Posterior sagittal exposure for reconstructive surgery for cloacal anomalies

We treated seven girls with a cloacal anomaly through a posterior sagittal exposure. Six patients, aged 5 months to 2 1/2 years, underwent a primary reconstructive operation with urethroplasty, vaginoplasty, and posterior sagittal anorectoplasty as a single procedure. All had undergone diverting sigmoid colostomies as newborns, four had previous vesicostomies, and one had a vaginostomy. The seventh girl, a 9-year-old, had undergone a number of attempts at reconstruction. All underwent endoscopy and contrast studies of the cloaca before definitive reconstruction. This preoperative evaluation gave necessary information regarding the length and caliber of the cloacal channel and the level of confluence of the urinary, genital, and intestinal tracts. However, major decisions regarding reconstruction were often possible only in the operating room. To construct a neoanus with optimal sphincteric control, all seven underwent posterior sagittal anorectoplasty. Two required laparotomies to mobilize additional colonic length. Three developed urethrovaginal fistulae after repair. Critical decisions regarding urethral and vaginal reconstruction depend on the findings at cystoscopy and operation. The posterior sagittal approach gives excellent exposure for these decisions and the subsequent reconstruction of three functioning perineal orifices.