who had undergone anorectal correction elsewhere with no attempt at urogenital reconstruction (Group IIA, n = 13), and those with attempted bowel and genitourinary reconstruction elsewhere (Group IIB, n = 5). The Group I children (one still awaiting reconstruction) underwent early rectal reconstruction followed by expectant management of the urogenital apparatus. The 18 referred cases had multiple problems, chiefly urogenital, of congenital or iatrogenic origin. While urinary reconstruction included bladder augmentation, ileal neobladder, bladder neck closure, and ureteric reimplantation, the foundation of urinary management was intermittent catheterization through mitrofanoff stoma and the avoidance of any dissection of the cloacal common channel. Surgery on the genital tracts included drainage of hydrocolpos, perineal surgery for low vaginae and abdominoperineal vaginoplasty for high vaginae in the peripubertal period with or without bowel supplementation. Spontaneous voiding was maintained in 17 of 25 (68%) Group I girls (including one death later from intestinal complications), 7 of 13 (54%), Group IIA girls, and 1 of 5 (20%) Group IIB girls. Painless menstruation was noted in eight postpubertal girls, three through the cloacal channel (awaiting reconstruction) and five through the reconstructed vagina. Most of the children are on a bowel management program for fecal cleanliness with washouts through the neoanus or Malone's stoma.

Conclusion:

We report a nonconventional approach to cloaca based on avoiding dissection of or around the common channel for urethrovaginal reconstruction, opting for mitrofanoff stoma for intermittent catheterization, when needed, and late vaginal reconstruction. We believe this approach has reduced the overall need for intermittent catheterization.

Long-term urological outcomes in cloacal anomalies

Cloacal anomalies are the most complex and severe form of congenital anorectal malformations (ARM) and urogenital malformations, and it has been well documented that increased severity of ARM leads to worse outcomes. While short-term data on persistent cloaca are available, a paucity of data on long-term outcomes exists, largely because of a lack of uniform terminology, inclusion with other ARM and evolution of the operative technique. On comprehensive review of the published literature on long-term urological outcomes in patients with cloacal anomalies, we found a significant risk of chronic kidney disease and incontinence, however, with improvements in surgical technique, outcomes have improved. Continence often requires intermittent catheterization and in some cases, bladder augmentation. The complexity of cloacal malformations and associated anomalies make long-term multidisciplinary follow-up imperative.

Congenital cloaca: Long-term follow-up results with emphasis on outcomes beyond childhood

Persistent cloaca remains a challenge for pediatric surgeons and urologists. Reconstructive surgery of cloacal malformations aims to repair the anorectum, urinary tract, and genital organs, and achieve fecal and urinary continence as well as functional genital tract capable for sexual activity and pregnancy. Unfortunately, even in most experienced hands these goals are not always accomplished. The endpoint of the functional development of bowel, urinary, and genital functions is the completion of patient's growth and sexual maturity. It is unlikely that there will be any significant functional improvement beyond these time points. About half of the patients with cloaca attain fecal and urinary continence after their growth period. The remaining half stay clean or dry by adjunctive measures such as bowel management by enemas or ACE channel, and continent urinary diversion or intermittent catheterization. Problems related to genital organs such as obstructed menstruations, amenorrhea, and introitus stenosis are common and often require secondary surgery. Encouragingly, most adolescent and adult patients are capable of sexual life despite often complex vaginal primary and secondary reconstructions. Also, cloacal malformation does not preclude pregnancies, although they still are quite rare. Pregnant patients with cloaca require special care and follow-up to guarantee uncomplicated pregnancy and preservation of anorectal and urinary functions. Cesarean section is recommended for cloaca patients. The self-reported quality of life of cloaca patients appears to be comparable to that of female patients with less complex anorectal malformations.

Early urologic considerations in patients with persistent cloaca

Cloacal malformations represent one of the most complex conditions among anorectal malformations. Urologic conditions occur with an increased frequency in cloaca patients compared to patients with other types of ARM. The morbidity of the upper and lower urinary tract dysfunction/malformations at times can be severe; manifested by urinary tract infection, lower urinary tract symptoms, urinary incontinence, chronic kidney disease, and even end stage renal disease. Long-term follow-up of patients with cloaca has described significant chronic kidney disease and end-stage renal disease. Whether this rate of chronic kidney disease is a function of intrinsic renal dysplasia or acquired renal injury from neurogenic bladder is currently unknown. However, it is well known that severe lower urinary tract dysfunction, no matter the etiology, poses significant risk to the upper tracts when untreated. Neonatal assessment of the urinary tract accompanied by early identification of abnormal structure and function is therefore fundamental to minimize the impact of any urologic condition on the child's overall health. Adequate management of any associated bladder dysfunction is essential to preserving renal function, minimizing risk of urinary tract infection, and potentially avoiding need for future reconstructive surgery. This article summarizes our institution's approach to the ongoing early urologic management in patients with cloaca.

A new approach for persistent cloaca: Laparoscopically assisted anorectoplasty and modified repair of urogenital sinus

PURPOSE

The aim of this study is to describe the surgical technique and evaluate midterm outcomes of the technique: laparoscopically assisted anorectoplasty (LAARP) and modified repair of urogenital sinus.

METHOD

Seven patients with persistent cloaca underwent LAARP and modified repair of urogenital sinus between November 2005 and December 2010. The ages of the patients at the time of operation were 6 months to 15 years. Distal colostogram and micturating cystogram were performed preoperatively to identify the type of persistent cloaca. The rectal pouch was above the pubococcygeal line in all patients. The operations were carried out using 3 trocars. CO2 pressure was maintained at 8-12 mm Hg.

RESULT

Laparoscopically assisted anorectoplasty and modified repair of urogenital sinus were successfully performed in all cases. Mean operation time was 125.7±8.4 minutes (range, 110-135 minutes). Intraoperative blood loss was minimal. There were no intraoperative complications. Follow-up was obtained in all patients. The median follow-up period was 5.7±2.1years (range, 4-9 years). Mucosal prolapse occurred in 2 cases (28.6%). No urethrovaginal fistula, acquired anorectal atresia or urethral injury was observed. Only 1 patient (14.3%) was incontinent of urine occasionally but urine retention or vesicoureteral reflux was not observed. Two patients (28.5%) had 2-4 stools per day but no social problem. Only 1 patient (14.3%) had constipation and required laxatives.

CONCLUSION

Anoplasty, vaginoplasty and urethroplasty can be performed simultaneously in patients with persistent cloaca through LAARP and modified repair of urogenital sinus.

Impact of spinal dysraphism on urinary and faecal prognosis in 25 cases of cloacal malformation

OBJECTIVE

Urinary and faecal continence are key challenges goal of cloacal malformation management. Most well-known prognostic factors are the length of common channel (CC) and the presence of a sacral defect, but the impact of associated spinal dysraphism is less well documented. The aim of this study was to investigate the impact of different types of dysraphism on urinary and faecal continence in this patient population.

MATERIALS AND METHODS

From 1991 to 2011, charts and office notes of 25 patients with cloacal malformation were retrospectively reviewed. At last clinic visit, urinary and faecal continence status according to Krickenbeck criteria were correlated with the length of CC, the presence of a sacral defect (sacral ratio), and the presence of different types of spinal cord dysraphism using magnetic resonance imaging (MRI) and Fisher's exact test.

RESULTS

Mean follow-up was 8 years (4 months-21 years). The sacral ratio was abnormal (below 0.74) in 18 cases out of 25 (72%). MRI review showed normal spinal cord in eight out of 23 cases (Group 1), spinal cord anomaly in 15 out of 23 cases (65%) including nine cases of tethered cord complex (Group 2) and six cases of a short spinal cord (Group 3). While statistical analysis showed a difference regarding urinary prognosis between the groups (p=0.005), no significant difference was found regarding faecal prognosis. None of the six patients with short spinal cord were continent for both urinary and faecal prognosis.

CONCLUSIONS

This is the first study, which highlights the impact of different types of spinal dysraphism on functional outcome in patients with cloaca. Short spinal cord seemed to carry the worst prognosis. A prospective study with a larger series is mandatory to confirm these preliminary results.

Endoscopic surgery as an adjuvant treatment modality before or after definitive correction of cloacal anomalies

OBJECTIVE

To evaluate the effectiveness of endoscopic surgery before or after definitive correction in patients with a persistent cloaca.

MATERIALS AND METHODS

The medical records of 16 patients diagnosed with persistent urogenital sinus at our institution were retrospectively reviewed. Of these 16 patients, five underwent endoscopic surgery, such as visual internal urethrotomy or transurethral incision by a single surgeon at the time of or after colostomy formation or corrective surgery.

RESULTS

All patients underwent colostomy 1-2 days after birth. Three patients were treated by endoscopic procedures before corrective surgery owing to voiding difficulty, urinary tract infection, or hydrocolpos, at a median age of 1 month. Another two patients underwent endoscopic surgery after definitive correction of the cloaca owing to urethral stricture or urinary incontinence. After endoscopic surgery, all patients voided well without residual urine or were catheterised easily without incontinence. Endoscopic modality played a substantial role in managing complications or resolving the anatomical barrier to decompress the genitourinary tract in patients with a common urogenital sinus length of <3 cm.

CONCLUSIONS

Endoscopic surgery for a cloacal anomaly is a minimally invasive adjuvant technique for bladder neck obstruction, urethral stricture, and hydrocolpos with a thickened vaginal septum.

The Surgical Correction of Urogenital Sinus in Patients with DSD: 15 Years after Description of Total Urogenital Mobilization in Children

Total urogenital sinus mobilization has been applied to the surgical correction of virilized females and has mostly replaced older techniques. Concerns have been raised about the effect of this operation on urinary continence. Here we review the literature on this topic since the description of the technique 15 years ago. Technical aspects and correct nomenclature are discussed. We emphasize that the term "total" refers to an en-bloc dissection and not to the extent of the proximal dissection. No cases of urinary incontinence have been reported following this operation. It is yet too early to evaluate results regarding sexual function but it is likely that the use of a posterior skin flap to augment the introitus will minimize the development of introital stenosis.

Long-term renal function and continence status in patients with cloacal malformation

INTRODUCTION

Urinary continence after cloacal repair is difficult to achieve and renal outcome in patients with cloacal malformations has been scarcely reported. As a result, we reviewed our experience with cloacal malformations to determine the status of continence and the long-term renal function in these children.

METHODS

A retrospective chart review from 1990 to 2003 identified 12 patients with cloacal malformation (1 posterior, 4 complex and 7 classical) who underwent surgical reconstruction. The confluence was defined as high (common channel >/= 3 cm) and low (< 3 cm) by cystovaginoscopy. Renal ultrasound, voiding cystouretrogram, renal scan and sacral radiograph were performed in all children. Most patients underwent 1-stage abdominoperineal pull-through, applying the principle of total urogenital sinus mobilization. We collected data regarding hydronephrosis, vesicoureteral reflux and split differential renal function. Renal outcome was evaluated based on glomerular filtration rate and age-adjusted serum creatinine values (mumol/L). Urinary continence was defined as a dry interval > 4 hours.

RESULTS

Patients' mean age at surgery was 20 months (range 7-29 mo). Of the 12 children who underwent cloacal repair, 7 (58.3%) had a common channel >/= 3cm. Renal anomalies were identified in 3 of 12 (25%) girls: there were 2 solitary kidneys and 1 pelvic kidney. Lumbar-sacral radiography demonstrated bony abnormalities in 11 of the 12 (91.6%) cases: hemivertebra in 3 cases, sacral agenesis in 4 cases, hypoplastic sacrum in 3 cases and bifid sacrum in 1 case. Total urogenital sinus mobilization through an abdominoperineal approach in a single stage was performed in 8 girls. Follow-up ranged from 4 to 14 years (mean 8.5 yr). Eight (66.6%) children had dry intervals > 4 hours, 5 (62.5%) of them were on clean intermittent catheterization through a Mitrofanoff channel and 1 (12.5%) was through the urethra. The remaining 2 (25%) patients were voiding spontaneously. Three (33.3%) patients were totally incontinent, and 1 (8.3%) patient was awaiting reconstruction. The mean measured glomerular filtration rate was 93.5 mL/min/1.73m(2) (range 34-152 mL/min/1.73m(2)). Four (57.1%) of 7 patients who had a common channel >/= 3 cm ended up needing augmentation cystoplasty, compared with none of the patients with a common channel < 3 cm (57.1% v. 0%, p = 0.038).

CONCLUSION

Urinary continence can be achieved in most patients with cloacal malformation at the expense of major reconstructive surgery and despite the presence of associated urological abnormalities. However, these children harbour an important risk for renal impairment later in life and should be closely monitored.

Anorectal malformation and associated end-stage renal disease: management from newborn to adult life

BACKGROUND/OBJECTIVE

Renal failure remains one of the most significant causes of morbidity in patients with anorectal malformations (ARM). In the modern era, an increasing number of children born with ARM and genito-urinary (GU) anomalies reach adulthood and require continued multidisciplinary care for the rest of their life. The aim of this study is to present our institutional experience in the management of pediatric chronic renal failure related to severe GU anomalies and anorectal malformations.

METHODS AND RESULTS

Three hundred twenty-one patients with ARM have been followed at our institution since 1987. Six patients developed end-stage renal disease (ESRD) and received a kidney transplant at different ages. One patient is currently followed for mild, progressive chronic renal failure. These seven cases are reported along with a broad discussion concerning etiology of renal failure, neonatal surgical management, pediatric dialysis, urologic issues, and kidney transplantation.

CONCLUSION

Complex GU anomalies associated with ARM require a long-term approach by specialized pediatric and adult clinicians to optimize the care of this selected population of patients.

Urological anomalies in anorectal malformations in The Netherlands: effects of screening all patients on long-term outcome

INTRODUCTION

Urological anomalies are frequently seen in patients with anorectal malformations (ARM) and can result in upper urinary tract deterioration. Whether the current method of screening is valid, adequate and needed for all patients is not clear. We, therefore, evaluated the urological screening methods in our ARM patients for changes in urological treatment, outcome and follow-up.

METHODS

The medical records of 331 children born with an ARM in the period 1983-2003 were retrospectively studied. Documentation of diagnosis, screening method, urological anomalies, treatment, complications, follow-up and outcome were measured.

RESULTS

The overall incidence of urological anomalies was 52%. The incidence of urological anomalies and urological follow-up time decreased with diminishing complexity of the ARM. Hydronephrosis, vesico-urethral reflux, lower urinary tract dysfunction and urinary incontinence were encountered most. Treatment invasiveness increased with the increase of complexity of an ARM. Lower urinary tract dysfunction needing urological care occurred in 43% in combination with lumbosacral or spinal cord anomalies and in 8% with no abnormalities in the lumbosacral-/spinal region.

CONCLUSIONS

Urological anomalies in patients with complex ARM are more severe than in patients with less complex ARM. Ultrasonography of the urinary tract should be performed in all patients. Voiding cysto-urethrography can be reserved for patients with dilated upper urinary tracts, urinary tract infections or lumbosacral and spinal abnormalities. All patients with complex ARM need urodynamic investigations. When using these indications, the screening for urological anomalies in ARM patients can be optimized with long-term follow-up in selected patients.

Self-report of difficult defecation is associated with overactive bladder symptoms

AIMS

The association of dysfunctional bowel elimination with lower urinary tract symptoms is well known in children, but not in adults. It was our objective to assess lower urinary tract symptoms (LUTS) in women who report difficult defecation (DD).

METHODS

This is a secondary analysis of 2,812 women, aged 35-64, who participated in a telephone interview. All subjects were asked "When you move your bowels, does the stool come out easily?" DD was considered present in those answering "no." All subjects were queried regarding LUTS, urinary infections in the past year, self-perceived health status, medical history, and demographics. Symptoms of stress incontinence (five items), urge incontinence (five items), and the impact of these symptoms on their quality of life were solicited from subjects reporting more than 12 episodes of incontinence in 1 year.

RESULTS

DD was reported by 10.4% (290/2,790) of women. Women with DD had higher LUTS than those who did not: nocturia (mean 1.8 ± 0.1 vs. 1.3 ± 0.0), urgency (47.6% vs. 29.2%), increased daytime frequency (mean 8.2 ± 0.3 vs. 7.2 ± 0.1), dysuria (22.9% vs. 13.7%), and a sensation of incomplete bladder emptying (55.6% vs. 28.2%). DD women were more often menopausal, reported a fair or poor self-reported health status, and had a higher number of comorbidities, less formal education, and lower annual household income.

CONCLUSIONS

Women with symptoms of DD have an increased rate of LUTS, consistent with the diagnosis of overactive bladder without incontinence. The pathophysiology underlying this association is worthy of future research.

Advances in pediatric colorectal surgical techniques

The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.

Impact of spinal cord malformation on bladder function in children with anorectal malformations

PURPOSE

Risk factors for the presence of neurogenic bladder dysfunction (NBD) in children born with high anorectal malformations (ARMs), were investigated, to identify the need for urodynamics in these patients.

MATERIAL AND METHODS

The study included 37 patients with high ARMs (21 boys and 16 girls). Bladder function was evaluated with urodynamics both before and after anorectoplasty (posterior sagittal anorectoplasty [PSARP]). All patients were investigated with spinal radiograph. Spinal ultrasound was performed in the neonatal period, and magnetic resonance imaging was added in case of abnormal ultrasound or urodynamics and in case of cloacal malformation.

RESULTS

In ARM patients with rectourethral and vestibular fistulas and cloacas, NBD was identified in 9 children (25%). The bladder dysfunction was innate in all cases except in one girl with cloaca, indicating that the risk of iatrogenic denervation seems minimal using the PSARP technique. All children with innate NBD had a spinal cord malformation either as spinal cord regression or tethering with or without a lipoma. Concerning vertebral status, almost all children with NBD had partial sacral agenesis. Abnormal perineal appearance was highly correlated to NBD in boys, especially in those with a spinal cord regression malformation. Innate NBD was not found in any child with normal spinal cord.

CONCLUSION

From these results, we suggest that spinal ultrasound and perineal inspection are used as screening procedures for NBD in children with ARM. Urodynamic investigation is recommended only when spinal cord anomalies or other signs indicative of NBD are present. In case of spinal cord malformation, repeated urodynamics during follow-up is mandatory because of the risk for developing tethered cord syndrome.

Importance of extrasphincteric mechanisms in the pathophysiology of faecal incontinence in adults with a history of anorectal anomaly

BACKGROUND

Although surgery for congenital anorectal anomalies (ARAs) aims to preserve anorectal function, faecal incontinence and constipation often result. Apart from the anal sphincters, continence is dependent on multiple anatomical and physiological factors. The aim of this study was to evaluate adults with a history of ARA to determine the role of such factors in functional outcome.

METHODS

The study included 20 consecutive adult patients with faecal incontinence who had undergone anorectal surgery as infants. Comprehensive testing included anal manometry, endoanal ultrasonography, tests of pudendal nerve function and rectal sensory function, evacuation proctography and colonic transit studies.

RESULTS

Anal resting tone and squeeze increments were both attenuated in 15 of 19 patients. Integrity of the internal and external anal sphincters was compromised in 16 and 15 of 18 patients respectively. Eleven of 13 had evidence of pudendal neuropathy. Rectal sensation was abnormal in 14 of 18 patients, of whom ten were hypersensitive and four hyposensitive. Rectal evacuation was abnormal in nine of 14. Colonic transit was delayed in five of eight patients with constipation.

CONCLUSION

Faecal incontinence in adult patients with ARA is related to various pathophysiologies. Structural integrity of the anal sphincters is a major factor, but extrasphincteric mechanisms, notably rectal sensory function, may be as important.

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography

The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.

Pediatric overactive bladder syndrome: pathophysiology and management

Detrusor overactivity, also known as the overactive bladder syndrome (OAB), urge syndrome, hyperactive bladder syndrome, persistent infantile bladder, and detrusor hypertonia, is the most common voiding dysfunction in children. Until recently, the concepts that had been used to dictate the management of this problem in children were based on the foundation that this was a primary bladder problem and or a delay in maturation in the nervous system of children. The expectation that children would outgrow their problems led many pediatric urologists and other practitioners to tell the parents of these children 'that they would not be wetting themselves on their wedding day.' However, it has become apparent from recent studies in adult patients with voiding dysfunctions that they had symptoms present as children. Recent findings of associations between lower urinary tract symptoms and sexual dysfunction and between voiding dysfunctions and neuropsychiatric problems have opened up a new frontier into the possible mechanisms of OAB in children that would explain these problems, link them together, and explain the continued problems that adult patients face. These findings point to OAB as a symptom of a more centrally located dysfunction that affects multiple systems. The objective of this review was to evaluate the neuroanatomy and neurophysiology of voiding and neuropharmacologic effects. We considered not only the available research and clinical data within the urologic field but also outside the field so that these data could be combined to generate a unified theory that could possibly explain many of the associated symptoms that are commonly found in pediatric OAB. Treatment modalities that are currently available for managing OAB were also explored. Currently available data indicate that pediatric OAB and many pediatric voiding dysfunctions may be part of a more generalized problem that affects multiple systems: notably bowels, bladder, sexual and ejaculatory function, control of blood pressure, and even mood and behavior. We explain the relationship that the bowel has with pediatric OAB and also the link that other neuropsychiatric problems have with OAB. This article describes which drug may be best suited to treat OAB in children and what treatment modalities are available when first-line drugs fail. In conclusion, the movement away from a vesicocentric way of thinking to a more corticocentric mode of thinking along with new imaging modalities that can examine the brain as it works will be of great value in determining future treatments of OAB. Medications generated from these evidence-based studies will hopefully treat the underlying disease process and not just the symptoms.

Overactive Bladder in Children. Part 1: Pathophysiology

PURPOSE

Detrusor overactivity is the most common voiding dysfunction in children. Detrusor overactivity is also known as overactive bladder syndrome, urge syndrome, hyperactive bladder syndrome, persistent infantile bladder and detrusor hypertonia. It has become apparent that the ideas that had been used to dictate the management of this problem in children were based on the foundation that this is a primary bladder problem and/or a delay in maturation in the nervous system of children. The expectation that children would outgrow the problems led many pediatric urologists and other practitioners to tell the parents of these children that they would not be wetting themselves on their wedding day. It has become apparent from recent studies in adults with voiding dysfunction that they had symptoms present as children. The recent findings of associations with lower urinary tract symptoms and sexual dysfunction, and the association of voiding dysfunction and neuropsychiatric problems has opened up a new frontier into the possible mechanisms of overactive bladder syndrome in children that would explain these problems, tie them together and explain the continued problems that adults face. These findings point to overactive bladder syndrome as a symptom of a more centrally located dysfunction that affects multiple systems, notably bowels, bladder, sexual and ejaculatory function, control of blood pressure, and even mood and behavior.

MATERIALS AND METHODS

We looked at the neuroanatomy, neurophysiology and neuropharmacology of voiding. Available research and clinical data in the urological field as well as outside of the field were combined to generate a unified theory that could possibly explain many associated symptoms that are commonly found in pediatric overactive bladder syndrome.

RESULTS

The available data indicate that pediatric overactive bladder syndrome and many pediatric voiding dysfunctions may be part of a more generalized problem that affects multiple systems, notably bowels, bladder, sexual and ejaculatory function, control of blood pressure, and even mood and behavior. We explained the relationship that the bowel has with pediatric overactive bladder syndrome and also the link that other neuropsychiatric problems have with overactive bladder syndrome.

CONCLUSIONS

The movement away from a vesicocentric way of thinking to a more corticocentric mode of thinking along with new imaging modalities that can look at the brain and examine it as it works will be of great value for determining future treatments. Medications generated from these evidence based studies will hopefully treat the underlying disease process and not just the symptoms.

The Surgical Outcome of Total Urogenital Mobilization for Cloacal Repair

PURPOSE

Total urogenital mobilization is deemed to preserve the urogenital sinus blood supply and avoid ischemic complications. We report our experience with this technique for cloacal repair.

MATERIALS AND METHODS

We retrospectively reviewed all consecutive cases of persistent cloaca managed by total urogenital mobilization via a posterior sagittal approach by a single pediatric urologist between 1998 and 2003. During this period 22 girls (12 with a common channel longer than 3 cm) underwent total urogenital mobilization for cloaca repair (1 redo) at a median age of 10 months (range 2 to 102). A total of 15 procedures (68%) could be completed by a perineal approach only. Four patients with a long common channel required additional maneuvers after mobilization to complete the reconstruction.

RESULTS

Urethral stenosis was observed in 2 patients after urethral separation from the vagina (1) and common channel retubularization (1). One child with a perineal hemangioma required a redo posterior sagittal anorectoplasty for complete vaginal and anal closure. In addition, 1 case of urethrovaginal fistula was diagnosed on cystovaginoscopy but was asymptomatic, and 1 child with a minor residual common channel underwent urethral revision to allow easier intermittent catheterization. With a median followup of 48 months (range 11 to 162) the latest examination involving endoscopy with anesthesia showed a good result in 17 patients, a tight introitus that might require further surgery in 3 and a minimal residual common channel of 0.5 cm in 2.

CONCLUSIONS

Total urogenital mobilization is an effective technique for repairing short and long common channels, and a low surgical complication rate can be anticipated.

Mutational analyses of UPIIIA, SHH, EFNB2 and HNF1beta in persistent cloaca and associated kidney malformations

OBJECTIVES

'Persistent cloaca' is a severe malformation affecting females in which the urinary, genital and alimentary tracts share a single conduit. Previously, a Uroplakin IIIA (UPIIIA) mutation was reported in one individual with persistent cloaca, and UPIIIA, Sonic Hedgehog (SHH), Ephrin B2 (EFNB2) and Hepatocyte Nuclear Factor 1beta (HNF1beta) are expressed during the normal development of organs that are affected in this condition. HNF1beta mutations have been associated with uterine malformations in humans, and mutations of genes homologous to human SHH or EFNB2 cause persistent cloaca in mice.

PATIENTS AND METHODS

We sought mutations of coding regions of UPIIIA, SHH, EFNB2 and HNF1beta genes by direct sequencing in a group of 20 patients with persistent cloaca. Most had associated malformations of the upper renal tract and over half had impaired renal excretory function. The majority of patients had congenital anomalies outside the renal/genital tracts and two had the VACTERL association.

RESULTS

Apart from a previously described index case, we failed to find UPIIIA mutations, and no patient had a SHH, EFNB2 or HNF1beta mutation.

CONCLUSION

Persistent cloaca is only rarely associated with UPIIIA mutation. Despite the fact that SHH and EFNB2 are appealing candidate genes, based on their expression patterns and mutant mice phenotypes, they were not mutated in these humans with persistent cloaca. Although HNF1beta mutations can perturb paramesonephric duct fusion in humans, HNF1beta was not mutated in persistent cloaca.

Outcome of excision of megarectum in children with anorectal malformation

BACKGROUND/PURPOSE

Megarectum in association with anorectal malformation contributes to chronic constipation and fecal incontinence. Resection of megarectum in anorectal malformation improves bowel function, but neuropathy and poor sphincter quality may affect the outcome of fecal continence adversely. The aim of this study was to evaluate the benefits of resection of megarectum in anorectal malformation and to ascertain the impact of anal sphincter quality and neuropathy on the outcome.

METHODS

We studied 62 children with intractable fecal incontinence after repair of anorectal malformation between January 1991 and January 2005. All patients were investigated with anorectal manometry and anal endosonography under ketamine anesthesia. On endosonography, an intact or scarred internal anal sphincter (IAS) was classified as good and a fragmented or absent IAS as poor. On manometry, a resting anal sphincter pressure equal to or more than 30 mm Hg was classified as good and a lower pressure as poor. Functional assessment of fecal continence was done before and after excision of megarectum using a modified Wingfield scores.

RESULTS

Sixteen children had excision of megarectum with median age of 9 years (range, 2-15 years) and postoperative follow-up of 5 years (range, 1-10 years). Seven had formation of antegrade continent enema stoma before excision of megarectum. Children were classified into three groups of anomalies: low (n = 6), intermediate (n = 4), and high (n = 6). All children were incontinent of feces. After excision of megarectum, of the 9 children with good IAS and no neuropathy, 7 became continent of feces. Of the remaining 7 children, 4 had poor IAS and 3 had neuropathy, 5 of whom required an antegrade continent enema stoma to be clean.

CONCLUSION

Excision of megarectum in children who had previous repair of anorectal malformation results in fecal continence in the presence of a good IAS and absence of neuropathy. Patients with a poor IAS or neuropathy will often require artificial means of fecal continence.

14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida

PURPOSE

The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra.

MATERIALS AND METHODS

From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800 artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients.

RESULTS

Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night.

CONCLUSIONS

The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.

Recent trends of genitourinary endoscopy in children

Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.