3D Reconstruction: Cloaca and Complex ARMs 2015

Speaking on the cloacogram and how we perform on them in interventional radiology using our modern day angiography equipment. Now, this is a work in evolution. We When we first started doing these procedures, we're doing them in main radiology with the patient awake, and over time, we moved them to interventional radiology where we had 3D imaging capabilities and then subsequently, we've, we've now combined all the endoscopy the patient gets with these procedures, making, making it a one-stop shop. The uh surgeons and the gynecologists, urologists are all in our rooms. They're scoping the patients, and then afterwards, we're performing the 3D reconstructed uh cloacogram. So, the technology we're using is basically the same technology that's available for 3D angiography. We're injecting contrast into a uh hollow structure, and then as you can see, the camera rotates around the patient and it uh generates images. Those images are immediately available at a workstation where we can then make uh different cuts and, and different views so we can clarify overlapping structures and also decisively try to figure out what structure is what. Conventionally, uh when um. Contrast studies are requested. They're done in, uh, main radiology, and you end up getting usually an AP and a lateral. There's a lot of overlapping structures and it's sometimes very difficult to decipher, um, what structure is which, and that's where this, uh, technique has come. Um, to play. How can you tell? Uh, Not able to switch slides. I just Against the side of Hi. So again, now we can uh put our various catheters in into the mucous fistula. They'll pacify the distal colon. We can put catheters into the bladder. There's a vaginostomy. We can put a catheter through it or inject contrast to the catheter that exists. Uh, as we're injecting contrast, the camera spins around the patient, and we can, uh, create this uh 3D model. These images can then be transferred to the workstation. Now the next slide, blend. And then we can look at these uh structures in any way we want here, we're looking at it with the bones in place. We can see where, what the level of the cloica is, and we can measure the length of the common channels and actually precisely see what the vaginas look like. On the next slide. Uh, this is a different patient. Again, if this was to have been done in main radiology, these would have been the images you would have received a frontal radiograph showing injection of the distal, uh, colostomy and then, uh, a lateral image, and it's very hard to decipher, is there a vagina in there? What does the bladder look like. So then we're able to take the same, uh, pictures, but again. Do the um or this is just the contrast injection of the mucus fistula. We're able to save clips to show what structures actually fill as, as we're injecting the mucus fistula. You can see how the vagina is filling in the background. And then we're able to do a rotational study. We're able to get a catheter into the bladder and, uh, again, it looks very dark on your screen. I apologize for that, but again, the 3D spin is performed where we can see the rectum, the rectal fistula, the vagina, and the bladder. Those images are then reconstructed in our workstation. Again, you can see much more clearly here, there's a catheter going into the bladder via the common channel. Here's the rectum coming down, rectal fistula. There's a single vagina, which is midline, and then the common channel leading out to the perineal opening. We can look at the images as if it was a CT. Again, this is a slice right down the center of the abdomen in a sagittal plane. You can see the rectum coming down, the rectal fistula inserting at the base of the cloaca. There's a vagina in front of it and then the bladder just north of there. Next image you just hit the button. Return, OK. Oh, there we go. OK. So, we can also measure the common channel. In the old days, we would put a ruler external to the patient. There'd be a lot of foreshortening, so, we were never able to get a precise measurement. Now, with our um modern technology, we're able to actually get a precise view of the common channel and then draw calipers along there and actually give a precise measurement of the common channel. Improved technology also, uh, on the previous image you can see how we pieced together a ruler. Now we can actually draw from one end of the where we want to measure to the other and the computer can generate a little line and actually uh give us a very precise measurement of the common channel. So again, what we've been able to do is combine the 2D imaging that's been traditionally available with Chloecograms, but involve uh the 3D imaging in one session. Again, we're doing this in conjunction with the endoscopy, so it gives us the capabilities of having fluoroscopy, but also having a 3D model so we can more precisely um. Uh, give an exam, precisely give the anatomic um. Positioning of all the structures and various lengths that are needed prior to surgical reconstruction. Thank you. Um, Richard, do you, do you do similar sort of studies at Nationwide, um, and your experience back in South Africa, I'm sure you didn't have the technology potentially, so how would you guys? So, I think to start off just to answer, we have exactly the same system at Nationwide with endoscopy in the, in the interventional radiology suite. I think it definitely lends itself to being able to compare the imaging you get from your endoscopy and the measurements you're taking with what is able to be reconstructed three-dimensionally. And um I think when we get into the complex decision making piece later as to exactly how to approach the more complex patients, we'll probably discuss that at more length as to what to do with that information. Um, to your point, in South Africa, we really didn't have the capability of doing the 3D reconstruction. And we're really doing 2D, uh, before. And, and there's definitely use, very useful information when it comes to decision making. Having done Clo Acres in Cape Town and now in Columbus, you definitely go in with more information, especially in those cases where you want to kind of get a good feel of whether the vagina will come down. And exactly what the relationship is with the rectum and whether you best approach it laparoscopically or something from above or from below primarily. I think those kind of decisions on relationships are really added to by the 3D approach. And Menise, there, there's a lot of talk now limiting radiation, um, the amount of radiation with the loogram, and is it a possibility or potential for MRI to give you the same amount of information. So in, in terms of radiation, I think the, the amount of radiation from the study, we've actually gone back and looked at numbers. It's, it's very similar to doing a conventional loacogram in the sense that we're not doing as many, uh, lateral images and not as many frontal images. So when you actually look at the, the amount of radiation from a spin and the static images you need to do the cloaogram with this technology versus the old fashioned way, it's actually very similar. We have done some with MRI. I think what you lose is the real-time capability of seeing what you're injecting and what you're filling. It actually also adds a lot more to the anesthesia time of doing the procedure, so. The trade-off of a small amount of radiation versus the increased anesthesia time to do it in terms of an MRI cloaiogram. Doctor Pena, when, when you look at the locograms now, you find that the images that we get, you go in with a lot more being able to plan and counsel the families? Yeah, the, um, the, um, studies that have been done by Doctor Patel and interventional radiology has been represent a big change for us in the prenatal diagnosis. Before that, we could make very accurate diagnosis, but never the, the fantastic images that we get is really uh fascinating to see how those images are, are presented to us and it's a very quick, very, very efficient. So we are very grateful to Doctor Patel for for those images and, and there is no more, there is no more mystery about the uh the internal anatomy of these patients with these studies and that represents a great help for us. The other question is how accurate, you know, when we measure common channel radiologically versus cystoscopy versus in the OR, um, does anybody have any input on? Yes, and we, I was very skeptical about their measurements, but then little by little they become more and more accurate, and now they are. They are just there, but the differences in millimeters they are very subjective, so they are, I don't know what they did, but right now when they say 3.5 milli 3.5 centimeters, usually it's 3.5 centimeters. So we really, we gain a lot, you gain a lot of experience for the benefit of these children. I don't know if Doctor Langer, I don't see his picture up there, but um, do you do similar sort of preoperative studies? Uh, we're in Canada, so we can't afford that kind of technology. So you do two it looks, I mean, it looks amazing, and I, I, I, as soon as this conference is finished, I'm walking over to radiology to ask them why we're not doing this. Well, you can, you can call on Doctor Manish Patel. I'm sure he'd be happy to collaborate with your interventional radiologist there. Yeah, will do. All right, thanks, Vanish. I think Venish, are you gonna hang around for some of the case studies or go do a couple of procedures, but I'll be back. All right, thank you. So we're gonna, um, uh, Doctor, um, Bischoff already talked a little bit about the prenatal counseling. We're gonna just sort of touch on it a little bit more here before we go into our actual case reviews. Um, one of the case that, uh, Doctor Calvo actually presented, you'll see that case sort of come to fruition as we go through, um, this, this global cast. You'll, we'll see some of the postnatal imaging and then the operative approach for that one. So, if you wanna keep that case in the back of your minds. So, let's go on to prenatal counseling. Um, in your practice, if you got a prenatal uh consult on a complex cloaca, what would happen to this patient? Would you counsel them to deliver at your institution, um, counsel them to transfer to a different institution after delivery, or, um, take care of the baby at your place? It depends on the type of anomaly that it's. Well, that's so, I'm complicated, so I'm not saying like straightforward short common channel. I'm saying if you look at the pictures that Doctor Calvo had shown, uh, the majority of kids that are diagnosed prenatally are the complex, of course, of course. So that's why. And and I'm not sure if the poll came through. It's coming through. We've got right now it's changing every few seconds, so it's, that's well. Uh, about the majority counsel to deliver in your institution and continued care, 75%. I mean I think the one thing which you raised earlier was how reliably you are concerned about a malformation because obviously it's a huge upheaval on a family to move them. To a different center and so you wanna be pretty sure it's not a subtle single umbilical artery. We think there might be something there. You probably want to be a little bit more careful than that, right? So I think, I think a lot of it depends on how reliable you think prenatal imaging is, and I think the way that prenatal imaging is now, you can get so much detail, um, that you can potentially counsel the family quite, quite well. I'm gonna skip to the next slide here. Um, workup and timing. Um, so, uh, we already sort of talked about, and I, these are a little bit, um, pre-surgical planning. Doctor Patel talked about the, the cloacograms that we do. Um, the initial tests, can I, does anybody wanna comment on the panel on sort of initial gynecology tests and initial urology tests that you would expect from a newborn baby with a cloacal anomaly? I think from a urologic standpoint, um, there can be a variety of uh upper tract and lower tract abnormalities and uh baseline renal bladder ultrasound seems to be the preferred method for identifying them. And obviously, as Doctor Dickey was saying that there's uh helps us to kind of confirm with that maybe the post, the first postnatal imaging modality. To expand upon any prenatal imaging abnormalities, so that's our preferred, uh, original and initial urologic survey. And I also know that uh Doctor Breech may comment that when they're imaging down in the pelvis of the bladder, the neighbor being the vagina is something that she may want to comment on. Sure, uh, I would agree. I think ultrasound would be the modality of choice. Primarily, we're looking to see if there's any fluid accumulated in the vagina or vaginas. Um, we also look at ovaries and that anatomy, but essentially looking for fluid in the vaginas. And uh that helps us to sort of guide sort of the timing of therapy if that fluid needs to be drained more acutely or not. So that would be the main uh imaging that we would do early on. So from the other non urology and gynecology we also want sacral X-ray AP and lateral to make sure the prognosis for bowel control is assessed as well as to suspect or not suspect a pre-sacral mass, a spinal ultrasound to rule out. That report and we wanna make sure that no other anomalies are missed. So we want an echocardiogram or a very good physical exam with a cardiologist or someone experienced on that, make sure the patient doesn't have esophage atresia or any other abnormalities. So if we go back to the slide, so, you know, we sort of touch on this, and this is why we have a collaborative sort of table here is that it's not just one thing that we wanna address in these babies. I think there's functional aspects to address with bowel colorectal. Um, gynecologic and urologic, and so as a team we often will see these patients together, discuss potential outcomes, and then discuss further management, and this is done both prenatally and postnatally. Melinda, I just might want to add one thing is that, you know, in many of the centers that don't have the 3D rotational that we have, I think 2 to 2D fluoroscopic images have proven to be very helpful. Um, and the timing of that, I think is also, um, somewhat controversial. We obviously want the child to be well because these are usually, uh, some uncertainty around their delivery when the child's well they then come down. I think the placement of the catheter into the common channel and then opacification of the pelvic structures is probably one of the challenging things, which is why I think we've kind of migrated more to an endoscopic evaluation at the time. Um, but, uh, because, uh, not quite certain most radiologists will feel comfortable repositioning the catheter on the floral table into urologic structures, gynecologic, but I think, you know, obviously from a lower tract and the whole complexity, you know, fluoroscopic studies, as we've said, are important. So, just back to the slides, I think initially the workup, um, of course, we all know about V or Vacteril, so all those things need to be ruled out initially when the baby's born, make sure there's no cardiac defects, as we all know with the echocardiogram, um, or the renal ultrasounds, when would you potentially get a VCUG? So that's kind of what my point was, is that placement of the catheter into the common channel, uh, we have 3 organ systems where it may go. So I am not in favor of a a VCUG to identify any potential reflux or anything separate than our collaborative endoscopic because I'm not quite certain where that catheter is going to go and the radiologist might say. I'm giving you fantastic vaginograms. I have the best distal colo colostogram. So typically, um, we are getting obviously a cystogram when our catheter is placed under endoscopic guidance for our, uh, rotational studies. This can be helpful if there's some reflux that's identified for counseling the family and, and potentially being something where you would. Consider that the patient is uh at risk for some more UTIs postoperatively, but I'd be surprised in my experience here, even with us being a ref referral center for tertiary cases, we're not really identifying high grade reflux in a lot of our Cloaca girls. It's gonna mostly be a mild reflux that warrants, I think, observation, but it's, uh, not necessarily in my opinion, mandatory preoperatively. Can I say, can I say something? Yes, of course, the, if we are talking about neonatal cloacas. In the real life and we don't make a very accurate diagnosis of the of the intrinsic anatomy of the cloaca during the newborn period and in fact trying to be very precise in the anatomic diagnosis is kind of useless and may actually hurt the baby, but we are very interested in a newborn babies to know if the baby has hydronephrosis and mega ureters and to know if the patient has a hydrocorpus that may be compressing the ureters. And that, that's very important to make decisions even without an endoscopy, of course, if you have the luxury to do an endoscopy, but you are not going to add very much with that. You are at that point, it's not so crucial to know if the baby has a reflux or not. It's not, it's what you want is the patient to, you want to be able to decompress the gastrointestinal tract and to decompress the eurogenital tract. And, and you know, you know how you, you learn about that by having a kidney ultrasound, pelvic ultrasound, and, and that's it. And then you and, and rule out all the other associated malformations. Then you take the baby to the upper end room, you may do an endoscopy, not everybody has the capacity to do it and don't force the endoscope in a tiny structure because you may end up hurting. And uh and don't try to drain very many things from below because I have seen problems with that, but rather open a colostomy and be sure to drain the hydrocorpus. And then not everybody has the luxury that we have to have specialized urologists with experience in cloacas. Many urologists don't have experience in cloacas and will end up doing nephrostom is not indicated, ureterostom is not indicated, and vesicostom is not indicated. So our specific recommendation is to drain the hydrocorpus, to open a colostomy, and re-evaluate the patient from the urologic point of view 48 hours later and then make a decisions. Some patients may need a vasicostomy, those who have an obstruction in the, in the common channel, but many of them don't. By, by simply decompressing the hydrocorpus, the, the, the picture completely changes. So, so that's very important in the neonatal period. I think that's a great point because you know, even when babies are born here, everybody's so eager to find out how long the common channel is, what's going on with the anatomy, but if you ever try to scope one of these neonates, A, I don't think you get accurate information all the time, and B, I think it's, it's very difficult and traumatizing to the common channel, which in turn could potentially hurt things more in the end. So here, at least, um, as Doctor Pena said, we would, we try and decompress the GI tract, decompress the hydrocopals if needed. Um, and then we get the anatomy studies much later once the baby's a little bit bigger, and we can do our endoscopy to define the anatomy for the locogram. Um,