The sacral ratio has been used as a tool for evaluating sacral development in patients with anorectal malformations. Sacral ratios can be calculated by obtaining sacral radiographs in the anteroposterior (AP) and lateral planes. The objective of the study was to determine the correlation and agreement in sacral ratio calculations. In this single institution retrospective cohort study, we reviewed medical charts of all pediatric anorectal malformation patients treated between March 2014 and September 2018 who had both AP and lateral images of their sacrum. All sacral ratios were measured by three radiologists. Pearson’s correlation coefficients and corresponding 95% confidence intervals (CIs) were used to assess the correlation between the AP and lateral radiographs. A weighted Kappa statistic was used to measure the agreement between how the AP and lateral sacral ratios categorized observations into risk groups. Our initial cohort consisted of 646 observations from patients with anorectal malformations who had radiographs obtained in both AP and lateral planes. We excluded all observations (n=76) where the radiographs were deemed to be inadequate or not appropriately centered to measure sacral ratio. For a given pair of measurements, the mean lateral sacral ratio was 0.07 units greater than the AP plane (95% CI 0.06–0.09, paired t-test P-value <0.0001). AP and lateral images had a moderate positive correlation (Pearson’s r=0.76, 95% CI 0.73–0.79, P<0.0001) and moderate agreement in risk categorization (unweighted kappa = 0.60, P<0.0001). AP and lateral readings conducted by all three radiologists had excellent inter-rater reliability with intraclass correlations for AP and lateral sacral ratios of 0.88 and 0.84, respectively. Even though the AP and lateral sacral ratios had moderate positive correlation, the mean sacral ratio determined by images in the lateral plane was 0.07 units greater than the AP plane. AP and lateral sacral ratios concluded different risk categories relatively often. Future studies are needed to determine whether AP or lateral sacral ratios correlate better with continence in patients with anorectal malformations.

There are limited MRI studies of craniofacial and velopharyngeal features in children with 22q11.2 deletion syndrome (22q11.2DS) and to date, none have explored the potential relationship between these features and the speech phenotype. The purpose of this study was to examine the relationship between craniofacial and related velopharyngeal structures in children with 22q11.2DS and to assess their correlation to resonance features using an unsedated MRI protocol.Fifteen children with 22q11.2DS and 15 age- and sex-matched controls with normal velopharyngeal anatomy (ages 4–12 years) successfully completed the study. Analysis of covariance was used to compare differences between the experimental (22q11.2DS) and control (children with normal anatomy) groups. Correlation analyses and regression models were also utilized.The 22q11.2DS group demonstrated significantly shorter nasion-to-sella, sella-to-basion, and basion-to-opisthion distances. The anterior cranial base angle was significantly more obtuse. The levator veli palatini (levator) muscle was significantly thinner and shorter, with an obtuse angle of origin in the 22q11.2DS group. Levator length was significantly correlated with the sella-to-basion measure and hypernasality was correlated with levator origin-to-origin distance. Preliminary results from this study indicate a significant association between hypernasality and levator origin-to-origin distance. Findings from the present study, provide an insight into the pathophysiology of velopharyngeal dysfunction related to this clinically complex population.

Imaging is extremely important throughout all phases of care provided to children with anorectal malformations (ARM). A preoperative determination of the patient specific malformation will help establish the operative plan. Moreover, the majority of ARM patients will have an associated anomaly that will require imaging workup for full understanding of those abnormalities prior to addressing the ARM. The complexity of ARM care will mandate continued imaging throughout the post-operative period even in those with straight forward malformations.

BACKGROUND:Anorectal malformations (ARMs) are a spectrum of congenital anomalies with varying prognosis for fecal continence. The sacral ratio (SR) is a measure of sacral development that has been proposed as a method to predict future fecal continence in children with ARM. The aim of this study was to quantify the inter-rater reliability (IRR) of SR calculations by radiologists at different institutions.MATERIALS AND METHODS:x-Rays in the anteroposterior (AP) and lateral planes were reviewed by a pediatric radiologist at each of six different institutions. Subsequently, images were reviewed by a single, central radiologist. The IRR was assessed by calculating Pearson correlation coefficients and intraclass correlation coefficients from linear mixed models with patient and rater-level random intercepts.RESULTS:Imaging from 263 patients was included in the study. The mean inter-rater absolute difference in the AP SR was 0.05 (interquartile range, 0.02-0.10), and in the lateral SR was 0.16 (interquartile range, 0.06-0.25). Overall, the IRR was excellent for AP SRs (intraclass correlation coefficient [ICC], 81.5%; 95% confidence interval, 75.1%-86.0%) and poor for lateral SRs (ICC, 44.0%; 95% CI, 29.5%-59.2%). For both AP and lateral SRs, ICCs were similar when examined by the type of radiograph used for calculation, severity of the ARM, presence of sacral or spinal anomalies, and age at imaging.CONCLUSIONS:Across radiologists, the reliability of SR calculations was excellent for the AP plane but poor for the lateral plane. These results suggest that better standardization of lateral SR measurements is needed if they are going to be used to counsel families of children with ARM.

Introduction: Precise and accurate measurement of the common channel and urethra is a critical determinant prior to the repair of cloacal malformations. Endoscopy and 3D reconstruction cloacagram are two common modalities utilized to help plan the surgical approach, however the consistency between these methods is unknown. Methods: Common channel and urethral lengths obtained by endoscopy and 3D cloacagram of cloaca patients at six pediatric colorectal centers were compared. Data are given as mean (range). Results: 72 patients were included in the study. Common channel measurements determined by 3D cloacagram and endoscopy were equal in 7 cases (10%). Endoscopic measurements of the common channel were longer than 3D cloacagram in 20 (28%) cases and shorter in the remaining 44 (62%) cases. The absolute difference between measurements of the common channel was 7.2 mm(0-2.4 cm). Urethral measurements by both modalities were equal in 8 cases (12%). Endoscopic measurement of the urethra was longer than that by 3D cloacagram in 20 (31%) patients and shorter in 37 (57%) of cases. The absolute difference between measurements of the urethra was 5.1 mm(0-2.0 cm). The reconstruction (e.g. TUM or urogenital separation) that would be performed according to measurements determined by 3D cloacagram and endoscopic measurements differed in 13/62 (21%) patients with each structure identified and common channel measurements of >1 cm. Conclusion: Significant variation exists in the measurements of the common channel and urethra in patients with cloacal malformations as determined by endoscopy and 3D cloacagram. This variation should be considered as these measurements influence the decision to perform either a TUM or urogenital separation. Based on these findings, 3D cloacagram should be performed in all patients prior to cloaca repair to prevent mischaracterization of the malformation. (C) 2019 Elsevier Inc. All rights reserved.

Surgeons have a steep learning capacity to understand 2-D images provided by conventional cloacagrams. Imaging advances now allow for 3-D reconstruction and 3-D models; but no evaluation of the value of these techniques exists in the literature. Therefore, we sought to determine if advances in 3-D imaging would benefit surgeons, lead to accelerated learning, and improve understanding for operative planning of a cloaca reconstruction. Questionnaires were used to assess the understanding of 2-D and 3-D images by pediatric surgical faculty and trainees. For the same case of a cloacal malformation, a 2D contrast study cloacagram, a 3D model rotatable CT scan reconstruction, a software enhanced 3D video animation (which allowed the observer to manipulate the structure in any orientation), and a printed physical 3D cloaca model that could be held in the observer’s hand were employed. Logistic mixed effect models assessed whether the proportion of questions about the case that were answered correctly differed by imaging modality, and whether the proportion answered correctly differed between trainee and attending surgeons for any particular modality. Twenty-nine pediatric surgery trainees (27 pediatric general surgery and 2 pediatric urology surgery trainees) and 30 pediatric surgery and urology faculty participated. For trainees, the percentage of questions answered correctly was: 2-D 10.5%, 3-D PACS 46.7%, 3-D Enhanced 67.1%, and 3-D Printed 73.8%. For faculty, the total percentage of questions answered correctly was: 2-D 22.2%, 3-D PACS 54.8%, 3D Enhanced 66.2%, and 3-D printed 74.0%. The differences in rates of correctness across all four modalities were significant in both fellows and attendings ( p < 0.001), with performance being lowest for the 2-D modality, and with increasing percentage of correct answers with each subsequent modality. The difference between trainees and attendings in correctness rate was significant only for the 2-D modality, with attendings answering correctly more often. The 2-D cloacagram, as the least complex model, was the most difficult to interpret. The more complex the modality, the more correct were the responses obtained from both groups. Trainees and attendings had similar levels of correct answers and understanding of the cloacagram for the more advanced modalities. Mental visualization skills of anatomy and complex 3-D spatial arrangements traditionally have taken years of experience to master. Now with novel surgical education resources of a 3-D cloacagram, a more quickly advancing skill is possible.

Introduction: Cloacal malformations, a confluence of the urinary tract, vagina and rectum into a single common channel, has a broad and complex anatomic spectrum requiring an imaging tool for visualization, measurement, and surgical planning for the reconstruction of these structures. We evaluated the role of 3-D fluoroscopy for this purpose, as it offers a combination of spatial correlation with precise anatomic measurements. Methods: We examined our imaging protocol for patients with a cloaca! malformation and report our experience with rotational fluoroscopy and 3-D reconstruction in 16 consecutive patients referred for cloacal reconstruction. The length of the common channel (CC), the length of the urethra from the bladder neck to the common channal, and the height (and existence or absence) of a vagina or vaginas were determinants of the surgical procedures used for the repair. Results: We performed 16 consecutive 3-D cloacagrams (age range 4 months to 9 years) using a new protocol (Figure 1) that provided the following data which helped with surgical planning: Gynecologic: 3 cases with a single vagina, 5 cases with a duplicated Mullerian system (3 of which were asymmetric) and 2 cases with high vaginas requiting vaginal replacement. Colorectal: Four had a high rectum requiring an abdominal approach, and 6 had a rectum reachable via a posterior sagittal approach. Urologic: Two ectopic ureters requiting reimplantation, 3 patients had vesicoureteral reflux (1 bilateral, 2 unilateral), 1 patient had no bladder, and 7 had a normal sized bladder. Common channel length and urethral length were demonstrated in all cases and used to decide between a total urogenital mobilization or a separation of vagina(s) from the common channel, urogenital separation. Conclusion: The 3-D cloacagram can help predict the surgical plan for urologic, gynecologic, and colorectal components of the cloacal repair. It can predict the CC length as well as the length of the urethra. It helps with predicting the need for vaginal replacement and whether an abdominal approach is needed for the rectum. Its effectiveness is based on the ability to adequately distend structures and see their distal most extent, an advantage over other modalities such as MRI. Added benefits (particularly from the 3D view) include a better spatial understanding of the defect and the diagnosis of concomitant urological abnormalities such as vesicoureteral reflux and ectopic ureters. Disadvantages to this procedure include the need for general anesthesia and a higher exposure to radiation. (C) 2019 Elsevier Inc. All rights reserved.

Objective: The 22q11.2 deletion syndrome (22q11.2DS) is the most common genetic cause of velopharyngeal dysfunction; however, limited information exists regarding variations in velopharyngeal anatomy in this clinically challenging population. The purpose of this study was to examine velopharyngeal characteristics among young children with 22q11.2DS in comparison to a normative cohort using an innovative, nonsedated magnetic resonance imaging (MRI) scanning protocol. Methods: Fifteen children with 22q11.2DS and 15 age- and gender-matched controls with normal velopharyngeal anatomy (ages 4-12) successfully completed the MRI protocol. Eighteen velopharyngeal and 2 related craniofacial measures were examined. Analysis of covariance was used to compare differences between the experimental and the control groups. Results: The 22q11.2DS group demonstrated a significantly thinner velum ( P < .0005) and a larger pharyngeal depth ( P = .007) compared to the matched control group. Findings in the current study also demonstrated that the levator veli palatini muscle is significantly shorter ( P = .037) and thinner ( P = .025) in the 22q11.2DS cohort, with a significantly shorter origin-to-origin distance ( P < .0005) and a greater angle of origin ( P = .001) compared to healthy peers. Conclusion: Children with 22q11.2DS demonstrated multiple variations that may contribute to velopharyngeal dysfunction by altering the anatomic characteristics of the velopharyngeal port, the levator muscle, and associated structures. This investigation represents the first and largest attempt to characterize velopharyngeal anatomy in children with 22q11.2DS using a nonsedated MRI protocol.

Imaging technologists are integral to our work.I am very pleased that, for the third year, there will be a Pediatric Imaging Technologists' Course, renamed from "Radiographers' Course to reflect its broader content.The course is again organized and directed by Laura Gruber and Christine Harris with guidance from Steve Simoneaux.The Imaging Technologists' Course is a great opportunity to learn and network.Please consider how your radiology department or group can facilitate the attendance of a deserving technologist (or more) who will surely benefit from this great program!Nashville is an extraordinary city.It is vibrant and full of life.I urge you to take time to explore what Nashville has to offer.The Omni Nashville Hotel is conveniently located close to the rich nightlife of downtown Nashville and close to many great restaurants.Be sure to try the barbecue, Prince's hot chicken and, if to your liking, local libations.Take time to listen to the music!Many choices abound and not just limited to country music.Nashville is a very progressive, diverse, inclusive, welcoming and fun city.It is a perfect environment of our meeting.We thank the people of the city of Nashville and the staff at the truly marvelous Omni Hotel Nashville for their hospitality.This meeting would not be possible if not for the extraordinary support and work of Angela Davis and Kasey O'Dea.They have been two or three steps ahead of me throughout the process.Angela and Kasey -thank you so much!!! Lastly, the SPR meeting is about people.Reacquaint yourself

AIM OF THE STUDY:The goals of urinary reconstruction in urogenital sinus and cloacal repair include: (1) positioning of the bladder neck above the urogenital diaphragm to maximize future urinary continence, and (2) creating a visible urethra that can be catheterized if needed. A recent algorithm in cloacal reconstruction proposed a urethral length of 1.5 cm as the key determinant in deciding whether to perform a total urogenital mobilization or a urogenital separation, the hypothesis being that a 1.5 cm length urethra is needed for the patient to remain dry. We wondered if the normal female urethral length correlated with this empiric technical determinant. METHODS:We reviewed voiding cystourethrograms of healthy female patients between ages 6 and 36 months and measured the patient's urethral length. RESULTS:Ninety-one children were included. The mean urethral length for patients age 6-12 months was 2.50 cm, age 12-24 months was 2.31 cm, and age 24-36 months was 2.59 cm. There was no difference between the urethral length in the three groups (p = 0.38). Of 91 patients, 87 (96%) had a urethral length >1.5 cm. CONCLUSION:A urethra of at least 1.5 cm was present in the majority of normal control patients. We believe therefore that for urogenital sinus and cloacal repair, surgeons can extrapolate that patients need a 1.5 cm urethra at the end of the reconstruction. Additional follow-up is needed to determine if this urethral length as an independent factor maintains dryness in the long term after cloacal repair. TYPE OF STUDY:Case Series. LEVEL OF EVIDENCE:III.

Introduction: The videofluoroscopic swallow study (VFSS) remains the primary method to evaluate swallowing function in infants and children. However, limited standards exist to guide the image acquisition during pediatric VFSSs, leading to inadequate images, variable assessment quality, and potential for suboptimal diagnostic accuracy. The goal of this quality improvement project was to standardize the radiological procedure for radiologists at our institution. Methods: A multidisciplinary team of project leaders established 3 imaging standards to target (magnification, the field of view, and pulse repetition rate), based on the best available evidence. The team used the Institute for Healthcare Improvement’s Model for Improvement to guide the project, identified key drivers, and implemented specific interventions. Project leaders observed a total of 170 VFSS examinations, performed by radiology faculty, fellows, and residents over 24 months. The primary outcome for this project was physician compliance with 3 established imaging standards: field of view, magnification, and pulse repetition rate. Project leaders collected data without the radiologists’ knowledge, and also recorded average radiation exposure as a balancing measure during this process. Results: At baseline, compliance with all 3 criteria was 20%. Following interventions designed to improve radiologist performance with the 3 identified standards, the compliance rate reached 100% for the last 50 recorded VFSSs. During this same time, there was no meaningful increase in average radiation exposure compared with the 6 months before the implementation of this project. Conclusions: Compliance with standardized image acquisition of VFSSs can be accomplished using a systematic quality improvement protocol targeting simple, inexpensive interventions.

The publisher regrets to inform that in regard to the manuscript titled "Cloaca Reconstruction: A New Algorithm which Considers the Role of Urethral Length in Determining Surgical Planning" by R. J. Wood, et al, published in the January 2018 APSA issue of the Journal, a very significant Discussion was missed to be included as part of the article. It is as below. The publisher would like to apologise for any inconvenience caused. UNIDENTIFIED SPEAKER: Wow, that was beautifully presented work, and it sounds like it’s going to help a lot of these children. My question is, what do you think the difference is? Does it have to do with the urethral sphincter mechanism and those with longer urethras generally have more native sphincter-type function? RICHARD WOOD: I think it’s probably multifaceted. Thank you for the question. I think we certainly are concerned that in patients with a very short urethra and just by bringing the bladder neck really low, it appears to affect their function. We haven’t noted with the patients that we’ve left the common channel with the urethra that they have had a difficulty to empty. Obviously that’s something that one needs to look at and see whether over the long term more patients need intermittent cath, but that has not been our experience for now. I don’t know entirely. I just feel that most children with a urogenital sinus have a normal bladder function, and a lot of kids with cloaca have abnormal bladder function. If the urologists think it’s that important to maintain the urethral length in patients with normal bladders, how much more so is it important for us to maintain that in children who in many cases have abnormalities to their bladder function. So we’re not entirely sure why, but it would appear that there is benefit. JASON FRISCHER (Cincinnati, OH): Great presentation and thank you for challenging us to try to continue to make and have better outcomes in this patient population. Couple questions. One, when you measure the urethral length, you showed a cloacagram, but I assume you also perform a cystoscopy. Which measurement do you use as your more preferred measurement for determining that 1.5-cm length? My other question is, does age play a role when you are performing this? In a 2 year old, you’re doing redo operations. Does urethral length in a 2 year old, or if a patient was diverted and you just encountered them at 2 years of age, is that a different length than a 3 month old that you are doing your original cloacagram? And then third question is more of a comment. I guess we really need to know what the functional outcomes of these patients are, and so do you have any data on that? I look forward to this presentation in 3-5 years again. RICHARD WOOD: Thank you very much. To answer your first question, we do measure and use the cloacagram. We will present that data in time when I think we have enough to significantly say, but my impression is the cloacagram may be better because we can – I think we can kid ourselves when we’re doing the cystoscopy by applying pressure. Same problem with ultrasound of the perineum. Functional outcomes, whereas we don’t have a lot of data yet and we have to wait for these patients to get older, I think we have anatomical data that the urethra is surviving, and they are not leaking, but we don’t have functional data yet. All our patients get urodynamics before surgery, and we follow them with urodynamics and other parameters, so hopefully we will be able to present that data in time. JASON FRISCHER: And age? RICHARD WOOD: We haven’t specifically used this protocol for the redos, but we are mindful of it because I think a lot of times the decisions are often made on the urethra by the time they come to for redo, but I think it is something we definitely consider in every single patient and the goal to maintain as much urinary continence as possible is certainly forefront to the discussion. Thank you. W. HARDY HENDREN (Duxbury, MA): I don’t have a question, but I would like to say that I agree completely with the message that you’ve just given us and to add that the time to do it is the first operation if you’re lucky enough to get one with the first operation. I got many of these kids who had had 2-3 operations before, and it’s tougher each time, so the time to do it is initially if it looks too short. Thank you. RICHARD WOOD: Thank you very much. MARC LEVITT (Columbus, OH): If I may, I don’t mean to follow Dr. Hendren, but I just want to thank him for a career of service on this very difficult patient population and also to Dr. Pena who made a lot of strides in addition to Dr. Hendren’s work. I was there looking over Dr. Pena’s and Dr. Hendren’s shoulder when Alberto for the first time showed Dr. Hendren what the urogenital mobilization was all about, and I remember the fascination in his eyes that it was going to advance the field, and in fact it did. What this paper was meant to show is that it was an incredible advance, but it cannot be applied too broadly. We have to go back to the original principles that Dr. Hendren gave us of the importance of the bladder neck, the urethral length, and urinary continence in order to get the best possible result. Thank you. Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planningJournal of Pediatric SurgeryVol. 53Issue 1PreviewCloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3 cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1 cm, .5 with an original 3 to 5 cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. Full-Text PDF

Background and aim: The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations. Methods: We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord. Results: 283 patients with ARM were included for analysis (156 females). The median age was 39 months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p < 0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p < 0.001). Conclusion: SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up. (C) 2018 Elsevier Inc. All rights reserved.

Background: Colonic dilation is common in children with intractable functional constipation (FC). Our aim was to describe the association between segmental colonic dilation and colonic dysmotility in children with FC.Methods: We performed a retrospective study on 30 children with intractable FC (according to the Rome III criteria) who had undergone colonic manometry and contrast enema within a 12-month time period. Colonic diameter was measured at 5 cm intervals from the anal verge up to the splenic flexure. Moreover, the distance between the lateral margins of the pedicles of vertebra L2 was measured to provide a ratio (colonic diameter or length/distance between the lateral margins; "standardized colon size" [SCS]). All manometry recordings were visually inspected for the presence of high-amplitude propagating contractions (HAPCs); a parameter for colonic motility integrity. The intracolonic location of the manometry catheter sensors was assessed using an abdominal X-ray. KeyResults: Colonic segments with HAPCs had a significantly smaller median diameter than colonic segments without HAPCs (4.08 cm vs 5.48 cm, P<.001; SCS 1.14 vs 1.66, P=.001). Children with prematurely terminating HAPCs had significantly larger SCS ratios for colonic diameter than children with fully propagating HAPCs (P=.008). SCS ratios for the length of the rectosigmoid and the descending colon and the SCS ratio for sigmoid colon diameter were significantly larger in children with FC compared to a previously described normative population (P<.0001, P<.0001 and P=.0007 respectively).Conclusions & Inferences: Segmental colonic dilation was associated with prematurely terminating HAPCs and may be a useful indicator of colonic dysmotility.

BACKGROUND:Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care.METHODS:We prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded.RESULTS:Of 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years.CONCLUSION:Urethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented.TYPE OF STUDY:Clinical cohort study with no comparative group.LEVEL OF EVIDENCE:Level 4.

Contrast enemas with barium or water-soluble contrast agents are sometimes performed in children with severe intractable constipation to identify anatomical abnormalities. However there are no clear definitions for normal colonic size or abnormalities such as colonic dilation or sigmoid redundancy in children.To describe characteristics of colonic anatomy on air contrast enemas in children without constipation to provide normal values for colonic size ratios in children.We performed a retrospective chart review of children aged 0-5 years who had undergone air contrast enemas for intussusception. The primary outcome measures were the ratios of the diameters and lengths of predetermined colonic segments (lengths of rectosigmoid and descending colon; diameters of rectum, sigmoid, descending colon, transverse colon and ascending colon) in relation to the L2 vertebral body width.We included 119 children (median age 2.0 years, range 0-5 years, 68% boys). Colonic segment length ratios did not change significantly with age, although the differences for the rectosigmoid/L2 ratio were borderline significant (P = 0.05). The ratios that involved the rectal and ascending colon diameters increased significantly with age, while diameter ratios involving the other colonic segments did not. Differences by gender and race were not significant.These data can be used for reference purposes in young children undergoing contrast studies of the colon.