From
StayCurrentMD
3D Reconstruction: Cloaca and Complex ARMs 2015
With Dr. Manish Patel
Part of
Cloaca 32 items
Chapter 1 of 4 · Diagnosis & Workup
3D cloacography
3D Rotational Cloacography Technique and Advantages
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
3D cloacography uses the same technology available for 3D angiography, with a camera rotating around the patient to generate images immediately available at a workstation for different cuts and views.
Conventional contrast studies done in main radiology typically provide only AP and lateral views with overlapping structures that are difficult to decipher.
Modern 3D cloacography technology allows precise measurement of the common channel by drawing calipers along the structure, eliminating foreshortening errors from external rulers.
Nationwide Children's Hospital has exactly the same 3D system with endoscopy in the interventional radiology suite.
3D reconstruction helps with complex decision making about whether the vagina will come down and the relationship with the rectum, informing whether to approach laparoscopically or from above versus below primarily.
The radiation dose from a 3D rotational study is very similar to a conventional cloacogram because fewer lateral and frontal static images are needed.
MRI cloacography loses the real-time capability of seeing what is being injected and filled, and significantly increases anesthesia time.
Doctor Pena states that 3D cloacogram measurements have become very accurate over time, now matching intraoperative measurements within millimeters (e.g., when radiology reports 3.5 cm, it is typically 3.5 cm at surgery).
Baseline renal bladder ultrasound is the preferred method for identifying upper tract and lower tract urologic abnormalities in cloacal malformations.
Pelvic ultrasound is used primarily to look for fluid accumulated in the vagina or vaginas, which helps guide the timing of therapy for whether fluid needs acute drainage.
Placement of a catheter into the common channel for VCUG is challenging because it may go into any of three organ systems (bladder, vagina, or rectum), and radiologists may not feel comfortable repositioning it.
High-grade reflux is not commonly identified in cloacal malformation patients at this referral center; when present, it is mostly mild reflux that warrants observation rather than mandatory preoperative intervention.
Doctor Pena states that trying to make a very accurate anatomic diagnosis of the cloaca during the newborn period is kind of useless and may actually hurt the baby.
In neonatal cloacas, the important information is whether the baby has hydronephrosis, megaureters, and hydrocolpos that may be compressing the ureters, which can be learned from kidney and pelvic ultrasound.
The goal in the neonatal period is to decompress the gastrointestinal tract and decompress the urogenital tract.
Doctor Pena warns against forcing an endoscope into a tiny neonatal structure because it may cause injury.
Doctor Pena states that nephrostomy, ureterostomy, and vesicostomy are not indicated in neonatal cloacal management.
The specific recommendation is to drain the hydrocolpos, open a colostomy, and re-evaluate the patient from the urologic point of view 48 hours later.
Some patients may need a vesicostomy if they have obstruction in the common channel, but many do not; simply decompressing the hydrocolpos completely changes the urologic picture.
Initial workup should include sacral X-ray (AP and lateral) to assess prognosis for bowel control and to suspect or rule out presacral mass, spinal ultrasound to rule out tethered cord, and echocardiogram to rule out cardiac anomalies.
Attempting to scope neonatal cloacas does not yield accurate information all the time and is very difficult and traumatizing to the common channel, which could potentially cause more harm.
At this center, anatomy studies including endoscopy and cloacogram are deferred until the baby is larger, after initial decompression of the GI tract and hydrocolpos.