82. Urethral meatoplasty and introitoplasty with cloacal repair: report of a modified reconstructive technique

Abstract

<h3>Background</h3> For complex cloacal reconstructions, urogenital separation is best for a short urethra (<2cm) or if there is concern that a total urethra mobilization may move the bladder neck out of the urogenital diaphragm. For such cases, the single perineal orifice is left to be the meatus. After separation from the vagina(s), the common channel is used with the urethra to construct a neourethra. This orifice, however, is anatomically high relative to the typical external female genitalia, leading to poor cosmesis and potential discomfort with intermittent urethral catheterizations. This case report describes a method of urethral meatoplasty during a cloacal repair with urogenital separation in which the distal common channel is used to create an anatomically correct placement of the urethral orifice relative to the vestibule. <h3>Case</h3> A 4-month girl with a cloaca was referred to the interdisciplinary surgical team of colorectal, gynecologic, and urologic surgeons. A cloacagram showed a 2.16 cm common channel, 1.5 cm urethra, and longitudinal vaginal septum, thus a urogenital separation was planned. After maintaining the common channel for the urethra, the vaginas were separated from the urinary tract. The vaginas and rectum were mobilized via laparotomy. Following septum resection, the vagina was tubularized and elongated. The labia minora, which were fused to the common channel, were separated. The posterior wall of the very distal common channel was opened 3mm and sutured to the anterior vaginal wall horizontally. Thus, the urethral meatus was more posterior to its original location, and the introitus lay next to the urethral opening's lateral walls. <h3>Comments</h3> With this meatal modification, the urethral and vaginal orifices are natural anatomic locations within a mucosal vestibule. There is a paucity of literature regarding cosmetic outcomes following cloacal repair; focus has been on a catheterizable, visible urethra. For a cloaca requiring a urogenital separation, leaving the common channel orifice in its original location leaves an anteriorly mislocated urethral meatus, closer in proximity to the clitoris. Our proposed technique for meatoplasty and introitoplasty yields urethral and vaginal orifices within a mucosal vestibule, improves cosmesis, and may improve comfort for future intermittent catheterizations as the urethral meatus is separate from the clitoris.