From
Dr. Marc Levitt
Colorectal Quiz Episode 33: Cloaca Exstrophy
With Dr. Levitt & Dr. Payam Sadai · hosted by Dr. Laura Tusaba
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Cloacal Exstrophy with Dr. Alberto Peña
53 min · Published Apr 2017
Video
Cloaca - Prental Imaging & Diagnosis - Counseling
Dr. Todd Ponsky · 36 min · Published Nov 2018
Video
Cloacal Exstrophy: A Modification of the Newborn Operation - Leaving the Cecal Plate Untouched
6 min · Published Oct 2024
Video
Surgical Management and Follow-Up: Cloaca and Complex ARMs 2015
25 min · Published Oct 2015
Video
ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?
48 min · Published Dec 2022
Video
Prenatal Imaging and Counseling: Cloaca and Complex ARMs 2015
CCHMC Pediatric Surgery · 31 min · Published Oct 2015
Video
Colorectal Quiz Ep. 50 -16th Annual European Pediatric Colorectal & Pelvic Reconstruction Conference
Marc Levitt · Published Mar 2026
Video
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Marc Levitt · 15 min · Published Sep 2025
Video
Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Care (with Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 47
Marc Levitt · 22 min · Published May 2025
Video
Colorectal Quiz: Episode 46 - Hirschsprung's Disease
Marc Levitt · 29 min · Published Apr 2025
What the experts said
Prenatal ultrasound and MRI findings of small bladder and sacral dysgenesis should raise concern for cloacal exstrophy
Cloacal exstrophy is the most complicated condition managed in the colorectal world and requires collaboration with urology and gynecology
Cloacal exstrophy patients almost always need a neurosurgeon in addition to colorectal, urology, orthopedics, and gynecology
Like any anorectal malformation, cloacal exstrophy is not an emergency; surgeons have 24-48 hours to complete workup and decide on operative plan
Essential preoperative workup includes echocardiogram to rule out congenital cardiac anomalies, spinal ultrasound, and abdominal ultrasound to assess kidneys
Cloacal exstrophy patients often have stool coming from the fecal plate/ileum, so there is not always a component of obstruction or dilated bowel loops
Key NICU management focuses on preventing dehydration through fluid loss management, using plastic covering (saran wrap) over hemibladders, keeping patient NPO, and placing nasogastric tube
The most devastating complication of cloacal exstrophy closure is dehiscence
Orthopedic surgeons believe the best time to bring the pelvis together is within the first 2-3 days because there is enough maternal relaxin on board
Two major decision points in cloacal exstrophy are: (1) whether the omphalocele is large or small enough to close the abdominal wall, and (2) the staging of the exstrophy procedure
The fecal plate represents more colon downstream from the cecum, not the end of the bowel; it is essentially a colonic atresia in the deep pelvis with good bowel that needs to be rescued
Creating an ileostomy and leaving behind a blind-ending fecal plate and hindgut is an unfortunate surgical error that has occurred in multiple cases
The traditional approach to cloacal exstrophy is to extract the fecal plate from within the two hemibladders, tubularize the fecal plate, and bring out the end of the hindgut as an end colostomy
The overriding principle in cloacal exstrophy management is bowel preservation, as small intestine can be shortened and patients may have long-term nutritional concerns
The traditional reason for separating the fecal plate from hemibladders was to avoid absorption of urine into the fecal plate and resulting acidosis
Many patients with colonic mucosa absorbing urine (bladder augmentation situations) do not develop acidosis, making this concern a non-issue
The tubularized fecal plate often becomes a boggy, fairly useless piece of bowel where ileum enters, stool sits, and then empties through the hindgut
Dr. Levitt's new approach leaves the fecal plate between the hemibladders as an auto-augmentation, connects distal ileum to hindgut as a primary anastomosis, with the cecum staying connected to the bladder
In the novel approach, the ileum and hindgut are the same size and make a nice match for anastomosis
Dr. Levitt learned the hindgut pull-through to anus technique from Ivo de Blaauw in the Netherlands
When leaving the fecal plate behind and separating the ileum, the hole in the fecal plate is oversewn
One reason for not pulling through cloacal exstrophy patients early is concern about rash and managing a perineal stoma
The decision to perform early pull-through should be based on how much hindgut is present; patients with substantial hindgut (like entire right colon) can develop good stool consistency
Patients who cannot develop thickened stool should never have a pull-through
In cloacal exstrophy cases, the mesentery can be so confusing and problematic that mobilizing the hindgut up and out of the pelvis risks losing the hindgut, which would result in permanent ileostomy
Reoperation in the pelvis of an older child or teenager with cloacal exstrophy is an experience surgeons want to avoid
A loop ileostomy is preferred over separated stomas because some passage across the stoma is acceptable, particularly when there is no long suture line from a tubularized fecal plate
When there is a tubularized fecal plate with many distal stitches, a loop ileostomy can be created with purse-string closure of the distal segment to protect the suture line
Refeeding the distal segment helps the skin handle stool, and once the skin is ready, the ileostomy can be closed
It is very important that urology not manage the bladder independent of the decision to pull through the colon
Cases have occurred where urologists performed augmentation, Mitrofanoff, and bladder neck closure at age 5 without considering colonic pull-through, making it very difficult to pull a colostomy behind an augment
Managing cloacal exstrophy patients when they are older is very difficult; spending extra time in the newborn period for comprehensive reconstruction can save significant future work
Leaving the cecal plate on the bladder makes future Mitrofanoff creation easier because the appendix is already connected and easy to bring up