Urinary Tract Reconstruction Patient 1: Undiversion Case with Cloacal Anatomy

This 5-year-old girl was referred in Sept. 1980 for extensive pelvic surgery. More than half her life since birth she had been hospitalized elsewhere. She had been born with cloacal anatomy with high confluence of her bladder, two vaginas, and rectum. The right kidney had a nephrostomy tube in place because the reimplanted right ureter was obstructed. The left ureter also had an obstructed ureteral reimplant and drained via a loop ureterostomy. The bladder was severely scarred.

The first procedure was to create a urethra and bring the two vaginas to the perineum. The left ureterostomy was closed, its lower end was reimplanted, and a right to left transureteroureterostomy was done. Six months later the bladder, which did not enlarge with hydrostatic stretching, was augmented with ileum.

This case illustrates the trouble which can be created when the surgery gets started “in the wrong direction.” High vaginas require a pull thru procedure, disconnecting them and using the UG sinus as a urethra. Her early years were a nightmare existence and lost most of her renal function.

With a devoted mother to lead her, the child entered adolescence as a young woman with self assurance, doing well socially and psychologically. 

Anatomy (Select Image for High-quality Version). (Before) Preoperative anatomy when referred at age 5 years. Note prior reimplanted ureters, both obstructed. Right kidney drained by nephrostomy tube; left by loop ureterostomy. (After) Initial surgery to fashion a urethra from what had been the urogenital sinus and covered with flap from buttocks. After undiversion 6 months later by left long tunnel reimplant, and transureteroureterostomy; and ileal augmentation to increase capacity of scarred and contracted bladder.

Patient X-rays (Select Image for High-quality Version). (Top Left) Antegrade perfusion of kidneys initially. (Top Right) Showing reconstructed urethra. Malformation: Confluence-Hi (Bottom Left) and (Bottom Right) Augmentation.