Partial Urogenital Mobilisation in Cloacal Malformation- Is it a viable option?
Naser Al Soudan Al Anazi, MD, Joseph I. Curry, FRCS Paediatric Surgery, Simon Blackburn, FRCS Paediatric Surgery, Divyesh Desai, FRCS Urol, FEAPU, Abraham Cherian, FRCS Paediatric Surgery, FEAPU.
Great Ormond Street Hospital, London, United Kingdom.
Background Total Urogenital Mobilization (TUM) has been the standard surgical approach for the urogenital complex in Cloacal Malformations (CM) since its inception in 1997. Partial Urogenital Mobilization (PUM) in CM remains an underutilized or under reported option. We explored the feasibility of PUM in a select subset of our patients with CM. The main anatomical landmark difference between TUM and PUM is the division of the pubourethral ligament. This ligament stabilizes the urethra and contributes to the continence mechanism; hence its preservation should generally translate to a better outcome. We present our experience with PUM and its outcomes.
Methods We retrospectively reviewed prospectively collected data of all our CM patients who had their primary reconstruction in our centre from 2012 to 2020. Mullerian abnormalities, spinal cord involvement, common channel length (CC), urethral length (UL), surgical reconstruction, and outcomes including urinary continence, recurrent UTI, upper tract dilatation on ultrasound, functional imaging by DMSA, cystovaginoscopy post-reconstruction, and post-void residuals were noted. For all CM patients with a common channel less than 3 cm, our default approach was PUM. Our technique of PUM only involves mobilizing the lateral and the posterior wall of the vagina. If the urethra could not be brought to the surface during reconstruction, we proceeded with TUM.
Results Fifty-three patients had primary reconstruction, and of these, eleven had a common channel less than 3 cm. Of the eleven, only one required TUM. In the PUM group, mullerian duplication in 5 patients (50%), two had abnormal spinal cord and underwent filum untethering (20%). The CC length was between 1.5 - 2.7 cm (median = 1.6 cm), and UL 1.5 - 2.5 cm (median = 1.5 cm). One patient had a horseshoe kidney (10%). Follow-up post PUM ranged from 9 - 134 months (median = 63 months). All had a separate urethral and vaginal opening when examined under anaesthesia and on cystovaginoscopy. Six patients are continent, void spontaneously and empty to completion (60%). Two patients are not potty trained yet (less than three years of age) (20%). One patient has daytime wetting with severe constipation and undergoing aggressive bowel management. One patient initially managed by clean intermittent catheterization (CIC) went on to have an ileocystoplasty and Mitrofanoff for poorly compliant bladder on urodynamic assessment and recurrent pyelonephritis. One patient with recurrent UTI underwent bilateral Deflux injection for VUR, and eight remained infection-free (80%). All the patients have no new upper tract dilatation on US. Equal split renal function on DMSA, and no renal scars following reconstruction were confirmed.
Conclusion PUM is a viable alternative in cloaca malformations with a common channel under 3 cm with good outcomes. It avoids the potential complications related to dividing the pubourethral ligament in TUM. It may also avoid the need for CIC which is often encountered in patients who underwent TUM. This is of course not possible in all patients but reserved for the ones that are appropriate.
Back to 2022 Abstracts