The effect of surgical reconstruction on bladder function in cloacal malformation: a study of urodynamics
Molly Fuchs, MD, Shruthi Srinivas, MD, Raquel Quintanilla Amoros, MD, Vankata R. Jayanthi, MD, Christopher Westgarth-Taylor, MD, Richard J. Wood, MD, Daniel G. Dajusta, MD.
Nationwide Children's Hospital, Columbus, OH, USA. Background Girls with cloacal malformation are at risk of bladder dysfunction, with nearly 90% exhibiting some degree of dysfunction. Surgical dissection, particularly with total urogenital mobilization (TUM), has been hypothesized as a possible cause of worsening bladder function. However, other associated conditions exist in this population including spinal cord and vertebral abnormalities that may also play a significant role in bladder dysfunction. Our institution follows a strict protocol in cloacal repair based on common channel and urethral lengths to determine if TUM or urogenital separation (UGS) is performed. We aimed to evaluate the effect of cloacal repair on bladder function based on pre and post-surgery urodynamics (UDS) testing. Methods A prospectively collected database of patient with anorectal malformation at a single center was queried for girls with cloacal malformations who had undergone surgical repair. It is our current protocol to perform UDS before and after cloacal repair. Only patients who completed both pre and post-surgery UDS were included. UDS were evaluated and classified using the UMPIRE protocol. Descriptive statistical analysis was performed. Results A total of 48 patients were included in the cohort (Table 1). The majority of patients (79.2%) had stable or improved UDS post-op leaving 10 patients (20.8%) who had worsening UDS. Of the ten patients with worsening UDS, all were upstage from safe classification to intermediate. Long common channel (≥ 3 cm) was the only factor significantly associated with worsening UDS (p=0.03) Nearly 30% of those undergoing UGS had worse post-op UDS compared to 9.5% with TUM (Table 2). All patients who worsened have safe UDS and progressed to intermediate except for one who worsened to hostile in the setting of significant social challenges and non-compliance. Only common channel length was predictive of worsening UDS, while the type of surgical approach and spine status were not. Furthermore, when we controlled for common channel length, looking only at those with long common channel, of which 3 had TUM and 25 had UGS, the type of operation did not predict worsening UDS. Additionally, while the overall risk of worsening UDS in these patients was found to be low, patients with a normal spina undergoing a TUM procedure had the lowest risk, with only one patient in 15 (6.6%). Conclusions Common channel length is a stronger predictor of worsening UDS, while surgical technique (TUM vs UGS) and spine status did not appear to impact this outcome. By following this established surgical protocol based on common channel and urethral lengths, the incidence of worsening post-op UDS is rare, particularly in those undergoing TUM for short common channel with normal spine.
Table 1. Comparison by UDS changes post-op
| Cohort (n=48) | Urodynamics Improved or Unchanged (n=38) | Urodynamics Worsened (n=10) | p-value | |
| Age at surgical repair, months | 9.4 [7.3, 14.0] | 9.4 [7.3, 13.5] | 9.4 [7.3, 13.5] | 0.849 |
| Spinal status | 0.225 | |||
| Normal (low conus, fatty filum) | 33 (68.8) | 28 (73.7) | 5 (50.0) | |
| Moderate (tethered cord) | 11 (20.8) | 8 (21.1) | 3 (30.0) | |
| Severe (MMC, sacral agenesis) | 4 (10.4) | 2 (5.3) | 2 (20.0) | |
| Common channel length | 0.033 | |||
| Short (<3 cm) | 18 (37.5) | 17 (47.2) | 1 (10.0) | |
| Long (≥3 cm) | 28 (58.3) | 19 (52.8) | 9 (90.0) | |
| Surgical approach | 0.057 | |||
| Total urogenital mobilization | 21 (43.7) | 19 (50.0) | 2 (20.0) | |
| Urogenital separation | 27 (56.3) | 19 (50.0) | 8 (80.0) | |
| Initial urodynamic findings | ||||
| Safe | 37 (77.1) | 27 (71.1) | 10 (100.0) | 0.134 |
| Intermediate | 10 (20.8) | 10 (26.3) | 0 (0.0) | |
| Hostile | 1 (2.1) | 1 (2.6) | 0 (0.0) |
Table 2. Comparison of patient factors TUM vs UGS
| Cohort (n=48) | TUM (n=21) | UGS (n=27) | p-value | |
| Age at surgical repair, months | 9.4 [7.3, 14.0] | 7.8 [7.3, 10.4] | 12.0 [7.7, 15.4] | |
| Spinal status | 0.242 | |||
| Normal (low conus, fatty filum) | 33 (68.8) | 15 (71.4) | 18 (66.6) | |
| Moderate (tethered cord) | 10 (20.8) | 3 (14.3) | 8 (29.6) | |
| Severe (MMC, sacral agenesis) | 5 (10.4) | 3 (14.3) | 1 (3.7) | |
| Common channel length | <0.001 | |||
| Short (<3 cm) | 18 (37.5) | 18 (85.7) | 0 (0.0) | |
| Long (≥3 cm) | 28 (58.3) | 3 (14.3) | 27 (100.0) | |
| Initial urodynamic findings | 0.580 | |||
| Safe | 37 (77.1) | 17 (80.9) | 20 (74.1) | |
| Intermediate | 10 (20.8) | 4 (19.1) | 6 (22.2) | |
| Hostile | 1 (2.1) | 0 (0.0) | 1 (3.7) | |
| Post op urodynamic findings | 0.062 | |||
| Safe | 31 (64.6) | 18 (85.7) | 14 (51.9) | |
| Intermediate | 16 (33.3) | 3 (14.3) | 12 (44.4) | |
| Hostile | 1 (2.1) | 0 (0) | 1 (3.7) | |
| UDS worsened post op | 10 (20.8) | 2 (9.5) | 8 (29.6) | 0.066 |
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