From
StayCurrentMD
Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...
With Dr. Marc Levitt & Dr. Dan Teitelbaum · hosted by Dr. Todd Ponsky
Chapter 1 of 10 · Case-Based Learning
Vaginal agenesis discovery
Initial examination and discovery of absent vaginal lumen
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In babies this small, MRI has difficulty delineating uterine and ovarian structures
Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping
Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane
In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged
In this patient population, there is thick wall between rectum and urethra in absent vagina situations
Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair
In surgeon's series of recto-vestibular fistula with no vagina (8 patients), only one had imperforate hymen; none of the others had uterus or fallopian tubes
Sigmoid colon pulled down to anus will not function as rectum - lacks same storage qualities and physiologic properties
When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall
In congenital cervical agenesis, there is no evidence that retaining the uterus and connecting to vagina enables successful live births
Uterus without cervix has risk of pyometra and ascending infection when connected to outflow tract
Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult
Staple lines should be removed from neovaginal segment rather than left in place
Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply
Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies
Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient
Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations
Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency
Total body prep from nipples to toes is standard for these patients, allowing flexibility to flip between supine and prone positions
MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos