RECONSTRUCTION OF THE HIGH UROGENITAL SINUS - EARLY PERINEAL PRONE APPROACH WITHOUT DIVISION OF THE RECTUM

Purpose: Reconstruction of the vagina and external genitalia in the in fant is quite challenging, particularly when a urogenital sinus is ass ociated with high confluence of the vagina and urethra. Many surgeons believe that children with such a malformation should undergo staged o r delayed reconstruction, so that vaginoplasty is done when the child is older and larger, Vaginoplasty early in life is thought to be diffi cult due to patient size and poor visualization. The posterior sagitta l approach has been beneficial for acquiring exposure to high urogenit al sinus anomalies but it has been thought to require splitting of the rectum and temporary colostomy. We report a modification of this tech nique. Materials and Methods: In the last 5 years all patients with ur ogenital 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 va gina even in infants, In all 8 patients reconstruction was done withou t difficulty and no patient required incision of the rectum or colosto my, This procedure did not preclude the use of a posteriorly based fla p for vaginal reconstruction, Conclusions: While patients with low con fluence can be treated with single posteriorly based flap vaginoplasty , those with higher confluence may benefit from a perineal prone appro ach to achieve adequate exposure for pull-through vaginoplasty. This p rone approach to the high urogenital sinus anomaly can be performed wi thout division of the rectum, provides excellent exposure of the high confluence even in small children and does not preclude the use of pos terior flaps for vaginal reconstruction.