Case Presentations Part II: Cloaca and Complex ARMs 2015

In high common channel cloacas, the common wall between the rectum, vagina, and bladder are not long common walls and are actually easy to separate the structures.

For high common channel cloacas where the rectum is reachable through the abdomen, it is not advisable to search for it posterior sagittally; laparotomy is the preferred approach.

Saline perturbation is a technique used intraoperatively to assess the patency of the reproductive tract in all cases when in the abdomen.

When assessing Mullerian structures intraoperatively, if one side is very well developed and the other side is very atritic, it may be advantageous to retain the well developed side and remove the atritic side that might be dangerous at the time of menstruation and not helpful for future childbearing.

When using colon for vaginal interposition, the segment is placed anti-peristaltic due to blood supply considerations and the way it reaches the perineum.

Using the rectum for vaginal replacement may change a patient who is potentially fecally continent into somebody who is not going to be fecally continent, because taking away the rectal reservoir affects continence.

In patients with vestibular fistulas and absent vagina who had the rectum used as a vagina with the colon brought down, bowel control was less than optimal in follow-up through the years.

Preservation of the rectum in patients with good functional prognosis (good sacrum, no tethered cord, and a good malformation) is extremely important for maintaining bowel control.

The rectum is a natural reservoir, and if removed in patients with an anorectal malformation, most likely the patient is going to be incontinent because they cannot tolerate the constant passing of stool that occurs when colon is connected down to the perineum.

Descending colon is increasingly used for vaginal replacement because the arcades are very nice for preserving blood supply, compared to small bowel or rectum.

Approximately 65 cases have been seen where babies had a colostomy at birth in another institution because a phallic-appearing structure led to a diagnosis of intersex, but extensive workup concluded they were chromosomally normal females with cloacas.

Doctor Pena has never seen a patient with intersex and a cloaca together.

To differentiate cloaca from adrenal hyperplasia when a patient has a pseudophallus and single perineal orifice, palpate the structure: in real adrenal hyperplasia you will palpate corpora (real penis), whereas in cloaca patients the structure is just folded skin.

The folded skin from the phallic-appearing structure in cloaca patients can be used to facilitate reconstruction of the vagina.