Urologic and Gynecologic Aspects in Anorectal Malformations: Pediatric...

Again, today is mostly pediatric surgeons in this room. So what do pediatric surgeons need to know about urology and about gynecology? This is not the esoteric urology and the esoteric gynecology, some of which will be discussed in some of the breakout parts of this, uh, of this meeting. But it's, what are the basic urologic and gynecologic aspects of a pediatric surgeon's life and care of, of ARM. So, let's first talk about, uh, urology. So, um, my good buddy, Shamael Elam is here, um, come from, uh, Columbia, a great, uh, partner institution for us. Uh, and he and I worked together for 8 years in Cincinnati. And, um, tell us, Shamael, what does this mean to you? Or what is it, what should it mean to a pediatric surgeon? So, um, this is, this is working, right? This is obviously a, a voiding cystourethrogram or a cystogram. Uh, and it's basically showing relatively high degree of reflux, but most importantly, dilation of the ureter and some tortuosity. With dilation of the renal pelvis. So if the pediatric surgeon has this study ordered in one of the inner ectum malformation patients, and this is what they see, this is a child who is at relatively high risk, and this is a child that should be followed pretty, pretty closely and definitely it warrants a urologic evaluation. The esoterics that you talked about are things like, do this, does the patient need emergent intervention? I don't think we're gonna get into that right now other than this is bad. Um, and, and Rama, your opinion about the newborn ultrasound, is that enough, or do all ARMs need a VCUG as well? Well, I, I think it kind of depends, uh, I, I think that an important point to remember is that. Back to pathology. You can have a normal appearing kidney and still have high grade reflux and and bladder pathology. So I think that you have to be clear on what an ultrasound can tell you and what it can't tell you. A normal ultrasound is very, very reassuring. That the kidneys at the time of birth are in good shape, but it doesn't give you all the answers. So is, uh, should it be the routine to get a kidney ultrasound and a VCUG on all ARM patients? I think that everybody absolutely has to have an ultrasound. I think that it can be debated where the child absolutely needs to have a VCUG early on. Uh, you, you can make those decisions based on the other parameters that are there. If there's spinal cord pathology, uh, you know, Shama was talking about the absent vagina and the increased incidence of urological abnormalities. So one can perhaps. Uh, decide on a VCUG based on other parameters, but it should be considered axiomatic that any child who has an anal rectal malformation has to have initial ultrasonography of the urinary tract at presentation and in follow up. Donald Shaw. One of the few people in the room who are trained in both urology and pediatric surgery. Do you have an opinion about this situation, ARM patient? With this pre uh newborn ultrasound and then this renal scan. Well, what the renal scan shows, first of all, is that there's no uptake at all. On, if this is a posterior image, that would be the patient's left side. I'm not sure if it's anterior posterior image, but this shows what's most likely renal agenesis. That's the important thing to note. So, you're already dealing with half the number, normal number of nephrons. And then the ultrasound shows significant hydronephrosis. Now, I don't know for sure if that's a multicystic dysplastic kidney or if that's, uh, a severely hydronephrotic kidney, but these two images taken together, it could mean what you're trying to show is that there is a, Uh, multicystic dysplastic kidney that's essentially renal agenesis on one side. So, you have to make sure you take good care of the other kidneys, so I would say that. And, if we have an ARM patient with a single functioning kidney, is that a higher risk category? So, the observation, again, not science, the observation is that the solitary kidney patients are at higher risk for, um, further injury of that solitary kidney. Generally, in the case of unrecognized or underdiagnosed neurogenic bladder, solitary kidney does not impart a risk for neurogenic bladder, but it is obviously something one has to be very careful about in the setting of one functioning kidney. So, uh, maybe, Rama, you could tell me, um, a patient with an ARM of very high type, like a bladder neck fistula, single kidney, and significant reflux in that kidney, what would be your, your plan of follow-up? How often would you see the patient? What studies would you do, and what would you be watching for? That's a great question. Um, because that particular patient, um, that you're describing is at high risk for long term renal problems. It's important to realize that all of us are born with all the nephrons we're gonna have for the rest of our lives. And even though there's continued nephron development for the 1st 6 months of after you're born. That's it. There's nothing else. So this particular situation you describe high grade reflux, solitary kidney, bladder neck fistula, uh, these are the kids who are at high risk of having infections and problems. These are kids who are at high risk of having underlying bladder dysfunction as part of their, um, of their pathophysiology. So these children need very, very close follow up with regard to serial ultrasonography. It's very, very important that these children maintain sterile urine reflux itself does not damage kidneys, but infection does. Reflux in conjunction with bladder dysfunction can damage kidneys. So these children need very close follow up not only of their upper tract anatomy with ultrasonography, they need close follow up with regard to blood work. Uh, serum creatinine cistatin C, they need close follow up with their bladder function. These children need regular urodynamic studies so we can assess how well their bladders are working, so they need very close follow up. I'd like to add one thing too, just since this is the pediatric surgeons in the room and there are a lot of trainees, just sort of thinking about the multidisciplinary interdisciplinary management of the children. Height and weight, growth and development, very important things to track. The creatinine may be 0.3 for the 1st 12 months of life or 18 months of life, but the child could be at the 4th percentile for height and weight. That's not a normal condition. And so in the setting where you have a solitary kidney. And you have a child who is at risk, we have to sort of look at the whole child, not just the numbers, and that's a, that's something that we all can do a little bit better job on. And this might be a patient that's, has a divided, Colostomy at the time of birth rather than taking a chance that a loop is going to be completely diverting, I would probably not do anything less than a completely dividing colostomy. And I think that's, I think that's a very good point. Put him on prophylactic antibiotics. Doesn't work. Can everyone hear? Can you hear in the back? Wait, did you, would you put this kid on prophylactic antibiotics? Uh, yes to prophylactic antibiotics for sure. OK. Can you hear in the back, Dan? Yes. OK. All right. We talked a little bit about this in the last session. This is a hydrocopo situation with hydronephrosis before and after drainage. We can skip that. And this is bilateral hydronephrosis in a hydrocopos patient that needs an intervention. And Let me talk a little bit about this. This is an image of a, a eurogenital mobilization in a cloaca. Tell me your thoughts, um, um, uh, Don, and perhaps about this situation, total urogenital mobilization, how is this going to hold up long term as far as the bladder neck and is this gonna be a good technique when this patient is 65 years old? What are your thoughts? Because obviously what we've done is we've mobilized the suspensory ligaments of the urethra here. And um there is some question about whether that's going to be a good long-term solution. In your opinion, patients who've had total urogen mobilization, do you find them to have competent bladder necks and voiding well? Do you see a deterioration later in life? Any thoughts about that? Yeah, done. Um, So, there are two basic urinary incontinence mechanisms. One is the external urinary sphincter, and the other one is the bladder neck. And when you do a total urogenital mobilization, You're basically eliminating any future function of the external urinary sphincter. So you're going to make those women to be continent based upon the function of their bladder neck. So I think they're all going to have some degree of sort of cough incontinence or balsalva induced incontinence. Um, just how continent they're going to be, I think is a hard question to answer, but it's it's not going to make them more continent when you do a total urogenital mobilization. So you predict it's going to be OK. We're not, uh, I think if it's a relatively, I think it depends more on the bladder function and the bladder compliance than it does upon the bladder neck. So I think that's the big question. I, I think that's a really, really important point. I think the, the concept that this is a pure anatomic problem is a little bit old fashioned thinking. Now it's function. Maybe Shamal, you can comment on, on that, and I will pose the question in this way to you. I have an ex Cloaca repair patient who's 12 years old. She is voiding well. She has urinary control, and she has no urinary tract infections. Is she perfectly safe and is everything going to be OK with her kidneys? I, I think that's the perfect example because the morbidity is the functional morbidity. The structural morbidity is something everyone in the room can see. It presents on ultrasounds. But the long term functional is a problem. That 12-year-old may be seeing us at 30 because they've gone through their kidneys and it could be an underlying neuropathic bladder. A neuropathic bladder doesn't mean that they leak. It doesn't always mean that they have urinary tract infections, and there's some subtleties, and that's what Rh alluded to earlier about getting things like renal function studies, a cistatin C, to look at the overall measurement of GFR to see where the child is regarding height and weight. Incontinence is one outcome. But it's not the most defining long-term important outcome. And I think as we move further and further away from thinking about CAICA as just an anatomic problem, we're going to get a better idea of what the long-term outcomes of all of our surgical interventions are actually doing. And then please, absolutely, um, if I may, I, I, I think that it's a very, very important point to understand about what the bladder does. You know, the bladder does two things it stores urine and it empties urine and everybody in this room, the only time we think about a bladder is, is when we have to pee. That's the only time we actually think about the bladder, but realistically, the emptying function is not as important as the storage function because the bladder is storing for about 23 hours and 40 minutes during the course of the day, and that's the silent part. Of the bladder function and that's why just if you ask somebody if they're continent that is not enough to assess the health of the bladder you really have to have some evidence as to how the bladder is storing urine to really know if the bladder is healthy or not. All right, let's throw another wrench in the situation. Um, single, uh, ARM, bladder neck fistula, single kidney reflux, and a tethered cord. Jamel. Uh, uh, that patient's a high risk for a neurogenic bladder. And I think it's all about how we discuss with the family and we present the approach for the care of that child starting at birth. Um, expectations should not be set in terms of volitional voiding in that patient population. It's nice to be wrong, and let's say they have volitional voiding and they're healthy, that's great, then we're wrong. But I can tell you based on the number of patients that are seeing me, especially in their 20s and 30s, um, I don't think we're right. I've opened up my practice and I will see some older anorectal malformation patients up to about 40 years of age without really bad comorbidities, and we're not actually doing what we think we're doing. I have a patient on my schedule in December for Metrofenoff. He's 19 years old, a former patient of Mark's who had him alone about 15 years ago, bladder neck fistula. He's doing great, but it turns out he's not doing so well. So these are the patients that we have to follow carefully, set the expectations appropriately for the family. No need to make predictions about what's going to happen or what's not going to happen. We just have to all agree that there's a certain number of tests we have to do, and we have to agree a little bit better on our disease definitions to know the long-term outcome. Let's talk a little bit about um collaborative reconstruction. Um, there's a lot of patients that I think that with the uh formulation of the collaborative approach are getting a plan from day one for their reconstruction. Maybe Rama, you could map out a typical case of a patient that we meet together and it's the child's 6 months old and we have a plan for. Age 4, what, what, what is, get a, have the audience get a sense of what we're, what, what our interactions are all about with a, let's say a, um, Cloaca patient who's been repaired, who, um, is on intermittent cath and is fecally incontinent for stool. Would be um. You know, the long term issues in that child are. With regard to fecal and urinary control, you said 6 months of age. Well, they're 6 months now, and we have, you know, we wanna get them clean and dry when they're 4. Yeah, so the plan is what to, what is going to be needed for when the child's 34 years of age down the road, you know, from the urinary point of view, you know, the questions are gonna be how healthy the bladder storage is, the bladder capacity. The issue is what the bladder neck mechanism is like. Can the child empty properly? Can the child void properly? For the sake of discussion, let us assume that this is a child who is not able to empty properly, a child who needs to have some type of urinary reconstruction down the road. The decisions that I need to make are with regard to whether the child has an outlet, uh, procedure that needs to be done. Does the child need to have a bladder augmentation to increase size and capacity? Does the child need to have a metrofenoff for for catheterization to create a new, another way to get to the bladder? But I have to think about what I need to do in conjunction with what Mark would need to do down the road. Does that child need to have a Malone also to help with uh with with fecal control and so we have to plan in advance about what we're gonna be doing down the road. Shamal, you want to talk a little bit about what I've shown in this picture? So what we see here is the concept of using the appendix to accomplish both ends. Um, the split appendix technique where the proximal appendix or the part closest to the cecum is utilized for them alone and the distal appendix is utilized for the Metrofenov. There are certain circumstances that this works and certain circumstances where it doesn't. Ideally, even if the child has a malrotation, you don't want to remove the appendix electively in this patient population. As this is sometimes an option. Uh, we usually try and share, and I use share in a very, uh, loose term. Uh, the appendix makes a really nice metrofenoff that tends to have a little bit longer, uh, durability, so to speak, than a tapered, uh, ileal piece for uh metrofenov. And so we like to use the appendix, and the proximal appendix or the part next to the cecum can always be lengthened with a variety of tricks, which are not illustrated here, um, using the staple line. So, these are, these are very carefully coordinated decisions that are made in the operating room. It's very helpful to have both the urologist and the pediatric surgeon kind of working in tandem for this decision process. A word of caution. Implant the metrofenoff very carefully and then see where the malone goes. If you try and push the alone to the umbilicus after you've implanted the metrofenoff, you're limited by your blood supply, and there have been reports of it ripping. So, that's one thing to be very careful about. Sometimes when we do this technique, it, Upsets Mark, but both stomas have to be in the right lower quadrant just based on blood supply issue. Well, Mark has learned to change and, and, and, uh, uh, Rama likes the umbilicus for the metrofanoff. And uh so therefore the um CCO, the malone can go into the right lower quadrant, which also works quite nicely. Uh, Chamael alluded to sharing. I don't know, this doesn't look like sharing, this looks like 1/3, 2/3, but Um, but, but it's a different version, uh, version of sharing, but it works, uh, it works quite well. Ram, any technical points about that? No, I mean, uh, yeah, we, the, the very first case we did together, we discussed, you know, where is the malone gonna go and where is Metrofanov gonna go, and my personal bias was to put the Metrofanov in the umbilicus and put the malone in the right lower quadrant, and it just seemed to me. That that just more natural if you look at that picture in the lower right it just seems that it maintains the the proper orientation of the blood supply by swinging the. Distal appendix into the midline to put that in the umbilicus and to leave the stump of the appendix on the right side for the malone. Any, any comments from the urology section? Where do you put your metrofein off and where do you put your malone? You know, another alternative would be to um to use the uh colonic wall flap because that gives you all the flexibility you want. You don't need to share anymore and you can use the whole length of the appendix for the uh the bladder part and then if you decide you wanted the left sided, uh, anti-grade enema, do that if you want the right side you could do that if you want something in the middle you could also do that. We agree we we we do that and if the. If the length of the appendix, the, if urology needs the whole appendix, they can have it and then we'll make a, a fecal flap. But as far as the location of the orifice, do you have an opinion about which gets the umbilicus and which gets the right lower quadrant? Anyone? I don't really think it matters. I think you just played by the anatomy and where the tension on the blood supply is. Sometimes the mesentery of the appendix lends itself to and the length of residual appendix lends itself to allow us to bring it up to the umbilicus and leave the other one in the quadrant, but it really doesn't, it's not an important part for me at all. So, uh, let's pull the audience. We have a patient with an absent sacrum. And a malrotation that needs a lad's procedure. A, lads plus appendectomy. B, lads without appendectomy. You're leading. You, you, you, you saw, you saw right through me, didn't you? OK, great so please um leave in the appendix in that situation if it's a patient who may need metrofenoff or Malone or both, um, in fact, um, in some countries I know, uh, in South Africa for example they don't take out the appendix during OLEDs. Anyone have that experience? Just South Africa? You take out the appendix? Oh. Very good. All right, let's carry on a little bit. Let's do um some gynecology. We talked about that earlier. Here are two examples of pretty impressive hydro copi. Um, and a, um, contrast study, maybe, uh, can we give, um, our radiology partners a comment here? What do you see? So, I presume that this is a imaging from a chocogram, and you can see a Foley catheter in the ostomy in the upper abdomen with injection and filling of two hemivagina. Usually the distal component of the bowel inserts very low on the midline septum. Don't see Any obvious filling of the bladder, but there is, appears to be a common channel extending inferiorly. I don't know where actually the bladder inserts. Yeah, I, I, we, I have to tell you it's been extremely helpful to do these contrast studies in IR and in three dimension. We, um, do the typical imaging of all the structures, uh, but then have the C arm spin. It's pretty easy protocol that all of your interventional radiologists, uh, can do, um, and it really gives some really nice, um, pictures. So, um, here's a situation maybe, uh, Paula can comment a little bit of a Cloaca patient who has a bilateral symmetric system. What are your thoughts? What does the pediatric surgeon need to worry about in a patient like this? After the definitive the repair, assuming you have successfully found the two vaginas, removed the septum. What's the plan now for such a patient? You want, you want to be sure that both, uh, system will drain eventually. Um, So you, you want during surgery, you want to assess that do you. The uterus are connected, uh, or if there is any remnant, you take it out, uh, whatever is not functioning. And um Uh, and, and then you, you described the malformation very well because later on it might be very difficult for the gynecologist to, uh, reconstruct what was fine at the beginning because you might not follow this patient for 20 years so if they come to your office and they have one system, uh, obstructed it might be difficult to understand. So, Don, uh, but when you have repaired a cloaca successfully, and you're happy with the anatomic result, and you're keeping an eye on the neurologic system. What's your next advice for the child gynecologically? When is their next gynecologic, um, evaluation? I tell the mom that at the time they start going through puberty, that we need to start thinking about doing periodic pelvic ultrasounds to make sure that there's no undrained menstrual fluid. In a, in a case like this, I mean, at least one side's likely to be open, if not both sides. And so, when she starts to menstruate, that, you would definitely get an ultrasound, but, I usually try to anticipate it. I'll give you another example, um, a case that's less clear, this looks very clear to me, but there are cases that are less clear as to whether or not the systems are patent, um, say there may be tubal obstructions that we're not really sure about. And in those cases in particular, um, or if I don't see a vagina, but wonder if maybe there's some rudimentary uterine structure that at the time of the repair, I elected to leave in. I know this is a little controversial and we've talked about this with. Leslie breach as well, but there can be cases where at the time of the original repair as a pediatric surgeon, you see something that looks like a rudimentary uterus, and the question is whether you should take it out or you should wonder 20 or 30 years in the future what sort of fertility potential it might provide for the patient. So the point is that if you leave structures like that in place, the parents have to be educated to know that at the time of the onset of puberty, you need to start looking for undrained fluid collections if they develop. So here is that image. Here's the uh laparotomy journey of Cloaca. Ovary ovary. Uterine remnant and vaginal uh halves here. So would you, what would you do with this? Remove these? No, no, they, they looks nice. I would leave it. I would leave it. They are attached and they, they are more than a remnant. So this is a hemi uterus and a hemi uterus, hemi vagina, hemi vagina, leave it, which successfully reaches the perineum. Jerry, you wanna add something I think. You know, the question that we always have in our mind is, are they all connected? You know, is the distal end of the fallopian tube connected to the uterine mallerian part of the structure? Is that connected to a cervix, because at this juncture we think a cervix is important to carry a pregnancy, and is that connected to a vaginal outflow tract. So, in that last picture you showed, I mean, glancing at that, it appears that those two uterine remnants are, Attached to the top of their vaginas, but sometimes that tissue there are just sort of fibrous bands. So oftentimes, I mean, I think it would be important to cannulate the distal ends of those those uterine remnants and make sure there actually was an outflow track because recognizing that sometimes those can just be fibrous and then we don't know necessarily whether that has endometrial tissue, so the important of following them. Shama, you wanna make a comment about these structures here that We're not supposed to hurt? Yeah, I, I know where you're headed with this. So, when we started our collaboration together, we had this concept that, uh, obviously repair the cloaca first and then deal with urinary tract abnormalities later. And, um, it's a pain sometimes cause those ureters get immobilized and they get really scarred in. And, uh, I had the unfortunate circumstance of having done a reimplant that failed and had to go back and redo the reimplant. So, based on that, Uh, sort of, and again, anecdotal observation. We started testing the patients a little bit more aggressively before surgery, and then sometimes going ahead and mobilizing the ureters and doing reimplants at the time of the initial claacal repair. And, um, I do have some follow-up on several of the patients that we've done that way. It does make that secondary operation for continence and sometimes augmentation and reconstruction a lot more pleasant, and the patients recover a lot faster. And again it's one of those things that we may want to start to look at as a group to see what's the best timing for the neurologic intervention because they can't be considered separate operations. I'm gonna continue the discussion, I just want to show you something Jerry was pointing out that here is, here is the fallopian tube. And then here is the vagina that's going to be pulled through, and what is happening here is this is being flushed to see that this is in fact a patent. But let's continue the discussion about the ureters because I, I think um during the cloacal repair, you may have to deal with ureters. And obviously, you want to know about that in advance, and there's a lot of variety in where the ureters are going to be found. Some of them are ectopic, some of them run right into the Mullerian structures and need to be disconnected. Um, John, you have some thoughts about that. Um, ureter management, uh, I think it's very, very important to know whether or not the patient has reflux before you undertake a colacal repair. So sometimes that's not a real easy study to get. You may even have to cystoscope the patient to get a catheter into the bladder. Then I usually would wait and you could do it on the table, but I don't think it's as physiologic, and Shamil and Rama can comment. But I would usually just leave a Foley catheter in the bladder and then send the patient to radiology when they're wide awake and have them do a. BCG in that fashion. But if you're going to do a cloacal repair, especially a complex cloacal repair that's got a long common channel, and you know you're going to be mobilizing the bladder neck and trying to separate the vagina from the urinary system, if you need to do that, reimplanting the ureter later is a total, totally difficult operation. So how would you manage that situation? So you, so you need to be prepared to do the reimplant at the time of the cloacal repair. OK. And is there any circumstance, Roma, that you can think of that you wouldn't do the reimplant, that you might do a cutaneous ureterostomy in that, in that situation? Well I think that I, I. First of all, cutaneous ureterostomies, you know, the biggest complication of a ureterostomy is stenosis. And so you really can't do a ureterostomy unless the ureter is dilated. And so I think that if you have a, a massively dilated ectopic ureter, then that is a situation where it would maybe be safer to do a ureterostomy up front as opposed to trying to do a primary uh reconstruction and then one can always go back at a later date to plug the ureter back in that's probably the one situation I can think of massively dilated ureter where it's difficult to do the reimplantation in the first place. Well, and Mark and I have actually done that before. Once we start getting into nuances of when to reimplant, when not to reimplant, we realize that our disease definition of WCA is not helpful. Uh, there are circumstances where the renal anatomy is defined and there are massive problems afterwards, and there are circumstances when they're ill-defined and the patients do very well. So, I, I think that, you know, the fundamental tenets are there. Are the, is the child refluxing? Is the child at risk? Um, I personally have no trouble dividing bladder necks and doing the reimplant, bringing down a vasicostomy, the time of flake repair for those 5 centimeter common channels because I really haven't seen any 5 centimeter common channels with volitional voiding that are very. Later in life and so I think it's just as we start to think about how to better manage the patients, we have to get a better idea of what the long term is and solve some of these problems, but clearly the way we've done in the past and going back and redoing reimplants is not always the best. So, um, you're embarking on a cloacal repair, and the patient has a vaginostomy and a vesicostomy. And you're happy with the um cloacal repair. Tell me what your process would be as far as Reopening the vasicostomy at the conclusion of the case perhaps, and then when do you get rid of the vasicostomy done? Well, I, I think this question came up earlier. If you in the newborn period, you have to do a vaginostomy and or a vesicostomy, I don't think you're gonna be able to do a cloacal repair without taking those structures down. So the very first someone, one of the urologists asked that question, and I don't consider myself a urologist, by the way, so I'm flattered by being able to sit up here, but I know, I know something about urology. The truth is, I think you have to take those structures down. So, I would close the vaginostomy, put it back inside I would close the vesicostomy, put it back inside. Then I would turn the baby prone and I would do the cloical repair and see if I could then accomplish what I wanted to accomplish, posterior sagyline. If I have to turn the baby back over and open the abdomen, then that's fine. But then, how do you leave the bladder drained? Personally, I would just put a Foley catheter in the bladder. I would not go back and do, I don't, I wouldn't go back and do a vasostomy. OK. Rama, I mean, uh, or smile first. Uh, one other option that we, uh, have employed rather successfully is the idea of what's called a circle stent or a small 6 or 8 fraselastic catheter that comes out of the urethral repair, also comes out of the bladder and then ties to itself, and that can be protected with a suprapubic tube. The benefit of doing that is you 100% know what's going to happen to your urethra. You can leave the circle stent in for a while. It's not a catheter hanging out from the perineum that gets pulled and hurts to repair. And then when it's time to remove it, the child is well healed, that if necessary, intermittent catheterization can be. Started. You have to remember that patients who tend to get to the point where they need a vesicostomy probably have some impairment in bladder function, and there may be a risk that those patients would then need intermittent catheterization. I think, I think a lot of it has to do with how much urethral work you had to do. And a total urogenital mobilization patient is likely going to void, and if they can't void, they're likely to be easily cathed. However, in a more complex urethral reconstruction, your ability to to be able to cath the patient is questionable. And then the strategy of leaving something stenting the urethra until the time where you can assess whether the patient can be cathed. So I think in some of those complex urethral repairs, our tendency is to leave the patient diverted with recreation of the vesicostomy and then down the road figure out about cathing and then assess the bladder and then figure out the vesicostomy can be closed. The other variable that needs to be added in is whether the ureters are refluxing ureters, because if you have a vesicostomy with refluxing ureters, you're safe and you can wait until the ultimate urologic reconstruction at. At age 4, and the thing, the other factor is how good is the family, and is the family going to be good quality catheters, or are they going to be completely unable to do that? And then you obviously want to have the patients safe. Doug, do you want to give a comment? Hi, hey, how are you? Nice to see you. I'm not sure I have anything meaningful to add except that that hasn't stopped you in the past, except that I'm enjoying the conversation. The principles are that you have to you have to keep the kidneys at low pressure, and there are many, many different ways to do that. and Shamel's outlined them, I think, very nicely. Uh, I want to, to show, uh, probably that. I do have one more comment from my colleague Joe Boh from Boston. I would say that, uh, at the, uh, definitive reconstruction of the calaca, cloaca, one thing that I favored is a suprapubic cystostomy tube, and in that way you divert the urine, keep the perineum a bit drier, but then you automatically have a way to assess how that child is either emptying the bladder well or not. And then you can continue to divert that way as needed as the family is learning CIC or returning to doing CIC if, as Tony mentioned, they do CIC in the beginning. I think that's a great Brad Brad Crop was whispering something in my ear a minute ago. I'm gonna let him tell everybody. In. No, I, I, Brad Crop, Oklahoma, uh, I, I agree with everything that's been said. I, I think that, that I am more prone to teach families intermittent catheterizations. Lots of my families travel quite a few distances. They're, they can get caught in a, in a no-care zone, uh, type situation and giving the families control of accessing both either pre, pre-reconstruction or post-reconstruction. Access to catheters and ability to empty the vaginas, uh, or empty the bladders, uh, so I'm. Probably not in the norm, but I, I have no trouble sending a family home for a couple of weeks to a couple of months on intermittent catheterization until we can assess what the bladder is actually going to do, because closure of that vesicostomy with reflux and no. You know, no management. And so the, the worst thing that happens is they spend a couple of extra months cathing. They're also dilating the rectum at that time too. So I mean they're, it's not, it's not anymore. It's much more easy than, than catheterizing. So yeah. And then I think anytime that you have a, a, a febrile urinary tract infection, you have to presume that somewhere along the way you're failing to keep the, the bladder at low pressure, and, and that should be your 1st, 2nd, and 3rd. You know, uh, concerns. And I, I think I want to emphasize that point. So as a pediatric surgeon covering a patient like that both with Cloaca or male ARM and they have a urinary tract infection, your immediate assumption needs to be that the bladder is not successfully emptying. And uh you gotta figure that out. You got to figure out whether the bladder is emptying pre and post-void and make sure there's no scarring. You want to avoid the UTI. Um, once they have it, then you really have to figure out how to prevent the second. The 2nd UTI Rama, yeah, just a quick comment. I, I think that. It's equally important that you have a pro who teaches the family how to do intermittent catheterization we can't ignore that. Uh, because these families are scared about putting that tube inside their little kid and so you have to have a pro who can explain to them what exactly they're doing, why they're doing it, and, uh, without that, uh, it, it, it often fails and so it's very, very important to have excellent nursing staff who can work with the family to show them how to do the catheterization that's as important as any of our surgical procedures. Yeah, I'm at Henry, you know, our family into the er, I mean, to show him that first time, you know, how to do recaization, it alleviates a huge amount of anxiety. Alleviates a huge amount of anxiety for them to be, you know, with their child asleep, you know, not thrashing around where they can catheterize multiple times, you know, whether it's a kuda, you know, at 12 o'clock, 12ka at 2 o'clock, you know, the little nuances of catheterizing that. I, I think it just makes a huge difference for them. They feel much more confident, you know, when the child wakes up, and then we do it again, you know, a couple of hours later when the child's awake. They, they feel very, very comfortable doing it. Can, can Christina Booth, can you make a comment about that? How do you teach parents, our nurse practitioner who straddles both uh urology and colorectal, who does a lot of this. How easy, how easy is it what he just described? Um, I think it's very difficult to teach, you know, children with sensation, teach their families how to catheterize them. Um, it's a lot of hand holding. I think the number one reason they need to know why they're catheterizing. They need to know the importance of it. Um, if you just tell a family, hey, start cathing, and they don't know why, then they're going to go home and their kid's gonna get angry with it and they're gonna, they're gonna stop doing it. So you have to instruct them why are they doing this. I think our reconstruction is very important too, because if you do total urogenital mobilization and you don't get the urethral opening as far out on the perineum as you can, you're leaving the little girls with what we might call a female hypospadius or an enteritis, which is way up on the inside, and that's even harder for them to find. Great. Well, there's lots more opportunity to talk about these two, aspects of pediatric surgical care and our collaboration with urology and gynecology. I think we'll take a much needed break, um, and, uh, we're gonna get.