This document discusses the management of cloacal malformations, which involve a common channel for the urinary, genital, and gastrointestinal systems. Key points include: - Associated anomalies that often occur include renal agenesis, vesicoureteral reflux, and cardiac defects. - Neonatal management involves dividing the colon, vaginostomy or vesicostomy, and later repairs to separate the systems. - For common channels less than 3 cm, posterior sagittal repair is usually sufficient. Larger channels require additional abdominal approaches and pubic bone resection. - Long-term concerns include urinary incontinence, bowel control issues, and ensuring normal sexual function

1. Cloaca
Ahmed oshiba, assistant lecturer, Pediatric Surgery and Urology
department

7. Associated
anomalies
Renal agenesis.
VUR.
Obstructing megaureters.
Ectopic ureters.
Hemivertebra.
Cardiovascular anomalies.
Tethered cord.
Esophageal atresia.
Duodenal atresia.

8. Goals of treatment
Urinary control. Bowel control. Sexual function.

9. Neonatal
management

17. Investigations
Renal and bladder ultrasound.
Pelvic ultrasound.
Plain X- ray abdomen and pelvis.
Echocardiogram.
Spinal ultrasound.
Exclude TOF.

18. Neonatal management
• Within 18- 24 hrs.
• Lower descending divided colostomy with distal reduction.
• If hydrocolpos, midline lower abdominal incision.
• Tube vaginostomy (pigtail tube).
• Vesicostomy when???

22. Main repair

27. Cloacas with
a Common
Channel of
Less Than 1
cm

28. Cloacas with a 1–
3 cm Common
Channel
• 66 %.
• Good prognosis
• CIC in 28%
• Bowel control according to the quality of sacrum and spine.
• 1-12 months.
• Cystoscopy and vaginoscopy as a separate setting is a must.
• Posterior sagittal approach and TUM without opening the
abdomen.
• Excellent cosmesis, very good function.
• Urinary catheter for 3 weeks postoperatively.
• Closure 0f colostomy after 2 months. Confirm wide vaginal
introitus.
• Urinary leakage, return normal function few weeks later.

38. Cloacas with a 3- to 5-cm Common Channel
• Total body preparation.
• Posterior sagittal+ abdominal approach.
• Extended transabdominal urogenital mobilization.
• Carving of the pubic cartilage: if we need .5-1 cm extra length.
•

42. Separations of
Vagina(s) from
the Urinary Tract
• Laparotomy.
• Midline bladder incision.
• Cannulate the ureters.
• If the patient suffers from reflux, this is a
golden opportunity to perform a ureteral
reimplantation.
• Vaginal pull through.

45. Vaginal switch
Two hemivaginas very separated,
as well as the hemiuteri with
a vaginal septum.
Originally two large hydrocolpi. If
we can estimate that the distance
between one hemiuterus and the
other is longer than the vertical
length of both hemivaginas

49. Vaginal replacement
Rectum. Colon.
Small
bowel.

50. Rectum
• Very large dilated rectum.
• Longitudinal division.
• If not dilated enough: distal resection.
• Intramural blood supply.
• If internal genitalia: anastomoses to the
native vagina.

55. Colon
Sigmoid.
Left transverse,
descending
colon.

58. Small bowel
• Last choice.
• Delicate and easily twisted blood supply.
• Terminal ileum.
• 15 cm proximal to the ileocecal valve.

61. Urinary
drainage
Foley
catheter.

62. Post operative care

63. • In cloaca type I and cloaca less than 3 cm, start feeding in the same
day, discharge after 48 hrs.
• If long operative time more than 6 hours, the best is to remain
intubated overnight in the intensive care unit.
• Nephrology care.
• Foley catheter remains for 3 weeks.
• Anal dilatation after 2 weeks.
• Cystoscopy and vaginoscopy at the time of closure.
• If any problems, closure should be cancelled.

64. • If rectal or vaginal prolapse, delay the closure at least 1 month after
the repair.
• If long and narrow vaginal stricture, reoperation may be needed.
• CIC may be needed.
• If difficult urethral cathetrization, vesicostomy is indicated, delay CIC
till be older.
• Urethrovaginal fistula usually at the bladder neck before the advent
of TUM: need for reoperation.

66. Urologic concerns

67. • Patients with normal sacrum, no tethered cord, and with a common
channel shorter than 3 cm should not have serious urinary problems.
• Vesicostomy is indicated in VUR, obstructing ureters, wait till ureters return
to normal caliber and good compliant bladder then consider
reimplantation.
• UDS is important before reimplantation.
• CIC.
• Bladder augmentations and Mitrofanoff procedures.
• Bowel management program.

68. Gynecologic
concerns

69. • After puberty: recurrent abdominal colic, no menstruation…. Ask for
Ultrasound or MRI pelvis.
• Check the patency of the fallopian tubes.
• If unilateral: Resection of the obstructed one .
• If bilateral: leave them and close follow up after puberty.
• Vaginal examination under anesthesia to determine sexual function.
• If limited narrowing (ring) stricture
• Vaginal septum.
• Vaginal replacement: malignancy, IBD.

72. Reoperations

73. • Persistent UGS: needs reoperation.
• Acquired vaginal atresia or stricture.
• Acquired urethral stricture.

76. Transpubic approach
• If the surgeon considers that the lesion,
fistula, mass, or structure that he or she
wants to reach is surrounded by excessive
fibrosis and is located in a place impossible to
reach from below or from above.
• Rectal patching to the narrow vagina is only
recommended if no bowel control.

80. Posterior cloaca
• Chronic pseudo diarrhea.
• External ambiguous genitalia.
• Single posterior opening at the normal anal
position.
• Endoscopy showed opening of UGS at the
anterior rectal wall.
• Posterior sagittal approach.
• TUM.
• Pubic craving: resection of 50% of pubic bone.

86. Posterior cloaca
and absent penis