title: Clean intermittent catheterization as an initial management strategy provides for adequate preservation of renal function in newborns with persistent cloaca.
abstract: BACKGROUND
  Persistent cloaca is a rare, congenital anomaly involving the genital, urinary, and rectal organ systems. While prompt bowel diversion is the standard of care, the optimal method of genitourinary decompression is unclear. Bladder outlet obstruction and hydrometrocolpos are common complications that can lead to obstructive uropathy, abdominal distention, infection, perforation, and acidosis. Proposed management strategies include early surgical diversion (vesicostomy, vaginostomy, ureterostomy, nephrostomy) or clean intermittent catheterization (CIC) of the common channel. We hypothesized that CIC is an adequate means of genitourinary decompression and preservation of renal function, regardless of the severity of cloacal anomaly.
  
  
  METHODS
  We reviewed all patients with persistent cloaca from a single, tertiary care center from 1995 to 2013. We collected data regarding renal function (serial serum creatinine prior to definitive reconstruction, and baseline estimated glomerular filtration rate [GFR]), presence of hydrocolpos, hydronephrosis, vesicoureteral reflux (VUR) or renal dysplasia, and length of the common channel. A linear mixed model was used to calculate creatinine change over time in relation to method of management and child age. Estimated GFR was calculated using the Schwartz equation for neonates = 0.45 × height in cm/serum creatinine in mg/dL. The t test was used for continuous data and Fisher's exact test was used for binomial data. A p value <0.05 was considered significant.
  
  
  RESULTS
  Twenty-five patients were identified. Nine (36%) patients underwent early surgical diversion versus 16 (64%) managed by CIC prior to formal reconstruction. Seven had short common channels (<3 cm) and 18 had long common channels (≥3 cm). Hydrocolpos was present in 14 (56%) of the patients. When comparing the two management groups, there was no significant difference in hydronephrosis, high-grade hydronephrosis (grades III-IV, p = 0.62), any VUR (p = 0.33), high-grade VUR (grades III-V, p = 0.62), hydrocolpos (p = 0.21), or renal dysplasia (p = 0.42). No significant differences were found between mean baseline GFR for diversion (22.9 mL/min per 1.73 m(2)) versus CIC (39.2 mL/min per 1.73 m(2), p = 0.22). There was no difference in creatinine trend between the two groups.
  
  
  CONCLUSIONS
  Currently, there is no consensus on the initial management of obstructive uropathy and resulting hydrocolpos in newborns with persistent cloaca. In addition to CIC, management strategies include surgical options such as vesicostomy, vaginostomy, or upper tract diversions such as ureterostomy or nephrostomy. Our results suggest that CIC is similar to these other proposed diversion procedures while minimizing morbidity. Creatinine trends over time were similar between the two groups and reached comparable nadirs. Limitations of our study include the retrospective nature of a small sample size. The primary risk is differences between the two groups that we were not able to appreciate. Furthermore, we did not attempt to assess the morbidity of the two different strategies.
  
  
  CONCLUSIONS
  CIC is an adequate initial management strategy to decompress the genitourinary tract in patients with persistent cloaca. CIC preserves renal function similar to early surgical decompression.
authors.affiliation: Department of Urology, Maine Medical Center, Portland, ME, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Chalmers
authors.affiliation: Department of Surgery, Division of Urology, University of Colorado, Aurora, CO, USA.
authors.forename: Kyle O
authors.initials: KO
authors.lastname: Rove
authors.affiliation: Department of Surgery, Division of Urology, University of Colorado, Aurora, CO, USA.
authors.forename: Cole A
authors.initials: CA
authors.lastname: Wiedel
authors.affiliation: Department of Biostatistics and Information, University of Colorado, Aurora, CO, USA.
authors.forename: Suhong
authors.initials: S
authors.lastname: Tong
authors.affiliation: Division of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA.
authors.forename: Georgette L
authors.initials: GL
authors.lastname: Siparsky
authors.affiliation: Division of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA. Electronic address: duncan.wilcox@childrenscolorado.org.
authors.forename: Duncan T
authors.initials: DT
authors.lastname: Wilcox
mesh_terms: D002988:Cloaca / Q000002:abnormalities*; D003404:Creatinine / Q000097:blood*; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate / Q000502:physiology; D019983:Guideline Adherence; D006801:Humans; D007231:Infant, Newborn; D057928:Intermittent Urethral Catheterization / Q000379:methods / Q000592:standards*; D007668:Kidney / Q000503:physiopathology*; D007677:Kidney Function Tests; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome; D014547:Urinary Diversion / Q000379:methods / Q000592:standards; D014555:Urination Disorders / Q000097:blood / Q000503:physiopathology / Q000628:therapy*; D014563:Urodynamics / Q000502:physiology*
chemical_list: D003404:Creatinine
keywords: Clean intermittent catheterization; Cloacal anomaly; Creatinine; Diversion; Renal function