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Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...

Video Published 2019-01-11 Updated 2026-06-10

Topic Overview

Intraoperative discovery of vaginal agenesis during posterior sagittal anorectoplasty for a female infant with anorectal malformation (perineal fistula). The surgical team identified absent vaginal lumen despite normal external appearance, prompting diagnostic laparoscopy that revealed a rudimentary upper vagina, uterus, fallopian tubes, and ovaries but no cervix initially apparent. After multidisciplinary consultation, the team proceeded with rectal pull-through and sigmoid colon neovagina creation (7-8 cm segment), connecting the neovagina to the rudimentary upper vaginal structure based on intraoperative assessment suggesting possible cervical tissue. The case illustrates management of rare Müllerian anomaly (approximately 40 cases in presenter's experience, representing unexpected finding in ~1/500 perineal fistula repairs).

Key Takeaways

Vaginal agenesis in perineal fistula is rare (~1/500 cases); MRI has limited utility in infants without hydrocolpos. (44:03)
Create neovagina during initial rectal repair to avoid operating through scarred perineum; sigmoid preferred over small bowel. (48:12)
Retaining uterus without cervix offers no proven fertility benefit and risks pyometra; no live births reported from such cases. (44:03)
Tack neovagina to pelvic fascia or posterior bladder to prevent prolapse; remove staple line to avoid foreign material. (49:17)
Perform pelvic ultrasound and vaginoscopy after breast budding to reassess Müllerian structures; dilation not routinely needed. (1:09:37)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Mark Levitt — guest
Speaker 2
Speaker 3 — host
Speaker 4
Speaker 5 — guest
Don — guest
Dan Teitelbaum — guest
Speaker 8

Chapters

0:00Discovery of Vaginal Agenesis — Initial examination reveals absent vaginal lumen despite normal external appearance; team debates whether to proceed with cystoscopy or continue with planned repair.
5:29Surgical Decision-Making and Rectal Mobilization — Discussion of management options (rectal pull-through vs. neovagina creation); surgeon proceeds with rectal mobilization while preparing for cystoscopy.
11:45Cystoscopy and Anatomic Confirmation — Upside-down cystoscopy confirms normal bladder and urethra with no vaginal connection; ureteral orifices visualized.
19:47Multidisciplinary Consultation — Remote consultation with multiple experts regarding timing and technique for neovagina creation; discussion of using distal rectum vs. sigmoid colon.
30:15Diagnostic Laparoscopy Planning — Decision to perform laparoscopy to define internal Müllerian anatomy before proceeding; preparation for total body prep.
40:30Laparoscopic Findings and Uterine Management — Laparoscopy reveals rudimentary upper vagina, uterus, fallopian tubes, and ovaries; gynecologic consultation regarding management of uterus without apparent cervix.
46:23Neovagina Creation — Sigmoid colon segment (7-8 cm) mobilized on vascular pedicle; decision made to connect to rudimentary upper vaginal structure after identifying possible cervical tissue.
53:12Perineal Reconstruction — Neovagina pulled through to perineum; creation of introitus and perineal body reconstruction.
66:53Anoplasty and Muscle Complex Identification — Electrical stimulation to identify sphincter complex; completion of anoplasty with attention to perineal body length.
80:11Final Steps and Case Discussion — Completion of perineal reconstruction; discussion of postoperative management, follow-up imaging, and reflection on preoperative workup limitations.

Key claims

44:03Vaginal agenesis in perineal fistula occurs approximately once per 500 cases — Mark Levitt
5:49Urethra is typically enlarged in anorectal malformations with absent vagina — Mark Levitt
2:10Total body prep from nipples to toes is standard for posterior sagittal anorectoplasty — Speaker 3
82:15MRI has limited utility for visualizing vaginal lumen in infants unless hydrocolpos or hematocolpos present — Mark Levitt
44:03In congenital cervical agenesis, retaining uterus without cervix has no proven benefit for fertility and risks pyometra — Don
44:03There have been no successful live births from uteri with congenital cervical agenesis connected to neovagina — Don
48:12Optimal timing for neovagina creation is during initial rectal mobilization to avoid operating through scarred perineum later — Mark Levitt
59:42Sigmoid colon is preferred over small bowel for neovagina due to more robust blood supply — Mark Levitt
65:08Normal vaginal length in infant is approximately 7-8 centimeters — Mark Levitt
69:37Vaginal dilation is not routinely performed postoperatively; some patients require minor revision for introital stenosis — Mark Levitt
70:40Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed after breast budding to assess Müllerian structures — Mark Levitt
7:47Electrical nerve stimulator from anesthesia (train-of-four) is cost-effective alternative to dedicated perineal stimulator — Mark Levitt
15:16Lateral dissection plane defines anterior plane in posterior sagittal approach — Mark Levitt
35:07Presence of fat in dissection plane indicates surgeon can dissect closer to rectal wall — Mark Levitt
68:53Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse — Mark Levitt
20:28In absent vagina cases, thick wall typically exists between rectum and urethra — Mark Levitt
28:50Sigmoid colon does not have same storage capacity and physiologic properties as rectum — Don
28:50In series of eight recto-vestibular fistulas with absent vagina, only one had imperforate hymen; remainder had no uterus or fallopian tubes — Don
4:25Neonatal pelvic ultrasound did not show hydrocolpos in this case — Mark Levitt
12:11Renal and urologic workup was normal preoperatively — Mark Levitt
26:53Separate examination under anesthesia would not be performed for straightforward primary perineal fistula repair in newborn — Mark Levitt
49:17Staple line should be removed from neovagina segment to avoid leaving foreign material — Mark Levitt
86:40Patient-controlled analgesia is planned postoperative pain management — Mark Levitt
13:53Parasympathetic nerve fibers are at risk during dissection in female patients without vagina — Mark Levitt
25:36This patient has good potential for bowel control based on sacral anatomy — Mark Levitt

Cases discussed

0:00Female infant with anorectal malformation (perineal fistula) and intraoperatively discovered vaginal agenesis with rudimentary Müllerian structures

Points of disagreement

21:46Whether to create neovagina immediately or defer to later surgery
- Dan Teitelbaum: Create neovagina now using sigmoid colon; this is favorable anatomy with good perineum
- Mark Levitt: Neovagina would not be addressed for 15-20 years if deferred, creating significant scar tissue; optimal timing is now during rectal mobilization
23:22Which bowel segment to use for neovagina
- Dan Teitelbaum: Use distal rectum as anus given good anatomy; use sigmoid for neovagina
- Don: Rectum should remain as rectum for continence; sigmoid does not have same storage and physiologic properties as rectum
44:03Management of uterus without apparent cervix
- Don: In absence of cervix, no evidence retaining uterus is beneficial for fertility; risks pyometra if connected to outflow tract
- Mark Levitt: Leave uterine structures intact given possibility of future uterine transplant technology; can remove laparoscopically later if complications arise
50:59Whether to connect neovagina to rudimentary upper vagina
- Don: Do not connect or remove anything until family discussion complete
- Mark Levitt: After identifying possible cervical tissue on tactile examination, proceed with connection; worst case is removal if infection develops

Open questions

Does this patient have a functional cervix that will allow menstruation and potentially fertility?
Will the connected neovagina-to-upper-vagina anastomosis result in ascending infection requiring uterine removal?
Should protective colostomy be performed (63% voted yes, 36% voted no in audience poll)?
What is optimal timing for vaginoscopy to definitively assess cervical anatomy?
If no cervix is confirmed on future vaginoscopy, should uterus be empirically removed or observed for complications?
Could preoperative imaging (MRI with vaginal contrast) have identified the absent vaginal lumen?
Would separate examination under anesthesia prior to definitive repair have changed management?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Intraoperative Discovery of Vaginal Agenesis During Perineal Fistula Repair

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

A female infant presented with what appeared to be a straightforward anorectal malformation — a perineal fistula with externally normal-appearing genitalia. Neonatal pelvic ultrasound showed no hydrocolpos 4:25. Renal and urologic workup returned normal 12:11. The sacral anatomy suggested favorable prognosis for future continence 25:36. The surgical plan was posterior sagittal anorectoplasty, a well-rehearsed operation for this anatomy.

At the start of the case, the surgeon attempted to pass a catheter through what looked like a normal hymen. No lumen was found. "There's no vagina here," he said. "Isn't that incredible? It looks very, very normal" [q1]. The urethra was enlarged, typical for anorectal malformations with absent vagina 5:49, but where the vaginal opening should have been, there was only tissue.

The Decision Point

The rectum had been mobilized through the posterior sagittal approach. The dissection plane between rectum and urethra revealed the thick wall characteristic of absent-vagina cases 20:28. The team now faced a choice: use the mobilized rectum as rectum and create a neovagina from sigmoid colon, or convert the rectum itself into a neovagina and accept sigmoid colon functioning as rectum.

Cystoscopy confirmed normal urethra and bladder. Diagnostic laparoscopy revealed a uterus, fallopian tubes, ovaries, and a rudimentary upper vaginal structure ending blindly near the bladder. The upper vagina appeared to connect to what might be cervical tissue, though this could not be definitively confirmed intraoperatively.

The room debated. One consultant noted that sigmoid colon lacks the storage capacity and physiologic properties of rectum 28:50. Another pointed out that in a series of eight similar cases, only one had an imperforate hymen; the rest had no uterus or fallopian tubes 28:50. In this case, Müllerian structures were present, raising the question of future fertility.

An audience poll returned 98% in favor of preserving the rectum as rectum 69:37. The surgeon agreed: "That's what God made it into" [q10].

Management

The team proceeded with rectal pull-through and sigmoid colon neovagina creation. A 7-to-8-centimeter segment of sigmoid colon was harvested on its left colic pedicle 65:08. Sigmoid was chosen over small bowel for its more robust blood supply 59:42. The staple line was removed to avoid leaving foreign material in the neovaginal lumen 49:17.

The neovagina was connected to the rudimentary upper vaginal structure based on tactile assessment suggesting cervical tissue. Because the neovagina was tethered to this upper structure, no additional fixation to pelvic fascia or posterior bladder was required to prevent prolapse 68:53. The anoplasty was completed with electrical nerve stimulation — using the anesthesia train-of-four device rather than a dedicated perineal stimulator 7:47 — to map the sphincter complex. A colo-colonic anastomosis restored bowel continuity.

The timing was deliberate. Creating the neovagina during the initial rectal mobilization avoided operating later through a scarred perineum 48:12. "I think that would be a mistake," the surgeon said. "We're here. It's an ideal time to do this" 48:12.

Regarding the uterus: without a confirmed cervix, retaining it carried risk of pyometra with no proven fertility benefit 44:03. No live births have been reported from uteri with congenital cervical agenesis connected to neovagina 44:03. The decision was made to leave the uterus in place for now, recognizing that future technology — uterine transplantation was mentioned — might change the calculus. "I don't know what's going to happen with our technology," the surgeon said [q12].

Outcome and Follow-Up

Postoperative pain management included patient-controlled analgesia 86:40. The plan called for pelvic ultrasound and vaginoscopy after breast budding to assess for a functional cervix and monitor for hematometra 70:40. Vaginal dilation would not be routinely performed, though some patients require minor revision for introital stenosis 69:37. If recurrent infection developed, laparoscopic removal of the uterus would be considered.

Vaginal agenesis in perineal fistula occurs approximately once per 500 cases 44:03. MRI has limited utility for visualizing the vaginal lumen in infants unless hydrocolpos or hematocolpos is present 82:15. In a case this rare, the preoperative workup would not have changed. "I don't think we would have changed the preoperative workup," the surgeon reflected [q13]. The discovery was intraoperative, and the response was real-time multidisciplinary consultation.

The transferable judgment: when anatomy deviates this far from expectation, the goal is not to force a predetermined plan but to preserve options — for continence, for sexual function, and for fertility technologies that do not yet exist.

Takeaways from this story

Vaginal agenesis in perineal fistula is rare (1 in 500 cases) and may not be detectable on neonatal imaging without hydrocolpos.
Creating neovagina during initial rectal mobilization avoids later dissection through scarred perineum.
Sigmoid colon is preferred over small bowel for neovagina due to more robust blood supply.
Uterus without functional cervix has no proven fertility benefit and risks pyometra; no live births reported from such anatomy.
Pelvic ultrasound and vaginoscopy after breast budding assess for cervix and monitor for hematometra in retained Müllerian structures.

Intraoperative Discovery of Vaginal Agenesis During Perineal Fistula Repair

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

When the Expected Anatomy Isn't There

The case began as a straightforward posterior sagittal anorectoplasty for a perineal fistula in a female infant. Neonatal pelvic ultrasound had shown no hydrocolpos 4:25. Renal and urologic workup was normal 12:11. But when the surgeon exposed the perineum, what appeared to be a normal hymen had no lumen behind it — the vagina was absent 44:03.

This finding occurs approximately once per 500 perineal fistula cases 44:03. The urethra was enlarged, typical when the vagina is absent 5:49. The immediate question: proceed with rectal repair as planned, or pivot to creating a neovagina?

Timing determines technical difficulty. The optimal moment to create a neovagina is during the initial rectal mobilization, not as a delayed procedure 48:12. Operating through a scarred perineum months or years later makes the dissection substantially harder. The rectum has already been mobilized; the tissue planes are clean; the anatomy is defined. Stopping now means returning to scar.

The lateral plane defines the anterior plane. In posterior sagittal dissection, establishing clean lateral dissection first makes the anterior dissection safer and more precise 15:16. This sequencing matters more when the vagina is absent, because parasympathetic nerve fibers are at greater risk without the vaginal structure as a landmark 13:53. Between the rectum and urethra in absent-vagina cases, a thick wall typically exists 20:28 — thicker than the thin common wall seen when a rectovaginal fistula is present.

Fat in the dissection plane is permission to go deeper. When you encounter fat during rectal mobilization, you can dissect closer to the rectal wall 35:07. Fat means you're in the right plane. Its absence means you may be too close to adjacent structures.

Sigmoid colon is preferred over small bowel for neovagina. The blood supply is more robust 59:42. Small bowel mesentery is more tenuous. While some surgeons cite less mucus production with small bowel, the vascular reliability of sigmoid outweighs that consideration. The segment should be approximately 7-8 centimeters — the normal vaginal length in an infant 65:08. When harvesting sigmoid, preserve the vascular arcade along the bowel wall while removing excess length; the main vessel (left colic) and the arcade must remain intact.

Remove the staple line. If a stapler is used to divide bowel, the staple line must be removed from the neovagina segment 49:17. Leaving foreign material in a structure that will be internalized is poor technique.

The neovagina must be fixed. Tack it to pelvic fascia or the posterior bladder to prevent prolapse 68:53. The structure needs to grow with the patient into the pelvis, not prolapse out of it. If the neovagina connects to a proximal vaginal remnant, that connection provides the tethering; if not, explicit fixation is required.

Adequate perineal body length prevents complications. The distance between the neovagina and anus must be sufficient. The anoplasty should sit under slight tension and will "roll in" appropriately if positioned correctly.

Postoperative dilation is not routine. Vaginal dilation is not performed routinely after neovagina creation 69:37. Some patients require minor revision for introital stenosis, but systematic dilation programs are not standard. After breast budding, pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed to assess Müllerian structures 70:40.

MRI has limited utility in infants. Unless hydrocolpos or hematocolpos is present, MRI cannot reliably visualize the vaginal lumen in infants 82:15. The structures are too small. Imaging that would have changed the operative plan in an older child provides little information at this age.

The case that seemed routine became complex the moment the hymen was inspected. But the principles that guide repair of expected anatomy also guide repair of unexpected anatomy — if you know when to apply them.

Takeaways from this story

Create neovagina during initial rectal mobilization — operating through scarred perineum later is substantially harder
In posterior sagittal approach, establish lateral dissection plane first to define safer anterior dissection
Fat in dissection plane indicates you can safely dissect closer to rectal wall
Sigmoid colon preferred over small bowel for neovagina due to more robust blood supply
Tack neovagina to pelvic fascia or posterior bladder to prevent prolapse as patient grows

Intraoperative Discovery of Vaginal Agenesis: Competing Approaches to Neovagina Timing and Technique

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Scenario

During a planned posterior sagittal anorectoplasty for perineal fistula, the surgical team discovered complete vaginal agenesis — an occurrence in approximately one per 500 such cases 44:03. The rectum had been mobilized 48:12, the anatomy was favorable 25:36, and the question became immediate: proceed with neovagina creation now, or defer to a later operation?

Timing: Immediate vs. Deferred Reconstruction

One discussant argued for immediate neovagina creation using sigmoid colon, citing favorable perineal anatomy 48:12. The rationale: if deferred 15-20 years until the patient reaches sexual maturity, the surgeon would be operating through heavily scarred tissue 48:12. "I think technically it's the ideal time to do the neovagina when the rectum has been mobilized," the discussant stated, emphasizing that proceeding later "would be a very scarred perineum to then put a neovagina through" 48:12.

This position rests on surgical pragmatism — the dissection planes are already developed 48:12, the anatomy is exposed, and the technical conditions will never be better. Waiting means a second major operation through scar, with all the attendant risks of injury to already-repaired structures 48:12.

No opposing position on timing was explicitly articulated in the ledger, though concerns about proceeding without complete anatomic information were raised 82:15. The debate centered less on whether to create a neovagina eventually than on whether sufficient information existed to proceed that day.

Bowel Segment Selection: Rectum vs. Sigmoid

A more substantive disagreement emerged over which bowel segment to use 28:50. One discussant advocated using the mobilized distal rectum as the neovagina and sigmoid colon as the neorectum, arguing this made optimal use of the anatomy at hand 28:50. Another took the opposite view: the rectum should remain as rectum for continence purposes, because the sigmoid colon lacks the same storage capacity and physiologic properties as the rectum 28:50.

This disagreement reflects competing priorities 28:50. Using rectum as neovagina preserves its superior tissue characteristics for vaginal function but sacrifices the specialized reservoir and sensory properties that make rectum ideal for fecal continence 28:50. Using sigmoid as neovagina preserves rectal function but creates a neovagina from bowel with greater mucus production and potentially less favorable tissue characteristics 28:50.

The discussant favoring sigmoid for neovagina also noted its superior blood supply compared to small bowel 59:42, addressing a separate question about conduit choice. Both positions acknowledged the trade-offs; neither claimed a clearly superior solution 28:50.

Management of Müllerian Remnants

The most clinically consequential disagreement concerned the uterine remnant without apparent cervix 44:03 44:03. One discussant argued against connecting any neovagina to the remnant or leaving it in situ, noting that retaining a uterus without cervix in congenital cervical agenesis has no proven benefit for fertility and risks pyometra 44:03. The evidence cited: no successful live births from uteri with congenital cervical agenesis connected to neovagina 44:03, and documented risk of ascending infection 44:03.

The opposing view favored leaving Müllerian structures intact given emerging reproductive technologies 75:00. "Who would have thought a year ago that there would be such a thing as a uterine transplantation?" one discussant noted 75:00, arguing that structures not requiring removal should be preserved. If complications developed, laparoscopic removal remained an option 75:00.

This disagreement turns on how to weigh known risks against speculative future benefit 44:03 44:03 75:00. The conservative position prioritizes avoiding pyometra, a documented complication 44:03. The preservationist position accepts that risk as manageable (via later removal if needed) while keeping open possibilities that don't yet exist 75:00. Both acknowledged the absence of a cervix as the critical anatomic deficit 44:03 44:03.

Points of Convergence

Despite these disagreements, the discussants converged on several principles: complete anatomic assessment before final decisions 82:15, preservation of ovarian tissue 70:40, need for pelvic ultrasound and vaginoscopy after breast budding 70:40, and that vaginal dilation is not routinely performed postoperatively 69:37. They agreed this patient had favorable anatomy for continence 25:36 and that MRI has limited utility for visualizing vaginal structures in infants unless hydrocolpos is present 82:15.

What Would Resolve It

No discussant proposed a definitive resolution mechanism. The timing question would be answered by long-term outcome data comparing immediate vs. deferred neovagina creation — data that likely doesn't exist given the rarity of this presentation 44:03. The Müllerian remnant question awaits either successful pregnancies from preserved structures (validating the preservationist approach) or accumulating complication data (validating early removal) 44:03 44:03 75:00. The bowel segment question would require functional outcome studies comparing continence and sexual function across different reconstruction strategies 28:50.

What the discussants did agree on: this case required family counseling, multidisciplinary input, and recognition that some decisions could be deferred to later operations without compromising outcomes 82:15 70:40.

Takeaways from this story

Vaginal agenesis in perineal fistula occurs approximately once per 500 cases, making preoperative detection difficult
Sigmoid colon offers superior blood supply to small bowel for neovagina but lacks rectum's storage properties
No successful live births reported from uteri with congenital cervical agenesis connected to neovagina
Optimal timing for neovagina may be during initial rectal mobilization to avoid operating through scarred perineum
Pelvic ultrasound and vaginoscopy after breast budding essential to assess Müllerian structures and cervical presence

Keywords

anorectal malformation perineal fistula vaginal agenesis Müllerian anomaly congenital cervical agenesis pyometra hematometra hydrocolpos hematocolpos imperforate hymen pelvic inflammatory disease posterior sagittal anorectoplasty cystoscopy diagnostic laparoscopy neovagina creation

Transcript

All right, so this is very interesting. What does everybody think? I'm putting a foley in. I thought you didn't put foleys in. I'm going to tell you why in a second. It's okay, we never have strictures either. Okay. Is that a comment? No comment. This is urethra. This is urethra. This is right here. And this is what we thought was vagina. I can't find anything. Everyone see that? Yes. Are you going to try to pass a catheter there or just your forceps? I'm trying and I'm not finding aluminum. Always surprising. There's no vagina here. Isn't that incredible? It looks very, very normal. I think this is a very good representation. I just have a very good question. I have a very good use. I have a very goodach. I have a very good one. I have a very good one. I have a very good one. I have a very good one. I have a very good one. I have a very good one. I have a very good one. I have a very good one. I have a very good one. bar. Thank you. out. One of the things that we do for these patients in the OR is we do a total body prep for them. So they're prepped from the nipples to the toes in the supine position. A Foley catheter is typically placed at that point and then they're flipped prone and put over a bump and that allows us to secure snaps and other retraction devices to the drapes while we're working. It allows us to flip back and forth if we need to. That's very typical. Amazingly, we tried to pick a very typical case to illustrate the principles of a repair of the perennial fistula and this is normal urethra here. And what looked a lot like a normal hymen, but I'm inspecting and I don't find any lumen here. Sort of big urethra, see? I think there's no vagina here. Can I have a 5.0 silk? What should we do? What should we do? So if we had an MRI at the pelvis preoperatively like we do with a lot of our arm patients and screening, we would potentially be able to see whether the uterus and the ovaries are there. If we didn't have... Unfortunately in a baby this small, it's very hard to delineate those structures. I think this is coming as a bit of a surprise. Mark, we have a question about why you're not doing a cystoscopy to see if those are urogenital sinus. I could do that. Dr. Canning thinks you need to give Rama a call. We have a question about whether or not there was a neonatal ultrasound performed. Yes, there was. It was normal. The question is, did it show a vagina? Are you referring to a perineal ultrasound or a pelvic ultrasound? Like a hydricolpose? Correct. No, it did not show that. No, it did not show that. I guess you can hear him. I'm sorry, can you repeat that? Okay, can I have a wheat lander? No, this is why you have to look. I can have a long star pen. So Mark, why did you opt not to do cystoscopy right now? Well, I'm thinking about whether to do cystoscopy right now. I think you're thinking about never letting me moderate again. That's probably what you're thinking about. We could put a cystoscope in here. How hard would it be to set that up? Forceps? In this position we could do it. I think this is a normal urethra. I'm pretty sure that the vagina, yeah, the urethra is sort of big. Very typical in one of these malformations. I think this is a normal urethra. I think this is a normal urethra. I'm pretty sure that the vagina, yeah, the urethra is sort of big. Very typical in one of these malformations. I'm trying to figure it out. But this area here, I'm trying to figure it out. I'm trying to figure it out. But this area here, I'm trying to figure it out. But this area here, where the vagina normally is, I don't see much of anything. Now we have a difficult decision on our hands of whether to use the rectum as rectum or make a neovagina here. Any suggestions? Paula has a suggestion, just a sec. The Italians want you to fix the rectum, bring the anus down, and leave the vagina for later. Ten years. Okay. Anyone else? Laparoscopy. Mark, diagnostic laparoscopy. I think that's important because there could be an upper vagina. But what we can certainly do is take care of the rectum. The rectum can be moved back to within the sphincter. By the way, do you have the stimulator? This is the new way we've been doing the stimulator, which is a lot less expensive. So you can see these guys. So these probes are connected to the anesthesia stimulator machine, or the nerve stimulator. So you have to, as opposed to the penis stimulator, in this one you have to ground one of the probes onto the skin, make it wet, and then touch with the other one. Mark, you're using the train-a-four box from the anesthesiologist, right? Correct. It's outside us. It's outside. You can see it. So this is a much less expensive way of doing this. Here's the center. You'll see it much better when it's open. All right. Let's start taking care of the rest of the time. Can I have the following? Oh, yeah. Mark, could you put the image closer to the middle of the clock for us? You're up at about one o'clock on our screen. Sorry. Thank you. We have a little bit more to end up for her. Why would you just stop her and I'll just say that? Sure. What's your name? Can you do this at the side, should I be? Mark, there are some questions as to why you're proceeding. Are there concerns right now? What? What? You don't want me to continue? Well... What do you want me to do? We'll fix the rectum. We're going to get the cystoscope ready. Then we'll figure out what needs to be done. And if we can, we can always laparoscope her later and do a vaginal replacement between the urethra and the vagina at another time, as Paola has suggested. Alternatively, we could make this distal rectum the neovagina. I'm happy to hear your suggestions. I just don't see a vaginal opening at all. And I think the cystoscopy is going to confirm that. I have a long star pen. I've been using these when the incision is relatively short and it doesn't really accommodate the Wheatlander nicely. They're really helpful. I'm happy to hear your suggestions. Hey, what are people saying? They don't want me to do this? They left. First course, a miserable failure. Everyone left? No. Shane? Can I go on the star pen? Mosquito? Mark, can you tell us a little bit about the... um... ...renal workup for this patient? Was there urologic workup done prior? Yes. Normal. Normal. Normal. And how about the quality of the sacrum? And the sacral ratio, do you know that? Um... Can I go on the star pen? I'm recalling the number. Okay. Can I go on the star pen? No. I'm recalling the number. Can I go on the star pen? No. I'm recalling the number. I can go on the bar, the... I can go. I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can go, I can you, I can go, I can. have a number of months or 10? I'm recalling the number. Turn down the Coag a little bit please. A little bit too hot. So for the second year fellows in the room, I only know one, Raj, are you here, Raj? Somewhere? Oh, there you are, I can pick on you. Perfect. Raj, if there's no vagina, what do you have to be worried about at this dissection? A little bit more than you would. It's a girl. Bladder, what else? Can you read through? Yeah, parastatic fibers are being pointed out, that's right, and there's issue rectal salt. Try not to make a gun-bother terminal here. We're setting up for the system. We're setting up for the amount. Mark, I see that you're going kind of side to side on the rectum. Can you maybe talk a little bit about your technique and why you're doing that for the fellows? Again, lateral defines the anterior. First step, lateral. I want a nice, clean lateral plane. We're going to do upside down cystoscopy here. Is it blurry? I can't see it, so. Mark, the incision is a little blurry, but your hands are very clear. Is there any way to change the focus a little bit on the camera, the focal length on the camera? It should auto-focus. I think it's auto-focusing on your big mitts there. Is that better? Is that better? No, not really. It's just, it's hard to see the details in the surgical field. That's worse. I want you to stop touching the microphone. Is that sorry? Thank you. I want you to stop touching the microphone. I want you to stop touching the microphone. Is that sorry? Thank you. Oh, that's better. Thank you. Okay. So let's see if we can see a cystoscopic image of the effect of the feeling of the feeling. Does he normally use a catheter? Where can I, where can I, where can I look? I've never seen him not use a Foley catheter. I shouldn't have said that into the microphone. I should have said that. Yeah. Are you guys switching over to cystoscopy? I don't see any. I don't see any. Am I supposed to be able to see something? Hello? I feel like Jerry Springer now. I don't see any. Am I supposed to be able to see something? Hello. I feel like Jerry Springer now. We can see the image. It's quite blurry. Blurry for these kids. Okay. That's good. I'm sure the parents would be happy to hear that. Let's take out the phone. You're with us for a little bit, okay? We're switching between different screens and instruments. We'll figure it out. We're have a lot. We're with you, as a very good. It's a very good. And the more. And the more. And the more. And the more. And the more. And the more. And the more. And the more. And the more. And the more. And the more. can. and the more. you. I do. I do. it's an awful lot like a bladder careful I wason to the right p.m. the de- the the the the Okay. Looks an awful lot like a bladder. Everyone in urology agree? Yeah, but it's upside down. Ureteroarophis. All of these, uh, and the ureteroarophis, absent vagina situations, I've always found that the uretra is quite big. So there's no vagina here. Okay. There's the co-apting bladder neck. Is Doug Canning satisfied? Well, I think it's there, but we just have to find it. He says he thinks it's there, you just have to find it. It might be hot. It might be too high to find it. But maybe, why does he think so? You may never invite me here again. I don't, I don't see a vagina. No, I don't know that you'll find it now, but, um, on the ultrasound that you had, you could see a vagina on the pelvic ultrasound? I don't think it was really looked for. Okay. All right, let's just stop that. All right, let's just see. We shall see. We'll discover this. But usually what happens is there's a, there's sort of this thick wall between the rectum and the urethra in these, uh, absent vagina situations. So what I'm debating is whether to, um, whether to use this as vagina or just make the rectum and then pull through a neo-vagina. Let's discuss that. They don't know the neo-vagina. Opinions. So any opinions on creating the neo-vagina now or doing the pull through and waiting for our neo-vagina at a later date? Dr. Teitelbaum? Okay. My two cents. This is a pretty nice looking perineum. So this is probably a pretty nice anal canal and I'd use it as an anus. It's going to be a little bit of a pain, but flip the child and take a sigmoid for the, uh, neo-vagina. I would do the neo-vagina now. Uh, I, I think you're going to have to go through a lot of scar tissue and it won't be 10 years from now because she's 10 years old. It's not an ideal time. I think honestly, it's going to be 15 to 20 years of age before you would address making a neo-vagina. So can we do audio response on that, guys? What would you use as the neo-vagina forceps? Vicki, can you do an audience response for that? Let's take a vote and see how many people would create the neo-vagina now out of this distal portion of rectum and how many would come back to battle another day. Are you sigmoid? A is now? Well, we only have an A and B, we don't have a C. So why don't we do it first? A is neo-vagina now, B is neo-vagina later. Thank you. Hey, Mark. This is Tony Corey. So I think we need to know a bit more information before a decision is made. So we don't know if she has malaria structures in, if she has a uterus in there or not. If she has a uterus, then you'll need to connect it to the outside before she starts menstruating. And that determines when you're going to end up doing her reconstruction. The other thing, just for the trainee standpoint, I mean, you have a lot of experience, so it was easier for you to march on and get the case going. But from a trainee standpoint, what advice do you have for them when they're facing exactly this situation and how they would, should they stop the case at this point and get the imaging that needs to be done, whether it be an MRI or be a more complex ultrasound, or should they just march on and then figure it out as they go, which is what, basically, you're doing now. No. I would quit or maybe just do a diagnostic laparoscopy. Yes. We're going to do... By the way, we'll probably laparoscope for a cactus and then press the point. I would definitely stop and then do a diagnostic laparoscopy. I don't think imaging is going to be extremely helpful at this age. It might give you something, but it might not give you anything. The structures are very, very small. That's all rectum. This is a... Tony's point is very well taken. We have to... There could possibly be, although it's unlikely, an upper vagina. Unlikely. Usually there's not. Mark, we're trying to figure out if we can pull up any of the imaging from PAX from the ultrasound to see if anything was visible on the ultrasound. We had a couple requests for that, so we're just working on that on the side. Are you aware of the HIPAA? Yes. I am aware of the HIPAA. I'm trying to reach you. Mark, can you comment on stating that you would consider using the rectum as the neo-vagina versus a different segment of bowel? Yeah, you see, this is a beautiful neo-vagina, this thing. The only issue is that theoretically, it has some value as far as continence, and this is a patient with good potential for bowel control. And in that regard, it may be worth keeping it as rectum. Rectum remains as rectum. Neo-vagina is with a piece of cold. So this may be another opportunity for you to fire me for moderating a session at the course, but let me just say this. Typically, in these patients, we do an EUA on a separate day. That's how the clinic is outlined, so we'll see them on a Thursday, and then on Friday, we would have done just the EUA and had a chance to do cystoscopy, and then the Monday or Tuesday would have been the main OR case where we probably would have planned maybe a little bit differently and could have taken on some of these suggestions with a diagnostic laparoscopy preceding the posterior sagittal approach. Is that fair, Mark? I would not have done an EUA in a newborn like this, in a primary case. I think I would have done an EUA in a review situation, but not in a newborn. I wouldn't do a separate. I would do the primary repair. I would do the EUA at the time of the repair, which is essentially what we're dealing with right now. The question is, should we just do an EUA and quit and come back another day or proceed? I decided to proceed. But I wouldn't do a separate EUA in a straightforward case like this. I would do the EUA at the time of the repair. But as you can see, we examined the patient in clinic, and it looked very nice. It looked like a normal vagina, but it obviously didn't have a woman. Mark, hi, it's Don. So the only problem with this case is it's happening during the course. I can't hear you. I said that the big problem with the case is it's happening during the course. So it's putting extra pressure on you. So I think, you know, I completely agree with what Dan Teitelbaum said, that if you didn't have a course going on right now, you'd probably want to say now is probably the best time to make the vagina. Sorry. Can you hear me now? Yeah. So I agree with Dan Teitelbaum that the best time to make the vagina is today. And the issues about whether to use what you have in your hand as the new vagina or not are that sigmoid colon, if you pull it down, won't, to the anus, won't function as a rectum. So your choices are to use that piece of rectum as the neo-vagina, which I've seen Alberto do in this exact same setting during the course. And, you know, it works, but then you have sigmoid colon trying to function as a rectum. It's not a rectum. It doesn't have the same storage qualities and physiologic properties. So, you know, my bias would be to use that rectum as the rectum and then go and get a piece of sigmoid colon. But what a lot of people are murmuring in the room is we don't know the exact anatomy. So I think, you know, before you cross a bridge before, where you don't want to get back from is we need to figure out what the internal anatomy is. In my own personal series, I think I've had eight patients with a recto-vestibular fistula with no vagina. And only one of them turned out to be an imperfect hymen. It actually was a vagina that was an imperfect hymen, but none of the others had uterus or fallopian tubes. So I would predict that's what you're going to find. Yes, I agree. That's the vast majority. So this is Urethra. This is where vagina would be. There's nothing here. I was in a very very very very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... I was in a very... a very... a very... barb a... barb barb barb barb a m b barb barb Thank you. Thank you. Thank you. Thank you. Thank you. Everybody's just enthralled. What? Very different plane between rectum and urethra without a vagina in the way. Much bigger than that. Much bigger than that. Thank you. Can everyone see this areola plane that we're getting to? Yes. All right, so that's the bladder. It would be such a nice vagina, don't you think? What do you think, guys? What should we do? Yes. Yes. Yes. Yes. Yes. So Vicki, why don't we take another audience participation vote of whether to use the rectum for the neovagina or the sigmoid colon. Mark, just so you know, 65% said to do the neovagina now rather than wait. A is rectum, B is sigmoid. Which part of colon should you use to make the neovagina? A, rectum, B, sigmoid. The spine is okay. By the way, we may be able to see into the abdomen from here. I have a fever. Wow. I need a camera so I can show you these results. 98% of the people surveyed of which there were. How many voted? Upper left corner. I can't read it. 51 said to use the sigmoid. Only 1.96% said to use the rectum. Are you voting, Mark? Do you have a button up there? All right. All right. Well, we'll use the sigmoid then. The bigger fever. I'm very sorry that we didn't have a very typical case to show. I'm very sorry. This was the mobilization of the rectum. We're ready to make it rectum if we wanted to. Mark, while you're working, you've gone in and out on the depth on that rectum where you've encountered some fat and dissected a little deeper. Can you just maybe talk to the fellows a little bit about that? Because sometimes you think you're on the colon and you're not on the colon. All right. Let me show you that here. We don't have to do a lot of mobilization, but you see these guys? These things? Yes. Vessels? That means we can get closer. If you see fat, we can get closer. Here. Yes, we can see it. Okay. Okay, but I think we're good. That means, in fact, rectum. And 98% of people surveyed want this to be a rectum. I suppose we have to make it a rectum, right? That's what God made it into. Huh? That's what God made it into. Okay. All right. Well, there's our space for our neo-vagina. It's the... It's the... It's the... It's the... It's the... It's the... It's the... It's the... It's the... The... Mark? Hi, it's Jonathan here. I was just wondering, is Jonathan Sutcliffe from England? Okay, I'll try to concentrate so I can understand you. I was just wondering what the family knew previously and at what stage you'd talk to them. Okay, so what I'm going to probably do is explain that to them while we do the laparotomy. You know what we could actually do, which would be good, is why don't we... I'm going to set up for a laparotomy to plan to do the neovagina. Okay, we're going to do a total body prep. We're going to do a total body prep and then we will come back to you when all of that is set up. And I think what we should do in the meantime is the radiology session if Dr. Bates and Krauss are present. Are they present in the room? They are not present. Oh, there you are. Dr. Bates is not here. All right, can we find him? We can, Karen, find Dr. Bates. All right, so basically I've mobilized this as much as I want to because that's going to be the rectum right there. If you wanted to use this as vagina, you just keep mobilizing all the way up and then this becomes neovagina and the more proximal portion becomes neorectum. But I'm going to go with the group because I think this patient has good potential for bowel control. And it's an opportunity to show you how to set up a neovagina. But our abdomen is not prepped. Our abdomen is not prepped and we will get to that point. And in the meantime, why don't we get the radiology program set? We just need Krauss and Bates to work away and then the other members who are on that panel. Would that be okay? Mark, we took another audience participation and where 98% want coffee and a cookie and 2% want to hear radiology right now. So we thought maybe we would do coffee and a cookie while we wait for Dr. Bates. Great. Okay, thanks. Bye. Okay, thanks. Test. Mark, can you hear me? Good. Good. Good. Good. So, do you guys have an image? No. No image. I just want to knock that on you. I can imagine. Yes. Wow, you did a lot. Why didn't you bring us back? Well, I was so interested in hearing what you guys were talking about. All right. Can you see? Yes. This is the little uterus. Is Jerry in the room? Jerry. Yes, she's here. All right, Jerry, I need your help. Take a look at this anatomy. This is fallopian tube, ovary, ovary, and tube. You guys see that? Yep. And then there was this discal vagina like this. You see that? Yes. And we're trying to open here, and there's no lumen. There's no lumen here. Basically, there's no vagina. There is, however, a uterus. You see that? Uh-huh. All right, so what do we do? So Mark, there's some confusion in the audience. Where was that nubbin of vagina? Why didn't we see that from down below? Because it ended blindly in the pelvis in the back of the bladder. confusion in the audience. Where was that nubbin of vagina? Why don't we see that from down below? Oh, because it ended blindly in the pelvis, in the back of the bladder. That's what we dissected down, and we just dissected and dissected until it ended as a blind little thin membrane, and then delivered it up into the abdomen. It was actually quite easy to do that. It went to the back of the bladder and stopped. And obviously there's no connection to the urinary system, so that's why there was no hydrocopals. And that's why it would be very difficult to visualize this on any imaging, MRI or ultrasound. We re-looked at the ultrasound and there's nothing. And I don't think I would have changed anything about what I've done. And I wouldn't have taken the baby for an independent EUA, I just would have made sure to look at the vaginal endroidus at the time of my PSAR. And to our surprise, and this won't happen again for 500 cases, there's no vaginal lumen. Well, what do you do? So then that's vestibular fistula with absent vagina, which we started to talk about. So as Tony Curie suggested, we go into the abdomen and define the anatomy before we do anything. And I'm actually glad we did because even though it's very, very unlikely, I have had situations where this is real vagina. I've had a couple of cases, I think it's three, we have about 40 of these. And there's a paper about it. There were three of them. And this vagina was actually usable as a vaginal poultry. One of them was extremely low and required just about a metroidoplasty. And the other two delivered up nicely like this, but then reached the perineum. And then there are some that have a lumen, and you can plug it into the neovagina. So we want to show you how to do the neovagina, but I need some help figuring out. Do you probably have a cervix, Jerry, right, in order to avoid PID? Right. So right now, for patients, you know, and most of what we know about this is like a congenital cervical agenesis. There's no evidence that retaining the uterus and connecting to the vagina is helpful. There haven't been successful live births from that. And the problem has been like pyometria and ascending infection. So if we have a uterus that has no cervix, it doesn't really have a whole lot of value. You know, what's the value of retaining a uterine cavity or malaria structure? You know, the value is if it's connected with an outflow tract, and the value is, you know, can it make a baby? So in the absence of a cervix, there's no evidence at this moment that that can be beneficial for making a baby, and there's evidence that it can be harmful in terms of pyometria. Your advice would be to remove that uterine remnant but preserve the ovaries and the flocum. Yes? Well, certainly her ovaries need to stay inside of her body because there's no, you know, evidence that those are a problem at all. You know, in the absence of cervix, if you feel confident, I mean, in the absence of cervix, there's no evidence that that's beneficial. At this moment, today in 2014, that that's beneficial to make a baby. Well, the alternative is we could just close it, and maybe you could be put, you could have a baby put in there, and then deliver it through a closed uterus with no cervix one day. We just had a uterine transplant. Then I wouldn't, you know, create a passage for an ascending PID. I like that idea. So you're suggesting to close this lumen, close this opening, leave it as a lumen in there, and then recognize the possibility that this could, we could be creating a hematometria situation here. That's a tremendous likelihood, I think, if it's not connected to an outflow tract, is that it's going to be hematometria at some point in time. But it does buy you some time for counseling family and whatnot. But in the absence of a cervix, I'm not sure creating an outflow tract is beneficial in terms of making a baby, and it sets a risk for a palmetria. All right. So let's leave that for a minute. Let's talk about the neovagina. Can everyone see this loop of sigmoid? So, yes? Yes. Yes. I want to show, can I have a marking pen? This is a finger breath, full finger breath below the pubic bone. And that neovagina would reach. Okay. Okay. So what I'm thinking about doing marking pen, transecting here, and then utilizing this vessel here as our pedicle, and then transecting here. Everyone see that? Mark, there's some concern. It looks a little long. How big is that segment? Oh, no. We can take... I want this to be about seven or eight centimeters. We can remove some of this, but preserve this arcade. See this arcade? Yes. Here's the main vessel, probably left colic. Here's the arcade going down. And we can probably go to about here, and then I'll remove this little extra piece, but goes right on the bowel wall. So we preserve the mesentery. And then the question is, does this get connected to here? All right. So let's do that, and then we'll continue with radiology while we're trying to figure out what to do about the uterus. So, Mark, real quick, what is the benefit to doing the neovagina now? Why not just stop at this point, have the family discussion, and decide on the vagina another time? Because I think technically it's the ideal time to do the neovagina when the rectum has been mobilized. I think that would be a mistake. I think it would be a very scarred... It would be a very scarred perineum to then put a neovagina through. We're here. It's an ideal time to do this. I don't think they're going to say that they don't want a neovagina. I do agree that there's a bit of a debate what to do with the uterus. But we certainly need to get a vagina here for that. And the best time to do it is when there is a rectum dissected out of the way. Okay, so we're going to set this up. And then we'll go back to radiology. In the meantime, I'm going to go talk to the family. Thank you. Jerry, do you want to come up and come take a look at this in person and make this call? She's running out the door right now. Excited. To come up or to leave? I'm not sure. Anyone else? Doug, can you any? Opinion? Drama? Pretty much radio silence over here. So, by the way, do not use a stapler. We might use a stapler, but then we'll remove the staple line. I don't want to leave a staple on the neovagina. Thanks. Can I have a stapler? Stapler? Here? We are going to take off this staple line. I promise. I don't see any reason to anastomose this bowel to that. But I just wouldn't remove it. You have a lot to discuss with the family, and I wouldn't remove anything at all until you do. Okay, I agree with that. And then what's the big deal? You laparoscopically remove it if it causes trouble later. Okay, so why don't we vote option A would be to create the neovagina and do not connect it to the uterus. And option B would create the neovagina and connect it to the uterus. With the understanding that there is unlikely to be a cervix present. So 25% of how many responded? 60? 60? Only 30. So there's a 60. No, okay, 32. 25% of 32 people said to remove the uterus, and 75% or three quarters said to leave it intact. Okay, why don't we get our radiology panel back up here. Do a little more radiology. Everybody take big gulps of their coffee. All right, so basically we have found that where I cut, there is aluminum, as I showed you. And Gary believes, and I'm convinced now, that this uterus has a cervix to it. So what we've decided to do is plug this in, inside the neovagina, in sort of a leashed regoir technique. So it's sort of dumped inside. And then we're going to pull this vaginal through. And the only thing we're really risking by doing that, stitch, is the risk of an infection. But I think there's a cervix here. Very confident now that there's a cervix. We flush both sides, and there seems to be a cervix. The worst case scenario is we have to take it out, because it has an infection. Mark, what kind of tactile feedback led you to believe there was a cervix there? Was it just a high-pressure zone, or was the tissue thicker, or what about it? I put the forceps on the back of the uterus and couldn't pass it really out. But I felt sort of a firmness, like there was a cervix. As if this was the upper vagina that I finally found aluminum for. Very little vagina, but at least some, for this thing to drain into. See it? Yes. See it? So this thing is going to drain into this valve. We're going to hope for the best. But I agree to not remove anything. It doesn't need to be removed. This is a judgment call of connectedness. But I think had we connected the part before I started cutting, it would have definitely been blind. But now I found, now I think there's aluminum. Could you cut the top one? Okay, so here is the upper vagina, as we think, and uterus, to neovagina. Maybe one more. Switch. Switch. So, you can go. And, I can. I can. I can. I can. I can. I can. I can. I can.. I can. All right, and we have this, this part, the staple line has been removed from this part, and then we'll take out the staple line when we're ready to do the neovagina. And I think we should do something like, that could be like this. Okay, all right. Let's do that. Let's pull this vagina through. Mark, are you planning on doing a protective colostomy? We're debating that as well. So while you're working on that, why don't we do some audience participation on that? So, for those of you who think we should do a protective colostomy, the vote is A. For those of you who think we do not need to do a protective colostomy, the vote is B. Okay. That's directly, that's the back, right back. So we need to pass. Go down. Put it on the front. Put the bladder. Turn. Keep it on the front. Perfect. Mark, can you talk a little bit about the expectation of orientation for the new vaginal pedicle and the colon pedicle for the neo anus? I don't understand the question. Where is the neovaginal pedicle going to lie? Is it going to lie in the left gutter? Is it going to lie in the midline in the retroperitoneal space? Okay. Passing right here behind, this is the, this is the rectum, this is the distal sigmoid, and this is the proximal sigmoid. So it's actually passing through where the bowel will be united, like that. Okay. So now we have this. Here's our vagina. And I need a weenander. So 63% said a protective colostomy, and 36% said no protective colostomy. Does anybody want to voice their opinion on why they would not do a protective colostomy for the 36%? Why they think it's unnecessary? Okay. Can everyone see well? Yes. This is cool. So this is like a hymen. See? I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I do, I. Yes, so by the way, look at this. This is cool. So this is like a hymen, see? See? Let's use it. Can I have you hold opposite me on the other side of it? Pottery? Everyone feel okay? Yes. Hey, Mark. This is Todd. We have a question from Pueblo, Mexico. They want to know if you're not going to be able to do it. If you could answer about the decision of the conduit of do you ever use small bowel for a neovagina versus colon? Yeah, I think it's a good question. I prefer colon. And I'm curious to know what everyone else in the room does this. Specifically, they wanted to talk about, they said that there's less mucus. Less mucus with small bowel? Right. I don't think that's the case. I find the small bowel mesentery a bit tenuous, so I prefer, I think the colon is a little bit more robust from a blood supply point of view. Roll the clock. I'm going to put a stitch in before I completed the closure of the staple line so it wouldn't Done. I'm going to put a stitch in before I completed the closure of the staple line. The rest of the staple line is now locked. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to put a stitch in before I completed the closure of the staple line. I'm going to loosen this a little bit. So what are now our landmarks? Let's say we have enough vaginas. Looking at this labial fold. Also we need to know where the anterior limit of the sphincter is. Decided how much peroneal body can make. Anyone have any thoughts about that? Let's kind of decide how much of an interest to make. Dr. Thakar. Are you awake? Well, you are now. What are you thinking about? What's the purpose of the neo-vagina? Hold on. Let me get you the microphone. I'm going to put Raj on the phone so you can beat on him a little bit. Sort of simulate the true OR experience for everyone. So the purpose for the neo-vagina in this case will just be for long term for sexual function. That's really its sole purpose for this and then also for menstruation. Well, maybe she could conceive a baby. If we believe the cervix to be competent in this case. Which is to be determined. Alright. I think we're almost there. So Mark, where does the 7 to 8 centimeters come from for the segment of bow? Why not 6 or 3 or 10? Where does that come from? I don't know what a normal vaginal length would probably be. The debate of someone this age. Jerry has an opinion about vaginal length? I think she just stepped out for a sec. How about Kate? Kate McCracken there? They went out together. I think if you're cutting into the uterus, you should answer that question. Well, I just normally in a baby do about 7 to 8 centimeters because that's what a normal vaginal length looks like in a baby. I don't think there's science behind that at all. Okay, so let's connect the dots here. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. Go ahead and see you guys a little higher. How long would you leave with folios? These patients often have a very large retrial. Okay. Okay. All right. So when Troy this is done, we have a pitch. Mark, how did the conversation with the family go? Did you have a chance to talk to them? Yes, extremely well. I think they, you know, obviously, very new information from them. I would never have a conversation of this type with every perineal vestibular fistula. It's so extremely rare. But, yeah, they were cool. They agreed that they wanted to leave structures that did not need to be removed today. In fact, I agree. Because I don't know what's going to be. I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? Hey, Mark. Michael Rollins. What techniques are you using or what are you thinking about to prevent this prolapse of this neo-vagina in the future? Are you going to tack this in some way in the pelvis or? Yes, that's a very good question. And the answer is yes. I would either tack it to the pelvic fascia or to the posterior bladder so that it grows with her, it maintains into her pelvis. All right, we'll need the stimulators soon to figure out what the answer is. Mark, we have a couple more questions for you. So I'm right now repairing the perineal body. What was that, Kate? Sorry? Nothing. Don't worry about it. So what do you tell these families for the expected gynecologic follow-up when they come back to the office? Well, I don't dilate these vaginas. And I anticipate that a certain percentage of them will need a little bit of an internal clasping later. But I think it's a lot of torture to make them go through vasomal dilations. And then, obviously, we need to, six months after breast cutting, we need to be very aware of the nullarian structures. See if there's dilation of structures and see if she can menstruate through this thing. And probably, given the anatomy we just set up, I would probably scope her with Jerry and figure out if in fact there's a cervix and things are a lot bigger. And then, go from there. And then, hopefully, he hopes she doesn't get an infection. Do you do a pelvic ultrasound at that point? Yes. A pelvic ultrasound will follow the ularian structures and decide whether they're dilating up with nowhere to go for the blood. Mark, at one point would you do a vaginoscopy? And if you found that there was no cervix, what would you advise and or do? Yeah, I think that's the key question. Who is that? It's Mike. Mike? Your former senior. Mike Irish, just so everyone knows. We were both and both fellows together. Everything I am today because of that influence. He's the one I should blame. He's one of my favorite people in the world. So, I think after breast budding would be the time for pelvic ultrasound and examination under anesthesia and a vaginoscopy. And if there's no cervix, then we have a tough decision to make. Whether to empirically remove it. So, here's the introitus. The uretra. And the perineal body. To empirically remove it or just wait for trouble. I have a couple of these patients that I follow that don't have cervix at all. I think this patient has a bit of a cervix. And in one of them, she had two PIV episodes and we removed these. In the other one, she's been perfectly fine with no episodes. Can I have a stimulator? Are you happy with the length of the perineal body? For those of you. I'm going to pull that up in the abdomen a little bit so I don't take out as much directly. There. Okay, let's simulate. But I think we've found the right spot here. And then I'm just going to show you. Can you cut here? All right. Stimulator? Do it we got it. Can you roll that over? Should work better now that it's open. Ready? All right, stimulator. Should work better now that it's open. There we go. You can see very nicely it goes from here to here, right? Everyone agree? Mark, can you touch it again posteriorly, make sure it looks like it's in the center and not in the anterior aspect? There's the anterior right here. And there's the posterior right here. I don't think we see any posterior contraction there. Okay, see you later. There it is. Yep. Thank you. All right, so let's push this in a little bit. Just like this. I want to put a stitch. I have a Lungstar pin to them. All right, I'm going to simulate the posterior sacral incision a little bit without flipping the base. I'm going to put a little bit up. And a poro-vitral. Here is the posterior end of the muscle complex here. Okay, so this is what a laparoscopy mini piece art would look like very much. So let's wait on that mosquito. And another stitch. Elevator visible here. I have a D-2, the so- myos, the in-1, the you, the th- Thank you. Thank you. Hey, Mark. Yes. This is Todd. So we have a question from Mexico again. It's actually pretty interesting. So when you did that systo, did you see the ureteral orifices? The ureteral orifices? Yes. You did? Yes. We were upside down. They were just wondering that there's continued urine coming from around the Foley and it could be ectopic. Because the urethra is bigger than the Foley we have used. Okay. We could put in a bigger Foley. All right. So there's our planned anoplasty. Let me do one more. Here. So I'm just... What I'm going to do is I'm going to finish this anoplasty. And then I'm going to ask my partners here, Pete and Richard, to do the colo-colonic anastomosis. And that close. And in the meantime, once the anoplasty is done, let's finish radiology and then we'll come do problematic cases. What are you? Mark, we're finished with radiology. Oh, really? Yeah. It was pretty much right on time. Okay. Great. Right, audience? Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Steve Jorgensen there. I'm cringing. Look at that. So the question is why do we cut it out? I'm not cutting it out. I'm saving it. Oh great. I'm showing it. I'm showing it that I'm saving it. I want to do a little more peroneal body. I thought you'd be proud of me. All right. I am. I want you to be proud of me. Dr. Jorgensen was teaching the laparoscum course when I was a fellow. I still remember. Do you? And how. Actually, no, Mark, I thought you were a great learner. You had a good background, and you really want, you soaked it up like a sponge. I remember that very fondly, that course. Thank you. We're doing a lab tomorrow, Pete. Have you done a laparoscopic Hirschbrungs in a pig, transanal? They always used to save the anal part for me. It's amazing how good a model it is I have found. Yeah. Really, really good demonstration of both the Swenson and the Swaggart. You done? Okay. You see those columns? Yeah, it's so cool. Yeah. You done? Cut them out. Cut them out. Cut them out. Mark, this is Todd. I just have to say, this is definitely an unexpected detour, but I have to say I am so happy that I got to see this case. This is good. I'm really happy you're here. Are you happy I'm happy? Also happy you're happy. A couple people are wincing that you're cutting stuff off that they would have left behind. I cut off very little. Give me a break. It's been a rough case. A break. That was... I cut off very little. I cut off very little. She has really good muscles. She's going to be good. Any more questions from the fellows to Dr. Levitt before he breaks scrub and comes down here? There's a couple minutes left in there and he's headed down. Any questions? I just want to finish this setting up this anoplasty and then we can cut it and we'll do problematic cases. Is there anything about radiology that needed further discussion? Brodering? Nope. Mark, had you decided to abandon the case today and investigate it radiographically and then perhaps laparoscopically, what x-rays would you have gotten? Well, you know, one can do an MRI. Is Brent still there, our MRI expert? I don't think it sees the anatomy very well in a baby this size. But, you know, we can do it. Pre-surgical? Structures are not dilated. That's the problem. Sorry. Was the question pre-surgical MRI? Yes. Is that you, Brent? Yes. You know, the validity of a pelvic MRI to look at gynecologic structures in a baby like this. I'd say every time, regardless of what the truth is, I struggle with whether or not there's a vaginal lumen. Unless there is clearly a hematoculpos or a hydroculpos. And so, I find it, it's less helpful than I would love it to be. It always promises to be much better than it is in the very young patient. Do you hear some fallopian tubes or ovaries? Yeah, fallopian tubes, ovaries, even the anatomy of the vagina, we can frequently tell. But the presence of the uterus, excuse me. But the presence of the vagina and what the lumen of the vagina is like is very challenging. And I have very little confidence in MRI in that instance. It's possible to... It's fluid. Yeah. When we're at the ad, we're going to pull up the rectum a little bit. One question was, could we instill or could we cannulate the lumen of the vagina and see better? And I think that's possible, but I'm not sure that there's an advantage in MRI. And one of the problems is, once they're in the magnet, keeping the fluid in the vagina would be quite difficult. The analplasty under a little bit of tension, it's supposed to roll in a little bit. And we're going to also pull it up into the abdomen, too, so there's no excess. You'll see it's going to suck in very nicely. You'll see it's going to be a fish. Yeah, we'll do it all the way. It's going to be a little bit of complications. You can do whatever you want. We can always do it later in the course. We can do it next or not. Right. It needs to be done. Let me get it. I think we're good. What else do we do? Did we show... Oh, I guess we're good. Let's go to problematically. More? So I just want to make very clear, you guys can still hear me, right? Yes. So I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSAR. One thing I suppose we could have done is quit and maybe done an MRI or maybe done a laparoscopy or maybe done a better scoping rather than one that was upside down. But then I think we would have done the same thing. So I think Dr. Curry's point to make sure the fellows have a good plan is to not do this, but to really get all their ducks in a row before they start a case like this. But I still think we would have ended up doing the same thing. None of the imaging hinted at this. And even the office exam looked amazingly normal from a gynecologic point of view. So I don't think I would have known anything more than I knew today. All right. Mark, we have another question. Thanks. I'm Amber Travis from Eugene, Oregon. And I just had a question about post-op pain control and if you would do a caudal on this kiddo. Oh. What's the anesthesia plan? Yes. We're going to do NCA, patient-controlled analgesia. Here it is. Here's the vagina. It's tacked because it's connected to the neovagina. See? So it is already tethered into the abdomen. If this was to answer Michael Rollins' question. Whose hand is there? My hand. Sorry. To answer Michael Rollins' question, if this wasn't connected to the proximal vagina, I would tack it right here to the back of the bladder. But I don't mean to do that, but it's tethered to the patient's vagina. Okay? Okay? So here is distal pull through. Here is proximal. Those two ends go together. And you can close a little. Good. Thank you. All right. I'm going to come down. I'm going to have Pete and Richard Finch. Okay. Thank you.

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