# Hydrocolpos — GCMD Library living collection

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

Updated: n/a · 4 episodes · 160 cited statements

## Episodes
### Case-Based Learning
- [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-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=0) Introduction and Prenatal Evaluation of Cloaca (Ep 2)
- [2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158) Prenatal Counseling and Indications for Fetal Intervention (Ep 2)
- [6:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=365) Newborn Physical Examination and Diagnosis (Ep 2)
- [9:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=586) Initial Workup and Management of Hydrocolpos (Ep 2)
- [13:26](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=806) Colostomy Creation and Vaginostomy Technique (Ep 2)
- [18:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1097) Pathophysiology of Hydrocolpos and Urogenital Sinus (Ep 2)
- [22:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348) Timing and Imaging for Definitive Repair (Ep 2)
- [28:41](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1721) Multidisciplinary Team and Surgical Planning (Ep 2)
- [34:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2067) Urethral Length and Surgical Technique Selection (Ep 2)
- [37:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2254) Management of Non-Reaching Vagina and Vaginal Replacement (Ep 2)
- [40:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2421) Common Errors in Cloaca Repair and Contact Information (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=0) Introduction and Prenatal Evaluation (Ep 1)
- [2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=158) Prenatal Counseling and Intervention Indications (Ep 1)
- [6:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=365) Newborn Physical Examination and Diagnosis (Ep 1)
- [10:02](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=602) Initial Workup and Imaging (Ep 1)
- [15:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=905) Hydrocolpos Management and Pathophysiology (Ep 1)
- [20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1229) Colostomy and Vaginostomy Technique (Ep 1)
- [23:43](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1423) Diagnostic Endoscopy and Cloacogram (Ep 1)
- [30:12](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1812) Surgical Planning and Urogenital Mobilization (Ep 1)
- [37:36](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2256) Vaginal Replacement and Redo Surgery (Ep 1)
- [41:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2499) Contact Information and Resources (Ep 1)
- [0:16](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=16) Introduction and Initial Diagnosis of Cloacal Malformations (Ep 3)
- [3:24](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=204) Clinical Presentation and Prenatal Diagnosis (Ep 3)
- [7:41](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=461) Hydrocolpos Management and Newborn Assessment (Ep 3)
- [11:31](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=691) Anatomical Assessment: Cystoscopy and Imaging (Ep 3)
- [15:56](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=956) Surgical Approach Selection: TUM versus UG Separation (Ep 3)
- [18:00](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1080) Technical Modifications: Urethral Recess and TUM Technique (Ep 3)
- [20:18](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1218) Vaginal Replacement and Future Directions (Ep 3)
- [21:44](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1304) Question and Answer Session (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=0) Introduction and Guest Background (Ep 4)
- [2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=125) Case Presentation and Prenatal Diagnosis (Ep 4)
- [5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=341) Physical Examination and Initial Workup (Ep 4)
- [9:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=550) Modern Hydrocolpos Management (Ep 4)
- [15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901) Colostomy Technique and Vaginostomy Alternatives (Ep 4)
- [20:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1211) Distinguishing Cloaca from Urogenital Sinus (Ep 4)
- [24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1476) Post-discharge Management and Summary (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 40:58](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2458)
- "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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 37:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2231)
- "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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 10: 1 item added automatically
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