# Cloaca — GCMD Library living collection

Everything in the library about cloacal malformation — built automatically from dossiers that name it.

Updated: n/a · 21 episodes · 559 cited statements

## Episodes
### Diagnosis & Workup
- [Cloaca - Prental Imaging & Diagnosis - Counseling](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682) — video · 36:15 · [machine version](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682.md)
- [Cloaca - Workup & Evaluation](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683) — video · 20:22 · [machine version](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683.md)
- [Prenatal Imaging and Counseling: Cloaca and Complex ARMs 2015](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021) — video · 31:23 · [machine version](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021.md)
- [Anorectal Malformation Radiology: Pediatric Colorectal Controversies 2014](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097) — video · 61:48 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097.md)

### Surgical Management
- [Enhancing Urethral Meatus Creation in Cloacal Malformations: A New Technique](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865) — video · 4:41 · [machine version](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865.md)
- [Enhancing Urethral Meatus Creation in Cloacal Malformations: A New Technique](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864) — video · 4:41 · [machine version](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864.md)

### Complications
- [Complications and Long-Term Outcomes of Patients With Cloacal Malformation After Bowel Neovagina...](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170) — video · 1:05 · [machine version](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170.md)

### Case-Based Learning
- [Cloaca - Long Common Channel](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686) — video · 14:55 · [machine version](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686.md)
- [Collaborative work: Complex Pediatric Anorectal Malformations 2017](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924) — video · 23:45 · [machine version](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322) — podcast · 27:29 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336.md)
- [Colorectal Quiz Episode 24: Cloaca Part 3](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055) — podcast · 45:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055.md)
- [Colorectal Quiz: Episode 47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846) — podcast · 22:19 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846.md)
- [Colorectal Quiz: Episode 47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847) — podcast · 22:19 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847.md)
- [Colorectal Quiz: Episode 40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852) — podcast · 18:43 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852.md)
- [Colorectal Quiz: Episode 40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853) — podcast · 18:43 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863) — podcast · 27:32 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863.md)

### In-Depth Reviews
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957) — podcast · 43:47 · [machine version](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299) — podcast · 43:47 · [machine version](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299.md)
- [ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228) — video · 48:03 · [machine version](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=0) Introduction and Panel Overview (Ep 2)
- [4:24](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=264) Audience Polling and Course Objectives (Ep 2)
- [10:53](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=653) Prenatal Imaging Diagnosis of Anorectal Malformations (Ep 2)
- [25:58](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1558) Panel Discussion on Prenatal Diagnosis and Counseling (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=0) Building Collaborative Teams in Complex Pediatric Care (Ep 4)
- [3:59](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=239) Case Presentation: Adopted Child with Cloaca (Ep 4)
- [7:56](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=476) Management of Hydrocolpos and Urinary Drainage (Ep 4)
- [13:06](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=786) Surgical Approach and Outcome for 2.5cm Common Channel (Ep 4)
- [17:21](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1041) Vaginal Replacement Options (Ep 4)
- [20:43](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1243) Urinary Diversion Decision-Making (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=0) Introduction and Study Design (Ep 15)
- [0:24](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=24) Study Findings and Complications (Ep 15)
- [0:51](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=51) Clinical Takeaway (Ep 15)
- [0:00](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=0) Introduction and Technique Rationale (Ep 14)
- [0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=56) Surgical Technique Demonstration (Ep 14)
- [3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=218) Case Series Results (Ep 14)
- [0:00](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=0) Introduction and Technique Rationale (Ep 13)
- [0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=56) Surgical Technique Demonstration (Ep 13)
- [3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=218) Case Series Results (Ep 13)
- [0:00](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=0) 3D Rotational Cloacography Technique and Technology (Ep 3)
- [5:19](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=319) Comparison of Imaging Modalities and Radiation Considerations (Ep 3)
- [9:55](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=595) Prenatal Counseling and Initial Postnatal Workup (Ep 3)
- [14:44](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=884) Neonatal Management Philosophy and Timing of Detailed Anatomic Studies (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=0) Introduction and Case Presentation (Ep 16)
- [1:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=94) Three-System Assessment in Cloaca Patients (Ep 16)
- [4:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=291) Physical Exam and Prior Workup (Ep 16)
- [7:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=451) Imaging Findings (Ep 16)
- [11:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=691) Pathophysiology and Historical Context (Ep 16)
- [14:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=887) Surgical Management Options (Ep 16)
- [20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1214) Final Recommendations and Case Disposition (Ep 16)
- [20:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1258) Closing and Joke Segment (Ep 16)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=0) Introduction and Case Presentation (Ep 17)
- [1:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=94) History and Three-System Assessment (Ep 17)
- [4:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=291) Physical Exam and Prior Workup (Ep 17)
- [7:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=451) Imaging Findings and Mega-rectosigmoid (Ep 17)
- [11:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=691) Surgical Management Options (Ep 17)
- [18:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1129) Treatment Plan and Follow-up (Ep 17)
- [20:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1258) Closing and Joke (Ep 17)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=0) Case Presentation and Initial Findings (Ep 18)
- [4:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=248) Anatomic Findings and Meyer-Rokitansky Discussion (Ep 18)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Genital urinary anomalies and anorectal malformations represent a broad spectrum; the more severe the malformations, the higher the chances that amniotic fluid volume will be abnormal" — Maria Calvos (clinical) [Ep 2 · 11:29](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=689)
- "Cincinnati Children's uses a combined approach with ultrasound and fetal MRI because they are complementary techniques" — Maria Calvos (clinical) [Ep 2 · 12:05](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=725)
- "On ultrasound, the first structure seen from the abdominal cord insertion is the bladder, outlined by umbilical arteries (three-vessel cord) or single artery (two-vessel cord)" — Maria Calvos (clinical) [Ep 2 · 12:50](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=770)
- "Echogenic concretions (meconium) in the hydrocolpos or bladder are clues for rectourinary fistula and anorectal malformation" — Maria Calvos (clinical) [Ep 2 · 13:45](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=825)
- "Ultrasound has technical limitations: it does not provide good imaging with poor amniotic fluid, is not good at detecting early stages of cystic renal dysplasia, and not all anorectal malformations will be detected even when searching for them" — Maria Calvos (clinical) [Ep 2 · 14:36](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=876)
- "In the fetal bowel, the stomach and proximal bowel contain mostly fluid (bright on T2-weighted MRI), while distal bowel contains meconium (dark on T2-weighted imaging, bright on T1-weighted imaging)" — Maria Calvos (clinical) [Ep 2 · 15:24](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=924)
- "Meconium is not expected to reach the rectum until 20 weeks gestation and will fill the entire colonic column by 26 weeks" — Maria Calvos (clinical) [Ep 2 · 16:23](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=983)
- "According to Seinda and co-authors, the rectum length from bladder base to the most distal segment should measure at least 10 millimeters on sagittal view" — Maria Calvos (host_summary) [Ep 2 · 16:44](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1004)
- "In a Cincinnati Children's review of prenatal MRI of cloacal malformations, long common channel cloacas presented with high position of the rectum and dilatation" — Maria Calvos (clinical) [Ep 2 · 18:02](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1082)
- "Cloacas and imperforate anus with rectourinary fistula can have fluid distention of the rectum and enterolith-like material" — Maria Calvos (clinical) [Ep 2 · 19:02](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1142)
- "Increased fluid content in the rectum (bright signal instead of dark on T2-weighted MRI) is a clue for rectourinary fistula" — Maria Calvos (clinical) [Ep 2 · 19:20](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1160)
- "Long common channel cloacas can present with hydrocolpos and urinary ascites" — Maria Calvos (clinical) [Ep 2 · 20:09](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1209)
- "Urogenital sinus can present with urinary hydrocolpos and obstructive uropathy and/or ascites, but the rectum follows a normal course posterior to the bladder and is not dilated" — Maria Calvos (clinical) [Ep 2 · 20:49](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1249)
- "Cloacal exstrophy patients typically present with persistent absent visualization of the bladder and normal amniotic fluid, indicating urine is making its pathway out" — Maria Calvos (clinical) [Ep 2 · 22:14](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1334)
- "Cloacal exstrophy babies frequently have an omphalocele that is typically lower in position and can have spinal defects, typically skin-covered" — Maria Calvos (clinical) [Ep 2 · 22:50](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1370)
- "The prolapsed terminal ileum in cloacal exstrophy appears as a tubular structure protruding and floating in amniotic fluid, called the 'elephant trunk sign'" — Maria Calvos (clinical) [Ep 2 · 23:05](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1385)
- "In Cincinnati Children's review, cloacal exstrophy patients did not present meconium signal in the bowel in the expected distribution of the rectum, which is completely different from bladder exstrophy" — Maria Calvos (clinical) [Ep 2 · 24:54](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1494)
- "Bladder exstrophy should have a normal rectum with bright T1 and dark T2 signal, absent bladder visualization, protruding structure in infraumbilical abdominal wall, and unusual external genitalia with epispadias" — Maria Calvos (clinical) [Ep 2 · 25:16](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1516)
- "Dr. Peña reviewed mothers of babies born with cloacas who did not have prenatal diagnosis; when he obtained their ultrasounds, many had abnormalities but radiologists misdiagnosed them as urethrocele, double bladder, ovarian cysts, or bladder diverticulum instead of recognizing hydrocolpos" — Alberto Peña (clinical) [Ep 2 · 30:42](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1842)
- "If a female fetus has a prenatal diagnosis of ovarian cyst, double bladder, or urethrocele, suspect the patient may have a cloaca; if the patient also has abnormal vertebrae, hydronephrosis, and dilated bowel, that confirms the diagnosis" — Alberto Peña (clinical) [Ep 2 · 32:15](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1935)
- "Advantages of prenatal diagnosis include transferring the patient to a specialized center for proper colostomy and hydrocolpos drainage, and preparing the mother so she has time to digest the news and can enjoy the birth knowing the baby will go to surgery 24 hours later" — Andrea Bischoff (opinion) [Ep 2 · 32:46](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1966)
- "For proper prenatal counseling of cloaca patients, surgeons want to know the common channel length and sacrum status, but this information is still limited in prenatal imaging" — Andrea Bischoff (clinical) [Ep 2 · 33:30](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=2010)
- "At 20 weeks gestation when most ultrasounds are done, cloacal findings may be very subtle with nothing that tips the community obstetrician off that there's anything wrong" — Jack Langer (clinical) [Ep 2 · 35:00](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=2100)
- "The institutional environment, not the individual surgeon, is the determining factor of patient outcomes in complex pediatric cases." (opinion) [Ep 4 · 0:15](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=15)
- "Effective multidisciplinary teams start with 2-3 completely dedicated practitioners and build incrementally, not with 30 members from the start." — Jason (opinion) [Ep 4 · 0:53](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=53)
- "True collaborative care requires coordination of time: shared clinic appointments, shared OR time, and dedicated conference time (Wednesdays at 9 a.m. for one hour in this team's case)." — Jason (clinical) [Ep 4 · 1:38](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=98)
- "The team is supported by nurses who serve as 'the glue that hold us all together' and back office staff who coordinate ORs, clinics, and conferences." (clinical) [Ep 4 · 2:23](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=143)
- "The team recently added a physical therapist and behavioral medicine team as the program grew and needs expanded." — Jason (clinical) [Ep 4 · 3:18](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=198)
- "When a vagina is filled with fluid/urine in a cloaca, it can prohibit urine emptying and put pressure on the ureters, threatening kidney health." — Leslie (clinical) [Ep 4 · 8:28](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=508)
- "Draining the vagina in hydrocolpos is primarily for kidney health and enabling urine release, not for the vagina's sake." — Leslie (clinical) [Ep 4 · 8:35](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=515)
- "Drainage approaches for hydrocolpos include: bladder drainage, vaginal drainage via tube through abdomen (placed at colostomy or laparoscopically), interventional radiology-placed tube, or vesicostomy." — Leslie (clinical) [Ep 4 · 9:00](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=540)
- "In patients with two hemivaginas, it is important to drain both adequately, sometimes requiring merging the vaginas or creating a defect in the septum." — Leslie (clinical) [Ep 4 · 9:53](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=593)
- "Vesicostomy is used when vaginostomy tube does not provide adequate drainage, evidenced by persistent hydronephrosis, persistent bladder distention, or urinary tract infections." (clinical) [Ep 4 · 10:55](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=655)
- "Hydronephrosis in cloaca is caused by pressure on the trigone and ureteral insertion points from vaginal distention and hydrocolpos." (clinical) [Ep 4 · 11:26](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=686)
- "Creating a vesicostomy will impair future surgery, so it must be taken down to facilitate tension-free mobilization of pelvic organs, then reassessed for need after surgery." (clinical) [Ep 4 · 11:39](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=699)
- "After any drainage procedure for hydrocolpos, verification with ultrasound is essential to confirm the system is draining what it should; failure to verify can lead to continued renal damage." — Jason (clinical) [Ep 4 · 12:00](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=720)
- "Ultrasound is a powerful tool in cloaca care: no radiation, widely available, and useful for evaluating pelvis, bladder, vagina, and kidneys." (clinical) [Ep 4 · 12:54](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=774)
- "Even with a short common channel, if the rectal insertion is very high on the vagina, a posterior sagittal approach from below will not work." (clinical) [Ep 4 · 13:06](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=786)
- "In the presented case, the distal colonic segment from the mucous fistula was long enough to complete the pull-through; sometimes it is too short and the mucous fistula must be closed." (clinical) [Ep 4 · 13:50](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=830)
- "At Cincinnati Children's, cloaca patients undergo serial ultrasounds until about 6 months after onset of menstruation to ensure no obstruction." — Leslie (guideline) [Ep 4 · 16:16](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=976)
- "The presented patient is hopeful for fecal continence based on normal sacrum, no tethered cord, and relatively short common channel." (clinical) [Ep 4 · 16:59](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1019)
- "Native vagina is always preferred for vaginal reconstruction when possible because it is hormonally responsive and has proven long-term function." — Leslie (clinical) [Ep 4 · 18:23](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1103)
- "When selecting vaginal replacement tissue, key considerations are durability, availability, and avoiding negative impact on the patient's future function." — Leslie (clinical) [Ep 4 · 18:35](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1115)
- "Rectum is considered for vaginal replacement when there is poor prognosis for bowel control (tethered cord, poor sacrum, multiple surgeries) or when avoiding abdominal surgery is advantageous due to geographic proximity." — Leslie (clinical) [Ep 4 · 18:53](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1133)
- "Colon is the tissue of choice for vaginal replacement at Cincinnati Children's, having proven durable for future vaginal function." — Leslie (clinical) [Ep 4 · 19:18](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1158)
- "Any patient with vaginal replacement requires cesarean section for delivery." — Leslie (clinical) [Ep 4 · 19:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1167)
- "Small bowel for vaginal replacement has limitations with pedicle, blood supply, and reaching the pelvis, but is used when all colon must be preserved for bowel function." — Leslie (clinical) [Ep 4 · 19:44](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1184)
- "Buccal graft acts more like native vagina than colon segments and is increasingly used, typically in pubertal patients requiring about one week hospitalization with minimal mobilization and a vaginal stent while the graft takes." — Leslie (clinical) [Ep 4 · 20:02](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1202)
- "Buccal grafts have been used more for augmentation vaginoplasty in patients with strictures rather than in prepubertal patients." — Leslie (clinical) [Ep 4 · 20:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1227)
- "For short common channel with normal spinal cord, urethral catheter alone may suffice post-operatively, with family taught intermittent catheterization if needed." (clinical) [Ep 4 · 21:29](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1289)
- "Setting expectations at each 'toll gate' in the care pathway is critical when managing children with ongoing complex surgical needs." (opinion) [Ep 4 · 21:55](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1315)
- "Post-void residual checks after catheter removal may reveal temporary voiding dysfunction from edema or stunned bladder that improves over time." (clinical) [Ep 4 · 22:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1347)
- "For longer common channels, suprapubic catheter is recommended: urethral catheter removed as stent, SP tube clamped/unclamped to assess emptying and prevent bladder overdistention during bladder rehabilitation." (clinical) [Ep 4 · 22:40](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1360)
- "Incomplete bladder emptying causes muscle overstretching where cross bridges in muscle fibers no longer connect and cannot contract." (clinical) [Ep 4 · 22:56](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1376)
- "In overtly neurogenic bladder where safe voiding is impossible and upper tracts are at risk, temporary vesicostomy is recommended to protect lower tracts and prevent blind catheterization of the reconstructed urethra." (clinical) [Ep 4 · 23:15](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1395)
- "The study was a single institution retrospective study of 40 patients with cloacal malformations who underwent bowel neovagina creation during reconstruction" — Megan Reed Evatori (clinical) [Ep 15 · 0:11](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=11)
- "Overall outcomes were similar between small bowel and colonic neovaginas" — Megan Reed Evatori (clinical) [Ep 15 · 0:25](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=25)
- "Major complications were uncommon but not negligible" — Megan Reed Evatori (clinical) [Ep 15 · 0:29](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=29)
- "Enterroidal stenosis was more common with colonic grafts" — Megan Reed Evatori (clinical) [Ep 15 · 0:32](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=32)
- "A subset of patients required roidoplasty" — Megan Reed Evatori (clinical) [Ep 15 · 0:32](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=32)
- "Vaginal prolapse was rare" — Megan Reed Evatori (clinical) [Ep 15 · 0:38](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=38)
- "Menstrual obstruction occurred in only a few patients" — Megan Reed Evatori (clinical) [Ep 15 · 0:40](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=40)
- "About 25% of patients reported bothersome discharge" — Megan Reed Evatori (clinical) [Ep 15 · 0:43](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=43)
- "Among the small number who were sexually active, dyspareunia was reported" — Megan Reed Evatori (clinical) [Ep 15 · 0:46](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=46)
- "Bowel neovaginas are a reasonable and durable option" — Megan Reed Evatori (opinion) [Ep 15 · 0:52](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=52)
- "Patients with bowel neovaginas need long term follow up with attention to function, stenosis and quality of life" — Megan Reed Evatori (guideline) [Ep 15 · 0:57](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=57)
- "In the previous technique, the urethra and vagina were brought up to the introitus and separately anastomosed, resulting in poor definition of the vaginal vestibule and labia, often with skin separation between the urethra and vagina." (clinical) [Ep 14 · 0:14](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=14)
- "In the new technique, the urethral meatus is positioned slightly recessed and posterior to the clitoris in a more orthotopic position, which rebuilds the vaginal vestibule." (clinical) [Ep 14 · 0:30](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=30)
- "Key components include careful dissection and reconfiguration of the anterior and posterior urethra to form a patent orthotopic meatus that is slightly recessed, in addition to creating well-defined labia minora." (clinical) [Ep 14 · 0:41](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=41)
- "In cloacal repair patients who underwent urogenital sinus separation and vaginal and anorectal pull-through, the common channel becomes the urethra." (clinical) [Ep 14 · 0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=56)
- "The first step is to recess the urethromeatus to a more orthotopic location by opening the urethromeatus and performing a urethromeattoplasty if necessary." (clinical) [Ep 14 · 1:10](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=70)
- "To recreate and build the vaginal vestibule, the vagina is slightly tubularized and then re-approximated to the neourethral meatus at its inferior aspect." (clinical) [Ep 14 · 1:28](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=88)
- "A retrospective case series included 50 patients with cloacal anomalies who underwent primary cloacal repair between 2020 and 2024." (epidemiological) [Ep 14 · 3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=218)
- "Of the 50 patients, 24 underwent urogenital sinus separation with vaginal and anorectal pull-through, and 17 underwent total urogenital mobilization." (epidemiological) [Ep 14 · 3:48](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=228)
- "The urethromiattoplasty technique was applied to 6 patients who underwent UG separation and 5 patients who underwent TUM." (epidemiological) [Ep 14 · 3:58](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=238)
- "On follow-up, all patients had satisfactory cosmetic results and successful neoatus creation with minimal scarring and a well-positioned urethral meatus." (clinical) [Ep 14 · 4:07](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=247)
- "There were no instances of stenosis or fistula in the case series." (clinical) [Ep 14 · 4:17](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=257)
- "1 patient required clean intermittent catheterization." (clinical) [Ep 14 · 4:20](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=260)
- "3 patients underwent vesicostomy for bladder management." (clinical) [Ep 14 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=263)
- "7 patients did not require assisted bladder emptying." (clinical) [Ep 14 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=263)
- "In the previous technique, the urethra and vagina were brought up to the introitus and separately anastomosed, resulting in poor definition of the vaginal vestibule and labia, often with skin separation between the urethra and vagina." (clinical) [Ep 13 · 0:14](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=14)
- "In the new technique, the urethral meatus is positioned slightly recessed and posterior to the clitoris in a more orthotopic position, which rebuilds the vaginal vestibule." (clinical) [Ep 13 · 0:30](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=30)
- "Key components include careful dissection and reconfiguration of the anterior and posterior urethra to form a patent orthotopic meatus that is slightly recessed, in addition to creating well-defined labia minora." (clinical) [Ep 13 · 0:41](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=41)
- "In cloacal repair patients who underwent urogenital sinus separation and vaginal and anorectal pull-through, the common channel becomes the urethra." (clinical) [Ep 13 · 0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=56)
- "The first step is to recess the urethromeatus to a more orthotopic location by opening the urethromeatus and performing a urethromeattoplasty if necessary." (clinical) [Ep 13 · 1:10](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=70)
- "To recreate and build the vaginal vestibule, the vagina is slightly tubularized and then re-approximated to the neourethral meatus at its inferior aspect." (clinical) [Ep 13 · 1:28](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=88)
- "A retrospective case series included 50 patients with cloacal anomalies who underwent primary cloacal repair between 2020 and 2024." (epidemiological) [Ep 13 · 3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=218)
- "Of the 50 patients, 24 underwent urogenital sinus separation with vaginal and anorectal pull-through, and 17 underwent total urogenital mobilization." (epidemiological) [Ep 13 · 3:48](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=228)
- "The urethromiattoplasty technique was applied to 6 patients who underwent UG separation and 5 patients who underwent TUM." (epidemiological) [Ep 13 · 3:58](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=238)
- "On follow-up, all patients had satisfactory cosmetic results and successful neoatus creation with minimal scarring and a well-positioned urethral meatus." (clinical) [Ep 13 · 4:07](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=247)
- "There were no instances of stenosis or fistula in the case series." (clinical) [Ep 13 · 4:17](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=257)
- "1 patient required clean intermittent catheterization." (clinical) [Ep 13 · 4:20](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=260)
- "3 patients underwent vesicostomy for bladder management." (clinical) [Ep 13 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=263)
- "7 patients did not require assisted bladder emptying." (clinical) [Ep 13 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=263)
- "3D rotational cloacography is performed in interventional radiology using angiography equipment, combining endoscopy with 3D imaging capabilities in a single session." — Manish Patel (clinical) [Ep 3 · 0:11](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=11)
- "The 3D cloacography technique uses the same technology available for 3D angiography: contrast is injected into hollow structures while the camera rotates around the patient to generate images." — Manish Patel (clinical) [Ep 3 · 0:42](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=42)
- "Images from 3D cloacography are immediately available at a workstation where different cuts and views can be made to clarify overlapping structures." — Manish Patel (clinical) [Ep 3 · 0:58](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=58)
- "Conventional 2D cloacography with AP and lateral views has overlapping structures that make it difficult to decipher which structure is which." — Manish Patel (clinical) [Ep 3 · 1:11](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=71)
- "Modern 3D cloacography technology allows precise measurement of the common channel, whereas the old method using an external ruler had significant foreshortening and imprecise measurements." — Manish Patel (clinical) [Ep 3 · 4:11](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=251)
- "The 3D approach helps determine whether the vagina will come down and clarifies the relationship with the rectum, aiding decisions about laparoscopic versus open approaches." — Richard (clinical) [Ep 3 · 6:16](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=376)
- "The radiation dose from 3D rotational cloacography is very similar to conventional cloacography because fewer lateral and frontal images are needed." — Manish Patel (clinical) [Ep 3 · 6:51](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=411)
- "MRI cloacography loses the real-time capability of seeing what is being injected and filled, and significantly increases anesthesia time." — Manish Patel (clinical) [Ep 3 · 7:17](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=437)
- "The measurements from 3D cloacography are accurate to within millimeters; when the radiologist reports 3.5 cm, the intraoperative measurement is typically 3.5 cm." — Alberto Peña (clinical) [Ep 3 · 8:46](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=526)
- "The majority of cloacal malformations diagnosed prenatally are complex cases." (epidemiological) [Ep 3 · 10:53](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=653)
- "Baseline renal bladder ultrasound is the preferred method for identifying upper tract and lower tract urologic abnormalities in cloacal malformations." (clinical) [Ep 3 · 12:23](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=743)
- "Ultrasound is used to look for fluid accumulated in the vagina or vaginas, which helps guide the timing of therapy and whether fluid needs to be drained acutely." (clinical) [Ep 3 · 13:15](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=795)
- "Sacral X-ray (AP and lateral) is needed to assess prognosis for bowel control and to suspect or rule out a pre-sacral mass." (clinical) [Ep 3 · 13:41](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=821)
- "Spinal ultrasound is performed to rule out tethered cord in cloacal malformation workup." (clinical) [Ep 3 · 13:41](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=821)
- "Placement of a catheter into the common channel is challenging because it may go into any of three organ systems (bladder, vagina, or rectum), making standard VCUG unreliable." (clinical) [Ep 3 · 16:02](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=962)
- "High-grade reflux is not commonly identified in cloacal malformation patients; most reflux is mild and warrants observation rather than mandatory preoperative intervention." (clinical) [Ep 3 · 16:54](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1014)
- "In neonatal cloacas, trying to make a very accurate anatomic diagnosis during the newborn period is useless and may actually hurt the baby." — Alberto Peña (opinion) [Ep 3 · 17:26](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1046)
- "In the neonatal period, the crucial information is whether the baby has hydronephrosis, megaureters, or hydrocolpos compressing the ureters, which can be determined by ultrasound without endoscopy." — Alberto Peña (clinical) [Ep 3 · 17:29](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1049)
- "Knowing whether a neonate with cloaca has reflux is not crucial; the priority is decompressing the gastrointestinal and urogenital tracts." — Alberto Peña (opinion) [Ep 3 · 18:09](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1089)
- "Forcing an endoscope into a tiny neonatal cloacal structure can cause harm." — Alberto Peña (clinical) [Ep 3 · 18:39](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1119)
- "Nephrostomy, ureterostomy, and vesicostomy are not indicated in most neonatal cloacas." — Alberto Peña (guideline) [Ep 3 · 19:04](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1144)
- "The recommended neonatal management for cloaca is to drain hydrocolpos, open a colostomy, and re-evaluate from the urologic point of view 48 hours later before making further decisions." — Alberto Peña (guideline) [Ep 3 · 19:14](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1154)
- "Some cloacal patients may need vesicostomy if there is obstruction in the common channel, but many do not; decompressing the hydrocolpos often completely changes the clinical picture." — Alberto Peña (clinical) [Ep 3 · 19:25](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1165)
- "Neonatal endoscopy of cloacas does not always provide accurate anatomic information and can be traumatizing to the common channel, potentially causing harm." (host_summary) [Ep 3 · 19:43](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1183)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Jason Frischer (clinical) [Ep 16 · 1:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=111)
- "Spina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage" — Jason Frischer (clinical) [Ep 16 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "A 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant" — Jason Frischer (epidemiological) [Ep 16 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "Cystatin C is helpful to check GFR and renal function in cloaca patients" — Jason Frischer (clinical) [Ep 16 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "Female anorectal malformation patients require cesarean section for childbirth" — Chris Geyer (clinical) [Ep 16 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=235)
- "Every patient with an anorectal malformation needs a gynecology colleague to ensure they are doing well" — Chris Geyer (opinion) [Ep 16 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=235)
- "Anorectal malformation patients can have excellent anatomical repair and still have soiling" — Jason Frischer (clinical) [Ep 16 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=309)
- "The most common cause for redoing anorectal malformation patients is anus placed in the wrong position" — Chris Geyer (epidemiological) [Ep 16 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=309)
- "Anorectal manometry is not part of standard initial workup for anorectal malformation patients" — Marc Levitt (guideline) [Ep 16 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=389)
- "There are many ways to tell if the anus is in proper position, such as electrical stimulation and rectal ultrasound or MRI" — Marc Levitt (clinical) [Ep 16 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=389)
- "All anorectal malformation patients get an exam under anesthesia (EUA)" — Jason Frischer (guideline) [Ep 16 · 7:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=434)
- "The rectosigmoid can be very inert in ARM patients even when the anus is not strictured" — Marc Levitt (clinical) [Ep 16 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=545)
- "Mega-rectosigmoid in ARM patients can be both inherent and acquired from failure to aggressively treat constipation over many years" — Marc Levitt (clinical) [Ep 16 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=619)
- "The rectum is vitally important for bowel control in anorectal malformation patients" — Jason Frischer (clinical) [Ep 16 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "ARM patients don't really have anal canal sensation or an internal sphincter unless the very distal aspect of the rectum was saved" — Jason Frischer (clinical) [Ep 16 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "Distention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool" — Jason Frischer (clinical) [Ep 16 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "If you remove the rectum in ARM patients, you lose the capacity for proprioception" — Jason Frischer (clinical) [Ep 16 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "Prior to 1980 and the PSARP, an abdominal perineal pull-through was done for ARM, throwing the rectum away and pulling sigmoid down, which was wrong" — Jason Frischer (clinical) [Ep 16 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=809)
- "Older ARM patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus and in the pelvis" — Jason Frischer (clinical) [Ep 16 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=809)
- "Removing the rectum in ARM almost guarantees incontinence" — Chris Geyer (clinical) [Ep 16 · 14:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=887)
- "Rectal tapering technique involves going in laparoscopically or open, tapering on the anti-mesenteric side with a stent or dilator in the rectum to ensure good lumen size" — Chris Geyer (clinical) [Ep 16 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=945)
- "After rectal tapering, bowel management becomes more manageable and anatomy studied one year after has not shown re-dilation" — Chris Geyer (clinical) [Ep 16 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=945)
- "Many ARM kids still have trouble with incontinence even with the best operative plans due to their anatomy and musculature" — Jason Frischer (clinical) [Ep 16 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1009)
- "A sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great" — Jason Frischer (clinical) [Ep 16 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1009)
- "Colons can empty surprisingly well with antegrade enemas only, potentially avoiding resection" — Jason Frischer (clinical) [Ep 16 · 17:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1062)
- "Very often ARM patients with mega-rectosigmoid have an analplasty that is not good—either strictured, mislocated, or prolapsed" — Jason Frischer (clinical) [Ep 16 · 19:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1164)
- "If the anus is just strictured, making it bigger might allow the colon to decompress and improve" — Jason Frischer (clinical) [Ep 16 · 20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1214)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Marc Levitt (clinical) [Ep 17 · 1:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=111)
- "Cystatin C is helpful to check GFR and renal function in cloaca patients" — Marc Levitt (clinical) [Ep 17 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "Spina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage" — Marc Levitt (clinical) [Ep 17 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "A 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant" — Marc Levitt (epidemiological) [Ep 17 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "Perineal-only repair approach suggests the original cloaca was relatively low" — Chris Geyer (clinical) [Ep 17 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Female patients with anorectal malformation require cesarean section for childbirth" — Chris Geyer (clinical) [Ep 17 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Every patient with an anorectal malformation needs a gynecologist colleague to ensure they are doing well" — Chris Geyer (guideline) [Ep 17 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Patients can have excellent anatomical repair and still have soiling in anorectal malformation" — Marc Levitt (clinical) [Ep 17 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=309)
- "The most common cause for redoing anorectal malformation patients is incorrect anal placement" — Marc Levitt (epidemiological) [Ep 17 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=309)
- "Anorectal manometry is not part of standard initial workup for anorectal malformation patients" — Jason Frischer (guideline) [Ep 17 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=389)
- "Electrical stimulation and rectal ultrasound or MRI are preferred methods to determine if anus is in proper position" — Chris Geyer (clinical) [Ep 17 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=389)
- "The rectosigmoid can be inert in ARM patients even without stricture" — Marc Levitt (clinical) [Ep 17 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=545)
- "Mega-rectosigmoid etiology is both inherent motility problems and acquired from failure to aggressively treat constipation over many years" — Marc Levitt (clinical) [Ep 17 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=619)
- "The rectum is vitally important for bowel control in anorectal malformation patients" — Marc Levitt (clinical) [Ep 17 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Anorectal malformation patients don't really have anal canal sensation or internal sphincter" — Marc Levitt (clinical) [Ep 17 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Distention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool" — Marc Levitt (clinical) [Ep 17 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "If you remove the rectum, you lose the capacity for proprioception and bowel control" — Marc Levitt (clinical) [Ep 17 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Prior to 1980 and the PSARP, abdominal perineal pull-through was performed, throwing the rectum away and pulling sigmoid down, which was wrong" — Chris Geyer (clinical) [Ep 17 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=809)
- "Older patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus in the pelvis" — Marc Levitt (clinical) [Ep 17 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=809)
- "Rectal tapering can be performed both laparoscopically and open at time of colostomy closure or after failed bowel management" — Chris Geyer (clinical) [Ep 17 · 14:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=862)
- "Tapering technique involves anti-mesenteric side tapering with stent or dilator in rectum, using stapling and sometimes over-sewing" — Chris Geyer (clinical) [Ep 17 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=945)
- "After rectal tapering, bowel management becomes more manageable and anatomy studied one year after has not shown re-dilation" — Chris Geyer (clinical) [Ep 17 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=945)
- "A sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great, making the patient likely a bowel management candidate" — Jason Frischer (clinical) [Ep 17 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1009)
- "Patients with poor sacral ratios will likely never achieve successful bowel control given the quality of their pelvis and amount of sacral regression" — Jason Frischer (clinical) [Ep 17 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1009)
- "Colons can empty well with antegrade enemas only, potentially avoiding resection" — Marc Levitt (clinical) [Ep 17 · 17:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1072)
- "Very often patients with mega-rectosigmoid have analplasty that is not good - either strictured, mislocated, or prolapsed" — Marc Levitt (clinical) [Ep 17 · 19:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1164)
- "If the anus is just strictured, making it bigger might allow the colon to decompress and improve" — Marc Levitt (clinical) [Ep 17 · 20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1214)
- "Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, occurring more commonly in females with a prevalence of about one in 5,000 births." — Thomas Hsu (epidemiological) [Ep 18 · 1:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=84)
- "About 60% of anorectal malformation patients in some regions are discharged home without being identified." — Chris Westgarth-Taylor (epidemiological) [Ep 18 · 1:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=65)
- "When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to preserve blood supply to the distal rectum." — Marc Levitt (clinical) [Ep 18 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=141)
- "A cloaca is defined by the presence of a single perineal orifice." — Marc Levitt (clinical) [Ep 18 · 4:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=248)
- "The anatomy in this case is similar to Meyer-Rokitansky-Küster-Hauser syndrome, with ovaries, remnant fallopian tubes, and no other Müllerian structures." — Marc Levitt (clinical) [Ep 18 · 5:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=332)
- "Meyer-Rokitansky-like anatomy with anorectal malformation is extremely rare." — Marc Levitt (epidemiological) [Ep 18 · 5:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=335)
- "The more common scenario is recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule with a normal urethra but no vagina." — Marc Levitt (clinical) [Ep 18 · 6:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=397)
- "The sacral anatomy in this case appears foreshortened, suggesting caudal regression syndrome." — Marc Levitt (clinical) [Ep 18 · 7:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=438)
- "Laparoscopic colostomy creation allows identification of incidental findings like malrotation that might be missed with standard left lower quadrant colostomy." — Thomas Hsu (clinical) [Ep 18 · 4:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=293)
- "In cases with limited dissection and a colocolonic anastomosis plus simple anoplasty, not diverting can be safe without risk of anastomotic breakdown." — Marc Levitt (opinion) [Ep 18 · 10:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=612)
- "If diversion were needed in this case, an ileostomy would be the preferred choice." — Thomas Hsu (clinical) [Ep 18 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- "Colonic neovaginas are not great for patients 20 years down the road and should be avoided when possible." — Marc Levitt (opinion) [Ep 18 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=674)
- "In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided." — Marc Levitt (clinical) [Ep 18 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=674)
- "Options for vaginal reconstruction include dilation of the existing introitus, buccal graft placement, or future tissue engineering solutions." — Jason Frischer (clinical) [Ep 18 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- "A neovagina could potentially serve as a temporary bridge to allow menstruation, with removal 20 years later when tissue engineering options become available." — Marc Levitt (opinion) [Ep 18 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=766)
- "If a neovagina functions well without problems, there may be no need to remove it even if it was intended as temporary." — Jason Frischer (opinion) [Ep 18 · 13:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=789)
- "Using the colon in this case for vaginal replacement would be risky due to compromised blood supply from the prior divided stoma." — Marc Levitt (clinical) [Ep 18 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=801)
- "Vascular anomalies associated with anorectal malformations are under-recognized and poorly documented in the literature." — Marc Levitt (clinical) [Ep 18 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=911)
- "Surgeons should be willing to stop an operation when encountering uncertain anatomy, gather more information, and return to complete the procedure rather than proceeding blindly." — Jason Frischer (opinion) [Ep 18 · 15:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=957)
- "Visualization of the bladder neck does not predict its competency and ability to hold back urine; urodynamics are needed for assessment." — Thomas Hsu (clinical) [Ep 18 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- "The odds of fecal continence for this child are concerning given the sacral anatomy, though sphincter stimulation response was very good." — Marc Levitt (clinical) [Ep 18 · 17:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1033)
- "The patient not leaking urine continuously is a positive finding for future urinary continence." — Chris Westgarth-Taylor (clinical) [Ep 18 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- "Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, causing abnormalities in the anal opening, rectum, and occasionally surrounding structures" — Thomas Hsu (clinical) [Ep 19 · 1:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=84)
- "Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births" — Thomas Hsu (epidemiological) [Ep 19 · 1:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=99)
- "About 60% of anorectal malformation patients in some regions are discharged home without being identified" — Chris Westgarth-Taylor (epidemiological) [Ep 19 · 1:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=65)
- "When you see a blind ending piece of colon during initial laparoscopy, the best approach is to use that as your end stoma rather than doing a divided colostomy to avoid interfering with blood supply to the distal segment" — Marc Levitt (clinical) [Ep 19 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=141)
- "The more common scenario in anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between, which would be called recto-vestibular fistula with distal vaginal atresia" — Marc Levitt (clinical) [Ep 19 · 6:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=383)
- "In most cloacas, you should be able to get the native vagina to reach, avoiding the need for vaginal replacement" — Marc Levitt (clinical) [Ep 19 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=674)
- "Colonic neovaginas are not great for patients 20 years down the road and should be avoided if possible" — Marc Levitt (opinion) [Ep 19 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=674)
- "A dilatable introitus can potentially be dilated in the future to create a functional vagina" — Jason Frischer (clinical) [Ep 19 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=695)
- "Buccal graft can be laid into the opened introital area as an option for vaginal reconstruction" — Marc Levitt (clinical) [Ep 19 · 11:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=716)
- "Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or potentially shorter" — Marc Levitt (opinion) [Ep 19 · 11:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=716)
- "A neovagina could be provided as a temporary bridge to allow menstruation, then potentially removed 20 years later when better options become available" — Marc Levitt (clinical) [Ep 19 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=766)
- "If there is no problem with a neovagina bridge, there is no need to go in and remove tissue later" — Jason Frischer (opinion) [Ep 19 · 13:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=789)
- "Using the colon in this case for vaginal replacement would be problematic due to blood supply concerns from the original divided stoma procedure" — Thomas Hsu (clinical) [Ep 19 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=801)
- "Vascular anomalies associated with anorectal malformation are a topic that has never been much written about" — Marc Levitt (clinical) [Ep 19 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=911)
- "Aberrant external iliac artery can loop up within the abdominal wall and look like the obliterated umbilical artery while actually supplying blood to an extremity" — Marc Levitt (clinical) [Ep 19 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=911)
- "Surgeons are judged by what they are willing to stop for; it is wise to stop an operation when uncertain about anatomy, gather more information, and return another day" — Jason Frischer (opinion) [Ep 19 · 15:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=957)
- "The visualization of the bladder neck will not predict its competency and ability to hold back urine" — Thomas Hsu (clinical) [Ep 19 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=1059)
- "This patient will need urodynamics in the future to assess bladder function" — Thomas Hsu (clinical) [Ep 19 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=1059)
- "The advantage of doing colostomy laparoscopically is that malrotation may be discovered, which might remain undiagnosed with a standard left lower quadrant colostomy" — Thomas Hsu (clinical) [Ep 19 · 4:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=293)
- "In this case with limited dissection and a colocolonic anastomosis at the colostomy closure site plus an analplasty with a couple of posterior sutures, not diverting is a safe decision" — Marc Levitt (clinical) [Ep 19 · 10:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=612)
- "If diversion were needed in this case, an ileostomy would be the preferred choice" — Thomas Hsu (clinical) [Ep 19 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=628)
- "The limited posterior sagittal incision was deliberately kept out of the perineal body to avoid scarring that would interfere with future gynecological reconstruction" — Chris Westgarth-Taylor (clinical) [Ep 19 · 10:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=653)
- "Definitive diagnostic workup for cloacal malformation is typically performed at 5-6 months of age" — Jason Frischer (clinical) [Ep 20 · 1:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=105)
- "The diagnostic workup includes multidisciplinary team evaluation with urology, gynecology, and colorectal surgery, followed by cystovaginoscopy and examination under anesthesia" — Richard Wood (clinical) [Ep 20 · 1:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=116)
- "Preoperative urodynamics catheter placement is performed as part of the examination" — Richard Wood (clinical) [Ep 20 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=151)
- "During cystoscopy of the common channel, the vagina or vaginas are the easiest structures to enter, while accessing the urethra and bladder is challenging because it requires pointing far upward" — Richard Wood (clinical) [Ep 20 · 3:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=188)
- "The rectal fistula entrance is not always apparent during endoscopy and may require fluid injection through the mucous fistula to define it" — Richard Wood (clinical) [Ep 20 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=210)
- "When a septum is present, the rectal fistula is very often visible in the bottom of the septum on the rectal side" — Richard Wood (clinical) [Ep 20 · 3:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=230)
- "3D cloacogram is acquired by injecting contrast into all three structures (urethra, vagina, rectum) and using vascular C-arm imaging with specialized software" — Richard Wood (clinical) [Ep 20 · 4:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=245)
- "During cystoscopy it is important to identify cervices to understand Müllerian development and to look for ureteral orifices which may have anomalous attachments to the bladder or bladder neck" — Jason Frischer (clinical) [Ep 20 · 4:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=274)
- "The common channel takes a very significant turn as it passes behind the pubis, particularly in longer common channel cases" — Amanda Jensen (clinical) [Ep 20 · 6:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=386)
- "Cystoscopy significantly undermeasures anatomical structures compared to 3D reconstruction because the straight scope cannot accurately measure the turn behind the pubis" — Amanda Jensen (clinical) [Ep 20 · 6:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=405)
- "Routine endoscopy allows general pediatric surgeons to differentiate straightforward from complex cloacas and identify cases that should be referred to specialized centers" — Jason Frischer (opinion) [Ep 20 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=461)
- "As recently as 10-15 years ago, many cloacal repairs required revision because surgeons attempted repairs that were more complicated than anticipated" — Jason Frischer (epidemiological) [Ep 20 · 8:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=510)
- "Lower confluence cloacas can be elegantly repaired by appropriately trained surgeons, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers" — Jason Frischer (opinion) [Ep 20 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=540)
- "Type 1 cloaca is defined as common channel length less than 1 centimeter and represents a hypospadiac urethra with rectovaginal fistula" — Richard Wood (clinical) [Ep 20 · 10:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=607)
- "For type 1 cloaca, the hypospadiac urethral orifice is not touched, and the repair consists of vaginoplasty, introitoplasty, and PSARP" — Richard Wood (clinical) [Ep 20 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=640)
- "Even in type 1 cloaca with short common channel, the true rectum can still be positioned high, making imaging important to determine rectal height" — Richard Wood (clinical) [Ep 20 · 11:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=665)
- "For common channel length between 1-3 cm with urethral length greater than 1.5 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP" — Richard Wood (clinical) [Ep 20 · 11:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=690)
- "If urethral length is less than 1.5 cm, urogenital separation is advocated because performing TUM would result in the bladder neck being sewn near the perineum, potentially rendering the patient incontinent" — Amanda Jensen (clinical) [Ep 20 · 11:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=717)
- "For common channel greater than 3 cm, patients often have urethral length less than 1.5 cm and require urogenital separation with repair of the common channel as the urethra" — Richard Wood (clinical) [Ep 20 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=766)
- "When vagina or vaginas cannot reach the perineum, vaginal replacement may be needed to bridge the gap" — Amanda Jensen (clinical) [Ep 20 · 13:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=788)
- "If the rectum is positioned high, an abdominal approach may be needed to mobilize length, changing the PSARP approach to LARP (laparoscopic-assisted PSARP)" — Richard Wood (clinical) [Ep 20 · 13:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=812)
- "Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction" — Marc Levitt (clinical) [Ep 20 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=844)
- "Alberto Pena developed total urogenital mobilization (TUM) in 1996 as a major advance, keeping urethra and vagina together as a unit to mobilize forward" — Marc Levitt (clinical) [Ep 20 · 14:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=875)
- "Prior to 1996, all cloacal patients underwent urogenital separation" — Marc Levitt (clinical) [Ep 20 · 14:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=890)
- "The algorithm using common channel length of 3 cm and urethral length of 1.5 cm as decision points was presented in 2017 and represents the next major change after TUM" — Marc Levitt (clinical) [Ep 20 · 15:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=914)
- "Hardy Hendren at age 91 endorsed the 2017 algorithm at APSA, stating he agreed with everything presented" — Marc Levitt (opinion) [Ep 20 · 16:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=970)
- "The algorithm has been validated in 116 consecutive patients without needing to change the surgical plan in any case" — Richard Wood (clinical) [Ep 20 · 17:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1056)
- "The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered" — Marc Levitt (clinical) [Ep 20 · 18:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1093)
- "Urethral length is defined as the distance from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single perineal orifice to bladder neck" — Richard Wood (clinical) [Ep 20 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1149)
- "Accurate urethral length measurement is fundamentally important to ensure the bladder neck lands above the urogenital diaphragm where the external sphincter complex lies" — Richard Wood (clinical) [Ep 20 · 19:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1190)
- "3D imaging provides the most accurate urethral measurement because cystoscopy straightens structures and can falsely measure them due to the anatomical curve" — Richard Wood (clinical) [Ep 20 · 20:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1200)
- "A single perineal orifice in a newborn should clue you into a cloaca, where the vagina, urethra, and rectum are fused together inside creating a single common channel" — Richard Wood (clinical) [Ep 21 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=125)
- "Hydrocolpos is the distension of the vagina caused by the accumulation of fluid" — Richard Wood (clinical) [Ep 21 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=145)
- "A cloaca or anorectal malformation is associated with VACTERL and needs to be worked up as such" — Richard Wood (guideline) [Ep 21 · 2:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=160)
- "VACTERL association consists of vertebral anomalies, imperforate anus, cardiovascular anomalies, tracheoesophageal fistulas, esophageal atresia, renal or radial anomalies, and limb defects; three or more anomalies are needed for the association" — Amanda Jensen (clinical) [Ep 21 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=190)
- "A hydrocolpos on prenatal ultrasound should alert to the possibility of a cloaca" — Richard Wood (clinical) [Ep 21 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- "Abnormal kidneys, a single kidney, or a two-vessel cord on prenatal ultrasound can be associated with cloaca" — Richard Wood (clinical) [Ep 21 · 4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=250)
- "The diagnostic yield for cloacal malformations on prenatal ultrasound is still much lower than desired" — Richard Wood (epidemiological) [Ep 21 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- "In a large majority of patients with cloaca, the diagnosis is made at birth" — Hira Ahmad (epidemiological) [Ep 21 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=341)
- "Children with cloacas are female and do not need workup for karyotyping or disorders of sexual differentiation, despite potentially prominent clitoral hood and labial tissue" — Richard Wood (guideline) [Ep 21 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=440)
- "Initial workup for cloaca should consist of NG tube and chest x-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis" — Richard Wood (guideline) [Ep 21 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=476)
- "If bilateral hydronephrosis and hydrocolpos are present, the hydrocolpos needs to be managed as part of initial treatment" — Richard Wood (clinical) [Ep 21 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=540)
- "Modern practice has moved away from routine vaginostomy toward clean intermittent catheterization through the common channel for hydrocolpos drainage" — Richard Wood (clinical) [Ep 21 · 9:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=551)
- "To perform CIC for hydrocolpos, pass a tube through the common channel, drain fluid, confirm tube placement in the hydrocolpos with ultrasound, then perform recurrent catheterization" — Richard Wood (clinical) [Ep 21 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=564)
- "When catheterizing the common channel, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff" — Marc Levitt (clinical) [Ep 21 · 11:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=668)
- "Initial catheterization should be performed with bedside ultrasound confirmation that the tube is in the hydrocolpos and is decompressing it" — Richard Wood (guideline) [Ep 21 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=753)
- "When the hydrocolpos is drained, the bladder fills, demonstrating that the hydrocolpos was obstructing the ureters" — Marc Levitt (clinical) [Ep 21 · 13:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=791)
- "A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead" — Marc Levitt (opinion) [Ep 21 · 13:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=839)
- "Initial catheterization frequency is three times daily, which can be reduced to twice daily when families begin performing it at home" — Richard Wood (guideline) [Ep 21 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- "Serial ultrasounds should be performed every 2-3 days initially, then stretched to weekly, to confirm adequate kidney decompression" — Richard Wood (guideline) [Ep 21 · 15:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=930)
- "After discharge, monthly ultrasounds should be performed to ensure continued kidney decompression, which can be stretched to every six weeks if doing well" — Richard Wood (guideline) [Ep 21 · 16:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=960)
- "Even with a vaginostomy tube, you must continue checking that the kidneys are decompressed, as the tube may not be doing its job" — Richard Wood (clinical) [Ep 21 · 16:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1000)
- "Colostomy should be performed as proximally as possible, at the descending-sigmoid junction, to ensure enough length for distal work" — Richard Wood (clinical) [Ep 21 · 17:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1073)
- "Laparoscopy for newborn colostomy formation provides good anatomical views of the pelvis, allows precise colostomy site selection, and avoids a wound between the two stomas" — Richard Wood (clinical) [Ep 21 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1122)
- "If a vaginostomy is needed in a patient with a vaginal septum, open the anterior wall of the hydrocolpos and remove a small portion of the septum to drain both sides through one hole" — Richard Wood (clinical) [Ep 21 · 20:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1215)
- "Vaginostomy tubes can become encrusted and colonized, so there is some advantage to tubeless vaginostomy" — Richard Wood (clinical) [Ep 21 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1260)
- "For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent to the anterior abdominal wall and inflamed" — Marc Levitt (clinical) [Ep 21 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1297)
- "A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup" — Marc Levitt (guideline) [Ep 21 · 22:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1371)
- "Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar management but without colostomy" — Marc Levitt (clinical) [Ep 21 · 23:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1420)
- "After initial management, follow patients closely to ensure kidneys are well decompressed, the baby is growing and thriving, and parents are managing the stoma" — Richard Wood (guideline) [Ep 21 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1476)
- "With urine and stool effectively drained, patients should be thriving unless other underlying issues are present" — Richard Wood (clinical) [Ep 21 · 25:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1520)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos)." — Marc Levitt (clinical) [Ep 8 · 2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158)
- "Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term." — Marc Levitt (clinical) [Ep 8 · 3:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=236)
- "Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves." — Marc Levitt (clinical) [Ep 8 · 5:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=314)
- "In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries." — Marc Levitt (clinical) [Ep 8 · 6:37](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=397)
- "A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities." — Marc Levitt (clinical) [Ep 8 · 6:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=417)
- "To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices." — Marc Levitt (clinical) [Ep 8 · 8:36](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=516)
- "Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule)." — Marc Levitt (clinical) [Ep 8 · 9:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=543)
- "Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum." — Marc Levitt (clinical) [Ep 8 · 9:59](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=599)
- "Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound." — Marc Levitt (clinical) [Ep 8 · 11:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=674)
- "If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides." — Marc Levitt (clinical) [Ep 8 · 13:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=794)
- "For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not." — Marc Levitt (clinical) [Ep 8 · 14:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=855)
- "Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction." — Marc Levitt (clinical) [Ep 8 · 15:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=905)
- "Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra." — Marc Levitt (clinical) [Ep 8 · 16:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=988)
- "Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair." — Marc Levitt (clinical) [Ep 8 · 17:54](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1074)
- "Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder." — Marc Levitt (clinical) [Ep 8 · 20:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1211)
- "Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle)." — Marc Levitt (clinical) [Ep 8 · 18:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1101)
- "Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos." — Marc Levitt (clinical) [Ep 8 · 18:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1128)
- "Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns." — Marc Levitt (opinion) [Ep 8 · 20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1229)
- "Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique." — Marc Levitt (clinical) [Ep 8 · 20:49](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1249)
- "For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube." — Marc Levitt (clinical) [Ep 8 · 21:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1277)
- "Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization." — Marc Levitt (clinical) [Ep 8 · 22:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348)
- "Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach." — Marc Levitt (clinical) [Ep 8 · 23:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1397)
- "Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth." — Marc Levitt (clinical) [Ep 8 · 23:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1437)
- "The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach." — Marc Levitt (clinical) [Ep 8 · 25:25](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1525)
- "Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers." — Marc Levitt (clinical) [Ep 8 · 25:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1527)
- "Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this." — Marc Levitt (clinical) [Ep 8 · 26:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1581)
- "3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better." — Marc Levitt (clinical) [Ep 8 · 28:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1714)
- "Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over." — Marc Levitt (opinion) [Ep 8 · 30:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1829)
- "Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques." — Marc Levitt (clinical) [Ep 8 · 32:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1935)
- "Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel." — Marc Levitt (clinical) [Ep 8 · 33:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2019)
- "With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation." — Marc Levitt (clinical) [Ep 8 · 34:26](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2066)
- "After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula." — Marc Levitt (clinical) [Ep 8 · 34:50](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2090)
- "If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra." — Marc Levitt (clinical) [Ep 8 · 35:09](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2109)
- "Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck." — Marc Levitt (clinical) [Ep 8 · 35:52](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2152)
- "Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence." — Marc Levitt (clinical) [Ep 8 · 36:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2165)
- "Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component." — Marc Levitt (clinical) [Ep 8 · 36:40](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2200)
- "Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization." — Marc Levitt (clinical) [Ep 8 · 37:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2231)
- "When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement." — Marc Levitt (clinical) [Ep 8 · 38:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2280)
- "For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade." — Marc Levitt (opinion) [Ep 8 · 38:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2326)
- "Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement." — Marc Levitt (clinical) [Ep 8 · 39:10](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2350)
- "Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm." — Marc Levitt (clinical) [Ep 8 · 39:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2388)
- "The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched." — Marc Levitt (clinical) [Ep 8 · 40:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2427)
- "The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina." — Marc Levitt (clinical) [Ep 8 · 40:58](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2458)
- "Common channel length measured 6 cm on cystoscopy, 5 cm on cloacogram (measurements sometimes differ between modalities)." (clinical) [Ep 1 · 1:05](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=65)
- "In high common channel cloacas, the common walls between rectum, vagina, and bladder are not long and are easier to separate abdominally than to search for posterior sagittally." (clinical) [Ep 1 · 2:53](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=173)
- "Saline perturbation is used intraoperatively to assess patency of the reproductive tract in cloacal cases." — Bree (clinical) [Ep 1 · 4:08](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=248)
- "When one hemivagina/hemiuterus is well developed and the other is atretic, it may be advantageous to retain the well-developed side and remove the atretic side to avoid menstrual complications and preserve childbearing potential." — Bree (clinical) [Ep 1 · 4:35](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=275)
- "Using the rectum as vaginal replacement may change a potentially fecally continent patient into an incontinent one by removing the rectal reservoir." (clinical) [Ep 1 · 8:13](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=493)
- "Rectum should be used for vaginal replacement only in patients who are not expected to be fecally continent (e.g., tethered cord, short sacrum)." (clinical) [Ep 1 · 8:13](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=493)
- "In Dr. Pena's early cases using rectum as vagina in vestibular fistula patients with absent vagina, long-term follow-up showed less than optimal bowel control." — Pena (clinical) [Ep 1 · 8:54](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=534)
- "Preservation of the rectum is extremely important in patients with good functional prognosis (good sacrum, no tethered cord, good malformation)." — Pena (clinical) [Ep 1 · 9:21](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=561)
- "The rectum is a natural reservoir; removing it in anorectal malformation patients will most likely result in incontinence because patients cannot tolerate constant stool passage when colon is connected directly to perineum." — Pena (clinical) [Ep 1 · 9:55](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=595)
- "Descending colon is increasingly used for vaginal replacement because the vascular arcades are favorable for preserving blood supply." — Pena (clinical) [Ep 1 · 10:56](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=656)
- "Dr. Pena has seen approximately 65 cases that came operated from other institutions with a diagnosis of intersex at birth due to phallic-appearing anatomy, all of which were chromosomally normal females with cloacas." — Pena (epidemiological) [Ep 1 · 12:33](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=753)
- "Dr. Pena has never seen a patient with intersex and a cloaca coexisting." — Pena (clinical) [Ep 1 · 13:09](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=789)
- "A patient with a pseudophallus and single perineal orifice can be differentiated from adrenal hyperplasia by palpation: true corpora are palpable in adrenal hyperplasia, whereas in cloaca the structure is folded skin." — Pena (clinical) [Ep 1 · 13:15](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=795)
- "The folded skin of the pseudophallus in cloacal patients can be used to facilitate vaginal reconstruction." — Pena (clinical) [Ep 1 · 13:30](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=810)
- "Families agonize during the 2-3 weeks that doctors spend trying to make an intersex diagnosis in cloacal patients with phallic structures." — Pena (opinion) [Ep 1 · 13:50](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=830)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos)." — Marc Levitt (clinical) [Ep 5 · 2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=158)
- "Fetal intervention for cloaca is unlikely but may be necessary for massive hydronephrosis with impending renal loss; one case report from Japan described hydrocolpos drainage similar to bladder drainage for urethral valves." — Marc Levitt (clinical) [Ep 5 · 3:59](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=239)
- "In newborn examination, cloaca presents as one hole below the clitoris with no anus; this is distinct from urogenital sinus which has one hole but a normal anus." — Marc Levitt (clinical) [Ep 5 · 6:35](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=395)
- "Cloaca is not ambiguous genitalia and has no adrenal problem; the baby is a normal female with two normal ovaries and will be hormonally normal." — Marc Levitt (clinical) [Ep 5 · 7:25](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=445)
- "Many patients considered cloacas are actually vestibular fistulas; with better examination pulling the labia up and out, you can see three distinct holes (urethra, vagina, and vestibular fistula)." — Marc Levitt (clinical) [Ep 5 · 9:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=543)
- "Initial workup includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, plain X-ray of spine for hemivertebrae and sacral quality, and echocardiogram at most centers." — Marc Levitt (guideline) [Ep 5 · 9:59](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=599)
- "Vesicostomy is rarely needed in cloaca because the problem is not the bladder but the hydrocolpos compressing the trigone and distal ureters; draining the hydrocolpos relieves the obstruction." — Marc Levitt (clinical) [Ep 5 · 15:02](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=902)
- "Vesicostomy or suprapubic tube is indicated only when the common channel is very narrow or absent, preventing bladder drainage even after hydrocolpos decompression." — Marc Levitt (clinical) [Ep 5 · 16:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=988)
- "Massive bilateral ureteral reflux is an exception where vesicostomy may be needed to decompress the system until later in life." — Marc Levitt (clinical) [Ep 5 · 17:54](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1074)
- "Hydrocolpos forms because the bladder preferentially fills the vagina through a fistula rather than exiting the common channel; the vagina also contains mucus, and maternal estrogen can increase mucus production." — Marc Levitt (clinical) [Ep 5 · 18:24](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1104)
- "The urethra in cloaca often requires a steep turn (scope on floor pointing to ceiling) to reach the bladder, explaining why urine does not drain easily and instead fills the vagina." — Marc Levitt (clinical) [Ep 5 · 19:31](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1171)
- "Cystoscopy is not performed in the newborn period; it is delayed until 2-3 months when a larger scope can be used, visualization is better, and the baby is healthier." — Marc Levitt (clinical) [Ep 5 · 20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1229)
- "For vaginostomy tube placement, use an 8 or 10 French pigtail catheter from interventional radiology; a curled catheter prevents tube fallout as the hydrocolpos recedes, unlike straight catheters which fall out." — Marc Levitt (clinical) [Ep 5 · 14:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=855)
- "For bilateral hydrocolpos, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides." — Marc Levitt (clinical) [Ep 5 · 13:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=807)
- "The two critical endoscopic measurements are common channel length (traditional measure, with 3 cm or less being straightforward) and urethral length from urethral takeoff to bladder neck (newly emphasized measure that determines surgical approach)." — Marc Levitt (clinical) [Ep 5 · 25:25](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1525)
- "Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum in the abdomen; a contrast study (cloacogram) is needed to determine this." — Marc Levitt (clinical) [Ep 5 · 26:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1581)
- "The cloacogram technique involves leaving catheters in the bladder, distal colostomy, and perineal orifice during endoscopy, then having interventional radiology inject these structures and create a 3D reconstruction." — Marc Levitt (clinical) [Ep 5 · 27:24](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1644)
- "Studies comparing 2D cloacogram, 3D reconstruction, 3D printed models, and virtual reality showed that more complex modalities led to more correct anatomic descriptions; 3D is definitely better than 2D." — Marc Levitt (clinical) [Ep 5 · 28:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1714)
- "Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes the urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate from prior techniques." — Marc Levitt (clinical) [Ep 5 · 32:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1935)
- "Urogenital mobilization is appropriate when common channel is 3 cm or less AND there is at least 1.5-2 cm of urethra above the urethral takeoff; this leaves adequate urethral length after splitting the common channel." — Marc Levitt (clinical) [Ep 5 · 33:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2019)
- "When urethral length is inadequate (less than 1.5 cm from takeoff to bladder neck), the common channel must be left alone to become the urethra, and the vagina must be separated from the common channel—a technically demanding operation." — Marc Levitt (clinical) [Ep 5 · 34:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2074)
- "If urogenital mobilization is attempted with inadequate urethral length and the complex does not reach, the only option is abdominal delivery of the urogenital complex, which often does not work and can lead to urethral devascularization and loss." — Marc Levitt (clinical) [Ep 5 · 35:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2117)
- "Leaving a patient with inadequate urethral length after urogenital mobilization results in leakage with no way to gain control without tightening or closing the bladder neck." — Marc Levitt (clinical) [Ep 5 · 35:52](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2152)
- "Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence." — Marc Levitt (clinical) [Ep 5 · 36:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2165)
- "For type 1 cloaca (common channel of 1 cm with adequate urethral length), mobilizing the vagina alone and leaving a slightly hypospadiac urethra is acceptable if the patient will void and not require intermittent catheterization." — Marc Levitt (clinical) [Ep 5 · 36:40](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2200)
- "When native vagina does not reach after full mobilization, options include vaginal switch (disconnecting one side while preserving ovarian blood supply) or vaginal replacement with colon (preferred), small bowel, or rectum." — Marc Levitt (clinical) [Ep 5 · 38:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2280)
- "Tissue engineering of vaginas using patient stem cells is on the horizon, with work done at Wake Forest and in Mexico; this could revolutionize cloaca care by eliminating the need for vaginal replacement." — Marc Levitt (opinion) [Ep 5 · 39:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2357)
- "The most common problem in redo cloaca surgery is that the surgeon never realized they were dealing with a cloaca and only fixed the rectum, leaving the urogenital sinus untouched." — Marc Levitt (clinical) [Ep 5 · 40:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2427)
- "The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina." — Marc Levitt (clinical) [Ep 5 · 40:58](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2458)
- "Cloacal repair timing is typically 2-3 months for diagnostic endoscopy and cloacogram, with definitive repair anytime thereafter within the first year; Dr. Levitt aims for before 6 months if managing from birth, before 1 year if referred." — Marc Levitt (clinical) [Ep 5 · 24:07](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1447)
- "Urogenital sinus (one hole with normal anus) requires workup for adrenal problems and virilization; if virilized, likely has adrenal hyperplasia requiring electrolyte monitoring." — Marc Levitt (clinical) [Ep 5 · 22:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1347)
- "Many cloaca patients have neurogenic bladder component whether or not they have tethered cord; a visible urethral orifice that is easily catheterized is needed if intermittent catheterization will be required." — Marc Levitt (clinical) [Ep 5 · 37:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2231)
- "Cloaca management has become a collaborative team effort involving pediatric surgery, urology, and gynecology, plus ancillary services (fetal medicine, neonatology, nephrology, GI, radiology, behavioral medicine, social work, nursing)." — Em Gootee (host_summary) [Ep 6 · 5:17](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=317)
- "On ultrasound, the bladder is the first cystic structure seen from the abdominal cord insertion, outlined by umbilical arteries; a cystic structure posterior/inferior to the bladder reaching into the abdomen is hydrocolpos in a cloacal malformation." — Maria Cappels (clinical) [Ep 6 · 8:10](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=490)
- "Echogenic concretions (meconium) in the hydrocolpos or bladder are clues for a recto-urinary fistula and anorectal malformation." — Maria Cappels (clinical) [Ep 6 · 9:11](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=551)
- "Fetal MRI shows meconium as dark on T2-weighted imaging and bright on T1-weighted imaging; fluid in the fetal bowel is bright on T2 and dark on T1." — Maria Cappels (clinical) [Ep 6 · 10:50](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=650)
- "Meconium reaches the rectum by 20 weeks gestation and fills the entire colon by 26 weeks." — Maria Cappels (clinical) [Ep 6 · 11:49](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=709)
- "On fetal MRI sagittal view, the normal rectum measures at least 10 mm from the bladder base to its most distal segment (per Seinda et al.)." — Maria Cappels (host_summary) [Ep 6 · 12:10](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=730)
- "Long-common-channel cloaca on fetal MRI presents with a high-positioned, dilated rectum that funnels distally but does not reach far enough, and a thick-walled bladder due to outlet obstruction." — Maria Cappels (clinical) [Ep 6 · 13:28](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=808)
- "Imperforate anus with recto-urinary fistula can show fluid distention of the rectum and enterocolitis on fetal MRI; increased fluid content (bright T2 signal instead of dark meconium) in a dilated rectum is a clue for recto-urinary fistula." — Maria Cappels (clinical) [Ep 6 · 14:28](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=868)
- "Urogenital sinus on fetal MRI shows a rectum following a normal posterior course (not dilated, reaching far enough), with hydrocolpos located between the bladder and rectum; this distinguishes it from short-common-channel cloaca." — Maria Cappels (clinical) [Ep 6 · 16:15](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=975)
- "Cloacal exstrophy typically presents with persistent absent bladder visualization, normal amniotic fluid, low omphalocele, skin-covered spinal defects, and sometimes a prolapsed terminal ileum (elephant trunk sign) protruding through the abdominal wall defect." — Maria Cappels (clinical) [Ep 6 · 17:40](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1060)
- "Cloacal exstrophy on fetal MRI shows no meconium signal in the expected distribution of the rectum, distinguishing it from bladder exstrophy (which has a normal rectum with dark T2/bright T1 meconium signal)." — Maria Cappels (clinical) [Ep 6 · 20:20](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1220)
- "Many cloaca cases are not diagnosed prenatally; retrospective review of donated ultrasounds from mothers of babies born with cloaca revealed abnormalities that were misdiagnosed as ureterocele, double bladder, ovarian cysts, or bladder diverticulum." (epidemiological) [Ep 6 · 26:08](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1568)
- "Hydrocolpos is not well described in the radiology literature, so many non-specialized radiologists are unfamiliar with the finding and may misinterpret it." (opinion) [Ep 6 · 27:15](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1635)
- "If a female fetus has a prenatal diagnosis of ovarian cyst, double bladder, or ureterocele—especially with abnormal vertebrae, hydronephrosis, or dilated bowel—suspect cloaca." (clinical) [Ep 6 · 27:48](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1668)
- "Prenatal diagnosis of cloaca allows transfer to a specialized center for proper colostomy and hydrocolpos drainage, and gives the family time to prepare emotionally and logistically for surgery within 24 hours of birth." — Andrea (opinion) [Ep 6 · 28:12](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1692)
- "Pediatric surgeons cannot yet predict long-term bowel control, urinary control, or sexual function from prenatal imaging alone; key information (common channel length, sacral anatomy) is still limited on prenatal studies." — Andrea (opinion) [Ep 6 · 28:56](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1736)
- "At Sick Kids (Toronto), an increasing number of cloaca cases have prenatal diagnosis, but the majority still do not." — Jack Langer (epidemiological) [Ep 6 · 30:18](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1818)
- "Findings of cloaca on routine 20-week ultrasound may be very subtle; community obstetricians may not suspect the diagnosis unless they have a high index of suspicion." — Jack Langer (opinion) [Ep 6 · 30:26](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1826)
- "False-positive prenatal diagnoses of ARM occur, causing parental alarm when the baby is born without any issues." — Em Gootee (clinical) [Ep 6 · 31:00](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1860)
- "Prenatal diagnosis of anorectal malformation in boys is not very good; it is often a surprise at birth." (clinical) [Ep 7 · 0:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=0)
- "In females, prenatal ultrasound showing bilateral hydronephrosis, small bladder, and dilated vagina suggests cloaca." — Greg Bates (clinical) [Ep 7 · 2:12](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=132)
- "Fetal MRI is used for abnormal level 2 ultrasounds, especially with other anomalies, for prognostication and surgical planning." (clinical) [Ep 7 · 6:03](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=363)
- "Calcified enteroliths in the GI tract on neonatal KUB indicate urine mixing with meconium, suggesting a recto-GU fistula at least at the bulbar level or higher." — Greg Bates (clinical) [Ep 7 · 7:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=434)
- "Patients with hydrocolpos can have significant urinary compromise with creatinine rising into the twos and threes if not managed urgently." (clinical) [Ep 7 · 9:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=554)
- "After 20 to 24 weeks gestation, T1 hyperintensity of meconium within the colon should be visible on fetal MRI; loss of T1 hyperintensity and bright T2 signal suggests urine mixing." — Greg Bates (clinical) [Ep 7 · 10:08](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=608)
- "On fetal MRI, the distal rectum should extend at least 10 mm below the bladder neck in the second trimester, up to 20–24 mm in the third trimester; high position suggests ARM." — Greg Bates (clinical) [Ep 7 · 10:08](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=608)
- "Hemisacrum (scimitar sacrum) is associated with presacral mass (teratoma or anterior myelomeningocele) and Currarino triad." (clinical) [Ep 7 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=758)
- "When hemisacrum is seen in a patient with anal malformation, Currarino triad must be assumed and presacral mass must be looked for." — Greg Bates (clinical) [Ep 7 · 15:35](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=935)
- "For sacral ratio measurement, a true AP pelvis (not angled sacral view) and lateral pelvis are required; the lateral view is more accurate." — Greg Bates (clinical) [Ep 7 · 17:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1020)
- "Normal sacral ratio ranges from 0.6 to 1.0; below 0.3 predicts very low likelihood of continence." — Greg Bates (clinical) [Ep 7 · 21:48](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1308)
- "Sacral ratio measurement has inter-observer variability, especially in abnormal sacra, and is not as exact as often assumed." (opinion) [Ep 7 · 30:35](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1835)
- "Sacral ratio is one of four components of an ARM index (perineum appearance, malformation type, sacral index, tethered cord) being developed to predict continence and compare outcomes across institutions." (host_summary) [Ep 7 · 26:02](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1562)
- "Cross-table lateral (invertogram) must be performed after 24 to 36 hours to allow enough air and pressure to show the true level of the distal rectal pouch." — Greg Bates (clinical) [Ep 7 · 36:40](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2200)
- "On invertogram, rectum within 1 cm of the perineal marker (BB) is considered safe for primary repair in selected cases." (clinical) [Ep 7 · 39:32](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2372)
- "Perineal ultrasound is more accurate than invertogram according to some radiologists, with ability to visualize fistulae and avoid radiation, but requires experience and standardized protocol." (opinion) [Ep 7 · 40:30](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2430)
- "It is never wrong to perform a colostomy if uncertain about the level of the malformation." (opinion) [Ep 7 · 49:51](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2991)
- "Complications of colostomy double the incidence of complications in ARM patients, so avoiding colostomy when safe is desirable." (clinical) [Ep 7 · 44:05](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2645)
- "In boys, approximately 95% have a fistula (outside of Down syndrome); the radiologist's job is to demonstrate it on distal colostography." (epidemiological) [Ep 7 · 52:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3120)
- "High-pressure distal colostography requires adequate pressurization to demonstrate fistulae; a small 'beak' off the rectal base indicates fistula location." (clinical) [Ep 7 · 52:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3120)
- "Distal colonic segments that are very dilated and atonic are at higher risk of perforation during colostography due to Laplace's law (thin wall, high pressure)." — Greg Bates (clinical) [Ep 7 · 56:56](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3416)
- "Perforation during colostography with hyperosmotic contrast (e.g., cystoconray, ~400 mOsm) causes immediate fluid shift and peritonitis requiring emergent IV fluids and surgical consultation." — Greg Bates (clinical) [Ep 7 · 58:21](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3501)
- "Iso-osmotic contrast is now preferred for distal colostography to avoid fluid shifts if perforation occurs." — Greg Bates (clinical) [Ep 7 · 59:58](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3598)
- "On distal colostography lateral view, the full sacrum should be included to show the relationship of the fistula to the tip of the sacrum." (clinical) [Ep 7 · 54:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3240)
- "It is difficult to distinguish radiologically between prostatic and bulbar urethral fistulae; the bend in the urethra is used as an approximate landmark." — Greg Bates (clinical) [Ep 7 · 55:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3300)
- "A single perineal orifice in a newborn indicates cloaca: the vagina, urethra, and rectum are fused internally into a single common channel." — Richard Wood (clinical) [Ep 9 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=125)
- "Hydrocolpos is distension of the vagina caused by accumulation of fluid." — Richard Wood (clinical) [Ep 9 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=151)
- "Cloaca or anorectal malformation is associated with VACTERL and requires workup as such." — Amanda Jensen (host_summary) [Ep 9 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=178)
- "VACTERL association comprises: Vertebral anomalies, imperforate Anus, Cardiovascular anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal/radial anomalies, and Limb defects. Three or more anomalies define the association." — Amanda Jensen (host_summary) [Ep 9 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=190)
- "Prenatal diagnostic yield for cloacal malformations is still much lower than desired." — Richard Wood (epidemiological) [Ep 9 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=224)
- "Hydrocolpos on prenatal ultrasound should alert to the possibility of cloaca." — Richard Wood (clinical) [Ep 9 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=240)
- "Subtle prenatal signs of cloaca include abnormal kidneys (e.g., single kidney) and two-vessel cord." — Richard Wood (clinical) [Ep 9 · 4:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=260)
- "In the majority of cloaca patients, diagnosis is made at birth rather than prenatally." — Marc Levitt (epidemiological) [Ep 9 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=341)
- "Physical exam of cloaca perineum with good lighting and labial distraction reveals a clitoral hood, underdeveloped labia minora, a single perineal orifice, and a perineal groove suggesting muscle complex." — Richard Wood (clinical) [Ep 9 · 6:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=388)
- "In a child with cloacal malformation who does not have an anus, there is no indication to investigate for ambiguous genitalia or disorders of sexual differentiation; these children are female and do not need karyotyping." — Richard Wood (guideline) [Ep 9 · 7:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=436)
- "Initial urgent management priorities in cloaca are: ensure kidney and urine decompression, diagnose hydrocolpos, and confirm patient is safe for anesthesia (cardiac assessment, TEF screen)." — Richard Wood (guideline) [Ep 9 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=476)
- "Initial workup should include NG tube and chest X-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis." — Amanda Jensen (host_summary) [Ep 9 · 8:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=525)
- "Bilateral hydronephrosis with hydrocolpos requires management of the hydrocolpos as part of initial treatment." — Amanda Jensen (host_summary) [Ep 9 · 9:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=550)
- "Modern practice has moved away from routine vaginostomy toward clean intermittent catheterization (CIC) through the common channel to drain hydrocolpos." — Richard Wood (guideline) [Ep 9 · 9:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=562)
- "CIC technique: pass a tube through the common channel, drain fluid, confirm by ultrasound that the tube is in the hydrocolpos/vagina, decompress it, and repeat catheterization regularly. If effective, proceed with colostomy and continue CIC postoperatively." — Richard Wood (clinical) [Ep 9 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=564)
- "Seattle Children's (Paul McGarrian, Jeff Evansino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing prior dogma of routine vaginostomy." — Marc Levitt (clinical) [Ep 9 · 10:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=606)
- "When catheterizing the common channel, the anatomy of the urethral takeoff makes it more likely to enter the vagina than the bladder." — Marc Levitt (clinical) [Ep 9 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=640)
- "After passing a catheter for hydrocolpos drainage, obtain bedside ultrasound immediately to confirm catheter position in the hydrocolpos and successful decompression." — Richard Wood (guideline) [Ep 9 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=753)
- "Live ultrasound during catheter drainage shows that as the hydrocolpos drains, the bladder fills—demonstrating the pathophysiology of ureteral obstruction by the hydrocolpos." — Marc Levitt (clinical) [Ep 9 · 13:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=781)
- "In almost every cloaca, vesicostomy is unnecessary; the hydrocolpos must be drained, and perineal catheterization can relieve bladder outlet obstruction by decompressing the hydrocolpos and allowing ureters to drain." — Marc Levitt (guideline) [Ep 9 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=820)
- "CIC frequency: initially three times daily in the NICU, then twice daily when families take over. Follow with serial ultrasounds every 2–3 days initially, then weekly, then monthly at home to confirm kidney decompression." — Richard Wood (guideline) [Ep 9 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=901)
- "The goal of hydrocolpos drainage is kidney decompression. If kidneys are completely normal despite hydrocolpos, the hydrocolpos is not urgent; if kidneys are obstructed, drainage is critical." — Richard Wood (clinical) [Ep 9 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=901)
- "Even with a vaginostomy tube, serial ultrasound is required to confirm the tube is keeping kidneys decompressed; do not assume it is working without imaging confirmation." — Richard Wood (guideline) [Ep 9 · 16:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=980)
- "Newborn cloaca management summary: good exam with lighting to diagnose, no endocrine workup needed, renal/pelvic ultrasound and anesthesia safety tests, drain hydrocolpos (preferably by CIC), and colostomy within 24–48 hours." — Richard Wood (guideline) [Ep 9 · 17:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1022)
- "Colostomy should be performed as proximally as possible—at the descending-sigmoid junction—to preserve distal bowel length for future reconstruction." — Richard Wood (guideline) [Ep 9 · 17:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1075)
- "Laparoscopic colostomy in non-distended newborns offers excellent pelvic anatomic visualization, precise stoma site selection, and the ability to create a stoma without a skin bridge between proximal and distal limbs." — Richard Wood (clinical) [Ep 9 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1122)
- "Laparoscopic colostomy technique: mobilize lateral attachments of descending colon, bring bowel through mucus-fistula site, staple and washout distal limb until clean, then create separate incision for proximal stoma, leaving clean skin around working stoma and closing mucus-fistula site partially." — Richard Wood (clinical) [Ep 9 · 19:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1150)
- "If vaginostomy is required and the patient has a vaginal septum, open the anterior wall of the hydrocolpos and remove a small portion of the septum to drain both sides through one opening." — Richard Wood (clinical) [Ep 9 · 20:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1212)
- "Vaginostomy can be performed with or without a tube. Tubes can become encrusted and colonized, so tubeless (suturing vagina to abdominal wall) may be preferable if the vagina reaches the abdominal wall easily." — Richard Wood (clinical) [Ep 9 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1260)
- "For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent and inflamed against the anterior abdominal wall. A standard left lower quadrant incision will not provide adequate access." — Marc Levitt (clinical) [Ep 9 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1297)
- "For large hydrocolpos, a tubeless vaginostomy can be created by opening the dome, removing part of the septum, and suturing the vagina to the abdominal wall like a vesicostomy or gastrostomy, avoiding an indwelling tube as a nidus for infection." — Marc Levitt (clinical) [Ep 9 · 22:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1330)
- "Single perineal orifice with no anal opening is a cloaca and does NOT require endocrine workup. A perineal orifice with a normal anus is a urogenital sinus and DOES require endocrine workup (e.g., for congenital adrenal hyperplasia)." — Marc Levitt (guideline) [Ep 9 · 23:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1388)
- "Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar drainage management but no colostomy." — Marc Levitt (clinical) [Ep 9 · 23:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1420)
- "Post-discharge follow-up for cloaca: monitor kidney decompression with serial ultrasounds, follow kidney function tests, ensure stoma management and growth. Definitive imaging and reconstructive planning are deferred until the patient is growing and thriving." — Richard Wood (guideline) [Ep 9 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1476)
- "Definitive diagnostic workup for cloaca is typically performed at 5 to 6 months of age." — Richard Wood (clinical) [Ep 10 · 1:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=113)
- "The workup includes multidisciplinary team evaluation (urology, gynecology, colorectal), cystovaginoscopy and examination under anesthesia, preoperative urodynamics catheter placement, and 3D cloacogram." — Richard Wood (clinical) [Ep 10 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=126)
- "During cystoscopy of the common channel, the easiest structure to enter is the vagina or vaginas; entering the urethra and bladder is challenging because the scope must point far upward to take the turn." — Richard Wood (clinical) [Ep 10 · 2:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=170)
- "The 3D cloacogram is acquired by injecting contrast into bladder, vagina(s), and rectal fistula, then using a vascular C-arm in radiology (or hybrid OR) with reconstruction software to create three-dimensional images." — Richard Wood (clinical) [Ep 10 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=224)
- "The major advantage of 3D reconstruction is spatial understanding of anatomy, because patients do not always present with textbook anatomy." — Richard Wood (opinion) [Ep 10 · 4:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=253)
- "During cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck." — Jason Frischer (clinical) [Ep 10 · 4:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=290)
- "The common channel takes a significant turn as it passes behind the pubis, especially in longer common channel cases." — Richard Wood (clinical) [Ep 10 · 6:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=375)
- "A multi-institutional study showed that cystoscopy significantly undermeasures common channel and urethral structures compared to 3D reconstruction, because a straight scope cannot measure the turn behind the pubis." — Richard Wood (clinical) [Ep 10 · 6:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=396)
- "The study 'Measure twice and cut once: comparing endoscopy and 3D cloacogram for common channel and urethral measurements in patients with cloacal malformations' was published in the Journal of Pediatric Surgery, October 2019." — Amanda Jensen (host_summary) [Ep 10 · 6:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=418)
- "Relying only on cystoscopy may result in significantly underreading the length of the common channel." — Richard Wood (clinical) [Ep 10 · 7:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=441)
- "Endoscopy performed by a general pediatric surgeon without extensive cloaca experience has value in distinguishing straightforward from complex cloacas and identifying cases that should be referred to specialized centers." — Marc Levitt (opinion) [Ep 10 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=461)
- "A major change in cloacal management occurred when surgeons began evaluating complexity before attempting repair and referring difficult cases to high-volume centers, reducing the need for reoperations that were common 10-15 years ago." — Marc Levitt (clinical) [Ep 10 · 7:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=479)
- "Lower confluence cloacas, if the surgeon knows the technique, are a beautiful and elegant operation; higher confluence cloacas requiring vaginal replacement and management of ectopic ureters should be done at specialized centers." — Marc Levitt (opinion) [Ep 10 · 8:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=524)
- "The algorithm published in 2017 ('Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning,' Journal of Pediatric Surgery) helps identify patients amenable to reproducible reconstruction vs. those needing complex reconstruction." — Richard Wood (clinical) [Ep 10 · 9:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=560)
- "Type 1 cloaca is defined as common channel length <1 cm; it is essentially a hypospadic urethra with a rectovaginal fistula." — Richard Wood (clinical) [Ep 10 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=628)
- "In type 1 cloaca, the hypospadic urethral orifice is not touched; the plan is vaginoplasty, anorectoplasty, and PSARP." — Richard Wood (clinical) [Ep 10 · 10:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=657)
- "Even in type 1 cloaca, the true rectum can still be high, so imaging is important to determine rectal position." — Richard Wood (clinical) [Ep 10 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=677)
- "For common channel length 1-3 cm, a normal urethra should be at least 1.5 cm long." — Richard Wood (clinical) [Ep 10 · 11:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=697)
- "If urethral length is >1.5 cm and common channel is 1-3 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP." — Richard Wood (clinical) [Ep 10 · 11:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=709)
- "If urethral length is <1.5 cm, urogenital separation (UGS) is advocated, because performing TUM on a 1 cm urethra would place the bladder neck near the perineum and could render the patient incontinent." — Richard Wood (clinical) [Ep 10 · 12:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=727)
- "The majority of 1-3 cm common channel cloacas have a normal length urethra and are amenable to TUM." — Richard Wood (clinical) [Ep 10 · 12:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=749)
- "For common channel >3 cm, patients often have urethral length <1.5 cm; in either case, UGS is advocated with repair of the common channel (left as the urethra), mobilization of the vagina to the perineum, and PSARP." — Richard Wood (clinical) [Ep 10 · 12:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=764)
- "If the vagina or vaginas cannot reach the perineum, the patient may need vaginal replacement to bridge the gap." — Richard Wood (clinical) [Ep 10 · 13:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=798)
- "If the rectum is high, consider an abdominal approach (open or laparoscopic-assisted PSARP) to mobilize rectal length." — Richard Wood (clinical) [Ep 10 · 13:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=814)
- "Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction." — Marc Levitt (clinical) [Ep 10 · 14:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=851)
- "Alberto Peña made a major advance in 1996 with the development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit and mobilized them forward; prior to that, all patients had urogenital separation." — Marc Levitt (clinical) [Ep 10 · 14:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=876)
- "The next major change in the cloaca protocol occurred 21 years later, in 2017, when the algorithm incorporating urethral length measurement was presented at ABSA." — Marc Levitt (clinical) [Ep 10 · 15:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=910)
- "At the 2017 ABSA presentation, 91-year-old Hardy Hendren stated from the microphone that he agreed with everything presented and had no questions." — Marc Levitt (clinical) [Ep 10 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=974)
- "The 2017 algorithm is the first reproducible approach to cloacal management after 50 years of work on this challenging problem." — Marc Levitt (opinion) [Ep 10 · 17:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1023)
- "The algorithm has been validated in 116 consecutive patients without a single intraoperative plan change." — Richard Wood (clinical) [Ep 10 · 17:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1072)
- "Following the algorithm using the 3 cm and 1.5 cm thresholds allows surgeons to stay out of trouble; it provides a guide for which cases are reproducible and which require referral." — Richard Wood (opinion) [Ep 10 · 18:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1081)
- "The major change in the 2017 algorithm was the addition of urethral length measurement; previously the decision was based only on common channel length (less than or greater than 3 cm)." — Marc Levitt (clinical) [Ep 10 · 18:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1104)
- "Measuring urethral length is critical because the patient needs an appropriately lengthed urethra at the end of the operation." — Marc Levitt (clinical) [Ep 10 · 18:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1119)
- "Urethral length is defined as the distance from where the common channel splits (urethra separates from vagina) to where the urethra enters the bladder, not from the single perineal orifice to the bladder neck." — Richard Wood (clinical) [Ep 10 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1149)
- "Measuring urethral length accurately with a cystoscope is difficult because the scope must navigate the curve behind the pubis, leading to significant under- or over-reading; this is especially important in longer common channel cases." — Richard Wood (clinical) [Ep 10 · 19:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1160)
- "The goal is to position the bladder neck above the urogenital diaphragm, where the external sphincter complex and urethra lie, so that intraabdominal pressure does not compromise continence." — Richard Wood (clinical) [Ep 10 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1180)
- "Urethral length can be measured using a ureteric catheter under fluoroscopy or with a scope, but the most accurate measurement comes from 3D imaging because it does not straighten structures and falsely measure them." — Richard Wood (clinical) [Ep 10 · 19:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1199)
- "About 30 to 50% of children with cloacal malformations will develop long-term renal dysfunction." — Richard Wood (epidemiological) [Ep 11 · 3:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=227)
- "Common channel length less than 3 centimeters sets up the possibility for total urogenital mobilization (TUM), but requires adequate urethral length of 1.5 centimeters or greater." — Marc Levitt (clinical) [Ep 11 · 8:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=482)
- "Common channel greater than 3 centimeters almost always means a urogenital separation is required." — Marc Levitt (clinical) [Ep 11 · 8:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=494)
- "When performing TUM, the rectum often reaches even when high, with good mobilization of the urogenital complex." — Marc Levitt (clinical) [Ep 11 · 9:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=575)
- "Lateral attachments posteriorly on the vagina, where the blood supply lies, represent an important safe plane for TUM mobilization." — Richard Wood (clinical) [Ep 11 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=628)
- "Full mobilization into the peritoneum is necessary to adequately release the rectum and visualize vaginal attachments during TUM." — Richard Wood (clinical) [Ep 11 · 10:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=652)
- "For TUM, the common channel is opened widely until the urethral and vaginal openings are clearly visible, often requiring opening into the vagina." — Richard Wood (clinical) [Ep 11 · 13:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=780)
- "Remeasuring the common channel intraoperatively after opening it is important to confirm preoperative measurements and ensure TUM is still appropriate." — Richard Wood (clinical) [Ep 11 · 13:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=829)
- "For TUM, full-thickness lateral dissection is essential; inadequate dissection causes the common channel to fall apart and leaves poor tissue for suturing." — Richard Wood (clinical) [Ep 11 · 17:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1038)
- "The common channel should be divided approximately 0.5 centimeters behind the clitoral tissue to avoid damaging nerve supply." — Richard Wood (clinical) [Ep 11 · 17:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1063)
- "Anterior dissection for TUM requires reaching the retropubic fat and incising the whitish fascia, which releases the complex and gains about 2 to 2.5 centimeters of length." — Marc Levitt (clinical) [Ep 11 · 19:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1191)
- "After TUM mobilization, the common channel is split down the middle, with the two sides becoming the labia minora." — Marc Levitt (clinical) [Ep 11 · 16:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=972)
- "A short common channel almost always has a good length urethra, though occasionally a short urethra occurs with a low common channel." — Marc Levitt (clinical) [Ep 11 · 22:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1333)
- "Performing TUM in a patient with a short urethra results in the bladder neck at the perineum, which is a miserable result." — Marc Levitt (clinical) [Ep 11 · 22:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1346)
- "When the vagina is the most posterior structure in a cloacal malformation, it is often stuck to the presacral fascia and more difficult to mobilize than the rectum." — Richard Wood (clinical) [Ep 11 · 23:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1423)
- "For urogenital separation, the common channel should NOT be opened; only a small meatoplasty (1-2 mm) is made to slip in a catheter." — Marc Levitt (clinical) [Ep 11 · 26:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1562)
- "During posterior sagittal separation, stay very midline because ureters are coming in from the sides." — Marc Levitt (clinical) [Ep 11 · 26:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1596)
- "Leaving a little cuff of vaginal tissue during separation allows urology to achieve a really nice urethral closure without tension." — Marc Levitt (clinical) [Ep 11 · 26:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1619)
- "In higher common channel cases, the ureters often come quite close to the bladder neck, requiring careful mapping during surgery." — Richard Wood (clinical) [Ep 11 · 28:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1729)
- "Once dissection reaches within 0.5 centimeters of where the ureters are, no more separation should be done safely from the posterior sagittal approach." — Richard Wood (clinical) [Ep 11 · 29:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1751)
- "Placing ureteric stents via cystoscopy prior to laparoscopic separation provides reassurance about ureter location during dissection." — Richard Wood (clinical) [Ep 11 · 29:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1785)
- "During laparoscopic separation, scissors with minimal or no cautery are used for the actual separation to avoid thermal injury to the urethra." — Richard Wood (clinical) [Ep 11 · 30:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1855)
- "Laparoscopic dissection appears to result in fewer vaginal replacements, possibly due to better visualization deep in the pelvis." — Richard Wood (clinical) [Ep 11 · 31:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1880)
- "Vaginal length is the most significant predictor of need for vaginal replacement; vaginas less than 4 cm are much more likely to need replacement, while those over 6 cm are much less likely." — Richard Wood (clinical) [Ep 11 · 31:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1899)
- "The vagina tends to envelop the bladder neck during separation, unlike the rectum in male repairs which stays in its lane, requiring careful circumferential dissection." — Richard Wood (clinical) [Ep 11 · 34:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2056)
- "After implementing double-layer urethral repair with SIS and fat pad interposition, no urethrovaginal fistulas have occurred in 5.5 years." — Richard Wood (clinical) [Ep 11 · 32:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1973)
- "The most important aspect of preventing urethrovaginal fistula is giving a little cuff of tissue to allow a nice urethral repair with good mucosa and no tension." — Marc Levitt (opinion) [Ep 11 · 36:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2169)
- "Using the protocol with preserved common channel, 97% of patients maintain a catheterizable urethra." — Richard Wood (clinical) [Ep 11 · 37:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2244)
- "Maintaining perineal access to the bladder is valuable even if a Mitrofanoff is eventually needed, as it provides a pop-off that allows patients to empty." — Richard Wood (opinion) [Ep 11 · 37:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2260)
- "Attempting TUM first and then converting to separation is dangerous because anterior urethral dissection during TUM can compromise blood supply, potentially leaving the patient with no functional urethra if separation is then needed." — Marc Levitt (clinical) [Ep 11 · 41:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2466)
- "Since implementing the measurement protocol, surgeons have never encountered a cloacal anatomy that differed from preoperative expectations." — Marc Levitt (clinical) [Ep 11 · 42:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2533)
- "The protocol has resulted in a significant reduction in the need for redo surgeries, likely because surgeons can define anatomy preoperatively and decide whether to proceed or refer." — Marc Levitt (clinical) [Ep 11 · 4:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=283)
- "A patient with no anal opening and a single perineal orifice has a cloaca, not ambiguous genitalia or urogenital sinus. If the patient has a normal anus, then urogenital sinus or ambiguous genitalia can be discussed." — Marc Levitt (clinical) [Ep 12 · 4:03](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=243)
- "Cloacal patients are normal females with normal typical ovarian anatomy, though a variety of Mullerian anomalies can occur." — Marc Levitt (clinical) [Ep 12 · 4:27](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=267)
- "The common channel in cloaca emanates just below the clitoral hood, which is not a typical location for the female urethra." — Marc Levitt (clinical) [Ep 12 · 4:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=280)
- "Leaving the urethral opening in the clitoral location is suboptimal both cosmetically and functionally if the patient needs intermittent catheterization." — Marc Levitt (opinion) [Ep 12 · 5:04](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=304)
- "In utero ascites in cloaca occurs when urine flows from the bladder into the vagina, cannot exit the common channel, and backs up through the fallopian tubes into the peritoneal cavity." — Marc Levitt (clinical) [Ep 12 · 8:08](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=488)
- "The vast majority of hydrocolpos can be drained perineally; many times abdominal surgery is not needed to drain a hydrocolpos." — Marc Levitt (clinical) [Ep 12 · 9:01](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=541)
- "Colleagues in Seattle taught that most hydrocolpos, including bilateral cases, can be drained with perineal catheterization." — Marc Levitt (host_summary) [Ep 12 · 9:12](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=552)
- "When hydrocolpos is decompressed perineally, the bladder will suddenly dilate because there is less pressure on the distal ureters, allowing them to empty into the bladder." — Marc Levitt (clinical) [Ep 12 · 9:23](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=563)
- "A vesicostomy in almost all cloacas is not the correct treatment because it will not solve the distal ureteral obstruction." — Marc Levitt (clinical) [Ep 12 · 9:46](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=586)
- "About 40% of cloacal patients have a bifid vaginal system." — Marc Levitt (epidemiological) [Ep 12 · 10:37](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=637)
- "Hydrocolpos only needs to be managed if it is causing hydronephrosis." — Marc Levitt (clinical) [Ep 12 · 10:46](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=646)
- "The measurements vital in cystoscopy are the bladder neck location, the length of the common channel, and the length of the urethra. The urethral length must not be forgotten." — Marc Levitt (clinical) [Ep 12 · 12:10](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=730)
- "Cloacas form in two groups: those with a low confluence and those with a high confluence." — Marc Levitt (clinical) [Ep 12 · 12:26](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=746)
- "Historically, total urogenital mobilization was done based on common channel measurement alone, but this was done in some cases for patients with inadequately lengthed urethra." — Marc Levitt (clinical) [Ep 12 · 12:34](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=754)
- "Doctor Hendren historically did only urogenital separations, and then Doctor Pena in 1996 showed the total urogenital mobilization, which was brilliant but overused for patients who did not have an adequately length urethra." — Marc Levitt (host_summary) [Ep 12 · 13:01](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=781)
- "Most low confluence cloacas have a long urethra, and when long means greater than 1.5 centimeters, which is needed for bladder function." — Marc Levitt (clinical) [Ep 12 · 13:23](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=803)
- "You do not want to disrupt the urogenital diaphragm or pull the bladder neck down out of the urogenital diaphragm, as this will result in urinary leakage." — Marc Levitt (clinical) [Ep 12 · 13:31](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=811)
- "For a patient with a 3.5 cm common channel and only 1.5 cm native urethra, the preference is to do rectal mobilization, vaginal mobilization, repair the back of the common channel, and leave the urethra to become 5 cm (native urethra plus common channel), which is more likely to result in a dry patient." — Marc Levitt (clinical) [Ep 12 · 14:01](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=841)
- "The distinction between TUM versus UG separation is based on: common channel length (3 cm or less is low confluence, likely TUM; greater than 3 cm is high confluence, likely UG separation) and urethral length (if urethra cannot be guaranteed to be 1.5 cm or greater, must do UG separation)." — Marc Levitt (clinical) [Ep 12 · 15:56](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=956)
- "A study of patients who underwent VCUG because of UTI found them to have at least 1.5 cm, if not greater, urethral length, which is where the recommendation for minimum urethral length comes from." — Marc Levitt (clinical) [Ep 12 · 16:28](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=988)
- "If you split a long common channel and there is very little urethra on the other side, you are essentially bringing the bladder neck down to the perineum, which must be avoided." — Marc Levitt (clinical) [Ep 12 · 17:19](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1039)
- "A new technique involves making an incision in the posterior common channel to recess the urethral meatus below the clitoral hood for better cosmesis and catheterization access." — Marc Levitt (clinical) [Ep 12 · 19:19](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1159)
- "Occasionally the vagina does not reach and requires vaginal replacement, ideally using a segment of sigmoid colon." — Marc Levitt (clinical) [Ep 12 · 20:18](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1218)
- "A nice trick for vaginal replacement is to use the sigmoid colostomy site itself, taking a segment needed for vaginal replacement and then recreating the colostomy slightly more proximal." — Marc Levitt (clinical) [Ep 12 · 20:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1240)
- "Tissue engineering for vaginal replacement is a key future endeavor; in theory, a tissue engineered vagina could be created from the patient's own stem cells over 3 months in the lab." — Marc Levitt (opinion) [Ep 12 · 21:17](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1277)
- "The best time for cloacal correction is somewhere between 2 months and 1 year, with most repairs done at about 6 to 8 months of age." — Marc Levitt (clinical) [Ep 12 · 23:13](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1393)
- "For a hypospadic urethra 1 cm away, you could consider leaving it hypospadic and doing only vaginal mobilization and introitoplasty, but must recognize the urethra might need catheterization one day, particularly if the patient has a spinal issue like tethered cord." — Marc Levitt (clinical) [Ep 12 · 18:28](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1108)
- "The TUM itself may be needed just to mobilize the posterior vagina to get the introitus to reach comfortably." — Marc Levitt (clinical) [Ep 12 · 19:05](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1145)
- "Fine needle cautery at low setting (usually 10, pure and spray for cut and coag) staying full thickness outside the TUM plane has not caused problems with stricture or fistula." — Marc Levitt (clinical) [Ep 12 · 25:51](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1551)
- "Complications of PSARP are quite minimal with good technique, but rectal stricture can occur. When the vagina is mobilized and separated from the common channel, if under tension, vaginal stenosis can result." — Marc Levitt (clinical) [Ep 12 · 26:19](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1579)
- "For vaginal stenosis after repair, as long as there is an opening, would not intervene at that point; would let the patient go through puberty and maybe consider an introitoplasty much later in life." — Marc Levitt (clinical) [Ep 12 · 26:45](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1605)
- "For patients with greater than 3 cm common channel who undergo UG separation, 4 out of 5 (80%) will need intermittent catheterization. For those with 3 cm or less common channel, 1 out of 5 need intermittent catheterization." — Marc Levitt (epidemiological) [Ep 12 · 27:24](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1644)
- "There is definitely increased mucus production with a bowel neovagina, so if it can be avoided, it should be, but it should be done if the vagina doesn't reach successfully to the perineum." — Marc Levitt (clinical) [Ep 12 · 28:19](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1699)
- "There is some literature on pregnancy in cloacal patients. A few patients have become pregnant, and C-section is definitely advised because of the extensive perineal dissection." — Marc Levitt (clinical) [Ep 12 · 28:36](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1716)
- "For stenotic vagina post-op, if the orifice is there, would leave the patient alone, let them go through puberty, and maybe do an introitoplasty later in life." — Marc Levitt (clinical) [Ep 12 · 29:05](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1745)
- "If the vagina has disappeared post-op, a very good time to correct it might be at the time of colostomy closure when you can take the colostomy site itself and bring down a neovagina independently." — Marc Levitt (clinical) [Ep 12 · 29:17](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1757)
- "Laparoscopic or robotic UG separation has been done by colleagues including Doctor Wood in Columbus and Belinda Dickey in Boston. Cases take a long time but are elegant and beautiful, and are a good approach for patients who would require laparotomy." — Marc Levitt (host_summary) [Ep 12 · 29:43](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1783)
- "The number of redo operations has dramatically reduced because surgeons are doing anatomy analysis first, doing it well, and not attempting complex cases they don't feel comfortable with." — Marc Levitt (opinion) [Ep 12 · 30:32](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1832)
- "In the speaker's hands, TUM is a very straightforward case with very good results, virtually no vaginal stenosis, and a very good urethral repair." — Marc Levitt (opinion) [Ep 12 · 31:02](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1862)
- "From a technical point of view, if dissecting the rectum and perineal body, vaginal replacement if needed should be done then, though it is much more difficult to do as a teenager." — Marc Levitt (clinical) [Ep 12 · 31:22](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1882)
- "Vaginal switch operation is no longer done; those patients ended up with a lot of stenosis." — Marc Levitt (clinical) [Ep 12 · 32:14](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1934)
- "Neovaginal dilatation is not done; would rather allow for a skin-level stenosis and later do an introitoplasty rather than subject the patient to vaginal dilatation." — Marc Levitt (clinical) [Ep 12 · 32:37](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1957)
- "The perineal sphincter muscle complex is absolutely preserved during a posterior sagittal repair." — Marc Levitt (clinical) [Ep 12 · 32:54](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1974)
- "For perineal vaginal drainage, the common channel may need catheterization 2 or 3 times per day. The baby may start to void between catheterizations, which can be followed on ultrasound." — Marc Levitt (clinical) [Ep 12 · 33:12](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1992)
- "Families are taught how to catheterize and brought to radiology to confirm by ultrasound that they are putting the perineal catheter in the correct location. Sometimes it needs to be directed right or left if there is bilateral hydrocolpos. A Coude catheter is useful because it can be twisted and directed." — Marc Levitt (clinical) [Ep 12 · 33:26](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2006)
- "When doing UG separation, dissection starts on the back of the vagina as it enters the common channel, lifting it up off the common channel and dissecting the plane between vagina and posterior urethra. Do not touch the common channel at all to avoid getting into spongiosum tissue." — Marc Levitt (clinical) [Ep 12 · 34:09](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2049)
- "Personal preference is to always start posterior sagittally if the confluence is low, below the peritoneal reflection. In the rare case where vagina and rectum are in the abdomen already, would start in the abdomen." — Marc Levitt (clinical) [Ep 12 · 35:25](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2125)
- "With laparoscopy or robotics, you can go much lower than with laparotomy, but you want to get to the very end of vaginal insertion onto the common channel, which is hard to do. It's easier to start posterior sagittally and then go into the abdomen to continue that dissection." — Marc Levitt (clinical) [Ep 12 · 35:48](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2148)
- "A TUM can always be done in prone position. If a TUM doesn't reach, can go into the abdomen, mobilize the confluence together, and pull through, but in such a case it would have been better to do a separation, not a TUM." — Marc Levitt (clinical) [Ep 12 · 36:36](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2196)
- "The key to saving kidneys in cloaca is keeping the bladder empty through aggressive intermittent catheterization and bladder management, with vesicostomy in appropriate patients, particularly those with grade 4 or 5 reflux. This is learned from spina bifida management." — Marc Levitt (clinical) [Ep 12 · 38:10](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2290)
- "Small bowel is the second choice after colon for neovagina. The blood supply of small bowel is quite tenuous and not as forgiving as that of colon." — Marc Levitt (clinical) [Ep 12 · 38:49](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2329)
- "Personal preference is to do the entire cloacal operation together rather than staging the rectum first and doing UG mobilization later, though it is reasonable to do TUM later if it can be done perineally without touching the rectum." — Marc Levitt (opinion) [Ep 12 · 39:21](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2361)
- "Perineal body length is individualized, measured from the bottom of the labia where they meet in the middle to the anterior limit of the anal sphincter. Everything in between is the perineal body." — Marc Levitt (clinical) [Ep 12 · 40:00](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2400)
- "Hydrocolpos can recur after procedure if vaginal stenosis occurs. In that case, would dilate up the vaginal opening to allow flow. Usually vaginal stenosis is quite skin level and does allow drainage of mucus." — Marc Levitt (clinical) [Ep 12 · 40:32](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2432)
- "There is rarely an occasion to close the bladder neck because most urethras are salvageable if you respect the principle of keeping the common channel intact to become the neourethra. They all have a smooth, catheterizable common channel, but you need to get the vagina off of it." — Marc Levitt (clinical) [Ep 12 · 40:57](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2457)
- "Only in very rare circumstances of congenital urethral atresia, where the patient never was able to drain urine and drained urine out the fallopian tubes with in utero ascites, do those patients need vesicostomy at birth and ultimately a Mitrofanoff." — Marc Levitt (clinical) [Ep 12 · 41:32](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2492)
- "Colon is preferred over small bowel for vaginal replacement for its more sturdy blood supply and because using the left colon at the colostomy site saves an anastomosis by taking the colostomy down and making a more proximal colostomy." — Marc Levitt (clinical) [Ep 12 · 43:58](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2638)
- "Patients are plugged into the concept of transition at about age 12 because that's when girls are going through puberty and need gynecology colleagues. Officially at age 21 they no longer are seen at Children's Hospital, though can flex till about age 30 if needed." — Marc Levitt (clinical) [Ep 12 · 45:32](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2732)

## Changelog
- Sep 7: 12 items added automatically
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