Colorectal Quiz Episode 18: Cloaca Part 2
With Dr. Jason Fisher & Dr. Richard Wood & Dr. Mark Levitt · hosted by Dr. Amanda Jensen · Colorectal Channel
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Definitive diagnostic workup for cloaca is typically performed at 5 to 6 months of age
The workup includes cystovaginoscopy, examination under anesthesia, preoperative urodynamics, and 3D cloacogram
During cystoscopy of the common channel, the easiest structure to enter is the vagina or vaginas; entering the urethra and bladder is challenging because it requires pointing very far up
If a septum is present, the rectal fistula is very often seen in the bottom of the septum on the rectal side
Cystoscopy significantly undermeasures structures compared to 3D reconstruction in the same patient, because a straight scope cannot measure the turn behind the pubis
Endoscopy has value in helping general pediatric surgeons differentiate straightforward from complex cloacas and determine whether referral to a specialized center is needed
Lower confluence cloacas, if the surgeon knows the technique, represent a beautiful, elegant operation
Higher confluence cloacas requiring vaginal replacement, high vaginas, and management of ectopic ureters should be done by specialized centers
A common channel less than 1 centimeter long is classified as a type 1 cloaca, essentially a hypospadic urethra with a rectovaginal fistula
For type 1 cloaca (common channel <1 cm), the hypospadic urethral orifice is not touched; the plan is vaginoplasty, anorectoplasty, and PSARP
Even in type 1 cloaca with short common channel, the true rectum can still be high, so imaging is important to determine rectal height
A normal urethra should be at least 1.5 centimeters in length
For common channel 1-3 cm with urethral length >1.5 cm, total urogenital mobilization (TUM) and PSARP is the appropriate approach
If urethral length is <1.5 cm, urogenital separation is advocated because performing TUM on a 1 cm urethra would place the bladder neck near the perineum and could render the patient incontinent
The majority of cloacas with 1-3 cm common channel have normal urethral length and are amenable to TUM
For common channel >3 cm, patients often have urethral length <1.5 cm; in either case, urogenital separation is advocated with repair of the common channel left as the urethra
If the vagina or vaginas cannot reach the perineum, the patient may need vaginal replacement to bridge the gap
If the rectum is high, an abdominal or laparoscopic-assisted PSARP approach may be needed to mobilize adequate rectal length
Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction
Alberto Pena made a major advance in 1996 with development of total urogenital mobilization (TUM); prior to that, all patients had urogenital separation
The next major change in cloaca protocol came 21 years after TUM, in 2017, with the algorithm incorporating urethral length measurement
The 2017 algorithm has been validated in 116 consecutive patients without once needing to change the surgical plan
The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously the decision was based only on common channel length (less than or greater than 3 cm)
Urethral length is measured from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single perineal orifice to the bladder neck
The goal is to position the bladder neck above the urogenital diaphragm where the sphincter complex lies, so intraabdominal pressure does not compromise continence
The most accurate urethral measurement comes from 3D imaging rather than cystoscopy, because imaging does not straighten structures and falsely measure them