Cloacal anomalies are the most complex of anorectal malformations, and before reconstruction, the existing anatomy must be defined. This is typically done by endoscopy and radiology. Inadequate vaginal length can lead to a vaginoplasty done under tension, and would thus require an augmentation of vaginal tissue, adding complexity to the surgery. Some have advocated for a delayed vaginoplasty, particularly in patients where a tension-free native vaginoplasty is not possible, however often the vagina must be mobilized to isolate the urethra and urinary system. Little data exists to guide this planning.

A retrospective cohort study was conducted of all patients who underwent primary cloaca repair surgery at our institution (2020 to 2023). Data collection consisted of demographic information, standardized preoperative measurements, type of surgery performed, and postoperative examination findings. Data was analyzed utilizing descriptive statistics. This study was classified as IRB exempt.

30 patients with a mean age at surgery of 14 months (range 4-77 months) formed our cohort. Co-existing conditions are shown in Table 1. Before reconstructive surgery, all patients underwent an exam under anesthesia, with cysto-vaginoscopy (if possible), and cloacagram (Table 2). For surgical reconstruction 15/30 underwent total urogenital mobilization (TUM), 13/30 required total a urogenital separation (TUS), and two patients with Mullerian agenesis underwent reconstructive surgery for the rectum only without vaginal reconstruction. For vaginal reconstruction 24/28 had a tension-free native vagina pull-through and 4/28 required a transposition graft (2 with colon, 1 with rectum, and 1 with small bowel). Postoperative findings are depicted in Table 2.

A tension-free vaginoplasty was able to be performed in both short and long common channel cloacas. Although a tension-free vaginoplasty is most commonly performed when the preoperative evaluation demonstrates a vaginal length of at least 4 cm, a tension-free vaginoplasty can even be achieved in shorter vaginal lengths. Stricture after a tension-free vaginoplasty might be indicative of poor vascular supply and/or excessive tension. Temporary vaginal replacement might aid in stricture prevention and serve as a bridge for final native vaginal reconstruction. Understanding the relationship between common channel length, vaginal length, and surgical and postsurgical outcomes will assist with surgical planning and anticipation of need for vaginal replacement in this patient population.