Reconstruction of the High Urogenital Sinus: Early Perineal Prone Approach Without Division of the Rectum

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Abstract
Purpose: Reconstruction of the vagina and external genitalia in the infant is quite challenging, particularly when a urogenital sinus is associated with high confluence of the vagina and urethra. Many surgeons believe that children with such a malformation should undergo staged or delayed reconstruction, so that vaginoplasty is done when the child is older and larger. Vaginoplasty early in life is thought to be difficult due to patient size and poor visualization. The posterior sagittal approach has been beneficial for acquiring exposure to high urogenital sinus anomalies but it has been thought to require splitting of the rectum and temporary colostomy. We report a modification of this technique. Materials and Methods: In the last 5 years all patients with urogenital sinus anomalies underwent reconstruction using a single stage approach regardless of the level of confluence. In 8 patients with a high level of confluence reconstruction was performed using a perineal prone approach. Exposure was achieved without division of the rectum. The operative technique is presented in detail. Results: This midline perineal prone approach has allowed excellent exposure of the high vagina even in infants. In all 8 patients reconstruction was done without difficulty and no patient required incision of the rectum or colostomy. This procedure did not preclude the use of a posteriorly based flap for vaginal reconstruction. Conclusions: While patients with low confluence can be treated with single posteriorly based flap vaginoplasty, those with higher confluence may benefit from a perineal prone approach to achieve adequate exposure for pull-through vaginoplasty. This prone approach to the high urogenital sinus anomaly can be performed without division of the rectum, provides excellent exposure of the high confluence even in small children and does not preclude the use of posterior flaps for vaginal reconstruction.