Colorectal Quiz Episode 36: Blind End Cloaca

Prenatal organ screening at 20-24 weeks pregnancy identified intraabdominal cyst, with prenatal MRI at 28 weeks showing double cyst configuration with differential diagnosis of mesenteric cyst, ovarian cyst, or hydrocolpos

In a female fetus with large abdominal cyst and associated neurologic issues, radius missing, or sacrum missing, hydrocolpos associated with cloaca should be suspected

A large perineal orifice in cloaca often indicates that the confluence of structures is very low

If the single perineal orifice is very tiny and right at the clitoris, that usually means a high confluence

Cystoscopy through the single perineal orifice revealed only a urethra entering bladder with no rectal or vaginal communication with that single channel

Hydrocolpos fluid appeared amber colored, mucous-looking, not infected, not urine-smelling, and was easy to drain

Maternal hormones affecting vaginal mucus is one explanation for large amounts of hydrocolpos fluid

Ectopic ureter connecting to one or both vaginas or uteri could contribute urine to hydrocolpos even without visible communication

Patient had grade 2 hydronephrosis on one side and grade 3 hydronephrosis on the other side

Pigtail catheter was chosen to drain hydrocolpos to minimize intraabdominal scarring and adhesions before future surgeries

Tubeless vaginostomy (suturing vagina to abdominal wall) is an option for draining large hydrocolpos that reduces infection risk by avoiding indwelling tube, and has not been found to cause tethering problems for later pull-through

When hydrocolpos shows no septum on ultrasound and is very large, single catheter drainage is appropriate; if smaller and divided, open drainage or laparoscopy is preferred

Colostomy technique using 1.5 cm incision, identifying sigmoid colon and white line if visible, bringing up loop and dividing outside, with purse string on one side brought through second incision creates stoma without skin bridge

Laparoscopic stoma creation in neonates helps avoid skin bridge which is helpful for wound care issues

Distal limb must be emptied with irrigations because meconium left for six months before definitive repair becomes almost petrified and extremely difficult to evacuate, causing problems

Pigtail catheter was lost two days before scheduled MRI, and hydrocolpos had refilled to massive amount by the time of imaging

Distal colostogram showed colon ending at PC line with good developed sacrum, indicating low rectal position reachable from below

Posterior sagittal approach was chosen because of low rectum position and assumption that vagina could be found from behind

During repair, only one cervix was found with no septum, though visualization was difficult due to redundant tissue from deflated hydrocolpos

Vagina was separated from bladder at the level of bladder neck and mobilized without tension, allowing successful vaginoplasty and anoplasty without need for interposition

When managing hydrocolpos, surgeons must be aware of potential septum and remove a piece of it to ensure both sides drain properly

Comprehensive preoperative imaging should include contrast study through vaginostomy tube, injection of distal rectum, hydrocolpos, and bladder together in 3D cloacogram or fluoroscopy with lateral projection

This case is classified as cloaca variant because patient has no anus and single perineal orifice, but uniquely has no vaginal or rectal connection to the common channel, with the common channel itself functioning as the urethra