Cloaca, Posterior Cloaca and Absent Penis Spectrum

Abstract

This is one of the most extensive chapters of the book because of its relevance. Since 1982, when the first cloaca was repaired via posterior sagittal approach, over 500 cases have been operated by the senior author, and many lessons have been learned. Based on this experience, it is that now cloacas are described as a spectrum of defects with multiple anatomic variations. For each anatomic variation, a different surgical maneuver is indicated. This experience is presented in a systematic way, describing what is called the decision-making algorithm in the management of cloacas, beginning with a simple type of defects with excellent functional prognosis and going into more complex defects, describing different surgical alternatives. Special emphasis is placed on the surgical treatment of cloacas with good functional prognosis with a common channel shorter than 3 cm, describing in detail a very valuable surgical maneuver called “total urogenital mobilization.” This is illustrated with photographic intraoperative material, artwork, and special animations. Also, this type of material is presented to describe more complex maneuvers like “vaginal switch” and vaginal replacement. Space is dedicated to the neonatal management of patients with cloacas because of its relevance for the preservation of renal function. Subsequently, the authors present a detailed description of the best way to protect the kidneys after the repair, considering the fact that most of these patients have very important urologic issues. Further discussion is focused on the obstetric and gynecologic implications of cloacas based on the long-term follow-up of patients born with these defects.