Vaginal Obstruction in Cloacal Anomalies - Is Vaginostomy Tube Placement the Procedure of Choice? A Multi-center Case Series.
Vinaya Pavithra Bhatia, MD1, Campbell Grant, MD2, Catherine Ingraham, MD3, Jordon CK King, MS1, Soo Kim, MD1, Brian A. VanderBrink, MD, FAAP2, Paul F. Austin, MD, FAAP1.
1Texas Children's Hospital at Baylor College of Medicine, Houston, TX, USA, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 3Scott Department of Urology at Baylor College of Medicine, Houston, TX, USA.
Objective: To determine whether vaginostomy tubes (VT) incur a higher risk of emergency evaluation and additional procedures when compared to cutaneous vaginostomy (CV) for patients with hydrometrocolpos (HMC) in the setting of cloacal anomalies.
Methods: We performed an IRB-approved, multi-center, retrospective chart review of patients with cloacal anomalies who presented to the hospital with HMC or HC in the setting of cloacal anomalies. Patients were excluded if they did not have a cloacal anomaly and vaginal obstruction. Descriptive statistics were used to analyze the rate of CV or VT readmission, indication for readmissions and complication rates after interventions.
Results: Nineteen patients were identified at two high-volume centers meeting inclusion criteria. In total, 12 patients (73%) had a cloacal anomaly, 3 had a urogenital sinus anomaly, and 4 patients had VACTER-L syndrome. Fifteen patients (78.9%) had an associated gastrointestinal anomaly and 16 (84.2%) had renal anomalies. Five patients (26.3%) required vesicostomy creation for urinary obstruction in the setting of HMC. The most common anomalies were uterine didelphus (5 patients, 26.3%) vaginal septum (4 patients, 21.1%). The majority of patients (16 patients, 84.2%) underwent VT placement, of which 6 patients (37.5%) required more than one procedure. The median number of procedures for patients undergoing VT was 2 procedures (range 1-6 procedures), versus 1 procedure (range 1-2 procedures) for those undergoing CV. No patients who underwent CV required ER visits for additional intervention, while 5 out of 16 patients (31%) required ER visits after primary VT. Of note, one patient underwent CV creation after VT and did not require any subsequent procedures. In addition, 10 out of 16 patients (62.5%) were hospitalized for sequelae of VT placement. One patient who had undergone primary CV creation required subsequent VT placement, while another who had undergone two VT placements required conversion to CV.
Conclusions: Although VT is a more common approach to HMC in cloacal anomalies, this procedure is associated with a frequent requirement for emergent intervention and ER re-evaluation. Consideration of CV is warranted particularly with long-term care to decrease the risk of additional emergency room procedures or hospital admissions. Larger multi-center studies will be needed to determine the superiority of CV or VT for HMC and the roles of each for HMC management with cloacal anomalies.
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