Journal of Pediatric Surgery 49 (2014) 1867–1869
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Technique
Cloaca and hydrocolpos: laparoscopic-, cystoscopic- and colposcopic-assisted vaginostomy tube placement K. Elizabeth Speck a, Meghan A. Arnold a, Vesna Ivancic b, Daniel H. Teitelbaum a,⁎ a b
Section of Pediatric Surgery, Department of Surgery, University of Michigan Section of Pediatric Urology, Department of Urology, University of Michigan
a r t i c l e
i n f o
Article history: Received 10 May 2014 Received in revised form 30 July 2014 Accepted 27 August 2014 Key words: Hydrocolpos Vaginostomy tube Cloacal malformation Minimally invasive surgical technique Colposcopy Laparoscopic
a b s t r a c t Hydrocolpos presenting at birth in a neonate with a cloacal malformation may lead to massive distension, with compression of adjacent structures. At times, the hydrocolpos requires urgent drainage. Additionally, these neonates need a divided colostomy to divert their fecal stream and prevent genitourinary contamination. We present a novel approach by which these two procedures can be performed as a single operation guided by a combination of cystoscopy, colposcopy, and laparoscopy. This provides a minimally invasive technique with excellent outcome and potentially superior visualization of the necessary intra-abdominal structures. © 2014 Elsevier Inc. All rights reserved.
1. Description A term 3.2 kg female was assessed by the neonatologists at birth and found to have an abdominal mass and an imperforate anus, prompting pediatric surgical consultation. Upon our initial evaluation, she was noted to have a diminutive introital opening and somewhat hypertrophied-appearing labia with a single external opening on the perineum (Fig. 1A). Additionally, a large firm mass could be palpated within the abdomen and pelvis extending above the level of the umbilicus. An abdominal ultrasound demonstrated a large abdomino-pelvic complex thick walled cystic mass extending into the presacral region (Fig. 1B). On the afternoon of her birth, she was taken to the operating room for initial exam under anesthesia, cystoscopy and vaginoscopy, where a diagnosis of a cloaca was confirmed. The following morning she was taken to the operative suite in conjunction with the pediatric urology team for examination and drainage of the hydrocolpos. She was placed in a frog-leg position at the end of the bed and prepped to include her abdomen and perineum. A thorough external exam delineated a very diminutive introitus, somewhat edematous labia majora, a singular opening with an imperforate anus and a small sacral dimple. The cystoscope was advanced into the common channel, which was carefully measured to be 3.5 cm ⁎ Corresponding author at: Section of Pediatric Surgery, University of Michigan, Mott Children’s Hospital, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI 48109-4211. Tel.: +1 734 936 8464; fax: +1 734 232 8667. E-mail address: [email protected] (D.H. Teitelbaum). http://dx.doi.org/10.1016/j.jpedsurg.2014.08.027 0022-3468/© 2014 Elsevier Inc. All rights reserved.
from the vaginal opening to the perineum, confirming it to be an intermediate to long channel cloaca. The urethral orifice was anterior and midline within the common channel. Once the urethra was traversed, the bladder was noted to be large without trabeculation. Bilateral solitary ureteral orifices were identified very medially and less than a centimeter from the very short bladder neck. The bladder was drained by placing an 8Fr Foley catheter over a guide wire. Just posterior to the urethral opening, the vaginal orifice was identified and traversed, noting a solitary cervix and vagina, with no didelphys or septum. At this point, we transitioned to the abdominal component of the operation, leaving the cystoscope in place within the vaginal cavity. Due to the extent of the large abdominal mass, the left upper quadrant was our chosen location for placement of a 5 mm port (STEP® trocar, Covidien, Mansfield, MA). Using a modified Hasson technique, the abdomen was entered and insufflated to 8 mmHg. A separate stab incision in the right upper quadrant was used for placement of a 3 mm instrument. It was clear that the abdominal mass noted on exam and imaging was a very large and dilated vagina with a smaller single uterus emanating from its superior-most portion. The left colon and rectum could be seen in the left lower quadrant and continuing posterior to the vagina into the pelvis. The bladder was located anteriorly and was adequately decompressed by the Foley catheter. Given the need for a descending colostomy, it was decided that the right lower quadrant was the best location for placement of a vaginostomy to allow for decompression of the vagina. To assess the optimal location for placement of the vaginostomy tube, a combination approach was utilized with the laparoscope in the abdomen and the cystoscope within the vagina (Fig. 2A). With the vagina fully distended, a suitable location on the anterior aspect of the
1868
K.E. Speck et al. / Journal of Pediatric Surgery 49 (2014) 1867–1869
A
A
B
B
Fig. 1. Preoperative Workup. A. Appearance of the infant’s perineum at the time of presentation. B. Ultrasound. Sagittal image shows a markedly compressed urinary bladder and a distended hydrocolpos.
vagina was identified for placement of three separate T-fasteners (Kimberly Clark, Gastrointestinal Anchor Set with Saf-t-pexy T-fasteners, Dallas, TX) transcutaneously under direct visualization (Fig. 2B). Each T-fastener was placed so as to triangulate for appropriate traction on the vaginal wall for subsequent vaginostomy tube placement. A 4 mm incision was made between the T-fasteners in the right lower quadrant, as low as possible but taking care to be above the inguinal crease. Using a percutaneous push gastrostomy tube kit (AMT, PEG Assist Initial Placement GI Kit, Brecksville, OH), an introducer needle was advanced into the abdominal cavity, in between the T-fasteners and under direct visualization with the laparoscope. Using the T-fasteners for upward traction, the vagina was then lifted up to the needle to identify the best location for entry, again confirming placement from within the vagina with the cystoscope. The needle was then advanced into the vagina and exchanged for a guide wire (Fig. 2C). This tract was then serially dilated to accommodate an adequately sized gastrostomy tube. In our patient’s case a 12Fr Mic-Gastrostomy tube was used (Kimberly-Clark) as the decompressive vaginostomy tube (Fig. 3). The balloon was filled with saline and pulled up to the abdominal wall. The tube was placed to a urinary drainage bag. The cystoscopic portion of the procedure was then completed. The laparoscope was then utilized to identify the appropriate level for colostomy placement. The superior-most portion of the rectum and inferior-most portion of the descending colon were identified and grasped after the descending colon was minimally mobilized laparoscopically. A small left lower quadrant incision was made through which the divided colostomy with mucus fistula was fashioned. The laparoscope was also utilized to ensure that the colon was not twisted and fashioned appropriately and also to reassess the vaginostomy tube placement prior to the termination of the procedure. The abdomen was desufflated, the port site was closed in standard fashion and
C
Fig. 2. Operative Procedure. A. Operative set-up which optimizes position of surgeon, assistant and cystoscopist. B. Cut-away diagram to illustrate the procedure as visualized via cystoscopy/colposcopy (within the vaginal cavity) and via the laparoscope. Colposcopy maintains vaginal distension. A T-fastener is traversing the abdominal wall and has been placed into the vagina under cystoscopic/colposcopic and laparoscopic visualization. Note that care was given to avoid the cervical opening. C. Three T-fasteners have now been placed. Between these, a needle has been exchanged for a guide wire into the vaginal cavity, and is now progressively dilated, using upward traction on the T-fasteners.
surgical adhesive was used for skin closure. At the conclusion of the procedure, once the abdomen was desufflated, the T-fastener discs were brought down to the abdominal wall and secured.
K.E. Speck et al. / Journal of Pediatric Surgery 49 (2014) 1867–1869
Fig. 3. Post-operative view with RLQ vaginostomy tube, LLQ colostomy and port sites labeled.
The child did well during the post-operative period and had the T-fasteners removed on the fifth post-operative day. She was discharged on post-operative day 11, and underwent her cloacal anomaly repair at 7 months of age. One month post-definitive surgery her vaginostomy tube was removed in clinic and closed spontaneously. 2. Discussion Cloacal malformations are one of the most complex and technically challenging congenital anomalies encountered by the pediatric surgeon. A female born with only one external orifice has a cloaca, the common channel of which includes a terminal opening for the gastrointestinal, urinary and reproductive tracts. Externally, it is clear that the child has an imperforate anus, which should prompt surgical evaluation. A number of complications may occur with cloacal malformations, one of which may present as a palpable abdominal mass as described above. Hydrocolpos, or distension of a fluid-filled vagina secondary to a congenital outflow obstruction, is often (28%–40%) [1,2] associated with a cloacal malformation and should be on the top of the differential in this clinical scenario. As in this child’s case, the hydrocolpos was associated with compression of adjacent structures, such as the urinary bladder. An abdominal ultrasound is needed to evaluate for associated anomalies and should help delineate the etiology of the mass. Prompt drainage of a hydrocolpos is important to prevent or treat obstruction of the adjacent urinary and gastrointestinal systems, and a failure to recognize this clinical entity can have long lasting effects [3]. Here we describe our technique for laparoscopic vaginostomy tube placement at the time of diverting divided colostomy formation. Standard laparoscopic access may be obtained through the umbilicus; however, given the size of the abdominal mass in our patient’s case, we elected to enter in the left upper quadrant with a modified Hasson technique for direct visualization of trocar placement and the avoidance of inadvertent visceral injury. Once insufflation is obtained, the abdomen is easily surveyed and one can assess for any other associated abnormalities (e.g., megaureters, reproductive anatomy).
1869
The right lower quadrant is the ideal location for drainage of a hydrocolpos. Percutaneous access is easily obtainable with laparoscopic assistance and avoids the ostomy appliance in the left lower quadrant. When choosing the location for vaginostomy tube placement, it is important to be as low as possible but above the inguinal ligament and just lateral to the inferior epigastric vascular bundle so as to be lateral enough that a midline vesicostomy or future incision could be placed if necessary. However, once the vagina is drained, it is highly likely that any preexisting outflow obstruction of the urinary system will be resolved [3] emphasizing the importance of early diagnosis and treatment of this common problem. The lower abdominal position also allows for adequate perineal mobilization of the vagina and prevents tethering of the vaginostomy in an excessively cephalad position. We advocate for a tube vaginostomy as opposed to maturing vaginal tissue to the skin. This allows easy placement, and the strong potential for spontaneous closure (as in this case) after the tube is removed following definitive cloacal repair. There are multiple advantages of the combined approach using laparoscopy and cystoscopy. First, the internal anatomy can be delineated with the cystoscope, evaluating for a persistent vaginal septum (59%), and the vagina can be kept distended during T-fastener placement and subsequent tube placement. Second, this method allows direct visualization of the cervix to avoid inadvertent injury and accurate placement of the drainage tube. Previously described options for drainage of a hydrocolpos have included performing a single drainage, intermittent or continuous catheterization of the common channel or vagina, tubeless vaginostomy or open vaginostomy tube placement [1]. Similar to the Cincinnati experience [1,4], we have found that a transabdominal indwelling vaginostomy tube is preferred as it avoids reaccumulation of the hydrocolpos, and allows for a more elective approach to the definitive cloacal repair. Certainly, these cases need to be addressed on a caseby-case basis. If a child has a complex medical condition due to meconium peritonitis (due to reflux of urine and meconium from the uterine horns) such a minimally invasive approach should not be undertaken. For infants with massive distension, laparoscopy may not be possible. However, as in the present case, a partial decompression can be done via the perineum with cystoscopy and vaginoscopy to allow for placement of an upper quadrant laparoscopic port. For infants with a duplication of the vaginal system (two hemi-vaginas), we would advocate adequate drainage of both lumens, which may require two vaginal tubes. More ideally however, a single tube could be placed after the partial resection of the septum by the urologic team using a similar approach to valve ablation with posterior urethral valves. At times infants may have bladder outlet obstructions (often from a urethral narrowing). Use of laparoscopy and cystoscopy could also be used to facilitate a definitive vesicostomy, which is typically needed in such children. In summary, in this report we have described a minimally invasive, combined cystoscopic, colposcopic and laparoscopic approach that is easily reproducible. References [1] Bischoff A, Levitt MA, Breech L, et al. Hydrocolpos in cloacal malformations. J Pediatr Surg 2010;45:1241–5. [2] Levitt MA, Pena A, Reynolds M, et al. Cloacal malformations. http://emedicine. medscape.com/article/933717; 2013. [3] Levitt MA, Pena A. Pitfalls in the management of newborn cloacas. Pediatr Surg Int 2005;21(4):264–9. [4] Pena A, Levitt MA, Hong A, et al. Surgical management of cloacal malformations: a review of 339 patients. J Pediatr Surg 2004;39(3):470–9.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Technique
Cloaca and hydrocolpos: laparoscopic-, cystoscopic- and colposcopic-assisted vaginostomy tube placement K. Elizabeth Speck a, Meghan A. Arnold a, Vesna Ivancic b, Daniel H. Teitelbaum a,⁎ a b
Section of Pediatric Surgery, Department of Surgery, University of Michigan Section of Pediatric Urology, Department of Urology, University of Michigan
a r t i c l e
i n f o
Article history: Received 10 May 2014 Received in revised form 30 July 2014 Accepted 27 August 2014 Key words: Hydrocolpos Vaginostomy tube Cloacal malformation Minimally invasive surgical technique Colposcopy Laparoscopic
a b s t r a c t Hydrocolpos presenting at birth in a neonate with a cloacal malformation may lead to massive distension, with compression of adjacent structures. At times, the hydrocolpos requires urgent drainage. Additionally, these neonates need a divided colostomy to divert their fecal stream and prevent genitourinary contamination. We present a novel approach by which these two procedures can be performed as a single operation guided by a combination of cystoscopy, colposcopy, and laparoscopy. This provides a minimally invasive technique with excellent outcome and potentially superior visualization of the necessary intra-abdominal structures. © 2014 Elsevier Inc. All rights reserved.
1. Description A term 3.2 kg female was assessed by the neonatologists at birth and found to have an abdominal mass and an imperforate anus, prompting pediatric surgical consultation. Upon our initial evaluation, she was noted to have a diminutive introital opening and somewhat hypertrophied-appearing labia with a single external opening on the perineum (Fig. 1A). Additionally, a large firm mass could be palpated within the abdomen and pelvis extending above the level of the umbilicus. An abdominal ultrasound demonstrated a large abdomino-pelvic complex thick walled cystic mass extending into the presacral region (Fig. 1B). On the afternoon of her birth, she was taken to the operating room for initial exam under anesthesia, cystoscopy and vaginoscopy, where a diagnosis of a cloaca was confirmed. The following morning she was taken to the operative suite in conjunction with the pediatric urology team for examination and drainage of the hydrocolpos. She was placed in a frog-leg position at the end of the bed and prepped to include her abdomen and perineum. A thorough external exam delineated a very diminutive introitus, somewhat edematous labia majora, a singular opening with an imperforate anus and a small sacral dimple. The cystoscope was advanced into the common channel, which was carefully measured to be 3.5 cm ⁎ Corresponding author at: Section of Pediatric Surgery, University of Michigan, Mott Children’s Hospital, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI 48109-4211. Tel.: +1 734 936 8464; fax: +1 734 232 8667. E-mail address: [email protected] (D.H. Teitelbaum). http://dx.doi.org/10.1016/j.jpedsurg.2014.08.027 0022-3468/© 2014 Elsevier Inc. All rights reserved.
from the vaginal opening to the perineum, confirming it to be an intermediate to long channel cloaca. The urethral orifice was anterior and midline within the common channel. Once the urethra was traversed, the bladder was noted to be large without trabeculation. Bilateral solitary ureteral orifices were identified very medially and less than a centimeter from the very short bladder neck. The bladder was drained by placing an 8Fr Foley catheter over a guide wire. Just posterior to the urethral opening, the vaginal orifice was identified and traversed, noting a solitary cervix and vagina, with no didelphys or septum. At this point, we transitioned to the abdominal component of the operation, leaving the cystoscope in place within the vaginal cavity. Due to the extent of the large abdominal mass, the left upper quadrant was our chosen location for placement of a 5 mm port (STEP® trocar, Covidien, Mansfield, MA). Using a modified Hasson technique, the abdomen was entered and insufflated to 8 mmHg. A separate stab incision in the right upper quadrant was used for placement of a 3 mm instrument. It was clear that the abdominal mass noted on exam and imaging was a very large and dilated vagina with a smaller single uterus emanating from its superior-most portion. The left colon and rectum could be seen in the left lower quadrant and continuing posterior to the vagina into the pelvis. The bladder was located anteriorly and was adequately decompressed by the Foley catheter. Given the need for a descending colostomy, it was decided that the right lower quadrant was the best location for placement of a vaginostomy to allow for decompression of the vagina. To assess the optimal location for placement of the vaginostomy tube, a combination approach was utilized with the laparoscope in the abdomen and the cystoscope within the vagina (Fig. 2A). With the vagina fully distended, a suitable location on the anterior aspect of the
1868
K.E. Speck et al. / Journal of Pediatric Surgery 49 (2014) 1867–1869
A
A
B
B
Fig. 1. Preoperative Workup. A. Appearance of the infant’s perineum at the time of presentation. B. Ultrasound. Sagittal image shows a markedly compressed urinary bladder and a distended hydrocolpos.
vagina was identified for placement of three separate T-fasteners (Kimberly Clark, Gastrointestinal Anchor Set with Saf-t-pexy T-fasteners, Dallas, TX) transcutaneously under direct visualization (Fig. 2B). Each T-fastener was placed so as to triangulate for appropriate traction on the vaginal wall for subsequent vaginostomy tube placement. A 4 mm incision was made between the T-fasteners in the right lower quadrant, as low as possible but taking care to be above the inguinal crease. Using a percutaneous push gastrostomy tube kit (AMT, PEG Assist Initial Placement GI Kit, Brecksville, OH), an introducer needle was advanced into the abdominal cavity, in between the T-fasteners and under direct visualization with the laparoscope. Using the T-fasteners for upward traction, the vagina was then lifted up to the needle to identify the best location for entry, again confirming placement from within the vagina with the cystoscope. The needle was then advanced into the vagina and exchanged for a guide wire (Fig. 2C). This tract was then serially dilated to accommodate an adequately sized gastrostomy tube. In our patient’s case a 12Fr Mic-Gastrostomy tube was used (Kimberly-Clark) as the decompressive vaginostomy tube (Fig. 3). The balloon was filled with saline and pulled up to the abdominal wall. The tube was placed to a urinary drainage bag. The cystoscopic portion of the procedure was then completed. The laparoscope was then utilized to identify the appropriate level for colostomy placement. The superior-most portion of the rectum and inferior-most portion of the descending colon were identified and grasped after the descending colon was minimally mobilized laparoscopically. A small left lower quadrant incision was made through which the divided colostomy with mucus fistula was fashioned. The laparoscope was also utilized to ensure that the colon was not twisted and fashioned appropriately and also to reassess the vaginostomy tube placement prior to the termination of the procedure. The abdomen was desufflated, the port site was closed in standard fashion and
C
Fig. 2. Operative Procedure. A. Operative set-up which optimizes position of surgeon, assistant and cystoscopist. B. Cut-away diagram to illustrate the procedure as visualized via cystoscopy/colposcopy (within the vaginal cavity) and via the laparoscope. Colposcopy maintains vaginal distension. A T-fastener is traversing the abdominal wall and has been placed into the vagina under cystoscopic/colposcopic and laparoscopic visualization. Note that care was given to avoid the cervical opening. C. Three T-fasteners have now been placed. Between these, a needle has been exchanged for a guide wire into the vaginal cavity, and is now progressively dilated, using upward traction on the T-fasteners.
surgical adhesive was used for skin closure. At the conclusion of the procedure, once the abdomen was desufflated, the T-fastener discs were brought down to the abdominal wall and secured.
K.E. Speck et al. / Journal of Pediatric Surgery 49 (2014) 1867–1869
Fig. 3. Post-operative view with RLQ vaginostomy tube, LLQ colostomy and port sites labeled.
The child did well during the post-operative period and had the T-fasteners removed on the fifth post-operative day. She was discharged on post-operative day 11, and underwent her cloacal anomaly repair at 7 months of age. One month post-definitive surgery her vaginostomy tube was removed in clinic and closed spontaneously. 2. Discussion Cloacal malformations are one of the most complex and technically challenging congenital anomalies encountered by the pediatric surgeon. A female born with only one external orifice has a cloaca, the common channel of which includes a terminal opening for the gastrointestinal, urinary and reproductive tracts. Externally, it is clear that the child has an imperforate anus, which should prompt surgical evaluation. A number of complications may occur with cloacal malformations, one of which may present as a palpable abdominal mass as described above. Hydrocolpos, or distension of a fluid-filled vagina secondary to a congenital outflow obstruction, is often (28%–40%) [1,2] associated with a cloacal malformation and should be on the top of the differential in this clinical scenario. As in this child’s case, the hydrocolpos was associated with compression of adjacent structures, such as the urinary bladder. An abdominal ultrasound is needed to evaluate for associated anomalies and should help delineate the etiology of the mass. Prompt drainage of a hydrocolpos is important to prevent or treat obstruction of the adjacent urinary and gastrointestinal systems, and a failure to recognize this clinical entity can have long lasting effects [3]. Here we describe our technique for laparoscopic vaginostomy tube placement at the time of diverting divided colostomy formation. Standard laparoscopic access may be obtained through the umbilicus; however, given the size of the abdominal mass in our patient’s case, we elected to enter in the left upper quadrant with a modified Hasson technique for direct visualization of trocar placement and the avoidance of inadvertent visceral injury. Once insufflation is obtained, the abdomen is easily surveyed and one can assess for any other associated abnormalities (e.g., megaureters, reproductive anatomy).
1869
The right lower quadrant is the ideal location for drainage of a hydrocolpos. Percutaneous access is easily obtainable with laparoscopic assistance and avoids the ostomy appliance in the left lower quadrant. When choosing the location for vaginostomy tube placement, it is important to be as low as possible but above the inguinal ligament and just lateral to the inferior epigastric vascular bundle so as to be lateral enough that a midline vesicostomy or future incision could be placed if necessary. However, once the vagina is drained, it is highly likely that any preexisting outflow obstruction of the urinary system will be resolved [3] emphasizing the importance of early diagnosis and treatment of this common problem. The lower abdominal position also allows for adequate perineal mobilization of the vagina and prevents tethering of the vaginostomy in an excessively cephalad position. We advocate for a tube vaginostomy as opposed to maturing vaginal tissue to the skin. This allows easy placement, and the strong potential for spontaneous closure (as in this case) after the tube is removed following definitive cloacal repair. There are multiple advantages of the combined approach using laparoscopy and cystoscopy. First, the internal anatomy can be delineated with the cystoscope, evaluating for a persistent vaginal septum (59%), and the vagina can be kept distended during T-fastener placement and subsequent tube placement. Second, this method allows direct visualization of the cervix to avoid inadvertent injury and accurate placement of the drainage tube. Previously described options for drainage of a hydrocolpos have included performing a single drainage, intermittent or continuous catheterization of the common channel or vagina, tubeless vaginostomy or open vaginostomy tube placement [1]. Similar to the Cincinnati experience [1,4], we have found that a transabdominal indwelling vaginostomy tube is preferred as it avoids reaccumulation of the hydrocolpos, and allows for a more elective approach to the definitive cloacal repair. Certainly, these cases need to be addressed on a caseby-case basis. If a child has a complex medical condition due to meconium peritonitis (due to reflux of urine and meconium from the uterine horns) such a minimally invasive approach should not be undertaken. For infants with massive distension, laparoscopy may not be possible. However, as in the present case, a partial decompression can be done via the perineum with cystoscopy and vaginoscopy to allow for placement of an upper quadrant laparoscopic port. For infants with a duplication of the vaginal system (two hemi-vaginas), we would advocate adequate drainage of both lumens, which may require two vaginal tubes. More ideally however, a single tube could be placed after the partial resection of the septum by the urologic team using a similar approach to valve ablation with posterior urethral valves. At times infants may have bladder outlet obstructions (often from a urethral narrowing). Use of laparoscopy and cystoscopy could also be used to facilitate a definitive vesicostomy, which is typically needed in such children. In summary, in this report we have described a minimally invasive, combined cystoscopic, colposcopic and laparoscopic approach that is easily reproducible. References [1] Bischoff A, Levitt MA, Breech L, et al. Hydrocolpos in cloacal malformations. J Pediatr Surg 2010;45:1241–5. [2] Levitt MA, Pena A, Reynolds M, et al. Cloacal malformations. http://emedicine. medscape.com/article/933717; 2013. [3] Levitt MA, Pena A. Pitfalls in the management of newborn cloacas. Pediatr Surg Int 2005;21(4):264–9. [4] Pena A, Levitt MA, Hong A, et al. Surgical management of cloacal malformations: a review of 339 patients. J Pediatr Surg 2004;39(3):470–9.
