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Cloaca - Long Common Channel

Video Published 2018-11-10 Updated 2026-06-10

Timestops (5)

Case Presentation

Presentation of a 12-month-old female with 6 cm common channel cloaca, horseshoe kidney, and associated anomalies. Cysto…

Operative Approach and Vaginal Reconstruction

Panel discussion of operative approach favoring laparotomy for high common channel. Intraoperative assessment revealed t…

Rectum Preservation and Functional Outcomes

Critical discussion of when to preserve versus use rectum for vaginal replacement. Emphasis on preserving rectum in pati…

3D Animation Review and Surgical Technique

Review of 3D animation demonstrating anatomy of long common channel with two hemivaginas, rectum, and ureters connected …

Laparoscopic Approach and Intersex Differentiation

Discussion of laparoscopy role in cloaca repair, noting most reported laparoscopic repairs are actually only rectal comp…

Topic Overview

A multidisciplinary panel discusses surgical management of cloacal malformations with long common channels, focusing on two cases: a 12-month-old with a 6 cm common channel requiring sigmoid colon vaginal replacement, and a neonate with prenatal diagnosis and hydrocolpos. The discussion emphasizes the importance of abdominal approach for high cloacas, preservation of the rectum in patients with good functional prognosis to maintain fecal continence, and recognition that a phallic-appearing structure with a single perineal opening in a chromosomally normal female indicates cloaca rather than intersex disorder. The panel addresses operative decision-making, vaginal replacement techniques using descending colon, and the role of laparoscopy in selected cases.

Key Takeaways

Preserve rectum in cloacas with good sacrum/cord—using it as vagina sacrifices fecal continence in otherwise continent patients (8:13)
Phallic structure + single perineal opening in XX female = cloaca, not intersex. Palpate for corpora to confirm—saves weeks of workup (12:33)
High cloacas need abdominal approach—common walls separate easily, and vaginas are too high to mobilize perineal route (2:53)
Descending colon preferred for vaginal replacement due to superior arcade blood supply vs small bowel or other colon segments (10:56)

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

Speaker 1 — guest
Speaker 2 — guest
Doctor Bree — guest
Doctor Van der Brink — guest
Speaker 5 — guest
Doctor Pena — guest

Chapters

0:00Case Presentation: 12-Month-Old with Long Common Channel Cloaca — Presentation of a 12-month-old female with 6 cm common channel cloaca, horseshoe kidney, and associated anomalies. Cystoscopy findings revealed three openings at bladder base: right hemivagina with abnormal cervix, middle opening as rectum, and left possible vagina. Imaging showed no hydronephrosis and high rectal position.
2:46Operative Approach and Vaginal Reconstruction — Panel discussion of operative approach favoring laparotomy for high common channel. Intraoperative assessment revealed two tiny vaginas unable to reach perineum, requiring sigmoid colon interposition graft from proximal mucous fistula. Discussion of Mullerian system assessment and saline perturbation technique.
6:00Rectum Preservation and Functional Outcomes — Critical discussion of when to preserve versus use rectum for vaginal replacement. Emphasis on preserving rectum in patients with good functional prognosis (good sacrum, no tethered cord) to maintain fecal continence. Historical experience showing that using rectum as vagina in patients with good prognosis results in suboptimal bowel control.
10:123D Animation Review and Surgical Technique — Review of 3D animation demonstrating anatomy of long common channel with two hemivaginas, rectum, and ureters connected to bladder neck. Discussion of separation technique through abdomen and use of descending colon for vaginal replacement due to favorable vascular arcades.
11:29Laparoscopic Approach and Intersex Differentiation — Discussion of laparoscopy role in cloaca repair, noting most reported laparoscopic repairs are actually only rectal component. Presentation of second case with prenatal diagnosis and phallic-appearing structure. Critical teaching on differentiating cloaca from intersex: phallic structure in cloaca is folded skin without palpable corpora, whereas adrenal hyperplasia has true penile tissue.

Key claims

3:04In high common channel cloacas, the common wall between structures (rectum, vagina, bladder) are not long common walls and are actually easy to separate — Speaker 2
2:53For high common channel cloacas visible on contrast study with rectum reachable through abdomen, it is not advisable to search for it posterior sagittally — Speaker 2
4:08Saline perturbation is used intraoperatively to assess patency of the reproductive tract in all cases when in the abdomen — Doctor Bree
4:41If one side of duplicated Mullerian system is well developed and the other is very atretic, it may be advantageous to retain the well developed side and remove the atretic side that might be dangerous at menstruation and not helpful for future childbearing — Doctor Bree
8:13Using the rectum for vaginal replacement may change a patient who is potentially fecally continent into somebody who will not be fecally continent — Speaker 1
8:54In patients with vestibular fistulas and absent vagina where rectum was used as vagina, bowel control was less than optimal when followed through the years — Doctor Pena
9:21Preservation of the rectum in patients with good functional prognosis (good sacrum, no tethered cord, good malformation) is extremely important to preserve bowel control — Doctor Pena
9:55The rectum is a natural reservoir and if removed in patients with anorectal malformation, the patient will most likely be incontinent because they cannot tolerate constant passing of stool when colon is connected down to perineum — Doctor Pena
10:56Descending colon is increasingly used for vaginal replacement because the arcades are very nice for preserving blood supply, compared to small bowel, rectum, and other colon segments — Doctor Pena
10:40In long common channel cloacas, vaginas are located very high in pelvis and it is often not possible to bring them down, requiring vaginal replacement — Doctor Pena
11:29Many laparoscopic cloaca repairs reported in literature are really only the rectal repair component of the cloaca — Speaker 1
12:33Approximately 65 cases have been seen that came operated originally with colostomy at birth due to phallic-appearing structure, were extensively studied for intersex, only to conclude they were chromosomally normal females with cloacas — Doctor Pena
13:09A patient with intersex and a cloaca has never been seen in the speaker's experience — Doctor Pena
13:15To differentiate cloaca with phallic structure from adrenal hyperplasia, palpate the structure: in adrenal hyperplasia you will palpate corpora (real penis), whereas in cloaca the structure is just folded skin — Doctor Pena
13:30The folded skin of the phallic-appearing structure in cloaca can be used to facilitate reconstruction of the vagina — Doctor Pena
13:50Families agonize during the 2-3 weeks that doctors are trying to make the diagnosis of intersex in cases that are actually cloacas — Doctor Pena
7:10Letting a significantly enlarged bladder maximally decompress via vesicostomy may help the bladder have some potential rebound recovery — Doctor Van der Brink
1:46Common channel length measured at cystoscopy versus radiology measurements are sometimes very similar and sometimes just a little bit off — Speaker 1
0:44Preserving the appendix at time of colostomy creation is important for long-term need for Malone antegrade continence enema — Speaker 1

Cases discussed

0:2112-month-old female with cloaca, 6 cm common channel, horseshoe kidney, left leg hypoplasia, clubbed foot, and small omphalocele
11:50Neonate with prenatal diagnosis of anorectal malformation with possible cloaca

Open questions

What is the optimal timing for vesicostomy closure in patients with massively dilated bladders after cloaca repair?
What are the long-term gynecologic and urologic outcomes in patients who receive sigmoid colon vaginal replacement?
Can laparoscopic techniques be expanded beyond the rectal component to include vaginal reconstruction in cloaca repair?

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:

Surgical Decision-Making in Long Common Channel Cloacal 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

Approach Selection: When the Abdomen Comes First

Contrast studies determine the operative approach before you enter the room. When the rectum sits high enough to be visible on imaging above the pelvic floor, reach for it abdominally rather than searching posterior sagittally 2:53. The common walls between rectum, vagina, and bladder in high cloacas are short and separate easily through the abdomen — the posterior sagittal dissection that works for lower malformations becomes a liability here 3:04. The imaging tells you where the anatomy lives; let that dictate your incision.

The Rectum Decision: Reservoir Versus Replacement

Preserving the rectum is not a reflex — it is a calculated trade based on continence potential. In patients with good sacrum, no tethered cord, and favorable anatomy, the rectum functions as a natural reservoir and its preservation is critical for fecal continence 9:21. Remove it and connect colon directly to the perineum, and the patient cannot tolerate constant stool passage 9:55. One discussant described using the rectum for vaginal replacement in early vestibular fistula cases with absent vagina, only to find bowel control "less than optimal" on long-term follow-up 8:54. The lesson: "if you use the rectum and take away that reservoir, you may change a patient who is potentially fecally continent into somebody who's not going to be fecally continent" 8:13.

But when the patient already has poor prognosis — tethered cord, short sacrum, unfavorable malformation — using the rectum for vaginal replacement becomes acceptable because continence is already compromised. The rectum's value as a reservoir only matters if the patient has the neurologic and anatomic substrate to use it.

Vaginal Reconstruction: Assessment and Material Selection

Intraoperative assessment of duplicated Müllerian structures requires systematic evaluation of both sides. Saline perturbation tests patency of the reproductive tract in all abdominal cases 4:08. When one hemiuterus is well-developed and the other severely atretic, retain the functional side and consider removing the atretic side if it poses menstrual risk without offering reproductive benefit 4:41.

In long common channel cloacas, vaginas sit too high in the pelvis to reach the perineum, requiring vaginal replacement 10:40. Descending colon has emerged as the preferred material because its vascular arcades preserve blood supply more reliably than small bowel, rectum, or other colon segments 10:56. The choice of replacement material matters less than the blood supply you can maintain.

The Intersex Mirage: Physical Examination Settles the Question

A phallic-appearing structure with a single perineal opening triggers intersex workup in many centers, leading to weeks of genetic and endocrine evaluation while families wait for answers 13:50. Approximately 65 such cases have been extensively studied for intersex only to conclude they were chromosomally normal females with cloacas 12:33. Physical examination differentiates these immediately: palpate the structure 13:15. In adrenal hyperplasia you feel corpora — true penile tissue. In cloaca the structure is folded skin without palpable substance 13:15. One discussant stated flatly: "I must say we have never seen a patient with an intersex and a cloaca" 13:09.

That folded skin is not diagnostic waste — it facilitates vaginal reconstruction 13:30. The structure that mimics a phallus becomes surgical material.

The Emphasis They Returned To

The discussants circled back repeatedly to rectum preservation in patients with continence potential. The rectum as reservoir is not interchangeable with colon as conduit. Early in one surgeon's experience, using the rectum for vaginal replacement seemed elegant — the anatomy was already posterior to the urethra. Long-term follow-up revealed the cost: suboptimal bowel control in patients who might have been continent 8:54. The teaching point they emphasized most: know which patients can use a rectal reservoir before you decide whether to sacrifice it.

Takeaways from this story

High cloacas with visible rectal position on imaging should be approached abdominally; posterior sagittal search is not advisable.
Preserve the rectum in patients with good sacrum and no tethered cord; removing it eliminates the reservoir needed for continence.
Palpate phallic structures to differentiate cloaca from intersex: corpora indicate true phallus, folded skin indicates cloaca.
Descending colon is preferred for vaginal replacement due to favorable vascular arcades compared to other bowel segments.
When Müllerian duplication is asymmetric, retain the well-developed side and remove atretic structures that pose menstrual risk.

Cloaca with Long Common Channel: When Anatomy Demands Abdominal Reconstruction

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Distinct Problem

Cloaca — a single perineal opening draining rectum, vagina, and urinary tract — is a rare congenital malformation in female births. Most cloacas have a short common channel and can be repaired through a posterior sagittal approach. But when the common channel exceeds 3 cm, the anatomy shifts: the rectum sits high in the pelvis, the vaginas (often duplicated) cannot reach the perineum, and the shared walls between structures are thin enough to separate cleanly from above. These long-channel cases require abdominal access, and the decisions made intraoperatively — which structures to preserve, which to replace, and how to balance future continence against reproductive function — define the subspecialty expertise.

The Core Clinical Problem

In a long common channel cloaca, three organ systems converge abnormally high in the pelvis. Contrast imaging shows the rectal pouch well above the levator musculature. The Müllerian structures — typically two hemiuteri and two hemivaginas in these cases — are small, high, and often asymmetric. The bladder is massively distended from chronic outflow obstruction. The surgical challenge is not simply separating these structures but deciding what can be preserved and what must be replaced, knowing that each choice carries lifelong functional consequences.

For high cloacas visible on contrast study with the rectum reachable through the abdomen, it is not advisable to search for it posterior sagittally 2:53. The common walls between structures in high common channel cloacas are not long and are actually easy to separate 3:04. The abdominal approach allows direct visualization of the anatomy, assessment of the Müllerian system, and mobilization of bowel for vaginal replacement when native vaginas cannot reach the perineum 10:40.

How the Approach Works

Laparotomy begins with identification of the massively dilated bladder, which may benefit from vesicostomy to allow decompression and potential functional recovery 7:10. The rectum is mobilized from its high position. The critical intraoperative decision involves the Müllerian structures. Saline perturbation is used in all abdominal cases to assess patency of the reproductive tract 4:08. When duplication exists, the surgeon evaluates symmetry: if one hemiuterus is well developed and the other atretic, it may be advantageous to retain the well-developed side and remove the atretic side that might be dangerous at menstruation and not helpful for future childbearing 4:41.

The next decision is whether the native vaginas can reach the perineum. In long common channel cloacas, they often cannot 10:40. This necessitates vaginal replacement. Descending colon is increasingly used because the vascular arcades are favorable compared to small bowel, rectum, and other colon segments 10:56.

The most consequential decision is whether to preserve the rectum. Using the rectum for vaginal replacement may change a patient who is potentially fecally continent into somebody who will not be fecally continent 8:13. The rectum is a natural reservoir, and if removed in patients with anorectal malformation, the patient will most likely be incontinent because they cannot tolerate constant passing of stool when colon is connected down to the perineum 9:55. In patients with vestibular fistulas and absent vagina where rectum was used as vagina, bowel control was less than optimal when followed through the years 8:54.

Preservation of the rectum in patients with good functional prognosis — good sacrum, no tethered cord, good malformation — is extremely important to preserve bowel control 9:21. Conversely, in patients with poor prognostic indicators (tethered cord, short sacrum), using the rectum for vaginal replacement is acceptable because continence is already compromised.

Where Practice Is Contested

The role of laparoscopy in cloaca repair remains limited. Many laparoscopic cloaca repairs reported in literature are really only the rectal repair component of the cloaca 11:29. The complexity of Müllerian assessment, vaginal replacement, and urogenital sinus division has not translated well to minimally invasive approaches in most centers.

Common channel length measured at cystoscopy versus radiology measurements are sometimes very similar and sometimes just a little bit off 1:46, which affects preoperative planning but rarely changes the fundamental surgical strategy.

When to Involve This Team

Cloaca is diagnosed at birth or prenatally. Initial management involves colostomy creation, ideally preserving the appendix for long-term need for Malone antegrade continence enema 0:44. Definitive repair is typically performed in infancy or early childhood.

A critical diagnostic pitfall: approximately 65 cases have been seen that came operated originally with colostomy at birth due to phallic-appearing structure, were extensively studied for intersex, only to conclude they were chromosomally normal females with cloacas 12:33. A patient with intersex and a cloaca has never been seen in the speaker's experience 13:09. To differentiate cloaca with phallic structure from adrenal hyperplasia, palpate the structure: in adrenal hyperplasia you will palpate corpora (real penis), whereas in cloaca the structure is just folded skin 13:15. The folded skin can be used to facilitate reconstruction of the vagina 13:30. Families agonize during the 2-3 weeks that doctors are trying to make the diagnosis of intersex in cases that are actually cloacas 13:50.

Referral to a center with experience in complex cloaca repair should occur at diagnosis. These cases require coordinated expertise in pediatric surgery, pediatric urology, and pediatric gynecology, with long-term follow-up extending through adolescence and reproductive years.

Takeaways from this story

Preserve the rectum in patients with good sacrum and no tethered cord — using it for vaginal replacement sacrifices continence.
Palpate phallic structures at birth: corpora indicate intersex, folded skin indicates cloaca. This exam prevents weeks of unnecessary workup.
Long common channel cloacas require abdominal approach — the high rectum and thin common walls separate easily from above.
Descending colon is preferred for vaginal replacement due to favorable vascular arcades compared to other bowel segments.

Rectum as Reservoir: Why Preservation Trumps Vaginal Reconstruction in Cloaca

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The Early Logic: Anatomic Convenience

The rectum in a high cloaca sits behind the urethra, already positioned where a vagina should be 3:04. For a surgeon facing an absent or unreachable vagina, the move seemed elegant: leave the rectum as the vagina, mobilize proximal colon to the perineum for bowel continuity, solve two problems with one operation 8:54. In vestibular fistula cases with absent vagina, this approach appeared to work 8:54. The anatomy cooperated. The operation was shorter. The logic held—until the patients grew up.

"Following those patients through the years I found that the bowel control was less than optimal in those cases" 8:54. The problem wasn't technical failure. The problem was that bowel control depends on the rectum functioning as a reservoir, and when that reservoir is repurposed or removed, the colon connected directly to the perineum cannot tolerate the constant passage of stool 9:55. Patients who might have achieved fecal continence instead lived with suboptimal control 8:54, not because their sacrum was bad or their cord was tethered, but because the operation had eliminated the one structure that could have given them continence 9:55.

The Shift: Functional Prognosis as the Decision Point

The critical reframe came from recognizing that not all cloaca patients have the same continence potential 8:13 9:21. A patient with a good sacrum, no tethered cord, and favorable anatomy has a real chance at fecal continence—but only if the rectum is preserved 9:21. Using the rectum for vaginal replacement in such a patient converts a potentially continent child into one who will not be continent 8:13. The rectum is not simply a tube; it is a natural reservoir, and removing it in a patient with an anorectal malformation almost guarantees incontinence because the patient cannot tolerate the physiology of colon-to-perineum connection 9:55.

This insight changed the operative algorithm 8:13. The decision to preserve or sacrifice the rectum now hinges on functional prognosis, not anatomic convenience 8:13. If the patient has poor prognostic indicators—short sacrum, tethered cord, severe malformation—then using the rectum as vagina may be reasonable, because continence was unlikely regardless 8:13. But in a patient with good anatomy and a realistic chance at bowel control, the rectum must be preserved and an alternative source found for vaginal replacement 8:13 9:21.

Current Practice: Descending Colon as the Preferred Substitute

With rectum preservation established as the priority in favorable cases 8:13 9:21, the question became what to use instead. Small bowel, rectum, and various colon segments were tried 10:56. Descending colon has emerged as the preferred choice because its vascular arcades reliably preserve blood supply, a critical advantage over other segments 10:56. In long common channel cloacas, the vaginas sit high in the pelvis and often cannot be mobilized to the perineum, making vaginal replacement necessary 10:40. Descending colon provides length, vascularity, and durability 10:56.

The technical approach has also clarified. High common channel cloacas visible on contrast study with rectum reachable abdominally should not be approached posterior sagittally 2:53. The common walls between rectum, vagina, and bladder in these cases are short and easily separated through laparotomy 3:04. The operation is now structured around preserving the rectum in its correct position 8:13, assessing the Mullerian structures with saline perturbation 4:08, and using descending colon for vaginal replacement when native vaginas cannot reach 10:56 10:40.

What Remains Unsettled

The decision matrix is clearer but not absolute. The threshold for "good functional prognosis" is not quantified—how much sacral development is enough, how mild a tethering is acceptable 8:13. The long-term sexual function outcomes of descending colon vaginas in this population are not fully reported. Whether partial vaginal replacement with native tissue plus colon graft offers advantages over complete colon replacement is not resolved. And the role of laparoscopy remains contested; most reported laparoscopic cloaca repairs address only the rectal component, not the full reconstruction 11:29.

The lesson is not that rectum should never be used for vaginal replacement 8:13. The lesson is that using it carries a functional cost, and that cost must be weighed against the patient's realistic chance at continence 8:13 9:55. When the prognosis is poor, the trade may be acceptable 8:13. When the prognosis is good, sacrificing the rectum sacrifices the patient's best chance at a continent life 8:13 9:21. That distinction—invisible in the early cases, obvious in retrospect—now drives the operation 8:13.

Takeaways from this story

Rectum preservation in good-prognosis cloaca patients is essential for continence; using it as vagina converts potential continence to incontinence
Descending colon is preferred for vaginal replacement due to favorable vascular arcades compared to small bowel or other colon segments
High common channel cloacas should be approached abdominally, not posterior sagittally, as common walls are short and easily separated
Rectum functions as natural reservoir; removing it in anorectal malformation patients causes intolerance to constant stool passage

Keywords

cloaca long common channel omphalocele horseshoe kidney leg hypoplasia clubbed foot malrotation tethered cord hydrocolpos vestibular fistula absent vagina adrenal hyperplasia anorectal malformation intersex sigmoid colostomy

Hashtags

#Cloaca #PediatricSurgery #Urology #Gynecology #SurgicalOutcomes #Anatomy #Vesicostomy #ReproductiveHealth #SurgicalTechniques #Colostomy #CongenitalAnomalies #ChildHealth #SurgicalEducation #LongTermOutcomes #SurgicalAnatomy #PediatricUrology #ClinicalCase #SurgicalApproach #PatientCare #MedicalEducation #CloacalMalformation #ReconstructiveSurgery

Transcript

So, um, we're gonna, in the interest of time, I think what we're gonna do is present a case with a very long common channel, and then we'll have, um, Doctor, um, Bree, and I think that's Doctor Lam in the camera there, um, presents, uh, a little bit on sort of long-term outcomes, um, in gynecology and urology. So, the next case is a 12-month-old female with a history of a cloica. She also had a small lymphalocele at birth, which was closed, horseshoe kidney, left leg hypoplasia, and a clubbed foot. At birth, she had a sigmoid colostomy with a mucous fistula creation. She also was found to be malrotated and had a lab procedure done at that time. Importantly, the surgeon at that point did preserve the appendix, um, which is, you know, for long term, as we previously talked about, need for a metrofenephrine malone at the time of the colostomy creation. So she came to us on her EUA cystoscopy, vaginoscopy, found one perineal opening, um, had a very phallic looking structure. Common channel length was 6 centimeters. The length from the perineal opening to the bladder, um, sorry, from the uh cloica to the bladder. neck was 3 centimeters. Within the bladder at the base of the bladder were 3 openings. The right hemivagina was seen with an abnormal cervix. The middle opening was the rectum, and the left looked like a possible vagina, but we were not able to enter into it. This is her preoperative imaging of her um uh kidneys, which um did not show any hydronephrosis. Picture of her cloacogram, you can see that this is her uh sigmoid colon here. Like we previously talked about, and that's why I asked Doctor Patel, um, the length of the common channel on radiology versus our measurements, um, uh, sometimes are very similar and sometimes just a little bit off. So we measured 6 in cystoscopy with this was 5 and then the additional almost became 6. Um, this is the picture of her bladder. So you can see a very large bladder. She had no previous drainage of any sort. She did not have hydrocopos at birth and so did not, um, have a vaginostomy tube. Sort of as we discussed before, you can see the end of her sacrum is right here. The end of the rectum is right here. So, at this point in time, um, operative approach, um, if the panel wants to weigh in, would you start with a laparotomy first? Would you start posterior sagittal, um, and counseling in the family for long-term fecal and urinary incontinence. So Down that end to my left. Go, I would start with laparotomy. I mean, just by looking at the contrast study, we can see that this rectum is reachable through the abdomen and it's not even advisable to search for it posterior sagittally. So as Doctor Pena mentioned in those high common channel cloacas, the common wall between the structures are, are not long common walls. They are actually easy to separate the structures, the rectum, if there is a vagina, the vagina, and the bladder. So there's some intraoperative pictures. You see, this is her very, very, very large bladder here. Here you can see, um, it's very small on my screen, um, but the structures that are coming off at the posterior aspect of the bladder. The two vaginas that we were able to identify were very tiny, and um Doctor Bree, do you want to sort of comment on how we assess the usability of that vagina, whether you want to preserve it or remove it? Right, so, um, when we entertain these, uh, larger procedures, we're all there in the operating room together, and it allows us to assess each of the, uh, systems together. In this patient, you can see there are 2 hemivaginas, 2 hemiuteri, and we'll make an assessment intraoperatively about the development of that Mullerian system. On each side we'll make an assessment of how well developed the uterine body is and in doing that I'll show you on some upcoming slides as well that you could do um what we call a saline perturbation. It's a way to sort of assess the patency of the reproductive tract. We do that in all of the cases when we're in the abdomen. We'll talk about how we can do that at other times as well, at other laparoscopic procedures and that sort of thing to assess the development of reproductive structures. I emphasized earlier how important it is to check out both sides and to assess the symmetry between those two sides. If one side is very well developed and the other side is very um atritic, it may be advantageous to retain the well developed side and perhaps remove a side that's very atritic and might be dangerous or risk at the time of menstruation and not helpful for future childbearing. We'll go over that a little bit later, but I think in this case we assess the uh development on each side and then we wanted to make an assessment of if the vagina or vaginas could reach the perineum, and I think those are the pictures that Doctor Dickey is trying to demonstrate that the vaginas were not able to reach the perineum adequately. So this is one vagina here. This is the other vagina here. You could, they're two very separate ones, um, and this would not reach the perineum. So we needed to put a bridge of tissue to get it to the perineum. And what we used in this case was um colon. Um, for her, since on her contrast study, I don't know if you saw that she had really redundant, um, colon from her mucous fistula down. So we actually use the proximal, um, mucous fistula, um, as her sigmoid replace or her colonic interposition graft. Um, this is the proximal portion and it's put anti um peristaltic, just due to blood supply and the way that it would reach the perineum. So just schematically, um, what you do is hers, she had two, but the two vaginas are anastomosed onto the sigmoid replacement. Once again, you can see that that's sort of the completed anastomosis and then it's brought down to the perineum. And sort of this is completion. Um, we ended up doing a formal vesicostomy on the patient, um, just due to her Uh, where she lived, her social situation, and how large her, her, her bladder was. Um, Doctor Van der Brink, do you want to comment on why we did the vasostomy on that, this patient? Uh I think specifically one of my partners might have done that, but I do believe, as we alluded to before the break that the psychosocial factors, I um might have been uh observing earlier on in the operation because I think the size of the bladder was so significant that this was an interesting finding that was making it way to the operating room. You got to go see the size of this bladder in this little girl, so. Um, I'm, I'm thinking that potentially letting this bladder maximally decompress to a functional vesicostomy may help, uh, her bladder from having some potential rebound recovery, um, but I think she's getting all of her urologic follow-up at an outside institution. Can I ask you a question, Belinda. Instead of using the mucous fistula as the vaginal replacement, why could you not use uh the distal rectum? And just turn it back on itself, leaving its blood supply completely intact. We could, we've done that in a few cases and it seems a little simpler, you know, we considered both of them, but the way that the blood supply and how things reached it actually reached better using the proximal mucus fish slug because then if we took a segment for the rectum, then the actual remaining segment had difficulty reaching down to the perineum because it was so high up. Um, the, the, when we have used rectum as vaginal replacement, I think it's important to note that um those are the patients where you believe that they won't be fecally continent, um, because if you use the rectum and take away that reservoir, you may change a patient who is potentially fecally continent into somebody who's not going to be fecally continent. So with her, it probably didn't matter because she had a tethered cord, she had a short sacrum, um, that we could have used the distal rectum or, or another portion of the colon. Let me, let me, uh, reemphasize what you just said, Belinda. That's a very important point because, um. In the first cases that I uh operated, not, not exactly cloacas, but patients with vestibular fistulas and absent vagina, I, I thought I had a brilliant idea of using the rectum that was already located behind the urethra and leave it as a vagina and take up the rectum down and, um, and then following those patients through the years I found that the bowel control was less than optimal in those cases. In addition, those patients have usually bad sacrum and tete cord, but anyway, what we learned is that the preservation of the rectum in patients with good functional prognosis, patients with good sacrum, not tete cord, and a good malformation is extremely important to preserve the rectum. So we use the rectum. With many, many vaginal replacement with rectum, but as, as you mentioned, it, if, if we have the, uh the, we know that the patient will have not, no bowel, will have no bowel control and therefore it's not gonna make a difference for her to have the rectum and not the rectum. The rectum is a natural reservoir and if we remove it in patients with an rectum malformation, most likely the patient is gonna be incontinent. Because they cannot tolerate the, the constant passing of stool that occurs when you connect colon down to the perineum. Doctor Pena, we have one of your 3D animations, so I'm gonna push play and be up on the screen for you. There you have the case of a a very long common channel and, and you look at, look at the anatomy you see two little hemi vaginas connected into the trigon or the bladder neck, the rectum also there and the ureter is also there, so these are easier to separate through the abdomen rather than from below. Once you separate them, you, you can bring the vaginas together, but very soon you, you may find out that the vaginas are located very high in the pelvis and there's, it's not possible to bring them down and at that point you have to decide a vaginal replacement. We have been using more and more the descending colon. We have tried small bowel, rectum, and colon, but we have been using more descending colon because the arcades are very nice in order to preserve the blood supply. So you can see the piece of bowel doing a partial vaginal replacement in this particular case and now you see the rectum placed in the right location and the, the uh vaginal, the partial vaginal replacement in front with a piece of colon. So, um, you know, these are the, we sort of talk about laparoscopy and whether laparoscopy is indicated in any of these procedures and a lot of the reports and literature reviews we've done, um, show that many of the repairs previously that say they've done laparoscopically is really the rectal repair of the, um, cloaca. So, you know, the addition, this is the case that um Doctor Cavill first presented, the prenatal diagnosis of the anal rectum malformation with a possible cloica. Um, This is what the baby looked like when she was born. So she had a little bit of vestigial tail. Um, you can note that this is why they called her ambiguous genitalia. Um, very phallic looking, um. Structure here with almost a scrotal looking sac um apparent. Um, Doctor Pena, you have, you have mentioned before, whenever you see some structure like this, what is it's indication of a very we, we have seen approximately 65. Those cases that came to us operated originally, I mean had a colostomy in another institution and at birth because the baby has similar anatomy, in other words, the presence of uh something that looked like a phalluss, the diagnosis of intersex was made and and then the patient was extensively uh studied by, you know, endocrinologists, geneticists and urologists and so forth only to conclude that they were chromosomally normal females. So they came here and. We treat the the actually those all those patients were cloacas. I must say we have never seen a patient with an intersex and a cloaca. So if you see a patient with a pseudohaus like that, a single perineal orifice, the way to differentiate that from uh adrenal hyperplasia is by palpating that structure and adrenal adrenal hyperplasia, you will be able to palpate. Corpora real real penis there whereas in these patients what you that that structure that looks like a penis actually is just folded skin and we as a matter of fact we use that folded skin to facilitate the reconstruction of the of the vagina so this is something that um. Should everybody should be alerted about because the the the families of the patients agonized during the 2 or 3 weeks that the doctors are trying to make the diagnosis of intersex. And, and, you know, even though we as the center see this baby prenatally, we saw this baby postnatally in the NICU, um, unfortunately, our neonatologists thought they knew better and sent off chromosomes on this child, which, of course, she had a prenatal diagnosis of being XX. So even in our institution, there is more education to be done. So, um, for her, we actually approached her colostomy, a mucous fistula, and uh, uh, she had hydrocopos, um, with the laparoscope. And so, Uh, you know, we were able to um perform it uh through sort of two incisions really. We had the colostomy, the mucous fistula, and our vaginostomy tube, um, which drained her hydrocopos. I'm going to um sort of Skip towards um Doctor Bree's talk at this point in time.

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