Pitfalls and challenges of cloaca repair: how to reduce the need for reoperations

Purpose: Cloacal malformations represent the most complex of genitourinary/anorectal anomalies. We have encountered a unique group of complications in referred patients after failed attempted repairs elsewhere and chose to review this experience with the hope of identifying pitfalls to avoid during the primary repair. Methods: In our series of 509 cloacas, 95 were repaired elsewhere but required reoperation. These cases were reviewed for specific indications for reoperation and methods used for reoperative repair. Key findings at reoperation to explain the complication(s) were specifically sought. Results: Indications for reoperation included the following: persistent urogenital sinus (46), rectal stricture or acquired atresia (45), acquired vaginal atresia or stricture (45), mislocated rectum (36), urethrovaginal fistula (16), rectal prolapse (12), urethral atresia or stricture (7), and rectovaginal fistula (5). Most patients had more than one indication. In cases of persistent urogenital sinus, the surgeons were unaware of the presence of a cloaca, referring instead to the malformation as a "rectovaginal fistula." From our reading of the operative reports of the original operations, we ascertain that rectal stricture, atresia, or fistula that occurred was most likely related to tension or ischemia. Prolapse was associated with poor pelvic musculature. The average length of the common channel of those patients with vaginal and urethral problems was 4.1 cm. Conclusion: We have observed key complications requiring reoperation in a large series of cloacal malformations that are potentially avoidable. A persistent urogenital sinus can be avoided by properly diagnosing a cloaca and repairing the entire malformation and not just the rectum during the initial repair. Vaginal and urethral complications occurred mainly in patients with a common channel longer than 3 cm. Repair of cloacas with common channels longer than 3 cm requires familiarity with a complex decision-making process, and atresias, strictures, and fistulae can be avoided with adequate mobilization of structures and preservation of blood supply. Rectal prolapse occurrence relates to the quality of the perineal muscles. Reoperations can restore the anatomy, but the functional results are not as good as those achieved after primary repair. (C) 2011 Elsevier Inc. All rights reserved.