LETTER TO THE EDITOR
Reply to Reck-Burneo et al.: imaging anorectal
and cloacal malformations
M. Luisa Lobo
Lil-Sofie Ording Müller
On behalf of the European Society of Paediatric
Radiology Abdominal Imaging Task Force
Received: 31 December 2017 /Accepted: 5 January 2018 /Published online: 15 January 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
We thank Dr. Reck-Burneo and coauthors  for their interest
in our recent article. We appreciate their valuable comments
and suggestions concerning our imaging recommendations
for patients with cloacal and anorectal malformations .
Our aim was to present imaging and procedural recommen-
dations based on consensus within the European Society of
Paediatric Radiology (ESPR) Abdominal Imaging Task Force
and following public discussion at an ESPR meeting. We took
into account differences in viewpoints among various
European centers/national societies. A comprehensive review
of imaging of cloacal and anorectal malformations was be-
yond our scope.
We completely agree that a multidisciplinary team ap-
proach is fundamental when treating patients with cloacal
and anorectal malformations. Particularly for patients with
cloacal malformation who require highly specialised recon-
structive surgery, an individualised imaging approach
resulting from close collaboration between the paediatric im-
aging and paediatric surgery teams (including all subspe-
cialties involved) is crucial, and these infants should be treated
in a dedicated paediatric centre.
Classifications are helpful for the majority of conventional
cases, and we agree that the Krickenbeck classification is in-
sufficient for the rarer and more complex cloacal anomalies.
All anatomical structures, including the urethra, must be
identified and analysed. Furthermore, any potential fistulous
tracts must be delineated. Because of their erratic nature and
unpredictable course, these tracts are better depicted, and eas-
ier for the surgeon to understand, on fluoroscopic studies.
Volumetric images can be achieved if rotational three-
dimensional fluoroscopy equipment is available, as mentioned
in Fig. 7 of our recommendations .
For the colostogram, after filling the colon, it is essential to
maintain pressure to allow filling of any potential fistula, as
also stated in Fig. 7 of our recommendations . Dynamic
filling techniques also apply for magnetic resonance studies,
although they may not be equally easily achieved for technical
reasons and particularly in young children.
We also agree that presacral masses must be ruled out, and
this is part of the initial investigation of associated anomalies
starting with a detailed and complete ultrasound examination
of the entire abdominopelvic cavity and the spine. More ad-
vanced imaging such as computed tomography and magnetic
resonance imaging may follow depending on the sonographic
The above highlights how important it is for radiologists
and surgeons to work together for a better understanding of
the imaging needs, technical restrictions and treatment options
for these complicated congenital anomalies.
1. Reck-Burneo CA, Vilanova-Sanchez A, Levitt RMA, Bates DG
(2017) Imaging in anorectal and cloacal malformations. https://doi.
2. Riccabona M, Lobo ML, Ording-Muller LS et al (2017) European
Society of Paediatric Radiology abdominal imaging task force rec-
ommendations in paediatric uroradiology, part IX: imaging in
anorectal and cloacal malformation, imaging in childhood ovarian
torsion, and efforts in standardising paediatric uroradiology terminol-
ogy. Pediatr Radiol 47:1369–1380
* M. Luisa Lobo
Department of Radiology, Hospital de Santa Maria – CHLN,
University Hospital, Lisbon, Portugal
Department of Radiology, Division of Pediatric Radiology,
University Hospital LKH Graz, Graz, Austria
Department of Radiology and Nuclear Medicine,
Unit for Paediatric Radiology, Oslo University Hospital,
Pediatric Radiology (2018) 48:445