Alberto Peña

1469 statements · 11 topics · summaries given as host listed separately

Abdominal Wall Defects · guest expert Colorectal / ARM & Hirschsprung · guest expert

Featured statements

In the real life and we don't make a very accurate diagnosis of the of the intrinsic anatomy of the cloaca during the newborn period and in fact trying to be very precise in the anatomic diagnosis is kind of useless and may actually hurt the baby, but we are very interested in a newborn babies to know if the baby has hydronephrosis and mega ureters and to know if the patient has a hydrocorpus that may be compressing the ureters.

quote · Cloaca

The surgeons should be careful not to stretch too much because you start the dissection and you forget you want to be comfortable. You put retractors and I walk into the operating room and see sometimes a big hole that what used to be the anus becomes a huge hole and that is damaging by definition the sphincter mechanism.

quote · Colorectal / ARM & Hirschsprung

If you take a child that has been traumatized with rectal maneuvers and you try to do rectal irrigations, it's going to be a lot of problems, whereas if a patient has an ileostomy and the mother does rectal irrigations once in a while with a soft catheter, the baby will accept that.

quote · Colorectal / ARM & Hirschsprung

Enemas consist in giving a certain amount of fluid with the, with the, with the ingredients that are irritant to the bowels that provoke a bowel contraction, but the, the disease consists in not having the normal peristalsis therefore are not indicated.

quote · Enterocolitis

You are at that point it's not so crucial to know if the baby has a reflux or not. It's not, it's what you want is the patient to, you want to be able to decompress the gastrointestinal tract and to decompress the urogenital tract.

quote · Cloaca

I don't pay attention to that and I don't perform myectomies and I don't recommend those myectomies and myotomies and buttock and those concepts because we don't know where where you inject. What area of the muscle, nobody knows

quote · Enterocolitis

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Alberto's statements about Abdominal Wall Defects 138 statements

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Cloacal Exstrophy with Dr. Alberto Peña

Statement Cloacal exstrophy is a spectrum of congenital malformations affecting the gastrointestinal/colorectal area, urogenital tract, spine and cord, and sometimes lower extremity motion. Open

Statement Babies with cloacal exstrophy are born with an omphalocele, bladder exstrophy (two separated hemibladders), open cecum between the hemibladders, and separated pubic bones. Open

Statement The small bowel can become exstrophic through the ileocecal valve, creating an 'elephant trunk' appearance. Open

Statement Male patients have two separated hemiphalluses with normal gonads; female patients have two hemivaginas below the exstrophic bladder leading to two hemiuteri. Open

Statement Cloacal exstrophy represents a spectrum of colonic anatomy from normal colon to almost absent or completely absent colon, sometimes with two ceca or two appendices and bizarre blood supply. Open

Statement The amount of colon present at birth has very important implications for the patient's management and outcomes. Open

Statement A variant exists where babies are born with intact abdominal skin (no omphalocele, no bladder exstrophy externally) but have a completely open bladder inside with no bladder neck and a single large perineal orifice. Open

Statement While surgical techniques, intensive care, parenteral nutrition, and metabolic management have improved, functional outcomes (bowel control, urinary control, sexual function, spinal abnormalities) remain severely limited and cannot be made normal. Open

Statement Historical practice was to perform bilateral gonadectomy, remove hemiphalluses, create a vagina with bowel, and assign female gender to XY patients with cloacal exstrophy. Open

Statement Patients raised as female despite XY chromosomes exhibited male attitudes and behavior, and many became upset upon learning their chromosomal sex and that gonads were removed without their consent. Open

Statement Patients argued that sex is not the most important aspect of being male, that they wanted their gonads back for fertility (modern techniques allow fertilization and children), and that being male is much more than having a phallus. Open

Quotation who told you that sex is the most important thing? I want, I wanted my go nuts back, and with modern techniques, those individuals can fertilize, they can have children. Open

Quotation being a male is much more than having a phallus Open

Statement Current consensus is that XY patients should be raised as male, with pediatric urologists and plastic surgeons working on phallus reconstruction techniques. Open

Statement When a prominent pediatric urologist dominates management, patients receive good urologic attention but inadequate gastrointestinal care; the reverse occurs when pediatric surgeons dominate. Open

Statement The pediatric surgeon's role in the initial operation is to close the omphalocele (if possible), separate urothelium from intestinal mucosa by placing stitches at the edges and making an incision, allowing the urologist to bring hemibladders together. Open

Statement It is very common but very harmful for pediatric surgeons to simply create an ileostomy, leaving all colon distally attached to the urinary tract. Open

Quotation That is a very bad thing to do, and the patient will suffer several consequences because of that Open

Statement Leaving colon attached to the urinary tract creates a congenital bladder augmentation that causes hyperchloremic acidosis from urine absorption, interfering with growth and development. Open

Quotation Isn't that beautiful from your point of view? Open

Statement Defunctionalized colonic tissue left distally will not grow; colon requires passage of fecal matter through its lumen to grow. Open

Statement The pediatric surgeon must incorporate all gastrointestinal tissue into the fecal stream and create a true end colostomy to ensure fecal matter passes through all colonic tissue. Open

Statement Patients who received ileostomy with defunctionalized colon present at 2-3 years with poor growth, hyperchloremic acidosis managed by nephrologists, and large ileostomy losses. Open

Statement The rescue operation involves taking down the ileostomy, finding and incorporating colonic tissue into the GI tract, and creating an end colostomy; acidosis disappears the next day. Open

Statement Surgeons must accept that cloacal exstrophy is a spectrum and be prepared to deal with complex, variable colonic anatomy rather than taking the easy way out with an ileostomy. Open

Quotation Do not leave gastrointestinal tract inside the functionalized. That's the main, main thing. Open

Statement Some institutions routinely perform pelvic osteotomy at the initial operation to facilitate bladder and omphalocele reconstruction, while others wait 2-3 months to do it separately. Open

Statement Even after osteotomy, it is very difficult to see a cloacal exstrophy patient with pubic bones completely together; they usually remain separated. Open

Statement Even a technically correct end colostomy often has poor motility, and babies may not pass stool easily, sometimes developing bacterial overgrowth similar to Hirschsprung disease. Open

Statement Families must be taught to irrigate the colostomy with small volumes of saline through a tube to evacuate fecal material when peristalsis is inadequate. Open

Statement Decision-making for bowel control begins around age 3 when parents want to send the child to school clean and dry (no stool or urine in diaper). Open

Statement Most cloacal exstrophy patients have an inadequate, tiny bladder requiring bladder augmentation with gastrointestinal tract, necessitating coordination between pediatric surgery and urology. Open

Statement Patients born with no colon are candidates for permanent colostomy and should never have terminal ileum pulled through, even if sphincter evidence exists, because they will never have bowel control. Open

Statement Pull-through is only considered for patients with capacity to form solid stool (adequate colon), as bowel management only works with solid stool. Open

Statement It is extremely unusual for cloacal exstrophy patients to have spontaneous bowel control; the overwhelming majority need a bowel management program (enema administration to keep patient clean). Open

Statement Pediatric surgeons should not underestimate the growth capacity of tiny colonic pieces during the newborn period; even small segments will grow over three years if fecal stream passes through them. Open

Statement Annual contrast studies through the colostomy (retrograde injection) are performed to assess colonic growth. Open

Statement Before committing to pull-through, a trial bowel management program is performed through the colostomy: enemas are given to empty the colonic pouch, and if the patient stays 24 hours without stool in the colostomy bag, pull-through is likely to succeed. Open

Statement Bowel management trial through colostomy is typically started after age 3 when families consider avoiding the stoma for school. Open

Statement If a patient has very little colon and cannot form solid stool, the urologist is free to use bowel for bladder augmentation; if the patient has borderline colon, the urologist must use stomach for augmentation to preserve bowel for fecal function. Open

Statement The colon to be pulled through is the most posterior structure in the pelvis, with the bladder and augmentation anterior to it; therefore, bladder augmentation must not be done before deciding on pull-through, or accessing the colon will be extremely difficult. Open

Statement Contrast enema through the colostomy can distinguish true liquid stool from paradoxical diarrhea (liquid stool around solid fecal impaction). Open

Statement Pull-through and bladder augmentation are ideally performed together in a single operation lasting approximately 12 hours, with pediatric surgery going first (posterior dissection) followed by urology (anterior augmentation). Open

Statement During pull-through, if the patient has one or two appendices, a Malone appendicostomy can be created for antegrade enema administration, as the appendix remains in the abdomen when colon is pulled down. Open

Statement Urologists almost never use colon for bladder augmentation in cloacal exstrophy because colon is needed to form solid stool; they typically use small bowel or stomach. Open

Statement Occasionally, when a patient has a giant colonic pouch with very poor motility, the poor motility makes it good for bowel management (irrigate once daily, stays clean between irrigations), and a piece can be shared with urology for augmentation. Open

Statement Midline abdominal incision from xiphoid to pubis is used for pull-through to preserve the flanks and quadrants for potential future stomas. Open

Statement The colostomy is circumferentially dissected and separated from the abdominal wall, then the blood supply is carefully studied because cloacal exstrophy patients have very bizarre, aberrant vascular anatomy. Open

Statement Careful observation of the vascular anatomy allows the surgeon to decide which vessels can be ligated to mobilize the colon to the perineum without compromising blood supply; sometimes no vessels need to be ligated. Open

Statement The space behind the bladder is easily created, and the bowel is placed posteriorly; patients do not need prone positioning because the exstrophy makes everything anterior, so a supine frog-leg position provides full perineal access. Open

Statement Cloacal exstrophy patients are lifelong patients due to orthopedic problems (separated pubic bones causing abnormal gait) and spinal problems (tethered cord requiring neurosurgical follow-up and potential cord release). Open

Statement Some teenagers are unhappy about separated pubic bones causing abnormal gait (feet pointing laterally); some dedicated orthopedic surgeons have been able to bring pubic bones closer together. Open

Statement During pull-through, vaginal reconstruction is attempted by approximating the hemivaginas as much as possible; the degree of separation varies on the spectrum. Open

Statement When hemivaginas are close with only a septum separating them superiorly, the septum is removed as high as possible; when vaginas run in completely different directions, one hemivagina may be removed, leaving the one with the better-looking cervix. Open

Statement Patients with functional hemiuterus may become pregnant, but it is high-risk pregnancy requiring specialized pediatric gynecology follow-up; in general, pregnancy is not advised. Open

Statement Hemiuterus has a great tendency to produce miscarriages and premature labor; delivery must be by cesarean section due to limited abdominal space. Open

Statement Bladder augmentation requires a Mitrofanoff conduit (appendix or part of a long appendix, sometimes shared half for urology and half for Malone) for intermittent catheterization to empty the bladder. Open

Statement Augmented bladders produce large amounts of mucus; if mucus is not removed, it forms stones, so families must be taught to irrigate the bladder (not just empty it) to remove mucus and prevent infections. Open

Statement Bladder irrigation is sometimes performed with gentamicin to ensure all mucus is removed. Open

Statement Lifelong urologic follow-up is needed to monitor for reflux and kidney damage; the Mitrofanoff may stop working or leak urine, requiring revision or valve tightening. Open

Statement Patients transitioning to adult hospitals often feel uncomfortable because adult urologists and orthopedic surgeons lack experience with these congenital malformations; patients prefer to remain in pediatric environments even as adults. Open

Statement Dr. Peña observes that cloacal exstrophy patients are particularly charming, intelligent, beautiful, and charismatic when they grow up, and some have energy to help others manage their own problems. Open

Statement The Pull-Through Network is a national organization (similar to cystic fibrosis or breast cancer organizations) for parents and patients with anorectal malformations, Hirschsprung disease, or bowel/urinary control problems; it has over 1000 members, holds annual meetings, and invites doctors to give talks. Open

Statement Colorectal and urogenital problems have been left behind in terms of scientific approach and research funding because they are not 'elegant' problems—they involve stool, urine, and sex—and institutions are not eager to receive these patients. Open

Statement The initial operation includes omphalocele closure (sometimes requiring staged closure), bowel-bladder separation, end colostomy creation, bladder closure attempt (sometimes requiring multiple stages), and in some institutions, pelvic osteotomy (either at initial operation or 2-3 months later). Open

Statement Between the initial operation and pull-through, colostomy irrigation is often needed to manage poor colonic motility. Open

Statement Prenatal diagnosis of anorectal and urogenital malformations is easier for complex defects (like cloacal exstrophy) than simple defects because complex cases have associated findings (spinal problems, absent bladder) visible on imaging. Open

Statement Absent bladder on prenatal ultrasound (due to exstrophy) is a bad sign and can be detected as early as week 20 of pregnancy. Open

Statement Prenatal diagnosis allows families to decide about pregnancy continuation and, if continuing, to deliver at a center with a multidisciplinary team experienced in these malformations. Open

Statement Certain malformations require centers of excellence where surgeons focus and sacrifice other areas of practice; attempting to train all surgeons superficially in complex conditions results in damaged children and no one becoming truly trained. Open

Alberto's statements about Anorectal Malformation 4 statements

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Cloaca - Prental Imaging & Diagnosis - Counseling

Quotation Not everybody gets the privilege to get a specialized radiologist is dedicated to the prenatal diagnosis of this malformation that we have. Open

Statement Dr. Peña reviewed mothers of babies born with cloacas who did not have prenatal diagnosis; when he obtained their ultrasounds, many had abnormalities but radiologists misdiagnosed them as urethrocele, double bladder, ovarian cysts, or bladder diverticulum instead of recognizing hydrocolpos Open

Quotation The images were there. What failed was the index of suspicion in the those radiologist. Open

Statement If a female fetus has a prenatal diagnosis of ovarian cyst, double bladder, or urethrocele, suspect the patient may have a cloaca; if the patient also has abnormal vertebrae, hydronephrosis, and dilated bowel, that confirms the diagnosis Open

Alberto's statements about Anorectal Malformations & Cloacal Reconstruction 8 statements

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Tell Me a Story: Pediatric Surgeons Putting Colorectal Center on the Map

Quotation Revealing episodes in your life, you read a book, you meet somebody, you, you hear some music, you see some painting, you see an operation that's, and then you say, I want this, and that changes your life. Open

Statement Dr. Alberto Peña is the director of the Colorectal Center at Cincinnati Children's Hospital. Open

Quotation I'm the director of the Colorectal Center. Open

Statement Dr. Peña advises young surgeons asking about the key to success to focus on doing the best version of whatever operation they are performing, even routine procedures like hernias. Open

Quotation Many surgeons come and many young surgeons say, what should I do? What's the key for success? And I said, What are you doing tomorrow? I said, they said, I'm doing a hernia, which is a kind of a simple operation. Open

Quotation And my answer is, why don't you? To think overnight and say tomorrow I'm going to do the best hernia in the world. Open

Quotation And they look at me like saying this man didn't understand the question and he's crazy, and I look at them and I said they didn't understand my answer. Open

Quotation You just concentrate on what you do and let the rest of the gods. That's all that I can say. Open

Alberto's statements about Cloaca 19 statements

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Cloaca - Workup & Evaluation

Statement The measurements from 3D cloacography are accurate to within millimeters; when the radiologist reports 3.5 cm, the intraoperative measurement is typically 3.5 cm. Open

Quotation I was very skeptical about their measurements, but then little by little they become more and more accurate, and now they are, they are just there, but the differences in millimeters very subjective, so they are. I don't know what they did, but right now when they say 3.5 3.5 centimeters, usually it's 3.5 centimeters, so we really, we gain a lot, you gain a lot of experience for the benefit of these children. Open

Statement In neonatal cloacas, trying to make a very accurate anatomic diagnosis during the newborn period is useless and may actually hurt the baby. Open

Quotation In the real life and we don't make a very accurate diagnosis of the of the intrinsic anatomy of the cloaca during the newborn period and in fact trying to be very precise in the anatomic diagnosis is kind of useless and may actually hurt the baby, but we are very interested in a newborn babies to know if the baby has hydronephrosis and mega ureters and to know if the patient has a hydrocorpus that may be compressing the ureters. Open

Statement In the neonatal period, the crucial information is whether the baby has hydronephrosis, megaureters, or hydrocolpos compressing the ureters, which can be determined by ultrasound without endoscopy. Open

Statement Knowing whether a neonate with cloaca has reflux is not crucial; the priority is decompressing the gastrointestinal and urogenital tracts. Open

Quotation You are at that point it's not so crucial to know if the baby has a reflux or not. It's not, it's what you want is the patient to, you want to be able to decompress the gastrointestinal tract and to decompress the urogenital tract. Open

Quotation Not everybody has the capacity to do it and don't force the endoscope in a tiny structure because you may end up hurting. Open

Statement Forcing an endoscope into a tiny neonatal cloacal structure can cause harm. Open

Quotation Many urologists don't have experience in cloacas and will end up doing nephrostom is not indicated, ureterostom is not indicated, and vesicostom is not indicated. Open

Statement Nephrostomy, ureterostomy, and vesicostomy are not indicated in most neonatal cloacas. Open

Statement The recommended neonatal management for cloaca is to drain hydrocolpos, open a colostomy, and re-evaluate from the urologic point of view 48 hours later before making further decisions. Open

Quotation Our specific recommendation is to drain the hydrocorpus, to open a colostomy, and re-evaluate the patient from the urologic point of view 48 hours later and then make a decision. Open

Statement Some cloacal patients may need vesicostomy if there is obstruction in the common channel, but many do not; decompressing the hydrocolpos often completely changes the clinical picture. Open

Quotation By by simply decompressing the hydrocorpus, the, the picture completely changes. Open

Cloaca - Prental Imaging & Diagnosis - Counseling

Quotation Not everybody gets the privilege to get a specialized radiologist is dedicated to the prenatal diagnosis of this malformation that we have. Open

Quotation The images were there. What failed was the index of suspicion in the those radiologist. Open

Alberto's statements about Cloacal Exstrophy 115 statements

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Cloacal Exstrophy with Dr. Alberto Peña

Statement Cloacal exstrophy consists of omphalocele, bladder exstrophy with separated hemibladders, exposed cecum (often with 'elephant trunk' prolapse through the ileocecal valve), variable colon length (spectrum from normal to absent), genital abnormalities (hemiphalluses in males, hemivaginas/hemiuteri in females), and associated spinal/orthopedic abnormalities. Open

Statement The amount of colon a patient with cloacal exstrophy is born with has very important repercussions and implications for management and outcomes. Open

Statement There is a variant of cloacal exstrophy where babies are born with intact abdominal skin (no omphalocele, no bladder exstrophy externally) but have all the internal malformations including completely open bladder inside and a single large perineal orifice. Open

Statement While surgical techniques have improved (safer operations, better intensive care, better parenteral nutrition), functional outcomes have not improved significantly—patients still suffer lifelong limitations in bowel control, urinary control, sexual function, and spinal abnormalities. Open

Statement Historical practice was to perform bilateral gonadectomy, remove hemiphalluses, create a neovagina, and raise chromosomal males as females, but these patients often had male attitudes and behavior despite female upbringing and hormones. Open

Statement When patients raised as females learned they were chromosomically male, many became upset, stating that sex is not the most important thing and that they wanted their gonads back for potential fertility with modern techniques. Open

Statement Current consensus is that patients with XY chromosomes should be raised as male, with ongoing efforts in phallic reconstruction, though functional outcomes remain uncertain. Open

Statement When babies with cloacal exstrophy were born in institutions dominated by pediatric urologists, they received good urologic attention but poor gastrointestinal management; the reverse occurred in surgeon-dominated institutions. Open

Statement At the initial operation, the pediatric surgeon must separate the urothelium (bladder) from intestinal mucosa by placing multiple stitches at the edges and making an incision to completely separate the gastrointestinal tract from the urinary tract. Open

Statement It is very common for pediatric surgeons worldwide to simply create an ileostomy rather than incorporating all colonic tissue and creating a true end colostomy, which is a serious error. Open

Statement Creating an ileostomy and leaving colon distally attached to the urinary tract causes hyperchloremic acidosis from urine absorption starting in the newborn period, which interferes with growth and development. Open

Statement Colonic tissue left defunctionalized or attached to the urinary tract will not grow; colon requires the passage of fecal matter through its lumen to grow. Open

Statement The 'rescue operation' for patients who received ileostomy involves taking down the ileostomy, finding and incorporating all colonic tissue into the GI tract, and creating a true end colostomy; hyperchloremic acidosis disappears the next day after this operation. Open

Statement Surgeons often create ileostomies because the colonic anatomy is so complex with bizarre blood supply that they prefer not to deal with it, taking the easier way out. Open

Statement The surgeon must be prepared for each case to be different, sometimes finding a large sac of colonic tissue with bizarre blood supply requiring careful study to determine which vessels can be ligated. Open

Statement Some institutions routinely perform pelvic osteotomy at the initial operation to facilitate bladder and omphalocele reconstruction, though pubic bones often remain separated long-term despite osteotomy. Open

Statement Even a technically correct end colostomy without stricture sometimes doesn't work well due to poor motility of the incorporated colon, requiring colostomy irrigation similar to management of Hirschsprung disease enterocolitis. Open

Statement Pull-through is only considered for patients who can form solid stool; patients with liquid stool (inadequate colon) should never have pull-through even if they show evidence of sphincter, as they will never have bowel control. Open

Statement It is extremely unusual for patients with cloacal exstrophy to have voluntary bowel control; the overwhelming majority will need bowel management programs. Open

Statement Bowel management only works if the patient has solid stool, and solid stool only occurs if the patient has enough colon. Open

Statement Small pieces of colon that look tiny at birth should not be discarded; they have the capacity to grow during the first three years of life. Open

Statement Annual contrast studies through the colostomy are performed to assess colonic growth during the first three years. Open

Statement Before pull-through, trial bowel management is performed through the colostomy to determine if enemas can keep the patient clean for 24 hours, predicting success of bowel management after pull-through. Open

Statement Coordination with pediatric urology is essential before pull-through because if the urologist wants to use bowel for bladder augmentation and the patient has borderline colon, the surgeon must not allow the urologist to take more GI tract. Open

Statement The colon to be pulled through is the most posterior structure in the pelvis, with the bladder augmentation anterior to it; the urologist should not perform augmentation before deciding about pull-through, as accessing the colon behind the reconstruction would be a nightmare. Open

Statement Patients with very little or no colon will have a permanent colostomy, and at that point the urologist has free hands to use whatever bowel is needed for bladder augmentation. Open

Statement The combined pull-through and bladder augmentation operation is ideally done together by urologist and pediatric surgeon, typically lasting about 12 hours, usually around age 3 when families want to send children to school clean. Open

Statement The pediatric surgeon operates first because the colon goes posteriorly, and separated pubic bones make the dissection somewhat easier. Open

Statement A Malone appendicostomy can be created for antegrade enema administration; patients may have one or two appendices, and if the appendix is very long, it can be split with half used for Malone and half for Mitrofanoff. Open

Statement Urologists almost never use colon for bladder augmentation in these patients because the colon is needed to form solid stool; they typically use small bowel or stomach. Open

Statement In colorectal pediatric surgery, midline abdominal incisions are always used to preserve the flanks, iliac fossae, and lateral quadrants for potential future stomas. Open

Statement Occasionally when patients are born with a giant colonic pouch with very poor motility, the pouch is so large that a piece can be shared with the urologist for augmentation, but this is unusual. Open

Statement The blood supply in cloacal exstrophy is very bizarre with aberrant abnormal vessels; careful study is required to determine which vessels can be ligated without compromising colonic viability. Open

Statement Patients with cloacal exstrophy do not need to be placed prone for the perineal portion of pull-through; everything is anterior due to the exstrophy, so a supine frog-leg position provides access to the entire perineum. Open

Statement Patients with cloacal exstrophy will be patients for life due to orthopedic problems, and some teenagers are unhappy about persistent pubic bone separation causing a wide-based gait with feet pointing laterally. Open

Statement Patients with severe spinal problems require lifelong follow-up by pediatric orthopedics and neurosurgery for tethered cord, sometimes requiring cord release. Open

Statement During pull-through, vaginal reconstruction attempts to approximate the hemivaginas as much as possible; when vaginas run in completely different directions and cannot be brought together due to blood supply, one vagina may be removed, leaving the one with the better-looking cervix. Open

Statement Patients with functional hemiuteri may become pregnant but it is high-risk pregnancy requiring specialized pediatric gynecology follow-up; hemiuterus has great tendency to produce miscarriages and premature labor, and delivery is by cesarean section. Open

Statement Most patients will require bladder augmentation and Mitrofanoff (using appendix or piece of bowel) for intermittent catheterization to empty the bladder. Open

Statement Augmented bladders produce a lot of mucus; if mucus stays in the bladder it forms stones, so families must be taught to irrigate the bladder (sometimes with gentamicin) to remove mucus and prevent infections. Open

Statement Urologic follow-up is needed to ensure kidneys are not suffering from reflux, and to manage Mitrofanoff complications such as leakage or valve failure requiring revision. Open

Statement Patients with cloacal exstrophy struggle with transition to adult care because adult urologists and orthopedic surgeons often lack experience with these malformations, so patients feel more confident in pediatric environments even as adults. Open

Statement Patients with cloacal exstrophy when they grow up are particularly charming, intelligent, and beautiful; some manage their own problems and still have energy to help others. Open

Statement Colorectal and urogenital problems have been left behind in terms of scientific approach and research funding because they are not considered elegant problems, being related to stool, urine, and sex, and institutions are not enthusiastic about receiving these patients. Open

Statement Prenatal diagnosis of cloacal exstrophy is easier in the most complex defects because they have visible spinal problems and absent bladder (bladder not visible in utero due to exstrophy), detectable as early as week 20 of pregnancy. Open

Statement Simple anorectal malformations like rectoperineal fistula are difficult to detect prenatally because imaging lacks necessary definition and these patients don't have other associated defects. Open

Statement Prenatal diagnosis allows families to make decisions about pregnancy continuation and, if continuing, to deliver at a center with a dedicated team for these malformations. Open