Cloacal malformation is the most complex anorectal malformation, and its treatment is still one of the most arduous procedures in pediatric surgery. The main urological goals of cloaca management are to preserve renal function and achieve urinary and fecal continence. Aim of our study was to analyze continence status, renal function and correlation with spinal dysraphism (SD) and length of the common channel (LCC).

We retrospectively reviewed medical records of cloaca malformation patients treated at our Hospital between October 1999 and January 2020. Only patients with a minimum follow-up  of 2.5 years were included. We evaluated urological and spinal anomalies, LCC (short <3 cm and long ≥3 cm), urodynamics (UD), urinary and fecal continence, renal function, urological procedures performed.

About 24 patients, 20 were included. Median age at cloaca surgical correction was 7.1 months. Median age at last FU (from surgery to the last outpatient visit) was 8 years (4–15 years). An LCC ≥3 cm was described in 11 patients (55%). 
Chronic kidney disease was found in 3 patients, 2 with LCC ≥3 cm (1 of these had SD) and 1 LCC <3 cm and SD. 
According to our protocol MRI was performed in all childern. SD was observed in 10 patients (50%), 2 underwent dethetering. Neuro-urological dysfunction at urodynamic exam was observed in 10 patients (50%). SD was more frequent among LCC ≥3 cm (8/11) than LCC <3 cm (2/9), but not statistically significant (p=0.06). Renal anomalies were more frequent among patients with SD (71% vs. 16.7%; p=0.04). Urinary continence was achieved in 8 patients (40%; 3 patients with LCC <3 cm and in 5 with LCC ≥3 cm) while dryness was reached in 9 (45%).
Of these, clean intermittent catheterization via urethra was prescribed in 6 patients; urinary diversion was carried out in 3 (2 Mitrofanoff, 1 button cystostomy).
Fecal continence was obtained in 3 (15%), fecal cleanliness in 14 (70%). 
Among the 10 patients with SD, 1 patient reached fecal continence and 7 obteined fecal cleanliness; 2 patients were urinary continent and 6 achieved dryness. The two patients who underwent untethering surgery reached fecal cleanliness; 1 of them was also urinary continent.

The presence of spinal anomalies and the LCC are effective risk factors for continence.  SD, LCC ≥3 cm and renal anomalies are commonly associated.

Continence and renal function can be preserved in long-term, even in the most complex anorectal malformation, due to an early diagnosis, comprehensive of neurosurgical and neuro-urological evaluation, and a multidisciplinary follow-up.