ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?

Hello, er, I hope that you can hear me now. Uh, my name is Michelle Batty, and I'm the manager of the European Reference Network called Eurogen, which is for rare eurogenital diseases and complex conditions. Um, and I'm really pleased to say that today's webinar is a collaborative effort between uh ERN Eurogen and ERN Ernica, which is the ERN for congenital anomalies. And it's also in collaboration with the ARMNET. Uh, just to say a little bit about what an ERN is, we're one of 24 ERNs created by the European Commission in 2017. And we aim to give a faster access to specific specialist evaluation or more equitable access to high quality diagnosis, treatment and healthcare for patients with these rare or complex diseases. Um, we're uh working on several different levels, educational activities, developing a registry together, um, and we also collaborate on education and training activities such as this. And without further ado, um, it's an absolute honor to have Professor Mark Lewitt here with us this evening. And he's focused his whole career on the care of children with colorectal and pelvic reconstructive needs. Um, he's had patients from all over the United States and he's performed more than 15,000 pediatric colorectal procedures. Um, he's currently Chief of Division of Colorectal and Pelvic Reconstruction at the Children's National Hospital, Washington DC, USA. Um, and we're delighted to have you here with us this evening, Mark, and, um, I'm really happy to give you the floor. Thank you so much for sharing your expertise with us. Thank you really very much, um, for the invitation. I, I really wish we could all be together, but before we can all be together, I guess we can still meet. Um, in the, in this way, and I'm really, uh, grateful to the collaboration that exists in Europe. I'm very jealous of that collaboration. We've tried to do something quite similar with the, uh, in a consortium that we have developed here, um, called the PCPLC. But we are taking your lead in Europe with how to handle these complex patients that need, uh, collaborative care. And there's some great representation of those collaborative teams. In Europe. And um I really appreciate the invitation to talk to you about Cloaca, which is near and dear to my heart and is clearly the most complicated um interectal malformation that we have to face. Cloacal atrophy being the, uh, uh, most complicated type of cloaca. And it certainly requires a, a uniquely organized collaborative team involving colorectal urology and gynecology. So, um, as the first step, obviously, we need to make an accurate initial diagnosis. Um, many of these patients can be diagnosed prenatally, which I will discuss in a moment, but many come out in the newborn period without any anticipated diagnosis, and the clinicians assessing such a patient have this view. And they know that the patient has no anal opening. And they look at the perineum and they see a single perineal orifice. Sometimes the tissue around the clitoris seems hypertrophied. It's actually excess skin. This is not a patient with ambiguous genitalia. This is not a patient with urogenital sinus. If the patient has a normal anus, then we can talk about ambiguous genitalia and urogenital sinus. Obviously, not the topic for today. If the patient has no anal opening in a single perineal orifice, and here's the perineal orifice, one hole, that patient has a cloaca. They are normal females with normal typical ovarian anatomy. A variety of Mullerian anomalies can occur, but this patient is a female. So, This is what this anomaly looks like, and I specifically point out on this slide that the common channel emanates just below the clitoral hood. This is not a typical location for the female urethra, and I think it's very important because this talk is about what's new in 2021. There are some cloacal patients that have been managed where the urethral opening has been left in this location. And I think both cosmetically and functionally, if the patient needs to do intermittent catheterization, this location is suboptimal, and I'm going to show you a very easy additional technique to make this urethral meatus a little bit more recessed. Well, I gave Richard Wood, my partner in Columbus, Ohio, this gift when he graduated from his fellowship. I don't know if you are familiar with bowling, if that occurs in other countries besides the United States. I think it does. And we gave him this gift, which was a play, of course, on the single perennial orifice joke. I do want you to think about the fact that I was at a bowling lane, having created this bowling ball. By the way, if you get a custom-made bowling ball, they don't, they don't cut the holes for the fingers for you, you have to have that done. And I want you to imagine the conversation that I had with the person at the bowling lane of why I only wanted one hole cut. We had a detailed analysis of Cloaca, and he only charged me 1/3 of the typical price. Well, I alluded to this before. Here is a prenatal image. This is a 22 week fetus. It's an MRI prompted by a cystic structure noted on ultrasound, and you can see a pretty good contrast study of what a cloaca would look like with a dilated uh vagina, a hydrocopos in the middle, a bladder towards the front, and the rectum towards the back. What would you say this looks like? So the single perineal orifice is clearly not in the location that I just showed you, and this is a posterior cloaca. Single perineal orifice. Urethra, vagina, and rectum are somewhere within that hole, but very posteriorly located and can actually be in the exact correct location of the anus, posterior cloaca. Interestingly, this diagnosis was made for the first time, oh, it's been about 30 years, but the patient presented at age 6 months with loose stool, chronic diarrhea. And the pediatrician looked carefully and noticed that there was nothing in the labial area. That's how a posterior cloica was first diagnosed. OK, well, the baby may come out with an abdominal mass if there's a hydrocopos. The abdominal X-ray, as you see in the middle photo, shows a dilated cystic structure with the colonic gas external to it. And I put this Shar Pei dog as a reminder that if the patient has in utero ascites, And how do they get ascites in a cloaca? Well, think about the anatomy. The urine flows from the bladder into the vagina, cannot seem to get out the common channel, and back into the fallopian tubes and into the peritoneal cavity. They can have a An abdominal wall that looks wrinkled in a female, but that is obviously could be a cloaca. And this is what that looks like. This baby came out with an abdominal wall looking very much like prune belly, but in a female with a massive abdominal distention in utero. And this distention can be very impressive. This is all a hydrocopos. This can compromise the baby's ability to move their diaphragms down and can affect their capacity to breathe. And these hydrocopi need to be drained. The vast majority can be drained perineally. Many times you do not need to do an abdominal surgery to drain a hydrocopos. This is quite a change. And I've learned this from my colleagues in Seattle that most of these hydroculpuses, and remember, there could be a right and a left side, can be drained with perineal catheterization. And interestingly, if you do that perineal catheterization with ultrasound on the abdomen, you're going to see that you'll, that the bladder will suddenly dilate up. What's happened? You've decompressed the hydrocolpos, you've gotten the fluid out. Now there's less pressure on the distal ureters. Now they can empty into the bladder and the bladder will now fill. So, therefore, a vesicostomy in almost all cloacass is not the correct treatment because it will not solve the distal ureteral obstruction. You need to drain the hydrocopos, and a a hydrocopos this large, I would probably do a cutaneous vaginostomy that would be tubeless, just like a vesicostomy. Operatively, if I can't get good decompression from the perineum. And here is the hydronephrosis that can be present and then improved just with drainage of the hydroculus. And here is an artistic diagram on the left of what this looks like. The very dilated vagina filled with urine and vaginal mucus leans forward and can compress the trigone and the entrance of the ureters into that common wall. The photo on the right, or the artistic diagram on the right, is a reminder that about 40% of these patients have a bifid system. Remember, if you do have a hydrocopos, you don't need to manage it at all, only if it's causing hydronephrosis. And here is what management of that hydrocopos looks like, dilated bilateral hydrocopos. Here on the right panel, we have opened the dome of the vagina, we remove a little bit of the septum, and now the two sides communicate with each other. And you can drain that with a tube or like a vesicostomy, you can make it tubeless, depending on the size. And remember, if there's no hydronephrosis, there's no reason to do this, and the vast majority can be managed with perineal catheterization alone. All right. I'm gonna show you the next step in our evaluation, which is cystoscopy. There you see the rectal fistula. And we are entering, there's a vaginal septum with two symmetric hemivaginas. In the urethra is sometimes difficult to find. You need to look up at the ceiling, and I think we're about to pass our scope in again. And now just above, there's a little tiny hole, and that's the urethra, and now we have a good visualization of the bladder neck and the bladder. And the measurements that are vital here are, there's the bladder neck, the length of the common channel, and the length of the urethra. Don't forget that we must know the length of the urethra. OK, because cloacas form in really two groups, those with a low confluence and those with a high confluence. And it used to be that based on this measurement alone, the common channel, a total urogenital mobilization was done for a low confluence cloaca. And a eurogenital separation was done for a high confluence cloaca. And what ended up happening is the total urogenital mobilization was done in some cases for patients with an inadequately lengthed urethra. Of note, historically, Doctor Hendren had done only urogenital separations, and then Doctor Pena, my mentor in 1996, showed the total urogenital mobilization. Which was brilliant, but I believe it was overused for patients who did not have an adequately length urethra. Most low confluence cloacas have a long urethra, and when I say long, greater than 1.5 centimeters. is needed, I believe, for bladder function and you do not want to disrupt the urogenital diaphragm. You do not want to pull the bladder neck down out of the urogenital diaphragm. You'll end up with urinary leakage. So, here is a 2D image of a cloaca. And I'm going to show you how we measure this. So this patient has a 3.5 centimeter common channel. The urethra then begins, but the urethra is only 1.5 centimeters long. Therefore, in this particular case, my preference would be to do a rectal mobilization, a vaginal mobilization, repair the back of the common channel, and leave this urethra to become 5 centimeters. Native urethra plus common channel becomes a 5 centimeter urethra. You're much more likely to get a dry patient. If you did that. If you did a TUM on this patient, you would leave the patient with a very short urethra, pulled down all the way to the perineum. And you can do this image in 3 dimensions, as you see here, it's a beautiful image, and this can be done in interventional radiology. And if you have the inclination, you can color these and really see some really nice imagery. Here, the rectum is entering high into the dome between the two hemivaginas, and the red images the bladder and the patient has bilateral reflux. So here is an image of 3 versions of a cloaca. On the left is a low confluence Cloaca amenable to a TUM. In the middle is a relatively low confluence coaca with a very nice length urethra, amenable to a TUM. On the right, there is virtually no native urethra. So if you were to separate the vagina from the back of the common channel, that entire common channel then becomes the neourethra. So this is the distinction, TUM versus UG separation, and we base it on the length of the common channel and the length of the urethra. And the minimums are 3 centimeters or less is a low confluence, most likely TUM greater than uh greater than 3 centimeters high confluence, most likely UG separation. Second factor, length of the urethra. If the urethra cannot be guaranteed to be 1.5 centimeters or greater, you must do a UG separation and let the native urethra plus the common channel become the neourethra. Well, we studied this and determined what is the typical length of the urethra. This is a group of patients that underwent VCUG because they had a UTI and we found them to have at least a 1.5, if not greater, centimeter urethra, which is where we got our recommendations. And the reason why this urethra issue is so vitally important is here is what a TUM looks like. This patient is in prone position. You see the native urethral orifice, and there's a lot of urethra proximal to this until you get to the bladder neck. The distal common channel is quite short. That needs to be split, and then the wings, after it's split, become the labia minora, which accentuates and lengthens the introitus. You see the vaginal septum is still here, that needs to be removed. If you were to split a long common channel, and there's very little urethra on the other side of it, You're essentially bringing the bladder neck down to the perineum, which must be avoided. And based on that criteria that I just described, we have made the delineation TUM or UG separation, and I think it's important for the surgeon to know in advance with proper endoscopy and imaging, is this a TUM case or is this more complicated, needs, needs a UG separation, and maybe that's a case that needs to be referred. Here's an interesting view. Here is a posterior sagittal approach, and through the posterior sagittal approach, anterior to the dissected rectum, we were able to see the uterus, the tubes, and the ovaries. Very cool view that you don't normally get to see. I do note from the chat, and I will take questions at the end, someone asked about allowing for a hypospatic urethra, and it's a really important question. If the urethra is 1 centimeter away, you could consider leaving it hypospaic and just doing a vaginal mobilization and an enteroidoplasty. However, you need to recognize that that urethra might be catheterized one day. If that patient does not have the capacity to empty their bladder efficiently, they will need to be catheterized and they will need to have an accessible urethral meatus. This is particularly relevant if the patient, let's say, has a spinal issue like tethered cord. So in that case, I'd be more likely to bring the urethra forward with a TUM than leave it hypostatic. The other issue is that the TUM itself. May be needed just to mobilize the posterior vagina. So you need to do the TUM just to get the introitis to reach comfortably. All right. And I think I talked about this a little bit at the beginning, but here you see, we have tried to make the urethral orifice lower than being where it was originally entering into the clitoral tissue. And here we've simply made an incision in the posterior common channel to then allow for a recessing of the urethral meatus. And here are some artistic diagrams of that. You see on the top left, a typical female urethral appearance, which is slightly lower than the clitoris. On the right, you see a cloaca, where the hole is literally in the clitoris. On the left bottom is the previous technique which left the hole exactly where it started, and on the right is the new technique where we have recessed the urethra just a little bit with a small posterior cut in the common channel. Occasionally, the vagina does not reach and you need to do a vaginal replacement. And here is a picture of a mobilized vagina that won't reach, and now we have interposed from the native vagina you see on the bottom panel to the perineum, a segment of bowel, ideally a segment of sigmoid. Sometimes a nice trick is to use the sigmoid colostomy site itself. Take a segment that you need for the vaginal replacement and then recreate the colostomy slightly more proximal. And occasionally we do this imagery of the blood supply. Here you can see that there's a rectal pull through and a vaginal pull through, and on the left, that segment, although it might look pink, in fact, is not well vascularized. This is uh this is with, um, fluoresce. But I do believe a key future endeavor relative to cloacal repair will be tissue engineering, and in theory, you have a vagina that doesn't reach in the urethra, you don't want to mobilize, you could sew in a tissue engineered vagina from that very patient, which you have selected and created in the lab over the prior 3 months by using their stem cells. I do believe this is going to happen in our lifetime. And remember the anatomy, the rectum, the vagina, and the bladder are all together in the pelvis, and that's why these three teams must collaborate. And for your reference, I would refer you to these 3 recent papers which have a very nice summary of a lot of what I've discussed. And then I would love to take your questions and discuss this topic further. So I'd like to stop sharing my screen, and then I'd like to be able to see you. So is there something I need to do? Stop sharing, OK. OK. All right, is everyone still there, I hope, and I'd love to go through your questions. Yeah, we're here, Mark, can you see the questions? Yes, it's not so easy for me to see. Oh, there, that I made it a little bit bigger. You took out the bigger box, yeah, that's that. OK, am I, am I no longer sharing? You still got, I can still, we can still see your slide. It's fine though, so it's OK. But is there, is there, so I can't see the audience. No, no, no. There's about 83 of them at the minute, so quite a few, so. All right, I'm very curious to know where everyone is from. Maybe you could tell me that if you've looked through everyone's, uh, all right, what is the best time for correction? Um, Fareed, happy to answer. You have a few questions actually. The best time for correction in my view, is somewhere between, let's say, 2 months and 1 year. Most of these are done about 6 to 8 months of age. I don't think there's a real great reason. Uh, to wait longer than that. Um, there's no rush. Essentially, when we do the evaluation is at about 3 months after they've recovered from their newborn procedure, make sure they're growing well, that their urine is draining successfully, um, that they don't have hydronephrosis. Um, short cloaca and female hypospaia. So we talked about that. Again, if you want to leave a 1 centimeter hypospatic urethra, that's fine and do only an entroidoplasty, but you need to base it on the fact that if you had to catheterize the urethra, could you? And if catheterization might be an issue down the road because the patient has a tethered cord, you might be more inclined to make a more obvious urethral meatus. And as I said, sometimes the introitus, the posterior vagina, does not reach well and requires a full UG mobilization, um, a TUM, a total urogenital mobilization, to get the posterior vagina to reach. Genitogram versus vaginoscopy versus cystoscopy. So we, we do this all together. We have um the colorectal team, urologic team, and gynecologic team together. We use the interventional radiology suite. We start with cystoscopy and vaginoscopy. We place catheters, one in the mucous fistula, one in the urethra, and into the bladder. Sometimes that has to be done cystoscopically over a wire, and one tube in the perineum that will light up the vagina. And so we get our measurements and we understand the anatomy. And then we have our radiologist inject contrast, and then do a spin with the CA. I believe it's CT essentially, CT technology, and then they can do a three-dimensional reconstruction. If you'd like a, um, if you'd like that protocol, um, it's actually nicely written up. Um, there is a, um, article that I didn't include here called, um, Measure twice, cut once. And feel free to email me. My email is M Levitt, M L E V as in Victor I T T at children'snational.org. Maybe Darren, you can put that into the chat box. Um, you can email me and I can provide your radiologist with that protocol. Dissecting the anatomy of the fine needle cautery can provoke stricture and fistula. So I have not found that problem, Fareed. I use a fine needle cautery and I stay full thickness outside of the TUM plane, and I have not, um, had, I, I keep it at a very low setting, usually 10, uh, pure and spray for cut and coag, and I have not had that problem with that elegant needle tip. Complications. So the complications of PSARP are um quite little, I think, if you, um, do a good technique, but obviously, you can develop a rectal stricture. Um, that happens with any, any PSARP. When you have mobilized the vagina and separated from the, um, common channel in the front, If that, uh, vagina is under some tension, you can be left with a stenosis. Honestly, I wouldn't intervene at that point as long as there was an opening. I would let the patient go through puberty and maybe consider an entroidoplasty much later in life. That's the one you most commonly might deal with. Incidence of urinary incontinence in TUM versus partial mobilization. So I don't have a lot of experience with partial mobilization. I think what, what is meant by partial mobilization, maybe what you're talking about there, um, that's Fareed again, is just the posterior vaginal wall. The urinary incontinence should be excellent. You should have good bladder neck function. However, does the patient need intermittent catheterization is the question. And that really depends mostly on the spine. Um, UG separations, we, we do know that um for those patients greater than a 3 centimeter common channel, 4 out of 5, 80% will need intermittent catheterization. Those with a 3 centimeter or less common channel, 1 out of 5 need total urogen, need uh intermittent catheterization, sorry. So most of those patients can void well. Interposition of bowel, short vagina, what is the follow up? OK, so another good question from Fareed. Um, so we are studying this. I don't think there's great data on this yet. Um, I try very hard to avoid a bowel neov vagina if I can and use the native vagina, of course. And if I do need a bowel vagina, I'd make it very short just to bridge the gap to the perineum. There is definitely increased mucus production. Um, with a bounty of vagina. So if you can avoid it, you have to, but otherwise, I would only do it if the vagina didn't reach successfully to the perineum. Um, Oh, I see some more questions coming. Uh, do you, pregnancy, yes, there is some literature on this. There have been a few patients that have become pregnant. I would definitely advise a C-section for these patients because they've had such an extensive amount of perineal dissection. And Pim Sluts is on the call from Rotterdam. Wow, what an honor to have you with us. Um, what should you advise on a synotic vagina post-op? When should you correct this? Well, Tim, I think if the orifice is there, I would leave the patient alone. Let them go through puberty and then maybe do an entroidoplasty later in life. If the vagina has disappeared, then a very good time to correct it might be at the time of the colostomy closure when you can take the colostomy site itself and bring down a neovagina independent and then close the colostomy. So I would have to know what type of vaginal problem you're having. Oh, the questions are, are pouring in now. Here we go. When would you employ a laparoscopic-assisted approach? So, um, so this is really new and exciting. And there have been some laparoscopic work been done. Uh, my colleague, Doctor Wood in Columbus and Belinda Dickey in, um, in Boston have talked to me about a few of their cases where they have actually done a UG separation. Laparoscopically. I think one of them has even attempted to do this robotically. The cases take a long time, but it's elegant and beautiful and certainly a good way to go for the patients who would require a laparotomy. Obviously, this is not relevant for a patient in whom the repair could be done posterior sagittally. OK, Farid writes, what are the incidents of redo operations in these low cloaca? I don't know what the denominator is Fareed, and luckily the the number of redos that I have done has dramatically reduced. I think it's because surgeons are doing the anatomy analysis first, and they're doing it well, and they're not attempting to do a complex case that they don't feel comfortable with. Um, but I don't know what the denominator is of all low confluence cloacas that have undergone TUM. And how well those sur those patients have done. I can tell you in my hands, that the TUM is a very uh straightforward case with very good results, virtually no vaginal stenosis, a very good urethral repair. At what time is it better to perform a vaginal replacement for Maria? Well, from a technical point of view, if you're dissecting the rectum and the perineal body, in my opinion, the vaginal replacement, if it's needed, should be done then. But I understand the question, and the question is, maybe it should be done later. From a technical point of view, as a teenager, it is much more difficult to do, and you already have a dissected perineal body plane. And those are the reasons why I advocate for a vaginal replacement early in life. Now, of course, we try very hard to get a good mobilization of the native vagina, if we can, and not need a vaginal replacement. OK. Sam Samuel, what is your tip to preserve adequate blood supply during vaginal switch? And what is your protocol for neovaginal dilatation? So, vaginal switch is out. No more vaginal switch. We found that those patients ended up with a lot of stenosis. I don't do that operation anymore. If I needed to bridge the gap from a high vagina to the perineum, I would use a segment of, of colon, preferentially, or small bowel as a second choice. Neovaginal dilatation, we don't dilate those patients. I would much rather allow for a skin-level stenosis and then later do an enteroidoplasty rather than subject the patient to vaginal dilatation. Is it possible to preserve the superficial perineal muscles? Absolutely. The perineal muscles, the perineal sphincter, the the um muscle complex is absolutely preserved during a posterior sagittal repair. How do you usually perform perineal vaginal drainage? Only one time or fix it for several days? Well, um, obviously, you need to catheterize the common channel. Sometimes it needs 2 or 3 times per day. You might find that the baby starts to void between catheterizations, and you can follow that patient on ultrasound. I teach the family how to do it. I would bring them to the radiology department and show by ultrasound and confirm that they are putting the perineal catheter in the correct location, and sometimes it needs to be directed towards the right, and sometimes it needs to be directed towards the left if there's a bilateral hydrocopos. And it's very nice to use a Cude catheter which you can twist and direct. Spongiosum tissue. Oh, yes. Mahmoud, if there wasn't spongiosum tissue, everyone would have gone into pediatric urology. So be very careful of the spongiosum tissue, you don't wanna get close to that. If you're doing a UG separation. You do not touch the common channel. Your dissection starts on the dome. I'm sorry, your your your dissection starts in posterior sagittal position. On the back of the vagina as it enters the common channel, you lift it up off of the common channel and dissect the plane between the vagina and the posterior urethra. Do not touch the common channel at all if you're doing a UG separation, and then you won't get into the um spongiosum tissue. Should you leave the pigtail drain in the hydrocopos as a tissue expander? That's an interesting question from uh Pim. Well, as I said, I will try to do, if the hydrocolvus is quite large, I will do a sutured vaginostomy, uh, tubeless, just like a vesicostomy. If you do leave a tube, I agree with you, Pim, to use a curled tube so it doesn't fall out. And I suppose what you could do is you could cycle that structure to get it to dilate and essentially, by that, I suppose you mean by doing a tissue, doing acting like a tissue expander. What are the indications for starting in the abdomen? Does it facilitate UG separation? My personal preference right now is to always start posterior sagitally if the confluence is low, below the peritoneal reflection. In the rare case of a cloaca, in whom the vagina and the rectum are in the abdomen already, I would then start in the abdomen. Now, footnote, if you're going to do laparoscopy or robotic dissection. You can obviously go much lower than you are able to do transabdominally with laparotomy. But remember, you want to get to the very end of the vaginal insertion onto the common channel, and that's very hard to do. I think it's easier to start that posterior sagittally and then go into the abdomen and continue that dissection. So if I were going to do this laparoscopically, I might consider a posterior sagittal approach, start that dissection even for a few millimeters, then go into the abdomen and find that same plane. Do you always manage the complete procedure in prone position? Do you sometimes turn the supine to completed TUM? Uh, a TUM can be done always in prone position. If you have a TUM that doesn't reach, yes, then you can go into the abdomen, mobilize the confluence together, and then pull that through. I, however, I would say in such a case, I would bet. It would have been better to do a separation, not a TUM. By the way, I'm almost ready to come out with uh a, a book on Cloaco management, which I think you all will enjoy, which are all the different scenarios. There are about 8 different Cloaca scenarios that we have, um, very methodically described, which I think you're gonna really like. OK, if you face two separate vaginas, not with a shared wall, yes, so you could leave, that's very rare, that's more typical in a cloacal atrophy. But yes, if the two structures, essentially a uterine, um, I suppose you mean a, um, uh, like separated hemiuteri with no shared wall. Yes, you can leave those independent, either connected to a bowovagina or potentially pulled through. However, if it's a situation where it could be pulled through, most likely there is a shared wall. Urinary tract problems. When is the timing to correct to save the kidneys? Fareed, again, Fareed, the key to saving the kidneys in cloaca, in my, in my belief is the stuff we've learned from spina bifida. Keep the bladder empty. Don't let the patient be. An incomplete emptier of their bladder. So aggressive intermittent catheterization and bladder management, vesicostomy in the appropriate patient, particularly those with grade 4 or 5 reflux, those are the moves that will save the kidney. Small bowel, small bowel neovagina from Eugenia Piminova. Uh, yes, I think it would be my second choice after colon. A segment of small bowel works very nicely. It's just that the blood supply of the small bowel is quite tenuous and not as forgiving as that of the colon, but it's a very nice, you take a segment of small bowel, you pull that through, you do the small bowel anastomosis behind it. Cynthia, thank you for your, thank you. Mahmoud wrote, Do you ever just bring the rectum down in a stage procedure and do the UG mobilization later? You know, that's a very good question, not my personal preference. I think that's an error because you have to do the UG mobilization at some point, and it's really nice to do the UG UG mobilization. TUM with the rectum out of the way. I would prefer to do one operation rather than two anyway, but I have heard people talk about doing the TUM later. If you can do the TUM perineally without touching of the rectum, then this is a reasonable approach. My personal preference is to do the entire operation uh together. OK, so Faried is asking about the perineal body length. The perineal body length is really individualized. It's from the, it's from the um Bottom of the labia, where they meet in the middle, where the skin fold meets in the middle, from there to the anterior limit of the anal sphincter. Everything in between is the perineal body. I don't have a specific measurement. Can hydroculpos. Recurrent after procedure in case of vaginal, that's a good question. So, um, can the hydrocopus recur after the procedure if the vaginal stenosis occurred? Certainly. And in that case, I would dilate up that vaginal opening to allow flow. Usually, when there's a vaginal stenosis, it's quite skin level and it does allow drainage of mucus. Any indication for bladder neck closure? Very good. Fareed, you have been extremely helpful to mention all the things that I forgot, so I appreciate your help very much. Um, I really don't believe there are ever, maybe, maybe rarely, an occasion to close the bladder neck. Because most of these urethras are salvageable if you respect the principle of keeping the common channel intact to become the neourethra. They all have a smooth, catheterrizable common channel, but you need to get the vagina off of it. So, only in a very rare circumstance where I have seen basically a congenital urethral atresia. Where there's a patient that actually never was able to drain urine. I see patients that have drained their urine, um, out, um, out the fallopian tubes. They have in utero ascites, for example. And those patients, yes, of course, they need a vasicostomy at birth and ultimately a metrofenoff. OK, my goodness. I, I survived the questions. Are there any more questions? We still have a little more time together. We'll just give him a minute then, Mark, yeah, if that's OK, you're OK to answer more questions. Yes, I'm, I'm happy to continue. We have 10 more minutes according to my clock. OK, I think, I think before we wait, um, sorry, go ahead. I'll just say, just while we wait, um, I was gonna say if you want to forward us, uh, details of your book that you mentioned, we can forward that on to registrants, uh, that might be good for them if you, if there are, I don't know how short, how close it is to publication, but, um. Um, also we're probably, we're probably, well, we're probably about 6 to 8 months, uh, away from that, um, that being published. I hope you have seen the other, the other books. Um, I can, uh, I can show them to you. Yeah I have them nearby. They're, they're this, this is very nice. This is a case studies. Which is, which I think you'd like. This is they're all CRC CRC Press. Then this is a great book. This is about fecal incontinence and constipation. The nurses and nurse practitioners that I've worked with have wrote this fantastic book. This is the secret sauce for the care of our patients. And then my colleague from Madrid, Spain, Alejandra wrote this beautiful, what I consider a bit of a masterpiece work on her part, which is really the practical colorectal and pelvic reconstruction. Um, these articles that you see up on the screen, I also would highly encourage you to look at the one on Cloaca, which really is essentially what I've just summarized for you today. Do you prefer? A couple more questions come through while we've been talking. Someone, someone wrote, do I prefer colon for vaginal replacement for its blood supply, or does it produce less mucus? Uh, I have found that the colon and the small bowel both produce mucus. I prefer the colon from a practical point of view. It's a little bit more um sturdy blood supply and also one nice trick is to use the left colon at the location of the colostomy site. So from a practical point of view, that saves you an anastomosis. If you take the colostomy down and then make a more proximal colostomy, you don't have a bowel anastomosis. So let's all commit to discuss this topic in person together one day soon. It's it's frustrating to be staring off into a space and only looking at myself. I, I thank you too, thank you to you, Darren. You're the only one that proves to me that I'm not talking to the air. Well, no, so thank you, Mark. It's been a really, really good lecture. Thank you. I think it's just your enthusiasms, but um, I, I don't know anything about this topic. I have to say I'm, I'm just a facilitator, but it's been, I've been really engaged with it. It's been fantastic. So, thank you very much. Thank you for answering all of those questions as well. I know there are quite a lot there, so thank you for taking the time. To do that, my pleasure. You know what, let me just mention one thing, uh, Fareed just asked another great question, which is transitional care. Um, so we like to plug our patients into the concept of transition at about age 12 because that's when the girls are going through puberty. Gynecology colleagues and then officially at age 21 we no longer see them here at the Children's Hospital we can flex till about age 30 if we had to, but in general that's a patient that ought to move on to the colorectal. Neurologic gynecologic and adding. Oh, someone asked about uh the video library. Yes, please go to, by the way, please don't hesitate to email me again, M Levitt M L E V as in Victor ITT at children'snational.org. Darren's gonna put that in the chat and videos. Uh www.expertsinsurgery.com. Some really nice videos there, including some of the Cloaca. OK, brilliant, yeah, so we, I put the, uh, I put your email address in the, in the chat, Mark, as well, so, um, we can add that experts in Surgery.com, that's where all the videos are. OK, we can add that to the email we'll send, so we send an email out tomorrow, so just for everyone who's listening, we, this, we've recorded, so we'll send you the links to the, um, direct, directly to the recording, uh, tomorrow, and we'll send it to all registrants as well for those who couldn't attend, so we can add that, those details in as well, Mark, to the email we send. So everyone's got it. Um, yeah, so thank you again, thank you very much to everyone for attending as well. I hope you enjoyed it all. Um, please do look at our website for future sessions. We've got a few more AR webinars coming up before Christmas, and we've also got some planned for next year already, and there will be a lot more being added to the website in the next few, uh, well, next month or so, I would say. Um, also, yeah, please, um, Check out our YouTube channel as well, and please register to that, if you subscribe to that if you haven't already. Um, we put all our, uh, webinars on there as well, uh, so that would be great if you subscribed, it'll help us, uh, kind of boost our, our, uh, numbers on there. Um, so yeah, thank you everyone and especially thank you to you again, Mark, um, uh, hopefully you can maybe do another one for us at some point, that was really, really good. So, um, but now for now I'll say thank you to everyone for joining and we'll hopefully see you all again soon. All right. Thank you so much. Goodbye everyone, thank you.