O3274: Discrepancies Between Imaging Reports and Operative Findings in Patients with Cloaca: A Call for Expansion of the Mullerian Anomalies Classification

Background: Cloaca is a rare congenital anomaly in females with variant anatomy of the urinary, gastrointestinal, and reproductive tracts. Mullerian structures (uterus, cervix, and upper vagina) may be completely absent, duplicated, or fused to urinary or bowel structures. There is wide variability in the language used by physicians to describe Mullerian structures. To standardize upper reproductive tract terminology, the American Society of Reproductive Medicine (ASRM) created the Mullerian Anomalies Classification (MAC) 2021, which updated a widely used classification from 1988 . The objectives of this study were 1) to evaluate the applicability of the ASRM MAC 2021 nomenclature to patients with cloaca and 2) to evaluate discrepancies between radiology reports and operative findings in describing Mullerian structures.

Methods: A retrospective chart review of all patients with cloaca was performed at a single pediatric institution. Descriptions of Mullerian structures were evaluated in operative notes, progress notes, and radiology reports. These descriptions were then compared to the ASRM MAC 2021 categories. For patients with both imaging reports and described operative findings, anatomy was compared within individual patient charts. Descriptive statistics were used to report findings.

Results: Thirty-six patients with cloaca were identified, and 13 of those (36%) had congenital Mullerian structures that could not be adequately described by the ASRM MAC 2021 terminology. All 13 patients had two hemiuteri that were not connected at all in the midline, including at the cervix, and were not accurately described as uterine didelphys, and 5 of the 13 patients had reproductive anatomy that was connected by a fistula or ectopic connection to other pelvic structures. Uterine didelphys is a classification in the MAC 2021, but separate hemiuteri and ectopic insertion of pelvic structures are not.

For the second objective, 29 patients had imaging available for review, and of those, 13 (45%) had discrepancies between radiologic descriptions of Mullerian structures compared to operative findings. In most cases the uterine anatomy was described as more normal than what was encountered intraoperatively.

Conclusion: Despite the expansion of the Mullerian anomalies classification by the ASRM in 2021, more than a third of our patients with cloaca could not have their Mullerian structures accurately described. Nearly half of patients who had imaging reports available had inconsistencies within the same patient chart. Describing anatomy with accurate and consistent language can improve communication between healthcare providers and may allow patients and families to better anticipate fertility options. Consideration should be given to expansion of the ASRM MAC 2021 to aid in describing the anatomy of patients with cloaca. Widespread adoption of the classification will allow for better longitudinal care of these complex patients.