Characteristics of pelvic anatomy predict need for vaginal replacement during initial reconstruction of cloacal malformations.

PURPOSE: Vaginal replacement may be required during surgically complex reconstruction of a cloaca. The purpose of this study was to identify characteristics of pelvic anatomy associated with vaginal replacement at initial reconstruction of a cloaca.

METHODS

A retrospective analysis of patients from a prospectively collected database (1981 - present) who underwent reconstruction for cloaca was conducted. Reoperations were excluded. Common channel length, mullerian and sacral anatomy, and associated pelvic organ anomalies were evaluated for association with vaginal replacement at initial reconstruction using multivariable logistic regression and backwards selection.

RESULTS

Four hundred and sixty patients underwent initial reconstruction and 84 (18.3 %). required vaginal replacement. On unadjusted analysis, common channel length, vaginal anatomy, and mullerian anatomy were associated with vaginal replacement. On multivariate analysis, common channel ≥3.5 cm (OR 14.2, p < 0.001), hypoplasia affecting both a single vagina (OR 97.9, p 0.003) and duplicated vaginal structures (OR 40.6, p < 0.001), and hypoplasia affecting duplicated mullerian structures (OR 6.3, p 0.026) were associated with vaginal replacement while sacral ratio ≥0.7 (OR 0.35, p 0.014) and hydrocolpos (OR 0.33, p 0.014) were protective against vaginal replacement.

CONCLUSIONS

This is the largest study cohort evaluating the association between anatomic characteristics and vaginal replacement reported to date. Patients with a common channel ≥3.5 cm or known vaginal or mullerian hypoplasia will likely require complex surgical management for reconstruction and should be approached with caution. Families should be counseled regarding anticipated operative complexity and possible need for vaginal replacement.